Medicine Science I International Medical Journal; E- Journal of Volume 7, Issue 4 by Medicine Science

Medicine Science International Medical Journal

EDITORIAL BOARD

Editor-in-Chief Osman CELBIS (MD, Professor), (editor.osmancelbis@gmail.com)

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Editors ➢

Yuksel ERSOY (MD, Professor) (editor.yukselersoy@gmail.com)

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Yunus KARAKOC (PhD, Professor) (editor.yunuskarakoc@gmail.com)

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Selami Cagatay ONAL (MD, Professor) (editor.cagatayonal@gmail.com)

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Ibrahim SAHIN (MD, Professor) (editor.ibrahimsahin@gmail.com)

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Nevzat ERDIL (MD, Professor) (editor.nevzaterdil@gmail.com)

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David O. CARPENTER (MD, Professor)

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Ronald S MacWalter (MD, FRCP)

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Ədalət Həsənov (MD, Professor)

Publishing Editor ➢

Fatih BATI (MD, Assistant Professor) (editor.fatihbati@gmail.com)

Medicine Science International Medical Journal

SCIENTIFIC ADVISORY BOARD (Alphabetical Order) •

Gökhan Akbulut, İzmir, Turkey

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Ferah Kızılay, MD, Antalya, Turkey

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Murat Alper, MD, Erzincan, Turkey

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Prakash Kinthada, PhD, Visakhapatnam, India

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Mustafa Altintas, MD, Antalya, Turkey

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Ozkan Kose, MD, Antalya, Turkey

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Sevil Atasoy, PhD, Istanbul, Turkey

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Zhiqiang Liu, MD, PhD, Houston, TX, USA

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Aysegul Atmaca, MD, Samsun, Turkey

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Liu Liu, MD, PhD, New Orleans, LA, USA

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Yasar Bayindir, MD, Malatya, Turkey

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Ronald S MacWalter, MD, Scotland, UK

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Turgay Bork, MD, Malatya,Turkey

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Bulent Mızrak, MD, Batumi, Georgia

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David O. Carpenter, MD, New York, USA

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Camal Musaev, MD, Azerbaycan

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Chang-Hwei Chen, PhD, New York, USA

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Musfiq Orucov, MD, Azerbaycan

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Gurkan Celebi, MD, Ankara, Turkey

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Ercument Olmez, MD, Manisa, Turkey

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Selcuk Cetin, MD, Tokat, Turkey

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Bedirhan Sezer Öner, MD, Malatya, Turkey

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Nefise Oztoprak Cuvalcı, MD, Antalya, Turkey

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Necdet Oz, MD, Antalya, Turkey

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Oguzhan Deyneli, MD, İstanbul, Turkey

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Abdullah Ozgonul, MD, Sanliurfa, Turkey

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Ahmet Hakan Dinc, Ankara, Turkey

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Hakan Parlakpinar, MD, Malatya, Turkey

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Ali Dogan, MD, Antalya, Turkey

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Erkan Pehlivan, PhD, Malatya, Turkey

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Teoman Dogru, MD, Balıkesir, Turkey

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Oguz Polat, MD, Cleveland , USA

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Nevzat Erdil, MD, Malatya, Turkey

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Nilufer Tulin Polat, PhD, Malatya, Turkey

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Bulent Eren, MD, Bursa, Turkey

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Nariman Safarli, MD, Baku, Azerbaijan

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Zerrin Erkol, MD, Bolu, Turkey

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Nusret Soylu, MD, Malatya, Turkey

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Kadir Ertem, MD, Malatya, Turkey

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Maryna Steyn, MD, South Africa

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Yasemin Ersoy, Malatya, Turkey

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Hülya Taskapan, MD, Malatya, Turkey

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Suraj K George, MD, USA

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Mehmet Tokdemir, MD, , Elazig, Turkey

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Mira R. Gökdoğan, PhD, Girne, North Cyprus

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Nilgun Ulutasdemir, PhD, Gaziantep, Turkey

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Ali Gunes, MD, Malatya, Turkey

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Ali Uzunkoy, MD, Sanliurfa, Turkey

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Hakan Gunen, MD, Istanbul, Turkey

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Yingjun Yan, MD, Nashville, TN 37232, USA

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Than Than Htwe, MD, Perak, Malaysia

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Dilek Yavuz, MD, İstanbul , Turkey

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S.Iqbal, MD, Kerala, India

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Ilhan Yetkin, MD, Ankara, Turkey

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Nur Efe Iris, MD, İstanbul, Turkey

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Tulay Öner Yıldırım, MD, Malatya, Turkey

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Servet Birgin Iritas, MD, Ankara, Turkey

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Oguzhan Yıldırım, MD, Malatya, Turkey

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Mehmet Yasar Işcan, PhD, Istanbul, Turkey

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Tuba Duygu Yılmaz, MD, Mersin, Turkey

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Om Prakash Jasuja, PhD, Patiala, India

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Eda Bengi Yılmaz, MD, Mersin, Turkey

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Kishore Kumar Jella, PhD, Atlanta GA, USA

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Saim Yologlu, PhD, Malatya, Turkey

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Mehmet Karaca, MD, Antalya, Turkey

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Menizibeya Osain Welcome, MD, Minsk, Belarus

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Abdullah Karaer, MD, Malatya, Turkey

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Ersoy Kekilli, MD, Malatya, Turkey

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Pavel Timonov, MD, Bulgaria

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Mehmet Kelles, MD, Malatya, Turkey

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Antoaneta Fasova, MD, Bulgaria

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Inam Danish Khan, MD, CH EC Kolkata, India

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Robert (Paweł) SUSŁO, MD, Poland

Ronald K Wright BS MD JD, FL , USA

Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):724-7

Efficiency of high intensity laser therapy in patients with knee osteoarthritis Ezgi Deniz Ciplak1, Semra Akturk2, Raikan Buyukavci2, Yuksel Ersoy2 1 Midyat State Hospital, Department of Physical Medicine and Rehabilitation, Mardin, Turkey Inonu University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Malatya, Turkey

Received 26 April 2018; Accepted 09 May 2018 Available online 21.06.2018 with doi: 10.5455/medscience.2018.07.8819 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract It is aimed to compare the effects of high-intensity laser treatment (HILT) and the transcutaneous electrical nerve stimulation (TENS) and ultrasound (US) combined treatment on pain, functionality, and quality of life in the patients with knee osteoarthritis. The patients were randomized into 2 groups. Combination of hot pack, TENS and US treatment were applied to the first group and HILT was applied to the second group for 2 weeks. At every visit; resting, movement and night pain scores, function, and stiffness scores were assessed.The patients were invited for the control after the treatment and in the 6th week. A total of 48 patients (33 women and 15 men, aged between 25 and 65 years, average age of 54.25 years) participated in this study. In both groups, a statistical significant change was observed in all the parameters in posttreatment measurements. In the between-groups comparison, it was observed that HILT provided a significant recovery in pain scores both after the treatment and in the 6th week than TENS and US combined treatment. HILT in knee osteoarthritis is a statistically significant efficient method on pain and functional scales compared to TENS+US combined treatment. Keywords: Knee osteoarthritis, hiltherapy, TENS, ultrasound

Introduction Osteoarthritis (OA) is a degenerative joint disease characterized by an increase in the thickness of joint capsule together with the loss of articular cartilage and also by synovitis at various grades that may accompany these pathologies [1]. It causes limitations in activities of daily living and impairment in the quality of life due to the accompanying pain and morning stiffness [2]. It increases by age and it generally affects the knee joint [3]. According to World Health Organization (WHO), it affects 9.6% of men and 18% of women over 60 years old [4]. In 2020, it is estimated that it will be the 4th biggest cause of disability in all the diseases. Generally, 43.4 million people in the world is affected by osteoarthritisassociated disability [5]. This disorder has become one of the most important problems decreasing productivity and increasing health costs today due to gradually increasing obesity and sedentary life in the community [6,7]. Knee osteoarthritis may develop as a result of overloading on a normal joint or the normal loads on a damaged cartilage and surrounding tissues. Generally, it is thought that it has developed depending on the mechanic and metabolic response secondary to the changes occurring in the cartilage tissue [8-10]. *Coresponding Author: Semra Akturk, Inonu University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Malatya, Turkey E-mail: semrakayakturk@hotmail.com

There are many different approaches used in the treatment of knee osteoarthritis. The recommended treatment in clinical practice is to use the combination of pharmacological and non-pharmacological treatments. Pharmacological treatments recommended in the final guidelines are acetaminophen, NSAID, topical anti-inflammatory drugs, capsaicin, chondroitin, intraarticular corticosteroid injection, glucosamine, duloxetine, hyaluronic acid, and oral/transdermal opioids. Non-pharmacological treatments are training, weight loss, nutritional recommendations, exercise, the use of appropriate shoes, walkers, balneotherapy and physical treatment modalities [11-13]. Physical treatment modalities used in the treatment are superficial heaters, transcutaneous electrical nerve stimulation (TENS), diadynamic current, magnetotherapy, ultrasound (US), and laser [14]. While argon, CO2 and neodymium YAG lasers were used generally in surgical processes beforehand, they are started to be used in musculoskeletal system diseases today. In knee osteoarthritis treatment, low-level laser treatment (LLLT) producing a laser beam at 600-800 nm wavelength is widely used [15]. High intensity laser therapy (HILT) is a laser having a wavelength of 1064 nm and it is started to be used in the treatment of musculoskeletal system diseases recently. Its primary effect is analgesic effect and reactive vasodilatation that are formed by affecting the cutaneous nerve endings [16]. Another mechanism of action is based on tissue stimulation. This stimulation forms at cell, vascular tissue, interstitial tissue and immune system level. 724

doi: 10.5455/medscience.2018.07.8819

It increases regeneration and beta-endorphin release by inducing the protein synthesis in synovial fluid, thus it shows analgesic and anti-inflammatory effect [17]. Electrotherapy is frequently used for the treatment of knee osteoarthritis. The most common types of electrotherapy are TENS, a method of pain relief in which a special device transmits low voltage electrical impulses through electrodes on the skin to an area of the body suffering from pain and it is indicated to be superior to placebo in the control of pain. US is a modality of treatment that uses sound waves to generate heat within a body part and it is usually combined with TENS for treatment of knee osteoarthritis [18]. The aim of this study was to compare the efficiency of HILT, a new treatment method, for the treatment of the patients diagnosed with knee osteoarthritis, with the combination of TENS and ultrasound. Material and Method The patients, who applied to outpatient clinic of Inonu University Faculty of Medicine Physical Medicine and Rehabilitation outpatient clinic between February 2016 and June 2016 due to knee pain and were radiologically assessed as Kellgren-Lawrence grade 2-3 after being diagnosed with Primary Knee Osteoarthritis according to the ACR criteria, were included in the study. The study was carried out in accordance with the Helsinki Declaration and approved by the Inonu University Faculty of Medicine Clinical Research Ethics Committee. All participants were informed about the study and each gave written consent. The study was designed as prospective, randomized, and single blind. It was calculated that a total of 48 individuals should be taken, with at least 24 subjects from each group when α=0.05 and 1-β=0.80 were taken in the power analysis performed. The patients, who underwent a previous knee surgery, had tendon or meniscus rupture, had central or peripheral neuropathy, had received physical treatment or intra-articular corticosteroid or hyaluronic acid injction within the last 6 months, had malignancy and were pregnant, were not included in the study. The patients were randomized into 2 groups. Randomization was made by drawing lots. A total of 10 sessions of hotpack, TENS (20 minutes/session) and active continuous ultrasound treatment (5 minutes/session at a dose of 1.5 w/cm2 ) were applied to the first group for 2 weeks. A total of 10 sessions of HILT and hotpack were applied to the second group for 2 weeks via BTL 6000 High Intensity Laser device following the hotpack application. HILT was first applied in biostimulation mode for 4 minutes at the dose of 12j/cm2 with power of 10 watt and frequency of 25 Hz and then in analgesia mode for 6 minutes at the dose of 150j/cm2 with power of 7 watt in of the device in the knee region of patients. Quadriceps strengthening, hamstring strengthening and isometric exercises were applied to both groups. The patients were invited for the control after the treatment and in the 6th week. At every visit; resting, movement and night pain scores, function, and stiffness scores were assessed. Visual Analogue Scale (VAS): The knee pain intensities of the

Med Science 2018;7(4):724-7

patients during resting, movement and night were assessed by using VAS. Accordingly, on a 10- cm long line, point 0 was accepted as no pain and point 10 was accepted as worst pain. The patients were asked to mark the intensity of their knee pains on this line. Then the distance between the point marked and point 0 was measured by a ruler [19]. Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index: It consists of three sections as pain, stiffness and physical function and totally 24 questions. The increase of this value shows that pain and stiffness increase and physical function impairs. In previous studies, validity and safety assessments were performed in osteoarthritis assessment and its use in osteoarthritis was accepted [20]. Statistical Analysis SPSS for Windows version 17.0 software was used to conduct the statistical analysis of the study data. Identification of data related to quantitative variables was performed by Arithmetic mean[Mean]±Standard deviation [Sd], and the identification of data related to qualitative variables via min-max was performed by using number [n] and percentage [%]. The data of quantitative variables were tested by using Shapiro Wilk normality test. Unpaired t test and Mann–Whitney U test were used to compare the groups. Paired t test and Wilcoxon test were used in the examination of within-group variances. The value of p<0.05 was accepted as statistically significant. Results A total of 48 patients (33 women and 15 men, aged between 25 and 65 years, average age of 54.25 years) participated in this study. Both groups included 24 patients. Average age of the groups was determined as 56.91±7.86 years for Group 1 (hotpack+TENS+US) and 51.62±10.3 years for group 2 (HILT+hotpack). There was no statistical significant difference between the groups in terms of age, gender, occupation, level of education, body mass index and period of complaint, accompanying systemic diseases and the radiological grades of knee osteoarthritis (p>0.05) (Table 1). Also, there was no significant difference between the groups in the baseline of VAS or WOMAC subscales (Table 2). Table 1. Demographic data of the patients Group 1

Group 2

56.91±7.86

51.62±10.3

0.070

30.14±5.8

28.65±4.99

0.208

Grade 2

0.968

Grade 3

0.928

Age (years) BMI (kg/cm ) 2

Kellgreen-Lawrence radiological stage

All treatment groups showed a significant reduction in VAS and WOMAC subscales in the post-treatment period (after 6 weeks) compared to baseline values (Table 2). When before/after treatment and before treatment/6th week within-group differences were compared, a more significant recovery was observed in favor of group 2 in terms of pain score in VAS resting, night pain and movement (p<0.05). When the within-group differences were compared in terms of WOMAC pain and total scores, a significant 725

doi: 10.5455/medscience.2018.07.8819

recovery was observed in favor of group 2 (p<0.05) (Table 2). When the within-group differences were compared in terms of WOMAC function score, no significant difference was observed between both groups (p>0.05). Table 2. Changes in VAS and WOMAC scores between treatment groups

VAS movement

VAS night pain

Womac pain

Womac stiffness

Womac function

Group 1 Mean±SD

Group 2 Mean±SD

Pre

6.95±1.82

7.33±1.46

0.43

6 weeks

4.58±1.99

3.41±1.47

0.02

0.000*

Pre

3.54±2.70

4.58±2.01

0.13

6 weeks

2.20±.2.30

2.20±1.44

1.00

0.001*

Pre

10.37±3.18

13.12±3.28

0.05

6 weeks

6.87±2.89

7.08±3.43

0.82

0.001*

Pre

3.37±2.68

4.29±2.54

0.23

6 weeks

2.70±2.10

2.70±1.78

0.53

0.001*

0.000*

Pre

40.66±11.06

42±10.70

0.67

6 weeks

32.04±8.57

31.08±9.17

0.71

0.000*

SD standard deviation, VAS visuel analog scale (score: 0–10) measures the intensity of pain (a higher score indicates a higher pain intensity), WOMAC Western Ontario and McMaster Universities Arthritis Index (score: 0–96) measures pain (0–20), stiffness (0–8), and function (0–68) (a lower score indicates less dysfunction) * Unpaired test (p<0.05) # Mann–Whitney U test (p<0.05)

Discussion IIn the present study, it was determined that HILT application on the patients with knee OA was more effective on pain and functional scales in a statistically significant manner compared to TENS and US combined treatment. In the literature, US is considered as an effective treatment modality which is used in the treatment of knee osteoarthritis [21-25]. It was used alone or combined with TENS or exercises. Symptomatic and functional recovery of therapeutic ultrasound application in the treatment of knee OA were revealed in two different meta analyses published in 2010 [26,27]. In another study, ultrasound and TENS treatment combined with exercise was compared with only exercise treatment and it was concluded that combined treatment was more efficient in the restoration of balance function [28]. It was reported that TENS application together with exercise and hot compression treatment was more efficient on pain than the placebo TENS application with the same treatments and it provided a significant recovery on the quality of life questionnaires [29]. In the present study, significant recoveries were observed in the VAS and WOMAC parameters that were the pain and functionality indicators of the patients together with the combination of US, TENS and exercise.

Med Science 2018;7(4):724-7

Recently, pulsed Nd:YAG laser therapy, a form of HILT, has been used for a wide range of musculoskeletal diseases. HILT applications include radiculopathy [30], myofascial pain syndrome [31], frozen shoulder [32], lateral epicondylitis [33], and low back pain [34]. Mechanism of action is based on tissue stimulation. This stimulation forms at cell, vascular tissue, interstitial tissue and immune system level. Moreover, the laser has direct effect when applied locally on the tissues and has systemic effects when applied on the acupuncture points. It forms reactive vasodilatation by reducing spasm in muscle arterioles and the pain sense at the sensory nerve endings. It increases regeneration and betaendorphin release by inducing the protein synthesis in synovial fluid, thus it shows analgesic and anti-inflammatory effect. Additionally, it induces hematopoiesis in the bone marrow and shows an anti-bacterial effect by stimulating the immune system [35]. These results showed that the potential physiological effects of laser were independent from heat. It was shown that Nd: YAG lasers contributed to the recovery process in tendons and ligaments and also prevented the formation of fibrosis [17]. In the study comparing the efficiency of high dose laser treatment with splint in the patients with lateral epicondylitis; the patients were divided in three groups as HILT, placebo HILT and splint groups and the results were assessed by VAS scores and SF-36. As a result, significant efficiency was observed in both groups and no significant difference was observed between the groups [33]. In another study conducted by Fiore et al. in the patients having low back pain; efficiencies of HILT and ultrasound treatment were compared and in the 3rd post-treatment week assessment, a significant decrease was observed in the VAS score in the HILT group compared to the ultrasound group [34]. In the study conducted by Danilov et al., to assess the efficiency of high dose laser treatment in the patients with knee osteoarthritis; a statistical significant difference was observed in all the WOMAC scores compared to the scores before treatment [36]. In two studies, efficiencies of placebo, LLLT and HILT were compared and significantly higher decrease was observed in HILT group compared to LLLT group in terms of post-treatment VAS and WOMAC scores. In placebo laser group; no recovery was determined observed after the treatment [37,38]. In the present study, a significant decrease was determined in pain in groups of TENS+US and HILT at the end of treatment and in the first month control compared to pre-treatment period in terms of resting, movement and night pain VAS score; but when within-group differences were compared, the decrease in HILT group was significantly evident compared to TENS+US group. Conclusion HILT application on the patients with knee OA is a significantly efficient method on pain and functional scales compared to TENS+US combined treatment and when it is combined with exercise, it might provide better outcomes for patients with OA. Limitations Different effects of laser on pain may be related to the wavelength, treatment period, power density applied and the no. of treatments and there was no specified optimal dose and treatment scheme yet. Also in the present study, because the efficiency of the current treatments is assessed in a short period of time as 6 weeks, more extensive studies assessing the long-term effects of high intensity 726

doi: 10.5455/medscience.2018.07.8819

laser, which is an adjuvant treatment are required. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):728-32

An analysis of the relationship between insomnia-fatigue levels of the mothers and their depression and maternal attachment status Songul Aktas1, Dilek Kucuk Alemdar2 1

Karadeniz Technical Universty, Faculty of Health Sience, Department of Birth, Women Health and Disease Nursing, Trabzon, Turkey 2 Giresun Universty, Faculty of Health Sience, Department of Midwifery, Giresun, Turkey Received 17 April 2018; Accepted 20 April 2018 Available online 28.04.2018 with doi: 10.5455/medscience.2018.07.8789 Copyright © 2018 by authors and Medicine Science Publishing Inc

Abstract The study was conducted to investigate the relationship between the insomnia-fatigue levels of the mothers with infants and their depression and maternal attachment status. The universe of this descriptive study consisted of the mothers with infants who applied to a state hospital in the north of Turkey with the mothers admitted to the pediatric polyclinic. The sample comprised 194 mothers who were selected by a simple random sampling method and who agreed to participate in the study. In the G power analysis, the sample calculation was performed based on the relationship between two means. As a result of the analysis, the sample was calculated as 178 people. This number was increased to 194 to improve the power of the research. As data collection tools, a Mother Introductory Information Form for descriptive features, Brief Fatigue Form, Sleep Status Rating Scale for Mothers, Beck Depression Scale and Maternal Attachment Scale were used. In the statistical analysis, arithmetic means, standard deviations and percentages were used for descriptive variables. Spearman correlation analysis was used to examine the relationships between the quantitative variables. The average age of the mothers was found as 29.28±5.52 and 52.7% of them were primary school graduates. 86.1% had planned pregnancy and 64.9% had a cesarean section. 68.7% of the mothers stated that they could take their baby on their laps more than one hour and 45.6% were breastfeeding them. It was determined that the mean fatigue scores of the mothers were 4.33±2.56, the mean insomnia score was 4.23±1.24, the Beck depression score was 14.01±11.06 and the maternal attachment score was 99.22±6.74. In our study, there was a significant weak relationship in the positive direction between maternal fatigue and insomnia levels and depression status (p <0.05) and no significant relationship between maternal fatigue and insomnia levels and maternal attachment status (p> 0.05). It was determined that there was a weak correlation in the positive direction between the fatigue-insomnia levels and the depression status of the mothers. In the light of these results, by identifying the factors that cause fatigue and insomnia, it could be suggested to prevent the maternal depression and to strengthen maternal attachment of the mothers with infants aged 2-6 months through social support provided by health professionals. Keywords: Postpartum, infant, fatigue-insomnia, depression, maternal attachment, health professionals

Introduction Fatigue has an important place among the postpartum complaints. Postpartum fatigue is a condition of discomfort, disability and negative feelings associated with psychological, physiological and situational factors. [1-3]. Bozoky and Corwin (2002) is stated that fatigue is more common than postpartum depression symptoms, and its early prediction and prevention could be possible [4]. In the study of Mc Queen (2003), the mothers were reported to have more fatigue after the postpartum period than during the postpartum period [5]. It is stated in the literature that maternal fatigue is 42.0%, 59% and 54% within 2 weeks, 8 weeks, and 18 months after birth respectively [5]. The some studies show that fatigue in mothers is more frequent after childbirth [5, 6]. This fatigue can negatively affect the health of both mothers and their babies. A prolonged fatigue can negatively affect maternal healing *Coresponding Author: Songul Aktas,Karadeniz Technical Universty, Faculty of Health Sience, Department of Birth, Women Health and Disease Nursing, Trabzon, Turkey E-mail: songulbora@mynet.com

after childbirth, maternal behavior, baby care, the relations with family members, work performance, self-fulfillment behavior and breastfeeding [6]. The infant’s sleep patterns may also lead to fatigue of mothers. Excessive fatigue means that mother’s sleep needs cannot be fulfilled adequately. Whereas mothers’ night sleep needs increase more than past after the birth [7]. Especially if the mother has other children to look after, her workload will increase and she may experience more insomnia. Prolonged insomnia can cause developmental crisis and depression in the mother [3,5]. Depression, a commonly seen psychological health problem across the world, prevents the functionality, creativity, happiness, and satisfaction of individuals, reduces their quality of life, and leads to losses in the work force [8,9]. Apart from insomnia and fatigue, there are some other obstetric factors that cause mothers to have depression [2,10]. They include risky pregnancy, unwanted pregnancy, depression in pregnancy [9], traumatic birth experience with low satisfaction [11], being a mother for the first time, newborn incubation [10], anomalous birth of the baby [12], birth 728

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mode, difficulty in baby care, lack of social support, infantile colic, infectious diseases, and receiving negative medical diagnosis and increase the probability of maternal depression [2,10]. The depression can lead to maternal sleep deprivation and insufficient maternal attachment (emotional connection between mother and baby) as well as affecting mothers’ mental health negatively [13]. Insufficient maternal attachment influences both the present and the future mental and physical health of the baby in a negative way due to the breastfeeding problems and the lack of positive interaction between mother and baby [14,15]. In a study conducted by Reck et al. in Germany, it was determined that about 30% of the mothers who were diagnosed with depression had a problem with attachment with their babies [16]. Therefore, an early detection and the support of mothers who are depressed are very important for the health of mother-newborn and family [2,8]. This study aimed to investigate the relationship between fatigue-insomnia levels of the mothers after postpartum period and maternal attachment and depression. There has not yet been another study conducted in our country for this purpose. Material and Method The type of this study is descriptive and it was conducted between May and October 2017 at a state hospital in the north of Turkey with the mothers admitted to the pediatric polyclinic. The sample was determined by the simple random sampling method and the number of samples was determined by G power analysis. In the G power analysis, the sample calculation was performed based on the relationship between two means. In the calculation, bi-directional correlation was used, and type 1 error rate was taken as (ɑ) = 0.05, and the power of the study (1- β) was taken as 0.90. As a result of the analysis, the sample was calculated as 178 people. Based on the probability of the missing data and the likelihood that the sample will better represent the universe, the data were collected from 194 pregnant women. The inclusion criteria for sampling in the study were being literate, being volunteer to participate in the research, being over 18 years old, being a mother with infants aged 2-6 months old, being admitted to the pediatric polyclinic, having given a term and healthy birth (38–42 gestational weeks, born in 2500–4000 grams, presented no known congenital disease) and being a mother without any visual and hearing impairment, not have psychiatric disease of mother. The exclusion criteria for sampling in the study included the mothers with infants previously diagnosed with colic and treated for it, twins and the babies with harelips and WolfHirschhorn syndrome. The reason for choosing the mothers with infants aged between 2 and 6 months in this study was partially because of the intention to assess the depression status of the mothers separately from the postpartum period (first 6-8 weeks after childbirth) and examine the relationship between the maternal attachment levels of mothers and their insomnia and fatigue in this period. In addition, it is recommended that the first 6 months babies are fed only with breast milk. The relationship between breastfeeding and maternal attachment was also taken into consideration. Data Collection The data were collected from the mothers who applied to the

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pediatric policlinic of the relevant hospital using five forms. These were; Mother Introductory Information Form (MIIF): It consists of 12 questions prepared by the researcher scanning the literature, including the socio-demographic (age, education etc.) and obstetric (the type and number of births, the previous birth type etc.) characteristics of the mothers. This form was collected by a face to face interview method. Brief Fatigue Inventory (BFI): To determine the level of fatigue, the (BFF) developed by the Anderson Cancer Center was used. The Cronbach alpha internal consistency coefficient of the BFF that was found appropriate for Turkish society by Çınar et al. (2000) was determined as 0.98 [15]. It includes the general fatigue levels (the fatigue experienced during the application of the questionnaire, the general fatigue experienced during the last 24 hours and the worst fatigue during the last 24 hours) and the level of its influence on the daily activities in the last 24 hours (general activity, mood, walking skills, work life, the relations with other people, the joy of life). It is a likert type scale consisting of nine items questioning the level of influence. The scoring is between “0” and “10”. “0” indicates not being influenced at all, “1-3” refers to a low level of fatigue, “4-6” indicates a middle level of fatigue, and “7-9” indicates the highest level of fatigue. Each item can be calculated individually in the BFF or total scores can be calculated as is in this study. Sleep Status Rating Score for Mothers: This scale was prepared in the light of the literature by researchers and was used to evaluate the sleep status of the mothers [3]. To assess mother’s general sleep status, a scoring between 0 (I could not sleep at all) - 10 (I slept very well) is used. Beck Depression Inventory (BDI): The BDI was developed by Beck et al. (1961) [17] and includes 21 self-evaluation statements about the depression and each item scores from 0 to 3. The aim of the inventory is not to diagnose depression but to measure the severity of the depression symptoms objectively. A score between 0 and 9 indicates no depression; a score between 10 and 16 indicates a mild level of depression; a score between 17 and 24 indicates a moderate level of depression; and a score of 25 or higher indicates a severe level of depression (major). The highest score to be obtained from the inventory is 63. The Turkish adaptation, reliability, and validity tests of the inventory were performed by Hisli and the cut-off point in the study was accepted as 17 [18]. A score of ≥ 17 detects depressive symptoms that require a medical treatment with an exactness of 90%. Maternal Attachment Inventory (MAI): This scale which determines the level of attachment between mother and baby was developed by Muller and adapted to Turkish by Kavlak (2004) [19]. There are 26 statements in MAI that the individuals can use to express their feelings. According to the severity of the feelings the mothers feel towards their babies, the scores of the expressions are calculated as follows; Always (a) = 4 points, Frequently (b) = 3 points, Sometimes (c) = 2 points and Never (d) = 1 point. A total score is obtained for all the items. The high scores indicate that maternal attachment is high. The lowest score to be obtained from the scale ranges from 26 to 104. 729

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Data Analysis The data were analyzed using SPSS 21.0 software package. In the statistical analysis, arithmetic means, standard deviations and percentages were used for descriptive variables. Spearman correlation analysis was used to examine the relationships between the quantitative. Ethical considerations Permission from the related institution and verbal and written consent from the mothers were obtained before the research. In the study, the related ethical principles of ‘‘Informed Consent Policy,’’ ‘‘Volunteer Policy,’’ and ‘‘Privacy Protection Policy’’ have been fulfilled since the use of human subjects requires the protection of individual rights. Results The results showed that 44.3% of the mothers participating in the study were between 25 and 29 years old, and 55.2% were primary school graduates. 86.17% of them reported to have planned pregnancy, 37.6 % were primiparous women and 64.9% gave birth by caesarean section. The gestational age, birth weight and birth height of the babies were between normal values. The average age of the babies was 2.96±1.81 month old and 45.7% were fed only with breast milk (Table 1).

Infants Gender Girl Boy Birth Spontaneous Section Diet Breastfed Formula+Breastfed Formula Gestational age (weeks) Postnatal age (mounth) Mothers Mean age, year [29.28 (5.52)] 20-24 25-29 30 and above Education Primary school Middle school University level Planning Status of Pregnancy Yes No Number of children 1 2 3↑ Time to start breastfeed First 30 minute 61 minute ↑ Infants Slept 10 Time 10 h ↓ 11-15 h 16 h ↑

n% 106 (54.6) 88 (45.4) 68 (35.1) 126 (64.9) 90 (45.6) 64 (34.2) 40 (20.2) Mean (Standart Deviation) 38.69 (2.02) 2.96 (1.81) n% 25 (16.9) 86 (44.3) 83 (42.8) 107 (55.2) 38 (19.6) 49 (25.3) 167 (86.1) 27 (13.9) 73 (37.6) 62 (32.0) 59 (30.4) 61 (31.3) 133 68.7) 118 (60.8) 54 (27.8) 22 (11.3)

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When the average scores of the mothers were examined it was found that fatigue was 4.33±2.56, insomnia was 4.23±1.24, depression was 14.01±11.06, and maternal attachment was 99.22±6.74 (Table 2). Table 2. The mean scores of the mothers in The Sleep Status Rating Scale, Brief Fatigue Inventory, Beck Depression Scale and Maternal Attachment. (N=194)

Sleep Status Rating Score Brief Fatigue Inventory Beck Depression Scale Maternal Attachment Inventory

Minimum

Maximum

Mean

Standard Deviation

0.00 1.00 0.00

10.00 6.00 54.00

4.33 4.23 14.01

2.56 1.24 11.06

78.00

104.00

99.22

6.74

In our study, a negative correlation was found between the average depression scores of the mothers and their sleep status (p <0.05), while a weak relationship in the positive direction was found between the average depression scores and their fatigue status (p <0.05). In our study, there was no relationship between the average maternal attachment scale scores and mothers’ sleep status rating scales of and their fatigue scores (p> 0.05) (Table 3). Table 3. An analysis of the relationship between the mean scores of depression and maternal attachment total scores of the mothers and their sleep status rating scales and fatigue total scores (N = 194)

Table 1. Distribution of Socio-Demographic Characteristics of Mothers and Their Infants (N=194) Characteristics

Beck Depression Scale Sleep Status Rating Score Brief Fatigue Inventory

r -0.174 + 0.204

p-Value 0.01* 0.00*

Maternal Attachment Inventory r -0.057 -0.174

p-Value 0.48 0.15

Discussion In this study it was determined that the mothers had moderate fatigue and insomnia levels (Table 2). Mothers may experience fatigue with insomnia. Fatigue can negatively affect newborn care as well as the risk of delay in physical recovery, decrease in selfcare and increase in health problems [20]. There are some studies in the literature that indicate that as the postpartum period progresses, fatigue and insomnia can reduce as well as opposite studies [5, 21]. Considering the fact that the majority of the mothers in our study delivered by cesarean section, it could be thought that these mothers might have more fatigue than those having vaginal births (Table 1). In a study by Karen et al. (1998) the parameters of sleeping habits of breastfeeding primiparous mothers 3 days, 3 weeks, 6 weeks and 9 weeks after the birth, perceived stress, fatigue, breastfeeding experiences and neonatal mobility were investigated and the relationship of fatigue with each of these parameters was determined. This study demonstrated that as the mobility of the baby increased, the sleep disturbances and the fatigue of the mothers increased and the breastfeeding behavior was adversely affected [22]. In our study, 45.6% of babies did not need an additional preparation because they were breastfed and 39.2% of them had a total sleep time of 11 hours or more per day (Table 1). This situation was thought to contribute positively to the prevention of fatigue and insomnia in severe levels by increasing the possibility of mothers’ resting. Tackett, Cong, and Hale (2011) found that the mothers with babies aged 0-12 months old and those fully breastfed were less tired than those who fed their babies in 730

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other forms of food (formula etc) and felt physically better [23]. Contrary to this study, Downs et al. (2010) determined that there was no difference between the fatigue status of mothers who breastfed their babies for 2- 12 weeks, those who fed with Formula and those who used two methods [24]. On the other hand, it should be kept in mind that the fatigue perception of the mothers will be individual; the breastfeeding in some mothers may increase the fatigue in the mothers and can cause the breastfeeding to be left [25,26]. Our study demonstrated that the mothers showed mild depressive symptoms (near moderate) (Table 2). It is a pleasing finding that the average depression scores of the mothers were below the cut-off point of 17. This finding is similar to some studies [2,10]. However, the presence of mothers who tend to have mild or moderate depression during this period requires health care staff to be more attentive to this group. The early detection of these mothers bearing the risk of depression and the provision of necessary psycho-social support are important for mother and family health [2,27]. The factors such as positive birth experience, skin contact immediately after birth, first breastfeeding, duration of breastfeeding, baby’s feeding style increase maternal attachment [14, 15]. In our study, when maternal attachment to infants was examined, it was found to be very high. This finding was consistent with the finding that showed that maternal depressive symptoms were low and insomnia and fatigue were not at high levels. The fact that there were healthy newborns, planned pregnancies, multiparous mothers who were experienced about baby care in our study were thought to be effective on high maternal attachment. Maternal attachment is especially affected by maternal depression [14]. In a study conducted at the University of Heidelberg, the maternal attachment levels of the mothers with depressive symptoms for four months postpartum was reported to be low [21]. In our study, the high maternal attachment score of the mothers could be due to the mild depression of the mothers. The presence of maternal sleep disorders is directly related to depression [2, 26]. The fact that the mother is depressed negatively affects both maternal attachment and the present and future mental and social health of the baby [13]. In our study, there was a weak relationship between the average depression scores of the mothers and their sleep status rating scores in the negative direction (p <0.05) and a weak relationship between the average depression scores of the mothers and the fatigue status in the positive direction (p <0.05). This finding is consistent with the literature [14,20,27]. In study Dennis and Rose’s (2005) was determined that the infant sleep patterns and maternal fatigue were strongly associated with a new onset of postpartum depressive symptoms [28]. For this reason, ensuring that mothers sleep enough by being well supported by the family and social environment, especially spouses in infant care, will contribute to reducing both fatigue and preventing depression. In our study, there was no relationship between the average maternal attachment scale scores and mothers’ sleep status rating scales of and their fatigue scores (p> 0.05). However, it is emphasized in the literature that as the fatigue level increases, sleep quality may deteriorate and maternal attachment may be weakened. Maternal fatigue can negatively affect maternal attachment, leading to the inability to deal adequately with the baby [14,29,30] due to the

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reduction of self-care power and breastfeeding self-efficacy [31]. Limitations of the study This study was conducted with the mothers who had healthy babies aged 2-6 months old with no known psychiatric problems. Implication for practice The causes of excessive insomnia and fatigue of the mothers who have infants between 2 to 6 months should be identified and social - medical support should be provided by health professionals. Home visits to mothers should be performed by the family health workers. During these visits, mothers should be evaluated in terms of breastfeeding self-efficacy and depression. At 2-6 months’ baby follow up (vaccination, growth etc.) health professionals (midwife, nurse, doctor) should also evaluate mothers in terms of sleep, fatigue, mood and mother-infant interaction. In this way, risky situations of mothers’ such as the depression and insufficient maternal attachment can be identified early. Additionally, it is suggested to provide fathers’ involvement in the care of the baby and thus further resting of the mothers. Conclusion In this study, insomnia and fatigue in the mothers with 2 to 6 month old babies were found to have a tendency to increase depression, and to reduce maternal attachment. It is suggested this study is to carry out with a larger population. This study was presented as verbal presentation in 1. İnternational 5. National Sivas Midwifery Sempozium, on 24-26 April 2018. Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Ethical approval was obtained from the hospital administration to use the patients’ data.

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Bozoky I, Corwin EJ. Fatigue as a predictor of postpartum depression. J Obstet Gynecol Neonatal Nurs. 2002;31(4):436-43.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):733-5

Home medical care waste collection by caregivers in Turkey Mehtap Omac Sonmez1, Feyza Nazik2, Senem Andi3 Kahramanmaras Faculty of Health Science, Department of Nursing, Kahramanmaras, Turkey 2 Bingol University, Facult of Health Science, Department of Nursing, Bingol,Turkey 3 Adana Numune Training and Research Hospital, Clinic of Oncology

Received 19 March 2018; Accepted 04 April 2018 Available online 11.09.2018 with doi: 10.5455/medscience.2018.07.8872 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Domestic medical waste is a constant concern and growing problem in home medical care. This study was carried out to determine the applications for collection of medical wastes that result from the home medical care performed by the caregivers/patients. This study was descriptive type. There were 3301 registered patients in home care services. A minimum sample size of 345 patients was reached by systematic sampling within homecare patient registration forms. The data were given as frequency distribution and averages. The person who provides care for 89.3% of the patients was the relative of the family. Although 31% caregivers have trained on home medical care waste collection, only 22.3% of caregivers collected and separated home medical care wastes. Totally 84.1% of the caregivers did not collect the home medical care wastes and threw into the domestic waste bin. The home medical care wastes thrown into the domestic waste have a great danger not only for caregivers but also for domestic waste collectors, the environment and even street animals. The home medical care waste should be collected by municipalities and health care institutions are responsible for collection all home medical care waste and they should be controlled. Keywords: Home care, medical waste, caregiver, Turkey

Introduction The World Health Organization has defined all wastes generated by health institutions, research institutes and laboratories and the wastes generated during home medical care (dialysis, insulin injections) as medical wastes [1]. One of the most important steps of medical care waste management is the collection of infected wastes separately from domestic. Although there is no specific regulation for home medical care wastes in Turkey, it is necessary to ensure that home medical care wastes (HMCW) are collected and disposed according to â&#x20AC;&#x153;medical waste control regulationsâ&#x20AC;? by home care personnel. In addition, home care personnel are responsible for educating and informing the homecare patients and their families [2]. The regulations on medical wastes and the control of medical wastes made in 1993 by the Turkey Ministry of Forestry and Environment for the first time were changed in June 2005. This regulation determined the principles for collection, transportation, temporary storage in the healthcare facilities, and removal of medical wastes [3]. In addition, this regulation was revised again in 2017. It is reported that all wastes should be transmitted to the medical waste collection centre operated by *Coresponding Author: Mehtap Omac Sonmez, Kahramanmaras Faculty of Health Science, Department of Nursing Kahramanmaras, Turkey E-mail: mehtapomac@gmail.com

municipalities in provinces within the framework of the medical waste regulation in Turkey and private contractors are hired for waste disposal in some cases [4]. The recently established home care services provide care for more patients with each passing day. When the home care team goes homes for treatment, the HMCW are collected by home care personnel but there is no explanatory data about how are collecting about HMCW (insulin, wound care, injection, colostomy, catheter care etc.) by the caregivers/patients. Therefore the purpose of this study was to investigate collection and disposal of separate HMCW by their caregivers/himself/ herself. Material and Methods Medical Waste Collection and Home care services in Turkey All of the medical wastes are collected according to Medical Waste Control Regulation (last devising, 2017). Infectious and sharps, hazardous (radioactive) wastes are segregated from the main waste stream in all of hospital. All hospitals is used red color bag for infectious waste and yellow color containers for sharps. Medical waste collection personnel who wear appropriate uniforms of the hospitals and doctors, nurses, other health staff was trained about waste management. All medical wastes were stored in medical waste depot in hospital. Medical wastes are collected by municipal waste collection personnel from these hospital depots. 733

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Home Medical Care in Turkey; home care services started for the first time in 2005. In regulation about homecare services are included as medical treatment, rehabilitation, physiotherapy, psychological treatment at home. In Turkey, homecare units were classified as primary health services, oral/dental health services and hospitals. The patients needing the service were recorded from a single center (Home Care Services), and the patients were distributed to the units according to their needs. Study Design and Participations This is descriptive study. The homecare patients in the Kahramanmaras (city of Mediterranean of Turkey), included the population of the study in January and June 2016. The number of homecare patients was 3301. The minimum sample size was calculated as 345. The minimum sample size was selected by systematic sampling from among 3301 registered home care patients. Kahramanmaras is a big city with culture and industry in Turkey. The population of the city center is 558.664 [5]. The questionnaire developed by the researchers was used. The questionnaires included the socio-demographic characteristics of patients and their caregivers and the HMCW collected by caregivers. Researchers went to home of selected home care patients (n=345). The questionnaire was conducted face-to-face to the caregiver of homecare patients. The data were analyzed in the SPSS 22.0 program. The data were given as frequency distribution and averages. Ethic Approval The study protocol had been approved by the Ethical Committee of the Kahramanmaras Sutcu Imam University (Ref. No.2015/109). The caregivers were informed about the research study. It was indicated to them that their personal data would be protected, and that they can withdraw their information at any time. Only voluntary participants were included in the study. Results The average age of the patients were 70.35Âą0.8 years and 53.3% of the patients were female and 46.1% of them were disabled. Total 25% of the patients were fully dependent in their life activities while more than half of them were fully dependent in instrumental activities and 2.3% of patients have infectious disease (hepatitis b, c). The caregiver for 89.3% of the patients is the first degree relative of the family. The variables about HMCW and daily treatment by caregivers are presented in table 1. Only 31% of caregivers reported that they received medical waste management training and 24.9% of caregivers reported that they decomposed HMCW. Caregivers collected used infected materials, needles, ampoule, sharps dressing a wound materials, urine bag, infusion set, inhaler and oxygen mask (Table 1). On the other hand, the collection rate of infected materials with body fluids was big compared with that for other home medical care materials (Table 1). The descriptive information regarding the collection of HMCW are presented in table 2.

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While a small part of HMCW are transported by municipal vehicles or hospital waste collection centers, 84.1% of them are thrown into domestic wastes and HMCW burned at home by thirteen of caregivers. The daily amounts of wastes of 70.1% of the patients are 0.5 kg and below (Table 2). Table 1. Description of variables about HMCW and daily treatment by caregivers (n=345) Variables

Yes

Have been received medical waste management training?

107

31.0

238

69.0

Do you decompose the HMCW?

24.9

259

75.1

Do you use prevent equipment?

181

52.5

164

47.5

Intravenous (IV) injection treatment

2.6

336

97.4

Intramuscular (IM) injection treatment

11.0

306

89.0

Subcutaneous (SC) injection treatment

108

31.3

237

68.7

Inhaler treatment

22.3

268

77.7

Dress a wound

103

29.9

242

70.1

Ampoule

125

36.2

220

63.8

Needles

137

39.7

208

60.3

Dressing a wound materials

108

31.3

237

68.7

Sharps

105

30.4

240

69.6

Urine bag

24.9

259

75.1

Infusion set

3.5

333

96.5

Infected materials with body fluids (salvia, mucus, seminal fluid, vaginal discharge)

231

67.0

114

33.0

Oxygen mask

8.1

317

91.9

Inhaler

21.2

272

78.8

Home medical care treatment/ daily

Categories of HMCW /daily

*Row Percent Table 2. Description variables of HMCW collections How does collecting and decomposing HMCW by caregivers?

Decomposing with domestic waste

290

84.1

Giving to municipal waste collection vehicles

3.8

Giving to hospital waste collection center

8.4

Burning at home

3.8

<0.5kg

242

70.1

1kg-1.9kg

14.5

2kg-2.9kg

11.6

>3kg

3.8

Total

345

100.0

HMCW mount kilogram (kg)/daily

Discussion The study demonstrated management of HMCW collection by caregivers. The HMCW items such as needles, sharps, infected materials with body fluids were collected and thrown into domestic waste by more caregivers. Recently, medical care waste management became an important and widespread 734

doi: 10.5455/medscience.2018.07.8872

public health problem. There are recommendations on medical waste management made by the World Health Organization and regulations are made in this regard in the countries [1]. In addition, the regulations regarding the management of HMCW collection by caregivers are inadequate. It is known that many diabetic patients in Turkey throw the pen-type self injection needles or a infected wound dressing materials into domestic wastes. In our study, although one-third of caregivers who received training on medical waste management, less than one third of them collected according to medical wastes guidance. This situation shows that the training provided is not sufficient. The special boxes are required for the collection of medical waste (needles, sharps, infected wound materials.etc.), but caregivers and patients thrown into domestic waste. At least one third of homecare patients have parenteral treatment performed by themselves or their caregivers. The needles, sharps and infected materials with body fluids are among the daily medical wastes. The infected and hazardous chemical wastes involved in domestic wastes pose a great danger for waste collectors, animals and environmental pollution [6]. There are studies indicating that municipal workers are wounded due to domestic medical wastes. For instance, Municipal workers in Japan are worried about needle stick accidents when collecting or transporting wastes [7]. Needle stick accidents have been reported 30.9% of 68 municipal governments in the metropolitan area [7]. Medical wastes are collected by special systems and teams in many countries [8-10 ]. In Turkey, as in other countries, the medical wastes that emerge when homecare treatment is performed by a nurse or doctor are collected by the homecare staff and transported to medical waste collection centers in hospitals. A study in the US about home medical care waste and HMC wastes infection control in the UK have recommended that sharp and infectious items be disposed of by doctors or nurses and infectious materials and needles should not be handled by nonmedical personnel [11]. In addition to this, the self-injection wastes are decomposed by patients in Japan and a system has been established to bring them to medical institutions [7]. In our study, HMCW was thrown into domestic waste by more caregivers. In Turkey, there is no established collection system for the collections of patients’ own treatment wastes or the wastes of medical treatments performed by their caregivers. In addition thirteen people reported that they disposed the emerging wastes and burned them at home. A study in Gana, disposal practices indicate that the majority of unwanted medicines and sharps are discarded in household bins. In addition the blood soaked items (especially sanitary items) are burned in backyard [12]. In our study, 12.1% of caregivers reported that they took the wastes to municipal waste collection vehicles or hospital waste collection centers. Variable definitions of MW exist in other parts of the world too [13]. In literature, it is not often clear whether household type wastes (non-hazardous wastes) are also included in the medical wastes [14]. Lack of public awareness about the environmental dangers of medical waste such as expired drugs, self-type injection is another concern [15].

In our study, although the majority of HMCW rates are less than 0.5 kg per day, there are also patients from whom more than 3 kg of medical wastes are collected. When the number and quantity

Med Science 2018;7(4):733-5

of patients are considered, this poses a risk increasing with each passing day. Conclusion In conclusion, it is necessary to take measures for the collection of wastes resulting from the medical treatments performed by the patient himself/herself or by caregivers. Consequently some waste components such as HMCW and domestic waste are mixed together. To provide caregivers with training is not enough for the collection and disposal of wastes. The HMCW must be controlled strictly or a new collection systems for these waste materials must be recommended in home. Furthermore, a system for the collection of HMCW should be established by municipality, patients and caregivers should be asked to decompose wastes, then the wastes should be collected from homes by homecare staff. Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves.

References 1.

Chartier Y, Emmanueal J, Pieper U, et al. Safe management of wastes from health-care activites. 2nd edition. WHO; 2014 available from www. who.int.

Republic of Turkey Regulation Homecare Services 2015. available from http://www.resmigazete.gov.tr/eskiler/2015/02/20150227-14.htm

Birpinar EM. Bilgili MS, Erdoğan T. Medical waste management in Turkey: A case study of Istanbul. Waste Management. 2009;29:445–8.

Republic of Turkey, Regulation Control of Medical Waste Management 2017. available from http://www.resmigazete.gov.tr/eskiler/2017/01/20170125-2.htm

Turkish Statistical Instıtute. 2017 available from www.tuik.gov.tr

Harhay MO, Halphern SD, Harhay JS, et al. Health care waste management: a neglected and growing public health problem worldwide. Trop Med Int Health. 2009:14:1414–7.

Myazaki M. Imatoh T, Une H. The treatment of infectious waste arising from home health and medical care services: Present situation in Japan. Waste Manag. 2007;27:130–4.

Memereki D, Baldwin A, Li B, et al. Healthcare waste management in Botswana: storage, collection, treatment and disposal system. J Mater Cycles Waste Manag. 2017;19:351–65.

Cessaro A, Belgiorno V. Sustainability of medical waste management in different sized health care facilities. Waste Biomass Valor. 2017;8:1819–27.

10. Eker HH, Bilgili MS, Sekmen E, et al. Evaluation of the regulation changes in medical waste management in Turkey. Waste Manag Res. 2010;28:1034–8. 11. Ikeda Y. Current Status of Home Medical Care Waste Collection by Nurses in Japan. J Air Waste Manag Assoc. 2017;67:139-43, 12. Udofia EA, Gulis G, Fobil J. Solid medical waste: a cross sectional studyof household disposal practices and reported harm in Southern Ghana. BMC Public Health. 2017;17:464:1-12. 13. Ananth AP, Prashanthini V, Visvanathan C. Healthcare waste management in Asia. Waste Manag. 2010;30:154–61. 14. Komilis D, Fouki A, Papadopoulus D. Hazardous medical waste generation rates of different categories of health-care facilities. Waste Manag. 2012;32:1434–41. 15. Uysal F. Medical waste management in Trachea region of Turkey: Suggested remedial action. Waste Manag Res. 2004;22:403–7.

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Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):736-44

Validity and prognostic value of serum albumin level in emergency acute ischemic stroke egyptian patients Adel Hamed Elbaih, Islam M Elshaboury, Rasha M Ahmed, Monira A Abd Allah Suez Canal University, Faculty of Medicine Department of Emergency Medicine, Egypt Received 05 January 2018; Accepted 04 April 2018 Available online 20.09.2018 with doi:10.5455/medscience.2018.07.8844 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract There are two main types of stroke: ischemic and hemorrhagic. Some studies showed the favorable relationship of serum albumin levels on the outcome of patients who suffer from ischemic stroke (IS). Some experimental studies have suggested a neuroprotective effect of albumin either by reducing brain edema or by its antioxidative or antiapoptotic effects. To detect serum albumin level and evaluate its prognostic value in patients with acute ischemic stroke in emergency department in compared to Scandinavian Stroke Scale (SSS). The study was carried out as descriptive (cross-sectional) study conducted on 60 patients with ischemic stroke attending emergency department in Suez Canal University hospital. It was found that all of died patients (100%) had hypoalbuminemia. While (92.5%) of patients who discharged from hospital had normal serum albumin level in follow up. but (7.5%) of them had hypoalbuminemia. And the ROC curve of both SSS and Serum albumin level on admission had Sensitivity: 100% and Specificity: 83% among studied patients. Thus serum albumin level has a direct correlation with short term prognosis of acute ischemic stroke patients. Patients with a lower SSS on admission and had higher levels of serum albumin had good short-term prognosis, and those with a high SSS and had a lower level of albumin had bad prognosis. higher levels of serum albumin is associated with a better short term prognosis. So they may act as indicators of short term prognosis. Keywords: Ischemic stroke IS, scandinavian stroke scale (SSS), serum albumin, outcome

Introduction A stroke or cerebrovascular insult is known as acute onset of a neurologic deficit that is due to a local vascular cause. The definition of stroke is clinical and neuroimaging of the brain are used to confirm the diagnosis [1]. There are two main types of stroke: ischemic due to decrease of blood supply to brain and hemorrhagic due to bleeding. This result in part of the brain does not work properly. Stroke Signs and symptoms may include motor and sensory deficits of one side of the body, confusion, dysarthria, vertigo, or loss of vision. Hemorrhagic strokes as well can be associated with a severe headache [2]. This signs and symptoms might appear early after the stroke has occurred. If symptoms last less than one or two hours it is known as a transient ischemic attack (TIA).(5) Diagnosis is clinically and confirmed by computerized axial tomography (CT) or magnetic resonance imaging (MRI) commonly [3]. In 2013, after coronary artery disease stroke was considered to be *Coresponding Author: Adel Hamed Elbaih, Suez Canal University, Faculty of Medicine of Emergency Medicine, Egypt. E-mail: elbaihzico@yahoo.com

the second most frequent cause of death worldwide, representing about 6.4 million deaths (12% of the total). About 17 million people had a stroke in 2010 and 33 million people have previously had a stroke and were still alive. Between 1990 and 2010 the number of strokes decreased by approximately 10% in the developed world and increased by 10% in the developing world [3]. An ischemic stroke, if diagnosed in about three to four and half hours, could be treatable with a medication which can break down the clot. Aspirin should be used. Stroke rehabilitation is the treatment which try recover lost function and ideally occurs in a stroke unit; however, these units are not available in many countries of the world [4]. The stroke severity on neurologic examination is typically the most important factor that affect short- and long-term outcome [5]. The Scandinavian Stroke Scale (Table 1) assesses the function of nine neurological states by using a scale of 0-6, where 0 represents severe malfunction and 6 represents full functionality. The scale’s minimum score is ‘0’ and the maximum ‘58’. The nine of the score items include: the Consciousness level, Movement of the eye, Motor power of arm, hand, leg (each assessed only on the affected side), Orientation, Speech, Facial palsy and Gait). Total scores can be used to stratify patients into four categories of stroke severity (Table 2) [6]. 736

doi: 10.5455/medscience.2018.07.8834 Table 1. Scandinavian stroke scale [6]. Patient Name: _________________________ STROKE Rater Name: ____________________ SCALE Date: ___________________________

Med Science 2018;7(4):736-44

doi: 10.5455/medscience.2018.07.8834 Table 2. Scandinavian Stroke Score (SSS) Category [6]. SSS score

category

0-18

Very severe stroke

19-32

Severe stroke

33-44

Moderate stroke

45-58

Mild stroke

Materials and Methods Study design This was a cross sectional descriptive study carried out to all patients with acute ischemic stroke attending to the Emergency Department (ED) at Suez Canal University Hospital. Sample size The sample size was calculated using the following formula: [8]. N = [(Zα+Zβ)/C) 2 + 3] Where: N= sample size Zα/2 = 1.96 (The critical value that divides the central 95% of the Z distribution from the 5% in the tail) Zβ = 0.84 (The critical value that separates the lower 20% of the Z distribution from the upper 80%) σ = the estimate of the standard deviation = 0.56 C = 0.5 *ln [(1+r)/ (1-r)] = 0.4902 R= 0.14 (correlation coefficient between serum albumin and Scandinavian Stroke Score) [6]. Dropout Percentage is 10%. So, by calculation, the sample size was equal to 60 cases. Inclusion criteria • Patients over 18 years of age with ischemic stroke diagnosed by CT, MRI or clinically • Patients diagnosed as having acute ischemic cerebrovascular stroke within 72 hours. • Both sexes. Exclusion criteria • Patients known to have hypoalbuminemia as (chronic liver disease, nephrotic syndrome, malnutrition, chronic heart failure.) • Patients presenting with other type of stroke (hemorrhagic stroke) Primary objectives 1- To study socio-demographic data and clinical pictures of ischemic stroke in patients attending emergency department. 2. To evaluate the serum albumin level in Patients with acute ischemic stroke at emergency room. 3. To evaluate the short term prognostic value of serum albumin as regards of outcome of patients with acute ischemic stroke. Research Question What is the level of serum albumin in patients with acute ischemic stroke and is it has a prognostic value in Emergency Department in Suez Canal University Hospitals?

Med Science 2018;7(4):736-44

Data collection Method Patients admitted to the Emergency Department of the University Hospital of Suez Canal (Ismailia, Egypt) with acute ischemic stroke and prospectively screened for inclusion in the study. Vital signs, clinical history, physical examination and albumin level was obtained in the Hospital Emergency Department. Data collected in pre-organized data sheet by the researcher from patients fulfilling inclusion and exclusion criteria. The Patients clinically assessed and managed according to the ABC protocol, after stabilizing the patient, the following questionnaire filled by the researcher of the patient diagnosed as acute ischemic stroke by the medical team in details. Questionnaire contain the following data 1- Full history (from patient or relatives): Socio-demographic data: Patient’s file number and Patient personal data e.g.: Age Medical History data: Complain and Present history (headache, vomiting, motor weakness, unconsciousness, dysarthria, vertigo, tingling, diplopia, convulsions) • Chronic illness (hepatic disease, cardiac disease, hypertension, diabetes, renal or malignancies) • Past history of cerebrovascular stroke. 2- Clinical examination: • Vital signs: pulse, blood pressure, respiratory rate, Temperature • Initial assessment of ABCDE (airway, breathing, circulation, dysfunction of central nervous system, Glasgow Coma Scale (GCS) and exposure) • Local examination complete neurological examination 3- Investigations: Investigations including CBC, ECG, fasting sugar, renal function test, liver function test, serum albumin, C.T or M.R.I. Scan examination. • Serum albumin level will be measured to the patients on admission at ER department and then measured within 28 days in follow up. • The Scandinavian Stroke Scale (SSS) score of the patients to assess severity of stroke at admission (baseline) and follow up within 28 days. (Table 1, Table 2). [6] 4- Outcome at Emergency Room: outcome of the patient will be recorded whether: 1-discharged on outpatient. 2-Admitted to inpatient under observation. 3-Admitted to intensive care unit. 4-Transferred. 5-Died at emergency room. Data analysis - Data were collected and presented in order of percentages and tabulated in tables and graphs. - Data has been analyzed using SPSS (Statistical Package for Social Science) software program version 14. - Continuous data as age has been described as mean and standard deviation. - The significance was considered statistically significant if (p value is 0.05) and insignificant if (p value more than 0.05). 738

doi: 10.5455/medscience.2018.07.8834

Ethical considerations: 1. An agreement will be taken from the head of the department. 2. All the parents of the participants will be informed a brief explanation of this study. 3. The study procedures will not affect the treatment modality the patient is intended to be given by anyway. Results This descriptive study (cross- sectional) was conducted to evaluate the serum albumin level and its prognostic value in patient with acute ischemic stroke. This study was conducted on 60 patients diagnosed to have acute ischemic stroke measuring of serum albumin level and application of Scandinavian stroke scale to evaluate their prognosis in Emergency room and follow up of their outcome at Suez Canal University Hospital. The data was collected from June 2016 to January 2017. Our study in Table (3) showed that the age of the studied patients ranged from 40-85 years old with majority of them between 55-64 years (30%) while the minority (10%) was between (40-44) years old and the mean age (60+13). And the studied patients the majority of them was females (58.30%) and male sex was (41.70%). Table 3. Age distribution among the studied patients Age

Number

Percent

40-44

10%

45-54

25%

55-64

30%

65-74

20%

75-84

15%

Mean ± SD Range

60 ± 13 44(40-84)

Our study in Figure (1) Showed that the majority of patients have hypertension and Diabetes mellitus (55%) while (45%) of them are non-hypertensive and non-diabetic .It was found that (35%) of patients have past history of old CVS and (65%) of them aren’t known to have any past history of CVS, (30%)(18) of them have AF and (25%) have Ischemic heart disease (IHD)(16).

Figure 1. Chronic illnesses among studied patients

Med Science

The symptoms in studied patients were the majority of patients (60%) had weakness, (55%) of them had weakness on both upper and lower limbs, (91.6%) of the weakness was on the same side of body. It was found that the majority of patients (45%) had dysarthria and disturbed level of consciousness (45%). With vital signs of the studied patients founded that the pulse was in (65%) within normal range and tachycardia in (35%) of the studied group with range (68-150 bpm).(90%) of patients were had normal respiratory rate and (60) were norm thermic. Our work revealed that (95%) of patients had patent airways, (9%) had normal breathing, and (100%) had normal circulation. Glasgow coma scale (GCS) was between (13-15) in the majority of patients (85%), (10%) had GCS between (9-12) and only (5%) had GCS less than 8. Our study revealed that most of patients (65%) were normglycemic and (35%) of patients were hyperglycemic. It also shows that (50%) of patients had normal level of albumin (3.5-5gm/dl) and (50%) of them had hypoalbuminemia (less than 3.5gm/dl). And also the majority of patients (50%) had normal ECG. It was found that (33.3%) of Patient had arrhythmia in ECG and (16.7%) of them had Ischemic changes (IHD) in ECG. Our study in Table (4) showed that the majority of patients (30%) had middle cerebral artery occlusion (MCA) while (5%) had brain stem infarction on admission. Table 4. CT Brain findings at admission among studied patients On admission Number

Percent

Normal

20%

Middle cerebral artery occlusion

30%%

Cerebellar infarction

10%

Lacunar infarction

Basal ganglia infarction

10%

Old cerebellar infarction

10%

Old Middle cerebral artery occlusion

10%

Brain stem infarction

While in follow up our study revealed that (10%) of patients developed MCA occlusion .It was found that (10%) developed lacunar infarction. Scandinavian stroke Scale (SSS) in studied patients. It showed that (35%) of patient were suffering from Disturbed level of consciousness, (15%) had gaze palsy of eye, (10%) had conjugate eye deviation. It else shows that (30%) of patients had raised arm with reduced strength, (20%) raised hand with flection in elbow, (5%) can move arm but not against gravity, 3% had paralysis. It else shows (15%) had some movement of hand finger tips not reach hand. it was found that (25%) Raise straight leg with reduced strength, (25%) Raise straight leg with flexion of knee, (5%) Can move but not against gravity, (5%) Paralysis. It else shows (5%) of patients were completely disoriented. It else shows that (25%) of patients had incoherent speech, (20%) can say more than yes/no, but no longer sentences. It was found that the majority of patients 739

doi: 10.5455/medscience.2018.07.8834

(20%) had Facial palsy. It else shows that (20%) of patients can walks with aids ,(10%) can walks with help of another person, (10%) can sit without support and (15%) of them was bedridden. Our study revealed that the majority of patients (55%) (N: 33) had mild stroke with SSS between (45-58), (40%) (N: 24) had moderate stroke SSS between (33-44).It was found that the minority of patients (5%) (N: 3) had sever stroke with SSS between (19-32) and in Table (5) showed that (95%) (N: 57) had prognostic score of SSS (>22) with good prognosis while (5%) (N: 3) had prognostic score (≤22) with poor prognosis.

Med Science 2018;7(4):736-44

Our study in Table (8) showed that on admission the majority of patients (100%) (N: 33) with normal albumin level had mild stroke. It else shows that (54.1%) (N: 13) of patients with hypoalbuminemia had moderate stroke while (45.9%) of them had mild stroke. It was found that all patients (100%) (N: 3) who had sever stroke had hypoalbuminemia. Table 8. Shows the Relation between initial serum albumin and Scandinavian Stroke Scale (SSS) Initial Serum albumin (gm/dl) SSS categories

Less than 3.5 (n:16)

3.5 – 5 (n:44)

Table 5. Show the Prognosis among studied patients using Prognostic value of SSS

number

Percent

number

Percent

Mild(33) (45-58)

100%

Prognostic score points of ( 0-58)

Number of patients (N)

Percentage (%)

Mild(33) (45-58)

54.1%

45.9%

≤ 22

100%

> 22

95%

Sever(3) (19-32) Mean +- SD

Our study revealed that (73.3%) (N: 44) of patients had normal albumin level and (26.7%) (N: 16%) had hypoalbuminemia as in Table (6). Table 6. Shows level of initial serum albumin among studied population Initial Serum albumin level (g/dl)

Number of Patients (N)

Percentage (%)

Normal albumin level (3.5-5gm/dl)

73.3%

Hypoalbuminemia (less than 3.5gm/dl)

26.7%

Table (7) showed that total number of patients (N: 57) who had prognostic score of SSS (>22) and good prognosis (N 44) of them had normal albumin level while (N: 13) had hypoalbuminemia. It was else found that (N: 3) of patients had prognostic score of SSS (≤22) with poor prognosis had hypoalbuminemia.

Test of Significance

3.1+_ (.3)

3.9+-(.4)

P=0.001*

*Statistically significant (p-value < 0.05)

Our study revealed that the majority of patients with normal albumin level (3.5-5g/dl) on admission was (N 44)(81.5%) and all of them (100%)were survived and discharged .While 16 Patients had hypoalbuminemia (less than 3.5gm/dl) (N 10)(18.5%) was survived . It was found that (N 6) (100%) of died patients had hypoalbuminemia. While (92.5%) of patients who discharged from hospital had normal serum albumin level in follow up. but (7.5%) of them had hypoalbuminemia. Our study in Figure (2) showed that on follow up of patients (86.6%) were discharged on outpatient treatment (55%) of them had mild stroke and (31.60%) had moderate stroke. It was found that (13.4%) of patients died, (8.40%) of them was suffering from moderate stroke and (5%) had sever stroke.

Table 7. Shows the comparison between initial serum albumin and SSS as prognostic score among studied patients Prognostic value of SSS (0-58)

Initial serum albumin

Total

Hypoalbuminemia

Normal albumin

less than 22 (poor prognosis)

More than 22 (good prognosis)

Total

Our study revealed that all patients (78%.6%) who had mild stroke admitted at inpatients ward while (21.4%) of patients who had moderate stroke admitted at inpatient ward .It shows else and (50%) of patients admitted in ICU had moderate stroke while and (50%) of them had sever stroke. While the majority of patients had mild and moderate stroke and admitted at inpatient ward. The majority of patients (90%) were admitted at inpatient ward and the minority of them (10%) were admitted in intensive care unit (ICU).

Figure 2. The relation between SSS and outcome of studied patients

Our study in Figure (3) showed the ROC curve of Serum albumin level on admission among studied patients which revealed that Sensitivity: 100% and Specificity: 83% with Cut of value: 3 of serum albumin while Figure (4) showed that ROC curve of Scandinavian Stroke Scale on admission among studied patients which revealed that Sensitivity: 100% and Specificity: 83% with Cut of value: 26 SSS. 740

doi: 10.5455/medscience.2018.07.8834

Med Science 2018;7(4):736-44

Discussion Recent studies have shown prognostic role of serum albumin level in cases of Acute Ischemic Stroke (AIS), a higher level of which correlate with a better prognosis as shown in some western studies [15]. The Scandinavian Stroke Scale (SSS) has been used extensively in clinical research to summaries the neurological deficits in stroke patients. It is useful in documenting and communicating baseline deficits, as well as changes over time and it consists of a prognostic score and a long-term score [6]. This was descriptive study (cross- sectional) had been conducted on 60 patients diagnosed to have acute ischemic stroke with measuring of serum albumin level and application of Scandinavian stroke scale to evaluate their prognosis in Emergency room and follow up of their outcome at Suez Canal University Hospital . The data was collected from June 2016 to January 2017.

Figure 3. ROC curve of Serum albumin level on admission among studied patients Area under the curve: 0.8 Sensitivity: 100% Specificity: 83% Cut of value: 3

Regarding the age distribution among the studied patients, this study showed that the age of patients ranged from 40-85 years old with majority of them between (55-64) years (30%) while the minority (10%) was between (40-44) years old and the mean age (60+13). These results agree with the results of the study conducted by Kasundra G & Sood I in which the age of patients ranged from 4085 years old with majority of them between (55-64) years (38%) [9]. Also these results agree with the results of the study done by Dev K & Joshi M in which the majority of the patients (41.5%) were in the age group from (56-70) years old with mean age (58.26Âą2) [10]. This study showed that the majority of the studied patients was females (58.30%) and male sex was (41.70%). These results match the results of a study by Dziedzic T et al, in which (49%) of the patients were males and (51%) were females [11]. These results donâ&#x20AC;&#x2122;t match the results of the study done by Dev K & Joshi M in which 63.5% of the patients were males while 36.5% of them were females [10].

Figure 4. ROC curve of Scandinavian Stroke Scale on admission among studied patients Area under the curve: 0.9 Sensitivity: 100% Specificity: 83% Cut of value: 26 Area under the curve

Sensitivity

Specificity

Cut off value

Serum albumin on admission

0.8

100%

83%

SSS on admission

0.9

100%

83%

This study showed that the majority of patients had hypertension and Diabetes mellitus (55%). It was found that (35%) of patients had past history of old CVS, (30%) of them have AF and (25%) had Ischemic heart disease (IHD). These results agree with the results of a study conducted by Dziedzic T et al, in which (67%) of the patients had HTN, (21%) of them had AF, however (20%) of them were Diabetic and (59.4%) of them had IHD [11]. This study showed that the majority of patients (60%) had weakness, (91.6%) of the weakness was on one side of body. It was found that the majority of patients (45%) had dysarthria and disturbed level of consciousness (45%).

741

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These results agree with the results of a study by Kasundra G & Sood I in which the majority of them (94%) had motor weakness, (92%) had dysarthria while (16%) only had disturbed level of consciousness [9]. Also these results agree with the results of another study by Dev K & Joshi M in which almost all patients had motor weakness and (98%) of the weakness was on one side [10]. This study showed that tachycardia was found in (35%) of the studied group, (40%) of them were HTN and (60) were normothermic. These results don’t match the results of a study by Kasundra G & Sood I in which the majority of the patients were HTN (92%) [9]. This study showed that the majority of patients (50%) had normal ECG and it was found that (33.3%) of patients had arrhythmia in ECG and (16.7%) of them had Ischemic changes (IHD) in ECG. These results match with the results of a study by Kasundra G & Sood I in which (52%) of the patients had a normal ECG, (14%) had ischemic heart disease on ECG, (44%) had stroke related changes and left ventricular hypertrophy on ECG [9]. This study showed that on admission (30%) of the studied patients had middle cerebral artery occlusion (MCA) while in follow up the majority of patients (80%) had the same CT finding and (10%) of had MCA occlusion and (10%) were have lacunar infarction. These results are close to the results of a study by Dziedzic T et al, in which (53.7%) of the patients had MCA occlusion, (19%) of them had lacunar infarction, (11.2%) of them had cerebellar infarction [11]. Also these results agree with the results of another study conducted by Bielewicz J et al, in which 55% of the patients had MCA occlusion, (17.9%) of them had lacunar infarction and (16.1%) of them had cerebellar infarction [13]. This study showed that (73.3%) of patients had normal albumin level and (26.7%) had hypoalbuminemia.

Med Science 2018;7(4):736-44

This study showed that (95%) had prognostic score of SSS (>22) with good prognosis while (5%) had prognostic score (≤22) with poor prognosis. These results disagree with the results of a study by Dev K & Joshi M in which (53.4%) of the patients had prognostic score of SSS (<22) with poor prognosis and (46.6%) of them had (>22) with good prognosis [10]. This study showed that the majority of patients (90%) were admitted at inpatient ward and the minority of them (10%) were admitted in intensive care unit (ICU) and it was found that all patients (78%.6%) who had mild stroke admitted at the inpatient ward while (21.4%) of patients who had moderate stroke admitted at inpatient ward. It showed that (50%) of patients admitted in ICU had moderate stroke while and (50%) of them had severe stroke. These results were disagree with the results of a study by Dziedzic T et al, in which (65%) of the studied patients admitted to the Inpatient while (35%) admitted to the ICU and such disagreement may be due to the large sample size of their study (n=759) while the present study (n=60) [11]. This study showed that on admission the majority of patients (100%) (N: 33) with normal albumin level had mild stroke. It else shows that (54.1%) (N: 13) of patients with hypoalbuminemia had moderate stroke while (45.9%) of them had mild stroke. It was found that all patients (100%) (N: 3) who had severe stroke had hypoalbuminemia. These results agree with the results of a study by Dziedzic T et al, in which the majority of the patients had normal serum albumin level with mild to moderate stroke and had mean SSS of 34.2+15.1 while the minority of them had hypoalbuminemia with severe stroke had mean SSS of (28.5 +16.1) [12]. This study showed that the majority of patients with normal albumin level (3.5-5g/dl) on admission was (81.5%) and all of them survived and discharged .While 16 Patients had hypoalbuminemia (less than 3.5gm/dl) (N: 10) (18.5%) was survived. It was found that (N: 6) (100%) of deceased patients had hypoalbuminemia.

These results agree with the results of a study done by Kasundra G et al, in which (68%) of the studied patients had normal serum albumin while (32%) had hypoalbuminemia [9].

These results agree with the results of the study conducted by Vahdani A et al, in which (67.5%) of the survived patients had normal serum albumin while (75%) of the deceased patients had hypoalbuminemia [14].

Also these results agree with another study conducted by Dziedzic T et al, in which (45.5%) of the patients had serum albumin level < 3.5 gm/dl and (55.5%) had normal serum albumin (3.5 – 5 gm/ dl) [11].

This study showed that (92.2%) of patients who discharged from hospital had normal serum albumin level in follow up while (7.5%) of them had hypoalbuminemia.

This study showed that the majority of patients (55%) had mild stroke with SSS between ‘’45-58’’ and (40%) had moderate stroke SSS between ‘’33-44’’. It was found that the minority of patients (5%) had sever stroke with SSS between ‘’19-32’’

Regarding the SSS and outcome, it was found that on follow up of patients (86.6%) were discharged on outpatient treatment (55%) of them had mild stroke and (31.60%) had moderate stroke. It was found that (13.4%) of patients died, (8.40%) of them was suffering from moderate stroke and (5%) had sever stroke.

These results agree with the results of a study conducted by Dziedzic T et al, in which the majority of the studied patients (54.5%) had mean SSS of 41.5+10.8 indicating mild stroke while (45.5%) of them had mean SSS of 19.7+12.8 indicating moderate to severe stroke [12].

Limitations of the study Although we used a larger sample size than that used in Bielewicz, Joanna, et al, [13] the sample size was still small and the study could not be blinded which might have introduced some bias into the results. Additionally some patients refused to be enrolled in 742

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Med Science 2018;7(4):736-44

this study and this study was conducted in one center at Suez Canal University hospital (SCUH). While some CVA patients shifted between more than one physicians in SCUH.

initiating any specific therapy to treat acute ischemic stroke .Either CT or MRI is recommended to exclude intracranial hemorrhage.

Conclusion

•Using of stroke rating scale as Scandinavian Stroke Scale (SSS) is recommended to evaluate short term and long term prognosis of patients.

HTN and Diabetes were the most common chronic illnesses the patients had a risk factors for stroke while minority had AF and were IHD.

•Evaluation of serum albumin level at time of admission is recommended as some trials and experimental studies revealed that it has a neuroprotective effect on brain.

It was found that the majority of patients had weakness, dysarthria and disturbed level of consciousness.

•Evidence based protocols for management of ischemic stroke should be developed for every aspect of care, from pre-hospital health education to post hospital discharge of ischemic stroke patients.

On admission (30%) of the patients had middle cerebral artery occlusion (MCA) while in follow up the majority of patients had the same CT finding and (10%) of had MCA occlusion and (10%) were have lacunar infarction.

•Emergency physicians should participate at all levels of planning for ischemic stroke care and management.

Most of the patients had normal albumin level while minority of them had hypoalbuminemia.

•Data in many developing countries currently suggest an increase in prevalence of ischemic stroke but also a decrease in mortality rate due to advanced management modalities.

The majority of patients were admitted at inpatient ward and the minority of them were admitted in intensive care unit (ICU) and it was found that all patients who had mild stroke admitted at the inpatient ward while half of patients admitted in ICU had moderate stroke and the other half had severe stroke.

•Emergency Medicine Service (EMS) providers should be trained and educated in the management of stroke patients and how to deal in critical cases.

On admission the majority of patients with normal albumin level had mild stroke and most of the patients with hypoalbuminemia had moderate and mild stroke. It was found that all patients who had severe stroke had hypoalbuminemia. This study showed that the majority of patients with normal albumin level and all of them survived and discharged .While (18.5%) had hypoalbuminemia was survived. It was found that all the deceased patients had hypoalbuminemia. This study showed that (92.2%) of patients who discharged from hospital had normal serum albumin level in follow up while (7.5%) of them had hypoalbuminemia.

•The Ministry of health should increase the awareness of general population about ischemic stroke and its possible complications. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

References

Regarding the SSS and outcome, it was found that on follow up the majority of patients were discharged on outpatient treatment most of them had mild and moderate stroke. It was found that (13.4%) of patients died, most of them were suffering from moderate and severe stroke.

G. Prabhu, AM Raadha, S Balasubramaniyan, et al. Study of anaemia as an individual risk factor in CVA: ischemic stroke.” Journal of evolution of medical and dental science. 2015;59:351-56.

Feigin VL, Lawes CM, Bennett DA, et al. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. The Lancet Neurology.2003;2:43-53.

IT was found that the sensitivity and specificity of serum albumin of 100% and 83% respectively regarding severity of stroke and SSS had sensitivity and specificity of 100% and 83% in prognosis of severity of stroke.

Chiang, Hsiang-Yu. Dementia risk and medical cost assessment model for patients with stroke. J Molecular Neuros. 2016;58:493-6.

GBD 2013 Mortality and Causes of Death Collaborators. Naghavi, Mohsen, et al. Global, regional, and national age-sex specific all-cause and causespecific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;3855:117-71.

Feigin VL, Forouzanfar MH, Krishnamurthi R, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014;383:246-54.

•An organized protocol for the emergency evaluation of patients suspected to have acute stroke is recommended.

Multicenter trial of hemodilution in ischemic stroke--background and study protocol. Scandinavian Stroke Study Group. Stroke. 1985;16:885-90.

Babu MS, Kaul S, Dadheech S, et al. Serum albumin levels in ischemic stroke and its subtypes: correlation with clinical outcome. Nutr. 2013;29:872-5.

•Emergency imaging of the brain is recommended before

Dawson B, Trapp, RG. Basic &Clinical Biostatistics. LANGE Basic Science

Our results indicate that higher levels serum albumin is associated with a better short term prognosis. Thus, they may act as indicators of short term prognosis. Recommendations

doi: 10.5455/medscience.2018.07.8834 4th Edition. 2004;28:456-9 9.

Kasundra, Gaurav, Isha Sood. Prognostic significance of serum albumin levels in acute ischemic stroke. Stroke. 2014;5:1-4.

10. K Dev, M Joshi. Functional Outcome of Stroke Patients, Correlation with Scandinavian Stroke Scale. Age Journal. 2013;40:13-9. 11. Dziedzic Tomasz, Agnieszka Slowik, Andrzej Szczudlik. Serum albumin level as a predictor of ischemic stroke outcome. Stroke J. 2004;35:156-8. 12. Dziedzic T, Pera J, Slowik A, et al. Hypoalbuminemia in acute ischemic

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stroke patients: frequency and correlates. Eur J clin Nutr. 2007;61:1318-22. 13. Bielewicz J, Kurzepa J, Czekajska-Chehab E, et al. Worse neurological state during acute ischemic stroke is associated with a decrease in serum albumin Levels. J Mol Neurosci. 2016;58:493-6. 14. Vahedi A, Lotfinia I, Sad RB, et al. Relationship between admission hypoalbuminemia and inhospital mortality in acute stroke. Pak J Biol Sci. 2011;14:118-22. 15. Taha M, Elbaih A. Review Article, Pathophysiology and management of different types of shock. NMJ. 2017;6:14-39.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):745-7

Evaluation of pain status and quality of life in patients with lumbar disc hernia who underwent microdiscectomy Abdurrahman Cetin1, Mehmet Tahir Gokdemir2 1 2

Health Sciences University, Gazi Yasargil research and training Hospital, Brain and Neurosurgery, Diyarbakir, Turkey Health Sciences University, Gazi Yasargil research and training Hospital, Emergency Department, Diyarbakir, Turkey Received 26 March 2018; 09 April 2018 Available online 21.07.2018 with doi: 10.5455/medscience.2018.07.8845 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc.

Abstract The objective of this study was to evaluate the emotional state, pain status, and quality of life in patients with lumbar disc herniation using preoperative Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and 1- and 3-months postoperative VAS scores. Between December 2017 and March 2018, 49 patients with lumbar disc herniation, who were admitted to our neurosurgery department, were enrolled in this retrospective study. According to the ODI questionnaire, pre- and postmicrodiscectomy analysis revealed a statistically significant improvement in all the parameters (for all parameters, p < 0.001). VAS scores of the patients showed a significant gradual decrease in the severity of pain at 1 and 3 months following the operation (p < 0.001). It was observed that lower back pain and quality of life in patients improved following microdiscectomy surgery. Microdiscectomy surgery is still an important option in lumbar disc herniation treatment. Keywords: Lumbar disc herniation, visual analog scale (VAS), microdiscectomy

Introduction Lumbar disc herniation is one of the primary causes of chronic lower back pain. It is a pathological process rather than a medical condition and occurs mostly at the lower lumbar spine, particularly at the L4-L5 and L5-S1 levels. Lower lumbar vertebrae, which carry a large amount of body weight, frequently degenerate, eventually leading to a breakdown of fibrous cartilage material (annulus fibrosus) and herniated nucleus pulposus. The most common symptom of patients with disc herniation is blunt and severe pain that spreads to the lower extremities from time to time. Symptoms occur depending on the anatomic location where a physiopathologically herniated nucleus pulposus creates compression. Median-level compression causes lower back pain, and lateral-level compression causes leg pain [1,2]. There are several surgical approaches for lumbar disc herniation, such as median-level, lateral, paraspinal, and intertransverse. Surgical procedures used for these approaches include open surgery, microsurgery with surgical microscopes, endoscopic surgery via a thin tubular channel, and percutaneous surgery [3]. In addition, the choice of surgical procedure mainly depends on the infrastructure of the hospital and the experience and preference of the surgeon. *Coresponding Author: Mehmet Tahir Gokdemir, Health Sciences University, Gazi Yasargil research and training Hospital, Emergency Department, DiyarbakÄąr, Turkey, E-mail: drtahirgokdemir@gmail.com

The objective of this study was to evaluate the emotional state, pain status, and quality of life in patients with lumbar disc herniation using preoperative Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and 1- and 3-months postoperative VAS scores. Material and Methods The study designed as a questionnaire study. Sixty-five patients underwent microdiscectomy with a diagnosis of lumbar disc herniation were admitted to the neurosurgery department of our Hospital, between December 2017 and March 2018. Sixteen of these 65 patients were excluded due to lack of data, and 49 patients were included in the study. Lumbar magnetic resonance imaging (MRI) was first performed to confirm the diagnosis of lumbar disc herniation in these patients who were referred to the neurosurgery department due to lumbar pain. Electromyography (EMG) and spinal MRI myelography were performed if required. The surgical intervention decision was made on the basis of the clinical examination, MRI, spinal MRI myelography, and EMG results. Lumbar microdiscectomy was performed with patients under spinal anesthesia or general anesthesia. Following dermis and subcutaneous tissue, fascia was incised. The muscles were incised by blunt dissection. A Taylor retractor was placed at the disc level. Soft tissues were cleaned with a rongeur. After placing a microscope into the surgical area, hemi-partial laminectomy was performed. Following hemostasis, ligamentum flavum was 745

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excised. The root medial was excluded with a root retractor. Discectomy was performed using disc forceps. Foraminotomy was performed if required. The surgical area was cleaned with an isotonic solution, and hemostasis was achieved. All the patients who underwent surgery were administered intramuscular analgesics for 2 days following the operation and oral nonsteroidal anti-inflammatory drugs for a week. Preoperative and postoperative 1.month values according to the were comparised. In addition, VAS pain and quality of life scores were recorded in all patients before and 1 and 3 months after the operation. Age, gender, and other sociodemographic data as well as pain and quality of life data were recorded. The data were recorded separately as pre- and postmicrodiscectomy. As per the exclusion criteria, patients aged ≤18 years, patients with a bleeding diathesis, patients with chronic pain for other reasons, patients with malignancy, and patients aged ≥70 years were excluded from the study. The ethical committee approval for this study was received from our Hospital. For the statistical calculations, data were uploaded to SPSS software v.16.0 (SPSS, Chicago, Illinois, United States), and statistical analysis was performed. A Shapiro-Wilks test was used to confirm the normality of the distribution in each group. Since the distributions were normal, statistics for continuous variables, including the mean and standard deviation (SD), were calculated. While a descriptive statistical analysis was performed as a number and percent for the figures, Friedman analysis was used for the continuous variables for multiple comparisons. They were considered significant for p < 0.05 values within 95% confidence intervals. Results All patients underwent microdiscectomy operation. Of 49 patients who were enrolled in the study, 26 (53.1%) were women, 23 (46.9%) were men, and mean age was 47.4 ± 12.8 years. Herniated disc was located at L4-L5 in 31 patients (63.3%), at L3-L4 in 10 (20.4%), and at L5-S1 level in 8 (16.3%) (Table 1). Table 1. Distribution of patients by age, gender, and level of disc herniation Gender

Male 23

46.9

Female 26

53.1

L3-L4 10

20.4

L4-L5 31

63.3

L5-S1

16.3

Level of disc herniation

As seen in Table 2, a preoperative and 1 month postoperative ODI Questionnaire was used in all patients. In the comparison of preand postoperative values, pre- and postoperative analysis revealed that all parameters statistically significantly improved in patients who underwent microdiscectomy (for all the parameters, p < 0.001). As seen in Table 3, the preoperative VAS scores and 1- and 3-months postoperative VAS scores were compared. The mean preoperative VAS score was 7.8 ± 1.0, the mean 1-months postoperative score

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was 2.5 ± 1.0, and the mean 3-months postoperative score was 2.1 ± 0.7. VAS scores of the patients showed a significant gradual decrease in the postoperative severity of pain (p < 0.001). Table 2. Comparison of pre- and postoperative values according to the Oswestry Disability Index Parameters

Preoperative

Postoperative

Severity of pain

4.2±0.9

1.5±0.5

<0.001

Personal Care

3.4±1.3

1.6±0.6

<0.001

Lifting Load

3.8±1.2

1.8±0.7

<0.001

Walking

4.1±1.0

1.8±0.7

<0.001

Sitting

4.7±1.0

1.3±0.4

<0.001

Standing

4.3±1.2

2.7±1.2

<0.001

Sleeping

3.6±1.1

1.6±0.5

<0.001

Social life status

3.8±1.4

2.0±0.8

<0.001

Traveling

3.8±1.4

2.2±0.8

<0.001

Degree of change in pain

4.8±1.0

1.9±1.1

<0.001

*Friedman’s analysis Table 3. Comparison of preoperative and 3- and 6-months postoperative VAS scores of the patients who underwent microdiscectomy Time of VAS score

Mean ± SD

Preoperative VAS

7.8±1.0

1.Months postoperative VAS

2.5±1.0

3.Months postoperative VAS

2.1±0.7

P <0.001

*Friedman’s analysis

Discussion In the present study, significant improvements were observed following microdiscectomy surgery in severity of pain, sleeping, physical activities, and social life according to ODI scores. In addition, the 1- and 3-months postoperative VAS scores showed a significant gradual decrease in severity of pain compared with the preoperative scores. Conventional conservative treatments, such as physiotherapy, epidural steroid injections, and daily life activity modifications, are effective to a certain degree in the management of pain associated with lumbar disc herniation. However, surgical intervention is inevitable for some patients. In patients with lumbar disc herniation who fail conservative treatment, lumbar microdiscectomy is recommended for the relief of nerve compression, radicular symptoms, and neurological deficits. The surgical success rate for radiculopathy caused by lumbar disc herniation is approximately 80%–90% [4]. The success of the procedure depends on the experience of the operating surgeon and health personnel as well as several preoperative factors. Clinical results following lumbar microdiscectomy are generally excellent, and 76.2% of such patients return to their jobs within a year [5]. The rate of patients with full symptomatic relief and full recovery following microdiscectomy is a compelling clinical issue that has not yet been sufficiently addressed in the literature [6]. Lumbar microdiscectomy is the preferred treatment for patients with radiculopathy in symptomatic lumbar disc herniation who fail conservative treatment and require surgical intervention. This procedure has become more popular thanks to encouraging postoperative results. Several studies have demonstrated that 746

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lumbar microdiscectomy is an effective procedure with a high level of patient satisfaction in terms of pain relief and recovery of functions [7,8]. Statistically significant postlumbar microdiscectomy results were published by Asch et al. in 2002. This study showed that 80% of 212 patients experienced pain relief in the leg and lumbar region [9]. In another study that included 28 patients with lumbar disc herniation, half of the patients were operated with microdiscectomy, and the other half were operated with discectomy; no difference was observed in the patient follow-ups. In addition, it was reported that the patients in the microendoscopic group used more analgesic compared with those in the microdiscectomy group. The main problem in open surgical procedures is the surgical trauma in the posterior paravertebral muscles [10]. This trauma can be minimized by microdiscectomy. In our study, patients were operated with the microdiscectomy method, and no complication was reported in the 1-month follow-up. Moreover, significant improvements were observed in the quality of life as well as severity of pain, sleeping, physical activities, and social life status following microdiscectomy surgery according to ODI scores. A significant gradual decrease was also observed in the severity of pain according to VAS scores in 1 and 3 months following the operation. Pain management following lumbar disc herniation procedures is important for patients’ quality of life. For this reason, usually opioids are used [11,12]. Recently, the use of nonsteroidal antiinflammatory analgesics has become popular [13,14]. In the present study, all the patients were administered nonsteroidal antiinflammatory drugs for 1 week following the operation. Bleeding complications associated with NSAIDs were noted; however, no bleeding was reported during the 1-month follow-up. The complication rate following microdiscectomy surgery is significantly decreased, and the incision is minimized. Significant improvements occur in daily life functions during the postoperative period, such as pain reduction, a regular sleep schedule, and improvement in physical activities [15]. In our study, significant improvements were observed in social and physical activities, including a regular sleep schedule. There were undoubtedly several restrictive conditions in this study. It was a single-center, and the number of patients was relatively limited. Another restrictive condition was that the patient followup records for the operations were limited. Conclusion In conclusion, herniated disc mostly was located at L4-L5 in our findings. The lower back pain status and quality of life in patients were improved following microdiscectomy surgery. VAS scores of the patients showed a gradual decrease in the postoperative severity of pain. Lumbar pain is a major cause for referral to emergency wards and outpatient clinics. One of the most important causes of lumbar pain is lumbar disc herniation. Microdiscectomy surgery is still an important option in lumbar disc herniation treatment.

Med Science 2018;7(4):745-7

Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval The ethical committee approval for this study was received from our Hospital.

References 1.

Akinduro OO, Kerezoudis P, Alvi MA, et al. Open versus minimally invasive surgery for extraforaminal lumbar disk herniation: a systematic review and meta-analysis. World Neurosurg. 2017;108:924-38.

Sharma SS, Sheth MS. Effect of neurodynamic mobilization on pain and function in subjects with lumbo-sacral radiculopathy. Medicine Science. 2018;7:5-8.

Epstein NE. Evaluation of varied surgical approaches used in the 4 management of 170 far-lateral lumbar disc herniations: indications and 5 results. J Neurosurg 1995;83:648-56.

O’Donnell JA, Anderson JT, Haas AR, et al. Preoperative opioid use is a predictor of poor return to work in Workers’ Compensation patients after lumbar diskectomy. Spine Phila Pa 1976. 2018;43:594-602.

Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006;296:2451-9.

McAnany SJ, Overley SC, Anwar MA, et al. Comparing the incidence of index level fusion following minimally invasive versus open lumbar microdiscectomy. Global Spine J. 2018;8:11-6.

Lebow R, Parker SL, Adogwa O, et al. Microdiscectomy improves painassociated depression, somatic anxiety, and mental well-being in patients with herniated lumbar disc. Neurosurgery. 2012;70:306-11.

Tharin S, Mayer E, Krishnaney A. Lumbar microdiscectomy and lumbar decompression improve functional outcomes and depression scores. Evid Based Spine Care J. 2012;3:65-6.

Asch HL, Lewis PJ, Moreland DB, et al. Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75 to 80% success rates be the norm? J Neurosurg. 2002;96:34-44.

10. Bokov A, Isrelov A, Skorodumov A, et al. An analysis of reasons for failed back surgery syndrome and partial results after different types of surgical lumbar nevre root decompression. Pain Physician. 2011;14:545-57. 11. Rosenow DE, Albrechtsen M, Stolke D. A comparison of patient controlled analgesia with lornoxicam versus morphine in patients undergoing lumbar disk surgery, Anestesia Anelgesia. 1998;86:1045-50. 12. Matarushi MR, Keis NA, Smouse DJ, et al. The effects of steroids on post operative nausea and vomiting. Nurse Anaest. 1990;1:l83-8. 13. Staunstrup H, Ovensen J, Larsen UT, Efficacy and tolerability of lornoxicam in postoperative pain, J.Clin pharmacol, August. 1999;39:834-41. 14. Balfour JA, Fitton A, Brarradell LB, Lornoxicam, areview of its pharmacology and theropatic potential in the manegament of painful and inflamatory conditions, Drugs. 1996;51:639-57. 15. Seçkin Sarı, Mehmet Aydoğan. As a common cause of back pain: lumbar disc herniation TOTBİD Dergisi. 2015;14:298-304.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):748-53

The use of serum hypoxia-inducible factor two alpha levels and diagnostic values in adult carbon monoxide poisoning Ismail Altintop1, Mehmet Tatli1, Cigdem Karakukcu2, Ahmet Ozturk3 Kayseri Training and Research Hospital, Department of Emergency Medicine, Kayseri, Turkey 2 Kayseri Training and Research Hospital, Department of Biochemistry, Kayseri, Turkey 3 Erciyes University Medical Faculty, Department of Biostatistics, Kayseri, Turkey

Received 22 March 2018; Accepted 09 April 2018 Available online 19.04.2018 with doi: 10.5455/medscience.2018.07.8780 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Carbon monoxide poisoning (COP) is a life-threatening intoxication which should be interfered immediately to be prevented from serious damages. The effect of carbon monoxide (CO) in the body at the cell level is mediated by a CO-releasing molecule. This molecule results in heme degradation via heme oxygenase. Because of the high affinity of CO on heme, many enzymes with biological signal transduction cause heme protein increase. Universally, this signal activation with similar enzymes and mechanisms are used in COP. The most widely used test is Carboxyhaemoglobin (COHb) in serum. The COHb is used as a standard parameter in the diagnosis of COP. COHb levels, are high after CO poisoning and decrease rapidly with oxygen therapy in the first four hours. So COHb is insufficient to demonstrate chronic ischemic damage of hypoxia. Hypoxia-inducible factors (HIFs) are the master regulators of oxygen homeostasis. The best known HIF isoforms in the literature are HIF-1ɑ and HIF-2ɑ. Recently, more data have found about selective HIF-2ɑ responsive genes and indicate the importance of this isoform in hypoxic gene regulation. The present study purposed to determine the change in HIF-2ɑ values in adult patients in diagnosing COP. A significant statistical correlation was found between (p=0.05) serum HIF-2ɑ levels and the first COHb level. HIF-2ɑ levels at 4th hour in COP patients were significantly higher like first COHb. HIF-2ɑ levels can be used as a new biomarker in long-term for monitoring COP patients. Keywords: Carbon monoxide, carboxyhemoglobin, hypoxia-inducible factor, poisoning

Introduction Carbon monoxide (CO) is a toxic gas in an environment and is one of the most common causes of poisoning-related deaths worldwide. Carbon monoxide poisoning (COP) is increasing due to the widespread use of carbon-based fuels universally. Carbon monoxide has various transient and permanent effects on the human body depending on the duration of CO exposure and effectiveness of therapy [1]. Long and high dose exposure even with immediate treatment may lead to permanent damages especially in organs vulnerable to hypoxia [2]. Carbon monoxide poisoning has an effect on both the neurological and cardiovascular systems, and recent studies have demonstrated prognosis [2]. Hence, the most important problem for emergency that neurological involvement in COP patients shows poor physicians is to cope with the neurological damage. Even if the neurological effect is understood in COP patients, the degree of influence cannot be predicted. Carboxyhaemoglobin levels in *Coresponding Author: Ismail Altintop, Kayseri Training and Research Hospital, Department of Emergency Medicine, Kayseri, Turkey E-mail: draltintop1@hotmail.com

blood gases have been used as the diagnostic test but recent studies found out that there was a weak relationship between COHb levels and clinical presentation [3]. In addition, COHb levels decrease rapidly after oxygen therapy so when investigating for long-term or delayed effects of CO, it becomes invisible in blood [3,4]. New, long-acting diagnostic markers seem to be needed not to fail in diagnosing COP. Carbon monoxide poisoning can be discussed pathophysiologically in two parts. The first is the hypoxic theory and the second is the cellular theory. According to the hypoxic theory, CO molecule binds to haemoglobin 230-270 times more than oxygen [4]. The haemoglobin-bound CO reduces oxygen transport capacity [4,5]. After all, it causes hypoxia in all tissues in the body [4]. According to cellular theory; CO inhibits the mitochondrial electron transport enzyme system in a cell [5,6]. Due to the high affinity of the CO on the heme, many enzymes induce the increase of the heme protein with biological signal activation [4]. Polymorphonuclear leukocytes increase and cause lipid peroxidation in the brain. This lipid peroxidation is responsible for the delayed neurological effects of COP [4,7]. In COP, the oxidative stress plays an important role in hypoxic-ischemic brain injury [5]. Furthermore, COP increases the production of reactive oxygen species [1]. 748

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Levels of free oxygen radicals in hypoxic conditions are not high enough to eliminate them [6]. Various markers have been used to determine the degree of damage. The diagnosis of COP is based on the level of carboxy haemoglobin measured by the co-oximeter [1,2]. Hypoxia has several effects on organs and systems [1]. Troponin is the most commonly used agent for determining heart damage [6]. But no consensus has been reached on determining ischemic brain damage. For this reason, our study aimed to use HIF-2α levels to diagnose and evaluate the severity of patients’ ischemic brain during COP. According to the literature review we conducted, there was no study that evaluated HIF levels in patients with acute CO poisoning. Hypoxia-inducible factor (HIF) When the tissues exposed to hypoxia the amount of oxygen in tissues is reduced. Reduced oxygen levels stimulate posttranslational modification of proteins and cell metabolism. This event simultaneously initiates gene transcription. HIFs are the main regulator molecules in oxygen hemostasis [8]. HIFs have 3 isoforms (HIF-1α, HIF-2α, and HIF-3α) [9]. The most known and studied forms are HIF-1α and HIF-2α. While HIF-1α is mainly involved in endothelial cells, HIF-2α isoform is involved in hypoxic gene regulation mentioned above. Although HIV-1α and HIV-2α coexist in tissues, their amounts and response to hypoxia are different in different conditions (e.g. ischemic diseases, vascular diseases or tumour presence) [8,9]. HIF-2α play role in certain tissues containing brain and kidney [10,11]. As a result, HIF-2α may be used as a beneficial tool to diagnose and follow-up COP in patients. Material and Method Study population A single-center, diagnostic randomize controlled study included patients older than 17 years of age who presented to the hospital with CO poisoning between December 2016 and June 2017, and a healthy control group. Prior to the study, a protocol was approved by the local hospital ethics committee. An informed consent form was approved by patients and control groups included in the study. This study confirmed to the Helsinki Declaration. Study protocol A total of 87random numbers were generated by SPSS software and assigned to a study and a control group. The study group was instructed with 66 participants at first who were exposed to CO and had clinical findings including a headache, dizziness, vomiting, fatigue and some degrees of unconsciousness. Unfortunately, 26 of them had to be excluded due to some chronic illnesses i.e. chronic kidney failure, severe lung disease, pregnancy, low age, the last but not the least low COHb levels. And the other five patients had been excluded due to insufficient samples. Finally, all the study were composed of 35 patients of a study group and 21 patients of control groups. The details of groups are shown in figure 1. Medical history was obtained from conscious patients and from the relatives of unconscious patients, and all home medications were recorded. Demographic data and Glasgow coma scores were also recorded. Blood was drawn at the time of hospital admission to measure arterial blood gas, COHb, electrolytes, and troponin I, along with other tests. The study’s inclusion and exclusion criteria are shown in Table 1 below. The diagnosis of COP was made

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with the patients’ medical history and blood carboxyhaemoglobin (COHb) levels above 10%. Biochemical measurements Blood gases were analysed immediately in emergency departments (ED) laboratory in a blood gas analyser (ABL700). COHb levels were measured and recorded. Troponin I was measured using an automatic autoanalyzer. Biochemical analyse were done with serum creatinine, AST, ALT, GFR, Lactate, CK-MB, and troponin. To analyse HIF-2α all other blood samples taken from the patients were stored at -80 °C after turning for 15 minutes at 3,000 cycles. Finally, blood samples were analysed in biochemical tubes to measure the value of HIF-2α by ELISA (Cayman Chemical Co, Ann Arbor, Michigan, USA). Statistical analysis Patients were divided into two groups (study, control) according to their clinical findings of COP and serum COHb levels. Power analysis was performed with a power-size for 2-sample t-test with the Minitab 17 program (α.0005, stdev 0.65, difference 1.0). The sample size was calculated as 17 by power analyse. Biochemical markers and blood gas analyses data were transferred to the computer environment. Chi-square test was used to examine categorical variables. Categorical variables were analyzed using the chi-squared test. Also, continuous variables with a normal distribution were compared using the independent t-test and the one-way analysis of variance (ANOVA). Pearson’s correlation analysis was used to examine the correlation between serum HIF2α and other tests. A receiver operating characteristics (ROC) curve was calculated for serum HIF-2α levels and other biomarkers. CCHb, cTnI, GFR. SPSS version 22.0 (SPSS Inc, Chicago, Illinois) statistical software and MedCalc® (2011statistical software version 11.5.1) were used for statistical analysis. The measured p-value of less than 0.05 was considered statistically significant. Results There were 34 females and 22 male patients, with an age range of 57.2±19.6 in the former study group and 41.6±14.8 in the control group. There was no significant difference between age and genus. There were no significant vital findings on admission to the hospital among groups. A headache, dizziness, vomiting, weakness and fatigue were statistically significant in a study group (p<0.001). Loss of consciousness and syncope were only observed in 6 patients in study group and were not statistically significant. The cause of poisoning was stove (coal or wood) in 30 (85.7%) cases. The demographic, clinical and laboratory characteristics of the patients are given in Table 2. Table 1. Exclusion criteria. Exclusion criteria Acute hypoxia caused by different factors and non-current diagnosis criteria of COPa. Severe lung, heart, liver, kidney and blood system diseases. Hematologic diseases. Pregnancy, lactating Inadequate medical record. Age <18 years. COHb level of <10%. World Health Organization-Examination COP criteria(24).

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Glasgow Coma Scale of 32 (91.4%) patients of the study group were GCS 14-15. GCS was found 9-13 in two patients and 9 in one patient. In the study group, 29 (82.9%) of the patients were discharged urgently and 6 patients (17.1%) were hospitalized. Mortality was not detected. Initial COHb (%) was 22.14±10.74 in the study group and 2.42±2.47 in the control group. And it was statistically significant (p<0,001). Control COHb (%) was found similar in two groups

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as expected (p=0,452). The CK-MB level was 1.53±0.63 U/L, the WBC level was 9.55±2.16 /mm3, the AST level was 25.37±11.4 U/L, the ALT level was 23.51±11.05 U/L, the GFR level was 101.49±15.36 U/L, and the Lactate level was 2.2±0.9 U/L in a study group. Creatinine Kinase-MB, WBCs, ALT, GFR and Lactate levels were all higher in the study group than the control group and statistically significant; only AST levels between groups were not statistically significant.

Table 2. Laboratory, clinical and findings, group I and group II of serum HIF-2α levels Variables Age (y) Sex (Female/Male) Cause of exposureto COP

Groups

pvalue

Study Group (n=35)

Control Group(n=21)

57.2±19.6

41.6±14.8

<0.001

21/14

13/8

1.000

n(%)

1 Stove (coalorwood)

30 (85.7%)

2 Gasboiler

5 (14.3%)

Exposure time of COP gas (h)

2.89±0.4

Vitalsigns

mean±SD

SBP (mm Hg)

110.8±13.5

113.3±18.5

0.108

DBP (mm Hg)

68.8±9.0

70.0±12.2

0.178

Heart rate (beats/min)

87.5±14.8

79.4±16.2

0.062

Respiratory rate (breaths/min)

23.1±6.1

21.4±3.5

0.647

Temperature (°C)

0.711

36.5±0.5

36.4±0.4

Symptoms

n(%)

Headache

26 (46.4%)

0 (0.0%)

<0.001

Dizziness and Vomiting

24 (42.9%)

1 (1.8%)

<0.001

Weakness and fatigue

23 (41.1%)

0 (0.0%)

<0.001

Lose of consciousorsyncope

6 (10.7%)

1 (1.8%)

0.237

Glasgow Coma Score (GCS)

n(%)

GCS 14-15

32 (91.4%)

GCS 9-13

2 (5.7%)

Final outcome

n(%)

Discharged

29 (82.9%)

Hospitalisation

6 (17.1%)

Exitus

0 (0.0%)

Blood gas analysis

mean±SD

7.38±0.4

7.41±0.5

0.830

PO2 (mm Hg)

79.6±53.2

57.2±35.2

0.162

PCO2 (mm Hg)

32.8±8.1

38.5±4.1

0.216

SaO2 (%)

81.2±18.1

75.7±21.3

0.688

Other laboratory findings

mean±SD

HIF 2 α (pg/mL)

1.72±0.65

1.16±0.48

<0.001

First COHb (%)

22.14±10.74

2.42±2.47

0.001

7.12±2.43

2.42±2.47

0.452

cTnI (ng/mL)

0.0078±0.25

0.0037±0.011

0.218

CK-MB (U/L)

40.0±59.5

25.06±16.10

0.007

WBCs (/mm3)

9.55±2.16

8.57±3.58

0.011

AST (U/L)

25.37±11.4

21.57±8.7

0.196

Control COHb (%)

ALT (U/L)

23.51±11.05

16.76±9.13

0.022

GFR

101.49±15.36

81.76±23.32

0.040

2.2±0.9

1.84±0.2

0.017

Lactate

The data are expressed as arithmetic mean and standard deviation (mean±SD). Abbreviations: Systolic blood pressure (SBP); diastolic blood pressure (DBP); aspartate aminotransferase (AST); alanine aminotransferase (ALT), glomerular filtration rate (GFR), white blood cells (WBCs), creatine kinase-MB fraction (CK-MB), carboxyhemoglobin (COHb).

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Table 3. Sensitivity and specificity values of the HIF-2α, GFR, CTnI and lactate counts tests at different cut-off levels. Cut-offvalue

Sensitivity

Specificity

+LR

-LR

HIF-2α

>0.575

100.0

9.52

1.11

0.00

64.8

100.0

HIF-2α HIF-2α HIF-2α HIF-2α GFR cTnI

>0.786 >1.101 >1.309 >1.817 >76 >0.015

100.0 82.86 71.43 31.43 97.14 5.71

19.05 66.67 71.43 95.24 47.62 95.24

1.24 2.49 2.50 6.60 1.85 1.20

0.00 0.26 0.40 0.72 0.06 0.99

67.3 80.6 80.6 91.7 75.6 66.7

100.0 70.0 60.0 45.5 90.9 37.7

Lactate

>2.4

90.48

4.20

0.66

87.5

47.5

PP, positivepredictivevalue; NP, negativepredictivevalue, LR, positivelikelihoodratio; –LR, negativelikelihoodratio

And finally, the average serum HIF-2α level was 1.72±0.65pg/mL in the study group and 1.16±0.48 pg/mL in control group. HIF-2α levels were significantly higher in the study group (p=0.001). HIF-2α levels, COHb, cTnI, and GFR were analyzed by receiver operating character analysis (ROC) and were shown in Figure 2. Areas under the receiver operating characteristic curves (AUC) were calculated. AUC for HIF-2α levels was found significantly different between areas (p<0.001). AUC was found 0.765 (95 % confidence interval, 0,632 - 0,868, p < 0.001) for HIF-2α levels. A cut-off value of 1,101 ng/ml was found with 83.9 % sensitivity and 66.7 % specificity for higher levels of HIF-2α. A significant statistical correlation was found between serum HIF-2α and first COHb (p<0,005) levels and shown in Table 3. According to bivariate Pearson correlation test HIF-2α and COHb had a significant correlation (p=0,005, 0.464). No significant correlation was found between other parameters and shown in Table 4. Table 4. Correlation test (Bivariate pearson correlation coefficients (r value) Variable Age (years) First COHb (%) Control COHb (%) cTnI (ng/mL) CK-MB (U/L) WBCs (/mm3) ALT (U/L) AST (U/L) GFR Lactate r, correlation coefficient.

r 0.069 0.464 0.105 0.222 0.195 0.082 0.114 0.095 0.042 0.321

pvalue 0.696 0.005 0.549 0.201 0.262 0.641 0.543 0.587 0.812 0.060

Figure 1. Consolidated Standards of Randomised controlled flow diagram for groups

Figure 2. ROC curve analysis showed the prognostic value of HIF-2&#945; levels,CCHb, CTnI, GFR and COHb in COP. Diagnostic values of HIF-2&#945; , CCHb, cTnI, and GFR tests to make an assumption in acute CO poisoning. AUC for HIF-2&#945;, CCHb, cTnI and GFR levels. HIF-2&#945; (AUC; 0.765 (95 % [CI], 0.632 to 0.868, pv0.01), CCHb (AUC; 1,00 (95 % CI, 0.936 to 1,00, pv0.001),cTnI (AUC; 0.586 (95 % CI, 0.446 to 0.716)

Discussion All body systems, especially the central nervous system, are affected by COP [3]. Symptoms in COP patients are not fully evident and varies from an ordinary dizziness to coma. Even in such studies, 20-30% of patients are generally asymptomatic though high COHb levels [2]. Common symptoms in patients are a headache, dizziness, vomiting, gastroenteritis, lethargy, convulsions, arrhythmias, pulmonary edema and coma [12]. Patients involved in this study had approximately 50% of headache, dizziness, vomiting and fatigue similarly but only six of them lost they’re conscious. Glasgow Coma Scales of 32 (91%) patients at ED admission were 14 and 15 so this study group seemed to moderately be poisoned by CO. However, Türedi S et al reported that there was a limited correlation of symptoms with COHb levels in their study [5]. Most effected systems in COP are a Central nervous system (CNS) and cardiovascular system in particular [13]. Measurement of COHb is the key factor to determine COP but its level reduces 751

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soon after oxygen therapy [5,13]. The fact that the COHb level is normal on the follow-up, the clinicians have trouble to decide how often the patients will be followed up or how long oxygen therapy will be given to minimize the acute and chronic effects of COP. So, monitoring the patients is important to determine the cellular damage. In COP patients, many researchers have searched for a new biomarker Giuseppe L et al. advocated a new biomarker, fatty acid-binding protein (FABP) and troponin could be used as an alternative for monitoring and determining of cardiac damage of COP [6]. Wunderlich et al. used heart-type fatty acid-binding protein (H-FABP) to demonstrate myocardial damage in COP patients [14,15] It was found that H-FABP levels reached its peak level in 3-4 hours of exposure to CO and showed myocardial damage in COP patients. Türedi S et al. found at 1-6 hours of exposure to CO that albumin concentration increases statistically significant in rat COP model [5]. Xiaofang Yu et al defined HIFs, heterodimeric nuclear transcription factor, as crucial in the defence mechanisms against hypoxia [16]. Stavik et al demonstrated stimulated angiogenesis through the upregulation of HIF sand VEGF expression after hypoxia [17]. There is a strong correlation between vascula endothelial growth factor (VEGF) and hypoxiainducible factors (HIFs). In particular, HIF-2α plays an important role in ischemic damage to proliferation and regeneration, unlike other HIFs [16]. Some proangiogenic and proinflammatory factors are regulated by HIF-2α [18,19]. While IL-8 is suppressed by HIF-1α in humans, NF-E2-related factor 2 (Nrf2) is induced by HIF-2α [20]. HIF-2α have been implicated in physiological and pathological processes such as inflammation, cell survival in ischemic tissue [21]. Kapitsinou PP et al, found increased HIF-2α of post-ischemic microcirculatory blood flow in the renal ischemia / reperfusion model [10]. HIF-2α seems to be a hypoxia-specific marker as it is detectable in hypoxia in various organs and tissues. Lui Jing et al had found HIF-2α in patients with ischemic kidney damage and showed the critical value of HIF-2α as a marker of hypoxia [22]. Similarly, HIF-2α could be detected through 1-4 hours in serum after inhalation of CO. It reaches a peak level at the end of four hours and the increase lasts for 12-24 hours [7,16,17]. The present study investigated the diagnostic value of HIF-2 α by finding out the correlation with the index test COHb During study the HIF-2α were measured in the first 4 hours of COP. Due to the nature of the study held on in ED, researchers could draw blood only once- few hours after CO exposure in ED – to examine HIF-2 α levels because patients were discharged rapidly. HIF-2α levels were correlated with first COHb measurements (p=0.005) so HIF2α may be a marker for following patients even at the 12th and 24th hours of CO exposure and be used to diagnose and follow COP as other markers in ED such as troponin. Lactate is another molecule related to ischemic intolerance and increased statistically significant at the 4th hour of CO exposure like HIF-2α during this study (P= 0.017). But extra work should be executed to reveal its specificity to hypoxia. Conclusion The crucial point in the follow-up and treatment of COP patients is to understand the presence and degree of ischemic damage happened. The grade of devastation and duration of treatment is critical for prognosis. HIF-2α looked promising as a long-lasting

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new marker to follow up patients and evaluate hypoxic damage in COP. More detailed studies and large numbers of a patient population are needed to reveal the diagnostic and prognostic value of HIF-2α. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval This work has been approved by the Institutional Review Board.

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Hampson NB, Piantadosi CA, Thom SR, et al. Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning. Am J Respir Crit Care Med. 2012;186:1095-101.

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Turedi S, Yilmaz SE, Mentese A, et al. The diagnostic value of serum ischemia-modified albumin levels in experimentally induced carbon monoxide poisoning and their correlation with poisoning severity. Acad Emerg Med. 2013;20:652-8.

Lippi G, Rastelli G, Meschi T, et al. Pathophysiology, clinics, diagnosis and treatment of heart involvement in carbon monoxide poisoning. Clin Biochem. 2012;45:1278–85.

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10. Kapitsinou PP, Sano H, Michael M, et al. Endothelial HIF-2 mediates protection and recovery from ischemic kidney injury. J Clin Invest. 2014;124:2396-409. 11. Nordquist L, Friederich-Persson M, Fasching A, et al. Activation of HypoxiaInducible Factors Prevents Diabetic Nephropathy. J Am Soc Nephrol. 2015;26:328-38. 12. Chiew AL, Buckley NA. Carbon monoxide poisoning in the 21st century. Crit Care. 2014;18:221. 13. Lippi G, Rastelli G, Meschi T, Pathophysiology, clinics, diagnosis and treatment of heart involvement in carbon monoxide poisoning. Clin Biochem. 2012;45:1278–85. 14. Yardan T, Meric M, Bozkurt A, Bilge S, Bas DB, Bedir A, Ozdemir T, Baydin A. The role of heart-type fatty acid-binding protein in the evaluation of carbon monoxide poisoning in rats. Hum Exp Toxicol. 2011;30(2):124–8. 15. Wunderlich MT, Hanhoff T, Goertler M, et al. Release of brain–type and heart–type fatty acid–binding proteins in serum after acute ischaemic stroke. J Neurol. 2005;252:718–24. 16. Yu X, Fang Y, Liu H, et al. The balance of beneficial and deleterious effects of hypoxia-inducible factor activation by prolyl hydroxylase inhibitor in rat remnant kidney depends on the timing of administration. Nephrol Dial Transplant. 2012;27:3110–9.

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Signal. 2009;11:1501–17. 21. Cramer T, Yamanishi Y, Clausen BE, et al. HIF-1α is essential for myeloid cell-mediated inflammation. Cell. 2003;112:645–57. 22. Liu J, Wei Q, Guo C, et al. Hypoxia, HIF, and Associated Signaling Networks in Chronic Kidney Disease. Int J Mol Sci. 2017;18:950. 23. Rosenberger C, Heyman SN, Rosen S, et al. Up-regulation of HIF in experimental acute renal failure: Evidence for a protective transcriptional response to hypoxia. Kidney Int. 2005;67:531–42. 24. Tefferi A, Vardiman JW. Classification and diagnosis of myeloproliferative neoplasms: the 2008 World Health Organization criteria and point-of-care diagnostic algorithms. Leukemia. 2008;22:14–22.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):754-8

Evaluation of probation implementations of drug users in Adiyaman university training and research hospital: A one-year retrospective study Mehmet Hamdi Orum1, Mahmut Zabit Kara2, Oguzhan Bekir Egilmez1, Murat Eren Ozen3, Aysun Kalenderoglu1 2

1 Adiyaman University, Faculty of Medicine, Department of Psychiatry, Adiyaman, Turkey Adiyaman University Training and Research Hospital, Child and Adolescent Psychiatry, Adiyaman, Turkey 3 Private Adana Hospital, Psychiatry, Adana, Turkey

Received 12 February 2018; Accepted 10 April 2018 Available online 22.07.2018 with doi: 10.5455/medscience.2018.07.8846 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Increasing the use of drugs all over the world and our country has become a very important social problem, making legal obligations necessary. Probation Implementation (PI) refers to the correction of the conduct of criminals causing criminal acts, the prevention of repeat offenses, the follow-up of prisoners, the rehabilitation of substance abusers, the elimination of the harm suffered by the victims, and the protection of the society in this way. In this study, it was aimed to investigate the substance use characteristics of people who applied to our hospital within the scope of PI law. 313 cases, applying to Adiyaman University, Training and Research Hospital, all of whom were decided to have PI on 01.01.2017-31.12.2017 were included in the study. PI was carried out by having psychiatric interview and evaluating psychoactive substance in urine in three-time and six-time programs. It was determined that totally 313 cases applied as required by PI during the study. These cases consist of people, 298 of whom were male and 15 of whom were female. Mean age was determined as 26.2±6.8 (15-55). It was also observed that 251 cases (80.2%) completed three-times program and 62 (19.8%) cases completed six-times program. According to the number of programs, there was no significant difference in terms of gender distribution and ethyl glucuronide positivity in two groups (p>0.05). PI, which is a fairly new practice in Turkey, has an important place in the care of substance users. In terms of gender distribution, results were consistent with studies in the literature. Alcohol comorbidities in PI-applied individuals are noteworthy. Keywords: Addiction, illicit drug detection, probation, retrospective study, substance use

Introduction Addiction is considered as both a cause and a consequence of different social problems that regulate social life through psychological, sociological and economic dimensions and threaten the functioning of almost all norms and institutional regulations [1]. Substance dependence is no longer explained as a form of behavior that is caused by individual behaviors alone or guided by the social circle, but rather in relation to many dynamics, such as the personal characteristics, the characteristics of the living zone, the social structure, its structural exclusion, and the dynamics of othering. Drug use and dependence has become one of the most important global problems faced by all societies, regardless of race, ethnicity, socio-economic situation, with the rapid development of technology and communication and the growth of the drug market [2,3]. The drugs may be illegal substances not prescribed with herbs such as heroin, cannabis, cocaine, etc., but may also be prescripted drugs, such as benzodiazepines, amphetamines, sedative hypnotic drugs and synthetic drugs, as it is in many countries of the world, *Coresponding Author: Mehmet Hamdi Orum, Adiyaman University, Faculty of Medicine, Department of Psychiatry, Adiyaman, Turkey E-mail: mhorum@hotmail.com

it is stated in our country that cannabis is the most common use among the narcotics. In addition to the use of cannabis in drug users, the use of substances such as cigarettes, alcohol, morphine, heroin and synthetic drugs such as bonsai and ecstasy are also common. The use of new types of synthetic drugs such as bonsai, ecstasy, amphetamine and methamphetamine is becoming increasingly widespread in developing countries like our country [4-6]. In countries where the use of illegal substances is widespread, both the individual and the social problems of substance addicts have become increasingly necessary to take legal measures. The Probation Implementation (PI), which was initiated as an important step in the criminal concept and security measures in our country, came into force with the publication of Official Gazette dated July 20, 2005 and numbered 25881. It has been explained how to implement the treatment of those who are drug addicts given the PI decision on the grounds of the crime of “buying, accepting or possessing drugs and stimulants for use” written in article 191 of Turkish Penal Code No. 5237 (TPC). Again, according to Article 109 of the Code of Criminal Procedure No. 5271, it is explained how to implement the treatment of those who are addicted to drugs from judicial decision to be taken under judicial control. According to the DS application, if the accused and the prisoners apply to the branch directorate or office within the determined time, they are required to write the referral letter to the health 754

doi: 10.5455/medscience.2018.07.8846

institution determined by the Ministry of Health and apply to this institution within five working days. As a result of the analysis and examination made by the health institution, a follow-up program about the non-dependents is prepared and the accused or convict is notified. An example of the program is also sent to the branch office. Those who are found to be addicted as a result of the analysis and examination are referred by the health care institution to the substance abuse treatment center and this is reported to the branch directorate. The accused or convict applies to the substance abuse treatment center within three days. The branch office keeps track of whether the suspect or the custodian applies for the substance dependency referred to the treatment center [7,8]. PI refers to “a community-based practice provided by all kinds of services, programs and resources that are necessary for the integration of the suspect, the defendant or the judiciary into the society in line with the audit and inspection plan in the conditions and time specified in the court”. In other words, the PI is the prevention of repeat offenses, the follow-up of the prisoners released from the prison, the rehabilitation of drug addicts, the elimination of the damage suffered by the victims, and the protection of the society in this way [9]. The total number of files created for PI between January 1, 2017 and December 31, 2017 is 5,583,948 (Adult: 5,439,503, Child: 144,445), according to the website of the General Directorate of Prisons and Detention Houses - Probation Branch Office. These files belong to 4,185,750 people. 641.235 (Adult: 602.224, Child: 39.011) of all the files were evaluated under the scope of “Treatment and Probation (TPC 191)” [10].

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People who come to the psychiatry outpatient clinic with a PI decision give urine samples for urine analysis three times for two weeks. The test result is “positive” when substance is detected, “negative” when not. If the three tests are negative, followup is done by the probation officer. If at least one of the three urine tests performed for two weeks is found to be positive, the individual is considered to continue to use the substance and the individual is admitted to the six-time PI drug addiction training program by the psychiatrist. In the meantime, it is reported that if the substance is found negative in the urine of the individual, the follow-up should be continued by the Directorate of Probation and Help Centre Branch (DPHCB). However, if the individual is not compliant with the six-time training schedule, the urine has a positive drug substance, a deprivation table or a suicide risk has been found, the DPHCB is informed to provide the closest ASATC. This practice is routinely performed in the psychiatric outpatient clinic. No additional work has been done. This data has been studied retrospectively. Individuals who are referred to as judicial cases in the Directorate of Probation of Adiyaman are assessed psychiatrically and the substance dependency is assessed according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [11] and the information form is filled. Afterwards, samples of urine are taken from the individuals and the drugs are analysed manually with the “instant-view multidrug of abuse urine test kit” in the biochemistry laboratory. In our laboratory, the analysis of intoxicated drugs and stimulants such as amphetamine, barbiturate, benzodiazepine, cocaine, phencyclidine, methamphetamine, morphine, tetrahydrocannabinol and tricyclic antidepressants is done by immune chromatographic methods.

Despite the fact that PI has been made in our country which is more than 10 years old, literature information is limited in this respect. With the number of people and files being known, it is not enough to study the substance use characteristics of these people. The aim of this study is to examine the data such as age and gender, the number of programs participated, the completion of the probation and the positive substances in the toxicological analyses of the persons who came to Adıyaman University Training and Research Hospital Psychiatry Department by taking decision of PI. According to these results, it is planned to obtain data about the prevalence of drug use in Adıyaman, to determine requirements and to carry out further researches.

In these analysis findings, the minimum limit for urine; it was accepted as 500 ng/mL for “Methamphetamine” (MAMP), 50 ng/mL for cannabis agent Tetrahydrocannabinol (THC), 200 ng/ mL for “Benzodiazepines” (BZD), 200 ng/mL for “Barbiturates” (BAR), 300 ng/mL for “Methadone” (EDDP), 1000 ng/mL for “Amphetamine” (AMPH), 25 ng/mL for “Phencyclidine” (PCP), 300 ng/mL for “Morphine” (OPIAT), 500 ng/mL for “Ecstasy” (MDMA), 10 ng/mL for “Acetylmorphine” (6AM), 20 ng/mL for “Bonsai” (K2-1), 10 ng/mL for “Bonsai” (K2-2), 5 ng/mL for “Buprenorphine” (BUP), 1000 ng/mL for “Ethyl Glucuronide” (EtG), and 300 ng/mL for “Cocaine” (COC). Local ethics committee approval was obtained (Adiyaman University ethics committee protocol number 2018/2-7).

Material and Methods

Statistical Analysis Windows SPSS 22.0 program (Statistical Package for the Social Sciences Inc.) was used for statistical analysis. Independent t test was used to assess the mean differences between the two groups. Pearson correlation test was used to evaluate the relationship between the scales. Descriptive statistics and continuous variables were expressed as mean±standard deviation, while categorical variables were given as frequency and percentage. Statistical significance level was accepted as p<0.05 for all values.

Study Design and Participants The sample consists of individuals who are admitted to the PI Unit of Adıyaman University Training and Research Hospital within five days from the date of dispatch and PI decision was made between 1 January 2017-31 December 2017. Between the dates mentioned, it was seen that 330 cases were recorded due to PI. 12 persons were excluded from the study because the audit decision was terminated by the court during the audit process. 5 people were referred to the nearest Alcohol and Substance Abuse Treatment Centre (ASATC) because of their incompatibility with the result of a 6-session PI process (toxicological analysis, positivity in one or more of the last 3 sessions). These people have not been included in the study. Only 313 cases were awarded to the study in 2017, in which PI decision was made, and 3 or 6 sessions were successfully completed in the same year.

Results 313 possible drug users were taken to work. 298 males (95.2%) and 15 females (4.8%) were included in the study and the mean age was 26.3 ± 6.8 (15-55) for male, 26.0 ± 8.1 for female, and 26.2 ± 6.8 for total. According to sex, the average age was similar. The distributions of males and females were similar compared to 755

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those under 25 years and above 25 years (≤25 male: 159 (53.4%); >25 male: 139 (46.6%); ≤25 female: 8 (53.3%); >25: female: 7 (46.7%)). Some of the individuals completed three-time program and some completed six-time program. According to the number of programs, there was no significant difference in gender distribution in both groups (p=0.519). 133 (79.6%) of the participants under the age of 25 completed three-time program. 118 (80.8%) of the participants over the age of 25 completed three-time program. There was no difference in distribution of age groups (p=0.794). During the first session of three-time program, 50 out of 251 respondents were positive for EtG. 11 out of 251 respondents were positive for EtG in second session and no positive result in

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third session of three-time program. Including first and sessions of three-time program, EtG positivity was similar in terms of sex (For first session, p=0.674; for second session, p=0.428). Including first and second sessions of three-time program, EtG positivity was similar in terms of age group (For first session, p=0.873; for second session, p=0.609). In the three-time program, the number of EtG-positive patients was 60 (23.9%) and 13 (21%) for sixtime program in any session. There was no significant difference between them (p=0.624). In those who complete the six-time program, substances that are positive according to the sessions are shown in table 1.

Table 1. Positive Substances-Drugs According to the Sessions of Six-Time Program 1st Session

2nd Session

3rd Session

4th Session

5th Session

6th Session

7th Session

8th Session

9th Session

None

16 (25.8%)

39 (62.9%)

48 (77.4%)

49 (79%)

45 (72.6%)

48 (77.4%)

54 (87.1%)

57 (91.9%)

61 (98.4%)

MAMP

0 (0%)

1 (1.6%)

0 (0%)

2 (3.2%)

1 (1.6%)

0 (0%)

THC

21 (33.9%)

10 (16.1%)

8 (12.9%)

3 (4.8%)

6 (9.7%)

9 (14.5%)

0 (0%)

BZD

0 (0%)

BAR

0 (0%)

EDDP

0 (0%)

AMPH

0 (0%)

1 (1.6%)

0 (0%)

PCP

2 (3.2%)

0 (0%)

1 (1.6%)

0 (0%)

OPIAT

3 (4.8%)

1 (1.6%)

2 (3.2%)

0 (0%)

MDMA

2 (3.2%)

0 (0%)

6AM

0 (0%)

4 (6.5%)

2 (3.2%)

3 (4.8%)

0 (0%)

K2-1

0 (0%)

K2-2

0 (0%)

BUP

0 (0%)

EtG

0 (0%)

5 (8.1%)

0 (0%)

4 (6.5%)

3 (4.8%)

1 (1.6%)

8 (12.9%)

5 (8.1%)

1 (1.6%)

COC

0 (0%)

Multiple*

18 (29%)

3 (4.8%)

1 (1.6%)

3 (4.8%)

1 (1.6%)

0 (0%)

*Multiple: THC+EtG, THC+MAMP, THC+OPIAT, THC+6AM+BUP, THC+6AM+BUP+OPIAT+EtG, EDDP+MAMP, THC+AMPH (We only wrote here these multiple drug results due to none idea for them) MAMP: Methamphetamine; THC: Tetrahydrocannabinol; BZD: Benzodiazepines; BAR: Barbiturates; EDDP: Methadone; AMPH: Amphetamine; PCP: Phencyclidine; OPIAT: Morphine; MDMA: Ecstasy; 6AM: Acetylmorphine; K2-1: Bonsai; K2-2: Bonsai; BUP: Buprenorphine; EtG: Ethyl Glucuronide; COC: Cocaine

Discussion Our study is important because it allows us to reach one year of probation data collectively. This study shows that the vast majority of follow-up people are men because of probation (95.2%). Since the average age is between 20-30, it is important to increase the level of knowledge about substance and psychoeducation in this age group. Again, the study allows us to see how much alcohol use is accompanied. We can see the compliance rates of the programme and which substances are used more. In Turkey, the scope of PI, studies in people referred to health institutions is increasing. Some of these studies have been designed prospectively [12,13] and some have been retrospectively [14-16] designed. Prospective ones are studies that examine patients who are applied by PI, treated and rehabilitated within a program on a timelier basis and how much they benefit from the treatment given. Retrospective studies are based on finding more epidemiological data. These retrospective studies have examined the sociodemographic characteristics and substance use

characteristics of the cases. Karadeniz et al. [17] have determined that the individuals registered for PI consist of males (98.5%) and females (1.5%). Again in that study, it was found that substance use was most frequently seen in the 27-36 age group (39.8%). Aslan et al. [14] stated that the cases applied by probation consist of males (98.5%) and females (1.5%). In this study, mean age was 32.5±9.8. Kulaksizoglu et al. [18] indicated that 97% of the persons in the PI process because of substance use were male, and 3% were female. In our study, it was found that the majority of people who were taken to PI because of drug use were male, similar to this information in the literature, and that the number of people aged 20-35 years was high. 9 out of 10 people who abuse or are addicted to nicotine, alcohol or other drugs began using these substances before they were 18. People who began using addictive substances before age 15 are nearly 7 times likelier to develop a substance problem than those who delay first use until age 21 or older [19,20]. The age of starting to use the substance varies according to the type of substance used. For example, volatile and cannabis 756

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(Marijuana, THC) use begins at very early ages [21-23]. In the studies conducted, it was found that the most frequently positive substance in toxicological analyses made by PI was cannabis. Bahceci et al. [24] found that the substance used in 196 of 201 cases (97.5%) was cannabis. Mutlu et al. [25] reported that they had possession of cannabis when most of the cases (55.7%) were caught. In the same study, synthetic cannabinoids were found to be 13.2%. According to the study of Aslan et al. [14], 70.5% of the cases stated that they used cannabis during a period of their life. In our study, cannabis positivity was high. In the literature, there are fewer studies examining the relationship between the number of sessions (3 or 6 sessions) and the use of drugs in relation to substance use characteristics of persons who have applied PI. In six-time PI drug addiction training program, patients are informed about substance use. The program is open and new members can be taken at any session. It is a circular program. The evaluation criteria are the number of attendance to sessions, the level of compliance in sessions, the number of negative urine, and the number of homework done. It is expected that the level of adjustment in the sessions will be between 9-12 points. It is expected to make at least 4 of the assignments. The urine may be positive from the beginning of the quince. However, the urine should be negative in the last three sessions. If negative, dependence is referred to treatment center. If the ruling negatively starts with the session 3 positive urination is found, the treatment is terminated and referred to the Dependence Center. This sixweek program includes the following: the concept of information and dependence on PI, drug/stimulants and effects, motivation, emotion-thinking and behavioral cycle, prevention of re-use, lifestyle changes to improve. We are less knowledgeable about the issues such as characteristics of positive substances according to the number of sessions, the relationship between the positive substances and the age, the relationship between the number of sessions and the age, in which session, which substance is positive, and the frequency of multiple substance use. In the one-year retrospective study of Bahceciâ&#x20AC;&#x2122;s study [24], it is demonstrated that 90.1% of the individuals were followed up by DPHCB, 8% were transferred to ASATC and 2% were taken to six-times training program has been decided. When Aslan et al. [14] examine the cases in terms of PI treatment and compliance levels; found that 46 (23.0%) completed the three-session program, 32 (16.0%) were referred to the Psychiatric Hospital and 19 (9.5%) were unable to adapt to the program. In the same study, it was seen that 10 (5.0%) completed six-time program, one (0.5%) was referred to the Psychiatric Hospital and three (1.5%) did not adapt to the program. In our study, it was seen that the number of those who completed the three-time program was higher. This can be interpreted as an indication of the effectiveness of PI treatment and rehabilitation services. Mancini [26] has linked the failure of the PI system to low socioeconomic status, youth, marital status, working status and alcohol use. In a study conducted in our country, the rate of substance use at least once during life was 31.9% for alcohol [27]. There are not enough studies to investigate the relationship between alcohol use and PI process, number of sessions and age. Zorlu et al. [28] retrospectively assessed the frequency of alcohol use disorders in patients referred to PI. The most important finding of their study was that higher unemployment rates in urine positive

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group and high alcohol use disorder rates in all patients. They stated that high alcohol use disorder rates show the importance of evaluating alcohol use in treatment. In our study, alcohol use comorbidity was found in an important number of individuals. This can be interpreted as the fact that the cases subjected to the three-sessions had lower substance abuse severity and they head for substances such as alcohol, which had a lower possibility of causing legal problems, to get pleasure. On the other hand, it was interpreted that the cases subjected to the three-session program had higher substance abuse severity and they do not need to head for alcohol use for pleasure. In this study, it was found that as many as half of the PI practitioners had cannabis. The cannabis is followed by synthetic cannabinoids, ecstasy, heroin and cocaine, respectively. Positive and non-positive substances were thought to change according to socioeconomic status and ease of access to the relevant substance. In the tests conducted during the PI period, no substances were found in some of the cases. This can be caused by the presence of the substance in the environment in which the substance is used, if the person does not use the substance. In addition, the fact that the test results are misleading and that the material used is discarded within a short period of time can also affect this. Our study supports the notion that some of the people convicted of possession of substance are not dependent on it or that they can abandon the use of the substance when they meet a legal problem. This suggests that PI may be able to keep people away from substance use, even if only urine analysis is required. On the other hand, highly addictive substances such as heroin are probably not left untreated. This is in line with the 6AM and OPIAT positivity of some of the 6 participants in our study. Likewise, the fact that we do not include it because it does not fit the study pattern and that it is incompatible with the PI and that the majority of the cases referred to ASATC are positive for heroin and similar substances, supports our thinking. Conclusions In conclusion, PI, which is a fairly new practice in Turkey, has an important place in the care of substance users. Further studies should be conducted with respect to PI to provide a greater understanding of its positive and missing sides. Major limitation of this study is its retrospective design. A prospective design starting from early periods of substance use with regular follow-up scale evaluations would yield more convincing results about nature of addiction. One of another major limitation of this study is its poor sociodemographic and scale content. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Local ethics committee approval was obtained (Adiyaman University ethics committee protocol number 2018/2-7).

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16. Akpınar A, Şalış O, Aksoy UM. Samsun Ruh Sağlığı ve Hastalıkları Hastanesi’nde denetimli serbestlik 2010 yılı sonuçları ve şehir merkezi dışından başvurularda tedavi uyumlarının değerlendirilmesi. Düşünen Adam The Journal of Psychiatry and Neurological Sciences. 2013;26:46-54. 17. Karadeniz H, Birincioğlu İ, Seçilmişoğlu B, ark. Trabzon’da Denetimli Serbestlik ve Yardım Merkezi Şube Müdürlüğü’nde madde bağımlılığı nedeniyle kayıtlı olgularda toksikolojik analiz bulguları ve tedavi uygulamalarının değerlendirilmesi. Adli Tıp Bülteni. 2009;14:80-7. 18. Kulaksızoğlu B, Kulaksızoğlu S, Ellidağ HY, ark. Antalya ilinde denetimli serbestlik kararı alınan kişilerde uyuşturucu madde kullanımının araştırılması. Adli Tıp Bülteni. 2015;20:21-6. 19. The national center on addiction and substance abuse at Columbia University (CASA Columbia). (2012a). CASA Columbia analysis of the alcohol and public health: Alcohol-Related Disease Impact (ARDI). [Online]. Centers for Disease Control and Prevention. Retrieved January 11, 2012 from http://apps. nccd.cdc.gov. 20. French MT, Rachal V, Harwood HJ, et al. Does drug abuse treatment affect employment and earnings of clients? Benefits Quarterly. 1990;6:58-67. 21. Tekalan A. Uyuşturucu maddelere genel bir bakış. Yeşilay, Bağımlılık Tedavisi, Aylık Sağlık, Eğitim ve Kültür Dergisi. 2012;87:32. 22. Springer JF, Sale E, Hermann J. Characteristics of effective substance abuse prevention programs for highrisk youth. J Prim Prev. 2004;25:171-219.

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Available online at www.medicinescience.org

ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2018;7(4):759-61

Diffusion-weighted magnetic resonance imaging of thorax in diagnosis of pulmonary embolism Sevgi Yumrutepe1, Muhammet Gokhan Turtay2, Hakan Oguzturk2, Zeynep Aytemur3, Taner Guven1, Kasim Turgut4, Ali Gur2 1 Malatya Education Research Hospital Emergency Medicine Malatya, Turkey Inonu University, Faculty of Medicine Department, Emergency Medicine, Malatya, Turkey 3 Inonu University, Faculty of Medicine Department of, Pulmonary Medicine, Malatya, Turkey 4 Adıyaman, Research and Training Hospital, Department of Emergency Medicine, Adiyaman, Turkey 2

Received 06 February 2018; Accepted 11 April 2018 Available online 09.07.2018.with doi: 10.5455/medscience.2018.07.8837 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Pulmonary embolism (PE) has a high mortality rate and a considerable incidence in emergency care. Thorax computed tomography (CT) angiography is the primary diagnosis method for PE, but has many contraindications. In the present study, we aimed to determine the usability of Diffusion-weighted magnetic resonance imaging (DWMRI) in diagnosis of pulmonary embolism. Patients, diagnosed as pulmonary embolism previously by thorax CT angiography, were taken DWMRI. Demographic parameters, complaints, laboratory values and imaging findings were recorded on standart forms. Twenty nine patients, who were diagnosed as pulmonary emboli, were evaluated. Many of them were female(69%) and the mean of age was 61 years. Dyspnea and chest pain were the main complaints. Atelectasis(69,1%) and pulmonary infarct(30,9%) were determined lesions on CT and DWMRI. Region of interest (ROI) were determined by using MRI (T2) images. Three different ROI values were placed on areas and apparent diffusion coefficient (ADC) values were calculated for peripheric lung lesions. Significant difference was determine between mean ADC values of atelectasis and pulmonary infarct lesions (p<0.05). DWMRI can differentiate peripheric lesions in PE patients, but it is not adequate for diagnosis of PE. Keywords: Diffusion-weighted magnetic resonance imaging, dyspnea, lung disease, pulmoary embolism

Introduction Pulmonary embolism (PE) diagnosis is rather difficult due to nonspecific signs and symptoms. The PE is the third most common cardiovascular disease that is seen in emergency services, following coronary artery disease and stroke [1]. Mortality rates are up to 10% [2]. When PE is accurately diagnosed and treated, this rate could be reduced to 3% [3]. Thorax computed tomography (CT) angiography, with a specificity rate of 96%, is the most frequently used technique to confirm the diagnosis of PE [1]. However, the exposure to radiation, contrast media and the long exposure period during CT are the disadvantages of this technique. Thus, thorax CT angiography cannot be used in patients; with renal failure, who have contrast media allergies, and unstable patients who require rapid imaging. Magnetic resonance imaging (MRI) became an alternative to CT in lung imaging because of no radiation risk [4].

does not require the use of a contrast medium, and has been initially used in early diagnosis of strokes in neuroradiology [5,6]. The use of this technique was initially limited in brain examinations since it was very sensitive to cardiac, respiratory, and peristaltic movements, but with the development of rapid MRI sequences such as echo-planar imaging, its use expanded to other physical parts [7]. With DWMRI, the apparent diffusion coefficient (ADC) for tissues and lesions is calculated and obtained values can be used in differential diagnosis [8]. There are some studies where DWMRI was used to diagnose various neoplastic and nonneoplastic diseases in lungs [9,10]. The aim of the present study is to investigate the significance and usability of thorax DWMRI in PE by conducting thorax DWMRI on patients previously diagnosed with PE by thorax CT angiography. Materials and Methods

Diffusion weighted magnetic resonance imaging (DWMRI) is a technique that can be obtained during a single hold of breath and

This study was approved by the Inonu University Clinical Research ethics committee (approval no: 2010/124). Informed consent was obtained from all participants prior to inclusion in the study.

*Coresponding Author: Kasim Turgut, Adıyaman, Research and Training Hospital Department of Emergency Medicine, Adiyaman, Turkey E-mail: kasimturgut@yahoo.com

This study was conducted with 29 patients diagnosed with PE using thorax CT angiography between January 2011 and December 2011. 759

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The following data was obtained from each subject: Age, gender, complaints during admission to the hospital, the laboratory results (hemoglobin, platelet, white blood cell, hematocrit, glucose, BUN, creatinine) and imaging (chest X-ray, thorax CT angiography) findings were recorded in the patient files. Then, thorax DWMRI was taken to all patients who were diagnosed as PE by using thorax CT angiography previously. MR imaging The study was conducted with a superconducting MRI device (Gyroscan Intera master, Philips, best Netherlands) with a main magnetic field of 1.5 tesla and a gradient power of 32 mTesla / m, and a trigger was used to prevent artefacts caused by linear polarized body coil and respiratory movements. Initially, axial T2 weighted conventional turbo spin echo sequence (TR 3540 ms, TE 90 ms) was applied to the cases. Then, diffusion weighted imaging (DWI) [TR 5000 ms, TE 100 ms, FOV 350 mm², cross-sectional thickness 8 mm, interlice gap 1 mm] value was taken with a singleshot echo planar pulse sequence with two different b values (0 and 1000 s / mm²). Two different b values (0 and 1000 s / mm²) were used in patients. Diffusion gradients were applied on 3 planes (x, y, z). ADC mapping was obtained automatically with software. The ADC value that determines the water diffusion coefficient was obtained by the signal regression analysis. Based on T2A images, the oval and round shaped region of interest (ROI) was determined, and the value measured at a certain pixel was automatically calculated by the computer. The mean ADC value was also automatically calculated with the corresponding pixel value in the ADC map. The mean ADC value was calculated by placing 3 different ROIs in the consolidation area. The ROI included 100-800 pixels and the average of the three obtained values was used in the statistical analysis. Statistical analysis Statisitical analysis was performed with the Statistical Package for Social Sciences (SPSS) version 18.0(Chicago, IL, USA). Measurable variables are presented in Mean ± Standard Deviation. The normal distribution of ADC values was determined by the Shapiro Wilks Normality test. The significance of the difference between atelectasis and infarct was determined by independent samples t test. P <0.05 values were considered statistically significant. Results Twenty-nine patients who admitted to the hospital and diagnosed with PE with thorax CT angiography between January 2011 and December 2011 were investigated prospectively. Nine of the 29 patients (31%) were male and 20 (69%) were female. The mean age was 61 (±16.7) years. We found that the most common complaints were dyspnea and chest pain (78.2% and 40.8%, respectively) among patients in the study. In 9 (31%) patients, infarct was detected in the lung parenchyma and in 20 (69%) patients lesions were consistent with atelectasis. No other lesions were detected in DWMRI, and findings were correlated with those of thorax CT angiography (Figures 1,2,3). For all observed lesions, ADC measurements were conducted with DWMRI. The mean ADC value was 2.39x10-³ ± 4.6 mm² / sec for

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all lesions, and the mean ADC value was 1.98x10-³ ± 4.5 mm² / sec for lesions consistent with the infarct. The average ADC value for atelectasis sites was measured as 2.57 × 10-³ ± 3.3 mm² / sec (Table 1). The difference between atelectasis and infarct based on the ADC values was statistically significant (p = 0.0001).

Figure 1. Infarct site of the same patient in thorax CT and diffusion-weighted MR imaging

Figure 2. Atelectasis and pleural effusion site of the same patient in thorax CT and diffusion-weighted MR imaging

Figure 3. Infarct and pleural effusion site of the same patient in thorax CT and diffusion-weighted MR imaging Table 1. Mean ADC values for infarct and atelectasis in DWMRI Variable ADC (mm /sec 2

Infarct (I)

A telectasis (A)

I+A

19.98x10 ±4.5

2.57x10 ±3.3

2.39x103± 4.6

0.0001

ADC: apparent diffusion coefficent, DWMRI: diffusion-weighted resonance imaging

Discussion The most common symptoms of PE are dyspnea and chest pain [11,12]. In the present study, it was determined that dyspnea was the most common symptom in PE with 78.2% prevalence followed by the chest pain with 40.8% rate. Previous studies reported that multisliced CT could replace conventional pulmonary arteriography in evaluation of PE [13]. Today, thorax CT angiography is the most common technique used in PE diagnosis [14]. In the present study, we used thorax CT angiography technique for the diagnosis of PE. Thorax CT angigraphy is used as the first diagnostic method in our emergencey service, because it can give us accurate diagnosis in a short time. PE risk increases five times during pregnancy and it is one of the important causes of maternal morbidity and mortality during and after pregnancy, however there is no adequate diagnostic approach for PE during pregnancy [15,16]. Thorax CT cannot be performed in pregnancy, in case of renal failure and contrast medium allergy [16]. In recent years, MRI has been increasingly 760

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used for the diagnosis of several diseases. Since it does not require iodized contrast media and radiation, MRI is superior to thorax CT angiography. MRI could be used in patients with renal failure, iodine contrast medium allergy, and during pregnancy [17]. The ADC values calculated with DWMRI depend on the specific diffusion capacities of biological tissues. The ADC value is highly dependent on the presence of diffusion barriers in cell membranes, fibers, macro-molecules, and cell organelles, called water microenvironment [18]. Different cellular building compartments can reveal dissimilar ADC values. Thus, ADC values could help determine different tissue types and tissue characteristics [19,20]. ADC values are at lower levels in various tumors with denser protons when compared to benign tissues and necrosis where the protons are less dense. Since tumors are more cellular than the tissue they originate from, they contain signaling features such as diffusion restriction in DWI [21]. In the present study, it was observed in thorax DWMRI that all patients diagnosed as PE, also had lesions in the lung periphery. We constituted the ADC maps from peripheral lesions and calculated mean ADC values. Based on these ADC values, the difference between atelectasis and infarct sites was determined as significant (p<0.05). Thus, ADC values that would be detected with diffusion MRI in patients diagnosed with PE may help us to differentiate the atelectasis and infarct sites. However, it was determined that it is difficult to diagnose the PE by observing the thorax DWMRI. This was the first study that aimed to determine the ADC values in peripheric lesions seen in PE. In the past, MRI was utilized for morphologic imaging of lungs. However, current MRI techniques enabled functional imaging of the lungs. Although DWMRI is a difficult technique, it is now possible to obtain DWMRI of the chest and mediastinum with MRI scanners. Despite the limited clinical experience, the use of DWMRI has shown promising results in the characterization and staging of the lung cancer, evaluation of mediastinal and pleural pathologies, determination of the characterization of pulmonary nodules, and characterization of lymph nodes and lung metastases, and ongoing research has enabled noninvasive evaluation of mediastinum by diffusion imaging technique [4,22]. In the present study, it was not possible to standardize the time of onset of patient complaints and the time of diagnosis of pulmonary embolism for all patients. Thus, to obtain clearer findings about the significance and availability of thorax DWMRI in the diagnosis of pulmonary embolism, it was concluded that the time of onset of patient complaints and the time it took to diagnose the PE should be standardized, and further studies that would be conducted with higher number of patients were required. Conclusion DWMRI can not be used for diagnosis of PE. It can only help us to differentiate peripheral lung lesions in PE by the ADC values. Thorax CT angiography is still the first diagnostic method for PE. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports Ethical approval The study was started after the approval of Inonu University Ethical Commision(Nu: 2010/124).

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References 1.

Burns SK, Haramati LB. Diagnostic imaging and risk sratification of patients with acute pulmonary embolism. Cardiol Rev. 2012;20:15-24.

Ballantine M, Bhimani M, Milne WK. Diagnostic approach to pulmonary embolism in a rural emergency department. Can J Rural Med. 2012;17:17-20.

Arseven O. Venous thromboembolism. In: Ozlu T, Metintas M, Ardıc S, edition. Basic Data about Lung Diseases. Ankara, 2008;341-56.

Henzler T, Schmid-Bindert G, Schoenberg SO, et al. Diffusion and perfusion MRI of the lung and mediastinum. Eur J Radiol. 2010;76:329-36.

Warach S, Chien D, Li W, et al. Fast magnetic resonance diffusion-weighted imaging of acute human stroke. Neurology 1992;42:1717-23.

Lutsep HL, Albers GW, DeCrespigny A, et al. Clinical utility of diffusionweighted magnetic resonance imaging in the assessment of ischemic stroke. Ann Neurol. 1997;41:574-80.

Muller MF, Prasad P, Siewert B, et al. Abdominal diffusion mapping with use of a whole-body echo-planar system. Radiology 1994;190:475-8.

Sinha S, Lucas-Quesada FA, Sinha U, et al. In Vivo Diffusion-Weighted MRI of the Breast: Potential for Lesion Characterization. J Magn Reson Imaging. 2002;15:693-704.

Baysal T, Bulut T, Gokırmak M, et al. Diffusion weighted MR imaging of pleural fluid differentiation of transudative vs exudative pleural effusions. Eur Radiol 2004;14:890-6.

10. Baysal T, Mutlu DY, Yoloğlu S. Diffusion-weighted magnetic resonance imaging in differentiation of postobstructive consolidation from central lung carcinoma. Magn Reson Imaging. 2009;27:1447-54. 11. Miniati M, Prediletto R, Formichi B, et al. Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med 1999;159:864-71. 12. Duru S, Ergün R, Dilli A, et al. Clinical, laboratory and computed tomography results in pulmonary embolism: Retrospective evaluation of 205 patients. Anatol J Cardiol. 2012;12:142-9. 13. Patel S, Kazerooni EA. Helical CT for the evaluation of acute pulmonary embolism. AJR Am J Roentgenol. 2005;185:135-49. 14. Hunt JM, Bull TM. Clinical review of pulmonary embolism: diagnosis, prognosis, and treatment. Med Clin North Am. 2011;95:1203-22. 15. McLintock C, Brighton T, Chunilal S, et al. Recommendations for the prevention of pregnancy associated venous thromboembolism.Councils of the Society of Obstetric Medicine of Australia and New Zealand; Australasian Society of Thrombosis and Haemostasis. Aust N Z J Obstet Gynaecol. 2012;52:3-13. 16. Arseven O, Sevinc C, Alatas F,et al. Actual diagnostic and treatment modalities for pulmonary embolism. Turkish Thoracic J. 2009;10:7-47. 17. Savas I. Pulmonary thromboembolism. In: Savas I, Acıcan T, Atasoy C. et al. Eds. 2009. Chest Diseases. Poyraz. Ankara:369-76 18. Benveniste H, Hedlund LW, Johnson GA. Mechanism of detection of acute cerebral ischemia in rats by diffusion-weighted magnetic resonance microscopy. Stroke. 1992;23:746-54. 19. Herneth AM, Naude J, Philipp M, et al. The value of diffusion weighted MRI in assessing the bone marrow changes invertebral metastases. Radiologe. 2000;40:731-6. 20. Finelli DA. Diffusion-weighted imaging of acute vertebral compressions: specific diagnosis of benign versus malignant pathologic fractures. AJNR Am J Neuroradiol. 2001;22:241-2. 21. Provenzale JM, Mukundan S, Barboriak DP. Diffusion-weighted and perfusion MR imaging for brain tumor characterization and assessment of treatment response. Radiology. 2006;239:632-49. 22. Luna A, Sánchez-Gonzalez J, Caro P. Diffusion-weighted imaging of the chest. Magn Reson Imaging Clin N Am. 2011;19:69-94.

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Medicine Science 2018;7(4):762-5

Prevalence of MMP-3 E45K polymorphism in Turkish patients with endometrial carcinoma Sibel Bulgurcuoglu Kuran1, Emine Hande Karagedik2, Cem Iyibozkurt1, Elif Sinem Iplik3, Bedia Cakmakoglu2, Arzu Ergen2 1 Istanbul University, Faculty of Medicine Department of Obstetrics and Gynecology, Istanbul, Turkey Istanbul University, Aziz Sancar Institute of Experimental Medicine, Department of Molecular Medicine, Istanbul, Turkey 3 Istanbul Yeni YĂźzyÄąl University, Faculty of Pharmacy, Department of Pharmaceutical Microbiology, Istanbul, Turkey

Received 09 March2018; Accepted 15 April 2018 Available online 31.08.2018 with doi: 10.5455/medscience.2018.07.8870 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Endometrial carcinoma is a metastatic and recurrent disease has a worse prognosis. We aim to investigate the MMP-3 gene polymorphism in Turkish patients with endometrial carcinoma. In recent years, number of genetic studies have been increased to find new prognostic and theraupeutic markers. Matrix metalloproteinases [MMPs] are proteolytic enzymes that degrade all components of the extracellular matrix which are play an important role of cancer metastasis and invasion. MMP-3, also known as stromelysin-1, to lyse basal membrane collagen and induce the synthesis of some other MMPs. 97 patients with endometrial carcinoma and 100 healthy controls were included in this study. MMP-3 E45K polymorphism was determined using polymerase chain reaction/ restriction fragment length polymorphism in study groups. There were no significant differences between any genotypes or allele in control and patient groups for MMP-3 E45K polymorphism. Besides no significant correlation was found between MMP-3 E45K polymorphisms and clinical characteristics, such as histology, grade, metastasis and family history. ur study suggests that the MMP-3 E45K polymorphism is not associated with endometrial carcinoma process in Turkish patients. Keywords: MMP-3, polymorphism, endometrial carcinoma, prevalence

Introduction Endometrial cancer is the most important female disease in genital tract [1]. The global morbidity rate is 6.5% and the global mortality rate is about 1.6% [2]. The extracellular matrix (ECM) hosts some structural molecules which may have roles to create cellular microenvironments or niches [3,4]. In case the regulation of ECM remodeling is failure to leading to development of some pathological processes such as cancer, and metastasis [5,6]. Matrix metalloproteinases (MMPs), an enzyme family that contributes the ECM remodeling, are responsible from degradation and turnover of ECM elements [7,8]. The type-IV collagenase group of MMP-2 and MMP-9 has been linked to endometrial cancer progression and invasion [9].

*Coresponding Author: Arzu Ergen, Istanbul University, Aziz Sancar Institute of Experimental Medicine, Department of Molecular Medicine, Istanbul, Turkey E-mail: a_ergen@yahoo.com

MMP3, also known as stromelysin-1, to lyse basal membrane collagen and induce the synthesis of some other MMPs [10]. MMP3 gene expressions and polymorphisms vary on different types of cancer pathogenesis. There are some evidence that MMP-3 has an important role in pathogenesis of astrocytomas. Mercapide et al reported that MMP-3 may play a crucial role in the molecular events that account for the invasive process in astrocytoma cell lines [11,12]. Blons et al suggested that a significant relation between the MMP-3 -1612insA polymorphism and response to chemotherapy in head and neck cancer patients [13]. Besides, there are some studies which is shown that no relation between MMP-3 and cancer. It is shown that the 5A/6A polymorphism of MMP-3 gene may not be linked with appearance and development to ovarian cancer [14]. There is an A/G transition at nucleotide position 28 within exon 2 resulting lysine/glutamate for E45K polymorphism. This changes may cause reduction of MMP-3 production [15]. The findings of Ricketts et al demonstrated that an association between MMP-1/ MMP-3 (rs1799750/rs679620) variants and sporadic renal cell carcinoma [16]. In another study, no association is found between MMP-1, -3, and -7 SNPs and endometrial cancer risk [17]. Another study have been pointed out that no relationship between MMP-3 E45K polymorphism and skin cancer risk [18]. 762

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Present study evaluates the correlation between MMP-3 E45K polymorphism and endometrial carcinoma. Material and Methods Study Design Blood samples were collected from 97 patients diagnosed with endometrial cancer in Gynecology Clinic of Medical Faculty of Istanbul University. Endometrial biopsy was performed and on the basis of diagnosis and histological examination by Gynecology Clinic of Medical Faculty. The control group consisted of 100 healthy individuals with a negative family history of cancer. The specimens were taken after obtaining informed consent and the study was conducted prospectively. Local Ethical Committee approval was obtained for the study and the samples were collected after obtaining written informed consent from the participants and approval from Istanbul University’s Ethics Committee based on World Medical Association Declaration of Helsinki. MMP-3 E45K [rs679620] Polymorphism DNA was extracted from peripheral blood lymphocytes using the salting-out procedure [19]. Polymorphism was genotyped using polymerase chain reaction (PCR)/restriction fragment length polymorphism (RFLP) methods. PCR was used to amplify the region of MMP-3 E45K polymorphism. PCR Primers were designed by using Primer 3 Input (version 0.4.0). Reaction were performed with 10 pmol of each primer: F:5’-AAATTTGCCATTATTTCAGCAAG3’,R:5’-CCCCTCTGAACCATTACCTG-3’. Template DNA [0.51.0 μg] was used in a PCR under stringent conditions to avoid the possibility of false positives for genotyping. Reactions were performed with 10 pmol of each primer in final volume of 50 μL containing 25 mM MgCl2, 10 mM Tris-HCl (pH 8.4), 2mM of each dNTP and 5 unit Taq Polymerase (Invitrogen, Carlsbad, USA). Amplification was carried out in a DNA Thermal for 35 cycles with denaturation steps at 94°C for 30 seconds, annealing at 59 °C for 30 seconds and extension at 72°C for 30 seconds for E45K polymorphism. Restriction enzyme was determined by using NEBcutter V2.0 program. For E45K genotypes, presence of the polymorphisms was determined by enzymatic digestion of the initial PCR product with TaqI at 60 °C for 3h. Three genotypes could be determined after electrophoresis: genotype AA (399 bp), GG (236, 163 bp) and AG (399, 236, 163 bp).

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of statistically significant (p=0,061). Besides no significant correlation was found between MMP-3 E45K polymorphisms and clinical characteristics, such as histology, grade, metastasis and family history (Table 3). Some histological groups had less number of patients, therefore it was not be able to evaluate as statistically. Table 1. Characteristics of patients with endometrial cancer

Parameters

Patient (n = 97)

Control (n=100)

54.86 ± 9.72

56.90 ± 6.99

Oral contraceptive use (%)

20.7

Family history (%)

41.7

Histology (%) Endometrioid Adenocarcinoma Seros Clear cell

89.7 2.6 2.6 5.1

Age, years ± SD

Grade (%) 1/2/3

64/23/12

CA 125 levels

30.98 ± 6.63

CA 19.9 levels

41.57 ± 18.37

CA 15.3 levels

223.52 ± 145.80

4.09 ± 1.65

CEA levels

n=number of subjects

Table 2. Distribution of MMP-3 E45K genotype and allele frequencies in patient and control groups MMP-3 E45K polymorphism

Patient (n = 97)

Control (n = 100)

p value

54(55.7%)

46(46%)

0.175

25(25.8%)

24(24%)

0.773

Results

18(18.6%)

30(30%)

0.061

We did not observe any differences between study groups according to ages (p>0,05; as mean age ± SD; patient = 54.86 ± 9.72; control = 56.90 ± 6.99). Table 1 summerizes the characteristics of patients with endometrial carcinoma. Table 2 shows that distribution of E45K genotypes in study groups. There were no significant differences between any genotypes or allele in control and patient groups for MMP-3 E45K polymorphism. Frequency of heterozygote genotype was increased in controls at the limit

Alleles A

126(64.9%)

122(61%)

0.773

68(35.1%)

78 (39%)

0.175

Statistical analysis Categorical variables such as genotypes and alleles were compared using Chi-Square (χ2) test. Allele and genotype frequencies were determined by direct counting. Differences in continuous variables between carriers and control subjects were tested using Student’s t test. Statistical analyses were performed with SPSS 16.0 software (SPSS Inc, Chicago, USA).

Genotypes

n=number of subjects

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Table 3. Distribution of MMP-3 genotypes and alleles according to clinical parameters in patients MMP-3 E45K polymorphism

AA (n = 54)

GG (n = 25)

AG (n = 18)

A (n = 126)

G (n = 68)

50 (92%)

22 (88%)

12 (66%)

112 (89%)

56 (82%)

2 (4%)

4 (3%)

3 (12%)

6 (9%)

2 (4%)

6 (34%)

10 (8%)

6 (9%)

39 (72%)

9 (36%)

12 (66%)

90 (71%)

30 (44%)

12 (22%)

9 (36%)

24 (19%)

18 (26%)

3 (6%)

7 (28%)

6 (34%)

12 (10%)

20 (30%)

Histology Endometrioid Adenocarcinoma Serous Clear cell Grade

n=number of subjects

Discussion

Conclusion

ECM degradation is an important factor for invasion of malignant tumors and metalloproteinases play a crucial role on this process. It has been needed the new studies to consolidate the effects of the metalloproteinases on this process. Our aim was to investigate the MMP-3 gene polymorphism in Turkish patients with endometrial carcinoma.

Present study suggests that the MMP-3 E45K polymorphism is not associated with endometrial carcinoma process in Turkish patients.

Recently, several studies have exam¬ined the MMP-3 polymorphisms in different cancers [20,21]. Motovali-Bashi et al suggest that the presence of 5A polymorphism at the MMP-3 promoter region could be looked at as a risk factor for a worse prognosis in colorectal cancer patients [22]. In another study, Guan et al implicate this MMP3 −1612 5A/6A polymorphism as a contributor to ESCC susceptibility [20].

References

We studied MMP-3 E45K polymorphism which may cause to changes of MMP-3 production levels. There is less number of studies about E45K polymorphism and diseases. Ling et al demonstrated that E45K polymorphism is significantly associated with increased susceptibility and severity of post-operative stiffness [23]. Ma et al suggested that there may be an association of MMP-3 polymorphisms (rs3025058, rs522616, rs679620) with susceptibility to stoke in northern Han Chinese population [24]. We did not find any statistically differences between genotypes and study groups. We observed A allele 64,9% and G allele 35,1% in patients with endometrial carcinoma. A similar result was observed by Nan et al. They studied different SNPs of MMP-3 including E45K, on skin cancers. They did not show any relationship between skin cancer and E45K polymorphism [18]. BeeglyFadiel et al was investigated MMP-1, -3, and -7 polymorphisms in endometrial carcinoma. They found G allele frequency as 32.9% in patients. Unfortunately, none of these polymorphisms were found to be significantly associated with endometrial cancer risk [17]. However, it is been known that MMP-3 is a risk factor for metastasis and invasion in cancer process [25], we did not show and association between clinical characteristics of patients such as histology, grade, metastasis.

Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves.

Colombo N, Preti E, Landoni F, et al. ESMO Guidelines Working Group. Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2011;22:35-9.

Nicholson MR, Iyengar P, Hummer AJ, et al. Immunophenotypic diversity of endometrial adenocarcinomas: implications for differential diagnosis. Modern Pathol. 2009;19:1091-100.

Noguera R, Nieto OA, Tadeo I, et al. Extracellular matrix, biotensegrity and tumor microenvironment. An update and overview. Histol Histopathol. 2012;27:693-705.

Rozario T, DeSimone DW. The extracellular matrix in development and morphogenesis: A dynamic view. Dev Biol. 2010;341:126-40.

Catalano V, Turdo A, Di F, et al. Tumor and its microenvironment: A synergistic interplay. Semin Cancer Biol. 2013;23:522-32.

Lu P, Weaver VM, Werb ZJ. The extracellular matrix: A dynamic niche in cancer progression. J Cell Biol. 2012;20:395-406.

Deryugina E, Quigley J. Pleiotropic roles of matrix metalloproteinases in tumor angiogenesis: contrasting, overlapping and compensatory functions. Biochim Biophys Acta. 2010;1803:103-20.

Butler GS, Overall CM. Updated biological roles for matrix metalloproteinases and new “intracellular” substrates revealed by degradomics. Biochemistry. 2009;48:10830-45.

Honkavuori M, Talvensaari-Mattila A, Soini Y,et al. 2007. MMP-2 expression associates with CA 125 and clinical course in endometrial carcinoma. Gynecol Oncol. 104:217-21.

10. Brinckerhoff CE, Rutter JL, Benbow U. Interstitial collagenases as markers of tumor progression. Clinical cancer research: an official journal of the American Association for Cancer Research. 2000;6:4823-30. 11. Bodey B, Bodey B Jr, Siegel SE, et al. Matrix metalloproteinase expression in childhood astrocytomas. Anticancer Res. 2000;20:3287-92. 12. Mercapide J, Lopez De Cicco R, Castresana JS, et al. Stromelysin-1/matrix

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doi: 10.5455/medscience.2018.07.8870 metalloproteinase-3 (MMP-3) expression accounts for invasive properties of human astrocytoma cell lines. Int J Cancer. 2003;106:676â&#x20AC;&#x201C;82. 13. Blons H, Gad S, Zinzindohoue F, et al. Matrix metalloproteinase 3 polymorphism: a predictive factor of response to neoadjuvant chemotherapy in head and neck squamous cell carcinoma. Clin Cancer Res. 2004;10:25949. 14. Szyllo K, Smolarz B, Romanowicz-Makowska H, et al. The promoter polymorphism of the matrix metalloproteinase 3 (MMP-3) gene in women with ovarian cancer. J Exp Clin Cancer Res. 2002;21:357-61. 15. Raleigh SM, van der Merwe L, Ribbans WJ, et al. Variants within the MMP3 gene are associated with Achilles tendinopathy: possible interaction with the COL5A1 gene. Br J Sports Med. 2009;43:514-20. 16. Ricketts C, Zeegers MP, Lubinski J, et al. Analysis of germline variants in CDH1, IGFBP3, MMP1, MMP3, STK15 and VEGF in familial and sporadic renal cell carcinoma. PLoS One. 2009;4:e6037. 17. Beeghly-Fadiel A, Xiang YB, Deming SL, et al. No association between matrix metalloproteinase (MMP)-1, MMP-3, and MMP-7 SNPs and endometrial cancer risk. Cancer Epidemiol Biomarkers Prev. 2009;18:19258. 18. Nan H, Niu T, Hunter DJ, et al. Missense polymorphisms in matrix metalloproteinase genes and skin cancer risk. Cancer Epidemiol Biomarkers Prev. 2008;17:3551-7.

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19. Miller SA, Dykes, DD, Polesky HF. A simple salting out procedure for extracting DNA from human nucleated cells. Nucleic Acids Res. 1988;16:1215. 20. Guan X, Wang X, Luo H, et al. Matrix metalloproteinase 1, 3, and 9 polymorphisms and esophageal squamous cell carcinoma risk. Med Sci Monit. 2014;20:2269-74. 21. Shevchenko AV, Konenkov VI, Garbukov EIu, et al. Associating ofpolymorphism in the promoter regions of genes of metalloproteinase (MMP2, MMP3,MMP9) with options of the clinical course of breast cancer in Russian women. Vopr Onkol. 2014;60:630-5. 22. Motovali-Bashi M, Hojati Z, Hajihoseiny S, et al. The stromelysin-1 5A/5A genotype enhances colorectal cancer cell invasion in Iranian population. J Res Med Sci. 2012;17:962-6. 23. Ling Y, Peng C, Liu C, et al. Gene polymorphism of IL-6 and MMP-3 decreases passive range of motion after rotator cuff repair. Int J Clin Exp Pathol. 2015;5:5709â&#x20AC;&#x201C;14. 24. Ma AJ, Fan LY, Li WJ, et al. Association of matrix metalloproteinase-3 gene polymorphisms with subtypes of ischemic stroke. Zhonghua Yi Xue Yi Chuan Xue Za Zhi. 2013;30:461-6. 25. Mannelqvist M, Stefansson IM, Bredholt G, et al. Gene expression patterns related to vascular invasion and aggressive features in endometrial cancer. Am J Pathol. 2011;178:861-71.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):766-8

Can neutrophil-lymphocyte ratio be a predictor of cerebral vasospasm in patients with subarachnoid hemorrhage? Huseyin Ulas Pinar1, Enes Duman2, Suleyman Deniz1, Ilker Coven3, Omer Karaca1, Rafi Dogan1 Baskent University Konya Research Center, Department Anesthesiology, Ankara, Turkey 2 Baskent University Konya Research Center, Department Radiology, Ankara, Turkey 3 Konya Education and Research Hospital, Department Neurosurgery, Ankara, Turkey

Received 16 March 2018; Accepted 17 April 2018 Available online 19.04.2018 with doi: 10.5455/medscience.2018.07.8781 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract This study aimed to investigate the relationship between neutrophil-lymphocyte ratio (NLR) and development of vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). Materials and Methods The study was performed by retrospectively analyzing the data of 170 aneurysmal SAH patients who admitted to the intensive care unit of our hospital between 2011 and 2017. We investigated the ability of NLR values calculated from the blood samples taken at the time of admission to predict for vasospasm. Results Thirty-five percent of the patients developed vasospasm. NLR values were associated with the development of vasospasm (OR 1.15; 95% confidence interval, 1.09-1.22; p<0.0001). When the ability of NLR to predict for vasospasm was analyzed, the area under curve (AUC) of ROC curve was 0.776 (95% confidence interval: 0.70-0.85). The optimal cut-off point was 14.48 using the Youden index. The sensitivity and specificity for this cut-off point were 61.7% and 83.6%, respectively. Conclusion NLR can be used as an independent predictor of vasospasm development as a cheap and practical method, along with other predictive factors. Keywords: Aneurysmal subarachnoid hemorrhage, vasospasm, neutrophil-lymphocyte ratio

Introduction Cerebral vasospasm is one of the most important causes of morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Vasospasm is detected angiographically in two-thirds of the patients after aneurysmal SAH, while almost half of these patients develop delayed ischemia due to vasospasm, leading to neurological disorder [1]. Therefore, after treatment of aneurysm by surgical and endovascular interventions, prevention of vasospasm which may cause secondary damage is of critical importance. Effective treatment and preventive approaches can be used earlier if post-SAH vasospasm can be predicted. In the recent years, neutrophil-lymphocyte ratio (NLR), one of the economical markers of systemic inflammation, started to be used as a prognostic factor in several diseases such as cancers, infections, and acute coronary syndromes [2-5]. Moreover, studies on NLR in cerebrovascular events were also conducted in the recent years. High NLR was associated with an increase in 30-day mortality in

*Coresponding Author: Huseyin Ulas Pinar, Baskent University Konya Research Center, Department Anesthesiology, Ankara, Turkey E-mail: huseyinpinar2002@gmail.com

patients with intracerebral hemorrhage [5] and in a meta-analysis, increased NLR was found to be associated with worse functional outcomes and increased mortality based on 3-month results in this patient group [6]. Based on these data, we aimed to evaluate if NLR values were associated with the development of vasospasm in aneurysmal SAH patients followed in our intensive care unit. Material and Method This study was performed retrospectively on 170 patients followed in our clinic for aneurysmal SAH between 2011 and 2017. Inclusion criteria were as follows: aneurysmal SAH diagnosis made with cerebral computed tomography (CCT) and confirmed with cerebral angiography; admission at the hospital within 24 hours of the onset of initial symptoms; surgical or endovascular treatment of aneurysm within 2 days of the event; complete blood count preformed at the time of admission; and patients at the age range of 18-80 years. Patients were excluded if they had acute or chronic infections, known malignancies, uremia, chronic hepatic failure, or heart or lung diseases. Data of patients including age, gender, smoking, alcohol intake, 766

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and medical histories were recorded at the time of admission. Neutrophil and lymphocyte counts were determined in the blood samples of the patients and NLR values were calculated and recorded. The neurological status at the time of admission was evaluated using World Federation of Neurosurgical Societies (WFNS) score, while modified Fisher scale was used for radiological classification. Digital subtraction angiography (DSA) was used to assess the localization and size of the aneurysm. Ruptured aneurysm treatment was performed by Interventional Radiology and Neurosurgery teams in 48 hours and the patients were followed in our intensive care unit for at least 14 days.

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Table 1. Association between NLR and vasospasm

NLR Gender (Male) Age

Simple Logistic Regression OR (95% Confidence Interval) 1.15 (1.09-1.22)

Multiple Logistic Regression OR (95% Confidence Interval) 1.16 (1.10-1.23)

p value <0.0001

0.44 (0.20-0.96)

0.039

1.04 (1.0-1.07)

0.02

Patients received standard treatments after aneurysmal SAH. Cerebral vasospasm development was defined as neurological deterioration as hemiparesis, aphasia, apraxia, hemianopia or sudden reduction at least two points in the Glasgow Coma Scale. Patients who developed cerebral vasospasm treated with appropriate treatment modalities like intra-arterial vasodilators or medical interventions. Statistical analysis Frequencies and percentages were presented for categorical variables. Means and standard deviation statistics were given for continuous variables. ROC analysis was performed and the optimal cut-off based on Youden Index was determined to investigate the power of NLR to predict vasospasm. Moreover, the effect of NLR on vasospasm was investigated by using simple and multiple regression models by controlling for age and gender and uncorrected odds ratio (OR) and corrected OR were presented. Sequential logistic regression models were used to investigate the association of NLR with clinical and radiological scores. Analyses were performed using the SAS (University Edition) software package (version 9.4; SAS Institute lnc., Cary, NC, USA) and a p value of <0.05 was considered significant. Results A total of 207 patients who admitted to our clinic for aneurysmal SAH between 2011 and 2017 were included in our study. Thirtyseven of these patients were excluded due to meeting exclusion criteria or having missing data. Ninety-five patients (55.8%) were female and 75 patients (44.2%) were male. The mean age of the patients was 56.51 ± 12.41 years. When CCT scans of the patients were examined, 23 patients (13%) had Grade 1, 57 patients (23%) had Grade 2, 43 patients (25%) had Grade 3 and 47 patients (27%) had Grade 4 SAH. When clinical scores the patients were examined, 61 patients (35%) had Grade 1, 48 patients (28%) had Grade 2, 16 patients (9%) had Grade 3, 39 patients (22%) had Grade 4 and 6 patients (3%) had Grade 5 SAH. Correlations were found between NLR and both WFNS score and Fisher’s Grade by logistic regression analysis (p<0.0001). Vasospasm developed in 35% of the patients (60 patients) at some point during the clinical course. Our total mortality rate was 31% (54 patients). When the power of NLR to predict vasospasm was analyzed, the area under curve (AUC) of ROC curve was 0.776 (95% CI: 0.70 0.85). The optimal cut-off point was 14.48 using the Youden index. The sensitivity, specificity, positive predictive value and negative predictive value for this cut-off point were 61.7%, 83.6%, 67.3%, and 80%, respectively [Figure 1].

Figure 1. ROC curve for NLR

Discussion Our study results show that increase in NLR values was independently associated with the development of vasospasm [Table 1] and increased NLR values correlated with the Fisher and WFNS values of the patients. Tao et al. investigated the clinical value of NLR in patients with aneurysmal SAH and demonstrated that high NLR values were associated with poor functional outcomes at 3 months and delayed cerebral ischemia caused by cerebral vasospasm. The authors stated that more correlated results were obtained when NLR and platelet-lymphocyte ratio were used together [7] In a study conducted in our country, among the patients admitted to emergency service, NLR values were significantly higher in SAH patients compared to those in patients presenting with migraine and other headaches [8]. Neuro-inflammation is seen after any cerebral damage and thus inflammatory reaction is also inevitable in SAH patients. Similar to the study by Tao et al., other studies also reported that inflammatory parameters may have a prognostic value in SAH patients [9,10]. Höllig et al. also showed that inflammatory parameters such as increased levels of IL-6 during the early phase after SAH are associated with poor outcomes [11]. The blood in the subarachnoid space initiates the inflammatory cascade involving vascular and cellular components, leading to leukocyte migration and expression of cell adhesion molecules in the endothelial cells [12]. Accordingly, the increase in NLR appears to be related to 767

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the initiation of neuroprotective mechanisms and inflammatory processes after SAH. Conclusion Younger age, smoking, low baseline clinical score, and presence of thick subarachnoid and intraventricular hemorrhage on cerebral CT were found to be the factors associated with cerebral vasospasm and delayed cerebral ischemia [13]. These factors together with the severity of the inflammatory reaction, which was also determined in our study and reported in other studies, may be considered as an increased risk for cerebral vasospasm. In conclusion, more vigorous monitoring and more aggressive treatment for cerebral vasospasm in patients with increased NLR will be clinically useful. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves.

References 1.

Karimi RJ, Choudry O, Prestigiacomo CJ. Intra-arterial pharmacotherapy of cerebral vasospasm. In: Prestigiacomo CJ and Bendok BR (eds) Endovascular Surgical Neuroradiology: Theory and Clinical Practice. New York, USA: Thieme. 2015, pp 210-217.

Zheng J, Cai J, Li H, Zeng K, He L, Fu H, Zhang J, Chen L, Yao J, Zhang Y, Yang Y, Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as prognostic predictors for hepatocellular carcinoma patients with various treatments: a meta-analysis and review. Cell Physiol Biochem. 2017;44(3):967-81.

Cataudella E, Giraffa C. M, Di Marca S, Pulvirenti A, Alaimo S, Pisano M, Terranova V, Corriere, T., Ronsisvalle M. L, Di Quattro R, Stancanelli B, Giordano M, Vancheri C , Malatino L. Neutrophil-To-Lymphocyte ratio: An emerging marker predicting prognosis in elderly adults with communityacquired pneumonia. J Am Geriatr Soc. 2017;65(8):1796-801. Chao-Hui Dong, Zhang-Min Wang, Si-Yu Chen, Neutrophil to lymphocyte

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ratio predict mortality and major adverse cardiac events in acute coronary syndrome: A systematic review and meta-analysis, Clin Biochem. 2018;52:131-6. 5.

Wang F, Hu S, Ding Y, Ju X, Wang L, Lu Q, Wu X. Neutrophil-tolymphocyte ratio and 30-Day mortality in patients with acute intracerebral hemorrhage. J Stroke Cerebrovasc Dis. 2016;25(1):182-7.

Zhang J, Cai L, Song Y, Shan B, He M, Ren Q, Chen C, Liu Z, Zeng Y, Xu J. Prognostic role of neutrophil lymphocyte ratio in patients with intracerebral hemorrhage. Oncotarget. 2017;8(44):7752-60.

Tao C, Wang J, Hu X, Ma J, Li H, You C. Clinical value of neutrophil to lymphocyte and platelet to lymphocyte ratio after aneurismal subarachnoid hemorrhage. Neurocrit Care. 2017;26(3):393-401.

Eryiğit U, Cakmak VA, Şahin A, Tatlı O, Paslı S, Gazioğlu G, Karaca Y. The diagnostic value of the neutrophil-lymphocyte ratio in distinguishing between subarachnoid hemorrhage and migraine. Am J Emerg Med. 2017;35(9):127680.

Rothoerl RD, Axmann C, Pina AL, Woertgen C, Brawanski A. Possible role of the C-reactive protein and white blood cell count in the pathogenesis of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. J Neurosurg Anesthesiol. 2006;18:68-72.

10. Tam AK, Ilodigwe D, Mocco J, Mayer S, Kassell N, Ruefenacht D, Schmiedek P, Weidauer S, Pasqualin A, Macdonald RL. Impact of systemic inflammatory response syndrome on vasospasm, cerebral infarction, and outcome after subarachnoid hemorrhage: exploratory analysis of CONSCIOUS-1 database. Neurocritic Care. 2010;13:182-9. 11. Höllig A, Remmel D, Stoffel-Wagner B, Schubert GA, Coburn M, Clusmann H. Association of early inflammatory parameters after subarachnoid hemorrhage with functional outcome: A prospective cohort study. Clin Neurol Neurosurg. 2015;138:177-83. 12. Kaynar MY, Tanrıverdi T, Kafadar AM, Kacira T, Uzun H, Aydın S, Aydın S, Gümüştaş K, Dirican A, Kuday C. Detection of soluble intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 in both cerebrospinal fluid and serum of patients after aneyurysmal subarachnoid hemorrhage. J Neurosurg. 2004;101(6):1030-6. 13. Crobeddu E, Mittal MK, Dupont S, Wijdicks E.F.M, Lanzino G, Rabinstein AA. Predicting the lack of development of delayed cerebral ischemia after aneurismal subarachnoid hemorrhage. Stroke. 2012;43:697-701

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):769-72

Airway management of difficult intubation in the pediatric population: A single center experience Melike Korkmaz Toker1, Ayse Gul Karabay2 Mugla Sitki Kocman University Training and Research Hospital, Department of Anesthesiology and Reanimation, Mugla, Turkey 2 Ota Jine Med private Hospital, Clinic of Anesthesiology, Istanbul, Turkey

Received 07 April 2018; Accepted 18 April 2018 Available online 24.07.2018 with doi: 10.5455/medscience.2018.07.8853 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Awareness and the management of the difficult airway in children are crucial. Although the incidence of difficult intubation in children is believed to be lower than in adults, there is insufficient data regarding it. The aim of this study was to determine what airway management techniques are being applied in the difficult airway situation, by a group of experienced Consultant Anesthetists, in a large pediatric center. The study conducted over a 2-year period, in a large pediatric hospital. For a 2-year period beginning from September 2014, consultant anesthetists completed pro-forma following all pediatric anesthesia procedures in which tracheal intubation was difficult. The collected information included: patient demographics; airway assessment; anesthetic technique and airway management strategies employed; and reasons of failure in intubation attempts. There were 50 cases which were assessed as difficult intubation, and 80% of the cases had an anticipated difficult intubation report with 40% having a history of previous difficult intubation. Fiberoptic Bronchoscope (FOB) was the first-choice rescue technique in 84% of the patients; 92% of oral FOB and 71% of nasal FOB were successful. Six cases required surgical airway as surgical tracheostomy. This study created a screenshot of the various methods used when we were faced with a difficult airway management in pediatric population. Fiberoptic intubation remains overall the best method whereas no method was 100% successful. The majority of the patients had anticipated difficult airway, which opportunely allows planning for surgical airway with other teams such as Ear-Nose Throat and pediatric surgery. Keywords: Difficult airway, pediatric, fiberoptic bronchoscope, tracheostomy, video laryngoscope

Introduction Awareness and the management of the difficult airway in children is crucial. Even the normal anatomy of younger children can be difficult to manage for anesthesiologists with limited pediatric experience. Restricted head extension, small mandibular space, increased size of the tongue, craniofacial dysmorphism and distinct distances from the lower lip to the chin and the ear tragus to the mouth are associated with difficult intubation conditions [1]. Similarly, in preschool and older children, adenotonsillar hypertrophy is common and the narrowest portion of airway may be at the tonsillar level. Furthermore, high metabolic demands and low oxygen reserves shorten the time to significant hypoxemia during apnea associated with tracheal intubation [2]. Although the incidence of difficult intubation in children is believed to be lower than in adults [3], there is insufficient data regarding it [4]. Fiberoptic intubation has been described as a useful technique in pediatric anesthesia [1] and probably remains (to be) the most

*Coresponding Author: Melike Korkmaz Toker, Mugla Sitki Kocman University Training and Research Hospital, Department of Anesthesiology and Reanimation, Mugla, Turkey E-mail: meltoker@gmail.com

common approach in the difficult airway. Newer devices, such as the video laryngoscope, have also been used with success in the pediatric difficult airway [5,6]. The aim of this study was to determine what airway management techniques are being applied in the difficult airway situation, by a group of experienced Consultant Anesthetists, in a large pediatric center. Materials and Methods After obtaining approval from Institutional Review Board, the study was conducted over a 2-year period, in a large pediatric hospital performing 4000-6000 pediatric surgical procedures per year; analysis of the database suggests approximately 6070% will be intubated. For a 2-year period beginning (from) September 2014, Consultant Anesthetists completed pro-forma following all pediatric anesthesia procedures in which tracheal intubation was difficult. The collected information included: patient demographics; airway assessment; anesthetic technique and airway management strategies employed; and reasons for failure of intubation attempts. For the purposes of this audit, a difficult intubation was defined as an unsuccessful 2 attempts at direct laryngoscopy and intubation, causing a change in airway management technique, or a situation where direct laryngoscopy 769

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was not attempted i.e. due to limited mouth opening, therefore leading to an alternative airway management strategy.

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The same airway assessment form was full filled for all children. Table 2 summarizes the features identified; the most common features were micrognathia (50%) and macroglossia (20%). Fifteen of the patients had a medical syndrome known to be associated with difficult airway management. Ten of these 15 patients had repeated operations during the study period. So, totally 20 of the cases in the study were associated with medical syndromes. Majority of cases had undergone abdominal surgeries.

Results There were 50 cases which were assessed as difficult intubation. The cases were classified according to age group and the average weight per group was calculated. Ninety percent of the cases required intubation for surgical operations, and 10% underwent ENT/maxillofacial procedures. Eighty percent of the cases had an anticipated difficult intubation, with 40% having a history of previous difficult intubation (DI). Mallampati assessment was performed in 90% of the patients, with an increasing incidence in older children (Table 1).

Table 3 gives details of different airway devices used to intubate patients, the intubation view obtained, the number of intubation attempts, the rates of successful intubation and the reason for failure. Table 4 gives details of operation types that patients underwent.

Table 1. Patient Variables Number of DA cases (%)

Median weight (Min-Max) (kg)

Number of anticipated DI (%)

Number of previous DI (%)

Mallampati of grade 2/3/4 documented

2-5 years

12 (24%)

12 (10-15)

10 (25%)

0/0/7

5-14 years

24 (48%)

27 (20-40)

22 (55%)

15 (75%)

1/2/21

14-18 years

14 (28%)

60 (55-63)

8 (20%)

5 (25%)

0/1/13

Age

DA: Difficult airway DI: Difficult intubation Table 2. Airway assessment features Airway features Number of cases (%)

Number of cases (%)

Mallampati score recorded

Mallampati score score 3/4

Previous history of DI

Micrognathia

25 (50%)

20 (80%)

TMJ ankylosis

5 (10%)

5 (100%)

3 (60%)

Macroglossia

10 (20%)

10 (100%)

8 (80%)

Prominent teeth

7 (14%)

7 (100%)

Short neck DI: Difficult intubation TMJ: Temporomandibular Joint

3 (6%)

3 (100%)

2 (66.6%)

Table 3. Advanced airway techniques and reason of failure Advanced airway technique

Number of cases (%)

Intubation view Cormack/Lehane Score (1/2/3/4)

Number of intubation attempts (1/2/>3)

Number of successful Intubations (%)

Reason for failure Poor view

Blood in airway

Oral FOB

25 (50%)

20/5/0/0

20/3/0

23 (92%)

Nasal FOB

7 (14%)

7/0/0/0

2/3/0/0

5 (71%)

8 (16%)

4/2/2/0

0/5/1/0

6 (75%)

FOB via LMA

10 (20%)

10/0/0/0

10 (100%)

Unable to pass ETT 1

FOB: Fiber optic bronchoscope VL: Video laryngoscope LMA: Laryngeal mask airway Table 4. Surgery types ENT surgeries (%)

Bowed chest (%)

Removal of diseased intestines (%)

Various abdominal cancer surgery (%)

2-5 years

1 (2%)

3 (6%)

5-14 years

2 (4%)

3 (6%)

2 (4%)

25 (50%)

14-18 years

2 (4%)

10 (20%)

Age

ENT: Ear Nose Throat

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All of the unsuccessful intubation procedures completed with surgical airway, tracheostomy. Before tracheostomy an LMA inserted than a pediatric surgeon performed the tracheostomy. Of the 50 patients, 25 discharged to ward and 25 to the pediatric intensive care unit. Discussion This study presented a detailed information of the difficult airway management of pediatric patients over 2 years period in a large tertiary pediatric hospital, utilized by experienced pediatric anesthesiologists. Investigation of data reveals that 80 % of cases were anticipated with 40% having a history of difficult intubation, 20% having repeated operations within the study period. Of 50 patients, 24% were under 5 years. In our study a fiberoptic technique either nasal, oral or via laryngeal mask was used as the first advanced airway strategy in 84% of cases. Only in 6 cases the techniques chosen were unsuccessful and the strategy changed to a surgical airway. The most common reason of unsuccessful attempts was blood in the airway. These findings highlight that difficult intubation is usually anticipated among the majority of cases. Pilsbury et al. reported their audit that difficult airway usually occurred in younger children because 60% of their difficult airway cases were under 6 years [7]. This is contrary with our results. The most possible reason for this result is the majority of children under 6 years undergoes inguinal hernia repair or circumcision in our clinic, so that their airway management consists of laryngeal mask airway. As a result, we didn’t experience a lot of difficult airway cases at these years of age. Heinrich et al performed a review of pediatric procedures and found that Mallampati score was documented in 66% of cases. In their study, as the age increased, the incidence of documentation increased, and reached to greater than 80% incidence in the children group over 6 year [8]. Our data is compatible to these results. In our study, 58.3% of children under 5 years had Mallampati documentation, while 100% in adolescents and school aged children. However, all the children should have a documented airway assessment preoperatively. In a recent study [7], maxillofacial surgery was found to be associated with most of the difficult airway cases (17%). However, majority of cases in our study were abdominal surgeries. Since its introduction in mid-1970s, pediatric fiber optic bronchoscopes (FOB) have been the gold standard for securing the airway when direct laryngoscopy is not possible [2]. Although there are a lot of benefits of FOB, the FOB has a steep learning curve and it is a fragile instrument that is expensive to repair, additionally a small amount of blood and secretions can worsen the quality of image. In our study mostly favored advanced airway technique was FOB (84%) either oral, nasal or via LMA. One study evaluating FOI in the difficult pediatric airway found a first attempt success rate of 80.4% and an overall rate of 95.6% [9]. In our study a first attempt success rate was 76% and overall rate was 94%. The success rate of oral FOB was higher than nasal FOB. Pediatric anesthetists in this study were more experienced in oral FOB.

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Video laryngoscopes (VL) have been found to improve the laryngeal view when compared to direct laryngoscopy [10], but this doesn’t mean that passing the ETT through the cords can be achieved easily [6]. In the current study although the glottic view was good with VL, generally intubation was successfully achieved in the second attempt. The increased intubation attempts may be associated with the fact that VL is a newer piece of equipment, so users are not as familiar with the technique as more established FOB. Multiple techniques have been described for intubation via LMA in children [11-13]. The correct position of the laryngeal mask should be confirmed by the fiberoptic bronchoscope in the first step, and any necessary adjustments in position should be made. Once the cords have been correctly identified, intubation can be facilitated either by deepening the plane of anesthesia or by using a neuromuscular blocking drug after ensuring that the patients’ lungs can be ventilated via the laryngeal mask [14]. During FOB, an attempted oral airway with chin lift position facilitate the FOB view but in patients with micrognathia, it is a very difficult situation to lift the mandibula. So LMA has an advantage to visualize the glottis easily in these situations. Hence, we administer FOB via LMA successfully in 10 patients. Furthermore, obtained glottic view with this technique was Cormach_Lehane grade 1 in all patients. Especially in specific difficult airway populations as Pierre-Robin FOB through a LMA might be superior to VL [15]. When we look at the last chance, surgical airway, in our study, we observed that the surgical airway was performed in “can’t intubate” situations, though the mask ventilation was appropriate. As a result of this, securing the ventilation of the children via LMA was more suitable while performing a tracheostomy. Either ENT surgeon or a pediatric surgeon performed the surgical airway. In lifethreatening situations when bag-mask ventilation and ventilation through Laryngeal Mask Airway (LMA) are not possible, the option to achieve the quickest possible oxygenation of the patient should be chosen, according to the available equipment and the physician’s experience. However, it has to be taken into account that cricoid puncture and cricothyroidotomy are associated with high morbidity in children – the smaller the patient, the higher the risk [6-18]. In the current study, none of the patients required a cricothyroidotomy. It is authors’ view that “can’t intubate can’t ventilate” scenario in pediatric population is not as common as in adults, but although it is a rare complication, special kits for emergence cricothyroidotomy should be ready at the operating rooms. This report has some limitations. The present review describes a single institution’s approach to the management of pediatric patients with a difficult airway over almost 2 years. Multiple center experiences would be instructive among pediatric anesthetists. The patient cohort didn’t include every type of pediatric surgery due to a lack of pediatric plastic and reconstructive surgery department in our institution. In our opinion if maxillofacial procedures increase, anticipated difficult intubation and nasal FOB method will increase. Conclusion In conclusion, the intention behind this study was to create a screenshot of the various methods used when we were faced with a difficult airway management in pediatric population. Fiberoptic 771

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intubation remains overall the best method whereas no method was 100% successful. As the majority of the patients had anticipated difficult airway, we have opportunity of planning surgical airway with other teams such as Ear-Nose-Throat and pediatric surgery. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval This work has been approved by the Institutional Review Board

References 1.

Walker RW, Ellwood J. The management of difficult intubation in children. Paediatr Anaesth. 2009;1:77-87.

Sunder RA, Haile DT, Farrell PT, et al. Pediatric airway management: Current practices and future directions. Paediatr Anaesth. 2012;22:1008-15.

Frei FJ, Ummenhofer W. Difficult intubation in paediatrics. Pediatr Anesth. 1996;6:251-63.

Aida J, Oda Y, Kasagi Y, et al. The management of difficult intubation in infants: a retrospective review of anesthesia record database. JA Clin Rep. 2015;1:18.

Kim JT, Na HS, Bae JY, Kim DW, Kim HS, Kim CS, et al. GlideScope® video laryngoscope: A randomized clinical trial in 203 paediatric patients. In: British Journal of Anaesthesia. 2008. p. 531-4.

C Karsli, Armstrong J, John. A comparison between the GlideScope® Video Laryngoscope and direct laryngoscope in paediatric patients with difficult airways - a pilot study: Original aticle. Anaesthesia. 2010;65:353-7.

Pilsbury JE, Wong E, Montgomerie J. Anaesthetic management of difficult intubation in the paediatric population when direct laryngoscopy initially has failed or is not possible : an audit of current practice at a tertiary paediatric

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hospital. 2015;3:1-9. 8.

Heinrich S, Birkholz T, Ihmsen H, et al. Incidence and predictors of difficult laryngoscopy in 11.219 pediatric anesthesia procedures. Paediatr Anaesth. 2012;22:729-36.

Blanco G, Melman E, Cuairan V, et al. Fibreoptic nasal intubation in children with anticipated and unanticipated difficult intubation. Paediatr Anaesth. 2001;11:49-53.

10. Sims C, Von Ungern-Sternberg BS. The normal and the challenging pediatric airway. Vol. 22, Paediatric Anaesthesia. 2012. p. 521-6. 11. Wheatley RS, Stainthorp SF. Intubation of a one-day-old baby with the PierreRobin syndrome via a laryngeal mask. Vol. 49, Anaesthesia. 1994. p. 733. 12. Patel B, Bingham R. Laryngeal mask airway and other supraglottic airway devices in paediatric practice. Contin Educ Anaesthesia, Crit Care Pain. 2009;9:6-9. 13. Agro F, Brimacombe J, Brain AI, et al. The intubating laryngeal mask for maxillo-facial trauma. Eur J Anaesthesiol. 1999;16:263-4. 14. Heard CM, Caldicott LD, Fletcher, JE, et al. Fiberoptic-Guided Endotracheal Intubation via the Laryngeal Mask Airway in Pediatric Patients:a Report of a Series of Cases. Anesth Analg. 1996;82:1287-9. 15. 1Jagannathan N, Sohn L, Fiadjoe JE. Paediatric difficult airway management: What every anaesthetist should know! Br J Anaesth. 2016;117:3-5. 16. Black AE, Flynn PE, Smith HL, et al. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015;25:346-62. 17. Navsa N, Tossel G, Boon JM. Dimensions of the neonatal cricothyroid membrane - How feasible is a surgical cricothyroidotomy? Paediatr Anaesth. 2005;15:402-6. 18. Corbett HJ, Mann KS, Mitra I, et al. Tracheostomy-a 10-year experience from a UK pediatric surgical center. J Pediatr Surg. 2007;42:1251-4.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):773-6

Frequency of depression, anxiety, and fatıgue in fmf patients and their association with disease parameters Sinem Sag1, Mustafa Serdar Sag2, Ibrahim Tekeoglu1, Ayhan Kamanli1, Kemal Nas1 2

1 Sakarya University Faculty of Medicine, Divison of Rheumatology, Department of Pysical Medicine and Rehabilitation. Sakarya, Turkey Sakarya University Research & Training Hospital, Divison of Rheumatology, Department of Pysical Medicine and Rehabilitation, Sakarya, Turkey

Received 23 March 2018; Accepted 18 April 2018 Available online 25.04.2018 with doi: 10.5455/medscience.2018.07.8785 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The aim of our study was to assess the levels of depression, anxiety, and fatigue in patients diagnosed with FMF (Familial Mediterranean Fever) and to examine their associations with drug compliance, attack, and being employed or not. Patients presenting to our rheumatology outpatient clinic Tel-Hashomer Classification Criteria were included in the study. Fifty-two diagnosed patients followed up in our rheumatology outpatient clinic (35 female, 17 male), and 30 healthy control subjects whose ages and genders match consisting of the accompanists and visitors of the patients (25 female, 5 male) were included. Risk for depression and anxiety was assessed with HADS (Hospital Anxiety and Depression Scale). Depression and anxiety were observed to be significantly more common in the patients with FMF compared to the healthy controls in this study. Also, the frequency of FMF attacks was found to be associated with depression, anxiety, and fatigue and that regular use of colchicine decreased fatigue. In the light of all these results, the mood should definitely be evaluated during the routine practice in case of a chronic disease such as FMF having a younger patient population compared to other rheumatic diseases, and, if needed, psychiatric support should be received. Also, it should be explained to the patients that the regular use of colchicine would be beneficial for both the disease and fatigue. There is a need for follow-up studies with large case series in order to support the results we obtained. Keywords: Familial mediterrean fever, anxiety, depression

Introduction Familial Mediterranean Fever (FMF) is the most common hereditary inflammatory disease characterized by recurrent attacks of fever and serosal inflammation [1]. It is defined by clinical criteria and is associated with mutations of the MEVF gene that are believed to lead to a gain of function in the pyrin protein and thereby to an inappropriate release of Interleukin-1b. [2-5] FMF patients have recurring attacks of fever, pleuritis, peritonitis, arthritis and skin lesions. Colchicine is used for treatment. Colchicine should be used regularly in order to prevent organ injury that may occur during the course of FMF [6].

The aim of our study was to assess the levels of depression, anxiety, and fatigue in patients diagnosed with FMF and to examine their associations with drug compliance, attack, and being employed or not. Material and Method

Anxiety and depression are commonly encountered problems in chronic rheumatologic diseases. They occur in diseases such as rheumatoid arthritis, ankylosing spondylitis [7-9]. However, they are ignored during daily practice. FMF is also a chronic disease characterized by recurrent attacks and, according to a widely accepted view, stress induces FMF attacks [10].

Patients presenting to our rheumatology outpatient clinic TelHashomer Classification Criteria were included in the study. The patients were selected from FMF patients presenting to the outpatient clinic consecutively. The control group was selected from patient accompanists with no known diseases affecting the musculoskeletal system and from patient visitors and the two groups were matched regarding age and gender. The study was planned as a prospective, cross-sectional study. Patients’ age, gender, body mass index (BMI), education status, disease duration, occupation, comorbidities, drugs used, and demographic data were recorded. In accordance with all the principles of Helsinki declaration, consent was obtained from the local ethics committee. Written consent was obtained from all patients.

*Coresponding Author: Sinem Sag, Sakarya University Faculty of Medicine, Divison of Rheumatology, Department of Pysical Medicine and Rehabilitation. Sakarya, Turkey E-mail: drsinemyamac@yahoo.com

Patients younger than 18 and older than 70 years, pregnant and lactating women, patients with orthopedic problems, patients with psychiatric disorders, those with severe systemic diseases 773

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that would prevent working (cardiovascular, respiratory, severe gastroenterological and metabolic pathology), those with another inflammatory disease were excluded from the study. Risk for depression and anxiety was assessed with Hospital anxiety and depression scale (HADS). It has been developed for determining the risk of anxiety and depression in the patient and for measuring its level and change in severity. Validity and reliability of the scale was studied by Aydemir et al. The lowest score that the patients could obtain from both subscales is 0 and the highest score is 21. Cut-off points of the Turkish version of HADS were 10 for the anxiety subscale (HAD-A) and 7 for the depression subscale (HAD-D) [11]. Fatigue severity scale was used to assess fatigue level [12]. Statistical analysis NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) program was used for statistical analyses. For evaluating study data, in addition to descriptive statistical methods (man, standard deviation, median, frequency, rate, minimum, maximum), in the comparison of quantitative data, student’s t test was used for comparing two groups with variables showing normal distribution and Mann Whitney U test for comparing two groups with variables not showing normal distribution. For comparing three or more groups not showing normal distribution, Kruskal Wallis test was used and Mann Whitney U test was used

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for identifying the group causing the difference. Pearson’s chisquare test, Fisher Freeman Halton Test, Fisher’s exact test and Yates’ continuity correction test (Yates corrected Chi-square) were used for comparing qualitative data. Spearman’s correlation analysis was used in the analysis of inter-variable correlations. Significance was evaluated at levels of p<0.01 and p<0.05. Results Fifty-two diagnosed patients followed up in our rheumatology outpatient clinic (35 female, 17 male), and 30 healthy control subjects whose ages and genders match consisting of the accompanists and visitors of the patients (25 female, 5 male) were included. All of the patients were taking colchicine medication. As an additional rheumatologic disease, three patients had spondiloartropathy. Of the patients, 47 (94%) used colchicine regularly. Thirty-four of them (%68) had a positive family history. The comparison of the demographic characteristics of the groups was summarized in Table-1. The depression, anxiety, and fatigue severity scales (FSS) of the groups were summarized in Table-2. Depression and anxiety levels of FMF patients, working and nonworking, are summarized in Table-3.

Table 1. Evaluation of demographic characteristics according to groups

Age BMI

Mean±SD Mean±SD

Sex Smoking Duration of diagnosis (year) Time between complaint and diagnosis Student-t Test

Patient group (n=52)

Healthy group (n=30)

38,13±12,08 25,24±6,07 n (%)

41,50±6,15 25,54±8,75 n (%)

0,078 0,099 0,092

Female

35 (67,3)

25 (83,3)

Male

17(32,7)

5 (16,7)

39 (75,6)

25 (82,9)

Yes

13(24,4)

5 (17,1)

Mean±SD Mean±SD

Pearson Chi-Square Test

0,247

7,04±8,29 14,38±10,76 *p<0,05

Table 2. Assessment of Hospital Depression Scale (anxiety and withdrawal subscale) and Fatigue Severity Scale scores by groups Patient (n=52)

Healthy (n=30)

HDO Anxiety HDO Depression FSS

Mean±SD Mean±SD Mean±SD

8,19±4,16 6,93±3,88 38,57±16,34

5,42±2,39 4,76±2,44 13,13±7,48

a0,008 a0,047 a0,004

Time between complaint and diagnosis

Mean±SD

14,38±10,76

aStudent-t Test Table 2. Assessment of Hospital Depression Scale (anxiety and withdrawal subscale) and Fatigue Severity Scale scores by groups

(n=20) HDO Anxiety HDÖ Depression

Non-working (n=32) Mean±SD Mean±SD

FSS

Mean±SD

Working

Healthy (n=30)

p 8,54±3,97 5,42±2,26

5,42±2,39 8,41±3,80 7,04± 3,95

a0,008 a0,758 a0,149

32,83±14,91

39,12±16,50

a0,421

aStudent-t Test

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In Table-4, the frequency of attacks was found to be significant with anxiety and depression in the positive direction, while the negative correlation between fatigue and regular drug use was shown. Table 1. Correlation of duration of depression, anxiety and fatigue with regular drug use and other parameters Depression

Anxiety

FSS

r 0,220

r 0,056

r 0,116

Frequency of attacks

0,592

0,401

0,328

Regular use of medication

-0,100

0,082

-0,301

Duration illness

r=Spearman’ın Korelasyon Katsayısı p<0,05

Discussion Depression and anxiety were observed to be significantly more common in the patients with FMF compared to the healthy controls in this study. Also, the frequency of FMF attacks was found to be associated with depression, anxiety, and fatigue and that regular use of colchicine decreased fatigue. The studies conducted today revealed that some cytokines as well as IL-1, IL-6 and TNF alpha were associated with anxiety [13,14]. Even during the attack-free periods of the FMF patients, it was suggested that the levels of some cytokines such as IL-18, IL-2, IL6, IL-12, IL-17 were high and that these elevated levels indicated subclinical inflammation [14-18]. The frequency of anxiety and depression were shown to be increased in some inflammatory diseases with chronic inflammation [19]. A study demonstrated that serotonin was also effective in the pathophysiology of FMF and that SSRI therapy could be useful [20-22]. All these changes brought on by chronic inflammation and their reflections on the clinical picture can lead to the mood changes of patients. Whether there are mood changes and fatigue or not in patients with FMF have also been an issue of concern. In a study conducted recently by Duruoz et al [19], depression, anxiety, and fatigue were investigated in FMF patients. Depression and anxiety scores were found to be higher in FMF patients compared to the control group. The other two studies conducted determined the prevalence of anxiety higher in FMF patients compared to the control subjects, however, no difference was detected among their depression scores [23-26]. Higher frequency of anxiety and depression was noted in FMF patients compared to healthy control subjects in the study conducted by Kucuksahin et al [27]. In a study including adolescents and children with FMF, depression scores were determined to be higher than healthy control subjects. The present study indicated an association between the frequency of FMF-attacks and levels of anxiety and depression. We also found the levels of anxiety and depression significantly higher in FMF patients than in healthy control subjects. There was a positive correlation between attack frequency and fatigue, anxiety, and depression. In contradistinction to our study, a

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negative correlation was detected between the number of attacks and fatigue in the study by Duruoz et al [19]. The changes in the patients’ gender, education status, disease severity, medication doses and variations in genetic mutations may have caused this result. The regular use of colchicine was not associated with anxiety and depression whereas we found a negative correlation between regular use of colchicine and fatigue. Unlike other studies, we divided the FMF patients into two groups, namely employed and unemployed. No difference was found between two groups in terms of depression, anxiety, and fatigue. The limitations of our study included not involving a very high number of patients into the study, not using an overall quality of life scale, not designing the study as a cross-sectional study, not including any patients during an attack. Cross-sectional planning of our work also has its limitations. Conclusion The frequency of depression, anxiety, and fatigue was found to be more common in FMF patients compared to the healthy control subjects in our study. The regular use of colchicine had a negative correlation with fatigue. In the light of all these results, the mood should definitely be evaluated during the routine practice in case of a chronic disease such as FMF having a younger patient population compared to other rheumatic diseases, and, if needed, psychiatric support should be received. Also, it should be explained to the patients that the regular use of colchicine would be beneficial for both the disease and fatigue. There is a need for follow-up studies with large case series in order to support the results we obtained. Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Ethical approval was obtained from the hospital administration to use the patients’ data.

References 1.

Firestein GS, Budd R, Gabriel SE, et al. Kelley’s textbook of rheumatology. Elsevier Health Sciences, 2012, Philadelphia.

Livneh A, Langevitz P, Zemer D, et al. Criteria for the diagnosis of familial mediterranean fever. Arthr Rheum. 1997;10:1879-85.

Consortium TIF. Ancient missense mutations in a new member of the RoRet gene family are likely to cause familial mediterranean Fever. Cell. 1997;90:797-807.

Consortium FF. A candidate gene for familial mediterranean Fever. Nat Genet. 1997;171:25-31.

Chae J, Wood G, Masters S, et al. The B30.2 domain of pyrin, the Familial Mediterranean Fever protein, interacts directly with caspase-1 to modulate IL-1beta production. Proc Natl Acad Sci. 2006; 103:9982-7.

Livneh A, Langevitz P. Diagnostic and treatment concerns in familial mediterranean fever. Baillieres Best Pract Res Clin Rheumatol. 2000;14:47798.

Isik A, Koca SS, Ozturk A, et al. Anxiety and depression in patients with rheumatoid arthritis. Clin Rheumatol. 2007;26:872-8.

Hanly JG, Fisk JD, McCurdy G, et al. Neuropsychiatric syndromes in patients

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doi: 10.5455/medscience.2018.07.8785 with systemic lupus erythematosus and rheumatoid arthritis. J Rheumatol. 2005;32:1459-66. 9.

Martindale J, Smith J, Sutton CJ, et al. Disease and psychological status in ankylosing spondylitis. Rheumatology (Oxford). 2006;45:1288-93.

10. Ozen S.New interest in an old disease: Familial Mediterranean Fever. Clin Exp Rheumatol. 1999;17:745-9. 11. Aydemir Ö, Güvenir T, Küey L, ve ark. Hastane Anksiyete ve Depresyon Ölçeği Türkçe Formunun Geçerlik Güvenilirlik Çalışması. Türk Psikiyatri Dergisi. 1997;8:280-7. 12. Gencay-Can A, Can SS. Validation of the Turkish version of the fatigue severity scale in patients with fibromyalgia. Rheumatol Int. 2012;32(1):27-31. 13. Reichenberg A, Yirmiya R, Schuld A, Kraus T, Haack M, Morag A et al. Cytokine-associated emotional and cognitive disturbances in humans. Arch Gen Psychiatry. 2001;58:445-52. 14. Von Känel R, Hepp U, Kraemer B, et al. Evidence for low-grade systemic proinflammatory activity in patients with posttraumatic stress disorder. J Psychiatr Res. 2007;41:744-52. 15. Bagci S, Toy B, Tuzun A, et al. Continuity of cytokine activation in patients with Familial Mediterranean Fever. Clin Rheumatol. 2004;23:333-7. 16. Simsek I, Pay S, Pekel A, et al. Serum proinflammatory cytokines directing T helper 1 polarization in patients with Familial Mediterranean Fever. Rheumatol Int. 2007;27:807-11. 17. Haznedaroglu S, Ozturk MA, Sancak B, et al. Serum interleukin 17 and interleukin 18 levels in Familial Mediterranean Fever. Clin Exp Rheumatol. 2007;23:77-80. 18. Erken E, Ozer HT, Gunesacar R. Plasma interleukin-10 and interleukin-12 levels in patients with Familial Mediterranean Fever. Rheumatol Int.

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2006;26:862-4. 19. Duruoz MT, Unal C, Bingul DK, et al. Fatigue in Familial Mediterranean Fever and its relations with other clinical parameters. Rheumatology International. 2018;38:75-81. 20. Ozcakar L, Onat AM, Kaymak SU, et al. Selective serotonin reuptake inhibitors in Familial Mediterranean Fever: are we treating depression or inflammation? Rheumatol Int. 2005;25:319-20. 21. Onat AM, Oztürk MA, Ozçakar L, et al. Selective serotonin reuptake inhibitors reduce the attack frequency in Familial Mediterranean Fever. Tohoku J Exp Med. 2007;211:9-14. 22. Onat AM, Ozçakar L, Oztürk MA, et al. Plasma and platelet serotonin levels in Familial Mediterranean Fever. Clin Exp Rheumatol. 2007;25:16-20. 23. Deger SM, Ozturk MA, Demirag MD, et al. Health-related quality of life and its associations with mood condition in Familial Mediterranean Fever patients. Rheumatol Int. 2011;31(5):623-8. 24. Sahin S, Yalcin I, Senel S, et al. Assessment life quality of Familial Mediterranean Fever patients by short form-36 and its relationship with disease parameters. Eur Rev Med Pharmacol Sci. 2013;17:958-63. 25. Giese A, Kurucay M, Kilic L, et al. Quality of life in adult patients with Familial Mediterranean Fever living in Germany or Turkey compared to healthy subjects: a study evaluating the effect of disease severity and country of residence. Rheumatol Int. 2013;33:1713-9. 26. Giese A, Ornek A, Kilic L, et al. Anxiety and depression in adult patients with Familial Mediterranean Fever: a study comparing patients living in Germany and Turkey. Int J Rheum Dis. 2014;1756-185x.12297. 27. Kucuksahin O, Omma A, Ozdemirel AE, et al. Incidence of sleep disturbances in patients with Familial Mediterranean Fever and the relation of sleep quality with disease activity. Int J Rheum Dis. 2017.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):777-80

Synergistic effect of Coriandrum sativum L. extracts with cefoxitin against methicillin resistant Staphylococcus aureus, extended-spectrum beta-lactamase producing Escherichia coli and Klebsiella pneumoniae Nilay Ildiz1, Ayse Baldemir2, Ufuk Ince1, Selen Ilgun2, Yusuf Konca3 1

Erciyes University, Faculty of Pharmacy, Department of Pharmaceutical Microbiology, Kayseri,Turkey 2 Erciyes University, Faculty of Pharmacy, Department of Pharmaceutical Botany, Kayseri,Turkey 3 Erciyes University, Faculty of Agriculture Department of Animal Science, Kayseri, Turkey Received 12 March 2018; Accepted 18 April 2018 Available online 29.07.2018 with doi: 10.5455/medscience.2018.07.8850 Copyright © 2018 by authors and Medicine Science Publishing Inc.

Abstract Antibiotic resistance has become a general health problem that makes the treatment decisions of clinicians more difficult. Recently, plants and their compounds have been suggested as a potential alternative to antimicrobials.The present study was carried out to evaluate for the first time, possible synergistic interactions on the antibacterial efficacy of Coriandrum sativum L. seed extracts and cefoxitin in combination against three important nosocomial pathogens (methicillin resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL) producing Escherichia coli and Klebsiella pneumoniae). The antibacterial effect studied using the disc diffusion and synergism was showed by checkerboard methods. In the disc diffusion method, combinations of both methanol (ME, 1250 µg/mL) and petroleum ether extracts (PE, 1250 µg/mL) with cefoxitin (30 µg/mL) showed an increase in antibacterial activity against all tested microorganisms. It was found that, combinations of Coriander seed ME and PE extracts with cefoxitin have synergistic interactions against ESBL positive K. pneumoniae at 0.03516 and 0.03125 Fractional inhibitory concentration (FIC) index (FICI), respectively. The FICI of combinations against MRSA and E.coli were found to be indifferent by the checkerboard method. An antagonistic effect was not found in these combinations. The current study clearly suggests the potential usage of Coriander seed extracts alone and in combination with cefoxitin for combating infections by ESBL positive K. pneumoniae strains Keywords: Coriandrum sativum, cefoxitin, enterobacteriaceae, MRSA, synergism, coriander

Introduction Antibiotic resistance has become a general health problem that makes thetreatment decisions of clinicians more difficult. Recently, plants and their compounds have been suggested as a potential alternative to antimicrobials [1]. While ~80% of the drugs are derived from plants, only a few of them are antimicrobial agents [2]. Secondary metabolites in plants havea wide range of antimicrobial properties [3]. In this context, diversity of thephytochemical structures and pharmacological properties of plant / plant active componentsand antibacterial drug interactions may be a solution in the search for new therapeutic agents [4]. Some studies reported that the combination of plant compounds with some therapeutic agents rather than just using the compounds alone can provide synergistic effect on resistant microorganisms. Hence, this synergism may help in the provision of more effective treatment [5,6]. Coriandrum sativum L. (Coriander) is an annual herb belonging to *Coresponding Author: Nilay Ildiz, Erciyes University, Faculty of Pharmacy, Department of Pharmaceutical Microbiology, Kayseri,Turkey, E-mail: nilaygucluer@erciyes.edu.tr

the Apiaceae family. In Turkey, Fructus Coriandri are traditionally used for medicinal purposes such as loss of appetite, carminative, dyspeptic and digestive complaints [7]. Previous studies have shownthat Coriander has shownvariety of pharmacological properties including antibacterial effects [8,9]. More recently, the essential oil (EO) components of plants showed a synergistic antibacterial effect with antibiotics [10,11]. During the last decade, several reports have confirmed the effect of plants combinations with antimicrobial agents [12,13]. Antibiotic insufficiency develops day by day in resistant strains and leads to an increase in the turnover of plant extracts that have been proven to have antibacterial effects in conventional medicine. Extended spectrum beta lactamase (ESBL) producing Enterobacteriaceae (ESBL- E) infections have become a major public health problem around the world[14-16]. Staphylococcus aureus which is normally found in the nasal cavity, can cause minor to potentially life threatening invasive diseases and nosocomial infections.Methicillin resistant S. aureus(MRSA) is posing a majorchallenge for treatment options almost all clinically available antibiotics,such as cefoxitin whichis a secondgeneration cephalosporin andhas strongin vitro activity against ESBL [17,18]. Additionally, cefoxitin and oxacillin are employed 777

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for the detection of MRSA according to the Clinical & Laboratory Standards Institute: CLSI guidelines by disc diffusion methods. The mecAmediated resistance to oxacillin can be detected by using the cefoxitin or oxacillin discdiffusion method but using cefoxitin is preferredmore due toit is easier to read and it also acts as an inducer of the mecA gene [19]. The antibacterial activitiesof individualCoriander extracts and a combination of Coriander extracts with cefoxitin were evaluated to determine synergismagainst MRSA, ESBL positive Escherichia coli and ESBL positive Klebsiella pneumoniae by the disc diffusion and checkerboard methods. Material and Methods Plant material Coriandercultivar seed was obtained from the Agricultural Faculty of Erciyes University it was harvested in 2014 and stored in normal room conditions. Bacterial strains Clinical isolates (MRSA, ESBL producing E.coli and K. pneumoniae) were identified from urine specimensand collected from the microbiology department of Necip Fazıl City Hospital, Kahramanmaraşin Turkey. The identification of microorganisms and sensitivity testing was performed on an automated system (VITEK® 2: Healthcare | bioMérieux). The double-disc synergy test was usedin order to screen their production of ESBLs. Preparation of the Coriander seed extracts To prepare the ME extract of Coriander seed,a 10 g sample was weighed and ground then 100 ml methanol was added and mixed with a magnetic stirrer (Jeio Tech, MS-53M) for 8 hours.This process was repeated three times at room temperature conditions (240C). To prepare the PE extract of coriander seed, a 10 g sample was weighed and ground then 100 ml PE was added and treated in an ultrasonic bath filled with ice water for 15 minutes. This was repeated three times.Afterwards, the plant extracts were filtered and both of them were evaporated to dryness (Heidolph®, HeizbadHei-VAP).The samples were stored at -20°C. Determination of antimicrobial activity Susceptibility screening of microorganisms was performed according to CLSI standards by disc diffusion and the minimum inhibitory concentration method. PE and ME extracts were dissolved in 1% dimethyl sulfoxide (DMSO) and a 1250 µg/mL standard was prepared for the disc diffusion method. Sterile blank discs were used to impregnate 20 µg/mL of plant extract thatwas taken from the stock solutionthen carefully dried. Cefoxitin and cefoxitin discs (30 mcg, Bioanalyse, Turkey) arecommercially available. Bacteria cultures were transferred on to Mueller-Hinton agar (Hi-Media, India) and incubated for 18 hours at 37°C. Then,the plates were examined for the presence of inhibition zones. The corresponding diameter was reported in millimeters. The MIC values of the bacteria were determined by a VITEK® 2 system(bioMérieux) for cefoxitin. The MICs were determined by the broth microdilution method according to CLSI guidelines for the extract and extract + cefoxitin combination. Final inoculums of bacteria were 2 × 106 CFU/ml and these were added to 96 well microtiter plates with 100 μl of extract/ extract+ cefoxitin

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combination in serial dilution. Plates were incubated at 37 °C for 24 h. The MICs were determined visually. All assays were performed in duplicate. Bacteria in Mueller- Hinton (Hi-Media, India) broth were used as a growth control. Synergy interaction assay Different interactions (synergistic, additive and indifferent) can be observed by the checkerboard method. The method was used to determine synergism[20,21]. between the cefoxitin and extracts.MICs were defined by the automated VITEK® 2 system (bioMérieux) and broth microdilution method. The fractional inhibitory concentration (FIC) index was calculated according to Pei et al.,2009 [22]. The calculations used are listed below [20,23,24]. FICA = (MIC specimen A in the presence of B)/ (MIC specimen A individually) FICB= (MIC specimen B in the presence of A) /(MIC specimen B individually) FIC Index = FICA+ FICB An FIC index ≤ 0.5 means synergism determined; An FIC index > 0.5 but ≤ 4.0 means indifference determined; AnFIC > 4.0 means antagonism shown Results The effects of Coriander seed extracts, cefoxitin and extract + cefoxitin on clinically resistant strains(MRSA, E.coli, K.pneumoniae) are shown in Tables 1 and Figure 1. These pathogen microorganisms were chosen due to their importance in several infections such as urinary tract infection, endocarditis, septicemia, osteomyelitis and hospital-acquired infection and have been reported to be antibiotic resistant. Table 1. Antibacterial activity of coriander seed extract, cefoxitin and their combination on clinically resistant strains Extract and combinations

Clinic isolates MRSA

E. coli

Klebsiella pneumoniae

1250 µg/ml coriander extract, ME

8.33c

8.00d

8.67d

1250 µg/ml coriander extract, PE

9.67c

8.67 d

25.33b

Cefoxitin, 30 µg

16.67b

19.33c

15.33c

Cefoxitin+ 1250 µg/ml coriander extract (ME)

19.67a

21.33b

24.67b

Cefoxitin+ 1250 µg/ml coriander extract (PE)

22.33a

24.33a

33.67a

SEM

0.333

2.844

0.494

Probability, p

: Values with different superscript in a column differ significantly, ***:p<0.05, **:p<0.01; SEM: pooled standard error of means

a.b,c,d

In disc diffusion assay, theME, PE extracts and cefoxitin inhibition zones of the MRSA strain wereidentified as 8,10 and 18 mm, respectively.However, the combination of extracts with cefoxitin were increased and inhibition zones were determined as 21 mm for the cefoxitin+1250 µg/ml ME extract and 22 mm for the cefoxitin+1250 µg/ml PE extract.Comparable results were alsoobtained for the E. coli isolate. Both combinations showed an increase in antibacterial activity in all tested microorganisms. However, according to the FIC results, there was no synergistic 778

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interaction on MRSAand E. coli by the checkerboard method. Cefoxitin showed a small zone of inhibition, but when used with plant extracts (especially with PE extract), it exhibited a larger zone of inhibition against ESBL positive K. pneumoniae.The inhibition zones of K. pneumoniae were determined as 15 mm for cefoxitin; 9 mm for the ME extract; 25 mm for the PE extract ; 25 mm for the cefoxitin+ 1250 µg/ml ME extract and 34 mm for the cefoxitin + 1250 µg/ml PE extract.The susceptibility of K.pneumoniae increased with cefoxitin + 1250 µg/mlPE extract and inhibition zone was measured as 34 mm.According to the interaction results of the checkerboard method, K. pneumoniae showed synergistic interaction against combinations of cefoxitin ME and PE extracts at 0.03516 and 0.03125 FIC index, respectively.

Figure 1. Inhibition zones of cefoxitin, Coriander extracts and their combinations against clinic isolates,(A) Inhibition zones of cefoxitin, Coriander PE extracts and their combinations against K. pneumoniae (B) Inhibition zones of cefoxitin, Coriander ME extracts and their combinations against K. pneumoniae (C) Inhibition zones of cefoxitin, Coriander PE extracts and their combinations against E.coli

Discussion Nowadays, antibiotic resistance is increasing globally and at a frightening level [25]. The effectiveness of antimicrobialdrugs for the treatment of resistant bacteria infectionsis limited. New antimicrobials can be developed for suppressing resistant mutants, but this is a difficult and long process. Extending the life of current antimicrobials might be possible if they were used in combination with natural products against resistant microorganisms. Synergistic combinations could represent therapeutic alternatives for the treatment of resistant pathogenic microorganisms [26,27]. In the last decade, the frequency of antibiotic resistant strains of ESBL producing K. pneumoniae has increased remarkably [1416]. Plasmid-mediated AmpC enzymes as a serious problemhave beenrevealed in enteric bacteria. These enzymes have caused nosocomial outbreaks and treatment failure against cephalosporins and alsoincreased mortality [28]. In the future, treatment problems due to the spread of resistant strainsmay arise. The current findings showed that the combination of cefoxitin with coriander extractis effective in resistant strains (Table 2).This combination may contribute to the treatment of the ESBL producing strain. More recently, “Plantaricin CS” namely a novel antimicrobial

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peptide with wide antibacterial activity, was isolated from Coriander leaf extract. The new peptide showed effective germicidal effects on K. pneumoniae (MIC = 2.65 mg/mL) [11]. In the present study, the synergistic effect of Coriander seed extracts against K. pneumoniaemay be due to the active components[29]in the ME and PE extracts. The PE extract + cefoxitin combination was found to be twice as effective as the theME extract + cefoxitin combination against the clinically resistant K. pneumoniae strain (Figure 1) by the disc diffusion method. The inhibition zones of the tested extracts against MRSA were lower than those against E. coli. The combination of cefoxitin with coriander extracts had stronger effect thancefoxitin alone on each resistant strain. Thissynergistic behavior was more visible in the clinically resistant K. pneumoniae strain. Cefoxitin showed a synergistic effect when combined with Coriander extracts on resistant K. pneumoniae by the checkerboard method. The difference in the results between the two methods may be due to the deficienciesof the disc diffusion method. In studies with such plant extracts, the MIC value is essential[11]. In this study, the disc diffusion method was performed for preliminary assessment of the synergistic effect.MRSA and E. coli synergism values were also found as indifferent near the borderline. For this reason, we think that the checkerboard method is a more sensitive method for evaluating synergistic interaction with MIC value. The most common cause of resistance to extended-spectrum ß-lactam antibiotics in Enterobacteriaceae is the enzymatic degradation of antibiotics[30]. According to the literature, some of the mechanisms adopted in combinations are as follows: protective enzymes and common biochemical pathway inhibition, combinations of cell wall-active agents, and use of cell wall active agents to enhance the uptake of other antimicrobials [23,31]. Linalool, which is the maincomponent of Coriander, causes permeability alteration of the outer membrane, alteration of cell membrane function and leakage of intracellular materials[29]. One of the efficient mechanisms may be that these enzymes which are responsible for the production of ESBLs, are excreted during bacterial content excretion. Similar mechanisms may also apply for plant and antibiotic combinations. The decline in antibiotic resistance with a combination of plant extracts and conventional antimicrobials has not yet been fully elucidated. Conclusion Antibiotic drug development is a rigorous, cost-effective and timeconsuming process. New methods to reduce the development of antibiotic resistance by pathogenic organisms in the pharmaceutical industry are needed. To the best of our knowledge, this is the first report on the synergistic antibacterial activities of Coriander extracts and cefoxitin combination. This study results demonstrated that the Coriander seed extracts and cefoxitin combination has strong synergistic antibacterial activity against ESBL producing K. pneumoniae. These synergistic interactions may increase the antibacterial efficacy of antimicrobials at low concentrations which may reduce their side effects. Combinations of antibiotics with plant extracts can be usedas potential natural antibacterial agents in the pharmaceutical industry. Competing interests The authors declare that they have no competing interest

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doi: 10.5455/medscience.2018.07.8850 Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

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Laribi B, Kouki K, M’Hamdi M, et al. Coriander (Coriandrum sativum L.) and its bioactive constituents. Fitoterapia. 2015;103:9-26.

Jiang DM, Zhu Y, Yu JN, et al. Advances in research of pharmacological effects and formulation studies of linalool. Zhongguo Zhong Yao Za Zhi. 2015;40:3530-3.

10. Zare-Zardini H, Tolueinia B, Momeni Z, et al. Analysis of antibacterial and antifungal activity of crude extracts from seeds of Coriandrum sativum. Gomal J Med Sci. 2012;10:167-71. 11. Zare-Shehneh M, Askarfarashah M, Ebrahimi L, et al. Biological activities of a new antimicrobial peptide from Coriandrum sativum. Int J Bio Sci. 2014;4:89-99. 12. Balouiri M, Sadiki M, Ibnsouda SK. Methods for in vitro evaluating antimicrobial activity: a review. J Pharm Anal. 2016;6:71-9. 13. Hemaiswarya S, Kruthiventi AK, Doble M. Synergism between natural products and antibiotics against infectious diseases. Phytomedicine. 2008;15:639-52. 14. Duman Y, Güçlüer N, Serindağ A, et al. Escherichia coli Suşlarında Antimikrobiyal duyarlılık ve genişlemiş spektrumlu-βeta laktamaz (gsbl) varlığı. Fırat Med J. 2010;15:197-200. 15. Duman Y, Bozkurt I, Tekerekoğlu MS. Investigation of Antibiotic Resistance and ESBL-Presence of Community Acquired Escherichia coli Strains Isolated from UTI in Afşin State Hospital. Med Sci. 2014;3:1408-18. 16. Toner L, Papa N, Aliyu SH, et al. Extended spectrum beta lactamase

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producing Enterobacteriaceae in hospital urinary tract infections: incidence and antibiotic susceptibility profile over 9 years. World J Urol. 2016;34:10317. 17. Mambie A, Vuotto F, Poitrenaud D, et al. Cefoxitin: An alternative to carbapenems in urinary tract infections due to extended - spectrum betalactamase-producing Enterobacteriaceae. Med Mal Infect. 2016;46:215-9. 18. Ansari S, Gautam R, Shrestha S, et al. Risk factors assessment for nasal colonization of Staphylococcus aureus and its methicillin resistant strains among pre-clinical medical students of Nepal. BMC Res Notes. 2016;9:214. 19. Clinical and Laboratory Standards Institute (CLSI). Performance standards for antimicrobial susceptibility testing, 17th informational supplement. (M100-S17). Wayne: CLSI; 2007. 20. Pillai SK, Moellering RC, Eliopoulos GM. Antimicrobial combinations. In: Antibiotics in Laboratory Medicine. 5th ed. Philadelphia: Lippincot Williams & Wilkins; 2005. 851 p. 21. Aliskan H, Can F, Demirbilek M, et al. Determining in vitro synergistic activities of tigecycline with several other antibiotics against Brucella melitensisusing checkerboard and time-kill assays. J Chemother. 2009;21:2430. 22. Pei RS, Zhou F, Ji BP, et al. Evaluation of combined antibacterial effects of eugenol, cinnamaldehyde, thymol, and carvacrol against E.coli with an improved method. J Food Sci.2009;74:M379-83. 23. Zhang D, Hu H, Rao Q, et al. Synergistic effects and physiological responses of selected bacterial isolates from animal feed to four natural antimicrobials and two antibiotics. Foodborne Pathog Dis. 2011;8:1055-62. 24. Zhao WH, Hu ZQ, Hara Y, et al. Inhibition of penicillinase by epigallocatechin gallate resulting in restoration of antibacterial activity of penicillin against penicillinase producing Staphylococcus aureus. Antimicrob Agents Chemother. 2002;46:2266-8. 25. Levy SB, Marshall B. Antibacterial resistance worldwide: causes, challenges and responses. Nat Med. 2004;10:122-9. 26. Musumeci R, Speciale A, Costanzo R, et al. Berberis aetnensis C. Presl. extracts: antimicrobial properties and interaction with ciprofloxacin. Int J Antimicrob Agents. 2003;22:48-53. 27. Duarte A, Ferreira S, Silva F, er al. Synergistic activity of coriander oil and conventional antibiotics against Acinetobacter baumannii. Phytomedicine. 2012;19:236-8. 28. Pai H, Kang CI, Byeon JH, et al. Epidemiology and clinical features of bloodstream infections caused by AmpC-type-beta-lactamase-producing Klebsiella pneumoniae. Antimicrob Agents Chemother.2004;48:3720-8. 29. Zengin H, Baysal AH. Antibacterial and antioxidant activity of essential oil terpenes against pathogenic and spoilage-forming bacteria and cell structure-activity relationships evaluated by SEM microscopy. Molecules. 2014;19:17773-98. 30. Mylvaganam H, Kolstad H, Breistein RI, et al. Extended spectrum cephalosporin resistance among clinical isolates of Enterobacteriaceae in West Norway during 2006-2013; a prospective surveillance study. Apmis. 2017;125:52-8. 31. Eliopoulos GM, Moellering RC. Antimicrobial combinations. In: Antibiotics in Laboratory Medicine. 3rd ed. Baltimore: Williams & Wilkins; 1991. p.432-92

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):781-4

Is an interval appendectomy still necessary in perforated appendicitis with inflammatory mass/abcess Kivilcim Karadeniz Cerit1, Rabia Ergelen2, Ruslan Asadov2, Merve Yilmaz1, Tural Abdullayev3, Tolga Dagli1, Gursu Kiyan1 Marmara University Faculty of Medicine, Department of Pediatric Surgery, Istanbul Turkey 2 Marmara University Faculty of Medicine, Department of Radiology, Istanbul Turkey 3 Emsey Hospital, Department of Pediatric Surgery, Istanbul Turkey

Received 15 March 2018; Accepted 19 April 2018 Available online 25.04.2018 with doi: 10.5455/medscience.2018.07.8783 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract We reviewed our experience in non-operative management without an interval appendectomy (IA), for patients who presented with perforated appendicitis with an abcess or inflammatory mass from November 2012 to November 2017 retrospectively. The data included age, sex, duration of symptoms, presence of appendicolith/ abcess on CT imaging, WBC and CRP levels, antibiotic treatment, fever at presentation, percutan drainage procedure and complications, recurrent abscess, total length of hospitalization, follow-up period. A total of 32 patients were treated with nonoperative management during the study period. Nonoperative management without an IA was successful in 31 patients (96%). Study patients included were admitted to the surgical ward for observation. The mean age of the patients was 9.74±3.55 years. 19 male and 13 female patients were included in the study. The mean duration of symptoms was 8.75±4.69 days. The mean number of Ct scans was 1.21±0.42 per patient. Percutan drainage was performed in 10 patients. The mean of WBC levels at presentation was 19030.00±7192.24 cells/μL and CRP levels was 156.61±94.23 mg/dl. Intravenous piperacillin-tazobactam (Tazosin®, Pfizer, New York, NY) were given 400 mg/kg/day in four divided doses. Diet were started to the patients who were afebrile and had diminished abdominal pain during observation. The mean length of hospitalization was 13.03±5.82 days. The mean duration of follow-up period 34.65±20.48 months. Nonoperative management without IA is a preferable choice for perforated appendicitis with abcess or mass. Keywords: Perforated appendicitis, nonoperative treatment, percutaneous drainage, abcess, inflammatory mass, interval appendectomy

Introduction Appendicitis is the most common reason for emergency surgery during childhood [1]. Currently, an emergency appendectomy is the preferred treatment option for the majority of children who present with acute appendicitis, although the operation is associated with technical difficulties in cases of perforated appendicitis that present at a later term with inflammatory masses or abscesses due to the disrupted anatomy and the need to dissect the mass in order to locate the appendix [2]. Nonoperative treatments that involve intravenous antibiotherapy and/or percutaneous drainage of the abscess are common treatment approaches in patients who present at this stage [3]. Following a successful nonoperative treatment, an interval appendectomy (IA) to prevent recurrence is a conventional surgical approach, which offers advantages regarding reducing the risk of complications and morbidity to which the patients are exposed during or after surgery [4]. However, whether there is a

*Coresponding Author: Kivilcim Karadeniz Cerit , Marmara University Faculty of Medicine, Department of Pediatric Surgery, Istanbul Turkey E-mail: kcerit@yahoo.com

need for this operation has the subject of much discussion recently due to the rate of IA-related morbidity and the risk of recurrence being low in different patient series [2,5]. The present study reported the long-term outcomes of nonoperative treatments without IA (intravenous antibiotics and/or percutaneous drainage) in patients with perforated appendicitis that present with an inflammatory mass or abscess. Material and Method The study sample included children aged 5–18 years who presented at the Marmara University School of Medicine Emergency Department with perforated appendicitis and with an abscess or inflammatory mass between November 2012 and November 2017. The data were analyzed retrospectively, and included age, sex, duration of symptoms, number of computerized tomography (CT) scans performed per patient, presence of appendicolith/abscess on CT imaging, percutaneous drainage procedure and complications, WBC, CRP levels and fever at presentation, antibiotic treatment, total length of hospitalization, duration of follow-up period, and presence of recurrent abscess/appendicitis. The patients’ radiological images from the time of presentation were reviewed 781

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by the same pediatric radiologist. Percutaneous drainages of abscess were performed by an interventional radiologist in patients who were eligible for the procedure. A post-discharge follow-up of the patients was carried out monthly for the first three months, and once every three months for the following nine months through radiological and clinical evaluations. In the oneyear follow-up, the patients were also contacted by telephone to obtain information on their status. Written informed consent was obtained from each patient, and this study was approved by the Ethics Committee (09.2017.662) and was conducted in accordance with the principles of the Declaration of Helsinki. Statistical analysis The statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0 software (IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as mean±standard deviation (SD) for continuous variables, and in number and percentage for categorical variables. Results A total of 32 patients were treated with a nonoperative management approach during the study period. The patients included in this study were admitted to the surgical ward for observation, and patients who were afebrile and who had diminished abdominal pain during observation were started on a diet. The mean age of the patients was 9.74±3.55 years, and 19 male (59%) and 13 female (40%) patients were included in this study. The mean duration of symptoms was 8.75±4.69 days; the mean number of CT scans was 1.21±0.42 per patient; all of the patients presented with an abscess, and 11 of them had appendicolith. The percutaneous drainage of abscesses was performed by an interventional radiologist in 10 patients who were eligible for the procedure (Figure 1). There were no complications secondary to the procedure. The mean WBC level at the time of presentation was 19030.00±7192.24 cells/μL, and the mean CRP level was 156.61±94.23 mg/dl. Of the total, 20 patients had a fever at presentation. As an initial antibiotherapy, all patients were administered intravenous piperacillin-tazobactam (Tazosin®, Pfizer, New York, NY) 400 mg/kg/day in four separate doses. Of the total, two patients, who had persistent fever were switched to another antibiotherapy based on the growth culture results of the percutaneous aspiration samples. The mean length of hospitalization was 13.03±5.82 days, and the mean duration of the follow-up period was 34.65±20.48 months. No recurrent abscess/ appendicitis was identified in 31 patients during the follow-up period, and only one patient was admitted to another clinic with abdominal pain and underwent an appendectomy. Nonoperative management without IA was successful in 31 patients (96.8%). Discussion Nonoperative treatment followed by IA for the management of perforated appendicitis presenting at a late-term with an inflammatory mass or an abscess was first defined 25 years ago [6]. While several pediatric surgeons still follow this approach, whether or not the need exists for IA has recently been a subject of discussion [2,5,7]. The present study investigated long-term outcomes in patients who received nonoperative treatment without IA (intravenous antibiotic and/or percutaneous drainage). In their literature review, Hall et al. found out that the risk of recurrent

Figure 1. On coronal CT image; inflammatory mass is seen on right lower quadrant with abcess formation

appendicitis was 20% in patients who followed a nonoperative treatment approach. Indeed, this finding indicates that five children undergo an operation to protect one child from recurrence [2]. Studies that investigated the outcomes of nonoperative treatments aimed to identify the potential risk factors associated with recurrent appendicitis [3,5,8]. Ein et al. demonstrated that the presence of appendicolith significantly increased the risk of recurrence in patients who undergo nonoperative treatment [3] and argued that an interval appendectomy is necessary for the presence of appendicolith. In the present study, although 34.3% of the patients had appendicolith, only one (3%) patient experienced a recurrence, and the radiological images of that patient showed no appendicolith. In their study evaluating the risk of recurrent appendicitis after initial nonoperative treatment, Puapong et al. reported a recurrence rate of 8% and concluded that a routine IA was not necessary in all cases [5]. Puapong et al. also analyzed the risk factors associated with recurrence. While the female gender and the presence of an abscess at presentation appeared to be associated with recurrence, no statistically significant relation was established due to the limited number of recurrent cases [5]. 782

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Similarly, due to the very low number of recurrent cases in this study, we were unable to identify risk factors related to recurrence in our patient group. In their study, Puapong et al. noted that 80% of all recurrences occurred within the first six months of the first episode [5]. In line with the literature, we believe that close monitoring of patients during the early-term, particularly for the first three months, is of vital importance for the early diagnosis of a recurrence. In addition, families should maintain an increased level of awareness of the symptoms of recurrence given that this will ensure a timely hospital admission and initiation of treatment. In another study, Tanaka et al. reported a recurrence rate of 34% after successful nonoperative treatment in their patients who declined the opportunity to undergo IA [7]. Moreover, they found out that almost 80% of the patients who did not develop a recurrence within the first three months also did not experience a recurrence over the following three years, and based on this finding, the authors concluded that IA may not be necessary at all [7]. In the present study, only one patient developed a recurrence within the first 3-month period, which indicates that our follow-up approach, which included radiological and clinical assessments performed monthly for the first three months, and once every three months thereafter for the following nine months, was adequate after successful nonoperative treatment. Keckler et al. evaluated the time between nonoperative treatment and IA in a perforated appendicitis patient series presenting with welldefined abscesses [4]. Of their patients, 17.3% developed a recurrent abscess, and 11.5% had to undergo new drainage, while 10% of the patients developed a complication during the percutaneous aspiration/drainage procedure [4]. In the present study, the rate of recurrence was lower (3%) than has been previously reported in the literature, and none of the patients developed a complication during the drainage procedure. We believe that the low recurrence rate and the absence of complications in our patient group is a result of the effective intravenous large-spectrum antibiotherapy administered to all patients during the nonoperative treatment period, and the fact that the abscesses of patients that were already present at the time of the initial presentation were successfully drained through a percutaneous drainage procedure performed by the same experienced interventional radiologist. Moreover, our patients received a longer course of IV antibiotherapy given that the mean duration of their hospital stays was longer than previously reported in the literature [9] because there is no follow-up system for outpatient IV antibiotherapy administration in our country. In their patient series, Keckler et al. performed a mean number of 3.5Âą2.0 CT scans [4], and this high number represents a significant increase in the risk of cancer and a serious workforce loss in outpatients. The number of CT scans performed in the present study was found to be lower than in other studies in the literature (1.21Âą0.42 per patient). Due to the increased risk of cancer associated with radiation exposure, the monitoring of recurrent abscess should be more vigilant in these patients, and we believe it would be appropriate to perform check-up CT scans only on patients presenting with clinical signs of recurrence. There are a limited number of studies in the literature that compared appendectomies and nonoperative management (drainage/IA) at the time of admission in cases of perforated appendicitis presenting with inflammatory mass/abscess [10,11]. St. Peter et al. performed

Med Science 2018;7(4):781-4

a prospective randomized trial to compare appendectomies and nonoperative management (drainage/IA) at admission and investigated the high number of repetitive CT scans and the presence of recurrent abscess and drainage complications [9]. In that study, the duration of hospital stay, the risk of developing recurrent abscess and the total costs were not significantly different between the two groups. While the operation time appeared to be longer in patients who initially underwent surgery, the overall quality of life assessments was improved in this group [9]. To our knowledge, there is currently no prospective study in the literature that compared nonoperative management without IA approaches and initial appendectomies. It should be noted that there are some limitations in this study, including its retrospective design and its small sample size. Following nonoperative treatment, our patients were followedup for one year through radiological imaging and clinical assessments. Patients who were followed-up for more than one year were contacted by phone and questioned about their current status, potential episodes of abdominal pain, admissions to any other center with abdominal pains or any operations performed at other centers. Conclusion It would appear to be a preferable option to omit IA procedures after successful nonoperative treatment in cases with perforated appendicitis that present with inflammatory masses or abscesses. It should be kept in mind that the rate of recurrence was found out to be low in this study because the mean duration of hospital stay was long and the patients underwent appropriate antibiotherapy during that period, as well as percutaneous drainage performed by the same experienced radiologist. Still, it is important that these patients be carefully followed-up to check for recurrence, and that the families are warned and informed about the potential symptoms of recurrence. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval: Written informed consent was obtained from each patient, and this study was approved by the Ethics Committee (09.2017.662) and was conducted in accordance with the principles of the Declaration of Helsinki.

References 1.

Rentea RM, St. Peter SD. Pediatric appendicitis. Surg Clin N Am. 2017;97:93112.

Hall NJ, Jones CE, Eaton S, et al. Is interval appendicectomy justi-fied after successful nonoperative treatment of an appendix mass in children? A system-atic review. J Pediatr Surg. 2011;46:767-71.

Ein SH, Langer JC, Daneman A. Nonoperative management of pediatric ruptured appen-dix with inflammatory mass or abcess: presence of an appendicolith predicts recurrent appendicitis. J Pediatr Surg. 2005;40:1612-5.

Keckler SJ, Tsao K, Sharp SW, et. al. Resource utili-zation and outcomes from percutaneous drainage and interval appendectomy for perfo-rated appendicitis with abcess. J Pediatr Surg. 2008;43:977-80.

Puapong D, Lee SL, Haigh PI, et al. Routine interval ap-pendectomy in children is not indicated. J Pediatr Surg. 2007;42:1500-3.

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Janik JS, Ein SH, Shandling B, et al. Nonsurgical management of appendicial mass in late presenting children. J Pediatr Surg. 1980;15:574-6.

Tanaka Y, Uchida H, Kawashima H, et al. More than one-third of successfully nonoperatively treated patients with complicated appendicitis experienced recurrent appendicitis: Is interval appendectomy necessary? J Pediatr Surg. 2016;51:1957-61.

St. Peter SD, Synder CL. Operative management of appendicitis. Seminars in Pediatric Surgery. 2016;25:208-11.

St. Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendec-tomy

Med Science

versus initial nonoperative management and interval appendectomy for perforated appendicitis with abcess: a prospective, randomized trial. J Pediatr Surg. 2010;45:236-40. 10. Simillis C, Symenonides P, Shorthouse A, et al. A meta-analysis comparing con-servative treatment versus acute appendectomy for complicated appendicitis (abcess or phlegmon). Surgery. 2010;147:818-29. 11. Blakely ML, Williams R, Dassinger MS, et al. Early vs interval appendectomy for children with perforated appendicitis. Arch Surg. 2011;146:6605.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):785-9

The prognostic factors for pregnancy after gonadotropin-induced controlled ovarian stimulation therapy with intrauterine insemination cycles Gorkem Tuncay Inonu University, Faculty of Medicine, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Malatya, Turkey Received 12 April 2018; Accepted 19 April 2018 Available online 25.04.2018 with doi: 10.5455/medscience.2018.07.8784 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract To identify the predictive determinants for pregnancy in patients who underwent controlled ovarian stimulation (COS) /intrauterine insemination (IUI). A total 458 gonadotropin-induced controlled ovarian stimulation and intrauterine insemination cycles in 361 couples using were studied between February 2014 and January 2018. The main outcome was clinical pregnancy rate, which has been analyzed according to baseline clinical characteristics (women age, length of infertility, day 3. follicle stimulating hormone, estradiol level) and variables related to intrauterine insemination cycle (number of preovulatory follicles, endometrial thickness), and sperm parameters (sperm concentration, sperm motility, sperm morphology and total motile sperm count (TMSC). The overall clinical pregnancy rate was 11.6% (53/458) per cycle. Clinical pregnancy rate per cycle was 12.0% (43/361) in the first cycle; 10.3% (9/87) in the second cycle, and 10% (1/10) in the third cycle. Among the predictive factors evaluated, more than 25x106 TMSC was also good predictor for clinical pregnancy. The TMSC in ejaculate proved to be a useful predictor of the chance for pregnancy after IUI treatment. Keywords: Intrauterine insemination, ovarian stimulation, predictive factors, TMSC

Introduction Around 10-15 % of couples are infertile. Intrauterine insemination (IUI). is a simple and first line treatment for infertile couples with unexplained infertility, cervical factors–related infertility, ejaculatory abnormalities, and male subfertility [1]. The pregnancy rate per IUI cycle changed from 3% to 65% [2,3]. These huge variances in pregnancy rate may be due to patients’ selection criteria, the incidence of several infertility factors, different ovarian stimulation protocols, and different sperm parameters, preparation techniques [4]. In the literature, many topics have been described as influencing pregnancy rates after IUI treatment, such as the female age, the length of infertility, type of infertility, number of mature follicles, estradiol (E2) level on the day of hCG application, and the nature of catheter used [5,]). In addition to, there was a significant difference in pregnancy rate in relation to stimulation protocols combined with IUI. A meta-analysis involving 556 women demonstrated that pregnancy rates were higher in women with gonadotropins than oral agents such as clomiphene citrate (OR: 1.8: 95 CI: 1.2-2.7) [2]. *Coresponding Author: Gorkem Tuncay , Inonu University, Faculty of Medicine, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Malatya, Turkey E-mail: drgorkem@hotmail.com

The objective of this study was to identify prognostic determinants for achieving a pregnancy in couples undergoing the IUI cycles with controlled ovarian stimulation (COH) using gonadotropins. Material and Method Subjects We retrieved the data from gonadotropin and IUI treatment cycles that conducted at the Division of Reproductive Endocrinology and Infertility, School of Medicine, Inonu University, between February 24, 2014, and January 31, 2018. During this period, 482 IUI treatment cycles were started. Of these, 24 IUI cycles were withdrawn because of polyfollicular development (8 cycles), premature luteinizing hormone (LH) peak (3 cycles), drug insensitivity/drug administration error (3 cycles), or for additional causes (10 cycles). In the 458 remaining IUI cycles, 87 patients had encountered 2 IUI treatment cycles, and 10 patients had encountered 3 IUI treatment cycles. The study participants had infertility which is defined as at least 12 months of intercourse without contraception. All couples had encountered an infertility assessment consisting of comprehensive couples medical story, serum hormone evaluation on the second or the third day of the menstrual cycle [Follicle stimulating hormone (FSH), Luteinizing hormone (LH), Estradiol (E2), 785

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Thyroid-stimulating hormone (TSH), and Prolactin (PRL)], baseline vaginal pelvic ultrasonography and semen examination. Gynaecological examinations were performed for all patients. Tubal patency was confirmed by hysterosalpingography or laparoscopy. In addition, at least two sample analyzed according to World Health Organization 2010 standards [7]. Total motile sperm count (TMSC) was calculated by multiplying the volume of the ejaculate in millimeters by sperm concentration and the proportion of fast forward progressive and slow progressive motile sperms divided by 100%. The study was accepted by the Malatya Ethical Review Board and was designed and conducted in accordance with the Declaration of Helsinki. Clinical and Laboratory Procedures All IUI cycles were accompanied by COH with gonadotropins. The management was started on the 2 or 3 day of the menstrual cycle. These women received ovarian stimulation with human menopausal gonadotropins (Menogon, Ferring, Switzerland) or recombinant FSH (Gonal F, Merck, Germany). The initial dose of gonadotropin (37.5–75 IU) relied on the patient’s age, day-3 FSH and E2 level, and antral follicle count. Patients were monitored with the usual hormonal serum hormone (LH and E2) level and through vaginal ultrasound examination for follicle number, size, and endometrial thickness. If the vaginal ultrasound showed an enough number of developed follicles of at least 17- 18 mm, the final oocyte maturation is achieved by the injection of 250 µg of recombinant human chorionic gonadotropin (hCG) (Ovitrelle Merck, Germany). Approximately, 34–36 hours after the hCG injection, we performed insemination. In cycles with a spontaneous LH surge, IUI was performed 24 hours after the surge. If more than two leading follicles (>17-18 mm) were present in the day of trigger, insemination was cancelled. Semen samples were collected after 72 hours of abstinence. After the first assessment, discontinuous Percoll centrifugation methods with gradients of 80% and 40% was performed [8]. Semen examples were evaluated according to the 2010 World Health Organization standards [7]. Prepared sperm inseminated with a soft catheter (Laboratoire C.C.D., Paris, France) in the procedure. A serum sample for quantitate β-hCG measurement was taken on 14 days after insemination. If β-hCG was positive, a transvaginal ultrasound was performed 21 days after pregnancy test. The clinical pregnancy rate defined as the presence of a gestational sac with a fetal heartbeat detected by ultrasound. Biochemical pregnancy loss and tubal pregnancy were noted, but both of them excluded from the analysis. Statistical Analysis Data were stored and analyzed by using the Statistical Package for Social Science Software for Windows, release 11.0 (SPSS, Inc; Chicago, IL, USA). The chi-square or Fisher’s exact tests were used for categorical variables. Parameters with a normal distribution were demonstrated as mean ± standard deviation (SD), and parameters with an abnormal distribution were demonstrated as median and interquartile range (IQR). To compare variables between the pregnant and non-pregnant groups, student’s t-test was used for parametric data and the Mann-Whitney U test was used for non-parametric data. A p-value less than 0.05 was considered statistically significant.

Med Science 2018;7(4):785-9

Results Four hundred fifty-eight (458) IUI cycles in 361 couples were analyzed. The mean women age was 29.06 ±4.4 years(y) and the mean age of men was 32.52± 4.2 y. The mean period of marriage was 4.87 ± 3.1y and the mean age of period of infertility was 3.53± 2.1 y. A majority of total subjects (73%) had primary infertility, and 27% of subjects had secondary infertility. The median serum basal FSH, LH, E2, TSH and PRL levels were 6.3 (IQR: 5.2-7.6) IU /l; 5.2 (IQR: 3.7-7.4) IU /l; 46(IQR: 34-69) pg /ml, 12.9 mIU /l (IQR: 9.05-18.2), and 1.7 ( IQR: 1.2-2.5) ng/ml, respectively. The median whole gonadotropin dose used per cycles was 600 (IQR: 412.5 -900) IU. On the day of hCG, the mean number of follicles measuring >14 mm diameter was 1.4 ±0.8 and the mean endometrial thickness was 9.9± 5.2 mm. A basal median sperm concentrations was 43 (IQR:28-58) million/ml, and median ratio of motility was 50 (IQR: 45-52)% , median morphology according to Kruger criteria was 2(2-3)%, and TMSC were 36 (IQR: 21-59) millions. The overall pregnancy rate was 13.1 % (60/458). After the exclusion of 5 biochemical pregnancy losses, and 1 anembryonic gestation, and 1 ectopic pregnancy, the clinical pregnancy rate was 11.6% (53/458). The clinical pregnancy rate per cycle was 12.0% (43/361) in the first cycle; 10.3% (9/87) in the second cycle, and 10% (1/10) in the third cycle. The clinical characteristics and smoking habits of the patients are showed in Table 1. There were no significant difference between the groups in respect to the age of couples, duration of infertility, previous live birth history, basal serum FSH, LH, and E2 concentrations, and smoking habits. Table 1. Sociodemographic and clinical characteristics among groups Clinical pregnant group (n= 53)

Non-pregnant group (n= 398)

p value

Women age (y)

29.3±4.6

29.0±4.3

0.58

Men age (y)

32.6±4.5

32.5±4.1

0.72

Length of marriage (y)

4.75± 3.0

4.86± 3.1

0.8

Length of infertility (y)

3.38±1.8

3.55± 2.1

0.57

Factors

Primer /Secondary infertility

0.79

Primer

38 (71.7)

292 (73.51)

Secondary

15 (28.3)

106 (26.5)

7 (13.2%)

56 (14.1)

Previous live birth Yes No

0.86 46 ( 86.8)

342 (85.9)

Basal serum FSH(mIU/ml)

6.3 (5.37- 7.56)

6.4 (5.2- 7.6)

0.69

Basal serum LH(mIU/ml)

5.4 (3.5- 9.24)

5.2 (3.8-7.2)

0.32

Basal serum E2(pg/ml)

42.7 (29.5-71.5)

47.0 (35-70.2)

0.41

Serum Prolactin(ng/ml)

13.1 (9.25-19.24)

13.0 (9.1-18.2)

0.83

2.0 (1.32-2.75)

1.7 (1.1-2.47)

0.55

6 (12.3%)

36 (10.8)

0.58

Serum TSH(mIU/ml) Smoking

The variables related to treatment with controlled ovulation induction and sperm parameters of the groups group are showed in Table 2. Both the number of pre-ovulatory follicle and the 786

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endometrial thickness was not the related to clinical pregnancy rate. The clinical pregnancy rate per cycle was 10.7% for one pre-ovulatory follicle development, whereas the pregnancy rate was 13.9% for two or more pre-ovulatory follicle development. Although no pregnancies were achieved with a thickness below 7 mm, the endometrial thickness was not a predictive factor of pregnancy. Table 2. Factors related to treatment with controlled ovulation induction and sperm parameters among groups Clinical pregnant group (n= 53)

Non-pregnant group (n= 398)

43 (81.1)

313 (78.6)

≥2

10 (18.9)

85 (21.4)

34 (64.2)

281(70.6)

≥2

19 (35.9)

117 (29.4)

0 (0) 53 (100%)

18 (4.5) 380 (95.5)

Factors Number of cycles

0.68

Number of follicle >14mm*

Endometrial thickness* <7mm ≥7 mm Sperm concentration (million/ml) <15 ≥ 15 Sperm motility (%)

0.33

0.14

1.00 2 (3.8) 51(96.2)

17 (4.3) 381 (95.7)

1 (1.9)

32 (8.0)

≥ 40 Sperm progressive motility (%) <32

52 (98.2)

366 (92.0)

20 (37.7)

162 (40.7)

≥ 32

33(62.3)

236 (59.3)

0-1

15 (28.3)

93 (23.4)

≥2

38 (71.7)

305 (76.6)

<25

11(20.8)

137 (34.5)

≥25

42 (79.2)

261(65.5)

<40

p value

0.16

0.68

Sperm morphology

0.43

TMSC (million) # 0.04

*On the day hCG # TMSC: Total motile sperm count

In this study, sperm concentration, motility, and morphology did not help to predict IUI success. But among the predictive factors evaluated, the TMSC more than 25x106 is also good predictor factor for clinical pregnancy (p=0.04). The clinical pregnancy rate per cycle reduced from 11.6 to 8.5 if TMSC lower than 25 million. Discussion In this retrospective study, we reported an overall clinical pregnancy rate 11.6% (53/458). Our results are within the range of previous studies [9,10]. In the present study, the clinical pregnancy rate per cycle was 12.0 % (43/361) in the first cycle; 10.3% (9/87) in the second cycle, and 10% (1/10) in the third cycle. Some studies demonstrated that the clinical pregnancy rate was significantly higher in the first IUI cycle [6,11], whereas other studies have described constant pregnancy rates for the first three to seven IUI cycles [12,13]. Eventually, most pregnancy after IUI took place within the first three treatment cycles, favoring maximum of three IUI cycles before IVF. Variables influencing the outcome of COH/IUI

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2018;7(4):785-9

Age In this study, we did not find any association between woman’s age and IUI success, which is in agreements with the results of earlier results [14,15]. This is evidently due to patient’s selection critaeria, because we did not recommended to older women than 38 years in vitro fertilization. A research by Brzechffa et al. [16] reported that, the age of female under 40 had no influence on the pregnancy after IUI. Similarly, Wainer et al. [15] showed that the pregnancy rate per cycle were similar between 25 and 40 years. In contrast, Bronte et al. [17] showed an age-related difference in gestation rate: 18.9% until age 26; 13.9% between 26-30; 12.4% between 31-35, 11.1% between 36-40; 4.7 between 41-45, and 0.5% over age 45 . Lastly, all these results showed that IUI is a poor treatment choice for women over age 40 years. Duration of infertility In this study there was no significant decrease in clinical pregnancy rate with an increasing period of infertility, as also reported formerly in some investigation [18,19].This is evidently due to patient’s selection criteria because we recommended to couples with at longer than 5 years duration of infertility in vitro fertilization. In contrast that some studies demonstrated that a significant decrease in pregnancy rate with increasing period of infertility [6,11,20]. Finally, IUI cannot be advised to patients when the infertility period longer than 5 years. Basal hormone assays There was no statistically significant difference in pregnancy rate according to FSH, and E2 levels. Likewise, Merviel et al. [10] did not find any significant differences in the pregnancy rate per couples: 9.4 IU/L when FSH baseline level and 80 pg/mL for the E2 baseline level. Smoking In this study, smoking status did not appear to affect pregnancy rates. As an agreement, Merviel et al. [10] did not find any association between smoking habits and pregnancy rates after IUI. Although smoking can negatively influence a couple’s fecundity, however the particular impact of these factors on IUI efficiency does not appear in the various reports. Endometrial thickness In this study, endometrial thickness did not appear to affect pregnancy rates. Endometrial thickness has been associated with the success rate of assisted reproductive technology as well as IUI [20], but the results of the studies about the importance of endometrial thickness have been contradictory. Several studies reported significant associations between endometrial thickness and pregnancy rates [6]. In this study there did not achieve any pregnancy when the endometrial thickness was less than 7 mm, which is in agreement with the lower limits of endometrial width described in earlier studies [21]. Number of leading follicles In this study, the number of leading follicles were not a good prognostic factor for the pregnancy after IUI. This result is agreement with earlier studies [20]. On the contrary, some studies reported the number of follicles was a good prognostic factor for pregnancy after IUI. Nuojua- Huttunen et al. [6] reported that the maximum pregnancy rate (16.3%) was detected in cycles with three pre-ovulatory follicles, whereas the pregnancy rate was 5.7 787

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in cycles with only one follicle.

References

Male factor In this study, sperm concentration, motility, morphology did not help to predict IUI success. Only TMSC in ejaculate proved to be a valuable prognostic factor of the chance for pregnancy after IUI treatment.

Ombolet W, Campo R, Bosmans E, et al. Intrauterine insemination (IUI) as a first-line treatment in developing countries and methodological aspects that might influence IUI success. Hum Reprod. 2008;1:64-72.

Cantineau AE, Cohlen BJ, Heineman MJ. Ovarian stimulation protocols (anti-oetrogens, gonadotrophins with and without GnRH agonist/antagonists) for intrauterine insemination (IUI) in women with subfertility. Cochr Data System Rev. 2007;2:1469-93.

Andersen AN, Gianaroli L, Felberbaum R, et al. The European IVFmonitoring programme (EIM) for the European Society of Human Reproduction and Embryology (ESHRE), Assisted reproductive technology in Europe, 2002: results generated from European registers by ESHRE. Hum. Reprod 2006;21:1680-97.

Dorjpurev U, Kuwahara A, Yano Y, et al. Effect of semen characteristics on pregnancy rate following intrauterine insemination. J Med Invest .2011;58:127-33.

Iberico G, Vioque J, Ariza N, et al. Analysis of factors influencing pregnancy rates in homologous intrauterine insemination. Fertil Steril. 2004;81:1308-13.

Nuojua-Huttunen S, Tomas C, Bloigu R, et al. Intrauterine insemination treatment in subfertility: an analysis of factors affecting outcome. Hum Reprod. 1999;14:698-703.

Rhemrev J, Jeyendran RS, Vermeiden JPW, et al. Human sperm selection by glass wool filtration and two-layer, discontinuous Percoll gradient centrifugation. Fertil Steril. 1989;51:685-90.

World Health Organization. WHO laboratory manual for the examination and processing of human semen. 5th ed., Geneva: World Health Organization; 2010.

Paulmyer Lacroix O, Molle L, Noizet A, et al. Intrauterine insemination with the husband’s sperm: conclusions of five years experience. Contracept Fertil Sex. 1998;26:300-6.

Regarding of male factor, some studies did not found any statistically significant differences about semen parameters [10, 20]. With respect to sperm count, Sakhel et. al. [22] obtained 30.3% pregnancy rate per cycle by using more than 5 million spermatozoa/ml vs 18.8 with less than 5 million spermatozoa/ml (p=0.1). Belashi-Allart et al. 823] demonstrated that a pregnancy rate per cycle of 12.5% with less than 10 million spermatozoa/ml and 17% with more than 20 million/ml. Although these differences are not statistically significant, those two studies illustrate a direct relationship between spermatozoa and the pregnancy rate. With respect to mobility, Belaish-Allart et al. [23] did not report any link between the proportion of motile spermatozoa and the pregnancy rate. In contrast, Sakhel et al. [22] described an rise in the pregnancy rate from 17.1% to 30.4% if the motility exceeded 20% (p=0.06). In a study by Merviel et al. [10] the pregnancy rate per couple decreased from 40.9 to 19.3 if 70% of the spermatozoa were immobile. Focusing on morphology, Burr et al. [24] reported a decline in the pregnancy rate from 18.2 to 4.3% when the ratio of teratozoospermia reaches 90%. Belaish-Allart et al. [23] did not recommended IUI to male as teratozoospermia rate over 80%. In contrast, Karabinus et al. [25] did not report any differences among pregnancy rates under this threshold. Weiner et al. [26] reported the pregnancy rate not significantly influenced by teratozoospermia as long as more than 5x 106 motile spermatozoa/ml were existing for insemination. Van Voorhis et al [18] reported that TMSC as the prognostic factor for clinical pregnancy after IUI. They found that pregnancy rates were very low in couples with the lowest average TMSC below 10x106 after IUI treatment (6.5 %), whereas pregnancy rates were improved and persistent above 10 million TMSC in ejaculate. However, Cohlen et al. showed that a pregnancy rate of 12% per cycle after IUI even if the average TMSC of men’s below <10 million [27]. Surely, the threshold value of TMSC is not absolute. Miller et al [76] demonstrated a pregnancy rate 12.4 when TMSC is over 20x106 compared with 7.4% when it is between 10-20x106. Conclusion In conclusion, the present study showed that the TMSC above 25x106 is also good predictor factor for clinical pregnancy. The TMSC in ejaculate proved to be a valuable clinical prognostic factor of the chance for pregnancy after IUI treatment. Competing interests The authors declare that they have no competing interest

10. Merviel P, Helene Heraud M, Grenier N, et al. Predictive factors for pregnancy after intrauterine insemination (IUI): An analysis of 1038 cycles and a review of the literature. Fertil Steril. 2010;93:79-88. 11. Tomlinson MJ, Amissah-Arthur JB, Thompson KA, et al. Prognostic indicators for intrauterine insemination (IUI): statistical model for IUI success. Hum Reprod. 1996;11:1892-6. 12. Nulsen JC, Walsh S, Dumez S, et al. A randomized and longitudinal study of human menopausal gonadotrophin with intrauterine insemination in the treatment of infertility. Obstet Gynecol. 1993;82:780-6. 13. Zadehmodarres S, Oladi B, Saeedi S, et al. Intrauterine insemination with husband semen: an evaluation of pregnancy rate and factors affecting outcome J Assist Reprod Gened. 2009;26:7-11. 14. Brzechffa PR, Buyalos RP. Female and male partner age and menotrophin requirements influence pregnancy rates with human menopausal gonadotrophin therapy in combination with intrauterine insemination. Hum Reprod. 1997;12:29-33. 15. Wainer R, Albert M, Dorion A, et al. Influence of the number of motile spermatozoa inseminated and of their morphology on the success of intrauterine insemination. Hum Reprod. 2004;19:2060-5. 16. Brzechffa PR, Daneshmand S, Buyalos RP. Sequential clomiphene citrate and human menopausal gonadotrophin with intrauterine insemination: the effect of patient age on clinical outcome. Hum Reprod. 1998;13:2110-4.

Financial Disclosure The financial support for this study was provided by the investigators themselves.

17. Bronte A, Stone PD, Ringler GE, et al. Determinants of the outcome of intrauterine insemination: analysis of outcomes of 9963 consecutives cycles. Obstet Gynecol. 1999;180:1522-64.

Ethical approval: Ethical approval was obtained from the hospital administration to use the patients’ data.

18. Van Voorhis BJ, Barnett M, Sparks AET, et al. Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization. Fertil Steril. 2001;75:661-8.

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doi: 10.5455/medscience.2018.07.8784 19. Dodson WC, Haney AF. Controlled ovarian hyperstimulation and intrauterine insemination for treatment of infertility. Fertil Steril. 1991;55:457-67. 20. Jeon YE, Jung JA, Kim HY, et al. Predictive factors for pregnancy during first four intrauterine insemination cycles using gonadotropin. Gynecol Endocrinol. 2013;29:834-8. 21. Coulam CB, Bustillo M, Soensksen DM, et al.Ultrasonographic predictors of implantation after assisted reproduction. Fertil Steril. 1994;62:1004-10. 22. Sakhel K, Schwark S, Ashraf M, et al. Semen parameters as determinants of success in 1662 cycles of intrauterine insemination after controlled hyperstimulation. Fertil Steril. 2005;84:248-9. 23. Belaish-Allart J, Mayenga JM, Plachot M. Intrauterine insemination Contracept Ferilt Sex. 1999;27:616-21. 24. Burr R, Siegberg R, Matthews C, et al. The influence of sperm morphology

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and the number of motile sperm inseminated on the outcome of intrauterine insemination combined with mild ovarian stimulation. Fertil Steril. 1996;65:127-32. 25. Karabinus DS. The impact of sperm morphology evaluated by strict criteria on intrauterine insemination success. Fertil Steril. 1997;67:536-41. 26. Wainer R, Albert M, Dorion A, et al. Influence of the number of motile spermatozoa inseminated and their morphology on the success of intrauterine insemination. Hum Reprod. 2004;19:2060-5. 27. Cohlen BJ, te Velde ER, van Kooji RJ, et al. Controlled ovarian stimulation and intrauterine insemination for treating male subfertility: acontrolled study. Hum Reprod. 1998;13:1553-8. 28. Miller DC, Hollenbeck BK, Smith GD, et al. Processed total motile sperm count correlates with pregnancy outcome after intra-uterine insemination. Urology. 2002;60:497-501.

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Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):790-6

Investigation of the efficacy of a novel topical hemostatic agent: Experimental rat study Ismail Altintop, Mehmet Tatli Kayseri Training and Research Hospital, Department of Emergency Medicine, Kayseri, Turkey Received 29 August 2018; Accepted 20 September 2018 Available online 12.10.2018 with doi:10.5455/medscience.2018.07.8909 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Uncontrollable bleeding constitutes nearly half of all deaths in the military field while in hospitals and the second cause of deaths due to trauma patient. It is important to stop bleeding early regardless of its size, cause. The inadequacy of hemostasis can lead to various bleeding complications so hemostatic agents are widely used all over the world. In our study, naturally occurring diatomite components from algae fossils were obtained through various processes as a topical hemostatic agent with hemostatic effect. The in vivo hemostatic effects of processed diatomite (PD) components is compared with the product commonly used as hemostatic agent chitosan (CeloxR) in this rat study. A randomized and controlled animal experimental study. The study was performed in the Experimental Research Center and 22 male Wistar albino rats. Rats were divided into 3 groups as follows: the control group (n=6), direct gauze compression was applied to the bleeding area without medication; the PD group (n=8), direct compression was applied with PD powder; and the chitosan group (n=8), direct compression was applied with chitosan powder. PD and chitosan groups were found to have a significantly lower bleeding rate (6 (100%)) than the control group (1 (12.5%) and 4 (50%) respectively). The mean time to stop bleeding in the control group was 305.00 ± 15.34 sec. , when it is 78.75 ± 22.32 sec., in the PD group, and chitosan group was determined as 101,25 ± 39,07 seconds. As a result, The PD is a useful topical agent because of its superior hemostatic effects and usefulness. PD demonstrated a more potent hemostatic efficacy than Chitosan due to its higher unique surface area. Therefore, the PD administered onto the wound could terminate bleeding. Keywords: Diatomite, algae fossils, chitosan, hemostatic agent

Introduction Diatomite is a sedimentary rock with a fossil character formed by the accumulation of silicic crusts of diatoms, which are water algae from the class of algae. It is a very small protoplasm that is settled in a silty crust or a shell that the diatom has obtained from the surrounding water. About 16,000 different varieties of freshwater diatom, are developing at sea or brackish waters [1]. The dead shells of the dead diatoms accumulate to form diatomite deposits. Al2O3, CaO, Fe2O3, MgO, K2O, Na2O, P2O5, TiO2 are also present to form a large proportion of the diatomite forming compounds [2]. The proportions of the compounds may vary slightly relative to the region in which the diatomite is located [3]. Diatomite skeletons are called frustules. Diatom frustules are formed by single-celled photosynthetic algae, mostly amorphous silica, dispersed in large aquatic environments [1]. The diatomite is characterized by a specific surface area of about 200 m2/g [1]. Sizes range from 2 nanometers to 2 mm. Diatomite may allow

*Coresponding Author: Ismail Altintop, Kayseri Training and Research Hospital, Department of Emergency Medicine, Kayseri, Turkey E-mail: draltintop1@hotmail.com

ion exchange as well as active barrier function [4]. It is especially successful in removing polluted water from micropores by filtration [5]. The water is cleaned by microparticles from nitrogen, phosphorus and organic residues [6]. One of the most critical features of diatomite is its high liquid absorption capacity. It has been known for many years that it absorbs more than twice the liquid of its particular weight [7,8]. Diatomite is commercially used in the form of filter, air filter, water filter for reasons of low density, high visibility, high absorption capacity and chemical inertness [9]. Diatomite is inert to many chemicals and is affected only by strong bases at high temperatures and HF (hydrofluoric acid) and sulfuric acid at elevated temperatures [10]. The most important features of diatomite are; nano-sized porous structure, high surface area relative to volume, lack of dissolution characteristics compared to body fluids, natural and non-toxic properties. Chitosan is a non-toxic biological polysaccharide polymer of deacetylated chitin [5]. It was approved by the United State Food and Drug Administration in June 2006. The positive loaded NH3+ groups interact with negative loaded thrombocytes and erythrocytes, attaching them with an ionic bond [11,12]. This induces the aggregation of thrombocytes in the constitution of thrombus. In vitro studies show its advantageous effects in wound healing on 790

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the activation of polymorphonuclear neutrophils, macrophages, and fibroblasts [13]. Chitosan possesses antimicrobic function versus fungi and gram-positive and gram-negative bacteria [14]. Celox® is a topical compound of chitosan. Chitosan is used as a hemostatic agent in over the world [15]. This study aims to process diatomite components received directly from nature physically and chemically to obtain the hemostatic effect, to show a hemostatic result of the PD components in vivo comparative studies, and to provide a brand new and unique topical hemostatic agent to the literature. Materials and Methods The study was carried out with approval from the local experimental animals ethics committee (Local Ethics Committee number, HADYEK-14.12.2016, 16/52). The study was performed in the Experimental Research Center and 22 male Wistar albino rats weighing 158-215 g were used. The rats were housed in polycarbonate cages (three rats per each cage), on coarse sawdust bedding, under conventional experimental animal housing conditions with controlled temperature (21±2 °C), humidity (50±5%), air change (12 air change per hour), temperature (12 hours light, 12 hours dark) and ad libidum feed. Rats (n=22) were divided into 3 groups as follows: the control group (n=6), direct gauze compression was applied to the bleeding area without medication; the PD group (n=8), direct compression was applied with PD powder; and the chitosan group (n=8), direct compression was applied with chitosan powder. Diatomite compounds have been obtained from the mines located in different cities of Turkey; Kayseri, Niğde and Nevşehir. Diatomite components are separated from impurities by subjecting it to wet milling and separation processes, calcination and after washing with hydrogen peroxide; a topical hemostatic agent has been obtained to have hemostatic effect by electrostatically being loaded with negative ions and used in our study after sterilization in an autoclave. Observation of the morphology The surface morphology of the PD microparticles was observed by a scanning electron microscope (SEM). Microparticles loaded aluminium foil was coated with gold metal under vacuum and then examined by SEM (EVOLS25, Zeiss, Germany). Evaluation of the Physical and Chemical Properties of PD. The elemental composition of the sample material was analyzed by XRF (X-ray fluorescence). X-ray diffraction (AXSD8 Advance, Bruker, USA) was used to illuminate the crystal structure. Rat femoral artery bleeding tests Rats were fed with the same amount of food. The rats were randomly selected for groups. Before starting the experiment, ketamine and xylazine hydrochloride were used for anaesthesia. Right inguinal regions of the rat were shaved and wiped with oktenisept®. The skin and subcutaneous tissue were dissected to show the femoral artery and vein. Haemorrhage comprised of a complete incision of the femoral artery and vein. One of the researchers was responsible for the dissection. Another researcher was responsible for compression. Other investigator collected the accumulated blood with a gauze by pressing. The gauze was moved

Med Science

out and instantly the homeostatic material was applied (Celox® or PD). In all applications, a standard weight of 200 gr was put on the bleeding area. At this time, the clock was started. The first check was taken at the 60th second. After every 30 seconds, the bleeding was checked. If the bleeding had stopped, it was recorded as bleeding stopping time (BST). if not, compression was continued. Eventually, if the bleeding had stopped, it was recorded as a BST. Rats were evaluated simultaneously whether shock occurred after bleeding, the shell formed on the wound(scaffold), cleaning the material on wound easily or not and finally whether bleeding continued after removing the scab or not. Pictures were shown and taken during the experiment. Histopathologic evaluation The study included formalin-fixed and paraffin wax embedded specimens from vessels of rats in all experimental groups. For routine histology, dissected wound area tissues removed from the rats and fixed in 10% formaldehyde. Then, dehydrated in a graded ethanol series, cleared in xylene and embedded in paraffin. 5μm thick paraffin sections were cut from each specimen. After deparaffinization and rehydration, all sections were stained with Masson’s trichrome. Morphological evaluation of vessels, photographs were taken with a photomicroscope (Olympus BX51, Tokyo, Japan). Statistical analysis Statistical analysis was carried out with SPSS 22.0 for Windows. Continuous variables were expressed as mean ± standard(mean±SD) deviation. Categorical parameters were given as numbers (n) and percentages (%). Fisher’s exact test was used for comparison of categorical variables. All calculations were compared with each other by means of a one-way ANOVA (post-Hoc test Tukey) with the paired sample t-test. The statistical significance level (p) was set at <0.05. Results Characterization of Diatomite In our preliminary studies, surface area measurements were performed on the diatomite-2 components. BET results show a surface area of 160.385 m² / g. Diatomite-2 samples were used in our studies. Diatomite-2 microcapsules have an average length of 77 μm (Pa2), width average 19 μm (PaR2) and capsules consist of an average of 6-12 layers (Pa2). There is microcapsule frame average 30 column (PaR2) similar structure and 20 units in each skeleton column (Da1) quadroreal pore (Da2). The average distance between skeleton columns is 1.45 μm, the number of pores reaches approximately to 1200 in each layer in the form of sieves, the average pores are in the range of 20-600 nm and expected to react as essential barriers for microorganisms (Figure 1). X-ray fluorescence analysis Diatomite compounds obtained from two different regions were examined by X-Ray Fluorescence (XRF) and their preliminary results were shown (Table 1) in order to investigate the properties of the compounds in the PD composition. The diatomites examined as diatomite-1 and diatomite-2 since they contain different proportions of the components according to the regions in which they are obtained. Al2O3 (4,42 %), Fe2O3 (5,50%), CaO (2,52 %) compounds are found in diatomite-2 composition. 791

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Animal study findings for hemostasis There was no statistically significant difference between control and Chitosan and PD groups weighing before and after treatment (p> 0.05). There was a statistically significant difference in comparison of mean bleeding time and weight differences (Line 3, p <0.05) between control and study groups (Table 2). According to the multiple comparison tests (Tukey) comparisons of the control group and study group by weight difference and bleeding time variables there were significant differences between the control group and Chitosan and PD groups separately (p <0.05). Both PD and Chitosan group had significantly high Scaffold formation rates respectively (3 (37.5%)), (7(87.5%)) where the control group had no scaffold observed (0 (0%)) (p <0.05). Likewise both PD (7 (87.5%)) and Chitosan (6 (75%)) were cleaned on wound significantly better than the control group (6 (100%)), (p <0.05).

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according to the control group (Figure 2). When the weight difference after bleeding was examined, it was determined that the control group was significantly different from PD and chitosan group (p <0.05). At the end of the study, the rats were sacrificed by cervical dislocation method under ketamine/xylazine anaesthesia.

While comparing the bleeding occurrence after scaffold formation; PD the Chitosan group, respectively 1 (12.5%)) and 4 (50%) rats had bleeding, but all the rats had bleeding in the control group (6 (100%)) (p <0.05).

Histopathological findings For histological evaluation, the Masson’s trichrome staining technique was used to stain the structure of the vessels. Histological sections of the treated and nontreated femoral vessels are shown in Figure 3. All picture shows a cross-section of femoral vessels following complete vessel dissection. The general architecture of the femoral vessels was structurally standard in all groups. Bleeding zones outside of the vein were noted in the control group where nothing was applied. It was observed that these bleeding areas were not observed in the treated groups and the endothelium, media and adventitia were not affected by the treatment of the blood vessel walls. The smooth muscle contraction is evident by the circular appearance of the vessel and by dense folding of the internal elastic lamina in Figure 3B, treated with PD.

Among PD and Chitosan group only 1 rat(s) emerged shock after bleeding in the group (1 (12.5%)), (1 (12.5%)), respectively, the rats emerging shock after bleeding in the control group were 3 (50%)and that was found to be significantly different (p> 0.05).

Examination of scaffold scab with SEM The scaffold images taken from the wound examined by SEM analysis are shown in figure 4.

In the control group, the mean time to stop bleeding was 305.00 ± 15.34 seconds, in the PD group, 78.75 ± 22.32 seconds and chitosan group was 101,25 ± 39,07 seconds (Table 3).

In our first laboratory review, the interaction of the absorbance properties of PD with whole blood and plasma is shown in figure 5.

Chitosan and PD were given a comparative box plot chart

Figure 1. A) Diatomite-2 The appearance of microcapsules. Pa 1(Microcapsule long axis size), Pa 2 (Microcapsule short axis size and capsule layers image). Diatomite-2 Microcapsule inner wall structure measurements. Da1 (Micro capsule nanometer pore size), Da2 (Microcapsule small pore size). PaR2 (Dimension between skeleton columns). 1B) Diatomite microcapsule inner layers image. Tablo 1. The distribution of XRF values of diatomite compounds obtained from two different regions XRF Results Name of compound

Diatomite-1 (%)

Diatomite-2 (%)

Al2O3

3,02

4,42

Fe2O3

2,76

5,50

CaO

1,52

2,52

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Table 2. Comparison of Control, Chitosan and PD groups Groups Continues

Control (n=6)

Chitosan (n=8)

PD (n=8)

Variables

x ± SD SD

First weight

189.0±15.3

187.8±17.0

188.8±16.4

0.988

Last weight

184.0±14.4

184.9±16.9

186.1±15.9

0.970

-5.0±1.3a

-2.9±1.1b

-2.7±1.0b

0.003

Weight difference Bleeding time

305.0±99.3

101.3±39.1

78.8±22.3

<0.001

n(%)

0(0)a

6(75)b

7(87.5)b

0.002

6(100)

2(25)

1(12.5)

6(100)a

3(37.5)b

7(87.5)ab

0(0)

5(62.5)

1(87.5)

3(50)

1(12.5)

3(50)

7(87.5)

Categoric Variables

Scaffold formation Complete Weak Cleaning from wound Easy Difficult

0.038

Bleeding after scaffold 0.250

PD; Processed Diatomite, Data n(%), mean±SD or average According to multiple comparison tests (Tukey), groups with different superscript letters were found to have statistically significant differences. Table 3. BT in the rat femoral artery model Treatment (mean)

Time(s)(mean)

No treatment group

305,00

Chitosan group

101,25

PD group

78,75

s. (second)

Figure 2. Distribution of control, chitosan and PD groups (box plot graph)

2A Control

2B PD

2C Citosan

Figure 3: Histology of the untreated, and treated with PD (B); Kito (3C) femoral vessels following complete vessel dissection. (3A) Control femoral blood vessels were cut and left bleeding for 3 seconds. Free flowing blood in the control vessel formed a detached clot during sample fixation. (3B) Treatment with PD caused complete occlusion of the vessel and termination of hemorrhage within a few seconds. (2C) Construction is evident by round shape of the vessel and folding in the internal elastic lamina Star; bleeding area, Arrow; internal elastic lamina. Masson’s trichrome, original magnification x20.

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Table 4. Bleeding time Bleeding Time (m)

First n(%)

Second n(%)

Third n(%)

Fourth n(%)

Fifth n(%)

Sixth n(%)

Seventh n(%)

Unsuccessful n(%)

Control

0(0)

1(16,6)

2(33,3)

1(16,6)

Chitosan

2(25)

3(37,5)

4(50)

3(37,5)

1(12,5)

The data are expressed as number (n) and percentage(%). m. (minute)

4 A (Chitosan)

4 B (PD)

Figure 4. SEM image of PD and chitosan nanoparticle Discussion One of the most critical features of diatomite is its high liquid absorption capacity. It has been known for many years that it absorbs more than twice the liquid of its own weight. The results of our SEM analyses indicated that PD is such a candidate of a good hemostatic agent having a high absorbent capacity with poriferous structure in nano size and having a high structure are more than its volume. In a study performed by Zhang et al. diatomite is used as a carrier for gastrointestinal nano prednisone and mesalamine have been found and successfully tested experimentally [16]. Most importantly, in this study, colon cancer cells (Caco-2, HT-29 and HCT-116) were accepted as non-toxic by cell viability test. It was also determined by Terracciano and colleagues that a nano-carrier was a potential drug carrier studied in different cell lines, and one of the most important points was a positive result in cytotoxicity tests [17]. This nanocarrier feature can be used to increase the bleed stopper feature when needed. Aluminium sulphate and ferric sulphate are hemostatic effective agents commonly used throughout the world to stop bleeding [18,19]. Al2O3, Fe2O3, CaO compounds are found in diatomite-2 composition.

Figure 5. Interaction of the absorbance properties of PD with whole blood and plasma

Hemostatic agents are mainly used to stop venous and small arterial bleedings. We used a hemostatic agent for significant rat arterial and venous bleedings model. Moreover, also we showed their efficiency even in arterial and venous bleedings model. In our study, in the PD group, the bleeding stopped in 87,5% of the rats. In 87,5% of the control group, the bleeding did not finish in the first 4 min, but in the PD group, the bleeding stopped in the first 3 min in all rats. Dikme O et al. used locally oxytocellulose powder as a bleeding stopper in rats and they performed their work by exploring the bleeding stop time at 0,1,2,3,4 minutes [20]. In 794

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our study, the femoral artery and venous haemorrhage model was planned similarly to the research performed with Crofton et al. [21]. Crofton et al. measured the bleeding time by applying chitosan directly to the hemorrhagic area in powder form [21]. Chitosan is used differently to increase this effect with the formation of the natural scaffold at the wound site [22]. It is essential not only to stop the bleeding, but it also forms scaffold s after the bleeding had stopped. The formation of the scaffold with PD was found to be significant in our study. One of the best models for calculating bleeding time in rats is controlling on the femoral artery and vein. Mirzakhanian Z et al. found that the lowest bleeding time was 3 sec in different doses in the study of superabsorbent hydrogels [20]. Kyung Eun You et al. found that the best time to bleed was 174.2 sec, during the investigation of a powdery medical adhesive composed of aldehydes dextran and ε-poly (L-lysine) [21]. Chitosan-based products have no intrinsic hemostatic properties and are reported to work by electrostatic interaction between negatively charged erythrocyte membranes, platelets, and positively charged chitosan to create a firmly adherent ‘gel’ over tissues [21]. Extensive research can be applied to investigate whether the PD has these properties or not. It is important that the hemostatic agents are natural and do not cause histopathological damage in the bleeding area. Histopathological sections with and without PD were investigated. It has been observed that PD has no effect on femoral vessels and is not different from non-administered tissues has been shown that endothelin, media and adventure are not affected in the area except the bleeding zones. Accordingly, the native structure of PD is shown by the histological study performed. PD hemostatic agent obtained by treating the components has a high absorption capacity due to the enormous natural porosity surface area. It allows gas exchange in the PD wound site with enhanced blood stopping not toxically compared to the other widely used hemostatic agents and last but not the least it is cleaned quickly and safely from the wound area. Formation of scaffold capacity was shown to be improved by PD also. As a result of all these considerations, we hope it will be a new and unique alternative blood-stopping agent with fundamental properties In this study, we compared one known homeostatic material to new hemostatic material PD and direct compression without medication. There are not many studies comparing the other hemostatic material with Celox®. The current hemostatic agents used commercially like Duraseal obtained from synthetic polymers, CoSeal, comprising fibrinogen, fibrin glue, Tissel, Berilast, Hemaseal and Crosseal, different from those based on bovine albumin and glutaraldehyde (BioGlue) are not natural products. Controversially PD is a natural product. Other Hemostatic agents originated from plants are known as Arista and HemoStase. These agents allow platelets and serum proteins to concentrate where they are applied [24]. They manifest their effect by denaturating protein but cause delayed wound healing, and micro embolisms. These undesired effects were examined in histological sections of PD during our study. It has been determined that there is no toxic injury at the wound site.

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In normal conditions, bleeding can be stopped by compression, but finalizing severe haemorrhage is only possible with hemostatic agents. Hemostatic agents are difficult to clean and remove from the wound area [25]. Due to its structural properties, the topical hemostatic agent PD obtained from natural diatomite components had been significantly easier to clean and remove from the wound site than chitosan. The microcapsule property of the PD provided a more significant efficacy in ending bleeding and formation of scaffold than current hemostatic agents. It also provides mechanical support to the fibrinous roof by allowing rapid fluid absorption at the wound site through to its porous structure with large surface area. Mechanical agents create a physical blockage leading to tamponade. In general, these agents are cost-effective and are often used as first-line modes of treatment. Similar to mechanical agents PD’s mineral zeolite acts by absorbing liquid in the wound bed through molecular sieves, thereby increasing the concentration of coagulants to propagate hemostasis. Its activity leads to an exothermic reaction [26]. Conclusion PD has superior hemostatic agent activity in severe femoral artery haemorrhage or combined arterial/venous hemorrhagic rat model. PD showed a stronger hemostatic activity than Chitosan because of its high specific surface area. Histopathologically, it is important for our study that the tissues are not damaged. More studies are needed on PD. Limitations PD, which was used in our study, was our first study and maximum effective products could not be prepared. It is difficult to use as powder. Studies with new innovative applications and varieties are needed. The femoral artery bleeding model in rats is quite difficult. It must be tested in new bleeding models. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

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Janicijevic J, Krajicnik D, Calija B, et al. Inorganically modified diatomite as a potential prolonged-release drug carrier. Mater Sci Eng C. 2014;42:412–20.

Hassan MS, Ibrahim IA, Ismael IS. Diatomaceous deposits of Fayium, Egypt; characterization and evaluation for industrial application. Chinese J Geochemistry. 1999;18:233–41.

Klinkajon W, Supaphol P. Novel copper (II) alginate hydrogels and their potential for use as anti-bacterial wound dressings. Biomed Mater. 2014;9:45008.

Archana D, Dutta J, Dutta PK. Evaluation of chitosan nano dressing for wound healing: Characterization, in vitro and in vivo studies. Int J Biol Macromol. 2013;57:193–203.

Wang L, Huang L-J, Yun L-J, et al. Removal of nitrogen, phosphorus, and organic pollutants from water using seeding type immobilized microorganisms. Biomed Environ Sci. 2008;21:150–6.

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Benson AA, Muscatıne L. Wax in coral mucus: Energy transfer from corals to reef fishes 1. Limnology and Oceanography. 1974;19.5:810-14.

18. Pourshahrestani S, Zeimaran E, Djordjevic I, et al. Inorganic hemostats: The state-of-the-art and recent advances. Mater Sci Eng C. 2016;58:1255–68.

MOBBS, Philip M. The mineral industry of Zambia. US Geological Survey. 2012.

BAKR, HEGMM. Diatomite: its characterization, modifications and applications. Asian journal of materials science. 2010;2.3:121-36.

19. Janićijević J, Krajišnik D, Čalija B, et al. Modified local diatomite as potential functional drug carrier - A model study for diclofenac sodium. Int J Pharm. 2015;496:466–74.

10. Li C, Zhang G, Wang M, et al. Pore structure modification of diatomite as sulfuric acid catalyst support by high energy electron beam irradiation and hydrothermal treatment. Appl Surf Sci. 2014;310:184–8. 11. Whang HS, Kirsch W, Zhu YH, et al, Hudson SM. Hemostatic agents derived from chitin and chitosan. J Macromol Sci Rev. 2005;C45:309–23. 12. Lan G, Lu B, Wang T, et al. Chitosan/gelatin composite sponge is an absorbable surgical hemostatic agent. Colloids Surfaces B Biointerfaces. 2015;136:1026–34. 13. Dai T, Tegos GP, Burkatovskaya M, et al. Chitosan acetate bandage as a topical antimicrobial dressing for infected burns. Antimicrob Agents Chemother. 2009;53393–400. 14. Muzzarelli RAA. Chitins and chitosans as immunoadjuvants and nonallergenic drug carriers. Mar Drugs. 2010;8:292–312. 15. Kozen BG, Kircher SJ, Henao J, et al. An alternative hemostatic dressing: comparison of CELOX, HemCon, and QuikClot. Acad Emerg Med. 2008;15:74–81. 16. Zhang H, Shahbazi M-A, Makila EM, et al. Diatom silica microparticles for sustained release and permeation enhancement following oral delivery of prednisone and mesalamine. Biomaterials. 2013;34:9210–9. 17. Terracciano M, Shahbazi M-A, Correia A, et al. Surface bioengineering of diatomite based nanovectors for efficient intracellular uptake and drug delivery. Nanoscale. 2015;7:20063–74.

20. Dikme O, Ersoy G, Yilmaz O, et al. The effect of application of local oxidised cellulose powder on hemostasis time in a rat model with femoral artery bleeding. Acta Medica Mediterr. 2015;31:179–82. 21. Crofton A, Chrisler J, Hudson S, et al . Effect of Plasma Sterilization on the Hemostatic Efficacy of a Chitosan Hemostatic Agent in a Rat Model. Adv Ther. 2016;33:268–81. 22. Kim IY, Seo SJ, Moon HS, et al. Chitosan and its derivatives for tissue engineering applications. Biotechnol Adv. 2008;26:1–21. 23. You KE, Koo M-A, Lee D-H, et al. The effective control of a bleeding injury using a medical adhesive containing batroxobin. Biomed Mater. 2014;9:25002. 24. Barnard J, Millner R. A review of topical hemostatic agents for use in cardiac surgery. Ann Thorac Surg. 2009;88:1377–83. 25. Kheirabadi B. Evaluation of topical hemostatic agents for combat wound treatment. US Army Med Dep J. 2011; 26. Howe N, Cherpelis B. Obtaining rapid and effective hemostasis: Part I. Update and review of topical hemostatic agents. J Am Acad Dermatol. 2013;69: 27. Campbell P, Bennett SL, Driscoll A, et al. Evaluation of absorbable surgical sealants: in-vitro testing. In-vitro Test. 2007; 28. Spotnitz WD, Burks S. Hemostats, sealants, and adhesives: components of the surgical toolbox. Transfusion. 2008;48:1502–16. 29. Datta D, Vlavianos P, Alisa A, et al. Use of fibrin glue (beriplast) in the management of bleeding gastric varices. Endoscopy. 2003;35:675–8.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):797-801

The study of diazepam, pregabalin and glucose effect on glutamate toxicity: In vitro study Ali Taghizadehghalehjoughi1, Muhammet Emin Naldan2 AtatĂźrk University, Faculty of Veterinary Science Department of Pharmacology and Toxicology, Erzurum, Turkey Erzurum Regional Training and Research Hospital, Department of Anesthesia and Reanimation, Erzurum, Turkey

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Received 29 May 2018; Accepted 25 July 2018 Available online 28.09.2018 with doi: 10.5455/medscience.2018.07.8891 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract In this study we used pregabalin, diazepam and glucose for evaluating which one are more effective agents against glutamate induced neurotoxicity. After cortex culture preparation glutamate toxicity induced by adding 10-5 mM glutamate to each wells except negative control group. After 10 min different dose of diazepam, pregabalin and glucose were added for 24 h and then 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT), Total Antioxidant Status (TAC) and Total oxidant status (TOS) assays were done. Diazepam, dose dependently shows neuroprotective effects and low dose of diazepam did not increase cell viability higher than 80 %. Combination groups only in high dose increased neurons viability. Total Antioxidant capacity of Pregabalin also show correlation with diazepam groups and highest dose of both show nearest value to negative control group. In addition, lowest and highest oxidant level were gained by the negative and positive control groups respectively. Except high dose of combination group, all groups show statically difference in compare with the negative control group P<0,05. According to our data combination of diazepam, pregabalin and glucose are more effective than pure drug to reduce glutamate toxicity in cortex neuron culture. Keyword: Diazepam, pregabalin, glucose, cortex neuron, total antioxidant capacity and total oxidant status

Introduction Glutamate is the main excitatory neurotransmitter in the mammalian brains. In addition, it has important role like memory and learning. The excitatory action of glutamate in mammalian has been known since the 1950s [1]. Glutamate acts mainly on post-synaptic neuron via ionotropic (ligand-gated ion channels) and metabotropic (G protein) receptors [2]. The all possess in ionotropic receptors were done by ion channels that are permeable to cations, although the relative permeability to Na+ and Ca++ varies according to the family and the subunit composition of the receptor [3]. NMDA is the mammalian biggest body receptor and have permeability to Ca++ ions also have role in long term memory. AMPA receptor is Na+ ion channels and have important role in short term memory [4-6]. Glutamate is a potent neurotoxin, and have a pivotal role in the pathogenesis of many devastating human neurological diseases such as depression, stroke, amyotrophic lateral sclerosis and enough long to cations cross the channel and induced toxicity and apoptosis to neurons [8,9]. Coresponding Author: Muhammet Emin Naldan, Erzurum Regional Training and Research Hospital, Department of Anesthesia and Reanimation, Erzurum, Turkey E-mail: muyama@mynet.com

Revers to glutamate GABA inhibits neurons function by opening Cl- channels. Negative ions take neuron action potential voltage from -90 to -110 -120 mv the excitation of neuron have been difficult and need to strong stimulation (5,10,11). Pregabalin and diazepam are GABA agonist drugs and widely are using for epilepsy, sizer control, sedation and pain killer to patients. Pregabalin is anti-epileptic drug and diazepam is benzodiazepine type (12). Diazepam widely are using for treatment of anxiety and central nervous system disorders. In present study we used Pregabalin and diazepam for evaluating which one are effective drug against glutamate toxicity (13-16). In addition, we added the glucose to well plate for evaluating is glucose can tolerate glutamate toxicity by regulation energy pathways or not. Tyler Barnes and colleagues show glutamate increased glucose uptake by AMPK mechanism. In brain hypoxia and physiological condition glutamate have been secrete to protect neurons (17). In brain hypoxia and physiological condition glutamate have been secrete to protect neurons (18,19). In current study we hypothesized, increase in glucose level and then regulation of energy consumption can increase neuroprotection status against induced glutamate toxicity or not. In addition, we investigate are diazepam and pregabalin able to protect neuron against glutamate by activating GABA mechanism. For this aim, pure drugs (diazepam, pregabalin and glucose) and combination of those drugs in different dose were added to culture for 24 hrs and 797

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then MTT, TAC and TOS assays were done for evaluation of cell viability, Total antioxidant capacity and total oxidant status.

Spectrophotometer reader (Thermo Scientific, Canada, USA) and the cell viability (%) was calculated [20, 25].

Materials and Methods

Viability % ratio

Chemicals and reagents Pregabalin was purchased from Roche (Basel, Switzerland) and Diazepam was purchased from Pfizer (New York, USA). Glucose, Dulbecco modified eagle’s medium (DMEM), Fetal calf serum (FCS), Neurobasal medium (NBM), MTT, phosphate buffer solution (PBS), antibiotic antimitotic solution (100×), L glutamine, B27 and trypsin–EDTA were obtained from SigmaAldrich (St. Louis, MO, USA). TAC and TOS obtained from Rel assay diagnostics (Turkey).

Total oxidant status (TOS) In total oxidant status (TOS) assay, the assessment is done by measuring spectrophotometrically the density of the color related to the amount of oxidants in the sample. In the present study, TOS (Total Oxidant Status) kits manufactured by Rel Assay Diagnostics® Company (Turkey) were used.

In vitro studies Cell cultures Cortex cell cultures were obtained from department of medical pharmacology of Ataturk University (Erzurum, Turkey). Briefly, the cells after centrifuged in 1200 rpm for 5 min were seed in 24 well plate (Corning, USA) by fresh medium (Neurobasal medium, FBS %10, B27 %2 and antibiotic %0,01 and store at incubator (5% CO2; 37°C)(20). Figure 1.

The components in the kit were Reactive 1 Solution, Reactive 2 Solution, Standard 1 solution, and Standard 2 Solution. In order to determine the TOS level; 500 µl Reactive 1 solution was added to the wells in which 75 µl plasma sample was present and after reading the initial absorbance value at 530 nm, 25 µl Reactive 2 solution was added in the same well and second absorbance was read at 530 nm at the end of the waiting period of 10 minutes at room temperature. Standard 2 solution in the kit was used for Standard 2. By using the absorbance values obtained and the following formula, TOS levels were determined in mmol Trolox Equiv./L. TOS =Δexample/ΔST2×20 Δ ST2 (Δstandard 2 = ST2 second reading - ST2 first reading), Δ Sample ( ΔSample= Sample second reading- Sample first reading) Total Antioxidant Capacity (TAC) In TAC assay; antioxidant capacity was determined by inhibiting formation of the 2-2’-azinobis (3-ethylbenzothiazoline 6-sulfonate= ABTS+) radical cation. In the assay process, Rel Assay Diagnostics® Company (Turkey) commercial kit was used.

Figure 1. Harvested cell line ×10: Olfactory neuron cells

Glutamate toxicity By day 10th the cells have adequate branches. All medium poured and glutamate 10-5 mM for inducing toxicity were added to each wells except negative controls. After 10 min Pregabalin (5, 10 and 20 µgr) [21], Diazepam (1, 5 and 15 µgr) [22], Glucose (5, 10 and 15 µgr) [23] and combination group (P; Pregabalin, D; Diazepam and G; Glucose) were added to each well excepts negative control (NC) groups and incubated for 24 h (5% CO2; 37°C). Negative control, received 150 μL of NBM and positive control contained only 10-5 mM glutamate for 24 h [24]. MTT assay Then, MTT assay was carried out by commercially available kit (Sigma alderich, USA). Briefly, MTT reagent (10 μL) was added to the well and the plate was incubated (5% CO2; 37°C) for 4 h. Then, the medium was discarded and 100 μL of dimethylsulfoxide (Sigma, USA) was added to each well. The optical density was determined at 570 nm using Multiskan™ GO Microplate

The components of the kit were Reactive 1 Solution, Reactive 2 Solution, Standard 1 solution, and Standard 2 Solution. In order to determine the TAC level; 500 µl Reactive 1 solution was added in the wells containing 30 µl sample and first absorbance was read at 660 nm. Then, 75 µl Reactive 2 was added to the same wells and allowed to wait at room temperature for 10 minutes. At the end of the waiting period, second absorbance value was read at 660 nm. While distilled water was used for Standard 1, Standard 2 solution in the kit was used for Standard 2. The absorbance values obtained were placed according to the following formula and TAC levels were determined in mmol Trolox Equiv./L [20, 25]. TAC =((ΔST1-Δexample))/((ΔST1-ΔST2)) Δ ST1 (Δstandard 1 = ST1 second reading - ST1 first reading), Δ ST2 (Δstandard 2 = ST2 second reading - ST2 first reading), Δ Sample (ΔSample= Sample second reading- Sample first reading) Statistically analysis The statistical analysis was performed by one-way analysis of variance (ANOVA) and Tukey’s HSD using the SPSS 20.0 software. P<0.05 was considered as statistically significant difference for all tests. Result MTT assay Cortex culture was prepared. After 24 h Pregabalin (5, 10 and 20 798

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µgr), Diazepam (1, 5 and 15 µgr), Glucose (5, 10 and 15 µgr) and combination groups (P; Pregabalin, D; Diazepam and G; Glucose) exposing time, the experiment was finished by adding MTT solution. The data were analyzed and showed in fig 2. According to our result negative control show highest viability ratio and glutamate control shows lowest viability ratio among each groups. Diazepam dose dependently shows neuroprotective effects and low dose of diazepam did not increase cell viability higher than 80%. Pregabalin groups show higher viability in 10 µgr groups but 5 and 15 µgr show difference (P<0,05) in compare to control groups. Glucose groups did not show significance protective effect and only in 5 µgr show highest viability ratio in compare highest dose. Combination groups increased viability only in DPG 10105 (D 10, P 10 and G 5 µgr) dose up to 91%. Figure 2

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TAC assay When the total antioxidant capacity of neurons examined the data showed in fig 3. NC showed highest antioxidant capacity compare to treatment. TAC status in glutamate 10-5 mM is lowest among all treatments. Diazepam in 5 and 10 µgr did not show any significance different in compare control group. Pregabalin also show correlation with diazepam groups and highest dose 10 and 15 shows nearest amount to control groups. Pregabalin 5 µgr shows P<0.05 difference and lowest antioxidant capacity among the group. Glucose group only in 5 µgr dose increased antioxidant capacity but high dose decreased antioxidant status in cortex neurons. Combination groups only in DPG 10105 (D 10, P 10 and G 5 µgr) dose increased antioxidant and cell viability. Figure 3

Figure 2. MTT assay result of olfactory cell line after 24 h treatment by remifentanil.* shows (P<0,05), ** shows (P<0,001)

Figure 3. Total antioxidant capacity assay result of olfactory cell line after 24 h treatment by remifentanil. * shows (P<0,05), ** shows (P<0,001)

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TOS Assay Total oxidant level of cells was shown in fig 4. Our data shows lowest oxidant level gained by negative control group. Also highest level of oxidant obtained by glutamate control groups. According to our data diazepam revers to TAC data only in 10 µgr dose decreased antioxidant status. Lowest dose of 1 and 5 µgr diazepam shows P<0.05 difference with control groups. Pregabalin

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group only in 10 µgr dose did not show any difference with control group whereas 10 and 15 µgr of pregabalin shows P<0.05 statically difference. Glucose groups increased oxidant level in all doses. Combination groups only in high dos all drugs did not show difference with control group but other combination groups show difference in compare with control group P<0.05. Figure 4

Figure 4. Total oxidant status assay result of olfactory cell line after 24 h treatment by remifentanil. * shows (P<0,05), ** shows (P<0,

Discussion Neurons have different type and function in brain cortex. Cortex neurons regulate complex behaviors pattern and also have role in motor and sensory behaviors. Those neurons mainly work by glutamate and GABA neurotransmitters. Diazepam and Pregabalin are benzodiazepine and anti-convulsion drugs respectively [26]. Those drugs by opening Cl- channels reduced action potential to -110 mv inhibit neuronal function and protects neurons. Cl- ions by tolerating negative and positive ions in neurons soma may be protect neuron [27,28]. Glutamate by attaching AMPA and NMDA receptors long than philological periods induced toxicity to neurons. Galeffi F et al shows diazepam promotes ATP recovery in ischemic hippocampal neurons. In this study ability of diazepam to prevent early signals of cell injury (before cell death) after in vitro ischemia were studied. According to author data 2 hours after diazepam administration cytochrome c levels significantly decreased and by recovery of ATP protects neurons. This data show correlation with our study diazepam protect neuron but directly glucose adding to culture did not show any protection. Moreover, diazepam has not effect on glucose but by recovery of ATP regulate energy circulation and protect neurons in ischemic conditions [29]. Cunningham MO et al in their studies evaluate Pregabalin and gabapentin effect on glutamate release in entorhinal cortex synapse (21). In this study showed pregabalin reduced glutamate release at cortical synapses. pregabalin by reducing P/Q-type voltagegated Ca channels and prevention of Ca influx into the presynaptic terminals protect neurons. The author think combination of

pregabalin and gabapentin done this effect. This data is same to our data, we found neuroprotection in pregabalin 10 µgr and combination of diazepam, pregabalin and glucose group. Brekke E et al in their studies investigate Astrocyte-Neuron Interactions Following Neonatal Hypoxia-Ischemia in rats neonatal. Flowing to this study author declare neonatal brain is vulnerable to oxidative stress, depression of mitochondrial metabolism decreased neurotransmitter release and reuptake [30]. Also Author highlights, flowing to ischemic injury and astrocyte malfunction cause failure to upregulate glutamate uptake in response to the massive glutamate release. This result show similarity to our data. According to our result after slight oxidative stress astrocyte lose their function and flowing to energy metabolism failure glutamate uptake reduced and caused excitotoxicity. In addition, glucose cannot revers neuronal injury alone because Krebs cycle did not work properly flowing to astrocyte malfunction. Rotter Sopasakis V and colleague show high glucose level preserve glucose uptake. In this study the author declares elevated glucose level decreased glucose uptake by chondrocytes [(31]. In addition, low glutamate secretion was seen in high glucose and Interleukin1β stimulation to chondrocytes. This data has correlation with our data. In our study high glucose level show lowest neuronal viability. But the combination of drugs high dose shows highest viability. This data maybe has relation with pregabalin and diazepam GABA mechanism. Negative ion influx to neuron increased glucose permeability and help to tolerate glutamate toxicity. This mechanism need to future investigate. Eintrei C and colleague showed diazepam decreased local cerebral 800

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glucose utilization. According to that study diazepam alone decreased whole body glucose metabolism up to 24% [32]. This significant data declaration negative ion by decreasing energy consumption reduced glucose uptake. In contrast, both pregabalin and diazepam combination by regulating glucose increased cell viability and antioxidant level shows neuroprotective effect in cortex neurons. Conclusion Diazepam, pregabalin and glucose alone did not have strong neuroprotective effect but combination of all drugs effectively protect neurons against induced glutamate toxicity. According to our data, patient with glutamate toxicity background usage of diazepam, pregabalin and glucose was recommended. Future study are need to investigate relation between diazepam, pregabalin and glucose neuroprotective effects with glutamate receptor and transporters expression levels. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

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10. Mohler H. GABAA receptors in central nervous system disease: Anxiety, epilepsy, and insomnia. J Recept Signal Transduct Res. 2006;26:731-40. 11. Brondino N, Fusar-Poli L, Panisi C, et al. Pharmacological modulation of gaba function in autism spectrum disorders: a systematic review of human studies. J Autism Dev Disord. 2016;46:825-39. 12. Fabritius ML, Strom C, Koyuncu S, et al. Benefit and harm of pregabalin in acute pain treatment: a systematic review with meta-analyses and trial sequential analyses. Br J Anaesth. 2017;119:775-91. 13. Generoso MB, Trevizol AP, Kasper S, et al. Pregabalin for generalized

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anxiety disorder: an updated systematic review and meta-analysis. Int Clin Psychopharmacol. 2017;32:49-55. 14. Ryu JH, Lee PB, Kim JH, et al. Effects of pregabalin on the activity of glutamate transporter type 3. Br J Anaesth. 2012;109:234-9. 15. Kumar N, Laferriere A, Yu JSC, et al. Evidence that pregabalin reduces neuropathic pain by inhibiting the spinal release of glutamate. J Neurochem. 2010;113:552-61. 16. Shimizu N, Tsuda M, Suzuki T, Misawa M. Role of metabotropic glutamate receptors in lowered seizure threshold of pentylenetetrazole during diazepam withdrawal. Naunyn-Schmiedebergs Archives of Pharmacology 1998; 358:R184-R184. 17. Barnes T, Di Sebastiano KM, Vlavcheski F, et al. Glutamate increases glucose uptake in L6 myotubes in a concentration- and time-dependent manner that is mediated by AMPK. Appl Physiol Nutr Metab. 2018;30. 18. Greenamyre JT, Porter RH. Anatomy and physiology of glutamate in the CNS. Neurology. 1994;44:7-13. 19. Meldrum BS. Glutamate as a neurotransmitter in the brain: review of physiology and pathology. J Nutr. 2000;130:1007-15. 20. Kamalak H, Kamalak A, Taghizadehghalehjoughi A. Cytotoxic effects of new-generation bulk-fill composites on human dental pulp stem cells. Cell Mol Biol (Noisy-le-grand). 2018; 64:62-71. 21. Cunningham MO, Woodhall GL, Thompson SE, et al. Dual effects of gabapentin and pregabalin on glutamate release at rat entorhinal synapses in vitro. Eur J Neurosci. 2004;20:1566-76. 22. Schuler M, Gudi R, Cheung J, et al. Evaluation of phenolphthalein, diazepam and quinacrine dihydrochloride in the in vitro mammalian cell micronucleus test in Chinese hamster ovary (CHO) and TK6 cells. Mutat Res. 2010;702:219-29. 23. Ueda Y, Inui A, Mifune Y, et al. The effects of high glucose condition on rat tenocytes in vitro and rat Achilles tendon in vivo. Bone Joint Res. 2018;7:362-72. 24. Gundogdu G, Miloglu FD, Nalci KA, et al. Protective Effect of Zn2+Loaded Fe3O4-SiO2-NH2-(Zinpyr-1) Nanocomposite on Glutamate Exercise Toxicity in Primary Cortical Neuron Cell Culture. Acta Physiolog. 2017;221:78-9. 25. Ahiskalioglu A, Ince I, Aksoy M, et al. Comparative Investigation of Protective Effects of Metyrosine and Metoprolol Against Ketamine Cardiotoxicity in Rats. Cardiovasc Toxicol. 2015;15:336-44. 26. Babateen O, Jin Z, Bhandage A, et al. Etomidate, propofol and diazepam potentiate GABA-evoked GABAA currents in a cell line derived from human glioblastoma. Eur J Pharmacol. 2015;748:101-7. 27. Brawek B, Loffler M, Weyerbrock A, et al. Effects of gabapentin and pregabalin on K+-evoked 3H-GABA and 3H-glutamate release from human neocortical synaptosomes. Naunyn Schmiedebergs Arch Pharmacol. 2009;379:361-9. 28. Errante LD, Petroff OA. Acute effects of gabapentin and pregabalin on rat forebrain cellular GABA, glutamate, and glutamine concentrations. Seizure. 2003;12:300-6. 29. Galeffi F, Schwartz-Bloom RD. Diazepam promotes ATP recovery following oxygen-glucose deprivation in the hippocampal slice. Faseb J. 2000;14:A1500-A1500. 30. Brekke E, Berger HR, Wideroe M, et al. Glucose and Intermediary Metabolism and Astrocyte-Neuron Interactions Following Neonatal Hypoxia-Ischemia in Rat. Neurochem Res. 2017;42:115-32. 31. Rotter Sopasakis V, Wickelgren R, Sukonina V, et al. Elevated glucose levels preserve glucose Uptake, hyaluronan production, and low glutamate release following interleukin-1beta Stimulation of differentiated chondrocytes. Cartilage. 2018:1947603518770256. 32. Eintrei C, Sakoloff E, Smith CB. Effects of diazepam and ketamine administered individually or in combination on regional rates of glucose utilization in rat brain. Br J Anaesth. 1999;82:596-602.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):802-4

Benzydamine gargle versus ketamine gargle for postoperative sore throat Basak Altiparmak, Mustafa Turan Mugla Sitki Kocman University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Mugla Turkey Received 12 April 2018; Accepted 23 April 2018 Available online 25.07.2018 with doi: 10.5455/medscience.2018.07.8856 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Postoperative sore throat is usually accepted as a minor complication, however it contributes to patient dissatisfaction. The primary aim of this study is to compare the effects of two different therapies for postoperative sore throat. The secondary aim is to determine the correlation of smoking and postoperative sore throat via visual analogue scale scores. The patients diagnosed as “postoperative sore throat” were detected from hospital database. The files of the patients with severe sore throat after tracheal intubation for laparoscopic cholecystectomy, were analyzed retrospectively. The patients treated with either benzydamine or ketamine gargle were included into the study. Age, sex and smoking habits, visual analogue scale scores at the 1st, 24th and 48th hour and the chosen therapy were recorded according to nurse care records.122 patients were included into the study. There were no significant differences for age, sex, smoking habits and visual analogue scale scores in the postoperative first hour among the therapy groups. Mean visual analogue scale was 2.8±0.83 in ketamine group and 3.3±0.99 in benzydamine group at the postoperative 24th hour (p < 0.05). At postoperative 48th hour, it was 1.06±0.756 in ketamine group and 1.5±0.718 in the benzydamine group (p < 0.05), At all time points, mean visual analogue scale were similar among smoking and non-smoking patients (p > 0.05). In this study, the ketamine gargle was more effective than the benzydamine gargle for attenuation of postoperative sore throat. Moreover, no significant effects of smoking were detected with regard to the POST incidence. Keywords: Benzydamine, ketamine, postoperative, sore throat

Introduction Most of the time postoperative sore throat (POST) is accepted as a minor complication, however it can contribute to postoperative morbidity and patient dissatisfaction [1]. It occurs due to pharyngeal, laryngeal, or tracheal irritation. Although the reported incidence of POST is as high as 40%-100% in intubated patients, it can be seen even in the absence of endotracheal intubation [2]. The primary aim of this study was to retrospectively compare the effects of two different POST therapies. The secondary aim was to determine the correlation between smoking and POST using visual analogue scale (VAS) scores. Material and Methods After obtaining institutional review board approval, the patients diagnosed with “postoperative sore throat” between January 2012 and January 2016 were extracted from the hospital database. The files of the patients with severe sore throat (VAS > 5) after tracheal intubation for laparoscopic cholecystectomy, were analyzed retrospectively. From this group, those patients treated with either benzydamine hydrochloride gargle or ketamine gargle were Coresponding Author: Basak Altiparmak, Mugla Sitki Kocman University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Mugla, Turkey E-mail: basakugurlu@me.com, basak_ugurlu@yahoo.com

included into the study. The exclusion criteria’s were age olderhan 65 years, difficult intubation story, operation time longer than two hours, and story of another therapy for POST. Each patient’s age, sex, smoking habits, VAS scores at the 1st, 24th and 48th hours and the chosen therapy were recorded according to the nurses’ care records. The patients had been treated by two different anesthesiologists who worked in the general surgery operating rooms at different time periods. In the benzydamine group, the patients were treated with 15 mL benzydamine hydrochloride 0.15% twice a day starting with the first hour postoperatively until the end of second day. In the ketamine group 20 ml of 0.5 mg/kg ketamine was administered to the patients in the same manner until the end of the second day. The patients who were treated for longer than 48 hours, were excluded from the study. The statistical evaluation was performed using the Statistical Package for the Social Science, version 18.0 (SPSS Inc., Chicago, IL, USA). The descriptive data of the study was specified with mean, standard deviation, and percentage. The normality of the variables was analyzed by Kolmogorov-Smirnov test. The Student’s t test and Mann Whitney U test were used to evaluate the associations between categorical and continuous variables. A oneway analysis of variance test was used to evaluate the VAS scores among the smoking and non-smoking patients at different time points. The values were considered to be statistically significant at p < 0.05.

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Results

Discussion

In total, 153 patients with POST diagnoses after laparoscopic cholecystectomy were extracted from the database. Twelve of the patients were excluded because they were older than 65 years, and six of the patients were excluded due to difficult intubation. In five of the cases, the operation time was longer than two hours and in eight of the cases, additional analgesic drugs were administered to the patients. Consequently 122 patients were included into the study.

In the current study, the ketamine gargle was found to be significantly more effective than the benzydamine hydrochloride gargle for attenuating POST at the postoperative 24th and 48th hours. Although smoking is well known to induce apoptosis in the respiratory epithelium, no significant differences in the VAS scores were detected among the smoking and non-smoking patients at any of the time points.

There were no significant differences with regard to the age, sex, smoking habits and VAS scores in the postoperative first hour among the therapy groups (Table1). Table1. Patient characteristics Benzydamine gargle

Ketamine gargle

Age 44.27 ±10.34 44.31 ± 10.74 Sex (m/f) 30/32 27/33 Smoking habit (+/-) 32/30 28/32 VAS1 7.5 ±0.82 7.5 ± 0.81 VAS1: VAS score within the first hour postoperatively before treatment

At the postoperative 24th hour, the mean VAS scores were 2.8±0.83 in the ketamine group and 3.3±0.99 in the benzydamine group. This difference was statistically significant (p < 0.05) (Table 2). Table 2. VAS scores at the postoperative 24th hour VAS24

Therapy

mean

Std. deviation

sig

Benzydamine

3.3065

78068

p = 0.01

Ketamine

2.8167

83345

VAS24: VAS score at the postoperative 24th hour

When the VAS scores at postoperative 48th hour were compared between the therapies, mean VAS score was 1.06±0.756 in ketamine group and it was 1.5±0.718 in the benzydamine group. The difference was statistically significant, too (p < 0.05) (Table 3). Table 3. VAS scores at the postoperative 48th hour VAS24

Therapy

mean

Std. deviation

sig

Benzydamine

1.5000

71861

p=0.02

Ketamine gargle

1.0667

75614

VAS24: VAS score at the postoperative 24th hour

When the effects of smoking habit on the VAS scores were analyzed at the different time points, no significant differences were detected among the groups (Table 4). At all the time points, the mean VAS scores were similar among the smoking and nonsmoking patients. Table 4. VAS scores of smoking and non-smoking patients Smoking habit Yes mean n Std. deviation No

mean n Std. deviation

VAS1 7.1 60 87

VAS24 3.03 60 82

VAS48 1.38 60 78

7.46 62 74

3.09 62 86

1.19 62 74

p = 0.739

p =0.679

p =0.172

POST is a widespread complication of anesthesia leading to discomfort in many patients [3]. It can cause postoperative difficulties in swallowing and respiration postoperatively. Moreover, it may extend the recovery period by negatively influencing the nutrition and fluid intake of the patients [4]. There are several pharmacological and nonpharmacological strategies to reduce POST. For example, smaller sized endotracheal tubes, the endotracheal tube lubrication with a water-soluble gel, gentle oropharyngeal suctioning, careful airway instrumentation, full relaxation before intubation, reduction of endotracheal tube cuff pressure and fully deflation of cuff before extubating have all been recommended as nonpharmacological methods [5]. In addition, steroids, non-steroidal anti-inflammatory drugs (NSAIDs), ketamine gargle and recently magnesium have been reported as pharmacological methods for the attenuation of POST [6]. Benzydamine hydrochloride is the most common NSAID used for the therapy of POST. It is a topical preparation with antibacterial properties that can be sprayed directly onto the tracheal tube and into the oropharynx [7,8]. It has also been reported to be useful when applied as a gargle. In the study of Agarwal et al, benzydamine hydrochloride gargle was reported to reduce the POST severity for 24 hours when compared to mineral water [1]. In recent years ketamine has been shown to have a protective role in lung injury based on its anti-inflammatory properties [9]. In an experimental model, anti-inflammatory effect of ketamine was also studied in airways [10]. Additionally, Canbay et al. used ketamine as a prophylactic therapy to reduce POST. They reported a significant reduction when a ketamine gargle 0.5 mg/ kg was used for 30 seconds 5 minutes before the surgery. [11]. In the current study, mean VAS score of all patients was 1.09±0.894 at the postoperative 48th hour. Although both therapies can be considered to be successful, the ketamine gargle was more effective for the POST attenuation then the benzydamine gargle. Nowadays N-methyl-D-aspartate (NMDA) receptors are thought to be present in both the central nervous system and peripheral nerves. An experimental study reported that NMDA antagonists to provide anti-nociception in the peripheral nerves [12]. According to these studies ketamine, as an NMDA receptor antagonist, is believed to play a local role in reduction of POST [11]. Smoking has been reported to cause structural and functional changes in the respiratory epithelium. In the study by Luppi et al, smoking caused a reduction in the vital functions of the cells and induced apoptosis in the respiratory epithelium [13]. In a recent study, smoking was shown to increase several laryngopharyngeal and oral cavity symptoms when compared with non-smokers 803

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[14]. So, higher VAS scores due to POST were expected from the smokers, however there was no significant difference. This result is similar to that of previous studies. Canbay et al. did not find any correlation between smoking habit and sore throat, either [11]. The duration of the smoking habit can be the reason for these results. Neither in the current study, nor in the study by Canbay et al., the duration of smoking habit has not been mentioned. Retrospective design is the main limitation of this study. Although the sample size was powerful enough to determine a significant difference, all the data was obtained from the patient files. Therefore, the validity of the results was completely dependent on the validity of the nurses’ care records. The second limitation was the lack of the detailed smoking habit of the patients. In most of the files, there was no data about the smoking duration. Conclusion In this study, the ketamine gargle was more effective than the benzydamine gargle for attenuation of postoperative sore throat. Moreover, no significant effects of smoking were detected with regard to the POST incidence. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

References 1.

Agarwal A, Nath SS, Goswami D, et al. An evaluation of the efficacy of aspirin and benzydamine hydrochloride gargle for attenuating postoperative sore throat: a prospective randomized, single-blind study. Anesth Analg. 2006;103:10001-3.

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Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anaesthesiol. 2005;22:307-11.

Hae Gyun Park, Jung Sik Im, Jeoung Sun Park. et al. A comparative evaluation of humidifier with heated wire breathing circuit under general anesthesia. Korean journal of anesthesiology. 2009;57:32-7.

Zuccherelli L. Postoperative upper airway problems. South Afr J Anaesth Analg. 2003;9:12-6.

Al-Qahtani AS MF. Quality improvement in anesthetic practice--incidence of sore throat after using small tracheal tube. Middle East J Anesthesiol. 2005;18:179-83.

El-Boghdadly K, Bailey CR, Wiles MD. Postoperative sore throat: a systematic review. Anaesthesia. 2016;71:706-17.

Hung NK, Wu CT, Chan SM, et al. Effect on postoperative sore throat of spraying the endotracheal tube cuff with benzydamine hydrochloride, 10% lidocaine, and 2% lidocaine. Anesth Analg. 2010;111:882-6.

Huang YS, Hung NK, Lee MS, et al. The effectiveness of benzydamine hydrochloride spraying on the endotracheal tube cuff or oral mucosa for postoperative sore throat. Anesth Analg. 2010;111:887-91.

Neder Meyer T, Lazaro Da Slva A. Ketamine reduces mortality of severely burnt rats, when compared to midazolam plus fentanyl. Burns. 2004;30:425-30.

10. Zhu MM, Qian YN, Zhu W, et al. Protective effects of ketamine on allergeninduced airway inflammatory injure and high airway reactivity in asthma: experiment with rats. Zhonghua Yi Xue Za Zhi. 2007;87:1308-13. 11. Canbay O, Celebi N, Sahin A, et al. Ketamine gargle for attenuating postoperative sore throat. British journal of anaesthesia. 2008;100:490-3. 12. Oatway M, Reid A, Sawynok J. Peripheral antihyperalgesic and analgesic actions of ketamine and amitriptyline in a model of mild thermal injury in the rat Anesthesia and analgesia. 2003;97:168-73. 13. Luppi F, Aarbiou J, van Wetering S, et al. Effects of cigarette smoke condensate on proliferation and wound closure of bronchial epithelial cells in vitro: role of glutathione. Respir Res. 2005;6:140. 14. Şanlı A, Bekmez E, Yıldız G, et al. Relationship between smoking and otorhinolaryngological symptoms. Kulak Burun Bogaz Ihtis Derg. 2016;26:28-33.

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Medicine Science 2018;7(4):805-9

Effect of caffeic acid phenethyl ester (CAPE) on vascular endothelial growth factor a (VEGF-A) gene expression in gentamicin-induced acute renal nephrotoxicity Zeynal Mete Karaca1, Hasan Ozen2, Muslum Akgoz3, Yilmaz Cigremis1 Inonu University, Faculty of Medicine, Department of Medical Biology and Genetics, Malatya, Turkey 2 Kafkas University, Faculty of Veterinary Medicine, Department of Pathology, Kars, Turkey 3 TUBITAK Ulusal Metroloji Enstitüsü (UME), Bioanalysis Laboratory, Gebze, Kocaeli, Turkey

Received 04 April 2018; Accepted 27 April 2018 Available online 29.07.2018 with doi: 10.5455/medscience.2018.07.8828 Abstract

Vascular endothelial growth factor-A (VEGF-A) gene expression in an experimental gentamicin-induced nephrotoxicity and ameliorative effect of caffeic acid phenethyl ester (CAPE) was investigated in rats. Animals were divided into four groups (n=8); control (C) group animals were given 10% dimethylsulfoxide (DMSO); gentamicin (G) group animals were given 100 mg/kg/day gentamicin; CAPE group animals were given 30 mg/kg/day CAPE and CAPE+G group animals were given 100 mg/kg/ day gentamicin plus 30 mg/kg/day CAPE. Serum creatinine and BUN levels significantly increased in gentamicin group as compared to the control group (p<0.05) while CAPE treatment did not significantly lower the levels of either BUN or creatinine (p>0.05). Gene expression level of VEGF-A in gentamicin group significantly decreased as compared to the control group, however, CAPE treatment did not have any increasing effect on the gene expression level. According to histopathological investigation, gentamicin treatment caused prominent degeneration in kidney tissue and CAPE treatment had only slight beneficial effect on lowering the tissue degeneration. The results showed that gentamicin decreases VEGF-A gene expression and this might be related to the tissue degeneration at cellular level. However, CAPE treatment did not have significant ameliorative effect in lowering the gentamicin induced nephrotoxicity. Keywords: VEGF, CAPE, gentamicin, nephrotoxicity, rat

Introduction Amino glycosides are commonly used in treatment of infections caused by gram (-) bacteria and gentamicin is the most frequently used agent in this group of medicine. However, nephrotoxicity induced by amino glycosides limits their safe usage [1]. Gentamicin impacts on kidney by causing degeneration in both proximal tubules and blood circulation in kidney, and hence, tissue degeneration results in renal failure [2]. It has been reported that 10 to 20% of patients treated by gentamicin develop acute renal failure [3], and 30% of patients receiving gentamicin more than seven days exhibit signs of nephrotoxicity [4]. Gentamicin nephrotoxicity is characterized by typical tubular epithelial cytotoxicity [3]. However, after stopping the use of gentamicin, nephrotoxicity can diminish and kidney tissue may return to normal functioning [5]. Vascular endothelial growth factor (VEGF) is a specific mitogen for vascular endothelial cells and regulates vasculogenesis and angiogenesis [6]. It is a heparin binding glycoprotein, and synthesized by macrophages as well as fibroblasts, endothelial and epidermal cells. It has been reported that VEGF is normally present in renal proximal tubule cells [7]. Members of VEGF function by *Coresponding Author: Yilmaz Cigremis , Inonu University, Faculty of Medicine, Department of Medical Biology and Genetics, Malatya, Turkey E-mail: yilmaz.cigremis@inonu.edu.tr

binding to their specific receptors. VEGF mediates microvascular tube formation of endothelial cells by modulating their migration and proliferation [8]. Therefore, VEGF can play roles in neovascularization, wound healing, vascular permeabilization, embryogenesis and regulation of menstrual cycle [9]. Caffeic acid phenethyl ester (CAPE) is a bioactive component of honeybee propolis. It is a strong antioxidant and inhibitor of nuclear factor kappa B (NF-ᴋB). Besides being a strong potent antioxidant, CAPE has anti-inflammatory, mitogenic, anticancerogenic, anti-virogenic, and immunomodulatory functions [10]. Its antioxidant effect was previously shown in a gentamicin induced acute renal toxicity model, in that CAPE normalized the altered levels of superoxide dismutase, catalase, nitric oxide and malondialdehyde upon gentamicin treatment [11]. In the current study, ameliorative potential of CAPE in gentamicin induced acute renal degeneration was evaluated by investigating specifically the gene expression of VEGF and kidney tissue through histopathological examination. Material and Methods Animals and treatments All animal treatments were carried out in compliance with guidelines of the Institutional Animal Ethics Committee and 805

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Nephrotoxicity was developed by the method of Parlakpinar et al. [11] with minor modifications. Total of 32 rats were equally divided into 4 groups as follows; Control group (C): 2 ml/kg/day dimethyl sulfoxide (DMSO) was given intraperitoneally (ip.) for 10 days; CAPE group (CAPE): 30 mg/kg/day CAPE diluted in DMSO was given ip. for 10 days; CAPE + Gentamicin group (CAPE+G): 30 mg/kg/day [12] CAPE diluted in DMSO was given ip. for 10 days plus 100 mg/kg/day gentamicin was injected ip. 15 min after CAPE treatment, starting at day 3; and Gentamicin group (G): 100 mg/kg/day gentamicin was given ip. for 8 days. At the end of the experimental period, blood was collected and then the rats were sacrificed for collection of kidney tissues.

RT-qPCR for VEGF mRNA expression Kidney samples collected from the groups were minced on ice, placed in RNA saving solution and kept until analysis in -80 ºC freezer. RNA was extracted with Pure RNA Tissue kit (Roche, Lot no: 14289400, ref no: 12033674001). cDNA synthesis was performed by Transcriptor First Strand cDNA Synthesis Kit (Roche, Lot no:14797225, Ref no: 04 897 030 001). Real-time PCR was performed in a Light Cycler Instrument (Roche Applied Science) using Start Essential DNA Probes Master Kit (Lot no: 14554900, Ref no: 06402682001)” and “Real Time Ready Assay (β-Actin lot no: 90014990, config no: 100072217; VEGF-A lot no: 90014991, config no: 100172226) with the primer pairs listed in Table 1. Reaction volumes were set at 10 µl. 5 µl master mix containing 0.5 µl real time ready mix, 2 µl PCR grade water and 2.5 µl cDNA was prepared. Samples were run as triplicate. The cycling protocol was set as the following; an initial 10-min denaturation step at 95°C, followed by 55 cycles of denaturation at 95°C for 10 s, annealing at 60°C for 30 s, and extension at 72°C for 1s.

Serum urea and creatinine measurements Blood samples were left in the room for 20 minutes and serum was separated by centrifugation at 5000 rpm for 15 minutes. Serum urea nitrogen and creatinine levels were determined using in the Abbott Architects c8000 auto analyser (Abbott Laboratories, Abbott Park, Illinois, U.S.A.) at Inonu University Medical School, Medical Biochemistry Laboratory.

To determine the change in VEGF-A gene expression among the groups, β-Actin gene was selected as housekeeping gene and relative mRNA expression levels were calculated according to housekeeping genes using the 2−ΔΔCt method. PCR products were also run in DNA agarose gels and expected PCR products were obtained as 76 bp and 73 bp for β-Actin and VEGF-A genes, respectively [13] (Figure 1A, Figure 1B).

approved by the Local Ethics Committee at Inonu University (2012/A-74). Wistar albino rats weighing 200-230 gr at 8-10 week-old were used in this study. Animals were kept at 21°C, with 50%-60% relative humidity and a 12 h/12 h light/dark cycle. The animals were given standard pellet food, and water was provided ad libitum.

Table 1. Primer sequences and expected product size for VEGF-A and β-Actin Genes β-Actin VEGF-A

Primer sequences F:5’-CTGGCTCCTAGCACCATGA-3’ R:5’-TAGAGCCACCAATCCACACA-3 F:5’- AAAAACGAAAGCGCAAGAAA-3’ R:5’- TTTCTCCGCTCTGAACAAGG-3’

NCBI Reference Sequence

PCR Product size (bp)

NM_031144.3

NM_001110335.1

Figure 1. Agarose gel electrophoresis (A) and amplification curves (B) of the RT-qPCR results of VEGF-A and β-actin mRNA. After total mRNA extraction of rat kidney, cDNA was obtained and PCRs were performed with primers for β-actin and VEGF-A (Table 1) and PCR products were run in an agarose gel (2%). Fermentas 75 bp DNA ladder was used as DNA marker

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Histopathology Samples of kidney tissues were fixed in 10% neutral buffered formalin and then embedded in paraffin blocks. Sections cut at 5 μm thicknesses from the paraffin blocks were routinely processed for hematoxylin and eosin (HE) staining and observed under a light microscope for evaluation of pathological changes. Statistical Analysis Statistical analysis of the data was performed by MedCalc® Software (11.4.2.0). The data was presented as media (min-max). Normal distribution of groups was determined by Shapiro-Wilk test. The data for serum creatinine, BUN and tissue VEGF gene expression presented non-normal distribution (p<0.05). Data for creatinine, BUN and VEGF-A gene expression was evaluated by Kruskal-Wallis analysis, and compared among the groups by

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Conover test. Differences were considered significant if the p value was less than 0.05. Results Biochemical analysis Biochemical analysis showed that serum BUN level increased significantly upon gentamicin treatment in group G as compared to the others (p<0.05). Serum BUN level in CAPE+G group was not different than group G (Figure 2A). Serum creatinine level was also significantly higher in group G than those of the others (p<0.05). As compared to group G, the level of serum creatinine in group CAPE+G did not significantly differ (p>0.05) (Figure 2B).

Figure 2. Statistical comparison the levels of serum BUN (A), creatinine (B) and gene expression of VEGF-A (C) among groups; Control (C), Caffeic acid phenethyl ester (CAPE), Caffeic acid phenethyl ester + Gentamicin (CAPE+G), Gentamicin (G). Data was presented as median (min-max). Values marked with different letters differ significantly (p<0.05)

VEGF-A mRNA expression VEGF/β-actin mRNA expression levels were determined and compared among the groups and the results were shown in Figure 2C. The expression level of VEGF-A mRNA in group G was significantly lower than those of C and CAPE groups (p<0.05). However, there was no statistical difference between group G and group CAPE+G (p>0.05). Histopathology In microscopic examination, normal histomorphology of kidney

was observed in C group (Figure 3A). Moderate to severe damage characterized by cellular degeneration and necrosis in proximal tubule epithelia was noted in group G (Figure 3D). Glomerular degeneration was quite evident in some animals. Mononuclear inflammatory cellular infiltration was also noted in some cases. Similar to group C, no pathological changes was observed in tissues of group CAPE (Figure 3B). In CAPE+G group, though individual differences were present, generally, limited number of degenerated tubules with no or little mononuclear cellular infiltration was detected (Figure 3C). 807

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According to several studies, VEGF gene expression did not decrease after nephrotoxicity. In an experimental gentamicin induced nephrotoxicity model where 80 mg/kg gentamicin was given intramuscularly for 7 days, no changes of VEGF gene expression was observed in rats [22]. On the other hand, increased gene expression was recorded in kidney tissues of streptozotocin given rats [23]. Although a relationship between the increased VEGF gene expression and glomerular degeneration exist, it is not known for sure that this increase is the cause or the result of pathological changes.

Figure 3. Histopathological evaluation of kidney tissues. A) Normal histomorphology of kidney in control group; B) Normal histomorphology of kidney in CAPE group; C) Moderate renal tubular degeneration in CAPE+G group (black arrows); and D) Severe renal tubular degeneration and necrosis (black arrows), glomerular degeneration (arrowhead) and mononuclear cellular infiltration (white arrows) in group G

Discussion In the present study, ameliorative effect of CAPE in acute renal toxicity was investigated by evaluating the expression of VEGF-A gene. Gentamicin treatment was shown to decrease the expression of VEGF-A gene as compared to the control group, and the CAPE treatment in gentamicin given mice did not have any increasing effect. Similarly, increased serum creatinine and BUN levels in gentamicin group was not affected significantly by CAPE treatment. In histopathological investigation, severe degeneration detected in kidney tissue of gentamicin given animals was observed to show limited amelioration with CAPE treatment.

It has been suggested that VEGF might act as a protector in some renal degeneration cases [24]. Therefore, we may postulate that VEGF expression increases initially during renal degeneration. However, increased VEGF might further affect on the endothelial cells, which are capable of producing VEGF itself, and hence cause the degeneration and death of these cells. In turn, degenerated endothelial cells could not produce enough VEGF in response [19]. Therefore, the reason of decreased gene expression seen in our study may be explained by the degeneration of cells normally producing VEGF. Increased free radicals, which are the main cause of cellular degeneration, might be involved in the decreased VEGF gene expression. Such a relationship was previously shown in hypertrophied rat heart where free radicals were detected to be increased [25]. Gentamicin might act in a similar way by involving in the production of free radical species [26]. Although the exact mechanism of how gentamicin induced nephrotoxicity develops is not known, free oxygen species were indicated to be involved, and hence cause lipid peroxidation by increasing mitochondrial hydrogen peroxide and nitric oxide [27].

VEGF expression was shown to be high in human kidney visceral epithelial cells by immunohistochemistry and in situ hybridizations techniques [14]. VEGF was suggested to involve in regulation of glomerular vascular permeability [15], saving of renal tubular cells [16] and glomerular basement membrane structure [17], calcium homeostasis and podocyte survival [18] in humans. Several roles in normal kidney functioning and presence in many locations suggests that VEGF may involve in regulation of endothelial cells. Many glomerular diseases are characterized by changes in the expression of VEGF, and hence suggested to be related to its expression in the kidney tissue [19].

Histopathological changes in gentamicin-induced nephrotoxicity were previously described [27,28]. In these investigations, increased serum creatinine and BUN levels was also reported. These findings comply with the results of the current study. The decrease in VEGF gene expression might be the probable cause of pathologies observed. It has been stated that VEGF might be involved in the glomerular regeneration in mesangio proliferative nephritis, and the decreased VEGF as a result of podocyte degeneration triggers endothelial cell loss and development of glomerulosclerosis [29]. Therefore, it might be speculated that the histopathological changes seen in the present study might be the result of decreased gene expression of VEGF. Supporting this assumption, it has been shown that anti-VEGF treatment causes renal degeneration indicating that VEGF is an important mediator in renal homeostasis [30-32].

VEGF gene expression was shown to change depending on the various pathological conditions and disease states. Decreased gene expression was described in psoriasis, highly vascularized tumors, leukemia, endometriosis, and on various steps of reproduction [20]. In kidney biopsy samples collected from patients with minimal change disease, VEGF expression was detected to be lower than normal while no change was reported in the VEGF receptor gene expression levels [21]. In another study conducted with 47 patients having glomerular diseases, VEGF gene expression was shown to decrease in focal and global glomerular sclerosis, amyloidosis, diabetes, crescentic glomerulonephritis, and diffuse endocapillary proliferative glomerulonephritis associated with systemic lupus erythematosus [19].

In the present investigation, CAPE treatment was shown to have no effect on the VEGF-A gene expression as well as serum creatinine and BUN levels. However, only limited recovery in kidney histology was observed. This histopathological result parallels the findings of Vardi et al.[33] in that necrosis developed during the nephrotoxicity induced by 100 mg/kg gentamicin in rats were ameliorated by CAPE treatment. It has been suggested that this ameliorative effect might be the result of free radical scavenging activity of CAPE. A similar conclusion has also been made by Parlakpinar et al. [11] for CAPE use in gentamicin nephrotoxicity. CAPE induced restorative effects was also described not only histologically but also biochemically in gentamicin and cisplatin toxicities [34]. 808

doi: 10.5455/medscience.2018.07.8828

Conclusion In conclusion, we have shown that VEGF might be one of the most important mediators in development of nephrotoxicity. Decreased expression of VEGF in kidney tissue might be linked to insufficiencies or irregularities in podocyte survival, glomerular vascular permeability, glomerular membrane structure deformation, and calcium homeostasis, which all help to the development of kidney degeneration. Acknowledgements This work was supported by the İnönü University Internal Project under Grant number 2012/139. The authors thanks to Dr. Sabri ULUKANLI, Department of Chemistry, Korkutata University, Osmaniye, for synthesis of CAPE. Competing interests The authors declare that they have no competing interest

Med Science 2018;7(4):805-9

14. Brown LF, Berse B, Tognazzi K, et al. Vascular permeability factor mrna and protein expression in human kidney. Kidney Int. 1992;42:1457-61. 15. Eremina V, Baelde HJ, Quaggin SE. Role of the vegf--a signaling pathway in the glomerulus: Evidence for crosstalk between components of the glomerular filtration barrier. Nephron Physiol. 2007;106:32-7. 16. Kanellis J, Fraser S, Katerelos M, et al. Vascular endothelial growth factor is a survival factor for renal tubular epithelial cells. Am J Physiol Renal Physiol. 2000;278:F905-15. 17. Pepper MS, Ferrara N, Orci L, et al. Vascular endothelial growth factor (vegf) induces plasminogen activators and plasminogen activator inhibitor-1 in microvascular endothelial cells. Biochem Biophys Res Commun. 1991;181:902-6. 18. Foster RR, Hole R, Anderson K, et al. Functional evidence that vascular endothelial growth factor may act as an autocrine factor on human podocytes. Am J Physiol Renal Physiol. 2003;284:F1263-73.

Financial Disclosure The financial support for this study was provided by the investigators themselves.

19. Shulman K, Rosen S, Tognazzi K, et al. Expression of vascular permeability factor (vpf/vegf) is altered in many glomerular diseases. J Am Soc Nephrol. 1996;7:661-6.

Ethical approval All applicable international, national, and/or institutional guidelines for the care and use of animals were followed.

20. Aiello LP, Wong JS. Role of vascular endothelial growth factor in diabetic vascular complications. Kidney Int Suppl. 2000;77:S113-9.

References

21. Boner G, Cox AJ, Kelly DJ, et al. Does vascular endothelial growth factor (vegf) play a role in the pathogenesis of minimal change disease? Nephrol Dial Transplant. 2003;18:2293-9.

Lopez-Novoa JM, Quiros Y, Vicente L, et al. New insights into the mechanism of aminoglycoside nephrotoxicity: An integrative point of view. Kidney Int. 2011;79:33-45.

Mazzon E, Britti D, De Sarro A, et al. Effect of n-acetylcysteine on gentamicin-mediated nephropathy in rats. Eur J Pharmacol. 2001;424:75-83.

Quiros Y, Vicente-Vicente L, Morales AI, et al. An integrative overview on the mechanisms underlying the renal tubular cytotoxicity of gentamicin. Toxicol Sci. 2011;119:245-56.

Pedraza-Chaverri J, Maldonado PD, Medina-Campos ON, et al. Garlic ameliorates gentamicin nephrotoxicity: Relation to antioxidant enzymes. Free Radic Biol Med. 2000;29:602-11. Bello SO, Chika A. Dose-dependent amelioration of gentamicin-induced nephrotoxicity in adult swiss albino rats by vitamin b-complex - a preliminary study. Trop J Pharm Res. 2009;8:111-6.

Bhisitkul RB. Vascular endothelial growth factor biology: Clinical implications for ocular treatments. Br J Ophthalmol. 2006;90:1542-7.

Kim BS, Chen J, Weinstein T, et al. Vegf expression in hypoxia and hyperglycemia: Reciprocal effect on branching angiogenesis in epithelialendothelial co-cultures. J Am Soc Nephrol. 2002;13:2027-36.

Lineaweaver WC, Lei MP, Mustain W, et al. Vascular endothelium growth factor, surgical delay, and skin flap survival. Ann Surg. 2004;239:866-73; discussion 73-5.

Neufeld G, Cohen T, Gengrinovitch S, et al. Vascular endothelial growth factor (vegf) and its receptors. Faseb J. 1999;13:9-22.

10. Lin HP, Lin CY, Liu CC, et al. Caffeic acid phenethyl ester as a potential treatment for advanced prostate cancer targeting akt signaling. Int J Mol Sci. 2013;14:5264-83. 11. Parlakpinar H, Tasdemir S, Polat A, et al. Protective role of caffeic acid phenethyl ester (cape) on gentamicin-induced acute renal toxicity in rats. Toxicology. 2005;207:169-77.

22. Ahn JM, You SJ, Lee YM, et al. Hypoxia-inducible factor activation protects the kidney from gentamicin-induced acute injury. PLoS One. 2012;7:e48952. 23. Xu X, Chen P, Zheng Q, et al. Effect of pioglitazone on diabetic nephropathy and expression of hif-1alpha and vegf in the renal tissues of type 2 diabetic rats. Diabetes Res Clin Pract. 2011;93:63-9. 24. Liu E, Morimoto M, Kitajima S, et al. Increased expression of vascular endothelial growth factor in kidney leads to progressive impairment of glomerular functions. J Am Soc Nephrol. 2007;18:2094-104. 25. Ji K, Minakawa M, Fukui K, et al. Increased superoxide radical with a decrease in vascular endothelial growth factor and inducible nitric oxide synthase level leads to the progression of left ventricular hypertrophy in a pressure-overload rat heart model. Ann Thorac Cardiovasc Surg. 2008;14:210-7. 26. Priuska EM, Schacht J. Formation of free radicals by gentamicin and iron and evidence for an iron/gentamicin complex. Biochem Pharmacol. 1995;50:1749-52. 27. Lee IC, Kim SH, Lee SM, et al. Melatonin attenuates gentamicin-induced nephrotoxicity and oxidative stress in rats. Arch Toxicol. 2012;86:1527-36. 28. Acharya C, Thakar H, Vajpeyee S. A study of oxidative stress in gentamicin induced nephrotoxicity and effect of antioxidant vitamin c in wistar rats. Natl J Physiol Pharm Pharmacol. 2013;3:14-20. 29. Schrijvers BF, Flyvbjerg A, De Vriese AS. The role of vascular endothelial growth factor (vegf) in renal pathophysiology. Kidney Int. 2004;65:2003-17. 30. Eremina V, Quaggin SE. The role of vegf-a in glomerular development and function. Curr Opin Nephrol Hypertens. 2004;13:9-15. 31. Izzedine H, Massard C, Spano JP, et al. Vegf signalling inhibition-induced proteinuria: Mechanisms, significance and management. Eur J Cancer. 2010;46:439-48. 32. Stokes MB, Erazo MC, D’Agati VD. Glomerular disease related to anti-vegf therapy. Kidney Int. 2008;74:1487-91.

12. Ek RO, Serter M, Ergin K, et al. The effects of caffeic acid phenethyl ester (cape) on tnbs-induced colitis in ovariectomized rats. Dig Dis Sci. 2008;53:1609-17.

33. Vardi N, Parlakpinar H, Ozturk F, et al. Gentamicin-induced nephrotoxicity and protective effect of caffeic acid phenethyl ester in rats. Fundam Clin Pharmacol. 2005;19:173-7.

13. Livak KJ, Schmittgen TD. Analysis of relative gene expression data using real-time quantitative pcr and the 2(-delta delta c(t)) method. Methods. 2001;25:402-8.

34. Levi J, Jacobs C, Kalman SM, McTigue M, Weiner MW. Mechanism of cis-platinum nephrotoxicity: I. Effects of sulfhydryl groups in rat kidneys. J Pharmacol Exp Ther. 1980;213:545-50.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):810-2

Visual recovery comes after anatomical recovery after intravitreal aflibercept treatment in macular edema secondary to branch retinal vein occlusion Alper Halil Bayat, Burak Erden, Akin Cakir, Seyma Gulcenur Ozturan, Selim Bolukbasi, Mustafa Nuri Elcioglu Okmeydani Research and Training Hospital, University of Health Sciences, Department of Ophthalmology, Istanbul, Turkey Received 27 Marc 2018; Accepted 28 April 2018 Available online 24.07.2018 with doi: 10.5455/medscience.2018.07.8854 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract To determine the time of anatomical and visual responses of intravitreal aflibercept (IVA) injections in patients with naive macular edema (ME) due to branch retinal vein occlusion (BRVO). 54 eyes of 54 patients who had three IVA injections after BRVO were retrospectively studied. All of the patients had three monthly IVA injections. SD-OCT was performed at the initial visit and one month after every injection. Changes in central macular thickness (CMT), best corrected visual acuity (BCVA) were determined. Results: 28 of 54 patients were women and 26 of 54 patients were man. Mean age was 62.56±2.35 years. Mean BCVA of the patients was logMAR 1.00±0.13 and the mean CMT was 476±35 µm. After first injections; mean BCVA and CMT were improved to logMAR 0.73±0.19, 279±15 µm respectively. These improvements were statically significant (p=0.047 and p=0.000 respectively). After second injections there was not any improvement in BCVA or CMT. The mean BCVA logMAR 0.75±0.18 and mean CMT 279±10 µm (p=0.725 and p=0.991). After third injections mean CMT was 267±6 µm and mean BCVA was logMAR 0.58±0.15. Although after third injections, CMT did not change but BCVA was statically significant improved (p=0.77 and p=0.036 respectively). Visual recovery comes after anatomical recovery after intravitreal aflibercept injections in patients with naive ME due to BRVO. Keywords: Branch retinal vein occlusion, macular edema, aflibercept treatment, anatomical recovery, visual recovery

Introduction Retinal vein occlusion (RVO) is the second most common type of retinal vascular disease after diabetic retinopathy [1,2]. RVO can be classified as central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO). Macular edema (ME) is the main cause of visual impairment in patients which has RVO [1-4]. There are some treatments for macular edema such as intravitreal dexamethasone implants, laser treatment, and intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents. Positive clinical outcomes have been reported on successful use of anti-VEGF such as bevacizumab and ranibizumab [4-13]. After these drugs, aflibercept has been used for ME due to RVO [14-15]. There are some studies in literature about aflibercept usage in ME due to BRVO.

in patients with naive ME due to BRVO. We want to determine the time of anatomical and visual responses of IVA injections in patients with naive ME due to BRVO. Materials and Methods This retrospective study was conducted in accordance with the Declaration of Helsinki. All necessary authorizations were obtained from the Institutional Review Board of Okmeydanı Research &Traning Hospital, İstanbul, Turkey.

But all of them are switch studies. There are not enough real life studies about aflibercept treatment in ME due to BRVO with naive patients. We aimed to evaluate the effectiveness of aflibercept

54 eyes of the 54 patients with treatment-naive acute ME due to BRVO were studied. All of the patients who had intravitreal aflibercept (IVA) injections at Okmeydanı retrospectively studied. Patients with CMT>300 in OCT were treated. All of the patients received 3 consecutive monthly IVA injections. Patients with a history of cerebral infarction, anti-VEGF therapy, dexamethazone therapy, vitrectomy, uveitis, glaucoma or other vitreoretinal diseases were excluded.

Coresponding Author: Alper Halil Bayat, University of Health Sciences, Okmeydanı Research and Training Hospital, Department of Ophthalmology, Istanbul, Turkey, E-mail: alperhalil76@hotmail.com

All of the patients had standard ophthalmic examinations before treatment and post treatment (first, second and third month and at the final visit). The examinations included slit-lamb microscopy, BCVA, tonometry, SD-OCT, indirect ophthalmoscopy. The BCVA 810

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was measured with Snellen chart, and the decimal visual acuity was converted to the logarithm of the minimal angle of resolution (logMAR) units for the statistical analyses. The OCT was performed on SD-OCT (Cirrus HD-OCT; Carl Zeiss Meditec).

Med Science 2018;7(4):810-2

(p=0.000). The change in CMT over time was depicted in Figure 2.

Statistical analyses were performed using the SPSS software version 21. The variables were investigated using means and standard deviations for normally distributed variables. When investigating the changes in BCVA and CMT by time; repeated measures of analysis of variance test (ANOVA) was used. A P<0.05 value was accepted statically significant. Results 28 of 54 patients were women and 26 of 54 patients were man. Mean age was 62.56±2.35. Mean BCVA of the patients was logMAR 1.00±0.13 and the mean CMT was 476±35 µm. Table-1 shows the baseline characteristics of the patients. Table 1. Baseline characteristics of the patients

Figure 2. The changes in CMT over time

Discussion

Age

62.56±2.35 years

Gender

28 women, 26 men

Lens status (phakic, psuedophakic)

15/39

Duration of symptoms (days)

17.2±6.1

Central foveal thickness (µm)

476±35

Best corrected visual acuity (logMAR)

1.00±0.13

After first injections; mean BCVA was improved to logMAR 0.73±0.19 (p=0.047). After second injections there were not any improvement in BCVA. The mean BCVA was logMAR 0.75±0.18 (p=0.725). After third injections mean BCVA was improved to logMAR 0.58±0.15 (p=0.036). From initial to third injections the improvement in BCVA was statically significant (p=0.003). The change in BCVA over time was depicted in Figure 1.

Figure 1 The changes in BCVA over time

After first injections; CMT was improved 279±15 µm (p=0.000). After second injections there were not any improvement CMT. The mean CMT was 279±10µm (p=0.991). After third injections mean CMT was 267±6 µm. There was not any improvement from the second injections to third injections (p=0.77). From initial to the final visit the improvement in CMT was statically significant

For a long time, argon laser photocoagulation has been used in BRVO and has been recommended as a treatment method for reducing macular edema and increasing visual acuity [16-17]. Then anti-VEGF therapy has started to be used and according to important results of ranibizumab and aflibercept in the BRAVO and VIBRANT studies, anti- VEGF has become the most effective drugs for the treatment of BRVO associated ME [4,18-19]. Several studies suggest that VEGF is a major mediator for ME in BRVO. Ischemic retinas express VEGF and vitreous fluid levels of VEGF was correlated with the severity of macular edema in patients with BRVO [20-21]. Aflibercept is a fully human, recombinant receptor fusion protein with a VEGF binding affinity higher than ranibizumab or bevacizumab with a longer duration of effect in the eye and it displays a prolonged VEGF inhibition in comparison with the other VEGF-antagonists ranibizumab and bevacizumab in retinal pigment epithelium/choroid organ cultures. It is also important that it binds other angiogenic factors including placental growth factors [22-25]. The efficacy of aflibercept, an anti-VEGF binding protein, was demonstrated in the VIBRANT phase 3 trial. This study demonstrated, aflibercept (2 mg) treatment was found to be much more effective than laser treatment in macular edema secondary to BRVO. And VIBRANT study has shown important treatment modality which results in markedly functional and anatomical improvement [19,24]. In VIBRANT study patients had anatomical gain more than 200 µm after first injection. While this gain was 280 µm at 6th month. If you look carefully, you will see that the vast majority of the anatomical gains come from the first injections. The patients had approximately 12 letters gain after first injection, while it was 17 letters at 6th month. If you look carefully, you will see that visual gain comes after anatomical gain in VIBRANT study too. GALILEO study was about efficacy of aflibercept in pateints with ME secondary to central retinal vein occlusion. In that study, six monthly aflibercept injections were performed. After first injection, patients had approximately 400 µm anatomical gain, while it was 448 µm at 6th month. When we consider visual gain, the patients had approximately 12 letters gain after first injection, while it was 18 letters at 6th month [26]. This studies confirmed that patients 811

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have fast anatomical recovery after first aflibercept injection in ME due to RVO, while anatomical recovery takes some more time. In Errol et al.’s study the mean age was 58.6 and 62.56 in our study [27]. Like our study the mean age was 63.3 in Wang JK et al. study, and according to them CMT significantly decreased after the first injection like our and VIBRANT trial [19,25]. We found that there was no significant difference of CMT was found in subsequent injections. After first injection, the CMT decreased significantly, while the visual acuity improved markedly. There was no significant change in CMT at subsequent injections, while visual acuity continued to increase. This result may make us think although anatomical recovery be maintained, visual recovery takes some times. This important outcome shows how important the continuity of treatment is. We should not terminate or switch the treatment, thinking that the vision has not increased enough. Before terminate or switch the treatment, we need to complete required injection dose. Conclusion In conclusion, patients have fast anatomical recovery after first aflibercept injection in ME secondary to BRVO, while visual recovery takes more time. Acknowledgements: None of the authors has conflicts of interest or financial interest. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval All necessary authorizations were obtained from the Institutional Review Board of Okmeydanı Research &Traning Hospital

References 1.

Klein R, Moss SE, Meuer SM, ğo ul, The 15-year cumulative incidence of retinal vein occlusion. The Beaver Dam eye study. Arch Ophthalmol. 2008;126:513-8. US Census Bureau. Annual estimates of the population by sex and fiveyear age groups for the United States: April 1, 2000 to July 1, 2007. NCEST2007-01. Release Date: May 1, 2008. Available from: https://www. census.gov/prod/2008pubs/p70-117.pdf. Accessed February 16, 2010.

P Hahn, S. Fekrat, Best practices for treatment of retinal vein occlusion, Current Opinion in Ophthalmology. 2012;23:175-81.

Campochiaro PA, Heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117:1102-12.

Hikichi T, Higuchi M, Matsushita T. et al. Two-year outcomes of intravitreal bevacizumab therapy for macular edema secondary to branch retinal vein occlusion Br J Ophthalmology. 2014;98:195-9. MA Leitritz, F. Gelisken, F Ziemssen, et al. Grid laser photocoagulation for macular edema due to branch retinal vein occlusion in the age of bevacizumab? Results of a prospective study with crossover design, Br Ophthalmology. 2013;97:215-9.

SJ. Ahn, J Ahn, SJ.Woo, et al. Initial dose of three monthly intravitreal injections versus PRN intravitreal injections of bevacizumab for macular edema secondary to branch retinal vein occlusion. BioMed Res Int. 2013;2013: 209735

Hayashi A, Yunoki T, Miyakoshi A, Intravitreal injection of bevacizumab

Med Science 2018;7(4):810-2

combined with macular grid laser photocoagulation for macular edema in branch retinal vein occlusion. J Ophthalmology. 2011;6:625-31. 9.

Wu L, Arevalo JF, Roca JA, Comparison of two doses of intravitreal bevacizumab (Avastin) for treatment of macular edema secondary to branch retinal vein occlusion: results from the Pan-American Collaborative Retina Study Group at 6 months of follow-up. Retina. 2008;28:212-9.

10. Sakanishi Y, Lee A, Usui-Ouchi A, et al. Twelve-month outcomes in patients with retinal vein occlusion treated with low-frequency intravitreal ranibizumab. Clin Ophthalmol. 2016;10:1161-5. 11. Campochiaro PA, Wykoff CC, Singer M, et al. Monthly versus as-needed ranibizumab injections in patients with retinal vein occlusion: the SHORE study. Ophthalmology. 2014;121:2432-42. 12. Brown DM, Campochiaro PA, Bhisitkul RB, et al. Sustained benefits from ranibizumab for macular edema following branch retinal vein occlusion: 12-month outcomes of a phase III study. Ophthalmology. 2011;118:1594-602. 13. Campochiaro PA, Sophie R, Pearlman J, et al; Long-term outcomes in patients with retinal vein occlusion treated with ranibizumab: the RETAIN Study. Ophthalmology. 2014;121:209-19. 14. Campochiaro PA, Clark WL, Boyer DS, et al. Intravitreal aflibercept for macular edema following branch retinal vein occlusion: the 24-week results of the VIBRANT study. Ophthalmology. 2015;122:538-44. 15. Wang JK, Huang TL, Su PY, et al. Intravitreal aflibercept for macular edema secondary to branch retinal vein occlusion in Chinese patients. Eye Sci. 2015;30:63-6. 16. Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol. 1984;98:271-82. 17. Battaglia Parodi M, Saviano S, Ravalico G. Grid laser treatment in macular branch retinal vein occlusion. Graefes Arch Clin Exp Ophthalmol. 1999;237:1024-7. 18. Patrick Oellers, Dilraj S Grewal, Sharon Fekrat. Role of aflibercept for macular edema following branch retinal vein occlusion: comparison of clinical trials. Clin Ophthalmol. 2016;10:411-8. 19. Campochiaro PA, Clark WL, Boyer DS, et al. Intravitreal aflibercept for macular edema following branch retinal vein occlusion: the 24-week results of the VIBRANT study. Ophthalmology. 2015;122:538-44. 20. Noma H, Funatsu H, Mimura T, et al.Vitreous Levels of Interleukin-6 and Vascular endothelial growth factor in macular edema with central retinal vein occlusion. Ophthalmology. 2009;116:87-93. 21. Noma H, Funatsu H, Yamasaki M, et al. Aqueous humour levels of cytokines are correlated to vitreous levels and severity of macular edema in branch retinal vein occlusion. Eye Lond). 2008;22:42-8. 22. Klettner A. Recber M, Roider J. Comparison of the efficacy of aflibercept, ranibizumab, and bevacizumab in an RPE/choroid organ culture. Graefe’s Arch Clin Exp Ophthalmol. 2014;252:1593-8. 23. Panakanti TK, Chhablani J, Clinical trials in branch retinal vein occlusion. Middle East Afr J Ophthalmol. 2016;23:38-43. 24. Hoy SM. Aflibercept: a review in macular oedema secondary to branch retinal vein occlusion. Drugs Aging. 2017;34:393-400. 25. Wang JK, Su PY, Hsu YR. et al. Comparison of the efficacy of intravitreal aflibercept and bevacizumab for macular edema secondary to branch retinal vein occlusion. J Ophthalmol. 2016;2016:8421940. 26. Holz FG, Roider J, Ogura Y, et al. VEGF Trap-Eye for macular oedema secondary to central retinal vein occlusion: 6-month results of the phase III GALILEO study.Br J Ophthalmol. 2013;97:278-84. 27. Errol WC, Eldeeb M, Dedhia CJ. One-year treatment outcomes of zivaflibercept for treatment-naive macular edema in branch retinal vein occlusion. Acta Ophthal. 2018;96:256-7.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):813-6

Platelet function and insulin resistance in aged and middle-aged obese female patients Sumru Savas1, Fulden Sarac1, Guray Saydam2, Fehmi Akcicek1 Ege University Faculty of Medicine, Department of Internal Medicine, Section of Geriatrics, Izmir, Turkey Ege University Faculty of Medicine, Department of Internal Medicine, Section of Hematology, Izmir, Turkey

1 2

Received 23 February 2018; Accepted 03 May 2018 Available online 25.07.2018 with doi: 10.5455/medscience.2018.07.8855 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract It is well known that obesity is associated with insulin resistance (IR), and IR may interact with platelet functions. Aging is also associated with IR and enhanced platelet aggregation (PA). Though platelet reactivity has been investigated in female individuals, to date there is insufficient data on PA in obese and elderly women for whom the physiological changes associated with aging may overlap the factors associated with obesity. Therefore we investigated PA and IR in obese aged and middle-aged female subjects. Thirty obese elderly women over 60 years of age and 30 middle-aged obese women under the age of 50 years with nonspecific complaints were enrolled in the study from internal medicine outpatient clinic. Anthropometric measurements, fasting blood glucose and insulin levels, and PA tests for collagen, epinephrine, and adenosine diphosphate were evaluated. Obesity was defined as body mass index (BMI) >30 kg/m2. Homeostasis model assessment of IR (HOMA-IR) index was calculated to estimate IR. PA tests were performed with a PA profiler. Mean age of the elderly and middle-aged women were 69.6Âą9.5 years and 38.6Âą10.5 years, respectively. Waist circumference and BMI were similar between two groups. Mean HOMA-IR index value and PA with epinephrine were higher in the elderly than the control group (P=0.04; P=0.01, respectively). There was a positive correlation between HOMA-IR and PA with epinephrine in the elderly. Insulin resistance and platelet function test for epinephrine increased with advancing age in obese women. Large-scaled studies are needed in this area. Keywords: Insulin resistance, platelet aggregation, elderly, obesity

Introduction Cardiovascular disease is the leading cause of death for older adults. Platelet functions, aging, menopause, and obesity are substantial factors for cardiovascular diseases for elderly women. Platelets have a dynamic functional repertoire which alters by aging and shown to be enhanced for platelet aggregation (PA) in the elderly [1-4]. The membranes of human platelets express complete insulin receptors. In insulin-sensitive subjects, hormones play an anti-aggregating role; however, in conditions of insulin resistance (IR), such as central obesity, a significant reduction of platelet sensitivity to anti-aggregating effects of insulin has been reported [5]. Central obesity and related IR both increase in the postmenopausal period with advancing age [5-9]. Aging is associated with an increase in the fat mass and decrease in the lean mass resulting in poor outcomes. Though IR tend to increase in obese individuals, it may also increase in non-obese elderly as well with regard to age related physiological changes in both cellular and system level such as changes in the hormone levels and body composition. Coresponding Author: Sumru Savas, Ege University Faculty of Medicine, Department of Internal Medicine, Section of Geriatrics, Izmir, Turkey E-mail: esumrusavas@yahoo.com

As IR is influenced multifactorial in the elderly [10] with the increased incidence of visceral obesity after menopause [8], there may be differences between the elderly and the middle-aged obese individuals. Previously, platelet functions were evaluated in the insulin-resistant state [5], and in postmenopausal women with hormone replacement therapy (HRT) about the effect of estrogen replacement therapy on PA [11]. Recently, in several studies, it has been reported that platelets from diabetic patients are generally more reactive, and less responsive to antiplatelet therapy, and it has been suggested that the status of hyperreactivity of platelets in diabetes may be explained by several factors such as IR, poor glycemic control, and increased response to adenosine diphosphate (ADP), reactivity on contact with collagen, as well as increased levels of inflammatory status, fibrinogen levels, and increased production of epinephrine and thrombin receptor agonist peptide [1]. However, little is known regarding age-related alterations for PA in obese and elderly women. Therefore, the aim of the study was to evaluate platelet function tests in the elderly and middle-aged obese women with regard to IR, and anthropometric measurements.

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doi: 10.5455/medscience.2018.07.8855

Materials and Methods Patient Population Ninety-seven consecutive female patients over 60 years of age with non-specific complaints, between December 2012 and March 2013 were recruited in the study from the internal medicine outpatient clinic. Subjects who had underlying diseases such as cardiovascular diseases, self-reported infections, diabetes mellitus (DM), autoimmune diseases and subjects with body mass index (BMI) <30 kg/m2, as well as smokers, were excluded from the study. Subjects using medications likely to influence the results during the last 4 weeks, such as acetylsalicylic acid, oral contraceptives or HRT were also excluded. Finally, thirty elderly obese women were enrolled in the study. The control group consisted of forty consecutive women (ages >30 and <48 years) with non-specific complaints from the same department. Elderly women were in postmenopausal period, but control group had to have regular cycles (recent history of regular menstruation with 25–35 days per cycle). After applying the aforementioned exclusion criteria described above, individuals with hysterectomy or bilateral oophorectomy were also excluded. Finally, thirty middle-aged obese women were also enrolled in the study. The study protocol was approved by the local Ethics Committee. All subjects gave written informed consent before the study.

Med Science 2018;7(4):813-6

µmol, 2 µg/L, and 10 µmol, respectively. The aggregation responses were quantified as the maximum extent of aggregation, calculated by the maximum change in light transmission. This response was expressed as a percentage, considering the difference between light transmission for the platelet suspension and suspension buffer as a value of 100% (normal values were 60%–90% for collagen; 70%– 90% for epinephrine; 70%–90% for ADP). Statistical Analysis For continuous variables, the differences between the elderly group and the control group were assessed using Student’s t-test. Pearson’s correlation coefficients were calculated to evaluate the correlations between continuous variables. Numerical variables were summarized as means ± standard deviations. A level of P <0.05 was considered statistically significant. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS/Windows version 18.0, SPSS Inc., Chicago, IL, USA). Results Demographic and anthropometric characteristics of the elderly and control groups are shown in Table 1. The elderly group was between 61 and 81 years of age where the middle-aged group was between 31 and 47 years of age. No statistically significant differences with regard to BMI and waist circumference were observed between the elderly and control group (P=0.70 and P=0.30, respectively).

Anthropometrics and Laboratory Assessments/Reagents Clinical examinations and laboratory blood analyses were carried out in the same center. Body mass index was calculated using the weight (kg) divided by the height (m) squared. Waist circumference was measured at the midpoint between the lower border of the rib cage and the iliac crest. Blood samples were collected after a 12hour fasting period.

Table 1. Demographic and anthropometric characteristics of the elderly and control groups

Serum concentrations of glucose were determined by enzymatic procedures. Serum insulin levels were measured by chemiluminescence (IMMULITE 2000, Diagnostic Products Corporation, Los Angeles, CA, USA). Insulin resistance was estimated using the Homeostasis model assessment of IR (HOMAIR) index, which was calculated by the following formula: Fasting insulin [µIU/mL] × fasting glucose [mg/dL]/405, with higher values indicating a greater amount of IR [12]. Epinephrine, ADP soluble calf skin collagen, and other nonspecific reagents were purchased from Bio/Data Corporation (Horsham, PA, USA) used as platelet aggregating agents. Platelet function tests were performed with a PA profiler (Bio/Data Corporation. Horsham, PA, USA). Human platelet-rich plasma (PRP) was prepared according to a previously published method [13]. Venous blood samples were freshly obtained from patients. In order to obtain PRP, the blood samples were immediately mixed with 3.8% citrate (9:1 volume/volume) and then centrifuged at 150 x g for 15 minutes at room temperature. PRP (the top layer) was removed using a plastic Pasteur pipette and transferred to a clean plastic centrifuge tube. The remaining red cells and buffy coat were centrifuged at 1500 x g for 15 minutes to obtain autologous platelet-poor plasma. In vitro PA was monitored simultaneously using a Lumi-Aggregometer (Bio/DataCorporation, Horsham, PA, USA) according to the manufacturers’ instructions [14]. Measurements were made for ADP, collagen, and epinephrine; the final concentrations were 10

Parameter

Elderly group (n=30)

Control group (n=30)

69.6 ± 9.5

38.6 ± 10.5

0.001

(61 – 81)

(31 – 47)

Body Mass Index (kg/m2)

31.3 ± 4.1

32.5 ± 6.3

0.70

Waist Circumference (cm)

117.0 ± 16.1

114.1 ± 19.8

0.30

Age, years (range)

Data are expressed as mean ± standard deviation

Biochemical parameters and platelet function tests for the two groups are presented in Table 2. Although the mean level of fasting insulin was found to be higher than the control group, this difference was not statistically significant (P=0.80). Mean HOMA-IR index value was higher in the elderly group than the control group (P=0.04). Platelet counts were similar between the groups (P=0.45). Epinephrine induced aggregation of platelet was higher in the elderly than the control group (P=0.01), where platelet function tests for ADP and collagen were similar between the two groups (P=0.9 and P=0.7, respectively). There was a strong positive correlation between HOMA-IR and platelet function test for epinephrine (r=0.980, P=0.01) in the elderly. The correlations between body weight and BMI as well as the associations between HOMA-IR, insulin, and and fasting blood glucose are not discussed for both groups and the sample as a whole. Moreover, the associations between the aggregating reagents are not mentioned, as these associations are beyond the scope of this article. No other correlations were present in the elderly and the control group. 814

doi: 10.5455/medscience.2018.07.8855 Table 2. Biochemical parameters and platelet aggregation tests in the elderly and control groups Parameter Fasting Glucose (mg/dL) Fasting Insulin (μU/mL) HOMA-IR

Elderly group (n=30)

Control group (n=30)

95.9 ± 16.1

89.1 ± 22.1

0.70

10.9 ± 3.1

8.9 ± 2.5

0.80

2.80 ± 0.01

2.01 ± 0.3

0.04

Platelet (x10 /mm )

415.7 ± 51.3

399.1±42.9

0.45

ADP (%)

68.5 ± 15.7

65.9 ± 19.0

0.90

Epinephrine (%)

79.2 ± 16.7

65.9 ± 22.9

0.01

Collagen (%)

69.5 ± 17.1

66.1 ± 11.6

0.70

Data are expressed as mean ± standard deviation. HOMA-IR, Homeostasis model assessment-insulin resistance; ADP, Adenosine diphosphate

Discussion Aging is generally associated with changes in platelet function and IR [3-6,15,16]. Since visceral obesity increases after menopause and relates with IR, and also platelet functions alter in the insulinresistant state [5] and during HRT [11], we aimed to investigate aforementioned variables in older and adult groups in order to reveal age related changes in IR, PA, and anthropometric measurements with obesity. We report that IR and epinephrine induced PA was higher in elderly obese women than the middle –aged group, in this study. In the present study, we investigated IR in elderly female subjects who are in postmenopausal period and in middle-aged women with no menstrual cycle deterioration. Though both groups were obese and there was no statistically significant difference for BMI between the two groups; IR in the elderly group was significantly higher than the control group. This data is consistent with the study of Gupte et al., that aging was associated with an increase in IR [15]. Recently, it has been suggested that the aging process was characterized by a progressive increase in fat mass and more central distribution of adipose tissue [16]. However, we failed to demonstrate such an association. Though mean waist circumference in the elderly group was higher than the control group, it was not statistically significant which may be due to the limited number of participants. Besides, body composition analyses were not available for our study group. Moreover, IR also increases in menopause [17]. It has been reported that estrogens improve glucose homeostasis in experimental and clinical studies [18]. However, through which mechanisms estrogen exactly influences IR remains unclear [19]. It may be speculated that higher IR in the elderly women group may be in part due to menopausal changes in the estrogens and other related hormones. The association of increasing age and platelet reactivity was investigated in several studies, though the longstanding view is that platelet reactivity increases with age, the results are not very clear [1-4,20-23]. Platelet aggregation in PRP was found to be increased with increasing age, relative to young individuals, in response to the agonists ADP, epinephrine, collagen, and arachidonic acid, in a previous study [20]. However, in this study by Johnson at al., the finding of enhanced platelet sensitivity to aggregating stimuli based on a group defined as ‘high-risk age group’ with a mean age of 45.7, and a younger group (mean age=24.2) [20]. In the present study, we found an increased response to one agonist rather than a uniform increase in platelet reactivity; the PA for epinephrine was

Med Science 2018;7(4):813-6

significantly higher in the elderly than the control group. The age range of the two study groups are very different from each other, this may have caused the difference in the results. The results from the study by Emery et al. are consistent with our findings of similarity of PA responses to ADP and collagen in the elderly and control group; in which they showed that there were not any significant age-related differences of PA in citrated whole blood in response to the agonists’ collagen, arachidonic acid, and ADP [21]. However, they did not study platelet responses to epinephrine [21]. In contrast with this study, Kasjanovova and Balaz reported that platelets of individuals aged 60 years of age demonstrated greater aggregation in response to ADP and collagen than younger individuals’ platelets [22]. Likewise, Chao et al. reported that collagen-induced PA increased with aging in non-smoker men where the range of age was 40 to 69 years [23]. However, both studies covered a restricted age range from middle age to 65/69 years old, incomparable to our range of age in the elderly group. In 2009, Gilstad et al. focused on individuals aged 45 to 92 years with stable angina where age was negatively correlated with PA, integrin alphaIIbbeta3 activation, and P-selectin exposure, suggesting that there may be differences for the changes of PA with aging [24]. In a recent study of 533 consecutive stented patients with chest pain, testing platelet function to predict hypo responsiveness to clopidogrel, reported that non-insulin-dependent DM, African American race, gender and age predicted hyporesponsiveness [1]. The significantly higher response to epinephrine in our older age group may be, in part, due to postmenopausal changes in the hormones. However, the results of the studies about the effect of estrogens, gender and HRT on adhesion and aggregation of platelets are sparse and conflicting. While Otahbachi et al. reported that females scored higher with epinephrine in comparison with male subjects [25], Bar J et al. reported that the use of HRT was associated with a decrease in the aggregation of platelets induced by adrenaline [11]. However, in another study, it has been reported that HRT may increase platelet activation [26]. Additionally, our findings are not consistent with the results of the subgroup of Johnson et al. where they reported that there was no significant difference in platelet responses to either ADP or adrenaline between the two groups of premenopausal women (mean age 45.9) and postmenopausal women (mean age 57.0) [20]. However, the age ranges of the two study groups were different from each other as described before. On the other hand, platelets are sites of insulin action and considered to be subject to variation of insulin sensitivity. Insulin is considered to reduce platelet responses to the agonists ADP, thrombin, adrenaline, platelet-activating factor, collagen and sodium arachidonate [27]. Insulin down-regulates the number of α2 adrenergic receptors on platelets in the presence of (-)-epinephrine by 50-60% when compared with the control [28]. However, the anti-aggregator ability of insulin is reduced in obese insulin-resistant subjects [29]. We found a strong positive correlation between HOMA-IR and platelet function test for epinephrine in the obese elderly group, it could be speculated that higher IR in the elderly group may have functioned against aforementioned down-regulation mechanisms. Recently, a lower-than-expected efficacy of antiplatelet drugs in the prevention of cardiovascular events has been defined as drug “resistance”, firstly described for acetylsalicylic acid treatment, has also been suggested for pharmacologically different antiplatelet drugs such as P2Y12 inhibitors. The “resistance” for clopidogrel 815

doi: 10.5455/medscience.2018.07.8855

has been suggested to be associated with DM, BMI, age, gender, smoking, and genetic polymorphisms [30,31] which also may suggest enhanced PA in the elderly in association with glucose metabolism disorders, gender, and body composition. However, in a systematic review and meta-analyses of randomized clinical trials on efficacy and safety of P2Y12 inhibitors according to diabetes, age, gender, BMI and body weight; it has been reported that across a wide spectrum of vascular diseases, clopidogrel does not seem to have a different efficacy profile according to diabetes, age, or gender [30]. Additionally, most of the studies reporting “resistance” to antiplatelet medication have relied on ex vivo measurements of platelet functions [31]. However, such tests have high within-subject variability, and the relation between ex vivo and in vivo platelet activation is unclear which could explain the varying associations across studies between baseline ex vivo “resistance” and cardiovascular outcomes [30,31]. The limitations of this study were limited number of the participants, lack of body composition analyses, and biochemical analyses regarding hormone levels. Conclusion Increasing age was associated with higher PA for epinephrine and IR shown as the HOMA˗IR value for women, in this study. The reason for the increased response to epinephrine and relationship regarding IR remain uncertain in the elderly obese women. Thus, underlying mechanisms in the age-related pattern of PA tests in the obese elderly women should be further investigated in large scaled studies investigating gender differences, especially in the very old age group. Acknowledgement

The authors would like to thank hematology laboratory of Internal Medicine Department, Medical School, Ege University, for performing platelet aggregation tests. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval The study protocol was approved by the local Ethics Committee. All subjects gave written informed consent before the study.

References 1.

Sharma RK, Erickson SW, Sharma R, et al. Platelet function testing to predict hyporesponsiveness to clopidogrel in patients with chest pain seen in the emergency department. Vasc Health Risk Manag. 2013;9:187-93.

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Stachowiak G, Pertyński T, Pertyńska-Marczewska M. Metabolic disorders in menopause. Prz Menopauzalny. 2015;14:59-64.

Kohrt WM, Kirwan JP, Staten MA, et al. Insulin resistance in aging is related to abdominal obesity. Diabetes. 1993;42:273-81.

10. Lee JW, Im JA, Park KD, et al. Retinol binding protein 4 and insulin resistance in apparently healthy elderly subjects. Clin Chim Acta. 2009;400:30-2. 11. Bar J, Tepper R, Fuchs J, et al. The effect of estrogen replacement therapy on platelet aggregation and adenosine triphosphate release in postmenopausal women. Obstet Gynecol. 1993;81:261-4. 12. Matthews DR, Hosker JP, Rudenski AS, et al. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985;28:412-9. 13. Nakahashi TK, Kambayashi J, Nakamura T, et al. Platelets in nonresponders to epinephrine stimulation showed reduced response to ADP. Thromb Res. 2001;104:127-35. 14. Toyoda H, Nakai K, Omay SB, et al. Differential association of protein Ser/ Thr phosphatase types 1 and 2A with the cytoskeleton upon platelet activation. Thromb Haemost. 1996;76:1053-62. 15. Gupte AA, Bomhoff GL, Geiger PC. Age-related differences in skeletal muscle insulin signaling: the role of stress kinases and heat shock proteins. J Appl Physiol. 2008;105:839-48. 16. Seo JA, Kim BG, Cho H, et al. The cutoff values of visceral fat area and waist circumference for identifying subjects at risk for metabolic syndrome in elderly Korean: Ansan Geriatric (AGE) cohort study. BMC Public Health. 2009;9:443. 17. Carr MC. The emergence of the metabolic syndrome with menopause. J Clin Endocrinol Metab. 2003;88:2404-11. 18. Louet JF, LeMay C, Mauvais-Jarvis F. Antidiabetic actions of estrogen: insight from human and genetic mouse models. Curr Atheroscler Rep. 2004;6:180-5. 19. Mu P, Tan Z, Cui Y, et al. 17β-Estradiol attenuates diet-induced insulin resistance and glucose intolerance through up-regulation of caveolin-3. Ir J Med Sci 2011;180:221-7. 20. Johnson M, Ramey E, Ramwell PW. Sex and age differences in human platelet aggregation. Nature. 1975;253:355-7. 21. Emery JD, Leifer DW, Moura GL, Whole-blood platelet aggregation predicts in vitro and in vivo primary hemostatic function in the elderly. Arterioscler Thromb Vasc Biol. 1995;15:748-53. 22. Kasjanovova D, Balaz V. Age-related changes in human platelet function in vitro. Mech Ageing Dev. 1986;37:175-82. 23. Chao FC, Tullis JL, Alper CA, et al. Alteration in plasma proteins and platelet functions with aging and cigarette smoking in healthy men. Thromb Haemost. 1982;47:259-64. 24. Gilstad JR, Gurbel PA, Andersen RE. Relationship between age and platelet activation in patients with stable and unstable angina. Arch Gerontol Geriatr. 2009;48:155-9. 25. Otahbachi M, Simoni J, Simoni G, et al. Gender differences in platelet aggregation in healthy individuals. J Thromb Thrombolysis. 2010;30:184-91. 26. Cano A, Van Baal WM. The mechanisms of thrombotic risk induced by hormone replacement therapy. Maturitas. 2001;40:17-38.

Wilkerson WR, Sane DC. Aging and thrombosis. Semin Thromb Hemost. 2002;28:555-68.

Jones CI. Platelet function and ageing. Mamm Genome. 2016;27:358-66.

Mohebali D, Kaplan D, Carlisle M, et al. Alterations in platelet function during aging: clinical correlations with thromboinflammatory disease in older adults. J Am Geriatr Soc. 2014;62:529-35.

Anfossi G, Russo I, Trovati M. Platelet dysfunction in central obesity. Nutr Metab Cardiovasc Dis. 2009;19: 440-9.

Rubio-Ruiz ME, Peredo-Escárcega AE, Cano-Martínez A, et al. An Evolutionary Perspective of Nutrition and Inflammation as Mechanisms of Cardiovascular Disease. Int J Evol Biol. 2015;2015:179791.

30. Zaccardi F, Pitocco D, Willeit P, et al. Efficacy and safety of P2Y12 inhibitors according to diabetes, age, gender, body mass index and body weight: Systematic review and meta-analyses of randomized clinical trials. Atherosclerosis.2015;240:439-45.

Zeyda M, Stulnig TM. Obesity, inflammation, and insulin resistance--a minireview. Gerontology. 2009;55:379-86.

31. Siller-Matula JM, Trenk D, Schrör K, Response variability to P2Y12 receptor inhibitors: expectations and reality. JACC Cardiovasc Interv. 2013;6:1111-28.

27. Trovati M, Anfossi G. Insulin, insulin resistance, and platelet function: similarities with insulin effects on cultured vascular smooth muscle cells. Diabetologia. 1998;41:609-22. 28. Kahn NN, Sinha AK. Down regulation of alpha 2 adrenergic receptor numbers in platelets by insulin. Biochim Biophys Acta. 1992;1134:292-6. 29. Anfossi G, Russo I, Trovati M. Platelet resistance to the anti-aggregating agents in the insulin resistant states. Curr Diabetes Rev. 2006;2:409-30.

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Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):817-20

The effect of manganese exposure on erythropoietic and reproductive system parameters Servet Birgin Iritas1, Lutfiye Tutkun2, Meside Gunduzoz3, Serdar Deniz4, Vugar Ali Turksoy5 1 The Council of Forensic Medicine, Ankara, Turkey Bozok University , Faculty of Medcine, Department of Medical Biochemistry, Yozgat, Turkey 3 Occupational Diseases Hospital, Department of Family Medicine, Ankara, Turkey 4 Provincial Health Directorate, Malatya, Turkey 5 Bozok University, Faculty of Medcine, Department of Public Health, Yozgat, Turkey

Received 18 April 2018; Accepted 03 May 2018 Available online 24.07.2018 with doi: 10.5455/medscience.2018.07.8851 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The aim of this study is determining the effect of manganese (Mn) exposure on erythropoietic and reproductive system. A study group consisting of 51 non-smoking welders older than 18 years old with Mn exposure, who visited Ankara Occupational and Environmental Diseases Hospital, and a control group consisting of 79 healthy office employees without Mn exposure, were chosen as study group. Blood Mn level, total testosterone (TT), freetestosterone (FT), alanine aminotransferase (ALT), aspartate aminotransferase(AST), thyroid stimulant hormone (TSH), triiodothyronine (T3), thyroxine (T4), uric acid, creatinine, complete blood count (CBC), prolactin, follicle stimulating hormone (FSH), luteinizing hormone (LH) levels were analysed along with the demographic data of the patient. The study and control groups consisting of a total of 130 persons were all male, 39.2% (n=51) of which represented the study group with manganese exposure and 60.8% (n=79) of which represented the healthy control group. A significant difference was identified statistically between Mn (t= 4,501, p= 0,000), FT (t= -6.959, p=0.000), TT (t= -2.835, p=0.005) values of those with and without manganese exposure. AST and ALT levels were not found significant although they were higher in the exposed group. When the values are examined according to uric acid, creatinine, TSH, T3, T4and complete blood count, it was observed that the values of exposure group and control group were almost identical. Although FHS, LH and PRL values were high in the study group, the differences were not found significant. Consequently, although Mn is a trace element, it was concluded that, in high levels,it might reduce the testosterone synthesis with direct toxic effect on the testicle in the long-term exposures leading. Keywords: Manganese, prolactin, FSH, LH, testosterone, reproductive dysfunction

Introduction

dysfunction [11-15].

Manganese is a metal naturally occurring in the earth’s crust, available in both organic and inorganic forms. Pure manganese is silver colored, but it does not occur naturally. They are available in organic compounds as they combine with the substances such as oxygen, sulphur and chlorine. Manganese is used in the industry as an oxidising agent to improve the steel production and to plate the welding rods and also used in the production of fireworks, battery, fertilizer, glass, paint, cosmetics, as a textile decolourant, as an imaging agent in medicine and as an additive some drugs and gasoline [1-3].

Material and Method

Daily intake of Mn with food is 2-9 mg and as a trace element it is necessary for various metabolic functions, such as energy metabolism in the growth of the metabolism, activation of metalloenzymes, reproduction hormone and antioxidant enzyme functions [3-9]. There are studies which have determine that serum prolactin and cortisol levels increased [10] in those with chronic Mn exposure, and high Mn exposure can cause sexual *Coresponding Author: Servet Birgin Iritas, The Council of Forensic Medicine, Ankara, Turkey E-mail: sbiritas@gmail.com

Study Groups 51 welders with Mn exposure, having an average age of 38.90, who visited Ankara Occupational and Environmental Diseases Hospital, were selected as the study group and 79 healthy office employees without any Mn exposure, having an average age of 38.26, were selected as the control group. In each group, the males above 18 years of age are non-smokers. The Decision of the Ethical Committee of Ankara Keçiören Training and Research Hospital is available for the study. Measurements The haematological analysis were made with Cell-Dyn Emerald Hematologic Analyser with blood samples taken in the tubes containing Ethylene Diamine Tetra Asiatic acid (EDTA), the manganese results, with Inductively Coupled Plasma – Mass Spectrometer (ICP-MS) Agilent 7.700 from the blood samples taken in the tubes containing EDTA and FSH, LH, PRL, TST analysis, with Abbott Architect i2000 Immunoassay device from blood samples taken in the tubes containing EDTA. 817

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Med Science 2018;7(4):817-20

Statistical Analysis SPSS22.0 software was used in statistical analysis. Data distribution was determined with Kolmogorov-Smirnow test. In the study, the statistical significance level of which was accepted as 0.05, the difference between the averages of two independent variables was evaluated with t-test; the difference between more than two variables was evaluated with two-way analysis of variance (ANOVA) and additionally with Pearson Correlation analysis. The averages are given with the standard deviations.

A significant difference was identified statistically between Mn (t= 4.501, p= 0,000), FT (t= -6.959, p=0.000), TT (t= -2.835, p=0.005) values of those of exposed and non-exposed group. AST and ALT levels were also higher in the exposed group (23.76 and 54.82) then in the non-exposed group (18.81 and 22.91) but the differences were not significant. When the values are examined according to uric acid, creatinine, TSH, T3, T4 and complete blood count, it was observed that the values of exposure group and control group were almost identical.

Result The study and control group are male, 39.2% (n=51) were manganese exposed and 60.8% (n=79) is non-exposed.

Although FHS, LH and PRL values were high in the exposed group, the differences were not found significant (Table 1).

Table 1. The Statuses of Continuous Variables, Based on Manganese Exposure Age Mn (µg/L) FT (ng/ml) TT (ng/ml) ALT (U/L) AST (U/L) TSH (µıu/ml) CREATININE (mg/dl) T3 (pg/ml) T4 (ng/dl) URIK ACID (mg/dl) WBC (x109/L) RBC(x1012/L) HGB (g/L) MCV (f/L) HCT (%) MCHC (g/L) MCH (pg/cell) RDW (%) PLT (K/uL) NEU (x109/L) LYM (x109/L) MPV (fL) PDW (%) PCT (%) FSH (mlu/ml) LH (mlu/ml) PROLACTINE (mlu/ml)

Group Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control Exposed Control

N 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79 51 79

Mean 38.90 38.26 22.99 8.97 9.00 13.38 5.21 6.42 26.66 22.91 20.92 18.81 1.62 1.65 0.82 0.82 3.00 3.00 1.02 1.02 5.65 5.32 7.15 7.38 5.22 5.30 15.30 15.58 87.70 87.88 45.64 46.52 33.51 33.52 29.42 29.46 15.63 15.74 219.17 223.94 4.03 4.12 2.25 2.44 8.10 7.97 17.97 18.14 0.17 0.17 4.14 3.55 4.11 3.94 13.06 12.65

Std. Deviation 8.02 8.90 22.11 2.96 2.67 3.95 2.51 2.26 15.85 11.08 7.32 4.66 0.94 0.97 0.09 0.10 0.55 0.39 0.15 0.13 1.32 1.11 1.83 1.82 0.57 0.47 1.51 1.32 4.94 5.58 4.58 3.88 0.96 1.05 1.96 2.24 1.19 1.39 62.15 49.24 1.21 1.32 0.64 0.76 1.42 1.33 1.52 1.34 0.05 0.03 1.74 2.21 1.67 1.61 6.09 6.95

0.413

0.680

4.501

0.000

-6.959

0.000

-2.835

0.005

1.589

0.115

1.831

0.071

-0.192

0.848

-0.128

0.899

0.073

0.942

-0.050

0.960

1.536

0.127

-0.691

0.491

-0.906

0.367

-1.115

0.267

-0.188

0.851

-1.176

0.242

0.061

0.951

-0.121

0.904

-0.490

0.625

-0.486

0.628

-0.398

0.691

-1.459

0.147

0.541

0.589

-0.663

0.509

-0.104

0.917

1.712

0.089

0.572

0.568

0.348

0.729

818

doi: 10.5455/medscience.2018.07.8851

The Pearson correlations between ages, manganese level, duration of employment, free testosterone, FSH, LH, PRL are given in Table 2. The strongest correlation was observed to be between FSH and LH and the free testosterone had a negative correlation with PRL and manganese level. Table 2. Pearson Correlations of Continuous Variables N=130

Age

Working Time FT

Age

-.042

.192

-.125 1

Mn Working Time

FT FSH LH PRL

FSH

-.262

.312

.247

-.007

-.214*

.012

-.011

.028

-.156

.227**

.041

-.048

-.165

-.037

.185*

.458**

.030

.288**

PRL **

While the testosterone levels varied according to the age groups (p<0.001) and whether there was any exposure (p<0.001) in the investigation conducted with two-way ANOVA, the collective effect of each variant was not found significant statistically (F=2.844 p=0.062) (Figure 1). The statistical study suggested a positive correlation between the Manganese level for the control group without any Mn level and HGB (r= 0.228, p=0.044), MCV (r=0.231, p=0.041), MCH (r=0.222, p=0.049). 1. 2. 3. 4. 5.

Med Science 2018;7(4):817-20

we have detected in our study accounts for the essential properties of Manganese at low levels. Kim et al. found out that FSH, LH and testosterone levels increased in the workers exposed to Mn, in the study they conducted on 251 welders to examine the effect of Mn exposure on the neuroendocrine system. In another study, no correlation was found between FSH, LH or testosterone levels in the welders [23]. In a study conducted on the employees working at a dry alkaline battery manufacturing plant, all erythropoietic parameters and serum iron concentrations is lower in Mn exposed group. On the other hand Ca, prolactin, FSH or LH levels were found to be similar in exposed group and control group [24]. Another study discovered that FSH, LH and testosterone levels have decreased [9]. The studies conducted on people with chronic Mn exposure at the workplace showed no haematological effect in high Mn levels [3,25-28], similar to our study. The liver has an active role in transport of manganese. A recent study revealed no pathological finding in the liver biopsy in a group consisting of 13 patients who have been monitored for chronic Mn intoxication [3,25]. The animal studies showed an increase in the liver enzymes following the long-term Mn exposure and when exposure was discontinued, liver enzymes were found to recovering different periods [3,29-32].Although, in our study, the levels of AST and ALT were high in Mn exposed group, they were found insignificant. Conclusion Testosterone is known to play a role in regulating the sexual activity, libido, social behaviors, cognitive functions, sleep control and wellbeing in males and females. We think that the effect of Mn exposure on the endocrine parameters needs to be reviewed in comprehensive studies which will also include the clinical reflections. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves.

Figure 1. Two-way ANOVA analyse

Discussion This seem to be the first study which investigated the correlation between Mn exposure and testosterone levels according to literature search. The mechanism of toxic effect of Mn exposure on the endocrine system is not very clear. However, oxidative stress is thought to be one of the important reasons in metal exposures [16-21]. It was found out that manganese caused maturation delays in the reproductive organs. Testosterone levels reduced following the manganese application and LH levels remained considerably unchanged. Manganese seems to target the Leydigcells [3,22].We found out similar results in our study. Nevertheless, the positive correlation between Mn and Hgb in the healthy control group that

Ethical approval The Decision of the Ethical Committee of Ankara Keçiören Training and Research Hospital is available for the study.

References 1.

Saric M. Manganese. Handbook on the toxicology of metals, vol. II: Specific metals. New York: Elsevier Science Publishing Co. 1986; p. 354-86.

Santamaria AB. Manganese exposure, essentiality & toxicity. Indian J Med Res. 2008;128:484-500.

U.S. Centers for Disease Control (ATSDR). “Toxicological Profile for Manganese” Registry. 2012. Available at: https://www.atsdr.cdc.gov/ toxprofiles/tp151.pdf

Barceloux. DG. Manganese. J Toxicol Clin Toxicol. 1999;37:293-307.

Institute of Medicine (US) Panel on Micronutrients. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc . Washington (DC): National Academies Press (US); 2001.

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Davis, CD, Greger, JL. Longitudinal changes of manganese-dependent superoxide dismutase and other indexes of manganese and iron status in women. Am J Clin Nutr. 1992;55,747-52.

19. Brouillet EP, Shinobu L, McGarvey U. et al. Manganese injection into the rat striatum produces excitotoxic lesions by impairing energy metabolism. Exp Neurol. 1993;120:89-94.

Rabin O, Hegedus L, Bourre JM, et al. Rapid brain uptake of manganese (II) across the bloodâ&#x20AC;&#x201C;brain barrier. J Neurochem. 1993;61:509-17.

Santamaria AB, Sulsky SI. Risk Assessment of an essential element: manganese. J Toxicol Environ Health A. 2010;73:128-55.

20. Desole MS, Esposito G, Migheli R. et al. Allopurinol protects against manganese-induced oxidative stress in the striatum and in the brainstem of the rat. Neurosci Lett. 1995;192:73-6.

Adedara IA, Subair TI, Ego VC, et al. Chemoprotective role of quercetin in manganese-induced toxicity along the brain-pituitary-testicular axis in rats. Chem-Biol Interact. 2017;263:88-98.

10. Alessio L, Apostoli P, Ferioli A. et al. Interference of manganese on neuroendocrinal system in exposed workers. Preliminary report. Biol Trace Elem Res. 1989;21:249-53.

21. Hussain S, Lipe GW, Slikker W, et al. The effects of chronic exposure of manganese on antioxidant enzymes in different regions of rat brain. Neuro sci Res. 1997;21:135-44. 22. Laskey JW, Rehnberg GL, Hein JF, et al. Effects of chronic manganese (Mn3O4) exposure on selected reproductive parameters in rats. J Toxicol Environ Health. 1982;9:677-87. 23. Hjollund NH, BondeJP, Jensen TK, et al. Semen quality and sex hormones with reference to metal welding. Reprod Toxicol 1998;12:91-5.

11. Huang YL, Tseng WC Lin TH. In vitro effects of metal ions (Fe2+, Mn2+, Pb2+) on sperm motility and lipid peroxidation in human semen. J. Toxicol. Environ. Health A. 2001;62:259-67.

24. Roels HA, Ghyselen P, Buchet JP. et al. Assessment of the permissible exposure level to manganese in workers exposed to manganese dioxide dust. Br J Ind Med. 1992;49:25-34.

12. Bowler RM, Roels HA, Nakagawa S, et al. Dose-effect relations between manganese exposure and neurological, neuropsychological and pulmonary function in confined space bridge welders. Occup Environ Med. 2007;64:16777.

25. Mena I, Marin O, Fuenzalida S. et al. Chronic manganese poisoning. Clinical picture and manganese turnover. Neurology. 1967;17:128-36.

13. Wirth JJ, Rossano MG, Daly DC, et al. Ambient Manganese Exposure is Negatively Associated with Human Sperm Motility and Concentration. Epidemiology. 2007;18:270-3. 14. Kim EA, Cheong HK, Joo KD, et al. Effect of manganese exposure on the neuroendocrine system in welders. Neurotoxicology. 2007;28:263-9. 15. Crossgrove J, Zheng W. Manganese toxicity upon overexposure. NMR Biomed. 2004;17:544â&#x20AC;&#x201C;53. 16. Jain M, Kalsi AK, Srivastava A, Gupta YK, et al. High serum estradiol and Heavy Metals Responsible for Human Spermiation Defect-A Pilot Study. J Clin Diagn Res. 2016;10:09-13.

26. Roels H, Lauwerys R, Buchet JP. et al. Epidemiological survey among workers exposed to manganese: Effects on lung, central nervous system, and some biological indices. Am J Ind Med. 1987;11:307-27. 27. Smyth LT, Ruhf RC, Whitman NE. et al. Clinical manganism and exposure to manganese in the production and processing of ferromanganese alloy. J Occup Med. 1973;15:101-9. 28. Whitlock CM Jr, Amuso SJ, Bittenbender JB. Chronic neurological disease in two manganese steel workers. Am Ind Hyg Assoc J. 1966;27:454-9. 29. Bernardino ME. Young SW. Lee JK, et al. Hepatic MR imaging with MnDPDP: Safety, image quality, and sensitivity. Radiology. 1992;183:53-8. 30. Lim KO. Stark DD. Leese PT. et al. Hepatobiliary MR imaging: first human experience with MnDPDP. Radiology. 1991;178:79-82.

17. Pahune PP, Choudhari AR, Muley PA. The total antioxidant power of semen and its correlation with the fertility potential of human male subjects. J Clin Diagn Res. 2013;7:991-5.

31. Wang C. Gordon PB, Hustvedt SO. et al. MR imaging properties and pharmacokinetics of MnDPDP in healthy volunteers. Acta Radiologica. 1997;38:665-76.

18. Rao B, Soufir JC, Martin M, et al. Lipid peroxidation in human spermatozoa as related to midpiece abnormalities and motility. Gamete Res. 1989;24:127-34.

32. Larsen LE. Grant D. General toxicology of MnDPDP. Acta Radiol. 1997;38:770-9.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):821-5

Burnout in health sector: Sample of public hospital Feyza Nazik1, Emine Yilmaz1, Halim Tatli2 Bingol University, Faculty of Health Sciences, Department of Nursing, Bingol, Turkey 2 Bingol University Faculty of Economics and Administrative Sciences

Received 26 April 2018; Accepted 10 May 2018 Available online 12.10.2018 with doi:10.5455/medscience.2018.07.8879 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The burnout is an emotionally negative reaction activated in individuals in response to difficulties encountered with in the work place. The aim of study was to ases the presence of burnout levels and related factors among health works in Bingol Public Hospital. This study was carried out in caregivers in Bingol. Of the 230 health workers in the hospital, 161 were surveyed. The socio-demographic guestionnaire form and Maslach Burnout Inventory were used to collect data. The mean age of participants was 32.8±7.5 years. Of the respondents, 62.1% was nurse. The mean scores taken by the respondents in the emotional exhaustion, depersonalization, and personal accomplishment sub-scales of the burnout inventory were 18.8±6.8, 6.6±3.6, and 21.1±4.1 respectively. The mean depersonalization score of the nurses was 7.0±3.3, whereas the mean depersonalization score of other healthcare workers (technicians, clinical secretary, etc.) was 5.1±3.9 (p<0.05). The mean emotional exhaustion score of the female staff was 20.0±6.8, whereas it was 17.5±6.7 for the male staff (p<0.05). Correlation analysis indicated that emotional exhaustion increases with increasing weekly working hours. It was found that gender, profession, weekly working hours, and having children were effective on burnout. It is recommended to extend social support provided to employees as well as regulating the working hours. Keywords: Health sector, burnout, hospital

Introduction

concept of burnout is that it is more prevalent among occupations

Burnout is one of the significant elements that affect the today’s working life adversely. Starting as a reaction to the stressors related to the job, it is a process that affects the behaviors and habits of employees negatively [1]. Burnout consists of three components: emotional exhaustion, depersonalization, and personal accomplishment. Emotional exhaustion subscale is the most important determinant of burnout and it indicates how people feel exhausted and overwhelmed emotionally. Being emotionally exhausted, the individuals keep themselves from people psychologically in the next stage by restricting their relationship with the people in their circle. The depersonalization subscale is the act of exhibiting attitudes and behaviors deprived of emotions by the individuals against the people to whom they give service. The individuals are approached as objects rather than a human. On the other hand, in the personal accomplishment subscale, individuals feeling incompetent in business and human relations start to consider themselves as insufficient for carrying out their work [2,3]. The other most significant point related to the

that require face-to-face relationship with others [4]. The risk of burnout among professionals working with people is higher as the sense of responsibility towards people is more than the sense of responsibility towards objects [2]. Healthcare personnel are at risk in terms of burnout due to nature of their professions. When examining the factors causing burnout in healthcare professionals, following factors can be regarded such as unclear job definition of some professions; lack of organizational support; performance of the same job by individuals having education at different levels; working system (shift); working with low salary; excessive weekly working duration and a larger number of patients [5,6]. In the studies investigating the burnout level of the healthcare professionals in Turkey, it was found that female professionals experienced emotional exhaustion more intense than the male professionals; and as number of watches and weekly working period increased, emotional exhaustion and depersonalization also increased [7,8]. The studies have revealed that the burnout levels of nurses are higher than the other healthcare professionals since they communicate with patients for a longer period and these patients are individuals who are children, elderly, and even terminally ill ones losing their health [1,2,5]. In the study conducted by Tunç on doctors and nurses, it was revealed that while doctors had a low burnout level, nurses had a moderate burnout level [5].

*Coresponding Author: Emine Yilmaz, Bingol University, Faculty of Health Sciences, Department of Nursing, Bingol, Turkey E-mail: emine.tog@hotmail.com

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It was found that burnout levels of nurses working in the intensive care clinic of the oncology hospital were high [9]. In the study conducted by Gandi et al., on 2245 nurses, it was determined that the burnout level of the nurses was high and especially emotional exhaustion was higher in female nurses than male nurses [1]. It was found in the study conducted abroad with 114 nurses that especially emotional exhaustion was higher among female nurses; as the working years increased, the depersonalization increased; and on those working in more stressful services such oncology, pediatrics, and emergency department, the burnout level was even more [2]. Studies have reported that burnout shall cause great cost both individually and organizationally. For instance, some of results of burnout are impaired health of the individual, deteriorated social life and family relations, decreased performance, and increased absenteeism and leave of employment [1,2,4-8,10]. In the study conducted by Kanai et al., on 100 nurses, it was determined that burnout was at high level, and especially emotional exhaustion; and with increasing burnout, job satisfaction and motivation decreased [11]. These results indicated that as a consequence of burnout, this situation could affect not only these individuals but also individuals to whom they provided care. Burnout is considered as an occupational hazard in people-oriented professions such as healthcare personnel [12]. The purpose of this study is to examine the burnout levels of health workers in terms of some variables in order to properly intervene in burnout.

Med Science 2018;7(4):821-5

confirmed by Ergin Cronbach alpha values 0.83, 0.65 and 0.72 for EE, D and PA respectively Alpha values of EE, DP and AP in this study were 0.81, 0.65 and 0.73 respectively. Statistical Analysis For analysis, SPSS 15 program wasused. Normal distribution of the variables was tested using Kolmogorov-Smirnov analysis. Mean and Standard deviations were given in descriptive analyzes. For comparisons between groups were made using the independent T test and one way anova analysis. The correlations between burnout dimension and continuous variables were calculated using the Pearson test. A p<0.05 was accepted as significant. Results Demographic and working status of health workers are presented in Table 1.According to Table 1, 53.4% of the health workers are female (85) and 68.3% are married (110). The mean age is 32.8 ± 7.5 and the working hours is 40.6 weekly. 51.6% remain night shift and the monthly number of night shift is 6.7. Table 1. Descriptive values of demographic and work variables Cathegorical variables

n (%)

Gender

Women Men

75(46.6)

Maritalstatus

Married

110(68.3)

Single

51(31.7)

Yes

98(89.1)

Materials and Methods This is a descriptive study. The study was carried out at Bingöl Public Health. The permission was obtained from Bingol Association of Public Hospitals. The number of people working at the hospital is 230 people. 161 health workers who agreed to complete the questionnaire and filled it completely were included in the survey. A questionnaire was performed between 31.01.2016 and 01.03.2016. The socio-demographic questionnaire form and Maslach Burnout Inventory were used to collect data. Descriptive Questionnaire Form The personal information form prepared by the researcher in the context of the literature includes ten questions. The study data were collected during face to face interviews with workers by authors. Each interview lasted for approximately 10 min. Maslach Burnout Inventory Burnout syndrome was measured using the Maslach Burnout Inventory (MBI) for health workers. MBI comprises 22 ıtems grouped into three domains; emotionalexhaustion (9 questions), depersonalization (D) (5 question)and personel accomplishment (PA) (8 question). The emotional exhaustion (EE) subscale defines the burnout level of an individual according to her/his job and work overload including exhaustion weariness and decrease in emotional energy. The depersonalization (DP) subscale assesses the degree to which and individual responds emotionally to those with whom he/ sheworks. The personel accomplishment(AP) dimension assesses the degree to which the employee feels a sense of accomplishment or success in his/her job. For each question, participants were required to rate their experiences on a 5 point likert scale ranging from 0 to 4. High scores for the first two dimension indicate high burnout, while third dimension suggest that the level of burnout is high. The MBI was translated into Turkish language by Ergin [13]. Reliability of the MBI among Turkish physicians and nurses were

Have a child Job

86(53.4)

12(10.9)

Physician

21(13.0)

Nurse

100(62.1)

Other

40(24.8)

Yes

83(51.6)

78(48.4)

Nightshift Continuousvariables

Mean (SD)

Age

32.8(7.5)

Number of children

1.9(0.8)

Working time in work(year)

9.0(5.4)

Workinghours (weekly)

40.6(4.0)

Number of nightshift (monthly)

6.7(2.3)

Note: SD= Standard deviation

Table 2 shows descriptive statistics of occupational burnout in health workers. The minimum score of emotional exhaustion scale was 0, the maximum was 35, and the average total score was 18.8. Depersonalization scores ranged from 0 to 19 and average score of10.6. While personal accoplishment scores ranged from 10 to 32,an average score of 21.1. Table 2. Descriptive statistics of occupational burnout in health workers Dimension

Mean (SD)

Min.

Max.

Emotional exhaustion (ED)

18.8±6.8

Depersonalization (D)

6.6±3.6

Personal accomplishment (PA)

21.1±4.1

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Table 3 shows the correlation between subscales of burnout inventory and categorical variables in health workers. As is seen in Table 3, the emotional exhaustion scores of the female health workers were significantly higher than male ones. There was no significance among gender, depersonalization and personal accomplishment. No correlation was found between marital status and the subscales of the burnout inventory. Emotional exhaustion of health workers with children was significantly lower than those who did not have children (p<0.05). Similarly, having children

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significantly increased personal accomplishment in professionals. While the emotional exhaustion scores of the nurses were significantly higher than other health workers, the depersonalization scores of nurses and doctors were significantly higher than the other health worker. Whereas those working at the night shift had significantly higher emotional exhaustion, there was no significance on depersonalization and personal accomplishment scores.

Table 3. Relation between burnout dimension and cathegorical variables Cathegoricalvariables

Emotional exhaustion Mean (SD) p value

Depersonalization Mean(SD) p value

Personal accomplishment Mean(SD) p value

Gender Female

20.0(6.8)

Male

17.5(6.7)

0.023

6.6(3.5)

0.863

6.5(3.8)

20.6(4.0)

0.077

21.7(4.1)

Marital status Married

19.0(6.8)

Single

18.4(7.1)

0.630

6.6(3.4)

0.891

6.6(4.1)

21.1(4.5)

0.950

21.1(3.2)

Have a child Yes

18.6(6.6)

22.6(7.3)

0.051

6.3(3.3)

0.022

8.7(4.0)

21.4(4.5)

0.008

19.0(2.9)

Job Physician

19.0(6.6)

Nurse

20.0(6.5)1

0.005

7.0(3.3)2

0.011

21.3(4.3)

Other

15.9(7.1)1

5.1(3.9)12

20.5(4.2)

7.5(4.0)1

21.6(2.7)

0.476

Nightshift Yes

19.9(6.4)

17.7(7.1)

0.036

6.9(3.9)

0.330

6.3(3.3)

The Pearson’s correlation analysis was used to evaluate the correlations between burnout subscales and continuous variables among health workers and the results are presented in Table 4. As is seen in Table 4, there was a positive significant correlation between the weekly working hours and emotional exhaustion (r=0.223, p<0.01). No significant correlation was found between the other variables and emotional exhaustion. No significant correlation of depersonalization and personal accomplishment

21.6(3.8)

0.110

20.6(4.3)

scores with the continuous variables was found. Table 5 shows analysis results made to determine whether or not some personal variables of the workers are an important predictor of emotional exhaustion levels within the scope of the study. It was determined that being other health workers and having children among the variables were important predictors. Gender and being on duty were not significant predictors.

Table 4.Spearman’s correlation coefficients between burnout dimension and continuous variables Continuous variables

Emotional exhaustion

Depersonalization

Personal accomplishment

Age

-0.067

-0.028

0.064

Number of children

-0.180

-0.029

0.091

Working time in work

0.018

0.027

-0.018

0.223**

0.036

0.060

0.096

0.099

-0.132

Working hours Number of nightshift

Table 5. Results of linear multiple regression analysis to determine the estimates of emotional exhaustion level of health workers Predictivevariables Constant

B 13.025

Standart error 3.477

Gender(Girl=0, Boy=1)

1.486

1.325

0.110

Doctor

0.753

1.920

0.039

Another

-3.385

1.727

-0.210*

Have a child(yes=1, no=0)

-4.309

2.054

-0.198*

Nightshift (yes=1, no=0)

0.216

1.388

0.016

Job**

Note: R2=0.10(p=0.036) *p<0.05 **Because the variable of profession was a categorical variable and since these variables were coded as slack variable, the variable category “nursing” was considered as a reference variable and excluded from the analysis.

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Discussion In this study, the burnout levels of the secondary care health workers as well as the occupational and personal characteristics affecting burnout were examined. The results of this study showed that health workers in second level of medical care had a relatively low means emotional exhaustion and depersonalization while they had high means personal accomplishment. In the study conducted by Kaya et al., on the primary care staff, it was found that the emotional exhaustion score was 14.63±6.38, the depersonalization score was 4.02±3.15, and the personal accomplishment score was 10.80±4.62 [14]. On the other hand, in another study conducted on physicians, emotional exhaustion, depersonalization, and personal accomplishment scores were found respectively as 15.48±6.70, 5.51±3.51, and 22.06±4.05 [15]. In another study conducted on physicians in Korea, the rates of emotional exhaustion and depersonalization were 37% and 21% [16]. The worker accomplishment rate, on the other hand, was high. In a study conducted on physicians in Yemen, the burnout levels were determined to be high [17]. In the province of Bingöl, the burnout scores were higher than the other provinces. This differences might be derived from culturel differences between health workers and region community, low health workers morale, low efficiency inequity in distribution manpower. In this study, females were significantly suffering from emotional exhaustion. It was found in other studies conducted in Turkey that women experienced more emotional exhaustion [14,18,19]. However, in the study by Yakut et al., no significance was found between gender and emotional exhaustion [20]. There are other studies indicating that there is no significance in terms of gender [21,22].In these studies, it is possible to see that emotional exhaustion may affect both genders. In Korea, on the other hand, burnout in the primary care worker was found to be higher in favor of men [16]. In the review by Thomas, the fact that the depression is more prevalent on women for a lifetime may be a factor, leading to burnout [23]. Emotional exhaustion was higher among women in the present study, which may be associated with the gender roles of women in society. Ongoing duties of women such as household chores and child care outside the hospital, their personal structure different from men and their emotional structure would pave the way for their exhaustion. In the present study, emotional exhaustion and depersonalization were prevalent among those having no children. In addition, the worker accomplishment of those having children was high. In the study by Taycan et al.,, those having children had higher personal accomplishment [24]. Şerik et al., revealed that as number of children increased, emotional exhaustion and depersonalization decreased [25] on the other hand, Erol et al., also indicated that those having children experienced less emotional exhaustion and depersonalization [26]. The results of the study by Yaman et al., are similar with the results of the present study It can be asserted that having children improved the time management and solution skills of people, increased social support and thus protect against burnout [22]. Based on the results of the study, nurses experienced significantly more emotional exhaustion than the other health workers. It was also found in the other studies that the group experiencing burnout

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at most among health workers was nurses [27,28]. Nurses are the occupational group that spends most of the time with the patients and their relatives. Intense and long working hours, unhealthy individuals receiving service, and working with individuals having chronic or fatal diseases are among the reasons of the high burnout and increased depersonalization among nurses. In the present study, it was found that the health workers that were working at night shift and had intensive working hours experienced emotional exhaustion at higher rate. Studies conducted on nurses also reveal that emotional exhaustion is high among employees working at shifts [29,30]. In the literature review by Günüşen and Üstün, it was stated that working at shifts and having increased working hours were significant factors causing job related burnout [31]. It is known that having sleep disorders may pave the way for the burnout process[32]. People working at shifts are negatively affected from psychological, social, and biological aspects. At the night shift, factors such as working with few people, having an increased work load, lack of communication, and disturbed sleep process affect people negatively and increase burnout. Intense and stressful working hours would lead individuals to stay away from work and have burnout. While no significant correlation was found between the time spent in the profession and burnout in the present study, in a metaanalysis study conducted in the USA, a negative correlation was determined between the working period and burnout [33]. The period spent on the profession may increase the skills of individuals to cope with problems and may decrease burnout. No significant correlation was found between marital status and burnout subscales in the present study. Taycan et al., found no significant correlation between the emotional exhaustion and depersonalization subscales [24].However, in the literature there are studies indicating that single ones are at risk in terms of depersonalization [31]. Based on the results of the present study, it was seen that there were individual and organizational factors that affect burnout among individuals. Being a woman and having no children were the demographic characteristics that increase burnout. Being a nurse, being at night shift, and long working hours were, on the other hand, found to be the organizational factors that increase burnout. Taking precautionary measures against burnout for health workers would increase job satisfaction and the quality of care while they perform their professions. Improving the shift conditions and working hours of the workers may decrease burnout. The employees may be provided with training for coping strategies. Conclusion Other suggestions may involve applications for decreasing the work load of the workers experiencing more burnout, especially the nurses, as well as increasing the number of personnel. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

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26. Erol A, Akarca F, Değerli V, et al. Burnout and job satisfaction among emergency department staff. Turk J Clin Psychiatry. 2012;15:103-10.

10. Garrosa E, Rainho C, Moreno-Jimenez B, et al. The relationship between job stressors, hardy personality, coping resources and burnout in a sample of nurses: a correlational study at two time points. Int J Nurs Stud. 2010;47:205–15.

27. Alacacıoğlu A, Yavuzsen T, Diriöz M, Öztop İV, Yılmaz U. Burnout in nurses a d physicians working at an oncology department. Psycho-Oncology. 2009;18:543–8.

11. Kanai-Pak M, Aiken LH, Sloane DM, Poghosyan L. Poor work environments and nurse inexperience are associated with burnout, job dissatisfaction and quality deficits in Japanese hospitals. J Clin Nurs. 2008;17:3324-9.

28. Buğdaycı R, Kurt Ö, Şaşmaz T. ve ark. Psychological burnout status and affecting factors in practitioner and specialist physicians working in Mersin. Health and Society. 2005;15:25-32.

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13. Kaya M, Sarp Ü, Karanfil E, et al. The Burnout conditidion of primary health care personnel. TAF Preventive Medicine Bulletin 2007:6:357-63. 14. Aslan D, Kiper N, Karaağaoğlu E, et al. Türkiye’de tabip odalarına kayıtlı olan bir grup hekimde tükenmişlik sendromu ve etkileyen faktörler. Türk Tabipleri Birliği Yayınları, Ankara,2005https://www.ttb.org.tr/kutuphane/ tukenmislik.pdf) 15. Abdulghafour YA, Bo-Hamra AM, Al-Mandi RS, Kamel MI, El-Shazly MK. Burnout syndrome among physicians working in primary health care centers in Kuwaıt. Alexandıra J Med. 2011;47:351-7. 16. Al-Dubai S, Rampal K. Prevalence and associated factors of burnout among

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):826-30

The relationship between serum lipid levels and lifetime suicide attempts in patients with schizophrenia Zeynep Baran Tatar Bakirkoy Training and Research Hospital for Psychiatric and Neurological Diseases, Clinic of Psychiatry, Istanbul, Turkey Received 25 April 2018; Accepted 11 May 2018 Available online 29.07.2018 with doi: 10.5455/medscience.2018.07.8849 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Patients with schizophrenia have a higher risk of suicide than the general population. Due to these high rates, researchers are investigating biomarkers associated with suicidal behavior to prevent suicide. Conflicting findings have also been reported in studies investigating the relationship between cholesterol and suicide in patients with schizophrenia. The aim of our study was to compare schizophrenia patients with and without a history of suicide attempt in terms of total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) levels and to investigate the relationship between cholesterol levels and lifetime suicide attempts. A retrospective, cross-sectional study was carried out in a psychotic disorders outpatient clinic at a psychiatric hospital in Turkey. Two hundred and twenty-eight patients with schizophrenia were evaluated. We present a retrospective analysis of longitudinal data addressing socio-demographic characteristics, metabolic parameters, lipid profile, scales. Lifetime suicide attempts were reported by %28 of patients. It was found that schizophrenia patients with suicide attempt had higher TC and TG levels than schizophrenia patients without suicide attempt. Similar findings were repeated male patients with schizophrenia. In female patients, only TG level showed a significant difference between those with and without suicide attempt. Our findings indicate an association between high cholesterol levels and lifetime suicidality. The findings of our study may indicate that lifetime suicide attempt in schizophrenia exhibits a different lipid profile. Keywords: Cholesterol, schizophrenia, suicide

Introduction Suicide is one of the primary causes of premature death in schizophrenia [1]. The lifetime risk of suicide in schizophrenia is reported to be 4.9%. Schizophrenia patients have a higher risk of suicide than the general population. The most important risk factors for suicide in individuals with schizophrenia are previous suicide attempts, substance abuse, and depression [2]. In the follow-up of patients who were discharged after the first episode, the patients who did not receive regular antipsychotic medication had a 37-fold increased risk of suicidal behavior [3]. Due to these high rates, researchers are still investigating biomarkers associated with suicidal behavior to prevent suicide. The relationship between low cholesterol levels and increased risk of suicide has been first noticed by the fact that the rate of deaths from suicide has increased because lipid-lowering drugs have reduced serum cholesterol levels [4]. However, a later metaanalysis could not repeat the same results [5]. The relationship between cholesterol and suicidality was also investigated in patients with various psychiatric disorders. Coresponding Author: Zeynep Baran Tatar, Bakirkoy Training and Research Hospital for Psychiatric and Neurological Diseases, Clinic of Psychiatry, Istanbul, Turkey E-mail: drzeynepbaran@gmail.com

However, conflicting results were obtained. While some studies have found a relationship between low cholesterol levels and increased suicidality [6,7], other studies have determined a positive relationship between lipid profile and suicide [8,9]. There are also studies that have not reported any relationship between them [10,11]. Conflicting findings have also been reported in studies investigating the relationship between cholesterol and suicide in schizophrenia patients. It has been recently found that schizophrenia patients who attempted suicide had lower cholesterol levels than schizophrenia patients who did not attempt suicide [12-14]. In a single study conducted in this field in our country, schizophrenia patients with and without suicide attempt were compared with age- and sexmatched healthy controls. It was found that schizophrenia patients with suicide attempt had lower cholesterol levels. However, the sample size was too small [12]. It should also be considered that there are also studies that have not found any relationship between lipid profile and suicide in this patient group [15-18]. Of these studies, two have been conducted in patients who have died of suicide [15,16], one has been conducted in patients who have been recently hospitalized due to suicide attempt [17], and one has been conducted in patients who have exhibited aggressive behaviors [18]. Studies conducted in schizophrenia patients often assess those with recent suicide 826

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attempt. Only one study involving schizophrenia patients with lifetime suicide attempt was conducted in Tunisia. In this study, schizophrenia patients with recent suicide attempt and patients with lifetime suicide attempt were compared with healthy controls [14]. To our knowledge, there are no studies in our country giving information on lipid profile in schizophrenia patients with lifetime suicide attempt. The aim of our study was to compare schizophrenia patients with and without a history of suicide attempt in terms of total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL), and lowdensity lipoprotein (LDL) levels and to investigate the relationship between cholesterol levels and lifetime suicide attempts. In addition, male and female schizophrenia patients were divided into two separate groups, and those with and without suicide attempt were compared with each other in terms of lipid profile. Material and Methods Sample This retrospective cross-sectional study was conducted in patients who were followed up in the Psychotic Disorders Outpatient Clinic of Training and Research Hospital and who were diagnosed with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) criteria [19]. Patients who were followed between 1 October 2016 and 1 January 2017 were included in the study. Patients who were not diagnosed with schizophrenia, who had missing data on blood tests and scales, who had significant neurological impairment and mental retardation, who had metabolic syndrome according to the Adult Treatment Panel III (ATP III) criteria [20], who received antihyperlipidemia drugs, who had alcohol and substance use disorder and major depression between the start and end dates of the study period, and who attempted suicide within the last 3 months were excluded from the study. The study was approved by the Ethics Committee of Training and Research Hospital. Informed consent form was obtained from the patients. Clinical evaluation Blood samples are taken regularly every 6 months between 8:00 am and 10:00 am by nurses working at our center from patients who fast for at least 8 hours and who agree to blood drawing. These blood tests include TC, TG, HDL, and LDL levels. Body weight, waist circumference, and arterial blood pressure are measured and recorded on the date on which blood samples are taken. These values were assessed to exclude patients with metabolic syndrome and to calculate body mass index (BMI). BMI is calculated by the formula kg/m² to determine whether a person’s weight is healthy. These information were obtained retrospectively from patient files between the start and end dates of the study period. In addition, sociodemographic information such as age, gender, duration of education, duration of illness, and antipsychotic and metabolic drugs used were collected for each patient. Life-time history of suicide attempts was questioned retrospectively. A suicide attempt was defined as a self-destructive behavior with the intention of ending one’s life, independent of the resulting damage [21]. In accordance with this definition, patients who attempted suicide were addressed. Positive and Negative Syndrome Scale (PANNS), Schedule for the Assessment of Insight (SAI), and Clinical Global Impression-Severity of Illness (CGI-S) are filled out at each visit. Scale scores that were determined at follow-up visit on the date on

Med Science 2018;7(4):826-30

which blood samples were taken were assessed. Sociodemographic data form It is a semi-structured data form prepared by the researchers. This form contained questions about age, gender, duration of education, duration of disease, antipsychotic drugs , alcohol and other substance use, additional medical illnesses, and other psychiatric medications. Positive and Negative Syndrome Scale (PANSS) The PANSS is a 30-item semi-structured instrument to perform psychopathological measurements related to positive, negative, and general symptoms of schizophrenia [22]. This scale included 30 items, 18 items for the Brief Psychiatric Rating Scale (BPRS) and 12 items from the Psychopathology Rating Schedule (PRS). The 30 items are arranged as seven positive symptom subscale items (P1 - P7), seven negative symptom subscale items (N1 N7), and 16 general psychopathology symptom subscale items (G1 - G16). All 30 items are rated on a 7-point scale (1 = absent; 7 = extreme). It consists of four measures including PANSS total score, PANSS positive subscale score, PANSS negative subscale score, and PANSS general psychopathology subscale score. The validity and reliability study of the Turkish version of this scale was performed by Kostakoğlu et al. [23]. Schedule for the Assessment of Insight (SAI) It is a semi-structured clinician-administered instrument developed for assessment of insight in schizophrenia by David in 1990 [24]. The validity and reliability study of the Turkish version of this scale was performed by Arslan et al. [25]. It is composed of four components including awareness of mental illness, ability to relabel psychotic experience as abnormal, adherence to treatment, and awareness of previous mental disorders. The items are rated on 3-point scales ranging from 0 to 2 points. Higher scores indicate higher levels of insight. Clinical Global Impression-Severity of Illness (CGI-S) It was developed by Guy et al. [26] to assess the clinical course of all mental disorders at all ages for clinical research purposes. It is filled out during a semi-structured interview conducted by the physician to assess the treatment response of individuals with psychiatric disorders. This scale yields three different measures: Severity of illness, overall improvement, and therapeutic index. The CGI-Severity (CGI-S), which is the first component of the scale, was assessed in our study. The CGI-S asks the clinician one question: “Considering your total clinical experience with this particular population, how mentally ill is the patient at this time?” which is rated on the following seven-point scale: 1=normal, not at all ill; 2=borderline mentally ill; 3=mildly ill; 4=moderately ill; 5=markedly ill; 6=severely ill; 7=among the most extremely ill patients. Statistical Methods The distributional properties of the variables were examined by the Kolmogorov-Smirnov test. Since the parameters were not normally distributed, Mann Whitney U test was used to compare quantitative data of the two groups (suicide attempters and nonsuicide attempters). Chi-square (X²) test was used to compare categorical data. Furthermore, male and female patients were divided into the two groups separately as suicide attempters and 827

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non-suicide attempters and evaluated in terms of total cholesterol, TG, HDL and LDL. The results were assessed at a 95% confidence interval, at a significance level of p<0.05, and at high significance levels of p<0.01 and p<0.001. The Statistical Package for the Social Sciences 18.0 (SPSS, SPSS Inc., Chicago, IL, USA) was used to analyze data. Results Two-hundred twenty- eight patients with schizophrenia participated in the study. Lifetime suicide attempts were reported by %28 of patients. In the total sample, 43 (18.8%) male patients and 21 (9.2%) women patients reported a history of attempted suicide. The duration of education was significantly shorter in the nonsuicide attempter group than in the suicide attempter group (9.07±3.33 years vs. 9.27±3.81 years, p<0.05). There was no significant difference between the suicide attempter group than the non-suicide attempter group in terms of age, type of the

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antipsychotic drugs, clozapine/olanzapine usage, BMI, and scale scores (Table 1). The mean TC levels (219.58±43.39 mg/dL vs. 200.00±44.95 mg/dL, p<0.05) and TG levels (182.43±124.05 mg/dL vs. 147.42±101.27 mg/dL, p<0.05) who attempted suicide was significantly higher than that of the patients who did not attempted suicide (Table 2). Male patients with schizophrenia with suicide attempts reported higher levels of TC (223.47±44.88 mg/dL vs. 199.18±46.34 mg/ dL, p<0.05) and TG (203.11±141.15 mg/dL vs. 159.13±111.07 mg/dL, p<0.05) (Table 3). The only significant difference was found in TG levels between female group of patients and higher levels was reported in suicide attempters (140.09±61.91 vs. 111.12±46.55 mg/dL, p<0.05) (Table 4).

Table 1. Demographic and clinical characterics of schizophrenic patients with and without suicid attempts Patient Characteristics

Patients

Male Famele Age (years±SD)

without suicide (n=164) 124(54.3%) 40 (17.5%) 41.29 (±9.9)

attempt

Patients with suicide attempt (n=64) 43 (18.8%) 21 (9.2%) 43.20 (±8.41)

x²

P value

2.211

.095ᵃ 4339.50

.054ᵇ

5131.00

.088ᵇ

3804.50

.002ᵇ*

Duration of education (years±SD)

9.27 (±3.81)

9.07 (±3.33)

Duration of disorder (years±SD)

18.13 (±7.87)

21.77 (±8.78)

19 (8.6%)

7(3.2%)

.007

.570ᵃ

162(71.1%)

63 (27.6%)

1.161

.377ᵃ

5.624

First-generation AP Second-generation AP Klozapin/olanzapin

113 (49.6%)

54 (23.7%)

BMI

26.98(±4.68)

27.30(±4.14)

Smoking

79 (34.6%)

37(16.22%)

PANSS-positive symptom subscale(±SD)

9.75(±3.42)

PANSS-negative symptom subscale PANSS-general psychopathology subscale

.012ᵃ* 4910,00

.450ᵇ

9.87(±3.76)

5136.50

.855ᵇ

13.40(±4.38)

12.69(±4.96)

4442.00

.086ᵇ

24.62(±6.71)

24.00(±7.05)

4847.00

.426ᵇ

PANSS- Total

47.86(±12.23)

46.68(±14.04)

4664.50

.231ᵇ

SAI

13.46(±5.36)

13.61(±5.40)

4963.50

.583ᵇ

2.148

.094ᵃ

CGI-S 2.16(±1.00) 2.11(±.98) 5072.50 .762ᵇ BMI: Body mass index, PANNS: The Positive and Negative Syndrome Scale, SAI: Schedule for Assessment of Insight, CGI-S: Clinical Global Impression Severity of Illness *p<.05 **p<.001 ᵃ Statistical significance of differences estimated with the Chi square (X²) test ᵇ Statistical significance of differences estimated with the Mann-Whitney U Table 2. Lipid profile of schizophrenic patients with and without suicide attempts Suicide attempt TC (mg/dL)

TG(mg/dL)

HDL(mg/dL)

LDL(mg/dL)

without

Mean (±SD)

164

200.00 (44.95)

with

219.58(43.39)

without

164

147.42(101.27)

with

182.43(125.05)

without

164

47.89(14.86)

with

47.6(13.51)

without

164

124.58(40.89)

with

129.84(43.20)

Table 3. Lipid profile of male patients with schizophrenia with and without suicide attempts Suicide attempt

3947.50

.004*

TC (mg/dL)

3989.00

.005*

TG(mg/dL)

5237.50

.981

HDL(mg/dL)

4813.00

.331

LDL(mg/dL)

HDL: High-density lipoprotein, LDL: Low-density lipoprotein, TC: Total cholesterol, TG: Triglyceride*p<.05

Mean (±SD)

without

124

199.18(46.34)

with

223.47(44.88)

without

124

159.13(111.07)

with

203.11(141.15)

without

124

44.04(13.22)

with

41.72(9.62)

without

124

125.40(40.98)

with

136.91(43.20)

1858.00

.003

1989.00

.013

2408.50

.384

2138.50

.054

HDL: High-density lipoprotein, LDL: Low-density lipoprotein, TC: Total cholesterol, TG: Triglyceride*p<.05

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doi: 10.5455/medscience.2018.07.8849 Table 4. Lipid profile of female patients with schizophrenia with and without suicide attempts N

Mean (ÂąSD)

without with

40 21

202.52 (40.78) 211.61 (40.02)

369.50

.443

without

111.12 (46.55)

with

140.09 (61.91)

279.50

.033*

without with

40 21

59.80 (13.39) 59.52(12.55)

403.00

.796

without

122.42(41.00)

with

115.36(40.40)

362.00

.379

Suicide attempt TC (mg/dL)

TG(mg/dL)

HDL(mg/dL)

LDL(mg/dL)

HDL: High-density lipoprotein, LDL: Low-density lipoprotein, TC: Total cholesterol, TG: Triglyceride *p<0.05

Discussion This study is the first study in Turkey investigating the relationship between lifetime suicide attempts and serum lipids in a large sample of patients with schizophrenia. It was found that schizophrenia patients with suicide attempt had higher TC and TG levels than schizophrenia patients without suicide attempt. These results are different from the results of previous studies showing the relationship between low cholesterol level and suicidality. This may be due to the fact that studies in spatients with schizophrenia have been conducted in those with recent suicide attempt [12-14]. Only one study involving schizophrenia patients with lifetime suicide attempt was conducted in Tunisia. It was determined that schizophrenia patients with recent suicide attempt had lower total cholesterol levels compared to those with and without lifetime suicide attempt [14]. Similar to our study, there are other studies that have found a relationship between high cholesterol levels and suicidality although they have been conducted in different psychiatric populations [8,9]. Brunner et al. [8] revealed that there was a positive relationship between suicide attempt and TC, TG, BMI in the patients with depressive symptoms for the last 12 months. Another study reported that low cholesterol levels were associated with a lower risk of recent suicide attempts. In this study, the groups with and without suicide attempt were examined [9]. In our study, similar findings found in schizophrenia patients were repeated in male schizophrenia patients. In female schizophrenia patients, only TG level showed a significant difference between those with and without suicide attempt. There are studies showing that the relationship between TC level and suicide risk in psychiatric disorders is specific for either female or male gender. In these studies it was found that low serum cholesterol levels were associated with suicide [27, 28]. A recent study found that higher TC and LDL levels might be associated with suicidal ideation only in female first-episode female patients [29]. The reasons why our study has different results from previous studies can include examining different dimensions of suicidal behavior (suicidal ideation, suicide attempt, suicide loss), conducting a study in a mixed psychiatric group by investigating only those with and without suicidal behavior, number of samples, geographical region where a study is conducted, ethnic origin of individuals, weight, different diet characteristics, and effect of antipsychotic drugs on lipid levels. Most suicide attempts occur during a depressive episode and are associated with decreased

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appetite and weight loss in depressed patients [30]. Low cholesterol levels that have been detected in patients with schizophrenia with recent suicide attempt may be associated with this. The different results of our study may be due to the examination of lifetime suicide attempts and the absence of depressive episodes and thereby vegetative symptoms on the date on which blood samples were taken. In addition, high lipid levels in schizophrenia patients may be related to the use of antipsychotic drugs (mainly clozapine and olanzapine), weight gain [31,32], and smoking [33]. However, the fact that most of schizophrenia patients without suicide attempt in our study highly received clozapine or olanzapine and there was no significant difference between the groups in terms of BMI and smoking status may exclude these possible reasons. Considering all results, the findings of our study may indicate that lifetime suicide attempt in schizophrenia exhibits a different lipid profile. Limitations Our study has some limitations. Comparison of schizophrenia patients with lifetime suicide attempt with schizophrenia patients with recent suicide attempt and healthy controls may provide more valid results. In addition, a prospective study will make it more possible to establish a causal relationship. Conclusion In conclusion, unlike other studies, our study found a relationship between lifetime suicide attempts and high cholesterol levels in schizophrenia patients. Given the high suicide rate in schizophrenia patients, the identification of biological markers related to suicidal behavior will provide the early detection of patients at risk for suicide and increase the chance of early intervention. Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval The study was approved by the Ethics Committee of Bakirkoy Training and Research Hospital. Informed consent form was obtained from the patients.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):831-3

Perinatal neurological results of patients ailing from advanced eclampsia and preeclampsia: A retrospective study Aykan Gulleroglu1, Melike Korkmaz Toker2, Ayse Gul Karabay3, Ilhan Guney Bicer4, Mustafa Tayfun Aldemir5 1 Baskent University Ankara Hospital, Department of Anesthesiology and Intensive Care Unıt, Ankara, Turkey Mugla Sıtkı Kocman University, Training and Research Hospital, Department of Anesthesiology and Reanimation, Mugla, Turkey 3 Ota-Jine Med Private Hospital, Clinic of Anesthesiology, Istanbul, Turkey 4 Osmaniye State Hospital, Clinic of Anesthesiology and Reanimation, Osmaniye, Turkey 5 Istanbul Saglik Bilimleri University, Kanuni Sultan Suleyman Training and Research Hospital, Clinic of Anesthesiology and Reanimation, Istanbul, Turkey 2

Received 30 April 2018; Accepted 12 May 2018 Available online 01.08.2018 with doi: 10.5455/medscience.2018.07.8860 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Preeclampsia/eclampsia is a contributing factor for high rates of maternal mortality worldwide. Data suggests that cerebral haemorrhage is a major cause of death among individuals suffering from preeclampsia. In this research, data was collected for over three years from pregnant women who were undergoing treatment at perinatology intensive care unit. They were admitted due to severe and uncontrolled eclampsia and preeclampsia. This research seeks to determine the frequency of patients who displayed cerebrovascular events, their clinical presentations and neuroimaging abnormalities. A retrospective evaluation of all obstetric patients who were diagnosed as pregnancy induced hypertension and followed-up between January 2011 and 2014 was performed. Retrospective computer records of age, neurologic symptom and neuroimaging findings were recorded and examined. Of the 222 participants in the study, 26 were diagnosed with severe preeclampsia while 10 patients have eclampsia. The study was performed on 36 patients whose age are ranking between 17 and 42 with a mean age of 30.06 ± 5.77. Mean systolic blood pressure was 156.89 ± 26.48 mmHg; and the average diastolic blood pressure was 98.29 ± 23.13 mm Hg. Of the 36-severe preeclampsia and eclampsia participants, 18 had begun to exhibit neurological attributes arising from eclampsia and pregnancy induced hypertension. Most common presenting symptom was generalized tonic-clonic seizures (eight, 44%). Five women had cerebral infarction and only one case had intraventricular haemorrhage. Two patients died after eclampsia crisis related intraparenchymal haemorrhage. Women ailing from advanced systolic hypertension (160 mm Hg) and severe eclampsia or preeclampsia have a higher risk of developing haemorrhagic stroke. Cerebral haemorrhage and stroke occurring in pregnancy and puerperium is a severe complication that can lead to maternal death. There should be recognition of using CT in those cases that are refractory to antihypertensive therapy can be lifesaving. Keywords: Preeclampsia, eclampsia, intraparenchymal haemorrhage, cerebrovascular events

Introduction Although there are a lot of improvements in health care, preeclampsia/eclampsia is an important cause of maternal mortality worldwide [1]. The rate of development of preeclampsia to the sudden form arises in %2 to %3. Furthermore, severe preeclampsia is based on a systolic blood pressure ranging at 160 mmHg or more, nephrotic range proteinuria (>3.5 gr/24 hours urine), hepatocellular injury, thrombocytopenia, diastolic blood pressure between 100 mmHg or more, pulmonary oedema and neurologic disturbances [2]. Cerebral haemorrhage is regarded as the most prevalent cause of high mortality rates among patients [3]. In this research, data was obtained for over three years from *Coresponding Author: Melike Korkmaz Toker, Mugla Sitki Kocman University Training and Research Hospital Anesthesiology and Reanimation, Mugla, Turkey, E-mail: meltoker@gmail.com

pregnant women. They had been admitted at the perinatology intensive care unit located in Istanbul Kanuni Sultan Suleyman Research and Training Hospital. They had been hospitalized due to unmanageable and advanced eclampsia and preeclampsia. This research seeks to establish the incidence of patients with cerebrovascular events at the facility, their neuroimaging irregularities and clinical attributes. Material and Methods The study will rely on the approval of the Istanbul Kanuni Sultan Suleyman Research and Training Hospital’s Local Ethics Committee before it commences. Additionally, an analysis was carried out on the records of all obstetric patients who have been treated at Perinatology Intensive Care Unit. The data was limited to those hospitalized between January 2011 and January 2014 and had been diagnosed with eclampsia and preeclampsia while showing neurologic symptoms.

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Statistical Analysis The statistical analysis aspect will rely on Statistical Software (Utah, USA), NCSS (Number Cruncher Statistical System) 2007, and PASS (Power Analysis and Sample Size) 2008. Results The results were obtained from 222 patients. They had been hospitalized due to pregnancy complications arising from induced hypertension. Furthermore, 10 patients had been diagnosed with eclampsia while 26 of the patients had severe preeclampsia. The study was performed on 36 patients whose age are ranking between 17 and 42 with a mean age of 30.06 ± 5.77. Mean systolic blood pressure was 156.89 ± 26.48 mmHg; and the average diastolic blood pressure was 98.29 ± 23.13 mm Hg, respectively. Of the 36 patients with severe preeclampsia and eclampsia, 18 had began to show neurological attributes depending on the eclampsia and pregnancy induced hypertension. Additionally, the range of recorded symptomatology was provided for the 18 patients as shown in Table 1. A major symptom was widespread tonic-clonic seizures (44%). Despite this, all eight participants began to have seizures while at the intensive care, and seven were diagnosed with eclampsia. Moreover, one developed a tonic clonic seizure that arose due to epilepsy that exhibited prior to the pregnancy. Finally, two patients passed away due to eclampsia, which was linked to intraparenchymal haemorrhage. Cranial computed tomography (CT) scans performed urgently for neurologic complication in 15 women (Table 2). Five women had cerebral infarction and only one case had intraventricular haemorrhage. CT data of one of the mortal participants is represented in Figure 1. Table 1. The spectrum of recorded morbidity and mortality for patients N

Coma

Stupor

Eclampsia

Blurring Vision

Retinal Detachment

Seizures

Death

Table 2. The Distribution of Cranial CT Findings CRANIAL CT FINDINGS

Encephalopathy compatible with pregnancy

13,33

Cerebral Infarction

33,33

Intraventricular haemorrhage

6,67

No pathology

46,66

Total

100

Figure 1. Noncontrast computed tomography (CT) of one of the mortal eclampsia patients showing basal ganglia haemorrhage open through the 4th left ventricle and moderate hydrocephalus.

Discussion Preeclampsia is a common multisystem disorder among pregnant women [1]. It arises in 2–10% of all pregnancies [4] and is characterized by increased blood pressure and proteinuria. Preeclampsia tends to occur after 20 weeks of gestation. Eclampsia refers to the abrupt occurrence of seizures in a woman with preeclampsia. [2]. Neurological complications due to hypertensive disorders of pregnancy are the most prevalent cause of death among pregnant women [3]. Sharshar et al [5]. reported that eclampsia was linked with both nonhemorrhagic and intracerebral hemorrhage strokes. In addition, some researchers established that 25–45% of stroke cases are linked to eclampsia or preeclampsia [5,9]. According to one study, among women with a history of preeclampsia, the incidence of nonpregnancy-associated ischemic strokes in the postpartum period was 60% [10]. In strokes that occur during the puerperal period and pregnancy, previous hospital-based [11,12] and community-based [13] studies reported that the incidence of cerebral infarctions was higher than that of intracranial hemorrhages and ranged from 5–219 per 100,000 deliveries. In the present study, of 15 patients who underwent cranial tomography, five had infarction areas, mostly in the occipital region. Only one patient had a cerebral hemorrhage arising at the basal ganglia and then opening through the fourth left ventricle. The findings of the present study are in accordance with those in the literature. The pathophysiological mechanism responsible for brain damage in preeclampsia is a form of hypertensive encephalopathy [3]. In a study of 39 patients who underwent cerebral computed tomography, Richards et al [14]. reported that acute hypertensive vascular changes appeared to be the underlying pathogenesis of central nervous system (CNS) lesions in eclampsia. Within the framework of their findings, they proposed a neurological pathophysiology of eclampsia (Figure 2). In the current study, the average systolic blood pressure was 156.89 ± 26.48 mmHg, and the average diastolic blood pressure was 98.29 ± 23.13 mm Hg. These elevated blood pressure values explain the cerebrovascular events in our patients. A previous study found that malignant hypertension or intracranial hemorrhages appeared to be the responsible for stroke-related 832

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mortality linked to pregnancy [15]. Maternal deaths linked to ischemic occurrences are infrequent. In reported cases, the authors attributed them most commonly to secondary hemorrhages [16,17]. In the present study, only one of the 15 patients had an intracranial diffuse hemorrhage, and this patient died during the follow-up. The results are in accordance with those in the literature.

Figure 2. The neurological pathophysiology of eclampsia [14]

In the current study, infarctions, hemorrhages, and hemorrhagic intracranial lesions mostly affected the posterior circulation of the brain, and the lesions were distributed in the basal ganglia and occipital area. The forms of the hemorrhagic lesions and localization of the lesions in the present study were consistent with the literature [14,18]. There are some limitations of this study. It was a retrospective analysis, and the number of patients was very small. Furthermore, magnetic resonance imaging (MRI) could not be performed in all patients. This may have reduced the detection of less severe hemorrhages. Pregnant women with hypertension may experience a wide range of neurological complications caused by ischemic lesions and intracranial hemorrhages. The indications for neurological-related complications include a reduced level of consciousness and blurred vision. Women with eclampsia or preeclampsia and systolic hypertension (>160 mm Hg) have an elevated risk of having a hemorrhagic stroke. To minimize the risk of this neurological occurrence, such women require urgent and specialized care, including antihypertensive therapy, in intensive care units [19]. Conclusion Cerebral hemorrhages and strokes in pregnancy and puerperium are severe complications, which can lead to maternal death. CT should be performed in cases refractory to antihypertensive therapy to prevent mortality.

Med Science 2018;7(4):831-3

Ethical approval The study will rely on the approval of the Istanbul Kanuni Sultan Suleyman Research and Training Hospitalâ&#x20AC;&#x2122;s Local Ethics Committee before it commences.

References 1.

Altman D, Carroli G, Duley L, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002;359;1877-90.

Lindheimer MD, Taler SJ, Cunningham FG. ASH position paper: hypertension in pregnancy. J Clin Hypertens. 2009;11:214-25.

Okanloma KA, Moodley J. Neurological complications associated with the pre-eclampsia/eclampsia syndrome. Int. J Gynaecol Obstet. 2000;71:223-5.

World Health Organisation International Collaborative Study of Hypertensive Disorders of Pregnancy. Geographic variation in the incidence of hypertension in pregnancy. Am J Obstet Gynecol. 1988;158:80-3.

Sharshar T, Lamy C, Mas JL. Incidence and causes of strokes associated with pregnancy and puerperium: a study in public hospitals of Ile de France. in Pregnancy Study Group. Stroke. 1995;26:930-6.

James AH, Bushnell CD, Jamison MG,et al. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol. 2005;106:509-16.

Pathan M, Kittner SJ. Pregnancy and stroke. Curr Neurol Neurosci Rep. 2003;3:27-31.

Wilson BJ, Watson MS, Prescott GJ, et al. Hypertensive disease of pregnancy and risk of hypertension and stroke in later life: results from cohort study. BMJ. 2003;326:845.

Kittner SJ, Stern BJ, Feeser BR, et al. Pregnancy and the risk of stroke. New Med. 1996;335:768-74.

10. Brown DW, Dueker N, Jamieson DJ, et al. Preeclampsia and the risk of ischemic stroke among young women: results from the Stroke Prevention in Young Women Study. Stroke. 2006;37:1055-9. 11. Simolke GA, Cox SM, Cunningham FG. Cerebrovascular accidents complicating pregnancy and the puerperium. Gynecol. 1991;78:37-42. 12. Cross JN, Castro PO, Jennett WB. Cerebral strokes associated with pregnancy and the puerperium. Br Med J. 1968;3:214-8. 13. Barnes JE, Abbott KH. Cerebral complications incurred during pregnancy and the puerperium. Am J Obstet Gynecol. 1961;82:192-207. 14. Richards A, Graham D, Bullock R. Clinicopathological study of neurological complications due to hypertensive disorders of pregnancy. J Neurol Neurosurg Psychiatry. 1988;51:416-21. 15. Witlin AG, Friedman SA, Egerman RS, et al. Cerebrovascular disorders complicating pregnancy-beyond eclampsia. Am J Obstet Gynecol. 1997;176:1139-45. 16. Lanska DJ, Kryscio RJ. Stroke and intracranial venous thrombosis during pregnancy and puerperium. Neurology. 1998;51:1622-8. 17. Bruijn SFTM, Stam J. Cerebral Venous Sinus Thrombosis Study Group. Randomized, placebo-controlled trial of anticoagulant treatment with lowmolecular-weight heparin for cerebral sinus thrombosis. Stroke1999;30:484-8.

Competing interests The authors declare that they have no competing interest.

18. Sanders TG, Cayman DA, Sanches Ramos L. Brain in eclampsia: MR imaging with clinical correlation. Radiology. 1991;180:475-8.

Financial Disclosure The financial support for this study was provided by the investigators themselves.

19. Demiraran Y, Toker MK. Management of Preeclampsia in Perioperative Conditions. Gen Med. 2015;S2:004.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):834-6

Comparison of the effects of ketamine-midazolam and ketamin-propofol anesthesia on recovery of circumcision operations Hatice Toprak, Canan Kocaoglu, Eyup Aydogan, Mehmet Sargin, Sadik Ozmen Konya Training and Research Hospital, Clinic of Anesthesiology and Reanimation, Konya, Turkey Received 11 April 2018; Accepted 16 May 2018 Available online 25.07.2018 with doi: 10.5455/medscience.2018.07.8858 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract To compare the effects of ketamine+midazolam or ketamine+propofol on analgesia, sedation and recovery time in children premedicated with midazolam for circumcision operations. Eighty American Society of Anesthesiologists physical status I-II, 5-12 years old children who undergone circumcision operations were included in the study. Both groups were administered of midazolam 0.04 mg/kg intravenously in the presence of besides their parents in the pre-operative holding area. Patients were induced with midazolam-ketamine in Group I or ketamine+propofol in Group II. There were no differenses observed between the groups according to sedation and analgesia. None of patients needed additional hypnotic agent doses. Recovery was faster in ketamine-midazolam group. Midazolam+ketamine provided faster recovery than ketaminepropofol in pediatric circumcision operations. No complication was observed during sedation. It is observed that ketamine+midazolam has provided a faster recovery in circumcision operation. Keywords: Circumcision, children, sedation, ketamine, propofol

Introduction Circumcision is a stressful and painful process for children [1-5]. Pain in children is treated far less vigorously than in adults. Anesthesia techniques for circumcision include penile block[6,7] and caudal block[8-10].The patients are sedated during these procedures [1,7,9,10]. General anesthesia can also be performed with a laryngeal mask[10-13].The ideal anesthetic to be used for the procedure should provide sufficient analgesia, amnesia, sedation, short-acting effects, and also should not cause cardiovascular and respiratory depression, nausea-vomiting, and agitation [1]. Preferred agents include opioids, ketamine, propofol, and dexmedetomidine [1,9,10]. In addition, penile block [7,10] with bupivacaine was used for postoperative analgesia in addition to sedative agents[4]. The aim of our study was to compare the effects of ketaminemidazolam and ketamine-propofol combinations on recovery from anesthesia. Material and Methods After ethical committee approval, 80 children, ASA I-II physical status, aged 5 to 12 years, and who will be circumcised in elective Coresponding Author: Eyup Aydogan, Konya Training and Research Hospital, Clinic of Anesthesiology and Reanimation, Konya, Turkey E-mail: eypaydogan@hotmail.com

conditions, were included in the study. Exclusion criteria: ASA III or IV clinical status, patients (parents) who do not want to be included, additional hypnotic need, emergency conditions. Institutional Protocol For Circumcision Operations: All cases are premedicated with midazolam (0.04 mg/kg intravenous) before the operation. Premedications are administered in the presence of parents in the pre-operative holding area (5 minutes before surgical sedation). Group 1: ketamine (2 mg/kg) + midazolam (0,05 mg/kg) Group 2: ketamine (1 mg/kg) + propofol (3 mg/kg) Additional penile block is administered by the surgeon using 0.5 % bupivacaine 1 mg/kg and 2 % lidocaine 2 mg/kg. There is no involvement of the work team for the preference, desire or combination of these agents. Anesthesia protocol was not restricted, institutional protocols were selected by anesthetists not included in the study. The study team has observed the clinical outcomes. Postoperative early recovery profile and pain of patients were observed. Additional penile block was administered by the surgeon using 0,5 % bupivacaine 1 mg/kg and 2 % lidocaine 2 mg/kg. Parameters that assessed as early recovery profile: Spontaneous breathing time (time from the end of surgery to the time when spontaneous breathing returns), eye-opening time (time 834

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from the end fo surgery to eye-opening with verbal stimuli). Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale and visual pain scale (0 - 10, 0 - no pain, 10 - maximum pain) were used for pain evaluation. SPSS software version 21.0 (IBM® SPSS® Statistics V21.0) was used for statistical analysis.Chi-square test was used for categorical data and other personal variables.The level of significance was accepted as α = 0.05. Results The age, weight, height, eye-opening with spoken stimuli, spontaneous respiratory return time, and FLACC pain scores were compared between the groups. There was no difference in demographical data of the groups. There was no difference in FLACC pain assessment. No additional hypnotic drug doses were needed in any patient. The time for eye-opening with verbal stimuli and spontaneous respiratory return was shorter in Group 1. The duration of spontaneous breathing with the combination of ketamine and midazolam and the duration of eye-opening with verbal stimulation were found to be significantly shorter than the group sedated with the propofol-ketamine combination. The penile block was applied to all patients and there was no significant difference between postoperative FLACC scores. Demographic data has been presented in table 1. Table 1. Demographic and anesthetic data of two grups

Patients (n)

Group 1 Group 2 (ketamine+midazolam) (propofol+midazolam) 40 40

Age (year)

7±1,6

7,6±1,8

Weight (kilograms)

23±6,8

26,7±7,1

Height (centimeter)

124,7±9,5

129,9±10

4,4±3,4

6,6±4

10,8±4

15,2±5,5

1,1±1,8

1±1,7

Spontaneous breathing start time (minute) Eye opening time with verbal stimulus (minute) FLACC pain score

Discussion Physicians frequently deal with procedures which require sedation of pediatric patients [14]. Circumcision is a stressful and painful process in children [1-5], and sedation is often needed. Preferred hypnotic agents include opioids, ketamine, propofol, and dexmedetomidine. For this purpose, the combination of propofol+ketamine or ketamine+midazolam are used in our institution and the penile block is applied for analgesia, additionally. The choice of these agents is shaped by the experience and preferences of physicians working in our clinic. In circumcision procedures early recovery was aimed because the cases are predominantly pediatric patients and the procedure is short. Early discharge is also prefered. For these reasons, the recovery times of the agents that were used in our clinic have been compared. The duration of spontaneous breathing with the combination of ketamine+midazolam and the duration of eye-opening with verbal stimulation were found to be significantly shorter than those with the propofol+ketamine combination. The penile block was applied

Med Science 2018;7(4):834-6

to all patients and there was no significant difference between postoperative FLACC scores. In a study, it was compared that the administration of propofol+ketamine and ketamine only in the study, applied penile block, and reported that a combination of propofol and ketamine provided more effective and safe sedation [1]. However, in our study, a combination of ketamine+midazolam was observed to make recovery earlier. Similarly, there were no significant complications in both groups. However, in the Gulec et al. trial, intramuscular midazolam + ketamine + atropine mixture was used for premedication purposes. In a study, it was compared the need for ketamine addition and/or general anesthesia in patients who underwent midazolam sedation followed by circumcision. In Bicer et al. study, patients were classified according to their age groups. 1-year-old patients were classified as group 1, 1-7 years as group 2, and 7+ years as group 3. In the study, our patient population is 5-12 years old. In their study in which they applied 0,1 mg/kg midazolam IV and 0,02 mg/ kg atropine IV for premedication, group 2 and group 3 required additional ketamine doses 80% and 38% for imperfect sedation and 12,8% and 3% need for general anesthesia was observed. In Group 1, these ratios are 2.7% ketamine supplementation requirement and 0% general anesthesia requirement, but these results are not used for comparison by considering the age range of our study group and our age groups [10]. As can be seen, adequate sedation was achieved in the majority of patients (87.2% - 97%) with ketamine-midazolam combination.The anesthetic awakening durations of the patients were reported as 3 and 1.5 minutes respectively in group 2 and group 3.In our study, when we used ketamine-midazolam, the mean duration of eye-opening by verbal stimulation was verified as 10.8 min. (Table 1) Observers have applied ketamine intramuscular and thiopental 25 mg/kg rectal to 2-4 mg/kg of patients up to 14 years of age and compared sedation adequacy and duration of action. As a result, sufficient sedation was obtained with ketamine application but it was stated that the recovery times were longer [14]. However, it has been reported to be more useful as it has been necessary to make additional doses. Gauntlett has reported that caudal anesthesia with bupivacaine/ketamine does not confer any advantage over a dorsal nerve block with the doses used in the study [15]. The author has used a dose of 0,5 mg/kg ketamine and it has been thought to be less for the sedation [15]. In our study, similarly, the recovery time in the ketamine+propofol group was delayed, but both groups completed procedure without the need for additional hypnotic doses. It must also be pointed that we used the dose of 2 mg/kg ketamine IV. Additionally, it has been reported that preincisional subcutaneous ketamine infiltration can suppress postoperative pain after the circumcision surgery [16]. We did not observe difference about in the postoperative pain. However, it has been reported that the combination of propofol and ketamine for invasive procedures in pediatric oncology resulted with agitation in recovery [17], agitation was not observed in our study (Table 1). In a study, comparing IM and IV ketamine administrations, reported that IV administration resulted in more efficacious results in terms of onset of action, duration of action and adequate sedation [18]. In our study, only IV ketamine was used. IM ketamine administration can be easily applied to children without intravenous access and IV treatment can be criticized for this reason. However, in our 835

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pediatric surgery department provides IV access in their clinic with in parental custody (parents are with their children to keep them calm), so we used the existing IV route. It has been reported that propofol sedation was as effective as midazolam sedation and recovery times were shorter than midazolam in studies performed on pediatric emergency room patients aged 2-18 years [19]. Conversely, when we applied ketamine+propofol in our study, time to eye open with verbal stimuli was longer than in the ketamin+midazolam group. This may be due to differences in the doses used, as propofol 3 mg/kg was used in our study and in the Havel et al study the dose was 1 mg/kg [19]. In a study, it was compared different combinations of propofol+ketamine with respect to sedation quality and side effects in pediatric patients who underwent bone marrow aspiration or lumbar puncture, reported that the 1:3 ketaminepropofol combination was more successful in terms of sedation quality [20]. In our study, the ratio was 1:3, similarly there was no problem with sedation quality and adequacy, but according to the results of our study, the disadvantage of this combination is that the duration of eye-opening with verbal stimulation is longer than that of the ketamine+midazolam group (Table 1). Conclusion Midazolam+ketamine combination has provided faster recovery than ketamine-propofol combination in pediatric circumcision operations. No complication has been observed during sedation. Although we have found out that midazolam+ketamine combination may be a preferable choice for circumcision operations, these results must be evaluated furtherly in larger groups for the evidence. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval The study was approved by the Ethics Committee

References 1.

Gulec H, Sahin S, Ozayar E, et al. Ketamine-propofol sedation in circumcision. Rev Bras Anestesiol. 2015;65:367-70.

Ghadami Yazdi A, Ayatollahi V, Hashemi A, et al. Effect of two Different Concentrations of Propofol and Ketamine Combinations (Ketofol) in Pediatric Patients under Lumbar Puncture or Bone Marrow Aspiration. Iran J Ped Hematol Oncol. 2013;3:187-92.

Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349:599603.

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Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve blockâ&#x20AC;&#x201D;a painless procedure. J Pediatr. 1978;92:998-1000.

Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr. 1984;5:246-50.

Wiliamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics. 1983;71:36-40.

Serour F, Cohen A, Mandelberg A, et al. Dorsal penile nerve block in children under-going circumcision in a day-care surgery. Can J Anaesth. 1996;43:9548.

Uguralp S, Mutus M, Koroglu A, et al. Regional anesthesia is a good alternative to general anesthesia in pediatric surgery: Experience in 1,554 children. J Pediatr Surg. 2002;37:610-3.

Dalens B, Hasnaoui A. Caudal anesthesia in pediatric surgery: success rate and adverse effects in 750 consecutive patients. Anesth Analg. 1989;68:83-9.

10. Bicer S, Kuyrukluyildiz U, Akyol F, et al. At what age range should children be circumcised? Iran Red Crescent Med J. 2015;17:e26258. 11. Ozkan A, Okur M, Kaya M, et al. Sedoanalgesia in pediatric daily surgery. Int J Clin Exp Med. 2013;6:576-82. 12. Haliloglu AH, Gokce MI, Tangal S, et al. Comparison of postoperative analgesic efficacy of penile block, caudal block and intravenous paracetamol for circumcision: a prospective randomized study. Int Braz J Urol. 2013;39:551-7. 13. Payne K, Moore E, Elliott R, et al. Anaesthesia for day case surgery: a survey of adult clinical practice in the UK. Eur J Anaesthesiol. 2003;20:325-30. 14. Azizkhani R, Esmailian M. Rectal thiopental versus intramuscular ketamine in pediatric procedural sedation and analgesia; a randomized clinical trial. Emerg (Tehran). 2015;3:22:22-6. 15. Gauntlett I. A comparison between local anaesthetic dorsal nerve block and caudal bupivacaine with ketamine for paediatric circumcision. Pediatr Anesth. 2003;13:38-42. 16. Tan P-H, Cheng J-T, Kuo C-H, et al. Preincisional subcutaneous infiltration of ketamine suppresses postoperative pain after circumcision surgery. Clin J Pain. 2007;23:214-8. 17. Aouad M, Moussa A, Dagher C, et al. Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability. Acta Anaesthesiol Scand. 2008;52:5615. 18. Gharavifard M, Zadeh BBR, Moghadam HZ. A randomized clinical trial of intravenous and intramuscular ketamine for pediatric procedural sedation and analgesia. Emerg (Tehran). 2015;3:59-63. 19. Havel CJ, Strait RT, Hennes H. A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department. Acad Emerg Med. 1999;6:989-97. 20. Yazdi AG, Ayatollahi V, Hashemi A, et al. Effect of two different concentrations of propofol and ketamine combinations (Ketofol) in pediatric patients under lumbar puncture or bone marrow aspiration. Iran J Ped Hematol Oncol. 2013;3:187-92.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):837-40

Effect of aspiration risk on mortality in older age pneumonia cases Deniz Dogan, Yakup Arslan, Ahmet Cagin Health Science University, Gulhane Training and Research Hospital, Department of Chest Diseases, Ankara, Turkey Received 06 April 2018; Accepted 26 May 2018 Available online 19.09.2018 with doi:10.5455/medscience.2018.07.8878 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The incidence of community-acquired pneumonia (CAP) increases with age and is the leading cause of morbidity and mortality in older ages. Development of aspiration in these cases is one of the most important reasons to increase mortality. We retrospectively reviewed the data of sixty ninepatients over 65 years of age who were admitted with the diagnosis of community acquired pneumonia in order to determine the effects of aspiration risk factors on hospital stay and mortality. According to risk factors (neurological diseases, COPD, immobilization, cancer, etc.), cases were divided into two groups as high and low risk of aspiration. We aim to compared hospital stay and mortality in these groups. A total of sixty nine patients were included in this study. There were thirty patients in the group with high aspiration risk (group I) and thirty nine patients in the group with low aspiration risk (group II). CURB-65 scores were similar between the groups; however, pneumonia severity index was statistically higher in group II patients (p = 0.002). Mortality rates were significantly higher in group I (nine versus one) (p = 0.001). This was also valid for hospitalization times (11.7 ± 4.6 versus 8.4 ± 3.9 days, respectively) (p = 0.004). We found that the high risk of aspiration in advanced pneumonia cases was associated with prolonged hospital stay and increased mortality. At the same time there was a correlation between pneumonia severity index and hospital stay. Keywords: Aspiration, mortality, older age, pneumonia

Introduction Community-acquired pneumonia (CAP) is one of the most important causes of hospital admissions and treatment costs worldwide. The annual incidence in all age groups ranges from 9.2 to 33 in 1000 people [1-4]. The incidence of CAP increases with age and is the leading cause of morbidity and mortality in the elderly population [2,5]. In developed countries such as the United Kingdom and the United States, 6 th. most reason of all causes of death, and 1 st. most reason of deaths due to infections [3,8]. Development of aspiration in CAP cases is one of the most important factors that increase mortality. Aspiration is described as the passing through of oropharyngeal and / or gastric contents to the airways [9]. Sufficient bacterial burden in the lower respiratory tract is necessary for aspiration pneumonia to occur. This occurs as a result of aspiration of oral cavities or nasopharyngeal microorganisms after a disorder in the protective mechanisms of the lower respiratory tract [10]. The most important factor preventing aspiration is cough reflex and swallowing function. The fact that these factors do not observe normal function for any reason is the basis for aspiration. Many conditions, such as older age, male sex, neurological diseases (stroke, dementia, Parkinson’sdisease,

*Coresponding Author: Deniz Dogan, Health Science University, Gulhane Training and Research Hospital, Department of Chest Diseases, Ankara, Turkey E-mail: dr_denizz@yahoo.com

multipl sclerosis), immobility,esophageal dysfunction, impaired conscious, dehydration, vomiting, dysphagia, reducedcoughreflex, poorswallow, oropharyngeal and dental plaque colonization by organisms, bad oral health, lung diseases, diabetes mellitus, angiotensin I-converting enzymes deletion, malnutrition, antipsychotic drugs, proton pump inhibitors, angiotensinconverting enzyme inhibitors, chronic cardio-pulmonary disease, and head and neck cancers pose aspiration risks [2]. Aspiration pneumonia is an important cause of morbidity and mortality, and it is the fourth most common cause of death in elderly patients. [8] We aimed to investigate the effects of aspiration risk factors on mortality and hospital stay in patients 65 years of age and older with CAP diagnosis. Materials and Methods We retrospectively reviewed the data of seventy seven patients over 65 years of age who were followed up and treated in our clinic between October 2016 and October 2017 with the diagnosis of pneumonia in the community. Patients were divided into two groups as patients group (group I) with high risk of aspiration according to risk factors and patient group (group II) with low risk of aspiration.The risk of aspiration of the patients was based on the presence or absence of comorbid diseases listed (Table 1). Group I patients were transferred from another clinic (4 patients), and 2 patients who were not able to receive file data were not included. In group II patients, 2 patients who were discharged from another 837

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hospital within the last 2 days were excluded from the study. Both groups were compared according to hospital stay and mortality. Statistical Analysis SPSS for Mac Version 20.00 (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis of the data obtained at the end of the study. Continuous variables were expressed as mean ± standard deviation (SS), and categorical variables as number and percentage (%). The continuous variables were assessed by the Kolmogorov-Smirnov test for normal distribution. MannWhitney U test and Student-t test were used for chi-squared test for continuous variables and normal distribution for continuous variables in comparison of groups. Statistical significance was accepted as p <0.05. Results

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2.43 ± 0.67 for group I and II, respectively); however, pneumonia severity index (PSI) (122.8 ± 22.8 versus 105.3 ± 19.2 for group I and II) was statistically higher in group I patients (p = 0.002). However, there was no significant correlation between PSI and hospital stay. The number of drugs used by the patients was higher in group I patients (5.6 ± 2.5 versus 1.3 ± 1.6, respectively) and this was statistically significant (p <0.001). Laboratory findings were not statistically significant when procalcitonin (PCT) levels were excluded (4.63 ± 4.23 ng / mL vs. 1.03 ± .99 ng / mL, respectively) (Table 3). At the same time, there was no significant correlation between PCT levels and PSI values in both patients and groupsWhen the mortality rates of our primary outcome were examined, mortality was significantly higher in group 1 (9 vs 1) (p = 0.001). This was also valid for hospitalization times (11.7 ± 4.6 versus 8.4 ± 3.9 days, respectively) (p = 0.004).

A total of sixty nine patients who met the criteria were included to the study. There were a total of thirty ninepatients in the group with high aspiration risk (group I) and a total of thirty patients with low aspiration risk (group II). Patients in group I had the most frequent neurological disease followed by COPD and immobilization (Table 1).In all cases, the mean age was 78.41 ± 7.53 years, BMI was 23.57 ± 4.31 kg/m2, and mean hospital stay was 10.10 ± 4.59 day. The mean age of groupI and II was 78.2 ± 8.11 years versus 78.2 ± 7.11 years, the BMI was 22.2 ± 4.1 versus 24.9 ± 4.1 kg/m2, and the mean duration of hospitalization was 11.7 ± 4.6 versus 8.4 ± 3.9 days.There was no statistically significant difference between the groups in terms of demographic features such as age, gender and duration of smoking, excluding body mass index (Table 2). The CURB-65 scores, which constituted the main indications for admission, were similar between the groups (2.23 ± 0.43 versus

Table 1. The distribution of aspiration risk factors in group GroupI n=30 (%)

Aspiration Risk Factors Neurological Disease

18 (60)

Dementia (Alzheimer- Parkinson’s-Senile)

11 (61.1)

CVD

5 (27.7)

HuntingtonKorea

2 (11.2)

COPD

5 (16.7)

Immobile

5 (16.7)

Cancer

3 (3.3)

Achalasia

2 (6.7)

CVD: Cerebrovascular Disease, COPD: Chronic Obstructive Pulmonary Disease, DM: Diabetes Mellitus

Table 2. Comparison of characteristics of the study population GroupI (n=30)

GroupII (n=39)

Gender, Male (%)

23 (%76.7)

31 (%79.4)

Age (year)

78.5 ± 8.11

78.2 ± 7.11

BMI (kg/m2)

22.2 ± 4.1

24.9 ± 4.1

0.005

Fever ©

36.9 ± .89

36.6 ± .57

Pulse Rate (Pulse/mn)

93.5 ± 18.1

91.5 ± 16.6

SBP (mmHg)

116.8 ± 17.3

121.0 ± 18.9

DBP (mmHg)

66.2 ± 10.7

68.5 ± 11.6

CigaretteUse (package/year)

14.5 ± 20

23.3 ± 27.2

Number of Drugs

5.6 ± 2.5

1.3 ± 1.6

0.001

122.8 ± 22.8

105.3 ± 19.2

0.002

CURB-65

2.43 ± .67

2.23 ± .43

Length of HospitalStay (day)

11.7 ± 4.6

8.4 ± 3.9

0.004

9 (30)

1 (2.6)

0.001

Characteristics

PSI

Exitus n (%)

SBP:Systolic Blood Pressure, DBP:Diastolic Blood Pressure, NS:NonSignificant, BMI: Body Mass Index, PSI:PneumoniaSeverity Index

838

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Table 3. Comparisonof laboratoryfindings of the study population GroupI (n=30)

GroupII (n=39)

Leukocyte103/μ)

13.74 ± 5.29

15.33 ± 7.45

Hemoglobin (g/dL)

12.24 ± 1.99

11.25 ± 2.65

Hematocrit (%)

37.51 ± 5.66

34.97 ± 8.32

240.01 ± 80.76

224.12 ± 84.43

12.81 ± 5.94

13.48 ± 6.94

1.16 ± .98

1.11 ± 1.02

16.24 ± 13.42

19.27 ± 15.18

Glucose (mg/dL)

145.8 ± 51

167.1 ± 85.5

Urea (mg/dL)

71.4 ± 47.2

77.5 ± 36.9

Creatinin (mg/dL)

1.14 ± .54

1.58 ± .73

Albumin (g/dL)

2.70 ± .55

2.93 ± .58

LDH (U/L)

325.1 ± 144.5

299.2 ± 107.4

Sodyum (mmol/L)

136.7 ± 7.25

136.8 ± 5.56

ESR (mm/h)

76.53 ± 30.1

78.10 ± 28.0

hs-CRP (mg/L)

131.53 ± 71.8

152.48 ± 71.2

1.03 ± .99

4.63 ± 4.23

< 0.001

7.426 ± .056

7.418 ± .068

PaO2 (mmHg)

59.3 ± 11.3

61.5 ± 13.6

PaCO2 (mmHg)

35.9 ± 13.9

34.6 ± 9.6

SaO2 (%)

88.5 ± 6.5

88.6 ± 7.3

LaboratoryFindings

Platelets (103/μL) Neutrophil (103/μL) Lymphocyte (103/μL) NLR

Procalsitonin (ng/mL)

NLR: Neutrophil lymphocyte ratio, ESR: Erytrocyte Sedimentation Rate hs-CRP:HighSensitive C-Reactive Protein, LDH: Lactatedehydrogenase

Discussion In this study, we compared mortality and hospital stay according to risk of aspiration in 65 years and older patients with CAP. The most important data obtained from our study are increased mortality and hospital stay durations in the group with high risk of aspiration. Changes in consciousness as risk factors for aspiration pneumonia were selected as comorbid diseases in which swallowing function and cough reflex suppressed comorbid diseases, mainly dysphagia resulting from various neurological diseases and diseases holding upper gastrointestinal system, as a result of changes in consciousness level.These risk factors are also the most important risk factors in various studies [10-13]. Immobilization, also identified as a risk factor, and COPD are accepted as risk factors, and malignancy and diabetes are also included in risk factors [6]. Although age was also identified as an important risk factor for aspiration risk [14], our study was not identified as a risk factor in our study because all of our patients were selected over the age of 65 years. The fact that age is not statistically significant among the groups indicates this situation.Compared to the two groups, there is no difference in clinical findings including fever, pulse and blood pressure. Smoking was not found statistically significant among the groups. Similarly, Hibberd et al. also investigated smoking as a risk factor, but did not find it significant [6].Again, in the same study it was stated that weight loss was not a risk factor but in general, malnutrition was defined as a risk factor

for aspiration pneumonia [15]. In our study, BMI was found to be significantly lower in the group with high risk of aspiration. When we look at the laboratory findings, the only difference was observed in PCT levels and PCT levels were significantly higher in the patient group with low risk of aspiration. Studies in this area have shown that serum PCT levels are not a good predictor of bacterial aspiration pneumonia in studies conducted by Ali A. ElSolh et al. [16]. In a recent study, the diagnostic value of PCT was compared between aspiration pneumonia and pneumonitis, but no difference was found [16]. In our study, mortality rates were found to be higher in the group with low PCT levels when the relation of PCT levels to mortality was examined. This can be explained by the fact that patients with high risk of aspiration usually have chronic and neurological disorders, most of these patients are bed dependent, the use of unconscious antibiotics is higher in these patients, and the hospital admission is later.In the studies of Kim et al. [17] involving 155 cases of CAP, 99 of the cases were over 65 years of age and in these cases, PCT levels did not have a relation with mortality. In the same study, it was found that there was a positive correlation between PCT levels and PSI values. In our study, there was no significant correlation between PCT levels and PSI values in both patients and groups.Another study looked at the diagnostic benefit of serum PCT levels in pulmonary aspiration syndromes, with increased PCT levels associated with hospital mortality [16]. Studies have shown that radiological involvement during aspiration pneumonia is mostly in the lower lobes and in 839

doi: 10.5455/medscience.2018.07.8878

the posterior segments. The main purpose of our study, mortality and hospitalization, was higher in the patient group with high risk of aspiration, and this difference was statistically significant. When we look at the studies done in the literature, it is seen that our results are compatible with the literature.Komiya K et al. in multicenter retrospective cohort studies involving 417 TGP and 220 healthcare-associated pneumonia cases, the presence of aspiration pneumonia was the most important independent risk factor for predicting 30-day mortality [18]. As a result of the same study, the authors stated that the presence of aspiration pneumonia may be an important predictor of mortality among these patient groups. In another study of a total of 628 aspiration pneumonia cases, of which 510 were TGP, mean age 77 and 30-day mortality was 21%. When the results of the same study were compared with TGP, it was concluded that the incidence of aspiration pneumonia in the community was older and the hospital admission, hospitalization frequency and intensive care need were higher in this patient group [19]. The retrospective nature of our study, the small number of cases and the inability to evaluate all of the factors described in the literature as aspiration risk factors in all cases constituted limited aspects of our study. Conclusion

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Turkish Thoracic Society: Report of diagnosis and treatment consensus on pneumonia in adults. Turk Thorac J. 2009;10:1-12.

Saltoglu N, Tasova Y, Yılmaz G, et al. Community acquired pneumonia: etiology, prognosis and treatment. Flora. 1999;4:245-52.

Coşkun Doğan, Önder Çetin, Nesrin Kıral, et al. Analysis of advanced age pneumonia cases and factors effective on treatment success. Eurasian J Pulmonol. 2014;16:94-8.

Judi Hibberd, Jenni Fraser, Claire Chapman, et al. Can we use influencing factors to predict aspiration pneumonia in the United Kingdom? Multidiscip Respir Med. 2013;8:39.

Antonella F. Simonetti, Diego Viasus, et al. Management of communityacquiredpneumonia in older adults. Ther Adv Infect Dis. 2014;2:3-16.

Garon BR, Engle M, Ormiston C. A randomized control study to determine the effects of unlimited oral intake of water in clients with identified aspiration. J Neurol Rehab. 1997;11:139–48.

Alataş F. Aspiration pneumonia and lung abscess. Interior: Özlü T, Metintaş M, Karadağ M, Kaya, ed. Respiratory System Diseases. 1st edition. Istanbul: Istanbul Medical Bookstore. 2010: 961-8.

10. Bartlett JG. Aspiration pneumonia in adult http://www.uptodate.com/ contents/aspiration-pneumonia-in-adults. 11. Ebru Çakır EDİS Aspiration Pneumonia, Review, ASYOD Current Pulmonary Disease Series. 2014;2:52-8.

In conclusion, the presence of risk factors such as COPD and immobilization, especially in neurological diseases in the elderly (≥65) pneumonia cases in the community, increases the hospitalization duration and mortality significantly in these patients.At the same time, the costs of treatment are also increasing in relation to the increased hospitalization time of these patients. Assessing the risk of aspiration in this patient group is an important parameter in predicting mortality. However, these data should also be supported by larger case series and prospective studies.

12. Ulukavak Çiftçi T, Mollarecep ER, Ekim N. Aspiration pneumonia (7case and literature review). Thoracic Magazine. 2004;5:100-5.

Competing interests The authors declare that they have no competing interest

16. El-Solh AA, Vora H, Knight PR 3rd, Porhomayon J. Diagnosticutility of serum procalcitonin levels in pulmonary aspiration syndromes. Crit Care Med. 2011;39:1251–6.

Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

13. Kocabaş A. Aspirasyon. In: Ekim N, Türktaş H (eds). Pulmonary Medicine Emergencies. Ankara 2000;125-39. 14. Langmore S, Skarupski KA, Park PS, Fries BE: Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002;17:298–307. 15. Bouchard J, Presse N, Ferland G. Association between aspiration and malnutrition in patients from active geriatric units. Can J Diet Pract Res. 2009;70:152-4.

17. Kim JH, Seo JW, Mok JH, et al. Usefulness of plasma procalcitonin to predict severity in elderly patients with community-acquired pneumonia. Tuberc Respir Dis. 2013;74:207-14.

Kaysin A, Viera AJ. Community-Acquired Pneumonia in Adults: Diagnosis and Management. Am Fam Physician. 2016;94:698-706.

18. Komiya K, Ishii H, Umeki K, et al. Impact of aspiration pneumonia in patients with community- acquired pneumonia and healthcare associated pneumonia: A multicenter retrospective cohort study. Respirology. 2013;18:514-21.

Ozturk ZA, Sayıner ZA, Kuyumcu ME, Yesil Y, Kepekcı Y. Pneumococcal vaccinations and cost-effectiveness in the geriatric population. Akad Geriatrics. 2013;5:1-4.

19. Lanspa MJ, Jones BE, Brown SM, et al. Mortality, morbidity, anddiseaseseverity of patients with aspiration pneumonia. J Hosp Med. 2013;8:83-90.

Reference

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Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):841-4

Prevalence of microscopic colitis in patients with chronic diarrhea Gokhan Pektas1, Meral Soylu Sozen2, Ayhan Vurmaz3, Osman Ersoy4 1 Mugla State Hospital, Hematology Clinic, Mugla, Turkey Ataturk Training and Research Hospital, Internal Medicine Clinic, Ankara, Turkey 3 Afyon Kocatepe University Faculty of Medicine Medical Biochemistry Clinic, Afyonkarahisar, Turkey 4 Ataturk Training and Research Hospital, Gastroenterology Clinic, Ankara, Turkey 2

Received 26 March 2018; Accepted 21 May 2018 Available online 11.07.2018 with doi:10.5455/medscience.2018.07.8842 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Microscopic colitis affects nearly 10% of the patients with chronic diarrhea which is defined as an increase in the number of daily defecation or the amount of stool lasting more than 4 weeks. The present study aims to analyze the Prevalence of Microscopic Colitis in patients who have admitted to a tertiary health center due to chronic diarrhea with unidentified etiology. This is a retrospective review of 54 patients (31 men and 23 women) with chronic diarrhea who were admitted to the gastroenterology department of the study center between July 2009 and July 2010. Data related with the patient age, patient gender, laboratory findings and histopathological alterations were obtained from hospital files. The men and women included in this study were statistically similar with respect to their mean age (36.4 Âą11.1 years vs 43.1 Âą18.0 years, p=0.125). The male and female patients with cheronic diarrhea had statistically similar incidences of duodenitis (8/31 vs 11/23, 25.8% vs 47.8%, p=0.097). These men and women had also statistically similar incidences of terminal ileitis (10/31 vs 8/23, 32.3% vs 34.8%, p=0.847) respectively. The male and female patients with chronic diarrhea had statistically similar incidences of non-specific colitis (19/31 vs 12/23, 61.3% vs 52.2%, p=0.499). However, non-specific colitis was significantly more frequent in patients with normal duodenum biopsy than patients with duodenitis (24/35, 68.6% vs 7/19, 36.8%; p=0.008). Microscopic colitis should be considered in differential diagnosis of middle aged and elderly women with chronic diarrhea. Although there is no general consensus about the localization and number of intestinal biopsies, a large number of biopsies should be collected, even from the colon mucosa with normal macroscopic appearance in these patients. Keywords: Chronic diarrhea, microscopic colitis, gastroenteritis

Introduction Chronic diarrhea is defined as an increase in the number of daily defecation or the amount of stool which lasts more than 4 weeks. Microscopic colitis affects nearly 10% of the patients with chronic diarrhea and its incidence varies between 3.7% and 13% [1]. It was first described by Read et al. in 1980 as a moderate increase in the number of inflammatory cells in biopsies taken from normal-looking mucosa during sigmoidoscopy in the mucosa of the rectum and colon with chronic watery diarrhea [2]. This clinical entity usually represents as chronic, bloodless, waterry diarrhea in the fifth and sixth decades of life. The presence of nocturnal diarrhea helps to distinguish microscopic colitis from irritable bowel diseases [3,4].

Colonoscopy may demonstrate normal appearing or hyperemic mucosa in microscopic colitis. The incidences of collagenous colitis and lymphocytic colitis were reported as 0.6-5.2/100000 and 3.7-4.5/100000 in Northern America and Europe (5,6). As for Turkey, the incidence of lymphocytic colitis is 9% and the incidence of collagenous colitis is 2.5% in patients with chronic diarrhea [7].

Microscopic colitis has two subtypes which are namely lymphocytic colitis and collagenous colitis. Lymphocytic colitis refers to intraepithelial lymphocytosis while collagenous colitis is characterized by an increase in the subepithelial collagen thickness.

The etiology of microscopic colitis is still unclear, abnormal immunoreaction to antigens, malabsorption of bile acids, HLA association and drugs (i.e., non-steroid anti-inflammatory agents, proton pump inhibitors, serotonine uptake inhibitors, beta blockers, statins, and bisphosphonates) have been proposed as the underlying factors. Clinical findings suggesting an underlying abnormal immune response include the presence of female dominance, the co-existence of autoantibodies and the association with autoimmune diseases such as celiac disease, thyroid diseases and spondyloarthritis [8,9].

*Coresponding Author: Ayhan Vurmaz, Afyon Kocatepe University Faculty of Medicine Medical Biochemistry Department, Afyonkarahisar, Turkey E-mail: ayhan.vurmaz@gmail.com

The present study aims to analyze the patients who have admitted to a tertiary health center due to chronic diarrhea with unidentified etiology. 841

doi: 10.5455/medscience.2018.07.8842

Materials and Methods The present study was approved by the Ethical Committe of Atatürk Research and Training Hospital. This is a retrospective review of 54 patients (31 men and 23 women) with chronic diarrhea who were admitted to the gastroenterology department of the study center between July 2009 and July 2010. The patients who had chronic diarrhea (ongoing for more than four weeks) with unexplained etiology were included in this study. Those with a previous history of radiotherapy and chemotherapy, surgery regarding the gallbladder, stomach or colon, those who were diagnosed with irritable bowel syndrome, those with a known history of liver and kidney failure and those using laxatives and antibiotics were excluded. Data related with the patient age, patient gender, laboratory findings and histopathological alterations were obtained from hospital files. The workup of the patients with chronic diarrhea consisted of normal stool microscopy and culture as well as laboratory tests within the normal spectrum. Hematological tests included complete blood count and erythrocyte sedimentation rate whereas biochemical evaluation referred to the measurement of glucose, urea, creatinine, hepatic transaminases, total protein, albumin, amylase, gastrin, total cholesterol, triglyceride, lipoprotein and thyroid stimulating hormone levels. Serological tests comprised C-reactive protein, anti-HIV, anti-gliadin and anti-endomysial antibody levels. All patients underwent abdominal ultrasonography, upper gastrointestinal endoscopy and colonoscopy. There was nothing particular in the abdominal ultrasonography scans of the reviewed patients. The duodenum, jejunum and ileum were visualized by endoscopy while rectum, sigmoid colon and descending colon were assessed by colonoscopy. As the aforementioned anatomical regions all appeared normal macroscopically in each participant, several biopsies were obtained during endoscopy and colonoscopy. Acquired biopsies were examined by a single experienced pathologist working at the study center. Results The demographic and clinical characteristics of the reviewed patients are enlisted in Table 1. Duodenum biopsies of 35 patients were normal (64.8%) whereas 19 patients had duodenitis (35.2%). Ileum biopsies of 36 patients revealed nothing particular (66.7%) while 18 patients had terminal ileitis (33.3%). Colon biopsies of 20 patients were normal (37%), whereas 31 patients had non-specific colitis (57.3%). In addition, one patient had collagenous colitis (1.9%) and one patient had amebiasis (1.9%). One patient was diagnosed with malabsorption syndrome (1.9%) histologically due to the presence of villous blunting, lymphocytosis within intestinal epithelium and lymphocytic infiltrates along with apoptotic debris in the deeper mucosa. The men and women included in this study were statistically similar with respect to their age (36.4 ±11.1 years vs 43.1 ±18.0 years, p=0.125). The male and female patients with chronic diarrhea had statistically similar incidences of duodenitis (8/31 vs 11/23, 25.8% vs 47.8%, p=0.097). Normal duodenum biopsy was detected at statistically similar rates in men and women reviewed by this study (23/31 vs 12/23, 74.2% vs 52.2%, p=0.097).

Med Science 2018;7(4):841-4

The men and women in this study were statistically similar with respect to normal small bowel biopsy (21/31 vs 15/23, 67.7% vs 65.2%, p=0.847). The male and female patients with chronic diarrhea had statistically similar incidences of terminal ileitis (10/31 vs 8/23, 32.3% vs 34.8%, p=0.847). Normal colon biopsy was detected at statistically similar rates in men and women reviewed by this study (11/31 vs 9/23, 35.5% vs 39.2%, p=0.499). The men and women with chronic diarrhea had also statistically similar incidences of nonspecific colitis (19/31 vs 12/23, 61.3% vs 52.2%, p=0.499). However, non-specific colitis was significantly more frequent in patients with normal duodenum biopsy than patients with duodenitis (24/35, 68.6% vs 7/19, 36.8%; p=0.008). Table 1. Demographic and Clinical Characteristics of the Participants Mean±Standard Deviation

Range (Minimum-Maximum)

Age (years)

39.3±14.7

20-87

Hemoglobin (g/dl)

14.2±1.9

8.1–18.3

Leukocyte count (k/μL)

7509.6±1894.7

4100.0–11400.0

Thrombocyte count (k/μL)

260890.5±57020.2

159000.0–432000.0

Erythrocyte sedimentation rate (mm/hour)

14.1±12.3

2.0–50.0

C-reactive protein (mg/L)

5.5±6.8

3.0–48.0

Fasting glucose (mg/dL)

93.5±9.6

72.0–112.0

Urea (mg/dL)

27.8±11.6

14.0–96.0

1.0±0.2

0.6–1.6

Alanine transaminase (U/L)

30.0±28.2

5.0–169.0

Aspartate transaminase (U/L)

23.1±9.6

8.0–60.0

Total protein (g/dL)

7.3±0.7

4.1–8.2

Albumin (g/dL)

4.5±0.8

3.3–8.6

Total cholesterol (mg/dL)

163.8±40.5

95.0–285.0

Creatinine (mg/dL)

Triglyceride (mg/dL)

127.0±75.2

36.0–445.0

Low density lipoprotein (mg/dL)

97.5±28.8

30.0–157.0

Gastrin (pg/ml)

65.0±24.6

33.0–183.0

1.6±1.1

0.4–6.0

Thyroid stimulating hormone (μIU/mL)

Discussion Chronic diarrhea is the most common complaint of the patients who are examined at the gastroenterology departments. The frequency of chronic diarrhea is about 4% to 5% in Western populations and chronic diarrhea affects 7% to 14% of the elderly individuals. Microscopic colitis is observed in 4% to 13% of the patients who have waterry diarrhea with unknown etiology [10-13]. Epidemiological data obtained from the studies performed on microscopic colitis in different parts of the world are summarized in Table 2. According to these data, the majority of the microscopic colitis cases are reported from Northern America and Europe. The number of microscopic colitis patients analyzed in British and French studies is lower than the number of patients investigated by studies held in Northern America and other European countries [13-22]. 842

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The incidence of microscopic colitis might change over a period of time within the same country. A study published in 1993 detected microscopic colitis in 4% of the Swedish patients with chronic watery diarrhea, but the same value increased to 10% in 1998 [23, 24]. About 9.5% of the cases which underwent colonoscopy due to chronic diarrhea throughout a five-year period were diagnosed with lymphocytic colitis in a Spanish study [25]. A study by Marshall et al. identified lymphocytic colitis in 11.7% and collagenous colitis in 0.9% of 111 patients who had chronic diarrhea with unknown etiology [26]. Another study investigating 132 patients with chronic diarrhea and abdominal pain found lymphocytic colitis in 16% of the patients and collagenous colitis in 5% of the patients [27]. Collagenous colitis was detected in 0.8 of every 100000 Swedish citizens between 1984 and 1988, and this ratio increased to 4.9 between 1993 and 1998 and to 6.1 between 1996 and 1998 [23, 24]. Based on the health records kept between 1995 and 1999 in Iceland, the annual incidence values for collagenous colitis and lymphocytic colitis were calculated as 5.2/100000 and 4.0/100000, respectively [6]. As for Turkey, microscopic colitis was detected in 11.5% of the patients who had chronic diarrhea with unknown etiology [7]. Since only one patient was diagnosed with collagenous colitis, the frequency of microscopic colitis was found to be 1.9% in patients who have chronic diarrhea with unidentified etiology. Such a low frequency can be attributed to the relatively small cohort size and probable unawareness of the dealing pathologists about microscopic colitis. The frequency of lymphocytic colitis is 4 to 20 times more than the frequency of collagenous colitis in European countries [1318]. For instance, the frequency of lymphocytic colitis is three times more than the frequency of collagenous colitis in a Spanish study [25]. On the other hand, the frequency of lymphocytic colitis was four times more than the frequency of collagenous colitis in a Turkish study [7]. Microscopic colitis affects females more than males and more specifically, collagenous colitis affects women seven times more than men [1-9]. Swedish women have twice the risk of microscopic colitis than Swedish men [23,24] and the women in Iceland have five times more risk of being affected by microscopic colitis than men [6]. Similarly, Canadian women are 3.5 times more likely to have collagenous colitis and 7 times more likely to have lymphocytic colitis than Canadian men [28]. In addition, Spanish women are 4.7 times more likely to develop collagenous colitis and 2.7 times more likely to develop lymphocytic colitis than Spanish men [25]. However, Turkish men and women were found to be almost equally affected by microscopic colitis (1/1.4) [7]. A similar result was found in a Mexican study and it was reported that the ratio of men to women affected by microscopic colitis was 1/1.8 [29]. Epidemiological studies point out 68 years as the mean age of the patients with microscopic colitis (1-16). The mean age of the patients diagnosed with microscopic colitis was 56.5 years in a Mexican study [29] and 38.6 years in an Indian study [5]. However, microscopic colitis was diagnosed at a mean age of 45.0 years in a Turkish study [7]. The risk of being diagnosed with microscopic

Med Science 2018;7(4):841-4

colitis was 5 times higher in Canadian patients aged ≥65 years [26]. The age of the lymphocytic colitis cases varied between 51 and 59 years while the age of the collagenous colitis cases varied between 64 and 68 years [13-16]. A Turkish study reported the mean age of lymphocytic colitis cases as 45 years (range 27-63 years) and the mean age of collagenous colitis cases as 60 years (range: 54-65 years) [7]. The only patient diagnosed with collagenous colitis was a 37-year-old woman in this study. In conclusion, microscopic colitis should be considered in differential diagnosis of middle-aged and elderly women with chronic diarrhea. Since microscopic colitis significantly impairs the quality of life in patients, it is important to make an early diagnosis of this disease. Therefore, the physicians examining patients with chronic diarrhea, the gastroenterologists performing the endoscopy, and the pathologists evaluating gastrointestinal biopsies should have knowledge and insight about microscopic colitis. Colonoscopy should be performed in all patients who have chronic waterry diarrhea with unidentified etiology and the gastroenterologists performing colonoscopy should take biopsies from the intestinal mucosa despite its normal macroscopic appearance. Although there is no general consensus about the localization and number of intestinal biopsies, a large number of biopsies should be collected, even from the colon mucosa which appeared macroscopically normal. Further research is warranted to clarify the role of microscopic colitis in Turkish patients who have chronic non-bloody diarrhea with unknown etiology. Table 2. Epidemiological Data on Microscopic Colitis Collagenous colitis

Lymphocytic colitis

Orebro, Sweden /1984–1988 (31)

0.8

Orebro, Sweden /1989–1993 (31)

2.7

Orebro, Sweden /1993–1995 (32)

3.7

3.1

Orebro, Sweden /1996–1998 (32)

6.1

5.7

Franche-Comté, Fransa/1987–1992 (33)

0.6

Terrassa, Spain /1993–1997 (34)

2.3

3.7

Iceland /1995–1999 (35)

5.2

4.0

Olmsted County, †USA/1985–1989 (36)

0.3

0.5

Olmsted County, USA/1990–1993 (36)

1.6

1.0

Olmsted County, USA/1994–1997 (36)

3.9

6.4

Olmsted County, USA/1997–2001 (36)

6.2

12.9

Lothian, İngiltere/1998–2003 (37)

0.8

Tayside, United Kingdom /1999–2004 (23)

1.1

0.6

USA: United States of America Incidence values are reported as per 100000 patients. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval The present study was approved by the Ethical Committe of Atatürk Research and Training Hospital.

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T helper cell type 1 mucosal cytokine profile. J Clin Pathol. 2007;60:382-7.

Datta I, Brar SS, Andrews CN, et al. Microscopic colitis: a review for the surgical endoscopist. Can J Surg. 2009;52:E167-72.

20. Pokorny CS, Kneale KL, Henderson CJ. Progression of collagenous colitis to ulcerative colitis. J Clin Gastroenterol. 2001;32: 435-8.

Read NW, Krejs GJ, Read MG, et al. Chronic diarrhea of unknown origin. Gastroenterol. 1980;78:264-71.

21. Pokorny CS, Selby WS. Microscopic colitis: An underdiagnosed cause of chronic diarrhoea-the clue is in the biopsies. Intern Med J. 2003;33:305-9.

Okamoto R, Negi M, Tomii S, et al. Diagnosis and treatment of microscopic colitis. Clin J Gastroenterol. 2016;9:169-74.

22. Saurine TJ, Brewer JM, Eckstein RP. Microscopic colitis with granulomatous inflammation. Histopathol. 2004;45:82-6.

Stoicescu A, Becheanu G, Dumbrava M, et al. Microscopic colitis-a missed diagnosis in diarrhea-predominant irritable bowel syndrome. J Clin Med. 2012;71:3-9.

23. Olesen M, Eriksson S, Bohr J, Microscopic colitis: a common diarrhoeal disease. An epidemiological study in Orebro, Sweden, 1993-1998. Gut. 2004;53:346-50.

Misra V, Misra SP, Dwivedi M, et al. Microscopic colitis in patients presenting with chronic diarrhea. Indian J Pathol Microbiol. 2010;53:15-9.

24. Olesen M, Eriksson S, Bohr J, Lymphocytic colitis: a retrospective clinical study of 199 Swedish patients. Gut. 2004;53:536-41.

Gentile NM, Khanna S, Loftus EV, et al. The epidemiology of microscopic colitis in Olmsted County from 2002 to 2010: a population-based study. Clin Gastroenterol Hepatol. 2014;12:838-42.

25. Fernandez-Banares F, Salas A, Forne M, et al. Incidence of collagenous and lymphocytic colitis: A 5-year population-based study. Am J Gastroenterol. 1999;94:418-23.

Erdem L, Yıldırım S, Akbayır N, et al. Prevalence of microscopic colitis in patients with diarrhea of unknown etiology in Turkey. World J Gastroenterol. 2008;14:4319-23.

26. Marshall JB, Singh R, Diaz-Ariaz AA. Chronic, unexplained diarrhea: are biopsies necessaryif colonoscopyis normal. Am J Gastroenterol. 1995;372-6.

Ianiro G1, Cammarota G, Valerio L, et al. Microscopic colitis. World J Gastroenterol. 2012;18:6206-15.

27. Gineston JL, Sevestre H, Descombes P, et al. Biopsies of the endoscopically normal rectum and colon: a necessity; incidence of collagen colitis and microscopic colitis. Gastroenterol Clin Biol. 1989;13:360-3.

Storr MA. Microscopic colitis: epidemiology, pathophysiology, diagnosis and current management-an update 2013. ISRN Gastroenterol. 2013;2013: 352718.

28. Williams JJ, Kaplan GG, Makhija S, et al. Microscopic colitis-defining incidence rates and risk factors: A population-based study. Clin Gastroenterol Hepatol. 2008;6:35-40.

10. Thomas PD1, Forbes A, Green J, Guidelines for the investigation of chronic diarrhoea, Gut. 2003;52:1-15.

29. Rubio-Tapia A, Martínez-Salgado J, García-Leiva J, et al. Microscopic colitides: a single center experience in Mexico. Int J Colorectal Dis. 2007;22:1031-6.

11. Nhylin N, Bohr J, Eriksson S, et al. Systematic review: microscopic colitis. Aliment Pharmacol Ther. 2006;23:1525-34. 12. Netzer P, Levkovits H, Zimmermann A, et al. Collagen colitis and lymphocytic (microscopic) colitis: different or common origin? Z Gastroenterol. 1997;35:681-90. 13. Raclot G, Queneau PE, Ottignon Y. Incidence of collagenous colitis. A retrospective study in the east of France. Gastroenterol. 1994;106:A23. 14. Rajan J, Noble C, Anderson C, et al. The epidemiology and clinical features of collagenous colitis in Lothian. Gut. 2005;54:A99. 15. Heron T, Walsh S, Mowat A. Microscopic colitis in tayside: clinical features, associations, and behaviour. Gut. 2005;54: A84. 16. Burch VC, Price SK, Wright JP, et al. Collagenous colitis-a rare cause of chronic watery diarrhoea. A case report. S Afr Med J. 1992;81:617-9. 17. Narita T, Akiyama M. Collagenous colitis in a Japanese patient. Pathol Int. 1996;46:211-5. 18. Valle Mansilla JL, Leon Barua R, Recavarren Arce S, et al. Microscopic colitis in patients with chronic diarrhea. Rev Gastroenterol Peru. 2002;22:275-8. 19. Tagkalidis PP, Gibson PR, Bhathal PS. Microscopic colitis demonstrates a

30. Falodia S, Makharia GK, Sateesh J, et al. Spectrum of microscopic colitis in a tertiary care centre in India. Trop Gastroenterol. 2007;28:121-5. 31. Veress B, Löfberg R, Bergman L. Microscopic colitis syndrome. Gut. 1995;36:880-9. 32. Riddell RH, Tanaka M, Mazzoleni G. Non-steroidal antiinflammatory drugs as a possible cause of collagenous colitis: a case-control study. Gut. 1992;33:683-6. 33. Genova G1, Arena N, Guddo F, Collagenous colitis: Morphologic and immunohistochemical study. Pathologica. 1993;85:489-95. 34. Golf JS, Barnett JL, Pelke T, et al. Collagenous colitis: histopathology and clinical course. Am J Gastroenterol. 1997;92:57-60. 35. Baert F, Wouters K, D’Haens G. Lymphocytic colitis: a distinct clinical entity? a clinicopathological confrontation of lymphocytic and collagenous colitis. Gut. 1999;45:375-9. 36. Wilcox GM, Mattia AR. Microscopic colitis associated with omeprazole and esomeprazole exposure. J Clin Gastroenterol. 2009;45:451-3. 37. Fernández-Bañares F, Esteve M, Espinós JC, et al. Drug consumption and the risk of microscopic colitis. Am J Gastroenterol. 2007;102: 324-30.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):845-7

Sociodemographic and clinical characteristics of patients admitted to the consultationliaison psychiatry clinic in a university hospital Fatma Kartal Sarioglu, Lale Gonenir Erbay Inonu University Faculty of Medicine Department of Psychiatry, Malatya, Turkey Received 21 February 2018; Accepted 16 May 2018 Available online 12.10.2018 with doi:10.5455/medscience.2018.07.8876 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Consultation-liaison psychiatry is an area of psychiatry researching the links between general medicine and psychosocial situations, and deals with the diagnosis, treatment and monitoring of psychiatric disorders and psychosocial problems accompanying physical diseases. The aim of this study is to review the sociodemographic data and treatment approaches for patients admitted to the consultation-liaison psychiatry unit of a university hospital within one year. The sociodemographic and clinical information for patients admitted to the consultation-liaison psychiatry unit of our hospital’s psychiatry ward from August 2015 to November 2016 were obtained by retrospectively investigating the hospital database and patient files and uploading the information to a structured form. Patients in the psychiatry ward were admitted by transfer with 64.9% from the clinic, 16.2% from the emergency service and 10.8% from other wards. The most common physical disease diagnosis of patients was neurologic diseases for 51.4%, endocrinologic diseases for 16.2% and other disease groups for 21.6%. The incidence of psychiatric diagnoses placed according to DSM-V were identified, in order, as psychotic disorders (18.9%), depressive disorders (16.2%), mental retardation (13.5%), somatic symptom disorders (13.5%), bipolar disorder (10.8%), personality disorders (8.1%), oppositional disorder (5.4%), anxiety disorders (5.4%), impulse control and behavior disorders (5.4%) and neurocognitive disorders (2.7%). A total of 10.8% of patients had suicidal thoughts, with 8.1% passive and 2.7% active. Inpatients admitted to our CLP unit, a high rate of 10.8% was identified to have suicidal thoughts. The association of increased suicide risk with many medical diseases shows the necessity of enquiring about suicidal thoughts for each patient. Cooperation between other clinics and CLP will be helpful in increasing the quality of service and offering a more holistic approach to these patients. It appears there is a need for broader cooperation in the area of consultation liaison. This data is considered to form a basis for future studies. Keywords: Consultation, liaison, psychiatry, sociodemographic data

Introduction Consultation-liaison psychiatry (CLP) is defined as a branch of psychiatry encompassing the necessary knowledge and skills to manage the psychological problems of patients with physical disease. The CLP model has begun to be applied as a system in hospitals in developed countries and together with advances in modern medicine has been conceptualized as a scientific discipline and upper area of expertise [1]. The intervention areas for CLP focus on assessment of psychiatric consultations requested by patients admitted to other wards; and pharmacotherapy and psychotherapy during patient admission and as for outpatients. Psychiatric accompanying diagnosis lengthens duration of hospital stays and increases repeated admissions to hospital [2]. CLP shortens the duration of hospital stays and lowers treatment costs [3]. Due to intense interest as a result of better knowledge about CLP, a consultation-liaison unit was created within the auspices of

*Coresponding Author: Fatma Kartal Sarioglu, Inonu University Faculty of Medicine Department of Psychiatry, Malatya, Turkey E-mail: fatonkartal@icloud.com

İnönü University Faculty of Medicine Department of Psychiatry. This unit provides clinical and in-patient services. Studies of CLP applications have commonly assessed some clinical variables like the reasons for requesting consultation, distribution of psychiatric diagnoses, clinics requesting consultation and time between the date consultation is requested and is received. During our literature review, we did not encounter any study assessing the in-patient admitted to the psychiatry ward CLP unit. In this study, differently, the aim was to investigate the sociodemographic and clinical characteristics to patients with physical disease admitted to a psychiatry ward CLP unit due to psychiatric discomfort. Materials and Methods The sociodemographic and clinical information for patients admitted to the consultation-liaison psychiatry unit of İnönü University Turgut Özal Medical Center psychiatry clinic CLP unit from August 2015 to November 2016 were obtained by retrospectively investigating hospital database and patient files and uploaded to a structured form prepared by the psychiatric specialist and assistant. This form comprised sections including 845

doi: 10.5455/medscience.2018.07.8876

sociodemographic characteristics of patients, hospital stay, number of admissions, form of admission (transfer from clinic, emergency or other wards), current physical and psychiatric diseases, previous psychiatric disease history, psychotic symptoms and suicidal thoughts, stressor factors present or not, history of physical trauma, family history of psychiatric disease, smoking habit, treatment applied during admission and follow-up after discharge. Diagnostic assessments were completed in accordance with DSM-5. The SPSS program version 17 was used for statistical analysis and results are given as percentage values. Results Our study included a total of 37 patients, with 15 female (40.5%) and 22 male (59.5%). Sociodemographic and clinical data during admission to the CLP unit were retrospectively investigated. Sociodemographic characteristics The mean age of patients was calculated as 44.6±15.81 years. Of patients 51.5% were married, 35.1% were single and 8.1% were widowed or divorced. There were 37.8% who did not have children, 8.1% had one child and 54.1% had 2 and/or more children. When educational level is examined, 75.7% were primary school graduates, 13.5% were high school graduates and 10.8% were university graduates. Of patients 27% were unemployed, 59.5% were employed and 13.5% were retired. In terms of residence, 62.2% lived in an urban center and 37.8% lived in rural areas (Table 1).

Female Male

15 (40.5%) 22 (59.5%)

Married Single Widowed/divorced

21 (56.8%) 13 (35.1%) 3 (8.1%)

Education Level

Primary school or less High school University

28 (75.7%) 5 (13.5%) 4 (10.8%)

Employment

Employed Unemployed Retired

10 (27%) 22 (59.5%) 5 (13.5%)

Number of Children

None Single child ≥2 children

14 (37.8%) 3 (8.1%) 20 (54.1%)

Urban center Rural

23 (62.2%) 14 (27.8%)

Marital Status

Residential area

Med Science 2018;7(4):845-7

disorders (16.2%), mental retardation (13.5%), somatic symptom disorders (13.5%), bipolar disorder (10.8%), personality disorders (8.1%), oppositional disorder (5.4%), anxiety disorders (5.4%), impulse control and behavior disorders (5.4%) and neurocognitive disorders (2.7%). Of patients, 27% had an additional secondary psychiatric disease diagnosis (most common mental retardation at 8.1%). There was physical trauma history present for 13.5% of patients. For 48.6% of patients, there were stressor factors present in the last 6 months. The rate of family psychiatric disease history was 16.2%. When psychiatric symptoms are investigated, 37.8% had psychotic symptoms. A total of 10.8% of patients had suicidal thoughts with 8.1% passive and 2.7% active suicidal thoughts. Among patients, 21.6% had history of smoking. Additional drug use was not encountered. Table 2. Comparison of admission duration and number of admissions of patients according to gender Age

Admission Duration

Number of admissions

Female patients n=15 mean±SD)

43.66±14.91

22.73±18.49

1.6±1.35

Male patients n=22 (mean±SD)

45.27±16.7

20.18±13.5

2.09±1.37

Total n=37 (mean±SD)

44.6±15.81

21.21±15.52

1.89±1.36

Table 3. Clinical characteristics of patients

Table 1. Sociodemographic characteristics of patients Gender

Clinical characteristics Of patients in the psychiatry ward, 73% were admitted from the policlinic, 16.2% from the emergency service and 10.8% were transferred from other wards. The mean hospital stay was 21.2±15.52 days with mean number of hospital stays 1.89±1.36. The most common physical disease diagnosis of patients was neurologic diseases for 51.4%, endocrinologic diseases for 16.2% and other disease groups for 21.6%. For 24.3% of patients there was a second additional physical disease diagnosis present. The incidence of psychiatric diagnoses according to the DSM-V of patients were in order: psychotic disorders (18.9%), depressive

FORM OF ADMISSION

Emergency Clinic Other ward

6 (16.2%) 27 (73%) 4 (10.8%)

PHYSICAL DISEASE DIAGNOSTIC GROUP

None Neurologic disease Endocrinologic disease Other

4 (10.8%) 19 (51.4%) 6 (16.2%) 8 (21.6%)

Psychotic disorders

7 (18.9%)

Depressive disorders

6 (16.2%)

Somatic Symptom disorder

5 (13.5%)

Mental Retardation

5 (13.5%)

Bipolar Disorder

4 (10.8%)

Personality disorders

3 (8.1%)

Anxiety disorders

2 (5.4%)

Disruptive DisordersImpulse Control Disorders

2 (5.4%)

Neurocognitive disorders

1 (2.7%)

SECONDARY PSYCHIATRIC DISEASE

None Mental deficiency Other

27 (73%) 3 (8.1%) 7 (18.9%)

HISTORY OF PHYSICAL TRAUMA

Yes No

5 (13.5%) 32 (86.5%)

PSYCHIATRIC STRESSOR

Yes No

18 (48.6%) 19 (51.4%)

FAMILY PSYCHIATRIC DISEASE HISTORY

Yes No

6 (83.2%) 31 (16.2%)

DSM-V DIAGNOSTIC GROUP

doi: 10.5455/medscience.2018.07.8876

When the pharmacological treatments applied during hospitalization are examined; 48.6% of the patients were given single antipsychotic (AP) or antidepressant (AD) treatment, and 43.2% were using a combination of antidepressant, antipsychotic, and mood stabilizer (MS) drug groups. Electroconvulsive therapy (ECT) was also applied to 8.1%. Discharge was with recovery for 48.6% of patients, partial recovery for 21.6% and by their own wishes for 29.7% of patients. After discharge, 35.1% of patients attended check-ups regularly (once a month), with 32.4% attending irregularly and 32.4% not attending check-ups (Table 3). Discussion Close cooperation with the CLP unit is very important in terms of psychiatric diagnoses accompanying medical diagnoses and for differential diagnosis. This cooperation will aid in increasing service quality by offering a more holistic approach to patients. There appears to be a need for broader cooperation in the field of consultation liaison. According to clinical observation and research, individuals with chronic health problems like disease and normal physical activity limitations are found to have higher rates of mental problems and compliance problems compared to healthy people [4]. In our study 89.2% of patients admitted to the CLP unit had additional physical disease diagnosis. Those without physical disease were admitted to the CLP unit with suspicion of organic pathology underlying psychiatric complaints; however no organic pathology could be determined. Of the patients that were consulted and admitted to our CLP inpatient service, 16.2% were assessed in emergency service, 10.8% were assessed in other inpatient services (dermatology and neurology).When studies assessing other wards requesting psychiatry consultations are examined, the departments requesting consultations most commonly were observed to be internal diseases and neurology [5,6]. In our study, though the most common department requesting consultation was the emergency service, the majority of our patients (73%) were patients applying to the psychiatry policlinic as out-patients. However, when all patients are investigated, the most common diagnostic groups among patients were neurologic and endocrinologic diseases. This diagnostic group situation in our study emphasizes the importance and necessity of psychiatry working in cooperation with other departments, as shown by other studies with similar characteristics. A noteworthy finding is that the most common psychiatric diagnostic group among patients admitted to the CLP unit was psychotic disorders, with 37.8% of patients displaying psychotic symptoms. Many studies in this area have found the most common diagnosis was depressive disorder [7,8]. This situation has been explained as depressive complaints most commonly accompany chronic diseases [9].The reason for the difference in terms of diagnostic incidence in our study compared to other studies may be that these studies assessed consultations requested for patients admitted to other wards. When treatment administered to patients during admission is investigated, 48.6% received AP or AD treatment, 43.2% used a double or triple medication combination (MS, AD, AP) and 8.1%

Med Science 2018;7(4):845-7

were administered electroconvulsive treatment (ECT). A study of treatment characteristics found combination treatments were used more often than single medications [10]. The use of single medications was slightly higher in our study, though the use of combinations was also higher compared to previous studies. Though patients admitted to the CLP unit did not have a history of suicidal attempts, a serious rate of 10.8% was identified to have suicidal thoughts. The association of many medical diseases with increased suicide risk and the fact that a majority of those completing suicide attend a doctor within a month before death shows the necessity to enquire about suicidal thoughts for every patient [11]. Conclusion In light of data obtained in the study, there is a need to complete more comprehensive and prospective observational studies in full cooperation with other clinics in the future. We believe this data will form the foundation for future studies. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

References 1.

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Fulop G, Strain JJ, Fahs MC, et al. A prospective study of the impact of psychiatric comorbidity on length of hospital stays of elderly medicalsurgical inpatients. Psychosomatics. 1998;39:273-80.

Andreoli PB, Citero V de A, Mari J de J. A systematic review of studies of the cost-effectiveness of mental health consultationliaison interventions in general hospitals. Psychosomatics. 2003;44:499-507.

Wiss M, Lenoir P, Malvy J, et al. Child consultation-liaison psychiatry within the hospital: a prospective study. Arch Pediatr. 2004;11:1-3.

JHochlehnert A, Niehoff D, Herzog W, et al. Elevated costs of treatment in medical inpatients with psychiatric comorbidity are not reflected in the German DRG-system. Psychother Psychosom Med Psychol. 2007;57:705.

Rothenhausler HB, Ehrentraut S, Kapfhammer HP. Changes in patterns of psychiatric referral in a German general hospital: results of a comparison of two 1- year surveys 8 years apart. Gen Hosp Psychiatry. 2001;23:20514.

Boztas MH, Arisoy O. Tibbi hastaliklarda depresyon: tanisal sorunlar. Psikiyatride Guncel Yaklasimlar. 2010;2:318-32.

Koroglu A, Celik FH, Arslan M, Hocaoglu C. Bir egitim hastanesinde psikiyatri konsultasyon hizmetlerinin degerlendirilmesi. Klinik Psikiyatri. 2011;14:44-50.

Mayda H. The Evaluation of Psychiatry Consultation Requested in a University Hospital. J Clin Analytical Med. 2016;6:177-80.

10. Onur E, Yemez B, Polat S, ve ark. Konsültasyon Liyezon Psikiyatrisi Uygulamalari ve Farmakoterapi Tercihlerindeki Degisim. Klinik Psikofarmakoloji Bulteni. 2007;17:167-73. 11. Juurlink, DN, Herrmann, N, Szalaj JP, et al. Medical illness and the risk of suicide in the elderly. Archiv Inter Med. 2004;164:1179-84.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):848-51

Relationship between adnexal mass and endometrial thickness in postmenopausal period Alper Basbug1, Ozan Dogan2, Murat Yassa3, Cigdem Pulatoglu4, Aski Ellibes Kaya1, Eray Caliskan5 1 Duzce University Hospital Department of Obstetrics and Gynecology, DĂźzce, Turkey Health Sciences University, Sisli Hamidiye Etfal Research and Training Hospital Department of Obstetrics and Gynecology, Istanbul, Turkey 3 Health Sciences University, Fatih Sultan Mehmet Training and Research Hospital Department of Obstetrics and Gynecology, Istanbul, Turkey 4 Bayburt Government Hospital Department of Obstetrics and Gynecology, Bayburt, Turkey 5 Bahcesehir University School of Medicine, Department of Obstetrics and Gynecology, Istanbul, Turkey 2

Received 18 May2018; Accepted 04 June 2018 Available online 10.09.2018 with doi:10.5455/medscience.2018.07.8874 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Endometrial cancer is the most common gynecological cancer. Increased postmenopausal endometrial thickness may be an indicator of endometrial cancer. Transvaginal ultrasound (TV-USG) is the primary imaging method for evaluating endometrial thickness in the postmenopausal period. The aim was to employ transvaginal ultrasonography in the evaluation of adnexal masses synchronously seen in postmenopausal women with increased endometrial thickness. The work was designed as a retrospective study. The medical records of 155 patients evaluated for increased postmenopausal endometrial thickness were examined. Ultrasonography had been performed on the women in the study for routine follow-up, postmenopausal hemorrhage, pelvic pain, pelvic mass on examination and family history of gynecological cancer. All patients had undergone endometrial evaluation with fractional dilatation and curettage (D & C) or pipelle endometrial sampling. Histopathological diagnosis was based on endometrial sampling results. Adnexal mass was present simultaneously in 17.4% (n = 27) of the women included in the study, while 82.6% (n = 128) had no gynecological pathology other than increased endometrial thickness. The endometrial thickness in the women with postmenopausal adnexal masses was greater than in those without adnexal mass (11.7 mm vs. 7.8 mm, p = 0.009). Non-atypical and atypical endometrial hyperplasia was more frequent in the group with postmenopausal adnexal mass (11.1% vs. 2.8%, 11.1% vs. 3.79, p = 0.03, p = 0.04, respectively). Final histopathological evaluation of patients operated on for adnexal masses revealed tubo-ovarian abscess in 1.9% (n = 1), benign ovarian tumor in 25.9% (n = 7) and malignant ovarian tumor in 11.1% (n = 3) of the patients. In postmenopausal women, adnexal masses can be seen simultaneously with increased endometrial thickness. In this regard, transvaginal ultrasound offers important opportunities for evaluation of both the endometrium and adnexa. Pre-surgery transvaginal ultrasound as well as multivariate serum markers may be used in evaluation models. Keywords: Adnexal masses, endometrial thickness, postmenopausal women

Introduction Endometrial cancer is the most common gynecological cancer and its frequency has risen gradually over the past 20 years [1]. Increased postmenopausal endometrial thickness as detected by sonography may be an indicator of endometrial cancer. Transvaginal ultrasound (TV-USG) is the primary imaging method for evaluating increase in endometrial thickness in the postmenopausal period [2,3]. When a thickness of the endometrium of more than 5 mm is detected in postmenopausal women by TV-USG, histopathological examination may be required [4,5]. In addition, TV-USG provides significant contributions in the imaging display of the adnexa. Although the efficacy of TV-USG for asymptomatic women in the screening for ovarian cancer is controversial, during assessment of the endometrium, the adnexa can be assessed simultaneously and *Coresponding Author: Ozan Dogan, Health Sciences University, Sisli Hamidiye Etfal Research and Training Hospital Department of Obstetrics and Gynecology, Istanbul, Turkey E-mail: ozandogan02@hotmail.com

abnormal findings recorded [6,7]. Postmenopausal adnexal mass is an important clinical condition that is usually detected incidentally, and thus gynecologists may experience some difficulties in followup or treatment [8]. Because many are benign, a good evaluation of these masses can defer the diagnosis of ovarian cancer and prevent unnecessary surgery [9]. There is insufficient evidence in the literature showing that increased postmenopausal thickness may be associated with adnexal masses. In the postmenopausal period, except for ovarian tumors that can continue hormonal activity, there is no information about adnexal masses that are synchronous with increased endometrial thickness [10]. In this study, we evaluated the possibility of postmenopausal adnexal masses being synchronous with increased endometrial thickness. Materials and Methods Study design This retrospective study included a total of 155 women who had 848

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undergone endometrial biopsy for increased postmenopausal endometrial thickness at the Düzce University Medical Faculty Obstetrics and Gynecology Clinic between January 2015 and January 2017. Patients who had hormone replacement therapy because of menopause, who had a history of gynecological cancer and those diagnosed with endometrial hyperplasia in previously excised biopsies were not included in the study. Written informed consent was obtained from all women before the study commenced. All procedures in the study were carried out in accordance with the ethical standards of the institutional research committee and in accordance with the Helsinki Declaration of 1964 and subsequent amendments or comparable ethical standards. The study was approved by the Düzce University Ethics Committee (Ethics Committee No. 2017/07). This study followed the Srengthening the Reporting of Oservational studies in Epidemiology (STROBE) guidelines Ultrasonography had been performed on the women in the study for various reasons including routine follow-up, postmenopausal hemorrhage, pelvic pain, pelvic mass on examination and family history of gynecological cancer. All sonographic evaluations were performed using a 6.5 MHz endovaginal probe with the patient at the lithotomy position and having an empty bladder. The cutoff value for increased postmenopausal endometrial thickness was taken as 5 mm [4,5]. The medical records of the patients were examined in terms of demographic characteristics such as age, body mass index (BMI), age at menopause, gravyda and parity. All patients had undergone endometrial evaluation with fractional dilatation and curettage (D & C) or pipette endometrial sampling. Histopathological diagnosis was based on endometrial sampling results. Histopathological results were classified as benign, endometrial polyp, endometritis, endometrial hyperplasia, or endometrium cancer. Proliferative endometrium, secretory endometrium, irregular and atrophic endometrium were considered as benign histologic changes. We did not perform the power or sample size calculation for this study, because we planned to include all eligible patients in the study. The Statistical Package for the Social Sciences (SPSS) 22.0 program was used to analyze the data. Quantitative data were tabulated with mean ± SD (standard deviation) and median (maximum-minimum) values, while categorical data were given as n (number) and percent (%).The Student’s t-test and MannWhitney U test were used to compare independent groups, whereas the Pearson Chi-Square and Fisher Exact tests were used to compare categorical data. The data were analyzed at 95% confidence level, with a p-value of 0.05 considered as significant, while greater than 0.05 was considered insignificant. Results A total of 155 women who had presented at our clinic and who had undergone sonographic evaluation for increased postmenopausal endometrial thickness were included in the study. Adnexal mass was present simultaneously in 17.4% (n = 27), while 82.6% (n = 128) had no gynecological pathology other than increased endometrial thickness. No statistically significant difference was seen in terms of age, gravida, parity, BMI or comorbid chronic diseases (Table 1). The number using tamoxifen because of breast cancer was greater amongst the group with simultaneous increased

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postmenopausal endometrial thickness and adnexal masses than in the group without adnexal masses. The difference between the groups was statistically significant (7.4% vs. 2.8%, p = 0.04). Table 1. Demographic data of patients included in the study Postmenopausal adnexal mass (+) (n=27)

Postmenopausal adnexal mass (-) (n=128)

p-value

Age 57.75 ± 11.89 Menopause duration 11.23± 7.65 Gravida 5 (0-12) Parity 4 (0-12) BMI (kg/m2) 33.60 ± 3.90 Concomitant systemic disease

60.44 ± 9.32 10.28 ± 8.11 4 (0-12) 3 (0-10) 31.62 ± 3.12

0.11 0.29 0.35 0.22 0.23

Diabetes Mellitus Hypertension Hypothyroidism Hyperthyroidism Chronic vascular disease Tamoxifen use

19 (15.2%) 42 (32.8%) 13 (10.3%) 10 (7.9 %) 9 (6.7%) 4 (2.8%)

0.69 0.06 0.34 0.26 0.23 0.04*

5 (18.5%) 11 (40.7%) 3 (11.1%) 4 (14.8%) 3 (11.9%) 2 (7.4%)

Values are expressed as mean ± standard deviation, median (min-max) and %. BMI: Body mass index

Women with postmenopausal adnexal masses had greater endometrial thickness than women without adnexal mass and the difference between the groups was statistically significant (11.7 mm vs 7.8 mm, p = 0.009). Histopathological examination of endometrial biopsy specimens showed benign endometrial tissues, endometrial polyps, endometritis and malignancy in similar proportions, whereas non-atypical and atypical endometrial hyperplasia was more frequent in the group with postmenopausal adnexal mass (11.1% vs. 2.8%, 11.1% vs. 3.9%; p = 0.03, p = 0.04, respectively). Of the patients, 59.2% (n = 16) were put under observation and 40.8% [11] were operated on. Final histopathological evaluation of patients operated on for adnexal masses revealed tubo-ovarian abscess in 1.9% (n = 1), benign ovarian tumor in 25.9% (n = 7) and malignant ovarian tumors in 11.1% (n = 3) of the patients (Table 2). Table 2. Sonographic and histopathological results of the patients included in the study Postmenopausal Postmenopausal adnexal mass (+) adnexal mass (-) p-value (n=27) (n=128) Endometrial thickness (mm)

11.73 ± 5.97

7.81 ± 2.82

0.009*

Endometrial histopathological evaluation Benign

16 (59.2%)

82 (63.7%)

0.12

Endometrial polyp

3 (11.1%)

26 (19.7%)

0.09

Endometritis

1 (3.3%)

4 (3.5%)

0.65

Non-atypical endometrial hyperplasia

3 (11.1%)

3 (2.8%)

0.03*

Atypical endometrial hyperplasia

3 (11.1%)

5 (3.9%)

0.04*

Endometrium cancer

1 (3.7%)

8 (6.3%)

0.16

Final histopathological result of adnexal mass after surgery Tubo-ovarian abscess

1 (3.7%)

Benign ovarian tumor

7 (25.9%)

Malignant ovarian tumor

3 (11.1%)

Values are expressed as mean ± standard deviation and %.

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Figure 1 shows the estimated diagnostic performance for adnexal mass synchronous with increase in endometrial thickness as measured by TV-USG. Accordingly, the area remaining under the ROC curve was 0.39 [95% CI (0.31-0.48)].

Figure 1. ROC curve for detection of adnexal mass with endometrial thickness measurement via TV-USG

Discussion Findings from our study show that 17.4% of patients with increased postmenopausal endometrial thickness had synchronous adnexal masses. The mean endometrium thickness was higher and both atypical and non-atypical endometrial hyperplasia were more common in the women with postmenopausal adnexal mass, However, the diagnostic performance was low for measurement of postmenopausal endometrial thickness with synchronous adnexal mass. Because of its high efficacy and non-invasiveness, TVUSG is used routinely in the evaluation of the postmenopausal endometrium. In general, this is done to rule out endometrial cancer [11,12]. Another problem seen in the postmenopausal period is adnexal masses. The use of TV-USG has been long acknowledged as a means of distinguishing benign and malign adnexal masses, but the method depends on the experience and evaluation of the person performing the ultrasonography. Thus, ultimately, the accuracy and reliability of the technique are based on subjective judgment. In many studies, the sensitivity and specificity of TV-USG has been reported as 80% and 60%, respectively, in distinguishing between benign and malignant adnexal masses [13,14]. Bakour et al. noted that adnexal mass was detected synchronously in 4.9% of the patients in their study who complained of postmenopausal hemorrhage, and that less than 10% of them were malignant; however, increased endometrial thickness was not evaluated in

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this study [7]. In our study, the incidence of malignant ovarian tumors in women with adnexal mass and synchronous increased postmenopausal endometrial thickness was found to be 11%. Long-term studies have been carried out on the screening of postmenopausal patients for gynecological cancers. Early on in these studies, postmenopausal women were recommended to undergo a full pelvic scan during ultrasonographic evaluation [15,16]. However, in recent years, some authors have suggested that due to the suboptimal specificity of TV-USG, adnexal scanning increases both the duration and cost of screening and exposes women to unnecessary surgical interventions and their complications, and if no pathological finding is found on the physical pelvic examination and if the endometrium is sonographically normal, there is no need for the adnexa to be seen [17,6]. The results from our study show that in postmenopausal women, atypical and non-atypical endometrial hyperplasia, in particular, may be synchronous with adnexal masses. Therefore, we believe that patients with endometrial hyperplasia detected as a result of histopathological examination should be screened by ultrasonography if they have not been previously evaluated. Various algorithms have been developed for the management of asymptomatic postmenopausal adnexal masses [18,19]. When serum markers such as Ca-125 and HE-4 are at normal levels, the observational approach is reasonable here. Patients can be checked again at intervals of 3-6 months. In these patients, the TV-USG findings alone should not be used to determine the surgical decision, but also the doppler USG and, if necessary, tomography and MRI. Multivariate evaluation models such as the Simple Rules Risk (SRrisk) score, Risk of Malignancy Index (RMI), Risk of Ovarian Cancer Algorithm (ROCA), and Risk of Ovarian Malignancy Algorithm (ROMA) can be used with both imaging and serum markers 20,21]. With postmenopausal patients having incidentally detected adnexal masses, the task of the gynecologists is to counsel them after undergoing TV-USG and, if deemed necessary, to refer them to gynecological oncologists. The data obtained with TV-USG alone may be insufficient. Making decisions only from TV-USG results in unnecessary anxiety in patients, and their possible exposure to unnecessary surgical procedures and resulting complications. Of the women with postmenopausal adnexal masses who participated in our study, 26.6% had undergone surgery for benign gynecological reasons. There are very few studies in the literature regarding postmenopausal endometrial pathologies and adnexal mass synchronization. In this study, symptomatic patients with postmenopausal hemorrhage or adnexal mass detectable on physical examination were evaluated. In this respect, our study can provide a strong base for future studies assessing asymptomatic patients. The retrospective nature of the study and the relatively low number with postmenopausal adnexal masses in the group can be seen as limitations of the study. Conclusion In conclusion, adnexal masses may be synchronous with increased postmenopausal endometrial thickness, but it should be kept in mind that a large majority of these masses may be benign. The TVUSG is a diagnostic tool that can simultaneously provide important contributions to both the examination of the endometrium and to the diagnosis of synchronous adnexal masses. In addition to TV850

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USG, evaluation models using multivariate serum markers can be used for distinguishing malignant adnexal masses.

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tumours before surgery: A critical appraisal of recent evidence. TOG. 2015;17:163-71.

Competing interests The authors declare that they have no competing interest

10. Famuyide AO, Shazly SA, Makdisi PB, et al. Impact of simple ovarian cysts on the ınterpretation of endometrial thickness in women with postmenopausal bleeding. J Womens Health. 2016;9:889-96.

Financial Disclosure The financial support for this study was provided by the investigators themselves.

11. Wolfman W, Leyland N, Heywood M, et al. Asymptomatic endometrial thickening. J Obstet Gynaecol Can. 2010;32:990-9.

Ethical approval Before the study, permissions were obtained from local ethical committee.

12. Dueholm M, Marinovskij E, Hansen ES, et al. Diagnostic methods for fasttrack identification of endometrial cancer in women with postmenopausal bleeding and endometrial thickness greater than 5 mm. Menopause. 2015;22:616-26.

References 1.

Timmermans A, Opmeer BC, Khan KS, et al. Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: A systematic review and meta-analysis. Obstet Gynecol. 2010;116:160-7.

Gupta JK, Chien PFW, Voit D, et al. Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: A meta-analysis. Acta Obstet Gyn Scan. 2002;81:799-816.

Tabor A, Watt H C, Wald N J. Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. Obstetrics & Gynecology. 2002;99:663-70.

Goldstein SR. The endometrial echo revisited: Have we created a monster? Am J Obstet Gynecol. 2004;191:1092-96.

16. Gupta JK, Wilson S, Desai P, et al. How should we investigate women with postmenopausal bleeding? Acta Obstet Gyn Scan. 1996;75:475-9.

Kanat-Pektas M, Gungor T, Mollamahmutoglu L. The evaluation of endometrial tumors by transvaginal and doppler ultrasonography. Arch Gynecol Obstet. 2008;277495-99.

Rosenthal AN, Fraser L, Manchanda R et al. Results of annual screening in phase ı of the united kingdom familial ovarian cancer screening study highlight the need for strict adherence to screening schedule. J Clin Oncol 2013;13:49-57.

17. Sharma A, Gentry-Maharaj A, Burnell M, et al. Assessing the malignant potential of ovarian inclusion cysts in postmenopausal women within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): A prospective cohort study. BJOG. 2012;119:207-19.

Bakour S, Emovan E, Nevin Jet al. Is routine adnexal scanning for postmenopausal bleeding of value? Observational study of 2101 women. J Obstet Gynaecol. 2017;37:779-82.

American College of Obstetricians and Gynecologists. Management of adnexal masses. ACOG Practice Bulletin No. 83. Obstet Gynecol. 2007;110:201-14. Kaijser J, Van Hoorde K, Van Calster B, et al. Diagnosing adnexal

13. Valentin L, Hagen B, Tingulstad S, et al. Comparison of pattern recognition and logistic regression models for discrimination between benign and malignant pelvic masses: A prospective cross validation. Ultrasound Obstet Gynecol. 2001;18:357-65. 14. Timmerman D, Schwarzler P, Collins WP, et al. Subjective assessment of adnexal masses with the use of ultrasonography: An analysis of interobserver variability and experience. Ultrasound Obstet Gynecol. 1999;13:11-6. 15. Gredmark T, Kvint S, Havel G, et al. Histopathological findings in women with postmenopausal bleeding. BJOG. 1995;102:133-6.

18. Myers ER, Bastian LA, Havrilesky LJ, et al. Management of adnexal mass. Evid Rep Technol Assess. 2006;130:1-145. 19. van Nagell JR, DePriest PD. Management of adnexal masses in postmenopausal women. Am J Obstet Gynecol. 2005;193:30-35. 20. Ueland FR, Desimone CP, Seamon LG, et al. Effectiveness of a multivariate index assay in the preoperative assessment of ovarian tumors. Obstet Gynecol. 2011;117:1289-97. 21. Hentze JL, Høgdall C, Kjær SK, et al. Searching for new biomarkers in ovarian cancer patients: Rationale and design of a retrospective study under the Mermaid III project. Contemp Clin Trials Commun. 2017;13:167-74.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):852-6

Bioinformatics; The comparison of softwares based on genetics data analysis Tahsin Ertas1, Celal Guven2, Onur Ozturk3 2

1 Istanbul University School of Medicine, Department of Biophysics, Istanbul, Turkey Nigde Omer Halisdemir University School of Medicine, Department of Biophysics, Nigde, Turkey 3 Inonu University School of Medicine, Department of Biophysics, Malatya, Turkey

Received 02 June 2018; Accepted 16 June 2018 Available online 11.10.2018 with doi:10.5455/medscience.2018.07.8903 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The comparative analysis with relational statistics programs Arlequin 3.5 and Power Marker 3.25 is performed, using the published polymorphic loci on the β-globin gene to investigate possible associations of these loci with the Hb D-Los Angeles mutation. It is envisaged that the results obtained by the processing of genetic data by different software will provide source data in terms of reliability of the analysis of the genetic data, compatibility of the programs, discrepancies, if any, and reasons for these differences and the researchers guide the program selection and benchmarking for the study purposes. Under this point of view; the main purpose of this study is to compare the possible differences or common results of analysis of gene data on beta globin gene family and beta globin gene in Hb D-Los Angeles [β121 (GH4) Glu→Gln] model with two statistical software. Arlequin and Power Marker software calculated the haplotype frequencies associated with the Hb D-Los Angeles mutation in both populations with equal frequency values. Considering the molecular diversity and mismatch distribution parameters, Arlequin software can provide important advantages in determining the historical development processes of populations. For each locus, parameters such as allele frequency calculations, allele pair frequency calculations, haplotype tendency regression, and difference test for both populations are presented as specific tests of Power Marker software. Findings from two different bioinformatics analyze and software advantages and disadvantages compared to each other are present. Keywords: Bioinformatics, genetic data analysis, arlequin, power marker, population genetics

Introduction At the point reached by modern technology today, researches on hereditary clinical problems or those that do not show any clinical symptoms but can be transferred by heredity have significant contributions to the development of the literature databases [1]. The rapid increase in data generated from studies involving genes and proteins is hopeful in understanding the diseases that cause health problems and in developing possible treatment methods. Naturally, the rapid increase in interest in genetic research and the generation of complex data clusters cause genetic technology and computer technology to find a common working area. For this purpose genetic database software is very useful in the basic issues such as storage, analysis and sharing of produced data. In this context, it is assumed that within the molecular biology there must be a basic research theme, such as collecting, processing, storing and using information in the living system model [2]. For *Coresponding Author: Onur Ozturk, Inonu University School of Medicine, Department of Biophysics, Malatya, Turkey E-mail: onurphysics@gmail.com

many years scientists have been trying to get the complete genome sequence of many organisms [3]. The greatest of these has been the ‘human genome project, which was launched in the 1980s and officially started in October 1990. Bioinformatics, which enables the co-operation of computer technology and medical science, enables the storage, analysis, processing, and use of results of DNA, RNA and protein data obtained from this major project and other genomic projects. The main aim of the bioinformatics science is; to collect, manage and distribute the rapidly growing and increasing knowledge, to ensure that the information is reached in the fastest and easiest way, to try to define the works of biological systems which are very complex [4]. The evaluation of these data may produce valuable information to the anthropological, paleoclimatic, archaeological and phylogeographical approaches to the process of biological development of the daily human being from the past [5]. Under this point of view; the main purpose of this study is to compare the possible differences or common results of analysis of gene data on beta globin gene family and beta globin gene in Hb D-Los Angeles model with two statistical software (Arlequin ver. 3.5 and Power Marker ver 3.25) [6-8]. 852

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Materials and Methods Sample definition We analyzed 40 patients with Hb D-Los Angeles and 59 normal DNA data. These DNA samples that we have analyzed have been obtained from previous studies and have been provided using published data in the literature [9-12]. Statistical analysis Firstly, we performed the data work of both populations with Arlequin 3.5 software, which uses an “unknown gametic phase method” and haplotype analysis [6,13], Hardy–Weinberg equilibrium tests [14,15] perform of genetic variation and group differentiation parameters, analysis of molecular variance (AMOVA) using F-statistics (FST, FIT, FIS) [16-19], Linkage disequilibrium (LD), historical-demographic analyses (Tajima’s Fu’s tests) [20,21], mismatch distribution analysis, analyses of tau (τ) and initial theta, SSD, the Harpending’s raggedness index (Hri) and p-values of SSD [22-28] as previously reported [9]. Historic demographic expansions were also investigated by the analyzed of frequency distributions of pairwise differences between sequences (mismatch distribution), which is based on three parameters: θ0, θ1 (θ number of individuals before and after) and τ (time since expansion expressed in the unit of mutational time). According to Rogers (1995), to re-express τ years must be divided by 2u (twice the mutation rate) and multiply by the length of a generation, say, 25 years. Unfortunately, the mutation rate is not known with great accuracy. The rate of human mitochondrial nucleotide divergence has been variously estimated at 2% and 4% per million years, but

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the confidence intervals around these estimates are unknown. The two estimates u to be 7.5 x 10-4 and 1.5 x 10-3, respectively [25,26]. In the course of our work, we analyzed two populations statistically using the tests included in the PowerMarker software [7,8]. PowerMarker is a statistical analysis program with a userfriendly interface, including other genetic analyzes supported by statistical models, which can perform SNP analyzes primarily. Genetic markers are highly advantageous in determining historical parameters such as past genetic research, allele links, gene diversity, population-migration relationship, linkage disequilibrium (LD) [7]. PowerMarker interface allows more than 50 statistical analyzes to be easily viewed and analysis data edited. These analysis methods include Hardy-Weinberg and linkage test, population genetics parameter tests, χ2 tests, likelihood ratio tests and exact tests. LD, D and r2, a commonly used analysis group, can be performed by PowerMarker. In addition, the obtained LD results can be displayed in graphical and matrix form with its 2D viewer. Traditionally, genetic relationships and differences between comparable groups are calculated using F-statistics. In the PowerMarker software, these relationships are tested using four different F-statistic analyzes [7,8]. Results Table 1 and Table 2 show the haplotype diversity and related frequencies obtained using the two software Arlequin 3.5 and PowerMarker. These tables summarize the top five highest frequencies.

Table 1. β-globin gene cluster haplotypes for the seven loci in association with the Hb D-Los Angeles population calculated with Power Marker and Arlequin No. 1. 2. 3. 4. 5.

Hb D-Los Angeles population Haplotype diversity +‒‒‒‒++ ‒++‒+++ +‒‒‒‒‒+ +‒‒‒‒+‒ ‒+‒‒+++

Power Marker % frequency 0.34694 0.29860 0.12496 0.06559 0.02500

Arlequin % frequency 0.34690 0.29863 0.12500 0.06559 0.02500

Maximum-likelihood haplotype frequencies generated by Arlequin 3.5 software. Sum of the 14 listed frequencies and generated by Power Marker software. Sum of the 25 listed frequencies Table 2. β-globin gene cluster haplotypes for the seven loci in association with the Normal population calculated with Power Marker and Arlequin No. 1. 2. 3. 4. 5. 6.

Hb D-Los Angeles population Haplotype diversity +‒‒‒‒++ ‒+‒++++ +‒‒‒‒+‒ ‒++‒+++ +‒‒‒‒‒+ +‒‒‒‒‒‒

Power Marker % frequency 0.24751 0.16464 0.12952 0.07326 0.08545 0.01111

Arlequin % frequency 0.26665 0.14668 0.12587 0.06264 0.05145 0.05438

Maximum-likelihood haplotype frequencies generated by Arlequin 3.5 software. Sum of the 14 listed frequencies and generated by Power Marker software. Sum of the 25 listed frequencies

We tested the genetic differentiation of both populations using the analysis of molecular variance (AMOVA) [28] implemented in Arlequin 3.5 and PowerMarker software [7] (Table 3). Between population diversity indices, the haplotype diversity (h), nucleotide diversity (π) and average number of pairwise nucleotide differences (k) with their standard deviations computed with Arlequin and are showed at Table 4.

Table 3. (AMOVA) F-statistics (FST) calculated with Power Marker and Arlequin AMOVA Genetics differentiation of among populations

Power Marker %

Arlequin %

4.37

4.27

Exact test of sample differentiation based on haplotype frequencies Global test of differentiation among populations. Analysis of molecular variance (AMOVA) performed using the program ARLEQUIN ver. 3.5 and Power Marker ver. 3.25.

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Harpending’s raggedness index (Hri) and P values of SSD computed with Arlequin and showed at Table 5 [23].

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shown in the table as indicated by the ‘+’ and ‘-’ signs (Table 6). According to our comparative analysis results, HWE (P> 0.05) was shown in both groups calculated with Arlequin 3.5 and PowerMarker software (Table 7).

The linkage disequilibrium (LD) P value is calculated by the chikare test and the permutation of its P value. In addition, the relation is Table 4. Summary of molecular diversity performed with Arlequin

Tajima’s D

Fu’s Fs FS

Mismatch distribution

Populations

No. of haplo.

k (95%CI)

θS

τ (95%CI)

Normal

3.03 (2.19-4.55)

1.30 ±0.56

0.93 ±0.02

0.43±1.76

3.00

0.99

-16.88 0.00

3.46 (4.71-2.07)

0.01 25.82

Hb-D Los Angeles

2.56 (1.87-4.25)

1.41 ±0.62

0.87±0.02

0.36±1.54

1.97

0.95

-6.37

3.16 (5.08-1.58)

0.00 12.64

0.00

θ0

θ1

Number of individuals (n), number of haplotype, average pairwise differences among individuals (k), number of segregating sites (S), haplotype diversity (h ± standard deviation), nucleotide diversity (π ± standard deviation) for each populations. Tajima’s D and Fu’s Fs, corresponding P-value, and mismatch distribution parameter estimates for each population. D Tajima’s D estimate population expansion, Fs Fu’s Fs estimate population expansion. Values for τ, θ0, and θ1 are the age of the expansion, the population size before the expansion, and the population size after expansion, respectively, all expressed in units of mutation time. Insignificant P > 0.05, significant P ≤ 0.05. Tajima’s D and Fu’s Fs, corresponding P values, mismatch distribution parameter estimates and error estimates for populations are ±standard deviation as calculated by Arlequin. Table 5. Values of the mismatch distribution test statistics SSD and rg performed with Arlequin Goodness-of-fit tests Populations

SSD

SSD-P value

P value

Normal

0.00352

0.290

0.02279

0.540

Hb-D Los Angeles

0.00304

0.570

0.02137

0.800

P (SSD) is the probability of observing by chance a less than good fit between the observed and mismatch distribution for a demographic history of the population defined by the estimated parameters τ, θ0, and θ1. SSD: sum of squared deviations / rg: Harpending’s raggedness

Table 6. Linkage disequilibrium (LD) calculated with Power Marker and Arlequin (significance level=0.05, P < 0.05; (+), P > 0.05; (−) ) Hb D-Los Angeles population

Power Marker

Arlequin

Pairs of loci

Chi-square p value

Significant LD diagram

Chi-square p value

Significant LD diagram

locus 1 - locus 2

0.0001

0.7548

−

locus 2 - locus 3

0.0001

locus 3 - locus 4

0.5377

−

0.1751

−

locus 4 - locus 5

0.0029

locus 5 - locus 6

0.0001

0.0009

locus 6 - locus 7

0.1222

−

0.7537

−

Normal population

Power Marker

Arlequin

Pairs of loci

Chi-square p value

Significant LD diagram

Chi-square p value

Significant LD diagram

locus 1 - locus 2

0.0001

0.5931

−

locus 2 - locus 3

0.0001

locus 3 - locus 4

0.0015

0.9113

−

locus 4 - locus 5

0.0001

locus 5 - locus 6

0.1179

−

0.0004

locus 6 - locus 7

0.0207

0.0012

There is a listing of the log-likelihoods under the null and alternative hypotheses, a p-value determined by permutation, the χ2 test statistic and its corresponding (asymptotic) p-value. Table is provided, in which a ‘+’ sign denotes nominal evidence of there are linkage disequilibrium (LD) between the alleles at two loci.

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doi: 10.5455/medscience.2018.07.8903 Table 7. Hardy-Weinberg equilibrium (HWE) test for all Loci calculated with Power Marker and Arlequin No. 1. 2. 3. 4. 5. 6. 7. Locus 1. 2. 3. 4. 5. 6. 7.

Normal population HWE P-value - Power Marker 0.4378 0.3052 0.6044 0.1303 0.2944 0.1059 0.3483 Hb D-Los Angeles population HWE P-value - Power Marker 1.0000 1.0000 0.4860 1.0000 0.0940 0.0750 1.0000

Normal population HWE P-value - Arlequin 0.4352 0.4345 0.6050 0.2487 0.3038 0.1916 0.5478 Hb D-Los Angeles population HWE P-value - Arlequin 1.0000 1.0000 0.4895 1.0000 0.1055 0.0820 1.0000

Tests for HWE for each locus within each population used an HWE test analogous to Fisher’s exact test. P values were obtained using power marker 3.25 and arlequin 3.5 software. Insignificant P > 0.05, significant P ≤ 0.05.

Discussion Our study aimed to analyze the frequency of alleles determined by haplotype analysis of populations and haplotype types using Arlequin and PowerMarker software and to compare the results. The data obtained for both normal and Hb D-Los Angeles populations is in Hardy–Weinberg equilibrium (P > 0.05) for each of the seven polymorphic loci in both software as shown in Table 7. In both populations, the 6th locus p values are calculated to be close to the limit values in both Arlequin and PowerMarker software results (Table 7). The nearly equal p values shown in Table 7 indicate that both software offer reliable results for the HWE test. The PowerMarker software offers an advantage for researchers in comparing HWE results with multiple statistical tests. In both softwares haplotype I [+ ‒ ‒ ‒ ‒ + +] is the most frequent haplotype block (Table 1 and Table 2). Differently, the PowerMarker software provides results that include a large number of (25 types) haplotypes with lower percentages. Arlequin software lists 14 haplotype types. This can be considered as an advantage and suggests that it would be useful to determine the minimum frequency of genetic variability within the group. Arlequin software combines low-frequency and similar haplotypes. However, if the purpose of the research is to identify the low-frequency haplotypes in the population, this computation of Arlequin software may be considered to be disadvantageous. Molecular diversity, historical gene flow parameters, Hri and SSD P values, population development and population age calculations provided by Arlequin can not be calculated by the PowerMarker software (Table 4 and Table 5). When mismatch distribution parameters are considered, Arlequin software can provide important advantages in determining the historical development processes of populations. Based on these data, we calculated the (AMOVA) fixation index (FST) to measure the degree of genetic differentiation between these populations with two softwares (Table 3). When the results of genetic differentiation of the two software are compared, it seems that there is a low difference. This low difference is caused by PowerMarker software calculation of

Med Science 2018;7(4):852-6

a greater number of haplotypes. Linkage disequilibrium (LD) means that the alleles in closest loci have similar frequencies in future generations. Given the genetic events, mutation and recombination may have quite pronounced effects on LD calculations, but other factors should not be ignored. Many of these factors affect the demographic characteristics of the population and cause to decrease the link between LD and loci [29]. According to the results of LD analysis, it was determined that there is a difference between the two software (Table 6). PowerMarker software only tests neighboring locus connections according to LD analysis method. However, Arlequin software performs LD analysis by comparing each locus, neighboring locus and non-neighboring locus. When evaluated in terms of LD test statistics, it appears that Arlequin software is more useful because it provides both the test parameters used and the LD results in an easy way to understand the format. Conclusion As a result, it is thought that findings presented in our study may provide valuable contributions for researchers to make appropriate software preferences in studies using bioinformatics and genetic data. Acknowledgments This study reflects the results of the MSc Thesis done by Tahsin ERTAŞ in İnönü University Graduate School in Health Sciences entitled as “Bioinformatics; The Comparison of Softwares Based on Genetics Data Analysis,” June 2017. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Author Contributions TE, provided support in the data analysis of the laboratory results. OÖ is thesis director and supervised study, involved in the data interpretation and manuscript preparation. CG is support as co-director in MSc Thesis.

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Kuonen D. Challanges in Bioinformatics for Statistical Data Miners, Bulletin of the Swiss Statistical Society. 2003;46:10-7.

Kumaresan V, Bhatt P, Palanisamy R, et al. Bioinformatics characterization, gene expression and proteolytic activity. Biologia. 2014;69:395-406.

Oppenheimer S. Out-of-Africa, the peopling of continents and islands: tracing uniparental gene trees across the map. Philos Trans R Soc Lond B Biol Sci. 2012;367:770–84.

Excoffier L, Laval G, Schneider S. Arlequin (version 3.0): an integrated software package for population genetics data analysis. Evol Bioinform Online. 2007; 23;1:47-50.

Kejun Liu, Spencer V. Muse. PowerMarker: an integrated analysis environment for genetic marker analysis. Bioinformatics. 2005;21:2128–9.

Liu K. PowerMarker: New Genetic Data Analysis Software, Version 3.0. 2003; Free program distributed by the author over Internet at http://www. powermarker.net

Ozturk O, Arikan S, Atalay A, et al. Analysis of the population genetic structure of Hb D-Los Angeles [β121 (GH4) Glu→Gln GAA→CAA] in

doi: 10.5455/medscience.2018.07.8903 Denizli, Turkey; genetic diversity, historical demography and estimation of the mutation rates based on haplotype variation. Am J Hum Biol. 2016;28:476-83. 10. Ozturk O. The beta globin gene cluster haplotypes associated with Hb D-Los Angeles in Denizli Province. M.Sc. Thesis, 41 p. Pamukkale University Graduate School of Health Sciences Denizli, Turkey, 2007. 11. Öztürk O, Atalay A, Köseler A, et al. Beta globin gene cluster haplotypes of abnormal hemoglobins observed in Turkey. Turk J Haematol. 2007;24:146-54. 12. Atalay EO, Atalay A, Ustel E, et al. Genetic origin of Hb D-Los Angeles according to beta globin gene cluster haplotypes. Hemoglobin. 2007;31:387–391. 13. Excoffier L and Heckel G. Computer programs for population genetics data analysis: a survival guide. Nat Rev Genet. 2006;7:745–58. 14. Excoffier L, Lischer H. E. L. Arlequin suite ver 3.5: A new series of programs to perform population genetics analyses under Linux and Windows. Mol Ecol Resour. 2010;10:564–7. 15. Excoffier L, Laval G, Schneider S. Arlequin ver. 3.0: An integrated software package for population genetics data analysis. Evol Bioinform Online. 2005;1:47-50. 16. Mantel N. The detection of disease clustering and a generalized regression approach. Cancer Res. 1967;27:209–20. 17. Schneider S, Roessli D, Excoffier L. Arlequin: A software for population genetics data analysis, version 2.000. Genetics and Biometry Laboratory, Department of Anthropology, University of Geneva, Switzerland. 2000; Retrieved from http://www.cmpg.uni be.ch/software/arlequin/archive/ website/software/2.000/manual/Arlequin.pdf 18. Slatkin M. A measure of population subdivision based on microsatellite allele frequencies. Genetics. 1995;139:457–62.

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19. Wright S. The interpretation of population structure by F-statistic with special regard to system of mating. Evolution. 1965;19:395–420. 20. Fu Y. Statistical tests of neutrality of mutations against population growth, hitchhiking and backgroud selection. Genetics. 1997;147:915-25. 21. Tajima F. Statistical method for testing the neutral mutation hypothesis by DNA polymorphism. Genetics. 1989a;123:585–95. 22. Excoffier L. Patterns of DNA sequence diversity and genetic structure after a range expansion: Lessons from the infinite-island model. Molr Ecol. 2004;13:853–864. 23. Harpending H. C. Signature of ancient population growth in a low-resolution mitochondrial DNA mismatch distribution. Human Biol. 1994;66:591–600. 24. Ray N, Curratand M, Excoffier L. Intra-deme molecular diveraity in spatially expanding populations. Mol Biol Evol. 2003;20:76–86. 25. Rogers A.R. Genetic evidence for a Pleistocene population explosion. Evolution. 1995;49:608–615. 26. Rogers A R, Harpending H. Population growth makes waves in the distribution of pairwise genetic differences. Mol Biol Evol. 1992;9:552–69. 27. Schneider S, Excoffier L. Estimation of past demographic parameters from the distribution of pairwise differences when the mutation rates vary among sites: application to human mitochondrial DNA. Genetics. 1999;152:1079– 108. 28. Excoffier L, Smouse P, Quattro J. Analysis of molecular variance inferred from metric distances among DNA haplotypes: Application to human mitochondrial DNA restriction data. Genetics. 1992;131:479–91. 29. Ardlie KG, Kruglyak L, Seielstad M. Patterns of Linkage disequilibrium in the human genome. Genetics. 2002;3:299–309.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):857-60

The role of neutrophil/ lymphocyte ratio (NLR) with ca 125 in preoperative predictıon of malignancy in adnexial mass Meryem Bekmezci, Oguzhan Gunenc Konya Training and Research Hospital, Clinic of Gynecology and Obstetrics Konya, Turkey Received 28 March 2018; Accepted 18 July 2018 Available online 08.10.2018 with doi: 10.5455/medscience.2018.07.8893 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract It is aimed to evaluate the neutrophil / lymphocyte ratio (NLR) and platelet / lymphocyte ratio (PLR) values with CA 125 value in order to distinguish benign / malign / borderline tumors in patients undergoing surgery for adnexal mass. In this retrospective study were included 290 randomized patients having adnexal mass. According to the results of postoperative pathology, 227 patients were benign and 63 were malign. Hematological parameters such as NLR, mean platelet volume (MPV), and PLR were measured in the preoperative period. Multivariate regression analysis was performed statistically to determine the association with CA 125 and hematologic parameters of malignancy in adnexal masses. Women with malignant adnexal mass were older than the ones having benign adnexal mass. CA 125, NLR and PLR levels were statistically higher in patients having malignant adnexal mass than the ones having benign adnexal mass. Age, CA 125 and NLR were associated with malignancy in women with adnexal mass. Multivariable logistic regression analysis depicted that age, CA 125 and NLR were related to increased malignancy risk in adnexal mass (OR=1.047, 95 %Cl =1.023-1.071, OR=1.007, 95 %Cl = 1.004-1.010 and OR=1.228, 95 %Cl = 1.032-1.460, respectively). CA 125, NLR and PLR were positively correlated to malignancy in women with adnexal mass. The CA125 value alone is insufficient for malignancy discrimination. Combination of it with age, and NLR may be useful in distinguishing malignant masses from benign ones in the preoperative period. Keywords: Adnexal mass, cancer antigen 125, neutrophil lymphocyte ratio, platelet lymphocyte ratio.

Introduction The etiology of adnexal masses ranges from physiologically normal luteal cysts to ovarian cancer. Ovarian cancer causes mortality than any other cancer of the female reproductive system. Ovarian cancer relative survival rate was 46.5% between 20072013 [1]. Evaluation of malignancy related factors are very important in preoperative period for prediction of malignancy risk, the planning of follow-up and treatment in adnexal mass. Despite the study of many markers to determine malignancy risk, the preoperative evaluation of some ovarian masses does not let the clinician to decide the malignancy potential; which includes; sonographic evaluation, computerized tomography and tumor markers [2,3].

as C-reactive protein (CRP) have been correlated to outcomes in ovarian carcinoma and renal cell carcinoma [4]. Neutrophil Lymphocyte Ratio (NRL) and Platelet Lymphocyte Ratio (PLR) are easily calculated markers that used as predictive in cancer and premalignant diseases [5,6]. Yıldırım et al., NLR, PLR, CA-125 , neutrophil and platelet counts levels were higher in the malignant compared to the benign cases [7] Kokcu et al. Concluded that NLR and PLR increased in advanced stage overcancer. They also stated that PLR is an independent risk factor for advanced stage epithelial over cancer. [8].

It is known that cancer increases the level of inflammation and infection markers. Some markers of systemic inflammation such

CA125 is widely used tumor marker in ovarian cancer; nevertheless, CA125 predictive power is low in ovarian cancer. CA125 is elevated in about 80% of women with epithelial ovarian cancer (EOC) but only in 50% of women with early stage disease [9]. The specificity of CA125 is limited, because of elevated in a range of common benign gynecologic or non-gynecologic conditions [10].

Coresponding Author: Oguzhan Gunenc, Konya Training and Research Hospital, Clinic of Gynecology and Obstetrics Konya, Turkey E-mail: oguzhangunenc@hotmail.com

In our study, we aimed to determine the predictive value of CA 125, in combination with simple and rapidly determined inflammation markers such as NLR and PLR for the malignancy potential of the adnexal masses, in the preoperative period. 857

doi: 10.5455/medscience.2018.07.8893

Materials and Methods 290 patients were admitted to Konya Training and Research Hospital Obstetrics and Gynecology Clinic with adnexal mass between January 1, 2010 and April 10, 2016. The pathology results, laboratory parameters and socio-demographic characteristics of these patients were retrospectively analyzed. Women with all adnexal masses aged 40-65 years were included in the study. Exclusion criteria for all participants included: masses outside the ovaries, patients having previous operations for ovarian masses, those receiving chemotherapy and / or radiotherapy, women with infectious diseases such as pelvic inflammatory disease, inflammation and abscess that could affect laboratory parameters. The study protocol was approved by the local ethical committee of our hospital. Anthropometric measurements were recorded for all participants included in the study.

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and 263.43 ± 13.65 in malign adnexal mass and 35.43 ± 5.58, 2.47 ± 1.76 and 152.60 ± 8.61 in benign adnexal mass, respectively. CA 125, NLR and PLR levels were significantly higher in malignant adnexal masses than in benign adnexal masses (p<0.001, p< 0.001 and p<0.001, respectively) (Table 1). There was no difference in smoking rate, neutrophil count, lymphocyte count and platelet counts between benign and malignant adnexal mass groups (p = 0.546, p = 0.232, p = 0.299 and p=0,086 respectively) (Table 1). ROC curves were performed in patients with malignant adnexial masses. NLR and PLR AUC (95% Cl) were calculated. NLR AUC was 0,702 (95%Cl: 0,630-0,774) and RPL AUC was AUC: 0,712 (95%Cl: 0,635-0,789) (Figure 1).

All analysis was performed in the hematology and biochemistry laboratory of our hospital with the use of a Beckman Coulter (High Wycombe, UK) Gen-S automated analyzer. Plasma CA 125 levels were determined unit/ milliliter. The findings of all the cases were noted. Specimen were included in the “frozen section” and postoperative histopathologic examination, and the results were compiled. Histopathological diagnosis was accepted as the gold standard in the interpretation of the results. In the postoperative period; patients were divided into two groups according to the presence of malignancy, by definitions of the World Health Organization (WHO) [11]. Statistical analysis Data analysis was performed by using SPSS for Windows, version 17 (SPSS Inc., Chicago, IL, United States).The results were expressed as mean ± SD (95% Confidence Interval). CA125, NLR and PLR receiver operator characteristic (ROC) curve analysis was performed, and the area under the curve (AUC) was calculated. Age, CA125, NLR, PLR and MPV between benign and malignant adnexal mass groups were assessed by independent t test. Multiple logistic regression analysis was performed to calculate the odds ratio (OR) and 95% confidence intervals to demonstrate the association of adnexal masses with malignancy. Correlation analysis was performed to determine correlation with CA 125 and other variables in malignant adnexal masses. A p value less than 0.05 was considered statistically significant. Results A total of 290 women with adnexal mass were enrolled in the study. 227 of those had benign adnexal mass, and 63 had malignant adnexal mass. 54 (85.71%) patients were epithelial over ca, 7 (11.11%) patients were germ cell and 2 (3,17%) patients were sexcord stromal over tumors of the malignant tumors. The baseline anthropometric, clinical and laboratory characteristics of both groups are given in Table 1. The mean age of the patients was 52.11 ± 15.62 years in malignant adnexal mass, and it was 41.51 ± 14.41 years in benign adnexal mass (p<0.001). Mean age of the patients having malignant adnexal mass were significantly higher than the benign mass (p< 0.001). CA 125, NLR and PLR levels were 360.16 ± 84.70, 4.97 ± 6.62

Figure 1. NLR and RLR ROC curve in malign adnexal mass

Univariate and multivariate logistic regression analysis were applied to determine the best predictors for an increased risk of malignancy in women with adnexal mass. Variables whose univariable test had a significantly was accepted as a candidate for the multivariable model along with all variables of known clinical importance. Multivariable logistic regression analysis revealed age, CA 125 and NLR were associated with independently increased risk variables of malignancy in women with adnexal mass (OR: 1.047, 95 %Cl =1.023-1.07, OR: 1.007, 95 %Cl = 1.004-1.010 and OR:1.228, 95 %Cl = 1.032-1.460, respectively). In conclusion, age, CA 125 and NLR have high predictive value for malignancy in women with adnexal mass (p<0.001, p<0.001 and p=0.002, respectively) (Table 2). 858

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Correlation analysis was performed to determine whether CA 125 was correlated with NLR and PLR levels in malign adnexal masses. Positive significant correlation was observed between CA 125, NLR and PLR levels (p=0.003 and p=0.001) (Table 3). Table 1. Demographic and laboratory features of benign and malign adnexal masses

Age

Benign n= 227

Malignant n=63

p value

41.51 ± 14.41

52.11 ± 15.62

<0.001

Smoking

84 (%37)

25 (%39,68)

0.546

35.43 ± 5.58

360.16 ± 84.70

<0.001

Neutrophil counts

4,44± 0,129

4,69 ± 0,163

0,232

Lymphocyte counts

2,39 ± 0,074

2,27 ± 0,090

0,299

Platelet counts (/mm3)

247,56 ± 5,62

231,30 ± 7,68

0,086

CA 125(U/mL)

NLR

2.47 ± 1.76

4.97 ± 6.62

<0.001

PLR

152.60 ± 8.61

263.43 ± 13,65

<0.001

MPV

9.77 ± 1.60

13.62 ± 3.75

0.053

CA 125: Cancer antigen 125; NLR: Neutrophil / Lymphocyte ratio; PLR: Platelet / lymphocyte ratio; MPV: Mean platelet volume; p; statistically significant. Table 2. Multivariate logistic regression analysis of several factors in the assessment of increased malignancy risk in women with adnexal mass Malign adnexal mass Univariate

Multivariate

OR (95%Cl)

p value OR (95%Cl)

p value

1.052(1.031-1.074)

<0.001

1.047(1.023-1.071)

<0.001

CA 125(U/mL) 1.007(1.005-1.010)

<0.001

1.007(1.004-1.010)

<0.001

NLR

1.269(1.117-1.441)

<0.001

1.228(1.032-1.460)

0.020

PLR

1.004(1.002-1.007)

0.001

0.999(0.996-1.002)

0.581

MPV

1.028(0.933-1.133)

0.575

Age

CA 125: Cancer antigen 125; NLR: Neutrophil / Lymphocyte ratio; PLR: Platelet / lymphocyte ratio; MPV: Mean platelet volume; OR: odds ratio; p; statistically significant Table 3. Correlation between variables in malign adnexal masses Malign adnexal mass CA 125(U/mL) Age

r=0.216

p=0.092

NLR

r=0.372

p=0.003

PLR

r=0.523

p=0.001

MPV

r=0.042

p=0.748

Ca 125: Cancer antigen 125; NLR: Neutrophil / Lymphocyte ratio; PLR: Platelet / lymphocyte ratio; MPV: Mean platelet volume; r: Correlation coefficient; p; Statistically significant

Discussion In this study; we evaluated the demographic and laboratory characteristics of patients with benign and malignant ovarian masses managed at our clinic. An adnexal mass such as mass of the ovary, fallopian tube, or connective tissue is a common gynecologic problem in reproductive age women. The most important problem in women with adnexal mass is to differentiate malignancy from urgent causes (adnexial torsion, ectopic pregnancy, etc). It is

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estimated that there is a 5 to 10 percent lifetime risk for women undergoing surgery for a suspected ovarian neoplasm [12]. In some complex adnexal masses, it is difficult to distinguish if it is benign or malignant, without surgery. It is very important to diagnose malignancy of ovarian tumors at the early stage, because the survival rate is 90% [13]. Ultrasonographic evaluation, menopausal status, and tumor markers such as CA 125 and human epididymis secretory protein 4 (HE4) are important predictors for malignancy [14, 15].In addition, Romagnolo et al., and Yanaranop et al., reported that risk of malignancy index (RMI) have been introduced to discern benign and malignant cases [14, 17]. Ultrasonography markers, CA125 level and menopausal status were evaluated with the RMI. Although pathological analysis is usually necessary to determine malign adnexal mass, complete blood count (CBC) may help to evaluate an adnexal mass malign or benign. We found statistically significant differences between the groups in terms of age, CA 125 levels, preoperative NLR and PLR. Also, we determined that age, CA 125 and NLR variables can be used to differentiate adnexal masses from preoperative malignancy in multivariate regression analysis. Preoperative CBC parameters are frequently used in many tumors. Tamussino et al., reported that preoperative thrombocytosis was also in ovarian cancer and other gynecological cancers [17]. Kuyumcuoglu et al. reported that progressively increased platelet number was related with poor prognosis in malign ovarian tumors [18]. NLR and PLR are easily calculated indicators that can be used in the assessment of malignant and benign tumors. Yang et al. reported that NLR and PLR were related to be prognostic indicators for many types of cancer [6, 19]. In our study, we evaluated age and preoperative NLR and PLR with CA 125. We found that preoperative NLR with CA 125 could be a potential marker for predication of malignant adnexal mass in older women. However PLR was found not to be a useful marker. Although PLR does not appear to be a useful marker in prediction of malignancy potential of an adnexal mass, we detected a positive correlation of it with CA 125, and NLR in malign adnexal mass. The limitation of our study is its retrospective design and relatively small number of patients included. Conclusion In conclusion, we suggest that preoperative workshop of an adnexal mass should include CA 125 levels, ultrasound examination and NLR levels. Prospective studies including more participants are needed for absolute results. Acknowledgements The authors would like to thank the staff at Konya Training and Research Hospital and to all women who participated in the study. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Ethics committee approval was received for this study from the ethics committee of Konya Training and Research Hospital

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Halazun KJ, Hardy MA, Rana AA, et al. Negative impact of neutrophillymphocyte ratio on outcome after liver transplantation for hepatocellular carcinoma. Ann Surg. 2009;250:141-51.

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Hafeez S, Sufian S, Beg M, et al. Role of ultrasound in characterization of ovarian masses. Asian Pac J Cancer Prev. 2013;14:603-6.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):861-6

A study of compulsive buying disorder comorbidity in psychiatric outpatients attending a foundation university outpatient clinic Baris Onen Unsalver1, Sedef Koc2, Alper Evrensel1 1

Uskudar University, Faculty of Humanities and Social Sciences, Department of Psychology, Istanbul, Turkey Uskudar University, Faculty of Medicine, Department of Clinical Psychologist Psychology, Istanbul, Turkey

Received 09 May 2018; Accepted 18 June 2018 Available online 12.10.2018 with doi: 10.5455/medscience.2018.07.8895 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The aim of this study was to screen for the comorbidity of compulsive buying disorder with psychiatric disorders and associated sociodemographic variables. One hundred and ninety-six volunteering psychiatric patients attending Üsküdar University Outpatient Psychiatry Clinic formed the study sample. Compulsive buying disorder (CBD) was screened with Compulsive Buying Scale (CBS). CBD was found among 17 people (8.67%) in this sample of 196 patients (female n= 127, 67.4%; male n=69, 32.6%). Psychiatric diagnosis of patients with CBD were as follows: major depressive disorder (n=3,1.5%),cyclothymic disorder (n=2,1%), mood disorder not otherwise specified (NOS) (n=2, 1%), bipolar disorder (n=2, 1%), anxiety disorder NOS (n=2, 1%), obsessive compulsive disorder (n=2,1%), substance dependence (n=1, 0.5%), Tourette disorder (n=1, 0.5%) and generalized anxiety disorder (n=1,0.5%). In this cross-sectional screening study there seems to be a remarkable comorbidity of CBD and mood disorders. CBD may not be an independent entity but a symptom of mood disorders. In all patients with a mood disorder buying behavior should be evaluated routinely. In those with a problematic buying behavior, any mood disorder should be examined. Keywords: Compulsive buying disorder, shopping addiction, mood disorder, problematic buying gehavior

Introduction Abnormal shopping behavior has drawn the attention of clinicians for more than 100 years, but this has not been a topic that is sufficiently focused on until 30 years ago [1]. In the beginning of the 20th century E. Kraepelin and E. Bleuler classified compulsive buying disorder (CBD) under the name of oniomania among impulse control disorders in their textbooks. Kraepelin mentioned oniomania as mania of buying and considered this situation as a type of pathological impulse [2]. Bleuler defined oniomania as a reactive impulse or impulsive insanity as in the cases of pyromania and kleptomania [2]. In addition to “compulsive buying disorder”, the literature contains different denominations about the topic which include compulsive buying, impulsive buying, shopping addiction / addictive shopping behavior and buying addiction / addictive buying. DSM-III-R includes CBD among impulse control disorders that cannot be named otherwise [3]. On the other hand, CBD was not included as a separate diagnosis in DSM-IV-TR, DSM-5 and ICD-10. Coresponding Author: Baris Onen Unsalver, Uskudar University, Faculty of Humanities and Social Sciences, Department of Psychology, Istanbul, Turkey E-mail: onenunsalver@gmail.com

Some authors considered CBD to be included in behavioral addictions [4-8]. According to Lejoyeux and Weinstein who defined shopping addiction, buying behavior emerges in an uncontrollable and repetitive fashion, the individual spends most of their time by shopping or thinking of shopping, always buys more than they have planned to, and keeps shopping despite the negative outcomes of it [9]. On the other hand, it was also argued that there are not enough data to classify this concept as addiction [10]. Some cases with CBD diagnosis have similar clinical pictures as those of OCD, impulse control disorder or behavioral addiction [11,12]. As the diagnostic criteria of CBD are not clear, epidemiology studies found the prevalence of CBD as 1.1-16% [13-17]. Clinical and field studies reported that 80-95% CBD cases were women [9,12,18-21]. While men are more interested than women in electronics, automotive or hardware, women’s interest towards clothes, shoes and CDs is higher than men’s [2]. A study on differentiation of hedonic shopping based on sex in Turkey found that female consumers gained more pleasure from shopping than male consumers [22]. Various studies reported that CBD starts towards the end of adolescence and becomes a noticeable issue in 30s [9,12,17,18,20,23]. 861

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Alain d’Astous likened the relationship between CBD and income to a bell curve and stated that CBD is more likely to be seen among middle-income individuals in comparison to low-income and high-income individuals [24]. Lejoyeux et al. found that the ratio women with CBD who were married (66%) was lower than that of the control group (85%) [25]. Two other studies did not find a significant relationship between marital status, education levels or employment [17,26]. As there are not enough studies on CBD and its clinical picture could not be defined clearly, its etiology is not completely known [2]. CBD’s increased presence in developed country may be explained by cultural mechanisms. Free market economy, breadth of product ranges and being able to access these, having a disposable income and having enough time for these activities may be influential in CBD development. This is why CBD prevalence is low in underdeveloped countries (except among the wealthy). CBD may be evaluated with a neuropsychiatric approach that focuses on inhibition, self-control and rule-based behaviors. While the effectiveness of antidepressants in treatment indicates serotonergic dysfunction, Devor et al. could not find an association between CBD and two serotonin transporter genes [11,27]. It was also proposed that the DRD1 receptor gene and opioid receptors have role in the etiology of CBD [28-30]. Compulsive buying is founded on negative moods, lack of selfesteem, perfectionism, the exclusivity and opportunities of buying something, difficulties in making decisions and incorrect beliefs about the emotional outcomes of buying [31]. Tamam et al. argued that individuals with low self-esteem increase their selfesteem by buying, and this way, they cope with stress, rejection and depression [32]. In this case, compulsive shoppers see the act of shopping as a way to escape from depressive thoughts. It was reported that CBD cases have higher levels of negative feelings such as depression, anxiety, boredom, self-criticizing thought or anger before the act of shopping [33]. Individuals with depressive moods tend to associate objects of consumption with emotional concepts rather than their functions [34]. Cross-sectional studies reported that while fluctuations are seen in the severity and intensity of CBD, it is chronic [18,20]. While the picture is continuous, and improvements longer than a month are not seen in some CBD cases, the disorder is periodic in others [13]. While these episodes are encountered hourly in some cases, they emerge one a month in others. While CBD signs are encountered along the years, holidays, birthdays and special days like the New Year’s Eve carry more risks for the progress of the disease [2,18]. CBD may be seen in combination with axis-1 and axis-2 disorders. It is known that especially mood, anxiety, eating, impulse control and substance abuse disorders accompany CBD cases [12,20]. The literature reported that CBD is accompanied by a mood disorder by 21-100% [2,12,23]. CBD and impulse control disorders are seen together by 21-46% [12,18,20]. While a study suggested that there was CBD diagnoses in 17.6% of cases of bulimia nervosa, another study did not find any relationship [35,36]. CBD accompaniment was reported in 45.6% of women with nicotine addiction [37]. Güngör et al. reported that they found CBD in 3.7% of 81 alcohol addicts [38].

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Turkey is a developing country. As a result of the increasing number of shopping malls, online shopping websites and easily accessible credit cards, there is a risk for the buying behavior in Turkey to become problematic. The data on CBD prevalence in Turkey is limited to a small number of studies. This study aimed to investigate the prevalence of compulsive buying behavior in outpatients with a psychiatric disorder based on the DSM-IV-TR criteria who visited a private psychiatry clinic and the relationship of this prevalence with sociodemographic variables. Material and Methods The design and the sample The sample of the study consisted of 196 adult volunteers who visited the Üsküdar University Neuropsychiatry Medical Research and Training Center between the dates of 2.11.2016 and 07.12.2016 with diagnoses of psychiatric disorders based on DSM-IV-TR diagnostic criteria. All the participants signed informed consent forms. During the five months period of the study, some patients had visited the clinic more than once for their follow-up appointments. After the exclusion of the repeated visits, 1210 individuals in total visited the clinic. The authors contacted all the participants personally, explained the procedure and handed the questionnaires. Most of the cases refused to fill out the questionnaires due to lack of time. 35 people including those who filled out the questions incompletely (n=18), those who were younger than 18 years old (n=7), those whose responses were lost (n=4) and those without an axis-1 diagnosis (n=6) were excluded. As a result, the questionnaires of 196 people were accepted to be valid and analyzed. Data collection tools Sociodemographic Information Form: Contains questions related to age, sex, marital status, socioeconomic status, place of growing up. Compulsive Buying Scale (CBS): Yüncü and Kesebir conducted the Turkish validity and reliability study of the scale which was developed by Valence et al. [39,40] It is a 5-point Likert-type scale filled out by the participant and contains 12 statements about the buying behavior of the person. In the ROC (Receiver Operating Characteristic) curve, its scale sensitivity was 0.790, specificity was 0.995, and prevalence was calculated as 9.6% in a 95% confidence interval. Internal consistency of the scale is 0.80, and its cutoff point was 42. Determination of psychiatric diagnoses: In this study which is the master’s thesis of the second author, the supervising faculty member retrospectively examined the files of the participants, contacted the physicians/psychiatrists of the patients, and determined the diagnoses based on DSM-IV-TR. No structured diagnostic tool such as SCID or MINI were used, because of time constraints. Each patient file includes 8 pages of information regarding the patient’s sociodemographics, main complaints, history of the current problems, previous psychiatric history, mental status examination, vital signs knowledge, medical history and a formulation section where the treatment aims are summarized and the patient’s psychiatrics status is formulated according to the 5 axis approach of DSM-IV-TR. Each patient fills out psychiatric self-report scales SCL-90, Beck Anxiety Inventory and Beck Depression Inventory before their psychiatric examination. All this information was 862

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reviewed daily by the first and third authors and if there was a difficulty of giving a diagnosis then the primary psychiatrist or psychologist of the patient was consulted. The diagnosis that was made according to the presenting symptoms on the day of filling out the test was accepted as the primary psychiatric diagnosis and was included in the analysis. Statistical analysis The data that were obtained in the study were analyzed using the SPSS 20.0 software. While the psychiatric diagnoses and sociodemographic variables of the participants were analyzed with CBS scores, tables of frequencies (percentages), cross-tabulations and chi-squared tests were used. RESULTS Among the 196 individuals (female n=127, 67.4%; male n=69, 32.6%), CBD was determined based on CBS in 17 individuals (8.67%). Among those with CBD, 76.5% (n=13) were female and 23.5% (n=4) were male. Among those without CBD, 63.7% (n=114) were female and 36.3% (n=65) were male. The mean ages were 31.3 for women with CBD (n=13), 34.5 for women without CBD (n=114), 24 for men with CBD (n=4) and 27.9 for men without CBD (n=65). Table 1 shows the sociodemographic findings. Table 1. Sociodemographic findings

Gender

Age

Education

Marital status

Monthly income

Place of residence

CBD (+) N

CBD (-) N

Women

114

Men

18-30

31-40

41-50

>50

8 years of basic education

high-school

university

masters degree

single

103

married

divorced

0-1000 tl/month

1001-3000 tl/month

3001-5000 tl/month

5001-10000 tl/month

>10000 tl/month

metropole

city

108

province

p* p=0.292

p=0.517

p=0.017

p=0.597

p=0.555

p=0.762

*p values reflect chi-squared analysis results

Among the cases diagnosed with CBD, the diagnoses were major depressive disorder (MDD) in four (2%), cyclothymia in two (1%),

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mood disorder not otherwise specified (NOS) in three (1.5%), bipolar affective disorder (BD) in two (1%), anxiety disorder NOS in two (1%), obsessive compulsive disorder (OCD) in one (0.5%), substance addiction in one (0.5%), Touretteâ&#x20AC;&#x2122;s disorder in one (0.5%) and generalized anxiety disorder for one (0.5%). Table 2 shows the distribution of the psychiatric diagnoses of the cases with and without CBD diagnosis. Regardless of CBD diagnosis, 76 individuals (38.7%) in the sample were diagnosed with a mood disorder. 11 of these cases (5.6%) satisfied the criteria for CBD diagnosis. 64.7 % of the cases that were diagnosed with CBD satisfied the criteria for a mood disorder diagnosis. Table 2. Distribution of the psychiatric diagnoses and compulsive buying disorder comorbidity Psychiatric diagnosis

CBD (+) N

CBD (+) CBD (-) N % 35 (4 of them were comorbid with other diagnoses) 17 (1 of them were comorbid with other diagnoses)

CBD (-) %

Major Depressive Disorder

2.0

Bipolar Affective Disorder

1.0

3 (1 of them was comorbid with other diagnoses)

1.5

11 (1 of them was comorbid with other diagnoses)

5.6

Cyclothymia

1.0

Dysthymia

1.5

Obsessive compulsive disorder

0.5

Panic Disorder

Social Anxiety Disorder

Generalized Anxiety Disorder

0.5

1.0

5.1

1.0

2.0

0.5

1.5

0.5

Dissociative Amnesia

2.0

Schizophrenia

2.0

3.6

0.5

10 (6 of them were comorbid with other diagnoses)

5.1

Touretteâ&#x20AC;&#x2122;s Disorder

0.5

Addictive Disorder

0.5

Dissomnia

0.5

Mood Disorder Not otherwise specified

Anxiety Disorder not otherwise specified Posttraumatic Stress Disorder Adjustment Disorder Hypochondriasis Somatoform Disorder Body Dysmorphic Disorder

Schizoaffective Disorder Delusional disorder Attention Deficit Hyperactivity Disorder

37 (4 of them were comorbid with other diagnoses) 9 (1 of them were comorbid with other diagnoses) 12 (5 of them were comorbid with other diagnoses) 14 (2 of them were comorbid with other diagnoses)

17.8 8.7

18.9 4.6 6.1 7.1

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Discussion This study used cross-sectional surveying to present the distribution of the cases diagnosed with CBD based on their CBS scores among 196 volunteering participants who attended the psychiatry clinic of a foundation university in Turkey, as well as accompanying psychiatric diagnoses. CBD was found in 8.67% (n=17) of the sample. This ratio, which seems low in comparison to those in the previous CBD and psychiatric comorbidity studies, may be explained by the small sample size and that a structured clinical interview which directly targeted compulsive buying was not conducted. Participants might not have considered their shopping behaviors as problematic, paid attention to their shopping tendencies, or they might have had a tendency to hide their shopping problems. This may have affected their responses to CBS and led the CBD comorbidity rates to come out low. In line with the literature, our study found CBD to be more prevalent in women (76.5% women, 23.5% men) [9,12,19-21]. According to the CBS results, the mean ages were 31.3 for women with CBD (n=13) and 24 for men with CBD (n=4), and this result was in compliance with the literature which reported that CBD starts in late adolescence and becomes a noticeable problem in early 30s [9,12,13,18,20,23]. However, our cross-sectional study did not provide information on the onset age of CBD. 58.8% (n=10) of the CBD cases were single, while 41.2% (n=7) were married. In a study conducted only with women which reported marital status, 66% of the CBD cases were married [25]. It is not possible to compare the data as Lejoyeux et al.’s study only included women. Being single might be making shopping easier by reducing financial responsibility. While no association could be made between education levels and CBD prevalence in the literature, 10 CBD cases in our study had at least associate degrees [18,26]. Increased education level may be in parallel with purchasing power. However, the size of the sample is not sufficient for us to comment on education. 35.3% (n=6) of the CBD cases had a monthly income of 3001-5000 TL and 29.4% (n=5) had a monthly income of 5001-10000 TL. Based on our study, it may be stated that CBD is seen more frequently among individuals who are accepted to have a medium-level income status. The study by d’Astous also reported that CBD is seen more in individuals with medium-level income in comparison to those with low-level and high-level incomes [24]. As opposed to these, in a study with 44 cases, the income levels of the CBD cases were found to be lower than the mean income [41]. Among the entire sample 76 individuals (38.7%) satisfied the criteria for a mood disorder. Among those with mood disorders, 11 individuals (14.5%) were diagnosed with CBD. In other words, 64.7% (n=11) of those who were diagnosed with CBD based on CBS were also diagnosed with a mood disorder. Depressive disorder is one of the diagnoses that accompany CBD frequently [16,18,43,44]. CBD is common in depressed patients [16,18,44, 45]. According to McElroy et al.’s study, patients stated that only shopping made them feel good when they were depressed [18]. Kesebir et al. applied CBS on 100 outpatient patients who were diagnosed with bipolar affective disorder and found that compulsive buying behaviors were more frequent in these patients in comparison to the control group. Cyclothymic and irritable (changeable, volatile) traits were seen more frequently in CBD

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cases [46]. In another study of 150 patients with depression, CBD rate was 14% [47]. During manic episodes, frequency of shopping may increase as a result of impulsivity. Depressive individuals may shop in order to increase their mood. Therefore, our findings regarding the relationship between mood disorders and CBD is in line with previous literature. This common co-occurrence of CBD and mood disorders may draw the attention to the question of whether CBD is a separate category of diagnosis, or is the disruption of buying behavior one of the signs that is observed in mood disorders. As stated in the introduction CBD is regarded by some authors as a behavioral addiction [4-9]. Buying behavior or preoccupation with shopping may have mood enhancing effects and the inability to shop may have mood depressing effects. People with mild or moderate depressive disorder might benefit from this rewarding effect of shopping which might result in the cycle of a behavioral addiction. So, compulsive shopping disorder may be an outcome of untreated or mismanaged mood disorder. It may be possible to understand whether CBD is a separate diagnosis that accompanies mood disorders, or it is only a sign, by longitudinally monitoring cases of mood disorders and observing their buying behaviors in remission periods. Only one (5.8% among CBD) among the 38 OCD patients in our sample satisfied CBD criteria based on CBS. While older studies reported CBD and OCD comorbidity as 10-35%, later studies showed these ratios as 2-6% [12,14,18,20]. Our findings were partly in compliance with the literature. Conclusion Our study had some limitations. Psychopathology diagnosis was not made by a structured diagnosis tool due to the operational conditions of the study, and this may explain the low rates of comorbidity in the general sample [48]. Psychiatric diagnosis was made by reviewing the psychiatric examination findings stated in the participant’s examination file on the day that the CBS questionnaire was applied. Psychiatric file notes may not have reflected psychiatric comorbidities sufficiently due to the lack of a structured interview. During this examination, CBD diagnosis was made by CBS, which is a surveying tool. Diagnosis could be clarified more by noting the detailed history of the forms of shopping behavior through faceto-face interviews. The relatively small size of the sample reduced the diversity of diagnoses. Such that, the distribution of the CBD cases outside the cases of mood disorders was too rare to allow any interpretation. The power of the study may be increased by broadening the sample. Axis-2 diagnoses were also not evaluated in our study. Problems in personality structuring may lead to various behavioral disorders, as well as disorders in shopping behaviors. Future studies should investigate axis-2 characteristics in people with problematic shopping behavior. Consequently, this study which was conducted with cases that were admitted to a private psychiatry center observed a noticeable association between CBD and mood disorders. In all mood disorder cases, shopping behavior should be routinely monitored in clinical interviews. Mood disorders should be investigated in cases that show problematic shopping behaviors. Despite its limitations, our study has the qualities to add onto the low number of studies on this topic in Turkey and act as a source for future research. 864

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Acknowledgments This article is based on some of the findings of the master’s thesis of the second author.

20. Schlosser S, Black DW, Repertinger S, et al. Freet D. Compulsive buying: demography, phenomenology, and comorbidity in 46 subjects. Gen Hosp Psychiatry. 1994;16:205-12.

Competing interests The authors declare that they have no competing interest

21. Cooms RH (Ed). Handbook of Addictive Disorders: A Practical Guide to Diagnosis and Treatment. Hoboken, New Jersey: John Wiley & Sons Inc. 2004;411-50.

Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Approval for conducting the study was received from the Üsküdar University Noninvasive Research Ethics Board

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):867-72

Evaluation of the lamina cribrosa in patients with multiple sclerosis using enhanced depth imaging optical coherence tomography Serkan Akkaya1, Bekir Kucuk1, Ender Sirakaya1, Ersin Kasim Ulusoy2 Kayseri Training and Research Hospital, Department of Ophthalmology, Kayseri, Turkey 2 Kayseri Training and Research Hospital, Department of Neurology, Kayseri, Turkey

Received 25 May 2018; Accepted 18 June 2018 Available online 05.10.2018 with doi: 10.5455/medscience.2018.07.8894 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Multiple sclerosis (MS) is a demyelinating disease of the central nervous system. Optic neuritis (ON) is common clinical manifestation of MS. Spectral domain optical coherence tomography (SD-OCT) has been used as a useful tool to quantify the neuronal damage in the eyes of MS patients. The study aimed to evaluate the lamina cribrosa thickness (LCT) and lamina cribrosa depth (LCD) in patients with MS and their relationship with Expanded Disability Status Scale (EDSS) score. Fifty-two eyes of 26 relapsing-remitting MS patients and 39 eyes of 39 healthy age- and sexmatched participants were evaluated in this prospective, cross-sectional, observational study. There were two MS subgroups: 38 MS eyes without an ON history (MS−ON), and 14 MS eyes with an ON history (MS+ON). The LCT and LCD were measured with SD-OCT. Of the 26 participants with MS, 14 (53.8%) were female and the mean (SD) age was 35.1 (6.2) years; of the 39 healthy controls, 26 (66.7%) were female and the mean (SD) age was 36.7 (8.2) years (P=0.19 for sex and P=0.27 for age). The mean LCT was not significantly different between MS patients and healthy controls (272.66 ± 33.52 μm and 272.58 ± 35.97 μm, respectively, P=0.992). The mean LCD was 325.15 ± 67.07 μm for the MS+ON group, 409.71 ± 93.18 μm for the MS−ON group, and 427.64 ± 91.65 μm for the healthy control group. The LCD was significantly decreased in MS+ON group compared to MS−ON group (P=0.011) and healthy controls (P=0.002). EDSS score was negatively correlated with LCD in MS patients (r= -0.313, P=0.025). This study revealed decreased LCD in MS eyes particularly with optic neuritis, and its relationship with increased disease severity. Additional longitudinal studies are needed to confirm the use of LCD as an imaging biomarker in patients with MS. Keywords: Lamina cribrosa thickness, lamina cribrosa depth, multiple sclerosis, enhanced depth imaging optical coherence tomography

Introduction Multiple sclerosis (MS) is an inflammatory-demyelinating disease of the central nervous system. MS often affects the brain and nerve tissues as well as the eyes. It causes visual loss, particularly due to optic neuritis (ON). ON is an acute inflammatory demyelinating disorder of the optic nerve which is common in MS. 50% of patients with MS develop ON at some point during the course of their disease and 15-20% of patients with MS have ON as their presenting demyelinating event. [1–3]. The lamina cribrosa (LC) is a mesh-like, multilayered collagenous structure that bridges the scleral canal aperture and supports the structure of the retinal ganglion cell (RGC) axons [4]. The optical coherence tomography (OCT) devices have enabled visualization of the LC in vivo [5,6]. Lamina cribrosa thickness (LCT) and lamina cribrosa depth (LCD) are studied in optic nerve disorders, Coresponding Author: Serkan Akkaya, Kayseri Training and Research Hospital, Department of Ophthalmology, Kayseri, Turkey E-mail: drsakkaya@gmail.com

particularly in glaucoma [7,8]. In glaucomatous eyes, increased IOP compresses the optic disc, and causes the thinning of lamina cribrosa [9]. Recently, it has been reported that LCTs of the eyes with glaucomatous optic neuropathy and non-glaucomatous optic neuropathy were thinner than those of control group eyes [10]. ON, a common feature of MS, may affect blood perfusion of the larger ocular vessels and possibly damage visual acuity [11]. Recently, a method was developed of measuring local circulation using highspeed OCT to perform quantitative angiography. Using the splitspectrum amplitude-decorrelation angiography algorithm, optic nerve head perfusion can be quantified [12]. The recent study measured the microcirculation in the ONH of MS eyes with and without a history of ON compared with healthy control eyes, and found that the mean ONH flow index in MS+ON group was significantly lower than the healthy control and MS− ON groups (p=0.004 for both), while there was no significant difference between the healthy control and MS−ON groups (p=0.924) [13]. 867

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To the best of our knowledge, evaluation of LCT and LCD using OCT in patients with MS has not been reported yet. In the present study we aimed to evaluate the lamina cribrosa thickness and the lamina cribrosa depth in MS patients with Enhanced Depth Imaging (EDI)-OCT. We also aimed to investigate the correlation of the LCT and LCD with disease duration and Expanded Disability Status Scale (EDSS) score. Material and Methods The study was approved by the local ethics committee and adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all participants after a detailed information of the study design. Subjects and Study Design Fifty-two eyes of 26 patients with relapsing-remitting MS and 39 eyes of 39 age and sex matched healthy individuals were enrolled in this cross-sectional study undertaken at a single tertiary referral hospital between May 27, 2016, and February 28, 2017. The diagnosis of MS was given according to the revised McDonald criteria, based on clinical and radiologic findings [14]. A complete neurological examination was performed, and physical disability score was assessed using the Kurtzke Expanded Disability Status Scale (EDSS) for each patient with MS [15]. The scores for the EDSS range from 0 to 10, and a higher score points greater disability. The presence of previous episodes of optic neuritis as reported by the neurologist or the patient was also recorded. Patients with a history of ON 6 months prior to the study, diabetes mellitus, any other neurologic disorders, or any other coexisting systemic disease, previous ocular trauma or surgery, and glaucoma or contact lens use were excluded from the study. The age and sex matched healthy subjects compromised the control group. In MS group the eyes were categorised into two subgroups, with respect to presence of ON history, as patients without ON history were included in the MS-ON group, and those with ON history were included in the MS+ON group. Of the 26 patients with MS, 14 (53.8%) had a history of unilateral optic neuritis, and 5 of them had three, 4 of them had two, and 5 of them had one previous episodes of optic neuritis. All participants underwent a complete ocular examination including slit-lamp biomicroscopy, fundus examination, gonioscopy, keratometry measurement using a Scheimpflug camera (Pentacam HR; Oculus GmbH, Wetzlar, Germany), central corneal thickness (CCT) measurement, and axial length (AL) using the IOL Master (Carl Zeiss Meditec, Dublin, California). The refraction of the participants was measured using a Tonoref II autorefractor/tonometer (Nidek Co. Ltd.). The spherical equivalent (SE) was defined as the sum of the spherical power and the half of the cylindrical error. Intraocular pressure (IOP) was measured using Goldmann applanation tonometry (GAT). Corrected IOP was calculated according to the formula reported by Kohlhaas et al [16]. In all participants, the Humphrey ﬁeld analyzer using the central 24-2 fields and the Swedish Interactive Thresholding Algorithm (SITA) standard strategy tests were performed. A fixation loss, false negative or positive test results less than 20% were accepted as reliable visual field results. The peripapillary retina nerve fiber layer (RNFL) thickness measurements were obtained using spectral-domain OCT (SD-OCT). The OCT scanning circle (diameter, 3.4 mm) was manually positioned at

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the center of the optic disc, and the mean peripapillary RNFL thickness was recorded. Lamina cribrosa assessment An SD-OCT (Spectralis, Heidelberg Engineering Inc., Heidelberg, Germany) was used to measure the LCT and the LCD of the participants. Obtained scans were excluded from the analysis, if the quality score was less than 20 or the provided image of the fundus and/or the border of the lamina cribrosa was unclear. The method for enhanced depth imaging of the optic nerve head with an SD-OCT device is published elsewhere [17]. The SD-OCT device was set to image a 15°× 10° rectangle centered on the optic disc. This rectangle was divided into approximately 65 sections, each comprising an average of 100 OCT frames. From these horizontal B scans, we selected three frames (center, mid-superior, and midinferior) that passed through the optic nerve head, and parameters were measured in each of these frames. During measurements of thickness, we assigned full weight to the center of the lamina cribrosa plate.Figure 1 demonstrates a representative OCT image of lamina cribrosa borders and Bruch’s membrane opening in an MS patient. The Bruch’s membrane opening corresponds to the line that connects both ends of Bruch’s membrane. The distances were measured on the line perpendicular to the reference line. The measurements were obtained as close as possible to the vertical center of the optic nerve head. Temporal side measurements were recorded, if a vessel trunk made the measurement impossible. Lamina cribrosa borders were defined as the anterior and posterior borders of the highly reﬂective region at the vertical center of the optic nerve head in horizontal SD-OCT sections, and the LCT was measured as the distance between them.

Figure 1. Optical coherence tomography images of a 33-year-old patient with multiple sclerosis (MS). Horizontal scans. (Top) Right eye with a prior optic neuritis (ON) history of the patient with MS. The thickness of the lamina cribrosa was 292 µm and depth of the lamina cribrosa was 316 µm. (Bottom) Fellow eye without ON history of the patient with MS. The thickness of the lamina cribrosa was 272 µm and depth of the lamina cribrosa was 350 µm

The clearest visualization of the lamina cribrosa was provided by the adjustment of contrast settings aided in the identification of 868

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images. The distance between the Bruch’s membrane opening and the anterior border of the lamina cribrosa was deﬁned as LCD. HEYEX software 6.0 (Heidelberg Engineering Inc., Heidelberg, Germany) were used to obtain the measurements. All images were analyzed by two independent researchers in a blinded fashion, who determined LCT and LCD twice. Hence, each LCT and LCD value was calculated four times, and the mean value was used in the primary analysis. Before the primary analysis, interexaminer and intraexaminer intraclass correlation coefﬁcients were calculated using 15 randomly selected images to test the reproducibility of the LCT and LCD measurements. Statistical analysis Statistical analysis was performed using SPSS, version 21.0 (SPSS Inc., Chicago, IL, USA). Basic descriptive statistics were calculated on all the data gathered and are reported as the mean (SD) or median (interquartile range [IQR]), as appropriate. The normal distribution of the data was evaluated with the Kolmogorov–Smirnov test and Chi-square test was used to compare categorical parameters between MS and control group. A p value of less than 0.05 was accepted as statistically significant. The independent samples t test for normally distributed data and Mann-Whitney test for nonnormally distributed data were used to compare the measures between the MS patients and healthy controls. A 1-way analysis of variance test followed by the Tukey test or Kruskal-Wallis test and Mann-Whitney test with Bonferroni adjustment were used to compare the measures among subgroups according to patient history of optic neuritis. After Bonferroni adjustment, a p value less than 0.017 (equal to 0.05/3) was considered as statistically significant. Spearman correlation analysis was performed to evaluate the correlation of LCT and LCD with disease duration and EDSS score. Results A total of 52 eyes of 26 MS patients and 39 eyes of 39 healthy control subjects were evaluated. Table 1 summarized the patients’

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demographics and measured OCT parameters in both groups. The mean (SD) age of the participants with 26 relapsing-remitting multiple sclerosis was 35.1 (6.2) years, and 14 (53.8%) of them were female. The mean (SD) age of the 39 healthy, age-matched controls was 36.7 (8.2) years, and 26 (66.7%) of them were female. Intraexaminer intraclass correlation coefﬁcient values (95% CIs for LCT and LCD were 0.895 (0.751–0.969) and 0.974 (0.916–0.992), respectively. Interexaminer intraclass correlation coefﬁcients for LCT and LCD were 0.849 (0.761–0.979) and 0.943 (0.816–0.972), respectively. There was no significant difference between MS and control groups with respect to age and sex (p = 0.27 and p = 0.19, respectively). The mean disease duration and the mean EDSS score of the MS patients was 6.92 ± 4.51 years, and 2.49 ± 1.01, respectively. The LCT was similar between MS and control groups (272.67 ± 33.53 μm , and 272.59 ± 35.97 μm, respectively, p = 0.92). However, the LCD was significantly lower in MS patients compared to control subjects (388.16 ± 94.29 μm and 427.64 ± 91.65 μm, respectively, p = 0.049). Moreover, the RNFL thicknesses were significantly decreased in MS group compared to those of control subjects (p < 0.05, except inferotemporal quadrant). The subgroup analyses of the MS patients with respect to presence of ON were shown in Table 2. The LCD was significantly decreased in MS+ON group (325.15 ± 67.07 μm) compared to MS-ON (409.71 ± 93.18μm, p = 0.011), and control groups (427.64 ± 91.65, p = 0.002). However, neither MS+ON, nor MS-ON groups were different than that of control subjects in terms of LCT ( p = 0.970 and p = 0.994, respectively). Spearman’s correlation analyses revealed that EDSS score was negatively correlated with LCD in MS patients (r = -0.313, p = 0.025). LCD did not correlate with global retinal nerve fiber layer thickness (r = -0.021, p = 0.884) and disease duration (r = -0.193, p = 0.175).

Table 1. The comparison of the demographics and the measurement parameters ( mean ± standard deviation) of multilpe sclerosis (MS) patients and controls Parameters

Patients With MS (52 eyes)

Healthy Control Participant (39 eyes)

P value

35.1±6.22 28/24

36.79±8.3 26/13

0.270 0.190*

LCT (µm)

272.67±33.53

272.59±35.97

0.992

LCD (µm)

388.16±94.29

427.64±91.65

0.049

Temporal RNFL (µm)

59.75±17.67

74.41±13.41

<0.001

Superotemporal RNFL (µm)

115.96±28.85

138.33±20.02

<0.001

Superonasal RNFL (µm)

102.31±25.6

118.26±18.93

0.002

Nasal RNFL (µm)

68.92±15.33

78.87±10.82

<0.001

Inferonasal RNFL, median (IQR), (µm)

89.0 (80-101)

128.0 (110-142)

<0.001‡

126.0 (104-144)

134.0 (111-149)

0.241‡

86.25±15.68

102.69±6.51

<0.001

Age (years) Sex (Female/ Male)

Inferotemporal RNFL, median (IQR), µm) Global RNFL (µm) Axial Length (mm) SE, median (IQR), (Diopter) CCT (µm)

23.43±0.74

23.3±0.62

-0.25 (-0.75-0.25)

-0.50 (-0.75-0.00)

0.252‡

0.358

533.69±24.58

550.36±26.91

0.003

Keratometry (Diopter)

43.25±1.12

43.07±1.03

0.434

IOP (mmHg)

13.73±1.99

14.92±2.64

0.016

Corrected IOP (mmHg)

14.43±1.75

14.92±2.60

0.288

LCT, Lamina Cribrosa Thickness; LCD, Lamina Cribrosa Depth; RNFL, Retina Nerve Fiber Layer; SE, Spherical equivalant; CCT, Central Corneal Thickness; IOP, Intra ocular pressure; IQR, interquartile range; *chi-square test; ‡ Mann-Whitney U test

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Table 2. The comparison of the demographics and the measurement parameters ( mean ± standard deviation) of MS With ON (MS+ON), MS Without ON (MS-ON) and control eyes Parameters

Control (39 eyes)

Patients With MS

P Value

MS+ON (14 eyes)

MS-ON (38 eyes)

MS+ON vs MS-ON

MS-ON vs Control

MS+ON vs Control

32.85±5.73

35.87±6.26

0.391*

0.838*

0.203*

8/6

20/18

0.940

0.209

0.406&

Age (years)

36.79±8.3

Sex(Female/Male)

26/13

LCT (µm)

272.59±35.97

275.23±40.57

271.79±31.34

0.949*

0.994*

970*

LCD (µm)

427.64±91.65

325.15±67.07

409.71±93.18

0.011

0.654

0.002*

Temporal RNFL (µm)

74.41±13.41

60.92±22.56

59.34±16.02

0.950

<0.001

0.028*

Superotemporal RNFL (µm)

138.33±20.02

108.62±30.14

118.47±28.37

0.450

0.003

<0.001*

Superonasal RNFL (µm)

118.26±18.93

86.46±23.99

107.74±24.09

0.009

0.096

<0.001*

Nasal RNFL (µm)

78.87±10.82

62.62±10.28

71.08±16.26

0.125*

0.032*

<0.001*

Inferonasal RNFL, median (IQR), (µm)

128(110-142)

84.00(74-98)

91(80.75-102.75)

0.336

‡

<0.001

<0.001‡

Inferotemporal RNFL, median (IQR), (µm)

134(111-149)

129(91.5-149)

124.5(104.75-142)

0.914

0.245

‡

0.526‡

Global RNFL (µm)

102.69±6.51

81.38±18.33

87.92±14.56

0.237*

< 0.001*

<0.001*

Axial Length (mm)

23.3±0.62

23.44±0.8

23.43±0.73

0.998

0.681

0.791*

SE, median (IQR), (Diopter)

-0.5(-0.75-0)

-0.5(-1.12-0)

-0.12(-0.75-0.5)

0.146‡

0.081‡

0.516‡

CCT (µm)

550.36±26.91

536.15±24.66

532.84±24.83

0.915

0.010*

0.202

Keratometry (Diopter)

43.07±1.03

43.1±1.43

43.3±1.01

0.825*

0.614*

0.997*

IOP (mmHg)

14.92±2.64

13.23±1.64

13.89±2.09

0.582*

0.127*

0.030*

Corrected IOP (mmHg)

14.92±2.60

13.83±1.32

14.63±1.85

0.642

0.174*

0.061*

EDSS score, median (IQR),

2.50(2.0-3.0)

2.50(1.50-3.0)

0.517#

Disease duration, median (IQR), (years)

7(4-14.5)

5(3-10)

0.329#

* * *

‡ ‡

LCT, Lamina cribrosa thickness; LCD, Lamina Cribrosa Depth; RNFL, Retina nerve fiber layer; SE, Spherical equivalant; CCT, Central corneal thickness; IOP, Intra ocular pressure; EDSS, Expanded disability status scale; IQR, interquartile range; NA, not applicable; *One-way analyses of variance test followed by Tukey test; &chi-square test; ‡ Kruskal-Wallis test followed by Mann-Whitney test with Bonferroni adjustment. (P < 0.017 [equal to 0.05/3] is considered statistically significant.); # Mann-Whitney U test

Discussion Multiple sclerosis is a neurodegenerative, inflammatory, demyelinating, and progressive disease of the central nervous system. Although MS generally affects the brain and spinal nervous system, it can also cause ON in the eye. ON may be an early sign of MS. The loss of retina nerve fiber and axons occur due to neurodegeneration in MS [18]. OCT was used as a useful tool to quantify the neuronal damage in the eyes of MS patients [19]. To the best of our knowledge, the present study is one of the first to study to evaluate the LCD, and LCT in patients with MS. We found that the LCT was similar between MS and healthy control subjects. However, the LCD was significantly decreased in MS patients, particularly with the presence of ON. The lamina cribrosa is a mesh-like structure that supports the axons of retinal ganglion cells [20]. It has been reported that posterior displacement of lamina cribrosa precedes early loss of RNFL and structural damage [21,22]. Particularly in patients with glaucoma, lamina cribrosa depression occurs before RNFL loss [23]. Xu et al. demonstrated that the optic disc surface becomes depressed before RNFL thinning in glaucoma [23]. Kim et al. reported that the lamina cribrosa morphology may help to predict the disease outcome in suspected glaucoma [24]. Omadoka et al. reported that LCT was significantly thinner in patients with glaucoma [25]. In

the present study the LCT was similar between MS and control groups. We suggest that LCT is not affected as reported in previous studies on glaucomatous eyes. In glaucoma, the lamina cibrosa might be vulnerable to IOP changes resulting lamina cribrosa thinning compared to MS patients. In the pathogenesis of glaucoma, increased IOP cause RNFL damage, results with enlargement of the cup to disc ratio. LCD is a potential indicator of lamina cribrosa morphology, since it is well correlated with the magnitude of deformation of the posterior lamina cribrosa [26]. Similar to that of occurs in glaucoma, ON may cause axonal loss and lamina cribrosa changes. The nutrients and oxygen pass through the laminar collagenase matrix to the lamina cribrosa [10]. Any cause including increased IOP, ocular ischemia, and inflammation may damage retina ganglion cell axons via impeding the axoplasmic flow [9]. Thitiwichienlert et al. [10] suggested that both glaucomatous and non-glaucomatous optic neuropathic eyes had similar mechanism of the loss of retinal ganglion cell axons. However, in the present study, the LCD was significantly lower in patients with MS. In contrast to glaucomatous optic neuropathy, in the present study, normal IOP measurements in MS patients, may be one of the cause of the lower LCD values. Secondly, since MS is a demyelinating inflammatory disorder, glial cell proliferation, and the composition of inflammatory 870

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infiltrates of the optic nerve may mask the increase in LCD of MS patients [27]. In an experimental study, Ueda et al. reported that oligodendrocytes contribute remyelinization of the optic nerve even with the absence of viable retinal ganglion axons [28]. Moreover, various optic disc morphologies including cup to disc ratio, total optic disc diameter may also affect the LCD measurements [29]. Previous studies demonstrated that RNFL thickness was decreased in patients with MS [30,31]. We also found significant thinning in the RNFL thickness in MS patients. The thinning of the RNFL is more evident in MS patients with ON, but also determined in MS patients without ON history. Even in the absence of an optic neuritis episode /history in MS, RNFL loss can be observed [32]. An increase in the EDSS score shows the progression of MS. Saidha et al. reported that EDSS score is correlated with RNFL and retina ganglion cell inner layer complex in MS patients [33]. In the present study we found a mild negative correlation between LCD and EDSS score in MS patients. Since the population in our study is relatively small, the use of LCD as a prognostic factor for MS needs further studies with larger sample. The present study has some limitations. First the number of patients are relatively low to make a definitive conclusion. Second, the lack of longitudinal follow up is the other weakness. Third, the lack of optic nerve head morphology parameters may also affect the results. The last, identifying the deeper border of the lamina cribrosa was relatively subjective, since the the contrast of the signals in deeper tissue is lower even with use of EDI-OCT. Conclusion In conclusion, our study showed that the LCD was decreased in MS patients with or without ON compared to healthy controls. Moreover, the LCD was mildly correlated with EDSS score in MS patients. EDI-OCT is a useful tool for documenting structural alterations of lamina cribrosa in MS patients. Further prospective, extensive, longitudinal studies with a larger sample size are warranted to define association between MS and the lamina cribrosa morphology. Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):873-7

The importance of ICD-10 applications on daily practice Leyla Serinoglu1, Onur Yarar2, Can Mehmet Eti3, Tugce Puturgeli3, Yusuf Vayisoglu3, Mehmet Farsak4, Ece Sevin Cukurova4, Cemnur Tancil4, Emine Arzu Kanik5, Derya Umit Talas3 Mersin University Medical Faculty, Hospital Information Technology Department, Mersin, Turkey Okan University Faculty of Health Sciences Department of Health Administration, İstanbul, Turkey 3 Mersin University Faculty of Medicine Department of Otorhinolaryngologic Diseases, Mersin, Turkey 4 Mersin University Faculty of Medicine Mersin, Turkey 5 Mersin University Medical Faculty, Department of Biostatistics and Medical Informatics, Mersin, Turkey 1

Received 12 March 2018; Accepted 18 June 2018 Available online 22.07.2018 with doi: 10.5455/medscience.2018.07.8843 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract This study assessed the adequacy of patient data entry in the context of International Statistical Classification of Diseases and Related Health Problems (ICD-10) in the Hospital Information Administration System. It was also aimed to study the adequacy and functionality of the ICD-10 coding in the current Turkish Otorhinolaryngology (ORL) practice in detail. The medical records of 1216 patients who presented to the ORL outpatient clinic between 2012 and 2013 were reviewed. Eight diagnostic codes used by the ORL department were selected from the patient diagnoses report to form patient lists. The accessibility of the ICD-10 codes was analyzed. The data was transferred into the MEdCalc 12.0 software package in a digital medium. The study data was analyzed using frequency tables, Chi-square test, and the two sided likelihood ratio test. Among the ICD-10 codes included in the study, the larynx malignant neoplasm diagnosis (C32.9) was recorded at a rate of 60% and had the greatest ratio of recorded medical history, followed by malignant disorders (C32.3) of the laryngeal cartilage, vertigo (R42) (12.4%) whereas facial asymmetry (Q67.0) (10.5%) had the lowest recorded medical history ratios. There was a significant difference between the recorded and unrecorded patient groups (p<0,0001). Hospital Information Administration Systems are needed to be effective and efficient in order to have appropriate future decisions in healthcare system. The ICD codes should be updated frequently according to the recent necessities and physicians should be trained about new developments. Keywords: Otorhinolaryngology, ICD-10, hospital information administration system, medical records

Introduction One needs to classify and code data incorporating administrative and clinical processes in the field of healthcare in order to transform them into information and to conduct quantitative studies [1]. Classification refers to listing similar diseases and procedures into a unified group while coding refers to the process of expressing diseases, injuries, and procedures in a numerical or α numerical pattern [1]. Among many coding and classification systems used in healthcare, ICD-10 is the most commonly preferred one for clinical diagnosis and training [2]. ICD-10 (International Statistical Classification of Diseases and Related Health Problems) is defined as an International Statistical Classification of Diseases and Health-related Problems, and also as a system of categories [3]. The purpose of ICD is to systematically record, evaluate, interpret, and compare morbidity and mortality data gathered from different countries or regions at different times [4]. *Coresponding Author: Leyla Serinoglu, Mersin University Medical Faculty, Hospital Information Technology Department, Mersin, Turkey. E-mail: leyla_serinoglu@yahoo.com

The need for using computers in human healthcare has arisen from the need of making the right diagnosis at the right time, providing healthcare service, and recording accurate patient information. Hospital Information Administration Systems gather information from different sources and integrate them to help the clinicians and administrative stuff to reach the most appropriate, accurate decision [1]. This system is also an important source to reach statistical data. In the present study, the adequacy of patient data entry in the context of ICD-10 in the Hospital Information Administration System was examined. The effectiveness and efficiency of the Hospital Information Administration System with respect to person-based and system-based defects were also analyzed. Lastly, it was aimed to elucidate the adequacy and functionality of the ICD-10 coding system in the current Turkish Otorhinolaryngology (ORL) practice. Materials and Methods This study reviewed the medical records of 1216 patients presenting to the ORL outpatient clinic of Mersin University Health Research 873

doi: 10.5455/medscience.2018.07.8843

and Application Center. A retrospective screening was performed to encompass a time period between 1stApril 2012 and 1stApril 2013. A total of 8 different disease codes were selected from the otology, neurotology, rhinology, neck and head branches, which were the most commonly encountered conditions at the ORL clinic deemed of special importance with respect to mortality, morbidity, and patient follow-up. The data were transferred to the “MedCalc 12.0” software package in a digital medium. The data were analyzed using frequency tables, Chi-square test, and twosided likelihood ratio test. Eight diagnostic codes used in the ORL department were selected from the patient diagnoses report of the Hospital Information Administration System to form patient lists (Table 1). Table 1. Diagnosis codes involved in the research DIAGNOSIS CODE

DIAGNOSIS

R42

Vertigo

Q67.0

Facial asymmetry

C32.3

Malignant neoplasm of the laryngeal cartilage

C32.9

Malignant neoplasm of the larynx

J33.9

Nasal polyps

D10.6

Benign neoplasm of the nasopharynx

D34

Benign neoplasm of the thyroid gland

C73

Malign neoplasm of the thyroid gland

The effectiveness of medical reporting of ICD-10 applications on the system and the adequacy of patient data entry were analyzed. In the medical information menu, patient files were examined to check past medical and family histories on the medical history screens to draw attention to the clinical importance of medical records. Eight diagnoses were compared with one another in terms of the studied parameters. •The ability of the ORL clinic to access ICD-10 diagnoses was analyzed. •It was examined how efficient the Hospital Information Administration System can be used; person- and system-related defects were also assessed. Results

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Qualitative results The names of the diagnoses that can’t be found for the ORL department in the ICD-10 diagnostic list of the Hospital Information Administration System were shown on Table 3. These diagnoses are also widely accepted terms and diagnoses in the international and national literature and in daily practice; however, they could not be found as widely known in ICD-10 coding list. For instance, although facial paralysis is frequently used in daily ORL practice, it is referred to as facial asymmetry in ICD-10 list, and used accordingly. Table 2. Percentage of taking medical history (by diagnosis) DIAGNOSIS CODE

DIAGNOSIS

MEDICAL HISTORY TAKEN

MEDICAL HISTORY NOT TAKEN

R42

Vertigo

75 (12,4%)

531 (87,6%)

Q67.0

Facial asymmetry

4 (10,5%)

34 (89,5%)

C32.3

Malignant neoplasm of the laryngeal cartilage

7 (38,9%)

11 (61,1%)

C32.9

Malignant neoplasm of 87 (60%) the larynx

58 (40%)

J33.9

Nasal polyps

34 (20%)

136 (80%)

D10.6

Benign neoplasm of nasopharynx

9 (19,1%)

38 (80,9%)

D34

Benign neoplasm of the thyroid gland

21 (14,7%)

122 (85,3%)

C73

Malignant neoplasm of the thyroid gland

11 (22,4%)

38 (77,6%)

Table 3. Diagnoses that are not included in the ICD-10 Facial Paralysis Glomus Tumor Cerebellopontine Angle (CPA) Tumor, Posterior Fossa Tumor, Acoustic Neuroma, Vestibular schwannoma Angiofibroma Endolymphatic Hydrops Inverted Papilloma

Quantitative results On the medical history screen, assessment of the past medical and family history panels showed that 20.4% of the patient histories were recorded whereas 79.6% of them were not. Two hundred and forty-eight patients had their history recorded whereas 968 patients had not. There was a significant difference between the patient groups with and without a recorded medical history (p<0,0001). According to eight ICD-10 codes included in the study conducted in the ORL clinic, the percentages of the recorded patient medical histories were given on Table 2.

A review of the ICD-10 diagnostic coding system in the Hospital Information Administration System revealed that some diagnoses in the ORL chapter were translated to Turkish (Table 4).

Among the ICD-10 codes included in the study, C32.9 Larynx malignant neoplasm diagnosis was recorded at a percentage of 60% and had the greatest ratio of having a recorded medical history. Facial asymmetry (Q67.0) diagnosis was recorded at a percentage of 10.5% and had the lowest ratio of having a recorded medical history.

When an attempt was made to match the ICD-10 list in the Hospital Information Administration System with the DRG (Diagnosis Related Groups) Program, defects related to definition were found on the screen. The different spellings of the diagnoses found in the ICD-10 list in the Hospital Information Administration System and the DRG screen are presented below (Table 5).

Table 4. Diagnoses spelled in Turkish in ICD-10 list Diagnoses in Turkish

Original spelling

Meniyer Disease

Meniere

Vestibüler Neuronit

Neuritis / Neurinitis

874

doi: 10.5455/medscience.2018.07.8843 Table 5. Comparison of the two diagnoses between the Hospital Information Administration System and the DRG system Hospital Information Administration System

DRG system

Meniyer Disease

Meniere Disease

Vestibüler Neuronit

Vestibüler Neuronit Neuritis

The assessment of the effectiveness and efficiency of the Hospital Information Administration System showed the followings • There was a variety of defects such as slow startup of the Hospital Information Administration System program, network failures (disconnection from network, Switch failures…), system crashes, keyboard failure, slowed system etc. • There was no on-screen warnings or screen encolouring for contagious diseases with high mortality and morbidity. For example, HIV (Human Immunodeficiency Virus). • No button existed on the system by which pathologists could indicate a malignant pathological examination result as the definitive diagnosis on the system, and such a button did not appear on physician procedures screen, either. • Having too many definitions like provisional diagnosis, primary diagnosis, definitive diagnosis, and main diagnosis on the diagnosis entry screen created complexity and confusion. • No information regarding blood group and nationality existed on patient diagnosis’s report. • Patient diagnoses report did not contain patients consulted with other departments. Discussion Hospital Information Management System Effective and efficient use of the Hospital Information Management System is important for administrative, financial, and medical purposes. Inability to obtain an accurate information from patient diagnosis report and the absence of consulted patients on the system will reduce quality and reliability of statistical data. Hence, information about blood group and nationality should be presented in order to conduct studies on the relationship between various disorders and blood groups. It was ascertained that information about past medical history and family history constitute 20% of patient medical records. Therefore, this percentage supports the notion that the necessity and importance of keeping electronic health records have not been appreciated. Filling history screens completely is necessary as it influences both daily practice and future decisions about healthcare. In a European study, medical data was found to have a high quality [5]. An analysis of the inspected patient files to select the diagnosis for which medical history was most commonly recorded showed that it was 60% for the malignant neoplasm of larynx, which can be an indicator of a special interest in recording medical history of specific diagnosis. Hence, being familiar with and questioning about it is necessary. In hospital information management system, it is important for pathologists to have a button on the screen to mark when the result is malignant and for physicians to be able to see it automatically from the physician procedures screen. As for contagious diseases,

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having an on-screen alert or screen encolouring for physician notification is necessary for carefully performing computer tasks. Screen complexity on diagnosis entry screen should also be prevented. The use of the latest updated version of the ICD-10-AM Australian Modification for the DRG system and the non-updated ICD-10 lists for the Hospital Information Administration System is flawed by some inconsistencies and defects. For example, the Meniere’s disease was included in the ICD-10 list of the Hospital Information Administration System in its Turkish spelling “Meniyer” but it appears in its original spelling on the screens of the DRG system, indicating translation errors. The word with an original spelling of Neuritis/Neurinitis appears as Neuronitis in the ICD-10 list of the Hospital Information Administration System. In the DRG system, on the other hand, it appears that the words neuronitis and neuritis are used collectively. This creates defects in matching stage of medical billing procedures. It is also important as an example of the complex situation with the translational errors. The use of different spellings by various coding systems used in Turkey for a given disease and syndrome is confusing and far from standardization. Coding should be specific for each clinic and be definitely standardized. An analysis revealed that 80 or more patients present daily to the ORL clinic. The number of residents was found to be insufficient creating a time constraint. Considering the busy triangle of outpatient clinic, inpatient clinic and operating room, patient medical histories were not paid enough attention. Patient medical histories, clinical course, medical reports, prescription, epicrisis, operative notes, patient orders, and ICD codes lay a burden on physicians and make them spend much of their time at the desk, underlying the necessity of medical secretaries. Moreover, lack of training is also troubling. It is of utmost importance that Hospital Information Administration System training provided by the Information Processing Unit be updated frequently. Computers in inpatient and outpatient clinics of hospitals should be able to remain open for long working hours and have an ample disc capacity, memory capacity, and processor speed. ICD ICD-1 has been updated every 10 years for over 90 years to ultimately be transformed to what is known as ICD-10 in 1999. Retrospective analyses and studies, however, indicated that diseases seen in normal routine practice and symptoms do not match perfectly and thus constant updates are required. Although Facial Paralysis of the Facial nerve has been used routinely on a daily basis, it appeared here as Facial Asymmetry and Bell’s Paralysis. Bell’s Paralysis is a subgroup of Facial Paralysis. Facial Paralysis is a broader and encompassing term and thus should be used. Coding a disease using the closest relevant code sometimes precludes the determination of the exact number of cases with specific diseases worldwide [6]. Hence, it is an important issue that must be addressed. In some countries like Australia, Canada, Germany, and Thailand 875

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some additional complementary studies have been conducted by healthcare professionals on country-specific epidemiological data and complications, and some necessary modifications have been made on ICD-10. We are of the opinion that conducting such studies by various departments and Professional observations would also be beneficial for our country [7]. Some internationally and nationally accepted common diagnostic codes like vestibular schwannoma do not appear in the Hospital Information Administration System, ICD-10 list, and World Health Organization’s list. There is an international standard classification system. However, when assessing the international validity and applicability of this system, an update of diagnosis by every clinic and department is necessary [8]. A specific code for a disease like essential tremor is absent in ICD-9 but added to ICD-10, and it is questionable for clinical coders, also indicating the need for updates [9]. According to several studies, transition from ICD-9 to ICD-10 involves serious costs. There is a significant numerical difference with respect to both diagnostic and procedural codes. Addition of new diagnostic codes and increasing the number of interventional codes are necessary for billing. Although it has gained acceptance by international healthcare institutions, and studies have been performed with limited data, researchers opine that little advance has taken place. Higher healthcare expenditures per capita in the USA show that in addition to healthcare service provided to patients, medical billing processes are important [10,11]. Having said that, the requirement of updating the codes at regular intervals is necessary for both patients and epidemiological studies. There are publications reporting that certain parts of the coding system are much more detailed and precise. A European study on ICD-10 coding of “injuries”, i.e. tissue damage, showed that sites of “injuries” were much more accurately coded in Hungary, Iceland, and Lithuania than the other European countries. Hence, coding quality is variable among persons performing institutional coding, clinical coding, and even between coders in different countries, and it actually requires a good training [5]. Several studies have indicated that a person with a thorough knowledge of the coding system may conceive much more details of it and thus may more objectively reach a diagnosis [12]. It has been asserted that it would be more useful to organize ICD-10 as a more general and larger database (meta-database) in order to compare different versions of it in various countries. The rationale of this is a particular increase in health tourism and tourism health worldwide [13]. A study from Sweden investigated the requirements to form a disease database of electronic patient records and showed a deficiency of tools facilitating coding in addition to lack of training in establishing a valid and reliable database, classification of diseases, and coding process [14]. Incorrect coding results in serious clinical and administrative, billing and purchasing errors. Additionally, coding errors about hospital complications are said to have diverse effects, especially on the clinical performance of a given hospital [15]. In a study conducted by Dixon et al in the UK, it was noted that the concordance between coding’s performed by two different groups

Med Science 2018;7(4):873-7

coming from other institutes was poorly understood when used by a third person or group for different symptoms or disorders. Particularly, the necessity of providing serious training about coding has been emphasized [16]. It has been recommended that particularly inexperienced persons must pay time and attention to coding in order to enhance their coding quality. It is equally important for the person performing coding to consult the physician and avoid abbreviations [17]. Studies from different clinics have shown that different persons may perform variable coding under normal conditions. Variations in coding certainly affect patient follow-up and future prospective studies [18]. Code users should determine ICD’s applicability and limitations in their own specific areas while coding. The use of ICD mortality and morbidity data provide benefits for statistical purposes; thus, ICD use is very relevant to health policies and healthcare finance [2]. Data from the relevant literature point to such coding errors and deficiencies. Coding errors constitute an objective issue overemphasized in international literature [17]. A study from Japan revealed coding errors at a rate of approximately 10% [19]. Diagnostic coding may not necessarily specify the main subject or a patient’s problem requiring treatment at the time of admission. It not only hardly specifies a disorder’s basic cause, but may also differ significantly from an issue for which a physician or healthcare institution should take longest time. It is a serious issue for outpatients [20]. Some unclassified or graphically expressed lesions are used by the physician in noted, written or signed forms. Hence, it may prove difficult to recall that form and to analyze it statistically for a large number of cases. In this context, it is necessary that every progressing prospective coding system incorporates such features. Using electronic health records is important for patients, physicians, and epidemiological studies [21]. Conclusion Hospital Information Management Systems should be effective, efficient, and user-friendly. The importance of taking a complete patient history was demonstrated since it affects both daily practice and future decision making. The lack of a specific code for every diagnosis in ICD-10 forces physicians to code for a similar or general diagnosis instead of the true diagnosis, which leads to the misuse of ICD-10. A common international and national language should be established. ICD updates should be done at frequent intervals to obtain quality statistical data and to ensure an appropriate and effective use of ICD. Physicians should be trained about new developments in ICD. Given the extra workload of physicians, the need for medical secretaries is also evident. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Ethics Committee approval was obtained Okan University (Date: 02.01.2014, Number: 02.01.2014-24).

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O’Malley KJ, Cook KF, Price MD, et al. Measuring Diagnoses: ICD Code Accuracy. Health Serv Res. 2005; 40(5 Pt 2):1620-39.

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13. Jetté N, Quan H, Hemmelgarn B, et al. The development, evolution, and modifications of ICD-10: challenges to the international comparability of morbidity data. Med Care. 2010;48:1105-10.

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Suárez-García I, Sethi D, Hutchings A. Mortality due to injuries by place of occurrence in the European region: analysis of data quality in the WHO mortality database. Inj Prev. 2009;15:275-7.

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Johnston ID, Bleasdale C, Hind CR, et al. Accuracy of diagnostic coding of hospital admissions for cryptogenic fibrosing alveolitis. Thorax. 1991;46:58991.

Nitsuwat S, Paoin W. Development of ICD-10-TM ontology for a semiautomated morbidity coding system in Thailand. Methods Inf Med. 2012;51:519-28.

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15. Pine M, Fry DE, Jones B, et al. Screening algorithms to assess the accuracy of present-on-admission coding. Perspect Health Inf Manag. 2009;6:2. 16. Dixon J, Sanderson C, Elliott P, et al. Assessment of the reproducibility of clinical coding in routinely collected hospital activity data: a study in two hospitals. J Public Health Med. 1998;20:63-9. 17. Farzandipour M, Sheikhtaheri A. Evaluation of factors influencing accuracy of principal procedure coding based on ICD-9-CM: an Iranian Study. Perspect Health Inf Manag. 2009;7:6:5. 18. Misset B, Nakache D, Vesin A, et al. Reliability of diagnostic coding in intensive care patients. Crit Care. 2008;12: R95. 19. Tanihara S. The proportion of uncoded diagnoses in computerized health insurance claims in Japan in May 2010 according to ICD-10 disease categories. J Epidemiol. 2014;24(5):392-6. 20. Katz A, Halas G, Dillon M, et al. Describing the content of primary care: limitations of canadian billing data. BMC Family Practice 2012;13:7. 21.

Afzal Z, Engelkes M, Verhamme KM, et al. Automatic generation of casedetection algorithms to identify children with asthma from large electronic health record databases. Pharmacoepidemiol Drug Saf. 2013;22: 826-33.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):878-81

A new approach in laparoscopic repair of inguinal and femoral hernias Kenan Buyukasik, Aziz Ari Istanbul Training and Research Hospital, Department of General Surgery, Istanbul Turkey Received 06 March 2018; Accepted 20 July 2018 Available online 08.10.2018 with doi: 10.5455/medscience.2018.07.8892 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract The aim of this study to analyze results of a new method which eliminates complications associated with the classic mesh fixation areas and does not increase recurrence rates. This prospective study included a total of 70 patients applied with inguinal or femoral hernia repair with the laparoscopic TEP method. The patients were randomly separated into two groups as Group 1 applied with tack fixation and Group 2 applied with plug mesh and subcutaneous vicryl fixation. The groups were followed up and compared. The group applied with the newly-developed repair technique of plug mesh and vicryl fixation were observed to have a shorter length of stay in hospital, a lower requirement for postoperative analgesia, and reduced urinary retention and seroma rates. No difference was determined between the two groups in respect of operating time and return to normal activities. In the 24-month follow-up period, there was no significant difference in respect of hernia recurrence. The results of the study showed that the use of the newly-developed repair technique of plug mesh and vicryl fixation in laparoscopic TEP inguinal hernia repair increased the life quality after surgery. There are also cost advantages. This is a technique that can be selected for suitable patients. Keywords: Hernia, plug, fixation, TEP, laparoscopic, pain

Introduction Inguinal hernia repair is one of the most frequently applied operations in general surgery practice. Due to reduced recurrence rates, tension-free hernia repairs made with mesh are preferred. Since laparoscopic hernia repairs were first introduced by Dulucq in 1992, these have tended to be more popular than open repairs because of various advantages [1]. Currently, approximately 20% of all inguinal hernia repairs are made with a laparoscopic approach. The most preferred method is total extra peritoneal patch plasty (TEP). Although there are some advantages specific to transabdominal pre-peritoneal patch plasty (TAPP) repair, complications such as intra-abdominal organ injury have a more severe course. This study was based on our previous study in which the TAPP approach was evaluated but in this new study, the TEP approach was selected [2]. In classic TEP inguinal hernia repair, the potential hernia development area is covered with mesh and the mesh is generally fixed to the abdominal wall with spiral tacks. Although mesh fixation is controversial, it has reduced recurrence rates [3]. However, fixation with tacks can cause the development of some complications such as nerve Coresponding Author: Kenan Buyukasik, Department of General Surgery, Istanbul Training and Research Hospital Istanbul, Turkey E-mail: op_dr_kenan@hotmail.com

damage and chronic pain. The femoral branch of the genitofemoral nerve and the lateral femoral cutaneous nerve have been reported to be damaged at the rate of 2%-4% in laparoscopic hernia repair [4]. In the light of the previous study, the aim of this study was to reduce the complication rates by eliminating mesh fixation with tacks in the pre-peritoneal area with a novel method of subcutaneous fixation of the mesh and to reduce recurrence rates [2]. Materials and Methods Approval for this prospective, randomized study conducted between 2013 and 2015 was granted by the Local Ethics Committee of S.B. Istanbul Training and Research Hospital. The study included 35 male patients aged 18-80 years, who were diagnosed with inguinal or femoral hernia and had an American Society of Anesthesiologists (ASA) score of 1-2. Patients were excluded if they had contra-indications to general anesthesia, drug or alcohol dependence, coagulopathy, or a history of hernia surgery. The 70 patients were randomly separated into 2 groups according to preoperative body mass index (BMI) and age as Group 1 who were applied with classic tack mesh fixation and Group 2 who were applied with plug mesh subcutaneous vicryl fixation. The procedure was performed by a single surgeon experienced 878

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in laparoscopic TEP. The data were collected in a double-blind manner with no knowledge of the groups. Surgical technique The TEP laparoscopic inguinal hernia repair was applied under general anesthesia with the patient in a mild Trendelenburg position. A Foley catheter was placed in position before the procedure and prophylactic antibiotics were administered at the incision stage. A 1-cm infra-umbilical skin incision was made then an incision to the anterior fascia of the rectus sheath. With lateral retraction of the rectus muscle, the area was exposed between the rectus muscle and the posterior fascia of the rectus sheath. A 10-mm trocar was inserted and the pre-peritoneal space was insufflated with CO2 to a pressure of 12 mmHg. Using a 0˚ video telescope, the preperitoneal space was dissected as far as the space of Retzius, then two 5-mm trocars were inserted on the midline, one just above the pubic symphysis and the other midway between the lower port and the camera port. Following the dissection and reduction of the peritoneal sac, a 10 x 15 cm polypropylene mesh (Prolenepolypropylene mesh, Ethicon) was inserted and spread to cover the myopectineal orifice. At this stage, one of two identical sealed envelopes was selected by one of the surgical team. One envelope contained a paper on which ‘‘tack fixation’’ was written and the other had a paper stating “plug mesh subcutaneous fixation”. In the classic tack mesh fixation group (Group 1), the mesh was fixed to the Cooper’s ligament and the anterior abdominal wall using 4-7 metal, spiral tacks (Covidien ProTackTM Tyco Autosuture 5 mm stapler). In the plug mesh subcutaneous fixation group (Group 2), a polyprolene mesh 15 x 15 cm in size was cut in a T-shape 2.5 cm from the edge and the short sides were rolled round into a cigar shape to form a plug. A third of the plug side of the mesh was folded over itself and fixed to itself with a vicryl suture. Thus, a 10 x 15 cm mesh was obtained which was folded over itself as a plug in the posterior third (Figure 1). The tip of the plug was fixed by gently drawing the vicryl suture together and this suture was left long to be pulled below the skin.

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a conventional laparoscopic instrument, the vicryl suture left long at the top of the plug was carefully advanced subcutaneously from the hernia defect in the pre-peritoneal area and taken outside the skin with a 1-2 mm cut applied to the skin. Thus, by sliding the plug within the defect, the mesh was spread to the pre-peritoneal area in such a way as to cover the mycopectineal orifice. The vicryl suture taken outside was fixed subcutaneously. Perioperative evaluation The preoperative level of pain of the patients was determined using the Numeric Rating Scale (0= no pain, 10= severe pain). During the operation, the degree of difficulty of the procedure was graded (0=not difficult, 1=slightly difficult, 2= very difficult). A record was made for each patient of the pain level, requirement for analgesia, development of complications, time to discharge from hospital, and time to return to work. After discharge from hospital, the patients were called for follow-up examinations at 7 days, then at 1, 6 and 24 months and were evaluated in respect of hematoma, seroma, orchitis, and findings of mesh infection, pain and recurrence. Statistical analysis Analysis of the study data was performed using SPSS Statistics software version 22.0. Conformity of the variables to normal distribution was assessed using the Kolmogorov–Smirnov test. The Independent Samples t test was applied for the analysis of quantitative data. Where appropriate, the Chi-square test was used for the analysis of qualitative data, otherwise the Fisher’s Exact test was applied. A value of p<0.05 was considered statistically significant. All p values were two-sided. In respect of sample size, the number of cases included (70) was determined to have 100% power in respect of postoperative pain score and 80% power in respect of urinary retention and seroma development. Results The demographic characteristics of the patients are summarized in Table 1. Table 1. Demographic characteristics of the patients

Age (years) BMI Hernia type Indirect Direct Femoral ASA 1 2

Group 1 N:35

Group2 N:35

42.5±2.0 28.0±2.8

43.6±1.5 28.3±2.8

17 17 1

15 19 1

32 3

31 4

P value

0.097 0.65 0.75 0.85 0.99 0.99 0.89

No complications were observed intraoperatively. All the patients were discharged on postoperative Day 1. Figure 1. The plug mesh subcutaneous fixation (AC 2.5 cm, CB 10cm, AD 15cm)

By adjusting this prepared mesh plug from the camera port according to the medial lateral co-ordination of the placement of the defect, it was placed in the pre-peritoneal area. With the aid of

Higher pain levels were observed in the first hour postoperatively in the Group 1 patients (Table 2) but the difference between the groups was not statistically significant. Patients in Group 2 had a statistically significantly lower requirement for analgesia in the first postoperative hour compared to patients in Group 1. The 879

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length of stay in hospital was shorter in Group 2 than in Group 1 (p=0.001). Urinary retention was seen in 7 (2.45%) patients in Group 1 and in 1 (0.35%) patient in Group 2 and the difference was statistically significant (p=0.001). There was no statistically significant difference between the groups in respect of the difficulty of the operation or of the time to return to work. In the longterm follow-up, there was no nerve damage or recurrence in any patient. Complaints of a moderate degree of pain were reported by 3 patients in Group 1. In the early postoperative follow-up period, seroma was observed in 7 (2.45%) patients in Group 1 and in 0 patients in Group 2, and the difference was statistically significant. Table 2. Postoperative findings Group 1 n:35

Group 2 n:35

P value

Operating time (mins)

60.2±12.4

58.4±16.5

0.65

Length of stay (days)

16.0±10.5

9.1±5.2

0.001

0.9±2.3

0.5±1.9

0.45

Postop analgesia

4.50±1.08

2.37±1.0

0.03

Urinary retention

0.001

Degree of difficulty of operation Difficult Moderately difficult Not difficult

4 8 23

5 7 23

Postoperative early stage (7th day) Hematoma Seroma Orchitis Infection

0 7 0 0

0 0 1 0

Pain (0-10) Preop

0.001 0.88

Discussion In laparoscopic TEP inguinal hernia repair, the necessity for fixation of the mesh to the pre-peritoneal area with tacks to prevent recurrence is controversial. Several experts have concerns that the mesh could migrate if not fixed and could cause recurrence. In several randomized, prospective, controlled studies, mesh fixation has been compared with non-fixed repair and research is ongoing for the best method of mesh fixation. The traditional fixation of mesh with tacks can prevent movement and recurrence [5,6]. However, it can also increase both costs and chronic pain in particular [7-10]. Khajanchee et al reported an increase in neuropathic complications in a series of 172 cases applied with laparoscopic inguinal hernia repair with mesh fixation [11]. Just as there are reports stating that not fixing the mesh does not increase recurrence rates some specific studies have emphasized the need for mesh fixation [12-15]. Lau and Patil reported an increase in recurrence rates in cases applied with repair without mesh fixation, especially in those with large defects. 16 In an extensive series of 686 cases, Dehal et al reported a higher rate of recurrence in the cases not applied with mesh fixation compared with literature [13]. With the newly-developed technique that is presented here, it was aimed to eliminate complications associated with mesh fixation with tacks and to reduce the recurrence rate by making the fixation in a safer location. Moreover, urinary retention, which can develop associated with mesh fixation with tacks, was not observed with this method in this study. The reason for this could be related to the lower level of postoperative pain and the reduced requirement for narcotic agents. In a study by Lau and Patil, the level of postoperative pain was found to be significantly higher in the

Med Science 2018;7(4):878-81

group applied with mesh fixation compared to those where fixation was not applied (p< 0.05) [16]. Taylor et al found the pain scores to be extremely high in patients applied with mesh fixation. An interesting point of that study was that in cases where the fixation was made with more than 6 tacks, the pain scores were measured at a significantly higher level [17]. In the current study, the postoperative pain levels of the patients in Group 2 who were applied with tacks to the pre-peritoneal area were determined to be statistically significantly lower. Koch et al reported that the postoperative use of narcotic agents was a risk factor for the development of urinary retention [18]. In a series of 1220 cases, the rate of seroma development was reported as 0.52%-37.8% and urinary retention as 0.38%-8.3% [19]. Mulroy reported that urinary retention was increased associated with the increased sympathetic stimulus of postoperative pain [20]. In the novel method used in the current study, the patients had a reduced need for narcotic agents. In some studies, the development of seroma has been seen to be a frequently encountered problem related to laparoscopic hernia repair and can be perceived by the patients as a recurrence of the hernia [21]. In the current study, although seroma developed in 7 patients in Group 1, it did not develop in any of the Group 2 patients. In this respect, the recommended new technique was seen to be of benefit. Conclusion No cost analysis was made in the current study. However, the elimination of tacks in mesh fixation is seen to be a factor in costs. Previous studies have reported that fixation of the mesh with tacks increased the cost of the operation from 120 USD to 375 USD [22]. In laparoscopic TEP hernia repair, some complications can develop associated with fixation of the mesh to the pre-peritoneal area. In the method of plug mesh subcutaneous vicryl fixation, recommended in this study, there was seen to be a reduction in complication rates with no increase in recurrence rates. In selected patients, this method is safe and advantageous. Nevertheless, there is a need for further studies with analyses of larger series and subgroups. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Approval for this prospective, randomized study conducted between 2013 and 2015 was granted by the Local Ethics Committee of S.B. Istanbul Training and Research Hospital.

Referance 1.

Dulucq JL. Treatment of inguinal hernia by insertion of a subperitoneal patch under pre-peritoneoscopy. Chirurgie. 1992;118:83-5.

Büyükaşık K. A new method for the video laparoscopic repair of femoroinguinal hernias (Sakman Procedure). Thesis, Istanbul, 1996.

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Med Science 2018;7(4):878-81

Chowbey PK, Bandyopadhyay SK, Sharma A, et al. Recurrent hernia following endoscopic total extraperitoneal repair. J Laparoendosc Adv Surg Tech A. 2003;13:21-5.

13. Dehal A, Woodward B, Johna S, et al. Bilateral laparoscopic totally extraperitoneal repair without mesh fixation. JSLS. 2014;18:e2014.00297.

Lau H, Patil NG. Acut pain fallowing endoscopic totally extraperitoneal (TEP) inguinal hernioplasty: multivariate analysis of predictive factors. Surg Endosc. 2004;18:92-6.

14. Christoffersen MW, Brandt E, Helgstrand F, et al. Recurrence rate after absorbable tack fixation of mesh in laparoscopic incisional hernia repair. Br J Surg. 2015;102:541-7.

Schwab R, Schumacher O, Junge K. et al. Biomechanical analyses of mesh fixation in TAPP and TEP hernia repair. Surg Endosc. 2008;22:731-8.

15. Schwab R, Schumacher O, Junge K, et al. Biomechanical analyses of mesh fixation in TAPP and TEP hernia repair. Surg Endosc. 2008;22:731-8.

Deans GT, Wilson MS, Royston CM, et al. Recurrent inguinal hernia after laparoscopic repair: possible cause and prevention. Br J Surg. 1995;82:539-41.

16. 16. Lau H, Patil NG. Selective non-stapling of mesh during unilateral endoscopic total extraperitoneal inguinal hernioplasty: a casecontrol study. Arch Surg. 2003;138:1352-5.

Beattie GC, Rumar S, Nixon SJ. Laparoscopic total extraperitoneal hernia repair: mesh fixation is unnecessary. J Laparoendosc Adv Surg. 2000;10:71-3.

17. 17. Taylor C, Layani L, Liew V, et al. Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomized clinical trial. Surg Endosc. 2008;22:757-62.

Poobalan AS, Bruce J, Smith WC, et al. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain. 2003;19:48-54.

Kaul A, Hutfless S, Le H, et al. Staple versus fibrin gluefixation in laparoscopic total extraperitoneal repair of inguinal hernia: a systematic review and meta-analysis. Surg Endosc. 2012;26:126978.

18. Koch CA, Grinberg GG, Farley DR. Incidence and risk factors for urinary retention after endoscopic hernia repair. Am J Surg. 2006;191:381-5. 19. Ismail M, Garg P. Laparoscopic inguinal total extraperitoneal hernia repair under spinal anesthesia without mesh fixation in 1220 hernia repairs. Hernia. 2008;13:115-9.

10. Schwab R, Willms A, Kroger A, et al. Less chronic pain following mesh fixation using a fibrin sealant in TEP inguinal hernia repair. Hernia. 2006;10:272-7.

20. Mulroy MF. Hernia surgery, anesthetic technique, and urinary retention-apples, oranges, and kumquats? Reg Anesth Pain Med. 2002;27:587-9.

11. Khajanchee YS, Urbach DR, Swanstrom LL, et al. Outcomes of laparoscopic herniorrhaphy without fixation of mesh to the abdominal wall. Surg Endosc. 2001;15:1102-7.

21. Lau H. Fibrin sealant versus mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty: a randomized prospective trial. Ann Surg. 2005;242:670-5.

12. Li JW, Zheng MH, Li HQ, et al. A randomized controlled clinical trial comparing stapling with non-stapling of mesh in laparoscopic total extraperitoneal inguinal hernioplasty. Chin J Gen Surg. 2007;22:4402.

22. Ferzli GS, Frezza EE, Pecoraro AM Jr, et al. Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair. J Am Coll Surg. 1999;188:461-5.

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Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):882-5

Prevalence of celiac disease in children with type 1 diabetes mellitus and the accuracy of serological tests Hulya Ozdemir1, Tufan Kutlu2, Mehmet Ozdemir3, Pinar Isguven4, Tulay Erkan2, Figen Cullu Cokugras2, Sergulen Dervisoglu5 1 Marmara University Pendik Training and Research Hospital, Department of Pediatrics, Division of Neonatology, Istanbul, Turkey Istanbul University Cerrahpaşa Faculty of Medicine, Department of Pediatrics, Pediatric Gastroenterology, Division of Hepatology and Nutrition, İstanbul, Turkey. 3 Goztepe Training and Research Hospital, Department of Pediatric Allergy, Istanbul, Turkey. 4 Sakarya University Faculty of Medicine, Department of Pediatric Endocrinology, Sakarya, Turkey 5 Istanbul University, Cerrahpasa Medical Faculty, Department of Pathology, Istanbul, Turkey

Received 30 April 2018; Accepted 30 June 2018 Available online 08.10.2018 with doi:10.5455/medscience.2018.07.8901 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract In children with type 1 diabetes mellitus (DM), prevalence of some autoimmune diseases like celiac disease (CD) has been increased. It is also reported that CD often can be asymptomatic and only serologically evident in patients with type 1 DM. In our study, we aimed to investigate the prevalence of asymptomatic CD and the specificity and sensitivity of anti-gliadin antibodies (AGA), anti-endomysium (EMA) and tissue transglutaminase (tTG) antibodies that used for diagnosis of CD in these patients. Anti-gliadin-IgA, AGA-IgG, EMA, tTG-IgA levels were evaluated. Small-intestine biopsies were applied to the children that parents were positive for at least one of AGA-IgA, AGA IgG, EMA and tTG-IgA. A total of 268 Type 1 DM children were included in the study. Of these sixty-four children who had at least one serological positive underwent small intestine biopsies and in five children (1.9%) CD was diagnosed. Anti-endomysium and tTG-IgA positivity were detected in all cases with Celiac disease, and sensitivity was 100% for both and 95% and 86% for specificity, respectively. The sensitivity and specificity of anti-endomysium and tTG-IgA antibodies were considered to be the most reliable indicator because of their higher specificity than other serological tests. Our results, which support current guidelines, suggest that children with Type 1 DM can be screened with tTG-IgA and EMA, which are the most sensitive and specific tests to detect asymptomatic CD in these patients. Keywords: Asymptomatic celiac disease, prevalence, type 1 diabetes mellitus

Introduction Type 1 diabetes mellitus (DM) is an autoimmune disease that occurs frequently in children and characterized by destruction of the pancreatic beta cells [1]. The incidences of the other autoimmune diseases are increased in children with type 1 (DM) and the best known among these is Celiac disease [2]. There is strong evidence indicating that the incidence of Celiac disease is increased in children with type 1DM [3,4]. The prevalence of coexistence of these two diseases has been reported to range between 0.6% and 16.4% in different studies [5]. Association of Celiac disease and type 1 DM based on autoimmune pathogenesis has been associated with common HLA DR3-DQ2/HLA DR/-DQ2 tissue antigens [6]. *Coresponding Author: Hulya Ozdemir , Marmara University Pendik Training and Research Hospital, Department of Pediatrics, Division of Neonatology, Istanbul, Turkey E-mail: hulyaakdenizozdemir@gmail.com

It has reported that typical gastrointestinal system findings including diarrhea and abdominal distention occur rarely and atypical findings including anemia, short stature and delayed puberty are observed more commonly in type 1 DM patients who develop Celiac disease. In addition, Celiac disease may be asymptomatic or latent in these patients and may be manifested with serologic markers [7,8]. Although tissue transglutaminase (tTG) IgA and anti-endomysial antibodies (EMA) among serological markers have been shown to be more reliable compared to anti-gliadin antibodies (AGA), it is known that there is no serological marker with 100% sensitivity and specificity [9]. Currently, guidelines recommend measurement of tTG-IgA or EMA levels for screening CD in type 1 DM patients [10,11]. In our study, we aimed to investigate the frequency of asymptomatic celiac disease in children with type 1 DM and the value of AGA, EMA and tTG-IgA that are used in the diagnosis of celiac disease as screening tests. 882

doi: 10.5455/medscience.2018.07.8901

Materials and Methods Patients who were diagnosed as having type 1 DM and were being followed up in Istanbul University, Cerrahpasa Medical Faculty, Department of Pediatrics, Division of Pediatric Endocrinology and Göztepe Education and Research Hospital, Division of Pediatric Endocrinology were included in the study. Before initiation of the study, it was retrospectively interrogated if the patients had been diagnosed as having Celiac disease and the patients who had been diagnosed as having Celiac disease were excluded from the study. Presence of the symptoms and signs suggesting Celiac disease, the time of onset of type 1 DM, degrees of metabolic control and longterm diabetes complications were recorded. The antigliadin-IgA, AGA-IgG, EMA, tTG-IgA and HbA1c levels of the patients who were included in the study were evaluated. Among serological markers, AGA-IgA and IgG were evaluated using the ELISA method (Lut Labmaster, Turku, Finland) (a value above 25 AU was considered positive for both markers), anti-endomysial antibodies were evaluated using indirect immunoflourescence method (Immun Diagnostics, AB, Uppsala, USA) (Test result +/-) and tTG-IgA was evaluated using the ELISA method (QUANTA Lite tTG, INOVA Diagnostics, Inc. San Diego, CA 92131) (>30 U positive). Small intestinal biopsy was performed in the children who had at least one positive marker among the markers AGAIgA, AGA IgG, EMA and tTG-IgA after obtaining informed consent from the families. Small intestinal biopsy was performed in Cerrahpaşa Medical Faculty, Department of Pediatrics, Division of Pediatric Gastroentorology using Olympus pediatric videoendoscopy device such that at least four biopsy samples were obtained from the second part of the duodenum. The diagnosis of Celiac disease was made in accordance with The European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria in the patients included in our study [2]. The biopsy samples were assessed in Istanbul University, Cerrahpaşa Medical Faculty, Department of Pathology and it was investigated if villus atrophy, crypt hyperplasia and increased intraepithelial lymphocytes were present. Statistical Analysis In this study, statistical analyses were performed using SPSS 10.0 (SPSS Inc, Chicago, IL) package program. In assessment of the data, independent t test was used for comparison of two groups and chi-square and Fisher exact tests were used for comparison of quantitative data in addition to descriptive statistical methods (mean, standard deviation). The results were evaluated at a significance level of p<0,05. Results A total of 268 children with type 1 DM that 138 female (51.5%) and 130 male (48.5%) were included in our study. Eleven of the patients had been newly diagnosed, while 257 had been diagnosed before and the mean age and the mean time of disease onset were found to be 12.0±4.3 and 7.6±3.7, respectively. The demographic features of all our patients are shown in Table 1. The serum AGA-IgA, AGA-IgG, EMA and tTG-IgA levels were evaluated in our type 1 diabetes patients for screening asymptomatic Celiac disease. Anti-gliadin-Ig A was found to be positive in 49 patients (17%), AGA-IgG was found to be positive in 21 patients (8%), EMA was found to be positive in 8 patients (3%) and tTG-IgA was found to be positive in 13 patients (Table 2). The serum IgA value was found to be within the normal limits in all patients.

Med Science 2018;7(4):882-5

Table 1. Demographic and clinical characteristics of the patients Number of patients (n)

268

Age (years)

12.1±4.3

Gender (Female) n (%)

138 (51.5)

Age at the time of the diagnosis of type 1 DM* (years) Mean ± standard devation

7.6±3.7

Duration of type 1 DM (years) Mean ± standard deviation

4.3±3.4

Age at the time of diagnosis of Celiac disease (years) Mean ± standard devation Number of patients who were diagnosed as having Celiac disease n (%)

11.2±5.6 5 (1.9)

* Diabetes mellitus

Small intestinal biopsy was performed in 64 of 65 patients who had any positive serologic test and total villus atrophy was found in three of the patients who underwent biopsy and crypt hyperplasia and increased intraepithelial lymphocytes together with subtotal villus atrophy were found in two (Table 3). The family of a patient who had positive AGA IgA (150 AU) did not accept small intestinal biopsy. Small intestinal biopsy was performed in 48 of 49 patients who had positive antigliadin IgA and celiac disease was found in three patients (6%). Small intestinal biopsy was performed in all 21 patients who had positive AGA IgG and Celiac disease was found in three (14%) (Table 2). EMA and tTG-IgA were found to be positive in all patients who were found to have Celiac disease, both AGA-IgA and AGA-IgG were found to be negative in one patient, AGA-IgA was found to be negative in one patient and AGA-IgG was found to be negative in another patient (Table 3). Histological findings of celiac disease could not be found in 45 patients (93%) who had positive antigliadin IgA, in 18 patients (85%) who had positive AGA-IgG, in 3 patients (37%) who had positive EMA and in 8 patients (61%) who had positive tTG-IgA. Annual follow-up was planned in these patients who had positive serological markers considering latent celiac disease. In five patients who were diagnosed as having celiac disease, the mean age was found to be 11.2±5.6 years, the mean time of diabetes was found to be 10.5±3.8 years and the mean HbA1c value was found to be 11.4±3.8 and no statistically significant difference was found compared with the patients who were not found to have celiac disease (p>0,05). In our study, the incidence of asymptomatic celiac disease was found to be 1.9% in diabetes patients. Table 2. Antibody positivity and percentages of performance of small intestinal biopsy AGA†-IgA AGA† -IgG Type 1 DM* n (%)

49 (18.2)

Patients who underwent biopsy n (%)

48 (97.9)

Number of the patients with a diagnosis of Celiac disease confirmed with biopsyn (%)

3 (6.2)

21 (7.8)

EMA§

tTG-IgA‡

8 (2.9)

13 (4.8)

21 (100.0) 8 (100.0) 13 (100.0) 3 (14.2)

5 (62.5)

5 (38.4)

* Diabetes mellitus, † antigliadin antibody, § antiendomysial antibody, ‡ tissue transglutaminase antibody

Table 4 shows the sensitivity, specificity, positive predictive value, negative predictive value and relative efficiency value of the tests, which we used in the diagnosis of Celiac disease. EMA and tTG-IgA positivity was found in all patients who were found to have Celiac disease (sensitivity 100%). Histological findings of celiac disease were not found on small intestinal biopsy in three patients with positive antiendomysial antibodies and in 883

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eight patients who had positive tTG-IgA and the specificities of these two tests were found to be 95% and 86%, respectively. The sensitivities of antigliadin-IgA and IgG were found to be lower (60% for both) compared to the other two serological markers and their specificities were found to be 26% and 70% respectively. Anti-gliadin-IgA was found to have the lowest positive predictive value and relative efficiency value (6% and 29%, respectively),

Med Science 2018;7(4):882-5

whereas EMA was found to have the highest positive predictive value and relative efficiency value (62% and 95%, respectively). Antiendomysial antibodies were found to have a sensitivity of 100%, a specificity of 95%, a positive predictive value of 62%, a negative predictive value of 100% and a relative efficiency value of 95% and it was considered the most reliable marker among serological markers.

Table 3. Clinical and laboratory findings of the patients who were diagnosed as having Celiac disease with small intestinal biopsy Patients Gender Age

Age at the time of Age at the time of diagnosis Duration of type AGA†-IgA AGA†-IgG tTG-IgA‡ diagnosis of Celiac EMA§ of type 1 DM* (years) 1 DM* (years) (AU) (AU) (U) disease (years)

Histological findings

4.8

3.8

1.0

4.8

28.8

47.9

Total villus atrophy, crypt hyperplasia, increased intraepithelial lymphocytes

5.6

4.6

1.0

5.6

121.4

129.9

Subtotal villus atrophy, crypt hyperplasia, increased intraepithelial lymphocytes

13.5

7.1

6.4

13.5

10.9

26.7

255

Subtotal villus atrophy, crypt hyperplasia, increased intraepithelial lymphocytes

15.8

10.3

5.5

15.8

23.4

6.8

130

Total villus atrophy, crypt hyperplasia, increased intraepithelial lymphocytes

16.7

10.5

6.4

16.7

152.6

20.6

250

Total villus atrophy, crypt hyperplasia, increased intraepithelial lymphocytes

* Diabetes mellitus, † antigliadin antibody, § antiendomysial antibody, ‡ tissue transglutaminase antibody Table 4. Diagnostic values of AGA†-IgA and IgG, EMA§ and tTG-IgA‡ in patients Sensitivity (%)

Specificity (%)

Positive predictive value (%)

Negative predictive value (%)

Relative efficiency (%)

†

AGA -IgG

EMA§

100

AGA†-IgA

tTG-IgA †

‡

Antigliadin antibody, § antiendomysial antibody, ‡ tissue transglutaminase antibody

Discussion Type 1 DM that occurs as a result of insulin deficiency due to autoimmune damage of the pancreatic ß cells may be observed in association with the other autoimmune diseases [1]. Celiac disease, which is an autoimmune enteropathy, is characterized by intestinal lesions, which occur with gluten intake in sensitive individuals [12]. Association of celiac disease and type 1 DM has been shown in many studies and this association has been associated with common HLA DR3-DQ2/HLA DR/-DQ2 tissue antigens [6]. Following numerous studies conducted in this context, it has been recommended that Celiac disease should be screened by measuring the antigliadin-IgA, IgG, tTG-IgA and EMA levels in children with type 1 diabetes even if they are asymptomatic, because type 1 diabetes and Celiac disease have similar underlying genetic properties [2,5]. It has been reported that the prevalence of celiac disease is 20-fold higher compared to the normal population [5]. In the European countries, the incidence of CD in children with type 1 diabetes has been reported to be 6,6% in Italy, 11% in Germany, 1,1% in Finland and 1,6% in France [13-16]. In the other countries, it has been reported to be 16.4% in Algeria and 8,6% in Israil [17,18]. This variable incidence is thought to be

associated with the distribution of HLA genotypes and interaction of environmental and immunological factors [19]. In our study, AGA-IgA and IgG, EMA and tTG-IgA were used as screening tests and small intestinal biopsy was performed in 64 patients (24%) who had at least one positive serological marker. A diagnosis of celiac disease was made in accordance with the ESPGHAN criteria in five patients as a result of examination of the tissue samples obtained and the incidence of celiac disease was found to be 1.9%. In studies conducted so far, the highest prevalence of celiac disease in type 1 DM patients has been reported in Algeria (16.4%) [17]. It is not clear if genetic differences play a role in the high prevalence of association of these two diseases, because there is no information related with HLA tissue groups in Algerian patients. Currently, noninvasive immunological markers with high sensitivity and specificity are being widely used for screening, because characteristic findings of celiac disease are absent in patients with type 1 DM [2]. A strong body of evidence has shown that antigliadin antibodies, antiendomysial antibodies, and antitissue transglutaminase antibodies are the most relevant serology tests for Celiac disease screening, diagnosis, and patient follow-up [20884

doi: 10.5455/medscience.2018.07.8901

25]. It is now accepted that both antiendomysial antibodies and tTG antibodies are highly sensitive and extremely specific [20,21]. The European Society for Pediatric Gastroenterology recommends screening with tTG-IgA in patients with type 1 diabetes and endoscopic biopsy in patients who are found to have positive antibody [26]. The most sensitive and specific tests are tTG-IgA and EMA [10,11,27]. In one study conducted in the United States of America, EMA was found to be positive in all 38 patients who had celiac disease and EMA positivity could not be shown in any subject in the control group [27]. It has been reported that atypical findings are more prevalent in type 1 diabetes patients who develop celiac disease and these patients may even be asymptomatic or have latent findings and can be specified with serological markers. Although tTG-IgA and EMA have been shown to be more reliable compared to AGA among serological markers, it is known that no serological marker has a sensitivity or specificity of 100% [28]. The most sensitive and specific tests include tTG-IgA and antiendomysial IgA (EMA). Similar to the literature, EMA and tTG-IgA were found to be more sensitive and specific compared to AGA-IgA and IgG in our study (sensitivity of EMA and tTG-IgA 100%, specificities of EMA and tTG-IgA 95% and 86%, respectively). Antigliadin-IgA and IgG were found to have a sensitivity of 60%. Their specificities were found to be 26% and 70%, respectively. Conclusion In our study, the incidence of asymptomatic CD was found to be 1.9% in children with type 1 DM. Our results, which support current guidelines show that celiac disease can be screened with tTG-IgA and EMA that are the most sensitive and specific tests and small intestinal biopsy can be performed in children with type 1 DM. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee. References

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28. Sugai E, Vázquez H, Nachman F, et al. Accuracy of testing for antibodies to synthetic gliadin-related peptides in celiac disease. Clin Gastroenterol Hepatol. 2006;4:1112-7.

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Medicine Science International Medical Journal

Medicine Science 2018;7(4):886-90

Effects of occupational lead exposure on testosterone secretion Lutfiye Tutkun1, Servet Birgin Iritas2, Huseyin Ilter3, Meside Gunduzoz4, Serdar Deniz5 Bozok University, Faculty of Medicine, Department of Medical Biochemistry, Yozgat, Turkey 2 Council of Forensic Medicine, Ministry of Justice, Ankara, Turkey 3 General Diroctorate of Public Health, Ministry of Health, Ankara, Turkey 4 Occupational Diseases Hospital, Clinic of Family Medicine Ankara, Turkey 5 Provincial Health Directorate, Malatya, Turkey

Received 14 May 2018; Accepted 21 June 2018 Available online 24.09.2018 with doi:10.5455/medscience.2018.07.8880 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract This study aims the determination of the relationship between blood lead levels (BLL) and reproductive hormones in workers with occupational lead (Pb) exposure. 58 workers who visited Ankara Occupational and Environmental Diseases Hospital between 2013 and 2017 and had a BLL of > 5 μg/dL and no infertility problem, were included in the study as the case group. The workers who have a chronic disease and use prescribed or herbal medicine were excluded. 63 healthy office workers with no heavy metal exposure at the workplace were selected as the control group. BLL, total testosterone (TT), free testosterone (FT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), thyroid stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), uric acid, creatinine, complete blood count (CBC), prolactin (PRL), follicle stimulant hormone (FSH), luteinizing hormone (LH) levels were examined and the occupational anamnesis of the workers were taken. As a percentage, 47.9 % (n=58) of 121 persons (all males) was the study group with Pb exposure and 52.1 % (n=63) were the control group. While the BLL was 34,20 μg/dL in the exposed group, it was 1,82 μg/dL in the control group (p<0.001). Total and free testosterone levels were 6,35 and 13,57 in the control group; 4,65 and 8,13 in the exposed group (p< 0.001), respectively. LH level was 4,01 in the exposed group while it was 4,58 in the control group (p=0.072). FSH were 4,50 and 3,99 respectively, for the control and exposed group (P=0,220) (Table 1). Our results shows that chronic Pb exposure toxicity on the male reproduction system seems to have a mixt effect, probably on the axial of hypophysis-testis. Keywords: Testosterone, lead exposure, follicle stimulant hormone (FSH), luteinizing hormone (LH), reproductive dysfunction

Introduction Lead is a blue-grey colour heavy metal, with a low melting point, which does not occur as a metal by itself. It usually exists as a compound of two or more elements. Metallic lead is rust-free and resistant against water and air [1]. Pb and Pb-alloys are widely used in pipes, batteries, scales, bullets and ammunitions, cable sheaths, anti-radiation sheets, paint production and ceramic glazing. The most frequent use is in batteries of the cars and other vehicles [2,3]. The use of chemicals have increased in parallel with the increasing industrialization today. Similarly, there are many scientific study on the endocrine disrupting effects of industrial chemical, including reproductive system. Recent studies revealed that the chemicals affecting the male hormones and leading to infertility *Coresponding Author: Servet Birgin Iritas, Council of Forensic Medicine, Ministry of Justice, Ankara, Turkey E-mail: sbiritas@gmail.com

are still worldwide used. Pesticides, heavy metals such as mercury, cadmium, lead and the chemicals such as polychlorinated biphenyls (PCBs) and dioxin are the examples. The studies, which were conducted in terms of the correlation between Pb exposure and male infertility, focused mainly on the sperm and its functions. Although the evidences are still obscure in the studies carried out, it is stated that fertility problems can be seen in males who have a BLL of 30-40 μg/dL [4]. Even though there are some studies that emphasize the relationship between Pb exposure and loss of fertility [5-8], there are also some other studies indicating no relationship between occupational Pb exposure and loss of fertility, as in the multinational study (Belgium, Finland, Italy and UK) conducted by Joffe et al. [9]. There are other studies that have conflicting results. While one study predicted normal LH, FSH and PRL level, while testosterone decreases (10), the other study presented increased FSH and LH levels in workers who have a BLL of 10-40 μg/dL (11). The spermatogenesis was found to decrease in workers of a battery factory where Pb exposure was severe [12,13]. In the study he 886

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focused on the effect of the working environment on the male reproduction system, Sheiner et al. found out that the workers who are employed in different industrial sectors had more frequent infertility. The further analysis of this study revealed that the infertility sources were varicocele, sperm anomalies and hormonal imbalance [14]. Also the sperm motility and sperm head morphology disorders are some other parameters that could be correlated with BLL [15]. The workers in molding presented hypogonadism and low testosterone hormone levels, caused by inorganic lead exposure [16]. In an another study, results revealed a correlation between the exposure time and testicular dysfunction [17]. Similarly, animal studies suggested that Pb exposure had harmful effects on male reproduction system, as in humans. The studies carried out on monkeys showed that Pb exposure decreased the LH level and inhibiting/FSH ratio [18]. Similarly, chronic lead exposure in monkeys has been proven to cause dysfunction in Sertoli cells [19]. In his study on monkeys, Foster et al. [20] has pointed out the deformations in Sertoli cells, basal lamina, seminiferous tubule epithelium and spermatids by using electron microscope. Similarly, Bizzaro et al. advocate this outcome, by means of his studies in which he showed a time-dependent increase, in the fraction of damaged mitochondria in the Sertoli cells in mice exposed to Pb acetate intermittently for a period of 4 weeks [21]. A more recent animal study showed that lead blocked dihydrotestosterone binding to the receptor in the prostate and seminal vesicle due to its divalent cation property [22]. Since most of the lead exposure occur at the workplace, semen disorder and lack of libido is observed more distinctively in those with occupational lead exposure [23, 24]. Materials and Methods Study population In this case-control study, 58 workers who visited the occupational diseases outpatient clinic at Ankara Occupational and Environmental Diseases Hospital, were included as the case group. Case group had a BLL > 5 μg/dL and no infertility problem. The workers who have a chronic disease and use prescribed or herbal

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medicine were not included in the study. 63 healthy office workers with no heavy metal exposure at the workplace were selected as the control group. The Decision of the Ethics Committee, Ankara Keçiören Training and Research Hospital, is available for the study. Measurements Demographic data of the study and control group was collected from occupational anamnesis. Cell-Dyn Emerald Hematologic Analysis device was used for the haematological analyses; Inductively Coupled Plasma – Mass Spectrometer (ICP-MS) Agilent 7.700 device was used for the blood lead analyses and Abbott Architect i 2000 Immunoassay device was used for FSH, LH, PRL, TST analyses of the blood samples taken into tubes containing Ethylene Diamine Tetra-Acetic acid (EDTA). Statistical Analysis The participants were divided into two groups: those with and without a lead exposure based on the severity of Pb exposure. Statistical analysis was performed using SPSS 22,0 software in order to assess the occupational anamnesis and laboratory results. Data distribution was determined with Kolmogorov-Smirnow test. In the study, the statistical significance level of which was accepted as 0.05, the difference between the averages of two independent variables was evaluated with t-test; the difference between more than two variables was evaluated with ANOVA (analysis of variance) and additionally with Pearson Correlation analysis. The averages are given with the standard deviations. Results A total of 121 male workers were included in the study. 47,9 % (n=58) was the study group while 52,1 % (n=63) was the control group. The average age of the exposed group was 37,9 while it was 40,4 in the control group. The average work duration of the control group was 8,68 ±8,02 years and 4,94 ±1,64 years in the exposed group. While the BLL was 34,20 μg/dL in the exposed group, it was 1,82 μg/dL in the control group (p<0.001). Total and free testosterone levels were 6,35 and 13,57 in the control group; 4,65 and 8,13 in the exposed group (p< 0.001), respectively. LH level was 4,01 in the exposed group while it was 4,58 in the control group (p=0.072). FSH were 4,50 and 3,99 respectively, for the control and exposed group (P=0,220). PRL levels were 12,00 and 12,17 respectively (P=0,880), (Table 1).

Tablo 1. Means of continuous variables of the control group and exposure group Age BLL (μg/dL) FT (ng/ml) TT (ng/ml) TSH (µıu/ml) T3 (pg/ml) T4 (ng/dl) FSH (mlu/ml) LH (mlu/ml) PRL (mlu/ml)

Group Control Group Exposed Group Control Group Exposed Group Control Group Exposed Group Control Group Exposed Group Control Group

N 63 58 63 58 63 58 63 58 63

Mean 40.4127 37.9828 1.8292 34.2016 13.5752 8.1331 6.3570 4.6522 1.5924

Std. Deviation 9.40939 8.46767 1.07345 22.64164 2.94580 1.70954 2.28270 1.80194 .90275

Exposed Group Control Group Exposed Group Control Group Exposed Group Control Group Exposed Group Control Group Exposed Group Control Group Exposed Group

58 63 58 63 58 63 58 63 58 63 58

1.6926 2.9952 3.0122 1.0313 1.0743 4.5087 3.9907 4.5871 4.0110 12.0056 12.1747

1.32333 .41452 .44444 .16621 .15985 2.79870 1.73847 1.85395 1.64034 5.05628 6.96578

p .138 .000 .000 .000 .631 .828 .149 .220 .072 .880

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In the analysis carried out according to BLL of the study group (group-1: 5-10 μg/dL, group-2: 10-40 μg/dL, group-3: >40 μg/dL), FT levels were significantly high in the control group compared to the exposed group (p<0,001). While the highest FT level of the study group was in group-2, the lowest FT level was seen group-3. However, this finding was not significant statistically. For LH and FSH levels, the highest levels were found in group-2 while the lowest was found in group-1. Nevertheless, no significant difference was found in terms of the LH and FSH levels between

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the control group and the groups classified according to the BLL (Table 2, Figure 1-3). The strongest negative correlations were between BLL and FT (r= -0,576, p < 0,01) and between LH and FSH (r= 0,527, p < 0,01) (Table 3). It was found that there was a negative correlation between BLL and TT (r= -0,262, p < 0,01) and a positive correlation between TT and FT (r= 0,461, p < 0,01).

Table 2. Means of continuous variables of the control group and 3 different lead levels

Age

BLL (μg/dL)

FT (ng/ml)

TT (ng/ml)

TSH (µıu/ml)

T3 (pg/ml)

T4 (ng/dl)

FSH (mlu/ml)

LH (mlu/ml)

PRL (mlu/ml)

Group Non-exposed 1 2 3 Total Non-exposed 1 2 3 Total Non-exposed* 1 2 3 Total Non-exposed* 1 2 3 Total Non-exposed 1 2 3 Total Non-exposed 1 2 3 Total Non-exposed 1 2 3 Total Non-exposed 1 2 3 Total Non-exposed 1 2 3 Total Non-exposed 1 2 3 Total

N 63 16 15 27 121 63 16 15 27 121 63 16 15 27 121 63 16 15 27 121 63 16 15 27 121 63 16 15 27 121 63 16 15 27 121 63 16 15 27 121 63 16 15 27 121 63 16 15 27 121

Mean 40.4127 38.9375 35.6667 38.7037 39.2479 1.8292 7.5181 27.8600 53.5370 17.3465 13.5752 8.2025 8.7327 7.7589 10.9666 6.3570 4.1800 5.2413 4.6048 5.5398 1.5924 1.9062 1.5700 1.6341 1.6404 2.9952 2.9344 2.9953 3.0678 3.0034 1.0313 1.1188 .9967 1.0911 1.0519 4.5087 3.7269 4.4793 3.8756 4.2604 4.5871 3.7519 4.1460 4.0896 4.3110 12.0056 11.0531 12.9227 12.4237 12.0866

Std. Deviation 9.40939 10.40172 8.74779 7.02641 9.01599 1.07345 1.53796 9.32231 15.03711 22.53498 2.94580 1.42498 1.72136 1.81227 3.65032 2.28270 1.50090 1.75832 1.95300 2.22842 .90275 2.07537 .87582 .94916 1.12045 .41452 .40735 .41595 .48687 .42740 .16621 .14165 .09116 .18703 .16394 2.79870 1.45311 2.18212 1.62764 2.35585 1.85395 1.28470 1.79398 1.77637 1.77129 5.05628 6.35232 4.07498 8.54358 6.02198

Minimum 24.00 25.00 22.00 24.00 22.00 .20 5.60 10.50 41.40 .20 10.11 6.14 3.96 4.16 3.96 2.34 2.00 3.84 2.01 2.00 .49 .30 .12 .57 .12 2.14 2.19 2.18 2.18 2.14 .72 .97 .88 .88 .72 1.93 1.34 1.76 1.01 1.01 1.93 1.98 1.91 1.41 1.41 4.34 5.89 6.35 3.80 3.80

Maximum 63.00 61.00 48.00 52.00 63.00 4.04 9.82 40.00 101.00 101.00 20.90 10.28 10.42 10.12 20.90 12.52 6.90 11.00 9.77 12.52 4.57 9.04 2.96 4.31 9.04 3.82 3.76 3.80 4.20 4.20 1.73 1.48 1.21 1.68 1.73 20.40 7.46 7.87 7.67 20.40 9.32 6.42 9.05 7.13 9.32 32.82 25.82 20.42 34.32 34.32

P .319

.000

.787

.791

.073

.504

.301

.840

The group that caused the difference

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doi: 10.5455/medscience.2018.07.8880 Table 3. Pearson correlations of continuous variables N=121 Age Lead FT Age 1 -.070 -.029 Lead 1 -.576** FT 1 TT TSH T3 T4 FSH LH PRL *.p<0.05 **. P< 0.01

TT -.008 -.262** .461** 1

TSH .191* -.009 -.150 -.106 1

T3 -.226* .018 .062 .120 -.056 1

T4 .025 .141 -.162 -.091 -.053 .188* 1

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FSH .335** -.099 -.058 -.052 .060 -.166 -.031 1

LH .146 -.142 .094 .152 -.130 -.128 .027 .527** 1

PRL -.089 .037 .126 .002 -.134 -.203* -.182* .007 .225* 1

Discussion

Figure 1. Free testosterone levels for control group and three different lead levels group

In our study that we carried out in the workers with a lead exposure of 4,94 ±1,64/year on an average, we observed that free and total level were statistically low in each group. Although FSH and LH levels have been found to be lower than the control group, it was not statistically significant. After we have sliced the exposed workers three groups according to their BLL, significantly low testosterone levels have been found in the first group. This result seems to be a consequence of deteriorated testosterone secretion in the testicle due to Pb exposure. In the second group, FSH and LH levels tend to increase although lead levels are higher than the first group (10-40 μg/dL) (table 2). These increases are estimated to be related to testicle Sertoli and Leydig cell insufficiency. As seen in the table, TT and FT levels increase like FSH and LH levels. However, FSH and LH levels have been found to decrease remarkably like testosterone levels in the severely exposed group (40 μg/dL). These findings indicate that Pb exposure initially causes testicular damage due to direct toxic effect and decreases the testosterone synthesis. This decrease seems to induce an increase in FSH and LH concentrations. There are similar results in the literature [16, 17]. In cases where BLL remains above 40 μg/dL, testosterone synthesis reduces parallel to FSH and LH synthesis. This result supports the idea regarding the secondary effect of lead on hypophysis, in the studies conducted. It was seen that the lead levels above 40 μg/dL caused adverse effects on the hypothalamic hypophyseal system. These studies points out that FSH and LH levels decrease in the long-term exposure [19, 25-28].

Figure 2. LH levels for control group and three different lead levels group

It has been found that lead exposure reduces thyroidal hormonogenesis [29-31]. However, this result is only caused by extremely high lead levels. This aspect should be addressed in exposure groups in higher levels. Conclusion The data we obtained in our study indicate that lead exposure causes damage to testicular Sertoli and Leydig cells and causes a decrease in testosterone levels. Additionally high BLL seems to suppress the hormone secretion in hypophysis.

Figure 3. FSH levels for control group and three different lead levels group

Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

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25. Gustafson A, Hedner P, Schutz A, et al. Occupational lead exposure and pituitary function. Int Arch Occup Environ Health. 1989;61:277-81.

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11. Ng TP, Goh HH, Ng YL, et al. Male endocrine functions in workers with moderate exposure to lead. Br J Ind Med. 1991;48:485-91. 12. Assennato G, Paci C, Baser ME, et al. Sperm count suppression without endocrine dysfunction in lead-exposed men. Arch Environ Health. 1987;42:124-7. 13. Mc Gregor AJ, Mason HJ. Chronic occupational lead exposure and testicular endocrine function. Human & Experimental Toxicolog. 1990;9:371-6. 14. Sheiner E, Hadar A, Shoham-Vardi I, et al. The effect of meconium on perinatal outcome: a prospective analysis. J Matern Fetal Neonatal Med. 2002;11:54-9. 15. Telisman S, Cvitkovic P, Jurasovic J, et al. Semen quality and reproductive endocrine function in relation to biomarkers of lead, cadmium, zinc, and copper in men. Environ Health Perspect. 2000;108:45. 16. Cullen MR, Kayne RD, Robins JM. Endocrine and reproductive dysfunction in men associated with occupational inorganic lead intoxication. Arch

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Medicine Science 2018;7(4):891-7

Effects of perineural administration of phenytoin in combination with levobupivacaine in a rat sciatic nerve block Ahmet Selim Ozkan1, Sedat Akbas1, Mehmet Akif Durak2, Mehmet Ali Erdogan1, Hakan Parlakpinar3, Nigar Vardi4, Onurhal Ozhan3, Ali Ozer5 Inonu University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Malatya, Turkey 2 Inonu Univesity, Faculty of Medicine, Department of Neurosurgery, Malatya, Turkey 3Inonu University, Faculty of Medicine, Department of Medical Pharmacology, Malatya, Turkey 4 Inonu University, Faculty of Medicine, Department of Histology and Embriology, Malatya, Turkey 5 Inonu University, Faculty of Medicine, Department of Health and Etic, Malatya, Turkey

Received 21 February 2018; Accepted 16 May 2018 Available online 05.10.2018 with doi:10.5455/medscience.2018.07.8899 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Peripheral nerve blocks are commonly preferred worldwide for the purposes of anesthesia application and postoperative analgesia. In this study, we investigated the effects of phenytoin which has a similar mechanism to local anesthetics in terms of the duration of analgesia and quality. The study was performed on 32 Sprague-Dawley male rats. Rats were randomly grouped into 4 groups. Group S: Sham group (n: 8); 0,2 ml saline perineural unilateral sciatic nerve. Group L: Perineural levobupivacaine (0,2 ml 0,5% levobupivacaine, n: 8); Group Ph: Perineural phenytoin (0,2 ml 62,5 mg / kg, n: 8); Group L + PH: Perineural phenytoin and levobupivacaine (0,2 ml 0,5% levobupivacaine + 62,5 mg / kg phenytoin, n: 8). Hot-plate and tail- ďŹ&#x201A;ick tests were performed to measure acute thermal pain and histological changes were evaluated. The latency time at 30 minute in Group L+Ph were significantly increased when compared to the other groups during evaluation of the hot plate test. There was a significant difference in terms of latency time at 30 minute in Group L+Ph in the Tail Flick test and the latency time in Group L+Ph was longer when compared to the other groups (p<0,05) These results were obtained according to hot-plate and tail-flick tests and indicated that the analgesic quality. Perineural administration of phenytoin in combination with levobupivacaine did not affect the duration of the sensory and motor blockade at doses used in our study. However, phenytoin combined with levobupivacaine increased the duration and quality of the analgesia. Keywords: Phenytoin, levobupivacaine, rat, sciatic nerve block

Introduction Peripheral nerve blocks are commonly preferred worldwide for the purposes of anesthesia application and postoperative analgesia. Peripheral nerve blocks reduce opioid consumption, which has serious side effects. Single-dose peripheral nerve block with longacting local anesthetics, such as bupivacaine, levobupivacaine or ropivacaine, maintains excellent analgesia for approximately 8-14 hours. Nevertheless, blocks administered in the early morning and mid-day may cause severe pain due to a loss of their effects late at night [1]. Many clinicians suggest taking opioids for analgesia to stop the pain that may occur during the night hours. Sleep disturbances, respiratory depression and other serious side effects caused by opioids may occur in these patients [2]. For this reason,

*Coresponding Author: Ahmet Selim Ozkan, Inonu University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Malatya, Turkey E-mail: asozkan61@yahoo.com

long-acting local anesthetic adjuvants are added to increase the analgesic quality and duration of peripheral nerve blocks. Levobupivacaine is a S-negative enantiomer of racemic bupivacaine and has similar potency to bupivacaine in nerve blocks. The combination of local anesthetics with clonidine, morphine or fentanyl is highly effective in the control of postoperative pain [3]. However, in addition to being a long-acting local anesthetic, levobupivacaine is known to have low lipid solubility, enhanced sensory blockade effect, less deep motor blockage, and less central nervous and cardiovascular system side effects compared to a racemic mixture [4]. Phenytoin is an antiepileptic drug that blocks voltage-sensitive and frequency-dependent sodium channels in neurons. Phenytoin stabilizes sodium channels in an inactive state [5]. This inhibitory effect is similar to local anesthetics. Phenytoin is an effective antiepileptic agent that is commonly used in all types of epilepsy, except absence epilepsy [6,7]. Phenytoin has no effect on the 891

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severity and duration of the action potential. Phenytoin limits the ability of high-frequency action potential by delaying the renewal of neurons. This function represses repetitive neuronal activity and prevents the distribution of seizure focus. At high concentrations, the neuronal refractory period is prolonged by preventing potassium excretion in the nerve (potassium channel blockage). However, previous studies have not examined the addition of perineural phenytoin to levobupivacaine on the effects of analgesia in rat sciatic blockage. In this study, we extended the duration of analgesia by levobupivacaine, a long-acting local anesthetic, with phenytoin serving as an adjuvant, which has a similar mechanism to local anesthetics and provides a more comfortable period by extending the painless period after surgery and reducing drug consumption. Materials and Methods This experimental study was approved by the Animal Experiments Local Ethical Committee (2015/A-61). The study was performed on 32 Sprague-Dawley male rats weighing between 250-350 g from our Animal Research Center. Care for the experiments was performed in 4 rat cages (Euro type 3, polycarbonate stainless steel cage, 50 × 35 × 20 cm, 8 animals per cage) and were provided with rat chow and water ad libitum at 21-22° C room temperature, 12-hour light/dark cycle, before and during the study. The study was performed according to the guidelines of animal experiments reported by the National Health Research Institute. Drug Administration Normal saline and levobupivacaine (1%) or phenytoin solution was mixed together to obtained a final concentration of 0,5% levobupivacaine for administration to the perineural area. Phenytoin doses were determined by the weight of each rat. The pH value of phenytion was delivered to physiological values using Phosphate Buffered Saline (pH 7.2) (Phosphate Buffered Saline,BD, Heidelberg,Germany) Experimental Design Non-neurobehavioral rats were administered with ketamine (Ketalar; Pﬁzer, Istanbul, Turkey) and xylazine (Rompun; Bayer, Toronto, Canada) intraperitoneally at a dose of 10 mg/kg, respectively. Rats were randomly grouped into 4 groups, in which each group consisted of 8 rats. Group S: Sham group (n: 8); the skin was closed after an injection of 0,2 ml saline perineural unilateral sciatic nerve. Group L: Perineural levobupivacaine (0,2 ml 0,5% levobupivacaine, n: 8); Group Ph: Perineural phenytoin (0,2 ml 62,5 mg / kg, n: 8); Group L + PH: Perineural phenytoin and levobupivacaine (0,2 ml 0,5% levobupivacaine + 62,5 mg / kg phenytoin, n: 8); and all study drugs were injected into the perineural zone. Sciatic nerve injections were performed by an investigator who was blinded to the conditions of drug administration, and another investigator performed the neurobehavioral tests. Laboratory assistants prepared the drugs. After a lateral incision was performed along the thigh and the superﬁcial fascia was separated, the sciatic nerve of the left hind limb was identified. The sciatic nerve was observed near the nerve’s bifurcation. Next, 0,2 ml of prepared

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drug was administered perineurally using a 1-ml syringe. At the midpoint of the dissection, an unabsorbable muscle fascia suture was performed as a marker for the removal of the nerve. After the injection, tests were performed every 30 minutes. After closing the skin in all groups, a paw withdrawal response was observed and recorded every 30 minutes until the sensory block of the test animal returned. Hot-plate and tail-flick tests were used to evaluate the analgesia. Histopathology of tissue was also examined for histopathological evaluation of the injection site. Analgesia Measurement Hot-plate and tail- ﬂick tests were performed to measure acute thermal pain. These tests were used to evaluate thermal analgesia in rats. Practice of the Hot-Plate Test The surface of the Hot-Plate (Electro mag Instruments, Istanbul, Turkey), which could be controlled using a digital thermometer, was heated to obtain a stable temperature of 50°C. The time (in seconds) between shaking, claw licking, and plate-to-jump was determined to be the latency time when the rats were placed on the hot plate surface. To avoid tissue damage, the cut-off time was set to 60 seconds [8]. The preliminary response was reflected as the mean response times ensured 0 and 30 minutes before drug injection and was accepted as the normal response of the rats to heat effect. The latency time in the hot-plate test was recorded at 0, 30, 60, 90 and 120 minutes of drug administration. Practice of the Tail-Flick Test Anti-nociception and thermal analgesia were evaluated using the previously described radial Tail-Flick Test instrument (Type 812; Columbus Instruments) [9]. The rats were placed into a rigid plastic cage and non-related tests were performed in 15-seconds time intervals. The mean latency time of Tail-Flick, which represents the baseline latency time, was obtained from measurements of 3 tests before drug administration. Animals with a latency time of Tail-Flick changing between 2 and 5 seconds before drug administration were used in the experiments. Shortly after the baseline assessment, rats were injected with drugs or saline as described by the experimental protocol. The response of the rats were recorded at 0, 30, 60, 90 and 120 minutes after the procedure by performing pressure to the end of rat tail using an analgesometer. The cut-off time was established at 10 seconds to prevent tail injury. The duration of drug administration was performed as previously described [10,11]. Sensory and Motor Functions The paw withdrawal response of the toes was used to evaluate sensory functions, while the force of the toes was applied laterally to the forceps. The forceps grip was limited to 1 second in order not to directly damage the claw tissue. The rats succeeded in pulling the paw tested in reaction to pain. Sensory reactions were defined according to withdrawal or dubbing and assessed as the following: the forceful paw withdrawal response after pinching (normal sensory function) was 0, moderate withdrawal was 1, lowest withdrawal was 2 and no response (complete sensory block) was 3. In addition, motor functions were evaluated using the following scale of 0-3; regular motor activation 0, regular dorsiflexion motion and moving with curved toes: 1, moderate dorsiflexion motion and moving with curved toes: 2, no dorsiflexion motion and moving 892

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with curved toes: 3. Sensory and motor evaluations were measured at 30-minute intervals by another blinded researcher. Histological Evaluation The nerve tissues were obtained and fixed with 10% formaldehyde after the termination of the study. After fixation, tissues were embedded into the paraffin blocks after dehydration and clearing. Tissue sections were obtained at 4-µm thickness from paraffin blocks. Following the deparaffinization and rehydration process, sections were dyed with hematoxylene-eosin (H-E) and toluidine blue (TB). Stained sections were analyzed under Leica Q Win Image Analysis System (Leica Micros Imaging Solutions Ltd., Cambridge, UK). H-E stained sections were evaluated for fibrillar degeneration (shrinkage of axons, disruption of the myelin sheath, fibril loss), and edema in endonorium at 100× magnification. These histological changes were scored as none (0), little (1), intermediate (2) and severe (3). When sections stained with TB were evaluated, the total area was examined and mast cells were quantified in the endonorium. The number of mast cells per millimeter squared of area was obtained by dividing the total number of cells with the total area. Statistical Analysis The sample size value was determined in our study with statistical

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power analysis and was determined as a power of 0.80. The records were examined using a software program for Windows (IBM SPSS statistics version 23, IBM Corp, New York). The records were expressed as the minimum and maximum (median). The estimate of the standard distribution was supported using the Kolmogorov–Smirnov test. The Kruskal–Wallis H-test was performed without providing an estimate of normality. The Mann– Whitney U test with Bonferroni’s correction was performed when multiple comparisons were required. All data were expressed as the median (minimum - maximum) and significance was established at p<0.05. For histological analysis, the statistical signiﬁcance was detected at p<0.01, and similarly, the Mann-Whitney U test was preferred when multiple comparisons were required. Results Measurement of Analgesia The latency times at 30 minutes in Group L+Ph were significantly increased compared to the other groups when the hot plate test was evaluated (Table 1). There was a significant difference in terms of latency times at 30 minutes in Group L+Ph in the Tail Flick test and the latency time in Group L+Ph was longer compared to the other groups (Table 2) (p<0,05). These results were obtained according to hot-plate and tail-flick tests and indicated that the analgesic quality and effect was better in Group L+Ph rats at 30 minutes compared with Group L rats.

Table 1. Hot-plate test latency time results Time (min)

Group S (n : 8)

Group L (n : 8)

Group Ph (n : 8)

Group L+Ph (n : 8)

P value

Median sec (minimum–maximum) Basal

14 (9-18)

11(6-17)

13(6-19)

12(9-20)

15(7-25)

20(9-26)

14(7-19)

26(13-29)

0,018*

14(8-24)

14(6-19)

12(7-19)

17(9-23)

13(9-20)

12(5-21)

11(4-20)

16(8-21)

120

14(6-21)

13(7-21)

13(7-22)

14(11-20)

NS: Not signiﬁcant, Group S: sham, Group L: perineural levobupivacaine (0,2 mL 0,5% solution) and subcutaneous saline, Group Ph: perineural phenytoin (0,2 ml of 62,5 mg/kg), Group L+Ph: perineural levobupivacaine plus phenytoin (0,2 mL 0,5% levobupivacaine + 62,5 mg/kg phenytoin) and subcutaneous saline *p<0.05, significantly difference Table 2. Tail-ﬂick latency time results Time (min)

Group S (n : 8)

Group L (n : 8)

Group Ph (n : 8)

Group L+Ph (n ¼:8)

P value

Median sec (minimum–maximum) Basal

9(5-10)

9(5-12)

8(5-11)

8(5-13)

6(3-13)

6(4-11)

4(2-7)

8(4-11)

0,042*

7(5-12)

5(3-9)

4(2-8)

5(2-13)

6(3-11)

4(3-7)

5(3-9)

6(3-13)

120

6(2-8)

5(3-10)

4(2-7)

6(3-13)

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Measurement of Sensory and Motor Functions No complete sensory and motor blockade was observed in all groups. In particular, no significant difference between Group L and Group L+Ph was observed with regards to sensory and motor blockade. Scores at 30 minutes showed no significant difference between all groups (p>0,05). Histological Findings The histopathological scores and number of mast cells are shown at Table III and p-values for the histological evaluation are shown at Table IV. Sections stained with H-E and TB are shown in Figure 1 and 2. 1st day; in this study, in groups L and Ph, prominent degenerative changes, such as shrinkage of axons, disruption of the myelin sheath and loss of nerve fibril, were observed. Moreover, in group L, edema was observed in the endonorium. However, groups S and L+Ph also showed slight changes. As a result of histological scoring, there was a statistically significant difference between groups S and L in terms of both fibrillar degeneration and edema.

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In addition, there was a statistically significant difference between groups S and Ph in terms of fibrillar degeneration (p<0.05). Furthermore, there was a significant difference between groups L and L+Ph for both fibrillar degeneration and edema (p<0.05). On the 14th day, compared to the 1st day of the study, the severity of histopathological changes increased in group Ph but decreased in other groups on the 14th day of the study. The lowest histopathological score of this study was observed in group S, and the highest score was observed in group Ph. Statistically significant differences were determined among group Ph and other groups (p<0.05). However, there was no statistically significant difference among groups L and L+Ph (p>0.05). Histological changes on the 14th day in groups S and L were significantly decreased compared to groups S and L on the 1st day (p<0.05). In group Ph, the severity of degenerative changes on the 14th day significantly increased compared to group Ph on the 1st day (p<0.05). Lastly, histological changes on the 14th day in group L+Ph were similar to the 1st day (p<0.05).

Table 3. Histopathological scores and number of mast cells

1st Day

14th day

Degeneration

Edema

Number of Mast Cells

Group S

1.0(0.0-2.0)

0.0 (0.0-2.0)

0.0 (0.0-18.1)

Group L

2.0 (0.0-3.0)

0.0 (0.0-0.0)

Group Ph

2.0 (0.0-2.0)

0.0 (0.0-2.0)

2.1 (0.0-6.7)

Group L+Ph

0.0 (0.0-2.0)

0.0 (0.0-1.0)

4.4 (0.0-6.6)

Group S

0.0 (0.0-1.0)

0.0 (0.0-0.0)

0.0 (0.0-11.0)

Group L

1.0 (0.0-3.0)

0.0 (0.0-1.0)

7.7 (5.7-13.8)

Group Ph

3.0 (1.0-3.0)

2.0 (0.0-3.0)

0.0 (0.0-10.8)

Group L+Ph

0.0 (0.0-2.0)

0.0 (0.0-1.0)

3.0 (0.0-14.3)

Group S: sham, Group L: perineural levobupivacaine (0,2 mL 0,5% solution) and subcutaneous saline, Group Ph: perineural phenytoin (0,2 ml of 62,5 mg/kg), Group L+Ph: perineural levobupivacaine plus phenytoin (0,2 mL 0,5% levobupivacaine + 62,5 mg/kg phenytoin) and subcutaneous saline Table 4. p values for histological evaluation

1st Day

14th day **

1th &14th day

Degeneration

Edema

Number of

Group S & Group L

0.001

0.140

Group S & Group Ph

0.019

0.422

0.652

Group S & Group L+Ph

0.131

0.429

0.428

Group L & Group Ph

0.111

0.001

0.015

Group L & Group L+Ph

0.001

0.004

Group Ph & Group L+Ph

0.001

0.121

0.416

Group S & Group L

0.007

0.152

0.043

Group S & Group Ph

0.001

0.592

Group S & Group L+Ph

0.018

0.004

0.397

Group L & Group Ph

0.001

0.007

Group L & Group L+Ph

0.651

0.062

0.195

Group Ph & Group L+Ph

0.001

0.165

Group S

0.001

0.009

0.833

Group L

0.001

0.002

Group Ph

0.004

0.001

0.259

Group L+Ph

0.988

0.294

0.791

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Figure 1. A (Group S, 1st day), C (Group L, 1st day), E (Group Ph, 1st day), G (Group L+Ph, 1st day) and B (Group S, 14th day), D (Group L, 14th day), F (Group Ph, 14th day), H (Group L+Ph, 14th day). Arrow, arrowhead, and star represent the shrinkage of axons, disruption of the myelin sheath and edema in each image, respectively. H-E 100Ă&#x2014;.

Figure 2. A (Group S, 1st day), C (Group L, 1st day), E (Group Ph, 1st day), G (Group L+Ph, 1st day) and B (Group S, 14th day), D (Group L, 14th day), F (Group Ph, 14th day), H (Group L+Ph, 14th day). Arrow represents the mast cells in each image. Notice that there is no mast cell in B1 group. TB 100Ă&#x2014;.

Number of Mast Cells

day was nearly normal in appearance, except for slight fibrillar degeneration. The presence of more degenerative changes on the 14th day in group Ph was observed.

On the 1st day, when each group was compared with each other in terms of the number of mast cells, it was shown that while there was a statistically significant difference among the groups L-Ph and groups L-L+Ph (p<0.05), there was no significant difference between the other pairs of groups (p>0.05). On the 14th day, according to the cell number results, there was a statistically significant difference between groups S & L and groups L & Ph (p<0.05), but a significant difference was not observed between in other pairs of groups (p>0.05). When each of the groups of the 1st day and 14th day were compared, it was observed that there was a significant increase on the 14th day only in group L compared to group L on the 1st day (p<0.05). However, no difference was observed between the 1st day and 14th day in group L+Ph (p>0.05). In contrast, there was a decrease in the number of mast cells on the 14th day in groups S and Ph compared to S and Ph at 1st day, respectively (p>0.05). Group S at 14th

Discussion The most important consequence of our study is the increase in analgesia quality in the first 30 minutes of sciatic block applied with levobupivacaine phenytoin combination at study doses as an adjuvant. In addition, histopathological changes in the group levobupivacaine + phenytoin are less than the phenytoin group compared to each other. Local anesthetics are long preferred worldwide in the management of postoperative acute or chronic pain, as well as regional anesthesia and peripheral nerve blocks [12]. Many peripheral adjuvant agents are selected to increase the duration of the local anesthetic block, improve the quality of anesthesia, prevent toxicity, and initiate the operation more quickly [13]. Epinephrine, clonidine (inhibition 895

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of voltage-gated sodium channels by perineural injection), buprenorphine (inhibition of voltage-gated sodium channels by perineural injection), dexamethasone (inhibition of C-fiber transmission) and midazolam are preferred as a single adjuvant or in combination in nerve blocks [14,15]. Kroin et al. [16] have shown that epinephrine is more potent when clonidine or epinephrine is added as an adjuvant, and clonidine substitution with epinephrine does not provide an additional benefit but may be used as an alternative in specific conditions. These researchers reported that the mechanism of action of clonidine is mediated via ion channel blockade, rather than via alpha-2 adrenoreceptors. Buvanendran et al. [17] reported that when they are combined with buprenorphine or dexamethasone, they reach the longest block in rat nerve block in combination with bupivacaine and clonidine [17]. ErdoÄ&#x;an et al. [2] reported that they applied a combination of levobupivacain and dexmedetomidine in rat sciatic nerve block and analgesic effects were better when assessed using the hot-plate test and tailflick test when dexmedetomidine was added. However, there were no effects on sensory and motor blockade [2]. In addition, when dexmedetomidine was used at high doses, it caused analgesia and sedation via adrenoceptors in the head and spinal cord, which may cause some central effects due to absorption [18,19].

alone, it had a neurotoxic effect on the nerves. Interestingly, when levobupicaine plus phenytoin were administered together, the neurotoxic effect was lower.

Levobupivacaine inhibits the transmission of nerve stimuli by blocking voltage sensitive ion channels expressed on neuron membranes. Local and reversible anesthesia is created by opening of the sodium channel, which prevents transmission of the action potential in the nerves, including sensory and motor activity and sympathetic activity. The effects on motor function are less than those on sensory function [3]. Phenytoin is an anti-epileptic drug that blocks sodium channels similar to local anesthetics. Activation of voltage-gated sodium channels is essential to pass the action potential between the axons. Anti-epileptic drugs suppress neuronal activation via a variety of mechanisms. Phenytoin is an antiepileptic drug with strong evidence that it has a basic mechanism of action [5]. Phenytoin is an effective anti-epileptic agent that is commonly used in all types of epilepsy, except absence epilepsy [6,7]. This study was aimed to determine the benefits of phenytoin with regards to its adjuvant effect due to its similar effects to local anesthetics. The levobupivacaine phenytoin group showed increased analgesia quality compared to the other groups.

Our study has some limitations. First, there was no knowledge regarding the systemic effects of phenytoin when administered perineurally. Due to the similarity of the mechanism of effect with local anesthetics, systemic effects must be studied for the emergence of the essential effect. Second, we used ketamine for anesthesia, and the analgesic effect of ketamine can affect our results. Anesthesia with inhaler anesthetics may be preferred to eliminate this limitation.

It was observed that clonidine, buprenorphine and dexamethasone adjuvants do not cause neurotoxicity due to local anesthesia but significantly developed neurotoxicity in combination with midazolam [15]. In this study, fibrillar degeneration was observed in the phenytoin group compared to other groups on the 1st day (p<0.05). Fibrillar degeneration and edema were also observed significantly more in group L+Ph than group L at 1st day. The severity of histopathological changes in group Ph increased on the 14th day compared to the 1st day but decreased in other groups. The lowest histopathological score of this study was observed in group S, and the highest score was observed in group Ph. Statistically significant differences were determined among group Ph and other groups (p<0.05). In group Ph, the severity of degenerative changes on the 14th day were significantly increased compared to group Ph on the 1st day (p<0.05). Thus, the application of phenytoin alone had a neurotoxic effect on the nerves. However, histological changes on the 14th day in group L+Ph were similar to the results obtained on the 1st day. Furthermore, when phenytoin was used

We would like to highlight the most important point of this study: phenytoin, which has a similar mechanism to local anesthetics and several adjuvants (such as clonidine and buprenorphine), has never been tested in peripheral nerve blocks. In this study, we observed that levobupivacaine in combination with phenytoin did not improve the duration and degree of sensory and motor blockade at the doses indicated in our study. However, levobupivacaine in combination with phenytoin improved the quality of analgesia in rats. Thus, we recommend that drugs combined with adjuvants can be used as peripheral nerve blocks to increase the quality of analgesia. However, the use of phenytoin as an adjuvant may be limited in terms of the histological outcome of the application according to our study. Phosphenytoin that was not toxic to tissue may be further studied for its effects on peripheral nerve block. Furthermore, our study may be serve as a guide for further studies in humans. Limitations

Conclusion Perineural administration of phenytoin in combination with levobupivacaine did not affect the duration of the sensory and motor blockade at doses used in our study. However, phenytoin combined with levobupivacaine increased the duration and quality of the analgesia. Histological effects of phenytoin on tissue may limit the use of levobupivacaine as an adjuvant drug. Thus, further studies are needed to reduce the toxic histological effects of phenytoin on tissue and to achieve more effective results for analgesia. . Competing interests The authors declare that they have no competing interest Acknowlegment This study was supported by a grant from The ScientiďŹ c Research Fund of Inonu University (No. 2016/71). The study was presented as oral presentation at 7th European Congress of Pharmacology, 2016. Manuscript was edited by native English speaker (American Journal of Experts) for proof-reading. Ethical approval Before the study, permissions were obtained from local ethical committee.

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Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Med Science 2018;7(4):898-904

A finite element analysis of the effects of different skeletal protraction and expansion methods used in class III malocclusion treatment Serhat Ozdemir, Merve Goymen Gaziantep University Dentistry Faculty, Department of Orthodontics, Gaziantep, Turkey Received 17 May 2018; Accepted 13 July 2018 Available online 12.10.2018 with doi: 10.5455/medscience.2018.07.8897 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract This study aims to carry out an in-silico examination of the different skeletal advancement methods used in the treatment of maxillary retrusion patients. Computed tomography images of a young adolescent patient with maxillary retrusion were processed using three-dimensional medical image processing software to obtain a patientspecific model. Three different treatment scenarios were envisaged for the finite element analysis. In the first scenario, rapid maxillary expansion (RME) and face mask (FM); in the second, bone-assisted maxillary advancement and RME, and in the third, hybrid hyrax+mentoplate combination method were used. The hyrax screw was activated by 0.25mm in each model, with a force of 500g in the first scenario and 250g in the second and third scenario for each side. Von Mises stresses and the initial displacements were evaluated when different maxillary protraction methods were applied. We found that similar stress distributions were observed in the skull where the methods of RME/FM model and bone-assisted maxillary advancement were used. These stresses were higher than the hybrid hyrax+mentoplate combination method. When the displacement values were compared, anterior movement was found in the maxilla in the bone-supported model to include the middle face, while maxillary anterior movement of maxilla was detected on the Le Fort 1 level with the hybrid hyrax+mentoplate combination method. Dentoalveolar anterior movement was detected in the RME/FM model. Given the obtained stress distributions and displacement values, it has been observed that the bone-assisted maxillary advancement method provides more skeletal efficiency than the RME/FM and the hybrid hyrax+mentoplate combination methods. Keywords: Finite element, Class III, mentoplate, hybrid hyrax, facemask

Introduction Patients with skeletal Class III anomaly are admitted to orthodontic clinics due to aesthetic problems and chewing disorders. Skeletal Class III anomaly may present as maxillary retrusion, mandibular protrusion, or a combination of both. Studies show that the prevalence of maxillary retrusion in patients with skeletal Class III anomalies is in the range of 19.5-37.5% [1]. Successful results have been obtained using facial masks (FM) in the treatment of skeletal Class III anomalies associated with maxillary retrusion. With the FM treatment, a frontward force is applied to the maxilla to promote its growth by activating the circum-maxillary sutures [2]. Frequent use of the support of the teeth in the mixed dentition period as an intraoral anchorage unit for traditional FM often poses a number of disadvantages. Undesirable effects such as mesialization of the maxillary teeth, extrusion of the maxillary molar teeth, counter-clockwise rotation in the maxilla, clockwise Coresponding Author: Merve Goymen, Gaziantep University Dentistry Faculty Department of Orthodontics, Gaziantep, Turkey E-mail: mervegoymen@gmail.com

rotation in the mandibula, and increase in face length are seen with dental supported FM [3-5]. The fact that this equipment requires absolute cooperation creates a separate disadvantage. Lately, investigators have been leaning towards skeletal anchorage to reduce or eliminate these unwanted effects [6,7]. In their study, De Clerck et al. placed mini-plates in the zygoma and between the mandibular canine, lateral incisor teeth on both sides and obtained protraction in the maxilla by applying intermaxillary elastics from these plates [6]. By applying direct force to the maxilla and mandibula with this method, they argued that pure orthopedic motion was obtained without dental side effects [6]. The disadvantages of this method are the need for surgical operation when plates are inserted and removed, and the fact that it is not recommended to perform the procedure before the eruption of the lower permanent canine teeth [6]. As an alternative to this technique, Benedict Wilmes applied two mini-screws to the anterior palatal region of the maxilla and fastened the rapid maxillary expansion (RME) screw to the mini-screws in the anterior and to the molar teeth in the posterior. In the mandibula, he inserted a single plate in the menthone region in the apical of the incisor teeth, and administered intermaxillary elastics from the 898

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upper molars to the two incisures on both sides. He stated that fewer surgical procedures were applied by placing two miniscrews in the anterior palate and placing plates one by one instead of two at a time in the mandibular region rather than the surgical placement and removal of miniplates placed on the right and left side of the zygomatic crests in the maxilla. He argued that this results in elimination of the dental side effects of both RME and maxillary protraction and achieving an effective maxillary advancement through early treatment before the lower permanent canine eruption [8]. When examining the literature, it is seen that studies reporting the treatment of Class III skeletal anomalies with skeletal anchorage methods are limited and the effects of these new methods are not yet known. Was the force really being transferred to the skeleton structures thanks to the screws on the palate, as argued by Wilmes? In current literature, although many new methods are suggested, no comparative results have been mentioned with conventional methods. The purpose of this study is to compare the effects of skeletal advancement methods applied to the maxilla with two different techniques (hybrid hyrax-mentoplate combination) with those of conventional FM in terms of stress and bone displacement. Material and Methods Computed tomography (CT) images of a young adolescent (10-year-old) patient with maxillary retrusion and Class III malocclusion (Wits: -5.8, N-A: -6.5mm) treated at the Orthodontics Department of Gaziantep University’s Dentistry Faculty received in the format of Digital Imaging and Communications in Medicine (DICOM) imagery with a cross-sectional thickness of 0.625mm were processed using three-dimensional (3D) medical image processing software (Materialise’s Interactive Medical Image Control System (MIMICS)) (Materialise, Leuven, Belgium) and a patient-specific 3D model was obtained. The maxilla, mandibula and teeth were separated by color assignment (mask thresholding) to all pixels in the range of specific Hounsfield Units (HU) values. HU values are defined with different limit values depending on the tissue type or whether the patient is an adult or not. With low threshold values, soft tissues (connective tissue, vessels, etc.) and with high threshold values, dense bones (teeth, cortical bone, etc.) can be masked. When constructing the periodontal ligament, the dental roots were given a thickness of 0.30 mm and then the PDL was created by obtaining the original shape of the teeth from this 3D model [9]. Later, all of the teeth were cut one by one according to their boundaries from the collum dentis and their PDL structures were obtained. On the raw CT images, the HU value was set to -1024/315 and the Temporamandibular Joint (TMJ) model was obtained roughly by creating a point cloud of the condyle head and glenoid fossa. Then, the exact TMJ model was obtained through checks according to the coronal, axial and sagittal sections and determining the incision lines. The regions where the condyle head and glenoid fossa were located were removed by Boolean operation to obtain the TMJ model that overlaps with the boundary anatomies. Drawings were made of the expanders, screws, mini-plates and bands using the Computer Aided Three-Dimensional Interactive Application (CATIA) (Dassault Systemes Simulia Corp.,

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Providence, RI, USA) run on a professional CAD/CAM-based software. All parts were prepared for the analysis model. The face mask was scanned using the Steinbichler Comet 5 4MP (Carl Zeiss OptotechnikGmbh Neubeuern, Germany) system method and transferred to the computer for finite element analysis. The Altair Hypermesh (Altair Engineering, Inc., Michigan, USA) software was used to make all the components interoperate and the analysis program Dassault Sytemes Abaqus 6.14 was utilized. A model of skull finite elements consisting of 4,250,445 tetrahedral elements and 828,747 nodes was obtained. Each of the models forming the structure was given a material (elastic modulus and Poisson’s ratio) value describing their physical properties to define the dental structures of the created model, the bone and other regions in the software. (Table 1) Table 1. Material Specifications (17, 34) Material

Young Module

Poisson Ratio

1,37 x 104

0.26

33 x 103

0,30

Teeth

1,96 x 104

0.30

Periodontal Ligament

2,70 x 104

0.45

Miniplak, screw, expander, molar band 1

1,05x105

0.35

Cortical bone Cancellous bone

The model needs to be fixed for a finite element analysis to be carried out. For this reason, the degrees of freedom on the appropriate parts of the model should be restricted. In our study, the same basic model was fixed at the foramen magnum [10], three different installations were planned, and the study was carried out on three models. In the first model, a hyrax screw was used, which received support from the maxillary second deciduous molar tooth and the first permanent molar tooth on the model. Together with the RME, a force of 500g was given to each side so as to make an angle of 30° downward from the occlusal plane from the FM and the canine region in the buccal [11]. Simultaneously, the RME was activated at 0.25mm. In the second model, a hyrax screw was applied to the model supported by the first permanent molar tooth and the second deciduous molar tooth in a similar way to the first model. Four plates were placed on the infrazygomatic crest of the maxilla between lateral incisor teeth in the mandibula and the canine teeth [12]. The plaques were secured to the bone with two screws on the lower jaw and three screws [20] on the upper jaw, which are 5mm long with a diameter of 2.3 mm. A force of 250g [13] was applied to each side. Simultaneously, the RME was activated at 0.25mm. On the third model, two mini-screws were placed on the model on the anterior of the palate, 2mm in width and 9mm in length, parallel to each other and adjacent to the median suture with 2mm in alignment with the premolar teeth [8, 14]. The hyrax was adapted to these two screws and molar bands on the first molar tooth (Table 2) (Figure 1). One mini-plate was inserted into the lower jaw horizontally into the apical region of the incisor teeth with four screws [14], 2 mm wide and 5 mm long. At the mucogingival level, the incisures were extended through the canine lateral teeth and a force of 250g [14] 899

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was applied to these incisures from the upper molars for one side. The RME was activated at 0.25 mm. (Table 2) (Figure 1) Table 2. Identification of treatment modalities Scenario Treatment Model No.

Force Force Direction Application

Rapid Maxillary Expansion + Facemask

500g

30Â° to occlusal plane

Rapid Maxillary Expansion + BoneAssisted Maxillary Advancement

250g

from miniplate to miniplate

Expansion with Hybrid Hyrax + Maxillary Advancement using Mentoplate

250g

from molar band to mentoplate

Figure 1. Treatment modalities and directions of force application (a) treatment scenario 1 (b) treatment scenario 2 (c) treatment scenario 3

Med Science

tooth). The high von Mises stress values measured here decreased towards the zygomatic arc and the glabella and ended in the frontal bone (Figure 2-b). An analysis of treatment model 2 showed that von Mises stress values were the highest in the second deciduous molar mesial alveolar crest. Decreasing upwards, forwards and backwards, they reached a value of 15-20 MPa in the frontonasal suture in the infrazygomatic area and in the zygomaticotemporal region in the frontozygomatic area (Figure 2-c). The highest von Mises stress value in the cortical bone was measured as 135.2MPa in the maxillary bone in the mesial of the left deciduous second molar tooth. The von Mises stress values in the buccal cortical bone region were high in the maxillary buccal bone region located between the canine tooth and the permanent first molar tooth. The high von Mises stress values measured here decreased towards the zygomatic arc and the glabella and ended in the frontal bone (Figure 2-d). When treatment 3 model was examined, it showed that the von Mises values were high in the alveolar crest in the buccal of the posterior teeth and in the zygomatic crest as they decreased upwards and forwards. The Von Mises values ended at the zygomatic protrusion of the glabella frontal bone. The values were measured at approximately 10MPa in the frontonasal suture and zygomaticofrontal suture and the infraorbital area. In the lateral examination, the highest stress was measured at 40MPa in the mesial of the permanent first molar tooth socket. The value decreased forward and upward, while it increased again in the alveolar crest in the canine area. It was in the region of 10-15MPa around the zygotico-maxillary suture and the frontonasal suture (Figure 2 d-e).

RESULTS In our study, the Von Mises stresses on the maxillary complex were evaluated when three different maxillary protraction methods were applied. In addition, movements in three planes of space in maxilla (X-axis represent the transversal plane, Y-axis the sagittal plane and Z-axis the vertical plane) were evaluated. The results of all the measurements were given as colored figures. In these images, each color corresponds to a numerical value. The color corresponding to each value was indicated on the left side of the figures. Stresses in our study were referred to as MPa and displacements as mm. The results of the analysis made in treatment model 1 showed von Mises stress in the buccal region of the maxillary posterior teeth. The von Mises values gradually decreased upwards, forwards and backwards, and ended in alignment with the glabella and frontozygomatic suture above, in the pterygoid processes in the posterior, and in the anterior nasal spinal region in the anterior. The von Mises values varied between 10-17.5MPa zygomaticomaxillary and frontonasal suture (Figure 2-a). Following a frontal examination and analysis, the highest von Mises stress value was measured as 136.5MPa in the maxillary cortical bone in the mesial of the second left deciduous molar tooth. The von Mises stress values were particularly concentrated in areas where the FM was applied (the region from the first permanent molar to the canine

Figure 2. Von Mises stress values of treatment types (a) lateral view of treatment scenario 1 (b) frontal view of treatment scenario 1 (c) lateral view of treatment scenario 2 (d) frontal view of treatment scenario 2 (e) lateral view of treatment scenario 3 (f) frontal view of treatment scenario 3

In the treatment 1 model, the displacements observed on the X-axis, the highest value being 12529x10-5mm, occurred in the alveolar crest aligned with the permanent molar tooth and the 900

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second deciduous molar. The movement on the X-axis gradually decreased towards the anterior, posterior, and superior, ending in the lateral tooth socket in the front, in the zygomatic diaphysis above and the pterygoid process behind. In the anterior, the X-axis displacement value was measured as zero (Figure 3-a). Looking at the displacement from the Y-axis, it was observed that the maximum movement was 63x10-5 mm in the posterior region of the alveolar crest. Anterior motion was observed in the frontal exit of the maxillary bone and in the zygomatic diaphysis with gradual decrease in the value upwards, forwards and backwards. In ANS and PNS, the amount of anterior movement was equal and measured as approximately 20x10-5 mm (Figure 3-b). In the treatment model 1, there was a vertical downwards movement in the anterior, posterior and alveolar of the maxillary complex. The highest value was measured as 70560x10-5 mm at the ANS point and the anterior region of the maxillary. The amount of downward motion in the posterior region was 1291x10-5 mm. The vertical movement reached up to the frontonasal suture (Figure 3-c). In the treatment 2 model, the transversal displacement in the maxillary complex was made to decrease gradually forwards, backwards and upwards where the molar region became the alveolar crest center as in the treatment 1 model and the highest value was measured as 12544x10-5 mm in the molar alveolar crest. In the anterior maxilla, the value was zero (Figure 3-d). It was observed that the displacement movement in the sagittal plane spread more than the maxillary complex. The forward maxillary movement showed a gradual decrease from the alveolar upwards, extending to the suture naso-maxillary above in the anterior and to the upper border of pterygoid processes behind. The highest values were 63x10-5 mm in the alveolar crest and decreased to as low as 13x10-5 mm in the upper limit (Figure 3-e). In the vertical displacement assessment, treatment model 2 showed a great similarity to model 1. The highest values were 7017x10-5 mm in the vicinity of the anterior nasal spine and downwards and 1291x10-5 mm in the posterior (Figure 3-f).

Figure 3. Displacement values of treatment types (a) x-axis of treatment scenario 1 (b) y-axis of treatment scenario 1 (c) z-axis of treatment scenario 1 (d) x-axis of treatment scenario 2 (e) y-axis of treatment scenario 2 (f) z-axis of treatment scenario 2 (g) x-axis of treatment scenario 3 (h) y-axis of treatment scenario 3 (i) z-axis of treatment scenario

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In the treatment model 3, displacement values on the X-axis started at 15481x10-5 mm with the molar tooth taking the central location and continued downwards, forwards and backwards, extending to the frontal exit of the zygomatic bone. The anterior value was zero (Figure 2-g). At the Y-axis a forward motion in the maxilla caught our attention at Le Fort 1 level with almost a homogeneous intensity. The highest value was 63x10-5 mm (Figure 2-h). For the Z-axis displacement values, there were equal values in the anterior and posterior of the maxilla and it was downwards at about 1291x10-5 mm. The anterior vertical movement was limited only to the area under the nasal floor (Figure 3-i). Discussion According to Wolff’s Law, bones will adapt to the stresses under which they are placed [15]. The functional changes in the bone are related to changes in the internal and external structures of the bones. Depending on the stress, the bones may become elongated, shortened or stretched [15,16]. In a study, Lee et al. [17] evaluated the application of protraction with two different methods using the finite element analysis via two mini-plates, one of which was inserted into the infrazygomatic crest, and the other into the outer edge of the nasal wall for the maxilla. They found a forward and downward maxillary movement in the simulation with the mini-plate placed outside the nasal wall, while the maxilla was found to rotate counterclockwise in the maxillary protraction on the infra-zygomatic area. Yan et al. [18] compared a maxillary protraction performed with skeletal and dental anchorage support using a finite element analysis. The dental anchorage was taken from the permanent first molar tooth and the skeletal anchor was taken from the infra-zygomatic region. The effects of the protraction forces applied at 0°, 10°, 20° and 30° angles on the two models downward from the occlusal plane were evaluated and as a result, it was found that the maxilla moves forward and downward without rotation through the application of a proximal force applied downwards for the skeletal support by 20° from the occlusal plane and by 30° for the dental support. In a finite element analysis, Tanne et al. [19] exerted force with a magnitude of 1000g on the maxillary through the first molar teeth and another force within the range of + 90° to -90° downward and upward from the occlusal plane and they determined that the rotation was removed when a force of 30° was applied downward from the occlusal plane. Katada et al. [20] conducted a finite element analysis when they applied a force of 1000g on the maxilla to be parallel to the occlusal plane from the permanent first molar tooth, and as a result, they found that the maxilla rotated counterclockwise. In a finite element analysis, Yu et al. [21] found that the counter-clockwise rotation of the maxilla was minimal when force was applied from the first premolar tooth with an angle of 20° downward from the occlusal plane. In a finite element analysis, Gautam et al. [10] performed maxillary protraction with a force of 1000g applied at the level of the canine teeth with an angle of 30° from the occlusal plane and they found that the maxilla rotated counter-clockwise. In this study, a downward movement of the maxilla was observed in the anterior and posterior regions on the Z-axis where vertical direction movements were evaluated under treatment model 1. The amount of downward movement around the spina nasalis anterior was less than that of the posterior, and therefore there was 901

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clockwise movement on the maxillary plane. Results similar to the first treatment model were obtained from the second treatment model. For the first model, there was little difference in the amount of movement (39x10-5mm), while in the second model there was clockwise rotation on the maxillary plane. In the third model, the amount of motion in the anterior and posterior regions was equal and there was no rotation on the maxillary plane. It was thought that this result was due to the fact that the skeletal anchorage is greater in the third model. We found that the maxilla rotated clockwise in the model where the FM was applied downwards from the occlusal plane at an angle of 30° and that the maxilla also rotated clockwise with the boneassisted maxillary protraction method and that the maxilla did not rotate with the hybrid hyrax mentoplate combination method. When evaluated in terms of the rotation of the maxillary plane, the hybrid hyrax/mentoplate model can be considered to be more advantageous than the other two methods. In the comparison of displacement values in our study, transversal changes occurred at very similar boundaries and the values on the X-axis for treatment models 1 and 2, while the changes in the third model extended to the upper and lower parts of the skull and the value at the center of motion (the circumference of the permanent molar teeth in model 3, the circumference of the second molar deciduous teeth, and the permanent molar teeth in the first two models) was greater in model 3. The transversal movement ended at the front of the maxilla. From these data, it can be said that the hybrid hyrax is more efficient for the transversal expansion process. Different distributions have taken place for the three models on the Y-axis, on which the forward movement of the maxilla has been evaluated. In the first treatment model, the highest motion occurred at the top of the alveolar crest and was concentrated in the crest in the canine tooth region. While the anterior movement reached the end of the frontal protrusion of the maxillary, it did not extend above the processus alveolaris in the posterior region. When these movements in the first model are examined, it is thought that molar teeth are exposed to motion and dragged forward, and that skeletal effect is more intense at the dentoalveolar level. It was seen that the forward movement of the maxilla in the second treatment model was more homogeneous in the alveolar process and that the first model had the highest value. It decreased gradually upwards, and in contrast to the first model, a more homogeneous movement occurred in the posterior maxilla. In the second model, the forward skeletal movement of the maxilla was much higher than that of the first model. The absence of localized areas of motion in the bone surrounding the teeth suggests that the movement in the teeth is only parallel to the maxillary motion. The maxilla’s forward movement was deep enough to cover the middle front. The amount of anterior movement of the maxilla in the third treatment model was equal in all areas under the zygomatic bone of the maxilla and was found to be the highest value and the same as the highest value of the first two models. The motion was homogeneous and higher, though lower than the first two models, and there was no separate density in the bones around the teeth. Although there were no dental side effects, the movement at Le Fort 1 level suggests that the positive effect on the middle front was lower compared with the second model.

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Tanne et al. [19] applied a protraction force of 1000g over the permanent first molar teeth from different directions and they found that the stress distributions were scattered. They reported that the most uniform distribution in the sutures was obtained at an angle of 30° to the occlusal plane. In another finite element analysis, Tanne et al. [22] applied force on the maxilla in alignment with the molar teeth and in parallel to the occlusal plane downwards at an angle of 30° and found that the stress distribution in the sutures was not uniform for both cases. In a finite element analysis, Tanne and Sakuda [23] applied a protraction force of 1000g in parallel to the occlusal plane from the region of the first permanent large molar teeth and they found stress in the bones around the zygomatico-maxillary, and the fronto-zygomatic and frontonasal sutures, as well as in the zygomatic maxillary and the frontonasal sutures. At the same time, they reported seeing high levels of strain on the maxillary bone side of the zygomaticmaxillary suture. Gautam et al. [24] found that the highest von Mises stress values were in the sphenozygomatic, zygomaticomaxillary and zygomatico-temporal sutures, respectively, in a finite element analysis study with RME and RME performed with a 30° angle and a protraction force of 1000g. The lowest stresses were found in internasal and nasomaxillary sutures. According to the authors, the different pushing and pulling strains in the sutures are the horizontal protraction force applied on the maxillary. Yan et al. [18] compared a maxillary protraction performed with skeletal and dental anchorage support using a finite element analysis. The dental anchorage was taken from the permanent first molar tooth and the skeletal anchor was taken from the infra-zygomatic region. The effects of the protraction forces applied at 0°, 10°, 20° and 30° angles on the two models downward from the occlusal plane were evaluated and higher values of straining were seen in the zygomatico-maxillary, zygomatico-temporal and pterygopalatine sutures in the skeletal supported model with the same force vector in comparison to the tooth supported model. The opposite was true in the case of the nasion and nasal ala. Based on these findings, the authors stated that there was stress that would induce growth in the sutures of the maxilla posterior with the skeletal-supported maxillary protraction and as for dental-assisted protraction, more osteogenesis activity occurred in the nasal region, and the profile reflection was better. In a limited element analysis in 2012, Lee and Baek [25] performed protraction with mini-plates placed in the maxillary aperturapiriformis and the infra-zygomatic region and as a result, the stress in the frontonasal and frontomaxillary and zygomatico-maxillary and pterygomaxillary sutures was found to be higher in the model with the infrazygomatic plate than in the model supported by the aperture piriformis region. Similarly, in parallel with the findings of Tanne and Sakuda [23] and Gautam et al. [10], the highest von Mises stress values in both models were seen in the pterygomaxillary, zygomatico-temporal, zygomaticomaxillary and frontonasal sutures, respectively. The stress distributions for the three models in our study were very similar to these studies, and were focused in the bones around the frontonasal, frontozygomatic, and zygomaticomaxillary sutures. Contrary to these studies, we think that excessive accumulation of stress in the buccal alveolar bone emanates from the RME. In our study, it was observed that the stress distribution in the first and second treatment simulations were very close to each other. In particular, the similar stress distribution in the areas directly 902

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affected by the RME showed consistency with the same amount of activation for the same expansion system. Stress distribution was almost the same for models 1 and 2, but at some points (in the zygomatic bone, frontonasal suture, frontozygomatic suture and zygomatic bone), a more intense stress distribution occurred in the bone-supported proximal model. The stress distributions in the hybrid hyrax model were lower than those in the first and second models. Especially striking were the lower stress levels in the frontonasal suture, the zygomatic bones and around the zygomatico-maxillary sutures compared to other models. The fact that the stress increased in model 3 in the mesiobuccal socket of the permanent molar tooth suggests that the protraction force was not indirectly transmitted to the maxillary bone, with the hyrax screw concentrating instead in the alveolar crest.

Referance

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Williams S, Aarhus CA. The morphology of the potential Class III skeletal pattern in the growing child. Am J Orthod Dentofac Orthop. 1986;89:302-11.

Sung SJ, Baik HS. Assessment of skeletal and dental changes by maxillary protraction. Am J Orthod Dentofac Orthop. 1998;114:492-502.

Cha K-S. Skeletal changes of maxillary protraction in patients exhibiting skeletal Class III malocclusion: a comparison of three skeletal maturation groups. Angle Orthod. 2003;73:26-35.

Franchi L, Baccetti T, McNamara JA. Postpubertal assessment of treatment timing for maxillary expansion and protraction therapy followed by fixed appliances. Am J Orthod Dentofac Orthop. 2004;126:555-68.

Hägg U, Tse A, Bendeus M, et al. Long- term follow-up of early treatment with reverse headgear. Europ J Orthod. 2003;25:95-102.

The limitation of this study is that the study was carried out in the laboratory and only gives the stress distribution and displacement values when force was first applied. Clinical randomized controlled studies to be performed in the future may better clarify this issue.

De Clerck HJ, Cornelis MA, Cevidanes LH, et al. Orthopedic traction of the maxilla with miniplates: a new perspective for treatment of midface deficiency. J Oral Maxillofac Surg. 2009;67:2123.

Klempner LS. Early orthopedic Class III treatment with a modified tandem appliance. J Clin Orthod. 2003;37:218-23.

Conclusion

Wilmes B, Nienkemper M, Ludwig B, et al. Early Class III Treatment with a hybrid hyrax-mentoplate combination. J Clin Orthod. 2011;45:15-21; quiz 39.

Yang I-H, Chang Y-I, Kim T-W, et al. Effects of cleft type, facemask anchorage method, and alveolar bone graft on maxillary protraction: a threedimensional finite element analysis. Cleft Palate-Craniofac J. 2012;49:221-9.

In the RME + FM model, anterior movement occurred mostly in the alveolar protrusion and the frontal region of the maxillary bone, while maxillary advancement at Le Fort 2 level occurred in the bone-assisted maxillary advancement model. Hybrid hyrax mentoplate combination model showed progress at Le Fort 1 level. It was seen that the undesired mesialization movement of the posterior teeth in the maxilla occurred in the RME + FM group and not in the other two models. In the RME + FM model and in the bone-assisted maxillary advancement model, the maxillary plane rotation was clockwise, while there was no rotational movement in the hybrid hyrax mentoplate combination model. Considering the maxillofacial complex, it was found that the stress values in the RME + FM model were similar to the bone-supported maxillary advancement model and at higher levels than in the hybrid hyrax mentoplate model. Given the obtained stress distributions and displacement values, it seems that the bone-assisted maxillary advancement method may provide more skeletal efficiency than the rapid upper jaw expansion/face mask and the hybrid hyrax + mentoplate combination methods. It is considered that the hybrid hyrax mentoplate combination method cannot be as effective as the bone-assisted maxillary advancement method on the middle front because of the anterior movement being limited to the lower parts of the maxilla. Acknowledgments This article is based on some of the findings of the master’s thesis of the first author. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

10. Gautam P, Valiathan A, Adhikari R. Skeletal response to maxillary protraction with and without maxillary expansion: a finite element study. Am J Orthod Dentofac Orthop. 2009;135:723-8. 11. Ngan PW, Hagg U, Yiu C, Wei SH, editors. Treatment response and longterm dentofacial adaptations to maxillary expansion and protraction. Semin Orthod. 1997, Elsevier. 12. Esenlik E, Ağlarcı C, Albayrak GE, et al. Maxillary protraction using skeletal anchorage and intermaxillary elastics in Skeletal Class III patients. Korean J Orthod. 2015;45:95-101. 13. Hino CT, Cevidanes LH, Nguyen TT, et al. Three-dimensional analysis of maxillary changes associated with facemask and rapid maxillary expansion compared with bone anchored maxillary protraction. Am J Orthod Dentofac Orthop. 2013;144:705-14. 14. Katyal V, Wilmes B, Nienkemper M, et al. The efficacy of Hybrid HyraxMentoplate combination in early Class III treatment: a novel approach and pilot study. Aust Orthod J. 2016;32:88. 15. Choi D-S, Cha B-K, Jang I, et al. Three-dimensional finite element analysis of occlusal stress distribution in the human skull with premolar extraction. Angle Orthod. 2012;83:204-11. 16. Frost HM. Wolff’s Law and bone’s structural adaptations to mechanical usage: an overview for clinicians. Angle Orthod. 1994;64:175-88. 17. Lee K-G, Ryu Y-K, Park Y-C, et al. A study of holographic interferometry on the initial reaction of maxillofacial complex during protraction. Am J Orthod Dentofac Orthop. 1997;111:623-32. 18. Yan X, He W, Lin T, et al. Three-dimensional finite element analysis of the craniomaxillary complex during maxillary protraction with bone anchorage vs conventional dental anchorage. Am J Orthod Dentofac Orthop. 2013;143:197-205. 19. Tanne K, Hiraga J, Sakuda M. Effects of directions of maxillary protraction forces on biomechanical changes in craniofacial complex. Europ J Orthod. 1989;11:382-91. 20. Katada H, Katada H, Isshiki Y. Changes in orthodontic cephalometric reference points on application of orthopedic force to jaw: three-dimensional finite element analysis. Bull Tokyo Dent Coll. 2005;46:59-65.

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21. Yu HS, Baik HS, Sung SJ, et al. Three-dimensional finite-element analysis of maxillary protraction with and without rapid palatal expansion. Europ J Orthod. 2007;29:118-25.

24. Gautam P, Valiathan A, Adhikari R. Maxillary protraction with and without maxillary expansion: a finite element analysis of sutural stresses. Am J Orthod Dentofac Orthop. 2009;136:361-6.

22. Tanne K, Hiraga J, Kakiuchi K, et al. Biomechanical effect of anteriorly directed extraoral forces on the craniofacial complex: a study using the finite element method. Am J Orthod Dentofac Orthop. 1989;95:200-7.

25. Lee N-K, Baek S-H. Stress and displacement between maxillary protraction with miniplates placed at the infrazygomatic crest and the lateral nasal wall: a 3-dimensional finite element analysis. Am J Orthod Dentofac Orthop. 2012;141:345-51.

23. Tanne K, Sakuda M. Biomechanical and clinical changes of the craniofacial complex from orthopedic maxillary protraction. Angle Orthod. 1991;61:145-52.

26. Gautam P, Zhao L, Patel P. Biomechanical response of the maxillofacial skeleton to transpalatal orthopedic force in a unilateral palatal cleft. Angle Orthod. 2011;81:503-9.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Med Science 2018;7(4):905-9

The effect of education and 4-year experience in the evaluation of preanalytical process in a clinical chemistry laboratory Medine Alpdemir1, Mehmet Fatih Alpdemir1, Zulfiye Akil2 Balıkesir State Hospital, Ministry of Health, Department of Clinical Biochemistry, Balıkesir, Turkey 2 Education Unit of Hospital, Balıkesir State Hospital, Ministry of Health, Balıkesir, Turkey

Received 28 May 2018; Accepted 18 July 2018 Available online 26.09.2018 with doi:10.5455/medscience.2018.07.8881 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Preanalytical errors have an important ratios in all laboratory processes. To reduce laboratory errors, the IFCC working group on Laboratory Errors and Patient safety (WG-LEPS) developed laboratory quality indicators (QIs) for the preanalytical process. The purpose of this study is to evaluate QIs of the preanalytical process over a 4-year period and show the effect of education. In this study, Balıkesir State Hospital biochemistry laboratory were retrospectively evaluated as rejected sample for four years (between 1st of January 2014 – 31st of December 2017). We examined QIs for preanalytical processes such as; misidentification errors (QIs-5), unintelligible test requests (QIs-6), lost-not received samples (QIs-7), incorrect container/tube (QIs-9), samples hemolyzed (QIs-10), sample clotted (QIs-11), insufficient sample volume (QIs-12), incorrect sample type (QIs-13, unsuitable transportation (QIs-14) and improperly labeled tube (QIs-15). In our hospital, regular training is given to hospital staff and laboratory staff at least twice a year for sample taking, specimen storage and transfer training, as well as laboratory staff, laboratory processes and management of improperly sample. In our study, the preanalytical process error frequency was 0.64%, 0.63%, 0.58% and 0.76% for all years respectively. It is seen that the most frequent error frequency is clotted sample (0.31, 0.32, 0.28 and 0.27 respectively). Other the most common errors was insufficient sample and incorrect container/tube (0.18, 0.15, 0.12, 0.07 and 0.18, 0.07, 0.07, 0.03, respectively). Our results were well below the optimum values recommended by IFFC-WG-LEPS. In order to achieve all these desired goals for QI, the training process must be sustainable and standardized and repeated at appropriate intervals. Keywords: Laboratory preanalytical errors, quality indicators, laboratory process, laboratory error management, education

Introduction The preanalytical phase, which encompasses all the activities necessary to obtain an appropriate biological sample, is an important part of the total test process [1]. Preanalytical errors constitute 60-70% of errors in the total test process. Clinical laboratories also need to be aware of the error rates in order to determine the level of risk, to perform the necessary remedial actions, and to ensure comparability between laboratories. The IFCC WG-LEPS has also developed quality indicators to detect and reduce errors in laboratory processes and to provide interlaboratory harmonization at the same time [2]. In addition, The European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) identified the objectives of the preanalytical phase working group (WG-PRE) for the standardization of the *Coresponding Author: Medine Alpdemir, Balıkesir State Hospital, Ministry of Health, Department of Clinical Biochemistry Balıkesir, Turkey E-mail: bitigic@hotmail.com

main preanalytical phase steps (such as test request, transport and storage, patient preparation, sample intake, management of inappropriate samples, QIs, patient identification, pediatric- newborn sample intake) and harmonization [3]. It is important to be aware that the most important sources of error in the laboratory diagnosis are the fact that they occur in the preanalytical phase. In this process it is important to develop the laboratory quality culture, to maintain the training activities and to ensure harmonization. Reducing preanalytical error rates, avoiding misdiagnosis and malpractice, adapting to service quality standards, increasing patient and employee safety, and avoiding workload and economic losses are achieved through regular education [4]. Thus, the preanalytical process may be appropriate, effective and standardized. We aimed to evaluate the efficacy of preanalytical process and education in a clinical laboratory for 4 years, starting from these reasons for our study.

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Materials and Methods

Table 1. Total and rejected samples by years Years

2014

2015

2016

2017

Number of samples rejected

3371

3850

3886

3700

530504

613160

671001

489156

0.64

0.63

0.58

0.76

Ratio (%)

Med Science 2018;7(4):905-9

Table 2. Quality indicators of preanalytical phase and calculation formulas

This study was made retrospectively. The samples number in the time period between 1 January 2014-30 December 2017 were obtained by laboratory information system of the Balikesir State Hospital. Table 1 was given rejected sample number for four years.

Total number of samples

We analyzed that identification errors (QIs-5), test request errors (QIs-6), loss-sample rejection (QIs-7), incorrect container/tube (QIs-9), hemolyzed sample (QIs-10), clotted sample (QIs-11), inadequate sample volume (QIs-12), incorrect sample type (QIs13), improper transfer (QIs-14) and improperly labelled tube (QIs15). The results were evaluated as percentage. The calculation formulas for each QIs are given in table 2. Laboratory QIs performance was classified as optimal, desirable, minimum, and unacceptable in according to IFCC WG-LEPS quality objectives (Table 4) (5). The error rates of QIs according to years for the preanalytical process are showed in figure 1.

Quality indicators (QIs)

Calculation formula

QIs-5

Percentage of: Number of misidentified samples/Total number of samples.

QIs-6

Percentage of: Number of unintelligible requests/Total number of requests

QIs-8

Percentage of: Number of samples lost- not received/ Total number of samples.

QIs-9

Percentage of: Number of samples collected in wrong container/Total number of samples.

QIs-10

Percentage of: Number of samples with hemolyzed (clinical chemistry)/Total number of samples (clinical chemistry)

QIs-11

Percentage of: Number of samples clotted/Totalnumber of samples with an anticoagulant

QIs-12

Percentage of: Number of samples with insufficient sample volume/Total number of samples.

QIs-13

Percentage of: Number of samples of wrong or inappropriate type (i.e. whole blood instead of plasma)/Total number of samples.

QIs-14

Percentage of: Number of samples transported at inappropriate /Total number of samples.

QIs-15

Percentage of: Number of unlabelled samples/Total number of samples.

Table 3. Training plan and frequency by staff groups Staff

Training topics

Training frequency

Doctor

Laboratory processes Appropriate utilization of clinical laboratory tests

Twice a year

Nurse

Test request Sample collection Sample storage and transfer Patient preparation

Twice a year (intermediate trainings when needed)

Phlebotomist

Sample collection Sample storage and transfer Patient preparation

Twice a year (intermediate trainings when needed)

Laboratory technician

Blood collection Sample storage and transfer Management of improper samples Laboratory processes (QÄąS) Laboratory safety

Twice a year (intermediate trainings when needed)

Sample transfer staff

Sample storage and transfer

Twice a year (intermediate trainings when needed)

The laboratory test groups are eight types, including clinical chemistry (metabolites, enzymes, electrolytes, lipids, drug levels), glycated hemoglobin (HbA1c), immunoassays (thyroid function tests, fertility hormones, tumor markers, cardiac markers), hematology (22 parameter cell blood count), coagulation (prothrombin time, active partial thromboplastin time, fibrinogen, D-dimer), erythrocyte sedimentation rate (ESR), urinalysis (chemical and sediment analysis), stool (fecal occult blood test) and blood gases. Personnel trainings were conducted regularly at least once, as indicated in table 3. The effectiveness of the trainings was

Evaluation of training effectiveness

Pre-Test ve Post-Test applications

evaluated by pre-post application. 70% of 116 doctors, 93% of 791 nurses, 100% of 30 laboratory technicians, 88% of 369 medical secretaries and 85% of 400 sample transfer personnel were trained. The effectiveness of training was assessed the according to the percentage of correct answers before and after the training. Additional training was given to subjects whose post-test was less than 80% correct. Laboratory quality indicators were evaluated every three months. In this evaluation, sub-analysis were made according to the place where the error was made, according to occupational groups. According to this, additional trainings were organized. Training plans were evaluated by laboratory experts and the education committee. 906

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Med Science 2018;7(4):905-9

Table 4. Assessing the frequency of QIs according to years for the preanalytical process Pre-analytical error

IFCC

QIs

2014

2015

2016

2017

Opt

Des

Min

Una

QIs-05

0.01

<0.40

0.40-0.50

0.51-0.60

>0.60

Inintelligible test requests

QIs-06

0.01

0.00

<0.2

0.2-0.25

0.41-0.50

>0.50

Lost-not received samples

QIs-08

0.02

0.01

0.04

<0.2

0.20-0.40

0.41-0.60

>0.60

Incorrect container/tupe

QsI-09

0.18

0.07

0.03

<0.07

0.07-0.113

0.114-0.20

>0,20

Samples hemolyzed

QIs-10

0.14

0.12

0.08

0.18

1.0-1.5

1.6-2.0

>2.0

Samples clotted

QIs-11

0.31

0.32

0.28

0.27

<0.5

0.5-1.0

1.1-2.0

>2.1

Insufficient sample volume

QIs-12

0.18

0.15

0.12

0.07

<0.4

0.40

0.81-1.2

>1.20

Incorrect sample type

QIs-13

0.08

0.04

0.02

<0.2

0.20-0.30

0.31-0.40

>0.40

Unsuitable transportation

QIs-14

0.01

0.02

0.01

Ä°mproperly labelled tube

QIs-15

0.03

0.05

0.04

0.03

0.16-0.20

>0.20

<0.1 <0.07

0.07-0.15

Opt: Optimum, Des: Desirable, Min: Minimum, Una: Unacceptable

Discussion IFCC WG-LEPS set acceptable performance criteria from lab QIs data obtained with the participation of international laboratories. However, it was aimed to monitor and control the activities of the entire total test process [2,5].

Figure 1. The error rates of QIs according to years for the preanalytical process Results In our study, the preanalytical process error frequency was 0.64%, 0.63%, 0.58% and 0.76%, respectively by years. When we look at all years, it is seen that the most frequent error frequency is clotted sample (QIs-11) (0.31, 0.32, 0.27 and 0.37, respectively, for years). This was followed by an incorrect container/ tube (QIs9), insufficient sample volume (QIs-12) and hemolyzed sample (QIs-10). The preanalytical process QIs error frequency was quite below the optimal values suggested by IFCC WG-LEPS (Table 4). Distribution according to the most frequently performed services of preanalytical error; blood collection units (25%), emergency services (24%), intensive care unit (20%), inpatient clinics (15%), surgery services (12%) and outpatient clinic (4%). The profession group that made the preanalytical error most frequently; nurses and laboratory technicians working in blood collection units (30%), nurses working in other services (55%), medical secretaries (10%) and sample transfer personals (5%). During the 4-year period, training was given twice a year. According to the analysis of the 3-month service error rates, additional trainings were organized to the emergency department, intensive care, outpatient clinic and blood receiving unit. The percentage of correct answers before and after the training was 62% and 91% for 2014, 85% and 96% for 2015, 84% and 97% for 2016 and 88% and 95% for 2017 respectively.

In this study, we performed an assessment of the frequency of errors in the QIs of the laboratory preanalytical processes within a 4-year period. We also assessed the effect of in-service training to increase the awareness of the preanalytical phase after graduation to health personnel and to reduce the error rates. According to the results obtained during the 4-year period, the QIs of the preanalytical phase were below the optimum rates recommended by the IFCC. There are publications showing that the prevalence of preanalytical errors in the literature is between 0.2% and 3.4% [6,7,8]. The error rate in our study was found to be 0.64%, 0.63%, 0.58% and 0.76%, respectively. The most frequent causes of errors in our study are the clotted sample (QIs-11), the insufficient sample (QIs-12), the inappropriate tube (QIs-09) and the hemolyzed sample (QIs-10). Lippi et al. found that hemolyzed samples, inadequate samples volume, and clotted samples were the most common preanalytical errors [9]. In another study, Ă&#x2013;zcan et al. determined the most frequent preanalytical errors as clotted sample and wrong sample collection [10]. Avci et al. identified the most common preanalytical errors for public health laboratories as clotted specimens, specimens that did not reach the laboratory/lost and unsuitable sample specimens [11]. Hemolyzed samples, inadequate samples, and incorrect sample taking were shown as the first three causes in the study of Plebani et al. [12]. In the study of Rattan et al. determined most frequency preanalytical errors as incorrect specimens received, hemolyzed samples and specimens not received [13]. As seen in these studies, preanalytical errors change according to the class of the laboratory or service differences. Identifying and documenting a problem for the identification of quality and quantity in laboratory medicine is an important step. The technological applications in laboratories have facilitated the follow-up and documentation of the development of the 907

doi: 10.5455/medscience.2018.07.8881

laboratory information system (LIS). In our study, it was seen that the most frequently performed parts were the blood collection unit (25%), emergency services (24%) and intensive care unit (20%). The determination of the origin of the error, the regular training according to the obtained data and the initiation of the corrective preventive action ensured to keep it below a certain level even if it does not prevent the error. Education for preanalytical process harmonization and standardization is one of the leading objectives of the international preanalytical working groups. WG-PRE was determined all stages involved in this process. In addition to, IQs defined by IFCC WGLEPS are designed to cover all steps of the pre-analytical phase [3,5]. In our training program in the light of this information, which covers the most important parts of the preanalytical phase, test request, patient identification, patient preparation, sample collection, sample transferring and storage, and management of inappropriate samples were emphasized. The pretest and posttest was used to evaluate the effectiveness of the training. When we examined the correct answer rates of pretest-posttest, pretest correct answer rates of the health care personals were low in the first year of study, but this rate has increased considerably in recent years. Many studies have shown that training reduces the frequency of errors when examining the effect on the preanalytical process. In one of these studies, Özcan et al. observed that the preanalytical error rates decreased during the following months after training [10]. In their study, however, the frequency of preanalytical error increased again in the months following the training. It has been shown that the frequency of education given as the reason for this is inadequate. In 2011-2012, Aykal et al.’s study, the training was shown to have a positive effect in the reduction of rejected samples [14]. In their study, in-service trainings on health personnel were given education concerning with the sample collection and the period before analysis, and technological developments were shared related with these processes Through these trainings, communication between laboratories and clinics has been improved, working efficiency and motivation have been increased. In another study, Avci et al. found a decrease in the preanalytical error rates in the results of the training and technological improvement carried out in the public health laboratory. Unacceptable error rates identified by QIs in the first year of this study were acceptable as a result of training in the second year [11]. In study of Avcı et al., family physicians and health care staff of the family health centers were trained about the preanalytical phases. In the their study of Lillo et al.[15], demonstrated how the numbers of preanalytical errors related to unsuitable samples in a hospital setting decrease following two improvement strategies that new technology and training activities and how their effects were measured by monitoring indicators. In their study, The set of indicators was used to monitor the improvement related to clotted, hemolyzed, insufficient, and uncollected samples. In resulting of their working, there was a reduction in all types of preanalytical sample errors by application of the improvement strategies. The indicators demonstrated that the unavailable, insufficient, and clotted samples decreased between two- and three-fold, whereas hemolyzed samples errors benefited more from these improvement strategies. In another study Arslan et al. determined the level of knowledge about this process of the phlebotomist with pretest and

Med Science 2018;7(4):905-9

posttest to reduce preanalytical errors. Training was provided to 454 health workers, many of whom were nurses. The proportion of correct answers as a result of pretest and posttest application increased from 59.1% to 92.1%. In addition, preanalytical error rate decreased from 0,6% to 0,5% after the training [4]. In our study, while the correct answer rate for the pre-test for the first year was 62%, this rate rised over 80% in the following 3 years. These results are indicated of the increased knowledge of the healthcare personnel in relation to the preanalytical process. When we examined the laboratory QIs performances in according to years in this study, it was seen that the error rates decreased year after year (except QIs-8 and QIs-10 for 2017). When we investigated reason of the error for QIs-8, the hospital information system in our hospital was changed in this year, resulting in a higher QIs-8 error rate. The reason for the increase in the error rate for QI-10 was caused by the increase in the summer term (one month) the number of trainee students in the emergency service. The additional training is given to the emergency medical staff and trainee students to reduce the error rate in the next month. In our study, the determined QIs by IFCC- WG-LEPS according to the recommended performance targets, only QIs-9 was in the minimum range (0.114-0.20) in 2014 year and then decreased to the desirable level (0.07-0.113) in 2015 and 2016 years. QIs-9 error rate reached an optimal level (<0.07) in 2017 years. We think that the error rates of examined all QIs in our study are very good levels because of the effectiveness of the applied education policy. In order to control the preanalytical process, the implementation of regular training program for healthcare professionals should needed to identify, detect and monitor of the laboratory errors for preanalytical phase. Thus, in this process, laboratory error numbers decrease, patient safety develops and health system results improve. Conclusion Consequently, in order to achieve all these desired goals for QI, the training process must be sustainable and standardized and repeated at appropriate intervals. Information about the preanalytical process can be updated by training new staff and regularly repeating training for senior staff. Conditions affecting patient safety resulting from preanalytical errors on this side will be minimized. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

References 1.

Lippi G, Sciacovelli L, Simundic AM, et al. Innovative software for recording preanalytical errors in the IFCC quality indicators. Clin Chem Lab Med. 2017;55:51-3.

Sciacovelli L, Lippi G, Sumarac Z, et al. Quality indicators in laboratory medicine: the status of the IFCC Working Group “laboratory errors and patient safety” project. Clin Chem Lab Med. 2011;49:348-57.

Lippi G, Simundic AM, on behalf of the european federation for clinical chemistry and laboratory medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE). The EFLM strategy for harmonization of the preanalytica

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Arslan FD, Karakoyun I, Isbilen Basok B, et al. The effects of education and training on phlebotomists for reducing preanalytical errors. J Med Biochem. 2018;7:1-9.

Sciacovelli L, Lippi G, Sumarac Z, et al. Quality indicators in laboratory medicine: the status of the ifcc working group “laboratory errors and patient safety” project. Clin Chem Lab Med 2017;55:348-357.

Atay A, Demir L, Cuhadar S, et al. Clinical biochemistry laboratory rejection rates due to various types of preanalytical errors. Biochem Med (Zagreb). 2014;15;24:376-82.

Grecc DS, Vlad DC, Dumitrascu V. Quality indicators in the preanalytical phase of testing in a stat laboratory. Lab Med. 2014;45:74-81.

Sakyi A, Laing E, Ephraim R, et al. Evaluation of analytical errors in a clinical chemistry laboratory: a 3-year experience. Ann Med Health Sci Res. 2015;5:8-12.

Lippi G, Bassi A, Brocco G, et al. Preanalytic error tracking in a laboratory

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medicine department: results of a 1-year experience. Clin Chem. 2006;52:1442-3. 10. Özcan O, Güreser AS. Sources of preanalytical errors and the role of training in error prevention. Dicle Med J. 2012;39:524-30. 11. Avcı E, Ceken N, Kangal Z, et al. Approach to pre-analytical errors in a public health laboratory. Turk J Biochem. 2017:42;59-63. 12. Plebani M, Ceriotti F, Messeri G, et al. Laboratory network of excellence: enhancing patient safety and service effectiveness. Clin Chem. 2006;44:150-60. 13. Rattan, Lippi G. Frequency and type of preanalytical errors in a laboratory medicine department in India. Clin Chem Lab Med. 2008;46:1657-9. 14. Aykal G, Yeğin A, Aydin Ö, et al. The impact of educational interventions on reducing the rejection rates in the preanalytical phase. Turk J Biochem. 2014:39;562-566. 15. Lillo R, Salinas M, Lopez-Garrigos M, et al. Reducing preanalytical laboratory sample errors through educational and technological interventions. Clin Lab. 2012;58:911-7.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):910-4

Total antioxidant stress and total oxidant stress levels in geriatric patients with open heart surgery Zinet Asuman Arslan Onuk1, Bilge Karsli2, Baris Arslan3 Antalya Training and Research Hospital, Department of Anesthesia and Intensive Care, Antalya, Turkey 2 Akdeniz University, Department of Anesthesia and Intensive Care Antalya, Turkey 3 Adana Numune Training and Research Hospital, Department of Anesthesia and Intensive Care, Adana, Turkey 1

Received 18 July2018; Accepted 22 July 2018 Available online 24.07.2018 with doi: 10.5455/medscience.2018.07.8857 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The aim at this study is to compare the association with oxidative stress with the patients over and below the age of 65, who underwent an open heart surgery. In our prospective and a single-center study, 45 patients, undergoing an elective isolated on-pump CABG and heart-valve surgery, were included. The patients were divided into two groups, including Group I (at the age of 65 over) and Group II (at the age of 65 and below). The serum total oxidant status (TOS) and total antioxidant status (TAS) values were assessed in the patients, by taking blood at the first hour before and after the pump. There is no statisti-cally significant diffrences between preoperative and postoperative TAS and TOS values within the groups. However, the postoperative TOS value in Group I is statistically greater than Group II. TAS and TOS in organism is affected by many factors. Futher controlled studies are needed on this topic. Keywords: Heart surgery, total antioxidant stress, total oxidant stress, oxidative stress

Introduction

immune disorders, and cancer and brain functions [1]. While

Oxidative stress has been reported to increase in the elderly subjects, possibly arising from an uncon-trolled production of the free radicals by aging mitochondria and decreased antioxidant defenses [1-3]. There is abundant experimental and observational evidence supporting the idea that aging is the sum of all free radical reactions throughout all cells and tissues. However, the results of studies investigating oxidative stress in aging are still controversial. In humans, there are Elderliness begins with the age of 65 according to World Health Organization (WHO). Aging is the irremediable structural and functional changes, occurring in our body’s molecules, cells, tissues, and organs, and revealing the progression of time [4]. The functional and anatomical changes occur in the molecular, cellular, tissular and organal structures with aging. The incidence of coronary artery disease and degenerative cardiovascular diseases shows an increase with advanced age.

a certain part of the antioxidants, trying to prevent the damages created by free radicals, was the enzyme; another certain part of them composed of the non-enzyme molecules. Although the body’s antioxidant/oxidant situation may be evaluated by separately measuring the antioxidant enzymes’ activity and antioxidant/ oxidant molecules’ concentration, the general antioxidant/oxidant situation may be easily evaluated by measurement of the total antioxidant situation (TAS) and total oxidant situation [5,6].

Oxygen, fat, protein and lipids are necessary to have energy in the metabolism. However, they may trans-form into the reactive and detrimental substances, also called as oxygen free radical (FR). The damages created by FR are known that they have important contributions to the disorders in aging, cardiovascular diseases, Coresponding Author: Zinet Asuman Arslan Onuk, Antalya Training and Research Hospital, Department of Anesthesia and Intensive Care, Antalya, Turkey E-mail: asumanonuk@hotmail.com

The aim at this study is to compare the association with oxidative stress with the patients over and below the age of 65, who underwent an open heart surgery. We searched the changes of oxidative stress by comparing the serum TAS (Total Antioxidative Stress) and TOS (Total Oxidative Stress) levels in the patients over and below the age of 65 geriatric patients, undergone an open heart surgery. Material and Methods The TAS and TOS levels were measured by taking blood at the first hour before and after pumping for the patients, divided into Group I (n=20) and Group II (below the age of 65, n=25). The patients having chronic kidney failure and liver disease were not included in the study. 910

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A standard anesthesia protocol is performed for all patients. After 0.1 mg/kg midazolam premedication a radial artery cannulation was made for the hemodynamic follow-up. All subjects were breathed with 100% O2 and intubated with 5-7 mg/kg thiopental, 5 mcg/kg fentanyl and 0.6 mg/kg rocuronium bro-mide during the anesthesia induction. In the maintenance, 5-6% desflurane, 50% O2 and 50% dry air, rocuronium bromide and fentanyl were used. The rectal body temperature and urination were followed-up by applying a 3-lumen central catheter from the right internal jugular vein during the surgery. Body Mass Index (BMI), left ventricular ejection fraction (LVEF), pump time, cross-clamp time, surgery and anesthesia times of the patients were recorded. Cigarette habits, associated diseases and peroperative inotrope uses of the patients were recorded. The study was approved by Ethics Committee of Antalya Education and Research Hospital. The blood samples were taken within 1-hour of the preoperative (before the anesthesia induction) and postoperative time period. Then, the serum samples were separated from cells for 10 minutes with a cen-trifuge working in 3000 revolutions a minute (rpm). The lipid parameters and other routine parameters were immediately measured. The remaining sections were kept at -80°C and used to analyze the TOS and TAS. The data was statistically analyzed by using the statistica 20 for Windows software. The Wilcoxon paired test was used to compare the mean values at each stage of the experiment. The Mann Whitney test was used to compare the differences in TAS and TOS activity between the groups according to their clinical features. The p values less than 0.05 were considered statistically significant. Results 45 patients, who were included in the study and whose 58% was male, were divided into two groups according to their ages (over and below the age of 65). While the mean age of 20 patients over the age of 65 was 72.35±6.05 in Group I, mean age of 25 patients was found as 46.60±10.50 in Group II (below the age of 65). While smoking histories of the patients were 30% in Group I, it was 28% in Group II. While the hypertension (HT), diabetes mellitus (DM) and COPD (Chronic Obstructive Pulmonary Disease) between associated diseases were 75%, 45%, and 10%, respectively in Group I; the HT and DM were 52% and 32%, respectively in Group II. There was not a patient having a COPD in Group II. The HT, DM, COPD and smoking history were not significant intergroup between associated diseases (p=0.114. p=0.371, p=0.192 and p=0.883). (Table I).

Med Science 2018;7(4):910-4

There was not a significant difference statistically in LVEF of the patients in both groups (58.20±7.78 in Group I and 58±9.51 in Group II, p=0.94). Not any significant difference was sta-tistically determined, when compared the pump and cross-clamp times of both groups. While the pump times were found as 68.45±14.06 and 58.44±19.51, respectively p=0.06; the cross-clamp times were found as 38.40±11.33 in Group I and as 33.16±11.93 in Group II p=0.14 (Table I). While the inotropic medicine was used by 100% of patients in Group I, it was used by 68% of patients in Group II (p=0.005). A significant difference was found intergroup in the peroperative inotropic medicine use (Table I). While the preoperative TAS values were 2.05±0.28 in Group I in which the geriatric patients took part; not any change was seen in the postoperative period (2.08±0.39). The preoperative and postoperative TOS values were similar in the geriatric patient group. The preoperative and post-operative TAS and TOS values were also recorded as similar in Group II. However, the TAS val-ues were seen high in the postoperative period and the difference could not be statistically found significant (1.92±0.21, 2.02±0.24) (p: 0.52, p>0.05). While the preoperative TOS value was 3.97±4.58 in Group II, it was seen as 1.93±2.27 by decreasing it to the postoperative period. Not any significant difference was statistically found by the preoperative and postoperative TAS and preoperative TOS, when compared in terms of the preoperative and postoperative TAS and TOS values in both study groups. However, while the postoperative TOS value was 4.30±4.88 in Group I, it was specifically seen as low with 1.93±2.27 values in Group II. This difference was statistically found significant (p=0.03). Table 1. Comparison of preoperative and intraoperative clinical characteristics between the two groups Group I (n=20) n %

Group II (n=25) n %

Women

0,138

Smokers

0,883

Hypertension

0,114

Diabetes Mellitus

0,371

Inotropic drug use

100

0,005*

COPD1

0.138 0.883

0.192

Mean±SD

0.114

Mean±SD

Age (years)

72.35±6.05

46.60±10.50

0.001

BMI2(kg/m2)

27.71±4.12

27.16±5.20

0.706

The information, belonging to operations performed for the patients, takes part in Table II.

LVEF3

58.20±7.78

0.138

58±9.51

0.940

Pump time(min)

68.45±14.06

0.883

58.44±19.51

0.061

While the anesthesia time and surgery time were 202.75±32.54 and 172.25±26.82, respectively in Group I; the anesthesia time and surgery time could not be statistically found significant, when measured them as 188.20±48.60 and 160.60±42.31, respectively in Group II (p>0.05, p=0.25, p=0.29).

Cross-clamp time(min)

38.40±11.33

0.14

33.16±11.93

0.142

Surgery duration(min)

172.25±26.82

160.60±42.31

0.291

Anesthesia duration(min)

202.75±32.54

188.20±48.60

0.258

The BMI was found as 27.71±4.12 in Group I and as 27.16±5.20 in Group II (p=0.706).

COPD: chronic obstructive pulmonary disease, 2BMI:Body Mass Index, LVEF3: Left ventricular ejection fraction,SD:Standard deviation, *p< 0,05 1

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GroupII (n=25)

In our study, the TOS values were found high in the preoperative (4.43±4.47) and postoperative (4.30±4.88) periods in the geriatric patient group. The number of smokers is similar in both groups. Therefore, we think that this high level in the TOS value does not have a relationship to the cigarette.

CABG1 2 greft

3 greft

4 greft

Aort valve replacement

Mitral valve replacement

Med Science 2018;7(4):910-4

total oxidative stress (TOS) was 8.08±3.43 in smokers, it was statistically found significant as 5.40±2.93 in the gynecologic tumor patients (p=0.0003) (20).

Table 2. Types of operations performed in groups Group I (n=20)

On the other hand, the antioxidant levels may be used as a diagnosis or prognosis indicator in some subjects. Measurement of the whole blood antioxidant capacity of an organism may give us valuable biological information about the status of an organism.

CABG : Coronary Artery Bypass Greftt 1

Table 3. TAS and TOS values of groups Group I (n=20)

Group II (n=25)

P value

Preoperatıve TAS1

2,05±0,28

1,92±0,212

0,07

Postoperative TAS1

2,08±0,39

2,02±0,247

0,52

Preoperatıve TOS2

4,43±4,47

3,97±4,58

0,73

Postoperative TOS2

4,30±4,88

1,93±2,27

0,03*

TAS1: Total Antioxidative Stress, TOS2: Total Oxidative Stress. *P<0,05

Discussion It is known that the oxidative stress induces or promotes various diseases such as atherosclerosis and heart diseases, cancer , neurodegenerative diseases (Alzheimer disease, Parkinson’s disease), hypertension, diabetes mellitus and aging [7-15]. It is also argued that the oxidative stress consti-tutes one of the main factors, responsible for the ischemia/reperfusion injury. It is well-known that various antioxidants in the plasma have an additive effect, protecting the organism from the free radicals [16]. In this respect, the measurement of TAC provides information about the antioxidant capacity of an organism [17]. The previous studies showed that the plasma antioxidant capacity was significantly reduced by the CAD patients. Demirbag et al showed that the TAC is decreased and DNA damage is increased by the CAD patients, when compared with the normal subjects [18] . The DNA damage is negatively correlated by the TAC and it is positively correlated by the severity of CAD. In another study, Demirbag et al found a strong correlation between the TAC level and severity of aortic atherosclerosis [19] . In our study, we searched the changes in oxidative stress by comparing the serum TAS (Total Antioxidative Stress) and TOS (Total Oxidative Stress) levels in the geriatric patients over the age of 65 undergone an open heart surgery and in the patients below the age of 65. We aimed at showing advanced age’s changes on the oxidative stress response made to the patients, under-gone an open heart surgery. The oxidative stress occurs as a result of excessive forming into the oxidants, decreasing to the antioxidants or combination of both of them in the body. Although we found the postoperative TOS, a general indicator of the oxidant molecules, high in the geriatric patient group (Group I); we saw a significant difference between them, when compared with Group II (below the age of 65). Alessandra et al compared the solid gynecologic tumor patients and smoker patients in terms of the oxidative stress. While the

At present, there are no consistent perspectives on an age-associated change of the antioxidant capacity. The certain researchers studied the presentation of catalase, peroxide oxidase, some antioxidant vitamins, lipid peroxidation or protein and DNA oxidation, and they found an in-crease or decrease of the different factors with the age [21, 22]. In most subjects, a serum Total Antioxidant Capacity (TAC) was observed to increase with the age. In our study, while the preoperative TAS values were 2.05±0.28 in Group I in which the geriatric patients took part, not any change was seen in the postoperative period (2.08±0.39). The preoperative and postoperative TOS values were similar in the geriatric patient group. The preoperative and postoperative TAS and TOS values were also recorded as similar in Group II (Table III). However, the TAS values were seen as high in the postoperative period and the difference could not be statistically found significant (1.92±0.21, 2.02±0.24) (p: 0.52, p>0.05). While the preoperative TOS value was 3.97±4.58 in Group II, it decreased and was seen as 1.93±2.27 in the postoperative period. The TOS values’ decrease was statistically significant in Group II, a geriat-ric patient group (p<0.05). Not any difference could be statistically found significant by the preoperative and postoperative TAS and preoperative TOS, when compared in terms of the preoperative and postoperative TAS and TOS values in both study groups. However, while the postoperative TOS value was 4.30±4.88 in Group I, it was specifically seen as low with 1.93±2.27 values in Group II. This difference was statistically found significant (p: 0.03, Table III) In most subjects, a serum Total Antioxidant Capacity (TAC) was observed to increase to the age. However, the different measurement methods lead to the different results. For example, meas-urement of the FRAP method, which may not determine the antioxidants with sulfhydryl groups, showed a decrease in TAC with the age [23, 24]. In other studies, an increase in TAC with the age was found as the second observation for the patients suffering from the cancer disease [25] Gupta R et al collected the blood samples of 146 volunteers and divided them into three age groups. They showed a substantial increase at the rate of 79% according to the low serum total antioxidant capacity (TAC) in young-aged (18-35 age) individuals when compared with middle-aged and aged individuals, and found that the total serum antioxidant situation increased by the age [23, 912

doi: 10.5455/medscience.2018.07.8857

Med Science 2018;7(4):910-4

24]. In another study, an increase in the TAC and patients suffering from the cancer was observed with the age [25].

in Group II p=0.14. We think that the differences seen in TAS and TOS values do not have a relationship with the pump.

In our study, the geriatric patients took part in Group II. The TAS and TOS values in Group II patients were found higher than Group I, in which the patients below the age of 65 took part. However, the difference between two groups was not significant statistically in terms of the TAS and TOS values.

Conclusion

The factors such as gender, stress, physical activity, smoking and diet also affect the total anti-oxidant capacity [26-28]. It was stated that the habits such as cigarette and malnutrition, oxida-tive stress and diet antioxidant intake might increase the total antioxidant capacity [29,30]. Kunt As et al measured the antioxidative situations and oxidative changes in 79 patients, whose on-pump coronary artery bypass grafting was performed. They evaluated the antioxidant situa-tion by measuring the total antioxidant capacity (TAC) and discussed the oxidative situation by measuring the total peroxide (TP) and OSI. They found a progressive decrease of the TAC and increase in the total peroxide (TP) and OSI values after the surgery begins. They also found a positive correlation between the ejection fraction and TAC [31]. In our study, the TAS and TOS values were compared by the patients, who were applied an on-pump CABG due to the CABG and valve (mitral, aortic) replacement operations. Although not any significant relationship could be established in terms of the TAS and TOS values with ad-vanced age, it is a reality that the TAS and TOS in an organism affected by many factors. In ad-dition, controlled studies and results are insufficient for the relationship between oxidative stresses and aging. Controlled studies, in which broad patient groups take part, are needed on this topic. Umit Mentese et al divided 23 patients, whose on-pump coronary artery bypass grafting was per-formed, into two groups according to the cross-clamp times (<42, >42 minutes). They signifi-cantly found the TOS levels high (p<0.015) at 30th minute according to the patients’ preoperative values after the reperfusion and they also found the TAS similar to the preoperative values [32]. Asuman et al researched 70 patients, whose CABG was performed (off-pump and on-pump CABG) and mean age was 64.6±1.2. They could not find a significant difference in the antioxi-dant enzyme activities such as TAS, PON and AES and consequently, and they proved that the antioxidant situation did not have a relationship of the CABG technique [33]. Viviana et al measured the urine isoprostane (IPF2-III) excretion and free malondialdehyde (MDA) level in the plasma related to the oxidative stress in 50 patients, whose coronary artery bypass grafting (CABG) and off-pump coronary artery bypass grafting (OPCABG) were per-formed. They found a lower oxidative stress formation of the OPCABG patients (35). In our study, our patients were the patients, whose on-pump CABG was applied due to the CABG and valve (mitral and aortic) replacement operations. Not any difference statistically determined significant, when compared the pump and cross-clamp times of both groups. The pump times were found as 68.45±14.06 and 58.44±19.51, respectively p=0.06, and the cross-clamp times were determined as 38.40±11.33 in Group I and as 33.16±11.93

The recent searches show that the oxidative damage to various biomolecules increases to the age, and the calorie restriction lengthening lifetime and delaying aging decreases the increase, depending on the age for the oxidative damage to biomolecules [34]. Competing interests The authors declare that they have no competing interest. Financial disclosure The financial support for this study was provided by the investigators themselves. Ethical approval The study was approved by Ethics Committee of Antalya Education and Research Hospital.

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Kasapoglu M, Özben T. Alterations of antioxidant enzymes and oxidative stress markers in aging. Exp Gerontol. 2001;36:209-20.

Sanchez MA, FavierNH Meunier E, et al. Age-related oxidative stress and antioxidant parameters in middle-aged and older. Europ J Clin Nutrition. 2005;59:58-62.

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Erel O. A novel automated direct measurement method for total antioxidant capacity using a new generation, more stable ABTS radical cation. Clin Biochem. 2004;37:277-85.

Erel O. A new automated colorimetric method for measuring total oxidant status. Clin Biochem. 2005;38:1103-11.

Evans MD, Dizdaroglu M, Cooke MS. Oxidative DNA damage and disease: induction, repair and significance. Mutat Res. 2004;567:1-61.

Boaz M, Smetana S, Weinstein T, et al. Secondary prevention with antioxidants of cardiovascular disease in endstage renal disease: randomised placebo-controlled trial. Lancet. 2000;356:1213–8.

Zureik M, Galan P, Bertrais S, et al. Effects of long-term daily low-dose supplementation with antioxidant vitamins and minerals on structure and function of large arteries. Arterioscler Thromb Vasc Biol. 2004;24:1485-91.

10. Klaunig JE, Kamendulis LM. The role of oxidative stress in carcinogenesis. Annu Rev Pharmacol Toxicol. 2004;44:239-67. 11. Parslow RA, Sachdev P, Salonikas C, et al. Associations between plasma antioxidants and hypertension in a community-based sample of 415 Australians aged 60-64. J Hum Hypertens. 2005;19:219-26. 12. Moriel P, Plavnik FL, Zanella MT, et al. Lipid peroxidation and anti-oxidants in hyperlipidemia and hypertension. Biol Res. 2000;33:105-12. 13. Dierckx N, Horvath G, van Gils C, et al. Oxidative stress status in patients with diabetes mellitus: relationship to diet. Eur J Clin Nutr. 2003;57:999– 1008. 14. Junqueira VB, Barros SB, Chan SS, et al. Aging and oxidative stress. Mol Aspects Med. 2004;25:5-16. 15. Erden-Inal M, Sunal E, Kanbak G. Age-related changes in the glutathione redox system. Cell Biochem Funct. 2002;20:61-6. 16. Wayner DD, Burton GW, Ingold KU, et al. The relative contributions of vitamin E, urate, ascorbate and proteins to the total peroxyl radical-trapping antioxidant activity of human blood plasma. Biochim Biophys Acta. 1987;924:408-19. 17. Erel O. A novel automated method to measure total antioxidant response against potent free radical reactions. Clin Biochem. 2004;37:112-9.

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doi: 10.5455/medscience.2018.07.8857 18. Demirbag R, Yilmaz R, Kocyigit A. Relationship between DNA damage, total antioxidant capacity and coronary artery disease. Mutat Res. 2005;570:197- 203. 19. Demirbag R, Yilmaz R, Kunt AS, et al. Relation between plasma total anti-oxidant capacity and thoracic aortic intima-media thickness. Echocardiography. 2006;23:183-8. 20. Buico A, Cassino C, Ravera M, et al. Oxidative stress and total antioxidant capacity in human plasma . Article in Redox report:2009;14. 21. Turkoglu MU, Ilhan E, Oztezcan S, et al. Age-related increases in plasma malondialdehyde and protein carbonyl levels and lymphocyte DNA damage in elderly subjects. Clin Biochem. 2003;36:397-400. 22. Finkel T, Holbrook NJ. Oxidants, oxidative stress and the biology of ageing. Nature. 2000;408:239-47. 23. Gupta R, Sharma M, Lakshmy R, et al. Improved method of total anti-oxidant assay. Indian J Biochem Biophys. 2009;46:126-9. 24. Οstka T, Drai J, Berthouze SE, et al. Physical activity, fitness and intergrated antioxidant system in healthy active elderly women. Int J Sports Med. 1998;19:462-7. 25. Huang HY, Appel LJ. Supplementation of diets with alpha-tocopherol reduces serum concen-trations of gamma- and delta-tocopherol in humans. J Nutr. 2003;133:3137-40. 26. Marangon K, Herbeth B, Lecomte E, et al. Diet, anti-oxidant status, and smoking habits in French men. Am J Clin Nutr. 1998;67:231-9. 27. Millen AE, Dodd KW, Subar AF. Use of vitamin, mineral, nonvitamin, and

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nonmineral sup-plements in the United States: The 1987, 1992, and 2000 National Health Interview Survey re-sults. J Am Diet Assoc. 2004;104:94250. 28. Greenberg ER. Vitamin E Supplements: Good in Theory, but Is the Theory Good? Ann Intern Med. 2005;142:75-6. 29. Omaye ST, Burri BJ, Swendseid ME, et al. Blood antioxidant changes in young women following beta-carotene depletion and repletion. J Am Coll Nutr. 1996;15:469-77. 30. John J, Ziebland S, Yudkin P, et al. Effects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: a randomised controlled trial. Lancet. 2002;359:1969-74. 31. Kunt AS, Selek S, Celik H, et al. Decrease of total antioxidant capacity during coronary ar-tery bypass surgery. Mt Sinai J Med. 2006;73:777-83. 32. Mentese Umit et al Oxidant-Antioxidant Balance during On-Pump Coronary Artery Bypass Grafting. The Scientific World Journal. 2014 33. Arslan OA, Yegin A, Ellidağ HY, et al. Paraoxonase Arylestarase and Oxıdatıve Stress in Coronary Artery Surgery Technıques with Desflurane Anesthesıa. Journal of Advances in Medicine and Medical Research. 2017;24:1-8. 34. Bokov A, Chaudhuri A, Richardson A. The role of oxidative damage and stress in aging. Mech Ageing Dev. 2004;125:811-26. 35. Viviana C, Erminio S, Fabrizio V, et al. Isoprostanes and oxidative stress in off-pump and on-pump coronary bypass surgery. Ann Thorac Surg. 2006;81:562-7.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):915-8

Relationship between autophagy and complete blood count in patient with acute myocardial infarction Ozgur Kaplan1, Gunnur Demircan2 1 Istanbul Bilim University School of Medicine Department of Cardiology, Istanbul, Turkey Istanbul Bilim University, School of Medicine, Department of Medical Biology and Genetics, Istanbul, Turkey

Received 24 September 2018; Accepted 09 October 2018 Available online 12.10.2018 with doi:10.5455/medscience.2018.07.8908 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Autophagy is a self-protective mechanism of living cells or organisms under various stress conditions. In this study level of autophagy enzyme in patients with coronary artery disease are measured. Then we investigated to effects of autophagy on the hematologic parameters. 66 patients were included in our study. Participants were separated 2 groups: Group 1- patients with acute myocardial infarction (n=36); and Group 2- normal controls patients (n=30). Blood samples of all patients were collected during coronary angiography process. The enzyme-linked immunosorbent assay (ELISA) kit for autophagy related protein 5(ATG5) in the plasma was studied for these two groups of blood sample. Then autophagy level and complete blood count were compared. Age, gender, prevalence of diabetes mellitus, body-mass-index (BMI) and dyslipidemia were similar between the groups. Autophagy levels are significantly different between the groups(11.7±3.4 ng/ml; ; 7.5±3ng/ml ; p < 0.001, respectively). Significant positive correlations were found between level of autophagy and white blood cell count (r = 0.491, p < 0.001), neutrophil /lymphocyte ratio ( r=0.287 , p=0.019) . Significant negative correlations were found between level of autophagy and ejection fraction (r = -0.427, p < 0.001 ). In the present study, the autophagy levels were higher in the patients with coronary artery disease than healthy controls. Serum autophagy levels demonstrated a significant positive correlation with white blood cell count and neutrophil/lymphocyte ratio .An increased autophagy level may be considered as an important activator and marker of the atherosclerotic inflammatory process in CAD. Keywords: Acute myocardial infarction ,autophagy, complete blood count

Introduction Coronary artery disease (CAD) is a leading cause of death worldwide, which is characterized by different manifestations such as acute myocardial infarction (AMI) and chronic coronary total occlusion. It is unclear how acute or chronic ischemic events activate and affect autophagy. Previous studies show that autophagy in the ischemic phase is protective because of an adaptive response of the heart [1-4]; these were animal studies and were designed by acute ischemic events. However, a comparison of autophagy levels in patients with AMI has not been studied thoroughly. Complete blood count (CBC) is the most widespread tests in clinics. Many different studies have demonstrated that the efficiency of CBC parameters to estimate various disease of severity and *Coresponding Author: Ozgur Kaplan , Istanbul Bilim University School of Medicine Department of Cardiology, Istanbul, Turkey E-mail: drozgurkaplan@yahoo.com

mortality risk such as neutrophil/lymphocyte ratio(NLR) and platelet /lymphocyte ratio (PLR) [6-10]. In our study, we aimed to investigate the role of autophagy in AMI and we also investigated relationship between autophagy and complete blood count in patient with acute myocardial infarction. Materials and Methods Study design This study was a prospective observational controlled study. Study populations 66 consecutive patients evaluated at a university hospital and diagnosed as having at least one major acute total occlusion of the coronary artery were included in this study. The number of study participants was based on power analysis. All participants were evaluated during coronary angiography (CAG). Participants were divided into two groups: group 1 included patients with acute myocardial infarction (n = 36); and group 2 included normal controls (n = 30). Participants in groups 2 had a ischemic test result. 915

doi: 10.5455/medscience.2018.07.8908

Patients in group 1 had ST-segment elevated myocardial infarction and underwent primary percutaneous intervention (PCI). PCI in these patients was performed within 3 hours after the symptoms started, and there were no signs of infection. Furthermore , patients with uncontrolled hypertension, renal dysfunction, autoimmune diseases, thyroid disorders, or history of coronary artery disease (CAD) were not included. The study was performed according to the principles of the Declaration of Helsinki, and its protocol was confirmed by İstanbul Bilim University Ethics Committee. Informed consent forms were taken for all participants.

Med Science 2018;7(4):915-8

blood cells counts ( 11,943 ± 2828, and 7145 ± 1623, respectively; p < 0.001), neutrophil /lymphocyte ratio ( 5±4.2 and 2.1±1.3 ; p< 0.001) and hemoglobin (14.2 ± 1.7, and 12.9 ± 1.1; p < 0.001). Table 1. Baseline characteristics, laboratory and echocardiographic parameters of the study population Variable

Acute TO (n=36)

Controls (n=30)

p value

Age, years

58.6.5±8.4

60.1±10

0.517

10/26

10/20

0,696

Gender, female/male

Biochemical measurements After CAG, approximately 2 mL of blood was drawn from the median cubital veins from each patients and collected into EDTA tubes. In addition, blood samples of all participants were collected during the coronary angiography process. All samples were centrifuged, and plasma samples were stored at −80°C. The enzyme-linked immunosorbent assay (ELISA) kit for autophagyrelated protein 5 (ATG5) in the plasma was studied. ATG5 evaluated two times for all samples and we used mean value. Biochemical and hematological parameters were studied on the same day. We measured red blood cell distribution width (RDW), platelet , mean platelet volume(MPV) ,hemoglobin and some ratios like NLR and PLR .

BMI, kg/m2

Coronary angiography analysis All patients underwent CAG by the Judkins technique via a femoral approach. During the procedure, images were recorded at a speed of 15 square/s on a digital angiographic system (ACOM. PC; Siemens AG, Germany). Our contrast agent was Iopromide. The recordings were studied by two cardiologists. CAD severity was determined on the basis of the Gensini score [11].

Platelet/ Lymphocyte

Statistical analysis SPSS for Windows version 17.0 software (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. All continuous variables were defined as mean ± SD, and categorical variables were described as percentages. In addition, categorical data were compared using a chi-square test, and continuous variables were compared between the groups using Student t test, Shapiro–Wilk test was used whether they were distributed normally. Finally, Pearson and Spearman correlation analysis was used to estimate the relationship between the test parameters, and p value of < 0.05 was accepted to be statistically significant.

26.2 ±2.9

27±1.6

0. 185

Dyslipidemia, n (%)

17(46)

19(63)

0.191

Hypertension, n (%)

28(77)

29(96)

0.026

Diabetes, n (%)

15(41)

12(40)

0,891

26(72)

17(56)

0.187

11943±2828

7145±1623

0.001

Smokers, n (%) WBC Hemoglobin

14.2±1.7

12.9±1.1

0.001

261441±72731

260200±51652

0.938

8526±2926

4267±1487

0.001

MPV

10.2±0.7

10.1±0.6

0.387

RDW

13.6±1

13.7±0.9

0.737

Platelet Neutrophil

Neutrophil/Lymphocyte

5±4.2

2.1±1.3

0.001

136±78

129±58

0.689

LVEDD, mm

50.5 ±5.1

47.6±3.5

0.011

LVESD, mm

36.6 ±5.7

31.7±3.6

0.001

LA, mm

40.9 ±3.6

39.1±2.4

0.018

IVS, mm

11.1 ±1.1

11.2±0.8

0.883

PW, mm

10.4 ±0.9

10.4±0.8

0,918

LVEF, %

46.6±6.7

58±1.7

0.001

Autophagy

11.7±3.4

7.5±3

0.001

BMI, body mass index; IVS, interventricular septum; LA, left atrium; LVEDD, left ventricular end-diastolic diameter; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; MPV; mean platelet volume, RDW; Red Cell Distribution Width ; PW, posterior wall; WBC , white blood cell count,

Autophagy levels were significantly different between the groups ( 11.7 ± 3.4, and 7.5 ± 3 ng/ml; p < 0.001) (Figure 1).

Results Overall, 66 participants were included in our study. Baseline clinical, demographic, and echocardiographic parameters of the participants are listed in Table 1. Age, sex, BMI, smoking , dyslipidemia and type of myocardial infarction were similar among the three groups; however, hypertension was different between the groups (p = 0.026). The results of the left ventricular (LV) echocardiographic and hematologic parameters were significantly different between the groups (Table 1), particularly LV end-diastolic diameter ( 50.5 ± 5.1, 47.6 ± 3.5 mm, respectively; p = 0.011), LV end-systolic diameter ( 36.6 ± 5.7, and 31.7 ± 3.6 mm, respectively; p < 0.001), ejection fraction ( 46.6 ± 6.7, and 58 ± 1.7, respectively; p < 0.001), left atrial diameter (40.9 ±3.6mm , 39.1±2.4 ; p= 0.018) white

Figure 1. Autophagy levels of groups

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Significant positive correlations were found between level of autophagy and WBC (r = 0.491, p < 0.001), NLR ( r=0.287 , p=0.019) . Significant negative correlations were found between level of autophagy and ejection fraction (r = -0.427, p < 0.001 ). Discussion Our study demonstrated that autophagy levels were higher in the CAD. In addition, serum autophagy levels have a significant positive correlation with white blood cell count and neutrophil/ lymphocyte ratio. We didn’t find PLR different between the groups. An increased autophagy level may be considered an valuable activator and marker of the atherosclerotic process in CAD. During the acute myocardial infarction neutrophils secrete inflammatory mediators. Then they may make plaques more vulnerable through the release of proteolytic enzymes, arachidonic acid derivatives, and superoxide radicals [12]. We are not sure about the etiology or significance of autophagy during the acute and chronic stages of CAD. Previously conducted animal studies revealed that autophagy protects the heart during the acute ischemic phase [1-4]. Both previous studies as well as our current study show that autophagy is activated in acute ischemic heart disease, following ischemia-reperfusion injury and in hibernating myocardium [13-17]. In addition, positive correlation between the autophagy and NLR shows that neutrophils work the process of autophagy. Similar results were seen in other studies, with increased autophagy levels in cases of heart failure [18], cardiac hypertrophy [19], and ischemic cardiomyopathy [13]. In addition, autophagy occurred constitutively in the normal myocardium. Insufficient autophagy or its defects causes the myocardium to perform poorly, and inhibition of starvation-induced autophagy results in cardiac dysfunction and dilatation [20]. We found a significant negative correlations between level of autophagy and ejection fraction. It shows that autophagy may protect the body. Although neutrophils and platelet have a role during AMI , we found only the relationship of NLR and autophagy in contrast to PLR. Therefore , our study has small population. Because previous studies revealed that PLR and acute coronary syndromes have relationship such as a prognostic factor and severity of coronary artery disease [9,21]. We found that LV echocardiographic and hematologic parameters were significantly different between the groups. Both differences of hematologic parameters and structural parameters of the heart can be responsible for different autophagy levels. In addition , several mechanism may also effect the autophagy levels such as age , diabetes mellitus and hypertension. Finally, microbiological studies revealed that autophagy is the basic component of the body and its activation is complex and incompletely understood, leading to the activation of a wide range of signaling pathways [22-25]. Study Limitation Our study was a single-center study that included a small study population. Furthermore, extensive studies with a large patient

Med Science 2018;7(4):915-8

cohort are warranted in the future to overcome these limitations. Conclusion We demonstrated that CAD patients have increased autophagy values . Serum autophagy levels demonstrated a significant positive correlation with white blood cell and neutrophil/lymphocyte ratio. An increased autophagy level may be accepted as an valuable activator and marker of the atherosclerotic process in CAD. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

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Tamhane UU, Aneja S, Montgomery D, et al. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am J Cardiol. 2008;102:653-7.

Kurtul A, Murat SN, Yarlioglues M, et al. Association of platelet-tolymphocyte ratio with severity and complexity of coronary artery disease in patients with acute coronary syndromes. Am J Cardiol. 2014;114:972–8.

10. Akboga MK, Canpolat U, Yayla C, et al. Association of Platelet to lymphocyte ratio with inflammation and severity of coronary atherosclerosis in patients with stable coronary artery disease. Angiology. 2016;67:89–95. 11. Gensini GG. A more meaningful scoring system for determining the severity of coronary artery disease. Am J Cardiol. 1983;51:606. 12. Eriksson EE, Xie X, Werr J,et al. Direct viewing of atherosclerosis in vivo: plaque invasion by leukocytes is initiated by the endothelial selectins. FASEB J. 2001;15:1149-57. 13.

Yan L, Vatner DE, Kim SJ, et al. Autophagy in chronically ischemic myocardium. Proc Natl Acad Sci USA. 2005;102:13807–12.

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Gustafsson AB, Gottlieb RA. Autophagy in ischemic heart disease. Circ Res 2009;104: 150–15

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doi: 10.5455/medscience.2018.07.8908 16. Demircan G, Kaplan O, Ozdas SB. Role of autophagy in the progress of coronary total occlusion. Bratisl Lek Listy. 2018;119:103. 17. Kaplan O.Effect of Autophagy and Apoptosis on the Hematologic Parameters in Patients with Coronary Artery Disease. Am j Cardiol. 2018;121:4. 18. Takemura G, Miyata S, Kawase Y,et al. Autophagic degeneration and death of cardiomyocytes in heart failure. Autophagy. 2006;2:212–4. 19. Hein S, Arnon E, Kostin S, et al. Progression from compensated hypertrophy to failure in the pressure-overloaded human heart: structural deterioration and compensatory mechanisms. Circulation. 2003;107:984–91. 20. Kanamori H, Takemura G, Maruyama R, et al. Functional significance and morphological characterization of starvation-induced autophagy in the adult heart. Am J Pathol. 2009;174:1705–14. 21. Ozcan Cetin EH, Cetin MS, Aras D, et al. Platelet to lymphocyte ratio as a

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prognostic marker of in-Hospital and longterm major adverse cardiovascular events in ST-segment elevation myocardial infarction. Angiology. 2016;67:336–45. 22. Ganley IG, Lam du H, Wang J, et al. ULK1.ATG13.FIP200 complex mediates mTOR signaling and is essential for autophagy. J Biol Chem. 2009; 284:12297–305. 23.

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Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):919-22

Prevelance of anemia types and etiology in patients with anemia Mehmet Zahid Kocak, Gulali Aktas, Edip Erkus, Tuba Duman, Burcin Atak Bolu Abant Izzet Baysal Unıversity, Faculty of Medicine Department of Internal Medicine, Bolu, Turkey Received 14 July 2018; Accepted 01 August 2018 Available online 18.10.2018 with doi:10.5455/medscience.2018.07.8911 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract In this study, we aimed to determine the frequency and etiologic causes of anemia types in a university clinic who were diagnosed with anemia, whether there were differences in anemia types by gender difference, and the relation of anemia types according to age and comorbidity. A total of 250 patients were included in the study. Iron deficiency anemia alone in 151, B12 deficiency anemia alone in 18, folate deficiency anemia alone in 2, anemia of chronic diseases in 11 and mixed anemia in 65 cases were detected. Underlying etiology of the anemia cases were diagnosed in 173 (69%) of the patients, however, the etiology of the anemia remained unclear in 77 (31%) cases. Iron deficiency was more frequent in women than in men (p <0.001). Mixed anemia was detected in 65 patients. Of these, 41 (64%) had both iron deficiency and B12 deficiency anemia; 12 (18%) had both iron deficiency and folic acid deficiency; 4 (6%) had both B12 and folic acid deficiency; and i 8 (12%) had iron, B12 and folic acid deficiencies. The most common type of anemia is iron deficiency anemia and is more prevalent in women. However, the frequency of other types of anemia is too high to be underestimated. Informing the patients about the anemia and its complications can make these patients more willing to proceed with further examination and thus, early diagnosis and treatment can reduce morbidity and mortality. Keywords: Anemia frequency, anemia classification, etiology, iron deficiency, B12 deficiency, mixed anemia

Introduction Anemia develops as a result of various causes and is defined as a decrease in erythrocyte count or hemoglobin (Hb) concentration. Anemia is not a disease, it is a finding and it is necessary to find out what the underlying cause is. Many etiologic factors cause anemia and many anemia types are defined according to the underlying cause. Globally, it is reported that iron deficiency is the most important factor affecting the development of the anemia [1]. It is generally assumed that 50% of anemia cases are due to iron deficiency [2], but this rate may vary between populations, and in many international studies, the prevalence of anemia has been shown to vary from population to population [3-5]. According to the Third National Health and Nutrition Examination Survey (NHANES III), anemia is roughly divided into three subtypes: anemia with nutrient deficiencies such as iron, folate or vitamin B12 deficiencies; anemia without nutrient deficiencies such as renal anemia or chronic anemia; and anemia which cannot be classified and thus called “unexplained anemia” [3]. In this

*Coresponding Author: Mehmet Zahid Kocak, Bolu Abant Izzet Baysal Unıversity, Faculty of Medicine Department of Internal medicine, Bolu, Turkey E-mail: mehmetzahidkocak@hotmail.com

study, the frequency of these anemia subtypes were reported to be similar [3]. In some studies, it has been shown that anemia of chronic disease was the most common subtype in elderly [6,7]. In this study, we aimed to determine the frequency and etiologic causes of anemia types in subjects presented to a university clinic, whether there were differences in anemia types by gender difference, and the relation of anemia types according to age and comorbidity. Materials and Methods In this study, 250 patients who were admitted to Abant Izzet Baysal University Medical Faculty, Internal Medicine outpatient clinics between October 2015 and 2017 for various reasons and who were found to have anemia as a result of the examinations and laboratory studies were retrospectively evaluated. The study was initiated after receiving the necessary authorization from the institutional board. Patient information was obtained from the outpatient clinic registry system. Patients older than 18 years of age and Hb <12 mg / dL in women with Hb and <13 mg / dL in men were included to the study. Mean corpuscular hemoglobin concentration, mean corpuscular hemoglobin, iron, total iron binding capacity, ferritin, B12 and folic acid, Hb, hematocrit (Htc), mean corpuscular volume (MCV), erythrocyte count, erythrocyte 919

doi: 10.5455/medscience.2018.07.8911

distribution width and routine biochemical values were recorded. Transferrin saturation (%) was calculated by using iron and total iron binding capacity values. Lower levels from 25 μg / dl for serum iron, 15 ng / ml for ferritin, 4 ng / ml for folate and 203 pg / ml for vitamin B12 were considered as deficiency [8]. History of gastric resection, age, sex, history of previous surgery, drug usage, gastrointestinal bleeding history, pica, hemorrhoids, history of colon tumor were observed from medical data. Comorbidities of study population were recorded. The underlying causes of patients diagnosed with anemia etiology were noted. Patients who were not identified with anemia etiology were also recorded separately. Statistical analysis The collected data were recorded on a statistics software (SPSS 15.0 for Windows, IBM, Chicago, IL, USA). KolmogorovSmirnov test was used to assess whether the variables fit the normal distribution. In the analysis of normal distribution variables, t test was used and values were expressed as mean ± standard deviation. Mann-Whitney U test was used for the analysis of the variables without normal distribution and the values were expressed as median (minimum-maximum). Chi-square test was used for comparison of categorical variables between study groups. P <0.05 was determined as statistical significance level. Results A total of 250 patients 37 male (15%) and 213 female (85%) were included in the study. The incidence of anemia in women was higher than in men (p <0.001). The mean age of men was 56.14 ± 19.9, while the mean age of women was 38.23 ± 16.6. Women were significantly younger than men (p <0.001). The Hb level of the women was 10.5 (6.06-11.9) mg / dL and the Hb level of the men was 10.8 (5.8-11.9) mg / dL (p = 0.04). 193 (90.6%) of the women were younger than 65 years old while 20 were older than 65 years of age. While 23 (62.2%) of the males were younger than 65 years, 14 (37.8%) were over 65 years old. The Hb value of patients aged> 65 years was 10.6 mg / dL in the study population, while the Hb level was> 10.35 mg / dL in those> 65 years (p = 0.63). The number of anemic patients in the geriatric age group was lower in both sexes, but there was no significant difference between the Hb values of the geriatric age group and the younger patients. When evaluated in terms of anemia type, 151 patients (134 women and 17 men) had isolated iron deficiency anemia. Iron deficiency anemia was more frequent in women than in men (p <0.001). In our study, there were 18 patients with vitamin B12 deficiency anemia alone and 8 (44%) of them were women and 10 (55%) were men. There was no significant difference between the sexes in terms of vitamin B12 deficiency anemia frequency (p = 0.06). Only two patients had folic acid deficiency anemia alone. Both of these patients were women. There were 14 patients with anemia of chronic disease alone; 11 of them (78%) were female and 3 (22%) were male and there was no statistically significant difference between the sexes (p = 0.343). Mixed anemia was detected in a total of 65 patients. Iron deficiency and B12 deficiency anemia together seen in 41 (39 women and 2 men), iron deficiency and folate deficiency together seen in 12 (10 females, 2 males), B12 and folate deficiency anemia together seen in 4 (1 woman and 3 men) and iron, folate and B12 deficiency anemia together seen in 8 (all were women) patients. Mean MCV of patients with mixed

Med Science 2018;7(4):919-22

anemia was 78.57 ± 1.27 fL. Of the 151 patients with iron deficiency anemia alone, 21 (14%) had comorbidities such as hypertension, type 2 diabetes mellitus, chronic gastritis, coronary artery disease. The anemia was accompanied by concomitant diseases in 16 (88%) of 18 patients with B12 deficiency alone and in 13 (20%) of 65 patients with mixed anemia. The age of the anemic patients with comorbidities was 52 (21-90), while the age of subjects without comorbidities was 36 (19-88) (p <0.001). The Hb value of the patients with and without comorbidities were 10.6 (5.83-11.9) mg / dL and 10.5 (5.86-11.8) mg / dL, respectively (p = 0.78). Underlying causes of the iron deficiency anemia were menometrorrhagia in 82 (54,3%), bleeding due to hemorrhoid in 19 (12,6%), nutritional insufficiency in 7, malignancy in 2 of the cases. Underlying cause of the anemia could not be detected in 41 of 151 patients with iron deficiency anemia alone. The underlying causes of B12 deficiency anemia were chronic atrophic gastritis in 11 (61.1%) and inadequate nutrition in 7 (38.9%) of the cases. The etiological cause of 2 patients with folic acid deficiency could not be established. Causes of mixed anemia were pregnancy in 3 (4%), menorrhagia or gastrointestinal blood loss in 27 (43%), nutritional deficits in 15 (23%) of the case. In 20 (30%) cases with mixed anemia, underlying cause or causes could not be determined. Eight of the 14 patients (50%) with anemia of chronic disease were due to chronic kidney disease and 6 were (50%) due to malignant diseases. When all of the study populations were evaluated, underlying causes of the anemia were detected in 173 (69%) of the cases 77 (31%) cases remained as unclear etiology. The age of the patients with clear underlying cause (36 ± 16.1 years) were significantly younger than the patients with unclear underlying cause (51.3 ± 18.6 years) (p <0.001). It has been found that the etiology of anemia is easier to detect in younger patients. The etiology of anemia could not be determined in 27% of women (57 of 213 women) and 54% of men (20 of 37). The difference between the sexes was statistically significant (p = 0.001). The mean hemoglobin of the patients was 10.18 ± 1.25 g / dL, the mean hematocrit was 32.11 ± 3.69% and the mean MCV was 80.31 ± 43 fL. Patients with iron deficiency anemia had ferritin 8.1 mg / dL (1.72-4.78), iron 18,57 ug / dL (17-20.14), total iron binding capacity 422 (413-431), transferrin saturation 3.8% (118). Vitamin B12 levels were 153.89 pg / ml (83-192) in those with B12 deficiency anemia, while folic acid level in the folic acid deficiency patients was 2.4ng / ml (2.3-2.5). The transferrin saturation of the cases with combined anemia was 3.9% (2-21%) while this value was found to be 24.1% (2-387%) in the cases with anemia of chronic disease. Discussion The most important consequences of this study are that the most common type of anemia in patients admitted to a tertiary health center is the anemia of iron deficiency and the majority of patients are women. Anemic women were younger than anemic men. However, Hb levels were not statistically different between men and women. The number of geriatric anemic subjects was found to be lower than in younger patients, but no difference was found in terms of Hb values. In our study, the underlying cause of anemia could not be determined in almost one third of the patients (77 of 920

doi: 10.5455/medscience.2018.07.88911

250 patients). In a study conducted in anemic patients, 73% of the patients had anemia due to iron deficiency, 2.7% had drug associated anemia, and 18.9% had no detectable cause of the anemia [9]. Iron, folate, B12 and vitamin A levels were investigated in anemic pregnant women and 23% of the cases had iron deficiency alone, 32% of the cases had iron deficiency in addition to at least one of folate, vitamin B12 and vitamin A deficiencies, 26% at least one of folate, B12 and vitamin A deficiency that not accompanied by iron deficiency, 19% had no deficiency in iron, folate, B12 or vitamin A levels [10]. Another study in 190 geriatric subjects with anemia showed that the rate of anemia due to iron deficiency was 12%, the rate of unexplained anemia was 35%, and the rate of possible myelodysplastic syndrome was 16% [11]. Authors suggested that approximately one third of the anemia in elderly individuals was caused by deficient iron, folate or B12 vitamins, and one third caused by chronic renal disease or other chronic conditions, and the remaining one third categorized as unclassified or unexplained anemia [3]. The most common cause of anemia in our study was iron deficiency. This finding is similar to the literature knowledge. Other causes of anemia in present study were B12 deficiency, anemia of chronic disease and folic acid deficiency. 31% of subjects in our study had no detectable cause of underlying etiology that was similar to the literature findings. It is noteworthy that these unclear anemia cases have not had the necessary tests for diagnosis. According to the World Health Organization survey, the prevalence of anemia was 69% in pregnant women and 73.5% in non-pregnant women, 40.2% in men and 39.1% in the elderly [2]. The prevalence of anemia in fast-developing countries was estimated at 9%, while the prevalence in slow developing countries was 43% [12,13]. The most common cause of anemia is iron deficiency, which is more common in women than men [2]. The most common type of anemia in our study was also iron deficiency. Mixed anemia was the second most common type of anemia, and the most common component of these combined anemia was iron deficiency. Low iron intake, poor absorption of iron due to phytate or phenolic compounds, iron loss from gastrointestinal or genitourinary system and increased iron requirement as seen in growth age children and pregnancy are the main risk factors for iron deficiency anemia. In present study, low iron intake and especially iron loss due to menorrhagia were noted as common causes of iron deficiency. Iron deficiency anemia is more frequent in women than in men [2,14]. In our study in accordance with the literature, the number of women who had iron deficiency anemia was higher than men. Vitamin B12 deficiency has been reported to affect 10-15% of people over age 60 [15]. In the A prevalence of 12% among the elderly was reported in Framingham study [16]. Some other studies reported the prevalence of B12 deficiency as high as 3040% in the elderly [17,18]. The absorption of vitamin B12 does not decrease with age. However, compared with the young population, the absorption of vitamin B12 is reduced in the geriatric age group due to high prevalence of atrophic gastritis [15]. In our study, 14 of the subjects with B12 deficiency anemia were younger than 65 years and only 4 were over 65 years of age. This inconsistency of our results and literature knowledge was due to the fact that low number of elderly patients in present study. Eight (44%) of

Med Science 2018;7(4):919-22

the patients with B12 deficiency were women and 10 (56%) were men. Atrophic gastritis was the most common underlying cause of B12 deficiency. Tight vegetarianism, which cause inadequate vitamin intake, was less common among etiologic factors for B12 insufficiency. No underlying causes were detected in 2 cases with folic acid deficiency in present report. In our study, 200 patients had no additional disease while 50 had a chronic disease such as hypertension, diabetes mellitus and chronic kidney disease. The average age of those with comorbidities was higher than those without comorbidities. However, there was no statistically significant difference between Hb and Hct values according to the comorbidity. Although lower levels Hb expected in subjects with comorbidities, we could not showed such a result possibly due to the low number of subjects with chronic conditions in present study. Conclusion In conclusion, the most common type of anemia encountered by physicians in tertiary care is iron deficiency anemia. As advancing patient age, the likelihood of detecting the cause of anemia decreases. Most anemic patients with unknown cause are in the elderly population and these patients are those who do not want to have further examinations such as upper and lower gastrointestinal endoscopy. Informing the patients about the anemia and its complications can make these patients more willing to proceed with further examination and thus, early diagnosis and treatment can reduce morbidity and mortality. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

References 1.

Benoist Bd, McLean E, Egll I, Cogswell M. Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia. Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia 2008.

Organization WH. Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers. 2001.

Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood. 2004;104:2263-8.

Paul SS, Abraham VJ. How healthy is our geriatric population? a communitybased cross-sectional study. J Family Med Prim Care. 2015;4:221-5.

Gaskell H, Derry S, Moore RA, et al. Prevalence of anaemia in older persons: systematic review. BMC Geriatr. 2008;8:1.

Bach V, Schruckmayer G, Sam I, et al. Prevalence and possible causes of anemia in the elderly: a cross-sectional analysis of a large European university hospital cohort. Clin Interv Aging. 2014;9:1187-96.

Röhrig G, Rücker Y, Becker I, et al. Association of anemia with functional and nutritional status in the German multicenter study “GeriAnaemie2013”. Z Gerontol Geriatr. 2017;50:532-7.

de Benoist B. Conclusions of a WHO Technical Consultation on folate and vitamin B12 deficiencies. Food Nutr Bull. 2008;29:238-44.

Nanas JN, Matsouka C, Karageorgopoulos D, et al. Etiology of anemia in patients with advanced heart failure. J Am Coll Cardiol. 2006;48:2485-9.

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doi: 10.5455/medscience.2018.07.8911 10. van den Broek NR, Letsky EA. Etiology of anemia in pregnancy in south Malawi. Am J Clin Nutr. 2000;72:247-56. 11. Price EA, Mehra R, Holmes TH, et al. Anemia in older persons: etiology and evaluation. Blood Cells Mol Dis. 2011;46:159-65.

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Health Nutr. 2009;12:444-54. 15. Baik H, Russell R. Vitamin B12 deficiency in the elderly. Annu Rev Nutr. 1999;19:357-77.

12. Patel KV. Epidemiology of anemia in older adults. Seminars in hematology: Elsevier; 2008. p. 210-7.

16. Lindenbaum J, Rosenberg IH, Wilson P, et al. Prevalence of cobalamin deficiency in the Framingham elderly population. Am J Clin Nutr. 1994;60:211.

13. Balarajan Y, Ramakrishnan U, Özaltin E, et al. Anaemia in low-income and middle-income countries. Lancet. 2011;378:2123-35.

17. Pautas E, Chérin P, De Jaeger C, et al. Carence en vitamine B12 chez le sujet âgé. Presse Méd. 1999;28:1767-70.

14. McLean E, Cogswell M, Egli I, et al. Worldwide prevalence of anaemia, WHO vitamin and mineral nutrition information system, 1993–2005. Public

18. van Asselt DZ, Blom HJ, Zuiderent R, et al. Clinical significance of low cobalamin levels in older hospital patients. Neth J Med. 2000;57:41-9.

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Available online at www.medicinescience.org

ORIJINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2018;7(4):923-9

A qualitative research on the factors determining product awareness and product preference in promoting medicines by digital tools Ali Karaman1, Yakup Durmaz2 2

1 Hasan Kalyoncu University, Institute of Social Sciences, Gaziantep, Turkey Hasan Kalyoncu University, Faculty of Economics Administrative and Social Sciences, Department of Marketing, Gaziantep, Turkey

Received 28 June 2018; Accepted 30 July 2018 Available online 08.08.2018 with doi: 10.5455/medscience.2018.07.8866 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The aim of the present study is determination of the factors that are effective in product awareness and product preference in digital promotion. A semi-structured interview form was used to identify the views of the nineteen participants in total. The interviews were done by the researcher. All the data obtained from the participants were coded, categorized and resolved by using content analysis technique with Maxqda12 program. The most important factor determining the product preference in the digital promotion is the product effectiveness in terms of the product characteristics. Factors that determine the product awareness include new developments and sharing up-todate data of products were at 34% rate; and, data sharing with evidence related to the products was important with rate of 24%. In conclusion, in order to increase product awareness, it is necessary to transfer the product characteristics in full, complete and unbiased version. However, when it comes to product preference, it was determined that the characteristics of triple multifactorial factors such as product, employee and firm are determinative. Keywords: Qualitative research, medicine, healthcare market, pharmaceutical products, drug prescribing

Introduction Pharmaceutical companies use various tools and methods to promote their products. As a result of innovations in digitalization management [1] and promotions, digital advertising tools have begun to be used in promoting products. In addition to product experts, digital technologies are also being used in promotional activities in the Turkish pharmaceutical sector [2]. The product specialists visit physicians, dentists and pharmacists within a certain plan and schedule to transfer the characteristics, advantages and benefits of the products on the basis of scientific evidence in order to promote the products of the company and to increase their sales. In promotion and marketing activities in Turkey, the product experts as representatives of pharmaceutical companies, they are obliged to comply with the laws and regulations set by the Ministry of Health. These obligations are stated in the “Regulation on the Promotion Activities of Medicinal Products for Human Use”. According to the directive, the product experts can not

*Coresponding Author: Ali Karaman, Hasan Kalyoncu University, Institute of Social Sciences, Gaziantep, Turkey E-mail: alikaraman09@hotmail.com

promote and submit the promotional materials to people other than health professionals (physicians, dentists, pharmacists) [3]. While product specialists perform promotional and marketing activities, they must also use the brochures and other promotional materials prepared by the marketing and medical departments of the pharmaceutical companies in accordance with the legal framework and competition rules related regulations. The purpose of this study is to determine what factors would affect the products’ awareness and the preference of the products in terms of the digital tools that the firms and the product specialists use during the visits and presentations for physicians due to the promotion. In the study, the following questions were identified as problems and investigated by interview method: • What are the factors that determine “product awareness” in promoting medicines with digital tools? • What are the factors that determine “product preference” in promoting medicines with digital tools? Material and Method The method of this research is the interview method which is widely used in the field of qualitative researches. In addition to the interviews, the documents used in the presentations were also included in the analysis. The main purpose of using the 923

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qualitative research method in the study is to identify the factors that determine the awareness and preference of the products in promotions made by the pharmaceutical companies with digital arguments through an exploratory approach. In this context, it is aimed to reach the data on the subject of research using semistructured interview form in order to reveal the determinants of awareness and preference [4,5]. The questions such as “what”, “why” and “how” were used in the interview questions in order to get a detailed idea about the research topic and to reach the details [6,7]. Data obtained by using the semi-structured interview method was analyzed using the content analysis method. For this study, ethical approvals from the ethics committee of the university with legal permits from the authorities in Turkey have been taken. Interviews are based on volunteerism. For this reason, the participants’ approvals were taken prior. Sampling In this study, it was looked at whether the participants included in the survey were directly involved in the research rather than their power to represent the universe [8]. For this reason purposeful sampling methods are used [9]. The number of interviewed participants started without a definite number, but interviews were terminated due to the fact that the information obtained from participants about the subject was found to be frequent and that the “saturation point” was reached. Saturation point to a situation means that there is sufficient evidence regarding to the research problem. Researchers reaching this point are advised to stop data collection [7]. In this direction, interviews were conducted with 15 expert physicians and 4 product specialists from 8 different branches which are Physical Therapy and Rehabilitation, Internal, Cardiology, Otorhinolaryngology, Neurology, Psychiatry, Brain and Neurosurgery, and Chest Diseases. Validity and Reliability of the Scale In this study, the validity of the questions was analyzed using Lawshe’s “content validity ratio” [10]. In Lawshe’s Content Validity Ratio (CVR) method, the experts evaluate the expressions in the measurement tool as “appropriate”, “acceptable” or “not appropriate”. The number of “appropriate” responses by the experts for each statement creates a high or low Lawshe coefficient. This coefficient varies from minus one to plus one. If more than half of the experts are marked as “not appropriate” for a substance, the result is negative and that substance has to be removed from the scale. In a different narrative, if more than half of the assessors indicate that they are “appropriate” for a substance, the relevant substance will have content validity. Thus, the conceptual form of the measurement tool has been pre-evaluated by experts [11]. The content validity of the interview form designed for this research was delivered to 18 specialist field experts (10 specialists and 8 experts) during February - April 2017 period via face to face interview or other ways of communication (mail, telephone). Since the content validity ratio (CVR) calculated as a result of the evaluations is close to + 1, the questions are found to be statistically significant. As a result, the content validity index of the research questions was determined as 0.96. Reliability and transparency are very important in qualitative research. In order to achieve this, each interviewer was asked to give a short summary of the interview by the researcher and to convey

Med Science 2018;7(4):923-9

it to the participant and to indicate the opinions of the participant about the accuracy of the summary. Participant confirmation is a method used to ensure the credibility of the research. In this method, the researcher passes a summary to each participant and asks what he/she understands at the end to get feedback from each participant to evaluate the accuracy of the summary. In this way, misunderstandings are avoided and credibility of the opinion is ensured [12]. Consistency ratios of the codes calculated to compare the codes generated by the researcher and an independent person who is an expert in the field of qualitative research. Code is considered to have a high degree of reliability if it exceeds 80%. In this study, the code consistency rate of the codes determined in the research was found as 91%. Thus, codes are thought to have a high degree of reliability [5]. Data Interviews were conducted with doctors who have different specialist fields and participants who work as product specialists. The average age of participants was 38 years old, and the average year of professional experience was 8 years. The lowest age among the participants was found as 31 years old, the highest age was 55 years old. Participants were found to have the lowest professional experience of 2 years and the highest of 24 years. Some of the interviews were done manually by the researcher and the majority was recorded with a voice recorder. Active use of the voice recorder in the study can be considered as a situation that reduces data loss. It was determined that all of the physicians involved in the study (100%) were visited by product specialists. It was identified with the help of demographic questions to see what kind of promotion tools were ussing during these visits. These were iPad, e-conferences and meetings, e-mail marketing and web site membership. Data Analysis In this study, the “content analysis” technique proposed by Strauss and Corbin [13] was chosen as the analysis unit. Therefore, all the data obtained from the participants were coded, categorized and resolved [7]. In the study, all data were readed repeatedly by the investigator to determine the codes to guide the analysis [6]. For the next stage, the codes that constitute a meaningful are gathered together and categorized [5,13]. Then all the generated codes and interview data were transferred to the “MAXQDA12” program to reach the results frequency and percentage distributions of codes [14]. Results As a result of the analysis, it is seen that awareness and preference factors are shaped around two main categories. These categories include; “Factors determining product awareness in digital promotion” and “Factors determining product preference in digital promotion”. Details of the findings of these categories are given below. The Results of the Factors Determining Product Awareness in Digital Promotion In this category, it was tried to discover what factors determine the product awareness in digital promotion. When the frequency and percentage distributions shown in Table 1 are examined, the ratio of “new development and up-to-date data” code is found to 924

doi: 10.5455/medscience.2018.07.8866

be 34.69% while the “evidence data sharing” with 24.49%. The third place is the “minimal comparison,” which is the code that has been created to express less comparison between medicines. The ratio of this code is 16.33%. The ratios of the other codes are as follows; indicating the importance of using an efficient tool “first efficiency then cost principle” and “interesting content meetings”

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is 6.12%. The ratio of “adverse effect sharing”, “highlighting differences” and “medicine-medicine interaction sharing” codes is 4.08%. For the factors that determine product awareness in digital promotion, eight codes were reached and a total of 49 statements were encoded.

Table 1.The Frequency and percentage distributions of factors determining product awareness in digital promotion Name

Frequency

Percentage

Percent(Valid)

The Factors Determining Product Awareness in Digital Promotion\New development and up-to-date data sharing

34,69

The Factors Determining Product Awareness in Digital Promotion\Data sharing with evidence

24,49

The Factors Determining Product Awareness in Digital Promotion\Minimal comparison

16,33

The Factors Determining Product Awareness in Digital Promotion\First efficiency then cost principle

6,12

The Factors Determining Product Awareness in Digital Promotion\Interesting content meetings

6,12

The Factors Determining Product Awareness in Digital Promotion\Adverse effect sharing

4,08

The Factors Determining Product Awareness in Digital Promotion\Highlighting differences

4,08

The Factors Determining Product Awareness in Digital Promotion\Medicine-medicine interaction sharing

4,08

THE FACTORS DETERMINING PRODUCT AWARENESS IN DIGITAL PROMOTION

0,00

Total (Valid)

100,00

Missing Data

0,00

Total

100,00

From the data in Table 1, it is seen that the factors that determine the product awareness, the new development and the up-to-date data sharing and data sharing with evidence are the most weighted. It is also emphasized that it is better to give as little space as possible to medicinal comparisons while promoting product awareness. It has been emphasized that the digital promotional tools that are planned to be use should be primarily efficient and their contents must be in an interesting way. Participants emphasized that when products are promoted, the side effects (adverse effects) of the products must be shared. Finally, it has been pointed out that the importance of informing about the differences between the medicines and the interactions of the drugs. It is thought that giving weight to these issues will contribute positively to the awareness of the products. Some participant statements about the factors that determine product awareness in digital promotion are given below. The participant statements about new development and up-to-date data sharing: “Literature sharing is important, the other criterion may be to share new developments” (INT-D\ID1; Position: 46-46). “...case presentations can be made. Reference to clinical trial data may be made. The price should not be emphasized frequently. The price is not determinant. Scientific study data should be emphasized more” (INT-D\ID3; Position: 50-50). The participant statements about data sharing with evidence: “At the e-conferences, to show the patient and say that this patient began to walk using this drug etc. It is very unnecessary to present things like. After all, you present it to physicians, to scientific people. No need to present it like a TV commercial. Using meta analyzes and scientific evidence would be better in promotion” (INT-D\IB1; Position: 31-31). The participant statements regarding minimal comparison between medicines: “...of course this is a marketing so they are making their advantages more prominent than other companies. If a product is new and

contain new information it may be shared in the first place by comparing with other products. But friends are always on it. This is not good” (INT-D\ID4; Position: 48-48). “Comparisons with rival products can cause adverse effects if done too often. It may cause discomfort. Comparisons can be made using scientific study data” (INT-D\ID3; Position: 50-50). The Participant statements regarding to share side effects and medicine-medicine interactions of products: “They should also describe the side effects of the drug. Because what to do when you are confronted with a side effect, and what to do to prevent side effects of the medicine should be explained. In particular, they should emphasize side effects of medicine in big letters. The side effects are not told very often but it should be explained. They probably do not explain side effects because of not wanting to reduce the preference of medicine” (INT-D\IG1; Position: 52-52). The Results of the Factors Determining Product Preference in Digital Promotion In this category, it was tried to find out what factors determine the product preference in digital promotion. When the frequency and percentage distributions shown in Table 2 are examined, it is seen that “potent” code that generated to indicate the product effectivity from the product characteristics has the highest frequency (f = 23). Subsequently, the “working style” code, which is a characteristic of the employee’s characteristics and which reflects the employee’s perception of work, comes with (f = 19) frequency. In the third place, it is seen that the “scientific study data” code which is created to identify the scientific evidence of the product from the product characteristics frequency (f = 18). This is followed by the the “good relationship” code which is belong to sub-codes from the work perception that are the characteristics of the employee (f = 17) frequencies. And another code “human factor” comes with (f=17) frequency. Another characteristic of the worker perception 925

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is the”regular frequent visits” code. The frequency of this code is (f = 16). Participants emphasized with (f = 13) frquency the code “firm strategies” which is created to emhisize the firm characteristics. And “product dominance” code that indicating the level of knowledge of the product that the employee is working with is (f = 12). The “personality” code reached to indicate the effect of personality on the product preference is (f = 11). The emphasis was placed on the “safety-quality” code (f = 9), which was established to express the effect of product safety and quality on product preference. Participants emphasized that the presentations must be supported by scientific videos that is seen as another factor as effective in product preference. They emphasized with (f = 9) frequency to the code “scientific video assisted presentations” created for this purpose. One of the remarkable aspects of the research is that they emphasize the use of both human and technological innovations among the factors that determine the product preference of the participants. In order to express this situation the code “digital + human factor” generated determined with (f = 8) frequency. And also clinical experiences and face-to-face visits have also been

Med Science 2018;7(4):923-9

identified by participant statements as the factors affecting product preference. These statements are sembolized with the codes “Clinic experience” and “Face-to-face visit.” The frequencies of these codes are (f = 7). As the factors that determine the product preference, the incidence of low side-effects, the original product, havin data in guidelines, low price, first product in market were also factors that were particularly emphasized by the participants. Other factors that are indicative of the preference in the product preference and which have a low frequency are as follows: well known company, the patient’s feedbacks, the clinical experience that transfered by the speakers at the conferences and meetings, the external appearance of the employee, to be able to behave in a balanced way between work and out of work life, innovator company, having plus effectivity besides indications, strong field staff and to be visited by the region managers of the company. The frequency and percentage ratios of these codes are as shown in Table 2. With regard to the factors that determine product preference in digital promotion, 33 codes including sub codes were reached and a total of 251 statements were encoded.

Table 2. The frequency and percentage distributions of factors determining product preference in digital promotion Name Product characteristics\Potent Work perception\Working style Product characteristics\Scientific study data The Factors Determining Product Preference in Digital Promotion\Human factor Work perception\Good relationship Work perception\Regular frequent visits Firm characteristics\Firm strategies Work perception\Product dominance Employee characteristics\Personality Product characteristics\Safety-quality The Factors Determining Product Preference in Digital Promotion\Scientific video assisted presentations Firm characteristics\Reliable company The Factors Determining Product Preference in Digital Promotion\Digital + human factor The Factors Determining Product Preference in Digital Promotion\Clinic experience The Factors Determining Product Preference in Digital Promotion\Face-to-face visit Product characteristics\Low side-effects Product characteristics\Original product Product characteristics\Data in guidelines Product characteristics\Low price Product characteristics\First product in market Firm characteristics\Well known company Product characteristics\Patient's feedbacks The Factors Determining Product Preference in Digital Promotion\Transferring clinical experience Work perception\Employee appearance Work perception\Balanced behavior Firm characteristics\Innovator company Product characteristics\Having plus effectivity The Factors Determining Product Preference in Digital Promotion\Strong field staff The Factors Determining Product Preference in Digital Promotion\ Region manager visits The Factors Determining Product Preference in Digital Promotion\Employee characteristics Employee characteristics\Work perception The Factors Determining Product Preference in Digital Promotion\Product characteristics The Factors Determining Product Preference in Digital Promotion\Firm characteristics THE FACTORS DETERMINING PRODUCT PREFERENCE IN DIGITAL PROMOTION Total (Valid) Missing Data Total

Frequency

Percentage

Percentage(Valid)

23 19 18 17 17 16 13 12 11 9 9 9 8 7 7 7 7 7 6 5 5 4 4 3 2 2 2 1 1 0 0 0 0 0 251 0 251

9,16 7,57 7,17 6,77 6,77 6,37 5,18 4,78 4,38 3,59 3,59 3,59 3,19 2,79 2,79 2,79 2,79 2,79 2,39 1,99 1,99 1,59 1,59 1,20 0,80 0,80 0,80 0,40 0,40 0,00 0,00 0,00 0,00 0,00 100,00 0,00 100,00

9,16 7,57 7,17 6,77 6,77 6,37 5,18 4,78 4,38 3,59 3,59 3,59 3,19 2,79 2,79 2,79 2,79 2,79 2,39 1,99 1,99 1,59 1,59 1,20 0,80 0,80 0,80 0,40 0,40 0,00 0,00 0,00 0,00 0,00 100,00 -

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From this data, it can be said that the most important factor determining the product preference in the digital promotion is the product effectivity from the product characteristics. Factors such as personality, working style, good relationship, regular and frequent visits and product dominance by the employee are found to have a decisive weight in the product preference. The fact that the firm is a reliable company and a well known company is also considered as a decisive factor in product preference. Pointing out the importance of the human factor, it has been specifically stated that it will not be possible to make sufficient promotions using digital tools alone. For this reason, it has been considered as an important factor that digital tools should be used with the human element as well. In the following paragraphs, the expression of some participants in high-rate codes for determining the product preference is included. The main purpose here is to increase the level of intelligibility of the codes that have high decisive in product preference by including participant expressions. In addition, the fact that the participant expressions are explicitly included can be considered as an important situation in terms of the reliability of the research findings. Participant statements regarding the potent of the product and other characteristics of the product: “I have people who work very well, but I can not write because the molecules, products they work on are not very good. So the molecule must be a good and efficient molecule. The personal relationship with the employee, company or employee is not the reason for my preference. Clinical experience and product-related scientific data lead to preference” (INT-D\IP3; Position: 18-18). “First of all, the product must be a very good product because you will write the product. You can not write a bad molecule. Actually, let’s sort it like this. The product is bigger than the worker, first comes the product and effectiveness...” (INT-D\IKR2; Position: 67-67). Participant statements about employee’s work perception and personality traits: “If the person is able to transfer the product in full with the concept and dominanting, then it will be really useful and effective” (INT-D\IG1; Position: 54-54). “...bilateral dialogue between doctor and product specialist, and sincerity are influencing product preference” (INT-D\ID2; Position: 62-62). Discussion In the present study, it was seen that the most important factor that has the decisive factor in the product preference in the digital promotion is the product effectivity from the product characteristics. Beside that it has been observed that other features of the product, such as scientific study data, safety-quality, incidence of low sideeffects, original product and price, also have a significant weight in product preference. It is seen that the characteristics of the product expert such as working style, good relationship, regular and frequent visits, dominance to the product have a decisive weight in the product preference.

Med Science 2018;7(4):923-9

In the literature, the working strategies of product experts who are pharmaceutical company employees investigated the effect of physicians on the product (drug) preference and conducted telephone interviews with nine product specialists in the Vietnamese pharmaceutical industry. For the international companies, the conclusion is that their medicines have high quality and reliability in order to convince physicians to prescribe their medicines. On the other hand, firms that work with equivalent products convince physicians to prescribe their medicines because of the low price. In addition, firms states that low price comes from due to less investment in research [15]. While it is seen that the properties such as efficiency, quality, reliability and originality are important in the preference of products, it is thought that the price is important in the presence of equivalent products and may be an effective element in preference. It is seen that similar results exist between these researches. According to a study conducted by Sezgin [16] in Turkey, the proportion of those who consider the work styles of product specialists as an important factor on prescribing decision is 48.7%. In the same study, it was emphasized that regular visits to the physicians performed by the product specialists were seen an important factor (51%) in keeping products on the market. Our research findings such as “work style”, “regular visit” and “product domination” which determine of the product preference has significant similarity with the results of this study. On the other hand, in the study titled “Role of product specialist in physician’s prescribing decision” made by Tosun and Arslan Kurtuluş [17], it was concluded that doctors’ weekly prescriptions and product specialist features were found to be positively but weakly correlated. On the other hand, 61.1% of the scientific articles and 50.4% of the previous experiences were stated to be factors that influence the prescribing decisions of physicians. In the study, 12 statements were emphasized for the “product dominance” code that was reached to express the dominance and knowledge level of the employee’s who promote product. High frequency emphasis on this code was interpreted that it is expected from product experts for to be fully dominance to their products by physicians. This result in our study is similar to the results of the Publicis Touchpoint Solutions, Sermo Survey [18]. According to the Sermo Survey results, 81% of physicians respect educated, experienced, product experts who dominate clinical research data and can add value to themselves and their patients. In the same study, 89% of physicians want product experts to convey their product promotions with clinical investigations, trainings, and to include them in their talk. It can therefore be clearly seen from both studies that product dominance is a factor that increases the effectiveness of the product expert. In this respect, the findings of our study and the findings of the Sermo Survey were found to be similar. In the present study, 17 expressions were emphasized in terms of the “good relationship” code, which is the code that was reached to express the well-developed of employees’ relations with physicians. This data has been interpreted as the fact that to have a good relationship with the physicians by product specialists may determine the product preference. This result is consistent with the results of a study conducted by John Mack and Mark Schmukler [19] on conditions affecting physician preference for medications in the United States. According to the research in the USA, in the 927

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first years when the product was introduced to the market, the good relationship between the physician and the product specialist is decisive on the product preference. Both studies emphasized the importance of good relationship. In this respect, similarities were found between the results of our research and the results of the above-mentioned research. On the other hand, emphasis is placed on the importance of scientific knowledge, efficiency, product guidelines and using digital tools such as e-conferences, e-mail marketing in the years when product sales increase and generics are given to the market. These results provide information to pharmaceutical companies about the stage in which digital promotional tools must be actively used. The view put forward in the research is that it is more useful using digital tools such as e- conferences, e-mail marketing after the point of product growth and after the point of entering the generics to the market. After this stage, the physician’s product preference will not be changed much. Because the physician has experienced and embraced the product since many years. It is also relevant to trusting the company, its employees, to the product and having a good relationship totally. Here, it is necessary to support the physicians with scientific and real knowledge with the existing relationship. In addition, findings of the triplet effect which is expressed as “confidence to the firm, the employee and the product” that has been carried out are found to be similar to our research results determining the product preference. It has been seen in the research that human word has been repeated 42 times. It can be thought that promotions made in situations where the human element is actively involved play an important role in product preference because this word has been repeated at a high rate. Some digital promotional tools such as iPad and e-conferences in Turkey are used in combination with the human element. Therefore, it can be said that human factor is seen as an important element in product preference. As a result, besides the digital promotional tools to be used, it is important that the human element is not neglected and both elements are used together. It is especially noted that this is the product specialist that needs to be understood from the human factor. On the other hand, the findings of research that contradict this data are available outside of Turkey. For example, according to a study in the United States, 60% of doctors are suggesting a variety of excuses not to see the product specialists who come for product promotion. And it is stated that this ratio will increase to 80% in 2-3 years. In addition, the majority of doctors said that instead of product experts, they hoped that digital promotional tools such as e-detailing, e-conferencing, e-video would be preferred. So it was expecting an important reduce to the visits to the physician offices by product specialists [19]. The differences in these two research findings are thought to be due to different practices for product promotion between countries and personal preferences of physicians. Conclusion In this study, it was determined that new development and current data sharing had the highest weight with 34% from the factors that determine product awareness. In digital promotions, it was concluded that the data sharing with evidence had a weight of 24%. Another important result has been the emphasis on making product awareness better, giving as little comparisons as possible between medicines. Instead of making comparisons, it has been determined

Med Science 2018;7(4):923-9

that the company employees should focus on the product they are promoting and that it is not appropriate to describe the weaknesses of competing products. It has been achieved that the adverse effects of the promoted medicines must be transferred to the physicians. This is necessary for the clinical success, social responsibility and ethically. In summary, factors that determine product awareness in digital promotion are shown in Table 3. Table 3. The factors determine product awareness in digital promotion New development and up-to-date data sharing Data sharing with evidence Minimal comparison on products First efficiency then cost principle in choosing digital tools Interesting content meetings Adverse effect sharing Highlighting differences Medicine-medicine interaction sharing

In the digital promotion, the factors that have the highest effect on the product preference are the product characteristics when it comes to the employee characteristics and the firm characteristics. In addition, it was stated that the human factor should continue to be used in promotions. It has been pointed out that it is important to make scientific video-aided presentations with digital tools. It has been observed that these conditions are the other factors determining product preference. As a result, it is possible to classify the factors that determine product preference in digital promotion as “Product characteristics”, “Employee characteristics”, “Firm characteristics” and “other characteristics”. All of these characteristics are shown in Table 4. As shown in Table 4, the factors that determine the product preference from product characteristics are as follows: potent product, scientific study data, safety - quality, low side-effects, original product, data in guidelines, low price, first product in the market, patient’s feedbacks and having plus effectivity. The factors that determine product preference from employee characteristics are: working style of company employee, have a good relationships with the physicians, regular frequent visits, product dominance, personality structure, employee external appearance and balanced behavior between work and private life. The factors that determine product preference from firm characteristics are: strategies of company promotion, being a reliable company, well known company, innovator company and having strong field staff. Other factors that are decisive in product preference include: human factor, presentation of scientific supported video presentations with digital tools, using digital and human factor together, clinic experience of physicians, face-to-face visit, transferring of clinical experience of speakers in e-conferences and region manager visits. As a result, it can be considered that the factors that determine the product preference are mulltifactorial but the characteristics of the product and the characteristics of the employee are more determinative in the product preference. This study was designed as a qualitative research. In this research, the factors that determine product awareness and product preference were found out in promotions made with digital tools. The use of these factors in quantitative research to be done is suggested for further research. 928

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Med Science 2018;7(4):923-9

Table 4. The factors determine product preference in digital promotion Product characteristics

Employee characteristics

Firm characteristics

Other characteristics

Potent product

Working style

Firm strategies

Human factor

Scientific study data

Good relationship

Reliable company

Scientific video assisted presentations

Safety-quality

Regular frequent visits

Well known company

Digital+human factor

Low side-effects

Product dominance

Innovator company

Clinic experience of physicians

Original product

Personality

Strong field staff

Face-to-face visit

Data in guidelines

Employee appearance

Transferring clinical experience by e-conferences

Price

Balanced behavior

Region manager visits

First product in market Patient's feedbacks Having plus effectivity Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval For this study, ethical approvals from the ethics committee of the university with legal permits from the authorities in Turkey have been taken. Acknowledgements This paper is based on a PhD thesis titled “The Effect of Digital Promotion Activities in the Pharmaceutical Sector on Product Awareness and Preference Behavior of Physicians: A Case Study in Adiyaman and Sanliurfa Provinces. I would like to express my sincere thanks and respects to the chairman of the jury Professor Mustafa Paksoy, and other members of the jury Associate Professor Mazlum Celik, Associate Professor Tuba Buyukbese, Associate Professor Filiz Golpek and Assistant Professor Nurhan Halisdemir.

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10. Lawshe CH. A Quantitative approach to content validity. Personnel Psychology. 28, 1975;563-75. 11. Gurbuz S. and Sahin F. Sosyal bilimlerde araştırma yöntemleri: felsefe, yöntem, analiz. 3rd edition. Seçkin, Ankara, 2016;166. 12. Erlandson DA, Harris EL, Skipper BL, Allen ST. Doing naturalistic inquiry: a guide to methods. Sage, Beverly Hils, CA. 1993. 13. Strauss AL, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Sage Publications, Newbury Park, CA, 1990. 14. Maxqda. https://www.maxqda.com access date, 17.08.2017

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16. Sezgin S. (2017). Tıbbi Mümessillerin Mesleki Algıları Üzerine Bir Araştırma: Muğla İli Örneği. 4th Ulusal Meslek Yüksekokulları Sosyal ve Teknik Bilimler Kongresi (MESTEK), 2017. Mehmet Akif Ersoy Üniversitesi, Burdur, 1041-62.

Bechhofer F, Paterson L. Principles of research design in the social sciences. routledge publications, London, 2000;56,57.

Miles MB, Huberman AM. Nitel veri analizi: genişletilmiş bir kaynak kitap. 1st edition. S. Akbaba Altun and A. Ersoy. Translation Eds. Pagem Akademi 34, Ankara, 2015;58,64.

17. Tosun N. and Arslan-Kurtulus S. The role of pharmaceutical representatives in the prescribing decision of physicians: a pilot study. J International Social Res, 2017;10:889-905.

Glesne C. Nitel Araştırmaya Giris. 4th edition. A. Ersoy ve P. Yalçınoğlu. Translation Editors. Anı Publications, Ankara, 2014;30,256.

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18. Publicis Touchpoint Solutions, Sermo Survey: what physicians want! Results of a sermo physician survey. 2012. http://www.publicishealthcare.com/ Libraries/News_Documents/2012_What_Physicians_Want_Survey.sflb.ashx access date, 08.01.2017 19. Mack J. and Schmukler M. Special report: e-detailing best practices & data. 2005. http://content.marketingsherpa.com/heap/pharma/1.pdf access date, 03.01.2017

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):930-4

Evaluation of drug use habits and rational drug use of persons registered to primary health care Serdar Deniz1, Ayse Ferdane Oguzoncul2, Recep Bentli1 1 Malatya Provincial Health Directorate, Malatya, Turkey Firat University Faculty of Medicine Public Health Department, Elazig, Turkey

Received 14 October 2018; Accepted 24 October 2018 Available online 25.10.2018 with doi:10.5455/medscience.2018.07.8916 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Wrong or unnecessary use of medications seriously affects public health. The aim of this study is to evaluate the drug use habits and rational drug use among people aged 15 and over who are registered to family health centers in Akçadağ district of Malatya. The population of the study consists of 21659 people in the 15 and older age group registered in the family physicians in Akçadağ district of Malatya. The frequency of rational drug use was determined as 46.6%, the margin of error was 5% and the confidence interval was 95% and the minimum sample size was calculated as 376. It was aimed to reach a total of 420 people. Not be using drugs other than doctor’s advice, using drugs as recommended time by the doctor and using drugs as recommended dose by the doctor, all of the features were evaluated as ‘’rational drug using’’. The mean age was 42.84 ± 16.39. Of the group, 50.2% were males and 7.1% were illiterate. It was determined that those who had difficulty in meeting health expenses accounted for 9.3% of the group, 61.9% of them were generally in good health, 36.0% had a long-term or chronic disease. Those who did not use the medication without a doctor’s recommendation were 31.4%, those who used the drug in the amount recommended by the doctor, 55.7%, and 54.5% of the patients who were taking the drug at the recommended time. The prevalence of rational drug use was 23.8%. Rational drug use was associated with gender and educational status (p <0.05). The frequency of rational drug use is low. The importance of rational drug use to each individual in society should be explained in accordance with the individual characteristics. Keywords: Drug, rational, using

Introduction According to the World Health Organization, rational use of medicines is the lowest cost of taking the drugs at the doses and times that meet the clinical needs of the patients. In other words, it can be said that the drug to be used is effective, safe, reasonable and low cost. In general, the obstacles to rational drug use are from diagnosis (insufficient examination, communication etc.), from prescription writing (wrong, over-prescription etc.), from drugs (lack of instructions, poor quality packaging etc.) and from patients (poor follow-up, environmental and cultural situation etc.). In our country and in the world, the use of wrong or unnecessary medication seriously affects public health. This effect leads to decreased treatment compliance, development of resistance to drugs, increased treatment costs and risk of death. Training, management, economic and regulatory strategies need to be developed to rationalize drug use [1,2]. *Coresponding Author: Recep Bentli, Malatya Provincial Health Directorate E-mail: dr_bentli@hotmail.com

The Ministry of Health has launched a website application to promote rational drug use and has made it available to health professionals and patients. In addition to this, many posters and brochures have been made to ensure the use of the right medication instead of many drugs, antibiotics are used only with a physician’s recommendation, the drugs are used in the dosage and duration recommended by the physicians, drugs are not shared with others [2]. Prescription writing is a complex process that includes the ability to diagnose, knowledge of medicine, understanding of the principles of clinical pharmacology, and evaluation of risks along with communication capabilities. The treatment plan to be established as a result of a prescription should include goals such as treatment of a disease, relieving symptoms without affecting the underlying condition (such as diarrhea), long-term prevention and diagnosis. It is possible to evaluate the results of the treatment with or without the benefit of the drugs or medications provided by the objective evaluation. Therefore, it is important to follow the treatment given in order to make changes in the treatment plan [3]. 930

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While the development of the pharmaceutical industry has had a positive impact on health levels in our country as well as in the world, the increase in the number and variety of drugs has increased the share allocated to medicines from health budgets to a more important place. The drug expenditure constitutes an important part of health spending in Turkey as a result [4,5]. There are many studies in which a significant number of patients have been found to hide increased drugs at the end of their treatment and then re-use it in their similar disorders without consulting anyone. However, it is also shown that the most frequently used drugs are painkillers without consulting the physician in case of illness [6–9]. In addition to the economically negative contribution of medicines that patients have at home and do not pay attention to their storage conditions, the risk of poisoning in children is also important. Without adequate knowledge or without a physician’s recommendation, the use of drugs threatens not only the individual but also the health of his / her dependents. While encouraging rational drug use, trainings that can provide access to accurate information along with legal measures are of great importance [10–12]. The factors such as the attitudes of the physicians and the personal and environmental characteristics of the patient while explaining the way of prescription are effective on the drug use habits. It is of utmost importance that the physician prescribes the prescriptions and instructions that the pharmacist reviews and passes on the necessary instructions to the patient, and that the patient understands and applies these directions [6–9]. The aim of this study is to evaluate the drug use habits and rational drug use among people aged 15 and over who are registered to family health centers in Akçadağ district of Malatya.

Med Science 2018;7(4):930-4

Results The mean age of the participants was 42.84 ± 16.39 (min. 15, max. 84). 74.5% of the group was married. The sociodemographic characteristics of the study group are presented in Table 1. Table 1. Sociodemographic characteristics of the study group N=420 HT Gender Marital status

Education status

Occupation

Male Female Married Single Seperated/widowed İlliterate Literate Primary school Secondary school High school University Houswife/Unemployed Officer Worker Retired Self-employment Student

Do not use drugs other than doctor’s advice, use the medication as recommended time by the doctor and use the medication as recommended dose by the doctor, all of the features were evaluated as ‘’rational drug using’’. Data were analyzed with SPSS package program. The differences between the averages were analyzed by t-test and the differences of the categorized data were analyzed by X2 (Chi-square) test.

50.2 49.8 74.5 22.1 3.3 7.1 6.7 18.1 21.4 31.9 14.8 42.6 11.0 7.6 11.7 15.5 11.7

42.6% of the participants had a minimum wage (1603 Turkish liras) and under monthly household income, 15.7% considered the economic situation to be poor. 3.3% of the group that does not have social security, 9.3% found it difficult to cover health costs (Table 2). Table 2. Socioeconomic characteristics of the study group N=420

Materials and Methods The population of this descriptive study is composed of 21659 people aged 15 and over, registered to family physicians in Akçadağ district of Malatya. The frequency of rational drug use was determined as 46.6% [7], the margin of error was 5% and the confidence interval was 95% and the sample size was calculated as 376. The aim was to reach a total of 420 people, 60 of whom were registered to each family medicine unit, considering the failure to reach the sampling due to the inability to participate in the research. After the lists which are registered to the family health units are sorted by age and gender, a number from 1 to 51 is selected and the next every 51st person is included in the sample. The questionnaire was applied to the volunteers from the individuals who were sampled by the researchers after obtaining permission from Fırat University Non-Interventional Clinical Research Ethics Committee.

211 209 313 93 14 30 28 76 90 134 62 179 46 32 49 65 49

Monthly household income (Turkish liras) How do you assess your economic situation? Are you having trouble meeting your health care expenses? Do you have social security?

≤1603 1604-3500 ≥3501 Good Middle Bad Yes No Yes

179 202 39 53 301 66 39 381 406

42.6 48.1 9.3 12.6 71.7 15.7 9.3 90.7 96.7

3.3

Patients with a long-term or chronic disease accounted for 36.0% of the participants. The most common (18.1%) chronic disease was cardiovascular disease, 61.9% of the group evaluated their health status as good and 33.1% as moderate. While 64.5% of the study group preferred to go to the doctor (family physician or hospital outpatient clinic) when they were sick, 19.0% of them stated that they used drugs at home and 8.3% of them applied to the emergency department. When the first preferred health care provider is queried; 74.5% of the group referred to the first health care institution as state hospital, only 21.9% used the primary health care facility as the first choice. When the drug he used showed an unexpected effect, he stated that more than half of the group (51.0%) had stopped taking the drug, only 37.9% had consulted a professional such as a doctor or pharmacist (Table 3).

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Table 3. Chronic disease status and use of healthcare services N=420 n

Cardiovascular diseases

18.1

Diseases of the musculoskeletal system

8.1

Diabetes

7.6

Diseases of the gastrointestinal tract

6.2

Chronic respiratory diseases

5.4

Other

5.0

Cerebrovascular diseases

1.2

Distribution of long-term or chronic diseases*

Cancers

0.7

I go to doctor (family physician or hospital clinic)

271

64.5

I use the drugs at home

19.0

I go to the emergency service.

8.3

I don't do anything

5.5

I consult people around me

2.1

I consult my pharmacy

0.5

State hospital

313

74.5

Family medicine

21.9

Private hospital

3.1

What do you usually do first when you’re sick?

Which health institution do you prefer first?

Unıvesity hospital

0.5

1-3 times

154

36.7

4-6 times

132

31.4

≥7 times

134

31.9

Stop using the drug

214

51.0

Go to doctor

112

26.7

How many times have you consulted a doctor in a year?

What do you do when there is an unexpected effect when using the drug?

Consult the pharmacist

11.2

Consult people around me

5.7

Keep using drug

5.5

*There are more than one long-term or chronic diseases in the research group.

The mean age of patients with long-term or chronic diseases was 53.72 ± 13.89, those with no long-term disease was found to be 36.73 ± 14.42. In the last year, the mean of referral to physicians (7.28 ± 4.55 and 5.39 ± 3.66) was different in favor of those with long-term or chronic disease (p <0.001).

When more than half of the patients were ill, they were on medication without a doctor’s recommendation. When using the drug, 55.7% of the group was in compliance with the amount recommended by the doctor and 54.5% of the time. However, only 29.8% of the group read the instructions for use of the drugs (Table 4).

Table 4. Drug use status and habits N=420 Yes

Do you use drugs without a doctor's advice / without consulting a doctor?

288

68.6

132

31.4

Do you use the drug in the amount recommended by the doctor?

234

55.7

186

44.3

Do you use the medicine during the time recommended by the doctor?

229

54.5

191

45.5

Do you recommend someone else to take the medicine that is good for you?

104

24.8

316

75.2

Do you pay attention to the expiration date of the drugs?

339

80.7

19.3

Do you read the instructions for use of the drugs?

125

29.8

295

70.2

Do you want your doctor to prescribe drug outside your treatment?

152

36.2

268

63.8

Do you keep drugs at home?

318

75.7

102

24.3

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The most common way of taking medication without doctor’s advice was to consult the pharmacy (61.1%). 60.7% of the

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participants who were taking home drugs were painkillers (Table 5).

Table 5. According to what the medicines were taken without doctor’s advice and the distribution of drugs in the home

How do you get the drugs you take without a doctor's recommendation? (N=288)

Which drugs are kept at home?

Consulting pharmacist

176

61.1

Consult people around me

157

54.5

According to my knowledge / before the drug from the good

146

50.7

Researching on the Internet

9.7

Painkiller

193

60.7

(N=318)

29.9

Stomach medicine

17.6

51 25

16.0 7.9

Antibiotic Other * Percentages are taken over N, there are patients who mark more than one option

The frequency of rational drug use (not be using drugs other than doctor’s advice, using drugs as recommended time by the doctor and using drugs as recommended dose by the doctor, all of the features were evaluated as ‘’rational drug using’’) was determined

as 23.8%. The relationship between rational drug using and some variables is shown in Table 6. According to gender and educational status, it was found that women used more rational medication than men (p<0.05).

Table 6. The relationship between rational drug using and some variables N=420 Rational drug using Yes

Gender Age group

Marital status

Educational status

Occupation

Monthly household income (Turkish liras)

Social security

General health status

Long-term or chronic disease

Doctor consulted in a year?

Male

18.5

172

81.5

Female

29.2

148

70.8

15-64

23.9

283

76.1

≥65

22.9

77.1

Married

23.3

240

76.7

Single

25.8

74.2

Seperated/widowed

21.4

78.6

≤Primary school

34.3

65.7

Secondary school

16.7

83.3

High school

17.9

110

82.1

University

24.2

75.8

Employee or retired

19.8

154

80.2

Unemployed

27.2

166

72.8

≤1603

27.4

130

72.6

1604-3500

19.8

162

80.2

≥3501

28.2

71.8

Yes

23.2

312

76.8

42.9

57.1

Good

22.3

202

77.7

Middle

25.2

104

74.8

Bad

33.3

66.7

Yes

25.8

112

74.2

22.7

208

77.3

1-3 times

20.8

122

79.2

4-6 times

23.5

101

76.5

≥7 times

27.6

72.4

6.631

0.010

0.024

0.877

0.289

0.865

13.280

0.004

3.147

0.760

3.458

0.177

2.897

0.089

1.517

0.468

0.529

0.467

1.855

0.395

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Discussion 42.6% of the group monthly household income was minimum wage and less. It was 15.7% of the group that evaluated their economic status as bad. In spite of all this, it was 9.3% of the group who had difficulty in meeting their health expenses. It shows that health policies are in favor of patients with regard to payment of medicines and medical expenses. In our study, the frequency of evaluating the health status as good (61.9%) data for Turkey (63.5%) were similar with [13]. In our study, the frequency of long-term and chronic disease (36%) was similar to that of Dağtekin et al (37.8%) [7]. In a similar study, although the mean age was close to our study (42.84 ± 16.39), because of questioning the presence of chronic disease in households, the incidence of chronic disease in the household was 52.6%. In another study similar to our research, the frequency of chronic disease was found to be 24.1% (8,14). The first health care provider referred to the first stage health institution (although our research was conducted in primary health care) accounted for only 21.9% of the group. Although the use of drugs in the amount and duration recommended by the doctor was 54.5%, it was found that the frequency of rational drug use was 23.8%. Among the parameters evaluated, there was a difference in rational drug use according to gender and educational status. Women were more advantageous than men in terms of rational drug use. It was seen that 36.2% of the group wanted to prescribe drugs except for their doctor’s treatment. It was determined that 29.8% of the participants read the instructions for use of drugs and 80.7% of the participants paid attention to the expiration date. Those who received medication without doctor’s advice were 68.6% of the group. More than half of them (61.1%) stated that they had taken the drug in consultation with the pharmacy. Most of the drugs in the house (60.7%) were painkillers. In the research of Dağtekin et al. (90.6%), the majority of the group stated that they used drugs without consulting their physicians, and 80.6% of them were painkillers [7]. According to the results of our research, it is seen that those who have higher education level in the research of İlhan et al. the frequency of those who read the instructions for use was 60.9%, in addition to the physician’s recommendation, the drug use was found to be 62.0% and the ones who had the drug at home were determined as 78.6%. It was found that the most common drugs used in the home (40.3%) were painkillers. In the same study, 44.0% of the group asked the doctor to prescribe the drug they wanted [8]. In the research of Koyuncuoğlu et al., it was found that the frequency of the drug users at the time recommended by the doctor was 42.0%, the frequency of drug users without referring to the physician was 29.3%, and 77.5% of them used painkillers during the research period. In the same study it was found that the attitude of men and women in the use of drugs without examination was similar [6]. In the study of Güngör et al., prevalence of antibiotics was 4.5% in children without the recommendation of a doctor. In the same study, it was determined that their mothers were more likely to start medication than their fathers without going to the doctor and 94% of the participants paid attention to the expiry date of the drugs [12]. In the study of Gökçe, which the high education level and women were seen to have an advantage in knowing the purpose of using antibiotics, the frequency of prospectus reading was 66.7%. However, it was determined that 46.2% of the participants asked

Med Science 2018;7(4):930-4

the physician to prescribe antibiotics. In the same study, it was determined that the use of non-prescription antibiotics was 35.7% of the group; It was determined that this situation did not differ according to gender, and as the level of education increased, those using non-prescription antibiotics decreased [15]. Conclusion Comparing the literature with our research findings, it is seen that it is difficult to distinguish the factors that affect the rational drug use. Therefore, the importance of rational drug use should be explained to each individual in the society in accordance with the individual characteristics. Nevertheless, healthcare providers should be encouraged to communicate more effectively with patients on rational drug use. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

References 1.

Rational use of medicines. WHO. cited 2018 Apr 29. Available from: http:// www.who.int/medicines/areas/rational_use/en/

Why rational drug use  : Rational drug use. cited 2018 Apr 29. Available from: http://www.akilciilac.gov.tr/?page_id=81

Maxwell SR. Rational prescribing: the principles of drug selection. Clin Med Lond Engl. 2016;16:459–64.

Bahat G, Akpınar TS, Tufan F, et al. Yaşlılarda akılcı ilaç kullanımı. J Gerontol Geriatr Arş. 2012;1:2–8.

Pınar N. Drug Expenditures in our country. J Inonu Univ Med Fac. 2012;19:59–65.

Koyuncuoğlu CZ, Kırmızı Nİ, Ceylan İ, ve ark. Diş Hekimliği Kliniklerine Başvuru Öncesinde Hastaların İlaç Kullanımı İle İlgili Tutumlarının Araştırılması. Marmara Pharm J. 2016;21:65–76.

Dağtekin G, Demirtaş Z, Alaiye M, et al. Ratıonal drug use attıtudes and behavıors of adults who apply for prımary health care ın semırural areas. Türk Dünya Uyg ve Araşt Merk Halk Sağlığı Derg. 2018;3:12–23.

İlhan MN, Aydemir Ö, Çakir M, et al. A study in three districts of ankara of behaviors associated with ırrational use of drugs. Turk J Public Health. 2014;12:188–200.

Toklu HZ, Dülger GA. Akılcı ilaç kullanımı ve eczacının rolü. Marmara Pharm J. 2011;15:89–93.

10. Göçgeldi E, Uçar M, Açıkel CH, et al. Investigation of frequency of leftover drugs at home and related factors. TAF Prev Med Bull. 2009;8(2). 11. Aydın B, Gelal A. Ratıonal drug use: promotion and the role of medical education. Dokuz Eylul University J. Medicine Faculty. 2012;26:57–63. 12. Güngör A, Çakır BÇ, Yalçın H, Çakır HT, Karauzun A. Evaluation of parents’ attitudes and behaviors related to the use of antibiotics in children. Turk J Pediatr Dis. [cited 2018 Sep 10; Available from: http://tchdergisi.org/index. php/tchd/article/view/1244 13. Health Statistics Yearbook 2016 Internet. Available from: https://dosyasb. saglik.gov.tr/Eklenti/13160,sy2016enpdf.pdf?0 14. Nayir T, Okyay RA, Yesilyurt H, et al. Assessment of rational use of drugs and self-medication in Turkey: a pilot study from Elazıg and its suburbs. Pak J Pharm Sci. 2016;29:1429–35. 15. Gökçe T. Birinci Basamak Sağlık Kuruluşuna Başvuran Hastaların Antibiyotik Kullanımı Konusundaki Davranış ve Bilgi Düzeylerinin Araştırılması. Uzmanlık Tezi, Pamukkale Üniversitesi, Denizli, 2017. .

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2018;7(4):935-9

Disseminated hydatid disease treated with albendazole: 15-year experience Sinem Gungor1, Murat Yalcinsoy2, Olga Akkan1, Bulent Altinsoy3, Zeynep Ferhan Ozseker4, Aysun Misirlioglu5, Semra Bati Kutlu6, Sibel Arinc1, Hatice Turker1, Esen Akkaya1 1

Sureyyapasa Chest Diseases and Thoracic Surgery Education and Research Hospital, Department of Pulmonary Medicine, Istanbul, Turkey 2 Inonu University Faculty of Medicine Department of Pulmonary, Malatya, Turkey 3 Bulent Ecevit University, Faculty of Medicine Department of Pulmonary, Zonguldak, Turkey 4 Istanbul University, Cerrahpasa Faculty of Medical Department of Pulmonary, Istanbul, Turkey 5 Sureyyapasa Chest Diseases and Thoracic Surgery Education and Research Hospital, Department of Thoracic Surgery, Istanbul, Turkey Received 19 July 2018; Accepted 06 August 2018 Available online 05.10.2018 with doi:10.5455/medscience.2018.07.8898 Copyright © 2018 by authors and Medicine Science Publishing Inc.

Abstract Medical therapy is recommended in various situations such as multiple cysts, high risk surgery , presence of small cyst and perioperative phase in the treatment of hydatid cyst. Present study was designed to determine the features of disseminated hydatid cyst cases, outcome of albendazole treatment , diagnosis and management of complications and patients’ outcome. Methods: 21 patients who had the diagnosis of hydatid cyst based on clinical, radiological, and pathological findings with multiple hydatid cyst in a single organ and/or more than one organ were retrospectively analyzed. The mean age was 34±17.9 (range, 7-71) and F/M was 17/4. Hydatid disease was detected as multiple cysts in the lung in four patients, as multiple cysts in the lung and pleura in one case, and as multiple organ involvement in 16 cases. The most common presentation was the involvement of both lung and liver. The most common symptom was cough. Four asymptomatic patients were detected during family screening. In six patients, Albendazole was started before the operation and the remainders were started after the operation. Cure was achieved in eight patients at the end of medical and/or surgical treatment. Convenient medical treatment with albendazole treatment in appropriately selected patients is an effective treatment option with minimal side effects in hydatid cyst disease. Keywords: Hydatid cyst, albendazole, multiple organ involvement

Introduction A hydatid cyst is the larval stage of Echinococcus granulosus at the metasestod phase. It is one of the major zoonoses [1]. Prevalence has been reported 5 to 10/100,000 [2,3]. It is estimated that 1,300 cases are newly diagnosed each year in Turkey [4,5]. The disease is most commonly observed in liver, followed by the lungs and it can involve any organ at a rate of 10% [2,3]. About 60% of the cases are solitary cysts, and multiple cysts are observed in 20 to 50% [6]. Although the process of the disease could be asymptomatic, it can lead symptoms which are specific to the involved organ depending on the localization and size of the cyst [7]. Surgery is accepted as the first treatment option. Medical therapy is recommended in multiple cysts, high risk surgery, the presence of small cyst, and perioperative phase [8]. *Coresponding Author: Murat Yalcinsoy, Department of Pulmonary Medicine, Sureyyapasa Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey, E-mail: mrtyalcinsoy@yahoo.com

The mortality rate has been reported as In the present study, we aimed to determine the clinical and radiological characteristics of the patients with multiple/disseminated hydatid cyst. Furthermore current study was designed to examine the effectiveness of albendazole treatment and possible complications, presence of relapse, etiological factors and treatment results based on our experience in the management and treatment of rarely seen complications. Materials and Methods Study design, setting, and population: The study was designed as a retrospective case-series study in a tertiary teaching hospital for chest diseases and thoracic surgery center between 2000-2015. The study protocol was approved by the institutional Ethics Committee and it was conducted in accordance with the principles of the Declaration of Helsinki. As the study was a retrospective study, no informed consent was obtained and the Scientific Committee of the hospital granted permission for the use of patient data in accordance with the patient privacy. During hospital procedure, all treatments and medications were done after obtaining informed consent of the patients. 935

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Patient Selection: The patients who were diagnosed with a hydatid cyst according to clinical, radiological, and pathological findings were included. The diagnosis was confirmed by the detection of positive indirect hemagglutination (IHA) test and pathological examination. The titration of 1/320 and above in IHA was considered positive. Exclusion criteria were as follows: the presence of a solitary cyst, lack of albendazole treatment, and refusing treatment. Data source: The data were gathered retrospectively from a password-protected database. Additional covariates: Demographic characteristics and symptoms, diagnostic methods, organ involvement, type of operation, results of treatment and follow-up were recorded. Living areas (country side/urban), occupation, dog contact, and family history were noted. Posterioanterior chest X-ray and radiological images, complete blood count, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyltransferase (GGT), and alkaline phosphatase (ALP) levels were recorded at the beginning of the treatment and during follow-up. Drug-related side effects such as alopecia, vertigo, nausea, and allergic reactions were recorded. Furthermore, type of surgery, treatment-related complications, relapse, and mortality were noted. Definitions: Risk factors were determined as living area, livestock breeding, and household transmission [10,11]. The results of treatment were checked radiologically using X-ray, computed tomography (CT), and ultrasound (US). According to the US findings, cysts were classified as active, transitional, and inactive [12]. Medical treatment: At the beginning of treatment, cranial CT is performed and medical treatment of complicated, multiple/ disseminated hydatid cyst cases without cranial involvement is performed with albendazole 10-15 mg/kg/day for three consecutive weeks and with a drug-free interval of a week [13]. The patients who had intracranial hydatid cyst are primarily operated. Following the operation, these patients are re-evaluated for medical treatment. Indications for surgery are complicated cysts, large cysts, and cysts involving the vital organs such as central nervous system, spinal cord, and the heart [8].

Med Science 2018;7(4):935-9

had hypertension, while the remaining two patients had diabetes mellitus (DM). Also, three patients had a previous history of tuberculosis. Clinical characteristics and diagnosis: Hydatid disease was detected as multiple cysts in the lung in four patients, multiple cysts in the lung and pleura in one patient, and multiple organ involvement in 16 patients. The most common presentation was involvement of both lung and liver (Figure 1). As rarely seen, three patients had muscle, vertebra, heart, and kidney involvement. The most common symptoms were cough, hemoptysis, pain, fever, and headache. Four asymptomatic patients were detected during family screening. Three patients were admitted to neurosurgery clinic with the symptoms of compression of the cranial lesion, and they were referred to our center with the diagnosis of a hydatid cyst following surgery. The diagnosis of a hydatid cyst was done by pathological examination in 14 patients, and radiologically in seven patients. IHA was found positive in 16 patients and negative in four patients. Treatment: The mean duration of albendazole treatment was 27Âą22 months. Twelve patients underwent several operations before the diagnosis. Albendazole was started before surgery in six patients and after surgery in other patients. Operation for several reasons was required in seven patients during follow-up. Splenectomy was performed in two patients among three patients with splenic involvement, while one patient received medical treatment due to the deep localization and cure was achieved following treatment (Figure 2). Cure was achieved in eight patients, whereas 11 patients recovered with sequelae. Two patients died due to other reasons independent from a hydatid cyst. Relapses: Relapse was observed in five patients. Relapses were determined as pulmonary and pleural involvement in four patients and cardiac involvement in one patient. All relapsed patients had multiple cysts with multiple organ involvement.

Statistical analysis Statistical analysis was performed using the Microsoft Office Excel program 2010 (Richmond,WA). Descriptive data were expressed in median with interquartile ranges for the nonparametric continuous variables and in meanÂąstandard deviation for the parametric continuous variables. Counts and percentages were also used, where applicable. Results Demographic characteristics of patients: Mean age was 34+17.9 (range,7 to 71) year and majority of the patients were females (81%). Considering the risk factors, there were no farmers. In terms of transmission of household contacts, there were six patients from two families and there were two patients who were neighbours of one of these families. All these patients were living in the rural area. Four patients had comorbidities. Two of them

Figure 1. Computed tomograpy scan showed bilateral and multipl cyst.

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Complications during albendazole treatment Ruptured cyst-related complications: Eleven complications due to a ruptured cyst was observed in eight patients (38%). Hemoptysis due to ruptured cyst was seen in six patients. During treatment, hydropneumothorax was detected and thoracotomy was planned in two patients (Figure 3). Medical treatment-related complications: Liver enzymes were elevated in five patients (24%). Therefore, treatment was discontinued for one cycle. Treatment was re-initiated, when the enzyme levels returned to normal limits. None of the patients had alopecia, vertigo, nausea, urticaria, allergic shock, leukopenia, and thrombocytopenia. Table 1 shows the characteristics of 21 patients treated with albendazole.

Figure 2. Case has multiple intraabdominal cysts Table 1. Characteristics of 21 hydatid disease cases treated with albendazole Case No

Sex

Age

Lung, liver, brain, heart, kidney

Lung, pleura

Lung, vertebra Lung, liver, spleen, brain

Lung, liver

9 10 11

F M F

21 69 68

Rural Area

Family Surgery before history Organ involvement albendazole treatment

Treatment Time to Surgery during duration Relapse relapse Result albendazole treatment (month) (year)

Cerebral cystectomy, Nephrectomy, Cardiac cystectomy

Cure

Lung, liver

Lung, liver Lung, liver Peritoneal cavity Lung, Lung Lung

3 3 22

Lung, liver

Lung, liver, s pleen, brain Lung, liver

Lung, liver

Lung, liver, brain

Pulmonary cystectomy

Lung, liver, muscle

Pulmonary cystectomy

Lung, liver

Pulmonary cystectomy

Lung, liver,

Pulmonary cystectomy

Cure

Cure in lung, liver inactive, peri-toneum inactive

Decortication, pulmonary Lung cystectomy cystectomy Vertebra cystectomy Pleural decortication, Cerebral cystectomy cystectomy Hepatic cystectomy, Hepatic cystectomy pulmonary cystectomy

Lung cystectomy

Cerebral cystectomy

Splenectomy

Hepatic cystectomy

Cerebral cystectomy

Lung, liver, spleen, peritoneal cavity, Splenectomy subcutaneous tissue

Lung

Pulmonary wedge resection, cystotomy, capitonnage

Cure

Cure in lung, liver inactive Cure in lung, liver inactive Cure Sequela in lung, liver inactive Exitus Exitus Sequela in lung Cure in lung, liver inactive Sequela in lung, liver inactive Cure Cure in lung, liver inactive Cure in lung, liver inactive Sequela in lung, liver inactive Cure

Cure

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in the staging of a liver hydatid cyst and in the evaluation of treatment response [12,21]. In patients with a hepatic hydatid cyst, inactive cyst presentation which was confirmed by abdominal US is the treatment discontinuation criteria. Furthermore, CT scan can provide detailed information such as localization, size, invasiveness, and structure of the cyst. Follow-up of the treatment had an important effect on the determination of recurrences and follow-up of the calcified cysts [22]. Beyond being benefical for the initial diagnosis, immunological tests are also used for the evaluation of surgery and treatment response [23]. In our study, serological tests were rarely useful to establish a definite diagnosis.

Figure 3. Left hydropneumothorax developed during treatment

Discussion In the present study including patients with a disseminated hydatid cyst treated with albendazole, we found that albendazole treatment is effective and safe with minimal side effects in selected patients. Hydatid cyst disease is frequently seen in females [3,14]. In the present study, the majority of patients were females. This can be associated with the fact that females meet the environmental factors more frequently. Although hydatid cyst disease is seen at all ages, in a meta-analysis including 1,211 patients, its prevalence increased at the age of 40 and above [15]. Cappello et al. also reported that the ratio of multiple hydatid cysts were significantly higher at the age of 50 and below [3]. Similarly, the mean age of our study population was consistent with the literature Although the incidence of intrafamilial hydatid cyst disease is not exactly known, there are some case reports about intrafamilial spread [16,17]. Incidence of the disease in four large families living in an endemic region was found 14.9% [10]. In our study, six patients from two families and two patients who were neighbours of one of these families were examined for environmental exposure. Their common features were living in the rural area. Pulmonary hydatid cyst disease was found to be 7 to 9 times more symptomatic than hepatic disease, which was attributed to the slow-growing nature of the cyst in the liver with less morbidity [18]. Except four patients who were detected during family screening, the majority of our patients were symptomatic. This can be related to the fact that the patients had multiple cysts or multiple organ involvement. Cough was frequently seen in our patients, which can be related to the presence of pulmonary involvement. Multiple hydatid cysts were reported at a rate of 60%, and the ratio of early diagnosed multiple hydatid cysts was significantly higher [3]. Rare organ involvement like muscle, bone, isoleted spleen, cardiac hydatid cyst varies between 7-13% [19,20]. In the present study, 7 patients had rare organ involvement. The diagnosis of a hydatid cyst was done by pathological examination in most of the patients. Abdominal US, which is the main non-invasive diagnostic method, is particularly essential

According to the World Health Organization (WHO), the usual dose of albendazole is 10 to 15 mg/kg/day in several one-month intervals separated by 14-day intervals. Treatment protocol as â&#x20AC;&#x153;three courses are routinely suggested, and more than six are usually not necessaryâ&#x20AC;? is recommended [8]. The reason for long duration of treatment in our patients is that all patients were complicated, and had more than one organ involvement. Furthermore the patients with hepatic involvement had late response to the treatment. In our patient group, high rate of cure was achieved with albendazole treatment. In Cappello et al. study, the mean duration of treatment was six months, except 120 months in one patient and reported that this patient had multiorgan involvement, same as in our study population [3]. Furthermore, it was concluded that it might be associated with prolonged treatment, advanced patient age, drugcyst interaction, and disease severity [3,24]. However, an important issue in this setting is the patientsâ&#x20AC;&#x2122; compliance to the long treatment duration. In our study, the patients who were initially admitted to internal medicine attended to their scheduled visits more regularly. One patient with splenic involvement completely recovered with only albendazole treatment, while he was in the waiting list for surgery. Among the patients with muscle, vertebra, heart, spleen, brain, and kidney involvement, those with muscle involvement recovered with only albendazole treatment. No complications were observed. In other types of involvement, surgery was preferred due to the presence of life-threatening risks. According to the WHO data, in more than 1,000 cases treated with benzimidazole and followed for 12 months, cure (complete disappearance of a cyst) was seen at a rate of 30%, whereas 30 to 50% showed cyst degeneration or significant reduction in the cyst size (improvement), and 20 to 40% showed no morphological changes (failure) [8]. Reporting the results of albendazole treatment, the cure rate was found to be 50 to 70% during a 12-month follow-up [25]. The high cure rate in the current study can be related to the use of albendazole, which is more effective compared to mebendazole, surgical intervention for complications, and prolonged medical theraphy. In the current study, relapse was seen in 23% patients following the treatment, and all patients with relapse had multiple cysts with multiorgan involvement. The mean time to relapse was 7 years, and relapse was seen 17 years after the initial treatment in one patient, which can be associated with re-infection. In other cases, relapse was thought to be related to be re-activation. In the previous studies, the relapse rate was reported as 0 to 30% with mean time to relapse 3 to 4 years [8,26]. In addition, the most common complication in endemic regions is biliary tract rupture and superinfection 5 to 17% and of 5.1% respectively. The most common side effect related to albendazole treatment is elevated liver enzymes. In about 10 to 20% of 938

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patients, elevated liver enzymes can be seen at any time during treatment. The levels usually return to normal by discontinuation of the treatment [8]. In our study, none of treatment-related side effects such as alopecia, vertigo, nausea, and allergic reactions were observed. Although elevated liver enzymes are rare, monthly control was performed. In patients with elevated liver enzymes, enzyme levels returned to normal in all patients when one cycle was cancelled. Furthermore, cyst-related complications such as massive hemoptysis were not observed, while short-term hemoptysis was seen during or after cyst rupture in patients with post-obstructive pneumonia. However, this complication was resolved with medical treatment and no recurrence was observed. In conclusion, taking preventive measures are very crucial for the hydatid cyst disease, which is an important health issue in Turkey. Our study results suggest that albendazole treatment is an effective treatment option with minimal side effects in conjunction with appropriate patient selection and close collaboration with surgery. Author Contributions Sinem Gungor conceived paper, participated in study design, wrote manuscript, data analysis and interpretation, critically revised manuscript and approved final version. Murat Yalcinsoy conceived paper, oversaw data collection, conducted data analysis, wrote manuscript and approved final version. Olga akkan participated in study design, data analysis, and interpretation of data and revision of manuscript and approved final version. Bulent Altinsoy participated in study design, interpretation of data and revision of manuscript and approved final version. Zeynep Ferhan Ozseker participated in study design and interpretation of data; critically revised manuscript and approved final version. Aysun Misirlioglu participated in study design and interpretation of data, and performed surgical procedures and critically revised manuscript and approved final version. Semra Bati Kutlu participated in data interpretation and revision of manuscript, and performed laboratory procedures and approved final version. Sibel Arinc participated in study design and interpretation of data; critically revised manuscript and approved final version. Haitce Turker participated in study design and interpretation of data; critically revised manuscript and approved final version. Esen Akkaya participated in study design and interpretation of data; critically revised manuscript and approved final version. The authors declare that they have no conflicts of interest. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval The study protocol was approved by the institutional Ethics Committee and it was conducted in accordance with the principles of the Declaration of Helsinki. References 1.

Morar R, Feldman C. Pulmonary echinococcosis. Eur Respir J. 2003;21:106977.

Mohamed RM, Abdel-Hafeez EH, Belal US, et al. Human cystic echinococcosis in the nalut district of western libya: A clinico-epidemiological Study. Trop Med Health. 2014;42:177-84.

Cappello E, Cacopardo B, Caltabiano E, et al. Epidemiology and clinical features of cystic hydatidosis in Western Sicily: a ten-year review. World J Gastroenterol. 2013;19:9351-8.

Canda MŞ, Canda T. Türkye Ekinokokkozis Haritası ve Kaynakçası. Türkiye Ekopatoloji Dergisi 2004;1.

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Esatgil mu. Türkiye’de Hidatidozis (eknokokkozis) sorunu. İstanbul Üniversitesi Veteriner Fakültesi Dergisi 2008;34:33-48.

Martínez S, Restrepo CS, Carrillo JA, et al. Thoracic manifestations of tropical parasitic infections: a pictorial review. Radiographics 2005;25:13555.

Arroud M, Afifi MA, El Ghazi K, et al. Lung hydatic cysts in children: comparison study between giant and non-giant cysts. Pediatric Surg Int. 2009;25:37-40.

Eckert J. Guidelines for treatment of cystic and alveolar echinococcosis in humans. WHO Informal Working Group On Echinococcosis. Bull World Health Organ. 1996;74:231-42.

Bedioui H, Bouslama K, Maghrebi H, et al. Predictive factors of morbidity after surgical treatment of hepatic hydatid cyst. Pan Med J.2012;13:29.

10. Yang YR, Ellis M, Sun T, et al. Unique family clustering of human echinococcosis cases in a Chinese community. Am J Trop Med Hyg. 2006;74:487-94. 11. Sanli A, Onen A, Karapolat S, et al. Social factors associated with pulmonary hydatid cyst in Aegean, Turkey. Afr Health Sci. 2011;11:S82-5. 12. WHO Informal Working Group. International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings. Acta Trop. 2003;85:253-61. 13. Wen H, Zou PF, Yang WG, et al. Albendazole chemotherapy for human cystic and alveolar echinococcosis in north-western China. Trans R Soc Trop Med Hyg. 1994;88:340-3. 14. Selek A, Selek MB, Karadayi N. Evaluation of the Cystic Eccinococcosis Cases Diagnosed in Dr. Lutfi Kirdar Kartal Education and Research Hospital Pathology Laboratory Between 2007 and 2013. Turkiye Parazitoloji Dergisi 2015; 39:112. 15. Budke CM, Carabin H, Ndimubanzi PC, et al. A systematic review of the literature on cystic echinococcosis frequency worldwide and its associated clinical manifestations. Am J Trop Med Hyg. 2013;88:1011-27. 16. Durgun Yetim T, Yetim İ, Davarcı I. Kistik ekinokokkozis: Aile enfeksiyonu. 17. Morakote N, Thamprasert K, Lojanapiwat B, et al. Cystic echinococcosis in Thailand with a special note on detection by serology in one family. Southeast Asian J Trop Med Public Health. 2007;38:796-8. 18. Larrieu E, Frider B. Human cystic echinococcosis: contributions to the natural history of the disease. Ann Trop Med Parasitol. 2001;95:679-87. 19. Demirci E, Altun E, Çalık M et al. Farklı Lokalizasyonları ile Kist Hidatik Olguları: Erzurum Bölgesi. Turkiye Parazitoloji Dergisi 2015;39:103-7. 20. Ç öl C, Ç öl M, Lafci H. Unusual localizations of hydatid disease. Acta Med Austriaca. 2003;30:61-4. 21. Tamarozzi F, Nicoletti GJ, Neumayr A, et al. Acceptance of standardized ultrasound classification, use of albendazole, and long-term follow-up in clinical management of cystic echinococcosis: a systematic review. Curr opin Infect Dis. 2014;27:425-31. 22. Pedrosa I, Saiz A, Arrazola J, et al. Hydatid disease: radiologic and pathologic features and complications. Radiographics. 2000;20:795-817. 23. Tenguria RK, Naik MI. Evaluation of human cystic echinococcosis before and after surgery and chemotherapy by demonstration of antibodies in serum. Ann Parasitol. 2014;60:297-303. 24. Brunetti E, White AC Jr. Cestode infestations: hydatid disease and cysticercosis. Infect Dis Clin Nrth Am. 2012;26:421-35. 25. John H. Albendazole for the treatment of echinococcosis. Fundamental, clin pharmacol. 2003;17:205-12. 26. Arinc S, Alpay L, Okur E, et al. Recurrent pulmonary hydatid disease: analysis of ten cases. Surg Today. 2008;38:983-6.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

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The efficacy of pneumatic balloon dilatation treatment on achalasia: Single center experience Mehmet Ali Erdogan, Ali Riza Caliskan Inonu University Medical Faculty Department of Gastroenterology, Malatya, Turkey Received 12 August 2018; Accepted 04 September2018 Available online 28.10.2018 with doi:10.5455/medscience.2018.07.8922 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract1 Achalasia is one of the most common motility disorders of esophagus characterized by deterioration of the lower esophageal sphincter due to loss of myenteric plexus. The main symptoms are progressive dysphagia towards fluids and solids, regurgitation of food, weight loss, aspiration pneumonitis. Methods such as pneumatic dilatation, pharmacological agents, laparoscopic heller myotomy, and peroral endoscopic myotomy are used in the treatment. We want to present our results of pneumatic dilatation in this study. 31 newly diagnosed patients who underwent pneumatic dilatation at Inonu University Turgut Ozal Medical Center between 2008 and 2016 , were included in the study. Pneumatic dilatation was applied once on 17 (55%) patients, twice on 6 (19%) patients, and thrice and over on 8 (26%) patients. In 27 (87%) patients, success was achieved with pneumatic dilatation and in 4 patients (13%) with laparoscopic Heller myotomy. Pneumatic dilatation being a less invasive method among available treatment methods, still maintains its efficacy when considering low complications and ease of administration. Keywords: Achalasia, pneumatic dilatation, laparoscopic heller myotomy

Introduction Achalasia is a rare disease of esophagus with the estimated prevalence ranging from 0.5-1.63 per 10000 per year. The main symptoms of the patients are progressive dysphagia towards fluids and solids, regurgitation of food, weight loss, aspiration pneumonitis and chest pain [1,2]. Achalasia is one of the most common motility disorders of the esophagus characterized by deterioration of the loosening of the lower esophageal sphincter due to the loss of myenteric plexus, which is regarded as an autoimmune, viral, neurodegenerative disorder in etiology [3]. It effects both genders equally and may occur at any age [2]. Diagnosis is confirmed with esophagial manometry after being determined by endoscopic and / or radiological methods [1]. Methods such as pharmacological agents, pneumatic dilatation (PD), laparoscopic heller myotomy (LHM), and peroral endoscopic myotomy (POEM) are used in the treatment. PD is the most effective non-surgical method. It is performed by inflating a 3.0, 3.5, 4.0 cm balloon which is placed with a guide wire through the lower esophageal sphincter with the help of Endoscopy [4]. In this study, we wanted to discuss the

*Coresponding Author: Mehmet Ali Erdogan, Inonu University Medical Faculty Department of Gastroenterology, Malatya, Turkey E-mail: mehmet_ali_erdogan@hotmail.com

efficacy and complications of dilatation by evaluating the results of PD that we performed in our clinic. Materials and Methods 31 newly diagnosed patients who underwent pneumatic dilatation at Inonu University Turgut Ozal Medical Center between 2008 and 2016 , were included in the study. The diagnosis was made after endoscopic, radiological and manometric studies. A barium esophagus graphy was performed in order to determine the level and length of the narrowness. In the graphy; narrowing and esophageal dilatation in the form of bird-beak, were observed in the distal part of the esophagus. Upper endoscopy was performed in all patients in order to eliminate secondary causes. Esophageal manometry was applied. Clinical, endoscopic and radiological parameters were used for the success of treatment before and after dilatation. All procedures were performed by experienced gastroenterologists under fluoroscopy. Consent form was taken from all patients before the procedure. Patients were sedated with midazolam and propofol. Rigiflex balloons (Boston Scientific Cop., MA) of PD 3.0, 3.5 and 4.0 cm in diameter were used. The balloon placed in the LES with fluoroscopy was inflated using 7-15 psi air for 60 seconds. This process was repeated twice. After the procedures, presence of blood was checked on the surface of the balloon dilatators. Presence of blood was considered significant in 940

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terms of success of the procedure. The procedure was started with the balloon having the smallest diameter and when the treatment of the patients failed who were called for check-up after 6-8 weeks, PD was performed by gradually increasing the balloon diameter in other sessions. Next follow-up periods were determined as 6-1224 months. Patient follow-up was performed with gastroscopy, clinic and esophageal barium graphy. The data were analyzed using SPSS version 16.0 (SPSS Inc, Chicago, IL, USA) after being entered manually. Results 14 (45%) of the patients were female and 17 (55%) were male and the mean age was 53.23 years (29-80). PD was performed once on 17 (55%) of the patients. 8 of these patients were followed- up for 0-18 months, mean follow-up period was 7.6 months; 3 of patients were followed-up for 19-36 months, mean follow-up period was 28

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months; 6 of patients were followed-up for more than 36 months and mean follow-up period was 72 months. PD was performed twice on 6 (19%) of the patients. 1 of these patients were followedup for 0-18 months and follow-up period was 16 months, 5 of patients were followed-up for 19-36 months and follow-up period was 26.4 months. PD was performed thrice and over on 8 (26%) patients. 6 of these patients were followed- up for 0-18 months, mean follow-up period was 10.6 months; 2 were followed-up for 19-36 months, mean follow-up period was 30 months. In patients who underwent dilatation thrice and over; 1 patient was dilated 3 times, 5 patients were dilated 4 times, 1 was dilated 5 times, and 1 was diluted 6 times. Balloon diameter was increased in the next process in patients who underwent PD more than once (Table 1). LHM was performed on 4 patients who underwent dilatation sessions 4 times and over. Three of them were male and one was female and the mean age was 43 years. None of the patients had complications such as perforation and major bleeding.

Table 1. Pneumatic balloon dilatation results 1 dilatation Follow-up duration (months)

3≥ dilatation

2 dilatation

0-18

19-36

36>

0-18

19-36

36>

0-18

19-36

36>

Age (mean)

49.4

49.5

Famele

Male

Discussion Although there is no definite treatment for achalasia, current approaches are aimed at evacuating alimentary canal, relieving symptoms, and preventing mega-esophageal development [5]. PD still maintains its first place of being the first choice in achalasia treatment in many centers [6]. Nowadays, the Eckardt score is widely used to evaluate the efficacy of treatment before and after treatment of achalasia patients. It is accepted that symptomatic recurrence is greater than 3 [7,8]. Remission rates are given in different rates in different publications for balloon dilatation. It is found that successful single post-PD remission rates were 62% for 6 months and 28% for 6 years. Young age, male gender, and broad esophagus were determined as risk factors for failure. No difference was observed between longterm and short-term results of PD and LHM [9]. While 27 of our patients (86.7%) had remission with PD, 4 of our patients (13.3%) underwent LHM. Pneumatic dilation is more successful in women and elderly, whereas, LHM is more successful in young and men [10]. In a study by Andreevski V and his colleagues, it was found that after a single session, the 1 year remission rate was 35% [11]. However, the success rate was increased in dilatations that were performed by increasing the balloon diameters. The success rate of study conducted by Kadakia and his colleagues was 93%. 18 of these patients were dilated with a 3.0 cm balloon. 3.5 cm balloon dilatation was performed on 11 patients with no responses. Dilatation was successfully performed in 5 of these patients and 4.0 cm dilatation was performed in the remaining 6 patients. Dilatation was successful in 4 of these patients and 2 patients were referred to surgery [12]. In a study involving 24 studies conducted until 2009,

74%, 80% and 90% success rates were determined in dilatations performed with 3.0, 3.5 and 4.0 cm balloons, respectively [10]. In an average 48 weeks follow-up conducted by Cheng and his colleagues on 35 patients, one session dilatation was performed on 30 patients (85.7%), two sessions on 4 patients (11.4%) and three sessions on 1 patient (2.9%). While remission rates were 87.5% between 6 and 36 months, it was determined to be 40% after 60 months [13]. In our study, PD was successfully performed on 27 (87%) patients. Perforation, being the most serious complication of balloon dilatation, has an overall rate of 1.9%. Age and starting dilatation with 3.5 cm first, are the risk factors. Other complications include chest pain, gastroesophageal reflux, bleeding and transient fever [14]. Chest pain and bleeding due to self-limiting mucosal rupture was observed in our patient group during the procedure. Severe complications such as abundant bleeding and perforation did not occur. Conclusion In conclusion, although new endoscopic techniques have been developed in recent years, these techniques can’t be performed in most centers. We believe that PD’s efficacy is high and as compared with more invasive methods such as surgery, it still maintains its efficacy. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval Before the study, permissions were obtained from local ethical committee.

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References 1.

Richter JE, Boeckxstaens GE. Management of achalasia: surgery or pneumatic dilation. Gut 2011;60:869–76.

Stavropoulos SN, Modayil R, Friedel D. Achalasia. Gastrointest Endosc Clin. 2013;23:53–75.

Uppal DS, Wang AY. Update on the endoscopic treatments for achalasia. World J Gastroenterol. 2016;22:8670-83.

Tack J, Zaninotto G. Therapeutic options in oesophageal dysphagia. Nat Rev Gastroenterol Hepatol. 2015;12:332–41.

Dobrucali A, Erzin Y,Tuncer M, Dirican A. Long-term results of graded pneumatic dilatation under endoscopic guidance in patients with primary esophageal achalasia. World J. Gastroenterol. 2004;10:3322–7.

Sabharwal T, Adam A. Balloon Dilatation of Esophageal Strictures/Achalasia. Semin Intervent Radiol. 2004;21:149–55.

Boeckstaens GE, Annese V, Bruley des Varannes S, et al. Pneumatic dilation versus laparoscopc Heller’s myotomy for idopathic achalasia. N Engl J Med. 2011; 364: 1807–16.

The American Society for Gastrointestinal Endoscopy PIVI committee,

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Chandrasekhara V, Desilets D, et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on peroral endoscopic myotomy. Gastrointest Endosc. 2015;81:1087–100. 9.

Vela MF, Richter JE, Khandwala F, et al. The long-termefficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia. Clin Gastroenterol Hepatol. 2006; 4: 580 –7.

10. Richter, J. E. Update on themanagement of achalasia: balloons, surgery and drugs. Expert Rev Gastroenterol Hepatol. 2008;2:435–45. 11. Andreevski V, Nojkov B, Krstevski M, et al. Shortand medium-term therapeutic effects of pneumatic dilation fo rachalasia: a 15-year tertiary centre experience. Pril (Makedon Akad NaukUmet Odd Med Nauki). 2013;34:15–22. 12. Kadakia, SC, Wong, RKH. Graded pneumatic dilationusing Rigiflex achalasia dilators in patient swith primary esophageal achalasia. Am J Gastroenterol. 1993;88: 34–8. 13. Cheng P, Shi H, Zhang Y, et al. Clinical effect of endoscopic pneumatic dilation for achalasia. Medicine 2015;94:1193. 14. Moonen A, Boeckxstaens G. Current diagnosis and management of achalasia. J Clin Gastroenterol. 2014;48: 484-90.

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CASE REPORT

Medicine Science International Medical Journal

Medicine Science 2018;7(4):943-5

Deletion of chromosomal regions 13q21 detected by genetic tests in a boy with special learning disorder: A case report Tayfun Kara, Semra Yilmaz University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital Department of Child and Adolescent Psychiatry, Istanbul, Turkey Received 22 March 2018; Accepted 24 April 2018 Available online 11.09.2018 with doi: 10.5455/medscience.2018.07.8865 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Specific learning disorder (SLD) is defined as significant and persistent learning difficulties leading to unexpected academic underachievement in terms of the subject’s age and cognitive ability, and the level of education provided. SLD has a biological basis determined by genetic and environmental factors. Neurobiological hypotheses have been proposed to account for SLD, and genetic factors have been proved to have a major effect on the etiology. Findings of specific language impairment (SLI), such as speech delay, are frequently seen in early childhood in SLD cases. Recent studies of the etiology of SLI have also focused on genetic causes and have suggested a genetic inheritance. We report the case of a nine-year-old SLD patient with 13q21 deletion, who was a prior diagnosed with language impairment in early childhood. The case is discussed in the light of the current literature. Keywords: Specific learning disorder, genetics, specific language impairment

Introduction Specific learning disorder (SLD) is a neurodevelopmental disorder characterized by persistent difficulties in learning and using academic skills. Impaired academic skills can occur in three domains, reading, written expression and mathematics. In the Diagnostic and Statistical Manual for Mental Disorders– Fifth Edition, (DSM–5) the prevalence of SLD across all these academic domains is cited at 5-15% among school-age children across different cultures and languages [1]. There is now strong evidence from twin and association studies implicating genes in the development of reading disorder [2]. Family studies have long shown that dyslexia and overall reading abilities have significant genetic components, with heritability estimated at 54-84% [3]. Language disorders are frequently seen in SLD patients in clinical practice. Research has shown that dyslexia tends to co-occur with other neurodevelopmental disorders, such as specific language impairment (SLI) [4], speech sound disorder [5], and attention deficit-hyperactivity disorder. Several prospective studies have reported an increased rate of subsequent reading disorder with SLI [6]. Relatives of probands affected by dyslexia also have an increased risk of language impairment, while studies of children with language impairments often report a high incidence of *Coresponding Author: Tayfun Kara, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital Department of Child and Adolescent Psychiatry, Istanbul, Turkey E-mail: akpolatcetin@yahoo.com

literacy problems. However, the exact relationship between the two disorders (SLI and SLD) remains unclear. We describe a patient with 13q21 deletion, who had been previously diagnosed with SLI in early childhood, and with SLD later during formal education, and discuss the case in the light of the current literature. The parents gave written consent for the publication of this report. Case Report A nine-year-old boy living in Istanbul with his family presented to our clinic with low academic achievement and learning difficulties. Despite being in the third year of school, he had failed to fully acquire reading and writing skills. His reading speed was below the expected level, and significant problems were present in reading accuracy. He was confusing letters and numbers. His writing was illegible, with entire words missing. He also had difficulty with arithmetical calculations and time-related concepts. The Wechsler Intelligence Scale for Children-Revised (WISC-R) was applied, eliciting Verbal IQ: 60 and Performance IQ: 85. Following tests and clinical evaluation, the patient’s mental level was evaluated as dull normal / low average. He was the youngest child of the family, and had been delivered via the physiological route following a normal pregnancy. Growth retardation was noted in the first few months of life. He was able to sit unsupported at nine months, and to stand while holding onto objects at one year, and started walking at approximately 15 months. He started producing consonant sounds at 10 months, babbled (“baba” or “dada”) at 15 months, and spoke his first words at 24 months. He began to form simple sentences at 3-3.5 years. He had no history of hospitalization, seizures, surgical 943

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procedures, or systemic disease. At approximately four years of age he had been referred to a child psychiatry clinic due to the complaints of poor vocabulary and limited sentence structure and had been diagnosed with expressive language disorder. Following two years of supportive rehabilitation education, he had caught up with his peers in terms of language skills. His family history was negative for any psychiatric or systemic disease. Specific learning disorder was diagnosed at psychiatric evaluation on the basis of DSM-V diagnostic criteria. No comorbid psychiatric diagnosis was determined. The current learning disability was prevalent in all areas of reading, writing and mathematics. Psychoeducation and special training were started following diagnosis. His appearance indicated physical development below the expected level for his age. Despite being nine years old, he was 121 cm tall and weighed 21 kg. His parents reported that he had always lagged behind his peers in terms of developmental percentiles. Since his recent values were below the third percentile for both weight and height for Turkish boys, the patient was consulted with pediatric medicine clinic. Laboratory examination revealed no pathological findings. Genetic evaluation revealed 16.6 Mb deletion in the band q21.32 q31.1 (66613570-83232587) in the q arm of chromosome 13. Discussion Dyslexia, the most commonly investigated form of SLD, is a complex neurodevelopmental disorder with a multifactorial etiology which probably involves small effects of numerous genes and gene-gene interactions [7], as well as gene-environment interactions [8]. Growing interest in genetic studies has led to an increase in the numbers of reports concerning associations between SLD with specific genes and chromosomes. Reviews discussing the genetics of dyslexia and learning disorders have identified several loci and chromosomes related to dyslexia, including 15q21.3, 6p22, 2p16-p15, 6q13-16.2, 3p12-q13, 18p11.2, 11p15.5, 1p36-p34, and Xq27.3 [9-11]. In SLD cases, language problems are often seen not only during the diagnosis of SLD but also in the developmental story. SLI is clinically defined as failure to develop language normally, despite the presence of a suitable environment for language development and the absence of hearing deficits, mental retardation, oral motor/structural abnormalities, or of neurological or psychiatric impairments affecting language acquisition [12]. The etiology of SLI, like that of many complex neurological disorders, is not well defined, although research over the last decade suggests that the condition is highly heritable. Several genes and loci have already been implicated in SLI through linkage and targeted association methods [13]. Chr13q21 has been identified as a major susceptibility locus for SLI [12]. Reviews summarizing the chromosomal etiology of reading disorder and SLI have identified 13q21 (SLI3) as a chromosome region linked to SLI, and 1p3436, 2p15-16, 3p12-q13, 6p22, 15q21, 18p11 and Xq27.3 as chromosome regions linked to reading disorder [5]. Many children diagnosed with SLI early in their life subsequently develop characteristics of dyslexia after starting school [14, 15]. Children with SLI often have other language disorders, or learning disorders, such as reading disorder, speech sound disorder, attention deficit hyperactivity disorder or autism. This suggest the possibility of an overlap of genetic risk factors [16]. The strong links between both dyslexia and SLI and phonological impairments

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have encouraged speculation that language impairments and reading disabilities may represent different manifestations of similar neurological deficits [14]. The biological cause of reading disorder and SLI remains poorly understood. However, the manifestations of the conditions are clearly the result of multiple interacting factors, many of which are genetic in origin. It is very probable that SLI and reading disorder arise due to various shared genetic/neurobiological mechanisms, as well as non-shared causal factors [17]. In their recent review of the literature, Snowling and Melby-LervĂĽg suggested that a phonological processing deficit can be conceptualized as an endophenotype of dyslexia that increases the continuous risk of reading difficulties [18]. Conclusion Similarly in our case, the patient had been diagnosed with expressive language disorder in early childhood and had received speech therapy for this. SLD was diagnosed after beginning formal school education. Physical examination indicated findings of growth retardation. In the literature, common clinical features of 13q21 deletion include moderate to severe mental retardation and growth retardation. Our subject exhibited growth retardation, but no mental retardation [19]. In one case with deletion in similar coordinates, bilateral sensorineural hearing impairment, cataract, corneal opacity, retinal detachment, weight loss, absent speech, generalized seizures, and severe global developmental delay were reported on a genetic database [20]. We think that the genetic coordinates detected at analysis probably represent the common genetic constituent of SLD and SLI. To the best of our knowledge, this is the first case in which SLI and SLD were both present in the context of 13q21 deletion. The only physical finding in the examination of our patient was poor physical development which let us to consider pediatric consultation. Considering the prevalence of SLD, clinicians should pay particular attention to minor phenotypic findings in patients with the condition, which may indicate the type of further examination required. This approach will also be helpful in identifying the etiology of SLD. We also think, in the light of the present case, that particular studies on the association between SLD and 13q21 are now needed. Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves.

References 1.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). 5th Edition. Arlington (VA): American Psychiatric Publishing. 2013.

Wadsworth SJ, DeFries JC, Willcutt EG, et al. The Colorado Longitudinal Twin Study of Reading Difficulties and ADHD: Etiologies of Comorbidity and Stability. Twin Res Hum Genet. 2015;18:755-61.

Astrom RL, Wadsworth SJ, DeFries JC. Etiology of the stability of reading difficulties: the longitudinal study of reading disabilities. Twin Res Hum Genet. 2007;10:434-9.

Melby-LervĂĽg M, LervĂĽg A. Oral language skills moderate nonword repetition skills in children with dyslexia: A meta-analysis of the role of nonword repetition skills in dyslexia. Scientific Studies of Reading. 2012;16:1-34.

Pennington BF, Bishop DV. Relations among speech, language, and reading disorders. Annu Rev Psychol. 2009;60:283-306.

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Nathan L, Stackhouse J, Goulandris N, et al. The development of earl literacy skills among children with speech difficulties: a test of the “critical age hypothesis”. J Speech Lang Hear Res. 2004;47:377-91.

genomic characterization of the critical interval and localization of translocations associated with speech and language disorder. Am J Hum Genet. 2000;67:357-68.

Newbury DF, Monaco AP, Paracchini S. Reading and language disorders: the importance of both quantity and quality. Genes (Basel). 2014;5:285-309.

McGrath LM, Smith SD, Pennington BF. Breakthroughs in the search for dyslexia candidate genes. Trends Mol Med. 2006;12:333-41.

14. Snowling M, Bishop DV, Stothard SE. Is preschool language impairment a risk factor for dyslexia in adolescence? J Child Psychol Psychiatry. 2000;41:587-600.

Gibson CJ, Gruen JR. The human lexinome: genes of language and reading. J Commun Disord. 2008;41:409-20.

10. Pennington BF, Bishop DV. Relations among speech, language, and reading disorders. Annu Rev Psychol. 2009;60:283-306. 11. Eicher JD, Gruen JR. Imaging-Genetics in Dyslexia: Connecting risk genetic variants to brain neuroimaging and ultimately to reading impairments. Mol Genet Metab.2013;110:201-12. 12. Bartlett CW, Flax JF, Logue MW, et al. A major susceptibility locus for specific language impairment is located on 13q21.Am J Hum Genet. 2002;71:45-55. 13. Lai CS, Fisher SE, Hurst JA, et al. The SPCH1 region on human 7q31:

15. Torppa M, Lyytinen P, Erskine J, et al. Language development, literacy skills, and predictive connections to reading in Finnish children with and without familial risk for dyslexia. J Learn Disabil. 2010;43:308-21. 16. Newbury DF, Monaco AP, Review Genetic advances in the study of speech and language disorders. Neuron. 2010;68:309-20. 17. Newbury DF, Paracchini S, Scerri TS, et al. Investigation of dyslexia and SLI risk variants in reading- and language impaired subjects. Behav Genet. 2011;41:90-104. 18. Snowling MJ, Melby-Lervåg M. Oral language deficits in familial dyslexia: A meta-analysis and review. Psychol Bull. 2016; 142:498-545. 19. Patient: 291602. https://decipher.sanger.ac.uk/patient/291602#overview access date 22.02.2018

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Bone marrow metastasis of alveolar rhabdomyosarcoma mimicking Burkitt’s lymphoma Sinan Demircioglu1, Omer Ekinci1, Ali Dogan1, Irfan Bayram2, Cengiz Demir1 Van Yüzüncü Yıl University, Faculty of Medicine, Department of Hematology, Van Turkey 2 Van Yüzüncü Yıl University, Faculty of Medicine, Department of Pathology, Van Turkey

Received 04 April 2018; Accepted 26 April 2018 Available online 02.07.2018 with doi: 10.5455/medscience. 2018.07.8831 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract Some rare malignant diseases exhibit clinical features and bone marrow aspirate morphology similar to that of acute leukemia. For instance, rhabdomyosarcoma, neuroblastoma, medulloblastoma, anaplastic oligodendroglioma, small cell carcinoma, Ewing’s sarcoma and neuroendocrine tumors have been reported to display an acute leukemia-like morphology in bone marrow aspirates after metastasizing to the bone marrow. Rhabdomyosarcoma (RMS), a malignant tumour of mesenchymal origin which can occur at various sites in the body, is one of the most common soft tissue sarcomas in both children and adolescents, but is rare in adults with a prevalence of less than 1 %. Bone marrow metastases associated with this condition may be readily confused with acute leukemia or lymphoma. Diagnostic confirmation requires immunohistochemical and flowcytometric examinations. In patients with positive CD56 and negative CD45, rhabdomyosarcoma should be included in the differential diagnosis. Here, we report an unusual case of RMS confined to the bone marrow in an older adult. Keywords: Rhabdomyosarcoma, Burkitt’s lymphoma, bone marrow, CD56(+), CD45(-)

Introduction Although rhabdomyosarcoma (RM) is the most common soft tissue tumor of childhood, it is a rare condition in adults. Alveolar rhabdomyosarcoma (ARM) reaches a peak incidence in adolescents, and typically arise from sinuses, breast, and soft tissue of the extremities. Of these tumors, approximately 23% are associated with bone marrow metastases [1]. Differentiation between acute leukemia and bone marrow metastasis of rhabdomyosarcoma is challenging, as both of these conditions may lead to diffuse involvement with blast-like cells [2-4]. Case Report A 53-year old male patient presented with complaints of fatigue, weight loss, and nasal bleeding for the past 2-3 month period. Physical examination showed multiple fixed, hard, painless palpable mass lesions bilaterally in submandibular, jugular, posterior cervical, and supraclavicular areas. Laboratory results were as follows: Leukocyte count: 5.4 x 10 3/μL, hemoglobin: 9.7 g/dl, platelet count: 34 x 103/μL, lactate dehydrogenase: 2099 *Coresponding Author: Sinan Demircioglu Van Yüzüncü Yıl University, Faculty of Medicine, Department of Hematology, Van Turkey Email: sinandemircioglumd@gmail.com

U/L, INR: 1.7, aPTT: 33.3 sec, fibrinogen: 60 mg/dl and d-dimer: > 20 μg/ml. He had disseminated intravascular coagulopathy. Peripheral smear showed a shift to the left, nucleated erythrocytes, and Cabot’s rings. Bone marrow aspiration showed 80% atypical cellular infiltration with large, dark basophilic cytoplasm and vacuoles in the cytoplasm and nucleus (Figure 1). Although these findings were suggestive of Burkitt’s lymphoma morphologically, the results of flow cytometry were not supportive of this diagnosis. Myeloid, lymphoid, and plasma cell surface markers were negative in P1 gate of flow cytometry, and 50% of the cell population had CD56 positivity only. Granulocytes showed normal distribution in P2, and lymphocytes showed normal distribution in P3 gate (Figure 2). Imaging studies revealed a mass lesion invading the left maxillary, sphenoid and ethmoid sinuses; bilateral multiple lymphadenopathies in cervix, the largest being 4.5x3 cm; and a hypodense 4x1.5 cm area in the posterior upper lobe of the right lung. Immunohistochemical staining of the bone marrow showed vimentine, desmine, and CD56 positivity. Based on these results, the patient considered to have alveolar rhabdomyosarcoma. Lymph node biopsy was also suggestive of rhabdomyosarcoma. Despite the initial morphological resemblance to Burkitt’s leukemia, flow cytometry was not supportive of our diagnosis. Pathological examination confirmed alveolar rhabdomyosarcoma.

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Figure 1. Atypical cellular infiltration with cytoplasmic and nuclear vacuolization

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most common type of metastatic non-hematopoietic tumor in children, with a CD56 +/CD90 +/CD45- immuno-phenotype [810]. The similar immuno-phenotypic characteristics in FCM may complicate the differentiation between RM and NB. As shown by previous studies, gangliocyte D2 (GD2) is expressed by neuroectodermal tumors such as retinoblastoma and NB [10-13]. RM cells exhibit negativity for GD2[8,9]. Also, CD56 expression is seen in a number of malignancies including acute myeloid leukemia, blastic plasmocytoid dendritic cell neoplasias, multiple myeloma, peripheral T cell lymphoma, small cell carcinoma, Merkel cell carcinoma, and Ewing’s sarcoma [14,15]. Due to the absence of CD90 and GD2 kits in our laboratory, FCM could not be used for that purpose. However, FCM was able to rule out the diagnoses of Burkitt’s lymphoma and other malignances, despite the morphological resemblance to Burkitt’s lymphoma. Immunohistochemically, RM exhibits > 99% polyclonal desmine staining, while muscle-specific actin, myogenin, and myoglobin positivity occurs in 95%, 95%, and 78% of the cases, respectively. Myogenin is more commonly expressed by alveolar type as compared embryonal RM. Typically, it is found in myogenic tumor cells with lesser degree of differentiation. It has been associated with a poor prognosis irrespective of the histological subtype, tumor area [16,17]. Conclusion In conclusion, bone marrow metastases associated with rhabdomyosarcoma may be readily confused with acute leukemia. This diagnosis may be easily overlooked, particularly when one considers its rare occurrence in adulthood. In patients with a morphological suspicion of acute leukemia without supportive findings in flow cytometry, a diagnosis of RM should be borne in mind. Competing interests The authors declare that they have no competing interest Financial Disclosure The authors declared that this study has received no financial support.

References Figure 2. Cells with CD56 positivity and lymphoid, myeloid, and plasma cell antigen negativity in P1 gate; normal granulocytic distribution of cells in P2 gate; and normal lymphocytic distribution of cells in P3 gate

Discussion In some malignant conditions, clinical signs and bone marrow findings may be similar to those of acute leukemia. Rhabdomyosarcoma, neuroblastoma, medullablastoma, anaplastic oligodendrioglioma, small cell carcinoma, Ewing’s sarcoma, and neuroendocrine tumors are among such malignancies that may exhibit morphological signs closely resembling those of acute leukemia [5-7]. A distinction between these conditions based on morphological findings alone may be challenging. Flow cytometry (FCM) is a technique that is commonly used in the diagnosis of hematological malignancies. It may also be useful for the detection of bone marrow metastasis due to RM. While FCM may rule out a diagnosis of leukemia and lymphoma, detection of CD56 +/CD90 +/CD45- immune-phenotype is suggestive of RM [8]. Also, neuroblastoma (NB) represents the

Weiss AR, Lyden ER, Anderson JR, et al. Histologic and clinical characteristics can guide staging evaluations for children and adolescents with rhabdomyosarcoma: a report from the Children’s Oncology Group Soft Tissue Sarcoma Committee. J Clin Oncol. 2013;31:3226-32.

Kahn DG. Rhabdomyosarcoma mimicking acute leukemia in an adult: report of a case with histologic, flow cytometric, cytogenetic, immunohistochemical, and ultrastructural studies. Arch Pathol Lab Med. 1998;122:375-8.

Sandberg AA, Stone JF, Czarnecki L, Cohen JD: Hematologic masquerade of rhabdomyosarcoma. Am J Hematol. 2001;68:51-7.

Maywald O, Metzgeroth G, Schoch C, et al. Alveolar rhabdomyosarcoma with bone marrow infiltration mimicking haematological neoplasia. Br J Haematol. 2002;119:583.

Lou Y, Meng H, Mao L, et al. Bone marrow relapse of medulloblastoma mimicking acute leukemia with translocation (1;18)(p33;q22). J Clin Oncol. 2011;29:e24-6.

Anand M, Kumar R, Jain P, et al. Metastatic anaplastic oligodendroglioma simulating acute leukemia. A case report. Acta Cytol. 2003;47:467-9.

Enzinger FM, Shiraki M. Alveolar rhabdomyosarcoma. An analysis of 110 cases. Cancer. 1969;24:18-31.

Bozzi F, Collini P, Aiello A, et al. Flow cytometric phenotype of

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rhabdomyosarcoma bone marrow metastatic cells and its implication in differential diagnosis with neuroblastoma. Anticancer Res. 2008;28:1565-9.

immunophenotype by flow cytometry in cerebrospinal fluids from a patient with retinoblastoma. Pediatr Hematol Oncol. 2013;30:30-2.

Ferreira-Facio CS, Milito C, Botafogo V, et al. Contribution of multiparameter flow cytometry immunophenotyping to the diagnostic screening and classification of pediatric cancer. PLoS One. 2013;8:e55534.

14. Bahrami A, Gown AM, Baird GS, et al. Aberrant expression of epithelial and neuroendocrine markers in alveolar rhabdomyosarcoma: a potentially serious diagnostic pitfall. Mod Pathol. 2008;21:795-806.

10. Sethuraman C, Simmerson M, Vora AJ, et al. Flowcytometric immunophenotyping in the diagnosis of pediatric lymphoma: how reliable is it and how can we optimize its use? J Pediatr Hematol Oncol. 2010;32:298303.

15. Farinola MA, Weir EG, Ali SZ. CD56 expression of neuroendocrine neoplasms on immunophenotyping by flow cytometry: a novel diagnostic approach to fine-needle aspiration biopsy. Cancer. 2003;99:240-6.

11. Swerts K, De Moerloose B, Dhooge C, et al. Detection of residual neuroblastoma cells in bone marrow: comparison of flow cytometry with immunocytochemistry. Cytometry B Clin Cytom. 2004;61:9-19. 12. Matthay KK, George RE, Yu AL. Promising therapeutic targets in neuroblastoma. Clin Cancer Res. 2012;18:2740-53. 13. Shen H, Tang Y, Xu X, et al. Detection of the GD2+/CD56+/CD45-

16. Dias P, Chen B, Dilday B, et al. Strong immunostaining for myogenin in rhabdomyosarcoma is significantly associated with tumors of the alveolar subclass. Am J Pathol. 2000;156:399-408. 17. Heerema-McKenney A, Wijnaendts LC, Pulliam JF, et al. Diffuse myogenin expression by immunohistochemistry is an independent marker of poor survival in pediatric rhabdomyosarcoma: a tissue microarray study of 71 primary tumors including correlation with molecular phenotype. Am J Surg Pathol. 2008;32:1513-22.

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Medicine Science 2018;7(4):949-50

Primary fistulectomy of congenital lacrimal fistula: A case report Muhammed Mustafa Kurt, Cetin Akpolat, Ferhat Evliyaoglu Okmeydani Training and Research Hospital Department of Ophthalmology, Istanbul, Turkey Received 28 March 2018; Accepted 02 May 2018 Available online 07.08.2018 with doi: 10.5455/medscience.2018.07.8863 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract A 13-month-old male patient presenting with epiphora and discharge in his left eye present since birth was assessed in our clinic. Epiphora and an orifice of fistulae next to the left nasal root were identified via physical examination. Punctual mucoid discharge was observed following a massage of the left lacrimal sac. Chronic lacrimal fistulae were diagnosed in terms of stain outflow from the fistula orifice following a trypan blue injection to the lacrimal sac under general anesthesia. The patency of the distal nasolacrimal duct was confirmed by performing lavage following the fistulectomy procedure. The epiphora disappeared and the nasolacrimal passage was open in post-operative care. Keywords: Lacrimal apparatus, congenital, fistula, fistulectomy

Introduction Congenital lacrimal fistula (CLF) is a rare developmental anomaly of the nasolacrimal drainage system and has been reported to have an incidence of 1 in 2,000 births. It is defined as an epithelialized inner wall of the pathway extending between the skin and the common canalicul, lacrimal sac, or nasolacrimal ductus. Most cases are unilateral and are usually located inferiolaterally to the medial cantus [1].

The case report was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from the parents of the patient for publication of this case report, accompanying images, and any additional related information. A lacrimal system evaluation was performed under general anesthesia. Fluid flow was seen from the fistula orifice after lacrimal irrigation. Trypan blue was injected into the lacrimal sac, and CLF was diagnosed subsequent to leakage of the stain from the fistula orifice (Figure 1).

CLF is asymptomatic in most cases and may be overlooked due to its small size. Some cases are symptomatic, and the clinical presentation is in the form of epiphora and mucus discharge from the punctum or fistula orifice [2]. In this study, we aimed to assess eared that the two groups have a significant statistical difference. Case Report A 13-month-old male patient was admitted to our clinic with epiphora and discharge in his left eye. The parents stated that even though long-term massage was applied, the condition did not improve. In a physical examination following a massage on the left lacrimal sac, in addition to mucus discharge from the punctum, a fistula orifice was detected approximately 3 mm inferiomedially to the medial canthus.

*Coresponding Author: Cetin Akpolat, Okmeydani Training and Research Hospital Department of Ophthalmology, Istanbul, Turkey, E-mail: akpolatcetin@yahoo.com

Figure 1. The leakage of trypan blue from the fistula orifice following its injection to the lacrimal sac

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An incision of approximately 0.5 cm was made to the edge of the fistula orifice. Following the excision three-quarters of the fistula, the remaining portion was cauterized to preserve the sac. The integrity and impermeability of the lacrimal sac was confirmed via lacrimal irrigation. The skin and subcutaneous tissue was sutured with 6.0 vicryl. The epiphora disappeared in the post-operative period. No recurrence was observed at the 6-month follow-up.

operatively without any recurrence during the study period.

Discussion

François J., Bacskulin J. External congenital fistulae of the lacrimal sac. Ophthalmologica. 1969;159:249-61.

Chaung JQ, Sundar G, Ali MJ. Congenital lacrimal fistula: A major review. Orbit. 2016;35:212-20.

Lee S, Kim N, Khwarg SI, et al. Congenital lacrimal fistula associated with down syndrome. Graefes Arch Clin Exp Ophthalmol. 2012;250:1515-9.

Singh M, Singh U. Bilateral congenital lacrimal fistula in down syndrome. Middle East Afr J Ophthalmol. 2013;20:263-4.

Harrison AR, Dailey RA, Wobig JL. Bilateral congenital lacrimal anlage ducts (lacrimal fistula) in a patient with the vacterl association. Ophthal Plast Reconstruct Surg. 2002;18:149-50.

Onaran Z, Yimazbas P, Ornek K. Bilateral punctum atresia and lacrimal sac fistula in a child with charge syndrome. Clin Exper Ophthalmol. 2009;37:8945.

Duru, Z, Hamurcu M, Boynueğri S, et al. Congenital lacrimal fistula: a case report. 2014.

Aslan L, Özdemir, M, Dilsizoğlu D, et al. Konjenital lakrimal fistül: fistülektomi. Turkiye Klinikleri Journal of Ophthalmology, 2012;21:192-4.

Ari S, Cingu K, Şahin A, et al. The outcomes of surgical treatment in fistulous dacryocystitis. Eur Rev Med Pharmacol Sci. 2013;17:243-6.

CLF is a rare anomaly and is usually asymptomatic. Especially in pediatric patients, it can be easily overlooked due to the smallness of the fistula orifice. Although CLF is often unilateral and isolated, it is rarely seen bilaterally. Bilateral cases are usually familial or sometimes accompanied by Thalassemia, Down syndrome, VACTERYL anomaly or CHARGE syndrome [3-6]. In this case report, there were no accompanying systemic anomalies. Observation is mostly sufficient in asymptomatic cases, whereas the definitive treatment is controversial in symptomatic cases [7]. Fistulectomy can be performed in isolated or combined form. If the lacrimal sac is intact and a nasolacrimal duct obstruction (NLDO) is not present, primary fistulectomy is sufficient [8]. If an NLDO is present, besides fistulectomy, probing can be performed or a bicanalicular silicone tube can be implanted depending on the age of patient. If the lacrimal sac is not intact, combined dacryocystorhinostomy with a fistulectomy will increase the chances of success [9,10]. Conclusion In our case, the primary fistulectomy technique was performed because the lacrimal sac was intact. Intra-operative lavage was performed, and it was observed that the distal tip of the nasolacrimal duct was patent. The epiphora disappeared post-

Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves.

References

10. Altun A, Kurna SA, Sengor T, et al. Unilateral congenital lacrimal fistula with renal agenesis and pelvic kidney: a case report and eview of the literature. Case Rep Ophthalmol Med. 2015;2015:368950.

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Anesthesia management in cesarean section with lown ganong levine syndrome Duygu Demiroz Aslan1, Fusun Adam1, Neslihan Altunkaya2 2

1 Istanbul Training and Research Hospital, Department of Anaesthesiology, Istanbul, Turkey Inonu University Faculty of Medicine Department of Anaesthesiology Deprtment, Malatya, Turkey

Received 08 May 2018; Accepted 08 May 2018 Available online 19.10.2018 with doi: 10.5455/medscience.2018.07.8875 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Lown Ganong Levine (LGL) which is a preexcitation syndrome is defined with paroxysmal tachycardia, dyspnea, anxiety, angina, and the complaint of fatigue accompanied by characteristic changes on ECG (short PR). Herein, we present a case of cesarean which we completed with a low-dose spinal anesthesia without problem, avoiding from general anesthesia which could be induced with numerous arrhythmogenic drugs, because of arrhythmia complication which might be mortal. Keywords: Lown ganong levine, cesarean, spinal anesthesia

Introduction Preexitation syndromes are defined as two types including WolffParkinson White (WPW) syndrome and Lown-Ganong-Levine (LGL) syndrome. In WPW syndrome, stimulus spreading from the atria toward the ventricles pass through an accessory pathway (Kent bundle) instead of a normal AV conduction pathway. This stimulus which pass through the Kent bundle with an abnormal by-pass reaches to the ventricles much more quickly than the stimulation passing through a normal AV conduction pathway, stimulating the ventricles (ventricular preexcitation). Apart from the kent bundle producing WPW syndrome, there are other accessory pathways termed as bundle of James (between the atrium and His bundle) and Mahain pathway (between AV node and His bundle or between a branch of His bundle and interventricular septum) which causes Lown-Ganong-Levine syndrome (LGL) [1]. I LGL Syndrome the stimulus spreading from the atria passes through the normal AV conduction pathway and then carried by Mahaim bundles to stimulate interventricular septum which results in short PR and normal QRS duration [2].

to the operating room. There was no pathology other than the short PR interval on electrocardiography. Admission laboratory outcomes were normal. After the patient was placed on the operating table, intravenous infusion of 500 ml colloid was initiated, and standard monitoring was performed with electrocardiography, pulse oximetry, and noninvasive blood pressure. Arterial pressure (BP) was measured as 150/70 mmHg, heart rate (HR) as 98 beats/min, and peripheral oxygen saturation (SpO2), as 98%. Subarachnoid space was accessed at L4-L5 level in the patient in sitting position, and after the flow of cerebrospinal fluid was observed, spinal anesthesia was induced by administration of 10 mg Bupivacaine Heavy. The patient was given a tilt position of 15oC and the operation was started where the block level reached T6. The operation lasted for 15 minutes, and delivery of the baby occurred at 8th minute a living baby was born with APGAR 1-5 scores of 8 and 9, respectively. The lowest tension during the operation was read as 90/50 mmHg. HR value continued as 90110 beats/min during the operation. The operation was completed without any problem and the patient was discharged to home on the second day.

Case Report

Discussion

A 25 year old, 67,5 kg, 163 cm pregnant patient who was scheduled for elective cesarean section with a gestation of 38W 2D was taken

LGL is a preexcitation syndrome resulted from an abnormal conduction pathway [3]. Although low, the risk of sudden death from malignant arrhythmia in these patients is between 0.9% and 3% [4]. LGL may develop due to congenital heart diseases, mitral valve prolapsus, and cardiomyopathies. LGL is diagnosed with tachycardia, dyspnea, anxiety, angina, and the complaint of fatigue accompanied by characteristic changes on ECG [5]. One

*Coresponding Author: Duygu Demiroz Aslan, Istanbul Training and Research Hospital, Department of Anaesthesiology, Istanbul, Turkey E-mail: drduygudemiroz@hotmail.com

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third of these patients may develop paroxysmal atrial fibrillation (PAF). The reason of this high incidence of PAF in preexcitation syndrome is yet to be known. PAF may be life threatening when an extremely rapid ventricular response develops against ventricular fibrillation [6]. The goal of anesthesia management is to avoid symptomatic stimuli such as pain, anxiety, intubation and extubation related stress response, and hypovolemia in LGL syndrome [7,8]. Anesthetic drugs and techniques tend to alter electrophysiology of atrioventricular (AV) conduction system. In case of general anesthesia, it is important to avoid sympathetic stimulation. Studies have found that fentanyl, midazolam, thiopental, isoflurane, and sevoflurane have no any effect on accessory pathway. In addition, propofol can be preferred, because it lacks any effect on refractory period of the accessory pathway [7,8].

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as an alternative to general anesthesia with multiple drug use to prevent malignant arrhythmias that may develop during cesarean section with LGL syndrome in this case. However, there is a need of randomized trials with large populations to clarify this issue. Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves.

References 1.

Goldberger AL. Electrocardiography. In: Kasper DL. Braunwauld E, Fauici AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. McGraw-Hill, 2005:1311-20

Rubart M, Zipes DP. Genesis of cardiac arrhthmias: electrophysiologic considerations. In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease. A Textboook of Cardiovascular Medicine. 6th ed. WB Saunders, 2003 659-99.

Reversal agents and cholinergic agents such as succinylcholine have arrhythmogenic effects [4]. Regional anesthesia is preferred to general anesthesia in order to avoid multiple drug application [7]. We also preferred regional anesthesia in our patient in order to avoid possible drug related complications [7,8].

Wolff L, Parkinson J, White PD. Bundle branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia. 1930. Ann Noninvasive Electrocardiol. 2006;11:340-53.

Scheinman MM. The history of the wolff–parkinson–white syndrome. RMMJ. 2012;3:e0019.

There are only a few case reported with spinal anesthesia for LGL syndrome. High spinal block has been avoided with a combination of low-dose bupivacaine and opioid in patients undergoing spinal anesthesia. The level of spinal anesthesia should be at a minimum dose to provide surgical facility [9]. Fluid preloading to prevent atrial distension which occurs during regional anesthesia that may increase arrhythmogenicity, may also helpful in reduction of the sympathomimetic needs that may trigger supraventricular tachycardia [5]. We also we performed fluid loading and administered bupivacaine with a low dose in order to prevent atrial arrhythmogenesis in this patient with malignant arhythmia potential.

Shora A, Gurkoo S, Farooqi A, et al. Anaesthetic management of Wolff Parkinson White syndrome for caesarean section. The Internet Journal of Anaesthesiology. 2007;16:1-4.

Centurión OA, Shimizu A, Isomoto S, et al. Mechanisms for the genesis of paroxysmal atrial fibrillation in the Wolff—Parkinson—White syndrome: intrinsic atrial muscle vulnerability vs. electrophysiological properties of the accessory pathway. Europace. 2008;10:294-302.

Kaur S, Gupta P, Aggarwal S. Anaesthetic management of Wolff-ParkinsonWhite syndrome for elective caesarean section. Int J Pharm Pharm Sci. 2012;4:755-6.

Sahu S, Karna ST, Karna A, et al. Anaesthetic management of WolffParkinson-White syndrome for hysterectomy. Indian J Anaesth. 2011;55:37880.

Conclusion

Garg R, Sinha R, Nishad PK. Patient with Wolff-Parkinson-White syndrome with intermittent pre-excitation under subarachnoid block for urological surgery. Indian J Anaesth. 2011;55:167-70.

We prefer to use regional anesthesia for the use of fewer drugs

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Stroke as fatal complication of ovarian hyperstimulation syndrome Mohammed Talaat Rashid1, Ahmed Kohail2 1

Saudi German Hospital,Department of Emergency, Madina Saudi German Hospital, Department of Neurology, Madina

Received 07 April 2018; Accepted 17 April 2018 Available online 28.06.2018 with doi: 10.5455/medscience. 2018.07.8827 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Ovarian hyperstimulation syndrome is a condition related to injectable hormonal medications used for stimulation the maturation of oocytes in infertility caused by lack of or delayed ovarian maturation. The incidence increased due to wide spread expansion of hormonal stimulation use. The scale of symptoms of this condition varies from mild outpatient managed symptoms as vomiting and bloating to sever fatal complication as hemocon centration, fluid overload, hypercoagulability, and multisystem organ failure. The main point of management is prevention and exclude the candidates with elevated risk of the condition. Here we present a case of 30-year-old woman who had ovarian hyperstimulation syndrome with rare but severe complications. Keywords: Ovarian Hyperstimulation syndrome, stroke, cerebrovascular accident

Introduction 30 years old female, African, came to Emergency Department (ED) on 24th of August 2016 with recurrent attacks of right sided headache, sudden onset, without aura, associated with nausea and vomiting. There was no blurred vision. These attacks triggered by noise and anxiety and revealed with analgesics. She had no significant past or family history. She had normal vital signs, physical examination and CT brain was unremarkable. She was discharged on oral medication and diagnosed with migraine. Case Report On 19th of September 2016, she was following up with an obstetrician for primary infertility for one year. She had irregular cycles, missed period and normal levels of Luteinizing Hormone (LH), Follicular Stimulating Hormone (FSH) and Thyroid Stimulating Hormone (TSH). Trans-vaginal Sonography (TVS) Showed normal ovaries with multiple premature follicles. She was started on metformin and clomiphene sulfate as a case of polycystic ovarian disease. On follow up, TVS showed no dominant follicles. Therefore, FSH injections, epigonal, started. After multiple visits, no improvement.

*Coresponding Author: Mohammed Talaat Rashid, Saudi German Hospital, Department of Emergency, Madina Email: dr_mtalaat@yahoo.com

On 4th of February 2017, she was started on norethisterone, primolut-N. Six weeks after that on 15-3-2017, she presented in ED with abdominal pain, nausea, acute increase in body weight, and fatigue. Hemoglobin was 17 and hematocrit was 48. She was diagnosed with Ovarian Hyperstimulation Syndrome (OHSS). She refused admission and discharged on Clexane with explanation about warning signs. On 18th of March 2017, she presented in ED with acute left sided weakness, upper limb is more affected than lower limb, hypotonia, deviation of mouth to right side, and dysarthria. There were no fits, trauma, Disturbed conscious level, nor fever. Moreover, planter reflex and pregnancy test were positive, hemoglobin was 12 and hematocrit was 33, +3 proteins and +2 bloods in urine. Ultrasonography (US) showed ovarian enlargement with multiple follicles, (33mm) uterine thickness, and marked ascites. Magnetic Resonant Imaging (MRI) of the brain showed right sided basal ganglion and peri-insular area of restricted diffusion, with abrupt termination of right middle cerebral artery. Prothrombin concentration was 90, prothrombin time was 14 and International Normalized Ratio (INR) was 1.0. She was admitted a a case of acute ischemic stroke and was treated accordingly. She was discharged on 23-3-2017 with clinical improvement and antiischemic medication. On 24th of March 2017, she was presented in ED with acute onset of headache all over with marked left sided weakness associated with hypotonia and deviation to right side, Glasgow Coma Scale 953

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was 3/15, and unequal pupils. Computed Tomography (CT) of the brain showed right parietal and basal ganglion intracranial hemorrhage (ICH) with bilateral occipital horns intraventricular hemorrhage. She was intubated and mechanically ventilated. She was admitted as a case of ICH with brain conization and announced dead on 28-3-2017 (Figure 1).

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thromboembolism, acute respiratory distress syndrome, and prerenal affection [3]. Ovarian hyperstimulation syndrome incidence was found to increase with certain concomitant conditions like migraine and hypercoagulable status. The aim of this case report is to highlight the higher risk of patients with such conditions. Moreover, to urge deeper history taking especially regarding migraine before proceeding for the induction process. The prevalence of ovarian hyperstimulation syndrome increases when the ovary is overstimulated, as detected by increased number of follicles on ultrasonography and elevated levels of estradiol. The incidence of ovarian hyperstimulation syndrome varies according to the risk factors and the protocols for ovarian stimulation, as it increases with the usage of combine GnRH agonists and gonadotropins compared to gonadotropins alone for treatment. Women of childbearing age only are affected by the syndrome. The frequency is estimated as 8-23% in mild form, 1-7% in moderate form, and 0.25-5% in severe cases [4].

Figure 1.

Computed Tomography (CT) for our patient: Right parietal and basal ganglion intracranial hemorrhage (ICH) with bilateral occipital horns intraventricular hemorrhage.

Discussion Ovarian hyperstimulation syndrome is an iatrogenic complication affects women taking injectable hormonal medications to stimulate oocytes development in the ovaries, which can cause serious psychological and physiological derangement and, in rare cases, may leads to maternal death [1]. The pathophysiology of ovarian hyperstimulation syndrome is not completely understood but it is happening in the ovary exposed to human chorionic gonadotrophin (hCG) or luteinizing hormone (LH) after its stimulation by follicle-stimulating hormone (FSH). This lead to start a cascade of production of proinflammatory mediators from the stimulated like vascular endothelial growth factor (VEGF), interleukins, tumor necrosis factor-Îą, and endothelin-1. These substances induce increase in vascular permeability and capillary leakage into third space causing the syndrome [2]. Ovarian hyperstimulation syndrome is classified according to severity into mild, moderate and sever. The mild form is manifested by abdominal distention and discomfort with nausea, vomiting, and/or diarrhea, all associated with ovarian enlargement of 5-12 cm. Moderate, is the same as mild plus ultrasonographic evidence of ascites. Severe Ovarian hyperstimulation syndrome has the features of moderate form with clinical picture of ascites and/or pleural effusion and shortness of breath associated with laboratory findings like oliguria (<300 ml/day or <30 ml/hour), hematocrit (>0.45), hyponatremia (<135 mmol/l), hypo-osmolality (<282 mOsm/kg), hyperkalemia (>5 mmol/l), hypoproteinemia (serum albumin <35 g/l). In more critical cases, it is associated with hematocrit (> 0.55) white cell count (>25000/ml), anuria,

There are plenty of studies that tried to find a way to prevent the occurrence of ovarian hyperstimulation syndrome. However, none of which has shown any significant reduction in the development of the syndrome. On the other hand, the change of the protocol of ovarian stimulation by GnRH from agonist protocol to antagonist protocol demonstrates significant reduction in the incidence of sever form of ovarian hyperstimulation syndrome [5]. Treatment of Ovarian hyperstimulation syndrome based on severity of the symptoms. The treatment of mild form is supportive like increase fluid intake and analgesia, and observation for progression to moderate or severe. Treatment of moderate ovarian hyperstimulation syndrome is also bed rest, adequate fluids intake and monitoring of both, the size of cysts by ultrasonography and serum electrolytes, hematocrits and creatinine. Management of Ovarian hyperstimulation syndrome mandates bed rest, frequent physical examination and fluid balance. Moreover, maintaining intravascular blood volume, electrolyte balance and managing complications like ascites and hydrothorax. Prevention of thrombosis also should be considered [6]. In more sever and critical Ovarian hyperstimulation syndrome, like with end organ damage, thromboembolism and Acute respiratory distress syndrome, requires intensive [7]. Conclusion Ovarian hyperstimulation syndrome is a condition related to hormonal medications used for oocytes maturation, it is associated with mild manifestations and, rarely, with sever and fatal complications. We recommend detailed personal and family history to uncover any red flags that can make the choice of injectable hormonal therapy for ovarian stimulation contraindicated and consideration of alternative therapies is essential as in migraine, hypercoagulation conditions, or previous history of thrombosis. On the other hand, once ovarian hyperstimulation syndrome is suspected or diagnosed, hydration, anticoagulation with close monitoring are imperative to control pathophysiologic manifestations and to minimize the risk of fatal complications. 954

doi: 10.5455/medscience.2018.07.8827 Competing interests The authors declare that they have no competing interest

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update review. Obstet Gynecol Surv. 1989;44:430-40.

Financial Disclosure The authors declared that this study has received no financial support.

Brinsden PR, Wada I, Tan SL, et al. Diagnosis, prevention and management of ovarian hyperstimulation syndrome. Br J Obstet Gynaecol. 1995;102:767-72.

References

Al-Inany HG, Abou-Setta AM, Aboulghar M. Gonadotrophin- releasing hormone antagonists for assisted conception. Cochrane Database Syst Rev. 2006;3:CD001750.

Speroff L, Fritz M. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2004. Clinical Gynecological Endocrinolgy and Infertility; pp. 1999â&#x20AC;&#x201C;200.

Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: Prevention and treatment. Fertil Steril. 1992;58:249â&#x20AC;&#x201C;61.

Whelan JG 3rd, Vlahos NF. The ovarian hyperstimulation syndrome. Fertil Steril 2000;73:883-96.

Evbuomwan IO, Davison JM, Murdoch AP. Coexistent hemoconcentration and hypoosmolality during superovulation and in severe ovarian hyperstimulation syndrome: a volume homeostasis paradox. Fertil Steril 2000;74:67-72.

Golan A, Ron-el R, Herman A, et al. Ovarian hyperstimulation syndrome: an

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CASE REPORT

Medicine Science International Medical Journal

Medicine Science 2018;7(4):956-8

Ganglioneuroma in a child with chronic constipation and abdominal pain Burcu Guven1, Akkiz Sahin Yasar2, Burhan Beger 3, Veli Avci3 1 Yuzuncu Yil University Faculty of Medicine, Department of Pediatric Gastroenterology, Van, Turkey Yuzuncu Yil University Faculty of Medicine, Department of Pediatric Hematology and Oncology, Van Turkey 3 Yuzuncu Yil University Faculty of Medicine, Department of Pediatric Surgery, Van, Turkey

Received 05 April 2018; Accepted 21 May 2018 Available online 11.09.2018 with doi: 10.5455/medscience.2018.07.8877 Copyright ÂŠ 2018 by authors and Medicine Science Publishing Inc. Abstract Ganglioneuromas are rare, benign, slow-growing tumors arising from the neural crest. They are most commonly in posterior mediastinum, retroperitoneum, adrenal medulla and neck. They are very rare in presacral region. A 15 year old girl presented with abdominal pain and chronic constipation. A mass was seen between the uterus and sacrococcygeal bone in abdominal CT. It is resected totally and evaluated as ganglioneuroma. Conclusion: Presacral ganglioneuroma is a benign tumor which is rarely encountered. Patients might present with abdominal pain and constipation complaints as seen in our patient. Therefore, imaging methods should certainly be used for patients with chronic constipation which is resistance to treatment. Keywords: Ganglionuroma, pediatric, chronic constipation

Introduction Ganglioneuromas are rare, benign, slow-growing tumors arising from the neural crest. When tumors in the sympathetic nervous system are examined in a spectrum, neuroblastoma represents in the malignant end of the spectrum, while ganglioneuroma in the benign end [1]. Ganglioneuromas can arise anywhere along the sympathetic chain. They are most commonly in posterior mediastinum (41.5%), retroperitoneum (37.5%), adrenal medulla (21%) and neck (8%) [2]. They are very rare in presacral region.

In the abdominal CT, a 9.5x11.5 cm sized heterogeneous mass with cystic degenerative areas and hypodensites was observed between uterus and sacrococcygeal region (Figure 1-2). There was no significant relationship between mass and ovary. Bone destruction was not detected in the lesion. In the colonoscopy, colon lumen and mucosa were normal; no external signs of pressure were found. A 10x9x6 cm-sized, beige-colored, smooth-faced, and encapsulated mass was surgically resected. Microscopically, mature ganglion cells scattered in the neurofibromatoid stroma were observed and evaluated as mature ganglioneuroma (Figure 3).

Here, a 15-year-old girl presented with abdominal pain and chronic constipation. Most of these cases are functional. Ganglioneuroma is a rare cause of chronic constipation. Case Report A 15-year-old girl was admitted to the emergency room with a 2-day complaint of abdominal pain. She was constipated for about 6 months. Neither her own nor the family history of the patient presented any specific conditions. On physical examination, there was mild abdominal distension and tenderness. In adnexal area, abdominal ultrasonography showed a 82x97 mm sized cystic mass with intensive content.

*Coresponding Author: Burcu Guven, Yuzuncu Yil University Faculty of Medicine, Department of Pediatric Gastroenterology, Van, Turkey E-mail: burcuguven55@gmail.com

Figure 1. A heterogeneous hypointense mass between the uterus and sacrococcys in posterior pelvic region (Sagittal CT imaging)

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The patient who was on a four-month follow-up did not have any problem.

Figure 2. A heterogeneous hypointense mass between the uterus and sacrococcys in posterior pelvic region (Horizontal CT imaging)

Med Science 2018;7(4):956-8

Ganglioneuromes are usually seen in older children. Two-thirds of the cases are under 20 years of age. The mean diagnosis age is 7 years. In females, it is slightly more common than males (1.5: 1) [4]. They are usually slow-growing tumors. Therefore, they usually accompany with pressure symptoms or endocrinological disorders. Ganglioneuromas are frequently localized in mediastinum, retroperineum and adrenal gland. Stout et al. reported 234 cases of ganglioneuroma [5]. Of these, 26% were located in the posterior mediastinum and 18% in the lumbar retroperitoneum [5]. Ganglioneuromas are rarely encountered in the presacral region. In previous studies, 19 cases of presacral ganglioneuroma were reported and only five of these patients were under 18 years of age. Six patients of them were diagnosed incidentally, while 10 patients had pain, 5 patients had constipation, and 1 patient had amenorrhea at the time of admission [6,7]. Our patient also presented with the complaint of abdominal pain and long-term constipation. Like our patient, a 70-year-old man presented with chronic constipation. Here, extrinsic compression in rectosigmoid segment was shown by barium enema study [8]. There was no barium enama study of our patient. In colonoscopy, it wasnâ&#x20AC;&#x2122;t seen any extrinsic compression If a barium enema study was done, partial obstruction could be detected. On the other hand, ganglioneuromas are usually asymptomatic. In recent years, the incidence of incidental diagnosis has also increased with the increase in imaging methods. In this case, This may have been detected incidentally. Ganglioneuromas can be seen as space occupying lesions, rib springs or erosions in the bones, while they are seen as homogeneous hypoechoic masses in USG. While in computed tomography, they are seen as a homogenous mass with lower density compared to muscle. In T1-weighted MRI, they are seen in the form of a homogenous mass with lower density compared to liver, while in T2-weighted MRI, in the form of a heterogeneous mass with a higher density compared to liver. Discrete or punctuate calcifications are seen in 42-60% of the cases [9]. The treatment of ganglioneuromas is surgical excision. The rate of recurrence after total excision is low. However, if there is a residual mass, annual follow-up is appropriate [10]. Since it is benign, there is no need for systemic chemotherapy or radiotherapy [11].

Conclusion Figure 3. Mature ganglion cells with scattered localization in neurofibromatoid stroma (Hematoxylin and Eosin stain, original magnification x100)

Discussion Peripheral neurogenic tumors are divided into three subgroups according to the degree, type, neurobehavioral differentiation, malignancy potential and development of schwann stroma, which are neuroblastoma, ganglioneuroblastoma, and ganglioneuroma. Among them, ganglioneuroma is a rare benign tumor, often originating from sympathetic ganglion cells or adrenal medulla cells. Histologically, the ganglioneuroma is composed of mature differentiation cells such as ganglion cells, schwann cells and nerve fibers [3]. It is not known whether pelvic ganglioneuromas are caused by neonatal neuroblastoma maturation or by a slowgrowing ganglioneuroma [1].

In conclusion, presacral ganglioneuroma is a benign tumor which is rarely encountered. Most are asymptomatic. Rarely, patients might present with abdominal pain and constipation complaints as seen in our patient. Therefore, imaging methods should certainly be used for patients with chronic constipation, which is resistance to treatment. Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves.

References 1.

Kattepura S, Alexander B, Kini U, et al. Sporadic synchronous ganglioneuromas in a child--case report and review. J Pediatr Surg. 2010;45:822-5.

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Geoerger B, Hero B, Harms D, et al. Metabolic activity and clinical features of primary ganglioneuromas. Cancer. 2001;91:1905-13.

Özdülger A, Ayan E, Köksel O, et al. A case of giant ganglioneuromaTurkish J Thoracic Cardiovascular Surg. 2007;15:72-5.

Lonergan GJ, Schwab CM, Suarez ES, rt al. Neuroblastoma, ganglioneuroblastoma, and ganglioneuroma: radiologic-pathologic correlation. Radiographics. 2002;22:911-34.

Stout AP. Ganglioneuroma of the sympathetic nervous system. Surg Gynecol Obstet. 1947;84:101-10.

Cerullo G, Marrelli D, Rampone B, et al. Presacral ganglioneuroma: a case report and review of literature. World J Gastroenterol. 2007;13:2129-31.

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Vardas K, Manganas D, Papadimitriou G, et al. Presacral ganglioneuroma: diagnostic considerations and therapeutic strategy. Case Rep Oncol. 2013;6:561-8.

Okai T, Minamoto T, Ohtsubo K, et al. Presacral ganglioneuroma arising in an elderly man with persistent constipation. Abdom Imaging. 2001;26:215-7.

Scherer A, Niehues T, Engelbrecht V. Imaging diagnosis of retroperitoneal ganglioneuroma in childhood. Pediatr Radiol. 2001;31:106-10.

10. Han PP, Dickman CA. Thoracoscopic resection of thoracic neurogenic tumors. J. Neurosurgery. 2002;96: 304-8. 11. Lynch NP, Neary PM, Fitzgibbon JF, et al. Successful management of presacral ganglioneuroma: A case report and a review of the literature. Int J Surg Case Rep. 2013;4:933-5.

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REVIEW ARTICLE Medicine Science 2018;7(4):959-61

Medicine Science International Medical Journal

Risk models for patients undergoing robotic surgery, minimal invasive heart surgery and open-heart surgery Habib Cakir1, Ismail Yurekli1, Koksal Donmez1, Hasan Iner1, Ihsan Peker1, Erturk Karaagac1, Ozcan Gur2, Mert Kestelli1 1

Izmir Katip Celebi University Ataturk Education and Training Hospital, Department of Cardiovascular Surgery, Izmir, Turkey 2 Namik Kemal University, Medicine Faculty, Department of Cardiovascular Surgery, Tekirdag, Turkey Received 20 July 2018; Accepted 23 July 2018 Available online 11.08.2018 with doi: 10.5455/medscience.2018.07.8862 Copyright © 2018 by authors and Medicine Science Publishing Inc.

Abstract In this study; we tried to compile risk scoring systems (Original EuroSCORE, EuroSCORE II and STS) used in robotic surgery, minimally invasive cardiac surgery and open-heart surgery in the context of the literature.As a result, literature study of risk scoring systems in the robotic surgery was not found. In minimally invasive cardiac surgery, few studies are available. The effectiveness of existing risk scoring systems has not been established in these studies. Therefore, further investigations are required for developing risk scoring systems in robotic surgery and minimally invasive cardiac surgery. In open heart surgery, there is still no “gold standard” scoring system in all populations. Due to the increased case diversity, we believe that the commonly used risk scoring systems must be updated. Widely used risk-scoring systems are not effective in minimally invasive cardiac surgery and this is supporting our idea. Each clinic should choose the appropriate risk scoring system according to their own experience and case diversity. Keywords: Robotic surgery, minimal invasive heart surgery, heart surgery, risk model

Introduction Invasive techniques or open surgical methods may be applied in addition to medical treatment in the management of heart diseases. Hybrid interventions, minimally invasive cardiac surgery and robotic cardiac surgery techniques have begun to develop in recent years to reduce the risks of open surgical procedures. The choice of treatment options is decided by National or International guidelines. In addition, the risk of mortality and morbidity that the treatment option will cause in the patient is taken into consideration. Mortality and morbidity associated with surgical procedures is one of the important performance indicators to assess the outcome of the relevant surgical procedure. Necessity to develop risk scoring systems arose for predicting the mortality and morbidity of the treatment option in the preoperative period. For this reason, many risk-scoring systems have been established and started to be used [1]. Risk scoring systems are statistical and objective. Today, the most commonly used risk scoring systems are the European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II and the Society of Thoracic Surgeons (STS).

*Coresponding Author: Habib Cakir, Izmir Katip Celebi University Ataturk Education and Training Hospital, Department of Cardiovascular Surgery, Izmir, Turkey E-mail: habibcakir35@hotmail.com

In this study; we tried to compile risk scoring systems (Original EuroSCORE, EuroSCORE II and STS) used in robotic surgery, minimally invasive cardiac surgery and open-heart surgery in the context of the literature. Discussion Risk scoring systems do not only give information about operative mortality and morbidity. It provides useful information in surgical strategy planning, a more accurate comparison of the results of different centers and a cost analysis foresight. It also informs the physician about the suitability of the surgical method preferred for the patient. Although there are many risk factor classifications designed for this purpose, most widely used original EuroSCORE, EuroSCORE II and STS risk scorings will be investigated in the context of the current literature in this review. EuroSCORE is the most commonly used risk scoring system. It is more frequently used in Europe than in the United States. The original EuroSCORE was developed in 1999 by examining the data of approximately 19,000 patients who underwent adult cardiac surgery [2]. Even though the original EuroSCORE is still in use today, in 2012 the meta-analysis of 67 trials concluded that the original EuroSCORE risk scoring system was not suitable. In the same study, Original EuroSCORE was found to be inadequate in predicting the mortality rate in high-risk patients [3]. EuroSCORE II risk classification was developed in 2012 after the fact that the 959

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original EuroSCORE was inadequate to predict operative mortality [4]. One of the most important reasons for the widespread use of EuroSCORE risk classification is to update itself. The STS score was developed in 1994 [5]. This system provides important information about mortality as well as morbidity. It may be more effective for evaluating the cost analysis of the preferred treatment. Table 1 shows the parameters evaluated in each of the 2 risk scoring systems (EuroSCORE and STS). When the parameters in Table 1 are examined, it is more likely that the STS score will give better information about mortality as well as morbidity. Table 1. Parameters assessed in EuroSCORE and STS risk scorings EuroSCORE

STS

Age

Female Gender

Risk Parameters

Obesity Diabetes Mellitus

+ -

Renal Disease

Dialysis

Peripheral Arterial Disease

COPD

Hypertension

Infective Endocarditis

Cerebrovascular Disease

Immunosuppression

Cardiogenic Shock

Past MI

IABP / Inotropic Drug

Emergency Surgery

Reoperation

Ejection Fraction

Ventricular Arrhythmia

Valvular heart disease

Post MI VSD

Pulmonary Hypertension

Stable Angina

COPD: Chronic Obstructive Pulmonary Disease, MI: Myocardial Infarction, IABP: Intraaortic balloon pump, VSD; Ventricular Septal Defect

In 1992, Higgins et al. had begun to develop and use the Cleveland clinical scoring system [6]. Although it was claimed to have similar results with EuroSCORE, it had significant disadvantages of being retrospective and focusing on mortality and giving less information about morbidity. It has been widely used in North America and has found relatively few uses in European countries. It is not frequently used in our country. For this reason, this study has not been discussed in detail in the literature. Ad et al. Compared the STS, the original EuroSCORE and the EuroSCORE II in the monocentric series of 11788 patients. EuroSCORE II was found to be superior to the original EuroSCORE in predicting operative mortality. EuroSCORE II and STS risk models were found to be similar in prediction of

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operative mortality. However, EuroSCORE II was superior to STS in complex surgeries [7]. Kuwaki et al found that EuroSCORE II was better in low-risk patients and STS scoring system was better in high-risk patients undergoing to aortic valve replacement [8]. When the literature was searched, especially in the last 10 years, it was determined that different risk scoring systems made more accurate estimations in different populations. EuroSCORE II risk scoring method was found to be better in patients undergoing single valve operation in Chinese population [9]. When the New Zealand patient population was examined, STS and EuroSCORE II showed similar results and were superior to the original EuroSCORE in this patient group [10]. In the population of Pakistan, EuroSCORE II was found to be better in patients with isolated aortic valve replacement patients, and STS scoring system found to be better in patients undergoing combined coronary and valve surgery. In isolated coronary artery bypass graft surgery, STS score was found to be superior to EuroSCORE risk classification [11]. In the Indian population, EuroSCORE II was found to be better for all surgical subgroups. EuroSCORE II was considered acceptable for coronary artery bypass graft surgery patients and excellent for valve surgery [12]. Fındık et al. reported that best risk scoring system for predicting mortality in Turkey was the original EuroSCORE risk stratification [13]. When we evaluate all these literature data, it is seen that different risk scoring systems are better in different surgical procedures in the same population. EuroSCORE risk classification is generally better in European countries and therefore seems to be widely used especially in European countries. Due to technology and increasing surgical experience, there has been an increase in the number and variety of patients who can be operated by cardiac surgeons. With the widespread use of primary percutaneous transluminal coronary angioplasty, use of clopidogrel and ticagrelor has increased before emergency or early surgery candidates. This will increase the risk of bleeding in the postoperative period and increase mortality and morbidity. For this reason, we think that these factors should be added in risk scoring systems which are widely used today. On the other hand, with development of technology and increasing surgical experience, there is an increase in the number of patients undergoing 3rd or 4th operation. We believe that risk scoring should be updated for patients who are undergoing to 3rd or 4th operation in an increasing way for each operation, rather than just re-operation. Based on our experience with open heart surgery in our clinic, we think that one of the most important factors determining operative mortality and morbidity is the general condition and effort capacity (so called “frailty”) of the patient. We observed that mortality and especially morbidity was higher in patients with poor general condition and effort capacity, despite low risk scoring system scores. We take these factors into account when taking patient’s informed consent for surgery, even these are not mentioned enough in risk-scoring systems. For this reason, we believe that these factors should be included in risk scoring systems. We use EuroSCORE risk scoring system at our clinic, based on our experience and concordant with the literature we think EuroSCORE risk scoring system is more appropriate for Turkey. The evaluation, creation and updating stages of risk scoring systems are based on patient-based results. Yes, these scores are 960

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statistical and objective, but the experience of surgeon is not taken into consideration. We believe that surgeons’ experience is as important as patient-based outcomes and that surgical experience should be taken into account when establishing risk-scoring systems. Can EuroSCORE be used in minimally invasive cardiac surgery? Margaryan et al. found that the original EuroSCORE and EuroSCORE II risk classification systems were inadequate to predict operative mortality in minimally invasive cardiac surgery [14]. We believe that this is due to minimally invasive surgery is not performed routinely in each patient. Since minimally invasive cardiac surgery is selected and applied in a limited group of patients, general risk scoring systems may not be appropriate for this type of surgery. Is every patient undergoing cardiac surgery eligible for minimally invasive or robotic surgery? It is clear that the experience of the center will play an important role as well as patient compliance. The major obstacles to the widespread use of minimally invasive and especially robotic cardiac surgery are the anatomical unsuitability of the patient, the difficulty and slowness of the surgeon’s learning process. These procedures should not be used in patients with low ejection fraction and severe cardiomegaly, as the cross-clamp times in robotic and minimally invasive cardiac surgery will be longer than in conventional methods. In addition, robotic and minimally invasive surgery should not be performed in patients with pericardial adhesions such as pericarditis and radiotherapy, patients with aortic aneurysm, cirrhotic bleeding disorder and femoral artery occlusion for cannulation. In patients with high risk scores, we believe that using minimally invasive techniques instead of conventional techniques, if there is anatomic suitability and surgical experience, may lead to better results. Long term results were similar in selected patients when compared with robotic isolated coronary artery bypass graft surgery and conventional coronary artery bypass graft surgery techniques. Early results of the robotic mitral valve surgery were also acceptable. Which risk scoring system should we use in robotic cardiac surgery? The answer to this question was searched in the literature and there were no statements in this regard. We believe that with the increase in the number of cases, more studies on comparison of risk-scoring system will be reported [15,16]. Conclusion Literature study of risk scoring systems in the robotic surgery was not found. In minimally invasive cardiac surgery, few studies are available. The effectiveness of existing risk scoring systems has not been established in these studies. Therefore, further investigations are required for developing risk scoring systems in robotic surgery and minimally invasive cardiac surgery. In open heart surgery, there is still no “gold standard” scoring system in all populations. Due to the increased case diversity,

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we believe that the commonly used risk scoring systems must be updated. Widely used risk-scoring systems are not effective in minimally invasive cardiac surgery and this is supporting our idea. Each clinic should choose the appropriate risk scoring system according to their own experience and case diversity. Competing interests The authors declare that they have no competing interest. Financial Disclosure The financial support for this study was provided by the investigators themselves.

References 1.

Nilsson J, Algatsson L, Höglund P, et al. Comparison of 19 preoperative risk stratification models in open-heart surgery. Eur heart J. 2006;27:867-74.

Roques F, Nashef SA, Michel P, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg. 1999;15:816-22.

Siregar S, Groenwold RH, Heer F, et al. Graaf Y, Herwerden LA. Performance of the orijinal Euro SCORE.Eur J Cardiothorac Surg. 2012;41:746-54.

Nashef SA, Roques F, Sharples LD, et al. Euro SCORE II. Eur J Cardiothorac Surg. 2012;41:734-44.

Clark RE. The Society of Thoracic Surgeons National Database status report. Ann Thorac Surg. 1994;57:20-6.

Higgins TL, Estafanous FG, Loop FD, et al. Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score. JAMA. 1992;267:2344-8.

Ad N, Holmes SD, Patel J, et al. Comparison of Euro SCORE II, orijinal Euro SCORE, and the society of thoracic surgeons risk score in cardiac surgery patients. Ann Thorac Surg. 2016;102:573-9.

Kuwaki K, Inaba H, Yamamoto T, et al. Performance of the Euro SCORE II and the society of thoracic surgeons score in patients undergoing aortic valve replacement for aortic stenosis. J Cardiovasc Surg. 2015;56:455-62.

Zhang GX, Wang C, Wang L, et al. Validation of Euro SCORE II in Chinese patients undergoing heart valve surgery. Heart Lung Circ. 2013;22:606-11.

10. Wang TK, Choi DH, Ramanathan T, et al. Comparing performance of risk scores for combined aortic valve replacement and coronary bypass grafting surgery. Heart Lung Circ. 2016;25:1118-23. 11. Rabbani MS, Qadir I, Ahmed Y, et al. Heart valve surgery: Euro SCORE vs. Euro SCORE II vs. society of thoracic surgeons score. Heart Int. 2014;9:53-8. 12. Kar P, Geeta K, Gopinath R, et al. Mortality prediction in Indian cardiac surgery patients: validation of european system for cardiac operative risk evaluation II. Indian J Anaesth. 2017;61:157-62. 13. Findik O, Haberal I, Akyildiz M, et al. A comparision of the sensitivity and specificity of the Euro SCORE, Cleveland, and CABDEAL risk stratification systems in the Turkish population. Turk Gogus Kalp Dama. 2012;20:458-66. 14. Margaryan R, Moscarelli M, Gasbarri T, et al. Euro SCORE Performance in minimally invasive cardiac surgery: discrimination ability and external calibration. Innovations (Phila). 2017;12:282-6. 15. Kofler M, Stastny L, Reinstadler SJ, et al. Robotic versus conventional coronary artery bypass grafting: direct comparison of long-term clinical outcome. Innovations (Phila). 2017;12:239-46. 16. Senay S, Gullu AU, Kocyigit M, et al. Robotic mitral valve replacement for severe rheumatic mitral disease: perioperative technique, outcomes, and early results. Innovations (Phila) 2014;9:292-6.

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REVIEW ARTICLE

Medicine Science International Medical Journal

Medicine Science 2018;7(4):962-6

Accreditation of forensic science laboratories in Turkey in the scope of TS EN ISO/IEC 17025:2017 standard Dilek Salkim Islek, Emel Hulya Yukseloglu Institute of Forensic Science, Istanbul University Cerrahpaşa Medical Faculty Campus, Istanbul, Turkeyy Received 10 May 2018; Accepted 18 June 2018 Available online 26.09.2018 with doi:10.5455/medscience.2018.07.8885 Copyright © 2018 by authors and Medicine Science Publishing Inc. Abstract The identification and interpretation of evidence are important in criminal disclosure. In addition to analyzing the investigated evidence using scientific and credible methods, it must be documented that the processes are carried out in accordance with nationally and internationally accepted scientific criteria. This can only be achieved with accreditation. Accreditation of test laboratories according to the 17025 standard in forensic sciences is an assurance that the expertise for courts is acceptable throughout the world. Compliance with the 17025 standard ensures that every detail of the laboratory operation is in accordance with an unchanging and understandable procedure, the workflow processes are always the same, thus minimizing possible errors and improving the efficiency of the laboratory service. For accreditation in laboratories, the requirements of TS EN ISO / IEC 17025 must be applied. It is possible to separate TS EN ISO / IEC 17025 into two main parts. The first part is the management requirements and the second part is the technical competence. Documentation, audits and quality management constitute an integral part of the terms of the management. The concept of technical competence includes personnel competence, test methods and devices. Appropriate equipment, selection of methods, implementation, competent personnel selection and training, continuous improvement of the practices in the laboratory to ensure quality are also parts of the accreditation process. The first accreditation is received by the Institute of Forensic Medicine of The University of Istanbul, which operates in the field of forensic science in Turkey as one of the four accredited institutions. In this study, the laboratories that want to apply the accreditation process are informed about the points that they should pay attention to, the attainments of accreditation in forensic sciences and the objectives such as expansion of scope for the future are mentioned briefly, suggestions are given to increase the number of accredited laboratories connected to universities as well as ensuring sustainability. Also designing the Forensic Science Laboratories in compliance with ISO / IEC 17025 standards, examining the technical requirements in this context, as well as the accreditation of laboratories in the field of forensic science in Turkey, have been addressed. Keywords: ISO / IEC 17025:2017, accreditation, forensic science laboratory, qualification

Introduction Accreditation according to Turkish EC is a quality infrastructure established to support the reliability and validity of the work carried out by conformity assessment bodies and consequently the conformity confirmation documents (test and inspection reports, calibration certificates, management system documentation, product documentation, staff documentation etc.) Accreditation of conformity assessment bodies is carried out on the basis of internationally recognized requirements set out to determine the eligibility criteria for the conformity assessment bodies, the relevant sector specific requirements and the internationally accepted requirements in the guidance documents specified by the regional or international accreditation bodies [1-5].

*Coresponding Author: Dilek Salkim Islek , Institute of Forensic Science, Istanbul University Cerrahpaşa Medical Faculty Campus, Istanbul, Turkey E-mail: salkimdilek@gmail.com

According to definitions within the scope of international accreditation organizations; Accreditation in the CITAC / Eurochem (Cooperation on International Traceability in Analytical Chemistry) guidelines is a procedure for recognition by the public authorities that the unit provides specific services and is competent. The definition of accreditation for a laboratory is the process during which the laboratory’s technical competence is assessed, approved and periodically audited by an internationally recognized authority in accordance with certain standards, for the reliability of the tests and analyzes. Quality assurance, on the other hand, is a measure of the quality of all precautions, procedures in the laboratory and is a system of quality assurance of the work to be carried out [1]. Another organization, ILAC (International Laboratory Accreditation Cooperation), is an international organization who aims at developing a communications network among accredited laboratories that deliver accurate and reliable results. It combines many worldwide laboratory accreditation systems and it operates on a voluntary basis. This mutual recognition system results in the 962

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acceptance of test results acquired from accredited laboratories for the goods of the companies who export to foreign markets. This is a cost-reducing factor for both sides, since the need for retesting is eliminated [2]. IAF (International Accreditation Forum), is an organization that monitors the reliability and appropriateness of accredited certification bodies [3] EA (European Co-operation for Accreditation) is a nonprofit organization where the members are the accreditation agencies of European Union countries and countries with candidate status [4]. These organizations provide communication by gathering the established agencies in various countries to accredit the conformity assessment activities in the world. Accreditation activities in our country are provided by Türk Akreditasyon Kurumu (TÜRKAK). In addition to the accreditation bodies, there are organizations who publish guidelines to establish standardization and ensure agreement on applications and terms used in various fields. For standards of test laboratories, ISO (International Organization for Standardization) and ASTM (formerly American Society for Testing and Materials) are the most preferred organizations. ASTM is the world’s largest voluntary organization who develops standards. TSE is providing service in standardization, conformity assessment, testing and calibration, in Turkey. It also provides service in countries such as Uzbekistan, Kazakhstan and Azerbaijan. In the field of chemistry IUPAC (International Union of Pure and Applied Chemistry) works especially on compatibility of terminology. Many different organizations work together in the field of metrology (ISO, IEC, BIPM, OIML, IUPAC, IUPAP, IFCC). These organizations came together to form a structure called VIM (International Vocabulary of Metrology). NIST (National Institute of Standards and Technology) publishes standards on measurement and methods. Organizations such as CITAC (Cooperation on International Traceability in Analytical Chemistry) and EUROLAB (Organization for Testing in Europe) provide useful guides for test laboratories [20]. In the world, ISO 17025 standard is used for the accreditation of testing and calibration laboratories. Accreditation in compliance with 17025 increases the competitiveness of a testing laboratory, develops its management system and increases the effectiveness and efficiency of its services [21]. 17025 accreditation in forensic science is a guarantee that the courts of the whole world would accept the testing laboratory’s expert services. Compliance with 17025 standards ensures that every detail of the laboratory process is carried out according to fixed procedures and the workflow process is always the same. In this way, possible errors are minimized, the efficiency of the laboratory increases in terms of operation and service. Being accredited enables mutual recognition and even research results to be internationally comparable, through guidelines on both the standards and the activities of other research laboratories. Nowadays, accreditation is a process based on sometimes a necessity, sometimes voluntariness. In countries that implement free market economies, laboratories; have to be accredited to prove their independence and credibility as well as to increase their competitive power. The standard named TS EN ISO/IEC 17025 “General Requirements for the Competence of Testing and Calibration Laboratories” have two main sections. These sections are named as “administration requirements” and “technical requirements”. While the administration requirements are primarily concerned with the operation and effectiveness of the quality management system in the laboratory, the technical requirements address the competence of the personnel, the methodology and the test / calibration equipments. In the quality

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system, regardless of anything, “do what you write” and “write what you do” motto is important [21]. For a correct application, the standard must also be correctly interpreted. In interpreting the standard correctly, it is important to get ideas from experienced laboratories and inspectors. The most important reasons of why standardization is required in forensic laboratories [20-22]: 1. The worldwide acceptance of the report of the forensic laboratories, 2. The increasing pressure of competition among companies and to have a place among the worldwide laboratories in international competition, 3. To realize the potential of employees and to increase the quality of workforce, 4. To satisfy the increasing expectations of customers in terms of services provided, 5. Globalization around the world, 6. To increase confidence in forensic laboratories, 7. To provide rapid production of laboratory services while ensuring quality. Application Process in Turkey Within the discipline of forensic sciences, quality assurance is important since the results affect the decision given in the justice system. In Turkey, TS EN ISO 17025 standard is used for the accreditation of laboratories. In Turkey, with the Law on Turkish Accreditation Authority and Establishment and Duties No. 4457, the tasks to accredit domestic and foreign institutions that will carry out laboratory, certification and inspection services and to ensure that these institutions are working in accordance with the determined national and international standards, and thus provide that the products / services system, personnel and laboratory documents are internationally accepted, were given to the Turkish Accreditation Agency. As of 2008, TÜRKAK, which started to provide accreditation services in 2001, has signed a mutual recognition agreement with the European Accreditation Association in all the accreditation fields subject to mutual recognition agreements. TÜRKAK is a full member of Europe Accreditation Association (EA), International Accreditation Forum (IAF) and International Laboratory Accreditation Cooperation (ILAC) [5]. Accreditation application file is prepared by the laboratory. Documents in the file are; quality handbook, organization chart, procedures, instructions, forms, etc. For the purposes of a preliminary audit, the file is sent to a specified auditor by TÜRKAK. RKAK. The auditor’s report as a result of his review on the file is forwarded to the laboratory, by the Agency. Laboratory fulfills the requirements and recommendations in this report and reapplies to the agency. The parties agree on the audit date of the laboratory and the auditors. After the audit, the auditors prepare the report and present it to the accreditation agency, for approval. Accreditation enters into force with the agency’s approval of the report. After that, there are probation controls each year and a full accreditation audit at four year periods. Following the declaration of accreditation decision, the first thing that the laboratory should do is to carry out a comprehensive inventory work on all main items such as their processes, personnel and equipment. For all tests, the laboratory should outline detailed 963

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workflows and the relationship of all units must be presented in a clear manner in this plan [9,16]. TS EN ISO/IEC 17025 standards The TS EN ISO / IEC 17025 standards are intended to be used for the development of management systems for the laboratory’s quality, administrative and technical operations. The use of this standard will help to establish cooperation between laboratories and other organizations, mutual exchange of knowledge and experience and will also help to harmonize standards and procedures [7,10] The purpose of the standard is to establish a management system open to constant improvement, to set up and follow up the goals of the management system, to provide traceability in technical and documentation aspects, as well as to achieve reliable testing and calibration results [6]. ISO/17025 laboratory accreditation is divided into two main sections. Management requirements and technical requirements. Quality management requirements is similar to ISO 9000 quality standards specified for quality management but an adapted version for the laboratory conditions. For this reason, the institutions or laboratories who have implemented quality systems in compliance with ISO 9000 standards can adapt easier to provide these conditions. There is a reason for all the conditions included in this section and they constitute a management system with adequate systems to maintain control. These requirements require a minimum amount of documentation to be generated in order to be available for the use of the laboratory which is a legal entity or a unit of a legal entity, as well as for its customers. It is required that the proposed system should be sustainable and leverageable in an appropriate manner. For the fulfillment of the conditions in this article as well as demonstrating its administration, there are detailed descriptions for various elements of the quality system [6,9-13] Technical competence shows the requirements that the laboratory must comply with in order to demonstrate its technical adequacy when performing various tests and/or calibrations. According to the General Conditions for the adequacy of laboratories for testing and calibration; the laboratory should have quality control procedures to monitor the validity of its test results and this monitoring process should be planned. Many factors determine the accuracy and reliability of tests and / or calibrations made by a laboratory. These factors include contributions from any of the following [6]: • • • • • • • • •

Human factor The layout and environmental conditions Testing and calibration methods and validation of these methods Equipments Measurement traceability Sampling Movement of test and calibration materials Assurance of the quality of test and calibration results Reporting of the results

Starting from how the samples coming to the forensic laboratories are collected, how they are transferred, how the reporting process work and up to how the report will be forwarded; all the phases should be described one by one and the task definitions of each

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personnel involved in these phases should be prepared very clearly. Procedures should be defined and written down for the activities which are an integral part of these tasks as well as for the activities which can be defined separately from them. Procedures should be written according to the functioning of the laboratory. If we group them under the main headings, they include procedures such as admissions and registration of sampling, test methods and validation of methods, provision of the quality of the analysis results, reporting of results, on the job training [13]. Each procedure should include the written instructions about the defined tasks. The instructions must contain all the details related to that topic and must provide the capability to perform that activity for the assigned personnel without the need of another person. In the meantime, the forms and schedules to be used should be prepared and put into practice after the approval of the management [9-10]. Personnel: It is one of the most important requirements of the standard and it includes authorization of the personnel who use the devices for calibration and test services, make measurements, calculate uncertainties, prepare reports and interpret measurement results when necessary as well as evaluating and recording their knowledge and skill, education status and training needs. Personnel competence is important and fundamental. The adequacy of all the personnel, who does the tests, evaluates data, interprets, and writes expert reports, must be maintained by the management of the laboratory. In evaluating the adequacy of all employees, primarily their education, training, skills and experience must be sufficient and acceptable. Even if the education records of the personnel are complete and sufficient during the audits, that they perform tasks which comply with calibration /test instructions and evaluating the competence of their knowledge and experience during implementation is essential for the audit results. Personnel’s job definitions of designated fields, the authorities and responsibilities should be defined and declared to them. Trainings and their timings must be specified in the annual training plan, in accordance with the tasks, applications and work processes in the laboratory. Training activities should be carried out in line with the specified plans and programs. At the end of these trainings, it should be determined if the personnel has acquired the desired qualifications and if shortcomings are identified, corrective actions must be taken. These activities are such as; retraining of the personnel, change of duty, expert assistance, and so on. The effectiveness of corrective actions should be measured [9-14]. Layout and Environmental Conditions: The infrastructure of the laboratory (energy sources, lighting etc.) and the environmental conditions should enable the tests to be carried out and should not affect the measurement results in the negative direction [14]. Documentation of technical conditions related to the layout and environmental conditions that may affect the calibration results for internal and external services that the laboratory serves, monitoring and controlling the environmental conditions affecting the calibration or testing, the requirement of stopping the calibration / testing if the environmental effects are adversely affecting the measurements must be all stated in the documents [10,14]. Testing and calibration methods and validation of these methods Forensic science laboratories are places where evidences are 964

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analyzed and interpreted with scientific methods. Therefore, the measurement results should be accurate and reliable. The measurement results of the method depend on many factors such as the conditions of the laboratory, equipment, chemicals used, personnel experience, etc. For this reason, the parameters affecting the measurement result of the method should be measured and the effects should be determined. Validation of the Method is; the measuring and testing operations to demonstrate that a device, a method, a measuring procedure or a system performance complies with the specified conditions. Validation parameters are; precision, accuracy, repeatability, reproducibility, determination limit, authenticity and selectivity, linear region, measurement range and substantiality [9-12]. Validation process; is applied when the method is going to be used for the first time in the laboratory, when a change is applied to a currently used method, when a validated method is going to be used in a different laboratory, when a different person is going to do it or a different device is going to be utilized and when a method parameter is changed. Laboratory must use appropriate methods and instructions within the scope of accreditation activities; such as sampling, handling, and transporting, storing, preparation of the materials to be tested/ calibrated, the analysis of the test/calibration data if appropriate as well as the budget of uncertainty measuring. The applied methods and instructions must be chosen to meet the needs of customers (911). Validated methods should all be documented in writing within the quality management system. Under some special conditions if non-standard methods are used, the customer should be informed that the obtained results may not be valid and the necessary validation processes would be carried out prior to the use of such methods [11-12]. Devices: Suitable devices to provide the necessary accuracy and uncertainty for laboratory, testing and calibration must be used. Calibration and intermediary control programs must be created when necessary and implemented for devices that may impact the results. The information should be recorded and maintained about the calibration, maintenance, repair etc. of devices. Implementations must be defined to prevent the use of devices, which are broken down or their validity of calibration has been expired, in tests/calibrations [13-15]. Traceability of Measurements: All devices used in tests and / or calibrations must be calibrated before starting to be used. The laboratory should have a program and procedures created for calibration of the devices. Sampling: If the laboratory is collecting samples from the scene of crime or from the materials or products directly transferred to the laboratory, it should have a sampling plan and procedures. Sample records should include the sampling procedure used, the definition of the sample, environmental conditions and the details to determine the location of the sample. Process implemented on the tested samples: The laboratory must take the necessary measures to avoid damage of the incoming sample for test/calibration. In this context, procedures should be established for the transfer, admission to the lab, handling, preservation, storage, retaining and handing-over of samples [12,14-15].

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Quality Assurance of Testing and Calibration Results: Laboratory should establish control procedures to follow up and maintain the validity of its calibration/testing services. In order to ensure accuracy and consistency of results, reference material should be used, interlaboratory comparison or proficiency test (LAC / PT) programs should be taken and appropriate results should be obtained and the consistency of the results should be evaluated by repeating tests and calibrations using the same or different methods [15]. The Preparation of the Reports on Results: Laboratory should turn the data, obtained from the calibration and test measurements it performed, into results and should report them. The results should be prepared accurately, clearly, objectively and in compliance with the test/calibration instructions and national/international standards. The content and format of the calibration certificates / test reports must comply with the requirements specified in the TS EN ISO / IEC 17025 standards and to the notifications of the institution issuing the accreditation document [13-15]. The standard is revised in 2017. In the last revision the following changes are done; configuration of the standardization items in line with ISO/CASCO document structure (item 4-8), defining the laboratory activities of testing, calibration and sampling (associated with testing or calibration) in the context of the standard, risk and opportunity-based approach adoption, more emphasizing on impartiality and confidentiality, replacing the phrase of laboratory management by the phrase management of laboratory, merging under one item the article on purchase of service and materials and the article on outsourcing testing and calibration to a subcontractor, adding the decision rule for making conformity assessment and introducing more clarity into metrological traceability. Advantages of Being an Accredited Laboratory Accreditation is the expression of national and international reputation demonstrating the reliability of technical proficiency. Accreditation certificate, in addition to the official recognition of the adequacy of the laboratory, also offers the customers the convenience of choosing reliable test, analysis and calibration services. Thanks to the common approach used for accreditation, reports issued by accredited laboratories are internationally accepted. Thus, in evaluating evidence of international offenses, repetition of evidence-related tests and analysis are avoided, providing benefits in terms of both time and cost [13,15]. Our laboratoryâ&#x20AC;&#x2122;s accreditation in the scope of forensic science includes tests on materials/products which constitute Forensic Genetics Review Blood (liquid), cheek epithelial cells, blood stain (dried blood) and extending the scope of the laboratory is undertaken. The laboratory also started the extension of its scope by including intra-analysis methods used in the field of toxicology, in addition to the work it is currently conducting for the purpose of improving individual and corporate quality of the laboratory one step further, maintaining the international validity of its analysis results and reports and ensuring the sustainability of the currently attained standards. Scope expansion studies have started in toxicology by including the methods of heavy metal analysis in urine with ICPMS and methods of alcohol analysis in the blood with HS-GCMS. When the required financial resources are provided, the next steps considered include drug analysis methods with GC-MS and LC-MS-MS. Besides these methods, new methods are constantly being developed and validated through scientific research. If the analysis demanded by the customer is not within the scope, then an in-house analysis method would be developed, validated and the 965

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sample is processed with this method. Accredited Organizations in the Field of Forensic Sciences in Turkey A drawback or an error occurring in any step of the work in forensic science lab may negatively affect the criminal investigation and maintaining justice. We are confronted with the fact that the following applications are indispensable in order to achieve a fair and impartial trial. The evidence which may be found at the crime scene should be investigated using modern scientific techniques and methods as well as duly collecting and recording the evidence. Also, it should be documented that the evidences are analyzed with validated and reliable methods and that the services are provided using national and internationally accepted scientific criteria by the accredited laboratories. Crimes of international dimension can only be processed if the analysis of the evidence is also valid at an international dimension. As a result, the laboratories working in this field needed accreditation in order to be traceable according to international standards and in order to be open to internal and external audit. Therefore Turkey’s first accredited laboratory is the T. C. Ministry of Interior Gendarmerie General Command Gendarmerie Criminal Department Afterwards, there are subsequently, the Forensic Medicine Institute of the Ministry of Justice of the Republic of Turkey, T. C. the Ministry of Interior, General Directorate of Security Criminal Department, İstanbul University Institute of Forensic Medicine Forensic Sciences Laboratory and KA-MİR Forensic Consulting Expertise and Consulting Co. Ltd. Conclusion The contribution of the forensic science to shed light on the crime depends on the reliability of the analysis done in the laboratory and the validation of the data interpretation. For that reason, from the arrival of the evidence to the lab up until the reporting process, each phase should comply with scientific validation, objectivity and auditability. In the accredited forensic institutions in Turkey, each stage from the admission of the sample until the reporting process can be monitored and the results of the analysis is open to internal and external audit. However, this is not the case in the recently opened non-accredited forensic science centers. This situation creates doubt about the operations and impartiality of these institutions as well as the substantiality of their tests. To eliminate this drawback and for the laboratories to meet on a common ground, it should be a requirement for the newly opened centers in the field of forensic science to apply for accreditation. Accredited laboratories which implement ISO 17025 standard; are the laboratories which best meet the expectations of the customers, provide the best quality service, has the quality system which has an audited documentation and backed up by proper maintenance, calibration and work instructions, as well as the current reference materials, ongoing quality control tests and trained personnel. These laboratories are operating independently and impartially, and consequently the test reports they issue achieve international validity. When a laboratory uses the same standards, the same test methods and the same documentations which are valid in every country, it means that accreditation results in worldwide acceptability. The quality management would

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become a demotivating activity for the personnel where the burden is more than the return only if the standard is misinterpreted. For this reason, the correct interpretation of the standard is the key to quality. Competing interests The authors declare that they have no competing interest Financial Disclosure The financial support for this study was provided by the investigators themselves.

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