Medicine Science I International Medical Journal; E- Journal of March 2020; Volume 9, Issue 1 by Medicine Science

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ISSN 2147-0634

MEDICINE ISSN 2147-0634

SCIENCE International Medical Journal

Volume 9, Number 1, March 2020, Pages 1-288

photo by Serhat Karaman photo by İbrahim ŞAHİN

E ditor-in-Chief Osman CELBIS

E ditors David O. CARPENTER Nevzat ERDIL Yuksel ERSOY Ədalət HƏSƏNOV Yunus KARAKOC Ronald S MacWALTER Selami Cagatay ONAL Ibrahim SAHIN

P ublishing E ditor Fatih BATI

Medicine Science International Medical Journal

EDITORIAL BOARD

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

➢

Editors ➢

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

➢

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

➢

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

➢

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

➢

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

➢

David O. CARPENTER (MD, Professor)

➢

Ronald S MacWalter (MD, FRCP)

➢

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

•

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 2020;9(1): 1-5

Life advices in patients with tracheostomy: Rational antibiotic use and cerebro-vascular prophylaxis-physiotherapy Eylem Tuncay1, Ozlem Yazicioglu Mocin1, Sinem Gungor1, Nezihe Ciftaslan Goksenoglu1, Ilim Irmak2, Cuneyt Salturk3, Feyza Kargin1, Huriye Berk Takir1, Mustafa Ay4, Veysel Garani Soylu5, Emine Aksoy1, Gokay Gungor1, Nalan Adiguzel1, Zuhal Karakurt1 1

University of Medical Sciences, Sureyyapasa Chest Diseases and Thoracic Surgery , Department of Pulmonology, Istanbul, Turkey 2 Hacettepe University, Faculty of Medicine, Department of Pulmonology, Ankara, Turkey 3 Yeni Yuzyil University Faculty of Medicine, Department of Pulmonology, Istanbul, Turkey 4 Batman Bölge State Hospital, Intensive Care Unit, Batman, Turkey 5 Kastamonu State Hospital, Intensive Care Unit, Kastamonu, Turkey Received 01 November 2019; Accepted 02 December 2019 Available online 14.12.2019 with doi:10.5455/medscience.2019.08.9126 Copyright © 2019 by authors and Medicine Science Publishing Inc.

Abstract Tracheostomy is life-saving procedure in critical care patients which require long-term mechanical ventilation (MV) and an alternative to endotracheal intubation.(1,2) The factors affecting the survival of tracheostomized patients are not clearly known. The aim of this study was to investigate the factors affecting intensive care unit (ICU) and long-term mortality in the tracheostomized patients due to respiratory failure. A retrospective observational cohort study was planned between January 20162019 in tertiary ICU. Each patient underwent percutaneous and surgical tracheostomy was included. Demographic characteristics, diagnoses, causes of tracheostomy, comorbidities, Charlson and APACHE 2 scores, culture antibiogram results, ICU day and mortality (1-3 and 12 months) were recorded. In the analysis of the data, appropriate statistical tests and analyzes were used. 115 of 3620 patients admitted to tertiary ICU and underwent percutaneous and surgical tracheostomy due to respiratory failure between January 2016-2019 were included. 75 (65%) of the patients were male and median age was 68±14 years. Hospital mortality was higher in the group with Acinetobacter baumannii growth (p=0.04). According to Kaplan-Meier survival analysis, long-term follow-up of Acinetobacter baumanii growth did not affect survival (p=0.938). Patients with cerebro-vascular accident (CVA) had lower survival in long-term follow-up (p <0.039). It was determined that presence of tracheal resistant Acinetobacter baumanii increases the ICU mortality in tracheostomized patients and existing CVA as a comorbidity increased the long term mortality. In conclusion, rational antibiotic therapy and CVA prophylaxis-physiotherapy could contribute to short and long term survival in these patient groups. Keywords: Critical care, stroke, tracheostomy, pneumonia, Respiratory infection

Introduction Tracheostomy is a frequently performed procedure in patients who are unable to be intubated , had prolonged mechanical ventilation and laryngeal pathology [1]. Tracheostomy shortens the intensive care unit (ICU) stay and reduces the endotracheal intubation-related complications , and furthermore, tracheostomy is an independent factor, which protects patients from ventilator associated pneumonia (VAP) development [2-4]. The risk of ventilator-induced pneumonia was shown to vary between 6% and

*Coresponding Author: Eylem Tuncay, University of Medical Sciences, Sureyyapasa Chest Diseases and Thoracic Surgery , Department of Pulmonology, Istanbul, Turkey, Turkey, E-mail: acarturkeylem@yahoo.com

26% in patients with tracheostomy [5,6]. Closure of the intensive care unit may be required due to high mortality risk in case of resistant A. baumanii infection in ICU [7]. In recent studies, ICU stay was prolonged in tracheostomized patients with ventilatory associated pneumonia (VAP), however mechanical ventilation time and mortality did not differ from the tracheostomized patients without VAP [8-10]. Currently, tracheostomy is a commonly performed procedure in prolonged intubation and the factors that influence the ICU and long-term morbidity and mortality are not clearly known in our country. The present study was conducted to investigate the factors affecting the mortality in the patients that have undergone tracheostomy due to prolonged mechanical ventilation.

doi: 10.5455/medscience.2019.08.9126

Material and Methods This retrospective, observational cohort study was conducted in the respiratory ICU of a tertiary hospital between January 2016 and 2019. All patients who had undergone percutaneous and/or surgical tracheostomy in the ICU was included in the study. The inclusion and the exclusion criteria and the patient characteristics have been summarized in Figure 1. The demographic characteristics, diagnoses, tracheostomy indications, co-morbid conditions of the patients, ICU severity score (APACHE 2, Charlson), tracheal aspirate culture antibiogram results, the duration of ICU stay and 1-3-12 month mortality rates were recorded from the death notification system. Ethics committee approval was obtained in accordance with the Helsinki Declaration (Number/date: 069/21.08.2018). The informed consent form was not obtained due to the retrospective design of the study but the patient data was de-identified. Patients The patients who had an indication for tracheostomy and undergone percutaneous and/or surgical tracheostomy were included in the study. Definitions Acute respiratory failure: Hypoxic respiratory failure was defined as the “ratio of partial arterial oxygen pressure to the oxygen fraction in respiration air (PaO2/FiO2) of <300 and an arterial partial carbon dioxide pressure (PaCO2) of < 45 mmHg; hypercarbic respiratory failure was defined as an arterial partial carbon dioxide pressure (PaCO2) of > 45 mmHg and the ratio of partial arterial oxygen pressure to oxygen fraction in respiration air (PaO2/FiO2) of >300; hypercarbic/hypoxemic respiratory failure was defined as an arterial partial carbon dioxide pressure (PaCO2) of > 45 mmHg and the ratio of partial arterial oxygen pressure to oxygen fraction in respiration air (PaO2/FiO2) of <300 [11,12]. The indications for tracheostomy were: a) failure to wean from the mechanic ventilator, b) the need for prolonged mechanic ventilation due to neurological diseases, c) failure to preserve airway integrity and insufficient clearance of bronchial secretions, and d) presence of laryngeal pathologies (trauma, burn, malignity, subglottic stenosis) [13-16]. Failure to wean from the mechanic ventilator: Failure in spontaneous breathing trial or re-intubation within 48 hours after weaning from the mechanic ventilator [17]. Spontaoneus breathing trial: The patient who had spontaneous breathing is weaned from the MV and inhales oxygen through the T- tube. This procedure is applied for 30 min and repeated 24 hours later in case of failure [17]. Failure in spontaneous breathing trial: Clinical assessment and subjective indices: Agitation and anxiety, dyspnea, cyanosis, increased respiration effort and suppressed mental functions [17]. Objective criteria: partial oxygen pressure (PaO2) of 50-60 mmHg (FiO2≥50%) or oxygen saturation (SaO2) of ≤90%. Partial carbon dioxide pressure (PaCO2) of ≥50 mmHg or >8 mmHg elevation in PaCO2 value; pH of 7.32 or a ≥0.07 U elevation in pH value; breathing frequency/tidal volume: 105 respiration/min; an increase

Med Science 2020;9(1):1-5

in breathing frequency of >35 /min or ≥50% increase in respiration /min; heart beat of >140 bpm or ≥20% elevation in the heart rate; systolic blood pressure (SBP) of >180 mmHg or ≥20% elevation in SBP; systolic blood pressure of <90 mmHg; presence of cardiac arrhythmia [17]. Prolonged mechanical ventilation was defined as need for mechanical ventilation more than 7 days or failure in spontaneous respiration [17]. Procedures: The percutaneous tracheostomy forceps dilation technique (Griggs) or the one-step dilation technique (Ciaglia Blue Rhino) was used according to its availability in the ICU. Percutaneous tracheostomy was performed under guidance of fiberoptic bronchoscopy in all patients [18,19]. Recorded Data The demographic characteristics of the patients, co-morbidities, causes of acute respiratory failure (pneumonia, acute exacerbation of COPD, bronchiectasis, decompensated congestive heart failure, obesity hypoventilation syndrome, amyotrophic lateral sclerosis), indications for tracheostomy, tracheostomy technique, ICU severity score [Charlson, APACHE II (acute physiologic and chronic health evaluation)], culture-antibiogram results, treatment regimens, ICU stay and the mortality were recorded. The mortality during 1-3 months after ICU stay and long term follow-up were recorded from the death notification system (DNS). Statistical Analysis The portable SPSS 20.0 package program was used for the statistical analysis. The demographic and clinical data of the patients were analyzed with the descriptive statistics. The paired groups, the nonparametric continuous variables were evaluated using the MannWhitney U test and the data were shown as median, 1st and 3rd quartile values (Q1-Q3). The parametric student t-test was used for the paired groups that showed a normality distribution, and the continuous variables were shown as mean and standard deviation (SD). The chi-square test was used for the paired variables. Numbers and percentages were used when required. The KaplanMeier survival test was used for the survival analyses. A p level of <0.05 was accepted as statistically significant. Results A total of 115 patients who had undergone percutaneous and/ or surgical tracheostomy out of 1930 patients in whom invasive mechanic ventilation was applied after intubation were included in the study. Of the patients, 75 (65%) were males and the median (±SD) age was 68±14 years. Sixty-six (57.4%) patients had undergone percutaneous tracheostomy. The demographic characteristics, hospital stay, the day of tracheostomy and the ICU severity score have been summarized in Table 1. The hospital mortality was determined as 71.1%, the first month mortality rate was 56% and the long-term mortality rate was 71.9%. Microbial growth was detected in the deep tracheal aspirate (DTA) culture and/or in 52 (45.6%) bronchial lavage cultures. Acinetobacter baumanii was detected in 39 (33.9%) cases, Pseudomonas aeruginosa was detected in 11 (9.6%) 2

doi: 10.5455/medscience.2019.08.9126

Med Science 2020;9(1):1-5

cases, Klebsieala pneumonia was detected in 5 (4.3%) cases and Escherichia coli was detected in 1 (0.9%) case.

Table 2. Tracheostomy indications Cases

n (%)

The causes for tracheostomy have been summarized in Table 2.

Prolonged mechanical ventilation

61(53)

When DTA and bronchial lavage culture growth were compared with regard to hospital mortality, no difference was determined between the groups in which microbial growth detected or not (p=0.24). When the hospital mortality was evaluated according to the type of bacteriae growth in the culture, it was significantly higher in the Acinetobacter baumanii group (p=0.04) (Table 3).

Degenerative and demyelinating

19 (17)

Sequelae of cerebrovascular event

12 (10.4)

Hypoxic encephalopathy after CPR

11 (9.6)

Acinetobacter baumanii growth was determined as not to affect the survival in the long term follow-up in the Kaplan-Meier survival analysis (p=0.938). Survival of the patients who experienced cerebro-vascular event (CVE) was significantly lower in the longterm follow-up (p<0.039) (Figure 2). Table 1. Demographic features and intensive care data of tracheostomy patients Cases, n Male, n (%) Age (year), Mean±SD Body mass index (kg/m2); Median (Q1-Q3)

CNS malignancy

2 (1.7)

Upper airway stenosis

2 (1.7)

CPR, Cardio-pulmonary resuscitation; CNS, Central nervous system Table 3. Mortality according to bacterial growth in deep tracheal aspirate and bronchial lavage cultures Non-survivor, (%)

Survivor, n(%)

p-value

Acinetobacter baumanii

23 (28.4)

16 (48.5)

0.04

Pseudomonas aeruginosa

10 (12.3)

71 (87.7)

0.13

68±14 22 (19-30)

Charlson score, Mean±SD

5±1.6

Survival time after discharge (day), Median(Q1-Q3)

3 (2.6)

75 (65)

28±8

ICU stay (day), Mean±SD

5 (4)

Dynamic airway collapse

115

APACHE II, Mean±SD Tracheostomy operation day, Median (Q1-Q3)

Post- intubation tracheal stenosis

12 (8-23) 31±14 153 (24-342)

Intensive care admission diagnosis, Pneumonia, n (%)

45 (39.3)

Acute exacerbation of COPD, n (%)

36 (31.3)

Bronchiectasis, n (%)

9 (7.8)

Congestive heart failure, n (%)

10 (8.6)

OHS, n (%)

11(9.6)

ALS, n (%)

4 (3.4)

Comorbidities; n (%)

186 (85.3)

Hypertension , n (%)

44 (38.3)

Diabetes mellitus, n (%) Congestive heart failure, n (%) Atrial fibrillation, n (%)

Figure 1. Abbrevations: ICU, intensive care unit; NIV, non-invasive mechanical ventilation; HFO, high flow oxygen therapy; APACHE II score, Acute physiology and chronic health evaluation

31 (27) 30 (26.3) 22 (19)

Coronary artery disease, n (%)

19 (16.5)

Cerebrovascular event, n (%)

14 (12.1)

Chronic renal failure, n (%)

13 (11.3)

Extrapulmonary malignancy , n (%)

10 (8.6)

Lung cancer, n(%)

10 (8.6)

Alzheimer diseases, n(%)

9 (7.8)

Sequelae of poliomyelitis, n(%)

3 (2.6)

Abbrevations: SS, Standart deviation; Q1-Q3, 1. and 3. quartile values, APACHE II, Acute physiology and chronic health evaluation; COPD, Chronic obstructive pulmonary disease; OHS, Obesty hypoventilation syndrome; ALS, Amyotropic lateral sclerosis.

Figure 2. Mortality of tracheostomized patients with CVA ( 9 deaths among 11 patients) and without CVA (40 deaths among 70 patients) were shown in the longterm Kaplan-meier cumulative survival analysis. Abbrevation: CVE, Cerebrovascular event

doi: 10.5455/medscience.2019.08.9126

Discussion The present study has revealed that Acinetobacter baumanii infection increased the mortality in the ICU, and the presence of a previous CVE increased the long-term mortality in the patients with tracheostomy. In the study of Tamir et al. which investigated the 30-day morbidity and mortality in 311 patients who had undergone surgical tracheostomy in advanced age, the mortality was found to be higher in the patients with chronic pulmonary disease, prolonged international normalized ratio (INR) and restricted neck extension movement [20]. The present study has revealed that presence of a previous CVE increased the mortality in the long term and the mortality rate was found to be higher in cases with resistant Acinetobacter baumanii infection during hospitalization at the ICU. Besides, the small sample size of the study and percutaneous tracheostomy which was a less invasive procedure, might be the reasons for contraversial results. Tamir et al. also reported that the time of tracheostomy did not affect the mortality [20]. Siempson et al. reported that although early tracheostomy did not affect the ICU mortality, it reduced the VAP development, shortened the duration of MV and enabled early mobilization [21]. Morbidity and mortality was found to be high in late tracheostomies (tracheostomies performed after the 14th day of intubation) in a multi-center study investigating 1175 cases who had undergone tracheostomy due to prolonged mechanic ventilation. [22] The effect of the time of tracheostomy procedure on ICU or long-term mortality was not analyzed in our study. While there are some studies reporting that VAP development increases the mortality in tracheostomized patients [9,10], some others have reported no association [6,23]. This conflicting result might be associated with patient-related factors and co-morbid conditions. Although VAP development was not analyzed in the present study, mortality was found to be similar between the groups, which had microbial growth and no microbial growth in the tracheal aspirate cultures. Besides, the hospital mortality was significantly higher in patients with Acinetobacter baumanii growth. Liu et al. investigated the risk factors for VAP development in patients who had undergone head and neck surgery in which %79 of them had been performed tracheostomy , and reported higher risk in the patients with chronic obstructive pulmonary disease (COPD) [4]. In recent studies, it has been shown that VAP development is higher in patients with COPD [24-27]. Risk factors for increased VAP development in COPD patients were found to be advanced age, COPD-related increased inflammation, corticosteroid use, malnutrition and respiratory muscle weakness [24-27]. Our study did not analyze the reasons for VAP development; however, microbial growth was present in almost half of the tracheal aspirates. Although microbial growth in the tracheal aspirates do not indicate VAP development, it is an important marker for VAP and tracheo-bronchitis together with a consistent clinical condition. The results of the present study are compatible with the other studies in regard to risk factors for VAP development, as COPD is the second leading diagnosis (31.3%)

Med Science 2020;9(1):1-5

following pneumonia (39.3%), and microbial growth is present in almost half of the tracheal aspirates. The present study has some limitations. First, the results may not be generalized as it was a single-center retrospective study. However, we consider that the results may be valuable for similar patient group as the patients were followed-up by the same pulmonologists and intensive care unit physicians. Conclusion In conclusion, Acinetobacter baumanii infection-related hospital mortality might be reduced through controlling the pathways that contribute to infection development in patients undergoing percutaneous and/or surgical tracheostomy. Rational antibiotic use may reduce A. Baumanii growth and therefore cause decrease in hospital mortality and costs. The presence of a previous CVE and related immobilization increase the long term mortality in case of tracheostomy indicates that physical therapy, which is usually avoided in this patient group, may contribute to improvement of the long term survival. Clinicians may need to be more careful for co-morbid conditions in the presence of CVE. Competing interests The authors declare that they have no competing interests. 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. Eylem Tuncay ORCID ID:0000-0002-5046-1943 Ozlem Yazicioglu Mocin ORCID ID:0000-0003-3161-6118 Sinem Gungor ORCID ID:0000-0002-1163-125X Nezihe Ciftaslan Goksenoglu ORCID ID:0000-0003-3860-5905 Ilim Irmak ORCID ID:0000-0001-5230-1575 Cuneyt Salturk ORCID ID:0000-0001-7459-9210 Feyza Kargin ORCID ID:0000-0002-1217-5284 Huriye Berk Takir ORCID ID:0000-0001-9262-7078 Mustafa Ay ORCID ID:0000-0001-6210-1083 Veysel Garani Soylu ORCID ID:0000-0002-4617-3367 Emine Aksoy ORCID ID:0000-0002-5692-8332 Gokay Gungor ORCID ID:0000-0003-2294-489X Nalan Adiguzel ORCID ID:0000-0001-7033-8494 Zuhal Karakurt ORCID ID:0000-0003-1635-0016

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Aşık G. Acinetobacter baumannii Virülansının Açıklanmasında Güncel

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11. Ambrosino N, Vagheggini G. Non-invasive ventilation in exacerbations of COPD. Int J Chron Obstruct Pulmon Dis. 2007;2:471–6. 12. Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet. 2009;374:250–9. 13. Jefferson ND, Cohen AP, Rutter MJ. Subglottic stenosis. Semin Pediatr Surg. 2016;25:138-43. 14. Dion GR, Teng S, Bing R, et al. evelopment of anin vivo model of laryngeal burn injury. Laryngoscope. 2017;127:186-90. 15. Bagheri R, Rahim MB, Majidi M,et al. Anteriormediastinal tracheostomy for malignancy: analysis of 12 cases. Asian Cardiovasc Thorac Ann. 2013;21:187-92. 16. Miles A, McLellan N, Machan R, et al. Dysphagia and laryngeal pathology in post-surgical cardiothoracic patients. J Crit Care. 2018;45:121-7. 17. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29:1033-56. 18. Sheu CC, Tsai JR, Hung JY, et al. A simple modification of Ciaglia Blue Rhino technique for tracheostomy: using a guidewire dilating forceps for

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):6-8

Mid-term outcome of wide resection in musculoskeletal fibrosarcoma patients Resit Sevimli1, Adem Emeli2, Semih Eriten3 1

Inonu University, Faculty of Medicine, Department of Orthopaedic and Traumatology, Malatya, Turkey 2 Usak Resarch Hospital, Clinic of Orthopaedic and Traumatology, Usak, Turkey 3 Malatya Education and Research Hospital, Department of Emergencey, Malatya, Turkey Received 25 July 2019; Accepted 21 August 2019 Available online 14.12.2019 with doi:10.5455/medscience.2019.08.9111 Copyright ÂŠ 2019 by authors and Medicine Science Publishing Inc.

Abstract The aim in this study, musculoskeletal system fibrosarcomas which are rare malignant soft tissue tumors that originate from fibroblasts, was to evaluate the mid-term outcome of patients that were diagnosed, treated and followed-up at our clinics. Included in the study were 12 patients treated for fibrosaecoma at our clinics between 2014 and 2017. The patients were evaluated in terms of age, location of tumor and time of resection, and were followed-up for mid-term recurrence. A wide resection was performed on all patients. No recurrence was found in all but one patient during follow-up. Musculoskeletal system fibrosarcomas are rare but represent high mortality and morbidity risks since the diagnosis is commonly delayed. The most frequently seen symptom is a painless mass reaching large dimensions. Early diagnosis plays a major role in prognosis, as is the case with other malignant tumors. In conclusion, we suggest that malignancy should be considered in the presence of giant, fixed and painful tumors, and a wide resection should be applied. Keywords: Soft tumor, fibrosarcoma, wide resection, recurrence, primary organs, diagnose

Introduction Fibrosarcoma is a malignant neoplasia arising from fibroblasts.1 Incidences increase among those in the 30â&#x20AC;&#x201C;55-year age group, and especially at around 45 years, although it can be seen in all age groups.2 The tumor is frequently located in the deep fascia of the distal extremity of the skeletal system. Growth is commonly painless, and so diagnosis may be delayed accordingly.3 The subgroups are adult fibrosarcoma, infantile fibrosarcoma, myxofibrosarcoma, low-grade fibromyxoid sarcoma and sclerosing epithelioid fibrosarcoma.4 Fibrosarcomas are solitary lesions and are generally infiltrative, however they can be misleadingly well demarcated. A histopathology reveals intersecting fibroblast bundles that are sometimes in a herringbone sequence. Nuclear atypia and mitotic activity will be present but may be mild in some cases and grading is important in terms of prognosis in such tumors.5 The invasion of the skeletal structure and superficial ulcerations are seen in advanced cases.6 They are normally encountered as painless masses, provided there has been no invasion into the nerve trunks.7 Recurrences are especially high

*Coresponding Author: Resit Sevimli, Inonu University, Faculty of Medicine, Department of Orthopaedic and Traumatology, Malatya, Turkey E-mail: resitsevimli@hotmail.com

in cases with an insufficient resection.8 In this study, recurrences identified at mid-term follow-up were evaluated in fibrosarcoma cases in which a wide resection was carried out. Material and Methods All patients participating in the study provided written informed consent. After obtaining the required informed consent, 12 patients who were treated in the clinic with a diagnosis of fibrosarcoma between 2014 and 2017 were included in the study. For the evaluation of the patients, after systemic physical examination of all patients, in radiological examinations, lesions reaching gigantic dimensions in direct radiographs were seen, in addition to mass lesions with an expending character; and pathological vascularizations that were heterogeneous in T1 and hyperintense in T2 images, located in the soft tissues, and separated from arterial and nervous structures by a thin capsule and causing obstructions, as seen in MRI images (Figure 1 and 2). The patients were followed-up for location of the tumor, age of the patients and time of resection, and the mid-term outcomes were evaluated. Statistical analysis Statistical comparisons were performed using the paired-samples 6

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t-test and IBM SPSS Statistics, version 21 (IBM Corp., Armonk, NY, USA). Statistical significance was accepted at p<0.05.

Figure 1. Direct graphy and MRI images of a 56-year old patient who presented with a forearm fibrosarcoma

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Results The age range of the patients was 15–70 years (mean 46) (Table 1). The tumors were localized in the upper and lower extremities in seven (60%) and five (40%) patients, respectively (Table 2). The most common localization in the upper extremity was at the level of the forearm/elbow. According to Eneking’s soft tissue tumor classification, three patients were at stage 1, five were at stage 2 and four were at stage 3 (Table 3). All tumoral structures were resected, reaching the mass by way of an incision around the tumor, including the skin, under general anesthesia. Skin defects were closed by plastic surgeons using autografts (Figure 3), and the patients were referred to the appropriate departments for chemotherapy and radiotherapy. The 12 patients included in the study underwent wide excisional surgery following diagnosis and neoadjuvant therapies. No recurrences were found in all but one patient in the Stage 3 group during routine follow-up visits performed in every six months. The case with the recurrence, which was detected in the 8th month of follow-up, underwent a radical resection again, excising the compartment involved. Table 1. Age distribution of patients AGE

Number of Patients

15–20

20–30

30–40

40–50

50–60

60–70

AGE RANGE: 15–70 MEAN: 46 Table 2. Distribution of patients by anatomic localization Figure 2. Fibrosarcoma reaching gigantic dimensions and skin necrosis seen in the same patient

Anatomic Distribution Localization

Number of Patients

Upper Extremity (60%) Shoulder and Arm

Elbow and Forearm

Hand and Wrist

Lower Extremity (40%) Hip and Thigh

Knee and Leg

Foot and Ankle

Table 3. Stage and rate of recurrence in 12 patients with fibrosarcoma Stage and Rate of Recurrence Stage

Figure 3. Neurovascular bundle seen intact after a wide excision

Number of Patients

Rate of Recurrence

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Discussion Fibrosarcomas account for 3 percent of all adult sarcomas among all soft tissue tumors and are generally seen more often in those of advanced age.9 No etiologic cause can be detected in most cases, although genetic factors, radiation, trauma and chemical agents are most frequently blamed for the development of fibrosarcoma. Fibrosarcomas originate from the deep tissues of the extremities, head and neck. They may originate in areas of the body subjected to radiotherapy, or areas with foreign material applications.10 Fibrosarcomas are formed from fibroblasts and include varying amounts of collagen. The lesions are hard and single lobuled with regular contours. The histories of patients reveal a painless mass with a slow growth, and this frequently causes tumors to reach large dimensions. Patients may complain of palpable masses that can lead to compressive symptoms. Computed tomography and magnetic resonance imaging are the commonly used methods in diagnosis, while fine needle aspiration or tru-cut biopsies can be helpful in making a histopathological diagnosis. Microscopic views of fibrosarcomas may be low grade or high grade.11 The most frequent site of metastasis is the lungs via the hematogeneous route. Low rates of local recurrence and fiveyear survival levels of up to 80 percent can be achieved through appropriate surgical margins and adjuvant radiotherapy. The use of chemotherapy has been suggested to decrease local recurrence rates, although the roles of chemotherapy and radiotherapy are still controversial.12 The treatment of choice in low grade tumors is surgery, as is the case with other soft tissue sarcomas. The tumor should be widely excised with the surrounding normal tissue (wide excision), and radiotherapy and chemotherapy can be applied preoperatively and/ or postoperatively, although it is not a rule in high-grade tumors. The rate of recurrence is around 5 percent in soft tissue sarcomas resected with an appropriate surgical margin, and the rate of success is even higher in childhood fibrosarcomas.13 Cases series of fibrosarcoma are rarely reported in literature, although case reports more frequent. Shvarts et al.14 reported bladder invasion in a case of fibrosarcoma with distant organ metastasis, while Bahrami et al. 15 reported a 5 percent rate of recurrence in a large series, compared to Scott et al.16 who reported a 6 percent recurrence rate. In this present case report, a recurrence was found in only one case, which is compatible with the findings in literature. No recurrence was found in the rest of our cases during mid-term follow-ups following a wide resection. Conclusion In conclusion, musculoskeletal tumors are rare, but are associated with high mortality and morbidity when they occur. That said, patient survival can be increased when the tumors are excised with the appropriate margins with surgical techniques.

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Competing interests The authors declare that they have no competing interests. Financial Disclosure All authors declare no financial support. Ethical approval Before the study, permissions were obtained from the local ethical committee. Reşit Sevimli ORCID: 0000-0002-5394-9100 Adem Emeli ORCID: 0000-0002-1640-4276 Semih Eriten ORCID: 0000-0001-8516-372X

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Sevimli R. Distribution and evaluation of primary bone and soft tissue tumors admitted from Malatya province and surrounding provinces. Med Sci 2017;6:546–550

Folpe AL, Lane KL, Paull G, et al. Low-grade fibromyxoid sarcoma and hyalinizing spindle cell tumor with giant rosettes: a clinicopathologic study of 73 cases supporting their identity and assessing the impact of high-grade areas. Am J Surg Pathol 2000;24:1353–60.

Abbott JJ, Oliveira AM, Nascimento AG. The prognostic significance of fibrosarcomatous transformation in dermatofibrosarcoma protuberans. Am J Surg Pathol 2006;30:436–43.

Hansen T, Katenkamp K, Brodhun M, et al. Low-grade fibrosarcoma–report on 39 not otherwise specified cases and comparison with defined low-grade fibrosarcoma types. Histopathology 2006;49:152–160.

Limon J, Szadowska A, Iliszko M, et al. Recurrent chromosome changes in two adult fibrosarcomas. Genes Chromosomes Cancer 1998;21:119–23

Weiss SW. Proliferative fibroblastic lesions. From hyperplasia to neoplasia. Am J Surg Pathol 1986; 10(suppl 1):14–25

Guillou L, Benhattar J, Gengler C, et al. Translocation-positive lowgrade fibromyxoid sarcoma: clinicopathologic and molecular analysis of a series expanding the morphologic spectrum and suggesting potential relationship to sclerosing epithelioid fibrosarcoma: a study from the French Sarcoma Group. Am J Surg Pathol. 2007;31:1387–402.

10. Sirvent N, Maire G, Pedeutour F. Genetics of dermatofibrosarcoma protuberans family of tumors: from ring chromosomes to tyrosine kinase inhibitor treatment. Genes, Chromosomes & Cancer. 2003;37:1–19 11. Ofluoglu O, Boriani S, Gasbarrini A, et al. Diagnosis and planning in the management of musculoskeletal tumors: surgical perspective. Semin Intervent Radiol. 2010;27:185–90. 12. Jemal A, Murrey T, Samuels A, et al. Cancer statistics. Cancer J Clin. 2003;53:5-26. 13. Evans HL. Low-grade fibromyxoid sarcoma: a report of 12 cases. Am J Surg Pathol. 1993;17:595–600. 14. Shvarts O, Lam JS, Kim HL, et al. ECOG performancestatus predicts bone metastasis in patients presenting with fibrosarkoma. J Urology. 2004;172:86770. 15. Bahrami A, Folpe AL. Adult type fibrosarcoma: a reevaluation of 163 putative cases diagnosed at a single institution over a 48-year period. Am J Surg Pathol. 2010;34;1504-13. 16. Scott SM, Reiman HM, Pritchard DJ, Ilstrup DM. Soft tissue fibrosarcoma. A clinico pathologic study of 132 cases. Cancer. 1989;64:925-31.

Available online at www.medicinescience.org

ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):9-15

Management of infective endocarditis and long-term outcomes of patients who underwent surgery: The fifteen-year experience of a tertiary care center Baris Akca, Nevzat Erdil, Mehmet Cengiz Colak, Olcay Murat Disli, Bektas Battaloglu Inonu University, Faculty of Medicine, Department of Cardiovascular Surgery, Malatya, Turkey . Received 04 November. 2019; Accepted 04 December 2019 Available online 04.02.2020 with doi: 10.5455/medscience.2019.08.9124

Abstract Infective endocarditis (IE) is still associated with severe complications and poor prognosis. The surgery of IE has various technical difficulties due to severe infection, inflammation of heart tissue, and systemic effects, so controversies continue about the optimal timing of operation. This study presents the treatment approaches, early and late-term outcomes of IE patients, who underwent surgery.This retrospective descriptive study is conducted with 46 patients (31males) operated between 2002-2018. The demographics and preoperative, intraoperative and postoperative data of patients were analyzed from the clinical database and patient records. Emergency surgery was performed to 15 (32.26%) patients.Numbers of patients with mitral valve, aortic valve, and prosthetic valve endocarditis were 14, 25, 7 respectively. Aortic valve replacement (AVR), mitral valve replacement (MVR), MVR + AVR and mitral valve repair were performed in 24, 12, 8 and 2 patients, respectively. Additionally, pericardial patch repair (periannular abscess or damage (n=12), aorta-right atrial fistulae (n=3)), debulking of associated tricuspid valve vegetation (n=2), tricuspid De Vega annuloplasty (n=3), Bentall operation (n=1) and aortic root enlargement (n=5) were performed. The mean follow-up period and mortality rates were 24.86 Âą 38.98 months, 13.04% respectively. The mean survival and reoperation-free time were 179.02 Âą 13.78 and 203 Âą 10.09 months, respectively. Patients can be managed appropriately with early diagnosis, aggressive medical and surgical treatment via a multidisciplinary approach with customized management according to guidelines in terms of individual characteristics. In cases of worsening hemodynamic status, uncontrolled infection, large and mobile vegetations surgery should be performed as soon as possible Keywords: Infective endocarditis, cardiac surgical procedures, disease management, heart valve diseases

Introduction Infective endocarditis (IE), which is a multisystemic disease, describes the infection of the endocardial surface of the heart which may also include the heart valves, and which is caused by microorganisms such as bacteria, viruses or fungi [1]. Although this rare disease has an annual incidence of 3-10:100,000 and recent epidemiological studies suggest increasing incidence [2]. The increasing number of older patients, along with iv drug abuse especially in developed countries and healthcare-associated IE can be counted among the factors that cause an increase in incidence [3-5]. The diagnosis of IE has remained a challenge due to its various etiology and changing epidemiological factors related to the disease [6].

*Coresponding Author: Bars Akca, Inonu University, Faculty of Medicine, Department of Cardiovascular Surgery, Malatya, Turkey E-mail: dr.baris.akca@yandex.com.tr

It is customary to establish a diagnosis of IE by using the modified Duke criteria [6]. However, in some clinical conditions such as the subclinical course of infection; diagnosis may be missed, and a delayed diagnosis made with the development of severe complications significantly reduces the success of surgical treatment. Surgery has been the choice of treatment for active IE in the last decades and has been progressively performed with a current ratio that almost reached up to half of the IE patients [4,5]. Despite the improvement in multidisciplinary management of IE with advanced diagnosis and treatment modalities using efficient systemic antibiotherapy and surgical intervention, IE is still associated with severe complications, poor prognosis, and high mortality rates. The surgical approach to IE patients has various technical difficulties due to severe infection, inflammation of the heart tissue, and systemic effects, so there are ongoing controversies about the optimal timing of the operation. This study presented the treatment approaches and the early and late-term outcomes of IE patients, who had undergone surgery in a tertiary care center. 9

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Materials and Methods Clinical data, study population and definitions This retrospective study, which complies with the ethical rules declared by the Helsinki Declaration and Good Clinical Practice, was conducted after the approval of the Ethics Committee. The demographics preoperative, intraoperative, and postoperative data of patients were analyzed from the clinical database and patient records retrospectively. A total of 46 patients with complete data were enrolled in the study (31 males, 15 females; mean age 35.89 ± 14.64 years; range 11-68 years). All patients fulfilled the modified Duke criteria, were precisely diagnosed with IE and underwent open-heart surgery between January 2002 and December 2018. A multidisciplinary team involving cardiologists, infectious disease specialists, and cardiac surgeons decided on the indications and timing of surgery. The criteria of exclusion from the study consisted of patients whose files showed a lack of data, who were older than 80 years, who had a comorbid diagnosis such as major embolic stroke with hemorrhagic transformation risk or different serious conditions like a malignant disease. Data of demographic variables, clinical findings, New York Heart Association (NYHA) functional classification, medications used, etiology, results of blood culture analysis and echocardiographic valve diagnostics, complications, surgical techniques and type of valve prosthesis used, and the outcome after surgery were recorded. All patients had at least one transthoracic echocardiogram at the time of diagnosis. Transesophageal echocardiography (TEE) was used in cases that required further information. If an urgent or an elective surgery was scheduled, a preoperative transthoracic echocardiogram was performed just before the surgery to figure out the latest findings. A total of eight patients had TEE (17.39%). The presence of NYHA class 3 or 4 symptoms and the need for inotropic drugs were defined as congestive heart failure. The persistence of fever despite intravenous antibiotherapy for at least a week was described as an uncontrolled infection. The presence of clinical stroke without supportive results from imaging studies was defined as embolic stroke while computed tomography verified cerebral lesions or clinical stroke was handled as cerebral embolism. If the size of vegetation was observed to be larger than 10 mm on echocardiogram, it was described as large vegetation. A classification of insignificant, mild, moderate and severe regurgitation was used according to semiquantitative or quantitative methods for assessing the degree of valve regurgitation. A region with heterogeneous echogenic or echolucent appearance raised the suspicion for a diagnosis of perivalvular extension and abscess. The length of maximal vegetation was also estimated. The time-lapse between the scheduling and the operation was defined as the timing of the surgery. In this study, the timing of the surgery was described by using a simple classification; “Emergency surgery” (operation was performed in the first 24 hours), “Urgent surgery” (operation was performed in less than a week), and “elective surgery” ( the operation was performed after at least 2 weeks of appropriate antibiotics treatment in cases, whose cardiac function was stable). The main indications for early surgical intervention, comprising of both “emergency” and “urgent” surgery in this study are heart failure (HF), uncontrolled

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infection, irreversible structural damage like paravalvular extension, abscess, fistulae, severe valvular regurgitation, size of the vegetation, microorganisms, and prevention of embolic events as previously reported [6,7]. Although the presence of cerebral emboli did not affect the timing of surgery, the patients with hemorrhagic cerebral infarction or with the risk of hemorrhagic transformation had conservative management procedures for 4-6 weeks before further evaluation for surgery. Surgical technique Surgery was performed during the antibiotic treatment. The definition of the surgery during the initial hospitalization stage for IE was regarded as the replacement or repair of the affected valve. Concomitant procedures during surgery included the repair of periannular abscess or destructions, the repair of fistula and dehiscence. The surgical operations of all patients were performed under general anesthesia conditions and via a median sternotomy approach. For ascending aorta, aortic cannulation was performed in cardiopulmonary bypass with mild hypothermia, while the venous drainage was provided either by atrial or separate cannulation of both the superior and inferior vena cava. In order to achieve cardiac arrest, the combination of antegrade and/or retrograde cold blood cardioplegia was administered. The valve repair technique or replacement with a mechanical valve was used when the infection was intraoperatively observed as limited to the valve leaflets. After the surgeon explored the extent of the infected tissue and considered it resectable with a high possibility of sufficient leaflet tissue that would be retained for a satisfactory outcome, the attempt for repair technique was performed. If the infection was observed to extend to the surrounding structures or there was an annular abscess and disruption or fistula, the technique of surgery consisted of annular reconstruction by using a pericardial patch, or the replacement of aortic root using valve graft. Radical resection of the affected tissue, followed by a topical antibiotic agent (Cefazolin Na) application, was performed in all of the patients as a routine procedure. The debridement of paravalvular infected structures was performed despite potential damage to the conduction system or myocardial/fibrous tissue. A careful examination of the valvular annulus and surrounding structures was carried out for potential extensive abscess resection. The use of artificial material was kept as low as possible. The type of valve implemented was generally determined by the preference of each surgeon and according to the patient characteristics. Postoperative care Apart from patient stabilization, in terms of hemodynamics and weaning from respiratory support, strict monitoring of the local and systemic infective process was the primary target of early therapy in the intensive care unit (ICU). The appropriate regimen for postoperative antibiotic therapy, which was recommended and initiated by infectious disease specialists was continued in ICU. Patients without any postsurgical complications were transferred to the infectious disease ward for finishing the rest of the 6-8 weeks of antibiotherapy. 10

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Statistical Analysis For statistical purposes, descriptive analysis was performed. Continuous and categorical variables were expressed in terms of median and mean, absolute values and percentage ratios, respectively. Data related to survival were indicated as mean standard deviation with a 95% confidence interval. Survival analysis was performed by Meier method, and related curves were drawn.

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Results

The diameter of the vegetation was measured to be over 10 mm. in 12 patients out of 24 (52.17%), who were found to have had vegetation on echocardiography. Additionally, three patients had concomitant right atrial vegetation. Among the cases with native valve endocarditis, aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, and tricuspid regurgitation were observed as the dominant valve pathology in 5, 22, 2, 16, and 4 cases, respectively. Two of the patients were found to have mitral valve leaflet perforation that caused regurgitation (one with anterior, one with posterior leaflet).

In this study, two patients were iv drug abusers while two patients had a history of embolism event, and three patients were dependent on hemodialysis due to chronic renal failure. The clinical, laboratory and echocardiography findings of the cases were listed in Table1.

The blood and tissue culture results that were obtained for 23 of the cases showed that responsible microorganism was not detected in culture samples of the 14 (30.43%) and detected in 9 (19.56%) of the patients. The microorganisms isolated by culture analysis are listed in Table 2.

Table 1. Demographic and Echocardiographic data of patients Variables

Mean ± SD / n

Age (years)

35.89 ± 14.64

Table 2. Identified Microorganisms from blood culture (%)

Microorganism

(%)

Streptococcus viridans

11.1

Male

67.39

Streptococcus pneumonia

11.1

Female

32.60

Staphylococcus aureus

33.3

Obesity

6.52

Brucella spp

11.1

Diabetes

10.86

Enterococcus faecalis

22.2

HTA

8.69

Staphylococcus Lugdunensis

11.1

Smoking

43.7

NYHA III- IV

84.78

Blood culture negative

30.43

CKD with hemodialysis

4.34

Cerebral Embolism

4.34

Blood culture positive

19.56

Euroscore

5.72 ± 3.18

Ejection fraction %

57.03 ± 7.96

SPAP (mmHg)

52.68 ± 18.06

LVESD (mm)

47.13 ± 8.08

LVEDD (mm)

60.15 ± 9.96

NVE

84.78

PVE

15.21

BMI: Body Mass Index, LVEDD: left ventricular end diastolic diameter, LVESD: left ventricular end systolic diameter, NVE: Native valve endocarditis, PVE: Prosthetic valve endocarditis.

The number of patients who were diagnosed with native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) was 39 (84.78%) and 7 (15.21%), respectively. Among the patients with NVE, 14 patients had mitral valve endocarditis while 25 of them had aortic valve endocarditis. The bicuspid aortic valve was present in 3 of the patients (6.52%). During initial hospitalization, 39 (84.78%) of the patients were recorded as NYHA functional class III or IV.

For all the cases in the study, the mean duration of ventilation, ICU, and hospital (surgery clinics) stay were 7.97 ± 4.78 hours,3.5 ± 1.96, and 11.59 ± 7.08 days, respectively. During the postoperative intensive care period, 18 patients received inotropic therapy. In this study, out of 9 (19.56%) patients who had a history of open-heart surgery, 2 had a coronary bypass, 5 had mitral valve replacement (MVR) (1 bioprosthesis), 1 had aortic valve replacement (AVR), and 1 had MVR + AVR operations. Emergency surgery was performed to 15 (32.26%) patients who were etiologically classified as congestive heart failure (13 patients) and recurrent embolism attacks (2 patients). Among the patients, who were operated in an emergency state, 4 of them were intubated before the onset of the surgery. Among all patients, isolated AVR, isolated MVR, MVR + AVR and isolated mitral valve repair were performed in 24, 12, 8, and 2 patients, respectively. Additionally, pericardial repair due to either periannular abscess or damage in 12 patients and aortaright atrial fistulae in 3 patients, debulking of associated tricuspid valve vegetation in 2 patients, tricuspid De Vega annuloplasty in 3 patients, Bentall operation in 1 patient, and aortic root enlargement in 5 patients were performed. Apart from redo operations, disseminated epicardial adhesions were present in 10 patients. The mortality rate was 13.04% (n= 6). Out of the deceased patients, three had prosthetic valve endocarditis (one of them with double valve replacement), one had coronary bypass surgery a year ago, and four patients had emergency surgery while intubated. Multiorgan failure, uncontrolled infection related to severe sepsis and low cardiac output were the etiology of in-hospital mortality 11

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in 2, 2, and 2 patients, respectively. The mean follow-up period of this study was 24.86 ± 38.98 months (2-214). There was no patient admission due to recurrent endocarditis during the followup period. A patient was re-operated for pseudoaneurysm due to aortic root separation after six months from endocarditis surgery. During the follow-up period, the mean survival and reoperationfree time were found to be 179.02 ± 13.78 (CI: 152.01-206.039) and 203 ± 10.09 (CI: 182.047-223.95) months, respectively as shown in Figure1-2.

Figure 1. The mean survival of patients during the follow-up period

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is not compatible with the IE patient profile that has been recently getting older. However, the number of patients, who were admitted due to IE as a result of highly virulent microorganisms or due to complications and IE of prosthetic valves, was similar to the literature. Although there is marked advances in the diagnosis and management of IE, it is still among the most fatal diseases with an in-hospital mortality rate of 10-30% that is mostly due to the lack of surgery in 25% and 50% of the patients with clear indications for cardiac surgery in the acute phase [12]. The mortality rate (13.04%) of this study was consistent with recent reports. The parameters of hemodynamic instability, stroke, expected poor prognosis independent from treatment, death before surgery, sepsis and surgeon denied operating were the reasons for avoiding surgery and maintaining nonsurgical treatment and also a lack of surgery reported in patients with Staphylococcus Aureus IE and poor prognosis factors [2,12]. Therefore, European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines both emphasize that patients should be referred to centers that have a specific team that would approach endocarditis from the most proper medical and surgical aspect with a special focus on the optimal timing for the surgical intervention [6,8]. The optimal timing of surgery is the main issue of IE and still unclear, actually, ESC guideline reported a proper staging according to the hemodynamic status of the patient [6]. According to this guideline, the surgery performed during the first 24 hours is graded as “emergency”, if it is performed within a week and in at least 1-2 weeks after the antibiotherapy, its stage is classified as “urgent” and “elective” respectively. While the patient receiving antibiotherapy in the active phase of IE, early surgery option should be considered in order to avoid the development of progressive HF, infection-related irreversible structural damage and to refrain from systemic embolism [6,13,14]. In this study, the management and surgery decisions of patients with IE were made by a multidisciplinary team and early surgery (starting from first 4-6 hours and lasting up to a week) preferred in high-risk patients with heart failure symptoms or severe valve regurgitation and/or stenosis, large vegetations (above 10 mm) and IE caused by Staphylococcus aureus.

Figure 2. The mean reoperation free time of patients during the follow-up period

Discussion Currently, the incidence of IE, especially in developed countries, has been on the rise as a result of either highly virulent microorganisms or health-related issues such as people with a history of medical intervention, or who have comorbid diseases, prosthetic valves, or intracardiac devices [4,5,8,9]. Therefore, rapid diagnosis and potent treatment of IE is essential for survival. Complications and poor prognosis would be a result of delayed diagnosis or the onset of treatment [10,11]. In this study, the mean age of patients

There are some occasions when the duration of the antibiotherapy is inconsiderable for deciding on an emergency (in the first 24 hours) or urgency (within a few days and in less than a week) based surgical intervention. At other times, however, the clinical course allows ample delay of surgery to complete one or two weeks of antibiotherapy under clinical and echocardiographic surveillance prior to scheduling elective surgery [6,14]. The primary indications for early surgical intervention for IE involve HF, uncontrolled infection, and the aim of avoiding embolic events [6,15,16]. However, the prognosis becomes dreadful whenever a heart failure accompanied by progressive symptoms, cerebral emboli, and reduced cognitive skills develop [17,18]. The decision to perform surgery in IE remains a challenge because of the potential for acute and life-threatening complications of this disease, uncertain response to antibiotic therapy, and comorbid host conditions [4,5]. Compared to delayed surgery, surgery in the 12

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early term is customarily accepted as riskier due to inflammation of tissues and technical difficulties related to surgery. In approximately half of the patients with IE are treated by both medical and surgical approaches via cardiac surgery and antibiotherapy [4,5]. It appeared that preoperative antibiotherapy duration did not either affect mortality in the perioperative period or the rate of recurrent IE [19,20]. In this study, all patients had surgery while receiving antibiotherapy; on the other hand, the reason for the relatively low ratio of patients with negative blood cultures for microorganisms was considered to be due to intensive antibiotherapy in the preoperative period. The essential purpose of surgical intervention like debridement of the infected tissue in IE is the limitation of infectious foci to prevent or treat heart failure and dissemination of the infection, and it also decreases the risk of embolism related morbidity and even mortality in the optimum clinical conditions [15,12,21-23]. The main principle of the surgical approach in this study depends on the repair of paravalvular complications by completely removing all the infected and necrotic tissue with a minimal residual foreign body. By using this approach, after initial evaluation of the affected valve intraoperatively, debulking and debridement of the vegetation and abscess foci was performed, and in case of a fistulae presence, preferred management included repair by pericardial graft and re-evaluation of the valves for valve preservation/repair when there is no rheumatic changes or there is an isolated leaflet perforation [24]. When medical therapy is not sufficient for treating IE, especially in complicated cases with abscess, fistulae, valve perforation, and alike, surgical intervention can be life-saving, however, the reciprocity among indications for surgery, acute clinical status, surgical considerations, and outcome prediction is very intricated, and has not been fully delineated yet. Surgery performed very early may improve survival with an increased surgery risk at seriously complicated IE patients. When the surgery is performed too soon, a high risk of relapses and dysfunction of the valves in the postoperative period is not surprising [14]. In this study, no admissions for recurrent IE in the postoperative follow-up period were found. We concluded that this outcome was the result of a multidisciplinary approach to the patients that included not only intraoperative source evaluation and proper removal of the infectious foci but also ensuring to complete a full course of antibiotherapy in the infectious disease ward, which the patients were transferred after the surgical surveillance in the postoperation period. However, a single patient had been reoperated for pseudoaneurysm due to aortic root separation in the sixth postoperative month. The surveillance is crucial in all the patients, especially the ones who have emergency surgery, and full attention should be paid for the complications that do not cause acute deterioration of the clinical course, i.e., valve dehiscence, pseudoaneurysm. It is possible to detect severe complications and intervene accordingly by rigorous patient follow-up before the development of any complaints or progression to the lifethreatening clinical status. The presence of a neurological complication is specifically a problem when considering the proper time for surgery [19,20]. When the patient has associated ischemic stroke, the risk of

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the surgical operation increases and complicated neurological findings by the addition of hemorrhagic infarct can be caused by early surgical intervention. On the contrary, the substantial risk of disease progression and cerebral embolism recurrence based on delayed surgery were pronounced by the advocates of early surgery [25]. In a meta-analysis of comparing results of studies regarding the timing of the surgery within one versus two weeks of diagnosis, Christos et al. found that the outcome of an early surgery for valvular IE which was complicated by embolic ischemic stroke was not favorable with an increased risk of mortality. The researchers stated that early surgery did not result in lowering the incidence of perioperative stroke or the 1-year survival and proposed that especially in high-risk patients, surgery might better be delayed if there are no absolute emergency indications for valve surgery [26]. However, when a patient develops heart failure associated with progressive symptoms or cerebral emboli associated with declined cognitive skills, the prognosis is dreadful [18]. In a recent update report of the 2014 ACC/AHA guideline, Nishimura et al. reported that when a neurological event did not cause widespread neurological injury or intracranial hemorrhage, recent data favored early surgery with a low risk of postoperative neurological deterioration for better overall outcomes. They also stated that when there was widespread neurological damage or intracranial hemorrhage, cardiac surgery posed a high mortality risk when performed in the first 4 weeks after a hemorrhagic stroke [27]. In this study, postponing the surgery based on the hemodynamic status, the size of the vegetation, and the clinical presentation of the patients with a cerebral complication during the acute phase in initial hospitalization was preferred. Early surgery is preferred especially in patients with Staphylococcus aureus related IE if the patients do not have any significant comorbid prohibitive conditions such as ischemic cerebral infarction which affects a broad region risky for hemorrhagic transformation, factors for poor prognosis (advanced age, cancer, chronic obstructive pulmonary disease, morbid obesity, cachexia), and hemodynamic instability. In a review by Delahaye, it was reported that no firm conclusions for performing early surgery in all IE patients could be drawn despite the results of observational studies that suggested the benefits of current surgical practices concerning the long-term survival [28]. A favorable outcome of the surgery was related to the surgeon who based the operation decision on the IE presentation and characteristics of the patient. Furthermore, the patients who fulfilled the criteria put forward in management guideline were the ones, who most benefited from the surgery [21,22,26]. The clinical course before the surgery is an independent predictor of survival in patients who had an operation for native mitral valve IE. The presence of preoperative embolic stroke, congestive heart failure or disseminated infection significantly decreased the five-year survival rate in patients with IE, accordingly, postponed surgery may raise the possibility and severity of preoperative complications and thereupon postoperative mortality [17]. In a recent meta-analysis by Liang et al., the association of early surgery with lower rates of in-hospital and long-term mortality was reported in IE, especially in NVE patients; however, there are still controversies concerning the optimal surgery time for both NVE and PVE [29]. 13

doi: 10.5455/medscience.2019.08.9127

The most severe type of IE is PVE, which has an incidence of 0.31.2% per patient-year and develops in 1-6% of patients who have valve prostheses [6]. PVE affects mechanical and bioprosthetic valves in equal rates and accounts for one-tenth to one-third of all IE cases [6,8]. It is still challenging to diagnose and determine the best treatment option for PVE, which consequently leads to poor prognosis. The diagnosis of NVE is more straightforward. If no surgical intervention is performed for complicated and staphylococcal PVE, the prognosis becomes dismal. Therefore, aggressive management approaches should be used for these advanced forms of PVE while uncomplicated and late PVE due to microorganisms other than staphylococcus can be treated conservatively by appropriate antibiotherapy and close followup [6]. The rates of morbidity and mortality can remain high due to ongoing infection, which might not even be controlled with aggressive surgical therapy [6]. In this study, half of the patients that had a fatal course were PVE patients, and their prognosis was worse than others. There is no consensus over the favorable type of aortic prosthesis for PVE patients, and the surgical techniques, as well as prosthetic valve types, show a wide range of variation among these patients [30]. There are no well-defined data on the proper valve substitute in IE, and in this study, it was found that all patients who required replacement had mechanical valve prosthesis. This was concluded to be the result of a relatively younger patient population. On the other hand, patients with complicated IE in this study had 26 additional procedures. One of the limitations of the present study was a single-center experience of the same surgical team with two senior surgeons. Also, retrospective design of the study and the relatively low number of patients were other limitations. Multicenter prospective studies with high number of patients can reveal significant results. This study includes both NVE and PVE so that the mortality rate may be biased, and predictors of mortality could be assessed with a larger sample size in both isolated groups of NVE and PVE. The relationship between causative microorganism and mortality could not be evaluated because of the high ratio of negative blood culture. Conclusion Despite high mortality and morbidity rates, patients can be managed appropriately with early diagnosis, aggressive medical and surgical treatment (early or elective) via a multidisciplinary approach with customized management according to guidelines in terms of individual characteristics. In cases of worsening hemodynamic status, uncontrolled infection, large and mobile vegetations surgical intervention should be performed as soon as possible. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval This study was approved by local ethics committee (No: 2019/298). Baris Akca ORCID: 0000-0001-9154-4764 Nevzat Erdil ORCID: 0000-0002-8275-840X Mehmet Cengiz Colak ORCID: 0000-0002-8508-2249 Olcay Murat Disli ORCID: 0000-0002-9699-4817 Bektas Battaloglu ORCID: 0000-0003-1221-8122

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Cahill TJ, Baddour LM, Habib G, et al. Challenges in Infective Endocarditis J Am Coll Cardiol. 2017;69:325-44.

Forestier E, Fraisse T, Roubaud-Baudron C, et al. Managing infective endocarditis in the elderly: new issues for an old disease. Clin Interv Aging. 2016;11:1199-206.

Selton-Suty C, Célard M, Le Moing V, et al. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54:1230-9.

Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the international collaboration on endocarditis prospective cohort study. Arch Inter Med. 2009;169:463-73.

Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC) Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36:3075-128.

Gaca JG, Sheng S, Daneshmand MA, et al. Outcomes for endocarditis surgery in North America: a simplified risk scoring system. J Thorac Cardiovasc Surg. 2011;141:98-106.

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2438-88.

Prendergast BD. The changing face of infective endocarditis. Heart. 2006;92:879-85.

10. Dickerman SA, Abrutyn E, Barsic B, et al. The relationship between the initiation of antimicrobial therapy and the incidence of stroke in infective endocarditis: an analysis from the ICE Prospective Cohort Study (ICE-PCS). Am Heart J. 2007;154:1086-94. 11. Lodise TP, McKinnon PS, Swiderski L, et al. Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect Dis. 2003;36:1418-23. 12. Chu VH, Park LP, Athan E, et al. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation. 2015;131:131-40. 13. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009;30:2369-413. 14. Thuny F, Beurtheret S, Mancini J, et al. The timing of surgery influences mortality and morbidity in adults with severe complicated infective endocarditis: a propensity analysis. Eur Heart J. 2011;32:2027-33. 15. Olmos C, Vilacosta I, Fernandez C, et al. Comparison of clinical features of left-sided infective endocarditis involving previously normal versus

doi: 10.5455/medscience.2019.08.9127 previously abnormal valves. Am J Cardiol. 2014;114:278-83. 16. Anguera I, Miro JM, Vilacosta I, et al. Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart J. 2005;26:288-97. 17. Ragnarsson S, SjĂśgren J, Stagmo M, et al. Clinical Presentation of Native Mitral Valve Infective Endocarditis Determines Long-Term Outcome after Surgery. J Card Surg. 2015;30:669-76. 18. Hasbun R, Vikram HR, Barakat LA, et al. Complicated leftsided native valve endocarditis in adults: Risk classification for mortality. JAMA. 2003;289:1933-40. 19. Olaison L, Pettersson G. Current best practices and guidelines indications for surgical intervention in infective endocarditis. Infect Dis Clin North Am. 2002;16:453-75.

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and long-term mortality in left-sided infective endocarditis: do differences in methodological approaches explain previous conflicting results? Eur Heart J. 2011;32:2003-15. 24. Disli OM, Karakurt C, Erdil N, et al. Use of autologous pericardium for mitral leaflet reconstruction in a child with endocarditis. Rev Bras Cir Cardiovasc. 2013;28:296-8. 25. Kang DH. Timing of surgery in infective endocarditis. Heart. 2015;101:178691. 26. Mihos CG, Pineda AM, Santana O. A Meta-Analysis of Early Versus Delayed Surgery for Valvular Infective Endocarditis Complicated by Embolic Ischemic Stroke Innovations. 2016;11:187-92.

20. Delahaye F, CĂŠlard M, Roth O, et al. Indications and optimal timing for surgery in infective endocarditis Heart. 2004;90:618-20.

27. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;70:252-89.

21. Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366:2466-73.

28. Delahaye F. Is early surgery beneficial in infective endocarditis? A systematic review. Arch Cardiovasc Dis. 2011;104:35-44.

22. Lalani T, Cabell CH, Benjamin DK, et al. Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias. Circulation. 2010;121:1005-13.

29. Liang F, Song B, Liu R, et al. Optimal timing for early surgery in infective endocarditis: a meta-analysis. Interact CardioVasc Thorac Surg. 2016;22:33645.

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30. Perrotta S, Zubrytska Y. Valve selection in aortic valve endocarditis. Kardiochir Torakochirurgia Pol. 2016;13:203-9.

Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):16-20

Platelet levels and neutrophil to lymphocyte ratio in thyroid nodules with and without cancer diagnosis Soycan Mizrak1, Sirin Kucuk2 Usak University Training and Research Hospital, Medical Biochemistry Laboratory, Usak, Turkey 2 Usak University Training and Research Hospital, Medical Pathology Laboratory, Usak, Turkey

Received 26 July 2019; Accepted 25 September 2019 Available online 05.02.2020 .2019 with doi:10.5455/medscience.2019.08.9125 Copyright © 2019 by authors and Medicine Science Publishing Inc. Abstract Nodular formation of thyroid tissue is a very common endocrinologic pathology. Approximately 5% of thyroid nodules can prove to be cancerous. The usefulness of mean platelet volüme(MPV) and neutrophil to lymphocyte ratio (NLR) is determined as an indicator of immunological response and subclinical inflammation in recent years. In this study we evaluate the association of thyroid stimulating hormone (TSH), platelet, mean platelet volüme(MPV) and NLR levels between the thyroid nodules that turn into cancer and do not convert. Our study consisted of patients with thyroid nodules that converted to thyroid cancer (n = 100) and didn’t convert to thyroid cancer (n = 100). These patients were selected retrospectively using the Hospital Information System. The TSH, NLR, platelet and MPV levels were recorded preoperatively and the difference between them was evaluated statistically with SPSS 21. Differences between groups were examined with using Mann Whitney U Test. P <0.05 were considered significant. Platelet, TSH and neutrophil values were significantly higher in the nodular group which convert to thyroid cancer (p <0.05). In addition, the likelihood of being thyroid cancer increased 1.47 times with a unit increase in the NLR variable, and 1.008 times with a unit increase in the platelet variable. High levels of platelet and neutrophil in thyroid cancer may be due to increased cytokine level changes. It can be shown that data obtained from total blood count, which is an easy, inexpensive and reproducible assay, can be used as a marker in predicting prognosis with further studies. Keywords: Thyroid cancer, neutrophil, lymphocyte, platelet

Introduction Nodular thyroid diseases which are seen in 32% of women and 33% of men are among the most common endocrinologic diseases [1]. Half of those thyroid nodules are solitary while the other half are multinodular. We can’t decide whether the nodüle is benign or malignant without a pathological examination. The clinical importance of thyroid nodules is to exclude the diagnosis of underlying thyroid cancer. The best test in order to make a diagnosis is fine needle aspiration biopsy (FNAB). However, there are two important problems of fine needle aspiration biopsy. First, inadequate or non-diagnostic results, the second is the indetermine category of lesions, which constitute 15-30% of all thyroid biopsies. Therefore, there is a need for biomarkers to be used in thyroid tumors, contributing

*Coresponding Author: Soycan Mizrak, Usak University Training and Research Hospital, Medical Biochemistry Laboratory, Usak, Turkey Turkey, E-mail: soycan.mizrak@usak.edu.tr

to predicting the accuracy of FNAB, tumor aggressiveness or behavior. 5-15% of thyroid nodules are proved to be cancerous [2]. Thyroid cancer incidence has rapidly increased during the past few decades due to increases in the incidence of papillary thyroid carcinomas [3]. The relationship between inflammation and cancer has started to investigated since leucocytes were observed in tumorigenic cells by Rudolf Virchow [4]. The inflammation around neoplastic tissues is characterized by the presence of leukocytes with macrophages, mast cells, and T cells [5]. The neutrophil–lymphocyte ratio (NLR) that is known as a marker of the systemic inflammatory response, has been associated with the progression and the survival of most cancers [6]. Increased NLR levels is a negative prognostic factor for various cancers [7]. The role of platelets is also important in the relationship between cancer and inflammation. Circulating platelets count and production are increased in inflammatory diseases. It is thought that these platelets migrate to the area of inflammation where highly reactive and large platelets are rapidly consumed. Mean platelet volüme (MPV) shows platelet activation and platelet function changes. Large platelets are more active than small platelets [8]. NLR and MPV levels analyzed in hemocytometers are useful markers that 16

doi: 10.5455/medscience.2019.08.9125

are easily accessible. The present study aimed to evaluate the association of NLR and MPV levels between benign and malignant thyroid nodules. Materials: The present study was a retrospective study. The Ethical Committee and Institutional Review Board of Usak University Faculty of Medicine, where the study was conducted, approved the study design. For this retrospective study, we reviewed the medical records of 200 patients who have thyroid nodules in our hospital between January 2015 and March 2018. Patients with history of heamatological disorders, chronic inflammatory disease or autoimmune disease, acute or chronic infection, other known malignancy were excluded from the study. All patients were divided into two groups. Group 1 (n=100) were patients with thyroid nodules that didn’t convert to thyroid cancer, group 2 (n=100) were patients with throid nodules that converted to thyroid cancer. We retrospectively analyzed the patient files to obtain data including age, gender, detailed disease history, and preoperative TSH levels, neutrophil, lymphocyte, platelet count and mean platelet volume values. The preoperative data reflect the values measured at the time of examination. TSH assays were performed on a fully automated ADVIA Centaur analyzer (Siemens Healthcare Diagnostics, Munich, Germany). The neutrophil to lymphocyte ratio were calculated by dividing the neutrophil value with the lymphocyte value and mean platelet volüme were noted. All of the CBC analyses were performed in the hematology laboratory of our hospital. An automatic blood counter (ABX Pentra 120 DF, Horiba Medical, USA) was used for whole blood counts.

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we evaluated the relationship between groups and gender with chi-square test. There was no statistically significant relationship between groups and genders (Table 1, p>0,05). Although not meaningful; 46.7% of males and 50.6% of females had Thyroid cancer. The data of the patients in the preoperative period were recorded by using the hospital information system. We examined TSH levels, neutrophil, lymphocyte, platelet counts and MPV levels in both groups. The relationship that we have obtained between the groups and the variables is given in Table 2. There was a statistically significant difference in age between groups (p <0.05). Age values of nodular goiter group were significantly higher. There was a statistically significant difference between the groups in terms of TSH (U / L) values (p <0.05). TSH (U / L) values of Thyroid cancer group were significantly higher. There was a statistically significant difference between the groups in terms of Neutrophil values (p <0.05). Neutrophil values of Thyroid cancer group were significantly higher. There was a statistically significant difference between the groups in terms of PLT values (p <0.05). PLT values of Thyroid cancer group were significantly higher. There was no statistically significant difference between the groups in terms of other variables (p> 0.05).

Material and Methods The results of the study transferred from forms to SPSS 21 computer statistical analysis software and statistical analyses were performed. Mann Whitney U test used for comparison of the groups. The chi-square analysis was applied to examine the relationships between the groups of nominal variables. Logistic Regression Analysis was used to determine the risk factors. Results were expressed as mean ± standard deviation and a p value of <0.05 was considered statistically significant. Results The study included 200 patients diagnosed and followed up with thyroid nodules. These patients were divided into 2 groups. Patients in Group 1 (n = 100) was diagnosed as thyroid nodules and Group 2 (n = 100) consisted of patients who were diagnosed as thyroid nodules and then turned into papillary carcinoma. First,

Logistic Regression analysis was performed to determine the Thyroid cancer status as a dependent variable and as a risk factor (Table 3). According to the results of logistic regression analysis, a one-year increase in the age variable decreases the probability of being a Thyroid cancer (OR = 0.974). One unit enhances in the NLR variable, increases the probability of being a Thyroid cancer 1.471 times (OR = 1.471). The probability of being one unit enhances in the platelet variable increased by 1,008 times (OR = 1,008). We can distinguish accurately 63% of patients using age, NLR and PLT variables a new future case of with Nodular Goiter, Thyroid cancer 62% of patients and 62,8%, in general, can accurately distinguish (Table 4).

Table 1. The chi-square test on the relationship between groups and gender Grup Nodular Goiter

Gender

Thyroid cancer

The Chi-Square Test

Total

Male

53.3

46.7

100.0

Female

49.4

50.6

170

100.0

Total

100

50.0

100

50.0

200

100.0

Chi-Square

0.039

0.692

doi: 10.5455/medscience.2019.08.9125

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Table 2. Mann whitney u test result on the difference between groups and variables Grup

Age

TSH (U/L)

NeutrophÄąl

Lymphocyte

NLR

Platelet

MPV

The Chi-Square Test

Mean

Median

Min

Max

Nodular Goiter

100

50.9

51.0

18.0

81.0

13.3

Thyroid cancer

100

46.4

44.5

24.0

77.0

12.4

Total

200

48.7

48.0

18.0

81.0

13.0

Nodular Goiter

100

2.20

.90

0.00

33.50

5.63

Thyroid cancer

100

2.88

1.45

0.00

51.30

6.37

Total

200

2.54

1.30

0.00

51.30

6.01

Nodular Goiter

100

4.0

3.9

1.0

7.9

1.5

Thyroid cancer

100

4.6

4.4

1.4

9.1

1.4

Total

200

4.3

4.2

1.0

9.1

1.5

Nodular Goiter

100

2.0

1.9

4.8

Thyroid cancer

100

2.1

4.4

Total

200

2.1

2.0

4.8

Nodular Goiter

100

2.1

1.9

4.1

Thyroid cancer

100

2.4

2.2

8.0

1.1

Total

200

2.2

2.0

8.0

1.0

Nodular Goiter

100

235.0

213.5

139.0

471.0

66.6

Thyroid cancer

100

268.5

257.0

129.0

556.0

69.9

Total

200

251.8

234.0

129.0

556.0

70.2

Nodular Goiter

100

9.0

6.4

12.0

1.0

Thyroid cancer

100

8.8

8.7

7.3

11.4

200

8.9

8.8

6.4

12.0

1.0

Table 3. Logistic regression analysis result

-2.6

0.009

-3.8

0.0001

-2.69

0.007

-1.14

0.253

-1.9

0.056

-4.05

0.0001

-1.29

0.194

Table 4. Classification table for thyroid cancer and nodule Classification Tablea

95% C.I.for OR p

Predicted

OR Lower

Upper

Age

.026

.974

.951

.997

NLR

.026

1.471

1.047

2.069

Platelet

.002

1.008

1.003

1.012

Group

Platelet

Percentage Correct

Nodular Goiter

Thyroid cancer

Nodular Goiter

63.6

Thyroid cancer

62.0

Overall Percentage

62.8

doi: 10.5455/medscience.2019.08.9125

Discussion Although the presence of thyroid nodules are common in adults, the occurence of thyroid cancer is rare. The important point for clinicians is to identify malignant (5–10%) and benign thyroid nodules. After an association between cancer and inflammation was discovered, markers of the systemic inflammatory response have been used to predict relapse and survival in patients with various cancers. Neutrophil and lymphocyte cells are the basis of the inflammatory response. Lymphocytes inhibit the proliferation and metastatic activities of tumor cells through the release of cytokines. Neutrophil-to-lymphocyte (NLR) is an independent risk factor in the diagnosis of tumor development. NLR has recently emerged as a simple and a valid composite marker of systemic inﬂammatory response [9]. Although it is inexpensive, easily calculated and readily available, its use in the preoperative assessment and postoperative follow-up of malignant thyroid cancer patients remains as a matter of debate. Nevertheless, the NLR is universally available from routine blood tests and does not increase the diagnostic workup cost [10]. On the other hand, the association of higher NLR with aggressive clinical and pathological characteristics may suggest a negative outcome. Oflazoglu et al found that high preoperative NLR and Platelet-tolymphocyte (PLR) levels correlated with better and disease-free survival at a statistically significant level. Several other studies also showed that high preoperative NLR levels correlated with better, disease-free survival at a statistically significant level [1113]. Therefore NLR is useful to predict long-term mortality. Seretis et al. [10] indicated that there is a higher neutrophil-to-lymphocyte ratio in patients with thyroid cancer when compared with patients with benign thyroid disorders but found no association between neutrophil-to-lymphocyte ratio levels and multifocality. In contrary to these findings, we have found no correlation between the NLR and the presence of thyroid cancer in our study. The number of neutrophils and lymphocyts increased in the same rate in thyroid cancer patients. In this study, no significant differences between the benign and malignant nodular groups were found in gender distribution. In addition, there was no difference in the NLR value and gender of the patients with benign and malign nodules examined in our study. The meta-analysis of McLeod DSA et al aimed to examine the associations between pretreatment NLR and differantiated Thyroid Cancer (DTC). In parallel to our findings, McLeod’s meta-analysis showed that the pretreatment NLR values were not significantly different for patients with DTC to those with benign nodules. [14]. These results suggest that an elevated NLR is neither a sensitive nor a specific indicator of progressing DTC in patients with nodular goiters. However, Kocer et al.’s report suggested that the NLR was a meaningful diagnostic tool for discriminating poorly differentiated thyroid cancer [15]. However the conclusiveness of these results require further validation as they were limited by the heterogeneity of subgroups and the small sample size used in the study. Neutrophil counts were significantly higher in the papiller thyroid cancer (PTC) group than the multinodular guatre (MNG) group (p<0.05). Lymphocyte counts were significantly higher in the MNG group than the other group (p<0.05) [15]. Several studies reported that inflammation and PTC are associated with each other. There is an increased incidence of PTC in patients with thyroiditis [9]. In Liu et al.’s study, it was noted that the age of the PTC

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patients (53.57 ± 13.32 y) appeared older than the age of patients with benign nodules (49.25 ± 13.15 y) as was the case in our study. As reported in several studies, NLR is correlated with thyroid cancer characteristics, such as tumor size, patient’s age, and the clinical stage parameters of thyroid cancer. Liu et al. found that the preoperative NLR correlated with DTC tumor size. However, Liu et al. and Kim et al. showed that tumor size, extra thyroidal invasion, and lymph node metastasis was not associated with the NLR value [9, 16]. Bayır O et al reported that preoperative NLRs and PLRs in atypia of undetermined significance and suspicious for malignancy groups can’t be considered as a predictive diagnostic marker of malignancy [17]. Platelets are activated by pro-inflammatory cytokines such as IL-1, IL-6, then they release angiogenic growth factors and stimulate the tumor progression. Thrombocytosis is an indicator of inflammation severity. Voutsadakis IA shows that high platelet to lymphocyte ratio is associated with poor prognosis and is used as a diagnostic or predictive instrument in several malignancies [18]. Similar to our findings, in Kocer D et al study, platelet counts were not significantly different between the groups (p>0.05) [15]. The thyroid functions must be examined for any patient with a thyroid nodule. The most useful marker directly reflecting the thyroid functions is the serum thyroid hormone levels or the tissue hormone concentration. The role of TSH as a predictor of thyroid nodule malignancy has been evaluated by several studies conducted during the last few years. In recent meta-analyses, higher serum TSH levels were associated with an increased risk of thyroid cancer [14]. Expression of growth factors, receptors and proto-oncogenes increase with TSH signaling pathway activation. Therefore, TSH is considered to be a major thyroid cell growth factor [19]. For this reason, clinician physicians suppress the TSH levels in treatment of thyroid cancer. Identification of the prognostic indicators for age, which are biologically different, is very important in deciding an appropriate therapeutic strategy. In our study, age is an important prognostic factor for patients with malignant nodules of thyroid. Significant differences were seen in young age groups in local recurrence. It may be a reflection of the underlying differences in harvested nodes at lymph node dissection or tumor size [20]. But in our study, we could not examine the relationship between the tumor size and the lymph node dissection width and age. Also, in our study, age values of nodular goiter group were found to be significantly higher than the cancer patients. Kim et al.and Liu et al. found that thyroid cancer patients who are older than 45 had significantly higher NLRs. However, it was found that the preoperative NLR was significantly lower in older patients. Consequently, there are only 2 studies where no differences were found in the NLR values between patients that are aged younger and older than 45 [21,16]. The mean TSH level increases with age and a higher TSH level is associated with a higher incidence of thyroid cancer [22]. The limitation of our study was that we did not investigate a correlation between the variables (NLR, PLT, TSH) and clinicopathological parameters of patients, such as lymph node metastasis, grade of differentiation or tumor stage because of its retrospective status. 19

doi: 10.5455/medscience.2019.08.9125

Conclusion In conclusion, our results indicate that the neutrophil and platelet counts of patients with thyroid cancer are significantly different than that of patients with benign nodules. An elevated level of these values seems to be a reliable indicator of progressing thyroid cancer in patients with MNG. The Neutrophil and platelet count is universally available from routine blood tests. Since these tests are inexpensive and are easy to analyze, the prognostic significance of benign and malignant nodules is important. Therefore larger, prospective and clinically-supported studies are required to confirm our findings. Competing interests The authors declare that they have no competing interests. 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. Soycan Mizrak, ORCID ID: 0000-0003-0287-9402 Sirin Kucuk, ORCID ID: 0000-0002-8552-2101

References 1.

Reiners C, Wegscheider K, Schicha H, et al. Prevalence of thyroid disorders in the working population of Germany: ultrasonography screening in 96,278 unselected employees. Thyroid. 2004;14:926-32. Frates MC, Benson CB, Doubilet PM, et al. Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography. J Clin Endocrinol Metab. 2006;91:3411-7. Pellegriti G, Frasca F, Regalbuto C, et al. Worldwide increasing incidence of thyroid cancer: update on epidemiology and risk factors. J Cancer Epidemiol. 2013;2013:965212.

Fugazzola L, Colombo C, Perrino M, et al. Papillary thyroid carcinoma and inflammation. Front Endocrinol. 2011;2:88.

Balkwill F., Mantovani A. Inflammation and cancer: back to Virchow? Lancet. 2001;357,539–54510.

Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011;144:646–74.

Oflazoğlu U, Alacacıoğlu A, Somalı I ve ark. Nötrofil/Lenfosit Oranı, Trombosit/Lenfosit Oranı ve Ortalama Trombosit Hacminin Kolorektal Karsinomlu Hastalardaki Prognostik Değeri [İzmir Oncoloji Grubu (IZOG) Çalışması]. Acta Oncologica Oncologica.

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Mangalpally KK, Siqueiros-Garcia A, Vaduganathan M, et al. Platelet activation patterns in platelet size subpopulations: differential responses to aspirin in vitro. J Thrombosis Thrombolysis. 2010;30:251-62.

Liu CL, Lee JJ, Liu TP, et al. Blood neutrophil-to-lymphocyte ratio correlates with tumor size in patients with differentiated thyroid cancer. J Surg Oncol. 2013;107:493-7

10. Seretis C, Gourgiotis S, Gemenetzis G, et al. The signiﬁcance of neutrophil/ lymphocyte ratio as a possible marker of underlying papillary microcarcinomas in thyroidal goiters: a pilot study. Am J Surg. 2013;205:691– 6. 11. Perisanidis C, Kornek G, Pöschl PW, et al. High neutrophil-tolymphocyte ratio is an independent marker of poor disease-specific survival in patients with oral cancer. Med Oncol. 2013;30:334 12. Chen J, Deng Q, Pan Y, et al. Prognostic value of neutrophil-tolymphocyte ratio in breast cancer. FEBS Open Bio. 2015;5:502–7 13. Ozdemir Y, Akin ML, Sucullu I, Balta AZ, Yucel E. Pretreatment neutrophil/ lymphocyte ratio as a prognostic aid in colorectal cancer. Asian Pac J Cancer Prev. 2014;15:2647–50. 14. McLeod DSA, Watters KF, Carpenter AD, et al. Thyrotropin and thyroid cancer diagnosis: A systematic review and dose-response meta-analysis. J Clin Endocrinol Metab. 2012;97:2682–92. 15. Kocer D, Karaman H, Karakukcu C. May the neutrophil/lymphocyte ratio be a predictor in the differentiation of different thyroid disorders? Asian Pac J Cancer Prev, 2015;16:3875-9. 16. Kim BW, Yousman W, Wong WX, et al. Less is more: comparing the 2015 and 2009 American thyroid association guidelines for thyroid nodules and cancer. Thyroid. 2016;26:759-64. 17. Bayır O, Polat R, Saylam G, et al. The principles of differentiated thyroid cancer surgery and anesthesia in pregnancy: three case reports. Tr-ENT. 2015;25:350-6. 18. Voutsadakis IA. Thrombocytosis as a prognostic marker in gastrointestinal cancers. World J Gastrointest Oncol. 2014;6:34–40 19. Golbert L, de Cristo AP, Faccin CS, et al. Serum TSH levels as a predictor of malignancy in thyroid nodules: A prospective study. Plos One. 2017;12:e0188123. 20. Cho J, Yoon J, Park M, et al. Age and prognosis of papillary thyroid carcinoma: retrospective stratification into three groups: J Korean Surg Soc, 2012;83:259–66. 21.

Liu J, Du J, Fan J et al. The neutrophil-to-lymphocyte ratio correlates with age in patients with papillary thyroid carcinoma. Orl, 2015;109–16.

22. Haymart MR, Cayo M, Herbert Chen. Papillary thyroid microcarcinomas: big decisions for a small tumor. Ann Surg Oncol. 2009;16:3132–9.

Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):21-5

The effects of anaesthesia induction with propofol or ketofol on cerebral oxygenation in patients above 60 years of age Harun Tolga Duran, Ersin Koksal, Yasemin Burcu Ustun, Sezgin Bilgin, Fatih Ozkan Ondokuz Mayıs University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Samsun, Turkey Received 29 May 2019; Accepted 10 September 2019 Available online 05.02.2020 with doi: 10.5455/medscience.2019.08.9128

Abstract Side effects such as hypotension and cerebral perfusion disorder may be encountered after anaesthesia induction, especially in elderly patients. Some studies have attempted to determine whether hypotension during induction and associated organ perfusion disorders can be prevented when propofol is used in combination with ketamine. However, no study has come to light investigating the effects of ketamine added to propofol on cerebral oximetry. The present study aimed to compare the effects of anaesthesia induction with propofol or propofol+ketamine (ketofol) on haemodynamic changes and cerebral oximetry in elderly patients undergoing anaesthesia induction. A total of 40 patients were randomly divided into two groups. Cerebral oximetry sensors were placed in the right and left of the frontal region. Patients in Group P were treated with 1.5 mg/kg propofol IV induction and patients in Group K were treated with the 0.2 ml/kg ketofol IV. The patients in both groups received 0.5 mg/kg lidocaine, 0.6 mg/kg rocuronium and a 0.1 mcg/kg/min infusion of remifentanil. Heart rate (HR), systolic, diastolic and mean arterial pressure (SBP, DBP, MAP) and cerebral oxygen saturation (RSO2) values before and 1, 3, 5, 10, 30 and 60 minutes after induction were recorded.SBP, DBP and MAP values were significantly lower in the propofol group at 1, 3 and 5 minutes after induction (p < 0.05). The right-side RSO2 values were significantly lower at 3 and 5 minutes after induction in the propofol group compared to the ketofol group and the left-side RSO2 values were similarly significantly lower after 1, 3 and 5 minutes (p < 0.05). Ketofol used in anaesthesia induction has less effect than propofol on mean arterial pressure and cerebral oxygen saturation values. Therefore, ketofol appears to be a good choice for use in anaesthesia induction in elderly patients. Keywords: Propofol, ketamine, cerebral oximeter, elderly patients

Introduction Elderly patients’ sensitivity to drugs used in anaesthesia induction is increased [1]. As a result, hypotension and consequently decreased brain blood flow may occur after anaesthesia induction [2]. This reduction in brain blood flow becomes more evident by the fact that propofol causes more myocardial depression and hypotension, especially in elderly patients.[3,4] Ketamine activates the sympathetic nervous system to increase heart rate and blood pressure, and consequently elevation of cerebral blood flow[5-7]. Cerebral oxygen saturation values are affected by hypotension and the decreased cerebral blood flow that may follow the hypotension. Propofol reportedly causes a temporary decrease in cerebral oxygen saturation in both young and old patients with a decrease in the mean arterial pressure following anaesthesia

*Coresponding Author: Sezgin Bilgin,.Ondokuz Mayıs University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Samsun, Turkey E-mail: sezgin.bilgin@omu.edu.tr

induction [4]. Undesired haemodynamic side effects can be reduced with the use of propofol and ketamine together [8-13]. However, to the best of our knowledge, there has been no study investigating how the combined use of propofol and ketamine affects cerebral oxygenation in elderly patients. Therefore, the aim of the present study was to compare the effects of propofol or ketofol (ketamine+propofol) on haemodynamic changes and brain oxygenation in anaesthesia induction in elderly patients. Materials and Method The study was carried out between January 2016 and June 2016 in the hospital operating theatre, after obtaining the approval of the ethics committee of Ondokuz Mayıs University (Year: 2015 Number: B.30.2.0DM.0.20.08/2120). All patients were informed about the study before the procedure and their voluntary informed consent was obtained. A total of 40 patients classified as ASA 1 or 2 and above 60 years of age who underwent elective laparotomy were included in our study. Patients with cerebrovascular disease, coronary artery 21

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disease, a diagnosis of carotid artery stenosis, liver or kidney failure and allergies to prescribed drugs were not included in the study. In order to determine a sufficient number of patients for the study, power analysis was performed. According to a power analysis with 85% power and a 95% confidence interval (α = 0.05, β = 0.95), a study with 34 individuals in each group has 80.6% power. A total of 40 patients included in the study were randomly divided into two groups of 20, Group P (propofol administered) and Group K (ketofol administered). The patients were evaluated in the preoperative anaesthesia outpatient clinic on the day before the operation, when their height, weight, age, sex and ASA scores were recorded. Patients were not premedicated. The study was carried out in patients who underwent laparotomy in the operating theatre of the General Surgery, Obstetrics and Gynaecology departments. The study protocol was conducted as double-blind for both groups. Systolic (SBP), diastolic (DBP) and mean arterial pressure (MAP), ECG monitoring, heart rate (HR) and peripheral oxygen saturation (SPO2) were monitored in patients. Then, right and left cerebral oxygen saturation (rRSO2 and lRSO2) monitoring (INVOS™ 5100 Somatic/Cerebral Oximeter; Medtronic, UK) was performed. Before induction, the cerebral oximetry sensors were placed at least 2 cm above the eyebrows and 3 cm away from the midline, right and left, according to the manufacturer’s instructions. The patient’s forehead was cleansed with acetone and alcohol before the sensor pads were mounted. The sensor pads were wrapped with a bandage to prevent them from being affected by the ambient light and movement.

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accepted as a 20% decrease in baseline after 1 minute. In this case, 5 mg ephedrine IV was administered to the patient. The presence of a CAH value of < 45 was accepted as bradycardia. Atropine was administered at 0.5 mg IV. The presence of CAH > 100 was considered as tachycardia. If there were no signs of topical anaesthesia, 10 mg esmolol IV was administered. Data were analysed using the IBM SPSS v23 (Chicago, USA) program. The Shapiro–Wilk test was used to test the normality of data from the quantitative variables. An independent sample t-test was used to compare means of groups for the variables with a normal distribution. The Mann–Whitney U-test was used to compare the means of the parameters deviating from the normal distribution. The Wilcoxon test was used for intragroup comparisons. The mean ± standard deviation of the quantitative variables with normal distributions was reported, whereas the median (minimum–maximum) were reported for the non-normal variables. The significance level was accepted as p < 0.05. Results There was no statistically significant difference between the two groups, P and K, in terms of age, height or weight (p = 0.869). The duration of anaesthesia and surgery was similar in both groups. The demographic characteristics of the groups are presented in Table 1 Table 1. Demographic characteristics of groups K group

P group

Age**

67.8 ± 6.9

68.2 ± 6.7

Height**

166.2 ± 7.9

162.9 ± 6.3

Preparation of ketofol: 2 ml of 50 mg/ml (total 100 mg) ketamine, 10 ml of 10 mg/ml (total 100 mg) propofol and 8 ml saline were loaded to a 20 ml syringe.

Weight **

78.7 ± 10.0

77.1 ± 10.4

2 (1 – 3)

2 (1 – 3 )

Anesthesia Time *

115 (75 - 150)

105 (80 - 260)

After preoxygenation, the induction was applied to the patients in Group P with 0.5–1 mg/kg lidocaine IV and 1.5 mg/kg propofol IV. The patients in Group K received 0.5–1 mg/kg lidocaine IV and 0.2 ml/kg ketofol IV. The patients who received 0.6 mg/kg rocuronium IV for neuromuscular blockade were intubated after 3 minutes. Anaesthesia was maintained with desflurane (4%) in the O2/air mixture (FIO2 0.40) and IV remifentanyl infusion (0.2 mcg/ kg/min) in both groups.

Surgery Duration *

100 (65 - 130)

95 (70 - 240)

Mean arterial pressure (MAP) and left and right cerebral oxygen saturation (RSO2) were measured and basal values were determined (T1). The values immediately after induction of anaesthesia (T2) and values at 1, 3, 5, 10, 30 and 60 minutes after the intubation (T3, T4, T5, T6, T7, T8) were recorded. Patients who had difficult intubation, difficult ventilation, chest wall rigidity, arrhythmia or allergic reactions were excluded from the study. An increase of 20% in the measured MAP value was considered as hypertension after 1 minute. In this case, topical anaesthesia findings were evaluated. The patients who underwent topical anaesthesia were treated with 0.05 ml/kg propofol or ketofol. After 1 minute, if hypertension persisted, esmolol 10 mg was applied to patients with a CAH value above 100 and perlinganit 100 μg to patients with a CAH value below 100. Hypotension was

ASA*

*Median (min-max), ** mean ± standard deviation Table 2. Right-side RSO2 values of groups. Time T1

K group

P group

68 (51 - 74)

66.5 (55 - 76)

65 (51 - 70)

66 (54 - 75)

64 (48 - 69)

58 (47 - 70)*

64.5 (51 - 70)

59 (47 - 71)*

65 (52 - 70)

60.5 (46 - 71)*

66 (60 - 71)

64 (55 - 82)

66 (57 - 70)

66 (50 - 76)

64.5 (51 - 71)

66 (52 - 70)

Median (min-max), *: significant difference from the preoperative value at the corresponding measurement time in intra-group comparison (p<0.05)

When the groups were compared in terms of right-side RSO2 measurements, the values in the propofol group were significantly lower than in the ketofol group at 3 and 5 minutes (T4, T5) after intubation. The right-side RSO2 values and comparison between the two groups and within groups are shown in Table 2 and Figure 1. 22

doi: 10.5455/medscience.2019.08.9128

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When the recorded values of the RSO2 in terms of time were compared to the preoperative values within the propofol group, RSO2 was found to be significantly lower after 1, 3 and 5 minutes (T3, T4, T5) after intubation in both the right and left sides. The RSO2 value decreased from the 10th minute (T6) to the same level as the initial value and no significant difference was found between the values at 30 and 60 (T7, T8) minutes after intubation and the value at the preoperative period. When the values of the RSO2 measured at various times were compared to the preoperative values in the ketofol group, no statistically significant difference was observed.

Figure 1. Comparison of the right-side RSO2 values of groups. # : significant difference between groups at the corresponding measurement time

Left-side RSO2 measurements revealed that the values at 1, 3 and 5 minutes (T3, T4, T5) in the propofol group were significantly lower than in the ketofol group. The left-side RSO2 values of the groups and their comparison are shown in Table 3 and Figure 2. Table 3. Left-side RSO2 values of the groups. Time

K group

P group

65 (49 - 72)

64.5 (54 - 74)

65 (50 - 70)

64 (51 - 73)

63 (48 - 70)

58.5 (45 - 73)*

63.5 (48 - 69)

59 (46 - 69)*

64 (50 - 68)

59 (45 - 75)*

66 (60 - 70)

64 (54 - 84)

64 (59 - 73)

64 (50 - 79)

63 (53 - 72)

63 (48 - 71)

Median (min-max), *: significant difference from the preoperative value at the corresponding measurement time in intra-group comparison (p<0.05).

Comparison of the mean arterial pressure values in the groups revealed that the values of MAP at 3 and 5 minutes (T4, T5) were significantly lower in the propofol group than in the ketofol group. MAP values and comparison of the groups are shown in Table 4 Table 4. MAP values of groups Time

K group

P group

97 (82 - 101)

97.5 (86 - 149)

96 (83 - 101)

97.5 (88 - 130)

93 (75 - 104)

80 (66 - 141)

92 (72 - 107)

77 (68 – 101)

89.5 (79 - 108)

75 (67 - 142)

95 (70 - 102)

83.5 (71 - 184)

96 (68 - 99)

89.5 (65 - 115)

90.5 (71 - 106)

92 (73 - 116)

*: significant difference between group at the corresponding measurement time

Discussion The effect of different anesthetic drugs on cerebral oxygenation has been investigated in a variety of surgical prosedures. In this study, we investigated the changes in vital signs after anaesthesia induction with propofol and ketofol in patients over 60 years of age and the effects of these changes on cerebral oxygen saturation. In terms of vital signs, the MAP values were lower in the propofol group compared to the ketofol group at 1, 3 and 5 minutes after induction. The possible explanation for the lower values for group P could be myocardial depression and decrease in peripheral vascular resistance caused by propofol. In the ketofol group, sympathetic stimulation by ketamine may have limited these effects. Aydoğan et al. [14] compared propofol and ketofol in the induction of anaesthesia in elderly patients. They concluded that while propofol use decreases MAP the combination of propofol and ketamine causes minimal hemodynamic changes. These results seem to be consistent with our findings. Kwok et al. [3] also coherently with our results reported that when propofol is used alone in patients older than 55 years causes hypotension for the 5 minutes after induction and that the addition of phenylephrine may prevent the development of hypotension by causing vasoconstriction. Likewise Özgül et al. [15] found that patients administered propofol had significantly lower MAP values after induction than those with ketofol.

Figure 2. Comparison of the left-side RSO2 values of groups. #: significant difference between groups at the corresponding measurement time

We found that post-induction RSO2 values were significantly lower in patients within the propofol group compared to baseline 23

doi: 10.5455/medscience.2019.08.9128

values. When the groups were compared, the RSO2 values were significantly lower in the propofol group compared with the ketofol group. Cerebral oxygenation is known to be affected by variables such as cerebral blood flow, cerebral oxygen consumption and mean arterial pressure [16]. Decreased preoperative hematocrit values, higher preoperative fluid deficit compared to young patients, cerebral fat embolism and hypotension in elderly patients after anaesthesia induction have been reported as potential causes of cerebral desaturation [17]. Anaemia or fluid deficit was not detected in the preoperative evaluation of the patients in our study. The main cause of the decrease in the RSO2 values appears to be the reduction of brain blood flow with propofol’s hypotensive effect. We found that the RSO2 levels were lower after 1, 3 and 5 minutes in the propofol group compared to the ketofol group. The higher RSO2 values evident at 1, 3 and 5 minutes in the ketofol group compared to the propofol group may be due to the lower rate of decrease observed in MAP values, owing to sympathetic stimulation of ketamine. A ketamine-induced increase in the brain blood flow may have contributed to higher levels of post-induction RSO2 values in patients in the ketofol group compared to the propofol group. Ketamine wich we added to propofol in our study activates the sympathetic nervous system and preserves cerebral perfusion pressure. Another outcome of the sympathetic activation is the increase in arterial blood pressure. The combination of propofol and ketamine may have maintained the CBF and provided higher RSO2 values. It is reported that propofol decreases cerebral metabolic rate of oxygen (CMRO2), reduses cerebral blood flow (CBF) and intracranial pressure. Hung et al. [4] compared the effect of propofol on haemodynamic changes and cerebral oximetry between young and elderly patients. There was a statistically significant decrease in both groups in MAP and RSO2 values after induction. Sevoflurane is known to reduce CBF less than propofol. Moreover sevoflurane can cause an increase on CBF with high concentrations. But the effects of both drugs on CMRO2 are similar. Various studies tested whether RSO2 diferred with sevoflurane or propofol anesthesia. Except for a few [18] most of them concluded that sevoflurane was associated with higher RSO2 values [19, 20, 21]. In the study performed by Güçlü et al. [22] propofol infusion was administered to one group and sevoflurane was administered to the other group. Cerebral oxygen saturation levels were found to be statistically lower in the propofol group. Valencia et al. [23] also investigated the effect of sevoflurane and propofol on cerebral oximetry. The results of the study revealed that the RSO2 values of the patients in the propofol group were lower than those of the sevoflurane group. There was a significant decrease in baseline RSO2 values after induction in the propofol group. In the present study, RSO2 values measured in the propofol group at 5 minutes and in the ketofol group at 3 minutes were similar to the baseline values. This might be because the drugs used in the maintenance of anaesthesia after the end of the induction period did not yield any significant difference between the groups Kwok et al. reported that RSO2 values returned to normal levels between 5 and 10 minutes after induction [3]. The aforementioned study of Hung et al. [4] reported that post-induction RSO2 value returned to baseline in 5 minutes.

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Based on the results of the study reported here, we believe that the effects of ketamine on sympathetic stimulation and cerebral blood flow are compensated by propofol, and that myocardial depression and the hypotensive effects of propofol are balanced by ketamine. Considering these aspects the temporary decrease in MAP and RSO2 values after induction could be due to the inability to balance the effects of propofol when used alone. Conclusions In conclusion, 1:1 ketamine addition to propofol (ketofol) provides more stable haemodynamics for the induction of anaesthesia in elderly patients compared to the sole use of propofol. Therefore, it helps to maintain cerebral oxygen saturation. When the results are considered ketofol administration as an induction agent in elderly patients will contribute to the preservation of cerebral oxygen saturation and hence the preservation of postoperative cognitive functions. However these results need to be confirmed with larger groups in future studies. Competing interests The authors declare that they have no competing interests. Financial Disclosure This study was supported by the Scientific Research Projects Office at Ondokuz Mayıs University with the project number PYO.TIP.1904.16.001. Ethical approval Ondokuz Mayıs University, Medicine Faculty Ethics committee approval was obtained with the following file number 2015 yılı Sayı: B.30.2.0DM.0.20.08/2120. Harun Tolga Duran ORCID:0000-0002-6521-8313 Ersin Koksal ORCID:0000-0003-1780-151X Yasemin Burcu Ustun ORCID:0000-0002-2628-7543 Sezgin Bilgin ORCID:0000-0002-3031-8488 Fatih Ozkan ORCID:0000-0002-1215-3966

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Kwok FY, Venugobal S, The effect of prophylactic phenylephrine on systemic hypotension during induction of anaesthesia with propofol in patients over 55 years old. Med J Malaysia. 2016;71:166-170.

Hung YC, Huang CJ, Kuok CH, et al. The effect of hemodynamic changes induced by propofol induction on cerebral oxygenation in young and elderly patients. J Clin Anesth. 2005;17:353-7.

Rowland LM, Beason-Held. L, Tamminga CA, et al, The interactive effects of ketamine and nicotine on human cerebral blood flow.Psychopharmacology. 2010;8:575-84,

Rascon-Martinez DM, Fresán-Orellana A, Ocharán-Hernández ME, et al. The Effects of Ketamine on Cognitive Function in Elderly Patients Undergoing Ophthalmic Surgery: A Pilot Study. Anesth Analg. 2016;122:969-75.

Strebel S, Kaufmann M, Maire L, et al. Effects of ketamine on cerebral blood flow velocity in humans Influence of pretreatment with midazolam or esmolol. Anaesthesia. 1995;50:223-28.

Ghatak T, Singh D, Kapoor R, et al.. Effects of addition of ketamine, fentanyl and saline with Propofol induction on hemodynamics and laryngeal mask airway insertion conditions in oral clonidine premedicated children. Saudi J Anaesth. 2012;6:140-4.

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Aydogmus MT, Türk HS, Oba S, et al., A comparison of different proportions of a ketamine-propofol mixture administered in a single injection for patients undergoing colonoscopy. Arch Med Sci. 2015;11:570-6.

10. Hosseinzadeh H, Eidy M, Golzari SE, et al. Hemodynamic Stability during Induction of Anesthesia in Elderly Patients: Propofol + Ketamine versus Propofol + Etomidate. J Cardiovasc Thorac Res. 2013;5:51-4. 11. Cetin M, Birbicer H, Hallioglu O, et al. Comparative study between the effects of dexmedetomidine and propofol on cerebral oxygenation during sedation at pediatric cardiac catheterization. Ann Card Anaesth. 2016;19:20-4. 12. Mikkelsen MLG, Ambrus R, Rasmussen R, et al. The effect of dexmedetomidine on cerebral perfusion and oxygenation in healthy piglets with normal and lowered blood pressure anaesthetized with propofolremifentanil total intravenous anaesthesia. Acta Vet Scand. 2017;59:27. 13. Casati A, Fanelli G, Pietropaoli P, et al. Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: A prospective cohort study. European Journal of Anaesthesiology. 2007;24;59-65. 14. Aydoğan MS, Demirel S, Erdoğan MA, et al. Effects of Ketamine-Propofol Mixture on Intraocular Pressure and Haemodynamics in Elderly Patients: A Randomised Double-Blind Trial. Turk J Anaesthesiol Reanim. 2013;42:1218. 15. Ozgul U, Begec Z, Karahan K, et al. Comparison of Propofol and KetaminePropofol Mixture (Ketofol) on Laryngeal Tube-Suction II Conditions and Hemodynamics: A Randomized, Prospective, Double-Blind Trial. Curr Ther Res Clin Exp. 2013;75:39-43.

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Neurobiol. 1999;58:541-60. 17. Papadopoulos G, Karanikolas M, Liarmakopoulou A, et al. Cerebral oximetry and cognitive dysfunction in elderly patients undergoing surgery for hip fractures: a prospective observational study. Open Orthop J. 2012;6:400-5. 18. Ishiyama T, Kotoda M, Asano N, et al. Effects of hyperventilation on cerebral oxygen saturation estimated using near-infrared spectroscopy: A randomised comparison between propofol and sevoflurane anaesthesia. European Journal of Anaesthesiology. 2016;33:929-35. 19. Guo JY, Fang JY, Xu SR, et al. Effects of propofol versus sevoflurane on cerebral oxygenation and cognitive outcome in patients with impaired cerebral oxygenation. Ther Clin Risk Manag. 2016;12:81–5. 20. Ruzman T, Simurina T, Gulam D et al. Sevoflurane preserves regional cerebral oxygen saturation better than propofol: Randomized controlled trial, Journal of Clinical Anesthesia. 2017;36:110-7. 21. Doe A, Kumagai M, Tamura Y, et al. A comparative analysis of the effects of sevoflurane and propofol on cerebral oxygenation during steep Trendelenburg position and pneumoperitoneum for robotic-assisted laparoscopic prostatectomy. Journal of Anesthesia. 2016;30:949-55. 22. Güçlü ÇY, Ünver S, Aydınlı B, et al. The effect of sevoflurane vs. TIVA on cerebral oxygen saturation during cardiopulmonary bypass--randomized trial. Adv Clin Exp Med. 2014;23:919-24. 23. Valencia L, Roriguez-Perez A, Kühlmorgen B, et al., Does sevoflurane preserve regional cerebral oxygen saturation measured by near-infrared spectroscopy better than propofol? Ann Fr Anesth Reanim. 2014;33:59-65.

16. Madsen PL, S.N.N.-i.o.o.t.b.-. Near-infrared oximetry of the brain. Prog

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):26-32

A retrospectiĚ&#x2021;ve evaluation of the epitelial lesions / neoplasms of the gallbladder in UĹ&#x;ak city and determination of the visual frequency Sirin Kucuk1, Ersoy Ercihan2, Asli Ucar Uncu2, Mehmet Gundogan2, Cengiz Kocak1 Usak University, Faculty of Medicine, Department of Pathology, Usak, Turkey Usak Training and Research Hospital, Department of Pathology, Usak, Turkey

1 2

Received 23 September. 2019; Accepted 19 November 2019 Available online 05.02.2020 with doi: 10.5455/medscience.2019.08.9129

Abstract Cholecystectomy is one of the most common types of surgical operations and includes many pathologies ranging from the most common cholecysistitis to randomly detected dysplasia and cancer. In this study, it is aimed to obtain a general regional incidence by documenting gallbladder pathology data in Usak province and to contribute to literature in this field. Between 2015 and 2019, 1712 cholecystectomy specimens were analyzed retrospectively in the Department of Pathology, Usak University Training and Research Hospital; adenocarcinoma (primary invasive carcinomas), low and high grade dysplasias (Biliary intraepithelial neoplasia - BillN1,2 ), neoplasms / adenomas, intestinal â&#x20AC;&#x201C; pyloric metaplasia, reactive atypia and other lesions were re-evaluated with Olympus CX41 light microscope and based on recent diagnoses. Epithelial changes / lesions were reported in 11.3% of cholecystectomy materials. Of these epithelial lesions, 6.18% had adenocarcinoma, 4,6% had high-grade dysplasia, 29,3% had low-grade dysplasia, 27,3% reactive / regenerative atypia and 2,06% - 14,9% - 15,4 %, neoplastic polyps, intestinal metaplasia and intestinal + pyloric metaplasic respectively. Of the cases with dysplasia and carcinoma, 39.3% and 33.4% were male, 60.7% and 66% female, respectively. The mean age was 57 in dysplasia and 66 in carcinoma. The female / male ratio in carcinoma cases was 2/1 and 41.6% of these cases had stones. The remaining lesions (88,7%) were non-neoplastic polypoid / hyperplastic leions and pyloric metaplasia. According to our findings, we suggest that, even in the absence of clinical symptoms, an adequate number of samples should be taken from the specimen during histopathological examination, especially in elderly women with long-standing stones due to the risk of developing precancerous lesions. Keywords: Gallbladder, cholecystectomy specimens, epithelial changes, sampling

Introduction Gallbladder diseases are one of the most common medical conditions requiring surgical intervention. Cholelithiasis and chronic cholecystitis affect approximately 10% of the adult population in the United States. Cases of chronic cholecystitis often affect women and the disease peaks in the 5th-6th decades. Gallbladder stones accompany in 95% of cases [1,2]. Histopathological examination of cholecystectomy materials includes chronic cholecystitis, cholesterolosis, muscle hypertrophy, polypoid and adenomatous proliferation of mucous glands - adenoma, metaplasia, hyperplasia - atypical hyperplasia, dysplasia, carcinoma in situ and malignancy. Histomorphologically, the gallbladder epithelium is monolayered, with columnar epithelium, contains sulphomucine, does not contain mucous gland and goblet cells.

*Coresponding Author: Sirin Kucuk, Usak University, Faculty of Medicine, Department of Pathology, Usak, Turkey E-mail: ata2012irin53@yahoo.com

Two major types of metaplasia occur in the biliary tract: gastric (pyloric ) and intestinal. Pyloric gland metaplasia is the most common type of metaplasia and is found in about 66-84 % of gallbladders removed for chronic cholecystitis or cholelithiasis . Also squamous metaplasia can be seen in rarely [3]. Metaplasia, hyperplasia - atypical hyperplasia and dysplasia are considered as precancerous lesions. Malignant tumors are rarely seen in the gallbladder and most of them are adenocarcinomas. A significant number of tumors are asymptomatic and detected incidentally during postoperative histopathological examination. Although there are different results in the literature, 0.19-3.3% of cancer cases are found after cholecystectomy. Although the pathogenesis is not fully elucidated, genetically dysplasiacarcinoma sequence and to a lesser extent adenoma-carcinoma sequence is held responsible for the development of gallbladder carcinoma. [4]. It is known that demographic features such as age, gender, obesity and clinical findings such as chronic cholecystitis and cholelithiasis play a role in this process. [4]. Early diagnosis is very difficult in patients with gallbladder carcinomas with 26

doi: 10.5455/medscience.2019.08.9129

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cholelithiasis and chronic cholecystitis, due to masking of specific symptoms. Therefore, routine histopathological examination of cholecystectomy materials is important. [2]. The aim of our study was to document the gallbladder pathology data in Usak to obtain a general local incidence, to review pathological lesions and clinical findings and to compare them with the literature findings. Materials and Methods Study design and data Sources Slides of 1712 cholecystectomy specimens sampled between 2015 and 2019 in the Department of Pathology, UĹ&#x;ak University Training and Research Hospital were re-evaluated retrospectively. Adenocarcinoma (primary invasive carcinomas), histhological grade, pathologic stage, lymphovascular and perineural invasion in adenocarcinoma cases were recorded. Low and high grade dysplasias (Biliary intraepithelial neoplasia BillN1,2 and 3 ), neoplasms / adenomas, metaplasias, reactive atypia, cholelithiasis, cholesterolosis and the other lesions were re-evaluated with the Olympus CX41 light microscope and based on recent diagnoses. In addition, diagnosis rates, age and sex distributions were determined. Pathological staging of the tumor was done based on American Joint Committee on Cancer (AJCC) criteria. Ethical considerations The study was in accordance with the principles outlined in the Declaration of Helsinki. Ethical approval was received from the local Human Non-invasive Clinical Research Ethics Committee. The informed consent was not requested, since the study was retrospective and the data were analyzed anonymously.

Figure 2. Pyloric metaplasia of the gallbladder (H&E; x200)

Results Of the 1712 cases, 1252 (73.1 %) were female and 460 (26.9%) were male. The female / male ratio was 2.8. The ages of the patients ranged between 11-84 and the mean age was 50.7 for females and 54.8 for males. There was no significant difference in the mean age of female and men.

Figure 3. Low-grade dysplasia in gallbladder (H&E; x400)

Figure 1. Ä°ntestinal metaplasia of the gallbladder (H&E; x400)

Chronic cholecystitis in 513 cases (29.9 %), 3 cases (0,12%) follicular cholecystitis, eosinophilic cholecystitis in one patient (0.05%), xanthogranulomatous cholecystitis in 9 cases (0.5%), chronic active cholecystitis in 193 cases (11.2%) and chronic cholecystitis in 981 cases (57.3%). When polypoid lesions were examined, nonneoplastic polyps were found in 78 cases (4.5%) (1 inflammatory polyp, 64 cholesterol polyp, 9 papillary hyperplasia, 4 adenomyomatous hyperplasia), neoplastic polyp were found in 2 cases (0.11%) (1 tubular adenoma, 1 pyloric gland adenoma). Cholelithiasis in 1100 cases (64.2%), reactive / regenerative atypia in 53 cases (3.09%), intestinal metaplasia in 29 cases (1.69%) ( Figure 1), pyloric metaplasia in 91 cases (5.3%) (Figure 2), and intestinal + pyloric metaplasia in 30 cases (1,75%) were detected. 27

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Metaplasia adjacent to or accompanied by dysplastic epithelium was detected in 35 (53%) of 66 cases with dysplasia. Metaplasia rates were intestinal in 37.2% (13 cases), intestinal + pyloric in 40% (14 cases), intestinal metaplasia in 22.8% (8 cases). Of the cases with dysplasia, 26 (39.3%) were male and 40 (60.7%) were female. The age range was 25-81 years and the mean age was 57 years. The mean age of the patients with chronic cholecystitis with stone was 47.9 years (range 18-84 years). Cholesterolosis was detected in 190 cases (1.1%) and 77 (40.5%) of these had chronic cholecystitis, 97 (51%) had chronic cholecystitis with stone and 13 (8.5%) had chronic active cholecystitis. The mean age of the patients with cholesterolosis was 48.2 years and the age range was 22-77 years. In the study cases, 12 cases (0.7%) had primary gallbladder carcinoma, 2 of them had intracystic papillary neoplasia (Figure 5) accompanied by invasive carcinoma and 10 of them had adenocarcinoma (2 of them containing signet ring cell components) (Figure 6). Figure

High-grade

dysplasia

gallbladder

(H&E;

x400)

Of the 150 cases with metaplasia, 60 (40%) had gallstones. Gall bladder stones were present in 13 (44.8%) of 29 gallbladder with intestinal metaplasia, 41 (45%) of 91 cases with pyloric metaplasia and 15 (50%) of 30 cases with intestinal + pyloric metaplasia. When the surface epithelium was examined, low grade dysplasia was detected in 57 patients (3.3%) (Figure 3) and high grade dysplasia was detected in 9 patients (0.52%) (Figure 4).

Figure 6. Adenocarcinoma (including) signet ring cell component of the gallbladder (H&E; x400)

Figure 5. Ä°ntracystic papillary neoplasm with invasive carcinoma (H&E; x400).

Of these carcinoma cases, 5 were pT2 (41.6%) and 7 (58.4%) were pT3. Among carcinoma cases, 5 (41.6%) and 7 (58.3%) of the metaplastic and dysplastic changes in malignant tissue or concomitant were detected. The average age of 12 patients with malignant tumors was 66 (53-79). Eight of the 12 cases (66.6%) were female and 4 (33.4%) were male. Although 8 (66.6%) of the cases were detected by preoperative imaging techniques, 4 (33.4%) had no suspicious symptoms and the tumor was found incidentally on postoperative histopathological evaluation. The histopathological distribution of the cases is shown in Table 1. Our incidentally detected gallbladder carcinoma rate is 0.23%. The macroscopic and histopathological findings and survival times of gallbladder carcinoma for each case are summarized in Table 2. The longest follow-up period was 36 months and follow-up results were not achieved in 4 cases. 28

doi: 10.5455/medscience.2019.08.9129

Med Science 2020;9(1):26-32

Table 1. Histopathological distribution of cases Female n=1252(%)

Male n=460 (%)

Total n=1712 (%)

151(29.5)

513(29.9)

Type of Inflammation Chronic cholecystitis

362(70.5)

Chronic active cholecystitis

112(58.1)

81(41.9)

193(11.2)

Chronic calculous cholecystitis

743(75.8)

238(24.2)

981 (57.3)

Eosinophilic cholecystitis

1(100)

1(0.05)

Xanthogranulomatous cholecystitis

5(55.6)

4(44.4)

9(0.12)

Follicular cholecystitis

2(66.7)

1(33.3)

3(0.12)

pyloric type

66(72.5)

25(27.5)

91(5.3)

intestinal type

17(58.6 )

12(41.4)

29 (1.69)

18(70)

12(30)

30 ( 1.75)

42(65.6)

22(34.4)

64(3.7)

Cholesterolosis Metaplasia

P + I type Polyp, hyperplasia Cholesterol polyp adenomyomatous hyperplasia

3(75)

1(25)

4(0.23)

6(66.6)

3(33.4)

9(0.52)

1(100)

1(0.05)

1(100)

1(0.05)

Low grade

32(56.2)

25(43.8)

57( 3.3)

High grade / Carcinoma in situ

7(77.8)

2(22.2)

9(0.52)

papillary hyperplasia Adenoma Tubular adenoma pyloric gland adenoma Dysplasia

Carcinoma Total

8(%66.6)

4(%33.4)

12(0.7)

1252(73.1 )

460(26.9 )

1712(100)

P: Pyloric, I: Intestinal

Table 2. Comparison of macroscopic-histopathological findings and survival Case No

Macroscopic tumor structuring

Pathological Diagnosis

Grade

LVI

Survival (months)

Age

Polypoid

İntracystic papillary neoplasm with invasive carcinoma

Moderately differentiated

pT2

present

Diffuse

Adenocarcinoma (ıncludıng) signet ring cell component )

Moderately differentiated

pT2

present

could not be reached

Polypoid

intracystic papillary neoplasm with invasive carcinoma

Poorly differentiated

pT2

present

Diffuse

Adenocarcinoma (ıncludıng) signet ring cell component )

Moderately differentiated

pT2

absent

could not be reached

Diffuse

Adenocarcinoma

Well differentiated

pT2

present

could not be reached

Diffuse

Adenocarcinoma

Moderately differentiated

pT3

present

Diffuse

Adenocarcinoma

Poorly differentiated

pT3

present

Diffuse

Adenocarcinoma

Moderately differentiated

pT3

present

Diffuse

Adenocarcinoma

Moderately differentiated

pT3

present

Diffuse

Adenocarcinoma

Well differentiated

pT3

present

could not be reached

Diffuse

Adenocarcinoma

Well differentiated

pT3

present

Diffuse

Adenocarcinoma

Poorly differentiated

pT3

present

Grade: Tumor differentiated, pT: Pathological Stage, PI: Perineural invasion, LVI: Lymphovascular invasion

doi: 10.5455/medscience.2019.08.9129

Discussion Chronic cholecystitis is the most common pathology in the gallbladder, and most of the cholecystectomy operations are due to chronic cholecystitis [2,5]. In many studies, chronic cholecystitis has been associated with cholelithiasis (85-95%). Gallbladder diseases are more common in women [1-5]. In the present study, the most common diagnosis was chronic cholecystitis with stone (57.3%) and the female / male ratio was 2.8. According to histopathological features, chronic cholecystitis are divided into sub-types such as follicular, eosinophilic, granulomatous, xanthogranulomatous, lymphoplasmacytic and AIDS-related [2,5]. Lymphoplasmacytic variant usually develops as cholecystitis with no stone associated with autoimmune diseases [5]. Cholecystitis presenting with germinal centers in the lamina propria are follicular cholecystitis and are seen in 0.1% of cases. Cases with more than 90% eosinophilic infiltration with other inflammatory cells in the gallbladder mucosa are defined as eosinophilic cholecystitis and constitutes 20% of cholecystectomy materials. Hypereosinophilic syndrome, eosinophilimialgia syndrome, parasitic infections, some herbal and drugs are responsible from etiology of eosinophilic cholecystitis [2,5]. Factors that are characteristic for particularly immunosuppressive patients such as cytomegalovirus, candida, mycobacterium and microsporidia have an important role in the formation of AIDSrelated cholecystitis [5]. Another type is xanthogranulomatous cholecystitis. Histopathological examination is important in the final diagnosis, because it can be confused with malignancy clinically, macroscopically and radiologically [2]. Microscopically, mixed inflammatory cell infiltration of the gallbladder wall with numerous foamy macrophage - histiocyte groups and occasional granuloma structures is characteristic [2,5]. In our study, 57.3% of cases had chronic cholecystitis with stone, 29.9% had chronic cholecystitis, and 11.2% had chronic active cholecystitis without specific subtypes. In addition, specific chronic cholecystitis types such as xanthogranulomatous cholecystitis (0.5%), follicular cholecystitis (0.12%) and eosinophilic cholecystitis (0.05%) were found. The accumulation of cholesterol esters and triglycerides in the cytoplasm of macrophages in the gallbladder wall results in a pathology called as cholesterolosis and it is found in 20% of cholecystectomy materials [2,3,6]. Macroscopically, there are yellow streaks on the mucosal surface, and microscopically, macrophages in villous mucosal hyperplasia are seen [2,3]. Occasionally, they are seen as 1-5 mm polypoid lesions in the mucosa, which are then called cholesterol polyps and in diffuse involvement they are called “strawberry sacs” [6]. It is the most common type of polyp in the gallbladder. Various inflammatory, reactive and neoplastic polyps can also be found in the gallbladder mucosa [2,3,6]. In our study, the most common polyp type was cholesterol polyp (3.7%), followed by inflammatory polyp (0.05%), tubular adenoma (0.05%), and pyloric gland adenoma (0.05%). Pyloric gland metaplasia (particularly in atrophic epithelium, in 66-84% of cholecystectomy materials) is the most common metaplasia type, and intestinal metaplasia (in 10-30% of cholecystectomy specimens) is the second common metaplasia type in the gallbladder [2,3,7]. In a study by Sharma et al. [8], pyloric metaplasia was observed in 30.2% of cases. MeirellesCosta et al. [9] reported that pyloric metaplasia was found in 4.3% of 1091 cases. In these studies, intestinal metaplasia rates were found as 3.36 and 1.1%, respectively. In a study by Akay et al.

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(10), 18 (64.3%) of 28 metaplasia cases had pyloric metaplasia and 10 (35.7%) had intestinal metaplasia. In addition, they reported that the rate of intestinal metaplasia was found to be more frequent in metaplasia in mucosa adjacent to cancer compared to intestinal metaplasia in mucosa no adjacent to cancer. In the series of 351 cases of Bahadir et al. [11], 81 had pyloric type metaplasia and 18 had intestinal metaplasia. Additionally, in their study, 8 cases had simultaneous pyloric and intestinal metaplasia. In our study, we detected intestinal metaplasia in 29 cases (1.69%), pyloric metaplasia in 91 cases (5.3%), and intestinal + pyloric metaplasia in 30 cases (1.75%). Although the high incidence of pyloric gland metaplasia compared to intestinal metaplasia has been in parallel with the literature, our rates have been below the reported rates. We think that this is due to differences in macroscopic sampling. Pyloric gland metaplasia and intestinal metaplasia occur as a result of prolonged inflammation and the presence of stones in the gallbladder [3]. In our study, we detected gallbladder stones and chronic inflammation in 44.8% of patients with intestinal metaplasia, 45% of patients with pyloric metaplasia, and 50% of patients with intestinal + pyloric metaplasia. Papillary epithelial hyperplasia and adenomyomatosis in the gallbladder are rarely seen and are usually associated with pyloric gland and intestinal metaplasia. Kılınc et al.[12] found adenomyoma / adenomyomatosis in 0.4%, Bolat et al. [3] found epithelial hyperplasia in 37.3% of the cases. Epithelial dysplasia or carcinoma in situ are the most important lesions in the development of carcinoma [2]. In our study, we detected papillary hyperplasia in 9 cases (0.52%) and adenomyomatous hyperplasia in 4 cases (0.23%). Pyloric metaplasia was found in 4 cases, intestinal + pyloric metaplasia in 1 case and intestinal metaplasia in 1 case of papillary hyperplasia [3]. It has been suggested that the gastric metaplasia-dysplasia cycle may be the onset of gallbladder cancer, so the detection of these lesions are important. Although the molecular changes seen in dysplasia are similar to those seen in carcinoma, there are no such molecular changes in adenomas. In dysplasia-carcinoma sequence and early stage carcinogenesis, p53 gene inactivation, K-ras oncogen activation, and cyclin D1 overexpression are characteristic. In contrast, p27Kip1 secretion has been shown to decrease in advanced gallbladder carcinogenesis such as tumor progression and metastasis [3]. Dysplasia may be present in the gallbladder alone or in combination with adenoma or carcinoma. The rate of dysplasia in cholecystectomy materials varies between 0.7% and 34% in various series. [3,7]. The rate of dysplasia was found to be 0.25% in the study of Esendağlı et al. [7 ]. In the evaluation of gallbladder pathologies, it is recommended to interpret the changes as reactive if there is ulceration and intense inflammation in cases which reactive atypia and low-grade dysplasia can be mimicked. Dysplasias are usually associated with stones and inflammation. Dysplasia is characterized by varying degrees of pseudostratification in the epithelium, nuclear atypia, loss of polarity and mitotic figures. Dysplasia is classified into two as mild and / or severe (low / high grade), or three as mildmoderate-severe (Biliary intraepithelial neoplasia, BilIN 1,2) according to cellular and structural atypia. [3,12]. Carcinoma and dysplasia are often accompanied by metaplastic lesions. It has been shown in several publications that intestinal metaplasia has an important role in the development of carcinoma and intestinal metaplasia - dysplasia relationship is more significant when compared with antral type metaplasia. [4]. However, there 30

doi: 10.5455/medscience.2019.08.9129

are studies advocating that gastric metaplasia-dysplasia cycle may also be the onset of gallbladder cancer. In many studies increased incidence of precancerous lesions such as dysplasia and metaplasia was seen by increasing the number of samples taken for microscopic examination. [3,4]. Mazlum et al.[13], Argon et al. [14] recommends taking a full slice of the gallbladder to detect the presence of more pyloric metaplasia, intestinal metaplasia, low-grade dysplasia, and invasive carcinoma. Seçinti et al. [4)] detected dysplasia in 85.7%, intestinal metaplasia in 100%, and gastric metaplasia in 28.5% of seven cases of gallbladder cancer. They found that all foci of intestinal metaplasia were intratumoral and detected that in six cases (85.7%) of all gallbladder cancer cases, 83.3% of incidental gallbladder cancer cases) dysplasia was accompanied by intestinal metaplasia, only in two cases (28.5% of all gallbladder cancer cases, 16.6% of incidental gallbladder cancer cases) dysplasia is associated with gastric metaplasia. In our study, dysplasia and in situ areas were detected in all patients with cancer, intestinal metaplasia in 6 (58.3%), intestinal + pyloric metaplasia in 3 (25%), and pyloric metaplasia in 2 (16.7%). The fact that some of the detected rates are below of the rates reported in the literature suggests that these epithelial lesions can not be sampled, are not sufficiently recognized or misinterpreted as regenerative atypia instead of low grade dysplasia. Adenoma - carcinoma sequence has also been extensively discussed recently. [2] Some authors have argued that adenomacarcinoma sequence is a natural process in the development of adenocarcinoma, while others claim that adenomatous residues are present in areas where invasive carcinoma develops. There are also other case series where early microcarcinoma development has been reported in the field of adenoma. [7]. Although malignant tumors of the gallbladder are rare, 80-95% of the malignant tumors in the hepatobiliary system comprise gallbladder origin. [4]. Gallbladder cancer is seen in 0.3 - 0.7% of all cancers and 0.19 - 3.3% of cases after cholecystectomy. [4]. The global incidence, mortality and prevalence rates for the 5-year gallbladder cancer that have identified current estimates in the GLOBOCAN Project have been reported to be 1.3%, 1.7% and 6%, respectively. [7]. 5-year prevalence rate of gallbladder cancer, in a multicenter study of Esendagli et al. in Turkey, were found to be 0.5% in 89.324 cholecystectomy materials. [7] . Incidental gallbladder cancer rate was found as 0.11% in the study of Keskin et al. [15], as 2.3% in the study of Utsumi et al. [1], and as 0.87% in the study of Dorobisz et al. [17] . This rate was 33.4% in our study. Gallbladder carcinoma affects the population 15-20 years older than those with gallbladder stones and peaks in the 7th decade. [15]. The mean age at presentation is 72 years, and 2/3 of the cases are over 65 years. [12]. The mean age of our patients was 66 years. Gallbladder cancer female / male ratio varies between 1 / 1-5 / 1 in different parts of the world and the average is 3/1. Hormonal changes such as multiparity and high pregnancy rate are blamed for the high incidence of gallbladder cancers in women. [4]. In our study, the female / male ratio was 2/1, which was consistent with the literature. Other risk factors include genetic factors, gallbladder stones, obesity, porcelain gallbladder and single sessile (> 10 mm) polyps. [4,15]. Gallbladder stones are found in > 80% of gallbladder with carcinoma. There was a positive correlation between the diameter, volume, weight and number of the stones and the risk of cancer. However, the effect of the constituents of the stone is not fully known. [4,15]. In our study, gallbladder stones were found in 5 (41.6%) of 12 cancer cases. Because of the presence of nonspecific

Med Science 2020;9(1):26-32

symptoms such as nausea and vomiting in early stage tumors, like as in chronic cholecystitis and cholelithiasis, and lack of specific serological markers and physical examination findings, patients who can be diagnosed preoperatively are usually in advanced stage. [4]. Approximately 50% of gallbladder carcinomas are diagnosed incidentally and therefore have a poor prognosis. Worldwide incidence is 1-2% and five-year survival rates are reported to be less than 5% for advanced stages. [15]. In our study, only 4 (33.3%) of 12 cases were found to be incidental and two of them were pT2 and two were pT3. Of the remaining 8 (66.7%) cases, 3 were pT2 and 5 were pT3. In other words, most of our cases (58.3%) were detected in advanced stage (pT3). Esendağlı et al. [7] reported that most of these tumors were diagnosed in advanced stages and the tumor muscle layer exceeded the tumor layer at the time of diagnosis [2]. In our study, 58.3% of the cancer cases were in advanced stage for the patients who passed the muscle layer. All of the cancer cases in our series are consisted of epithelial origin and 83.3% of them were diagnosed as adenocarcinoma. Histological grading of adenocarcinomas is done according to tubule formation. If the tubule formation is above the 95%, it is well differentiated; It is defined as when 40% to 95% moderately differentiated, 5% to 39% less poorly differentiated. In the literature, the differentiation of these tumors has been described as poor, and moderate or low differentiation was observed in 2/3 of the cases. Macroscopically diffuse enlargement (70%) or polypoid mass (30%) can be seen as the most common histopathological examination [2,4]. In our study, 6 (50%) of 12 cases were moderately differentiated, 3 (25%) were good and slightly differentiated. İn terms of growth patterns, we found that 10 of them showed diffuse (wall thickening) and 2 of them showed polypoid growth. Other epithelial tumors include papillary, mucinous, squamous, and adenosquamous carcinomas. Less frequently, small cell carcinoma, undifferentiated carcinoma and other tumors are seen [2,4]. One of the important limitations of the present study is that the low- and high-grade dysplasia rates, which might accompany the findings such as chronic cholecystitis, choleithiasis, ulcer- erosion, and reactive-reparative changes – atypia, were detected to be lower than they should be because no common sampling protocol other than the routine protocol, in which three specimens (one from each of neck, corpus, and fundus) were obtained, due to retrospective nature of the present study Conclusion As a result, we conducted a local retrospective study covering the province of Usak and its environs and detected epithelial changes in the general population at a considerable rate. Considering that most premalignant lesions and even malignancy do not give macroscopic and clinically specific findings, it is a fact that increasing the number of samples in cases with metaplasia and dysplasia detected during microscopic examination will increase the chance of catching a further lesion. For this reason, we believe that it is necessary to carry out further studies multicentric and prospectively in the way involving different geographical regions and according to the results to be obtained from those studies, the accurate incidence values should be determined and a standard should be set for macroscopic sampling, pathological diagnosis criteria, and reporting template. 31

doi: 10.5455/medscience.2019.08.9129 Informed Consent Informed consent was obtained from all individual participants included in the study.

Ethical approval The study was in accordance with the principles outlined in the Declaration of Helsinki. Ethical approval was received from the local Human Non-invasive Clinical Research Ethics Committee. The informed consent was not requested, since the study was retrospective and the data were analyzed anonymously. Sirin Kucuk ORCID: 0000-0002-8552-2101 Ersoy Ercihan ORCID: 0000-0002-3690-5886 Asli Ucar Uncu ORCID: 0000-0003-1503-3385 Mehmet Gundogan ORCID: 0000-0002-3890-5396 Cengiz Kocak ORCID: 0000-0003-3819-6822

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Stancu M, Caruntu ID, Gıuşca S et al. Hyperplasia, metaplasia, dysplasia and neoplasia lesions in chronic cholecystitis – a morphologic study. Romanian Journal of Morphology and Embryology 2007;48:335-42.

Turan G, Aslan F, Altun E. Kolesistektomi Spesmenlerimizin Histopatolojik Sonuçları ve Malignite Sıklığı. Balıkesir Medical J 2017;3:107-11.

Bolat F, Kayaselçuk F, Nursal TZ, et al. Kolesistektomilerde örnek sayısının artırılması ile histopatolojik bulguların korelasyonu. Türk Patoloji Dergisi 2007;23:137-42.

Seçinti İE, Akıncıoğlu E. İnsidental safra kesesi karsinomlarında metaplazi araştırılması: tek merkez deneyimi. Mustafa Kemal Üniv Tıp Derg 2016;7: 9-18.

Amiraslanov A, Zade YK, Musayev J. Laparoskopik kolesistektomi uygulanan olgularda safra kesesinin histopatolojik profili. Marmara Medical J 2015;28:32-7.

Mellnick VM, Menias CO, Sandrasegaran K et al. Polipoid lesion of the gallbladder: Disease spectrum with pathologic correlation. Radiographics. 2015;35:387-99.

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Esendağlı G, Akarca FG, Balcı S et al. A Retrospective Evaluation of the Epithelial Changes/Lesions and Neoplasms of the Gallbladder in Turkey and a Review of the Existing Sampling Methods: A Multicentre Study. Turkish J Pathology. 2018;34:41-8.

Sharma R, Chander B, Kaul R et al. Frequency of gall bladder metaplasia and its distribution in different regions of gallbladder in routine cholecystectomy specimens. Int J Res Med Sci. 2018;6:149-53

Meirelles-Costa ALA, Bresciani CJC. Are histological alteratıons observed in the gallbladder precancerous lesions? Clinics (Sao Paulo). 2010;65:143-50.

Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports

10. Akay EKAY, Çoban G, Deniz K et al. Safra Kesesinin Metaplazi-DisplaziKarsinom Sekansında p16ve p21İmmünreaktivitesi. Turkiye Klinikleri J Gastroenterohepatol. 2014;4:21:1-8. 11. Bahadır B, Gün BD, Çolak S. Safra kesesinde metaplazi, displazi ve karsinom dizgesi. Akademik Gastroenteroloji Dergisi. 2007;6:25-9. 12. Kilinc F, Gulper U, Oltulu P et al. Risk Management of Incidental Gallbladder Cancer in Cholecystectomy Materials. Selcuk Med J 2019;35:9-14. 13. Mazlum M, Dilek FH, Yener AN et al. Profile of gallbladder diseases diagnosed at Afyon Kocatepe University: A retrospective study. Turk Patoloji Derg. 2011;27:23-30. 14. Argon A, Yağcı A, Taşlı F et al. Kolesistektomi materyallerinin makroskobik örneklemesine farklı bir bakış. 22. Ulusal Patoloji kongresi. Sözlü bildiri özetleri (S-012). www.turkpath.org.tr/ UlusalPatoloji2012/?page=sozlu_ bildiri_ozetleri. 15. Keskin E, Pala E, Çakır E et al. Incidental gallbladder carcinoma and precancerous lesions in laparoscopic cholecystectomy specimens. Tepecik Eğit. ve Araşt. Hast. Dergisi 2017;27:229-35. 16. Utsumi M, Aoki H, Kunitomo T et al. Evaluation of surgical treatment for incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy: single center results. Utsumi et al. BMC Res Notes. 2017;10:2-5. 17. Dorobisz T, Dorobisz K, Chabowski M et al. Incidental gallbladder cancer after cholecystectomy: 1990 to 2014. Onco Targets and Therapy. 2016;9:4913-16.

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Medicine Science International Medical Journal

Medicine Science 2020;9(1):33-8

Disturbed sleep quality and increased depression scores in alopecia areata patients Aynure Oztekin1, Coskun Oztekin2 2

1 Hitit University, Faculty of Medicine, Department of Dermatology, Corum, Turkey Hitit University, Faculty of Medicine, Department of Family Medicine, Corum, Turkey

Received 23 August 2019; Accepted 27 September 2019 Available online 24.02.2020 with doi:10.5455/medscience.2019.08.9130 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract Alopecia areata (AA) is a chronic inflammatory disease that affects the hair follicle and sometimes the nails. Comorbidity between alopecia areata and psychiatric disorders is well known. The aim of this study is to evaluate the relationship between the clinical characteristics of AA and sleep quality and depression. This study included 52 patients above 18 years of age who admitted to the dermatology clinic and diagnosed as alopecia areata, and 51 healthy volunteers. Sociodemographic data form, Beck Depression Inventory (BDI), and the Pittsburgh Sleep Quality Index (PSQI) were filled by the patients. Information about the severity of AA, the duration of the disease, the treatments they received, and comorbid illnesses were also recorded. The median BDI total score of the AA patients was higher than that of the control group. In AA patients, PSQI total score and most of the subscale scores were significantly higher than those of the control group. No difference could be found in BDI or PSQI scores according to the presence or absence of poor prognostic criteria. The results of our study support the long-standing relationship between AA and psychiatric disorders and indicate that sleep quality is impaired in addition to the increase in depression level. In particular, a more careful assessment of female AA patients and patients with comorbid atopic dermatitis is important in order not to miss comorbid psychiatric problems. Keywords: Alopecia areata, depression, sleep quality, hair

Introduction The etiology of alopecia areata (AA), a chronic inflammatory disease that affects the hair follicle and sometimes the nails, has not yet been fully understood. Besides the genetic background, nonspecific immune response, organ-specific autoimmune reactions, and environmental factors are among the most frequently discussed issues in the pathogenesis of this disease [1].

Family problems, work-related problems, and mourning have also been reported by AA patients [4]. It has been suggested that neuroendocrine immunology as well as psychosocial factors may be responsible for the association between AA and depression [5].

It has long been claimed that AA is a psychosomatic disease triggered by stressful life events [2]. In a study investigating comorbid diseases in patients with AA, prevalence of depression and anxiety was found to be high (25.5%) in an 11-year period [3]. On the other hand, depression may be present before AA [4].

It is well known that sleep has important effects on immunity. There is evidence of a relationship between sleep disorders and autoimmune diseases including rheumatoid arthritis, ankylosing spondylitis, Sjögren’s syndrome and systemic lupus erythematosus [6]. It has been reported that patients with sleep disorders, especially young people, had an increased risk of AA [7]. In the same study, sleep disorders were also associated with other autoimmunity related diseases such as Graves’ disease, Hashimoto’s thyroiditis, vitiligo and rheumatoid arthritis.

*Coresponding Author: Aynure Oztekin, Hitit University, Faculty of Medicine, Department of Dermatology, Corum, Turkey, E-mail: aynureoztekin@gmail.com

Alopecia areata may occur in different clinical types. In the most common type, there is hair loss in the scalp[8]. If all of the scalp hair is involved, it is called alopecia totalis and, if all of the body hair is involved, it is called alopecia universalis. In the ophiasis type hair loss is seen at the junction of occipital hair line and 33

doi: 10.5455/medscience.2019.08.9130

dermis, and in the reticular type the hair loss is reticular [8]. Nail changes are seen in 30% of patients with AA [9]. The most common nail finding is small pits, and the other findings are the Beau line, longitudinal line, koilonychia, onychorhexis, onychomadesis, leukonychia, red-staine lunula, and other nail defects can [9]. It has been suggested that nail change is related to the severity of the disease and indicates possible resistance [10]. It is hard to predict natural course in alopecia areata. In some patients, hair completely reappears, in some others, some improvement in AA occurs, and, in still others, the hair loss further increases [11]. Poor prognostic criteria include presence of atopia, extensive involvement, family history, onychodystrophy, presence of disease for more than 5 years, autoimmune disease, ophiasis type, asthma, and the presence of nevus flammeus, allergic rhinitis, and atopic dermatitis [12]. The aim of our study was to evaluate the frequency of depression and sleep quality in patients with AA, and to investigate the relationship between the clinical characteristics of the disease such as duration, severity, and type of illness and depression, and sleep quality. Material and Methods Sample This study was conducted in Skin and Venereal Diseases Department of the Medical School of Hitit University. This study included 52 patients above 18 years of age who admitted to the dermatology clinic and were diagnosed as alopecia areata and 51 healthy volunteers. Healthy volunteers were selected from hospital staff and the relatives of hospital staff who didn’t have any history of psychiatric, systemic or dermatological disease and agreed to participate in the study. The patients and control group included in the study were informed about the study, and the questionnaires were completed after obtaining their written informed consents. Illiterate patients and those couldn’t fill the scales due to cognitive dysfunction were not included in the study. Patients who were being treated for a systemic disease or who had treatment for a psychiatric disease during the last year were excluded. This study was approved by the local ethics committee and performed in accordance with the ethical standards of the Helsinki Declaration. Instruments Beck Depression Inventory (BDI): This scale has been developed by Beck et al and aims to measure the severity of depression[13]. The scale consists of 21 items and is scored between 0 to 3. Pittsburgh Sleep Quality Index (PSQI): It was developed by Buysse et al.[14] and consists of 24 questions, 19 questions are filled by the subject himself and 5 questions are filled by the spouse or a room partner. From the scored questions of the scale 7 subscale scores are obtained: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleep medications, and daytime dysfunction. The total score of seven subscales gives total scale score which varies between 0 and 21.

Med Science 2020;9(1):33-8

by Olsen et al. [15] and calculated by measuring how much of the total body surface is affected considering involved body parts. In this study, patients with hair loss below 25% were classified as mild, 25-50% moderate and above 50% as severe loss. Procedures All of the included cases were informed about the study, informed consent forms were obtained, and then sociodemographic data form, BDI, and PSQI were filled by the patients. In addition to these, information about the severity of alopecia areata, duration of the disease, treatments they received, and information about their illnesses were also recorded. Statistical Analysis To summarize data obtained from the study, descriptive statistics were given as mean ± standard deviation or median and interquartile ranges depending on the distribution for continuous variables. The normality of the numerical variables was checked by the Kolmogorov-Smirnov test. Independent Samples t test was used in the comparison of two independent groups when the numerical variables showed normal distribution, and Mann Whitney U test was used otherwise. In comparison of more than three independent groups, one-way ANOVA was used where the numerical variables were normally distributed and Kruskall Wallis test was used otherwise. For between group differences, Tukey’s test was used when the distribution of the data was homogenous and Games-Howell test was used otherwise. Between group differences in nonparametric tests were evaluated with DwassSteel-Critchlow-Fligner test. Pearson Chi-Square test was used for categorical variables, and Fisher’s exact test was used for RXC tables. To evaluate the associations between numerical variables, Pearson test was used when the data were normally distributed and Spearman’s Rho was used otherwise. Statistical analyses were performed with Jamovi Project software (2019; Version 0.9.5.12) and p<0.05 was considered to be significant in statistical analyses. Results This study included 52 AA patients and 51 controls. There was no significant difference in age, sex, education status, cigarette smoking, height, weight, and body mass index (BMI) values between the groups (Table 1). Alopecia areata was localized only to scalp hair in 24 patients (%46.2). In 20 (38.5%) patients the disease duration was less than 1 month. In 29 patients (55.8%) single, patchy AA was found. According to SALT, the severity of AA was mild in 46 (86.4%) of the patients. The number of patients who had at least one poor prognostic criteria was 28 (53.8%). The most common poor prognostic criterion was family history (n=10, 19.2%). Beginning age of the disease was mean 27.5 (± 7.8) (Table 2). Median BDI total score of AA patients (8.5) was higher than that of the control group (2) (p<0.001). In AA patients, besides PSQI total score, subjective sleep quality, sleep latency, sleep disturbance, and daytime dysfunction subscale scores were statistically higher than those of the control group (p<0.001, p=0.002, p=0.001, and p<0.001 respectively).

Severity of Alopecia Areata Tool; SALT: This scale was developed 34

doi: 10.5455/medscience.2019.08.9130

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Table 1. Comparisons of age, sex, education status, cigarette smoking, height, weight, and BMI values between the groups Group Patient (n=52)

Control (n=51)

28.8 ± 7.7

29.3 ± 8.7

0.792

Male. n (%)

40 (76.9)

40 (78.4)

Female. n (%)

12 (23.1)

11 (21.6)

Primary school. n (%)

6 (11.5)

4 (7.8)

Secondary school. n (%)

6 (11.5)

5 (9.8)

High school. n (%)

19 (36.5)

15 (29.4)

University. n (%)

21 (40.4)

27 (52.9)

No. n (%)

27 (51.9)

31 (60.8)

Yes. n (%)

25 (48.1)

20 (39.2)

Height (cm), Mean± SD

174.3 ± 9.3

171.4 ± 8.6

0.107

Weight (kg), Mean ± SD

70.5 ± 11.6

71.3 ± 11.6

0.741

BMI (kg/m2), Mean ± SD

23.2 ± 3.3

24.1 ± 2.6

0.103

Age, Mean ± SD Sex Education status

Cigarette smoking

0.854

0,637

0.365

BMI: body mass index, SD: standard deviation

Table 2. Clinical features of the individuals n (%) Localization of alopecia areata

Type of alopecia areata

Alopecia areata severity

Onychodistrophy

Poor prognostic criteria

Only scalp

24 (46.2)

Only beard

18 (34.6)

Only scalp, eyelashes

5 (9.6)

Scalp+ beard

4 (7.7)

Scalp + eyelashes + eyebrows

1 (1.9)

Single patch

29 (55.8)

Multiple patches

23 (44.2)

(Mild) Hair loss < %25

46 (88.5)

(Moderate) Hair loss %26-50

5 (9.6)

(Severe) Hair loss %50

1 (1.9)

45 (86.54)

Yes

7 (13.46)

28 (53.8)

Yes

24 (46.2)

Atopy history

8 (15.4)

Family history

10 (19.2)

Longer than 5 years

3 (5.8)

Asthma

3 (5.8)

Allergic rhinitis

4 (7.7)

Atopic dermatitis

3 (5.8)

Age of onset of disease

27.5 ± 7.8

Previous treatments

36 (69.2)

Topical

8 (15.4)

Intralesion

7 (13.5)

Systemic

1 (1.9)

Onychodystrophy was detected in 7 patients (13.46%). As onychodystrophy type, 5 patients (9.6%) had pitting, 1 patient had longitudinal striation, and 1 patient (1.9%) had opaque nail. No difference could be found between patients who had or who didn’t have onychodystrophy in BDI, PSQI total score, and PSQI subscale scores. Comparisons for Beck Depression Inventory scores demonstrated that the localization of alopecia areata didn’t cause any effect (p=0.303). BDI scores of the patients who had moderate or severe alopecia areata were higher than those of the patients who had mild disease (p=0.023). No difference could be found in BDI score according to the presence or absence of poor prognostic criteria. Evaluation for the presence of poor prognostic criteria separately demonstrated that the BDI score was higher in the presence of only atopic dermatitis (p=0.016). Prior treatment did not affect the mean BDI score (Table 3). Comparisons for the Pittsburgh Sleep Quality Index (PSQI) revealed no difference for alopecia areata localization. Although scores were higher in patients with moderate or severe alopecia areata, the difference couldn’t reach statistical significance (p=0.092). No difference could be found in PSQI scores according to the presence or absence of poor prognostic criteria. Evaluation of the PSQI scores in the presence of separate poor prognostic criteria revealed that the presence of alopecia areata for more than 5 years (p=0.001) and presence of atopic dermatitis (p=0.016) were associated with higher PSQI scores (Table 3). Comparisons in terms of gender revealed that in the patient group the median BDI (16) and PSQI (7.5) scores in females were statistically significantly higher than BDI (7.5) and PSQI (6) scores in males (p=0.026 and p=0.012, respectively). Also in the control group the median BDI (9) and PSQI (4) scores in females were statistically significantly higher than BDI (1.5) and PSQI (2) scores in males (p=0.001 and p=0.035, respectively) 35

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Table 3. Association between the clinical features of alopecia areata and BDI, PSQI scores BDI

PSQI

Localization of alopecia areata Limited to scalp, (n=24)

9 [3.5 – 16]

7.5 [4.5 – 9]

Limited to beard, (n=18)

7 [4 – 16]

5.5 [5 – 8]

Only eyebrows, eyelashes, (n=5)

17 [13 – 19]

Scalp + beard, (n=4)

11 [9 – 15]

7 [3 – 11.5]

1 [1 – 1]

5 [5 – 5]

Scalp + eyebrows, eyelashes (n=1) α

0.303

7 [6 – 13]

0.740

Severity of alopecia areata Mild hair loss 25%, (n=46) Moderate hair loss 26-50%, (n=6)

8 [4 – 15] 17.5 [12 – 18]

0.023*

6 [4 – 8] 9 [9 – 9]

0.092

Poor prognostic criteria No, (n=28)

8.5 [4.5 – 15.5]

Yes, (n=24)

9 [4 – 17.5]

0.576

6 [4.5 – 9] 7 [5 – 9]

0.372

Poor prognostic criteria Atopy, (n=8)

12.5 [6.5 – 23]

0.361

8 [5.5 – 10.5]

0.417

Family history, (n=10)

6 [2 – 19]

0.862

8.5 [5 – 13]

0.160

Onychodystrophy (n=7)

17 [6 – 18]

0.243

7 [5 – 9]

0.639

More than 5 years (n=3)

6 [4 – 12]

0.569

5 [4 – 5]

0.001*

Asthma (n=3)

6 [0 – 15]

0.376

4 [2 – 7]

0.184

8.5 [3.5 – 12.5]

0.570

7.5 [4.5 – 8]

0.671

28 [18 – 39]

0.016*

12 [9 – 14]

0.016*

Allergic rhinitis (n=4) Atopic dermatitis (n=3) Previous treatments No, (n=36)

8 [4 – 15]

Yes, (n=16)

11 [5 – 18.5]

0.393

6 [5 – 8.5] 7 [4.5 – 10]

0.434

*p<0.05 Mann Whitney U test was used. Descriptive statistics were given as median [IQR]. α: Not included in analyses. AA, alopecia areata; BDI: Beck Depression Inventory, IQR: Interquartile Range, PSQI: Pittsburgh Sleep Quality Index

Discussion In our study sleep quality of alopecia areata patients which was measured by PSQI scale was lower than that of the control group. There may be a two-way relationship between sleep and AA. Sleep deprivation was reported to increase serum interleukin (IL)-1 and tumor necrosis factor in mice[16]. By this way, decreased sleep quality might induce autoimmunity and cause AA in addition to other autoimmune diseases. On the other hand, AA may increase susceptibility to depression by causing loss of self-esteem due to induction of a loss in self-esteem [3]. In a previous study which evaluated sleep quality in AA patients, the Epworth Sleepiness Scale was applied to 105 AA patients and the mean ESS score was found to be 5.66±3.93 [17]. Although there was no control group in this study, considering that no difference could be found from a previous study on the normal Japanese population, the sleep quality in AA patients was hypothesized to be normal. Absence of a control group is a major limitation of this study. This might have prevented finding a significant result. To the best of our knowledge, no previous study had evaluated sleep quality in AA patients with PSQI.

In our study, the BDI scores in the AA group was higher than the control group. This result suggests the findings of the previous studies in the literature. Sellami et al used the Hospital Anxiety and Depression Scale and found higher depression and anxiety scores in the AA group than the control group [18]. Another controlled study using the Hamilton Depression Scale found that depression scores of the AA patients were higher than the control group [19]. The prevalence of onyschodystrophy in AA patients was reported to be between 7-66% in previous studies [9]. The rate we detected (13.46%) was in accordance with previous studies. Pitting, which was the most common nail change in our study, has also been reported as the most frequent nail change in most of the previous studies[10]. Nail changes were more commonly reported in severe AA forms like AA totalis (AAT) and AA universalis (AAU) [20]. In our study, the absence of more severe AA types like AAU and AAT may have caused low rate of onychodystrophy and absence of a relationship between the presence of onychodystrophy and the PSQI and the BDI scores. In our study, depression level was significantly higher in patients 36

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with severe disease measured by SALT; the disturbance in sleep quality was also higher in these patients but the difference could not reach statistical significance. In most of the studies in the literature, severity of the psychiatric symptoms like depression and anxiety increased with increasing severity of the disease [18,19].

Taheri R, Behnam B, Tousi JA, et al. Triggering role of stressful life events in patients with alopecia areata. Acta Dermatovenerol Croat. 2012;20:246-50.

Huang KP, Mullangi S, Guo Y, et al. Autoimmune, atopic, and mental health comorbid conditions associated with alopecia areata in the United States. JAMA Dermatol. 2013;149:789-94.

We couldn’t find a relationship between the localization of AA and depression or sleep quality. Aghaei et al. reported higher rates of depression in AA patients with face involvement [21] which couldn’t be found in other two studies [19,22].

Alfani S, Antinone V, Mozzetta A, et al. Psychological status of patients with alopecia areata. Acta Derm Venereol. 2012;92:304-6.

Chu SY, Chen YJ, Tseng WC, et al. Psychiatric comorbidities in patients with alopecia areata in Taiwan: A case control study. Br J Dermatol. 2012;166:52531.

Hsiao YH, Chen YT, Tseng CM, et al. Sleep disorders and increased risk of autoimmune diseases in individuals without sleep apnea. Sleep. 2015;38:581– 6.

Seo HM, Kim TL, Kim JS. The risk of alopecia areata and other related autoimmune diseases in patients with sleep disorders: a Korean populationbased retrospective cohort study. Sleep. 2018;41:zsy111.

Dastagiri J, Shankar M, Supriya T, et al. A current view on alopecia areata. Am J Biol Pharm Res 2016;3:76-82.

Chelidze K, Lipner SR. Nail changes in alopecia areata: an update and review. Int J Dermatol. 2018;57:776-83.

No association could be found in our study between the beginning age of the study or disease duration and depression or sleep quality similar to the findings of previous studies [19,22]. Firooz et al. reported longer disease duration was associated with higher hopelessness about the treatment [23]. In most of the studies that evaluated depression and anxiety levels, women were found to have higher levels than men [18,19,22]. This finding was evaluated by some authors as that the aesthetic stress of women was higher than that of men [19]. In our study, the level of depression in female AA patients was higher and sleep quality was more impaired than male patients. However, we think that it would be wrong to interpret this finding as AA has more psychological effects in women. Because, in this age group, the level of depression is higher in females than that in males and sleep quality is more impaired [24]. However, the results emphasize the importance of screening for women with AA in terms of psychiatric symptoms. In our study, the evaluation of the effect of poor prognostic criteria on AA patients in depression and sleep quality revealed that the presence of atopic dermatitis was associated with an increase in depression level and deterioration in sleep quality. Considering the association between atopic dermatitis and psychiatric symptoms, this finding is not a surprise. The evaluation of sleep quality in 100 patients with atopic dermatitis by PSQI revealed poor sleep quality [25]. Conclusion The results of our study support the long-standing relationship between AA and psychiatric disorders and indicate that sleep quality is impaired as well as the increase in depression level. In particular, a more careful assessment of female AA patients and patients with comorbid atopic dermatitis is important in order not to miss comorbid psychiatric problems. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study.

10. Kasumagic-Halilovic E, Prohic A. Nail changes in alopecia areata: frequency and clinical presentation. J Eur Acad Dermatol Venereol. 2009;23:240-1. 11. Spano F, Donovan JC. Alopecia areata: Part 1: pathogenesis, diagnosis, and prognosis. Can Fam Physician. 2015;61:751–5. 12. Goh C, Finkel M, Christos PJ, et al. Profile of 513 patients with alopecia areata: associations of disease subtypes with atopy, autoimmune disease and positive family history. J Eur Acad Dermatol Venereol. 2006;20:1055-60. 13. Beck AT, Word CH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psyc. 1961;4:561-71. 14. Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193-213. 15. Olsen EA, Hordinsky MK, Price VH, et al. National Alopecia Areata Foundation: Alopecia areata investigational assessment guidelines--Part II. National Alopecia Areata Foundation. J Am Acad Dermatol. 2004;51:440-7. 16. Hu J, Chen Z, Gorczynski CP, et al. Sleep-deprived mice show altered cytokine production manifest by perturbations in serum IL-1ra, TNFa, and IL-6 levels. Brain Behav Immun. 2003;17:498-504. 17. Inui S, Hamasaki T, Itami S. Sleep quality in patients with alopecia areata: questionnaire based study. Int J Dermatol. 2014;53:e39-e41. 18. Sellami R, Masmoudi J, Ouali U, et al. The relationship between alopecia areata and alexithymia, anxiety and depression: a case-control study. Indian J Dermatol. 2014;59:421.

Ethical approval This study was approved by the local ethics committee and performed in accordance with the ethical standards of the Helsinki Declaration.

19. Baghestani S, Zare S, Seddigh SH. Severity of depression and anxiety in patients with alopecia areata in Bandar Abbas, Iran. Dermatol Reports. 2015;7:6063.

Aynure Oztekin, ORCID: 0000-0002-3669-6631 Coskun Oztekin, ORCID: 0000-0002-4490-7136

20. Gilhar A, Etzioni A, Paus R. Alopecia areata. N Engl J Med. 2012;366:151525.

References

21. Aghaei S, Saki N, Daneshmand E, et al. Prevalence of psychological disorders in patients with alopecia areata in comparison with normal subjects. ISRN Dermatol. 2014; Article ID 304370.

Ito T. Recent advances in the pathogenesis of autoimmune hair loss disease alopecia areata. Clin Dev Immunol. 2013; Article ID 348546.

doi: 10.5455/medscience.2019.08.9130 22. Ruiz-Doblado S, Carrizosa A, Garcia-Hernandez MJ. Alopecia areata: psychiatric comorbidity and adjustment to illness. Int J Dermatol. 2003;42:434-7. 23. Firooz A, Firoozabadi MR, Ghazisaidi B, et al. Concepts of patients with alopecia areata about their disease. BMC Dermatol. 2005;5:1.

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24. Albert PR. Why is depression more prevalent in women? J Psychiatry Neurosci. 2015;40:219-21. 25. Kaaz K, Szepietowski JC, Matusiak L. Influence of itch and pain on sleep quality in atopic dermatitis and psoriasis. Acta Derm Venereol. 2019;99:17580.

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Medicine Science International Medical Journal

Medicine Science 2020;9(1):39-44

Evaluation of helicobacter pylori eradication therapy with serum myeloperoxidase levels Meside Gunduzoz1, Servet Birgin Iritas2, Servet Guresci3, Murat Buyuksekerci4, Osman Gokhan Ozakinci5, Yasar Nazligul6 1 Ankara Occupational Diseases Hospital, Department of Family Medicine, Ankara, Turkey The Council of Forensic Medicine, Department of Ankara Branch Directorate, Ankara, Turkey 3 Numune Education and Research Hospital University of Health Sciences, Department of Pathology, Ankara, Turkey 4 Occupational and Environmental Diseases Hospital, Department of Pharmacology, Ankara, Turkey 5 Occupational and Environmental Diseases Hospital, Department of Public Health, Ankara, Turkey 6 Kecioren Teaching and Research Hospital, Department of Gastroenterology, Ankara, Turkey 2

Received 24 October 2019; Accepted 19 November 2019 Available online 24.02.2020 with doi:10.5455/medscience.2019.08.9131 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract Helicobacter pylori (H. pylori) is associated with chronic gastritis, peptic ulcers, and gastric adenocarcinomas. H. pylori-infected patients produce reactive oxygen species (ROS) in gastric mucosa. Production of ROS induces the myeloperoxidase (MPO) activity. This study aims the determination of the relationship between MPO level and H. pylori infection and eradication therapy. One hundred seven (107) patients were enrolled in the study. H. pylori were detected by histopathological examination of the specimens. The patients were divided into two groups: Group 1 (H. pylori-negative), Group 2 (H. pylori-positive). The tissue MPO activity and serum MPO levels of these two groups were compared. Patients with H. pylori infection received eradication therapy. Post-treatment serum MPO levels were also compared. Histopathological examination revealed that 28(26.2%) patients were H. pylori-negative (Group 1), whereas 79(73.8%) patients were H. pylori-positive (Group 2). Tissue MPO activity of the groups was compared, and a significant difference was found between two groups, 0.5(1) and 2(1), respectively (p<0.001). There was no significant difference between the groups in terms of serum MPO levels 2.19(1.91) ng/mL and 2.69(2.45) ng/mL, respectively (P=0.266). There was a significant difference between pre-treatment and post-treatment serum MPO levels after eradication therapy 2.69(2.45) and 1.26(2.36), respectively (p=0.002). Consequently, MPO levels may be determinant in monitoring the effectiveness of H. pylori eradication therapy. Keywords: Helicobacter pylori (H.pylori), myeloperoxidase (MPO), H.pylori eradication therapy, reactive oxygen species (ROS)

Introduction Nearly half of the world’s population is infected with Helicobacter pylori (H.pylori) [1]. H.pylori, associated with gastric cancer, has become a challenging pathogen since its discovery in 1983 and confirming its oncogenicity in 1994 [2-4]. However, the role of H.pylori in carcinogenesis has not been identified. H.pylori is also be held responsible for non-gastric diseases like coronary heart disease (CAD), atherosclerosis, insulin resistance and diabetes mellitus [5]. In a small number of patients, the infection spontaneously disappears within a few weeks to a few months and the mucosa returns to normal. However, in most cases, the host’s immune response is insufficient to eliminate the infection; chronic gastritis characterized by intense lymphoplasma-cell infiltration,

*Coresponding Author: Servet Birgin Iritas, The Council of Forensic Medicine, Department of Ankara Branch Directorate, Ankara, Turkey, E-mail: sbiritas@gmail.com

increased polymorphic neutrophils [6,7]. The relationship between H.pylori and gastric cancer is obvious. Persistent inflammation of the gastric mucosa with H. pylori results in atrophic gastritis, a risking for gastric cancer. Atrophic gastritis has an intense neutrophil infiltration. Myeloperoxidase (MPO) is released from neutrophils, which creates gastric mucosal damage [8-10]. Myeloperoxidase, the lysosomal enzyme, localized in polymorphonuclear neutrophils and monocytes and released in oxidative stress. MPO catalyzes the reaction producing hypochlorous acid (HOCl) which causes DNA damage in the host cell [11]. In a study, the MPO level of neutrophils was found to be higher in gastric cancer patients than the healthy control group [12]. With H.pylori inflammation, ROS production, MPO activity, tissue factor, and plasminogen activator inhibitor release are stimulated [13]. Myeloperoxidase plays an active role in the antibacterial mechanism associated with H2O2 and has a bactericidal effect on microorganisms such as Escherichia coli, Lactobacillus acidophilus, Staphylococcus aureus and Actinobacillus 39

doi: 10.5455/medscience.2019.08.9131

actinomycetemcomitans [14]. In response to infectious agents and other stimuli, the phagocytic cells of the immune system (neutrophils, eosinophil’s, and monocytes/macrophages) show a rapid consumption of O2, called respiratory burst. Respiratory burst is the main source of superoxide, hydrogen peroxide, hydroxyl radical, HOCl and reactive nitrogen compounds (RNOS). Recent research has shown that high MPO levels are associated with atherosclerotic diseases, coronary artery disease (CAD) formation, and myocardial infarction (MI) [15]. Increased MPO activity combined with decreased catalase (CAT) activity creates an environment of increased reactive oxygen species (ROS) that are implicated in various cancers and chronic respiratory inflammation [16]. Eradication treatment is indicated for H. pylori infection. With eradication treatment, H.pylori-associated gastric cancer formation can be prevented [17]. After the eradication of H.pylori, the patients who have unexplained iron deficiency anemia and immune thrombocytopenic purpura (ITP) in addition to H.pylori gastritis, showed improvement in other conditions also [18]. In this study, we investigated gastric mucosa and serum MPO enzyme levels in H.pylori infected patients and the effect of eradication therapy on serum MPO level. Material and Methods Patients admitted to Gastroenterology Clinic and underwent esophago-gastroduodenal endoscopy between 2010 and 2012 were assessed for enrollment. The medical ethics committee of Ankara University (12.09.2011 / 35-766) approved the study protocol and all patients gave informed consent. All patients were informed about the study protocol and written consent was obtained from each. Patients between 18 and 65 years of age were included in the study. Patients with previous gastric surgery, cholecystectomy, liver failure, renal failure, cardiac failure, malignancy, chronic obstructive pulmonary disease, diabetes mellitus, cerebrovascular disease, collagen tissue disease were excluded. Patients’ medical history, liver function tests, kidney function tests, blood glucose tests and physical examination results were used to identify the presence of exclusion criteria. Patients who received antibiotics, histamine two receptor antagonists or proton pump inhibitors within the past two weeks and patients with alcohol and tobacco consumption were also not included. Venous blood samples were drawn from all patients at the time of admission. Aspartate Transaminase (AST), Alanine Transaminase (ALT), Gamma-Glutamyl Transferase (GGT), Alkaline Phosphatase (ALP), total protein, albumin, total bilirubin, direct bilirubin, total cholesterol, high-density lipoprotein, low-density lipoprotein (LDL), triglycerides, sedimentation, white blood cell count, hemoglobin and platelet count were analyzed within 30 minutes. Blood samples were centrifuged and stored at -80°C until the analysis of serum MPO activity. Endoscopic examinations were performed using Fujinon, EG–450WR5. During endoscopy, biopsy samples from antrum and corpus were taken for histopathological examination and H.pylori diagnosis. For histopathological assessment, the Sydney Classification was used, and the samples were stained with

Med Science 2020;9(1):39-44

hematoxylin and eosin. H.pylori was identified by Giemsa staining. Measurement for the human MPO activity, the human MPO Instant ELISA kit of eBioscience Company, was used. The serum MPO level was measured following the instructions of the manufacturer. The serum MPO level was given in pg/mL. MPO kit was purchased from Immundiagnostik AG. Data were analyzed using GrapHPad Prism version 4.0 c (GrapHPad Inc., San Diego, California, USA). For the detection of myeloperoxidase activity in tissues, immunohistochemical staining with anti-myeloperoxidase antibody (rabbit polyclonal, 1:100; Thermo, USA) was applied for 30 minutes, using an indirect peroxidase method on the autostainer (Bond; Leica Biosystems, Newcastle, UK). Normal tonsil tissue was used as a positive control. Cytoplasmic staining in granulocytic cells in gastric biopsies was accepted as a positive result. The extent of staining was scored as follows: negative (no staining in inflammatory cells), mild (staining of less than 10% of inflammatory cells), moderate (staining of 10% to 50% of inflammatory cells), severe (staining of more than 50% of cells). In the evaluation of Tissue MPO activity, categories were compared numerically also. For this purpose, the categories for tissue MPO activity scored as; Negative (no staining in inflammatory cells), mild (less than 10% staining of inflammatory cells), moderate (10% to 50% staining of inflammatory cells), sever (over 50% staining of cells) activities. Patients who were diagnosed with H.pylori received quadruple therapy including rabeprazole 20 mg b.i.d., colloidal bismuth subcitrate 600 mg b.i.d., tetracycline 500 mg q.i.d. and metronidazole 500 mg t.i.d. for 14 days. Eight weeks after eradication therapy, patients were assessed with the C14 urea breath test (Heliprobe, Kibion AB Uppsala, Sweden). Patients with negative urea breath test were drawn blood samples again for MPO measurement. Blood samples were centrifuged and stored at -80°C until assay. SPSS version 15 was used for statistical analysis. Continuous variables were expressed as mean or median according to their homogeneity, and categorical variables were expressed as a ratio. The normal distribution of the variables was assessed using the Kolmogorov Smirnov test. Comparison of variables was made with Student’s t-test, Mann Whitney U test or Chi-square test, where applicable. Wilcoxon test was performed for comparison of pre and post-treatment serum MPO levels. P-value <0.05 was considered as statistically significant. Results In total, 107 patients were included in the study. H. pylori-negative group (Group 1) was 28 patients and H. pylori-positive group (Group 2) was 79 patients. Serum and tissue MPO activity were examined in 107 patients, serum MPO levels of 43 patients were determined following eradication therapy. The demographic and clinical characteristics of the patients in Group 1 and 2 are shown in Table 1. There was no significant difference between the groups in terms of gender and age. Tissue MPO levels were significantly higher in Group 2 than in Group 1 (p <0.001). Serum MPO levels were not significantly different between Group 1 and Group 2 patients (P = 0.266) (Table 2). 40

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Table 1. Laboratory and demographic parameters of groups Parameters

H. Pylori negative group (n=28) *

H. Pylori positive group (n=79) *

P value

35.2 (± 11.5)

36.0(± 10.4)

0.731

17/11 (%60.7/39.3)

44/35 (%55.7/44.3)

0.645

WBC (kμ/L)

6.9(±2.4)

7.1(±1.8)

0.774

Albumin (mg/dL)

4.3(0.44)

4.3(0.28)

0.911

43.2(± 12.3)

44.6(± 11.4)

0.589

Glucose (mg/dL)

89(13.25)

89(16)

0.559

HGB (g/dL)

13.9(2.58)

14.6(2.4)

0.129

Thrombocyte (103/μL)

228(±65.6)

224(±55.4)

0.738

Sedimentation (mm/hour)

8(16.25)

7(13)

0.249

AST (U/L)

20(7.5)

21(8)

0.865

ALT (U/L)

16(13)

19(17.25)

0.177

GGT (U/L)

16(10.5)

17(10.5)

0.744

ALP (U/L)

71.5(75.5)

72(61.25)

0.821

Total protein (mg/dL)

7.4(± 0.4)

7.4(±0.4)

0.886

Total Bilirubin (mg/dL)

0.83(0.67)

0.74(0.46)

0.411

Direct Bilirubin (mg/dL)

0.18(0.17)

0.18(0.11)

0.425

BUN (mg/dL)

25.5(8.63)

23.7(12.2)

0.994

Creatinine (mg/dL)

0.79(0.24)

0.8(0.2)

0.755

LDL (mg/dL)

92.2(47.75)

97.4(44.6)

0.356

75(76.5)

85(82.5)

0.392

Mean age, years Female/male (n %)

HDL (mg/dL)

Triglyceride (mg/dL)

*The values are presented as median (interquartile range IQR) or mean (±standard deviation). Abbreviations: WBC - White Blood Cell; HDL - high-density lipoprotein; HGB – Hemoglobin; AST - aspartate transaminase; ALT – alanine transaminase; GGT Gamma-Glutamyl Transferase; ALP - Alkaline Phosphatase; BUN - Blood Urea Nitrogen; LDL - low-density lipoprotein. Table 2. Serum and tissue MPO of study groups

Tissue MPO activity Serum MPO levels

Group 1 (n=28) H. pylori-negative

Group 2 (n=79) H. pylori-positive

P value

0.5(1)

2(1)

<0.001

2.19(1.91) * ng/mL

2.69(2.45) * ng/mL

0.266

*The values are presented as median (interquartile range IQR). Abbreviations: H. pylori - Helicobacter pylori; MPO – Myeloperoxidase.

When tissue MPO activity distribution of H.pylori positive and negative groups were examined; 79 patients who were positive for H.pylori, 13 (16.5%) had no tissue MPO activity, 22 (27.8%) were mild, 28 (35.4%) were moderate, and 16 (20.3%) had high levels of tissue MPO activity. Twenty-eight patients with H.pylori negative, 14 (50%) had no tissue MPO activity, 12 (42.9%) were mild, 1 (3.6%) was moderate, and 1 (3.6%) had high levels of tissue MPO activity (Table 3), (Figure 1). A total of 79 H.pylori positive patients who received eradication therapy; only 46 of them admitted to our clinic a performed urea breath tests, of those 43 were negative, and three were positive. Post-treatment serum MPO levels were found to be significantly lower than pre-treatment serum MPO levels (p = 0.002) (Table 4).

Table 3. Comparison of tissue MPO activity distribution between H.pylori positive and negative groups Tissue MPO activity*

H.pylori positive group

H.pylori negative group

Negative

13 (%16.5)

14 (%50)

Mild

22 (%27.8)

12 (%42.9)

Moderate

28 (%35.4)

1 (%3.6)

Severe

16 (%20.3)

1 (%3.6)

Total

79 (%100)

28 (%100)

*For Tissue MPO activity numeric comparison categories scored as: Negative: No staining in inflammatory cells; Mild: Staining <10% of inflammatory cells; Moderate: Staining 10% -50% of inflammatory cells; Severe: Staining >50% of cells.

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Table 4. Pre and post-treatment serum MPO activity of study groups

Serum MPO activity

Pre-treatment H. pylori-positive patients (n=43)

Post-treatment H. pylori-positive patients (n=43)

P value

2.69 (2.45)

1.26(2.36)

(P=0.002) *

*a significant difference was found between the groups. The values are presented as mean (interquartile range IQR).

1A. Mild MPO activity in lamina propria (MPO, immunoperoxidaseX100).

1B. Moderate MPO activity in lamina propria (MPO, immunoperoxidaseX100).

1C. Severe MPO activity in lamina propria (MPO, immunoperoxidaseX100). Figure 1. Scoring the gastric tissue MPO activity either in H. pylori-positive or negative groups patients using immunohistochemical staining with anti-myeloperoxidase antibody (A: Mild; B: Moderate; C: Severe).

Discussion This study differs from other studies by the evaluation of both serum and tissue MPO levels in H.pylori infected patients. The effect of eradication therapy was also investigated on serum MPO levels. Tissue MPO activity was found to be significantly increased in H.pylori infection. There was no significant difference in serum MPO levels between H.pylori positive patients and H.pylori negative patients. However, eradication treatment significantly decreased serum MPO levels. Increased MPO is effective in the antioxidant defense system. MPO is induced by inflammation due to H.Pylori infection.

Induced MPO and HOCl can be effective in local tissue damage, oxidative stress, and cancer pathogenesis. Also, MPO involved in the circulatory system during inflammation may enter the endothelial space and may affect the atherosclerotic process. In a similar study by Sasayama et al. reported that MPO activity in the gastric mucosa was significantly higher in H.pylori-positive patients than in H.pylori-negative patients, but serum MPO activity was not investigated in this study [19]. Similar studies on this subject have shown that patients infected with H.pylori have increased MPO activity in the gastric mucosa, and this increased tissue MPO activity has been associated with atrophic gastritis and gastric cancer due to this gastritis [8,10,11,20]. 42

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In another study in which the relationship between gastric cancer and MPO was investigated, the MPO level of neutrophils was found to be high in these patients [12]. Also, H.pylori density and neutrophil infiltration were correlated with MPO levels in gastric mucosa with H.pylori positive gastritis [21-23]. Nevertheless, Akçam et al. investigated the level of MPO activity in gastric mucosa of children infected with H.pylori and not infected with H.pylori. They found no difference in MPO activity between the two groups [24]. However, the number of patients with tissue MPO measured in that study was very low (n = 14).

Ethical approval Medical ethics committee of Ankara University (12.09.2011 / 35-766).

Özden A. Helicobacter pylori. Güncel Gastroenteroloji. 2006;10:287-91.

In the present study, no significant difference was found between H.pylori-positive patients and H.pylori negative patients in serum MPO level. This result may be interpreted as the tissue MPO activity that may be a stronger marker than serum MPO for H.pylori - MPO association. In a similar study by Rautelin et al. H.pylori gastritis and systemic MPO, response relation was investigated and serum MPO levels were reported to increase significantly compared to H.pylori negative patients [25].

International Agency for Research on Cancer. Schistosomes, liver flukes and Helicobacter pylori. IARC monographs on the evaluation of carcinogenic risks to humans, 61. Lyon. France: IARC, 1994.

Ahn HJ, Lee DS. Helicobacter pylori in gastric carcinogenesis, World J. Gastroint. Oncol. 2015;7:455.

Nemattalab M, Shenagari M, Taheri M, et al. Co-expression of interleukin17a molecular adjuvant and prophylactic helicobacter pylori genetic vaccine could cause sterile i̇ mmunity i̇ n treg suppressed mice. Cytokine. 2019;126:154866

Terasawa T, Hamashima C, Kato K et al. H.Helicobacter pylori eradication treatment for gastric carcinoma prevention i̇ n asymptomatic or dyspeptic adults: systematic review and bayesian meta-analysis of randomised controlled trials. H.Bmj Open. 2019;9:E026002

Mégraud F. Helicobacter pylori, gastric inflammation and its consequences. Ann Pharm Fr. 2003;61:282-7.

Atherton JC. The pathogenesis of Helicobacter pylori-induced gastroduodenal diseases. Annu Rev Pathol. 2006;1:63-96.

Pasceri V, Patti G, Cammarota G et al. Virulent strains of Helicobacter pylori and vascular diseases: a meta-analysis. Am Heart J. 2006;151:1215-22.

Correa P. Human gastric carcinogenesis: a multistep and multifactorial process – first American Cancer Society Award lecture on cancer epidemiology and prevention. Cancer Res. 1992;52:6735-40.

In this study, it was shown that there was a significant decrease in serum MPO levels in patients, which became after eradication treatment compared to pre-treatment situation. A similar study on this issue conducted by Nazlıgül et al. has shown that serum MPO levels were significantly reduced after eradication treatment in patients infected with H.pylori. However, in that study, pretreatment tissue and serum MPO values of H.pylori positive and negative patients were not compared [26]. Also, there are other studies that reported that tissue MPO activity decreased after the eradication of H.pylori [27-30]. Fukuda et al. investigated the neutrophil and MPO activity histologically in H.pylori infected patients after treatment and did not report a significant difference between before and after treatment [31]. However, unlike our study, only H2 receptor antagonists were used for treatment in that study. In another study about this issue, neutrophil infiltration was investigated in the mucosa of patients with a duodenal ulcer and it was observed that neutrophil infiltration containing MPO enzyme decreased as a result of H.pylori eradication treatment [32]. Conclusion The ROS produced due to H.pylori infection, results in MPO release from neutrophils. MPO has a strong proinflammatory effect. Decreased MPO activity by H.pylori eradication therapy prevents inflammatory damage to the stomach tissue. Thus, monitoring the effectiveness of H.pylori eradication therapy with MPO levels may reduce the incidence of future gastric neoplasia. Limitations After eradication treatment, H.pylori negativity was evaluated by a noninvasive urea breath test. Therefore, gastric endoscopy did not perform, and post-treatment tissue MPO was not evaluated. Seventy-nine patients with H.pylori were treated with eradication therapy, but 47 efficacy of the treatment of patients was evaluated after eradication in follow up. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study.

Meside Gunduzoz, ORCID: 0000-0001-6140-8331 Servet Birgin Iritas, ORCID: 0000-0001-5283-9973 Servet Guresci, ORCID: 0000-0003-2243-090 Murat Buyuksekerci, ORCID: 0000-0001-9921-0507 Osman Gokhan Ozakinci, ORCID: 0000-0001-5344-3305 Yasar Nazligul, ORCID: 0000-0003-1926-4594

References

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17. Zullo A, Hassan C, Andriani A. et al. Eradication therapy for Helicobacter pylori in patients with gastric MALT lymphoma: a pooled data analysis. Am J Gastroenterol. 2009;104:1932-7.

25. Rautelin Hilpi I, Oksanen Aino M, Veijola Lea I. et al. Enhanced systemic matrix metalloproteinase response in Helicobacter pylori gastritis. Ann Med. 2009;41:208-15.

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27. Keto Y, Takahashi S, Okabe S. Healing of Helicobacter pylori-induced gastric ulcers in Mongolian gerbils: combined treatment with omeprazole and clarithromycin. Dig Dis Sci. 1999;44:257-65. 28. Suzuki M, Mori M, Miyayama A. et al. Enhancement of neutrophil infiltration in the corpus after failure of Helicobacter pylori eradication. J Clin Gastroenterol. 1997;25:222-28. 29. de Cássia Dos Santos R, Bonamin F, Périco LL. et al. Byrsonima intermedia A. Juss partitions promote gastroprotection against peptic ulcers and improve healing through antioxidant and anti-inflammatory activities. Biomed Pharmacother. 2019;111:1112-23. 30. Bauer G. HOCl and the control of oncogenesis. J Inorg Biochem. 2018;179:1023.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):45-8

Serum angiostatin levels in diabetic patients with heart failure taking oral antidiabetic therapy or basal insulin and its clinical significance Birol Yildiz1, Ismail Erturk1, Galip Buyukturan2, Bilgin Bahadir Basgoz2, Ramazan Acar1, Kenan Saglam2 Gulhane Education and Research Hospital, Department of Medical Oncology, Ankara, Turkey Gulhane Education and Research Hospital, Department of Internal Medicine, Anakara, Turkey

1 2

Received 13 September 2019; Accepted 25 November 2019 Available online 24.02.2020 with doi:10.5455/medscience.2019.08.9132 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract Diabetes mellitus is a metabolic disorder with an increasing incidence all over the world leading to high sequelae and high mortality rates behind other microvascular and macrovascular complications. The deterioration in angiogenesis in particular is known to cause deterioration of vascular complications of diabetes. After the discovery of a natural angiogenesis inhibitor, angiostatin in the ethiopathogenesis of retinopathy and nephropathy, which are frequent complications of diabetes, several successful clinical trials have been made. However, the most lethal complication of diabetes, diabetic heart failure, lacks any trial about effectiveness of angiostatin. In this study, the levels and the clinical significance of angiostatin were investigated in oral antidiabetic or Insulin treated diabetic patients with heart failure. The patient group consisted of 31 patients with a diagnosis of diabetes mellitus and heart failure and the control group included 30 patients with heart failure without diabetes mellitus. Serum levels of angiostatin were studied. A total of 61 subjects were enrolled in the study. The patient group consisted of 31 patients; between the age of 56-88 (73.06 ± 8.7) years, of which 16 (51.6%) were female and 15 (48.4%) were male. The control group included 30 patients; 15 (% 50) women and 15 (50%) of were male, between the ages of 57 to 85 (74.23 ± 8.27). In the case group, the average angiostatin levels were 133.25 ± 78.46 and in the control group it was found to be 121.7 ± 71.81. The average angiostatin levels were similar in diabetic and non-diabetic heart failure groups (p=0.55). The average serum angiostatin levels showed a significant negative correlation with the level of fasting blood glucose. In our study, diabetic patients with heart failure, when compared with non-diabetic patients with heart failure, showed no significant difference in the levels of angiostatin. Levels of angiostatin are not affected by the level of HbA1c. Fasting blood glucose level has a negative correlation with the level of angiostatin. In order to be used in determining the prognosis in diabetic patients with heart failure, further studies are needed on angiostatin levels. Keywords: Diabetic heart failure, angiogenesis, angiostatin, HbA1c

Introduction The majority of patients with diabetes mellitus (DM) develop various complications over time. These complications have significant effects on mortality and sequelae cessation [1]. 70-80% of deaths in DM patients are due to cardiovascular diseases, the mortality rate due to cardiovascular disease is 2-4 times higher in patients with DM compared to those without DM [2]. As a result of clinical studies, DM is the most common cause of cardiovascular disease. It may be accepted as equivalent to coronary artery disease (CAD) in patients with a genetic predisposition [3,4]. Diabetic heart failure is a consequence of macrovascular complications of DM. Also, disrupted angiogenesis formation plays a crucial role in the development of DM related complications

[4]. Studies have accelerated with the discovery of angiostatin, an inhibitor of angiogenesis. Angiostatin is a proteolytic part of plasminogen [5-7]. The anti-angiogenic effect of angiostatin is evident and acts by inhibiting proliferation, in particular, vascular endothelium, and triggering programmed cell death [8-10]. Successful clinical studies have been conducted on the effect of angiostatin in patients with diabetic retinopathy and nephropathy. However, no research has been done on the efficacy of angiostatin in diabetic heart failure, the most significant complication of DM [11]. This study aimed to determine the effects of the use of angiostatine blood level in diagnosis, treatment, and follow-up in patients with diabetic heart failure receiving oral antidiabetic or basal insulin therapy. Material and Methods

*Coresponding Author: Birol Yildiz, Gulhane Education and Research Hospital, Department of Medical Oncology, Ankara, Turkey E-mail: bfyildiz@gmail.com

We included the study heart failure patients with or without DM applied to the GATA School of medicine outpatient settings or clinics between May 2012 and March 2013. We enrolled a total 45

doi: 10.5455/medscience.2019.08.9132

of 61 heart failure patients meet inclusion criteria Thirty-one of them have DM, and 30 of them were not. We recorded age, gender, height, body weight measurements, echocardiography reports performed last year, and results of hemogram, routine biochemistry, sedimentation rate, C-reactive protein, pro-BNP, and receiving treatments to the follow-up cards. We determined angiostatin levels from the serums of by using commercially available ELISA kits and using the Synergy HT plate reader (Bio-Tek Instruments Inc, Winooski, VT, USA) according to the manufacturer’s procedure (Eastbiopharm, Hangzhou, China, catalog no. CKE90461). The local ethics committee approved the study, and we obtained informed consent from all attendants. Statistical Analysis Descriptive statistics are shown as number (%) for discrete data and as mean ± standard deviation for continuous data. In intergroup comparisons, if the assumptions are met in paired comparisons where the difference is investigated, “t test for independent samples” is used. The nonparametric version of the Mann Whitney U Test was used in cases where the number of measurements in the comparison groups was low or the assumptions were not met. One Way Anova was required when the number of groups compared was more than 2, but the non-parametric Kruskal Wallis Test was preferred because the assumptions of this test were not met. Pearson Product-Moment Correlation Coefficient was used to investigate the relationship between two variables. The significance of the relationships between categorical variables was investigated by Chi-Square Test. The values of the study data which were p <0.05 were considered statistically significant. Results

Age Height

Weight Body Mass Index

Gender

Patient

Women

Patient

15(50%)

Men

Control

15(50%)

Group

Median

Standard Deviation

Patient

73.06

8.7

Control

74.23

8.27

Patient

163.06

7.16

Control

163.57

7.28

Patient

75.11

13.41

Control

72.23

11.09

Patient

28.24

4.41

Control

26.78

3.58

p 0.59

0.79

0.36 0.16

Control

p=0.9

Diabetic retinopathy in 16 patients (51.6%), 38 diabetic nephropathy in 15 patients (48.4%), history of coronary artery disease in 12 patients (38.7%), retinopathy in 16 patients (53.3%) and retinopathy in 16 patients (53.3%). (53.3) had nephropathy and 11 (36.7%) had coronary artery disease. According to the NYHA (New York Heart Association) staging of the case and control groups, the stages are given in Table-3. There were no patients with stage-1 heart failure, 7 (22.6%) had stage-2 heart failure, 12 (38.7%) had stage-3 heart failure and 12 (38.7%) had stage4 heart failure. In the control group, 1 (3.3%) stage 1 heart failure, 9 (30%) stage 2 heart failure, 11 (36.7%) stage 3 heart failure and 12 (38.7%) stage -4 had heart failure clinic. Table 3. Distribution of case and control groups according to heart failure stages Heart Failure Stage Stage-1 Stage-2

Stage-4

Group

Number

Ratio (%)

Patient

Control

3.3

Patient

22.6

Control

Patient

38.7

Control

36.7

Patient

38.7

Control

The results of the angiostatin levels of the participants are shown in Table-4. The mean angiostatin level of the patient group was 133.25±78.46, while the mean angiostatin level of the control group was 121.7±71.81. The difference was not statistically significant (p=0.55). Table 4. Angiostatin levels of case and control groups Variable

Table 1. Demographic characteristics of case and control groups Variable

Table 2. Distribution of case and control groups by gender

Stage-3

The demographic characteristics of the case and control groups are shown in Table-1 and the distribution by gender is shown in Table-2. A total of 31 patients (16 women (51.6%) and 15 women (48.4%) between the ages of 56-88 (73.06 ± 8.7) were included in the study. A total of 30 patients, 15 (50%) female and 15 (50%) male, aged 57-85 (74.23 ± 8.27) years were included in the control group. The mean length of the patient group was 163.06 ± 7.16 cm, body weight was 75.11±13.41 kg and body mass index was 28.24±4.41 kg / m2. In the control group, mean length was 163.57±7.28 cm, body weight was 72.23±11.09 kg, and body mass index was 26.78±3.58 kg / m2.

Med Science 2020;9(1):45-8

Angiostatin

Group

Median

Standard Deviation

Patient

133.25

78.46

Control

121.7

71.81

p 0.55

Angiostatin levels were correlated with white blood cell, hemoglobin, hematocrit, platelet, urea, creatine, high density lipoprotein, low density lipoprotein, sedimentation, crp, pro-BNP. Since the case group consisted of DM patients and there was no diagnosis of DM in the control group, the correlation analysis between fasting blood sugar and HbA1c levels and angiostatin was evaluated separately in the case and control groups. There was a negative correlation between mean angiostatin level and fasting blood glucose level in laboratory data (p=0.01), but not with other laboratory data.

doi: 10.5455/medscience.2019.08.9132

Retinopathy was present in 16 (51.6%) of the patient group and 16 (53.3%) of the control group. The mean angiostatin level was 127.74±84.83 in patients with retinopathy and the mean angiostatin level in patients without retinopathy 43 was 139.13±73.56. In the control group, the mean angiostatin level was 132.61±72.23 in patients with retinopathy and the mean angiostatin level in patients without retinopathy was 109.23±71.90. The difference between retinopathy complication and angiostatin level in patient and control groups was not statistically significant (p = 0.57). Nephropathy was present in 15 (48.4%) of the patient group and 16 (53.3%) of the control group. The mean angiostatin level was 131.44±86.46 in patients with nephropathy and the mean angiostatin level in patients without nephropathy was 134.95±72.99. In the control group, the mean angiostatin level was 132.61±72.23 in patients with nephropathy and the mean angiostatin level in patients without nephropathy was 109.23±71.90. There was a significant difference in the correlation between angiostatin levels and nephropathy complications in the patient and control groups, but this difference was not statistically significant (p=0.62). Coronary artery disease was present in 12 (38.7%) of the patient group and 11 (36.7%) of the control group. The mean angiostatin level was 138.07±88.50 in patients with coronary artery disease and 130.21±73.81 in patients without coronary artery disease. In the control group, the mean angiostatin level was 144.34±84.12 in patients with coronary artery disease and the mean angiostatin level in patients without coronary artery disease was 108.59±62.31. Correlation between coronary artery disease and angiostatin levels was found to be different in the patient and control groups, but this difference was not statistically significant (p=0.64). 17 patients (54.8%) were using insulin in the patient group. The mean angiostatin level was 134.65±72.09 in the insulin group, 131.76±87.29 in the non-insulin group and 121.70±71.81 in the control group. Angiostatin level was found to be different between the insulin users and non-users, but this difference was not statistically significant (p = 0.78). In the patient group, 3 (9.7%) people were using meglitinide. The mean angiostatin level was 116.73±50.44 in the patients receiving meglitinide, 135.02±81.35 in the patients not using meglitinide, and 121.70±71.81 in the control group. There was a significant difference in the correlation between angiostatin levels between participants receiving meglitinide and those who did not, but this difference was not statistically significant (p=0.87).

Med Science 2020;9(1):45-8

who did not, but this difference was not statistically significant (p=0.71). Discussion In our study, we tried to show angiostatin level and clinical significance in patients with diabetic heart failure receiving oral antidiabetic or insulin therapy. In our study, age, BMI, gender, HbA1c level, Pro-BNP level, inflammation marker sedimentation and angiostatin levels were not found to be correlated with the average. In addition, no significant difference was found between angiostatin levels of diabetic retinopathy, nephropathy, and CAD. Xi et al, 311 patients underwent coronary angiography in their study pro-BNP was observed to stimulate angiogenesis [11]. They observed that increased levels of proBNP increased collateral formation and more regular collateral formation in patients with high pro-BNP levels. Depending on the study, angiostatin with anti-angiogenic effect was expected to have a negative relationship between pro-BNP, but no significant correlation was found between angiostatin and Pro-BNP. Pro-BNP is significantly elevated in patients with heart failure. In our study, it was evaluated that no significant relationship was observed due to the diagnosis of heart failure in all case and control groups and due to high levels of proBNP due to heart failure. Patel et al., 102 heart failure and 110 healthy participants evaluated the level of angiogenesis stimulating angiogenesis in the study, angiogenin level of heart failure (according to the NYHC class) have determined that the level of angiogenin increases [12]. In our study, no significant relationship was found between EF and mean angiostatin level. This situation was attributed to the lack of a healthy control group in our study. Papathanassiou and colleagues in their study of 28 patients with DM, sulfonylureas have been found to have no effect on the endothelium [12]. In our study, we found that the average of angiostatin level in the sulfonylurea group was higher than the other treatment group. This was not clinically significant. These results are consistent with the literature and can be considered to be effective on endothelial function in DM patients receiving treatment other than sulfonylurea.

Nine patients (29%) were using sulfonylurea DM. The mean angiostatin level was 150.3±31.8 in the sulfonylurea group DM, 135.2±33.06 in the sulfonylurea group and 121.70±71.81 in the control group. There was a significant difference in the correlation between the levels of angiostatin between participants using glylazide and those who did not, but this difference was not statistically significant (p=0.19).

Studies have shown that metformin has an antiangiogenic effect by suppressing VEGF and proangiogenic factors in women with polycystic ovary syndrome. In the study of Soraya et al., Metformin has been shown to have antiangiogenic effect by reducing VEGF-A mRNA secretion [13]. Similar results were obtained in our study. Since the high level of angiostatin causes damage to coronary collateral vasculature, the lower mean level of angiostatin levels of 7 participants receiving metformin may be due to the protective effect of impaired angiogenesis. The difference was not statistically significant, which may be related to insufficient number of patients.

Seven patients (22.6%) were taking metformin in the patient group. The mean angiostatin level was 110.60±66.03 in the patients receiving metformin, 139.86±81.79 in the patients not using metformin and 121.70±71.81 in the control group. There was a significant difference in the correlation between the levels of angiostatin between the participants using metformin and those

In the ACCORD and VA-DT studies, which were published in 2007 and 2008, it was shown that strict metabolic control increases the risk of cardiovascular disease in elderly and DM groups with a duration of more than 10 years and the increase in risk is associated with a decrease in blood glucose levels [14]. The negative correlation between glucose and angiostatin, which is one 47

doi: 10.5455/medscience.2019.08.9132

of the results of our study, was evaluated in accordance with this literature.

Med Science 2020;9(1):45-8

diabetics in theFramingham population. Sixteen-year follow-up study. Diabetes. 1974;23:105-11.

Limitations of our study; compared to other studies in the literature, the number of participants is less, the lack of a healthy control group, and age, inflammation and renal failure, such as conditions that may affect angiogenesis status was not excluded during the choice of case and control groups.

Haffner SM, Lehto S, Ronnemaa T, et al. Mortality from coronary heart disease in subjects with type-2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339:229-34.

Donahue RP, Orchard TG. Diabetes mellitus and macrovascular complications; An epidemiological perspective. Diabetes Care. 1992;15:1141-55.

Conclusion

Distler JW, Hırth A, Kurowska-Stolarska M,et al. Angiogenic and angiostatic factors in the molecular control of angiogenesis. Q J Nucl Med. 2003;47:14961.

Konukoglu D, Turhan MS. Anjiyogenezin temel moleküler mekanizmaları ve tümor anjiyogenezi. Cerrahpasa Tıp Dergisi. 2005;36:42-8.

Andriana N, Klemens A, Moritz C. et al. Endogenous angiogenesis inhibitors prevent adaptive capillary growth in left ventricular pressure overload hypertrophy. Ann Thorac Surg. 2012;94:1509–18.

Zhao G, Yan W, Chen E, et al. Numerical simulation of the inhibitory effect of angiostatin on metastatic tumor angiogenesis and microenvironment. Bull Math Biol. 2013;75:274-87.

Radziwon-Balicka A, Ramer C, Moncada de la Rosa C, et al. Angiostatin inhibits endothelial MMP-2 and MMP-14 expression: a hypoxia specific mechanism of action. Vascul Pharmacol. 2013;58:280-91.

In conclusion, angiostatin level was not different when diabetic heart failure patients were compared with non-diabetic heart failure patients. In addition, angiostatin level was not affected by HbA1c level. There is a negative relationship between fasting blood glucose level and angiostatin level. We think that angiostatin blood level is not effective in the diagnosis, treatment and clinical follow-up of patients with diabetic heart failure. However, more comprehensive studies are needed in patients with diabetic heart failure to better address this issue. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval Ethical approval was obtained from GATA Ethics Committee

10. Koshida R, Ou J, Matsunaga T, et al. angiostatin: a negative regulator of endothelialdependent vasodilation. Circulation. 2003;107:803-6.

Birol Yildiz,ORCID: 0000-0001-8920-6467 Ismail Erturk, ORCID: 0000-0001-6835-0988 Galip Buyukturan, ORCID: 0000-0003-4781-9737 Bilgin Bahadir Basgoz, ORCID: 0000-0002-5795-533X Ramazan Acar, ORCID: 0000-0001-5864-0076 Kenan Saglam, ORCID: 0000-0003-2543-8853

11. Patel JV, Sosin M, Gunarathne A, et al. Elevated angiogenin levels in chronic heart failure. Ann Med. 2008;40:474-9.

References 1.

Stamler J, Vaccaro O, Neaton JD, et al. Diabetes, other risc factors, and 12 year cardovascular mortality for men screened in the Multipl Risk Factor Intervention Trial (MRFIT).Diabetes Care. 1993;16:434-44.

Garcia MJ, McNamara PM, Gorden T, et al. Morbidity and mortality in

12. Papathanassiou K, Naka KK, Kazakos N, et al. Pioglitazone vs glimepiride: differential effects on vascular endothelial cfunction in patients with type 2 diabetes. Atherosclerosis. 2009;205:221–6. 13. Soraya H, Esfahanian N, Shakiba Y, et al. Anti-angiogenic effects of metformin, an ampk activator, on human umbilical vein endothelialcells and on granulation tissue in rat. Iran J Basic Med Sci. 2012;15:1202-9. 14. ADA Clinical Practice Recommendations. ADA standards of medical care in diabetes-2007. Diabetes Care. 2011;34(Suppl.1):42-5.

Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):49-53

Volume of intensive care unit patients in the emergency department: clinical experience in a training and research hospital Murat Guzel1, Şener Cindoruk1, Mehmet Tevfik Demir1, Mehmet Yorgun1, Erdinc Yavuz2, Emre Ozgen1, Murat Yucel3, Ahmet Baydin4 Samsun Training and Research Hospital, Department of Emergency Medicine, Samsun,Turkey 2 Samsun Training and Research Hospital,Department of Family Medicine, Samsun,Turkey 3 Sakarya University, Faculty of Medicine, Department of Emergency Medicine, Sakarya, Turkey 4 Ondokuz Mayıs University, Faculty of Medicine, Department of Emergency Medicine, Samsun, Turkey 1

Received 28 May 2019; Accepted 26 Juny 2019 Available online 24.02.2020 with doi:10.5455/medscience.2019.08.9133 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract There is an increasing tendency for critically ill patients to present to emergency departments (EDs). In this study, it was aimed to assess patients who presented to the ED and admitted to the intensive care unit (ICU) and to identify waiting times in the ED. This retrospective study was conducted by reviewing data from 4904 patients (aged >18 years) who presented to the ED for whom the decision was made for hospitalization in the ICU between January 1st, 2016, and December 31st, 2017. Waiting time in the ED, demographic data, and length of ICU stay were reviewed for 3572 patients who were admitted to ICUs from the ED. The total number of patients who presented to the ED between January 1st, 2016, and December 31st, 2017 was 200,603. Among these patients, the ICU admission rate was 2.4%. Of 4904 patients who presented to the ED and the decision was made for ICU admission, 1332 patients were transferred to other facilities. When these patients were excluded, the ICU admission rate was found as 1.8% in our facility. When time to ICU admission from the ED was assessed, it was found that the shortest time recorded for admission from the ED to the burns unit was 48 minutes. The second shortest waiting time (148 min) was seen in patients admitted to the coronary intensive care unit. The mean waiting time of ICU patients in the ED was 282 min. The increase in the patients who have been decided to hospitalization in the ICU in the ED remains an important problem that should be managed in the ED crowd. Long waiting times for ICU patients in the ED make the already existing crowd more complicated. Keywords: Emergency department, intensive care, emergency department crowding

Introduction Emergency department (ED) crowding is a major global healthcare issue. The increase in patients who require treatment in the intensive care unit (ICU) and the elderly population along with the insufficient number of hospital beds, general increase in ED presentations, delays in laboratory and radiology results, prolonged time of consultations, and ED use for inappropriate presentations leads to crowding of patients in the ED and prolonged stay [1-4]. Longer stay in the ED or non-acceptance to ICUs has resulted in areas known as virtual ICUs in EDs. In these areas, it is attempted to provide intensive care treatment in the ED. However, ICUs are different from EDs due to factors such as specialized care, lower

*Coresponding Author: Murat Guzel, Samsun Training and Research Hospital, Department of Emergency Medicine, Samsun,Turkey E-mail: drmuratguzel@gmail.com

patient circulation, appropriate equipment, and the presence of a closed area [3]. In this study, our primary objective was to assess patients who presented to the ED and were subsequently admitted to an ICU. The secondary objective was to identify waiting times in the ED. Material and Methods This study was approved by the Medical Board of Expertise of the Samsun Training and Research Hospital (Date 30.04.2019, No. 2019/09). This retrospective study was conducted by reviewing data from 4904 patients (aged >18 years) who presented to the ED for whom the decision was made for hospitalization in the ICU between January 1st, 2016, and December 31st, 2017. Patients who had insufficiency in the hospital automation system and did not meet the criteria of intensive care hospitalization were excluded from the study. Overall, 1332 patients were transferred to other facilities due to the lack of available ICU beds. Waiting 49

doi: 10.5455/medscience.2019.08.9133

time in the ED, demographic data, and length of ICU stay were reviewed among 3572 patients who were admitted to the ICU. The hospital database was used to extract patient data. Intensive care hospitalization decision was made after the patients were evaluated by the specialist physicians about the department. ICU admissions were classified as level 1, level 2, and level 3 according to the level of ICU admission Which patient was admitted to the level 1, level 2, and level 3 intensive care units was decided according to the current clinical status of the patient.. In addition, ICU admissions were assessed separately according to the type of ICU. Results Overall, 200,603 patients presented to Samsun Research and Training Hospital between January 1st, 2016, and December 31st, 2017. Among these, the ICU admission rate was 2.4%. After exclusion of patients who transferred to other facilities from the ED, the ICU admission rate was 1.8% for our hospital. Of the 4904 patients who presented to the ED and decision was made for ICU admission, 1332 patients were transferred to other facilities due to the lack of available ICU beds. Of these, 348 (26%) patients were transferred within working hours and 984 patients (74%) were transferred out of working hours. The patients were most commonly transferred to Cardiology, Internal Medicine and Chest ICUs. In general, the least referred patients were found to have been hospitalized due to surgery. (Table 1). Table 1. Should change to â&#x20AC;&#x2DC;Intensive care unit patients transferred from the emergency department to other hospitals Transferred in working hours

Transferred out of working hours

Departments

Number of patients transferred

Emergency department

124

9.30

Neurosurgery

4.57

Pediatric surgery

0.75

Infectious diseases

1.42

Gastroenterology

0.67

General surgery

4.35

Thoracic surgery

2.92

Chest diseases

219

144

16.44

Internal medicine

224

159

16.81

Cardiovascular surgery

1.05

Cardiology

413

356

Neurology

116

8.70

Orthopedics

Plastic surgery

Total

1332

100

Med Science 2020;9(1):49-53

Table 2. Sex distribution in patients admitted to the intensive care unit Departments

Male

Female

Total

Discharged

ED ICU

177

155

332

255

General ICU

141

139

280

211

Surgical ICU

311

179

490

326

Medical ICU

206

188

394

237

Coronary ICU

1062

530

1592

1539

CVS ICU

Neurology ICU

176

182

358

287

Burns Unit

Anesthesia ICU

Total

2151

1421

3572

2954

60.2

39.8

100

82.7

When time to ICU admission from the ED was assessed, it was found that the shortest time recorded for admission from the ED to the burns unit was 48 minutes. The mean waiting time of ICU patients in the ED was 282 min. The second shortest waiting time (148 min) was seen in patients admitted to the coronary intensive care unit. The waiting times of patients admitted to other ICUs were similar. Table 3 presents the number of patients admitted to ICUs, time to admission to the ICU, and length of ICU stay. The mean length of ICU stay was 13.5 days. The shortest length of stay was recorded in the coronary ICU as 4 days. The mean age of patients admitted to ICUs was 40 years, the youngest age group associated with the burns unit (Table 3). When assessed according to ICU type, it was seen that 45.3% of patients had cardiologic disorders. The second most common disease group was internal diseases (16.5%) (Table 4). Table 3. Time to admission from the emergency department to the intensive care unit and length of stay in the intensive care unit n

Age

Time to admission from ED to ICU (minutes)

Length of stay (days)

ED ICU

332

9.3

396

General ICU

280

7.8

385

Surgical ICU

490

13.7

321

Medical ICU

394

398

Coronary ICU

1592

44.6

148

1.65

CVS ICU

2.43

234

0.30

Neurology ICU

358

209

348

984

100

Burns unit

0.8

26.12

73.87

Anesthesia ICU

0.25

398

Mean

3572

100

282

13.5

Of the patients admitted to our ICUs, 2151 (60.2%) were male and 1421 (39.8%) were female (Table 2).

doi: 10.5455/medscience.2019.08.9133

Med Science 2020;9(1):49-53

Table 4. Patient distribution according to intensive care unit level Level 1 ICU

Level 2 ICU

Level 3 ICU

Number of patients

Anesthesia and Reanimation

0.2

Neurosurgery

125

3.5

Pediatric Surgery

0.5

Endocrinology

0.7

Infectious diseases

1.1

Gastroenterology

General Surgery

103

126

3.6

Thoracic Surgery

2.6

Chest Diseases

108

164

285

Hematology

1.1

Internal Medicine

297

263

588

16.5

1.7

Cardiology

1578

1617

45.3

Nephrology

2.6

Neurology

275

316

8.9

Orthopedics

0.7

Plastic Surgery

0.8

Urology

0.2

Total

2199

368

1005

3572

100

61.4

10.4

28.2

100

Cardiovascular Surgery

Discussion There is an increasing tendency for critically ill patients to present to EDs [5]. Failure to expand the capacity of ICUs to a level sufficient to meet the needs of care for critically ill patients promotes triage for admission of patients [6]. The aim is to admit patients who would most benefit from ICU care by triage [6,7]. However, failure to admit patients to appropriate critical care areas has led to several problems. Thus, the length of ED stay and crowding in EDs are increasing, resulting in poorer care of quality and increased morbidity and mortality rates [8-13]. In addition, although there are guidelines about admission to ICUs, these guidelines provide insufficient information regarding which patients should be admitted to the ICU or acute care or palliative care areas [14]. In the present study, we intended to assess ED presentations, ICU admissions, and length of ED stay among critically ill patients. It was aimed to assess the process of admission to the ICU in critically ill patients who presented to the ED. According to 2001-2009 data from the United States National Hospital Ambulatory Medical Care Survey, presentation to EDs by critically ill patients had increased by 79% (from 1.2 million to 2.2 million). The rate of all ED presentations that resulted in ICU admission was found to be increased from 0.9% to 1.6%. Again, in the 2001-2009 period, length of ED stay for critically ill patients was found to be significantly prolonged from 195 to 245 minutes.

It was also observed that one-third of critically ill patients spent more than 6 hours in the ED. Stay in the ED may prolong to hours or even days. Moreover, the length of ED stay has progressively increased over time [5]. In our study, the mean length of ED stay was found as 280 minutes (Table 3), which was higher than our country average and that in other areas of the world [1, 10, 15-17]. In a study on patients admitted to the ICU from the ED, it was found that the mean length of ED stay was 5 hours [1]. In our study, we think that the short waiting times of the patients admitted to the burns unit were due to the fact that they are specialized ICUs and that patients other than those with burns cannot be hospitalized. Furthermore, we believe that the shorter waiting times of the patients admitted to the coronary ICU were due to the fact that they are specialized ICUs and the patient circulation is fast. The increase in the population of critically ill patients plays an important role in ED crowding; however, delays in admission also result in similar consequences. In other words, both the increased number of critically ill patients and delays in admission results in crowding in the ED [19]. In our study, it was found that 1331 (27%) patients who required admission were transferred to other facilities due to the lack of available beds (Table 1). We think that the reason for this is that the hospital intensive care bed capacity for critical patients cannot meet the demand. In agreement with the literature, it was found that there was a male preponderance (60.2%) among patients who presented to the ED and were subsequently admitted 51

doi: 10.5455/medscience.2019.08.9133

to the ICU [16]. The mean age of the critically ill patients who were referred to the ICU was 63 years. Our data is similar with the literature from other areas of world [16, 18]. According to data from US National Hospital Ambulatory Medical Care Survey, the mean age of patients requiring admission to the ICU has been increasing [16], which is attributed to the increase in average life expectancy worldwide. With aging, the incidence of chronic diseases and need for hospitalization including the ICU has increased together with the involvement of several clinical specialties. Departments wait for results from other departments and the ED process can be prolonged by orders from these departments. In addition, it becomes challenging to decide to which department patients should be admitted due to several distinct symptoms related to many departments. Together, these factors prolong time to admission. In a study by Simchen et al., the most common causes of admission were reported as pulmonary, cardiac, and neurologic disorders, as well as shock-sepsis [19]. Similarly, in our study, when assessed based on diagnosis, it was seen that cardiac disorders, chest disorders, and neurologic disorders were the most common causes of ICU admission (Table 4). Implementing palliative care facilities providing care for chronic disorders, oncologic problems, and bedridden patients will markedly reduce presentations to EDs by these patients [20-22]. In addition, increasing the number of intermediate care units will shorten the length of ED stay in critically ill patients [22]. It was seen that patients in the ED of our hospital were referred to other hospitals because there was no area where critical ICU-like patients could be followed for critical patient follow-up; one-quarter of patients who required admission were transferred to another facility. For this purpose, we think that intermediate intensive care units could be a solution for critical patient management. For the care and follow-up of these patients, it is important to support them with an experienced health perspective. Chalfin et al. suggested a possible benefit from expeditious transfer of critically ill patients from the ED to the ICU, and the need to further evaluate factors responsible for delayed ICU admission, as well as the specific determinants of adverse outcomes [10]. In our study, although the main reason for the insufficiency of patient transfer to the ICU was the lack of beds, we think that this problem may be different in every ED and necessary precautions should be taken accordingly. Limitations There are some limitations in our study. First, our study is the single-centered and may not be generalizable to other hospitals or settings. Second, our study is limited by the retrospective nature Conclusion The increase in the patients who have been decided to hospitalization in the ICU in the ED remains an important problem that should be managed in the ED crowd. Long waiting times for ICU patients in the ED make the already existing crowd more complicated. We believe that making the necessary arrangements in terms of health policies related to this patient group will contribute to the ED crowd. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study.

Med Science 2020;9(1):49-53

Ethical approval This study was approved by the Medical Board of Expertise of the Samsun Training and Research Hospital (Date 30.04.2019,No. 2019/09). Murat Guzel, ORCID: 0000-0003-0276-4576 Sener Cindoruk, ORCID: 0000-0001-9177-587X Mehmet Tevfik Demir, ORCID: 0000-0003-0319-9572 Mehmet Yorgun, ORCID: 0000-0003-1129-3702 Erdinc Yavuz, ORCID: 0000-0002-3275-8399 Emre Ozgen, ORCID: 0000-0001-8153-4132 Murat Yucel, ORCID: 0000-0003-0220-9230 Ahmet Baydin, ORCID: 0000-0003-4987-0878

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Abir M, Goldstick JE, Malsberger R, et al. Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged pati-ents. Int J Emerg Med. 2019;12:4.

Cowan RM, Trzeciak S. Clinical review: Emergency department overcrowding and the po-tential impact on the critically ill. Crit Care. 2005;9:291-5.

Karaca MA, Erbil B, OĚ&#x2C6;zmen MM. Waiting in the Emergency Room: Patient and Attendant Satisfaction and Perception. Eur J Surg Sci. 2011;1:1-4.

Herring AA, Ginde AA , Fahimi J, et al. Increasing critical care admissions from U.S. emer-gency departments, 2001-2009. Crit Care Med. 2013;41:1197204.

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10. Chalfin DB, Trzeciak S, Likourezos A, et al. Delay- ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477-83. 11. Duke G, Green J, Briedis J. Survival of critically ill medical patients is timecritical. Crit Ca-re Resusc. 2004;6:261-7. 12. Cardoso LT, Grion CM, Matsuo T, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care. 2011;15:R28. 13. Sprung CL, Artigas A, Kesecioglu J, et al. The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: intensive care benefit for the elderly. Crit Care Med. 2012;40:132-8. 14. Chang AM, Lin A, Fu R, et al. Associations of Emergency Department Length of Stay With Publicly Reported Quality-of-care Measures. Acad Emerg Med. 2017;24:246-50. 15. Nguyen HB, Rivers EP, Havstad S, et al. Critical care in the emergency department: A phy-siologic assessment and outcome evaluation. Acad Emerg Med. 2000;7:1354-61. 16. Mullins PM, Goyal M, Pines JM. National growth in intensive care unit

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Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):54-9

The knowledge and approaches of parents to tick bite and tick-borne disease Mehmet Kayhan, Sebahat Gucuk Bolu Abant Izzet Baysal University, Medical Faculty, Department of Family Medicine, Bolu, Turkey Received 31 August October 2019; Accepted 29 October 2019 Available online 24.02.2020 with doi:10.5455/medscience.2019.08.9134 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract The present study aims to evaluate the knowledge and approaches of parents to a possible tick bite and tick-borne diseases that may develop in their children. Methods: The descriptive study enrolled 504 voluntary parents living in Bolu, having children under the age of 18 and applying any reason to the outpatient clinic of family medicine between September 2018 and December 2018. A 33-question questionnaire was applied to all participants. The mean age of participants was 39,8±13,9 (18-68). Considering the measures taken by parents in their children, 240 (47.6%) of them were careful to wear light-colored and closed clothing and 379 (75.2%) of them were careful to tuck their pant legs into their socks. 169 (33.5%) of them were roughly checking the presence of tick on their children’s body, when they were in risky areas for ticks, while 78 (15.5%) of them were fully checking their children body, including the back of the underarm, the nape, the hair bottoms, the groin for presence of tick. When the participants with being engaged in farming compared with the patients without being engaged in farming, we observed the statistically significant differences concerning type of clothing styles, previous educational history and being familiar with a tick (p= 0.006, 0.014 and <0.001, respectively). The present study shows that people who are engaged in farming and live in risky areas for tick-bite are well-informed about the tick-borne disease. Furthermore, the people who are not engaged in farming must be trained on tick-bite and tick-borne disease. Keywords: Tick bite, tick-borne disease, tick control

Introduction Parasitic diseases, emitted by endoparasites or ectoparasites such as tick, are important health problems [1]. Parasites could carry and spread many different pathogens such as bacteria, spirochetes, rickettsia, protozoa, viruses, nematodes, and toxins [2]. To date, no combat method has been successful in tick eradication, so tick eradication is impossible. It was understood that ticks could cause medical and economic damages after realizing that ticks could infect humans and animals [3]. The fact that tick-borne diseases cause death in humans and animals is very important and notable for public health [4]. Tick-borne disease is more common in regions where ticks are endemic [5]. Therefore, when in the risky areas in terms of a tick, you need to beware of a tick bite [6]. In the last decades, the incidence of some rare tick-borne diseases, including Crimean-Congo Hemorrhagic

*Coresponding Author: Mehmet Kayhan, Bolu Abant Izzet Baysal University, Medical Faculty, Department of Family Medicine, Bolu, Turkey E-mail: dr.mehmetkayhan@gmail.com

Fever (CCHF), Lyme disease, tularemia, babesiosis, erliosis and the epidemic relapsing fever has increased and has become more popular due to climate changes in the world [7]. Previous studies have shown that only one tick could carry more than one infectious pathogen. They have also shown that 23% of patients with Lyme disease were accompanied by babesiosis, and 10-30% of them were accompanied by erliosis [8]. It should be kept in mind that combined pathogens will cause a worse clinical course. Lyme disease, which can cause serious problems due to cardiac, joint, and nervous system involvement, is the most common disease in the USA and the world. Since Lyme disease can cause serious sequelae, early diagnosis and treatment of this disease are essential. [9-11]. CCHF, a zoonotic disease increasing in recent years in Turkey, with a mortality of 3-30%, with symptoms such as fever, widespread muscle pain, headache, redness of the face and eyes, nausea, vomiting, diarrhea and widespread hemorrhage [12,13]. As in all infectious diseases, protection in tick-borne disease is very important. Therefore, it is necessary to increase the familiarity 54

doi: 10.5455/medscience.2019.08.9134

and knowledge of tick-borne diseases of people who live in risky areas. There are a limited number of studies evaluating the behaviors and knowledge of people about tick-borne diseases in literature. [14,15]. Especially to protect children from tick-borne disease, their parents’ knowledge and consciousness should be evaluated and measures should be taken, where they appreciate. Previous studies have shown that tick-borne disease is less common in children of parents whose knowledge and awareness about tick-borne disease have increased [16]. We aimed to evaluate the knowledge and approaches of parents to a possible tick bite and tick-borne diseases that may develop in their children.

Results The mean age of participants was 39.8±13.9 (18-68). 254 (50.4%) of participants were male, and 250(49.6%) of them were female. 199 (39.5%) of participants graduated from high schools. 223 (44.2%) of them were actively working. 313 (62.1%) of them thought their income and expenses were equal. 273 (54.2%) of them engaged were agriculture, while 30 (6%) of them were engaged in animal husbandry (Table 1). 338 (67.1%) of the parents were in the risk group in terms of tick contact. While 81 (16.1%) of them lived in the district, 51 (10.1%) of them lived in the village. 420 (83.3%) of them informed about the tick. Table 1. Demographic characteristics of parents

Material and Methods The descriptive study enrolled 504 voluntary parents applying any reason to polyclinic of family medicine, between September 2018 and December 2018. The inclusion criteria were as follows: 1) being over 18, 2) having any psychiatric disease, 3) being volunteer 4) having children under the age of 18. Written informed consent was obtained from all patients in the study. The study was approved by the Abant İzzet Baysal University Ethical Committee and Review Board.

Age

Gender

A 33-question questionnaire was applied to all participants. The questions in the questionnaire were prepared based on the information given in the brochures of the Public Health Directorate [17].

Occupation

The socio-demographic characteristics in the first part, the information about the tick and tick-related diseases in the second part, and the information related to the measure and intervention for tick-borne disease in the third part of the questionnaire were questioned. The questionnaire, which was prepared with the use of posters, asked the participants what they were doing to prevent tick bite and what they would do in case of a tick bite. They were asked how they were dressed at the picnic, in the garden or in the field and the precautions they had taken in contact with the animals. They were asked whether they fully checked their child’s body, including the back of the underarm, the nape, the hair bottoms, the groin for the presence of a tick, when they are risky areas. Checking at least three risky areas mentioned above of the body was accepted as “fully checking.” Multiple-choice questions were asked to determine what they would do following the possible tick bite

Education level

As defined by the Public Health Agency of Turkey, those who are engaged in agriculture and animal husbandry, camping and picnics, and those who are exposed to unprotected green areas (garden, vineyard, field, forest, and forest edge agricultural land etc.) were defined as the risk group. Data analysis was performed by using IBM SPSS Statistics version 23.0 software (IBM Corporation, Armonk, NY, USA). Continuous variables were shown as mean ± SD (min-max). A number of cases and percentages were used for categorical variables. ChiSquare Test compared the mean differences of socio-demographic characteristics and answers between groups. A p-value of less than 0.05 was considered statistically significant.

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Living place

In terms of tick contact

<25

10.5

26-35

154

30.6

36-45

134

26.6

>45

162

32.1

male

254

50.4

female

250

49.6

actively working

223

44.2

retired

14.9

not actively working

206

40.9

literate

3.0

primary education

167

33.1

high school

199

39.5

college

123

24.4

center

363

72.0

district

17.9

village

10.1

risky

338

67.1

risky free

166

32.9

84 (16,7%) of them had previously received training on ticks and tick-borne diseases. Of those who did not receive education, 332 (79%) of them were willing to be educated on this subject. 434 (86.1%) of them (90.2% of men and 82% of women, p:0.080) knew that some diseases could pass by tick bite (Table 2). 397 (78.8%) of them stated that tick diseases in the spring and summer (April-September) were more frequent. 394 (78.1%) of them stated that the time of tick bite on the human body is important for disease transmission. 213 (42.3%) of them answered as “ I have no idea” to the question as “How long the disease begins after the tick bite? Considering the measures taken by parents in their children, 240 (47.6%) of them were careful to wear light-colored and closed clothing and 379 (75.2%) of them were careful to tuck their pant legs into their socks. 39.6% of the parents stated that they would not touch the tick on the animals and the blood and urine of the animals with the bare hands. 55

doi: 10.5455/medscience.2019.08.9134

169 (33.5%) of them were roughly checking the presence of tick on their children’s body, when they were in risky areas for ticks, while 78 (15.5%) of them were fully checking their children body, including the back of the underarm, the nape, the hair bottoms, the groin for presence of tick. The percentage of those who said that they would remove the tick

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bite on the body without touching the bare hands, with gloves, cloth or pouches, was 89.7%. The percentage of those who said that they would apply cologne or alcohol on bite tick was 8.1%, who said that they would wait for it to fall spontaneously was 3.8%, who said that they would crush it with their hands was 11.1% (Table 3). 468 (92.8%) of the participants said that they would go to the nearest health center to remove the tick.

Table 2. Information about the tick and tick contact of parents

Informed about tick Previously received training on ticks and tick-borne diseases

Have you ever seen a tick?

Have you ever been bitten by a tick?

Have you ever taken a tick? After tick bite

I removed myself

I remove with tweezers

I would apply cologne or alcohol

I would wait it to fall spontaneously

I would go to the nearest health center for remove the tick.

10.4

yes

452

89.6

420

83.3

yes

16.9

339

67.3

yes

165

32.7

485

96.2

yes

3.8

470

93.3

yes

6.7

452

89.7

yes

10.3

442

87.7

yes

12.3

448

88.9

yes

11.1

486

96.4

yes

3.6

7.1

yes

468

92.8

Table 3. Approaches of parents to prevent tick clinging and tick related diseases in children

Careful to wear light-colored and closed clothing

Careful to tuck their pant legs into their socks In areas where tick bitting is risky

Bare hands touching the tick on animals. blood and urine of animals Check for ticks including the back of the underarm. the nape. the hair bottoms. the groin for presence of tick. when they are risky areas. (Checking least 3 areas) Fully checked their child's body

I don’t

264

52.4

I do

240

47.6

I don’t

125

24.8

I do

379

75.2

I don’t

304

60.4

I do

200

39.6

I wouldn't check

335

66.5

I would check

169

33.5

I wouldn’t check

426

84.5

I would check

15.5

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Although the participants living in the village had significantly lower educational level compared to those living in the district of the city (p:0.030), the percentage of the those children who were living in the village was covered with light-colored and closed clothing rate of 31.4% as similar to those living in the district of the city (p:0.160). The percentage (51%) of “roughly checking for a tick” in their children was significantly higher than the others (p:0.020). However, the percentages of “fully checking for a tick” were similar among the groups (p:0.284). The participants at risk in terms of tick contact showed a higher incidence of tick encounter, tick bite and informing about tick than others (p:0.001, p:0.090 and p:0.013, respectively). The participants, informed about the tick, stated that they benefited

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most from the education they received from health workers (62.1%). Considering the measures taken by parents in their children, 162 (47.9%) of them, who were living in risky areas, we’re careful to wear light-colored and closed clothing. 243 (71.9%) of them, who were living in risky areas, we’re careful to tuck their pant legs into their socks as similar to others (p:0.082). While 338 (%62.6) of participants were being engaged in farming, 166 (%37.4) of participants were without being engaged in farming. Compared to those who engaged with and without farming in terms of variations with tick, there was a statistical difference in terms of dress type (p:0.006), previously received training on ticks and tick-borne disease (p:0.014), whether the ticks sees (p<0.001), whether the tics bite (p:0.006) (Table 4).

Table 4. Comparison of tick-related variables of with or without being engaged farming N(%)

Being Engaged Farming (n:338)

Without Engaged Farming (n:166)

Light-colour

162 (47.9)

56 (33.7)

Dark colour

69 (20.4)

50 (30.1)

No answer

107 (31.7)

60 (36.1)

Yes

66 (19.5)

18 (10.8)

272 (80.5)

148 (89.2)

Yes

138 (40.8)

27 (16.3)

200 (59.2)

139 (83.7)

Yes

18 (5.3)

165 (99.4)

320 (94.7)

1 (0.6)

Yes

33 (9.8)

165 (99.4)

305 (90.2)

1 (0.6)

Dress Type

0.006

Previously received training on ticks and tick-borne diseases 0.014

Have you ever seen a tick? <0.001

Have you ever been bitten by a tick? 0.006

Have you ever taken a tick?

Discussion Ticks have a great potential to carry many pathogenic factors that can cause disease in humans and animals since they are compulsory blood-sucking arthropods. Ticks can live in every region of the world; more than 850 species have been identified in Turkey. The provinces where tick-borne diseases are seen intensively were Erzurum, Erzincan, Gümüşhane, Bayburt, Tokat, Yozgat, Sivas, Amasya, Çorum, Çankırı, Bolu, Kastamonu, Karabük, Giresun and Samsun in Turkey [18]. In other regions of Turkey, although

<0.001

rare, it has been reported cases of different tick-borne diseases [19]. Bolu, where the present study was conducted, is one of the regions where both tick bites and tick-borne diseases are frequently reported in Turkey [20]. In patients bitten by ticks, other diseases such as CCHF and Lyme disease should be kept in mind, the differential diagnosis should be made by using clinical and laboratory findings and early treatment should be initiated for prevention of serious complications that may develop [21]. 57

doi: 10.5455/medscience.2019.08.9134

Dzul-Rosado et al. have found that 98.5% of the people living in endemic regions recognized the tick [22], as like the current study [89.6%). Since the vital activity of ticks increase in hot air and more people going to picnic in summer, tick-borne diseases show a seasonal tendency and most cases of them are observed between June and September [23,24]. Another study showed that schoolage children had more risk of tick attachment because they spent more time outside [25]. Because the time of tick bite is one of the most important factors determining the transmission of tick-borne disease, it is necessary to remove the biting tick from the body as soon as possible [24]. Most of the participants in the present study knew that tick-borne diseases were most frequently seen in the summer months, tick-borne diseases could be transmitted, and the risk of disease transmission increased as tick- bite time increased. 83.3% of the participants in our study were educated on these mentioned subjects. The participants, living in the village, were educated more than others. These results are important in terms of demonstrating how much training is required within the scope of primary health care. The emergence of deaths related to tick-borne diseases led to the development of awareness and knowledge about ticks in society [26]. Butler et al. have reported that the cases of the tick-borne disease have been seen more in the uneducated areas about tick [27]. Another study showed that uneducated people about tick are mostly oblivious to the tick bite on their body; however, when they come to tick-borne disease in the people around them, they admitted to the health center due to tick bite [28]. People living in the areas with low socio-cultural levels try to treat the tick-holding area or to prevent the tick bite with fat, salt or other substances. However, studies are reporting that these approaches are successful [29,30]. The participants in previous studies, like our study, have stated that the tick should be removed in the professional health center without using the bare hands [26,31]. Previously given education emphasized that at the health center. However, recently given education have emphasized that tick should be removed as soon as possible with the appropriate method Physical examination of patients admitted to the health center due to tick bite should be performed carefully, and the tick should be removed with the right technique. After removal of the tick, the patient and his / her family should be informed that they should re-apply to the health center if possible, disease symptoms such as sudden fever in ten days, head and muscle pain or weakness are observed. People in areas where the ticks are endemic take measures to prevent tick infestation even in the houses; where they live. Unlike vectors such as mosquitoes or bedbugs, ticks are very difficult to destroy. Protective measures and changing individual behaviors are considered as the most important factors in protection against tick-borne diseases [26,25]. Another study has demonstrated that people did not take any measures about ticks in the habitats they were accustomed to, but they considered to take more measures about tick in environments where they were not familiar [32]. Previous studies have reported that people who live in low sociocultural level in which the tick is endemic remain insensitive to possible tick-borne diseases [26,33]. It is known that changing individual behavior takes time and requires a professional training process. Aenishaenslin et al. have

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emphasized that health education should be given individually rather than high participation meetings and should be compatible with the educational level of the community [34]. Beaujean et al. found that only 18% of the parents fully checked their children for tick, similar to our study (15.5%) [35]. The tick is easier to detect on visible parts of the body, while it may be more difficult to detect the tick on unseen parts of the body. Therefore, all patients should be examined carefully in a patient who is admitted with a tick bite. Duman et al. have revealed that the most common bite area of the tick was head and neck (31.2%), lower extremity (18.3%), genital area (13.4%) [36]. Oğuz et al. have also reported that the most common bite area of the tick was head and neck head and neck (50%), body (28.3%) and arm and leg (21.7%) [37]. Kömüroğlu et al. have shown that tick bites were more common in the lower extremity in adults, while they were more common in the head and neck region in children [24]. The high rate of the tick bite in the head and neck region indicates that the standard measures (wearing boots and thick socks on the feet) to protect children from tick attachment are not sufficient. Therefore, the possibility of a tick bite in rural areas should always be considered. Beaujean et al. have underlined that the training given in rural areas should be of interest to children [35]. Limitations The limitations of the current study include that the majority of the participants live in urban areas and inadequate information about the disinfestation. Further multi-center prospective studies should be designed to investigate the level of education related to the prevention of tick-borne disease. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval The study was approved by the Abant İzzet Baysal University Ethical Committee and Review Board. Mehmet Kayhan, ORCID: 0000-0001-7493-5165 Sebahat Gucuk, ORCID:0000-0003-3194-6221

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25. Shadick NA, Zibit MJ, Nardone E, et al. A school-based intervention to increase lyme disease preventive measures among elementary school-aged children. Vector Borne Zoonotic Dis. 2016;16:507-15. 26. Ser Ö, Çetin H. The current situation of Crimean-Congo Hemorrhagic Fever TAF Prev Med Bull. 2016;15:58-68. 27. Butler AD, Sedghi T, Petrini JR, et al. Tick-borne disease preventive practices and perceptions in an endemic area. Ticks Tick Borne Dis. 2106;7;331–7. 28. Kisinza WN, Talbert A, Mutalemwa P, et al. Community knowledge, attitudes and practices related to tick-borne relapsing fever in dodoma rural district, central Tanzania. Tanzan J Health Res. 2008;10:131–6. 29. Wanzala W. Potential of tradition-al knowledge of plants in the manage-ment of arthropods in livestock indus-try with focus on (Acari) ticks. Evid Based Complement Alternat Med 2017; Article ID: 8647919. 30. Wanzala W, Takken W, Mukabana WR, et al. Ethnoknowledge of Bukusu community on livestock tick prevention and control in Bungoma District, western Kenya. J Ethnopharmacol. 2012;140:298–324 31. Zöldi V, Turunen T, Lyytikäinen O, et al. Knowledge, attitudes, and practices regarding ticks and tick-borne diseases, Finland. Ticks and Tick-borne Diseases. 2017;8;872–7. 32. Valente SL, Wemple D, Ramos S, et al. Preventive behaviors and knowledge of tick-borne ill-nesses: results of a survey from an endemic area. J Public Health Manag Pract. 2015;21;E16–23. 33. Mead P, Hook S, Niesobecki S, et al. Risk factors for tick exposure in suburban settings in the Northeastern United States Ticks and Tick-borne Diseases 2018;9;319–24. 34. Aenishaenslin C , Bouchard C, Koffi JK, et al. Exposure and preventive behaviours toward ticks and Lyme disease in Canada: Results from a first national survey Ticks and Tick-borne Diseases. 2016;8:112–8. 35. Beaujean DJ, Gassner F, Wong A, et al. Determinants and protective behaviours regarding tick bites among school children in the Netherlands: a cross-sectional study. BMC Public Health. 2013;13:1148. 36. Duman M, İnceboz T, Gençpınar P, et al. Investigation of the Cases Presenting to the Pediatric Emergency Department with a Tick Attachment. Turkiye Klinikleri J Med Sci. 2103;33:164-71. 37. Oguz S, Korkmaz V, Kurt F, et al. Tick bite in pediatric emergency department: is laboratory necessary in asymptomatic patients? Turk Hij Den Biyol Derg. 2015;72:109-14.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):60-6

Factors influencing influenza and pneumococcal immunization rates of COPD patients in Bolu, Turkey Manolya Ballar, Tuncer Tug, Mehmet Kayhan, Suat Konuk Bolu Abant Izzet Baysal University, Department of Chest Diseases, Bolu, Turkey Received 06 November 2019; Accepted 04 December 2019 Available online 24.02.2020 with doi:10.5455/medscience.2019.08.9135 Copyright ÂŠ 2020 by authors and Medicine Science Publishing Inc. Abstract The aim of this study was finding out the rates of pneumococcal and influenza vaccination, the factors influencing vaccination, and non-vaccination in COPD patients. The study was conducted with 104 COPD patients diagnosed by a pulmonologist. The diagnosis was made according to the GOLD 2019 document via an FEV1/FVC ratio below 70%. The patients were inquired about getting vaccinated for influenza in the last year and pneumococci in the last five years. The patients were then grouped according to their vaccination status and inquired about their perception of the necessity of vaccination. The study revealed a significant association between COPD levels and the awareness of the necessity of annual influenza vaccination (p=0.019). However, there was no significant association between COPD levels and being vaccinated for influenza in the last year (p=0.434). There was no significant association between COPD levels and pneumococcal vaccination in the last five years or the awareness for the necessity of the vaccine (p=0.0559 and p=0.495). 22.2% of the patients who were vaccinated for pneumonia were also vaccinated for influenza and 98.7% of the patients who were not vaccinated for pneumonia were also not vaccinated for influenza in the last year. 85.7% of the patients who got an influenza vaccine in the last year also knew the necessity of getting annually vaccinated (p=<0.001). Every patient who has gotten the pneumonia vaccine in the last five years knew the necessity of getting a pneumonia vaccine as well (p<0.001).This study shows that most patients who got the influenza vaccine in the last year also knew the necessity of getting an influenza vaccine every year. Furthermore, all the patients who got the pneumococcal vaccine in the last five years knew the necessity of getting the pneumococcal vaccine. Most patients who were not vaccinated for pneumonia in the last 5 years were not vaccinated for influenza either. Keywords: COPD, vaccine, pneumococcus, influenza

Introduction Chronic obstructive pulmonary disease (COPD) is a common chronic disease and a significant cause of mortality and morbidity in the whole world. Exacerbations are an important determinant for deterioration and mortality among COPD patients, and reducing exacerbations is one of the primary goals of treatment [1]. The most commonly shown viruses in acute exacerbations are; rhinovirus, RSV and influenza. The most frequently isolated virus in the first week of exacerbation is the human rhinovirus [2]. The most common cause of secondary bacterial infection after an influenza infection is pneumococci [3]. In addition to the pharmacological treatment of stable COPD, international guidelines recommend vaccination with 23PPA and 13KPA is recommended in patients 65 years and older. 23PPA is recommended in young COPD cases in the presence of co-morbidities including chronic heart diseases [1] . *Coresponding Author: Suat Konuk , Bolu Abant Izzet Baysal University, Department of Chest Diseases, Bolu 14030, Turkey E-mail: suatkonukk@windowslive.com

influenza vaccination for all patients. Additionally, pneumococcal This study aimed to determine the frequency of influenza and pneumococcal vaccination in COPD patients and the factors affecting the vaccination rates; thus, raising awareness among physicians for the steps to be taken to solve the underlying causes of non-vaccination behavior. Material and Methods This study was a single-center cross-sectional study carried out at The Bolu Abant Izzet Baysal University, Training and Research Hospital, Chest Diseases Service, data were collected between 15.02.2019-15.04.2019. The study was approved by the Bolu Abant Izzet Baysal University Clinical Researches Ethics Committee with the protocol number 2019/33. Patients who decided to participate in the study signed an informed consent form. 104 COPD patients diagnosed by pulmonologists were included in the study. All patients were diagnosed according to the GOLD criteria of FEV1/FVC <%70 of what is expected. There were no exclusion or inclusion criteria beyond that. The form used 60

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for data collection was composed of 13 questions and was based on recent literature. The questions were about socio-economical characteristics, knowledge and behaviors about vaccination. The descriptive findings of the census data are shown as frequency, distribution, and percentages. The descriptive findings of the data indicated by the measurement are shown as mean, median, standard deviation, minimum and maximum values. When examining the difference between groups in terms of a numeric variable, in cases where parametric test assumptions were accurate, the significance test of the difference between the two means was used. When parametric test assumptions were not accurate, the Mann-Whitney U test was used. The analysis of categorical variables was examined by Chi-square test and the level of statistical significance was taken as p <0.05. SPSS v.21 was used for statistical analysis. Results The mean age of the participants was 64. 85% were male, 75% were primary school graduates. When classified according to GOLD groups, 51% (n=52) were in group A, 26% (n=26) were in group B, 11% (n=11) were in group A, and 13% (n=13) were in group D (Table 1). Even though 41.3% (n = 43) of the participants knew that they should be vaccinated for flu, the rate of actual vaccination was 26.9% (n = 28) in the last year. Of those who knew that they needed to get the flu vaccine, 41.9% (n = 18) reported that they got this information from a pulmonologist or assistant physician, 25.6% (n = 11) from a family physician, 7% (n = 3) from media, 4.7%

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(n = 2) from a pharmacist, and 16.3% (n = 7) from their social environment. 73% (n = 76) of the participants did not receive the flu vaccine in the last year. When asked why, 67.1% (n = 51) did not get a recommendation from their physician, 1.3% (n = 1) feared the vaccination, 5.3% (n = 4) did not know where to do it, and 13.2% (n = 10) forgot. 7.8% (n = 8) of participants knew that they should receive pneumonia vaccination and 6.8% (n = 7) received pneumococcal vaccination in the last five years. Of those who knew that they needed to get the pneumococcal vaccine, 50% (n = 4) reported that they got this information from a pulmonologist or assistant physician, 12.5% (n = 1) from a family physician, 12.5% (n=1) from an auxiliary health personnel, and 12.5% (n=1) from a pharmacist. 93.2% (n = 96) of the participants did not receive pneumococcal vaccine in the last five years. When asked why, 87.5% (n = 84) did not get a recommendation from their physician and 6.3% (n = 6) did not know where to do it. There was no statistically significant relationship between GOLD groups and vaccination in the last year ( =0.434). The highest vaccination rate was in group C with 45.5%, while the lowest rate was in group A with 21.2%. The GOLD groups did not affect the status of influenza vaccination. Yet, there was a statistically significant relationship between the GOLD groups and the awareness for an annual vaccination (p = 0.019). When we look at the rates in groups, 81.8% of group C stated that they knew the necessity of a flu vaccine every year. This rate was found to be considerably higher than in other groups (Table 2).

Table 1. Demographic characteristics Mean ± Std. Deviation Age

Sex

Education

Tobacco use *

GOLD groups

Min - Max

64.173 ± 11.22

30 – 84 Number

Percentage

Female

15.4

Male

84.6

İlliterate

5.9

Literate

3.9

Primary school

74.5

Middle school

5.9

High school

8.8

University

1.0

Non-smoker

18.0

Active user

26.0

Past user

56.0

51.0

25.5

10.8

12.7

*Those who had no past smoking experience were classified as “non-smokers”, current users were classified as “active users”, those who had previously used but were not currently smoking classified as “past users”

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Table 2. Relationship between demographic characteristics and flu vaccination awareness Awareness about annual flu vaccination Yes

65.69 ± 12.51

63.09 ± 10.19

0.142

67 [30 - 84]

64 [34 - 80]

Female

5 (31.3)

11 (68.8)

Male

38 (11.6)

50 (56.8)

İlliterate

1 (16.7)

5 (83.3)

Literate

3 (7.0)

1 (25.0)

Primary school

28 (36.8)

48 (63.2)

Middle school

4 (66.7)

2 (33.3)

High school

6 (66.7)

3 (33.3)

University

0 (0.0)

1 (100.0)

Non-smoker

3 (16.7)

15 (83.3)

Active user

12 (46.1)

14 (53.8)

Past user

26 (46.4)

30 (53.6)

17 (32.7)

35 (67.3)

12 (46.2)

14 (53.8)

9 (81.8)

2 (18.2)

4 (30.8)

9 (69.2)

Age

Sex

Education

Tobacco use *

GOLD groups

0.373

0.068

0.019

There was no statistically significant relationship between GOLD groups and pneumonia vaccination status in the last five years (p = 0.559). When we look at the rates in different groups, it is shown that 10% of group C was vaccinated for influenza annually and also for pneumonia in the last 5 years. This rate was higher than in other groups, but the difference was not statistically significant. There was no statistically significant relationship between GOLD groups and pneumonia vaccination awareness (p=0.495). Strikingly 100% (n=13) of group D patients were unaware of the need for a pneumonia vaccination (Table 3). There was no statistically significant relationship between GOLD groups and pneumonia vaccination status in the last five years (p = 0.559). When we look at the rates in different groups, it is shown that 10% of group C was vaccinated for influenza annually and also for pneumonia in the last 5 years. This rate was higher than in other groups, but the difference was not statistically significant. There was no statistically significant relationship between GOLD groups

and pneumonia vaccination awareness (p=0.495). Strikingly 100% (n=13) of group D patients were unaware of the need for a pneumonia vaccination (Table 3). There was a statistically significant relationship between the influenza vaccination status in the last year and the knowledge that the vaccine should be administered every year (p = <0.001). While 85.7% of those who have had the flu vaccine in the last year knew that they should have it every year, only 25.0% of those who have not had the flu vaccine in the last year knew that they should have it every year. Similarly, there was a statistically significant relationship between pneumococcal vaccination status in the last five years and the knowledge that the vaccine should be administered every five years (p<0.001). All of those who have had pneumonia vaccination in the last five years knew that they should get this vaccine, while only 1.0% of those who have not had pneumonia vaccination in the last five years knew about the necessity of the vaccine. 62

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Table 3. Relationship between demographic characteristics and pneumonia vaccination awareness Awareness about annual flu vaccination Yes

69.62 ± 7.99

63.65 ± 11.40

0.222

68 [61 - 84]

65 [30 - 84]

Female

1 (6.3)

11 (93.8)

Male

7 (8.0)

50 (92.0)

İlliterate

0 (0.0)

6 (100.0)

Literate

0 (0.0)

4 (100.0)

Primary school

5 (6.6)

71 (93.4)

Middle school

1 (20.0)

4 (80.0)

High school

2 (22.2)

7 (77.8)

University

0 (0.0)

1 (100.0)

Non-smoker

1 (5.6)

17 (94.4)

Active user

1 (3.8)

25 (96.2)

Past user

6 (10.9)

49 (89.1)

5 (9.6)

47 (90.4)

2 (7.7)

24 (92.3)

1 (10.0)

9 (90.0)

0 (0.0)

13 (100.0)

Age Sex

Education

Tobacco use *

GOLD groups

0.805

0.478

0.495

* Inter-group evaluation could not be done because the data was concentrated in one category.

Discussion Currently, the GOLD document states that both influenza and pneumococcal vaccines should be administered to patients with COPD, and the annual flu vaccination is recommended for all patients regardless of the COPD groups [1]. Viruses are thought to be responsible for 25-30% of COPD exacerbations caused by infection [5]. Influenza virus infections lead to exacerbations in this group of patients, facilitating the development of pneumonia and secondary bacterial infection, increasing morbidity and mortality, and it is thought that 8-10% of acute exacerbations are due to influenza virus. In our study, only 26.9% of the participants had the flu vaccine in the last year, and this rate is quite low considering the severity of a condition such as COPD. The reason for the low rate of vaccination may be; that the beneficial effects of vaccines in disease management are not known by the participants, the average age of the patient population is high, the level of education of patients is low, clinicians or health workers do not inform the patients and their relatives about the vaccination and there may be some obstacles arising from access to the vaccine. In similar studies conducted in Turkey, the frequency of influenza vaccination was shown to be 35-40% [5-7]. In a study conducted in the UK “The Health Improvement Network (THIN)” database, vaccination

rates in 60 years or older COPD patients were shown to be less than 30% before 1995 and the rate increased to over 70% in 2005. [8] In a study conducted in the USA in 2005, vaccination rates in the general population over 65 years of age were 63.7%.[9] The reasons for the difference to our country may be influenced by many factors such as the educational status of the patients, health policies of the countries, the severity and duration of the disease, the history of frequent consultations, and the attitudes of physicians about the vaccination of their patients. In a study conducted with 95 patients by Özol et al., 40% of the patients had been vaccinated at least once in the last 5 years and the influenza vaccination rate was similar in those above and below the age of 65, but influenza vaccination rates were higher in university graduates.[9] In our study, when the distribution of participants according to educational level is examined, primary school graduates make up the majority with 74.5%. The fact that the study center is in a rural area and the population is predominantly elderly may explain the low level of education. The overall level of literacy is linked to health literacy, but it does not guarantee a high level of health literacy. Although studies have found that people with low literacy levels have difficulty understanding their health, individuals with high levels of literacy may have low levels of health literacy as well [10].

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67.1% of the participants who did not get the flu vaccine stated that the reason for it was a lack of recommendation by their physician, while 13.2% forgot to get vaccinated. In our study, the rate of nonvaccination due to physician attitude was very high. In a study conducted by Balbay et al., the pneumococcal vaccine was not recommended to any patient by family physicians, whereas the flu vaccine was recommended at a rate of 16.4% [11]. In a study conducted in Germany, it was found that the most important factor determining the vaccination was physicians’ advice [12]. In a study conducted by Szcus et al. to evaluate the coverage of influenza vaccines during two consecutive influenza seasons (2002/20032003/2004) in six European countries, family physicians were found to be the most potent factors in immunizing individuals against influenza. Additional information about vaccine efficacy and tolerance increased the odds of vaccination in the general public [13]. In a study conducted in the USA, it was found that 27% of patients who initially refused to be vaccinated, accepted the vaccine on the recommendation of a physician [14]. In the study of Erer et al., the majority of the patients who were aware of the vaccine but were not vaccinated stated that the reason for nonvaccination was a lack of recommendation [15]. In our country, immunization information is given less frequently to patients compared to other developed countries. The increased workload in our country, prolonged working hours with intensive outpatient clinics and insufficient time to examine patients are a possible cause of this difference. Although there is no statistically significant effect on exacerbations by pneumococcal vaccination, influenza and pneumococcal infections are the most common causes of acute exacerbations of COPD [16,17]. Both influenza and pneumococcal vaccination have been reported to reduce the incidence of lower respiratory tract infections. Vaccination is, therefore, a cost-effective, economical and life-saving approach. Evidence suggests that pneumococcal and influenza vaccines may prevent communityacquired pneumonia and acute exacerbations in COPD patients and that early pneumococcal vaccination in COPD may help maintain stable health status [1]. In our study, 93.2% of the patients did not receive the pneumonia vaccine in the last 5 years. 77.8% of those who had the flu vaccine did not receive the pneumococcal vaccine and the underlying causes should be addressed. This may be because influenza can remain on the agenda by making outbreaks every year and maintaining its popularity in the media, while pneumococcal infections remain in the background affecting at-risk populations and stay unheard of by the general public. In the study of Balbay et al., the rate of patients who had received the pneumococcal vaccine in the last five years was found to be similar to our study with 8.2% [11]. The results of Erer et al.’s study in Izmir were similar, the influenza vaccination rate was 40% and the pneumococcal vaccination rate was 10%. The pneumococcal vaccination rate was higher in women and those with higher educational level [5]. In a study conducted with 178 patients in the Catalonia region of Spain, the ratio of pneumococcal vaccination was reported to be 84.2%, which is considerably higher than in our country [18]. In two different studies conducted in Spain and Sweden, the proportion of patients receiving both vaccines was found to be 62.5% and 78%, respectively, and is still very high compared to our country [18,19].

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87.5% of those who have not received the pneumonia vaccine in the last 5 years have not been vaccinated because the physician did not recommend it. Other reasons include the family physician saying that the vaccine is not needed and the patient’s belief that the vaccine will not help. As can be seen from these results, the most important factor in pneumococcal vaccination is the physician’s advice. In the study of Balbay et al., 27.9% of the patients were offered influenza vaccination by a pulmonologist or an assistant physician, whereas pneumococcal vaccine was recommended only to 4.9% and their family physician recommended none of the patients a pneumococcal vaccine [11]. Despite the availability of effective pneumococcal vaccines and recommendations from national health authorities, vaccine coverage is low in many countries. These levels are 70% in the United Kingdom, 76% in Spain, 36% in Ireland, 15-30% in Norway, 15% in Germany and 5% in France [20]. The reason for low vaccine coverage may be the perception levels and low vaccine awareness of elderly patients. In a phone survey conducted between November 2015 and February 2016 on individuals over 50 years of age with more than 9000 participants, pneumonia and vaccine awareness was measured. It was found that 85% of the participants trusted vaccines, 27% avoided vaccines (for safety reasons), and 29% thought that they did not need them because they were not at risk. Also, respondents stated that they followed their physicians’ recommendations (92%) and preferred to receive additional medical information from their physicians. In general, awareness of pneumococcal vaccine was found to be low and the most common cause for non-vaccination (55%) was shown to be a lack of recommendation from their physician [21]. The inclusion of pneumococcal vaccination in the early treatment of COPD may improve the long-term natural course of the disease. Since patients trust their physicians as their main source of health information, physicians need to make more effective efforts to inform their at-risk patients about the dangers of pneumonia and the benefits of pneumococcal vaccination [20]. There was no statistically significant relationship between influenza or pneumonia vaccination and age, sex, smoking, or COPD severity. Since in our study, almost all patients were primary school graduates, no statistical evaluation was made in terms of education level. A statistically significant correlation was found between the awareness of influenza vaccine and COPD severity. This may be since in advanced disease stages, health institutions are more frequently referred to and the outcome of the disease is felt more vividly. In international publications examining the factors affecting the vaccination rates in COPD patients, it was shown that vaccine acceptance and vaccination rates decrease in patients with milder disease severity [22,23]. Influenza vaccination rates have been shown to be higher in older patients, patients with a higher number of physician visits, and patients with poor overall health [24]. In the study conducted by Bülbül et al., the rate of pneumococcal vaccination increased by 4.1 fold in patients with advanced-stage COPD [25]. In a multicenter study of 5135 patients by Özlü et al., influenza vaccination rates were found to be significantly higher in patients with advanced age, higher education, severe COPD and comorbid diseases, as well as smokers and urban residents. The lifetime vaccination rate for pneumococci was 13.3%, and similarly to influenza, pneumococcal vaccination rates were significantly higher in smokers who quit smoking, in patients with higher education, in patients with comorbidities, and 64

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in urban residents, regardless of COPD group. Also significantly higher pneumococcal vaccination rates were found in female patients [15]. Similarly, a study conducted abroad reported that the most important determinants of pneumococcal vaccination were female gender, advanced age, and the severity of COPD [26]. In our study, the reason that the sociodemographic characteristics did not affect vaccination may be due to the low number of participants. To determine the factors affecting vaccination in COPD, larger sample sizes will need to be studied. According to our study, there was a statistically significant relationship between influenza vaccination in the last year and pneumonia vaccination in the last five years. While 22.2% of those who have received pneumonia vaccination in the last five years have also had the flu vaccine in the last year, 98.7% of those who have not had pneumonia vaccination in the last five years have not received the flu vaccine in the last year either. The flu vaccine is known by the general population and most patients with chronic diseases. Pneumococcal vaccine is not even known by atrisk patients who should receive this vaccine. However, patients who are aware of the severity of their disease know they need the pneumococcal vaccine and this awareness may have led to higher flu vaccination rates. Vaccination is as vital as medical treatment in COPD and is effective on both morbidity and mortality. The primary determinants of the patients’ vaccination behaviors are the physicians who treat them. Especially in chronic diseases such as COPD, where both the disease is severe, and the costs of care is high, primary preventive activities are very important and specialist physicians have great responsibilities. In this context, pulmonologists and even general practitioners should not only concentrate on medical treatment, but should also focus on preventive treatments, give sufficient time to vaccination awareness and convince patients about the vaccine [27]. Conclusion In conclusion, vaccination is vital in severe and chronic diseases such as COPD. In our study, it was shown that the most important factor affecting the vaccination behavior was the physician’s advice. Therefore, pulmonologists and family physicians should not only treat COPD patients medically but also should raise awareness about vaccination. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval Bolu Abant Izzet Baysal University Clinical Researches Ethics Committee with the protocol number 2019/33 Manolya Ballar, ORCID: 0000-0002-7790-1398 Tuncer Tug, ORCID: 0000-0003-2622-5104 Mehmet Kayhan, ORCID: 0000-0001-7493-5165 Suat Konuk, ORCID: 0000-0002-8240-4775

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Medicine Science International Medical Journal

Medicine Science 2020;9(1):67-72

Comparison of the caregiver burden of the mothers of children with cerebral palsy and healthy children Ercan Kaydok1, Sezin Solum2, Nesibe Sultan Cinaroglu3 Nigde Omer Halisdemir University Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Nigde, Turkey 2 Nigde Bor Physical Medicine and Rehabilitation Education and Training Hospital, Nigde, Turkey 3 Nigde Omer Halisdemir University, Nesibe Sultan Cinaroglu Zubeyde Hanim Vocational School of Health Services, Nigde, Turkey 1

Received 16 August 2019; Accepted 20 October 2019 Available online 24.02.2020 with doi:10.5455/medscience.2019.08.9136 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract The study aims to compare caregiver burden levels of mothers of children with cerebral palsy (CP) to mothers with healthy children. Methods: Participants comprised 40 mothers of children with CP (Group 1), and controls comprised 40 mothers with healthy children(Group 2). Caregiver burden inventory (CBI), hospital anxiety depression scale (HADS) were applied. The functional status of children with CP was evaluated by the Gross Motor Function Classification System (GMFCS). Secondary problems accompanying CP were also noted. Results: A secondary problem was seen in 75% of children with CP. The caregiver burden (CB) and the frequency of depression among Group 1 mothers were significantly higher than Group 2 mothers (p<0,001). CB was found to be higher in children with CP with poor functional status. The CB of caregivers in children with CP with secondary problems was significantly higher than the mothers of children without secondary problems (p<0.05). Conclusion: CP causes a higher burden on care for mothers than on healthy children, and at the same time, more frequent depression is observed in these mothers. Long-term prospective studies are needed to investigate the possible effects of the time shift in the functional status of patients with CP on the CB. Keywords: Cerebral palsy, children, mother, caregiver burden

Introduction According to Zarit, the person who undertakes the care of an individual who is inadequate in performing daily activities due to physical or mental illness is called caregiver [1]. The decrease in the frequency of death of people and the prolongation of the average life expectancy caused an increase in the number of individuals who need care [2,3]. The caregiver may vary with socio-cultural conditions. However, the care of patients is often undertaken by one of the family members or the patient’s husband or wife [4]. Maintenance is usually not limited to a single kind of help. It also includes health care of the patients (medication use, treatment, follow-up, etc.), personal care (washing, feeding, toileting, living in the same house [1,3]. In Turkish society, care services are often given by family members. Caregiving has positive contributions such as increased emotional communication with the

*Coresponding Author: Ercan Kaydok, Nigde Omer Halisdemir University Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Nigde, Turkey, E-mail: ercankaydok@ohu.edu.tr

dressing, etc.), organizing the patient’s social services, shopping, and domestic work, money management, financial support and patient, personal development, development of close relationships, social support from other individuals, self-esteem, and personal psychosocial satisfaction. However, there are many negative and difficult aspects [3,5,6]. Caregiver Burden (CB) is expressed as a multidimensional response related to caregiving, including physical, psychological, emotional, social, and economic problems [7]. Depression and anxiety may both affect the caregiver’s quality of life and indirectly affect the care of the patient [4,8]. Cerebral Palsy (CP) is a permanent neurological disorder that is common in childhood, affecting movement and posture throughout life [9]. Many additional problems may accompany motor retardation. Sensory (vision, hearing problems), cognitive (mental retardation), communication (speech disorder), perception (such as lack of attention) problems, incontinence, difficulty in swallowing, and epilepsy are the most common accompanying problems [10]. The incidence of cerebral palsy in the world was reported 2-2.5 per 1000 live births [11], while in Turkey, it was reported as 4.4 per 67

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1000 live births in the most comprehensive study [12]. Functional limitations due to physical, mental, emotional, and social disorders of children with CP prevent them from fulfilling their roles in the society they live in [13,14]. The families of children with CP, especially their mothers, spare much less time and pay attention to themselves and if exists, to their children because children with CP are in need of constant care, have more frequent health problems, have more frequent follow-ups, and need regular and continuous physiotherapy, and also because caregivers assume the role of the child with their roles in society. For these reasons, the quality of life of family members who care for children with CP is also negatively affected [13,15-17]. In this study, we aimed to examine the caregiver burden, depression, and anxiety levels of mothers of children with CP and compare them with mothers with healthy children. Material and Methods Patients This cross-sectional study was carried out between March 2018 and October 2018 with the mothers of patients with CP who were being treated at the local hospital Physical Medicine and Rehabilitation Service. Approval was obtained from the local ethics committee before starting the study. Written consent was obtained from the mothers who agreed to participate. Mothers of children without any chronic physical or psychiatric problems were contacted through a study brochure and posters on social media. The inclusion criteria of the mothers of children with CP (Group 1) were; having a child with CP and living with the child, lack of a chronic psychiatric disorder, and the inclusion criteria of the mothers with healthy children (Group 2) were; inclusion criteria, having children without any chronic health problems and living together. Exclusion criteria were; using antidepressant and anxiolytic drugs that affect depression and anxiety scales, caring for another patient or disabled person with a child with CP, and the existence of any obstacle that will negatively affect the activities of daily living. Demographic data, age, gender, CP type, additional problems, and functional status of children with cerebral palsy were evaluated and noted to the related form. Age, education level, marital status, the total number of children, and income levels of the mothers were questioned in both groups. Scales Children with CP were categorized by Swedish classification. According to this classification, the children are classified as; spastic (diplegic, quadriplegic and hemiparetic), ataxic, dyskinetic (including athetosis and dystonia), and mixed types [18]. To define functional levels, Gross Motor Function Classification System (GMFCS) was used in individuals with CP. GMFCS is a classification system rated between levels 1 and 5. A patient at Level 1 can walk comfortably indoors and outdoors without the need for assisting devices, while a patient at level 5 completely beds dependent. The difference between levels is determined by functional constraints and the use of assisting devices [19,20].

Med Science 2020;9(1):67-72

The effect of the chronic disease on the caring mother and the mothers coping with this condition were evaluated by the caregiver burden (CB) inventory. This scale was developed in 1989 by Novak and Guest in Canada [21], its validity and reliability studies were conducted in Turkey in 2009 and was published under the name of Caregiver Burden Inventory by Küçükgüçlü [22]. CB is a 24-item inventory developed to determine the caregiving burden of relatives of patients with cognitive impairment. CB, based on the view that the burden of caregivers is multidimensional, consists of five sub-factors; the time-dependency burden (TDB), developmental burden (DB), physical burden (PB), social burden (SB) and emotional burden (EB). While FD consists of 4 items and the other four factors consist of five items, each factor can get a minimum of 0 to a maximum of 20 points, and the total load score varies between 0 and 100. As the score from the inventory increases, the burden of the caregiver is increasing too. Inventory is a comprehensive tool suitable for use in both clinics and research [22]. The Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith, is a quadruple Likert-type scale developed to determine the risk of anxiety and depression in individuals and to measure the level of depression and anxiety. The HADS scale consists of 14 items, 7 of which search depression symptoms (even numbers), and 7 of which search anxiety symptoms (odd numbers) [23-24]. The reliability and validity of the Turkish version were performed by Aydemir, and the scale was found to be dependable in terms of screening for symptoms of depression and anxiety in patients with physical illness. There are subscales of the scale for anxiety (HAD-A) and depression (HAD-D). The lowest score that patients and caregivers can take from both subscales is 0, and the highest score is 21. In the study conducted in Turkey, cut-off scores for anxiety subscale was 10, and for the depression subscale, it was 7. Based on this result, those scores above these are considered to be at risk. Statistical Methods SPSS 22 software was used for statistical analysis. Descriptive statistical findings were given as mean ± SD. Student t and chisquare tests were used to compare the parameters. The statistical significance and confidence interval were accepted as <0.05 and 95%, respectively. Results Forty mothers, who gave care to the children with cerebral palsy(Group 1), and 40 mothers with healthy children (Group 2) between 3-13 years were included in the study after informed consent was taken. Table 1 shows the sociodemographic data of each group of mothers, including age, education level, income level, marital status, number of children, and occupational groups. There was no significant difference between the two groups (p>0.05). The mean ages of children with cerebral palsy and healthy children were similar (7.6±3.2, 6.8±2.6, respectively). 60% of children with cerebral palsy and 55% of healthy children were female. There was no significant difference determined between healthy children and children with CP (p>0.05).

doi: 10.5455/medscience.2019.08.9136

Med Science 2020;9(1):67-72

Table 1. Baseline demographic data of groups

Mother Age Mean ± SD

Group 1

Group 2

P value

34.92±6.1

33.02±5.3

>0.05

40 (100%)

38 (95%)

>0.05

0(%0)

2(5%)

Marital Status (n (%) Married Other Education level (N (%)) Illiterate

1(2.5%)

2(5%)

Primary Education

22 (55%)

24 (60%)

High school

14(35%)

10(25%)

College Education

3 (7.5%)

4(10%)

Housewife

32 (80%)

31 (77.5%)

Worker

1(2.5%)

4(10%)

Officer

6 (15%)

4(10%)

Other

1(2.5%)

2.32±0.8

2.30±0.7

>0.05

Occupation N(%)

Number of Children (Mean ± SD)

>0.05

Income Level (N (%)) Poor

5(%12.5)

4(10%)

Moderate

26 (65%)

28 (70%)

Good

9 (22.5%)

8(%20)

>0.05

SD Standart Deviation

The distribution percentages of patients according to Swedish classification ; 17 patients (42.5%) were spastic diplegic, 9 (22.5%) were spastic tetraplegic, 8 (20%) were spastic hemiplegic, 3 (7.5%) were dyskinetic, and 3 (7.5%) were mixed type. We didn’t have hypotonic CP patients. GMFCS scores of children with cerebral palsy are shown in Table 2. While 30% of the patients were bed-dependent (Stage 5), only one (2.5%) patient was able to walk independently. Table 2. GMFCS Scores of Children with CP

palsy were 16.25±7.09, the HADS total scores of the mothers with healthy children were 14.5±6.39, and there was no statistically significant difference between these groups (Table 3, p>0.05). The number of mothers, who scored higher than the cut-off value, which was accepted as anxiety [11], was higher in mothers of children with CP, but this difference was not statistically significant (p> 0.05). The number of mothers, who scored higher than the cutoff value, which was accepted as depression [7], was higher in mothers of children with CP, and the difference between the two groups was statistically significant (p <0.05).

GMFCS

Number

Percentage

Level 1

2.5

Level 2

Level 3

HADS Total

Level 4

Level 5

27.5

GMFCS Gross Motor Function Classification System, CP Cerebral Palsy

In 75% of patients (30) with cerebral palsy, secondary problems were present except movement disorder. The most common additional problems and their frequencies are monitored as; epilepsy (25%), mental problems (17.5%), communication and hearing problems (17.5%), incontinence (15%), eating disorders (10%), visual problems (7.5%). The HADS total scores of the mothers of children with cerebral

Table 3. Comparison of HADS Measurements and Anxiety-Depression Frequencies Group 1

Group 2

P value

16.25±7.0

14.5±6.3

p>0.05

HADS Anxiety score

8.3±4.1

7.82±3.2

p>0.05

HADS Depression Score

7.92±3.8

6.62±3.6

p>0.05

Yes

15 (37.5%)

10 (25.0%)

p>0.05

25 (62.5%)

30 (75.0%)

Anxiety N(Percentage)

Depression N(Percentage) Yes

21 (52.5%)

19 (47.5%)

* p = 0.041

HADS Hospital anxiety and depression scale

doi: 10.5455/medscience.2019.08.9136

The mean total score of caregiver burden was significantly higher in mothers of children with cerebral palsy (35.17±14.7) than mothers with healthy children (22.05±11.4) (p<0.001). In the caregiver burden sub-scales, the time-dependency burden (TDB) and developmental load (GY) scores were significantly higher in mothers of children with cerebral palsy (p<0.05). Even though the other sub-scales were high in mothers in the CP group, there was no statistically significant difference (Table 4). Table 4. Comparison of Caregiver Burden scales between groups Group 1 Mean ± SD

Group 2 Mean ± SD

P value

16.25±7.0

14.5±6.3

p>0.05

35.17±14.7

22.05±11.4

*p<0.001

16.58±4.8

8.72±4.9

*p<0.001

Developmental Burden

7.3±4.2

5.15±3.5

* p = 0.016

Physical Burden

6.21±4.8

5.0±3.6

p>0.05

Social Burden

3.55±3.3

2.41±2.2

p>0.05

Emotional Burden

1.72±1.8

1.02±1.5

p>0.05

CB Total

Time-Dependency Burden

CB Caregiver Burden, SD standart deviation

The ratio of patients with CP who had GMFCS scores 1 and 2 was 37.5% and showed functionally good patients. The caregiver burden was significantly lower in mothers with functionally good CP children than those with poor functional status (p=0.019). However, this significance was not observed in HADS scores and anxiety-depression frequencies (p>0.05). All caregiver burden scale scores were significantly higher in mothers who had children with CP with secondary problems compared to children without any secondary problems (Table 5, p<0.05). Table 5. The Relationship Between HADS and Caregiver Burden with Secondary Problems Secondary Problem (n = 30)

No Secondary Problems (n = 10)

P value

17.0± 7.3

14.27±6.2

p>0.05

CB Total score

40.25±13.2

21.77±9.3

*p<0.001

Time-Dependency Burden

17.96±3.5

12.93±5.9

* p = 0.02

Developmental Burden

8.62±4.0

3.81±2.4

* p = 0.01

Physical Burden

7.58±4.9

2.61±1.8

* p = 0.02

Social Burden

4.0±3.5

2.36±2.7

p>0.05

Emotional Burden

2.03±1.9

0.90±0.9

p>0.05

HADS Total score

HADS Hospital anxiety and depression scale, CB Caregiver Burden

There was no significant difference in HADS scores, caregiver burdens, and anxiety-depression prevalence between children under eight years and older than eight years of age within the CP group (p> 0.05). In the healthy children group, mothers of children under eight years of age had a significantly higher time-dependency burden than the children older than eight years (9.81±4.8 vs. 6.46±4.3 p=0.043).

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Discussion Cerebral palsy is a chronic neurological disorder with movement abnormalities beginning from childhood and monitored in the world and our country. There are many reasons prenatally, natally, and postnatally. Children with cerebral palsy often need care because of their movement disorder and other accompanying problems (mental disorders, epilepsy, eating problems, incontinence, etc.). CP is classified according to the movement patterns as spastic, dyskinetic, ataxic, and mixed forms. 70-80% of patients are spastic type cerebral palsy [25]. In our study, 85% (n=34) of the children with CP were spastic, 7.5% (n=3) were dyskinetic and 7.5% were mixed type. In this study, we compared the caregiver burden and emotion status of mothers with healthy children and children with cerebral palsy. Mothers, as a result of cultural influences in Turkey, assume responsibility for disabled children and have to devote most of their time only to difficulties caused by the disability. Therefore, we think that mothers’ physical and emotional health conditions are impaired. In a study conducted on 486 CP children, 89.7% of caregivers were found to be mothers of children [26]. In our study, caregivers were all mothers of the children. Previous studies have shown that the quality of life and emotional status of mothers who give care to children with CP are worse than mothers with healthy children [27]. However, there is no study comparing the caregiver burden in these two groups. Disability in the child deeply affects the family and the mother, who is especially caring for the child. The physical and psychological health of the family members who have to look after a disabled child during the whole day and years are affected negatively [28,29]. The objective results of caregiving involve the physical changes and preventions in the lives of the caregiver and the family, and are associated with physical problems, such as fatigue due to care, prevention of the family’s social and physical routines, physical problems, such as the occurrence or exacerbation of the caregiver’s physical illnesses. In many previous studies, it was found that as a result of long-term care, CB can lead to severe depression, anxiety, a decrease in physical health, social isolation, and exhaustion [5,6]. There are many studies [30-32] reporting that mothers of children with cerebral palsy have higher levels of anxiety and depression than mothers with healthy children. Yilmaz et al. found in their study, in which they compared the levels of depression and anxiety in mothers with healthy children and mothers of children, that the levels of depression and anxiety were significantly higher in mothers of children with CP and that they were closely associated with speech disorders and functional status. In our findings, it was found that depression and anxiety levels were significantly higher in mothers of children with CP, who we evaluated with the HADS scale, similar to the previous studies. In our study, we found that the prevalence of depression in the mothers of children with CP (52.5%) was significantly higher than the mothers with healthy children (30%) (p = 0.041). However, no significant difference was found between the groups in terms of frequency of anxiety. Disabled individuals constitute a significant burden on the family. In 2013, Karahan et al. compared the caregiver burdens in caregivers of 25 cerebral palsy and 25 adult hemiplegic patients and reported a higher burden on caregivers for hemiplegic individuals [33]. 70

doi: 10.5455/medscience.2019.08.9136

Parents, especially mothers of children with CP, may be adversely affected and may have high burden levels [34,35]. This burden of care has been shown to cause a lower quality of life in parents of children with CP [30,36]. In our study, when compared to mothers with healthy children, caregiver burden was significantly higher in mothers of children with CP. The low functional capacity of the child with cerebral palsy increases the burden on the family. Wijesinghe et al. 375 [37] compared the caregiver burdens of caregiving mothers of children with cerebral palsy and reported that male gender, low functional capacity, and low socioeconomic level increased the caregiver burden. In our study, the caregiver burden, which was evaluated with GMFCS, was found to be significantly higher in mothers of children with lower functional capacity (Stages 3-4-5).

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Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval All procedures performed in experiments involving human participants were following the ethical standards of the institutional and national research committee and with the 1964 Declaration of Helsinki. Ercan Kaydok, ORCID: 0000-0003-2262-7261 Sezin Solum, ORCID: 0000-0002-7792-7248 Nesibe Sultan Cinaroglu, ORCID: 0000-0002-6032-1143

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Another important parameter that increases the caregiver burden is that the child is having secondary problems (epilepsy, cognitive problems, speech disorder, vision problem, etc.) except movement disorder. Studies are reporting that mothers of children with CP with cognitive problems have more depression and higher burden than children with CP, who do not have problems [38]. In our study, the caregiver burden of mothers caring for children with CP with additional problems was significantly higher than the children without problems.

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Our study is the first study in the literature comparing the caregiving burden of mothers with healthy children and mothers who give care to children with cerebral palsy. There are a few limitations of our study. The first is the limited number of participants. The second is that since our study is cross-sectional, the effect of the functional improvement in the children with CP on the caregiver’s burden and the mother’s mood was not measured. Third, the relationship between caregiver burden of the mothers and their quality of life was not evaluated. Conclusion Cerebral palsy is a chronic neurological disorder that causes a significant burden of care for the mothers in society and among the societies, especially in patriarchal societies like ours. In our study, both the burden of caregiver and that the frequency of depression was found to be significantly higher than the mothers with healthy children is compatible with this fact. Long follow-up studies are required to examine the changes in quality of life and caregiver burden of mothers of the children with CP and functional recovery in children over time. We think that mothers of children with CP should undergo a regular psychological evaluation and that the mother should be given more psychological and social support.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):73-7

Is C-type natriuretic peptid level can be an early ındicator for acute kidney ınjury? Ilker Akar1, Muzaffer Katar2 Tokat Gaziosmanpasa University Faculty of Medicine Department of Cardiovascular Surgery, Tokat, Turkey 2 Tokat Gaziosmanpasa University Faculty of Medicine Department of Biochemistry, Tokat, Turkey

Received 27 December 2019; Accepted 02 February 2020 Available online 24.02.2020 with doi:10.5455/medscience.2019.08.9137 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract Acute kidney injury (AKI) is defined as a reduction of renal function in hours, including both structural damage and loss of function. There are limited number of biomarkers for early detection and staging of severity. C-type natriuretic peptide (CNP) has been detected in at several tissues. We aimed to evaluate plasma CNP and creatinine levels correlated with duration of ischemia in an experimentally induced AKI rat model. Forty male Sprague-Dawley type rats (aged 8 to 12 weeks, weighing 250-350 g) were used. The animals were randomly seperated into 4 groups: Group 1(n:10): Only laparotomy was performed. The left renal artery was clamped for 3, 6 and 9 hours in groups 2 ( n:10), 3 (n:10) and 4 (n:10) respectively. CNP and creatinine levels were measured in serum samples from rats. A significant increase in creatinine levels was determined in group 2 according to group 1 (p=0.006). The mean plasma creatinine values in group 3 and 4 were decreased compared to group 2 but this difference was not statistically significant (p=0.0862). The mean CNP level in Group 2 (39.5 ± 7.93 mg/dl) was found numerically higher than group 1 (37.90 ± 5.38mg/dl). There was a statistically insignificant decrease in mean CNP levels in group 3 and 4 compared with group 2. Renal ischemia increases the level of CNP. Although the increase in CNP levels is not significant, it can be said that clinical and experimental studies evaluating the timing of ischemia involving different durations should be performed. Keywords: Acute Kidney Injury, renal ischemia, C-type natriuretic peptide

Introduction Acute kidney injury (AKI) is very important pathology for morbidity and mortality in clinical practice. For this reason early diagnosis and treatment are necessary to prevent permanent damage. Regardless of the etiology, various pathophysiological processes such as endothelial dysfunction, microcirculation changes, tubular injury, venous congestion and inflammation occur respectively [1]. The most common cause of AKI is ischemia and may results from various diseases such as renal artery stenosis, renal vein thrombosis, vasculitis, atherosclerotic and thrombotic embolism, etc. Furthermore, in some surgical procedures, the risk of renal ischemia may be observed, particularly in relation to the involvement of renal arteries in the dissection of the aorta and vascular surgery procedures [2]. Although not exactly defined in clinical trials, it is shown that clamping renal veins in animal studies also causes kidney injury [3]. The current diagnostic approach of AKI is based on a decrease in an acute glomerular filtration rate as reflected by an acute increase in serum creatinine

*Coresponding Author: Ilker Akar, Tokat Gaziosmanpasa University Faculty of Medicine Department of Cardiovascular Surgery, Tokat, Turkey E-mail: ilkerakar16@yahoo.com

levels and / or a decrease in urine output over a period of time [2]. Kidney damage biomarkers have several potential roles in AKI including early detection and staging of severity, and as end points of clinical trials [4-6]. There are several early damage biomarkers as urinary creatinine, kidney injury molecule-1 (KIM-1), Cystatin C, Interleukin 8, Neutrophil Gelatinase,associated lipocalin (NGAL), clusterin, monocyte chemotactic protein, osteopontin etc. But none of these except creatinine were usable in clinical practise [7-10]. In addition to these markers, new studies are carried out in this subject and the searches are continuing. C-type natriuretic peptide (CNP) is a new member of the family of natriuretic peptides, including atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). Although these ones exhibit similar properties, CNP releasing from vascular endothelium has shorter half-life and low circulating concentration. Natriuretic peptides show their effects by binding to receptors containing guanylate cyclase [11]. There are two forms of Natriuretic peptide receptors A and B. In studies on vascular smooth muscle cells, CNP was determined as an agonist of type B natriuretic peptide receptor [12]. There are several studies showing the effect of natriuretic peptides on different types of ischemia [13-17]. The aim of this study was to evaluate plasma CNP and creatinine levels correlated with duration of ischemia in an experimental model of acute kidney injury. 73

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Material and Methods This study was performed on 40 Wistar rats aged 8 to 12 weeks and weighing between 250 to 350 gr after the approval of the Animal Experimental Committee of Gaziosmanpasa University Faculty of Medicine. The rats were kept in a light-controlled room with a 12:12-h light-dark cycle; temperature (22 ± 0.5 °C) and relative humidity (65 %–70 %) were kept constant. They received a rat diet, water and libitum. The rats were deprived of food for 12 h before the experiment. Rats were seperated into 4 groups by simple randomisation. Group 1 (sham group) (n:10): Only laparotomy was performed in this group of rats without cross-clamping the left renal artery. Group 2 (n:10): The left renal artery was clamped for 3 hours following laparotomy in this group of rats. Group 3 (n:10): Following laparotomy in this group of rats, the left renal artery was clamped for 6 hours. Group 4 (n:10): The left renal artery was clamped for 9 hours following laparotomy in this group of rats. At the end of the study 3 cc intracardiac blood was taken from each rats in all groups then euthanized by cervical dislocation. C type natriuretic peptide levels and creatinine levels were measured in serum samples from rats in groups. Biochemical analysis The plasma levels of CNP were measured using CNP Elisa Kit ( No: 201-11-0056; Sunredbio Biological Technology, China) with elisa method and plasma levels of creatinine were measured

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using Creatinine Colorimetric Assay Kit ( No: 700460; Cayman Chemical, Ann Harbor, MI) with colorimetric method acording to manufacturer’s instructions. Statistical analysis Data are expressed as mean±standard deviation. One way analysis of variance were used to compare the continious normal data among groups. For post-hoc comparisons between the pair-wise groups, the Tukey HSD test was used. Analyses were performed using SPSS 19 (IBM SPSS Statistics 19, SPSS inc., an IBM Co., Somers, NY). Lower than 0,05 a p-value was accepted as significant. Results Mean plasma creatinine levels were measured as 0.53±0.08 mg / dl in Group 1. A significant increase in creatinine levels was seen in group 2 compared with group 1 [0.64±0.09 mg/dl (p=0.006) ]. The mean plasma creatinine values in group 3 and 4 (0.59±0.05 mg/ dl, 0.56 ± 0.04 mg/dl) in six and nine hours kidney ischemia were decreased compared to group 2 but those were not statistically significant (Table 1, Fig 1). The mean CNP level in group 1 was 37.90 ± 5.38 mg/dl. The mean CNP level in Group 2 (39.5±7.93mg/ dl) was found to be numerically higher than group 1, but this was not statistically significant. There was statistically insignificant decrease in mean CNP levels in group 3 and 4 compared to group 2 (p = 0.862) (Table 1, Figure 2).

Table 1. Distributions of CNP and creatinine levels according to groups Group Age

1 (n=10)

2 (n=10)

CNP

37.90±5.38

39.5±7.93

Creatinine

0.53±0.08a

0.64±0.09b

3 (n=10)

4 (n=10)

37.6±9.14

36.1±11.71

0.862

0.59±0.05ab

0.56±0.04ab

0.006

CNP: C-type Natriüretic Peptid One-way ANOVA test was used. Data are shown as mean ± standard deviation. For groups, different superscripts (a,b,c) in the same row (ANOVA) indicate a statistical significant difference

Figure 1. The levels of creatinine according to groups. Bar graph with standard deviation of creatinine

Figure 2. The levels of CNP according to groups. Bar graph with standard deviation of C-Type Natriüretic Peptide

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Discussion

relationship with kidney structure and function [27].

Kidney; is highly sensitive to ischemia-related injury resulting in vasoconstriction, endothelial damage and inflammatory process [18]. This sensitivity can be partly explained by structural relationships between the renal tubules and blood vessels in the external medulla of the kidney [19]. Following reduction in effective renal perfusion, epithelial cells can not protect sufficient intracellular ATP for the required processes. This ATP depletion leads to cell damage and can cause cell death by necrosis or apoptosis if it is severe enough [20]. All segments of nephrons may be affected in the ischemic process, but proximal tubular cells are the most frequently affected cells. In addition, the function of the nephron is to filter, concentrate, and reabsorb many substances from the tubular lumen. Because of the deterioration of tubular function in ischemia, toxic substances that cannot be cleaned can reach toxic levels for renal epithelial cells [21].

In an experimental nephropathy secondary to ureteral obstruction, Hu et al. [28] determined an increase in urinary CNP excretion before changes in urinary protein, albumin, blood urea nitrogen, and creatinine were observed. In the same study, it was observed that CNP levels in the abdominal aorta and renal vein were increased in the first 24 hours but this was not statistically significant and this increase was observed to regress within weeks

Although serum creatinine is sensible to acute changes in renal function; age, sex, muscle mass, diet, medications and hydration status may vary its levels. It isn’t a direct indicator of tubul damage. Even if the kidneys are structurally intact, it may also increase in renal hypo-perfusion and prerenal azotemia. For these reasons, serum creatinine is considered to be an ‘imperfect gold standard’ for the diagnosis of AKI [2]. Over the last few years, some new AKI biomarkers have been studied out and confirmed to improve early detection. Some of them are neutrophil gelatinaseassociated lipocalin (NGAL), kidney injury molecule 1 (KIM1), liver-type fatty acid-binding protein, interleukin 18 (lL-18), insulin-like growth factor-binding protein 7, tissue inhibitor of metalloproteinase 2 (TIMP2), calprotectin, urine angiotensinogen (AGT), and urine microRNA [7-10,22]. C-Type natriuretic peptide; although mainly found in the brain [23], it has been later suggested that it is also present in the heart [24]. In addition, it was found in endothelial cells of human coronary arteries, peripheral circulation, arteries and veins in various regions. CNP; it has been shown to play a role in the regulation of vascular tone rather than natriuretic function [23]. The studies about the effects of natriuretic peptides on different types of ischemia can be seen at litherature . However, according to our knowledge there were no studies evaluating CNP levels in the acute kidney ischemia model in english litherature. In a study, Sward et al. [13] investigated the effect of recombinant human atrial natriuretic peptide (h-ANP) in ischemic acute kidney failure and found h-ANP administration corrected renal function. In a clinical study, it was shown that BNP is associated with inducible myocardial ischemia [14]. Kamakura et al. [16] detected high BNP levels in critical leg ischemia. Furthermore in an experimental study Demirtaş et al. [17] evaluated the relationship between serum CNP levels in acute mesenteric ischemia and showed that CNP levels increased correlating with ischemia time. The use of CNP as an indicator in detecting inducible peripheral ischemia has been investigated in experimental study and it has been reported that plasma CNP is associated with cellular response in ischemic tissues depending on the time [26]. Also; it is believed that CNP is produced in tubuler cells and is presented as a local modulator with anti-inflammatuary and anti-proliferative effects under pathological conditions. Determination of urine CNP levels in experimental nephropathies has led us to understand the

In our study, a statistically insignificant increase was observed in serum CNP levels at the 3rd hour of acute renal ischemia but there was a decrease in CNP levels at the 6th and 9th hours. Renal ischemia causes changes in tubular cell polarity, loss of tubular epithelial barrier cell integrity, necrotic and apoptotic cell death, expression of characteristic genes of embryonic kidney mesenchyma [29]. The damaged kidney epithelium can be completely restored structurally and functionally unlike the heart and brain. The kidney has regenerative capacity after acute ischemic and / or toxic damage. This is manifested by the proliferation and migration of weakly differentiated cells along stripped basal membranes of the damaged tubuler segments after ischemia [30]. In animal models after ischemic injury repair; proliferation is seen as a maximum in the flat segments of the proximal tubules in the outer medulla, where damage is prominent. There are several probabilities for the origin of regeneration of epithelial cells. In response to damage, they may be redefined to dedifferentiating, proliferating, and then mature tubular cells. Bone marrow cells may lead to damaged epithelial cells. Renal mesenchymal stem cells after damage replace epithelial cells [30]. Morphological reparation is manifested by the emergence of differentiated epithelial cells expressing vimentin, a marker for multipotent mesenchymal cells [27-31]. In next step, the cells upregulate and encode specific genes for various growth factors such as IGF-1, hepatocyte growth factor (HGF) and fibroblast growth factor. At the end stage, the cells express differentiation factors are redifferentiated until preciselly transformed into polarized epithelium. So, in the process of recovery after ischemia; renal tubular cells repeat the phases and processes takes place during normal kidney development [31-33]. While cell death itself does not produce a regenerative response, epithelial cells in the death process produces signals that initiate the repair process. Cytokines may play a role in the formation of signals for neutrophils and monocytes resulting in infiltration of them to the tissue, and promotes the dedifferentiation and proliferation of epithelial cells. These cytokines may arise from kidney tissue, epithelial and mesenchymal cells or infiltrating cells [33]. Some of genes that support the concept of “recaputilation of phylogenin by ontogenesis” include NGAL, leukemia inhibitor factor, transcription factor Ets-1 and WNT -4. Not all these transcripts are critical for early kidney repair, but also play an important role in the regeneration and repair processes of mature kidneys after ischemic injury [34]. This may be one of the explaining factor why CNP levels decrease depending on the duration of ischemia in this study.

doi: 10.5455/medscience.2019.08.9137

The increase in plasma CNP levels positively correlate with ischemia time in mesenteric ischemia and peripheral ischemia models. Because of some pathologies as renal artery thrombosis, thrombosed abdominal aortic aneurysms affecting one of the renal arteries and especially aortic dissection including involvement of one of the renal arteries that requires surgical intervention in vascular procedures, we prefer to clamp one of the renal artery. There was not a consensus in animal models about the renal injury performed by clamping only one or bilateral renal artery, only renal vein or pedicle. It is important to mention that renal pedicle (artery and vein together) clamping was used in most murine ischaemic AKI, which is different from patients with AKI. In humans, AKI is induced either by renal artery hypoperfusion during shock and cardiac surgery or by renal vein occlusion by thrombosis and during liver transplantation in which the inferior vena cava is clamped. According to our results and to the regenerative capacity of kidney and compansatuar mechanisims of the other kidney we believe that significant results may be obtained by clamping bilateral renal artery clamping. The clamping one of the renal artey is a partial limitation of this study. Conclusion Although CNP levels do not correlate with acute kidney injury, better biochemical results may be produced with different acute renal ischemia models including long term follow-up and besides the experimental studies, randomized clinical trials are needed. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval This study was performed after the approval of the Animal Experimental Committee of Tokat Gaziosmanpasa University School of Medicine with the number of 2018 HADYEK-02 Ilker Akar ORCID: 0000-0002-6426-0894 Muzaffer Katar ORCID: 0000-0002-6296-2390

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):78-81

Evaluation of the effects of pterygium surgery on visual acuity and anterior segment measurements using corneal topography Fikriye Ordulu1, Cetin Akpolat2, Muhammed Mustafa Kurt2, Halit Oguz1 2

1 Harran University, School of Medicine, Department of Ophthalmology, Urfa, Turkey Okmeydani Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey

Received 17 October 2019; Accepted 22 November 2019 Available online.03.03.2020 with doi:10.5455/medscience.2019.08.9139 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract This study was carried out to evaluate the effects of pterygium surgery on visual acuity, corneal astigmatism, corneal refraction, and corneal topography and the changes of these parameters in the postoperative period. Forty eyes of 34 patients presented with only primary pterygium were included in the present study. Patients with features that could affect corneal topography, such as previous ocular trauma or surgery, corneal scarring, keratoconus, dry eye, and contact lens use, were excluded from the study. After excisional pterygium surgery, primary conjunctival closure was performed. The mean baseline visual acuity measured by the Snellen chart in decimal improved from 0.78±0.19 to 0.97±0.54 in the 3rd month of the postoperative period. The mean values of SimK were 43.33±1.54 diopters (D) and 44.27 ± 1.43 D preoperatively and postoperatively (at 3rd month), respectively. The baseline topographic astigmatism was significantly decreased from 1.85 ± 1.77 (0.50-7.00) D to 0.65 ± 0.40 (0.20-1.75) D at 3rd month of postoperative period (P = 0.000). While 77.5 % of the patients had regular astigmatism at baseline, oblique and irregular astigmatism was observed in the early postoperative period, but 65 % of these patients turned back to regular astigmatism in the late postoperative period. Corneal topographic values were stabilized in the first month of the postoperative period. So, the plan of refractive or cataract surgeries may be appropriate after the stabilization of the corneal refractive components following the first month of pterygium surgery. Keywords: Pterygium, corneal topography, pterygium surgery, astigmatism

Introduction Pterygium is the nasal expansion of conjunctiva and fibrovascular tissue to the corneal surface due to several factors such as ultraviolet light, genetic factors, and other environmental factors. Conjunctival epithelium usually has dysplasia, and there is fibrovascular tissue accompanied by elastoid degeneration of collagen tissue under the epithelium [1]. Pterygium before age 20 is rare [2]. The prevalence of pterygium is highest in people over 40 years of age, and the incidence is the highest between the ages of 20-40 [3]. Although pterygium has a worldwide distribution, it is more common in dry climates [4]. There are some conditions such as pseudo-pterygium (pterygoid), and pinguecula that should be considered in the differential diagnosis of pterygium [5]. Medical and surgical treatment of pterygium is possible. Surgical excision indications are; reduced visual acuity, ocular movement disorder, symblepharon, diplopia, chronic inflammation, and cosmetic defect [6-7].

*Coresponding Author: Cetin Akpolat, Okmeydani Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey E-mail: akpolatcetin@yahoo.com

It is known that pterygium affects corneal topography. The pressure of pterygium on the cornea, more flat appearance of cornea than usual due to tear accumulation around pterygium and corneal distortion by pterygium are of the several hypotheses regarding to the mechanism of pterygium-induced corneal changes [8-9]. So, in this study we aimed to investigate the effects of pterygium surgery on visual acuity, corneal astigmatism, corneal refraction, corneal topography and changes in these parameters after surgery. ¬ Material and Methods Study Design and Patients Our study was conducted in patients admitted to the Department of Ophthalmology. The study was adhered with the tenets of the Declaration of Helsinki. The local ethics committee approved the study protocol. Informed consent was obtained from each participant before the enrollment. Forty eyes of 34 patients with primary pterygium were included in the study. Firstly, ophthalmologic history was taken from the patients, and then the patients had an ocular biomicroscopic examination. Those with features that could affect corneal topography, such as previous ocular trauma or surgery, corneal 78

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scarring, keratoconus, dry eye, contact lens use, were excluded from the study. After the excisional pterygium surgery, only primary conjunctival closure was performed. Surgical Technique Eyelid speculum was used in all cases. Local anesthesia was achieved by injecting subconjunctival Lidocaine HCl (Jetokain, Adeka Pharmaceutical Industry Inc.) into the pterygium region. The pterygium body was separated from the conjunctiva with the aid of conjunctival scissors. The pterygium head and body were separated by a parallel incision to the limbus. The pterygium head was removed from the cornea with a peeling technique. Bleeding control was provided with bipolar cautery. The conjunctiva was sutured with 6/0 vicryl sutures, and the operation was terminated. In the postoperative period, topical antibiotic (Tobrased, Bilim Pharmaceutical Industry Inc.), steroid (Predni-Pos, Biem Pharmaceutical Industry Inc.), artificial tears (Refresh, Abdi İbrahim Pharmaceutical Industry Inc.) and analgesics in necessary cases were applied fort the treatment. Postoperative visits were performed at day 1, week 1, month 1, and 3. Measurement During the topographic measurements, no medication was used, including artificial tears, and no instruments were used for eyelid retraction. All measurements were taken in the same room, in the same dim light conditions, and by the same masked observer. The measurements were performed by telling the patients to look at the target light in the center of the keratoscopy containing 16 circles by opening their eyes as much as possible. The measurements were repeated when required, and the best images were recorded. Topcon KR-8800 Auto-Kerato-Refractometer and i-Trace Corneal Topography devices with a wide form of Placido EyeSys 2000 systems were used to measure refractive, keratometric, and topographic measurements of the patients. The refraction power is measured from a 3 mm central zone like the measurement of ‘K’ values. The difference between the keratometric values in the horizontal and vertical axes were defined as keratometric astigmatism. The values of the simulated keratometry (Sim K) and topographic astigmatism were expressed as diopter (D). Astigmatism was considered to be regular, irregular and oblique if the axis was between 90±20 degrees, between 180±20 degrees and out of 70-110 and/or 160-20 degrees, respectively [10]. All patients underwent a detailed ophthalmic examination

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including visual acuity (VA) measured in Snellen chart, topographic astigmatism, keratometric astigmatism, astigmatism axis, and mean corneal refraction power (Sim K) before the surgery and at the 1st day, 1st week, 1st and 3rd month of the postoperative period. Statistics Statistical analysis was performed using SPSS version 11.5 (SPSS Inc. Chicago, IL) for Windows. Descriptive statistics (mean ± standard deviation) were used to present the data. The T-Test (Paired Samples t-Test) was used to compare the means of the two dependent groups. Analysis of variance (ANOVA) for repeated measurements was used for the comparison of the mean values in case of more than two dependent groups. Pearson correlation analysis was used to assess the relationship between the two variables. A P value less than 0.05 was considered to indicate statistical significance. Results No serious complication was observed in the postoperative period. There was no recurrence during the three months follow-up. A complete cosmetic improvement was achieved for all patients after surgery. The numbers of male and female patients were similar (P>0.05). The ages of patients were ranged in a small area (40-50 years). All pterygiums were located nasally. Demographics of the patients and the properties of the eyes were noted in Table 1. The changes in the mean of VA, keratometric astigmatism, topographic astigmatism, and simulation keratometry values at baseline and during the follow-up are shown in Table 2. Table 1. Distributions of CNP and creatinine levels according to groups Variables

Values

Patient Number

Age (Mean± SD, years)

44.80±12.92

Age Range (years)

(40-50)

Gender (M/F)

16 / 18

Eye Side (R/L)

23 / 17

Eye (U/B)

20/ 20

Pterygium (P/R)

40/ 0

SD: Standard deviation, M/F: Male/Female, R/L: Right/Left, U/B: Unilateral/ Bilateral, P/R: Primary/Recurrent

Table 2. Changes in the parameters of corneal topography before the surgery and after the surgery Group Parameters

Preop. Mean±SD

Postop. Day 1 Mean±SD

Postop. Week 1 Mean±SD

Postop. Month 1 Mean±SD

Postop. Month 3 Mean±SD

0.78±0.19

0.84±0.17

0.89±0.14

0.93±0.11

0.97±0.54

0.000*

Keratometric Astigmatism(D)

1.85±1.77

1.42±0.77

1.14±0.67

0.67±0.38

0.66±0.38

0.000*

Topographic Astigmatism(D)

1.85±1.77

1.42±0.77

1.14±0.67

0.66±0.38

0.65±0.40

0.000*

Sim K(D)

43.33±1.54

43.63±1.48

43.96±1.57

44.19±1.50

44.27±1.43

0.000*

SD: Standard deviation, VA: Visual acuity, Sim K: Simulation keratometry, D: Diopter, *: Statistically significant

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The mean postoperative VA was found to be higher than the preoperative level (P=0.000). Postoperative keratometric astigmatism was found to be decreased significantly compared to baseline (P=0.000). There was a significant difference in the mean of keratometric astigmatism between baseline and postoperative 1st month (p=0.000). A statistically significant difference was also found between the baseline and postoperative 3rd month (P=0.000). However, no statistically significant difference was found between the postoperative 1st month and 3rd month (P=0.06). The preoperative keratometric astigmatism axis was regular in 23 (57.5℅) eyes, irregular in 13 (32.5℅) eyes, and oblique in 4 (℅10) eyes. These values were 16 (40%), 8 (20%) and 16 (40%) at first postoperative day; 19 (47.5%), 7 (17.5%) and 14 (35%) at first postoperative week; 23 (57.5%), 9 (22.5%) and 8 (20%) at first postoperative month; 25 (62.5%), 7 (17.5%) and 8 (20%) at third postoperative month, respectively. Postoperative topographic astigmatism was found to be decreased significantly compared to baseline (P=0.000). There was a significant difference in the mean of topographic astigmatism between baseline and postoperative 1st month (p = 0.000). A statistically significant difference was also found between the baseline and postoperative 3rd month (P = 0.000). However, no statistically significant difference was found between the postoperative 1st month and 3rd month (P = 0.453). The preoperative topographic astigmatism axis was regular in 31 (77.5℅) eyes, irregular in 9 (22.5℅) eyes, and oblique in no (℅0) eyes. These values were 12 (30%), 14 (35%) and 14 (35%) at first postoperative day; 16 (40%), 11 (27.5%) and 13 (32.5%) at first postoperative week; 18 (45%), 11 (27.5%) and 11 (27.5%) at first postoperative month; 26 (65%), 10 (25%) and 4 (10%) at third postoperative month, respectively. Postoperative corneal refraction was found to be significantly higher than the preoperative level (P = 0.000). There was a significant difference in the mean of corneal refraction between baseline and postoperative 1st month (p = 0.000). A statistically significant difference was also found between the baseline and postoperative 3rd month (P = 0.000). However, no statistically significant difference was found between the postoperative 1st month and 3rd month (P = 0.342). There was a strong positive correlation between mean topographic astigmatism and mean keratometric astigmatism in the postoperative period (P = 0.000, r = 1.000). We did not find any significant correlation between other parameters. Discussion Vision loss is associated with high asymmetric corneal astigmatism besides the covered visual axis due to pterygium [11]. There is a close relationship between the size of the pterygium and astigmatism it produces [12]. Similar to some studies in the literature, in our study, postoperative VA increased significantly compared to the preoperative level. This increase in VA was observed from the postoperative 1st day up to postoperative 1st and 3rd month [13-14]. Adıgüzel et al. [15] showed a significant reduction in postoperative regular and irregular astigmatism in the 3 mm and 6 mm areas by using the Fourier analysis method.

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Yılmaz et al. [16] performed pterygium surgery in 115 patients using four methods; conjunctival autograft, limbal-conjunctival autograft, bare-sclera, and mitomycin C plus bare sclera. Postoperative astigmatism decreased statistically in all four surgical techniques. Oltulu et al. [17] studied 21 eyes of 21 patients with primary pterygium, both before and two months after the pterygium excision using conjunctival autograft technique. Parallel to our study; they found that corneal topographic changes induced by pterygium are almost reversible after surgical treatment of the pterygium. There was a significant decrease in the mean keratometric astigmatism after the pterygium surgery in some other studies [18-19]. Corneal astigmatism induced by pterygium is reduced after the pterygium excision. Nevertheless, the changes and stabilization in astigmatism after the surgery have not been clearly demonstrated. In our study; preoperative, postoperative 1st day, 1st week, 1st, and 3rd-month measurements were performed, and the changes in astigmatism could be observed. Similar to previous studies, postoperative astigmatism was significantly reduced in our study compared to the preoperative period. This reduction started at postoperative day 1, and the reduction reached the highest value in postoperative 1st and 3rd month. The fact that there was no significant difference in astigmatism between postoperative 1st and 3rd months suggests that astigmatism may be stabilized after 1st postoperative month. However, Özdemir et al. [20] found stabilized topographic appearance at a later period (third month). In our study, although the preoperative regular astigmatism was turned to irregular and oblique astigmatism in the early postoperative period, returning to regular astigmatism was observed in the late postoperative period. This result is coherent with the literature, and it is thought to be associated with the nature of pterygium surgery. Sim K values are one of the most important and most commonly used corneal topography parameters. Sim K values reflect the refractive power of the most straight and flat axis of the corneal surface in keratometer. These parameters show values on both spheroclyndiric and non- spheroclyndiric (on irregular surfaces) corneal surface. Sim K values are parallel with keratometer values but provide more detailed and reliable information [21]. In a study, mean Sim K values after the pterygium excision were increased statistically [22]. In our study, the mean values of Sim K were also increased postoperatively, and a significant decrease was detected in the corneal flattening (P = 0.000). However, the absence of a statistically significant difference between postoperative 1st and 3rd month in the mean corneal refractive power leads us to believe that the topographic values of the cornea are stabilized at 1st month. Conclusion In conclusion, corneal topography is one of the best methods for diagnosing and following the changes in the cornea due to pterygium. In our study, the mean visual acuity increased, the mean keratometric and topographic astigmatism decreased, and the mean corneal refraction increased after successful pterygium surgery. We observed that the preoperative regular 80

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astigmatism turned to irregular and oblique astigmatism in the early postoperative period and then again returned to regular astigmatism in the late postoperative period. The similar values of the mean topographic astigmatism and mean corneal refractive power in the postoperative 1st and 3rd month suggests that the topographic values of the cornea are stabilized at postoperative 1st month. For this reason, it may be appropriate to wait for the first postoperative month if the patient needs glasses. Moreover, pterygium surgery should be performed first, then cataract or refractive surgery can be planned after the postoperative 1st month when the corneal refractive components are stabilized. Retrospective nature, lack of control or comparison group, and the small sample size are the limitations of the study. Considering these disadvantages, new studies are warranted. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval The local ethics committee approved the study protocol. Fikriye Ordulu, ORCID: 0000-0002-0910-3191 Cetin Akpolat, ORCID: 0000-0002-7443-6902} Muhammed Mustafa Kurt, ORCID: 0000-0002-4667-3046 Halit Oguz, ORCID: 0000-0002-0983-5878

References

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Prabhasawat P, Barton K, Burket G, et al. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology. 1997;104:974-85.

Walland MJ, Stevens JD, Steele AD. The effect of recurrent pterygium on corneal topography. Cornea. 1994;13:463-4.

Maden A. Oküloplastik Cerrahi. İzmir, Punto Yayıncılık. 1995;301

10. Güler C, Aydın P, Akova YA. Gözün Refraktif Durumu, Temel Göz Hastalıkları. 1. Baskı, Güneş Kitabevi, Ankara. 2001;99-100. 11. Ma DH, See LC, Liau SB, et al. Amniotic membrane graft for primary pterygium: comparison with conjunctival autograft and topical mitomycin C treatment. Br J Ophthalmol. 2000;84:973-8. 12. Duman F, Kösker M. Demographics of Patients with Double-headed Pterygium and Surgical Outcomes. Turk J Ophthalmol. 2015;45:249-53. 13. Errais K, Bouden J, Mılı- Boussen, et al. Effect of pterygium surgery on corneal topography. Eur J Ophthalmol. 2008;18:177-81. 14. PL Wu, CN Kuo, HL Hsu, et al. Effect of pterygium surgery on refractive spherocylinder power and corneal topography. Ophthalmic Surg Lasers Imaging. 2009;40:32-7. 15. Adıgüzel U, Yeşilli M, Sarı A, et al. Effect of Pterygium surgery on corneal regular and irregular astigmatism: Evaluation with Fourier analysis. Turk J Ophthalmol. 2008;38:4-8. 16. Yılmaz S, Yüksel T, Maden A. Corneal topographic changes after four types of pterygium surgery. J Refract Surg. 2008;24:160-6. 17. Oltulu R, Demirel S, Sarac O, et al. Evaluation of corneal and anterior chamber changes following pterygium surgery using a Pentacam Scheimplug system: a prospective study. Semin Ophthalmol. 2013;28:206-9.

Bengisu Ü. Göz hastalıkları, 4. Baskı: Kornea Anatomisi ve Fizyolojisi. Ankara, Palme yayıncılık. 1998;69-72.

Perra MT, Maxia C, Corbu A, et al. Oxidative stress in pterygium: relationship between p53 and 8-hydroxydeoxyguanosin. Mol Vis. 2006;30:1136-42.

Varma R, Vajaranant TS, Burkemper B, et al. Visual impairment and blindness in adults in the United States: demographic and geographic variations from 2015 to 2050. JAMA Ophthalmol. 2016;134:802–9.

19. Yagmur M, Altan A, S Sarı, et al. Visual Acuity and Corneal Topographic Changes Related with Pterygium Surgery. J Refract Surg. 2005;21:166-70.

Kanski JJ. Konjonktiva Hastalıkları, Klinik Oftalmoloji, Orağlı KM. 3. Baskı, İstanbul; Nobel Tıp Kitabevleri. 2001;56.

20. Özdemir M, Cinal A. Early and late effect of pterygium surgery on corneal topography. Ophthalmic Surg Lasers Imaging. 2005;36:451-6.

Sowka JW, Gurwood AS, Kabat AG. Pterygium, Handbook of Ocular Disease Management, Jobson Publishing, USA. 2001:1-2.

21. Tomidokoro A, Miyata K, Sakaguchi Y, et al. Effect of pterygium on corneal spherical power and astigmatism. Ophthalmology. 2000;107:1568-71.

Yaycıoğlu RA, Aydın Akova Y. Amnion membran transplantasyonunun oftalmolojide yeri. T Klin Oftalmoloji. 2003;12:227-36.

22. PL Wu, CN Kuo, HL Hsu, et al. Effect of pterygium surgery on refractive spherocylinder power and corneal topography. Ophthalmic Surg Lasers Imaging. 2009;40:32-7.

18. Bahar I, Loya N, Weinberger D, et al. Effect of pterygium surgery on corneal topography: a prospective study. Cornea. 2004;23:113-7.

Available online at www.medicinescience.org

ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):82-5

The value of blood parameters as a diagnostic biomarker for congenital sensorineural hearing loss Mustafa Celik Harran University, Faculty of Medicine, Department of Otorhinolaryngology, Sanliurfa, Turkey Received 04 October 2019; Accepted 11 November 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9141

Abstract Blood parameters such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and mean platelet volume (MPV) have been used as systemic inflammation and infection indicators, recently. In this study, we aimed to determine the diagnostic value of blood parameters such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and mean platelet volume (MPV) for congenital sensorineural hearing loss (CSNHL) and to investigate its relationship with disease severity. Fifty-three pediatric patients (29 males, 24 females; mean age 23.85 ± 5.35 months; distribution 12-35 months) diagnosed with CSNHL and 53 healthy individuals (32 males, 21 females; mean age 22.92 ± 6.10 months; distribution 12-35 months), were included in this retrospective study. NLR, PLR and MPV values of CSNHL and control groups were calculated and compared statistically. The correlation between blood count values and hearing loss degree was investigated in CSNHL group. NLR levels were significantly higher in the CSNHL group than in the control group. (Mean NLR: CSNHL group = 2.71 ± 1.11; Control group = 2.28 ± 0.99; p = 0.04). PLR levels were also significantly higher in the CSNHL group compared to the control group. (Mean PLR: CSNHL group = 139.19 ± 59.41; Control group = 111.89 ± 59.91; p = 0.02). There was no correlation between NLR and PLR values and hearing values. NLR and PLR values obtained by low-cost tests, which can be applied easily on patients with CSNHL, can be used as a new inflammatory biomarker. Further studies with larger patient series are needed to confirm these findings. Keywords: Congenital sensorineural hearing loss, neutrophil, platelet, lymphocyte, ratio

Introduction Pediatric congenital sensorineural hearing loss (CSNHL) affects 1.1% to 19.5% of children and disrupts language development, psychosocial maturation, and social adjustment of the patients, leading to individual and social problems [1-4]. Hearing loss can be classified as syndromic (20%-30%) and non-syndromic (70%80%). In pediatric hearing loss; although genetic mutations and factors such as environmental factors (exposure to noise and tobacco smoke, heavy metal toxicity, cisplatin, gentamicin) and infectious factors (cmv, measles, mumps, meningitis) have been implicated, most of the cases remain idiopathic [1-4]. Neutrophils and lymphocytes play important roles in inflammatory and immunological processes. Under inflammatory conditions, neutrophil and lymphocyte numbers undergo transient changes. The increase in neutrophil count (neutrophilia) and decrease in lymphocyte count (lymphopenia) reflect any inflammatory condition in the human body [5-9]. Mean platelet volume (MPV) may also be used as an indicator of inflammation [10-12]. *Coresponding Author: Mustafa Celik, Harran University, Faculty of Medicine, Department of Otorhinolaryngology, Sanliurfa, Turkey E-mail: mustafareyhan@yahoo.com

Ear-nose-throat diseases such as idiopathic sudden sensorineural hearing loss (ISSNHL) [5,6], tinnitus [7], Bell palsy [8] and vestibular neuritis [9] are associated with NLR and PLR. In addition; these parameters are suggested to reflect an inflammatory response and disease activity in many inflammatory and autoimmune diseases such as chronic otitis media (COM) with effusion [13], Familial Mediterranean Fever(FMF) [14], Systemic Lupus Erythematosus (SLE) [15] and coronary artery diseases such as cardiovascular diseases [16,17]. Furthermore, these parameters have also been suggested to be high in some malignant diseases and indicate poor prognosis [18-21]. In our previous study, we had demonstrated that pediatric patients with CSNHL were exposed to oxidative stress [1]. Inflammation may occur as a result of OS. Chronic inflammation may play a critical role in the development and progression of the physiopathogenesis of CSNHL. We assume that blood parameters such as NLR, PLR and MPV can be used as systemic inflammation indicators in patients with CSNHL. In this study, by accepting that chronic inflammation forms the basis of the formation process of CSNHL, we evaluated NLR, PLR, and MPV levels, which are the parameters of systemic inflammation in these patients. Also, we aimed to investigate the correlation of the levels of these parameters with the severity of hearing loss. 82

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Materials and Methods Fifty-three pediatric cases diagnosed with bilateral profound congenital SNHL and followed-up in the cochlear implant program between August 2015 and February 2019 at Harran University, School of Medicine, Department of Otorhinolaryngology, were included in this retrospective case-control study as a patient group. The control group included patients who were admitted to our center for hearing screening, and their hearing was within normal limits. The control group consisted of 53 healthy individuals with age and sex-matched with that of the patient group. The files of the cases included in the study were analyzed retrospectively through a systematic database search. The study protocol was approved by the Ethics Committee of Harran University, School of Medicine (13.06.2019 / 06-38), and was conducted under the ethical principles described by the Helsinki Declaration. A detailed history was obtained from the parents of the patient group, and the healthy control group and basic otoscopic examinations were performed. Pure tone/free field audiometry, tympanometry, acoustic reflex measurements, auditory brainstem response (ABR) and auto acoustic emission (OAE) tests of all cases were evaluated. Exclusion Criteria Patients with congenital inner ear anomalies, syndromic patients, inflammatory or infectious diseases, autoimmune diseases, history of temporal bone trauma, history of neuro-otologic surgery, liver, renal, hematologic, cardiovascular, metabolic and neurological diseases and malignancies and white cell count <4x10³ and >11x 10³, were excluded from the study. Laboratory Methods Blood samples were collected from the peripheral veins of all participants using the Cell-Dyne Ruby fully automated hemogram device through the optical laser scattering method (Abbott Cell-Dyne Ruby; IL 60064, Chicago, USA). CBC parameters, white blood cell (WBC), hemoglobin, erythrocytes, leukocytes, neutrophils, lymphocytes, platelet counts, and MPV of all participants were analyzed with an automated hematology analyzer. The NLR value was calculated by dividing neutrophil count by lymphocyte count, and PLR value was calculated by dividing platelet count by lymphocyte count. Leukocyte, neutrophil, lymphocyte, platelet, NLR, PLR, and MPV values of both groups were separately compared statistically. NLR, PLR and MPV values found to have statistically significant differences between the two groups were correlated with the results of ABR test Statistical Analysis Statistical analyses were performed using SPSS 25.0 (IBM Corporation, Armonk, NY, USA). Parametric tests were used for normally distributed data, and non-parametric tests were used for non-normally distributed data in the comparison of blood parameters of the patient group and control group. P <0.05 value was considered to be significant. Results Demographic characteristics and all laboratory findings of the participants are shown in Table 1. 53 individuals (male: 29 (54.7%); female: 24 (45.2%)) were included in the CSNHL group and 53 individuals (male: 32 (60.3%); female: 21 (39.6%)) were

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included in the control group. The mean age was 23.85±5.35 months (distribution 11 to 33 months) in the CSNHL group and 22.92±6.10 months (distribution 12 to 35 months) in the control group. When the groups were compared in terms of gender and age distribution, no statistically significant difference was found, and these two groups were interpreted as statistically comparable (p> 0.05). According to the mean values of ABR measurements, the patient group was recorded to have bilateral severe and profound SNHL (Right ear: 101.57 ± 19.24 dBnHL; Left ear: 98.48 ± 13.41 dB nHL). According to the mean values of ABR measurements, the hearing levels were normal in the control group (Right ear: 15.03 ± 5.46 dBnHL; Left ear: 14.4 ± 3.22 dB nHL). (Table 1) Table 1. The demographic characteristics and laboratory values of the csnhl patients and control groups Patients group (n=53)

Control group (n=53)

P value

23.85 ± 5.35

22.92 ± 6.10

0.409

Age (months) Gender (male/female)

29/24

32/21

Right

101.57 ± 19.24

15.03 ± 5.46

0.001

Left

98.48 ± 13.41

14.43 ± 3.22

0.001

WBC

7.740 ± 1.550

7.533 ± 1.274

0.454

Neutrophil, × 103/L s,

6.777 ± 1.483

5.294 ± 0.928

0.001

Lymphocytes, × 103/L

2.691 ± 0.685

2.618 ± 0.804

0,618

ABR (dB nHL)

PLT, × 10 /L

310.35849±82.81479

279.02641±76.12790

0.045

MPV, fL

9.243 ± 4.236

9.035 ± 4.283

0.802

NLR

2.714 ± 1.110

2.287 ± 0.996

0.04

PLR

139.195 ± 59.418

111.899 ± 59.911

0.02

Data are presented as means ± standard deviation. ABR: auditory brainstem response. dB nHL; decibel normalized hearing level. WBC: white blood cell. NLR: neutrophil to lymphocyte ratio. PLR: platelet to lymphocyte ratio. MPV: mean platelet volume. PLT: platelet Table 2. Correlation between ABR values of patients group and NLR and PLR values NLR

PLR

NEUTR

PLT

Pearson Correlation

0.254

0.226

0,072

-0,112

0.066

0.104

0,61

0,425

ABR

p value is calculated by 2-tailed t-test. ABR: auditory brainstem response. NLR: neutrophil to lymphocyte ratio. PLR: platelet to lymphocyte ratio. NEUTR: neutrophil. PLT: platelet.

The mean NLR value was 2.71±1.11 in the patient group and 2.28±0.99 in the control group. NLR value was found to be significantly higher statistically in the patient group (p = 0.04). The mean PLR value was 139.19±59.41 in the patient group, whereas it was 111.89±59.91 in the control group. PLR value was found to be significantly higher statistically in the patient group (p = 0.02). As shown in Table 2, there was no significant correlation between ABR test results and laboratory findings. Discussion In our study, we found that NLR and PLR values were significantly higher in patients with pediatric CSNHL than the healthy control group. There was no significant correlation between laboratory values and ABR test results. To the best of our knowledge, this is the first study to investigate NLR, PLR and MPV levels as 83

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inflammatory biomarkers in patients with pediatric CSNHL. As far as the literature is concerned, we could not find a similar study. The physiopathology of CSNHL could not be fully understood. Many factors, such as inflammation, genetic factors, environmental factors, and bacterial and viral infections, have been implicated in the etiopathogenesis of CSNHL [1-4]. Chronic inflammation may have a vital role in CSNHL physiopathology. Furthermore, many different cytokines secreted from inflammatory cells may play an important role in the physiopathogenesis of SNHL. Neutrophils, lymphocytes, and platelets are important blood elements involved in inflammatory processes. Cytokines involved in the pathogenesis of inflammatory processes are known to increase NLR [6-9]. Neutrophils secrete large amounts of inflammatory mediators and function as mediators of tissue destruction under inflammatory conditions [17]. Also, platelets play a role in inflammatory processes by affecting T lymphocytes, neutrophils, mononuclear phagocytes and endothelial cells [11,12]. According to recent studies, activated platelets can trigger inflammation [11,12]. Globally, NLR, PLR, and MPV values are being widely used as systemic inflammation and infection indicators. NLR, PLR, and MPV values are cheap and easy to calculate parameters. These parameters have been shown to increase in many diseases such as ISSNHL [5, 6], tinnitus [7], Bell palsy [8], vestibular neuritis [9], chronic otitis media with effusion [13], FMF [14], SLE [15] and cardiovascular diseases such as coronary artery diseases [16,17]. Seo et al. [5] found that NLR and PLR values were significantly higher in ISSNHL patients than in the control group, and they suggested that this indicates the presence of atherosclerosis in the pathogenesis of ISSNHL. Studies have shown that higher NLR values indicate a higher inflammation [22]. High neutrophils and NLR values have been implicated in causing increased damage to endothelial cells [23].

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without cholesteatoma. In this study, no statistically significant difference was found in the parameters other than MPV in both groups. Contrary to this, MPV values have been shown to be significantly lower in patients with cholesteatoma than in the control group [12]. To determine cholesteatoma in COM patients, it has been suggested that MPV level can be used as an independent predictor with high sensitivity and specificity [12]. In a study examining the relationship between chronic otitis media with effusion (COME) and NLR and PLR values, NLR was found to be significantly higher in the patient group compared to the control group [13]. The PLR parameter was found to be high in COME patients; however, it was not statistically significant. It has been claimed that NLR can be used as a diagnostic parameter in patients with COME [13]. In a study of cases with FMF, NLR values of patients with frequent attacks were found to be higher than those without attacks and healthy controls [14]. In a study, NLR, PLR, and MPV levels were found to be high in patients with Systemic Lupus Erythematosus (SLE) [15]. High NLR and PLR levels have been suggested to show a positive correlation with inflammatory markers and disease activity. It has been claimed that NLR and PLR levels, together with other serum inflammatory markers such as C-reaction protein and erythrocyte sedimentation rate, can be used as useful biomarkers in determining inflammatory response or disease activity in SLE patients [15]. NLR and PLR may reflect inflammatory response and disease activity in SLE patients. It has been shown that WBC and its subtypes can be used as inflammatory markers in cardiovascular diseases [16,17]. It has been suggested that NLR value as an inflammatory marker may help predict prognosis in patients with acute coronary syndromes.

Another study suggests that NLR and MPV can be used to predict prognosis in patients with sudden hearing loss [6]. In patients with sudden hearing loss and high NLR, a decreased response to treatment has been seen, and this has been reported as a poor prognostic factor [6].

In other words, mortality has been shown to increase in patients with higher NLR values [16,17]. Furthermore, it has been suggested that parameters such as NLR and PLR are found to be high in various malignancies, and these high parameters are associated with poor prognosis [18-21].

Ozbay et al. [7] reported significantly higher NLR values in patients with severe tinnitus than the control group. They argued that high NLR should be considered a potential clinical marker of tinnitus.

Limitations The presented study has some limitations. First, the sample size is relatively small, and all subjects are from the same center. Second, there are no long-term follow-up results. Third, a retrospective case study may not be accurate in nature due to the possibility that patient characteristics may not be fully recorded.

Bucak et al. [8] showed that neutrophil and NLR values were significantly higher in patients with Bell palsy than the control group. They also claimed that NLR could be used as a new potential marker for predicting the prognosis of patients while evaluating patients with Bell palsy. Chung et al.[9] showed that NLR and PLR levels were significantly higher in patients with vestibular neuritis than in the healthy control group. They claimed that NLR and PLR values could be used as simple and reliable parameters to estimate the cause and severity of the disease. Eryilmaz et al. [12] examined MPV, NLR, PLR and erythrocyte distribution width values in chronic otitis media children with or

Conclusions In conclusion, this study showed that NLR and PLR values in CSNHL patients were significantly higher compared to the control group. MPV values did not show a significant difference between the two groups. The findings of this study are generally consistent with the literature. To the best of our knowledge, the relationship between CSNHL and NLR and PLR has been demonstrated for the first time. Based on these data, it can be said that NLR and PLR values, which can be easily calculated at low cost, can be used as a suitable auxiliary parameter for the detection of inflammation in CSNHL patients. Further studies are needed to determine the 84

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relationship between hearing loss etiopathogenesis and hearing loss levels and NLR, PLR, and MPV.

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ratio and platelet to lymphocyte ratio in vestibular neuritis. Laryngoscope. 2015;125:257-61.

Competing interests The authors have no financial conflicts of interest.

10. Seo YJ, Park YA, Bong JP, Park D-J, Park SY. Predictive value of neutrophil to lymphocyte ratio in first-time and recurrent idiopathic sudden sensorineural hearing loss. Auris Nasus Larynx. 2015;42:438-42.

Financial Disclosure The authors declared that this study has received no financial support.

11. Aktas G, Sit M, Tekce H, et al. Mean platelet volume in nasal polyps. West Indian Med J. 2013;62:515-8.

Ethical approval The study protocol was approved by the Ethics Committee of Harran University, School of Medicine (13.06.2019 / 06-38), and was conducted under the ethical principles described by the Helsinki Declaration. Mustafa Celik ORCID: 0000-0002-6237-2518 References 1.

Celik M, Koyuncu İ. Oxidative stress in prelingual sensorineural hearing loss and the effects of cochlear implant application on serum oxidative stress levels. Int J Pediatr Otorhinolaryngol. 2019;119:177-82. Celik M, Karatas E, Kanlikama M. Outcomes of cochlear implantation in children with and without inner ear malformations. Pak J Med Sci. 2018;34:380.

Kenna MA. Medical management of childhood hearing loss. Pediatr Ann. 2004;33:822-32.

Seo YJ, Choi JY, Moon IS. Neutrophil-to-lymphocyte ratio and plateletto-lymphocyte ratio: novel markers for diagnosis and prognosis in patients with idiopathic sudden sensorineural hearing loss. Dis markers. 2014;2014: 702807.

Ulu S, Ulu MS, Bucak A, et al. Neutrophil-to-lymphocyte ratio as a new, quick, and reliable indicator for predicting diagnosis and prognosis of idiopathic sudden sensorineural hearing loss. Otol Neurotol. 2013;34:1400-4. Ozbay I, Kahraman C, Balikci H, et al. Neutrophil-to-lymphocyte ratio in patients with severe tinnitus: prospective, controlled clinical study. J Laryngol Otol. 2015;129:544-7. Bucak A, Ulu S, Oruc S, et al. Neutrophil-to-lymphocyte ratio as a novelpotential marker for predicting prognosis of Bell palsy. Laryngoscope. 2014;124:1678-81. Chung JH, Lim J, Jeong JH, et al. The significance of neutrophil to lymphocyte

12. Eryilmaz MA, Derin S. Mean platelet volume as a potential predictor of cholesteatoma in children. J Craniofac Surg. 2016;27:575-8. 13. Atan D, Apaydın E, Özcan KM, et al. New diagnostic indicators in chronic otitis media with effusion: neutrophil to lymphocyte ratio and thrombocyte lymphocyte ratio. ENT Updates. 2016;6:12-5. 14. Ünal Uluca AE, Şen V, Karabel D, et al. Usefulness of mean platelet volume and neutrophil-to-lymphocyte ratio for evaluation of children with Familial Mediterranean Fever. Med Sci Monit. 2014;20:1578. 15. Qin B, Ma N, Tang Q, et al. Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) were useful markers in assessment of inflammatory response and disease activity in SLE patients. Mod Rheumatol. 2016;26:372-6. 16. 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. 17. Papa A, Emdin M, Passino C, et al. Predictive value of elevated neutrophil– lymphocyte ratio on cardiac mortality in patients with stable coronary artery disease. Clin Chim Acta. 2008;395:27-31. 18. Wang D, Yang J-X, Cao D-Y, et al. Preoperative neutrophil-lymphocyte and platelet-lymphocyte ratios as independent predictors of cervical stromal involvement in surgically treated endometrioid adenocarcinoma. Onco Targets Ther. 2013;6:211. 19. Peng W, Li C, Wen T-F, et al. Neutrophil to lymphocyte ratio changes predict small hepatocellular carcinoma survival. J Surg Res. 2014;192:402-8. 20. Templeton AJ, Knox JJ, Lin X, et al. Change in neutrophil-to-lymphocyte ratio in response to targeted therapy for metastatic renal cell carcinoma as a prognosticator and biomarker of efficacy. Eur Urol. 2016;70:358-64. 21. Cedres S, Torrejon D, Martinez A, et al. Neutrophil to lymphocyte ratio (NLR) as an indicator of poor prognosis in stage IV non-small cell lung cancer. Clin Transl Oncol. 2012;14:864-9. 22. Imtiaz F, Shafique K, Mirza SS, et al. Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. Int Arch Med. 2012;5:2. 23. Ott I, Neumann F-J, Gawaz M, et al. Increased neutrophil-platelet adhesion in patients with unstable angina. Circulation. 1996;94:1239-46.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):86-9

Retrospective analysis of inguinofemoral hernias Turgay Karatas1, Davut Ozbag1, Murat Kanlioz2 Inonu University, Faculty of Medicine, Departmant of Anatomy, Malatya, Turkey Private Beylikduzu Kolan Hospital, Departmant of General Surgery, Istanbul, Turkey 1

Received 22 August. 2019; Accepted 05 November 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9142

Abstract We aim to present the operative findings of inguinal and femoral hernias that were operated.The records of 732 patients who underwent surgery for inguinal and femoral hernia between March 2000 and January 2013 were evaluated retrospectively. The number, sex, and age of patients, type and side of hernias, the existence of strangulation, structure, and content of hernia sac were recorded.684 (93.4 %) of patient is male, 48 (6.5 %) of patient is female. The average age was 46.2. The rate of inguinal hernia was 96.7 %. However, the rate of femoral hernia was 3.2 %. Inguinal hernia 97.9 % and femoral hernia 2 % was found among males. Inguinal hernia 79.1 % and femoral hernia 20 % was found among females. Indirect hernia rates were 70.4 % among males and 75 % among females. Direct hernia rates were 20.7 % among males and 4.1 % among females. Hernias were located in 59 % on right-side, in 37 % on left-side, in 3.1 % on bilateral. The strangulated hernia was seen at 3.1 % in all cases. Strangulation rate was higher among women (6.2 % - 2.9 %). The strangulation rate was 16.6 % in femoral hernia, but this ratio was 2.6 % in inguinal hernia. Hernia sac consisted of peritoneum frequently (99.4 %). The structure that was found mostly in hernia sac was omentum majus (40.4 %).Inguinal hernias are encountered more than femoral hernias. The strangulation rate in femoral hernias is higher than in inguinal hernias. Since the strangulation rate is higher in femoral hernias, the surgical urgency of this type of hernias is higher than inguinal hernias. At the same time, because the internal organs can form the hernia sac or the organ inside the sac, the surgeon should pay maximum attention during the operation. Keywords: Inguinal hernia, femoral hernia, strangulated hernia, surgery

Introduction One of the most common surgical diseases is groin hernias. Groin hernia repair is one of the most common surgical operations. The rate of inguinal hernia repair is 10 per 100,000 people in the United Kingdom and 28 per 100 000 people in the United States [1]. Learning of the inguinal region anatomy following the nineteenthcentury cadaver dissections has made significant progress in the surgery of inguinal region hernias. The publications of surgeons such as Cooper, Franz Hasselbach, Antonio Scarpa and JulesGermain Cloquet on the formation mechanisms and treatment of inguinal hernia formed the basis of modern surgery [2]. Most abdominal anterior wall hernias are inguinal hernias, followed by femoral and umbilical hernias, respectively. *Coresponding Author: Turgay KarataĹ&#x;, Inonu University, Faculty of Medicine, Departmant of Anatomy, Malatya, Turkey E-mail: drkaratas44@hotmail.com

Gallegos et al. reported that 439 of 476 hernias were inguinal, and 37 were femoral hernias [3]. Femoral hernias account for 2% to 8% of all groin hernias in adults. A femoral hernia is more common in females than in males [4]. The proportion of indirect hernias in groin hernias is higher than direct and femoral hernias. Inguinal hernia may be congenital or acquired. Most inguinal hernias in the young population are indirect hernias of congenital origin. These occur when the processus vaginalis remains open [5]. Direct hernias are mostly acquired and are found in adults. They emerge from the Hasselbach triangle in the inguinal region. Disorders of collagen metabolism (low levels of hydroxyproline) have been implicated in these hernias [6]. Smokers, patients with positive family hernia history, patent processus vaginalis, collagen disease, patients with an abdominal aortic aneurysm, after an appendectomy and prostatectomy, with ascites, on peritoneal dialysis, after long-term heavy work or with the chronic obstructive pulmonary disease have an increased risk of inguinal hernia. This is not proven concerning (occasional) lifting, constipation and prostatism [7]. 86

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The patient with groin hernia has complaints of swelling and pain in the inguinal region. Surgical treatment is usually used to treat groin hernias. Hernia surgery aims to prevent possible strangulation and related complications.

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2). The mean age of indirect hernia was 45.6 years, the mean age of direct hernia was 53.9 years, and the mean age of femoral hernia was 51.9 years. Table 2. Distribution of hernia types by gender (n = number, % = percentage)

Materials and Methods The records of 732 patients who underwent surgery for inguinal and femoral hernia between March 2000 and January 2013 were evaluated retrospectively. The number of inguinal and femoral hernia, distribution by gender and age, type (femoral-direct-indirect-pantaloon), and side of hernia, whether they were a recurrent or strangulated hernia, concomitant pathologies, structure, and content of hernia sac, type of anesthesia and type of surgery were recorded. The distribution of inguinofemoral hernia according to gender and age, the rate of hernia types and its distribution by gender and age, the rate of hernia side and its distribution by gender, rate of recurrent hernia and its distribution by gender, incarceration rate and its distribution by age, gender and hernia types, and the rate of concomitant pathologies and its distribution by gender were compared with those obtained from the literature and the results were evaluated. Results 93.4% (684) of the patients were male, and 6.5% (48) were female. The age range of the patients was 2 to 86 years. The mean age was 46.2 years. Most of the patients (78%) were 40 years or older. The age range of males was 2 to 86 years. The mean male age was 46.8 years. The age range of female was 3 to 73 years. The mean female age was 36.5 years. 96.7% of all hernias were inguinal, and 3.2% were femoral hernias. According to anatomical localization, hernias were inguinal (indirect, direct, pantaloon) and femoral hernia. Indirect hernia rate was 73.1%, direct 20.3% and pantaloon 6.4% (Table 1). Table 1. Hernia types according to anatomical localization (n = number, % = percentage) Hernia types

Sex

Male Female

Indirect hernia n/%

Direct hernia n/%

Pantaloon hernia n/%

Femoral hernia n/%

482/70.4

142/20.7

46/6.7

14/2

36/75

2/4.1

10/20

59% of the hernias were located on the right side, 37% on the left, and 3.1% bilaterally. Both sexes had the right dominance. Bilateral hernia incidence was higher in males than in females (Table 3). Table 3. The distribution of hernia sides by gender Sex

Right

Left

Bilateral

Male

59.2%

19.8%

21%

Female

56.2%

41.8%

5% (37) of all patients were operated for recurrent inguinal hernia. 4.8% (33) of males and 8.3% (4) of females were operated for recurrent inguinal hernia. The incarcerated hernia was seen in 3.1% of all cases (20 males - 3 females). The incarceration rate was higher among females than males (6.2% - 2.9%). 60.8% of incarcerated hernia cases were over 40 years of age. Incarceration was seen in 4 femoral hernias (3 females and one male), and the incarceration rate was 16.6% in femoral hernias. 19 incarceration was detected in an inguinal hernia, all of them were male, and the incarceration rate of inguinal hernia was 2.6% (Table 4). Most of the incarcerated inguinal hernias were indirect hernia (89%), and a small number of them were direct hernia (10.5%). Table 4. Distribution of incarcerated hernias (n=number of incarcerated hernias, incarceration percentage = %)

Distribution of incarcerated hernias

Inguinal Hernia

708

96.7

Incarcerated femoral hernias

16.6

Indirect

518

73.1

Incarcerated inguinal hernias

2.6

Direct

144

20.3

Pantaloon

6.4

Femoral hernia

3.2

97.9% (670) of the male had an inguinal hernia, and 2% (14) had a femoral hernia. 79.1% (38) of the female had inguinal, and 20% (10) had a femoral hernia. The indirect hernia was detected in 70.4% of males, while indirect hernia was found in 75% of females. 20.7% of males and 4.1% of females had a direct hernia. 6.7% of the male had pantaloon hernia, while the female had no pantaloon hernia. 2% of the male had a femoral hernia, while 20% of females had a femoral hernia (Table

5.1% (38) of the patients had concomitant pathology. These were more common in men. Concomitant pathologies were often related to male reproductive organs (12 hydrocele, eight cord cysts, seven varicocele, four undescended testes, three epigastric herniae, three umbilical herniae, one Spigelian hernia). The hernia sac was mostly consisting of the peritoneum (99.4%). It consisted of caecum in two cases, sigmoid colon in one case and bladder in one case (0.54%). Most of the hernia sacs were empty (55.7%). The most common structure in hernia sac was omentum majus (40.4%). Intestines were last seen (3.8%). 87

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Spinal (73.3%), general (25.5%), epidural, and local anesthesia were used. Mesh herniorrhaphy was performed in 77% of the cases, and herniorrhaphy without mesh was performed in 23%. Discussion Hernia in Latin means rupture. Hernias occur in any part of the body but often occur in the anterior abdominal wall, especially in the inguinal region. Hernias in the inguinal region develop anatomically from the myopectineal orifice described by Fruchaud [8]. Abdominal hernias are common, with a prevalence of 1.7% for all ages and 4% for those over 45 years of age. Inguinal hernia accounts for 75% of abdominal wall hernias, and the lifetime risk of inguinal hernia is 27% in men and 3% in women [1]. The incidence of inguinal hernia in males and females is given differently in different sources (M / F = 25, M / F = 12) [9,10]. William B. Coley et al. reported that 756 of 937 inguinal hernia cases were male, and 181 were female [11]. In Seward Erdmanâ&#x20AC;&#x2122;s study, 1093 of 1154 inguinal hernia were seen in males and 61 in females. The age range of these patients ranged from 6 months to 70 years [12]. 684 of the 732 patients were male, and 48 were female in our cases. The age range was 2 to 86 years. The mean age was 46.2 years. The mean age was 46.8 years for males and 36.5 years for females. It was reported that inguinofemoral hernias were more common between the two and third decades [11]. In another report, inguinofemoral hernias were found to be more between the third and fourth decades [13]. Most inguinofemoral hernias in our study were observed over the fourth decade. In groin hernias, inguinal hernias are more common than femoral hernias. In one study, only 66 femoral hernias were found in the groin hernia series of 1003 cases [11]. Femoral hernias are ten times more common in females. Although the proportion of femoral hernia among females is higher, an inguinal hernia is still the most common type of hernia in the female. A femoral hernia is rare among males [9]. Seven hundred eight of the groin hernias were inguinal, and 24 were femoral in our study. 97.9% of the male had an inguinal hernia, 2% had a femoral hernia, 79.1% of females had inguinal, and 20% had a femoral hernia. According to the anatomical localization, groin hernias are inguinal (indirect, direct, pantaloon) and femoral hernia. In 1093 cases of inguinal hernia series, the indirect hernia rate was 68.4%, direct hernia rate was 25.8%, and pantaloon hernia rate was 5.8% [12]. We found an indirect hernia rate as 73.1%, direct rate as 20.3%, and pantaloon rate at 6.4%. Among the male, indirect hernias are reported to be twice the direct hernias [9]. In the literature, the mean age of indirect hernia was 27.8 years, and the mean direct age was 38 years. It is stated that direct hernias are acquired in later life rather than developmental defects [12]. Femoral hernias are reported to be more common between 40 and 70 years of age [4]. In our study, the indirect hernia rate was 70.4%; the direct hernia rate was 20.7% in males. The mean age of indirect hernia was 45.6 years, the direct mean age was 53.9 years, and the femoral mean age was 51.9 years. Both indirect and femoral hernias are more common on the right

Med Science 2020;9(1):86-9

side. One reason is the usual slow descent of the right testis into the scrotum during fetal development and the delay in atrophy of the procesus vaginalis. Another reason is that the left femoral canal is tamponed by the sigmoid colon [9]. Groin hernias are more frequent on the right in both sexes. In a groin hernia series of 1600 cases, 41.6% right, 30.1% left, 28.3% bilateral hernia was found [13]. We found 59% right, 37% left, 3.1% bilateral hernia. There is a right dominance in both sexes. Bilateral hernia rate was higher in males (M=21%, F=2%). In the studies, the rate of cases operated with a diagnosis of recurrent hernia was found to be 5.6% [12]. In our study, the rate of cases operated for recurrent hernia was 5%. The rate of patients who were operated on with a diagnosis of recurrent hernia was 8.3% among females and 4.8% among males. Incarceration is the inability to insert the contents of the hernia sac into the abdomen. Strangulation is the disruption of the blood circulation of the organs in the hernia sac. This is a serious situation. Incarceration is common in indirect and femoral hernias. The reason for this is that the neck region of the hernia sac is narrow in such hernias. Indirect hernias, incarceration is not common as the neck region of the hernia sac is large. Strangulation occurs in 1-3% of the groin hernias and is usually more common in advanced ages [6]. Femoral hernias have a higher incarceration rate, so femoral hernias are more urgently operative than other hernias [3]. Incarcerated hernias are usually seen in older ages. In the study of Lawrence S. Fallis, 22 (1.4%) of 1600 cases were operated with the diagnosis of an incarcerated hernia; only one patient underwent small bowel resection [13]. The incarcerated hernia was found in 23 (3.1%) of our patients. The incarceration rate was higher among females (F=6.2%, M=2.9%). 60.8% of our incarcerated hernia cases were over 40 years of age. There was incarceration in 4 femoral hernias (in 3 females and 1 male), and the incarceration rate in femoral hernias was 16.6%. Strangulation occurred in 2 femoral hernias (2 females), and one underwent omentum resection, and the other underwent small bowel resection. Incarceration was detected in 19 of the inguinal hernias. The incarceration rate in inguinal hernias was 2.1%, and all of these patients were male. Most incarcerated inguinal hernias were indirect hernias (89%). Hernia sacs are usually consisting of the peritoneum. In sliding hernias, a part of the hernia sac consists of internal peritoneal organs. The rate of sliding hernia has been reported as 3.3% in the literature [13]. In our study, hernia sacs mostly consisted of the peritoneum (99.4%). Our sliding hernia rate was 0.54% (2 caecum, 1 sigmoid colon, one vesica urinaria). Hernia sacs may have abdominal organs. In our study, 55.7% of hernia sacs were empty, 40.4% had omentum, and 3.8% had intestines. There may be concomitant pathologies in groin hernias. Concomitant pathologies were reported in 10.4% of the cases. Most of these pathologies were related to male reproductive organs [13]. In our series, 38 patients (5.1%) had concomitant pathologies, and as in the literature, concomitant pathologies were mostly related to male reproductive organs. 88

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Med Science 2020;9(1):86-9

Conclusion

Hachisuka T. Femoral hernia repair. Surg Clin North Am. 2003;83:1189-205.

As a result, since incarceration and strangulation rates are higher in the femoral region hernias, the urgency of this type of hernias is higher than inguinal hernias. Also, hernia sac can consist of internal organs, or there may be organs in the hernia sac, so it should be careful during surgery to avoid any complications.

van Wessem KJ, Simons MP, Plaisier PW, et al. The etiology of indirect inguinal hernias: congenital and/or acquired?. Hernia. 2003;7:76-9.

Ertaş E, Polat KY, Bulut T, et al. Hydroxyproline levels in rectus sheat in inguinal hernias. Türkiye Klinikleri J Med Res. 1991;9:395-7.

Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009; 13:343-403.

Fruchaud H. Anatomie chirurgicale des Hernies de I’ Aline. Paris: C. Doin. 1956

Towsend CM, Evers BM, Beauchamp RD, et al. Sabiston Textbook of Surgery-Modern Cerrahi Pratiğin Biyolojik Temeli. Çeviri Ed: Ali Naki Ulusoy. In:Herniler. Nobel Tıp Kitabevleri Ltd. Şti, İstanbul, 2010;1199-218

Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki. Turgay Karataş ORCID: 0000-0002-1480-606X Davut Ozbag ORCID: 0000-0001-7721-9471 Murat Kanlıoz ORCID: 0000-0003-4271-184X

References 1.

Jenkins J T, O’Dwyer P J. Inguinal hernias. BMJ. 2008; 336:269-72.

Rutkow IM. A selective history of groin hernia surgery in the early 19. century:The anatomic atlases of Astley Cooper, Franz Hesselbach, Antonio Scarpa, and Jules-Germain Cloquet. Surg Clin North Am. 1998;78:921-40.

Gallegos NC, Dawson J, Jarvis M, et al. Risk of strangulation in groin hernias. Br J Surg. 1991;78:1171-3.

10. Ponka JL (ed): Hernias of the abdominal wall. W.B. Saunders, Philadelphia, 1980:2-90. 11. Coley WB. I. Result of One Thousand Operations for the Radical Cure of Inguinal and Femoral Hernia. Ann Surg. 1903;37:801-24. 12. Erdman S. Inguinal hernia in the male: late results in 978 traced cases. Ann Surg. 1923;77:171-89. 13. Fallis LS. Inguinal Hernia: a report of 1600 operations. Ann Surg. 1936; 104:403-18.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):90-3

The effect of gestational hypertension on the maternal mean platelet volume Emre Baser1 , Funda Salgur2, Melek Bilge3, Safak Ozdemirci4, Deniz Esinler5, Eylem Unlubilgin4, Aykan Yucel5, Ozlem Moraloglu Tekin4 Yozgat Bozok University, Faculty of Medicine, Department of Obstetric and Gynecology, Yozgat,Turkey 2 Baskent University, Faculty of Medicine, Department of Family Medicine, Ankara, Turkey 3 Dr. Ali Kemal Belviranli Women Birth And Child Diseases Hospital, Department of Obstetric and Gynecology, Konya, Turkey 4 Etlik Zubeyde Hanim Womens Health Education and Research Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey 5 Etlik Zubeyde Hanım Womens Health Education and Research Hospital, Department of Obstetrics and Gynecology, Perinatology High Risk Pregnancy Clinic, Ankara, Turkey 1

Received 11 September 2019; Accepted 20 October 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2018.08.9143

Abstract To evaluate the effect of gestational hypertension on the maternal mean platelet volume (MPV). The study group comprised pregnant women with gestational hypertension who gave birth to single, term, healthy fetuses and control group was pregnant women without any complications. MPVs were calculated within 24 hours in the intrapartum period. The mean MPV of 68 hypertensive and randomly selected 135 normotensive pregnant women were compared. The MPV of gestational hypertensive group was significantly higher (9.5±0.98 vs 9.2±0.9 fL; p=0.015). Using ROC analysis, the optimal MPV cut off value was found 9.25 fL with the sensitivity of 60.0% and the specificity of 61.0% (AUC=0.622, 95% CI=0.538-0.707, p=0.004) for the prediction of gestational hypertension. This study demonstrated that maternal MPV cannot be used to predict gestational hypertension in clinical practice due to its low sensitivity and specificity. However, further studies are needed to examine the predictive value of MPV in the progression of the hypertensive diseases of pregnancy. Keywords: Pregnancy, gestational hypertension, mean platelet volume

Introduction Gestational hypertension was defined as new-onset hypertension (systolic BP ≥ 140 mmHg and/or diastolic BP (phase 4) ≥ 90 mmHg) without proteinuria after 20 weeks’ gestation which returned to normal within 12 weeks of delivery [1]. Hypertensive disorders complicate healthy nulliparous and multiparous pregnancies at a rate of 6–17% and 2–4%, respectively [2,3]. In 10–50% of cases, gestational hypertension progresses to preeclampsia between one and five weeks after diagnosis [4]. The recurrence rates of gestational hypertension and preeclampsia in further pregnancies are 22% and 7%, respectively [5]. Despite the unknown pathogenesis of preeclampsia, endothelial cell damage and dysfunction [6] and platelets play essential roles in its progression [7]. Thrombocytopenia is used as a defining criterion for the diagnosis of severe preeclampsia [8].

*Coresponding Author: Emre Baser, Yozgat Bozok University, Faculty of Medicine, Department of Obstetric and Gynecology, Yozgat,Turkey E-mail: emrebasermd@gmail.com

An enhanced mean platelet volume is associated with both incremental platelet activation [9] and newly produced platelet from bone marrow [10]. There is sufficient discussion in the literature about the relationship between preeclampsia and MPV [10-13], whereas there is a paucity of information about the effects of gestational hypertension. The early prediction of the progression to preeclampsia, eclampsia and HELLP syndrome can be important in reducing maternal and fetal mortality and morbidity. The aim of this study is to evaluate the presence or absence of the effects of gestational hypertension on MPV. Materials and Methods A retrospective case-control study was performed between January 2011 and December 2012 in our hospital. The study group was defined as women whose pregnancies were complicated with only gestational hypertension. The control group consisted of uncomplicated pregnant women. All data were obtained from the files of pregnant women and computerized registration documents. This study was approved by the local ethical committee (13.12.2017/25). 90

doi: 10.5455/medscience.2018.08.9143

The study group consisted of 68 patients with gestational hypertension and the control group consisted of 135 healty pregnant women without hypertension. The criteria for inclusion in both the study and the control group were: healthy individuals aged between 18 and 35 years, singleton pregnancy and delivered after 37 gestational weeks. The exclusion criteria were: chronic hypertension, other pregnancy-induced hypertension disorders, hematologic disorders, all systemic disorders, gestational diabetes, intrauterine growth retardation, abnormal umbilical artery blood flow Doppler findings, fetal anomalies, antihypertensive drugs, magnesium or other drugs (with the exception of iron or vitamin supplements such as calcium, etc.) smoking or substance abuse. The level of maternal MPV and another hemogram parameters were measured within 24 hours of intrapartum and used for statistical analysis. The calculation of body mass index was performed by dividing maternal weight with the square of maternal height (kg/ m2).

Med Science 2020;9(1):90-3

However, the mean maternal hemoglobin, thrombocyte count and serum creatinine levels were not significantly different between the two groups (p= 0.505, p= 0.911, p= 0.678, respectively) (Table 2). Using ROC analysis, the optimal MPV cut off value was found 9.25 fL with the sensitivity of 60.0% and the specificity of 61.0% (AUC=0.622, 95% CI=0.538-0.707, p=0.004) for the prediction of gestational hypertension (Table 3 and Figure 1). Table 1. Demographic characteristics GHT group n = 68

Control group n= 135

Maternal age (year)

26.9±5.3

25.8±4.2

0.090a

Maternal body mass index (kg/m2)

29.4±2.8

28.5±3.8

0.070a

% 52.9 (36/68)

%50.4 (68/135)

0.729b

Nullipar

Statistical analysis was performed using SPSS (version 20, SPSS, Chicago, IL). The data were express as mean ± SD and in percentile. The distribution of the variable data was determined using visual (histograms, probablity plots) and analytical methods (Kolmogrov Simirnov / Shapiro-Wilk’s test). The normal distributions of the groups’ variables were compared using the Student’s t-test. The chi-square test was used to compare the proportional properties of both groups. The ROC (receiver operating characteristics) curve analysis was used to predict the capacity of maternal MPV. Sensitivity and specificity were presented to observe the cut-off level value. A p-value less than 0.05 was accepted as statistically significant.

Gestational birth week (LMP)

39.1±1.2

39.3±1.2

0.118a

Neonatal birt weight (g)

3194±393

3234±402

0.494a

Results A total of 139 women were found to have their pregnancies complicated with gestational hypertension. However, only 68 of these women fulfilled the criteria for our study. Of the women excluded, 19 were aged 38 or more, two were adolescents, 16 pregnancies were also complicated with intrauterine growth retardation, 12 pregnancies were concomitant with thyroid disorders, one pregnant woman had existing deep venous thrombosis, one had rheumatoid arthritis and one suffered from concurrent asthma. Of the remaining 19 excluded pregnant women: six had coexisting abnormal umbilical blood flow (Doppler evaluated), seven were taking antihypertensive drugs, five women smoked and one woman was taking low molecular weight heparin (see Flowchart). The control group comprised randomly selected healthy pregnant women who delivered during the same time period. Demographic characteristics of the patients are shown in Table 1. The mean age of the patients in the study group was 26.9 ± 5.3 years and the control group was 25.8 ± 4.2 years, and there was no significant difference between the groups (p=0.090). Examining the body mass index of the patients was no a statistically difference between groups. The mean birth weight was 3194 ± 393 in the study group and 3234 ± 402 in the control group, and there was no significant difference between the groups (p=0.494). In our study, there was a statistically higher mean maternal MPV in the study group than in the control group (9.5±0.98 vs 9.2±0.9 fL; p=0.015).

a: t-student’s test b: Chi-square test. p <0.05 was statistically significant. LMP: last menstrual period. GHT: Gestational Hypertension

Table 2. Laboratory findings GHT group n = 68

Control group n= 135

Hemoglobin (g /dL)

11.6±1.4

11.6±1.2

0.505a

Platelet count (mm3)

234.0±68.5

232.7±77.9

0.911a

Mean platelet volume (fL)

9.5±0.98

9.1±1.19

0.014a

Serum cretainin level (mg / dl)

0.6±0.06

0.6±0.05

0.678a

a: t-student test. p <0.05 was statistically significant. GHT: Gestational Hypertension

Figure 1. ROC curves for MPV value in predicting gestational hypertension

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Table 3. Sensitivity and specificity for MPV value in predicting gestational hypertension

GHT

MPV cut- off (fL)

Sensitivity

Specifity

AUC

9.25

0.622

CI (95%) Lower

Upper

0.538

0.707

p 0.040

p: <0.05 was statistically significant. GHT: Gestational Hypertension

Discussion We noted that the maternal MPV is statistically significantly increased in pregnancies complicated with gestational hypertension. In preeclampsia, endothelial injury leads to increased intravascular coagulation by platelet activation [14]. Furthermore, the volume of the newly produced (young) platelets is higher than that of the old platelets [15]. In our opinion, intravascular pressure can be higher by occurrance of vasoconstriction in gestational hypertension. This mechanism may lead to changing platelet surface and activating platelets function. Consequently the increment in volume of it can be seen without developing endothelial cell demage in gestational hypertension. MPV level was found to be significantly higher in hypertensive patients [16]. This finding can support our hypothesis. The study found that there was no difference between the mean platelet counts of both groups; the balance between thrombocyte consumption and the production of bone marrow are adequate for gestational hypertension. Thrombocyte consumption is greater than production in severe preeclampsia and this has been seen to lead to thrombocytopenia [10]. Compared with preeclampsia, the lower microparticle concentration in gestational hypertension [17] can be explained by the lower degree of intravascular microthrombus formation and the reduced degree of endothelial injury. There are studies in the literature that report different results concerning MPV. Although some studies have shown an increase in MPV in preeclampsia [10,13,14], others have reported no change [7,18,19]. However, the studies that report no change in MPV have some important limitations. First, the pregnancies were not grouped as preterm or term, so the effect of gestational age on MPV was neglected [7, 18, 19]. Second, the low sample size of the preeclampsia groups and the failure to specify factors that affect MPV values, such as diabetes, are important limitations of the studies that reported no change in MPV. Third, the classification of preeclampsia was not definitively described as mild or severe. One study in the literature reports that maternal weight gain and Grade III preterm placental calcification are the most important risk factors for the progression of gestational hypertension to preeclampsia [1]. However, in that study, gestational hypertension and preeclampsia were not divided into as two different groups [1], which would have been more appropriate given their different properties. The gestational age at birth was preterm in hypertensive pregnancies, whereas normotensive pregnancies produced term births [1]. Therefore, this introduced bias into the studyâ&#x20AC;&#x2122;s research results. In another study reported in the literature, severe preeclampsia and normotensive pregnant women were divided into three subgroups early, late preterm and term birth deliveries in order to rule out the effect of the gestational week on MPV [10]. Further, the mean birth weight of all the subgroups of severe

preeclampsia women was significantly lower than those of the normotensive subgroups [10]. In our study, we observed that there was no difference in the groups according to birth weight. This is because all pregnancies came to term and there was no difference in the gestational ages between two groups. Furthermore, the cases with intrauterine growth restriction and abnormal umbilical artery Doppler parameters were excluded. Consequently, gestational hypertension without antihypertensive drug treatment may not have an adverse effect on increasing birth weight. There are studies in the literature that have reported increased MPV in preeclampsia, thus the use in clinical practice should be discussed extensively [4,13,14]. There are no studies in the literature that address the clinical usefulness of MPV. In our findings, the sensitivity of MPV is 60% and specificity is 61% for the cut-off value of 9.25 fL. In our opinion, this suggests a limited use in clinical practice. Although the MPV values were significantly different in gestational hypertensive patients compared to the control group, there was no difference in the platelet number. Our study has some limitations. This is a retrospective study and we did not take preterm pregnancies as another group. The small sample size meant that we were unable to compare the multiparous and nulliparous cases. The paucity of our data with regard to the sonographic measurement of the amniotic fluid index, newborn Apgar scores and complications in the neonatal period was a further limitation, as was our inability to provide any information about how many cases of gestational hypertension might have progressed to preeclampsia, eclampsia or HELLP syndrome. Due to lack of effect of progressive pregnancy induced hypertensive disorders on changing MPV, have not observed. However, the term pregnancies were included and the exclusion criteria were well defined, thus ensuring that this was a homogenous group. These are the main advantages of our study. In our study, maternal MPV cannot be used clinically to predict gestational hypertension due to its low sensitivity and specificity. However, further studies are needed about the predictive value of MPV in the progression of the hypertensive diseases of pregnancy and of thrombocytopenia as an early marker in this progression. This study may be a pioneer for further research. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval Ethics committee approval was received from Etlik Zubeyde HanÄąm Educational & Research Hospital of Health Science, University in Ankara, Turkey

doi: 10.5455/medscience.2018.08.9143

Med Science 2020;9(1):90-3

Emre Baser ORCID: 0000-0003-3828-9631 Funda Salgur ORCID: 0000-0001-5502-7751 Melek Bilge ORCID: 0000-0003-3154-5065 Safak Ozdemirci ORCID: 0000-0002-6326-7234 Deniz Esinler ORCID: 0000-0001-5166-7962 Eylem Unlubilgin ORCID: 0000-0002-1529-2523 Aykan Yucel ORCID: 0000-0002-5888-692X Ozlem Moraloglu Tekin ORCID: 0000-0001-8167-3837

References

12. Kashanian M, Hajjaran M, Khatami E, et al. Evaluation of the value of the first and third trimester maternal mean platelet volume (MPV) for prediction of pre-eclampsia. Pregnancy hypertension. 2013;3:222-6.

Chen KH, Seow KM, Chen LR. Progression of gestational hypertension to pre-eclampsia: A cohort study of 20,103 pregnancies. Pregnancy Hypertens. 2017;10:230-37.

Delmis J. Hypertension in pregnancy. Lijec Vjesn. 2006;128:357-68.

10. Ozdemirci S, Baser E, Kasapoglu T, et al. Predictivity of mean platelet volume in severe preeclamptic women. Hypertens Pregnancy. 2016;35:474-82. 11. Han L, Liu X, Li H, et al. Blood coagulation parameters and platelet indices: changes in normal and preeclamptic pregnancies and predictive values for preeclampsia. PloS one. 2014;9:114488.

13. Dogan K, Guraslan H, Senturk MB, et al. Can Platelet Count and Platelet Indices Predict the Risk and the Prognosis of Preeclampsia? Hypertens Pregnancy. 2015;34:434-42.

Yoder SR, Thornburg LL, Bisognano JD. Hypertension in pregnancy and women of childbearing age. Am J Med. 2009;122:890-5.

Buchbinder A, Sibai BM, Caritis S, et al. Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia. Am J Obstet Gynecol. 2002;186:66-71.

Saudan P, Brown MA, Buddle ML, et al. Does gestational hypertension become pre-eclampsia? Br J Obstet Gynaecol. 1998;105:1177-84.

15. Kanat-Pektas M, Yesildager U, Tuncer N, et al. Could mean platelet volume in late first trimester of pregnancy predict intrauterine growth restriction and pre-eclampsia? J Obstet Gynaecol Res. 2014;40:1840-5.

Van Oostwaard MF, Langenveld J, Schuit E, et al. Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis. Am J Obstet Gynecol. 2015;212:1-17.

16. Yarlioglues M, Kaya MG, Ardic I, et al. Relationship between mean platelet volume levels and subclinical target organ damage in newly diagnosed hypertensive patients. Blood pressure. 2011;20:92-7.

Kumru P, Aka N, Kose G, et al. The Value of Mean Platelet Volume in Predicting The Severity of Preeclampsia and of Hellp Syndrome. Obstet Gynaecol Reprod Med. 2007;13:9-13.

17. Gonzalez-Quintero VH, Smarkusky LP, Jimenez JJ, et al. Elevated plasma endothelial microparticles: preeclampsia versus gestational hypertension. Am J Obstet Gynecol. 2004;191:1418-24.

Ceyhan T, Beyan C, Baser I, et al. The effect of pre-eclampsia on complete blood count, platelet count and mean platelet volume. Ann Hematol. 2006; 85:320-2.

18. Altinbas S, Togrul C, Orhan A, et al. Increased MPV is not a significant predictor for preeclampsia during pregnancy. J Clin Lab Anal. 2012;26:403-6.

Ozdemir S GH, Acar A, Celik C, et al. The Comprasion of Maternal and Fetal Outcomes Pregnancies of Complicated by Moderate to Severe Thrombocytopenia Caused by Gestational Thrombocytopenia Preeclampsia/ HELLP Syndrome and Immune Thrombocytopenic Purpura. Obstet Gynaecol Reprod Med. 2008;14:154-8.

14. Dundar O, Yoruk P, Tutuncu L, et al. Longitudinal study of platelet size changes in gestation and predictive power of elevated MPV in development of pre-eclampsia. Prenat Diagn. 2008;28:1052-6.

19. Yavuzcan A, Caglar M, Ustun Y, et al. Mean platelet volume, neutrophillymphocyte ratio and platelet-lymphocyte ratio in severe preeclampsia. Ginekol Pol. 2014;85:197-203.

Available online at www.medicinescience.org

ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):94-9

The clinicopathologic features of multiple primary malignancies in hematology: A cross sectional descriptive study Pelin Aytan1, Mahmut Yeral1, Cigdem Gereklioglu2 , Mutlu Kasar1, Asli Korur2, Nurhilal Buyukkurt1, Suheyl Asma2, Ilknur Kozanoglu1, Hakan Ozdogu1, Can Boga1 2

1 Adana Baskent University, Faculty of Medicine, Department of Hematology, Adana, Turkey Adana Baskent University Faculty of Medicine, Department of Family Medicine, Adana, Turkey

Received 01 September. 2019; Accepted 25 November 2019 Available online with doi: 10.5455/medscience.2019.08.9144

Abstract In Turkish literature there are very few studies regarding multiple primary malignancies (MPM). The aim of this study was to analyze the synchronous and the metachronous malignancies that occurred with a hematologic malignancy. All the patients with a hematologic malignancy were enrolled in this cross-sectional, definitive retrospective study. Data were obtained from the medial records. Patientsâ&#x20AC;&#x2122; characteristics including demographic features, treatment protocols and overall survival (OS) were recorded. Among 663 patients with a hematologic malignancy, there were 26 patients with MPMs (3.9%). Synchronous malignancies constitute 0.9% and metachronous malignancies were present in 3%. In men diffuse large B-cell lymphoma (DLBCL) and non-small cell lung carcinoma (NSCLC) and in women breast and acute myeloid leukemia were the most common primary and secondary MPMs respectively. The mean cumulative OS of all patients with MPMs was 246.3Âą33.4 months and the 5 yearsOS was 91.3%. In synchronous MPMs the most frequent concomitant tumors were DLBCL and NSCLC. In metachronous tumors the median time interval between first and second malignancies was 69.5 months (range: 31-312). In four patients there were three MPMs. After radiotherapy three patients developed breast, thyroid and skin cancers and in one patient who received radioiodine for the treatment of thyroid carcinoma, DLBCL had developed. The chemotherapeutic agents applied for the primary malignancies consisted of alkylating agents, antimetabolites, anthracyclines, topoisomerase II inhibitors, monoclonal antibodies and mitotic inhibitors. In 75% of the patients with DLBCL who had received R-CHOP chemotherapy regimen, NSCLC had developed during the follow-up period. In conclusion secondary malignancies with hematologic malignancies are not rare and the clinicians should keep the possibility of secondary malignancies in mind and be suspicious during diagnostic evaluations. Warning with regard to the risk of development of secondary malignancies due to the primary treatment should be given to any patient with a hematologic malignancy. Keywords: Multiple primary malignancy, hematologic malignancy, synchronous malignancy, metachronous malignancy

Introduction Multiple primary malignancies (MPMs) are the malignancies with different histological origins that occur at different sites in the same person [1]. Their exact incidence is not known; however, it is believed that the incidence tends to increase. This increase may be attributed to the recent therapeutic and diagnostic improvements. In the USA, cancer survivors constitute 5% of the population and the number of survivors is projected to increase by 29.1% by the year 2029 [2]. The trend is similar in our country; by the year 2030, the incidence of new cancer cases is estimated to increase by 75% [3]. All these cancer survivors have a higher risk of developing second cancer than adjusted age groups (8-16%) [4-6].

*Coresponding Author: Pelin Aytan, Adana Baskent University, Faculty of Medicine, Department of Hematology, Adana, Turkey E-mail: drpelinaytan@gmail.com

In a large study, the risk of developing a secondary cancer was found to be increased six times compared to the basal population risk [7]. As the number of long-term survivors increases, the risk of developing a secondary malignancy increase. This may be due to the presence of genetic cancer-predisposing syndromes, immunologic defects, prolonged exposure to genotoxic treatment modalities including chemotherapy and radiotherapy [8]. The Surveillance Epidemiology and End Results (SEER) Program which is the main source for cancer statistics in the United States and provides epidemiologic information on the incidence and survival rates of cancer to reduce the cancer burden, classified multiple malignancies as being synchronous if diagnosed within two months of each other and metachronous if diagnosed more than two months apart [9]. In hematologic malignancies, the development of asynchronous or metachronous secondary malignancy is not uncommon. New hematologic malignancies may arise in the first five years and solid cancers tend to develop 94

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after the first five years following the initial treatment in these patients [4,5,10]. Over 20 years of follow-up, the cumulative risk of secondary cancer has been reported to be 2.6 to 4.9% [11,12]. In a study, the overall elevated risk was detected as 14% in nonHodgkin lymphoma survivors [13]. Breast and lung cancers are the most frequently detected solid organ malignancies in lymphoproliferative disorders [14]. In Turkish literature, there are very few studies regarding MPMs. [14-16]. Studies on synchronous or metachronous malignancies with hematologic malignancies are much more limited. This study aimed to analyze the synchronous and the metachronous malignancies that occurred with hematologic malignancy. Materials and Methods All the patients who were diagnosed to have or followed-up with hematologic malignancy in Adana Baskent University Medical Faculty Department of Hematology between January 2007 and July 2019 were enrolled in this cross-sectional, definitive retrospective study. Data were obtained from the medical records, either from patient files or the hospital’s electronic database. Informed consent was obtained from alive patients. Institution’s ethics committee’s approval was obtained (KA19/283). The criteria of Warren and Gates for diagnosis of MPMs were used [1]. Briefly, tumors with definitive features of malignancy, separate and distinct from the index tumor, and the tumors that have no possibility of being metastasis of the index tumor were

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included. Only the patients with histopathologic confirmation were included. Tumors were grouped as synchronous if they were diagnosed within two months of each other and metachronous if diagnosed more than two months apart. Patients’ characteristics including demographic features, tumor sites, stages of the hematologic tumors, pathologic results, duration between the appearance of primary and secondary or tertiary tumors, treatment protocols, and overall survival (OS) after the diagnosis were recorded. Statistical analysis was accomplished by using SPSS version 22 (IL, USA). Nominal data are expressed as percentages. Continuous data were expressed as means ± standard deviation if normally distributed and as median (minimum-maximum) if not normally distributed. Survival analysis was performed with Kaplan - Maier test and mean survival time is shown as mean ± standard error. Chi-square, t-test, and Mann-Whitney U tests were used where appropriate. A p-value of ≤ 0.05 was considered significant. Results Among 663 patients with hematologic malignancies assessed between the study period, there were 26 patients with MPMs with an incidence of 3.9%. The clinicopathological features are depicted in Tables 1-3. The mean age of the patients with MPMs was 57.0 ± 11.6 years (range 25 – 81 years). There were 17 males (65.4%) and nine females (34.6%) with a male to female ratio of 1.9.

Table 1. Clinicopathologic features of patients with two syncronous multiple primary malignancies Age

Sex

First primary site

Treatment

Second primary site

Treatment

Smoke

FHC

Death

Lung, non small cell carcinoma

Carboplatin, Paclitaxel Cisplatin, Gemcitabine

Diffuse large B cell lymphoma

Lung, non small cell carcinoma

Carboplatin, Paclitaxel Cisplatin, Gemcitabine

Diffuse large B cell lymphoma

Breast invasive ductal carcinoma

Anastrozele

Multiple myeloma

Bortezomib, Lenalidomide, H-Melphalan AutoSCT

Lymhoplasmocytic lymphoma

Cyclophospamide, Vincristine, Rituximab

Plasma cell dyscrasia

Bortezomib, Dexamethasone

Thyroid papillary carcinoma

Radioactive iodine

Breast invasive ductal carcinoma

Surgery, Anastrazole

FHC: Family history of cancer, OS: Overall survival, M:Male, F:Female, RT: Radiotherapy, H: High, AutoSCT: Autologous stem cell transplantation

The mean age at diagnosis of the primary tumor was significantly younger in women when compared to men (49.4 ± 13.5 vs. 61.1 ± 8.4 years, p=0.038). Synchronous malignancies were detected in 23.1% of the patients (n:6) and 76.9% had metachronous MPMs (n:20) (Tables 1 and 2). In 4 of the metachronous patients, there were three primary cancers (Table 3). The mean cumulative OS of all patients with MPMs was 246.3 ± 33.4 months and the five years-OS was 91.3%.

The total number of malignancies in 26 patients was 56, and overall the most frequent malignancy was non-small cell lung carcinoma with an incidence of 23.2% (n:13), followed by diffuse large B cell lymphoma (DLBCL) which was seen in 16.1% (n:9) of the patients. The most frequent primary malignancies were DLBCL (30.8%, n:8/26) and invasive ductal breast carcinoma (19.2%, n: 5/26). When analyzed concerning gender, DLBCL was the most common primary cancer found in 47.1% of all the males and breast 95

doi: 10.5455/medscience.2019.08.9144

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Table 2. Clinicopathologic features of patients with two metachronous multiple primary malignancies Age

Sex

First site

Treatment

Second site

Treatment

Stage

Time interval

Smoke

FHC

Death

DLBCL

R-CHOP

Lung, non small cell carcinoma

Cisplatin, Pemetrexed, Carboplatin, Paclitaxel, RT

R-IPI

Breast, invasiv ductal

Epirubicin, Cyclophosphmide

Follicular lymphoma

FLIPI-H

144

Myelodysplastic Synd

Decitabine

Lung, small cell carcinoma

Surgery

IPSSR-H

Breast invasive ductal

Carboplatin, Paclitaxel, Tmx, Anastrazole

Acute myeloid leukemia (transformed from MDS)

Induction/consolidation

High

Multiple myeloma

VAD, H-Melphalan, AutoSCT

Lung, non small cell carcinoma

ISS-1

Multiple myeloma

VAD, H-Melphalan, Lenalidomide

Lung, non small cell carcinoma

Carboplatin, Paclitaxel

ISS-1

Breast invasive ductal

Epirubicin, Cyclophosphamide Dosetaxel, Anastrazole RT

Acute myeloid leukemia

Induction/consolidation

Multiple myeloma

Bortezomib, Melphalan, Lenalidomide

Prostate adenocarcinoma

ISS-2

DLBCL

R-CHOP

Lung, non small cell carcinoma

Carboplatin, Paclitaxel

R-IPI-2

Multiple myeloma

VAD H-Melphalan, Bortezomib, AutoSCT

Kidney renal cell carcinoma

Surgery

ISS-2

Hairy cell leukemia

Cladribine, Rituximab

Colon adenocinoma

Neo-adjuvant CT, Surgery

Surgery, Carboplatin, Paclitaxel, Cisplatin, Cyclophosphamide

Acute myeloid leukemia (transformed from MDS)

Induction/consolidation

High

312

Low-Int

Ovarian adenocarcinoma

Hairy cell leukemia

Cladribine, Rituximab

Lung, non small cell carcinoma

Carboplatin, Doseaxel

108

Breast invasive ductal

Surgery

DLBCL

Rituxumab, V, Etoposid

R-IPI-3

Acute myeloid leukemia

Idarubicin, Cytarabine, Tretinoin, AlloSCT

Lung, non small cell carcinoma

Carboplatin, Paclitaxel, RT

Int.

Thyroid papillary, Carcinoma

Radioactive iodine

DLBCL

R-CHOP

R-IPI-3

FHC: Family history of cancer, OS: Overall survival, M:Male, F:Female, DLBCL: Diffuse large B cell lymphoma, RT: Radiotherapy, R-CHOP: Rituximab - cyclophosphamide, doxorubicin, vincristine, prednisolone, VAD: Vincristine, doxorubicin, dexamethasone, AutoSCT: Autologous stem cell transplantation, MDS: Myelodysplastic syndrome, H: High, ISS: International Staging System, R-IPI: Revised International Prognostic Index, Int: Intermediate, IPSS-R: Revised International Prognostic Scoring System, FLIPI: Follicular Lymphoma International Prognostic Index.

doi: 10.5455/medscience.2019.08.9144

carcinoma was the most common malignancy with an incidence of 55.6% among females with MPM. Non-small cell lung carcinoma was the most frequent secondary malignancy constituting 46.2% (n:12/26) of all secondary malignancies followed by acute myeloid leukemia (AML) (11.5%, n: 3/26). In 64.7% of males, the secondary malignancy was non-small cell carcinoma and in 33.35 of females, it was acute myeloid leukemia. There were six synchronous MPMs (Table 1). The most common concomitant tumors were non-small cell lung cancer and DLBCL (50% of synchronous malignancies). All three patients with lung carcinoma had a cigarette smoking history. Relevant therapies including chemotherapy and radiotherapy had been given for the treatment of each malignancy (Table 1). There were no deaths during the study period and the median OS was 44.5 (18-96) months in these patients.

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There were 16 patients with metachronous two primary malignancies (Table 2). The most frequent primary malignancies were invasive ductal breast carcinoma and multiple myeloma; both were present in 25% of the patients. The most frequently diagnosed secondary metachronous malignancy was non-small cell lung carcinoma, which developed in 50% of these 16 patients. The median time interval between the first and second malignancies was 69.5 months (range: 31-312). The chemotherapeutic agents applied for the primary malignancies consisted of alkylating agents, antimetabolites, anthracyclines, topoisomerase II inhibitors, monoclonal antibodies and mitotic inhibitors (Table 2). Most of the hematologic malignancies were in an advanced stage. During the study period, 31.5% of the patients died. The estimated cumulative overall survival was 219.2 Âą 43.3 months with a five years-OS of 86.6%.

Table 3. Clinicopathologic features of patients with three multiple primary malignancies Age

Sex

First site

Trt

Second site

Trt

Time interval

Third site

DLBCL

R-CHOP

Lung, non small cell carcinoma

Skin, basal cell carcinoma

DLBCL

R-CHOP

Prostate adenocarcinoma

Brain, Glioblastoma

Temozoamide, RT

Breast invasive ductal

Surgery, paclitaxel

DLBCL

R-CHOP, H-melphalan, AutoSCT

Skin basal cell carcinoma

Excision

Time interval

Trt

Death

Excision

Thyroid Papillary carcinoma

Radioactive iodine

Precursor B cell 21 leukemia

Induction

Lung non small cell carcinoma

Carboplatin Paclitaxel

Trt: Treatment, FHC: Family history of cancer, OS: Overall survival, M:Male, F:Female, DLBCL: Diffuse large B cell lymphoma, RT: Radiotherapy, R-CHOP: Rituximab - cyclophosphamide, doxorubicin, vincristine, prednisolone, AutoSCT: Autologous stem cell transplantation, H: High

In four patients, third malignancy developed after a median of 21.5 months (range: 12-48) from the second malignancy. In 3 of these patients, the primary malignancy was DLBCL and they had been treated with R-CHOP chemotherapy (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone) and in two of them, one of the other malignancies was non-small cell carcinoma. None of these patients die and the median overall survival was 78 months (range: 51-96). Half of the patients (50%) were smokers, males having a significantly higher proportion (70.6% vs. 11.2%, p=0.002). A family history of malignancy was confirmed in 34.6% of the patients and there was no difference between males and females. Discussion Lack of knowledge in variables about a condition in a population may make it impossible to conduct investigations about causality. In such cases, cross-sectional descriptive studies are mandatory and only such studies help to fill the information gap [17]. This cross-sectional study is aimed to provide descriptive data on synchronous and metachronous multiple primary malignancies accompanying at least one hematologic malignancy and is one of the very few, if not the only, studies on this subject in our country.

In a large study from Turkey, the incidence of MPMs was 1.4% [15]. The hematologic malignancies were reported to constitute 12.3% of all single and 11.9% of all multiple primary malignancies and among the MPMs, B cell neoplasms were the most frequent ones [15]. However, the incidence and features of multiple primary tumors in hematologic malignancies were not known in the Turkish population. The incidence of MPMs in hematologic malignancies was found to be 3.9% in our studied population. Synchronous malignancies constitute 0.9% of all hematologic malignancies, and metachronous malignancies were present in 3% of the whole population. The most frequent primary and secondary malignancies were DLBCL and non-small cell lung carcinoma respectively. In men, this order is the same; however, in women, breast carcinoma was the most common primary and AML was the most common secondary MPMs. In men and the whole population, DLBCL and non-small cell lung carcinomas were the most frequent concomitant tumors. In women, breast carcinoma and AML were the most frequent concomitant tumors. The role of radiotherapy and anti-cancer chemotherapeutics on the development of a secondary carcinoma in pediatric or adult cancer survivors is well known. [18]. It has been reported that after radiotherapy breast, lung, and thyroid carcinomas, osteosarcoma and acute lymphoblastic leukemia may develop [19]. Radioactive 97

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iodine has been related to the development of secondary cancers such as leukemia, hematological malignancies, salivary gland cancer, colorectal cancer and soft tissue sarcoma [20]. In the present study, after radiotherapy 3 patients developed breast, thyroid and skin cancers and in one patient who received radioiodine for the treatment of thyroid carcinoma, DLBCL had developed after about two years. Alkylating agents, platin based chemotherapeutics, anthracyclines and topoisomerase-II inhibitors have been related to secondary malignancy development, especially AML [21,22]. These agents pose the highest risk of initiating carcinogenesis especially in normal cells sensitive to chemotherapy like cells of the bone marrow, hair follicles, and the epithelial cells of the gastrointestinal tract. Therefore, there is an increased risk of development of secondary hematologic cancers such as leukemia and lymphoma [23]. AML had developed in 15% of the patients in the metachronous group as a secondary malignancy, following the treatments for breast and ovarian carcinomas. Alkylating agents and radiotherapy were given for the treatment of the primary malignancies. Again, after treatment of breast cancer with an alkylating agent and an anthracycline, follicular lymphoma had developed in another female patient. It was observed that in 75% of the patients with DLBCL who had received R-CHOP chemotherapy regimen in the metachronous group, non-small cell lung carcinoma had developed during the follow-up period. Alkylating agents and anthracyclines that are components of the R-CHOP regimen given for lymphoma treatment have been related to secondary cancers including solid tumors [24]. Several studies have observed that alkylating chemotherapy significantly increases the risk of particularly lung cancer [25,26]. For lung cancer, the increased relative risk from smoking appeared to multiply the elevated risks from chemotherapy and radiotherapy [25]. From this point, it would be a good clinical practice to give counseling to the patients about the secondary cancer development potential of such chemotherapeutic agents especially in the smoking setting. The male to female ratio of MPMs in hematologic malignancies was 1.9, and MPMs seemed to develop in younger ages among women cancer survivors. These findings in the present study are consistent with the findings of the studies about the MPMs conducted in the Turkish population [16,27]. Lung has been reported to be the most common secondary tumor followed by breast as in our study [16]. Although those studies reported results all of the MPMs and no studies are assessing only the MPMs with a hematologic malignancy like this study, the results are in accordance. The main limitation of this study was that it was impossible to analyze the exact causality between clinicopathologic features, including treatment regimens and risk of developing a secondary malignancy due to the retrospective design of the study and there would be too many confounding factors. Previous cancer treatments, genetics, immunity, hormonal status, environmental factors and lifestyle play a complex role in the development of secondary malignancy and it is difficult to conduct a causality analysis. However, this study aimed to present baseline data about a critical clinical situation as the secondary malignancies begin to constitute the second most frequent cause of deaths from cancers following the relapse [22] Conclusion In conclusion, knowledge about the clinical features of the MPMs that accompany a hematologic malignancy is crucial as the number

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of cancer survivors increases with improvements in diagnostic and therapeutic strategies as well as management of complications. This study provides an awareness of the secondary malignancies in hematology. Clinicians should keep the possibility of secondary malignancies in mind and be suspicious during diagnostic evaluations. Warning about the risk of development of secondary malignancies due to the primary treatment should be given to any patient with hematologic malignancy. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval Institution’s ethics committee’s approval was obtained with the number KA19/283. Pelin Aytan ORCID: 0000-0002-4213-1565 Mahmut Yeral ORCID: 0000-0002-9580-628X Cigdem Gereklioglu ORCID: 0000-0003-3556-9865 Mutlu Kasar ORCID: 0000-0003-3856-7005 Asli Korur ORCID: 0000-0002-5086-5593 Nurhilal Buyukkurt ORCID: 0000-0002-0895-4787 Suheyl Asma ORCID: 0000-0001-5335-7976 Ilknur Kozanoglu ORCID: 0000-0002-5268-1210 Hakan Ozdogu ORCID: 0000-0002-8902-1283 Can Boga ORCID: 0000-0002-9680-1958

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Hodgson DC, Gilbert ES, Dores GM, et al. Long-term solid cancer risk among 5-year survivors of Hodgkin’s lymphoma. J Clin Oncol. 2007;25:1489-97.

Ng AK, Travis LB. Subsequent malignant neoplasms in cancer survivors. Cancer J. 2008;14:429-34.

Inskip PD, Curtis RE. New malignancies following childhood cancer in the United States, 1973-2002. Int J Cancer 2007;121:2233-40

Tanba K, Chinen Y, Uchiyama H, et al. Prognostic impact of a past or synchronous second cancer in diffuse large B cell lymphoma. Blood Cancer J. 2018;8:1.

Howe HL (ed). A Review of the Definition for Multiple Primary Cancers in the United States. Workshop Proceedings From December 4–6, 2002, in Princeton, New Jersey. Springfield (IL): North American Association of Central Cancer Registries, 2003.

10. Ganz PA. Late effects of cancer and its treatment. Semin Oncol Nurs. 2001;17:241-8.

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11. Olsen JH, Garwicz S, Hertz H, et al. Second malignant neoplasms after cancer in childhood or adolescence. Nordic Society of Paediatric Haematology and Oncology Association of the Nordic Cancer Registries. BMJ. 1993;307:1030-6.

19. Bhatia S, Blatt J, Meadows A. Late effects of childhood cancer and its treatment. In Principles and Practice of Pediatric Oncology. 5th ed. Pizzo P PD, Ed. Philadelphia, Lippincott Williams & Wilkins, 2006;1490-514.

12. Jenkinson HC, Hawkins MM, Stiller CA, et al. Long-term population-based risks of second malignant neoplasms after childhood cancer in Britain. Br J Cancer. 2004;91:1905-10.

20. Iyer NG, Morris LG, Tuttle RM, et al. Rising incidence of second cancers in patients with low-risk (T1N0) thyroid cancer who receive radioactive iodine therapy. Cancer. 2011;117:4439-46

13. Dores GM, Cote TR, Travis LB. New malignancies following Hodgkin lymphoma, non-Hodgkin lymphoma and myeloma. In: Curtis R, Freedman D, Ron F et al.New malignancies among cancer survivors: SEER cancer registries, 1973-2000 (NIH Publ. No: 05-5302). 397, 2006, National Institutes of Health, Bethesda MD

21. Travis LB, Holowaty EJ, Bergfeldt K, et al. Risk of leukemia after platinumbased chemotherapy for ovarian cancer. N Engl J Med. 1999;340:351-7

14. Demirci U, Ozdemir N, Benekli M, et al. Lymphoproliferative disorders in multiple primary cancers. Asian Pac J Cancer Prev. 2012;13:383-6. 15. Kılçıksız SÇ, Kaynak C, Eşki E, et al. Çok primerli ve tek primerli kanser olguları: İzmir kanser kayıt merkezi verilerinden hastane tabanlı bir inceleme. Türk Onkoloji Dergisi 2007;22:55-62. 16. Gursel B, Meydan D, Özbek N, et al. Multiple primary malignant neoplasms from the black sea region of Turkey. J Int Med Res. 2011;39:667-74 17. Jemal A, Ward EM, Thun MJ. Epidemiology of cancer; cancer statistics. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 7th ed. CD-Room. Lippincott Williams& Wilkins. 530 Walnut Street Philadelphia PA 19106 USA LWW.com. 2005. Chapter 11; Section 2

22. Cecen E, Bolaman Z. İkincil kanserler. UHOD, 2010;20:190-200. 23. Vega-Stromberg T Chemotherapy-induced secondary malignancies. J Infus Nurs. 2003;26:353-61. 24. Colvin M. Alkylating agents. In: Kufe DW, et al. (Eds). Holland-Frei Cancer Medicine (6th ed). Hamilton: BC Decker, 2003. 25. Travis LB, Gospodarowicz M, Curtis RE, et al.: Lung cancer following chemotherapy and radiotherapy for Hodgkin’s disease. J Natl Cancer Inst. 2002;94:182-92. 26. Swerdlow AJ, Schoemaker MJ, Allerton R, et al: Lung cancer after Hodgkin’s disease: a nested case-control study of the relation to treatment. J Clin Oncol 2001;19:1610-8, 27. Engin K. Cancers in multiple primary sites. Int Surg. 1994;79:33-7.

18. van Leeuwen FE TL. Second cancers. In. Cancer: principles and practice of oncology. 7th ed. DeVita VT HSRS, Ed. Philadelphia, Lippincott Williams &Wilkins, 2005; 2572-602

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):100-2

Ovarian torsion as an emergency clinical entity Evrim Gul1, Yeliz Gul2, Salih Burcin Kavak3, Mustafa Ucarel1 Firat University, Faculty of Medicine, Department of Emergency, Elazig, Turkey 2 Fethi Sekin City Hospital, Clinic of Radiology, Elazig, Turkey 3 Firat University, Faculty of Medicine, Department of Obstetrics and Gyenology, Elazig, Turkey 1

Received 04 November. 2019; Accepted 04 December 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9145

Abstract In this study, we aimed to evaluate the diagnostic characteristics of ovarian torsion cases. This study was conducted between December 2017 and December 2019 by examining the records of patients diagnosed with ovarian torsion in Fırat University Hospital at Emergency Department. Age, number of pregnancy and birth numbers and clinical (symptoms and findings) and laboratory parameters (hemoglobin, hematocrit, platelet and white blood cell count) supporting ovarian torsion were evaluated. Symptoms and symptoms such as preoperative nausea, vomiting, tenderness, defense and rebound presence were recorded. Ultrasonographic parameters (ovarian size, presence of ovarian cysts, peripheral sequenced follicles, presence of vascular flow in doppler ultrasonography, presence of free fluid in the pelvic region) were evaluated. Descriptive statistics were used in the statistical evaluation of the data. In this study, the following parameters of 15 patients were evaluated retrospectively. Mean age, 26.02±5.3 years; mean number of gravidas, 2,21±1.35, mean White blood cell count 13250±2600 (/L), mean hemoglobin and hematocrit values were 12.4±2.5 (gr/dL) and 35.0±4.2 (%) respectively. All patients with ovarian torsion had pelvic pain (100 %) and 61% had nausea and vomiting. The most prominent feature of the examination was defensive rebound with43% and tenderness with 76 %. Enlargement of ovarian (>5 cm) were present in 86 % of the patients and accompanying ovarian cysts and fluid in pelvis were found in 80 % of the cases. Additionally, in 73 % of the patients loss of blood flow on Doppler examination was observed. 5 cases (25 %) were single and 4 patients (25 %) had concomitant pregnancy. Three pregnants were in 1st trimester (7,9 and 13 weeks of gestation), one of them was 34 weeks of gestation. There is no clinical or laboratory findings specific to ovarian torsion. Therefore, all signs and symptoms of the patients should be carefully evaluated. Evaluation of the symptoms, clinical and laboratory findings together will increase the diagnostic accuracy. Keywords: Ovarian torsion, clinical evaluation, white blood cell, ultrasonography

Introduction Ovarian torsion refers to the total or partial twisting of the ovary and almost always involves part of the fallopian tube and its vascular axis that may cause an interruption in the ovarian blood and lymphatic flow [1]. The estimated prevalence is 2–3% of all acute gynecological emergencies and it is the fifth most common surgical emergency [2]. Ovarian torsion occurs at any age from pre-puberty to post-menopause with the greatest incidence in women reproductive years [3]. Ovarian torsion may also occur during pregnancy and post-hysterectomy [4,5]. Early diagnosis is essential in preserving ovarian and tubal function and preventing adnexal necrosis. Unfortunately, diagnosis of an ovarian torsion is challenging due to lack of sensitivity and

*Coresponding Author: Evrim Gul, Firat University, Faculty of Medicine, Department of Emergency, Elazig, Turkey E-mail: evrimgl@yahoo.com.tr

specificity of its clinical signs [6]. Currently, the diagnosis of ovarian torsion is based on clinical findings such as pelvic pain, nausea and vomiting, and defense-Rebound [4]. Because of the diagnostic difficulties of ovarian torsion, mortality and morbidity may develop. Therefore, signs and symptoms of torsion should be evaluated carefully and diagnostic problems should be prevented. This often requires detailed examination. In this study, we aimed to obtain diagnostic clues by evaluating cases of ovarian torsion. Materials and Methods Clinical data, study population and definitions This study was conducted between December 2017 and December 2019 by examining the records of patients diagnosed with ovarian torsion in Fırat University Hospital at Emergency Department. Between the dates of the study, 125 patients were followed up for pelvic pain due to gynecological reasons. The diagnosis of ovarian cyst rupture in 36 patients, pelvic inflammatory disease in 41 100

doi: 10.5455/medscience.2019.08.9145

patients, primary dysmenorrhea in 26 patients and ovarian torsion in 22 patients were diagnosed. Twenty-two patients who presented to the emergency department with pelvic pain, nausea and vomiting or defensive rebound in the pelvic region were evaluated. Seven patients whose pain had decreased after admission to the emergency department, ovary was detected less than 5 cm or no significant pelvic pathology were detected were excluded from the study. Patients who were followed up as ovarian torsion were determined according to the following criteria [4];

Med Science 2020;9(1):100-2

of the cases. Additionally, in 73 % of the patients loss of blood flow on Doppler examination was observed. 5 cases (33%) were single and 4 patients (27%) had concomitant pregnancy. Three pregnants were in 1st trimester (7,9 and 13 weeks of gestation), one of them was 34 weeks of gestation. The symptoms and findings of the cases are shown in Table 2. Table 1. The laboratory and obstetric parameters of the patients Minimum

Maximum

Mean±SD

Age (year)

26.02±5.3

•Patients with pelvic pain, tenderness, nausea-vomiting and/or defense-rebount,

Gravidy (number)

2.21±1.35

Parity (number)

1.61±1.81

•Those with ovary greater than 5 cm in pelvic ultrasonography and those with ovarian flow loss or decrease in Doppler ultrasonography and

Abortus (number)

31±0.52

Curretage (number)

02±0.11

Hemoglobin(gr/dl)

8.1

13.7

12.4±2.5

Hematocrit (%)

43.1

35.0±4.2

7100

16000

13250±2600

110000

260000

146000±3700

•Cases with increased WBC in laboratory tests.

Parameters

Fifteen cases with suspected torsion and confirmed by surgery were recorded.

White blood cells (/L)

Age, gynecological and obstetric characters of patients (such as number of pregnancy, parity, curretages, menstrual cycle pattern etc.) and clinical (symptoms and findings) and laboratory parameters (hemoglobin, hematocrit, platelet and white blood cell count (WBC)) supporting ovarian torsion were evaluated retrospectively. Symptoms such as preoperative nausea, vomiting, tenderness, defense and rebound presence were recorded.

SD: Standart Deviation.

Ultrasonographic parameters (ovarian size, presence of ovarian cysts, peripheral sequenced follicles, presence of vascular flow in doppler ultrasonography, presence of free fluid in the pelvic region) were evaluated. Statistical analysis was performed using SPSS 21.0 program. Descriptive statistics were used in the statistical evaluation of the data. Results Twenty-two cases were identified for the study, seven cases were excluded from the study because they were excluded from ovarian torsion parameters. Fifteen patients underwent surgery for suspected ovarian torsion. The diagnosis of ovarian torsion was confirmed by surgery in all cases. In this study, the following parameters of 15 patients were evaluated retrospectively. Mean age, 26.02±5.3 years; mean number of gravidas, 2.21±1.35, mean WBC 13250±2600 (/L), mean hemoglobin and hematocrit values were 12.4±2.5 (gr/dL) and 35.0±4.2 (%) respectively. All patients with ovarian torsion had pelvic pain (100%) and 61% had nausea and vomiting. The laboratory and obstetric parameters of the patients are shown in Table 1. The most prominent feature of the examination was defenserebound with 43% and tenderness with 76%. Enlargement of ovarian (>5 cm) were present in 86 % of the patients and accompanying ovarian cysts and fluid in pelvis were found in 80 %

Platelets (/L)

Table 2. The symptoms and findings of the cases Symptoms and Signs

Pelvic Pain

100

Ovarian Enlargement

Tenderness

Nause-Vomiting

Defense-Rebound

Current Pregnancy

Dysuria

Menses Irregularity

%: Percent

Discussion Despite the improved diagnostic methods, the diagnosis of ovarian torsion is the most difficult in gynecological emergencies. There is no clinical or laboratory findings specific to ovarian torsion. Therefore, all signs and symptoms of the patients should be carefully evaluated. The typical presentation of ovarian torsion is acute pelvic pain, adnexal mass, nausea, vomiting, fever, and abnormal genital tract bleeding [4]. We also encountered these symptoms and signs in different rates in our patients. In adults, functional cysts or neoplastic cysts are encountered in 50-80% of cases with ovarian torsion [7]. In our study, the presence of ovarian cyst was present in 80% of the cases. We did not find any malignant mass in our cases. However, ovarian torsion can be observed without any mass. Ovarian torsion seen in the adolescent group is observed in normal ovarian tissue. In normal adnexal torsion, the twisted adnexa do not have any visible morphologic 101

doi: 10.5455/medscience.2019.08.9145

Med Science 2020;9(1):100-2

pathology and is very rare, occurring in about 8%–18% of all cases of torsions [8]. Our two patients had enlarged and torsioned ovaries due to stromal edema.

Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki.

Ovarian torsion encountered during pregnancy is problematic. Diagnosis is more difficult because of an enlarged uterus. Among pregnant women, the most common symptom related to adnexal torsion was lower abdominal pain, regardless of the gestational week. Adnexal torsion frequently occurs either in the first or early second trimester, rather than in the third trimester [9,10]. Our study found that the most of the pregnant were in their first trimester of pregnancy.

Evrim Gul ORCID: 0000-0001-9049-5446 Yeliz Gul ORCID: 0000-0001-9280-3254 Salih Burcin Kavak ORCID: 0000-0002-6318-5175 Mustafa Ucarel ORCID: 0000-0001-6837-0508

One of the diagnostic difficulties of ovarian torsion is the inadequacy of imaging methods. The most commonly used tool for imaging is ultrasonography. Ultrasound has the same diagnostic performance as CT scans and magnetic resonance imaging (MRI) and is less expensive [11]. The most common ultrasonographic finding is ovarian enlargement. An adnexal mass equal to or greater than 5 cm is strongly associated with adnexal torsion [12]. However, its spesivity is low (approximately 63%) [13]. Doppler ultrasonography provides useful information in diagnosis. However, over-flow loss cannot always be observed on ultrasonography. Persistence of adnexal vascularization does not exclude torsion. In one study, doppler flow was found to be normal in 61% of right-sided torsions and 27% of left-sided torsions [14]. Ovarian torsion is one of the most common causes of acute abdomen that should be kept in mind because it is the 5th most common surgical cause. If patients are suspected after being evaluated clinically and radiologically, diagnostic surgery should not be taken without waiting for intervention and should not be given the opportunity to delay. Once ovarian torsion is highly suspected or confirmed, a quick surgical management should be obtained. Laparoscopic evaluation and detorsion are preferred and associated with fewer side effects. However, laparotomy can be performed in unstable cases. The retrospective nature of the study and the limited number of cases seem to be the limiting factor. Further studies are needed on this area.

References 1.

Schraga ED, Blanda M. Ovarian torsion. Adv Emerg Nurs J. 2009;31:123-30.

Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152:456-61.

McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin North Am. 2008;88:265-83.

Wang Z, Zhang D, Zhang H, et al. Characteristics of the patients with adnexal torsion and outcomes of different surgical procedures: A retrospective study. Medicine (Baltimore). 2019;98:14321.

Larraín D, Casanova A, Rojas I. Ovarian Torsion after Hysterectomy: Case Report and Concise Review of the Reported Cases. Case Rep Obstet Gynecol. 2018;2018:6267207.

White M, Stella J, “Ovarian torsion: 10-year perspective,” Emergency Medicine Australasia, 2005;17:231-7.

Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2010;150:8-12.

Pansky M, Smorgick N, Herman A, et al. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstet Gynecol. 2007;109:355‑9.

Hasson J, Tsafrir Z, Azem F et al. Comparison of adnexal torsion between pregnant and nonpregnant women. Am J Obstet Gynecol 2010;202:536.

10. Chang SD, Yen CF, Lo LM, et al. Surgical intervention for maternal ovarian torsion in pregnancy. Taiwan J Obstet Gynecol. 2011;50:458-62. 11. Kroger-Jarvis MA, Pavlik-Maus T, Mullins K. Ovarian Torsion: ED Recognition and Management. J Emerg Nurs. 2018;44:647-9. 12. Varras M, Tsikini A, Polyzos D, et al. C. Uterine adnexal torsion: Pathologic and grayscale ultrasonographic findings. Clin Exp Obstet Gynecol 2004;31: 34-8.

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

13. Ghulmiyyah L, Nassar A, Sassine D, et al. Accuracy of Pelvic Ultrasound in Diagnosing Adnexal Torsion. Radiol Res Pract. 2019;2019:1406291.

Financial Disclosure There are no financial supports.

14. Grunau GL, Harris A, Buckley J, et al. Diagnosis of Ovarian Torsion: Is It Time to Forget About Doppler? J Obstet Gynaecol Can. 2018;40:871-5.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):103-8

Surgeon factor in pediatric supracondylar humerus fractures Ali Yuce1, Niyazi Igde2, Yunus Imren2, Suleyman Semih Dedeoglu2, Hakan Gurbuz2 1 Sarikamis State Hospital, Clinic of Orthopaedics and Traumatology, Kars, Turkey Okmeydani Research and Training Hospital, Clinic of Orthopaedics and Traumatology, Istanbul, Turkey

Received 27 August 2019; Accepted 19 November 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9146

Abstract The surgeon and the surgical approach of the clinic where the surgeon was trained may have an impact on perioperative outcomes. In this study, among the surgeons with similar surgical experiences, we aimed to investigate the association of open-closed reduction rates, postoperative sagittal, coronal and axial plan deformities, and preference of open surgical approaches to surgeons and the clinics they were trained. We evaluated 90 cases retrospectively who underwent surgery upon diagnosis of Gartland type 3 pediatric supracondylar humerus fractures associated with extension deformity. Those whose surgery was performed after 24 hours, or patients with open fractures, flexion type supracondylar fractures, non-Gartland type 3 supracondylar fractures, fractures with neurovascular deficits, multiple comminuted fractures, pathologic fractures, or additional injury and fractures were not included to the study. All the surgeons who had >5 years of surgical experience as a specialist and >15 of pediatric elbow fracture surgery as an operator (n=12) were numbered between 1 and 12. The clinics of these surgeons were classified from A to F (n=6). Data on patients’ age, gender, duration of surgery, follow-up time, postoperative sagittal, coronal angulation, postoperative rotational deformity, operation time, rates of open-closed surgery, the surgical approach in those open surgery was performed, the number and characteristics of the pins used were collected to analyze in relation with their assigned surgeons and the clinics they were trained. Among the 90 cases, 54 (59.3%) were male patients. The mean age was 6.21±3.03 years. There was no significant difference between the clinics in terms of sagittal and rotational deformities and open reduction rates (p>0.05). The clinics significantly differed in preference of the side of incisions (medial, lateral, posterior), (p<0.05). The number of pins, Baumann, and lateral humerocapitellar angles was similar between the clinics. The mean duration of the surgery (41.54±17.02 min) of the surgeons from the F clinic was lower than that of the other clinics (p: 0.004). In open surgeries, there was not a significant difference between surgeons in terms of single or double incision and side of the incision (medial, lateral, posterior) (p: 0.094). The number of pins also significantly differed among surgeons (p: 0.009). The type of surgical approach and treatment modality in pediatric supracondylar fractures is at the surgeon’s discretion and therefore may be influenced by the approach of the clinic where the surgeon had specialty training. Nevertheless, within-clinic variations might also occur depending on the surgeon’s preference or their role model advisor. Individual preferences may result in differences in operative time and case-specific complication rates. Keywords: Surgeon factor, pediatric, supracondylar humerus fractures, surgical experiences

Introduction Supracondylar humerus fractures are a very common type of elbow fractures and their treatment could be very compelling [1]. These fractures constitute 60% of all elbow fractures and 3% of all fractures in childhood [2].

Open reduction is a reasonable alternative in cases where closed reduction is insufficient or in the presence of vascular injury or open fractures [7].

Treatment of pediatric supracondylar fractures is controversial and technically difficult. The treatment aims to obtain a functional and cosmetically acceptable upper extremity with a normal range of motion [3]. Closed reduction and pinning is the preferred surgical treatment modality in these fractures [4-6].

Several articles reported that surgeons’ experience and their training might have an impact on the rate of open reduction and the success of postoperative surgical reduction in the surgical treatment of pediatric supracondylar humeral fractures [3,8-10]. Also, it was suggested that the tolerance shown by the surgeon towards angulation in closed reduction might also be important for observed open surgery rates [10].

*Coresponding Author: Ali Yuce, Sarikamis State Hospital, Clinic of Orthopaedics and Traumatology, Kars, Turkey E-mail: dr_aliyuce@hotmail.com

In this case, one of the most important factors in surgery may be the surgeon itself and her/his approach to the condition. A surgeon’s approach to the disease may also have been shaped by her/his characteristics and the training at which she/he was trained. Our 103

doi: 10.5455/medscience.2019.08.9146

hypothesis is surgical approaches of the surgeons, open-closed reduction rates, preferences of surgeons pin application features and postoperative fracture reduction acceptances may vary by surgeons and the clinics they were trained. Therefore, among the surgeons with similar surgical experiences, we aimed to investigate the association of open-closed reduction rates, postoperative sagittal, coronal and axial plan deformities, and preference of open surgical approaches to surgeons and the clinics they were trained. Materials and Methods In this retrospective study, we examined medical records of 187 cases who underwent surgery due to pediatric distal humerus fracture in the orthopedics and traumatology clinic of our hospital between January 2011 and December 2018. After excluding those whose surgery was performed after 24 hours, or patients with open fractures, flexion type supracondylar fractures, non-Gartland type 3 supracondylar fractures, fractures with neurovascular deficits, multiple comminuted fractures, pathologic fractures, or additional injury and fractures; 90 cases with diagnosis of Gartland type 3 pediatric supracondylar humerus fractures associated with extension deformity were included to the study. Baumann’s angle was measured as the angle between lateral condylar physis and shaft of the humerus, where the values between 64° and 81° were regarded as normal [11]. Angulation above normal values was accepted as varus deformity and below those as valgus deformity. As described by Singh et al., the difference of thickness between both cortices of proximal and distal fragments at anteroposterior and lateral elbow X-ray views was considered as rotation and measured in mm. Rotation of the distal part at coronal plane was grouped into three categories: values between 0-2 mm were accepted as good, those between 3-5 mm were moderate, and those >5 mm as poor (1). All the surgeons had >5 years of surgical experience as a specialist and >15 of pediatric elbow fracture surgery as an operator (n=12). These surgeons were numbered between 1 and 12. The clinics of these surgeons were classified from A to F (n=6). We collected data on patients’ age, gender, duration of surgery, follow-up time, postoperative sagittal, coronal and axial angulation, operation time, rates of open-closed surgery, the surgical approach in those open surgery was performed, the number and characteristics of the pins used to analyze these variables concerning their assigned surgeons and the clinics they were trained. Statistical analysis Statistical analysis was performed with SPSS version 17.0 software. The normality test of the variables was analyzed with histogram graphs and the Kolmogorov-Smirnov test. Descriptive data were expressed as the mean, standard deviation, median, minimum, and maximum values, where appropriate. Comparisons were performed with Pearson Chi-square and Fisher’s exact tests. For non-normally distributed variables, Mann Whitney-U and Kruskal Wallis tests were used for two or more groups,

Med Science 2020;9(1):103-8

respectively. An overall 5% Type-I error level was used to infer statistical significance. Results Among the 90 cases, 54 (59.3%) were male patients. The mean age was 6.21 ± 3.03 years. The mean operative time was 55.86 ± 27.15 minutes. Open reduction was performed in 38 patients. The mean operative time of open surgery (78.47 ± 25.93 min) was significantly longer than that in closed surgery (39.33 ± 11.76min) (p: 0.001). The mean Baumann’s angle was 70±8.85 degrees, and the lateral capitohumeral angle was 57.76± 15.47degrees. The rotation was present in 20 patients. Among these, eight patients were evaluated as good, five patients as moderate, and seven patients as poor. Three patients had >3-mm translation. While this did not occur in a closed reduction group, it constituted 7.9% of those who underwent open reduction (p=0.039). Nine patients had varus, and 15 patients had a valgus deformity. The rate of the latter was significantly higher in those who underwent closed reduction (25.0%) than open reduction (5.3%), (p: 0.045). Four patients developed flexion deformity and eight patients had extension deformity. There were five surgeons from Clinic D and three from Clinic F and one each from the remaining clinics. Characteristics of the clinics in terms of rates of the type of surgery, rotation, side of the incision, surgical incision, and coronal and sagittal deformity were demonstrated in Table 1. There was no significant difference between the clinics in terms of sagittal and axial deformities and open reduction rates (p>0.05). The clinics significantly differed in preference of the side of incisions (medial, lateral, posterior), (p<0.05). The rate of open surgery via a posterior incision (37.5%) was highest at Clinic F and all of these operations were performed by the same surgeon. The rate of single medial incision was highest (100.0%) at Clinic C. The rate of lateral incision was highest (66.7%) at Clinic B. The rate of postoperative valgus angulation in the coronal plane (44.44%) was higher for the single surgeon who was trained in Clinic E than for the surgeons from other clinics (p: 0.007). There was no significant difference between the clinics in terms of sagittal and axial deformities and open reduction rates (p>0.05). The clinics significantly differed in preference of the side of incisions (medial, lateral, posterior) (p: 0.041). While seven of the surgeons preferred to use lateral pin in the majority of cases, the remaining six were found to prefer applying cross-pinning. One of those surgeons who preferred the latter pinning style used a medial pin by preserving the ulnar nerve via the mini-open medial incision. The number of pins, Baumann, and lateral humerocapitellar angles was similar between the clinics (p>0.05). The mean duration of the surgery (41.54±17.02min) of the surgeons from the F clinic was lower than that of the other clinics (p: 0.004) (Table 2). In open surgeries, there wasn’t a significant difference between surgeons in terms of single or double incision and side of the incision (medial, lateral, posterior) (p: 0.061). The number of pins also significantly differed among surgeons (p: 0.009) (Table 3). 104

doi: 10.5455/medscience.2019.08.9146

Med Science 2020;9(1):103-8

Table 1. Rates of surgery type, rotation, incision and deformity by surgeons’ clinics Clinics the surgeon was trained in A

(40.00)

(42.86)

(71.43)

(38.46)

(66.67)

(30.77)

Closed

(60.00)

(57.14)

(28.57)

(61.54)

(33.33)

(69.23)

None

(53.33)

(71.43)

(57.14)

(84.62)

(88.89)

(88.46)

Present

(46.67)

(28.57)

(42.86)

(15.38)

(11.11)

(11.54)

(16.67)

(.00)

(10.00)

(16.67)

(37.50)

(16.67)

(33.33)

(100)

(.00)

(25.00)

(50.00)

(66.67)

(.00)

(60.00)

(33.33)

(25.00)

M-L

(16.67)

(.00)

(30.00)

(50.00)

(12.50)

Closed

(60.00)

(57.14)

(28.57)

(61.54)

(33.33)

(69.23)

Single

(33.33)

(42.86)

(71.43)

(26.92)

(33.33)

(26.92)

Double

(6.67)

(.00)

(11.54)

(33.33)

(3.85)

None

(60.00)

(85.71)

(42.86)

(84.62)

(44.44)

(84.62)

Valgus

(13.33)

(14.29)

(11.54)

(44.44)

(15.38)

Varus

(26.67)

(.00)

(42.86)

(3.85)

(11.11)

(.00)

None

(93.33)

(85.71)

(84.62)

(88.89)

(84.62)

Extension

(6.67)

(14.29)

(11.54)

(.00)

(7.69)

Flexion

(.00)

(3.85)

(11.11)

(7.69)

Anteroposterior Deformity

Surgical incision

Open

Type of incision

Rotation

n Type of surgery

Lateral deformity

% 0.284

0.071

0.041

0.168

0.007

0.921

Pearson ve ExactChi-square test

Table 2. Duration of surgery, number of pins, and Baumann’s and lateral humerocapitellar angles by surgeons’ clinics

Clinics the surgeon was trained in

Duration of surgery, min

Number of pins used, n

Baumann’s angle, degree

Lateral humerocapitellar angle, degree

Mean±SD

Median

Mean±SD

Median

Mean±SD

Median

Mean±SD

Median

53.67±23.49

55.00

2.33 ±.49

2.00

75.27 ±13.33

74.00

52.13 ±12.72

54.00

51.43±16.51

45.00

2.71 ±.49

3.00

69.14 ±4.06

71.00

53.29 ±13.90

61.00

77.43±28.22

75.00

2.71 ±.76

3.00

72.29 ±12.20

75.00

57.57 ±21.04

68.00

59.04±30.27

50.00

2.92 ±.80

3.00

68.73 ±7.46

70.00

58.88 ±14.53

60.50

78.33±31.02

80.00

3.11 ±.78

3.00

66.89 ±8.89

63.00

64.56 ±24.74

61.00

41.54±17.02

40.00

2.62 ±.57

3.00

68.92 ±5.82

70.00

58.77 ±12.58

62.00

0.004

0.081

0.326

0.450

¹Kruskal Wallis Test

105

Extension

Flexion

(0)

(18.18)

(81.82)

(0)

(9.09)

(90.91)

(0)

(18.18)

(81.82)

(0)

(50)

(0)

(50)

(27.27)

(72.73)

(81.82)

(18.18)

Pearson ve ExactChi-square test

Sagittal plane

None

Double

Varus

Single

Closed

Valgus

M-L

None

Present

Closed

Open

(12.5)

(75)

(0)

(12.5)

(87.5)

(12.5)

(37.5)

(50)

(25)

(50)

(0)

(25)

(0)

(100)

(50)

(0)

(100)

(0)

(100)

(0)

(100)

(0)

(100)

(0)

(6.25)

(93.75)

(25)

(18.75)

(56.25)

(6.25)

(31.25)

(62.5)

(16.67)

(50)

(16.67)

(50)

(62.5)

(37.5)

(22.22)

(0)

(77.78)

(0)

(11.11)

(88.89)

(0)

(33.33)

(66.67)

(0)

(33.33)

(0)

(66.67)

(0)

(100)

(66.67)

(33.33)

(0)

(14.29)

(85.71)

(42.86)

(14.29)

(42.86)

(0)

(71.43)

(28.57)

(0)

(100)

(0)

(42.86)

(57.14)

(28.57)

(71.43)

(0)

(16.67)

(83.33)

(0)

(100)

(0)

(50)

(0)

(66.67)

(33.33)

(0)

(16.67)

(83.33)

(50)

(11.11)

(0)

(88.89)

(11.11)

(44.44)

(33.33)

(50)

(33.33)

(0)

(16.67)

(11.11)

(88.89)

(33.33)

(66.67)

(0)

(100)

(0)

(100)

(0)

(100))

(0)

(100)

(0)

(12.5)

(87.5)

(0)

(100)

(25)

(50)

(25)

(33.33)

(66.67)

(0)

(12.5)

(87.5)

(25)

(75)

(0)

(12.5)

(87.5)

(12.5)

(25)

(62.5)

(0)

(100)

(0)

(37.5)

(62.5)

(100)

(0)

(100)

(0)

(33.33)

(66.67)

(16.67)

(33.33)

(50)

(33.33)

(0)

(66.67)

(0)

(100)

(50)

0,800

0,111

0,183

0,094

0,072

0,061

Coronal plane

Surgical incision

Type of incision

Rotation

Type of surgery

Table 3. Rates of surgery type, rotation, incision, and deformity by performing surgeons

doi: 10.5455/medscience.2019.08.9146 Med Science 2020;9(1):103-8

106

doi: 10.5455/medscience.2019.08.9146

Discussion As very common types of elbow injuries, supracondylar fractures constitute approximately 16.6% of all childhood fractures [12]. Treatment of these fractures depends on the degree of displacement of the fracture. The preferred method of surgical treatment is the closed reduction and percutaneous pinning whereas indications for open reduction include irreducible fractures, vascular injury and open injuries. Medial, lateral, posterior, anterior surgical approaches or combinations of these can be applied in open surgery. The fracture could be stabilized by fixation through lateral parallel or divergent or crossed Kirschner wire (K-wire), [13]. Surgical goals include anatomic reduction, stable fixation, good functionality, and good cosmetic appearance [14]. It was reported that rates of open-closed reduction and surgical success were associated with the surgical experience [3,10,15]. This experience may be affected by the region or the clinic at which surgeons received training or by their trainers. That was the reason for the fact that we investigated the effect of clinics or personal factors on the approach to pediatric supracondylar fractures among surgeons with similar experience in duration or number of cases. The study by de Francisco et al. reported no association of the open reduction rates to the number of cases operated by the surgeon. The authors suggested that the rate of open reduction was strongly influenced by the surgeon’s instructors and the clinics they were trained in [10]. In our study, there was no significant difference between surgeons or clinics in terms of open reduction rates. Surgeon’s tolerance and acceptance of the reduction is an important factor, and open reduction depends on the surgeon [10]. Cubitus valgus does not cause too many problems in these fractures whereas cubitus varus is associated with cosmetic problems and rarely results in a limited range of motion [16]. On the other hand, postoperative hyperextension deformity affects elbow function [17]. Although many angulations can be restored by remodeling of the pediatric bone, sagittal plane deformities and rotation may not be fully remodeled [8,17,18]. In our study, while sagittal and coronal plane deformities were similar across the clinics tested, valgus angulation at coronal plane significantly differed. This may be attributed to the fact that while no surgeon is likely to tolerate the deformities that would result in functional or cosmetic problems or fail to show remodeling, the tolerance to valgus angulation might vary on the individual or clinic basis. There were significant differences in the duration of surgery and surgical approaches across the clinics the surgeons were trained in. For example, while the surgeons of the clinics with the shortest operation time mostly performed lateral incisions and applied two lateral parallel pins, other clinics also performed ulnar nerve dissection with the posterior or medical incision. This may be explained by the possible effect of the training on the surgical approach, which, in turn, might influence the operation time based on the clinic the training was received. There are many different surgical approaches suggested for supracondylar fractures of the humerus in children [3,19]. Liu et al., in their study where they investigated the association of surgeon’s experience to the surgery in supracondylar fractures, reported that reduction loss rates increased after a certain level of experience. The authors further reported that some of these

Med Science 2020;9(1):103-8

were malreduction after reviewing the images in the operating room. They concluded that this might result from the fact that lack of instructor’s emphasis on ideal angulations and rotations at the operating room could lead the former trainee surgeon to be likely to adopt this behavior as her/his experience increased later in the profession [9]. In orthopedic surgery, wide variations of surgical approaches can be seen among surgeons [20]. Flint et al. reported that the opportunity of trainee surgeons to choose his/her instructor was associated with an increased level of happiness [21]. Differences in preferences of surgical approaches and incisions across the clinics and surgeons may originate from the possible inheritance of the different surgical approaches of the clinics through surgeons. In our study, on the other hand, two out of three surgeons from the same clinic were found to perform the surgery routinely with lateral single or lateral-medial double incisions whereas the other surgeon was detected to perform the posterior incision. This may result from the variations in periods when the training was received or from different role model instructors. Iatrogenic ulnar nerve injury is associated with closed reduction and crossed K-wire. This may be reduced only with lateral pinning or applying K-wire through the mini-medial incision [3,13,22]. Iatrogenic radial nerve injury can be seen with a lateral open approach [22]. On the other hand, posterior intervention may be associated with poor functional outcomes and joint stiffness [19,23]. In our study, while the lack of comparison of the pin configurations by surgeons and its complications was a shortcoming, the difference of surgeons in terms of surgical approaches and numbers of pins was significant. For instance, in cases where three pins were applied, medial pinning was also performed. Also, one of the surgeons applied the medial pin with a mini-open incision while preserving the ulnar nerve in closed interventions. The variation of surgical approaches and its application techniques may be associated with decreased or increased rates of complications depending on the practice. This might cause differences in types and rates of complications based on the operating surgeon. Our study has several limitations, including retrospective design and lack of long-term follow-up and functional outcomes. Also, we did not compare pin configurations and had no information about the types and rates of its complications. Conclusion The type of surgical approach and treatment method in pediatric supracondylar fractures is at the surgeon’s discretion. It, therefore, may be influenced by the approach of the clinic where the surgeon had specialty training. Nevertheless, within-clinic variations might also occur based on the surgeon’s preference or their rolemodel advisor. Individual preferences may result in differences in operative time and case-specific complication rates. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki.

doi: 10.5455/medscience.2019.08.9146 Ali Yuce ORCID: 0000-0003-3751-6644 Niyazi Igde ORCID: 0000-0001-9097-5992 Yunus Imren ORCID: 0000-0002-8056-6156 Suleyman Semih Dedeoglu ORCID: 0000-0002-7441-5028 Hakan Gurbuz ORCID: 0000-0002-6437-5771

References 1.

Singh I, Rupabati Devi RK, Sharma GS. A Prospective Study of Supracondylar Fractures of the Humerus in Children Treated by Closed Reduction. Journal of Evidence-based Medicine and Healthcare. 2015;2:4958-67. Shah SA, Asimuddin M. Management of supracondylar fractures of the humerus in children: Conservative versus operative. International J Orthopaedics Sciences 2017;3:14-20.

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M, Poitras B. Cubitusvarus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop. 1982;2:539-46. 12. Cheng JYC, Shen WY. Limb fracture pattern in different paediatric age group: a study of 3,350 children. J Orthop Trauma.1993;7:15-22. 13. Mangwani J, Nadarajah R, Paterson JMH. Supracondylar humeral fractures in children TEN YEARS’ EXPERIENCE IN A TEACHING HOSPITAL. J Bone Joint Surg. [Br] 2006;88:362-5. 14. Li J, Fu D, Yu C, et al. Surgical management of delayed irreducible Gartland III supracondylar fractures in children: open reduction and internal fixation versus external fixation. J Shoulder Elbow Surg. 2017;26:299-304. 15. Mazda K, Boggione C, Fitoussi F, et al. Systematic pinning of displaced extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg. [Br] 2001;8:888-93.

O’Hara LJ, Barlow JW, Clarke NMP. Displaced supracondylar fractures of the humerus in children. J Bone Joint Surg. 2000;82:204-10.

Mehserle WL, Meehan PL. Treatment of the displaced supracondylar fracture of the humerus (type III) with closed reduction and percutaneous cross-pin fixation. J Pediatr Orthop. 1991;11:705-11.

Rasool MN, Naidoo KS. Supracondylar fractures: posterolateral type with brachialis muscle penetration and neurovascular injury. J PediatrOrthop.1999;19:518-22.

Archibeck MJ, Scott SM, Peters CL. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results. J Pediatr Orthop.1997;17:298-302.

Yildirim AÖ, Unal VS, Oken OF, et al. Timing of surgical treatment for type III supracondylar humerus fractures in pediatric patients. J Child Orthop 2009;3:265-9.

Pesenti S, Ecalle A, Peltier E, et al. Experience and volume are determinative factors for operative humeral fractures in children. J Shoulder Elbow Surg. 2017;1-7.

Liu RW, Roocroft J, Bastrom T, et al. Surgeon Learning Curve for Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop 2011;31:818–24.

21. Flint JH, Jahangir AA, Browner BD, et al. The Value of Mentorship in Orthopaedic Surgery Resident Education: The Residents’ Perspective. J Bone Joint Surg Am. 2009;91:1017-22.

10. DeFrancesco CJ, Shah AS, Brusalis CM, et al. Rate of Open Reduction for Supracondylar Humerus Fractures Varies Across Pediatric Orthopaedic Surgeons: A Single-Institution Analysis. J Orthop Trauma.2018;32:400-7.

22. Ramachandran M, Birch R, Eastwood DM. Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children. J Bone Joint Surg. [Br] 2006;88:90-4

11. Williamson DM, Coates CJ, Miller RK, et al. Normal characteristics of the Baumann (humerocapitellar) angle: an aid in assessment of supracondylar fractures. J Pediatr Orthop 1992;12:636-9). (Labelle H, Bunnell WP, Duhaime

23. Gruber MA, Hudson OC Supracondylar fracture of the humerus in childhood. End-result study of open reduction. J Bone Joint Surg Am. 1964;46:1245-52.

16. Aiyer S, Naskar R, Raja BS, et al. Incidence of residual varus deformity in operated cases of supracondylar humerus fracture in children. International J Orthopaedics Sciences. 2017;3:153-9. 17. Kao HK, Lee WC, Yang WE, Chang CH. Clinical significance of anterior humeral line in supracondylar humeral fractures in children. Injury Int J Care Injured. 2016. 18. Hagglund G, Hansson LI, Norman O. Correction by growth of rotational deformity after femoral fracture in children. Acta Orthop Scand. 1983;54:85861. 19. Mazzini JP, Martin JR,Esteban EMA. Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review. J Child Orthop. 2010;4:143-52. 20. Stürmer T, Dreinhöfer K, Gröber-Grätz D, et al. Differences in the views of orthopaedic surgeons and referring practitioners on the determinants of outcome after total hip replacement. J Bone Joint Surg. [Br] 2005;87:1416-9.

Available online at www.medicinescience.org

ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):109-13

Comparison of antivenom effects between pediatric and adult patients presented to emergency department with scorpion stings Ertugrul Altinbilek1, Kaan Yusufoglu1, Abdullah Algin2, Sahin Colak3 University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey 2 University of Health Sciences Umraniye Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey 3 University of Health Sciences Haydarpasa Numune Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey 1

Received 15 August 2019; Accepted 23 September 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9148

Abstract The aim of this study was to compare the use of antivenom, and admission to ICU, scorpinism between adult and pediatric patients. This study included 99 patients who were admitted to the emergency department with scorpion sting within 1 year. Patients’ demographics including age and gender, and clinical findings such as ionized Ca values, body region of sting contact and complications were recorded from the patient files and hospital records. In addition, regarding management of patients with scorpionism the use of antivenoms, admission to intensive care unit and complications developed by the patients were also recorded. Patients were divided into two groups according to age as the pediatric group including patients aged ≤ 18 years (Group 1) old and the adult group consisting of patients aged> 18 years old (Group 2). Antivenom administration was performed in 12 patients (12.2%). Antivenom was administered in 38% (n=8) of the patients in Group 1 and 5.13% (n=4) of the patients in Group 2. The mean age of patients who received antivenom was statistically significantly lower than the patients who did not receive antivenom (p<0.05). There was a statistically significant difference between the groups in terms of hospitalization in the intensive care unit. Mean age was statistically significantly higher in patients aged ≤ 18 years and hospitalized in the intensive care unit (p<0.05). The management of scorpion stings shows differences between children and adults. Given potential side effects of the use of antivenom; existing classification guidelines should be followed especially in pediatric patients, and new strategies should be developed for the management of children with scorpion stings. Keywords: Scorpion sting, scorpionism, antivenom, children

Introduction Scorpion sting, also known as scorpionism is a serious public health problem and an acute life-threatening medical emergency in many regions of the world, and especially in rural areas of the developing countries. Scorpion envenomation is a potentially life threatening condition, leading to serious health consequences and neurological manifestations depending on severity of the scorpion sting. Signs and symptoms of envenomation are more severe especially in young children, because toxic effects of envenomation increase since the amount of toxin exposed is increased due to lower body weight of children. Severity of the sting made the treatment difficult in these cases because of the wide spectrum of clinical manifestations [1-4].

*Coresponding Author: Abdullah Algin, University of Health Sciences Umraniye Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey E-mail: dralgin@hotmail.com

Scorpion venom is a water-soluble, heterogenous and antigenic mixture. The venom consists of various low-molecular weight neurotoxic peptides. Its heterogeneity make reactions given against the venom variable. Scorpion venom mainly exerts its toxic effects on central nervous system, neuromuscular transmission and cardiovascular system. Symptoms of scorpionism begin immediately after the sting, reach to peak within a few hours and may last 24 to 48 hours. The most common clinical effects of envenomation are neuroautonomic, neuromuscular and local tissue effects. Local effects include pain, swelling and erythema around site of the sting. Clinical manifestations include autonomic disturbances such as hypertension, hypotension, tachycardia, bradycardia, excessive salivation and lacrimation, incontinence and pulmonary edema. These disturbances are caused by release of catecholamines into the bloodstream or due to direct cardiac toxicity of the venom [5]. Mortality from scorpion stings is usually resulted from cardiogenic shock or pulmonary edema. Scorpion antivenom therapy (SAV) is the widely accepted and single primary treatment strategy for scorpinosim. However, 109

doi: 10.5455/medscience.2019.08.9148

SAV must be given only with appropriate local and systemic indications because of its potential serious side effects varying from mild complications such as fever, nauseas / vomiting, chill, burning on face and headache to severe complications including hypotension, loss of consciousness. However, indications for the use of antivenom remain controversial. There are numerous studies in the literature investigating management of scorpionism in adults and in pediatric patients [2,6-12]. However, the number of studies comparing management of scorpion sting envenomation between adults and childrens in emergency departments are scarce. Therefore, the objective of this study was to compare the use of antivenom, admission to ICU, ionized Ca values and complications of scorpinism between adult and pediatric patients. Materials and Methods

Med Science 2020;9(1):109-13

Mann-Whitney U test was used for the analysis of quantitative independent variables. Qualitative variables were analyzed with Chi-square test, and when conditions were not met Fischer test was used for the analysis. p<0.05 values were considered statistically significant. Results A total of 99 patients who presented to the emergency department of due to scorpionism were included in the study. Of all patient included in the study, 51 (51.52%) were female and 48 (48.48%) were male with a mean age of 44.7 ± 27.6 years. The mean age was found as 45.73 years in female and 43.69 years in male patients. Of the patients, 21 (21.21%) were in the ≤ 18 years old (Group 1), and 78 (78.79%) in >18 years old (Group 2) groups. Distribution of patients according to age and gender is given in Table 1. Table 1. Distribution of patients according to age and gender

This study included 99 patients who were admitted to the emergency department with scorpion sting within 1 year g were evaluated retrospectively. A detailed medical history was received and physical examination was carried out in all patients with scorpionism. Patients’ demographics including age and gender, and clinical findings such as ionized Ca values, body region of sting contact and complications were recorded from the patient files and hospital records. In addition, regarding management of patients with scorpionism the use of antivenoms, admission to intensive care unit and complications developed by the patients were also recorded. Patients found to have another diagnosis and patients with insufficient informations were excluded from the study. Patients were divided into two groups according to age as the pediatric group including patients aged ≤ 18 years (Group 1) old and the adult group consisting of patients aged> 18 years old (Group 2). Accordingly Group 1 included 21 patients and Group 2 consisted of 78 patients. Eight (38.1%) patients in Group 1 were girls and 13 (61.9%) patients were boys in Group 1, while 43 (55.1%) patients were female and 35 (44.9%) patients were male in Group 2.Routine monitorization of the patients was performed with regular measurements of heart rate, respiratory rate, blood pressure and oxygen saturation at certain intervals.

Age (year)

Femal

Male

0-5

2.02

4.04

6-11

3.03

1.01

12-18

3.03

8.08

19-49

21.21

12.12

50-65

8.08

10.10

> 65

14.14

13.13

Total

51.52

48.48

Contact sites were found as lower extremity in 40 (40.40%), upper extremity in 37 (37.37%), head & neck region in 14 (14.4%), and trunk in 8 (8.08%) of the patients. Distribution of contact sites is shown in Figure 1.

Antivenom was administered in patients with severe local and systemic indications. For this purpose, a single 5 mL equine derived antivenom (Acsera, Vetal Ltd Sti, Turkey) was injected with half administered to the wound site and the other half was given as intramuscular. Repeat dose was administered in patients hospitalized in the intensive care unit as 1 vial in pediatric patients and 0.5 vial in adult patients. Patients administered antivenom were observed for a minimum period of 24 hours before being discharged. Statistical Methods Data obtained from this study was analyzed using SPSS software (version 22.0, SPSS Inc., Chicago, Illinois) Descriptive statistics are expressed as mean, standard deviation, median, minimum, maximum, frequency and percentage. Normal distribution of the variables was analyzed with Kolmogorov-Smirnov test.

Figure 1. Numerical distribution of scorpion sting contact sites

In Group 1; contact sites were found as upper extremity by 38% (n=8), lower extremity by 33% (n=7), head & neck region by 24% (n=5), and trunk by 5% (n=1). Whereas in Group 2; contact sites were found as lower extremity by 42% (n=33), upper extremity by 37% (n=29), head & neck region by 12% (n=9), and trunk by 9% (n=7). 110

doi: 10.5455/medscience.2019.08.9148

The mean ionized Ca value of the patients included in the study was measured as 1.2±0.2. The mean ionized Ca value was found as 1.30 in Group 1 and 1.22 in Group 2. Antivenom administration was performed in 12 patients (12.2%). Antivenom was administered in 38% (n=8) of the patients in Group 1 and 5.13% (n=4) of the patients in Group 2. The mean age of patients who received antivenom was statistically significantly lower than the patients who did not receive antivenom (p<0.05). In addition, the rate of antivenom administration was significantly higher compared to Group 2 (p<0.05). Antivenom administration was used in 9 male (18.75%), and 3 female (5.88%) patients. The use of antivenom was significantly higher in male than in female patients (p<0.05). A total of 10 patients (10.10%) were admitted to the intensive care unit. The mean ages of patients with and without hospitalization in the intensive care unit were found as 45.3±26.8 years and 40.0±35.0 years, respectively. There was no statistically significant difference between the patient hospitalized in the intensive care unit and those not hospitalized in terms of age (p>0.05). However, there was a statistically significant difference between the groups in terms of hospitalization in the intensive care unit. Mean age was statistically significantly higher in patients aged ≤ 18 years and hospitalized in the intensive care unit (p<0.05). Among the patients hospitalized in the intensive care unit, 5 (50%) patients were in Group 1 and 5 (50%) patients in Group 2. The rate of hospitalization in the intensive care unit due to scorpionism was found as 4.17% (n=2) in female and 15.67% (n=8) in male patients. Total three patients developed complications with all of them being in the group administered antivenom. No mortality occurred in our any patient. Demographic data, status of antivenom administration, hospitalization in the intensive care unit and complication data are given in Table 2. Table 2. Demographic and clinical data according to antivenom Antivenom (-)

Antivenom (+)

N (%), (ort)

1.25 ±0.24

1.13±0.31

0.018

(-)

86 (96.9)

3 (3.4)

0.000

(+)

1 (10.0)

9 (90.0)

0.000

(-)

87 (90.6)

9 (9,4)

0.000

(+)

0 (0,0)

3 (100.0)

0.000

10 (71.4)

4(28.6)

0.064

Body

7 (87.5)

1 (12.5)

1.000

37 (92.5)

3(7.5)

0.246

33 (89.2)

4 (10.8)

0.758

Group 1

8 (72.7)

3(27.3)

Group 2

74 (94.9)

4 (5.1)

Iyonize Ca Intensive care

Complication

CBA

HN: Head Neck, LE: Lower Extremity, UE: Upper Extremity, CBA: Contact Body Area

Med Science 2020;9(1):109-13

Discussion As in many areas around the world, scorpion stings are and important public health problems in our country especially in Southern and Southeastern Anatolia regions, and particularly in summer months [4,13]. This is caused by climate, geographic location, and socioeconomic structure of the region [3]. Studies in the literature have reported different results about the global incidence of scorpionism. The number of worldwide scorpion stings is estimated as 1.2 million annually, with 3,250 (0.27%) resulting in death [2,11]. However, there are studies reporting 100.000 scorpionism cases annually with 800 resulting in death globally [14-16]. In the literature screening, we could not reached to healthy data about the incidence in Turkey. In our study, 21.21% of the patients who presented with scorpion stings were under 18 years old. On the other hand, the rate of patients aged under 19 years was reported as 26% in a study from Brazil [17], and 28.6% in a study conducted in the USA [18]. Different results reported by the studies about age groups were thought to be resulted from several factors including climate characteristics, socioeconomic and environmental conditions, number of cases etc. In a study by Yilmaz et al. performed in Diyarbakir province, which is again located in Southeastern region of Turkey; 22% of 123 patients who presented with scorpionism were under 18 years old [4]. The similarity between the results of that study and our results might be resulted from that both areas are in close proximity with similar geographic and socioeconomic characteristics. In our study, 51.52% of the patients referred due to scorpion stings were female and 48.48% were male. Whereas 61% of the patients in ≤ 18 years group were male and 39% were female, these rates were found as 45% and 55%, respectively in> 18 years group. When frequency of contact sites were examined in our study; the most common contact site was lower extremity with 41% followed by upper extremity by 37%, head & neck region by 14% and trunk by 8%. Similarly, in a study by Ahmed et al. from Egypt, the most common contact sites were reported as low and upper extremities [13]. Again in a study by Nejati et al. from Iran with 1522 cases of scorpion stings, the most common contact sites were reported as legs and hands [19]. This may be caused by that the lower and upper extremities are the most mobile body parts with the most frequent contact with external environment. Local signs in scorpion sting include pain, hyperemia, itching and swelling; neurologic signs include irritability, hypothermia, hyperthermia, sweating, convulsion, coma, and myosis; cardiovascular signs include tachycardia, bradycardia, hypotension and hypertension; gastrointestinal signs include vomiting, abdominal pain, diarrhea and distension; respiratory findings include bradypnea, tachypnea, bronchial congestion, and acute pulmonary edema; and genitourinary system signs include priapism, oliguria, and hematuria [13]. Before the introduction of antivenoms, supportive care measures have been used for the treatment of scorpionism. Commonly used medical therapy has been administration of benzodiazepine and opioids to relieve agitation and pain [20]. Supportive care alone 111

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often requires hospitalization in intensive care unit and mechanical ventilation. Whereas the use of antivenom has enabled patients to be discharged directly from emergency department [21]. Today, scorpion antivenom treatment is the only treatment strategy widely accepted for scorpion stings [22]. Efficiency of antivenom in scorpion stings has been shown in many studies [15,23,24]. When injected, antivenom binds to venom and facilitates its excretion [25]. Besides it neutralizes the unbound venom in circulation, antivenom also creates a concentration gradient between plasma and target tissue. Thus, venom bound to antivenom is excreted from the body [26,27]. In a recent randomized controlled study, it was reported that administration of scorpion venom in children significantly shortened the time for complete resolving of autonomic symptoms and duration of hospitalization [28]. However, this treatment should be limited with local and systemic symptoms together, because its potential serious side effects. Antivenom application has side effects including early allergic reactions such as skin rash, urticaria, bronchospasm, and itching [29,30]. Again, antivenom application potentially carries risk for anaphylaxis, hypotension, cyanosis and loss of consciousness [31]. In addition, overuse of antivenom without clinical indications may pose problems in the areas with limited resources [32]. In a study by Sahin et al., it was found that antivenom was used in 22.5% of patients without systemic and/or local indications, and the result was statistically significant [8] . In the present study, 87 (87.88%) patients were healed with appropriate treatment method without use of antivenom. Whereas antivenom was administered in 12 (12.12%) of patients with severe local and systemic indications. In a study by Furtado et al. in Brasil, antivenom was applied in 10.54% of the patients [17] . In a study by Sahin et al., antivenom was given in 28.2% of the patients with scorpionism [8]. We attributed the different results about the rate of antivenom use to the differences among the studies for indications of antivenom use. There is no consensus in the literature, especially on the indications and criteria for the use antivenom in pediatric patients. In addition, because scorpion stings in different regions are caused by different scorpion species, the use of antivenom shows difference among centers. In our study, antivenom was administered by 38% in patients aged 18 years or younger, and by 5.13% in patients aged over 18 years. Antivenom administration was statistically significantly higher among the patients aged 18 years or younger (p<0.05). In a study by Coorg et al. with 156 cases of scorpion sting, mean age of patients administered antivenom was significantly lower compared to patients given supportive treatment [1]. Because of the smaller body size in pediatric patients, venom spreads to the body more rapidly, and local and systemic symptoms develop more quickly. This makes the use of antivenom more important in pediatric patients compared to adults. Studies have reported that, higher doses of antivenom may be required in pediatric patients especially in cases of severe scorpion stings [10]. In our study, repeat antivenom dose was administered in pediatric patients (23.8%) who required intensive care. Again in our study, rate of hospitalization in the intensive care unit was significantly higher in patients aged 18 years or younger. Since there was no study in the literature comparing the management of scorpion stings between children and adults, we could not compared this result with other studies.

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Studies in children with scorpion stings were limited and majority of them were case reports. The use of antivenom in children is primarily based on the studies conducted in adults [15,23]. Even low doses of antivenom may cause deterioration in some children because of their body size [33]. This study has certain limitations. Firstly, the relatively low number of evaluated cases may be considered as a limitation. It is necessary to undertake a further study with a higher number of cases to obtain more reliable results. Another limitation is lack of grading in scorpion stings. Finally, we could analyzed only the data existed in hospital records. However, as a strength to our knowledge our study is the first study in the literature comparing children and adults with scorpion stings. Conclusion The management of scorpion stings shows differences between children and adults. Local and systemic symptoms, develop earlies in children because of the same amount of venom covers a lower distance. Given potential side effects of the use of antivenom; existing classification guidelines should be followed especially in pediatric patients, and new strategies should be developed for the management of children with scorpion stings. Further studies with larger number of patients are needed to compare children and adults with scorpionism. We believe that, our results will guide further comprehensive studies to be conducted on this issue. Acknowledgments We would like to thank you to Mardin Public Hospital management for supporting this study. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval Ethical approve of the study protocol was not applicable due to retrospective nature. The study was conducted in accordance with the principles of the Declaration of Helsinki. Ertugrul Altinbilek ORCID: 0000-0003-4201-8850 Kaan Yusufoglu ORCID: 0000-0002-9248-7527 Abdullah Algin ORCID: 0000-0002-9016-9701 Sahin Colak ORCID: 0000-0001-8192-9652

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Coorg V, Levitan RD, Gerkin RD, et al. Clinical presentation and outcomes associated with different treatment modalities for pediatric bark scorpion envenomation. J Med Toxicol. 2017;13:66-70.

Chippaux JP. Emerging options for the management of scorpion stings. Drug Des Devel Ther. 2012;6:165-73.

Ozkan O, Uzun R, AdigĂźzel S, et al. Evaluation of scorpion sting incidence in Turkey. J Venom Anim Toxins incl Trop Dis. 2008;14:128-40.

YÄąlmaz F, Arslan ED, Demir A, et al. Epidemiologic and clinical characteristics and outcomes of scorpion sting in the southeastern region of Turkey. Ulus Travma Acil Cerr Derg 2013;19:417-22.

Del Brutto OH. Neurological effects of venomous bites and stings: snakes, spiders, and scorpions. Handb Clin Neurol. 2013;114:349-68.

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Al-Asmari A, Manthiri RA, Abdo N, et al. Saudi medicinal plants for the treatment of scorpion sting envenomation. Saudi J Biol Sci. 2017;24:1204-11.

Nasim MJ, Asad MH, Sajjad A, et al. Combating of scorpion bite with Pakistani medicinal plants having ethno-botanical evidences as antidote. Acta Pol Pharm. 2013;70:387-94.

Sahin A, Arici MA, Hocaoglu N, et al. Antivenom use in bite and sting cases presenting to a public hospital. Ulus Travma Acil Cerrahi Derg. 2018;24:34350.

Dudin AA, Rambaud-Cousson A, Thalji A, et al. Scorpion sting in children in the Jerusalem area: a review of 54 cases. Ann Trop Paediatr. 1991;11:217-23.

10. Abimannane A, Rameshkumar R, Satheesh P, et al. Second dose of scorpion antivenom in children with Indian red scorpion (Mesobuthus tamulus) sting envenomation. Indian Pediatr. 2018;55:315-8. 11. Dokur M, Dogan M, Yagmur EA. Scorpion-related cardiomyopathy and acute pulmonary edema in a child who is stung by Leiurus abdullahbayrami. Turk J Emerg Med. 2017;17:104-8. 12. Oyedeji OA, Musa TL, Adebami OJ, et al. Fatal scorpion sting in a child. Niger J Clin Pract. 2014;17:112-4. 13. Ahmed AE, Abdel-Baseer KA, Saad K, et al. Endocrinological and biochemical changes of scorpionism in children in Upper Egypt. Ther Adv Endocrinol Metab. 2015;6:210-6. 14. Abourazzak S, Achour S, El Arqam L, et al. Epidemiological and clinical characteristics of scorpion stings in children in Fez, Morocco. J Venom Anim Toxins inci Trop Dis 2009;15:255-67. 15. Bawaskar HS, Bawaskar PH. Management of scorpion sting. Heart. 1999;82:253-4. 16. Gümüştekin M. Çevresel toksinler: Hayvan ısırma ve sokmaları. T Klin J Pharmacol. 2003;1:53-7. 17. Furtado SDS, Belmino JFB, Diniz AGQ, et al. Epidemiology of scorpion envenomation in the state of Ceará Northeastern Brazil. Rev Inst Med Trop Sao Paulo. 2016;58:15. 18. Kang AM, Brooks DE. Nationwide scorpion exposures reported to US poison control centers from 2005 to 2015. J Med Toxicol. 2017;13:158-65. 19. Nejati J, Saghafipour A, Rafinejad J, et al. Scorpion composition and scorpionism in a high-risk area, the southwest of Iran. Electron Physician. 2018;10:7138-45.

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21. Boyer L, Degan J, Ruha AM, et al. Safety of intravenous equine F(ab’)2: insights following clinical trials involving 1534 recipients of scorpion antivenom. Toxicon. 2013;76:386-93. 22. Mishra OP, Prasad R. Myocardial dysfunction in children with scorpion sting envenomation. Indian Pediatr. 2015;52:291-2. 23. Pandi K, Krishnamurthy S, Srinivasaraghavan R, et al. Efficacy of scorpion antivenom plus prazosin versus prazosin alone for mesobuthus tamulus scorpion sting envenomation in children: A randomised controlled trial. Arch Dis Child. 2014;99:575-80. 24. Natu VS, Kamerkar SB, Geeta K, et al. Efficacy of anti-scorpion venom serum over prazosin in the management of severe scorpion envenomation. J Postgrad Med. 2010;56:275-80. 25. Hammoudi-Triki D, Ferquel E, Robbe-Vincent A, et al. Epidemiological data, clinical admission gradation and biological quantification by ELISA of scorpion envenomations in Algeria: effect of immunotherapy. Trans R Soc Trop Med Hyg. 2004;98:240-50. 26. Sevcik C, D’Suze G, Díaz P, et al. Modelling Tityus scorpion venom and antivenom pharmacokinetics. Evidence of active immunoglobulin G’s F(ab’)2 extrusion mechanism from blood to tissues. Toxicon. 2004;44:73141. 27. Ghalim N, El-Hafny B, Sebti F, et al. Scorpion envenomation and serotherapy in Morocco. Am J Trop Med Hyg. 2000;62:277-83. 28. Krishnamurthy S, Mahadevan S. Efficacy of scorpion antivenom in children. Indian Pediatr. 2014;51:499-500. 29. Dehesa-Davila M, Possani LD. Scorpionism and serotherapy in Mexico. Toxicon. 1994;32:1015-8. 30. Ismail M. The treatment of the scorpion envenoming syndrome: the Saudi experience with serotherapy. Toxicon. 1994;32:1019-26. 31. de Silva HA, Ryan NM, de Silva HJ. Adverse reactions to snake antivenom, and their prevention and treatment. Br J Clin Pharmacol 2016;81:446-52. 32. Dissanayake V, Dalka ET, Koh C, et al. A pilot study on the management and outcomes of self-poisoning in a rural Ugandan Emergency Centre. Afr J Emerg Med. 2018;8:25-28. 33. Bawaskar HS, Bawaskar PH. Efficacy and safety of scorpion antivenom plus prazosin compared with prazosin alone for venomous scorpion (Mesobuthus tamulus) sting: randomised open label clinical trial. BMJ. 2011;342:7136.

20. O’Connor A, Ruha AM. Clinical course of bark scorpion envenomation managed without antivenom. J Med Toxicol. 2012;8:258-62.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):114-7

Assessment of the readability of online texts related to specific learning disorder Aziz Kara1, Hatice Polat2 University of Health Sciences, Konya Education and Research Hospital, Department of Child and Adolescent Mental Health And Diseases, Konya, Turkey 2 Ministry of Health Kayseri City Hospital, Department of Child and Adolescent Mental Health And Diseases, Kayseri, Turkey

Received 01 August 2019; Accepted 04 September 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9149

Abstract The aim of this study was to investigate the readability and content of texts on specific learning disorder published on Turkish websites. In the study, the first three hundred websites which were accessed by writing three main word groups (dyslexia, learning disability, specific learning disorder) to the search engine in July 2019 were evaluated. Of these, chat and forum sites, commercial sales sites, the sites that contained advertising, video and pictures only and less than 10 sentences of information, and news sites that do not contain information about the disorder were excluded. One hundred and two websites remained after the exclusion criteria were applied. Websites are classified according to their makers. The readability values of the texts were calculated using the Ateşman and Bezirci-Yılmaz formulas. The contents of the text were compared according to the subject headings. There was no significant difference between the groups in terms of readability values. The readability values of the groups were found to be at the level of undergraduate education. As a result, in our study, it was observed that the readability of websites prepared for specific learning disorder was low. It was thought that this result may adversely affect the awareness about the disorder and may reduce the possibility of early diagnosis and treatment in children. Keywords: Readability, specific learning disorder, dyslexia

Introduction Specific Learning Disorder (SLD) is a neurodevelopmental disorder characterized by symptoms such as the inability of the individual to use his/her academic skills in the fields of reading, writing or mathematics, as well as performing less than expected learning performance from his/her cognitive level [1]. In the past, in order to describe the disorder, terms such as word blindness, dyslexia, minimal brain damage, specific developmental disorders and learning disorders have been used at different times. Studies have reported that the prevalence of SLD is between 5% and 12% in childhood [2-5]. Disorders such as attention deficit hyperactivity disorder, mood disorders, anxiety disorders, behavioral problems, motor coordination disorders and language and speech disorders are frequently associated with SLD [5,6]. Today, with the development of technological facilities, 72.9% of the population in Turkey have access to the Internet and a majority of 66.3% also use the Internet to research information on health [7,8].

*Coresponding Author: Aziz Kara, University of Health Sciences, Konya Education and Research Hospital, Department of Child and Adolescent Mental Health And Diseases, Konya, Turkey E-mail: aziz.kara@yahoo.com

However, some of the texts on the Internet are not user-friendly. In addition, the value of the information obtained makes sense with the extent to which the individual can comprehend it [9]. This shows us the importance of how readable and understandable the information is, as well as its’ actuality and reliability. The measure of readability provides numerical data about whether the text is comprehensible to the user or not, by using syllable, word and sentence features in the language. The readability of a text is influenced by quantitative values such as average word length, word frequency, number of multi-syllable words, average sentence length and number of words with more than one meaning [10]. The readability of each language can be calculated using a number of mathematical formulas developed for its unique structure. Two types of readability formulas developed by Ateşman and BezirciYılmaz are used for Turkish [10-12]. If parents of children having the disorder have the opportunity to find on the Internet the adequate and accurate information about the disorder appropriate to their education levels, they may be able to better manage their concerns about the disorder and its treatment. In this way, they can better understand their children and organize their lives according to their needs. In our literature review, no study on the readability level of the texts on the websites 114

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on specific learning disorder was found. In this study, we aimed to investigate the readability and content of the texts on specific learning disorder published on Turkish websites. Materials and Methods This is a descriptive study by design. Permission was obtained from the the Education Planning Board of University of Health Sciences Konya Training and Research Hospital with the decision registration number: 13.06.2019/26-11. Google (http://www. google.com.tr), which is among the most commonly used internet search engines in Turkey was used for data collection. In July 2019, the keywords dyslexia, learning disability, specific learning disorder were searched for our study. A total of 300 websites that were returned on the first 10 pages were reviewed. Of these, chat and forum sites, commercial sales sites, the sites that contained advertising, video and pictures only and less than 10 sentences of information, and news sites that do not contain information about the disorder were excluded. The articles in the sites that were included in the research were transferred to Microsoft Word 2016 program. The headings, author information, site URLs and links in the content of the articles were removed in order not to affect the readability results. Finally, these texts were transferred to the software program and readability values and other numerical values were obtained according to Ateşman and Bezirci-Yılmaz formulas. The 102 sites that remained after the exclusion criteria were divided into three main groups. The websites of hospitals, associations and health professionals were classified as group 1, the sites of special education and rehabilitation centers and consultancy centers as group 2, and national news sites as group 3. Ateşman Readability Formula: The formula was developed by Ateşman in 1997 by adapting the Flesch Reading Ease Formula [13] into Turkish and based on the lengths of words and sentences. According to this formula, the readability level of a text is described as very easy between 100-90, as easy between 89-70, moderately difficult between 69-50, difficult between 49-30, very difficult between 29-1 [11]. Ateşman readability formula: Readability Score = 198,825 40,175 x (total syllables/total words) - 2,610 x (total words/total sentences). Bezirci-Yilmaz Readability Formula: In 2010, Bezirci and Yılmaz developed a new readability formula based on the statistical characteristics of the Turkish language, using sentence lengths

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and word syllable numbers in the texts. According to this formula, as the number of syllables in words and sentence lengths in texts increase, the legibility of the text becomes more difficult. The final score calculated corresponds to the grade levels of the education system in Turkey. Grades 1-8 represent primary education, grades 9-12 represent the high school, grades 12-16 represent undergraduate, grades 16 and later represent academic level [12]. NRV=√(MWN×((S3×0.84)+(S4×1.5)+(S5×3.5)+(S6×26.25))) NRV: New readability value MWN: Mean number of words in a sentence S3: Mean number of three-syllable words in a sentence S4: Mean number of four-syllable words in a sentence S5: Mean number of five-syllable words in a sentence S6: Mean number of six-syllable words in a sentence Statistical Analysis All statistical analyses were performed using SPSS 21 program. Descriptive statistics of the categorical data in the study were expressed using frequency and percentage values while for numerical data, mean and standard deviation were used. Normal distribution of the data was checked using the Shapiro–Wilk test. Kruskal-Wallis test was used for numerical data comparisons between independent groups and ChiSquare test was used for categorical data comparisons. All statistical analyses performed in the study were two-tailed and had 5% significance limit and 95% confidence interval Results The first group consisted of 35 sites (34.3%) sites, the second group 47 sites (46.1%) and the third group 20 sites (19.6%). The mean number of words in the analyzed texts was 13.64 ± 0.41, the mean number of four-syllable words and above was 4.20 ± 0.13, the mean number of syllable numbers of words was 2.91 ± 0.1, the readability value as calculated by Bezirci-Yılmaz formula was 13.82 ± 0.41, and the readability value as calculated by Ateşman formula was found as 46.01 ± 1.16. The word numbers (p = 0.702), the numbers of four-syllable words and above (p = 0.602), the average number of syllable numbers of the words (p = 0,200), and the readability values calculated with Bezirci-Yılmaz (p = 0.438) and Ateşman (p = 0.392) formulas were found to be similar among the study groups (Table 1).

Table 1. Readability scores of the study groups All Sites n=102 Mean±Std.Err. (Min-Max)

Group 1 n=35(%34.3) Mean±Std.Err.

Group 2 n=47(%46.1) Mean±Std.Err.

Group 3 n=20(% 19.6 ) Mean±Std.Err.

13.64±0.41 (5.67-30.33)

13.94±0.64

13.52±0.68

13.40±0.82

0.702

Average number of words with four and more syllables

4.20±0.13 (1.34-9.53)

4.30±0.20

4.21±.22

4.00±0.25

0.602

Average number of syllables

2.91±0.1 (2.54-3.21)

2.92±.01

2.91±0.01

2.89±0.02

0.200

Bezirci-Yılmaz readability score

13.82±0.41 (4.78-28.04)

14.30±0.64

13.70±0.68

13.27±0.81

0.438

Ateşman readability score

46.01±1.16 (2.22-82.02)

44.72±1.69

46.39±1.94

47.39±2.40

0.392

Average number of words

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According to Ateşman’s readability scores of the websites, nine texts were found to be “very difficult”, fifty-three texts were “difficult”, thirty-nine texts were “of medium difficulty”, and one text was “easy”. No text was in the “very easy” range. There was no significant difference between the study groups in terms of readability intervals (p = 0.388) according to Ateşman scores (Table 2). Table 2. Readability ranges according Ateşman Group 1 n=35

Group 2 n=47

Group 3 n=20

Difficult and above (n=62)

Moderate and below (n=40)

0.388

When the contents of the websites were examined, ninetynine sites (97.1%) were found to contain information about the definition and symptoms of SLD, fifty-one sites (50%) about the causes of SLD, fifty-eight sites (56.9%) about the conditions that may co-exist, forty sites (39.2%) about diagnosis process of the disorder, seventy-four sites (72.5%) about treatment and special education, and thirty-seven sites (36.3%) had information about pharmacological treatment. The correlation between the scores of the groups according to Ateşman and Bezirci-Yılmaz readability formulas was examined. There was a negative correlation between the two categories (pearson correlation score = -0.957). The concordance between the two scoring systems was examined and the kappa value was found to be -0.374. Discussion

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as 9-10, Bezirci-Yılmaz as 10-11 words and the average number of syllables as 2.6 [11,12]. In our study, the average number of words was 13.64 ± 0.41, the average number of syllables was 2.91 ± 0.1, the average number of words with four syllables and above was 4.20 ± 0.13. This result is above the average of our country and corresponds to a low level of readability. The low readability of the texts related to the SLD on the Internet may cause families not to have enough information about the disorder, which may, as a consequence, decrease the possibility of early diagnosis and treatment of the patients. Besides its readability, it is also important how comprehensive the information a text contains. Almost all of the websites in our study included the definition and symptoms of the disorder. But only fifty-eight sites had information about possible co-morbidities. It is known that SLD is frequently associated with other psychiatric disorders [22-24]. Pharmacological agents are used for the treatment most of these comorbidities. Among the texts assessed in our study, only thirty-seven sites were mentioning these treatment methods. Therefore, a delay in diagnosis and treatment may be interpreted as a risk factor for the emergence of other psychiatric disorders. A study in the United States found that about half of children referred to special education programs were diagnosed with specific learning disorder [25]. If the websites are more comprehensive and readable, the chance of early diagnosis and treatment of children at risk of SLD may increase. According to a study conducted in 2014, health literacy in our country was found to be low [26]. Since the average levels of education and health literacy in our country are low, it is very important to reorganize the contents of the informative texts about disorders.

As for many disorders in our country, the awareness level is low for specific learning disorder. Detecting and referring children with this disorder often starts with suspicion of the situation by class teachers and parents. In two separate studies conducted in our country in 2003 and 2009, different prevalence rates have been reported [14,15]. In addition, due to the high number of patients per physician in many medical institutions as well as long waiting times for patients to make appointments and medical visits, families often conduct research on the Internet. For this reason, the parents’ attempts to recognize the disorder and get acquainted with the treatment options before seeing a professional is of significant importance [16].

Our study is a valuable study in the field of child psychiatry in that it is the first to investigate the concept of readability in our country. Further studies will contribute to the awareness of the concept of readability in the field of child psychiatry. On the other hand, difficulties were faced in classifying the groups in our study due to the lack of a standardization in internet domain extensions in our country. The use of a search engine to find the websites, which returns the results based on the number of page visits might have caused some pages with valuable information on the subject being missed.

The concept of readability has long been used for many years and gives information about whether a written text in the language it belongs to is suitable for the reader level [17]. There is, in general, a direct association between the education level and reading comprehension. In addition, knowing which level of education a text is written for can give us a chance to predict the legibility of the text. In our study, the readability level of the websites providing information about the SLD was found to be at the undergraduate level. This is similar to other studies conducted both in our country and throughout the world [9,16,18-20]. However, given the low level of education in our country, this finding may indicate a negative situation for readers [21]. In the studies conducted for the Turkish language, Ateşman found the average sentence length

As a result, considering the factors that affect the legibility, the formation of the language in a plain and simple manner with shorter sentences to include people with low educational levels may raise awareness about specific learning disorder. In addition, besides language selection, the website owners can add academic level options to their websites. In this way, people can choose the option that suits their level of education so that they can better understand what they are reading. As a result, they will become more aware of their children and the difficulties that they are facing, and will have the chance to better organize their lives.

Conclusion

Acknowledgments We would like to thank our instructors for the software program prepared by Asım Egemen Yılmaz and Burak Bezirci that was used in our research.

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

11. Ateşman E. Measuring readability in Turkish. AU Tömer Language J. 1997;58:171-4.

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

12. Bezirci B, Yılmaz A. A software library for measurement of readability of texts and a new readability metric for Turkish. DEÜ FMD. 2010;12:49-62.

Ethical approval The study was approved by the Education Planning Board of University of Health Sciences Konya Training and Research Hospital (Decision No: 13.06.2019/26-11).

13. Flesch R. A new readability yardstick. J Appl Psychol. 1948;32:221-33.

Aziz Kara ORCID: 0000-0003-0925-5723 Hatice Polat ORCID: 0000-0002-8457-6765

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American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. American Psychiatric Pub, 2013.

Katusic SK, Colligan RC, Weaver AL, et al. The forgotten learning disability: epidemiology of written-language disorder in a population-based birth cohort (1976-1982), Rochester, Minnesota. Pediatrics. 2009;123:1306-13.

Altarac M, Saroha E. Lifetime prevalence of learning disability among US children. Pediatrics. 2007;119:77-83.

18. Bağcı Z, Kozanhan B, Tutar MS. Readability of patient education texts presented on the internet related to vaccines. J Pediatr Infect Dis 2019;14:1805.

Norton ES, Beach SD, Gabrieli JD. Neurobiology of dyslexia. Curr Opin Neurobiol. 2015;30:73-8.

19. Sabo RM. Autism consumer health websites: are readability levels too high? Journal of Consumer Health on the Internet. 2008;12:337-48.

Trzesniewski KH, Moffitt TE, Caspi A, et al. Revisiting the association between reading achievement and antisocial behavior: new evidence of an environmental explanation from a twin study. Child Dev. 2006;77:72-88.

20. Yildiz M, Kozanhan B, Tutar MS. Assessment of readability level of informed consent forms used in intensive care units. Med-Science. 2019;8:277-81.

Margari L, Buttiglione M, Craig F, et al. Neuropsychopathological comorbidities in learning disorders. BMC Neurol. 2013;13:198.

Turkish Statistical Institute. http://www.tuik.gov.tr/PreHaberBultenleri. do?id=27819 access date 22.07.2019.

22. Pastor PN, Reuben CA. Diagnosed attention deficit hyperactivity disorder and learning disability: United States, 2004-2006. Vital Health Stat 10. 2008:1-14.

Turkish Statistical Institute. http://www.tuik.gov.tr/PreHaberBultenleri. do?id=18660 access date 22.07.2019.

23. Mugnaini D, Lassi S, La Malfa G, et al. Internalizing correlates of dyslexia. World J Pediatr. 2009;5:255-64.

Kozanhan B, Tutar MS. Readability of patient education texts presented on the internet in the field of anesthesiology. Turkiye Klinikleri J Anest Reanim. 2017;15:63-70

24. Nelson JM, Harwood H. Learning disabilities and anxiety: a meta-analysis. J Learn Disabil. 2011;44:3-17.

10. Boztaş N, Özbilgin Ş, Öçmen E, et al. Evaluating the readibility of informed consent forms available before anaesthesia: a comparative study. Turk J Anaesthesiol Reanim. 2014;42:140-4.

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25. Cortiella C, Horowitz SH. The state of learning disabilities: facts, trends and emerging issues. New York: National center for learning disabilities. 2014;25. 26. Tanrıöver MD, Yıldırım HH, Ready ND, et al. Türkiye sağlık okuryazarlığı araştırması. Birinci Baskı. Sağlık-Sen Yayınları; Ankara, 2014.

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Available online at www.medicinescience.org

ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):118-27

Trends and determinants of quality of life and self-rated health in the course of medical education among medical students Kursat Gurel1, Allahverdi Aghayev1, Hande Ipek1, Ozen Tugba Simsek1, Muhammed Aziz Ulusoy1, Erhan Eser2 1 Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey Manisa Celal Bayar University, Faculty of Medicine, Department of Public Health, Manisa, Turkey

Received 01 August 2019; Accepted 04 September 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9150

Abstract The aim of this study is to determine the change in the self-rated health and quality of life of students of a school of medicine during the course of their education and the predictive factors of health and quality of life such as socioeconomic factors, health status and healthy lifestyle, social relationships and social support, and academic burden. The study is a cross-sectional study that aimed to reach the entire registered students of Manisa Celal Bayar University School of Medicine in 2016-2017. Dependent variables in this study are the overall quality of life, self-rated health and annual self- rated health transition About 10.1% of the students stated their overall quality of life as poor or very poor whereas nearly 10.9% were dissatisfied about their health and 20.3 % of them stated their current health as worse than the previous year. There is a linear trend in a year in medical school in terms of quality of life. The logistic regression Model suggested that having a non-depressed mood is the best predictor of a better quality of life. Lower BMI, being healthy, taking care of their health and having a nuclear family are found the most important variables that affect self-rated health positively. The final term students (interns) perceived the worse overall quality of life than the first and second-year students. Additionally, the majority of the 3rd, 4th, and 5th term students reported their health worse than the previous year. These facts in self-rated health and QOL may be regarded as pieces of evidence that may lead the university authorities to take measures especially in clinical terms of medical education. Keywords: Quality of life, self-report, health, young adults

Introduction Self-rated health (SRH) and perceived quality of life are widely used to assess the general health and life satisfaction of the young populations. It has been reported that the perception of poor health in youth is associated with an increase in mortality in later life. [1] There are multiple views on the definition of quality of life. WHO defines Quality of Life (QOL) “as individuals’ perception of their position in life in the context of the culture and value systems in which they live and concerning their goals, expectations, standards, and concerns. ”[2]. Health statuses, environmental factors –physical and social-, social relations, personal beliefs, physical and spiritual well-being affect Quality of life [3]. Older age, female gender, low socioeconomic status, low educational attainment, and poor health are the main negative determinants of quality of life in adult populations.

*Coresponding Author: Kursat Gurel, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey E-mail: kursatgurelcbu@gmail.com

In addition to these known variables, some other important factors such as health-promoting behaviors, arise in young adults and adolescents, affect the health and quality of life of the person. Recent literature findings showed that these health-promoting behaviors and their results, such as physical inactivity [4], obesity [5], tobacco use, and drug addiction [6], sleep problems [7] affect the quality of life negatively. Healthy life behaviors may be considered more important in young adults than in adults since these would persist in the life-course of a person. Moreover, healthy lifestyle behaviors to be established during the university period affect a person’s health perception and quality of life in the future [4]. University education is an important life period in which individuals begin to establish their lifestyle in their life. There are several papers about tobacco use, nutrition, physical activity, obesity among university students in Turkey [8-11]. Medical School students face many obstacles that prevent doing exercise, having healthy food and increase the likelihood of exposure to tobacco, alcohol and other addictive drugs [12]. The time trends of self-rated health, annual Health Transition Item (HTI), and quality of life of medical faculty students may show the evidence of this academic 118

doi: 10.5455/medscience.2019.08.9150

burden in different periods of the education course that may lead to faculty managers taking preventive measures. However, research on the change of quality of life and health perception during the full course of education among medical school students in Turkey is scarce, and the annual health transition of the students was never questioned before. The aim of this study is to determine the change in the self-rated health and quality of life of students of a school of medicine during the course of their education and the predictive factors of health and quality of life such as socioeconomic factors, health status and healthy lifestyle, social relationships and social support, and academic burden. Materials and Methods The study is a cross-sectional study that aimed to reach the entire registered students of Manisa Celal Bayar University School of Medicine in 2016-2017. This study is a part of the “Health promotion behaviors and their causality in medical faculty students [officially approved under the title: “Tıp Fakültesi Öğrencilerinin Sağlığı Geliştirme Davranışları ve Nedenselliği”]. This study examines the self-rated health, quality of life and annual change of their health status (health transition) of students of a school of medicine during their education. Verbal informed consent was obtained from all of the participants, and the Ethical Committee approved this study of Celal Bayar University Faculty of Health Sciences (ref no: 47114). The questionnaires were collected from the participants who agreed to participate in the study, just following the information given to the students about this project. The population of all medical students enrolled in Celal Bayar University Medical School is 1154 from 2016 to 2017, and 53.4% of these students are female. It is aimed to include all students studying in medical school. So no sample selection was required. The overall participation rate in this study was 58.08%, whereas the participation rate was 87.4% for first-year students, 57.1% for second-year students, 61.7% third-year students, 58.3% fourth-year students, 32.6% fifth-year students; and 40.6% for senior students (interns). Dependent variables in this study are the overall quality of life, self-rated health, and annual self- rated health transition. All items have five-point Likert type response options. The overall quality of life item is “How would you rate your quality of life?” and its response scale is: very poor (1), Poor (2), neither poor nor good (3), good (4), very good (5). Self-rated health item is “How satisfied are you with your health?” and its response scale is: very dissatisfied (1), dissatisfied (2), neither satisfied nor dissatisfied (3), satisfied (4), very satisfied (5). The global health transition question of the SF-36 scale is used as a stand-alone item in this study, and we named this item as “Health Transition Item (HTI).” Its wording is, “Compared to one year ago, how would you rate your health in general now?” and its response scale is: Much better now than one year ago (1) Somewhat better now than one year ago (2), About the same (3), Somewhat worse now than one year ago (4), Much worse now than one year ago (5). The “Annual Health Perception Variation Value (AHVV), proposed by Eser et al. [13],” is a group based value, developed by

Med Science 2020;9(1):118-27

using the health transition item. This AHVV is calculated as: For each group of participants (age group, gender group, social group etc.), “The percentages of the two options “Much better now than one year ago” and “Somewhat better now than one year ago” are summed and then subtracted from the sum of the percentages of “Somewhat worse now than one year ago” and “Much worse now than one year ago” for each of the age group. The method may be formulated as: AHVV= [(Much better ... %) + (Somewhat better … %)] – [(Somewhat Worse ...% + Much Worse...%)]. The middle descriptor of the response scale (i.e., “About the same...”) is considered as a neutral option and is omitted from this formula. The independent variables of the study are academic grade level (1 to 6), age, family type, marital status, living condition (with peers, alone, dormitory, with family), having own room, number of siblings, educational level of mother and father, family income status, having a chronic disease, existence of a person who have chronic disease in the family, self-assessment of take care of own health and own oral health, spirituality/personal beliefs, being hopeful about future, presence of an intimate friend ,daily average study time, time spent on social media and internet; vacation length in the last year, membership of a society or an association or a social group; participation of an art or an entertainment group ; body mass index, body image perception, watching own weight, frequency of skipping meal, weekly fruit consumption, being on diet in the last year, frequency of drinking alcoholic beverage; addictive substance use (except smoking/alcohol intake) and frequency of any sleep problems. Self-reported weight and height data is obtained from the students. Body mass index is calculated by dividing the weight by the square of the height. Physical activity is assessed by the WHO’s definition for physical activity item: “How often do you do daily physical activity that lasts for at least 30 minutes that sweats your underwear?” WHO suggested adequate physical activity as “Adults aged 18–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week” [14]. Smoking status evaluated by the two questions. The first question is, “Have you smoked at least one cigarette per day or more during the previous six months?” [15] With a dichotomous response yes/ no. The second question is, “Do you smoke currently?” with an ordinal response scale: Yes, I am currently smoking at least once a day; I smoke occasionally; I have quitted smoking; No, I have never smoked. World Health Organization Well-Being Index (WHO5) is used to assess the depressive mood of the students [16]. WHO5 is a five-item scale and detects depressive mood and the validity and reliability of this index (scale). Turkish validity results were published by Eser et al. [17, 18]. Analyses Chi-square and univariate logistic regression analyses were conducted in univariate analyses. Multivariate stepwise (Backward Wald) logistic regression models were established by including the variables that were found significant in univariate analysis. All analyses were performed using SPSS 23.0 statistical package program. Type 1 error was accepted as 0.05 in the statistical analysis. 119

doi: 10.5455/medscience.2019.08.9150

Results

Marital status

Living situation

Having his/her own room

Family Type

Number of siblings

Educational status of the mother

Educational status of the father

Family income status

Variables

Categories

Frequency (%)

Having a chronic disease

Yes No Missing

68(10.1) 597(89.2) 5(0.7)

Yes

222(33.2)

Existence of a person has a chronic disease in the family

Table 1. Socio-demographic characteristics of the study population

Academic grade level (terms)

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Table 2. Medico-social characteristics of the respondents

The mean and median ages of the students are 21.25Âą2.18 and 21.0 (min-max:17-33). 670 of the 1152 students participated in the study, as a coverage rate of 58.06%. The socio-demographic characteristics of the respondents are presented in Table 1.

Variables

Categories

Frequency (%)

181 (27.0)

126 (18.8)

129 (19.3)

109 (16.3)

56 (8.4)

69 (10.2)

Single

658 (98.3)

Married

5 (0.7)

The mood in last the two weeks*

Taking care of general Health

Taking care of oral health

448(66.9)

Depressed Non-depressed

292 (43.6) 370 (55.2)

Missing

8(1.2)

None

16 (2.4)

Very little

106 (15.8)

Not bad

402 (60.0)

Quite well None Very little Not bad

146 (21.8) 7 (1.0) 57 (8.6) 315 (47.0)

Quite well

288 (43.0)

Missing

3(0.4) 171(25.5)

Missing

7(1.0)

Very strong(excellent)

With family

226 (33.7)

Fairly strong(good)

31(47.3)

Dormitory

162 (24.3)

Slightly strong(Not good)

113(16.9)

Not strong(poor)

62(9.3)

Missing

7(1.0)

Very unhopeful

24(3.6)

Spirituality/Personal beliefs

With peers

202 (30.1)

Alone

80 (11.9)

Yes

595 (88.8)

73 (10.9)

Missing

2(0.3)

Extended family

49 (7.3)

Nuclear family

582 (86.9)

Fragmented family

39 (5.8)

None

65 (9.7)

One or two

523 (78.1)

Missing

4(0.6)

Three or more

73 (10.9)

549(81.9)

Missing

9(1.3)

Daily average study duration

0-4 hours More than 4 hours

94 (14.1)

Illiterate

17 (2.5)

Primary school graduate

111 (16.6)

27(4.0) 59 (8.8)

One or two days a week

294 (43.9)

Middle school graduate

43 (6.4)

Spending time with friends after school

Missing Never Three days or more a week

317 (47.3)

High school graduate

165 (24.6)

College degree or more

333 (49.8)

0-2 hours

234 (34.9)

2-4 hours

216 (32.3)

Missing

1(0.1)

4 hours or more

159 (23.7)

Illiterate

9 (1.3)

Uncertain

61(9.1)

Primary school graduate

71 (10.6)

0-10 days

308 (46.0)

Middle school graduate

30 (4.5)

More than ten days

362 (54.0)

High school graduate

116 (17.3)

Yes

184 (27.5)

College degree or more

441 (65.9)

Missing

3(0.4)

No Missing Never

475 (70.9) 11(1.6) 233(34.8)

Higher than family expenditure

304 (45.4)

Lower than family expenditure

50 (7.5)

Equal to family expenditure

313 (46.7)

Missing

3(0.4)

Being hopeful about future

Presence of intimate friendship

Time spent on social media in a day

Vacation length in last year Membership of nongovernmental organization or of a social group Participation of organization as music band theater group, dance group, except sport organizations

Fairly(quite) hopeful

50(7.5)

Neither hopeful nor unhopeful

267(39.9)

Fairly(quite) hopeful Very hopeful Missing

240(35.8) 86(12.8) 3(0.4)

I have

570(85.0)

I havenâ&#x20AC;&#x2122;t(absent)

36 (5.4)

Uncertain

60 (9.0)

Seldom

317(47.3)

Sometimes

84(12.5)

Often Missing

24(3.6) 12(1.8)

According to WHO 5 wellbeing index cut off point 13

120

doi: 10.5455/medscience.2019.08.9150

The study population has a gender balance (female/male: 1.15). The majority of the students are the members of the middle-high class families. Only 7.5% of the students are relatively poor, and only 33.7% of the students are living with their families. 10.1% of the respondents reported that they have a chronic illness, and 33.1% reported having a chronic illness in his/her family (Table 2). 43.6% of the students reported that they are in a depressed mood. General health and oral health attention rates are in acceptable limits. 25.5% of respondents reported that they have strong spiritual beliefs, and only half of them are hopeful about their future. 14.1% of the respondents study more than four hours a day, and 23.7% of them spend more than four hours a day on the internet and social media. 85.0% of the students have an intimate friend and 47.3% go out for leisure three days or more a week. 34.8% of students did not have any relations with music or dance or any social activities; 25.8% are members of any authorized society or associations, and 54.0% of students have had a vacation in the last year (Table 2).

Categories

Body image perception

Do you watch your weight?

Frequency of skipping a meal

How many days do you consume fruit in a week?

Yes

206 (30.7)

452 (67.5)

Missing

12(1.8)

Never

85 (12.7)

Occasionally

332 (49.6)

1-2 days in a week

137 (20.4)

3-4 days in a week

80 (11.9)

5-6 days in a week

14 (2.1)

Every day

22 (3.3)

Every day

122 (18.2)

Not every day but occasionally

46 (6.9)

Quit,

90 (13.4)

donâ&#x20AC;&#x2122;t smoke

412(61.5)

Never

307 (45.8)

alcoholic beverage

138 (20.6)

One time or more a month

133 (19.9)

One time or more a week

77 (11.5)

Every day

11 (1.6)

Missing

4(0.6)

Yes

43 (6.4)

622 (92.9)

Missing

5(0.7)

Physical activity frequency

Smoking/Alcohol/Substance use

Current smoking status

Frequency (%)

Anthropometry/Nutrition and Physical activity

BMI

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Diet in the last year

Table 3. Frequency of the healthy lifestyle (health promotion) variables in the study population Variables

Frequency of drinking

Less than 18.0

39 (5.8)

18.0-24,99

455 (67.9)

25.0-29.99 and over

86 (12.9)

30 and over

23 (3.4)

Missing

67(10.0)

Too thin

9 (1.3)

Thin

68 (10.6)

Just right

352 (52.4)

Fat

206 (30.6)

Never

138 (20.6)

Too fat

31 (4.5)

A Little

228 (34.0)

Somewhat

153 (22.8)

Ever used addictive substances use during lifetime (except smoking/ alcohol intake) Sleep problems

Missing

4(0.6)

Never

72(10.7)

Much

89 (13.4)

Seldom

227 (33.9)

A great deal

55 (8.2)

Sometimes

264 (39.5)

Missing

7(1.0)

Often

106 (15.8)

Missing

1(0.1)

Never

164 (24.5)

Seldom

307 (45.8)

Sometimes

156 (23.3)

Often

41 (6.1)

Missing

2(0.3)

Never or 1 day

90 (13.4)

2 or 3 days

285 (42.6)

4 or 5 days

154 (23.0)

6 or 7 days

130 (19.4)

Missing

11(1.6)

Frequency of any sleep problems

The healthy lifestyle behaviors of the students have presented in Table 3. 16.3% of the students are overweight or obese, whereas 35.1% of the students find themselves as fat or too fat. 30.7% of the respondents reported that they applied a strict diet for the past year, and 6.1% of the students often skip a regular meal. Only 42.4% of the students consume fruit more than four days and over a week. Physical activity levels are rather worse among the students. Only 3.3% do regular daily physical activity, and 12.7% never do. 18.2% of the students are regular smokers, and just about 13.1% take alcohol regularly, and 6.4% of students have tried drugs at least once (Table 3). 10.1% of the students stated their overall quality of life as poor or very poor whereas 10.9% were dissatisfied with their health, and 20.3 % of them stated their current health as worse than the previous year (Table 4). 121

doi: 10.5455/medscience.2019.08.9150 Table 4. Quality of life and Self-rated health Variables

Categories

Frequency (%)

Quality of life perception

Very poor

21(3.1)

Poor

47(7.0)

Neither poor nor good

262(39.2)

Good

301(44.9)

Very good

36(5.4)

Missing

3(0.4)

Very dissatisfied

Med Science 2020;9(1):118-27

Table 5. Perceived quality of life, self-rated health and annual change in self-rated health according to the terms in the school of medicine Perceived QOL n(good +Neither poor nor good %)

Self-rated health Annual transition n(good+ Neither in self-rated AHVV* satisfied nor health n(about the (%) dissatisfied %) same+ better %)

Term 1

167(93.3)

155(86.1)

138(76.7)

12.3

Term 2

118(93.7)

106(84.1)

18.2

23(3.4)

Term 3

114(88.4)

111(86.7)

98(76.0)

7.8

Dissatisfied

50(7.5)

Term 4

97(89.0)

95(87.2)

82(75.2)

-0.9

Neither satisfied nor dissatisfied

236(35.2)

Term 5

49(89.1)

54(96.4)

49(87.5)

3.6

Satisfied

301(44.9)

Very satisfied

58(8.7)

Term 6

54(78.3)

62(89.9)

60(87.0)

27.6

Missing

2(0.3)

p values

0.001

>0.05

0.020**

Much worse now than one year ago

23(3.4)

Somewhat worse now than one year ago

113(16.9)

Self-rated health perception

Annual health transition in self-rated health

About the Same

322(48.1)

Somewhat better now than one year ago

168(25.1)

Much better now than one year ago

43(6.4)

Missing

1(0.1)

Annual Health Variation/Transition Value Terms are dichotomized as terms 1-4 vs. terms 5-6

The overall quality of life, self-rated health, and annual change in self-rated health of the students according to the terms are presented in Table 5. There is a linear trend in the academic grade level in terms of quality of life. The best percentages were obtained for the first two terms whereas the worse ones were calculated for the 5th and 6th terms. On the other hand, annual health transition (better health than one year ago) percentage is higher for the term five students and interns (term 6) than the students in term one to four (p=0.020), but self-rated health percentages do not significantly differ among terms. (Table 5).

The effects of socio-demographic variables on the quality of life are presented in Table 6. Students living in a fragmented family have poorer self-rated health. Income and fatherâ&#x20AC;&#x2122;s education are inversely related to annual self-rated health transition. Senior students (interns) reported worse quality of life than the other terms, and students who live with their peers have a worse selfrated quality of life than those living with their family or living in a dormitory. The only interesting results are the higher quality of life status in students who are members of families with balanced income-expenditure compared to those who belonged to a wealthier family. Another important finding is the obvious quality of life difference between the first two terms and the seniors (interns): perceived overall quality of life is 4.0 (CI 95%: 1.9-8.2) times worse in the interns compared to the medical students in terms one and two (Table 6).

Table 6. Univariate analyses of Socio-demographic variables Variables

QOL (poor and very poor) OR (95% CI)

SRH (dissatisfied and very dissatisfied) OR (95% CI)

Annual HT (somewhat worse and much worse) OR (95% CI)

Socio-demographic variables Academic grade level(ref: Term1 and 2) Term 3, 4, and 5

1.1(0.6-1.8)

1.1(0.8-1.7)

***

1.8(1.1-3.2)

Term 6 (Intern)

0.9(0.4-2.2)

0.5(0.2-1.2)

1.0

1.3(0.5-3.2)

1.5(0.7-3.6)

0.7(0.4-1.7)

1.7(0.7-4.4)

2.7(1.2-6.1)

1.5(0.7-3.2)

1.0

Equal to expenditure

0.5(0.3-0.9)

0.9(0.6-1.5)

1.5(1.1-2.3)*

Less than expenditure

0.9(0.4-2.2)

1.1(0.4-2.7)

2.4(1.3-4.8)*

Fatherâ&#x20AC;&#x2122;s Low Education (ref: high school and over)

1.6(0.9-3.0)

1.2(0.7-2.4)

2.0(1.3-3.2)**

1.0

1.3(0.7-2.6)

0.9(0.5-1.7)

0.8(0.5-1.3)

2.3(1.2-4.3)*

1.2(0.7-2.2)

0.9(0.6-1.5)

4.0(1.9-8.2)

Family type: (ref: nuclear family) Extended Fragmented Income status: (ref: income higher than expenditure)

Living situation(ref: with family) Dormitory or alone With peers *

Chi square: = p<0.05; = p<0.01;

***

= p<0,001

122

doi: 10.5455/medscience.2019.08.9150

Univariate analyses of health and health promotion variables are presented in Table 7. Students who have chronic disease perceive their health 3.6 times worse than healthy students. Also, those who have chronic diseases perceived their health 2.3 times worse than the previous year. Additionally, taking care of their general health is associated with a better quality of life, better health perception and better health transition compared to one year ago. Students who take care of their oral health have a better quality of life and health perception

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than students who donâ&#x20AC;&#x2122;t take care of their oral health. Students with depressive moods have 6.3 and 2.8 times poorer quality of life and health perception, respectively. The group of students who have a body mass index higher than 30.0 has a poorer quality of life (OR=3.2) and poorer health perception (OR=5.9). Participants whose perception of their body image is fat and too fat have poorer self-rated health, and their health perception is worse compared to one year ago. The group of students who are watching their weight perceives their quality of life better than others (Table 7).

Table 7. Univariate analyses of Health and Health promotion variable Variables

QOL (poor and very poor) OR (95% CI)

SRH (dissatisfied and very dissatisfied) OR (95% CI)

Annual HT (somewhat worse and muchworse) OR (95% CI)

1.4(0.7-3.1)

3.6(2.0-6.6)***

2.3(1.3-3.9)**

2.2(1.4-3.9)**

3.8(2.3-6.4)***

2.0(1.3-3.1)**

2.2(1.1-4.5)*

2.9(1.5-5.4)**

1.8(1.0-3.1)

6.3(3.4-11.9)***

2.8(1.7-4.8)***

2.3(1.5-3.3)***

BMI is more than 30 (ref: lower than 30)

3.2(1.2-8.5)*

5.9(2.4-14.2)***

2.3(0.9-5.4)

Watching body weight, never and seldom(ref: often)

2.0(1.2-3.4)**

1.2(0.8-2.0)

1.1(0.8-1.7)

1.0

Fat and too fat

1.2(0.7-2.0)

2.3(1.4-3.9)*

2.3(1.5-3.5)*

Thin and too thin

0.4(0.1-1.2)

1.7(0.7-3.7)

1.1(0.6-2.2)

No physical activity at all (ref: at least once a week)

1.9(1.1-3.4)*

1.6(0.9-2.7)

0.9(0.6-1.4)

Frequently skipping meal (ref: never or seldom)

0.6(0.3-1.1)

2.0(1.2-3.4)**

1.3(0.9-1.9)

Drinking alcohol at least once a week (ref: never or seldom)

0.4(0.1-1.1)

1.9(1.1-3.4)*

1.2(0.7-2.0)

2.6(1.5-4.7)**

2.4(1.4-4.3)**

2.3(1.4-3.6)**

1.4(0.8-2.4)

2.0(1.2-3.3)**

1.4(0.9-2.1)

Having a sleep problem (ref: never or slight problem)

0.7(0.4-1.2)

1.3(0.8-2.1)

1.9(1.3-2.9)**

Going vacation less than 10 days(ref:10 days or more)

3.2(1.9-5.5)***

1.0(0.6-1.7)

1.2(0.8-1.8)

1.0

1.8(1.0-3.3)

2.8(1.6-4.9)*

2.0(1.3-3.0)*

5.6(2.8-11.2)*

4.1(2.0-8.5)*

2.92(1.6-5.2)*

1.0

3 or more times a week

1.2(0.7-2.0)

1.3(0.8-2.2)

1.0(0.7-1.5)

Never

2.7(1.3-5.8)*

2.0(0.9-4.4)

1.5(0.8-2.9)

Health and Health promotion variable Having chronic illness (ref: healthy) Take care of general health : None or very little (ref: not bad or quite good) Take care of oral health : None or very little (ref: not bad or quite good) Depressed mood (ref: nondepressed mood)

Body image perception: (ref: just right)

Does not have an intimate friend (ref:have an intimate friend) Spirituality and beliefs: Slightly strong or Not strong (ref: strong)

Being hopeful for the future: (ref: hopeful) Nor hopeful neither hopeless Hopeless Spending time with friends after school: (ref one or two days a week)

Chi square: *= p<0.05; **= p<0.01; ***= p<0,001

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Drinking alcohol at least once a week is found a risk factor for the poor perception of health. Those students who frequently skipped meals were almost twice as risky in terms of poor health perception. Doing adequate physical activity increased the quality of life of medical students. Participants who have gone on vacation for more than ten days in the past year have a better quality of life. The students who do not have any intimate friends have a poor quality of life, poor health perception, and worse self-rated health

Med Science 2020;9(1):118-27

compared to one year ago. Furthermore, the existence of personal beliefs and spirituality has a positive effect on students’ health perception. Being hopeless for the future is associated with poorer quality of life, poorer health perception, and deterioration of health perception compared to last year. Students who don’t spend their time with their friends after school have a poorer quality of life than students who spend their time with their friends (Table 7).

Table 8. Regressions of quality of life, self-rated health and annual perceived health transition (Logistic regression, reduced final models)*

Variables

Model 1 QOL(poor and very poor) OR (95% CI)

Model 2 SRH (dissatisfied and very dissatisfied) OR (95% CI)

Model 3 Annual HT (somewhat worse and much worse) OR (95% CI)

Negelkerke R2

0.265

0.258

0.155

Age

p>0.05

0.85(0.74-0.98)*

p>0.05

5.2

2.0

1.7

(2.7-11.2)***

2.0

(1.1-2.6)*

2.0

3.5

p>0.05

(1.1-3.8)*

(1.9-6.5)***

2.4(1.1-5.5)*

2.7(1.2-5.9)*

2.3(1.1-4.4)*

2.1(1.1-4.1)*

p>0.05

1.0

Equal to expenditure

0.4(0.2-0.7)**

1.48(1.0-2.3)

Less than expenditure

0.5(0.2-1.6)

2.1(1.1-4.4)*

Having chronic illness

3.3(1.5-7.1)**

1.8(1.0-3.4)

1.0

Nor hopeful neither hopeless

p>0.05

2.0(1.1-3.9)*

1.8(1.2-2.9)*

Hopeless

p>0.05

2.7(1.1-6.7)*

2.5(1.3-4.8)**

Depressed mood (ref: nondepressed mood) Take care of general health: None or very poor (ref: not bad or quite good) Take care of oral health : None or very poor (ref: not bad or quite good) Does not have an intimate friend (ref: have an intimate friend) Income status: (ref: more than expenditure)

(ref: healthy) Being hopeful for the future: (ref: hopeful)

Going vacation less than 10 days(ref:10 days or more) Spending time with friends after school: (ref one or two days a week)

2.6(1.4-5.0)**

1.0

3 or more times a week

0.9(0.5-1.7)

Never

2.8(1.2-6.8)*

1.8(1.1-3.0)*

1.8(1.2-2.8)**

Body image perception: (ref: just right)

1.0

Fat and too fat

p>0.05

1.9(1.2-2.9)**

Thin and too thin

p>0.05

0.8(0.4-1.6)

Family type:

1.0

1.2(0.4-3.3)

3.3(1.2-8.9)*

p>0.05

5.2

Father’s Low Education (ref: high school and over) Having a sleep problem (ref: Never or slight problem)

(ref: nuclear family) Extended Fragmented BMI is more than 30 (ref: lower than 30)

(1.7-15.7)**

“-” Not included in the multivariate analyses. *=p<0.05; **= p<0.01; ***= p<0,001

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Only the variables that were found significant in the univariate analyses (see Table 7) were included in the multivariate logistic regression models presented in Table 8. The logistic regression Model suggested that having a non-depressed mood is the best predictor of a better quality of life. Besides, quality of life is negatively affected by not care of general and oral health, the absence of an intimate friend, unbalanced income-expenditure of the family, not having a vacation, and not spending adequate time with friends. (Table 8) Lower BMI, being healthy, taking care of their health and having a nuclear family are found the most important variables that affect self-rated health positively. The results also revealed that younger age, having a nondepressed mood, taking care of oral health, presence of an intimate friend, being hopeful about future positively associated with better health perception. As for the Annual Health transition, low-income status, father’s low education, depressed mood, having any chronic disease, having a sleep problem, perception of self-body image as fat or too fat; having no hope for future increase the risk of deterioration of self-rated health compared to that of the previous year. Discussion Self-rated health and quality of life may not always link to a diagnosed disease. Many young people may report feeling unhealthy, although they don’t have a diagnosed disease. The overall quality of life perception in university students varies in different regions of Turkey and different countries. Poor and very poor cumulative QOL frequency is about 10.1% in this study. This is a similar rate that was reported for a medical faculty in Turkey [19] but higher than the results of Lebanon study (2.5%) conducted on university students [20]. The trends of quality of life scores in this study presented a special pattern. QOL was better in the first two years students than the students of the following years and this trend sharpened in the final year in medical education (internship term). The 3rd-year and 4th-year students also reported worse SRH and QOL. Our results are consistent with a Brazilian study that presents worse QOL in 3rd term [21]. The 3rd term is the period of the highest theoretical and 4th term, both theoretical and practical academic burden of the school. Interns have significantly lower QOL than those studying in the first two terms. This deterioration trend is observed in other studies such as China [22], Thailand [23], USA [24] and Brazil [25]. In only one study conducted on Pakistani medical students reported contradictory results rendering worse QOL in the second year of medical education [26]. Then the question is “why interns perceive the worse quality of life than others.” This trend may be explained by the increasing academic responsibility of the students as education evolves. Additionally, the specialty board examination called (TUS) in Turkey, loads a very heavy theoretical academic burden on the interns. As for the self-rated health, poor and very poor self-rated health percentage is similar to the quality of life figures of our study (10.9%). Poorer self-rated health scores were found in medical students compared to other university students in several studies. Hence, the results of two Turkish studies that were conducted on nonmedical students reported better self-rated health scores than ours [27, 28].

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Univariate and multivariate analyses for quality of life (model 1), self-rated health (model 2) and annual health transition (model 3) as dependent variables, revealed that, family income and father’s education; physical (e.g., having chronic illness and obesity) and mental health problems (e.g., sleep problems and depressive mood); social relations and peer support and hope about future are the variables that predict QOL and self-rated health. We will first discuss both QOL and SRH concurrently since QOL and SRH may have similar risk factors, and subsequently, we will continue with the discussion on HTI. The term and age of the students were not entered in the same logistic model due to potential collinearity problems, and different models are employed. The term (although significant in the univariate analyses) was not found significant in the final logistic regression model whereas advanced age was found protective in model 2 (SRH). The advantage of advanced age on SRH may be attributed to the professional development and maturation of the student. Similarly, a study from Lebanon, advanced aged students, has better SRH than that of younger [20]. QOL was sensitive to family income as expected. Several studies support this fact in the literature [29]. Health status, depressed mood and taking care of their health and oral health were also sensitive to QOL and SRH. Furthermore obesity is found associated with QOL. Although the presence of chronic illness is rare amongst students, it stayed in the final regression model (Model 2, SRH), similar to obesity. On the other hand, depressive mood affects QOL and SRH with very high odds ratios. So depression is one of the highest predictors of QOL and SRH in our study. Not surprisingly, several literature findings support our results [29-32]. The depressive mood is probably due to the long hours of studying and social isolation of the students resulting inability to self-actualize. Taking care of your health can be expressed as a self-responsibility of health. The students who are taking care of their health and oral health reported better selfrated health and better QOL. A few previous studies support our findings [33,34] indicating that self-health responsibility is very close to the feeling of health and being happy in life. Social relationships and social support consist of another major group of variables that are very influential on SRH and QOL. Having intimate friends and time spent with friends are crucial variables for good health perception and QOL in this study. Numerous national and international studies agree with these findings [3538] in the literature. As it was mentioned above for the depressive mood, having an intimate friend and share time with friends may serve as a good way of overcoming social isolation and the pressure of heavy workload over the students. Having a vacation also increased the QOL of the students in this study. An Australian study confirms this finding, mentioning that vacations contribute to the quality of life in adults [39]. Vacation refers to leisure and peace of mind and mostly integrated with social relations. Family composition and relationships with family still play a great role in the life of students either in terms of social and economic support. In this study being a member of a fragmented study affects SRH negatively. Just one study conducted on a sample of Brazilian adolescents has similar results with ours [40]. Hopefulness about the future is very important for youth and motivated the young to be more active and happy in life. As expected, we found hope 125

doi: 10.5455/medscience.2019.08.9150

for the future a very effective determinant of SRH, and this was supported by only one study conducted on high school students in west Turkey [41]. Assessment of annual perceived health transition is a relatively new approach that has been used in health inequality researches. Following the development of SF-36 as a health-related quality of life tool, its second item served as “health transition item - HTI” and some researchers isolate this item and have used it in the health management programs and research. This HTI was proposed to be used in population group comparisons, as well. Eser et al. suggested a new method, namely as “Annual Health Variation Value “(AHVV) as a “group-based value,” as described in the Methods section above [13]. AHVV in our sample, in general, is less than that of the population-representative sample Eser et al. ’s study in the same age groups. Also, AHVV for each of the years of education is presented in Table 5 and present a U shaped trend. It was rather good in the first two years and especially very low in years 3, 4 and 5. The poor quality of life levels in the 3rd and 4th terms is already discussed above, and so, this finding supports it differently. Global health transition item is a brief retrospective item that can add value to cross-sectional surveys where there is no opportunity for follow-up by identifying groups of subjects who have experienced a recent change in health status [42]. So this item is very valuable for us since we could only conduct a cross-sectional study with a moderate level of participation of the medical students. Many descriptors affect annual health transition among adults and young people, such as socio-demographic variables and the presence of any illness or risk factors of illnesses and psychosocial factors. Family income, father’s level of education, the existence of any chronic disease, sleep problems, taking care of own health, depressed mood and hope for the future were the independent variables retained in the final reduced logistic regression model for health transition item. Not taking care of oneself properly, depressed mood and hope for the future is sensitive to all three dependent variables, including health transition in this study. Taking good care of oneself is an abstract variable that covers all health-promoting behaviors, and hope about the future for university students is naturally a very important one. Depression may associate with both self-care and hope for the future and may also be very predictive of health change. Family income and father’s education both renders socio-economic status as one of the predictors of health transition. The Annual Health Variation Value (AHHV) is higher in the first two years of education and the interns, whereas it is very low in especially 3rd and 4th term students. The AHVV for 3rd and 4th terms are less than that of found by Eser et al. [13], in a populationbased sample. We found AHVV as 12.3 in the 1st term students and 18.2 in 2nd term students, which are lower than the reported AHVV of 30.3 in the 15-19 age group in Eser et al.’ study. On the other hand, AHVV was reported as 11.2 in the 20-24 age group in Eser et al. study, whereas it was 7.8 in the 3rd term students and -0.9 in the 4th term students in this study, which are also lower than Eser et al.’s population-based figure for the same age group. The final year students (interns) perceived the worse overall quality of life than the first and second-year students. Additionally, the majority of the 3rd 4th and 5th term students reported their

Med Science 2020;9(1):118-27

health worse than the previous year. These facts in self-rated health and QOL may be regarded as pieces of evidence that may lead the university authorities to take measures especially in clinical terms of medical education. Conclusion Based on the hypothesis of this study, we can conclude that, all of the four hypotheses, namely: socio-demographic factors, health, healthy lifestyle, social relations, social support, and academic burden are the predictors of perceived overall quality of life and self-rated health. Low socioeconomic status of the family, poor health and poor health-promoting lifestyle, and inadequate social relations and social support have negative effects on quality of life and self-rated health. On the other hand, it was found that the medical school term, which is a representative of the academic burden, was also an effective factor. Acknowledgment We acknowledge the efforts of the student leaders, Mehmet Emirbaş, İsmet Üzüm, who helped the study team to disseminate questionnaires to the medical students and to the general secretariat of the Manisa Celal Bayar University School of Medicine, who made things easier for us. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports Ethical approval This study was approved by the Ethical Committee of Celal Bayar University Faculty of Health Sciences (ref no: 47114). Erhan Eser ORCID: 0000-0002-2514-0056 Kursat Gurel ORCID: 0000-0003-1484-803X Hande Ipek ORCID:0000-0002-6422-9221 Ozen Tugba Simsek ORCID: 0000-0003-4262-8165 Muhammed Aziz Ulusoy ORCID: 0000-0003-2198-8778 Allahverdi Aghayev ORCID: 0000-0003-3538-369X

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):128-31

Histopathological gastric mucosal changes in patients using proton pump inhibitors Saadet Alan, Ayse Nur Akatli Inonu University, Faculty of Medicine, Departmant of Pathology, Malatya, Turkey Received 31 July. 2019; Accepted 12 September 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9151

Abstract As a result of the widespread use of proton pump inhibitors (PPI), parietal cell hyperplasia/ hypertrophy (PCH/H) and a significant increase in fundic gland polyp (FGP) is observed in gastric mucosa in recent years. The aim of this study is to evaluate clinical and histopathological results of patients diagnosed with PCH/H and FGP. Clinical data and archieved slides of 60 patients who were diagnosed with PCH/H or FGP at our institution between 2012-2019 were reviewed. Of the patients included in the study , 40 were women and 20 were men. Thirty-three cases, diagnosed with PCH/H and 27 cases diagnosed with FGP were investigated. H. Pylori gastritis was seen in 6 cases. In one case with a FGP, micronodular-linear neuroendocrine cell hyperplasia was observed. The FGPs, developing in the later stages of PPI use, are identified by endoscopic and pathological findings. Enterocromafine cell-like hyperplastic changes can become apparent in patients using PPI. H. Pylori gastritis was found to be less common in patients diagnosed with FGP and PCH/H than in the general population. Keywords: Parietal cell hyperplasia, proton pump inhibitor, fundic gland polyp, neuroendocrine cell

Introduction Proton pump inhibitors (PPI) are used for peptic acid-related diseases as the first-line treatment. In the last 20 years, these drugs have been used widely all over the world [1-3]. The suppression of gastric acid release by the long term use of PPI is reported to be associated with pneumonia, clostridium enteritis and osteoporosis [1]. After chronic PPI use, single-multiple small , exophytic, polypoid lesions often localized in the fundus or corpus of the gastric mucosa appear, and while these are usually asymptomatic, they are visible endoscopically [2,3]. Menegassi et al. showed PPI use to be associated with proliferative changes in the fundus and corpus mucosa, but the length of treatment that could provoke those changes was not determined [3]. Fundic gland polyps (FGP) are small exophytic and usually asymptomatic lesions. Histopathologically, dilated cystic glands usually lined with parietal and chief cells and occasionally mucous foveolar cells are seen . Dysplastic changes are rare [2,3]. These

*Coresponding Author: Ayse Nur Akatli, Inonu University, Faculty of Medicine, Departmant of Pathology, Malatya, Turkey E-mail: aysenurakatli@gmail.com

polyps can occur in a sporadic or hereditary context. Hereditary cases are mainly associated with the Familial AdenoÂŹmatous Polyposis Syndrome (FAP) and frequently multiple FGPs can be found in the gastric mucosa [2]. Sporadic FGPs are the most common type of gastric polyps. Prolonged use of PPI may result in parietal cell hyperplasia/hypertrophy (PCH/H), glandular lumen obstruction, and cystic dilatation of the glands. In fact, there are publications indicating that the incidence of FGP increases with the use of PPI. A negative relationship with Helicobacter pylori (H.pylori) infection was also noted [2-4]. As a result of the widespread use of PPI, PCH/H and a significant increase in FGP in the gastric mucosa have been observed in recent years. Because there is still contoversy on the effects of PPI use, clinical and histopathological features of patients diagnosed with PCH/H, and FGP were evaluated in this study. Materials and Methods A retrospective analysis of the pathology files, diagnosed as PCH/H and/or FGP between 2012-2019 at the Pathology Laboratory of Inonu University Faculty of Medicine was performed. Ethics committee approval (2019/299) was obtained. A total of 60 patients with a histopathological diagnosis of PCH/H and FGP were reviewed based on histopathological examination and 128

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Med Science 2020;9(1):128-31

clinical information. Haematoxylene-Eosin and Giemsa stained slides were re-evaluated by two pathologists. Results Of the 60 patients in this study, 30 were PPI users according to the medical records. However, we were not able to determine whether the other 30 cases used PPI or not. Of the 30 PPI users, 19 were women and 11 were men. The mean age of the patients was 58.71(Table1). The mean age of women with PPI was 58.57 (23-92Y), and the mean age of men with PPI was 52.53 (18-78y). Histopathological evaluations determined parietal cell protrusions, PCH/H and occlusive glandular dilatation in oxyntic glands in all cases (Figure 1a,b). Table 1. Age, sex and histopathological findings in patients with and without history of PPI use Parameters

PPI + (n)

PPI-(n)

Female

Male

Gender

Age <30

31-60

>61

Fundus

Corpus

Antrum

Positive

Negative

Localisation

H.pylori

Fundic gland polyp Positive

Negative

Morphological analysis showed a mixed cell population, which consisted of parietal, chief, and mucous neck cells lining the cysts and surface epithelium in FGP (Figure 1c,d). All patients were re-evaluated according to Sydney system. H.Pylori gastritis was seen in 6 cases. In one case using PPI, micronodular-linear neuroendocrine cell hyperplasia was observed within FGP (Figure 1d-f). Fundic gland polyps were seen in two FAP patients using PPI. In another FGP case, low grade dysplasia was observed in the epithelium. Fundic gland polyps were observed in half of the cases (15/30) known to be using PPI.

Figure 1. A-B Parietal cell hyperplasia/hypertrophia, parietal cell protrusion ( white arrow), dilatation of oxyntic glands (black arrow), HEx100, HEx200. C: Parietal cell hyperplasia/hypertrophia, dilatation of oxyntic glands (black arrow), HEx100 .D-E: glandular cystic dilatation in FGP (white arrow), micronodular-linear neuroendocrine cell hyperplasia (black arrow), HEx100, HEx200. F:Chromogranin A positivity in neuroendocrine cell hyperplasia area in FGP, HEx200

Discussion Fundic gland polyps can be defined in 0.8 to 23% of patients who underwent routine esophagogastric duodenoscopy, in various locations [5]. They are more common in middle aged women [2, 5]. Most of our cases with mucosal changes due to PPI were female and they had a mean age of 58.57 years. Graham first described the FGP in three patients using omeprazole, in 1992 [6]. As a result of the widespread use of PPI in recent years , many studies have reported an increase in the incidence of FGPs. The presence of such a relationship associated with the long-term use of PPI can cause anxiety for both physicians and patients [2]. Jalving et al. reported that patients using PPI for less than 1 year did not have an increase in the FGP frequency. However, long-term use of PPI has been found to increase the risk of FGP development by 4 times. There was no increase in the risk of dysplasia. It was observed that FGP development increased significantly in patients using PPI for more than five years [6,7]. However, an increase in FGP frequency with PPI use has not been observed in other studies. Fundic gland polyps may be associated with congenital syndromes such as familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome, but it more often appears sporadically, constituting an incidental finding [5]. Sporadic FGPs are associated with PPI use in up to 23% [5]. Gastric polyps are seen in 30-100% of FAP patients. The majority (over 95%) of these are syndromic FGPs and the rest minority are adenomas with true malignancy potential [5]. Many studies have revealed frequent somatic mutations of the APC gene in FGPs associated with FAP. Although inactivation of the APC gene rarely happens in sporadic cases , mutations in Î˛-catenin have been defined in sporadic multiple FGP [8-11] APC / Î˛-catenin genes can cause parietal cell proliferation and may cause glandular obstruction and cyst formation by altering cell function [9]. In two of our patients using PPI, multiple FGPs were found to be associated with FAP syndrome.

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The vast majority of FGP are small lesions that can be identified correctly on endoscopy, but the diagnosis should be confirmed pathologically [5,6]. FGP typically range from 1 to 8 mm in size, usually sessile and small. In our cases, the mean polyp size was 6,28 mm (3-10 mm). FGP can be single or multiple. In two cases, who were FAP cases, multiple polyps were reported in the mucosa. The polyps were often located in fundus and corpus in accordance with the literature. The supression of peptic acid release by excessive PPI use, which causes significant changes in gastric mucosa, is frequently implicated in the literature. Gastritis or intestinal metaplasia may be accompanied [2,3,5]. Sporadic FGP are not associated with H. pylori infections, and an active infection can be protective against FGP. However, if active H. Pylori gastritis is detected, H. Pylori should be treated. [12]. H. Pylori gastritis was found in 10% of our cases. This situation was in accordance with the literature. Cats et al., showed parietal cell proliferation, protrusions and glandular cystic dilatation in patients treated with chronic PPI. Histopathological changes in oxyntic mucosa were observed in 18% of the patients receiving short-term treatment and in 86% of the patients receiving treatment for more than one year [13]. Long-term acid suppression therapy induces obstruction of parietal cell canaliculi with hydrochloric acid, PCH/H and cytoplasmic protrusions. Increased intraglandular pressure results in cystic dilatation [2,9]. It has been reported that the formation of PPI-related FGP may be associated with a binary mechanism of cellular proliferation and obstruction of glandular secretion flow [2-4,9]. Histopathologically, dilatation of oxyntic glands, parietal cell protrusion and PCH/H were observed in all cases in this study. The classical histological appearance of FGP, mixed cell population with disorgan¬ized glands, substantiated the classification of these lesions as hamartomatous lesions in the past. Brito et al. described in their study that the cysts in FGP were lined by a mixed cell population in 77% of the cases, [2]. Foveolar hyperplasia was only observed in 27% of the cases. In fact, proliferative changes in the foveolar epithelium are more related to chronic active gastritis and H. pylori infection. The presence of intraglandular mucous plugs and exfoliated cells supports the glandular flow obstruction hypothesis of FGP development [2-4]. According to Abraham, low-grade dysplasia is found only in 1% of sporadic FGP [14]. In this study, only 1 of the 27 cases demonstrated low grade dysplasia concomitant with FGP. Several cases of neuroendocrine tumor development have been reported in patients using PPI [15,16]. Hypergastrinemia induces ECL cell hyperplasia and ECL cell carcinoids Malignant transformation of a well differentiated type I gastric carcinoid has also been shown [16]. In one of our cases , micronodularlinear neuroendocrine cell hyperplasia was detected in a FGP. Because PPI use may raise the possibility of neuroendocrine cell hyperplasia and malignant transformation , patients using PPI should be investigated carefully with endoscopy for any suspicious lesions. If neuroendocrine cell hyperplasia is detected histopathologically,the question of which therapeutic modality should be chosen , and whether or not PPI should be stopped will remain unanswered. Further studies are required to determine the side effects of excessive PPI use.

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Conclusion In conclusion, gastric mucosal changes were evident in patients using PPI and the polypoid lesions developing in the later period, was supported by endoscopic and pathological findings. Enterochromaffin cell-like hyperplastic changes can become apparent in patients using PPI. Some of the cases were shown to have accompanying syndromic diseases. H. Pylori gastritis was found to be less common in patients diagnosed with FGP and PCH/H than the general population. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval A retrospective analysis of the pathology files, diagnosed as PCH/H and/or FGP between 2012-2019 at the Pathology Laboratory of Inonu University Faculty of Medicine was performed. Ethics committee approval (2019/299) was obtained. Saadet Alan ORCID: 0000-0003-2329-151X Ayse Nur Akatli ORCID: 0000-0002-9677-2456

References 1.

Kato M, Miyamoto S, Proton pump ınhibitor-associated mucosal change. Intern Med. 2017;15;56:2697.

Brito HLF, Barros C, Freire MV, et al. Gastric Fundic Gland Polyps: Can Histology Be Useful To Predict Proton Pump İnhibitors Use? Arq Gastroenterol. 2018;55:380-4.

Camilo SM, Almeida ÉC, Miranzi BA, et al. Endoscopıc And Hıstopathologıc Gastrıc Changes In Chronıc Users Of Proton-Pump Inhıbıtors. Arq Gastroenterol. 2015;52:59-64.

Declich P, Belloni J, Tavani E, et al. Fundic gland polyps and proton pump inhibitors: an obvious link, or an open question? Hum Pathol. 2014;45:1122-3.

Cheesman AR, Greenwald DA, Shah SC. Current Management of Benign Epithelial Gastric Polyps. Curr Treat Options Gastroenterol. 2017;15:676-90.

Olmez S, Sayar S, Saritas B, et al. Evaluation of patients with gastric polyps. North Clin Istanb. 2018;10;5:41-6.

Jalving M, Koornstra JJ, Wesseling J, et al. Increased risk of fundic gland polyps during long-term proton pump inhibitor therapy. Aliment Pharmacol Ther. 2006;24:1341-8.

Sekine S, Shibata T, Yamauchi Y, et al. β-Catenin mutations in sporadic fundic gland polyps. Virchows Archiv. 2001;440:381-6.

Rubio CA. Plugs clog the glandular outlets in fundic gland polyps. Int J Clin Exp Pathol. 2010;3:69-74.

10. Torbenson M, Lee J-H, Cruz-Correa M, et al. Sporadic Fundic Gland Polyposis: A Clinical, Histological, and Molecular Analysis. Mod Pathol. 2002;15:718-23. 11. Abraham SC, Park SJ, Mugartegui L, et al. Sporadic Fundic Gland Polyps with Epithelial Dysplasia. Am J Pathol. 2002;161:1735-42. 12. Genta RM, Schuler CM, Robiou CI, et al. No Association Between Gastric Fundic Gland Polyps and Gastrointestinal Neoplasia in a Study of Over 100,000 Patients. Clin Gastroenterol Hepatol. 2009;7:849-54.

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doi: 10.5455/medscience.2019.08.9151 13. Cats A, Edschenk B, Bloemena E, et al. Parietal cell protrusions and fundic gland cysts during omeprazole maintenance treatment. Hum Pathol. 2000;31:684-90. 14. Abraham SC. Fundic Gland Polyps: Common and Occasionally Problematic Lesions. Gastroenterol Hepatol (N Y). 2010;6:48-51.

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15. Takahari K, Haruma K, Ohtani H, et al. Proton pump inhibitor induction of gastric cobblestone-like lesions in the stomach. Intern Med 2017;56:2699-703. 16. Jianu CS, Lange OJ, Viset T, et al. Gastric neuroendocrine carcinoma after long-term use of proton pump inhibitor. Scand J Gastroenterol. 2012;47:64-7.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):132-5

Ischemic stroke in young adults: Gender-based differences Fatma Ebru Algul1, Yuksel Kaplan2 Malatya Education and Research Hospital, Clinic of Neurology, Malatya, Turkey Inonu University, Faculty of Medicine, Department of Neurology, Malatya, Turkey

1 2

Received 22 August.2019; Accepted 12 November 2019 Available online 27.02.2020 with doi: 10.5455/medscience.2019.08.9152

Abstract Stroke is becoming a growingly more prevalent and significant public health problem among young adults around the world. Modifiable lifestyle-related risk factors are the most common cause of stroke in young adults. The aim of this study was to perform a gender-based evaluation of risk factors, stroke subtypes, severity of stroke, level of dependency at hospital discharge, and length of hospital stay among young patients with ischemic stroke in our region. The retrospective study included patients that were diagnosed with ischemic stroke based on patient history and clinical and radiographic findings at Inonu University Medical School Neurology Department between 2015 and 2018. The patients were divided based on gender and the two groups were compared with regard to age, gender, prior stroke, risk factors, neurologic deficits at hospital admission, etiology, radiographic localization, length of hospital stay, and the levels of disability and dependency at hospital discharge were reviewed for each patient. The study included a total of 105 patients diagnosed with ischemic stroke, comprising 65 (61.9%) men and 40 (38.1%) women. Mean age was 46.02Âą7.29 years in men and 41.18Âą8.2 years in women and a significant difference was observed between the two groups (p=0.002). The incidence of diabetes mellitus (DM), myocardial infarction (MI), and smoking was significantly higher in men compared to women (p=0.008, p=0.001, and p<0.001, respectively), whereas the incidence of mitral stenosis was significantly higher in women compared to men (p=0.0019). The results indicated that modifiable lifestyle-related risk factors are the most common cause of stroke in young adults and the significance of risk factors associated with stroke in young individuals differs between genders. Future studies with larger patient populations are needed to identify further risk factors and precautions for stroke in young adults. Keywords: Young stroke, gender differences, risk factors

Introduction Stroke is a leading cause of disability and death worldwide [1]. Although it is traditionally a disease of elderly people, stroke is becoming a significant public health problem among young adults as well [2]. The cases of stroke in young adults account for approximately 10-12% of all stroke cases [3], and more than two million young adults will suffer a stroke every year [4]. The longer disabled life expectancy in young adults with a history of stroke compared to old-age individuals and the resultant longer durations of clinical complications result in increased socioeconomic costs [5]. On the other hand, the risk factors, prevalence, and etiology of stroke in young adults show significant differences from those of old-age individuals [3,6].

*Coresponding Author: Fatma Ebru Algul, Malatya Education and Research Hospital, Clinic of Neurology, Malatya, Turkey E-mail: ebruycl86@yahoo.com

In this study, we aimed to perform a gender-based evaluation of risk factors, stroke subtypes, severity of stroke, level of dependency at hospital discharge, and length of hospital stay among young patients with ischemic stroke in our region. Materials and Methods Study design The retrospective study included patients that were diagnosed with ischemic stroke based on patient history and clinical and radiographic findings at Inonu University Medical School Neurology Department between 2015 and 2018. Patient data were retrieved from a computerized hospital database (called ENLÄ°L) which has been operant in our hospital since 2010 and allows access to all patient data recorded in all polyclinics, inpatient clinics, laboratories, and Radiology department. Clinical evaluation A definitive diagnosis of ischemic stroke established by radiographic examination (brain computed tomography [CT] or 132

doi: 10.5455/medscience.2019.08.9152

magnetic resonance imaging [MRI]) was accepted as the principal diagnostic criteria of the study even if the diagnosis had been made via patient history and clinical findings. Demographic and clinical characteristics including age, gender, prior stroke, risk factors, neurologic deficits at hospital admission, etiology, radiographic localization, length of hospital stay, and the levels of disability and dependency at hospital discharge were reviewed for each patient. Inclusion and exclusion criteria 1. Inclusion criteria were as follows: aged 18-55 years, a history of sudden-onset ischemic stroke that lasted for at least 24 h and/ or resulted in death, and detection of focal neurological deficits on neurological examination. 2. Exclusion criteria were as follows: presence of hemorrhage or absence of infarction on brain CT or MRI despite the presence of clinical features consistent with ischemic stroke. The risk factors considered for ischemic stroke included hypertension (HT), diabetes mellitus (DM), hypercholesterolemia (HC), prior stroke, alcohol abuse, cigarette smoking, hematologic diseases, myocardial infarction (MI), coronary artery disease (CAD), cardiac spontaneous echo contrast (SEC)/thrombus, patent foramen ovale (PFO), prior coronary artery bypass surgery, congestive heart failure (CHF), atrial fibrillation (AF), and a family history of stroke. These factors were considered present in the patients that were found to have been diagnosed with any of these conditions and received treatment accordingly (e.g. antihypertensive or antidiabetic medication, coronary artery bypass surgery, coronary stent implantation) during their previous medical follow-ups and in patients that were diagnosed with any of these conditions based on clinical diagnostic tests prior to discharge from our clinic. Depending on their neurological symptoms, the patients were classified as having total anterior circulation infarction (TACI), partial anterior circulation infarction (PACI), posterior circulation

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infarction (POCI), or lacunar infarct (LACI) according to the Oxfordshire Community Stroke Project (OCSP) classification system [7]. The etiological subtypes of stroke were classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification into the following categories: (i) large artery atherosclerosis, (ii) cardioembolism, (iii) small vessel occlusion, (iv) ischemic stroke associated with other factors, and (v) idiopathic ischemic stroke [8]. The severity of presenting neurologic deficits was assessed using the National Institutes of Health Stroke Scale (NIHSS) [9]. The levels of disability and dependency at discharge were evaluated using the modified Rankin Scale (mRS) [10]. The patients were divided based on gender and the two groups were compared with regard to age, clinical syndrome, etiological subtype, risk factors, NIHSS score, mRS score, and length of hospital stay. Statistical analysis Data were analyzed using SPSS 15 for Windows (SPSS Inc. Co, Chicago, IL, USA). The two groups were compared using t-test. Nonparametric data were compared using Fisher’s exact chi-square. Descriptives were expressed as mean and standard deviation (SD). A p value of <0.05 was considered significant. Results The study included a total of 105 patients diagnosed with ischemic stroke, comprising 65 (61.9%) men and 40 (38.1%) women. Demographic and clinical characteristics Mean age was 46.02±7.29 years in men and 41.18±8.2 years in women and a significant difference was observed between the two groups (p=0.002). However, no significant difference was found with regard to clinical syndrome, etiological subtype, NIHSS score, mRS score, and length of hospital stay (Table 1).

Table 1. Demographic and clinical characteristic Women n=40 (%)

Men n=65 (%)

41.2±8.2

46.0±7.2

0.002*

LACI

7 (17.5)

11 (16.9)

syndrome

17 (42.5)

25 (38.5)

POCI

7 (8.8)

16 (14.2)

TACI

6 (15)

9 (15)

Age (years)

Clinical

0.729

Large artery atherosclerosis

6 (15)

13 (20)

0.699

Cardioembolism

10 (25)

20 (30.8)

0.815

Small vessel occlusion

3 (7.5)

5 (7.7)

0.996

Other factors

11 (27.5)

12 (18.5)

0.546

Idiopathic

11 (27.5)

13 (20)

0.374

NIHSS Score

5.75±6.02

6.69±5.8

0.431

Modified Rankin Score

2.18±2.02

2.45±2.09

0.516

Hospital stay (days)

15.28±19.7

14.82±16.6

0.899

Stroke Etiology (according to TOAST)

LACI: lacunar infarct, PACI: partial anterior circulation infarction, POCI: posterior circulation infarction, TACI: total anterior circulation infarction, TOAST: Trial of ORG 10172 in Acute Stroke Treatment, NIHSS: National Institutes of Health Stroke Scale

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Risk factors The incidence of DM, MI, and smoking was significantly higher in men compared to women, whereas the incidence of mitral stenosis was significantly higher in women compared to men (p<0.05 for both). Nevertheless, no significant difference was found with regard to the incidence of HC, hereditary thrombophilia, PFO, CHF, cardiac SEC/thrombus, AF, alcohol abuse, and prior stroke (p>0.05) (Table 2). Table 2. Risk factors Women n=40 (%)

Men n=65 (%)

Hypertension

10 (25)

24 (36.9)

0.146

Diabetes Mellitus

5 (12.5)

21 (32.3)

0.018*

Smoking

7 (17.5)

43 (66)

<0.001*

Alcohol abuse

1 (2.5)

7 (58)

0.118

Hypercholesterolemia

12 (30)

26 (40)

0.205

Hematologic Gene Mutation

14 (35)

15 (23.1)

0.275

0(0)

1(1.5)

0.619

Mitral Stenosis

4 (36)

0 (0)

0.019*

Myocardial Infarction

0 (0)

7 (10.8)

0.001*

Cardiac SEC/Thrombus

1 (2.5)

5 (7.7)

0.257

Congestive Heart Failure

4 (10)

12 (18.5)

0.187

Atrial Fibrilasyon

6 (15)

4 (6.2)

0.125

Prior stroke

4 (10)

5 (7.7)

0.381

Family history of stroke

2 (5)

8 (12.3)

0.187

Patent Foramen Ovale

SEC: spontaneous echo contrast

Discussion Recent epidemiological studies have shown a significant increase in the global incidence of first-ever stroke, stroke, and strokerelated mortality and in disability-adjusted life-years (DALYs) in adults aged 20-64 years as a result of increased prevalence of metabolic disorders associated with poor lifestyle practices [4,11]. Additionally, the incidence of ischemic stroke in deaths associated with DALY loss and stroke has been shown to increase by 1.4-1.8 times over the last 25 years [12]. It is widely known that stroke is more common in men than in women and the association between stroke and gender shows age-related differences. Additionally, stroke has been shown to be more prevalent in women aged 35-44 years and ≥85 years than in men of the same ages [13]. In our study, most of the patients were men aged less than 55 years. Recent studies have indicated that poor lifestyle practices, in addition to commonly known stroke-related risk factors, play a key role in the development of stroke in young adults [14-16]. In our study, smoking was revealed as the most prevalent risk factor in men and was also found to be a significant risk factor for men compared to women. Literature indicates that smokers have two-to-four-fold increased risk of stroke compared to nonsmokers or individuals who had quit smoking more than 10 years prior [17]. Moreover, the risk of

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stroke increases with the amount of smoking (15). On the other hand, passive smoking is also a major risk factor or stroke and adult passive smokers have a 30% higher risk of stroke compared to non-exposed adults [18]. Meaningfully, the risk of stroke increases with the dose of exposure to passive smoking [19]. The chemical substances in tobacco smoke increase the production of reactive oxygen species (ROS) that cause endothelial dysfunction and inflammation, thereby accelerating atherosclerosis. Moreover, cigarette smoking increases platelet aggregation and also leads to elevated hematocrit and carboxyhemoglobin levels and to decreased high-density lipoprotein (HDL) levels via fibrinogen synthesis [17]. In our study, cigarette smoking was found to be a significant risk factor particularly for men, as consistent with the literature. In a Tunisian study, Kefi et al. also found cigarette smoking as the most prevalent risk factor in their patients, although they performed no gender-based analysis [20]. In a Korean study, Kwon et al. evaluated young adults with stroke and also found that cigarette smoking was the most important risk factor among the patients. The authors also noted that the prevalence of smoking was significantly higher in men compared to women [21]. In a study conducted in a Greek population, Spengos et al. also reported that cigarette smoking was the most prevalent and the most important risk factor and also was more prevalent in men compared to women [22]. In a German study, Aigner et al. evaluated young adults with stroke and indicated that cigarette smoking was a more prevalent risk factor in men compared to women and was a more important risk factor in adults aged 45-55 years compared to individuals in younger age groups [23]. A previous case-control study by O’Donnell et al. found that cigarette smoking was more prevalent in young adults with stroke compared to old-age individuals (16). Aigner et al., in contrast to O’Donnell et al., did not compare young adults (18-55 years) with old adults (≥55 years) in terms of stroke risk, although they compared the subgroups of the young-adult group with each other [23]. In our study, the incidence of MI was significantly higher in men compared to women. The reported significant risk factors associated with ischemic stroke include a history of acute MI within the last four weeks and rarely seen cardiac diseases such as dilated cardiomyopathy, rheumatic valve disease, PFO, and mitral stenosis [24]. Putaala et al. evaluated a large cohort of 1,008 young patients with stroke and, in a similar way to our study, found a significantly higher incidence of MI in men compared to women [25]. Spengos et al. reported similar findings in a Greek population [22], whereas a Polish study by Lasek-Bal et al., unlike our study, found that the incidence of MI was significantly higher in women than in men [26]. In our patients, the incidence of mitral stenosis was significantly higher in women compared to men. Nevertheless, we found no study in the literature that performed a gender-based analysis for the incidence of mitral stenosis in young patients with stroke. The incidence of DM in our patients was significantly higher in men compared to women. Numerous studies have indicated that the presence of DM and prediabetes increases the risk of ischemic stroke by 1.4-6 times. DM is an early-onset and fast-progressing disease triggering early atherosclerosis and leads to a significant 134

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increase in the risk of stroke in individuals aged less than 65 years as well [27]. In a similar way to our study, the studies by Spengos et al. [22], Aigner et al. [23], and Putaala et al. [25] reported that the incidence of DM was significantly higher in young men with stroke compared to women [22]. In contrast, Lasek-Bal et al. found that the incidence of DM was significantly higher in young women with stroke compared to men [26].

Bamford J, Sandercock P, Dennis M, et al Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1995;337:5211526.

Adams HP Jr, Bendixen BH, Kappelle LJ, et al. 3rd. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24:3541.

Conclusion

http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

Both the present study and numerous studies around the world indicated that modifiable lifestyle-related risk factors are the most common cause of stroke in young adults. The disability in young adults, who are in their productive ages, leads to more serious outcomes compared to that of old-age individuals. Accordingly, identification of novel risk factors in addition to the known modifiable lifestyle-related risk factors and investigation of gender-based differences with regard to these risk factors are of paramount importance both for primary and secondary protection in atherothrombotic diseases. Meaningfully, these investigations are also highly important for the prevention of stroke in the Turkish population as well, which is dominated by individuals aged 18-55 years. Future studies with larger patient populations are needed to identify further risk factors and precautions for stroke in young adults.

10. http://www.strokecenter.org/wp-content/uploads/2011/08/modified_rankin. pdf

Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki. Fatma Ebru Algul ORCID: 0000-0003-0318-7571 Yuksel Kaplan ORCID: 0000-0002-5581-2968

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GBD 2013 Mortality and Causes of Death Collaborators. Global, regional and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385:117-71. Maaijwee NA, Rutten-Jacobs LC, Schaapsmeerders P, et al. Ischemic stroke in young adults: risk factors and long-term consequences. Nat Rev Neurol. 2014;10:315-25.

Nedeltchev K, der Maur TA, Georgiadis D, et al. Ischemic stroke in young adults: predictors of outcome and recurrence. J Neurol Neuosurg Psychiatry. 2005;76:191-5.

Bejot Y, Bailly H, Durier J, et al. Epidemiology of stroke in Europe and trends for the 21st century. Presse Med. 2016;45:391-8.

Bogousslavsky J, Pierre P. Ischemic stroke in patients under age 45. Neurologic Clinics. 2002;10:113-24.

Varona JF, Guerra JM, Bermejo F, et al. Causes of ischemic stroke in young adults and evolution of the etiological diagnosis over the long term. Eur Neurol. 2007;33:1950-5.

11. Feigin VL, Norrving B, Mensah GA. Global Burden of Stroke. Circ Res. 2017;120:439-48. 12. Feigin VL, Krishnamurthi RV, Parmar P, et al. Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study. Neuroepidemiology 2015;45:161-76. 13. Boehme AK, Esenwa C, Elkind MS. Stroke Risk Factors, Genetics, and Prevention. Circ Res. 2017;120:472-95. 14. Putaala J, Haapaniemi E, Metso AJ et al. Recurrent ischemic events in young adults after first-ever ischemic stroke. Ann Neurol. 2010;68:661-71. 15. Oâ&#x20AC;&#x2122;Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376:112-23. 16. Oâ&#x20AC;&#x2122;Donnell MJ, Chin SL, Rangarajan S, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet. 2016;388:761-75. 17. Shah RS, Cole JW. Smoking and stroke: the more you smoke the more you stroke. Expert Rev Cardiovasc Ther. 2010;8:917-32. 18. Guzik A, Bushnell C. Stroke Epidemiology and Risk Factor Management. Continuum (Minneap Minn). Cerebrovascular Disease. 2017;23:15-39. 19. Lee PN, Forey BA. Environmental tobacco smoke exposure and risk of stroke in nonsmokers: a review with meta-analysis. J Stroke Cerebrovasc Dis. 2006;15:190-201. 20. Kefi Asma, Larbi T, Abdallah M, et al. Young ischemic stroke in Tunisia: a multicentric study. International Journal of Neuroscience 2016. 21. Kwon SU, Kim JS, Lee JH, et al. Ischemic stroke in Korean young adults. Acta Neurol Scand. 2000;101:19-24. 22. Spengos K, Vemmos K. Risk factors, etiology and outcome of first-ever ischemic stroke in young adults aged 15 to 45- the Athens young stroke registry. Europan J Neurology.2010;17:1358-64. 23. Aigner A, Grittner U, Rolfs A, et al. Contribution of Established Stroke Risk Factors to the Burden of Stroke in Young Adults. Stroke. 2017;48:1744-51. 24. Kamel H, Healey JS. Cardioembolic Stroke. Circ Res. 2017;120:514-26. 25. Putaala J, Metso AJ, Metso TM, et al. Analysis of 1008 consecutive patients aged 15-49 with first-ever ischemic stroke: the Helsinki Young Stroke Registry. Stroke. 2009;40:1195-203. 26. Lasek-Bal A, Kopyta I, Warsz-Wianecka A, et al. Risk factor profile in patients with stroke at a young age. Neurological Research 2018. 27. Tun NN, Arunagirinathan G, Munshi SK, et al. Diabetes mellitus and stroke: A clinical update. World J Diabetes. 2017;8:235-48.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):136-9

The role of ductus venosus doppler, fetal liver length and placental thickness in gestational diabetes Murat Cevik1, Ruya Deveer2 1 Silopi Public Hospital, Clinic of Obstetric and Gynecology, Sirnak, Turkey Mugla Sitki Kocman University, Faculty of Medicine, Depatrment of Obstetric and Gynecology, Mugla,Turkey

Received 21 August 2019; Accepted 20 October 2019 Available online.24.02.2020 with doi:10.5455/medscience.2019.08.9153 Copyright ÂŠ 2020 by authors and Medicine Science Publishing Inc. Abstract To detect the possible adaptive changes that may have an impact on placenta and fetus in the presence of gestational diabetes mellitus using ultrasonography. We compared ductus venosus peak systolic flow velocity, fetal liver length and placental thickness between 25 healthy pregnants and 25 pregnants with gestational diabetes mellitus; diagnosed by 75 gram oral glucose tolerance test during their 24â&#x20AC;&#x201C;28 weeks of pregnancy. Measurements were conducted with a 2 D transabdominal convex probe. In addition, gravida, parity, type of birth, gestational diabetes mellitus story, diabetes mellitus story in family, body mass index and demographic characteristics were also compared. In the demographic characteristics, family history of diabetes mellitus and personal history of Gestational Diabetes Mellitus were significantly higher in the group with gestational diabetes than the control group. No statistically significant difference was found between other demographic features The mean ductus venosus peak systolic flow was measured 35 cm/s in group with gestational diabetes mellitus while it was 45 cm/s in the control group, hence significantly lower in the group with gestational diabetes mellitus. The mean fetal liver length was measured 48 mm in group with gestational diabetes mellitus while it was 44 mm in the control group, thus higher in the group with gestational diabetes. The mean placental thickness was measured 40 mm in group with gestational diabetes while it was 37 mm in control group. There was no statistically significant difference in placental thickness between pregnants with gestational diabetes and healthy controls. Ductus venosus peak systolic flow and fetal liver length measurements are different in patients with gestational diabetes than healty controls. Keywords: Gestational diabetes mellitus, ductus venosus, placental thickness, fetal liver length

Introduction Gestational diabetes mellitus (GDM) has been traditionally defined as first detection of abnormal glucose tolerance during pregnancy [1]. It is one of the main complications of pregnancy. Its prevalance diverges among different ethno-racial groups. In our country one of reported prevalance was in the range of 1.2%-9.2% [2]. There is no universal consensus in screening and diagnosis for GDM. Some of the well known risk factors for GDM include older maternal age, higher BMI, being member of a certain ethnic groups (Hispanic, African, Native American, South or East Asian, or Pacific Islands ancestry), polyhydramnios, past history of GDM, macrosomia in a previous pregnancy, history of unexplained stillbirth, type 2 diabetes mellitus in a first degree relative, polycystic ovary syndrome, and metabolic syndrome [3]. *Coresponding Author: Ruya Deveer, Mugla Sitki Kocman University, Faculty of Medicine, Depatrment of Obstetric and Gynecology, Mugla,Turkey E-mail: ruyadeveer@hotmail.com

Recently, an avoidance has emerged among Turkish society against performing oral glucose tolerance test concerning the potential harms of oral glucose tolarence test (OGTT) for both fetus and mother. This situation led us to seek for easily applied ultrasonographic indicators of gestational diabetes. In order to predict GDM numerous sonographic markers have been studied including fetal body composition measurements such as subcutaneous fat, liver size, cardiac muscle thickness, placental volumes. Blood flow velocities of different vessels were also investigated [4-6]. In the presence of hyperglysemia various placental changes, especially increase in size has been defined [7,8]. Fetal liver plays an important role in fetal growth by tuning the umbilical venous perfusion. Haugen et Al. suggested that with unbalanced maternal diet fetal liver blood flow increases and the amount of blood shunting from liver through ductus venosus (DV) decreases [9]. 136

doi: 10.5455/medscience.2019.08.9153 Med Science 2020;9(1):136-9

So we aimed to study whether measurements of DV peak systolic velocity, fetal liver length and placental thickness are different in patients with GDM. Material and Methods After local Ethics Committee approval, this prospective, casecontrol study was performed on 50 pregnant women attending antenatal polyclinics in the department of Obstetrics and Gynecology at Mugla Sitki Kocman University hospital between September 2015-April 2017. Women of singleton, uncomplicated pregnancy of 24-28 weeks were taken. A 75-g OGTT was performed. Diagnosis of GDM was made if one of the three measurments exceeds the threshold value (92 mg/dl, for fasting, 180 mg/dl for 1 hour, 153 mg/dl for 2 hour). Patients were diveded as GDM and control group. All patients were consented. Once taking a comprehensive history, obstetrical and ultrasound examinations were performed. Age of women, parity, family history of diabetes mellitus and history of GDM, body mass index (BMI) before pregnancy and at admission were recorded. All the patients were evaluated prospectively at 4-week intervals from 24 weeks of gestation until delivery. Patients with pregestational diabetes, multiple gestations, hypertension, intra uterine growth restriction, fetal, umbilical cord and placental anomalies were excluded from the study. Ultrasonographic and doppler examinations were performed transabdominally by the same investigator using a GE Voluson 730 pro with a 3.5-5 MHz transducer with the lowest setting of high-pass fitler. DV measurments were performed in the transvers or sagittal sections. The size of the sample volume was in 2-5 mm, adapted to the vessel diameter. The angle between direction of blood flow and the ultrasound beam was held below 60 degrees. At least five heart cycles were used for the measurment of peak systolic velocity of DV. The fetal abdominal sagittal and coronal sections were employed in order to measure fetal liver length (FLL). After clearing the boundary of the right lobe, measurements were made from the dome of the right hemidiaphragm to the tip of the right lobe (Figure 1). Placental thickness was measured at its graetest thickness. (Figure 2).

Figure 1. Fetal liver length measurment

Figure 2. Plecental thickness measurment

Statistical Analysis Statistical analysis was performed using SPSS for Windows, v21. Kolmogorov-Smirnov test was used to evaluate normality of the distribution. T test for two independent samples were used provided the distribution of the means was normal. For nonnormal distribution, Mann-Whitney U test was performed. The determined level of significance was p<0.05. Categorical data were summarized as frequencies and percentages before being analyzed using the Chi-squared test. For continuos variables, Student’s T test and Mann-Whitney U-test were utilized Results Fifty pregnant women were recruited in the study. Of those, half with GDM (study group) and the other 25 were controls without GDM. Mean age of patients was 30.18 ± 5.85. No statistically significant differences were measured in mean maternal age, parity, or initial visit BMI between the two groups (Table 1). Family history of diabetes mellitus was significantly higher in GDM group (p<0.05). 20 patients in GDM group had diet therapy while the remaining 5 had insulin therapy. Although women in GDM group had therapy after the diagnosis, increase in weight throughout pregnancy and BMI at delivery were measured higher in GDM group (Table 1). The mean birth weight in GDM group was 3430±514 grams, while it was 3230±310 grams in the control group (p=0.105). Previous birth of an infant ≥4000 grams were higher in the GDM group but it was not statistically significant (p=0.104). Personal history of GDM was higher in GDM group and it was statistically significant (p=0.041). Birth weight, mode of delivery and number of neonatal intensive care unit admission were not statistically significant between the two groups. The mean ductus venosus peak systolic flow was measured 35 cm/s in group with gestational diabetes mellitus while it was 45 cm/s in the control group, hence significantly lower in the group with gestational diabetes mellitus (p=0.001). The mean fetal liver length was measured 48 mm in group with gestational diabetes mellitus while it was 44 mm in the control group, thus higher in the group with gestational diabetes (p=0.030). The mean placental thickness was measured 40 mm in group with gestational diabetes while it was 37 mm in control group. There was no statistically significant difference in placental thickness between pregnants 137

doi: 10.5455/medscience.2019.08.9153 Med Science 2020;9(1):136-9

with gestational diabetes and healthy controls (p=0.171). (Table 2). Table 1. Characteristics of the study groups GDM (n=25)

Normal (n=25)

Maternal age (years)

31.04±6.39

29.32±5.23

0.303

Parity

1.00 (0-3)

0.350

11 (44%)

3 (12%)

0.025

BMI (kg/m ) Before pregnancy

25.48±5.44

23.86±3.49

0.211

BMI (kg/m2) at 24-28 weeks gestation

28.77±5.68

26.13±3.27

0.055

BMI at delivery (kg/m2)

31.60±5.32

28.81±3.19

0.027

Weight gain during gestation (kg)

15.92±3.52

13.48±2.48

0.008

8 (32%)

1.00

17(64%)

1048 (734-1466)

922 (653-1370)

0.013

39 (34-40)

38 (36-41)

0.830

Birth weight(gr)

3430.00±514.64

3230.80±310.52

0.105

NICU admission

3 (12%)

2 (8%)

1.00

Family history of DM 2

Mode of delivery NSD CS Usg efw (gr) Gestation at delivery(weeks)

Resuls are expressed as mean ± SD, median (minimum-maximum), number and frequency (%) BMI, Body mass index; NSD , normal spontaneous delivery; CS, Cesarean section; EFW, estimated fetal weight; NICU, neonatal intensive care unit.

Table 2. Comparison of OGTT values and ultrasonographic markers in women with and without GDM GDM (n=25)

Normal (n=25)

89 (72-126)

77 (68-89)

<0.001

OGTT 1hour(mg/dl)

196 (145-266)

128 (90-178)

<0.001

OGTT 2 hour (mg/dl)

156 (110-240)

111(65-149)

<0.001

DV Peak Systolic Velocity (cm/s)

35 (25-40)

45(30-60)

<0.001

Fetal liver length (mm)

48.32±6.88

44.16±6.36

0.031

Placental Thickness (mm)

40 (27-65)

37 (20-77)

0.171

Fasting Glucose (mg/dl)

Resuls are expressed as mean ± SD, median (minimum-maximum)

Discussion It is important to detect gestational diabetes mellitus during pregnancy, because women with gestational diabetes mellitus are at increased risk of developing adverse obstetrical outcome. Yet there is no consensus regarding screening and diagnostic testing for gestational diabetes even in the same clinic. In the present study we aimed to study some possible sonographic markers which may be useful in the diagnosis of gestational diabetes besides conventional tests. The study group and the control group had patients with similar age, gravida, parity and BMI. Although

family history of diabetes mellitus and personal history of GDM were higher in the GDM group, most of our patiens had no risk factors for GDM. According to our results, the GDM group had lower DV peak velocity and higher FLL than those of the control group. As far as we know, our study is the first involving peak systolic velocity of DV, FLL, and placental thickness in comparing GDM with healthy controls. DV is a small fetal vessel that shunts oxygenated blood from umbilical vein to the left side of inferior vena cava towards the foramen ovale [10] . Approximately 25% of the umbilical venous blood flow goes through DV and bypasses the hepatic circulation, whereas 55% goes to the left and 20% goes to the right liver lobes, respectively [11]. DV doppler measurement has multiple clinical uses including DV assessment of first trimester screening, twinto-twin transfusion syndrome and fetal growth restriction [12]. DV waveform consists of two peak and two trough phases. The first peak is S wave and represents systole in the cardiac cycle. Three different measurment technics can be used including Semiquantitative analysis of the pulsatility index for the vein, visual assessment, [13] and velocity ratios assessments [14]. We used the peak systolic velocity measurement for DV doppler and found it lower in the group with gestational diabetes. In previously conducted studies, Stuart et al. discovered that diabetic pregnants (pregestational vs gestational diabetics) had increased pulsatility index of DV blood flow than non-diabetics had [15]. Their study consisted of more pregestational than gestational diabetics and retrospective in design. They associated the change they found with a possible fetal cardiac effect. We, on the other hand, did not include pregestational diabetes in our study and believe that the low systolic blood flow we found is originated from umbilical liver perfusion in presence of hyperglycemia. There are a lot of studies investigating the relationship between gestational diabetes and fetal liver length. Perovic et al. found FLL as a predictor of GDM in population with high risk for GDM. They measured a cut-off value for FLL as 39mm on the USG they performed in the 23rd gestational week [16]. We measured FLL as 48 mm for the GDM group and 44 mm for the control group. Mirghani et al measured FLL as 36 mm for patients with gestational diabetes and 31 mm for non-GDM patients between weeks 21-24 [17]. A recent publication by Ilhan et al. suggested that FLL evaluation throughout the second-trimester ultrasound scanning by three dimensional USG may predict GDM [18]. Due to the fact that 3D USG is not widespread in our country, using it will not be a useful method. Tongprasert et al established the nomogram of fetal liver length in a Thai population from 14 to 40 weeks of gestation and they claimed that it would be a useful tool in predicting pathologic conditions [19]. We also believe that for FLL value, measuring FLL after reference values are determined based on pregnancy weeks would be more accurate concerning GDM. Another commonly inquired topic for GDM is placental thickness. Various functional and structural pathological changes occur in the placenta of patients with diabetes[20]. In their study, Edu A et al. found that sizes of placentas in patients with gestational diabetes did increase [8]. They discovered that throughout the weeks 24-28, patients with GDM had placental thickness of 33 mm; while the patients not having GDM had placental thickness of 27 mm. They recommended that increased placental size can be used in GDM scannings, but they had quite a few number of GDM patients. Placental thickness >40mm throughout second trimester and 138

doi: 10.5455/medscience.2019.08.9153 Med Science 2020;9(1):136-9

>60mm throughout third trimester is defined as placentomegali [21]. In our study, mean placental tkickness was 40 mm in GDM group while it was37 mm in the control group, but the difference was not statistically significant. Berceanu et al. found that 56% of GDM patients had placental thickness more than 40mm throughout weeks 24-28 and that as pregnancy weeks progress the increase in placental thickness becomes more significant [22]. But they had so few patients and all patients had either type 1 DM or GDM, they lacked a healthy control group and patients had no regular glycemic control. Perovic et al suggested placental thickness as one of the ultrasonographic criterion in GDMI prediction [23]. Their group consisted solely of patients with GDM risk factors as well. Though there were studies investigating increased placental thickness in GDM patients, they were not methodologically uniform and usually contained limited number of patients. Despite finding the placental thickness in GDM group more than non-GDM group in our study, this difference was not statistically significant. The increase in placental thickness that is detectable with USG, may be a result of long term hyperglycemia; cannot be found at early stages.

Limitation of our study is that being a case control study with a small sample size and lack of nomograms of fetal liver length and placental thickness of our population. We believe that simple measurements of DV peak systolic flow and FLL may be helpful in the evaluation of GDM. These sonographic parameters may further be useful for monitoring the efficacy of the treatment in future studies

10. Kiserud T. Hemodynamics of the ductus venosus. Eur J Obstet Gynecol

Conclusion In conclusion, ultrasonographic findings may help scan tests due to the fact that there is no consensus between GDM methods and their ratios of diagnosing the disease. Broader studies with more number of patients are needed. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval After local Ethics Committee approval, this prospective, case-control study was performed on 50 pregnant women attending antenatal polyclinics in the department of Obstetrics and Gynecology at Mugla Sitki Kocman University hospital between September 2015-April 2017. Murat Cevik ORCID: 0000-0001-6514-4214 Ruya Deveer ORCID: 0000-0002-4445-8086

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Proceedings of the 4th International Workshop-Conference on Gestational Diabetes Mellitus. Chicago, Illinois, USA. 14-16 March 1997. Diabetes Care. United States; 1998. p. B1-167.

Ozyurt R, Asıcıoglu O. The Prevalence of Gestational Diabetes Mellitus in Pregnant Women Who were Admitted to İstanbul Teaching and Research. JOPP Derg. 2013;5:7-12.

Hartling L, Dryden DM, Guthrie A, et al. Screening and diagnosing gestational diabetes mellitus. Evid Rep Technol Assess (Full Rep). 2012;210:1-327.

Dantas AMA, Palmieri ABS, Vieira MR, et al. Doppler ultrasonographic assessment of fetal middle cerebral artery peak systolic velocity in gestational diabetes mellitus. Int J Gynaecol Obstet. 2019;144:174-9.

Wong CH, Chen CP, Sun FJ, et al. Comparison of placental three-dimensional power Doppler indices and volume in the first and the second trimesters of pregnancy complicated by gestational diabetes mellitus. J Matern Fetal Neonatal Med. 2019;32:3784-91.

Garcia-Flores J, Cruceyra M, Cañamares M, et al. Predictive value of fetal hepatic biometry for birth weight and cord blood markers in gestational diabetes. J Perinatol. 2016;36:723-8.

Saha S, Biswas S, Mitra D, et al. Histologic and morphometric study of human placenta in gestational diabetes mellitus. Ital J Anat Embryol. 2014;119:1-9.

Edu A, Teodorescu C, Gabriela Dobjanschi C, et al. Placenta changes in pregnancy with gestational diabetes. Rom J Morphol Embryol. 2016;57:50712.

Haugen G, Hanson M, Kiserud T, et al. Fetal liver-sparing cardiovascular adaptations linked to mother’s slimness and diet. Circ Res. 2005;96:12-4.

Reprod Biol. 1999;84:139-47. 11. Haugen G, Kiserud T, Godfrey K, et al. Portal and umbilical venous blood supply to the liver in the human fetus near term. Ultrasound Obstet Gynecol. 2004;24:599-605. 12. Turan Ş, Turan ÖM. Harmony Behind the Trumped-Shaped Vessel : the Essential Role of the Ductus Venosus in Fetal Medicine. 2018;124-30. 13. Kessler J, Rasmussen S, Hanson M, et al. Longitudinal reference ranges for ductus venosus flow velocities and waveform indices. Ultrasound Obstet Gynecol. 2006;28:890-8. 14. Turan OM, Turan S, Sanapo L, et al. Semiquantitative classification of ductus venosus blood flow patterns. Ultrasound Obstet Gynecol. 2014;43:508-14. 15. Stuart A, Amer-wåhlin I, Gudmundsson S, et al. Ductus venosus blood flow velocity waveform in diabetic pregnancies. Ultrasound Obstet Gynecol. 2010;36:344-9. 16. Perovic MD, Gojnic M, Arsic B, et al. Relationship between mid-trimester ultrasound fetal liver length measurements and gestational diabetes mellitus. J Diabetes 2015;7:497-505. 17. Hisham Mirghani M, Reem Zayed M. Gestational Diabetes Mellitus: Fetal Liver Length Measurements Between 21 and 24 Weeks’ Gestation. J Clin Ultrasound. 2007;35:27-33. 18. İlhan G, Gultekin H , Kubat A, et al. Preliminary evaluation of foetal liver volume by three-dimensional ultrasound in women with gestational diabetes mellitus. J Obstet Gynaecol. 2018;3615:1-5. 19. Tongprasert F, Srisupundit K, Luewan S, et al. Normal length of the fetal liver from 14 to 40 weeks of gestational age. J Clin Ultrasound. 2011;39:74-7. 20. Huynh J, Yamada J, Beauharnais C, et al. Type 1, type 2 and gestational diabetes mellitus differentially impact placental pathologic characteristics of uteroplacental malperfusion. Placenta. W.B. Saunders. 2015;36:1161-6. 21. Dashe JS, BL H. Callen’s Ultrasonography in Obstetrics and Gynecology. Philadelphia: Elsevier; 2017;674-703

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doi: 10.5455/medscience.2019.08.9153 Med Science 2020;9(1):136-9 22. Berceanu C, Tetileanu AV, Ofiteru AM, et al. Morphological and ultrasound findings in the placenta of diabetic pregnancy. Rom J Morphol Embryol = Rev Roum Morphol Embryol. Romania. 2018;59:175-86.

23. Perovic M, Garalejic E, Gojnic M, et al. Sensitivity and specificity of ultrasonography as a screening tool for gestational diabetes mellitus. J Matern Fetal Neonatal Med. England. 2012;25:1348-53.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):140-4

The role of education levels on patientsâ&#x20AC;&#x2122; treatment in type 2 diabetes Turkan Pasali Kilit1, Kevser Onbasi2, Nazif Yalcin1 1

Kutahya University of Health Sciences, Faculty of Medicine, Department of Internal Medicine, Kutahya, Turkey 2 Kutahya University of Health Sciences, Faculty of Medicine, Department of Endocrinology, Kutahya, Turkey Received 29 July 2019; Accepted 23 September 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9154

Abstract One of the main problem in the treatment of diabetes is difficulty of achieving treatment target levels. In recent years, despite the improvements in diagnosis, treatment and follow-up methods, target hemoglobin A1c levels in diabetic individuals cannot be reached to the desired extent. In this study, it was aimed to investigate the effects of the education status (levels) of patients on diabetes treatment. Four hundred and thirty-six diabetic individuals who applied to the internal medicine and endocrinology clinics between September 2017 and December 2017 were asked to fill in a questionnaire. The subjects were divided into 5 groups according to their education status. The groups were compared in terms of age, gender, cholesterol, hemogram parameters, hemoglobin A1c, and urinary microalbumin levels. The primary school graduate group consisted of the most crowded group (302 patients). Significant differences were found between education status groups in terms of age, gender distribution, body-mass index, and hematocrit values. Fasting blood glucose, hemoglobin A1c, lipid parameters, and urinary microalbumin levels were similar between groups. There was no relationship between education status and hemoglobin A1c. And also there was no relationship between education status and lipid levels. While we could not observe any relation between education level and the course of diabetes treatment we recommend to observe all diabetic patients closely. Keywords: Diabetes mellitus; educational status; hemoglobin A1c protein

Introduction Diabetes mellitus is a chronic metabolic disease with impaired insulin secretion [1]. DM affects all aspects of life by causing many microvascular and macrovascular complications [2]. The most important problem in the treatment of DM is a failure to achieve treatment goals. Achieving a normal hemoglobin A1c (HbA1c) reduces the frequency of development of microvascular and macrovascular complications [3]. Despite recent advances in diagnosis, treatment and follow-up methods, the desired HbA1c levels in DM patients are still not observed mostly reached. Therefore, the management of diabetic patients is very important and treatment should be determined considering the sociodemographic characteristics of each patient. Recently diagnosed DM patients should undergo a comprehensive diabetes self-management training program on nutrition, physical activity, optimizing metabolic control and preventing complications. Diabetes self-management is an important cornerstone of good diabetes control [4]. *Coresponding Author: Turkan Pasali Kilit, Kutahya University of Health Sciences, Faculty of Medicine, Department of Internal Medicine, Kutahya, Turkey E-mail: turkandr@yahoo.com

Training of patients and their relatives is very important in order to reduce the risk of acute complications and to avoid chronic complications. Type 2 DM is characterized by impaired insulin secretion and insulin resistance and hyperglycaemia. The prevalence of DM is increasing from day to by day. With lifestyle change, a 58% reduction in the development of DM was achieved in these patients. In 2000, World Health Organization foresaw that the number of 3 million with diabetes in Turkey would reach to 6.5 million in 2030, but according to the results of studies this number was already exceeded in the year 2014 and the number of patients exceeded to 7 million. Necessary measures should be taken for the disease of our age, which has increased above expectations yet, and patients should have the necessary knowledge and skills about their diseases and treatments. In this study, it was aimed to investigate the effect of educational levels on metabolic parameters of patients with DM. Materials and Methods The study was designed as a descriptive, cross-sectional survey. The study was conducted in by face-to-face interviews with 436 diabetic patients over 18 years of age, and were admitted to the 140

doi: 10.5455/medscience.2019.08.9154

Internal Medicine and Endocrinology Clinics of Evliya Çelebi Training and Research Hospital, Kütahya Dumlupınar University Medical Faculty. Written informed consents were obtained from all participants and ethics committee approval was received from Kütahya Dumlupınar University Faculty of Medicine Clinical Research Ethics Committee. The study complies with the World Health Organization Declaration of Helsinki and the World Psychiatric Association, Good Clinical Practices and Good Laboratory Practice rules. The data of the study was collected by using the Diabetes Education Form, which was prepared by the researcher in accordance with the literature. In addition to the sociodemographic data, the drugs used for the treatment of DM, the forms of the drugs (oral, subcutaneous), frequency and duration of administration, method of administration (intermittent or continuous) were recorded. Concomitant diseases and drug use history for these diseases were questioned. The patients were divided into 5 groups according to their educational level. Group 1 was defined as illiterate, group 2 as primary school graduates, group 3 as middle school graduates, group 4 as high school graduates, and group 5 as university graduates. In the laboratory parameters, fasting blood glucose, HbA1c, total cholesterol, HDL cholesterol, LDL cholesterol, triglyceride, creatinine, C reactive protein, urinary microalbumin and hemogram parameters were recorded. The groups were compared in terms of sociodemographic data, responses to the questionnaire, and laboratory parameters. Statistical Analysis For the analysis of the study data, SPSS (Statistical Package for Social Science) version 16 program was used. The suitability of continuous variables to normal distribution was examined by Kolmogorov-Smirnov and Shapiro-Wilk tests. Data showing normal distribution were expressed as mean ± standard deviation and categorical variables were expressed as percentages. Differences between the groups were evaluated by one-way analysis of variance (ANOVA) and post-hoc multiple comparison tests. Categorical parameters were analyzed using the Chi-square test. P <0.05 was considered statistically significant for all tests.

Med Science 2020;9(1):140-4

Table 1. Demographic data of the subjects Parameters

n = 436

Age (years)

57.8 ± 12.2

Female gender (%)

293 (67.2%)

Body-mass index (kg/m2)

30 (27-34)

Level of education n, (%) Illiterate

50 (11.5%)

Primary school

302 (69.3%)

Middle School

37 (8.5%)

High School

28 (6.4%)

University

19 (4.4%)

Diabetes duration (years)

8 (4-15)

Treatment regimen n, (%) Oral anti-diabetic drug

220 (50.5%)

Oral anti-diabetic drug + Insulin

78 (17.9%)

Insulin

138 (31.7%)

Family history of diabetes n, (%)

310 (71.1%)

History of complications related to diabetes in the family n,(%)

88 (20.2%)

Regular blood glucose measurement n, (%)

270 (61.9%)

Blood glucose measurement frequency n, (%) Every day

197 (45.2%)

Every other day

67 (15.4%)

1 per week

57 (13.1%)

Results

Less than 1 per week

48 (11.0%)

Demographic data of 436 patients are given in Table 1. Of the patients, 293 (67.2%) were female and 143 (32.7%) were male. 216 patients (49.5%) were using insulin for treatment. The comparison of the demographic data of the 5 groups determined according to the educational level of the patients is given in Table 2. Mean age of the illiterate group was significantly higher than the other groups. The mean age of primary school graduates was higher than that of middle school graduates (p <0.05). The female gender ratio was highest in the illiterate group (84%) and lowest in the university graduates group (10.5%). As the level of education increased, the female gender ratio decreased. Body-mass index was lower in the university graduates compared to the primary school graduates (p <0.05). In addition, the body-mass index of the high school graduate group was lower than the illiterate group (p <0.05). Family history of diabetes was lowest in the illiterate group (54%) and highest in the high school graduate group (82.1%). As the education level of the patients increased, the rate of attending to regular outpatient controls increased (p = 0.010). Groups were similar in terms of diabetes duration, regular blood glucose measurement and frequency, diabetic diet administration, regular HbA1c control and diabetes complications.

In the presence of symptoms

67 (15.4%)

Blood glucose measurement time n, (%) Hungry Full Hungry and full

263 (60.3%) 40 (9.2%) 133 (30.5%)

Regular hemoglobin A1c control n, (%)

224 (51.4%)

Regular outpatient control, n (%)

241 (55.3%)

Outpatient control in terms of diabetes complications, n (%)

211 (48.4%)

Following diabetic diet, n (%)

257 (58.9%)

Reaching LDL cholesterol target value, n (%)

146 (33.5%)

Reaching rate of target hemoglobin to A1c (<6.5%), n (%)

101 (23.2%)

Obesity (Body-mass index>30 kg/m2), n (%)

234 (53.7%)

Albuminuria (>30 mg/day), n (%)

163 (37.4%)

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Med Science 2020;9(1):140-4

Table 2. Comparison of demographic data of the groups Parameters

Group 1 (Illiterate) n = 50

Group 2 (Primary school) n = 302

Group 3 (Middle school) n = 37

Group 4 (High school) n = 28

Group 5 (University) n = 19

Age (years)

66 ± 9

58 ± 11a

51 ± 12a, b

54 ± 17c

50 ± 12a

<0.001

42 (84.0%)

220 (72.8%)

20 (54.1%)

9 (32.1%)

2 (10.5%)

<0.001

Diabetes duration (years)

11 ± 9

9±7

8±6

11 ± 8

8±9

0.141

Body-mass index (kg / m2)

31 ± 5

32 ± 6

30 ± 6

Family history of DM, n (%)

27 (54.0%)

219 (72.5%)

28 (75.7%)

Regular blood glucose measurement, n (%)

26 (52.0%)

195 (64.6%)

Every day

23 (46.0%)

Every other day

7 (14.0%)

1 per week Less than 1 per week

Female gender, n (%)

27 ± 5

27 ± 3

<0.001

23 (82.1%)

13 (68.4%)

0.049

20 (54.1%)

17(60.7%)

12 (63.2%)

0.408

138 (45.7%)

15 (40.5%)

15 (53.6%)

6 (31.6%)

49 (16.2%)

3 (8.1%)

4 (14.3%)

4 (21.1%)

7 (14.0%)

35 (11.6%)

7 (18.9%)

4 (14.3%)

4 (21.1%)

7 (14.0%)

32 (10.6%)

5 (13.5%)

2 (7.1%)

2 (10.5%)

In the presence of symptoms

6 (12.0%)

48 (15.9%)

7 (18.9%)

3 (10.7%)

3 (15.8%)

Regular HbA1c control, n (%)

22 (44.0%)

149 (49.3%)

21 (56.8%)

20 (71.4%)

12 (63.2%)

0.108

Regular outpatient control, n (%)

19 (38.0%)

165 (54.6%)

22 (59.5%)

21 (75.0%)

14 (73.7%)

0.010

Outpatient control in terms of diabetes complications, n (%)

21 (42.0%)

142 (47.0%)

20 (54.1%)

17 (60.7%)

11 (57.9%)

0.418

Following diabetic diet, n (%)

26 (52.0%)

176 (58.3%)

22 (59.5%)

20 (71.4%)

13 (68.4%)

0.468

b, c

Blood glucose measurement frequency, n (%)

0.950

p<0.001 when compared to Group 1, p<0.05 when compared to Group 2, p<0.05 when compared to Group 1

Table 3. Comparison of the laboratory parameters of the groups

Parameters Fasting blood sugar (mg/dL) HbA1c (%) Total cholesterol (mg/dL) Triglyceride (mg/dL) HDL (mg/dL) LDL (mg/dL) Hemoglobin (g/dL) Haematocrit (%) RDW (%) WBC (x1000/µL) Platelet (x1000/µL) MPV (fL) Neutrophil (x1000/µL) Lymphocyte (x1000/µL) Monocyte (/µL) Neutrophil - Lymphocyte ratio Platelet-Lymphocyte ratio Monocyte-HDL ratio CRP (mg/L) Creatinine (mg/dL) Albuminuria (mg/day)

Group 1 (Illiterate) n = 50

Group 2 (Primary school) n = 302

Group 3 (Middle school) n = 37

Group 4 (High school) n = 28

Group 5 (University) n = 19

158 ± 85

178 ± 73

164 ± 90

178 ± 78

210 ± 131a. b

0.028

8.1 ± 1.8

8.3 ± 2.0

8.1 ± 2.4

8.1 ± 1.8

8.7 ± 3.0

0.836

195 ± 49

192 ± 49

180 ± 38

198 ± 44

199 ± 52

0.537

177 ± 82

183 ± 143

174 ± 93

211 ± 205

171 ± 79

0.982

45 ± 14

44 ± 11

44 ± 12

43 ± 9

42 ± 11

0.774

114 ± 39

116 ± 40

103 ± 39

118 ± 39

123 ± 42

0.372

13.1 ± 1.5

13.3 ± 3.9

13.9 ± 1.7

14.0 ± 1.9

14.5 ± 1.1

0.393

39.3 ± 3.9

39.3 ± 4.6

41.6 ± 4.9

41.5 ± 5.1

42.8 ± 2.6a. c

<0.001

14.0 ± 1.4

14.3 ± 2.6

13.9 ± 2.1

14.1 ± 2.1

13.4 ± 0.8

0.230

8.10 ± 2.00

8.65 ± 2.99

8.06 ± 2.02

8.11 ± 1.62

8.34 ± 2.15

0.668

270 ± 74

264 ± 76

254 ± 50

248 ± 61

271 ± 58

0.573

9.5 ± 1.4

9.6 ± 1.1

9.5 ± 1.2

9.3 ± 1.2

0.578

4.82 ± 1.89

5.36 ± 2.38

4.71 ± 1.54

4.89 ± 1.57

5.29 ± 2.02

0.361

2.54 ± 0.80

2.52 ± 1.41

2.46 ± 0.81

2.47 ± 0.74

2.31 ± 0.90

0.964

520 ± 171

516 ± 176

540 ± 161

516 ± 184

516 ± 151

0.920

2.25 ± 1.84

2.78 ± 4.73

2.08 ± 0.83

2.40 ± 2.19

3.07 ± 3.62

0.548

114 ± 45

124 ± 85

120 ± 71

110 ± 45

139 ± 90

0.589

14.7 ± 17.6

12.8 ± 6.3

13.3 ± 5.8

12.5 ± 5.5

13.7 ± 6.7

0.915

10.7 ± 20.9

10.5 ± 15.4

10.2 ± 21.5

10.0 ± 20.3

5.3 ± 4.2

0.434

1.66 ± 4.42

1.08 ± 0.52

1.65 ± 3.69

1.25 ± 0.87

1.05 ± 0.33

0.080

34 ± 38

122 ± 236

75 ± 196

123 ± 253

122 ± 290

0.965

RDW: Red blood cell distribution width, MPV: Mean platelet volume p<0.05 when compared to Group 1, bp<0.05 when compared to Group 3, cp<0.05 when compared to Group 2

142

doi: 10.5455/medscience.2019.08.9154

The comparison of the groups in terms of metabolic parameters is given in Table 3. The fasting blood glucose level of the university graduates group was higher than the illiterate group and the primary school graduate group (p <0.05). There was no difference between the groups in terms of other metabolic parameters. Discussion DM is a chronic metabolic disease that affects the life of patients and their relatives in many ways, decreases the quality of life and can cause many complications. According to the 8th Diabetes Atlas data published by the International Diabetes Federation in 2017, it is thought that 425 million DM patients worldwide and half of these patients are not diagnosed [5]. Therefore, early diagnosis of diabetes and effective treatment of patients diagnosed with diabetes is important. Patient education is an integral part of treatment in diabetic patient management [6]. Socioeconomic and demographic factors such as age, educational level, ethnic and cultural background limit diabetes self-management [7]. For that reason, while educating the patients, the socioeconomic status of the patient should be taken into consideration and the treatment given should be tailored to the patient. Studies have shown that obesity and diabetes are more common among individuals and groups with low levels of education, and this leads that these patients receive late diagnosis and treatment [8]. In this study, the awareness levels of participants about DM follow-up and treatment were investigated. It was found that the percentage of subjects participating in the study for regular outpatient follow-up visits was 55.2%. In a study conducted by Altundağ, it was found that 82.6% of children with type 1 DM applied for control every 3 months [9]. The difference between the studies suggests that regional and sociocultural variables affect the patient’s awareness of the disease. In this study, the rate of coming to regular outpatient control in the illiterate group was found to be 38% and it was thought that this low rate was due to low education level. The level of education of the patient is a factor that provides easier and earlier access to the information necessary for awareness of maintaining a healthier life [10]. Therefore, it should be remembered that the ability to apply the recommended treatment and to adhere to the correct diet and exercise program, to go to the outpatient clinic control and to comprehend their diseases may be insufficient in patients with low educational level. Several studies and meta-analyses have shown that diet and exercise can provide significant improvements in glucose control in people with type 2 DM [11]. It has been shown that the diet can reduce HbA1c by approximately 0.12% to 0.5% for blood sugar control [12]. It was seen that 58.9% of the subjects participated in the study followed a diabetic diet and a significant proportion of them did not. In a study by Aslan et al., only 24.5% of the subjects were found adhere to the diet and 40% did not obey to the diet at all [2]. Patients with DM should be told that medical treatments alone will not be sufficient to regulate blood sugar and that only the desired result can be achieved with a diabetic diet. In the study conducted by Tavakolizadeh et al., it was determined that blood sugar levels of diabetic patients were lower after the training and that the training had a positive effect on dietary habits [13]. When the frequency of regular blood glucose measurement of DM subjects in this study was examined, it was found that the rate was

Med Science 2020;9(1):140-4

61.9%. As a result of the study, it was found that 12% of illiterate and 15.8% of university graduates measured blood sugar levels only in the presence of symptoms. In all groups, the frequency of measuring blood glucose in the presence of symptoms was 15.4% and this rate was very low. Hypoglycaemia can often lead to nonspecific symptoms such as sweating, palpitation, dizziness, visual impairment and neurological symptoms, and may lead to loss of consciousness [14]. All diabetics and their family members should be taught to measure blood glucose at home and should be trained to make appropriate treatment changes based on blood glucose measurement results [15]. In this study, the low blood glucose measurement rate in the presence of symptoms revealed the importance of training. In a study conducted by Maneze et al., it was shown that individuals with high educational level had higher health literacy and lower diabetes self-management [16]. When the groups in this study were examined, there was no significant difference in HbA1c and cholesterol levels, although fasting blood glucose levels of university graduates were higher than individuals with low education levels. Similar results in this study indicate that high educational level of individuals is not a determining factor for DM treatment success. Conclusion As a result, in planning and monitoring DM treatment, physicians should be equally sensitive to individuals with all educational levels and apply regular training programs to each patient. It is considered that individual differences of the patients should be determined and training and treatment plans should be prepared accordingly. Recognizing and increasing awareness of patients will contribute to achieving good results by providing more accurate and effective treatment. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval Ethics committee approval was received from Kutahya Dumlupinar University Faculty of Medicine Clinical Research Ethics Committee. Turkan Pasali Kilit ORCID: 0000-0003-1126-7336 Kevser Onbasi ORCID: 0000-0003-2230-9263 Nazif Yalcin ORCID: 0000-0002-0110-0498

References 1.

IDF Diabetes Atlas 7th ed. International Diabetes Federation. Brussels, Belgium; 2015.

Aslan Ü, Korkmaz M. Diyabetli Bireylerin İnsülin Uygulama Bilgi-Beceri Düzeyleri: Doğru ve Yanlışlar. DEUHFED. 2015;8:18-26.

Baxter M, Hudson R, Mahon J, et al. Estimating the impact of better management of glycaemic control in adults with Type 1 and Type 2 diabetes on the number of clinical complications and the associated financial benefit. Diabet Med. 2016;33:1575-81.

Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ. 2015;41:417-30.

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IDF Diabetes Atlas 8th ed. International Diabetes Federation. Brussels, Belgium; 2017.

11. Thomas DE, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2006;3:CD002968.

Assal JP. A Global integrated approach to diabetes: a challenge for more efficient therapy. In: Davidson JK, ed, Clinical Diabetes Mellitus: A Problem Oriented Approach. 2nd ed. Thieme Medical Publishers, New York, 1991;703-16.

12. Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013;97:505-16.

Onwudiwe NC, Mullins CD, Winston RA, et al. Barriers to self-management of diabetes: a qualitative study among low-income minority diabetics. Ethn Dis. 2011;21:27-32.

Al Shafaee MA, Al-Shukaili S, Rizvi SG, et al. Knowledge and perceptions of diabetes in a semi-urban Omani population. BMC Public Health. 2008;8:249.

Altundağ S. Tip 1 diyabetli çocukların hastalığa uyumunda eğitimin ve sosyal desteğin etkisi. Pamukkale Tıp Dergisi. 2018;11:137-44.

10. Usta Atmaca H, Akbaş F, Şak T, et al. Diyabetik Hastalarda Hastalık Bilinç Düzeyi ve Farkındalık. İstanbul Med J. 2015;16:101-4.

13. Tavakolizadeh J, Moghadas M, Ashraf H. Effect of Self-regulation Training on Management of Type 2 Diabetes. Iran Red Crescent Med J. 2014;16:13506. 14. Workgroup on Hypoglycemia, American Diabetes Association. Defining and reporting hypoglycemia in diabetes: a report from the American Diabetes Association Workgroup on Hypoglycemia. Diabetes Care. 2005;28:1245-9. 15. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care. 2001:24:561-87. 16. Maneze D, Everett B, Astorga C, et al. The Influence of Health Literacy and Depression on Diabetes Self-Management: A Cross-Sectional Study. J Diabetes Res. 2016;2016:3458969.

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Available online at www.medicinescience.org

ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):145-9

Evaluation of the relationship between the level of spinal vertebra injuries due to traffic accidents and additional injuries Celil Alkan1, Hatice Seyma Akca1, Mehmet Necdet Yildiz2, Kamil Kokulu1, Serdar Ozdemir1, Serkan Emre Eroglu1 University of Health Scienses, Umraniye Training and Research Hospital, Istanbul,Turkey 2 Sultanbeyli State Hospital, Clinic of Emergency, Istanbul,Turkey

Received 29 July 2019; Accepted 06 September 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9155

Abstract Vertebral injuries are mostly seen in patients with multiple trauma. Because of high energy trauma, especially in young patients, it is associated with additional injuries. It was observed that there are not enough studies on this subject in our country. In this study, we aimed to explain the incidence of vertebral injuries and the characteristics of both concomitant and vertebral injuries and contribute to the literature by investigating the presence of additional injuries in patients with vertebral injuries resulting from traffic accidents. Data were recorded on the age, sex, type of trauma, spinal injury level, additional organ injury, GCS, neurological deficits, intensive care admittance, and mortality status of all patients. The data used in the study were obtained from the hospital’s automation system and patients’ files. The mean age of the 166 spinal trauma patients included in the study was 36.7±15.4 (Median:35; 95% Cl:34.1-38.7) years and 65.7% of the patients were male. Mortality rate in emergency department was 0.6%, mortality frequency was not associated with additional organ injury, trauma cause and spinal level but the results were not statistically significant (p> 0.05). The presence of additional injury increased the frequency of intensive care admission, the results were statistically significant (p <0.05). Because of spinal injuries are sult of high-energy traumas, additional organ injuries are common pathologies. For this reason, patients with spinal trauma should be evaluated for additional injuries. Although vertebral injuries are mostly evaluated together with patients with multiple trauma, it should not be forgotten its relationship with additional injuries. Keywords: Spinal trauma, motor vehicle accidents, organ injuries

Introduction In most countries, the rate of acute injuries of the spinal cord is 20–40 cases per 1 million. In Turkey, the spinal cord injury frequency is 12.7 cases per 1 million, with a reported incidence rate of between 500–600 cases annually [1]. According to clinical tables, complete spinal cord injuries makes up 45% of injuries, whereas incomplete spinal cord injuries account for 55% of injuries [2]. In terms of the site of injury, spinal cord injuries most commonly affect the cervical spinal cord (55%), followed by the thoracic spinal cord(30%) and lumbar spinal cord (15%) [2]. Direct radiography is the most common visualization method for thoracic and lumbar vertebrae [3]. The high number of patients admitted, the age-related osteoporotic changes and, of course, the occurrence of vertebral injuries mostly in multiple trauma patients require computed tomography using. Breathing difficulties are the most common symptom of spinal trauma.

*Coresponding Author: Hatice Seyma Akca, University of Health Scienses, Umraniye Training and Research Hospital, Istanbul, Turkey E-mail: drhaticeseyma_@hotmail.com

Other common spinal cord injury symptoms include atelectasis, pneumonia, and respiratory failure [4]. In cases of spinal trauma, muscle weakness, venous stasis, and increased clotting increases the risk of. Due to excessive and uncontrolled sympathetic nervous system discharge, autonomic dysreflexia may also develop in cases of spinal injury. In patients without respiratory and neurological symptoms, we may encounter vertebral injuries. After the diagnosis of vertebral injury, the possibility of additional pathologies should not be forgotten. Vertebral injuries are mostly seen in patients with multiple trauma. Because of high energy trauma, especially in young patients, it is associated with additional injuries. It was observed that there are not enough studies on this subject in our country. A retrospective study was designed considering that missed injuries or surgical complications may be added. In addition to the approach to multiple trauma patients, it should be kept in mind that the severity of vertebral injuries and vertebral injuries may be overlooked even with detailed examination and physical examination. 145

doi: 10.5455/medscience.2019.08.9155

The frequency of cervical, thoracic and lumbar spine injuries varied in studies in different countries. The accompanying injuries also differed by country. We wanted to emphasize that additional injuries should not be overlooked in severe injuries such as vertebral injuries. In this study, we aimed to explain the incidence of vertebral injuries and the characteristics of both concomitant and vertebral injuries and contribute to the literature by investigating the presence of additional injuries in patients with vertebral injuries resulting from traffic accidents. Different types of vertebral injuries may coexist with different types of additional injuries. We wanted to provide systematic diagnosis and treatment of patients presenting with vertebra injury with our statistically significant results. Materials and Methods The study population comprised patients with suspected spinal trauma who were brought to the Ümraniye Emergency Medical Clinic between 1 January 2015 and 31 December 2015 following traffic accidents. Data were recorded on the age, sex, type of trauma, spinal injury level, additional organ injury, GCS, neurological deficits, intensive care admittance, and mortality status of all patients. The data used in the study were obtained from the hospital’s automation system and patients’ files. Inaccessible patients’ data from hospital records due to the patient consent was required or waived by the local ethics committee will likely be required were excluded from the study. The data were evaluated using the Statistical Package for Social Sciences. The Kolmogorov–Smirnov test was conducted to determine the distribution range of the descriptive statistics. For the expression of quantitative data, the mean, standard deviation (SD), and median values are presented. For qualitative data, the number of cases (n) and percentage (%) are presented. For the analysis of quantitative data, the Kruskal–Wallis test was used. For analyzing quantitative data, Pearson’s chi-squared and Fisher’s exact chi-squared tests were conducted. The results are presented with their 95% confidence intervals (CIs). Significance was accepted at p<0.05. Patients with and without additional injuries were evaluated using the registry system. The relationship between vertebral level and age, gender, GCS, ICU hospitalization, neurological deficit and mortality were evaluated. The relationship between additional injuries and vertebral level was evaluated.

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Patients with vertebral trauma admitted within 1 year were screened retrospectively. Vertebra traumas diagnosed in the emergency department were included in the study. Severe vertebral traumas that were not admitted to our hospital despite the suggestion of follow-up were excluded from the study. Patients with examination findings and soft tissue trauma that could not be obtained from the records were excluded from the study. The permission is taken from the patients who are cooperative and oriented; It was obtained from relatives of patients with low GCS. Results The mean age of the 166 spinal trauma patients was 36.4 ± 15.0 (95% CI: 34.1–38.7), and the age range of the patients varied between 9 and 91 years. One hundred-nine (65.7%) patients were males. In the study, 99 (59.6%) patients had been injured due to in-car traffic accidents (ICTAs), 50 (30.1%) patients had been injured in non-car traffic accidents (non-CTAs), and 17 (10.3%) patients had been injured in motorcycle accidents. The most common sites of injuries were as lumbar vertebrae (56%). Among the study population, 86.7% of the patients have a GCS score of 15 or lover. Table 1. Comparing with Travma and Additional Injuries

Head

ICTA (n:99)

Non-CTA (n:50)

Motorcycle (n:17)

n (%)

10 (10.1)

4 (8.0)

0.365

14 (14.1)

5 (10.0)

1 (5.9)

0.697

Abdomen

10 (10.1)

3 (6.0)

2 (11.8)

0.654

Pelvis

14 (14.1)

8 (16.0)

1 (5.9)

0.472

Upper Extremities

10 (10.1)

8 (16.0)

3 (17.6)

0.455

Lower Extremities

14 (14.1)

7 (14.0)

3 (17.6)

0.716

Fisher’s Exact test (n: case, ICTA:in car trauma accident, non-CTA: non car trauma accident.)

Table 2. Comparing with Toracic Vertebral Injuries and Additional İnjuries Thoracic Vertebral Injuries

Yes (n:47)

No (n:119)

n(%)

Head

5 (10.6)

9 (7.6)

0.542**

Thorax

11 (23.4)

9 (7.6)

0.005*

Abdomen

5 (10.6)

10 (8.4)

0.764**

Pelvis

4 (8.5)

19 (16.0)

0.210*

Upper Extremities

7 (14.9)

14 (11.8)

0.585*

Lower Extremities

10 (21.3)

14 (11.8)

0.116*

We tried to find out which vertebral level additional injuries are more common, and whether these additional injuries affect mortality and hospitalization. Severe soft tissue injuries, open or closed extremity fractures, intraabdominal free fluid, solid organ injuries, rib fractures, pneumothorax, hemothorax, severe vascular injuries, cardiac injuries, myocardial contusion, pericardial effusion were included in the additional injuries.

Pearson ki-kare, ** Fisher’sExact test (n: case)

Additional injuries were detected in 60 (36.1%) patients. The most common sites of injury were the pelvis (n=x, 13.9%) and lower extremities (n=x, 14.5%). There was no statistically significant relationship between the spinal injury level and age (p> 0.05). (Table 1). 146

doi: 10.5455/medscience.2019.08.9155

Among males and females, the most common cause of injury was an ICTA. There was no significant relationship between the trauma type and sex (p> 0.05), the results were not statistically significant. Among vertebral injuries, lumbar vertebrae injuries were the most common in males and females. There was no statistically significant relationship between the spinal injury level and sex. When the relationship between the trauma type and the Glasgow Coma Scale was examined, non-CTAs, and motorcycle accidents. There was no association between GCS and trauma (p> 0.05) but the results were not statistically significant. The most frequently injured areas in cases of ICTAs were the thorax, pelvis, and lower extremities. In cases of non-CTAs, the most commonly injured sites were the pelvis and upper extremities. In motorcycle accidents, the most frequently injured areas were upper and lower extremities. There was no statistically significant association between cervical and coccyx injuries and additional injuries. Head, abdomen, pelvic, upper and lower extremity injuries showed no statistically significant association with thoracic vertebrae injuries (p> 0.05). However, the frequency of thoracic trauma was significantly higher in patients with thoracic vertebral injuries(p<0.05) (Table 2). The pelvis was the most frequently (12.9%) injured area in patients with lumbar vertebrae injuries. Head, abdomen, upper pelvic, and lower extremity injuries showed no statistically significant relationship with lumbar vertebrae injuries (p> 0.05). However, the frequency of thoracic trauma was significantly lower in patients with lumbar vertebrae injuries(p<0.05) (Table 3). Table 3. Comparing with lumbal vertebral injuries and additional i̇ njuries Lumbal Vertebral Injuries No (n:93)

11 (11.8)

3 (4.1)

0.076

Thorax

7 (7.5)

13 (17.8)

0.043

Abdomen

8 (8.6)

7 (9.6)

0.826

12 (12.9)

11 (15.1)

0.689

Upper Extremities

9 (9.7)

12 (16.4)

0.193

Lower Extremities

11 (11.8)

13 (17.8)

0.277

Pelvis

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Table 4. Comparing with sacral vertebral injuries and additional i̇ njuries Sacral Vertebral Injuries

Yes(n:27)

No(n:139)

Head

4 (14.8)

10 (7.2)

0.248

Thorax

5 (18.5)

15 (10.8)

0.328

Abdomen

8 (29.6)

7 (5.0)

0.001

Pelvis

13 (48.1)

10 (7.2)

0.001

Upper Extremities

5 (18.5)

16 (11.5)

0.343

Lower Extremities

7 (25.9)

17 (12.2)

0.076

Fisher’s Exact test (n:case)

Table 5. Comparing with trauma type and neurological defisits Neurological Deficitis Yes (n:5)

No (n:161)

ICTA

4 (80.0)

95 (59)

Non-CTA

1 (20.0)

49 (30.4)

17 (10.6)

Motorcycle

0.649

Fisher’s Exact Test (n: case, ICTA: in car trauma accident, non-CTA: non car trauma accident.)

In patients admitted to the intensive care unit, head injuries (64.3%) most commonly accompanied spinal trauma. There was no statistically significant relationship between thoracic and upper and lower extremity injuries and admittance to the intensive care unit(p>0.05). Head, abdomen, and pelvic trauma were significantly higher among patients admitted to the intensive care unit(p<0.05) (Table 6).

Yes (n:73) Head

Table 6. Comparing with i̇ ntensive care unit admissions and additional i̇ njuries

Pearson ki-kare (n:case)

In patients with sacral vertebrae injuries, the pelvis (48.1%) was the most frequently injured site. There was no statistically significant correlation of head, thorax, upper extremity, and lower extremity injuries with sacral vertebrae injuries (p> 0.05). However, the frequency of abdominal and pelvic trauma was significantly higher in patients with these types of injuries (p<0.05) (Table 4). Neurological deficits were detected in 5 (3%) patients. In these patients, 4 (80%) cases were the result of were ICTAs, and 1 (20%) was the result of non-CTA. No statistically significant correlation was found between the trauma type and neurological deficits (p> 0.05) (Table 5).

Intensive Care Unit Admissions Yes (n:14)

No (n:152)

n(%)

Head

9 (64.3)

5 (3.3)

<0.001

Thorax

4 (28.6)

16 (10.5)

0.069

Abdomen

6 (42.9)

9 (5.9)

<0.001

Pelvis

6 (42.9)

17 (11.2)

0.005

Upper Extremities

3 (21.4)

18 (11.8)

0.391

Lower Extremities

6 (42.9)

18 (11.8)

0.007

One patient died. This patient had thoracic and sacral vertebrae injuries. There was no statistically significant association between the mortality rate and spinal trauma level (p> 0.05) (Table 7).This patient had thoracic, cavernous, pelvic, and upper extremity injuries, in addition to spinal trauma.There was no significant association between the mortality rate and additional pathologies associated with spinal trauma (p>0.05) (Table 8) 147

doi: 10.5455/medscience.2019.08.9155 Table 7. Comparing with mortality and spinal trauma level Mortality Rate p*

Yes (n:1)

No (n:165)

n(%)

Cervical

147 (89.1)

>0.999

Thoracal

1 (100)

46 (27.9)

0.283

Lumbal

93 (56.4)

0.440

Sacral

1 (100)

26 (15.8)

0.163

Coxics

3 (1.8)

>0.999

* Fisherâ&#x20AC;&#x2122;s Exact test (n: case)

Med Science 2020;9(1):145-9

most frequent causes of spinal trauma were ICTAs, followed by motorcycle accidents[13-17].In our study, 36% of spinal trauma patients had additional injuries, and there was no statistically significant relationship between the type of spinal trauma and type of additional injury. A number of studies reported that spinal injuries were accompanied by a high possibility of brain injuries [18-20]. Studies indicated that GCS was lower in motorcyclists, and that this was associated with direct exposure of the head area to trauma [6,21,22]. In some studies, the most common additional injuries in motorcycle accidents were spinal trauma, in addition to bone fractures and dermabrasions [17,23,24]. Studies have reported differences in the rate of neurological deficits due to spinal trauma [6,7,11]. In the present study, the neurological deficit frequency was 3%, and neurological deficits were not correlated with the trauma type or trauma level.

Table 8. Comparing with mortality and additional injuries Mortality Rate p*

Yes (n:1)

No (n:165)

n(%)

14 (8.5)

>0,999

Thorax

1 (100)

19 (11.5)

0.120

Abdomen

1 (100)

14 (8.5)

0.090

Pelvis

1 (100)

22 (13.3)

0.139

Upper extremities

1 (100)

20 (12.1)

0.127

Lower extremities

24 (14.5)

>0.999

Head

* Fisherâ&#x20AC;&#x2122;s Exact test (n: case)

Discussion In our study, the mean age of the patients was 36.7 years, and 66% of the patients were males. The majority of injuries were the result of non-CTAs, with motorcycle accidents accounting for the lowest number of injuries and hospital admissions. In Turkey, vehicles carrying more than one passenger in the traffic and the high frequency of ICTAs cause more than one person injuried in these accidents. The absence of a seating area for every passenger on public transport and a lack of compliance with traffic laws are also potential causes of accidents leading to spinal injuries. Previous studies on motor vehicle accidents reported that, spinal trauma, thoracic, cervical, cervicothoracic, and thoracolumbar vertebrae injuries are the most common one in the injury ranking [5-10]. Cervical injuries (so-called whiplash injuries) are common in CTAs due to rear-impact collisions [11]. In the present study, the most frequent vertebra injuries were lumbar puncture injuries. Thoracic vertebra injuries was second frequency. Cervical trauma may have been missed because of the retrospective nature of our study. Only traffic accidents are included in the system records of the registered patients, and only the registration is made with this record. In particular, the lack of protective equipment for motorcycle drivers may result in fewer cervical injuries but more of widespread traumas and the presence of cervical injured patients at the scene. Previous studies reported various additional injuries (e.g., thoracic, head, or extremity)in motor vehicle accidents that caused spinal trauma [7,10-12].According to some studies, the

In a previous study 61% of spinal trauma patients who died also had cranial trauma [18]. Studies reported lower fatality levels among spinal trauma patients with lung, liver, and splenic injuries, as well as among spinal trauma patients with lower extremity and pelvic fractures [19,20]. In our study, the rate of intensive care admittance was 8.4%.The frequency of admittance to the intensive care unit was higher among spinal trauma patients with additional injuries (head, warts, and pelvic), although there was no correlation between the trauma type and spinal trauma level.Considering the frequency of admittance to the intensive care unit in our study, it is likely that many spinal trauma patients with additional injuries were followed up in the clinic. Our study is important in terms of showing that spinal traumas associated with additional injuries increase the ICU stay. Detailed physical examination should be performed at the first admission of patients with multiple trauma with vertebral injury. Vital signs and symptoms should be reviewed during follow-up. Discharged decision should not be made early and patients discharged should be informed. Limitations Since our study was retrospective, deficiencies in the records caused us to exclude some cases. Cardiac arrest was excluded because the causes of death were not only vertebral trauma. This caused a change in mortality rates. Conclusion The mortality rate in our study was % 0.6. The mortality rate was not related to the trauma type, spinal trauma level, or presence of additional organ injuries. It is likely that the trauma type, trauma level, and additional organ injury on the mortality are effective. In conclusion, additional organ injuries are common in cases of spinal injuries caused by high-impact trauma. The spinal trauma level in traffic accidents was related to the occurrence of additional organ injuries. Therefore, patients with spinal trauma should undergo assessments for additional organ injuries, particularly at 148

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the level of the spinal injury. Although additional organ injuries were not found to be effective in mortality; increased the rate of hospitalization. Detailed research and meta-analyzes may show that additional injuries also cause statistically significant increases in mortality. For this, there is a need for researches where patient follow-up can be performed for months. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki. Celil Alkan ORCID: 0000-0001-6728-0404 Hatice Seyma Akca ORCID: 0000-0003-2823-9577 Mehmet Necdet Yildiz ORCID: 0000-0001-6728-0404 Kamil Kokulu ORCID: 0000-0002-6132-0898 Serdar Ozdemir ORCID: 0000-0002-6186-6110 Serkan Emre Eroglu ORCID: 0000-0002-3183-3713

References 1.

Çolak A, Karaoğlan A, Barut S, et al.Neuroprotection and Functional Recovery after Application of the Caspase-9 inhibitor z-LEHD-fmk in a Rat Model of Traumatic Spinal Cord Injury, J Neurosurg Spine. 2005;3:327-34. Dryden DM, Saunders LD, Rowe BH, et al. The Epidemiology of Traumatic Spinal Cord Injury in Alberta, Canada. The Canadian Journal of Neurological Sciences Le J Canadien des Sciences Neurologiques. 2003;2:113-21.

Go S. Spine travma In Emergency Medicine. A Comprehensive Study Guide. 8 th edition Tintinalli JE. (eds.)McGraw-Hill, New York 2016;1708-24.

Sweileh WM, Abu-Hadeed HM, Al-Jabi SW, et al. Prevalence of Depression among People with Type 2 Diabetes Mellitus: a Cross Sectional Study in Palestine. BMC Public Health. 2014;14:163.

Amar AP, Levy ML. Pathogenesis and Pharmacological Strategies for Mitigating Secondary Damage in Acute Spinal Cord Injury. Neurosurgery. 1999;5:1027-40.

Robertson A, Giannoudis PV, Branfoot T, et al. Spinal Injuries in Motorcycle Crashes: Patterns and Outcomes. J Trauma and Acute Care Surgery. 2002;1:58.

7. 8.

Leucht P, Fischer K, Muhr G, et al Epidemiology of Traumatic Spine Fractures. Injury. 2009;2:166-72. Prasad V, Schwartz A, Bhutani R, et al. Characteristics of Injuries to the Cervical Spine and Spinal Cord in Polytrauma Patient Population: Experience from a Regional Trauma Unit. Spinal cord. 1999;8:560-8. Vives MJ, Kishan S, Asghar J, et al. Spinal Injuries in Pedestrians Struck by Motor Vehicles. Journal of Spinal Disorders & Techniques. 2008;4:281-7.

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10. Nelson DW, Martin MJ, Martin ND, et al. Evaluation of the Risk of Noncontiguous Fractures of the Spine in Blunt Trauma. Journal of Trauma and Acute Care Surgery. 2013;1:135-9. 11. Dolay K, Kocataş A, Alış H, et al. Cervical Spine Injuries. Turkish J Trauma. 1999;1:31-4. 12. Yilmaz F, Sonmez BM, Beydilli I, et al. Spinal fractures as an Indicator of Concurrent other System Injuries: An analysis of 242 cases. Biomedical Research. 2017;3:1006-11. 13. Roberge RJ, Wears RC, Kelly M, et al. Selective Application of Cervical Spine Radiography in alert Victims of Blunt Trauma: a Prospective Study. J Trauma. 1988;6:784-8. 14. Loo GT, Siegel JH, Dischinger PC, et al. Airbag Protection Versus Compartment Intrusion Effect Determines the Pattern of Injuries in Multiple Trauma Motor Vehicle Crashes. Journal of Trauma and Acute Care Surgery. 1996;6:935-51. 15. Siegel JH, Smith JA, Siddiqi SQ. Change in Velocity and Energy Dissipation on impact in Motor Vehicle Crashes as a Function of the Direction of Crash: Key Factors in the Production of Thoracic Aortic Injuries, Their Pattern of Associated Injuries and Patient Survival a Crash Injury Research Engineering Network (CIREN) study. Journal of Trauma and Acute Care Surgery, 2004;4:760-78. 16. Hart R, Mayberry JC, Herzberg A. Acute Cervical Spinal Cord Injury Secondary to Air Bag Deployment without Proper use of Lap or Shoulder Harnesses. Journal of Spinal Disorders. 2000;1:36-8. 17. Ekmejian R, Sarrami P, Naylor JM, et al. A Systematic Review on the Effectiveness of back Protectors for Motorcyclists. Scand J Trauma Resusc Emerg Med. 2016;1:115. 18. Smith JA, Siegel JH, Siddiqi SQ. Spine and Spinal Cord Injury in Motor Vehicle Crashes: a Function of Change in Velocity and Energy Dissipation on Impact with Respect to the Direction of Crash. Journal of Trauma and Acute Care Surgery. 2005;1:117-31. 19. Iida H, Tachibana S, Kitahara T, et al. Association of Head Trauma with Cervical Spine Injury, Spinal Cord Injury, or Both. Journal of Trauma and Acute Care Surgery. 1999;46:450-2. 20. Macciocchi SN, Bowman B, Coker J, et al. Effect of co-morbid Traumatic Brain Injury on Functional outcome of Persons with Spinal Cord Injuries. American J Physical Medicine & Rehabilitation. 2004;1:22-6. 21. Cannell H, King J, Winch R. Head and Facial Injuries after Low-speed Motorcycle Accidents. British Journal of Oral Surgery. 1982;3:183-91. 22. Sarkar S, Peek C, Kraus JF. Fatal Injuries in Motorcycle Riders according to Helmet Use. Journal of Trauma and Acute Care Surgery. 1995;2:242-5. 23. De Rome L, Ivers R, Fitzharris M, et al. Motorcycle Protective Clothing: Protection from Injury or Just the Weather? Accid Anal Prev. 2011;6:1893900. 24. Giustini M, Cedri S, Tallon M, et al. Use of Back Protector Device on Motorcycles and Mopeds in Italy. Int J Epidemiol, 2014;6:1921-8.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):150-3

Evaluation of the relationship between southwest wind parameters and hospital applications related to headache symptoms Hatice Seyma Akca, Sumeyra Acar Kurtulus, Deniz Tengerek, Berra Kalkavan, Serkan Emre Eroglu University of Health Scienses Umraniye Education and Research Hospital, Department of Emergency, Umraniye, Istanbul Received 17 July 2019; Accepted 05 September 2019 Available online 24.02.2020 with doi: 10.5455/medscience.2019.08.9147

Abstract Although it is known that headache can be caused by many factors, it is difficult to assess whether it is related to meteorological data. The aim of this study was to investigate the relationship between headache observed in patients presenting to emergency units and the Southwest wind parameters.This was a prospective study including patients over 18 years of age who had presented to the University of Health Sciences Ümraniye Education and Research Hospital emergency unit with headache symptoms between 01.01.2017 and 31.06.2017. The patient data were compared to the parameter “presence of southwest wind”, which was obtained from the Forests, Water Sources and Meteorology Directorate Office of Republic of Turkey. Records that were determined to comprise insufficient data were excluded during the data collection. A total of 286 patients were investigated in our prospective study. 93 patients (32.5%) had presented on days when there was southwest wind. 187 had no diagnosed type of headache and were evaluated to have primary headache. Primary headache was more common in patients with no wind exposure, which was statistically significant (p<0.05). No significant difference was observed between genders with regard to admission on windy days (p=0.387).We believe that our study would contribute to studies that investigate the relationship between headache and meteorological parameters, which are limited in number. The fact that there are more hospital admissions when there is no wind exposure indicates that studies required detailed analysis. It is also known by our society that patients who do not apply to the hospital because of the idea that southwest wind is associated with headache. Keywords: Southwest wind, headache, meteorologycal parameters, hospital application with headache symptoms, wind parameters.

Introduction Types of headache may be classified as primary (without an underlying disease and/or drug-substance use) (‘and’, ‘or’) secondary (with cause). In secondary headache disorders, the ache is related to another disease and IHS (International Headache Society) criteria provides a scoring system that classifies this group of headaches according to their etiological causes. In primary headache, there is no detectable underlying cause. When considering a patient with headache, secondary headache should be eliminated from the differential diagnosis at the beginning [1]. More than 90% of the patients with headache have primary type headache. Southwest wind is effective in winter and spring in Turkey. Southwest wind has dry and hot characteristics and slightly *Coresponding Author: Hatice Seyma Akca, University of Health Scienses Umraniye Education and Research Hospital, Department of Emergency, Umraniye, Istanbul. E-mail: drhaticeseyma_@hotmail.com

elevates the air temperature [2]. It may lead to fatigue, nausea, and upper airway symptoms. Although it is known that headache can be caused by many factors, it is difficult to assess whether it is related to meteorological data. There are a limited number of studies showing whether headaches are associated with meteorological events. We preferred this prospective study because there may be deficiencies in the evaluation of our study with recorded data. In addition, differences in the cultural level of our patients and their capacity to define pain and of course subjective symptoms were limited in our study. The aim of this study was to investigate the relationship between headache observed in patients presenting to emergency units and the southwest wind parameters. The patients were classified according to meteorological data. Patients with additional symptoms except headache were noted. Primary-secondary headache distinction was made according to the anamnesis of the patients. Not only limited to the days when the southwest winds were effective, but also questioned whether there was wind exposure.

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Materials and Method This was a prospective study including patients over 18 years of age who had presented to the University of Health Sciences Ümraniye Education and Research Hospital emergency unit with headache symptoms between 01.01.2017 and 31.06.2017. The patient data were compared to the parameter “presence of southwest wind”, which was obtained from the Forests, Water Sources and Meteorology Directorate Office of Republic of Turkey. Records that were determined to comprise insufficient data were excluded during the data collection. Ethics committee approval was received in November 2016. Form signed with the consent of patients to be included in our prospective study. The quantitative data were expressed as mean, standard deviation (SD) and median (minimum – maximum value), and the qualitative data were expressed as case number (n) and percentages (%). The outcomes were evaluated in 95% confidence interval and the significance was accepted at a level of p<0.05. The study consisted of patients examined by the authors. Record screening was not performed retrospectively. Only prospective cases were collected. In addition to the demographic characteristics of the patients, exposure to southwest wind, presence of diagnosed headache, frequency of headache, whether the headache was periodic or not, and the presence of known chronic diseases were questioned. The patients were classified according to meteorological data. Patients with additional symptoms except headache were noted. Primarysecondary headache distinction was made according to the anamnesis of the patients. Patients were also asked if headaches were related to southwest winds before. Those who applied on days when southwest winds were effective were asked whether there was wind exposure. Wind exposure was also evaluated. Although evaluation of the patient symptom ın retrospective studies can not be performed very well, it has limited our study in which probable headaches of the patients could not be diagnosed in prospecive studies. Since there was no problem of not accessing the data, the information was tried to be taken completely and patients whose general status deteriorated and were unable to speak were excluded from the study. Results A total of 286 patients were investigated in our prospective study. Among these, 115 were men (40.2%) and 171 were female (59.8%). 209 patients had not been exposed to wind, and among these, 152 had no periodic pain; therefore, the data were observed not to comply with the normal distribution. The median age was 37 years (IQR 26-75), the median value of oxygen saturation was 98% (IQR 96.75-99), the median value of systolic blood pressure was 125 mmHg (IQR 115-140), and the median value of diastolic blood pressure was 75 mmHg (IQR 70-80). 93 patients (32.5%) had presented on days when there was southwest wind. 187 had no diagnosed type of headache and were evaluated to have primary headache. 232 patients (81.1%) had no history of disease; 3 patients (1%) had otitis media, 9 patients

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(3.1%) had hypertension, 1 patient (0.3%) had asthma, 1 patient (0.3%) had chronic sinusitis, 1 patient (0.3%) had a history of ischemic cerebrovascular disease, and 39 patients (13.6%) had been followed-up by the neurology clinics due to undiagnosed headache. 14.7% of the patients had a history of trauma, and 10.8% had obesity. 15.7% of the patients described their headache on admission as the most severe pain. 49.3% described repetitive headache, whereas 25.2% stated that they had periodic headache. 209 patients (73.1%) had experienced no wind exposure, whereas 77 patients (26.9%) had. Periodic headache was more common in patients with no wind exposure compared to those with exposure (79.2%); however, this was not statistically significant. Among the 187 patients with primary headache, 155 had no wind exposure. Primary headache was more common in patients with no wind exposure, which was statistically significant (p<0.05). 20.3% of the patients related their headache to seasons, and 14% to the weather. 173 patients (60.5%) demonstrated no pre-finding, whereas 64 (22.4%) had nausea, 1 (0.3%) had dizziness, 1 (0.3%) had tinnitus, 1 (0.3%) had a cough, 3 (1%) had fatigue, 31 (10.8%) had findings of upper respiratory tract infection, and 12 (4.2%) had hypertension. Among 209 patients with no wind exposure, 47 (22.5%), and among 77 patients with wind exposure, 46 (59.7%) had headache during southwest wind breeze. The outcomes were statistically significant (p=0,000) (Table 1). No significant relationship was determined between exposure to southwest wind and periodic headache; primary headache on the other hand, was observed more commonly among those with wind exposure. 73.9% of male patients (n=85) and 72.5% of female patients (n= 124) had no wind exposure. No significant difference was observed between genders with regard to wind exposure (p= 0.452) (Table 2). 33.9% of the male patients with headache on admission, and 31.6% of the female patients were observed to present to emergency unit on windy days. No significant difference was observed between genders with regard to admission on windy days (p=0.387). Table 1. Wind exposure and headache complaints during southwest wind Patients with headache complaints during southwest wind

Patients who don’t have headache complaints during southwest wind

Total

Patients with wind exposure

%59.7(n=46)

%40.3(n=31)

%100 (n=77) (p=0.00)

Patients with no wind exposure

%22.5(n=47)

%87.5(n=162)

%100 (n=209) (p=0.00)

Among 209 patients with no wind exposure, 47(22.5%), and among 77 patients with wind exposure, 46(59.7%) had headache during southwest wind breeze. The outcomes were statistically significant (p=0,000)

Table 2. Wind exposure and genders Wind exposure Male Female

No wind exposure

Total

%26.1(n=30)

%73.9(n=85)

%100(n=115) (p=0.452)

%27.5(n=47)

%72.5(n=124)

%100(n=171) (p=0.452)

No significant difference was observed between genders with regard to wind exposure (p= 0.452)

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Discussion One of the main complaints of societies, headache, is a symptom that may accompany neurological diseases, as well as systemic diseases, and may lead to personal, social and economic problems. In our study, the number of patients with southwest wind exposure was 77, whereas the number of patients presenting on windy days was 93. Wind exposure out of certain hours may not mean much, or short exposure may be disregarded by the patients. This prospective study may include fallibility in the 24-hour weather forecast parameters. Thus, in a study investigating the relationship between migraine attack and atmospheric pressure, air temperature and relative humidity, 6 measurements with equal intervals were obtained within a day [3]. Nevertheless, no correlation was determined between meteorological parameters and migraine type headache. We know that headache is a symptom, but it can be seen as the disease itself in our hospitals. It is easier to make this mistake in emergency departments where patient admissions are high. Patient admissions are very high in emergency services. Therefore, sometimes only analgesic is applied to the patient and the disease is not questioned enough. There are approximately 500.000 patients admitted to the emergency department of our hospital annually. In our study although wind exposure was associated with headache, it was not associated with primary headache. Detailed questioning and each headache should be evaluated separately.â&#x20AC;&#x2122; In some studies, a correlation was observed between migraine and cold weather, and in others, increased migraine attacks were observed as the air temperature increased [3-5]. There are studies demonstrating that migraine is affected by alterations in the weather [6] and there are studies reporting that headaches of different types are affected by alterations in the weather [7]. In our study, primary and secondary type headaches were evaluated together and the risk of headache was observed to be increased in patients with wind exposure, which was statistically significant (p=0,000). Different studies have demonstrated that patients with diagnosed headache may report increased or decreased complaints according to the seasons, humidity and temperature. In a study investigating the relationship between cluster-type headache and air temperature, cluster-type headache was observed to be more common in winter months and concluded that both hot and cold air could have different effects on different patients with clustertype headache [8]. In another study-investigating patients with headache retrospectively, increased number of admission was reported during high and low temperature and humidity. No significant relationship was determined between the phases of the moon and patient admission [9]. Although there are many environmental factors that affect headache, the number of studies investigating the relationship between meteorological parameters and undiagnosed headaches is very limited. There are studies demonstrating the effects of changes in temperature and climate on diagnosed headaches; however, it should be considered that they report varying outcomes. In our study, primary and secondary type headaches were separately

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defined and undiagnosed headache was observed in 187 patients. Primary headache was more common among patients with no wind exposure. Secondary headache, which may have different diagnoses, was not evaluated in detail. The effects of Chinook winds on migraine have been investigated. Accordingly, admissions due to migraine have been observed to increase on days when chinook reached its highest velocity and prior to the days of chinook; however, no pathophysiology could be demonstrated [10]. Instead of the 24-hour forecast of the meteorological data, the duration of follow-up prior to and/or after southwest wind may be delayed, which would lead to a lower number of mistakes. It was observed in a study comparing loxoprofen sales in pharmacies in Japan and meteorological data that the loxoprofen sale rate was increased when the mean barometric pressure was low, and when there was rain, the mean humidity and minimum humidity rates were increased compared to the day before loxoprofen sale [11]. In a study, admission to emergency units with headache was demonstrated to increase with every 5-degree increase in the air temperature and with the rate of air pollution [12], whereas there are studies demonstrating no relationship between the development or permanency of migraine or headache and subjective perception of the weather [13]. In our study, primary headache was more common among patients with no exposure to wind. In studies with longer duration of followup, two studies have investigated the effect of changes in the weather on headache in Uppsala; the various climate properties of the observation period were recorded. The frequency of headache in patients with migraine were found to be lowest on sundays and mondays, and were highest on Thursdays and Saturdays. In patients with stress-related headache, the frequency was highest on Thursdays and Fridays, and was lowest on Sundays and Tuesdays. This pilot study demonstrated that people working in poor weather conditions had headache more frequently. A tendency towards developing headache was determined a day prior to windy days [14]. There are many studies investigating the relationship between meteorological parameters such as humidity, wind and temperature; however, the outcomes of these studies are contradictory to the subjective nature of the perception of both headache symptoms and climate conditions and seasonal changes. Wind exposure, which was questioned in our study, may be classified as subjective as well. Non-exposure to wind on a day when southwest wind is active may not necessarily mean that there would be no headache. Furthermore, undiagnosed periodic and/or repetitive headache were evaluated as primary headache, which was a limitation of our study. Primary headache was more commonly observed in patients with no exposure to the wind; however, when all patients with primary and secondary headache were considered together, among the 77 patients presenting on the days of southwest wind, 46 (59.7%) had developed a headache. This analysis revealed statistical significance (p=0,000). Although evaluation of the patient symptom Äąn retrospective studies can not be performed very well, it has limited our study in which probable headaches of the patients could not be diagnosed 152

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in prospecive studies. Of course, what we classified as primary headache also included secondary headaches that were not yet diagnosed. Patients whose general status deteriorated and were unable to speak were excluded from the study so previously stable patients who subsequently deteriorated could not be included in the study it may not be possible to identify some diseases that can be diagnosed by advanced examination and such patients may be considered as primary headache.

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Sahin K, Bagci HR. A sinoptic climatology of Lodos in Turkey (a case of Samsun province) Int J Social Res. 2015;8:413-22.

Hoffman J, Schirra T, Lo H, et al The influence of weather on migraine-are migraine attack spredictable? Ann Clin Translation Neurol. 2015;2:22–8.

Hoffmann J, Lo H, Neeb L, et al. Weather sensitivity in migraineurs, J Neurol. 2011;258:596–602.

Scheidt J, Koppe C, Rill S, et al. Influence of temperature changes on migraine occurrence in Germany. Int J Biometeorol. 2012;57:649-54.

Millson DS, Tepper SJ. Secondary Headaches. J Head Face Pain. 2004;44:627.

Prince PB , Rapoport AM, Sheftell FD, et al. The effect of weather on headache, Headache. 2004;44:596-602.

Lee YJ, Ou SM, Yang AC, et al. Temperature variation and the incidence of cluster headache periods: A nation wide population study , Cephalalgia. 2011;31:391-400.

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

Yılmaz M, Gurger M, Ateşçelik M, et al Meteorologic parameters and migraine headache: ED study, Am J Emerg Med.2015;33:409-13.

Financial Disclosure All authors declare no financial support.

10. Cooke LJ, Rose MS, Becker WJ. Chinook winds and migraine headache, Neurology. 2000;54:302-7.

Ethical approval Ethics committee approval was received in November 2016. Form signed with the consent of patients to be included in our prospective study.

11. Ozeki K, Noda T, Nakamura M, et al Weather and headache onset: a large-scale study of headache medicine purchases, Int J Biometeorol.2015;59:447-51.

Conclusions Further studies with longer durations of observation that mainly evaluate primary headache and compare meteorological parameters in different countries should be conducted. We believe that our study would contribute to studies that investigate the relationship between headache and meteorological parameters, which are limited in number.

Hatice Seyma Akca ORCID: 0000-0003-2823-9577 Sumeyra Acar Kurtulus ORCID: 0000-0002-6479-7093 Deniz Tengerek ORCID: 0000-0001-6788-5534 Berra Kalkavan ORCID: 0000-0002-9358-7810 Serkan Emre Eroglu ORCID: 0000-0002-3183-3713

References 1.

Altunkaynak Y. Approach to elderly patient with headache, Klinik gelişim. org. 2012;25:29-37.

12. Vodonos A, Novack V, Zlotnik Y,et al. Ambient air pollution, weather and Daily emergency department visits for headache, Cephalalgia. 2015;35:108591. 13. Zebenholzer K, Rudel E, Frantal S,at al. Migraine and weather: a prospective diary-based analysis. Cephalalgia. 2011;31:391-400. 14. Osterman PO, Lundberg PO, Lundquist S, et al. Weekly periodicity of headache and the effect of changes in weather on headache.Ups J Med SciSuppl. 1980;31:23-6.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):154-9

Respiratory muscle strength: Effects on functional capacity, quality of life and fatigue in women with multiple sclerosis Ayla Fil Balkan, Yeliz Salci Hacettepe University Faculty of Medicine, Department of Physical Therapy and Rehabilitation, Ankara, Turkey Received 17 February 2020; Accepted 24 February2020 Available online 03.03.2020 with doi: 10.5455/medscience.2020.09.9157

Abstract The aim of our study was to investigate the effect of respiratory muscle strength on functional capacity, fatigue and quality of life (QoL) in patients with multiple sclerosis (pwMS). Thirty-two fully ambulatory female pwMS were included in the study. The maximum expiratory pressure (MEP) and inspiratory pressure (MIP) were recorded for respiratory muscles strength. Functional capacity was assessed with the 6-Minute Walk Test (6MWT), fatigue with Fatigue Impact Scale and Fatigue Severity Scale, and QoL with the MSQoL-54. The partial correlation was made for removing the effect of age and examining the relationship between parameters. There were significant correlations between MIP and functional capacity, change in health, social function, sexual function and satisfaction sub-parameters of MSQoL-54 (rho:0.579, -0.490, -0.545, -0.594, -0.585 respectively). MEP had also significant correlations with functional capacity, change in health, social function, sexual function and satisfaction (rho:0.708, -0.490, -0.556, -0.608, -0.572 respectively). Conversely, no relation was found between respiratory muscle strength and fatigue. Respiratory muscle strength is an important factor that effects functional capacity and different QoL dimension such as sexual functions. It should be evaluated the earliest period in pwMS. However, fatigue is a multidimensional and complex phenomenon that cannot be simply associated with respiratory muscles strength. Keywords: Multiple sclerosis; fatigue; walk test; respiration; quality of life

Introduction Multiple sclerosis (MS) is a chronic inflammatory and autoimmune disease characterized by demyelination and axonal degeneration of the central nervous system. It causes neurological signs and symptoms according to the affected area in the central nervous system. [1]. MS affects mostly the young and female population. It causes various problems such as ataxia, strength losses, muscle tone changes, cranial nerve and autonomic disorders, fatigue, respiratory problems, mood disorders and adversely affects the daily life activities and quality of life. [2]. Pulmonary dysfunctions appear to be most life-threatening findings among many symptoms. [3]. Deterioration in respiratory functions was previously associated with advanced and terminal course of disease in MS patients [4-5]. However, recent studies have reported that respiratory muscle strength has decreased from the early stages of the disease [6-8].

*Coresponding Author: Ayla Fil Balkan , Hacettepe University Faculty of Medicine, Department of Physical Therapy and Rehabilitation, Ankara, Turkey, E-mail: aylafil@gmail.com

Functional capacity decreases in MS patients compared to healthy population [6]. There are controversial results on relationship between respiratory muscle strength and functional capacity. Ray et al. [9] found that there was no relationship between respiratory muscle strength and functional capacity in MS patients. Wetzel et al. [10] determined that there is a weak-to-moderate correlation between functional capacity and respiratory muscle strength. Fatigue is a complex and multifactorial symptom in MS patients. It could be related to muscle weakness, balance disorders, depression and hypothalamic disorders. In previous studies, it has been investigated the effect of respiratory muscle strength on fatigue however the results are not clear [9, 11-12]. Quality of life tends to decrease in MS patients associated with disease severity as with many chronic diseases. In the literature, the number of studies carrying out the effect of respiratory muscle strength on quality of life is limited and the results are contradictory. While MuhtaroÄ&#x;lu et al. reported that respiratory functions affect the quality of life in MS patients regardless of the level of disability [13], Ray et al. determined that there was no relationship between respiratory muscle strength and quality of life [9].

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Respiratory muscle strength is affected by age, gender and disability level [6, 14-16]. Although the effect of gender on respiratory function is known and MS is more common in women [17-18], these confounding factors are not controlled by carefully patient selection or by using suitable statistical method in studies. Our hypothesis is that the effects of respiratory muscle strength on functional capacity, fatigue and quality of life could be more effectively observed in MS by controlling the effect of age, gender and disability level. Therefore, the aim of this study is to investigate the effect of respiratory muscle strength on functional capacity, fatigue and quality of life in minimally effected women MS patients by controlling age.

Thoracic Society guidelines were followed for the test. 6MWT was performed in a 30-m hallway and turnaround points were identified. The total distance covered in 6 minutes were recorded in meters [24].

Materials and Methods

Quality of life was evaluated with the Turkish version of MSQOL-54. This questionnaire contains fifty-four items consisting of twelve subsections and two additional single-item measures. These subsections were physical function, role limitation due to physical problems, role limitation due to emotional problems, pain, emotional well-being, energy, health perceptions, social function, cognitive function, health distress, sexual function, and overall quality of life. The single item measures are change in health and satisfaction with sexual function. Individuals are asked to answer each item by choosing one of the numbers (1,2,3..). There are two summary scores at the end of the MSQOL-54 test. These are physical health and mental health scores [27].

Patients Patients who were admitted to Hacettepe University Department of Neurology were included in the study. Ethical approval for the present study was obtained from Hacettepe University NonInterventional Clinical Research Ethics Board. The inclusion criteria were: a) female sex b) diagnosed with multiple sclerosis c) Mini Mental State Test score>25 d) to be full ambulatory (Expanded Disability Status Scale–EDSS≤4.5). Patients who had another neurological, psychiatric, neuromuscular, systemic or cardiovascular system disease and had attack within 3 months were excluded. Outcomes Measurements The degree of disability was measured with Expanded Disability Status Scale (EDSS), respiratory muscle strength with mouth pressure device and functional capacity with 6 Minute Walk Test (6MWT). Fatigue were evaluated with Fatigue Severity Scale (FSS) and Fatigue Impact Scale (FIS) and quality of life with Multiple Sclerosis Quality of Life Questionnaire (MSQoL-54). The EDSS score was determined by the neurologist. Other assessments were performed by physiotherapists with at least ten years of experience. EDSS is the most widely used scale to evaluate disability level and to monitor disease progression in MS patients. Its score ranges from 0 to 10 (0= neurologically normal and 10= death due to MS). EDSS scores 1.0–4.5 refer to patients with MS who are fully ambulatory, and scores 5.0–9.5 are defined by impairment to ambulation [19]. Respiratory muscle strength (MIP and MEP) depends on the abdominal muscle strength, auxiliary respiratory muscles, the elasticity of the lungs and of the thoracic cage [7]. In this study, MIP and MEP were assessed with the portable electronic mouth pressure device (Micro MPM, Micro Medical Ltd, Kent, England). In addition, normative values (MIP = 104-0.51×age and MEP = 170-0.53×age) were calculated using the formula developed by Black and Hyatt [20]. Predicted values of MEP and MIP were determined by using normative and real values. Respiratory muscles were considered as weak if they were less than 80% of predicted MIP and MEP values [21-22]. 6MWT is reliable and valid test used to evaluate functional capacity in MS patients [23]. In present study, The American

Fatigue was assessed by FSS and FIS which are self-reported scales. FSS includes nine items scored on a seven-point scale from 1 (strongly disagree) to 7 (strongly agree). The higher score indicates greater fatigue severity. The FIS consists of 40 items scored from 0 (no problem) to 4 (extreme problem) on a five-point Likert scale. High scores indicate more functional limitations caused by fatigue [25-26].

Statistical analysis Statistical analysis of the data was performed with Statistical Package for Social Sciences (SPSS) Version 17 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics (mean, standard deviation and median) were calculated for participant characteristics, respiratory muscle strength (including percent predicted values), functional capacity, fatigue and quality of life. Frequency counts and percentages were calculated for disease severity, marital status and type of MS. Non parametric partial correlations to remove the effect of age were computed between the respiratory muscle strength and fatigue, 6MWT and quality of life, with tests of significance to determine that “r” was not equal to zero. Strength of the positive and negative correlation was defined very weak (0.00–0.19), weak (0.20–0.39), moderate (0.40–0.59), strong (0.60–0.79) and very strong (0.80–1.0) [28]. Significance coefficient (p value) was accepted as 0.05. Results As shown in Table 1, the study included 32 women patients aged 18 to 58 years. Their EDSS scores ranged from 1 to 4. Twentynine (90.6%) patients had relapsing remitting MS and three (9.4%) patients had primer progressive MS (Table 1). The mean of MIP values was 67.33 ± 24.83 cmH2O (median: 65 cmH2O). Predicted MIP % value was calculated as 77.85 ± 33.02 (median: 72.85). The mean of MEP values was 82.90 ± 26.91cmH2O (median: 86.50cmH2O) and the predicted MEP% value was 53.53 ± 19.79 (median: 56.46). It was observed that the MEP% and MIP% values of our patients were low (<80%). FSS score was 42.22±17.16 point and FIS score 58.19±39.74 (Table 1). In our study, there was a moderate correlation between MIP and 155

doi: 10.5455/medscience.2020.09.9157

functional capacity evaluated by 6MWT (Rho: 0.579, p = 0.002). In addition, 6MWT had strong correlation with MEP (Rho: 0.708, p = 0.0001). However, respiratory muscle strength (MIP and MEP) was not related to fatigue. Similarly, there was no relationship between fatigue and functional capacity (Table 2). Total the quality of life score and the values of all sub-parameters were slightly to moderately decreased (Table 3). The relationship was found between respiratory muscle strength (MIP and MEP) and sub-parameters of MSQoL-54. MIP and MEP mildly to moderately correlated with social function, sexual function, change in health and sexual satisfaction. In addition, there was a relation between MEP and emotional well-being and health perception (Rho: -0.406, p = 0.044 and Rho: -0.450, p = 0.024, respectively) (Table 4). Table 1. Demographic and clinical features of patients X±SD Age (year)

36.97±11.00

BMI (kg/m2)

23.31±3.97

MS duration (year)

8.35±5.44

Respiratory Muscle Strength MIP (cmH2O)

67.33±24.83

MEP(cmH2O)

82.90±26.91

MIP%

77.85±33.02

MEP%

53.53±19.79

6MWT (m)

520.51±70.35

Fatigue FSS

42.22±17.16

FIS

58.19±39.74 (%) N

MS type RRMS

(90.6) 29

PPMS

(9.4) 3

Marital status Single

(25) 8

Married

(75) 24

EDSS score 1-2,5

(53.1) 17

3-4

(46.9) 15

X±SD: Mean ± standard deviation, BMI: Body Mass Index, kg / m2: Kilogram / Square meter, N: Number of patients, %: Percentage, m: Meter, cmH2O: Centimeter water, MIP: Maximal Inspiratory Pressure, MEP: Maximal Expiratory Pressure, MIP%: predicted MIP values MEP%: predicted MEP values, 6MWT: Six Minute Walk Test, FSS: Fatigue Severity Scale, FIS: Fatigue Impact Scale, MS: Multiple Sclerosis, RRMS: Relapsing Remitting Multiple Sclerosis, PPMS: Primary Progressive Multiple Sclerosis, EDSS: Extended Disability Status Scale, MSQoL-54: Multiple Sclerosis Quality of Life Scale-54

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Table 2. The relationship between respiratory muscle strength, functional capacity and fatigue MIP

MEP

6MWT

FSS

FIS

0.898

0.579

0.245

0.171

0.0001

0.002

0.238

0.415

0.708

0.262

0.260

0.0001

0.207

0.209

6MWT

MIP

MEP

0.293

0.155

FSS

0.928

0.0001

FIS

R p R: Spearman Correlation Coefficient, p: Level of Significance, MIP: Maximal Inspiratory Pressure, MEP: Maximal Expiratory Pressure, 6MWT: Six Minute Walk Test, FSS: Fatigue Severity Scale, FIS: Fatigue Impact Scale

Table 3. MSQoL-54 total score and sub-parameter scores SUB-PARAMETER

X±SD

Physical Health

74.06±18.37

Role limitations due to physical problems

56.25±43.53

Role Limitation Due to Emotional Problems

56.25±43.54

Pain

64.06±22.80

Emotional Well-being

56.12±17.98

Energy

43.62±22.26

Health Perceptions

50.46±21.03

Social Function

75.78±18.12

Cognitive Function

58.90±23.88

Health Distress

56.25±26.91

Sexual Function

75.26±24.55

Change in Health

55.46±25.18

Satisfaction with sexual function

68.75±33.60

Overall quality of life

59.32±16.14

Mental Health Composite

57.16±19.56

Physical Health Composite

61.31±18.08

X±SD: Mean ± standard deviation

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Table 4. The relationship between respiratory muscle strength and quality of life PH

PRL

ERL

PAIN

EWB

SEF

SSF

OQL

0.292

0.076

-0.089

-0.043

-0.332

-0.272

-0.384

-0.545

-0.227

-0.198

-0.594

-0.490

-0.585

-0.201

0.156

0.717

0.673

0.838

0.105

0.188

0.058

0.005

0.276

0.342

0.002

0.013

0.002

0.336

0.252

-0.043

-0.197

-0.106

-0.406

-0.311

-0.450

-0.556

-0.286

-0.251

-0.608

-0.494

-0.572

-0.297

0.225

0.837

0.349

0.614

0.044

0.130

0.024

0.004

0.165

0.226

0.001

0.012

0.003

0.150

MIP

MEP

R: Spearman Correlation Coefficient, p: Level of Significance, MIP: Maximal Inspiratory Pressure, MEP: Maximal Expiratory Pressure, PF: Physical Function, PRL: Role Limitations Due to Physical Problems, ERL: Role Limitations Due to Emotional Problems, EWB: Emotional Well-being, EN: Energy, HP: Health Perceptions, SF: Social Function, CF: Cognitive Function, HD: Health Distress, SEF: Sexual Function, CH: Change in Health, SSF: Satisfaction with Sexual Function, OQL: Overall Quality of Life

Discussion In the present study, it was demonstrated that respiratory muscle strength decreased in female MS patients with mild to moderate disability, was related to functional capacity and different dimension of quality of life such as sexual function. However, no relationship has been shown between fatigue and respiratory muscle strength. Respiratory muscles weakness has been demonstrated in MS patients from the early course of disease regardless of the degree of disability in previous studies [6]. Altıntaş et al. reported respiratory dysfunction in patients with minimal disability even without respiratory symptoms and findings [7]. According to the present study’s results, MS patients with minimal disability had lower respiratory muscle strength than expected values. These results are compatible to prior studies although this study was conducted on female patients unlike other studies. We also observed MEP% values lower than MIP% values. Normal expiration performed passively while forced expiration needs muscle activity. Auxiliary respiratory muscles and abdominal muscles weakness can decrease the MEP values [29]. The lower MEP values may be attributed to the progressive ascending muscle weakness in MS patients. Additionally, later influence of inspiratory muscles and diaphragm [6, 30-31] causes low MIP values which is relatively higher than MEP values. Savcı et al. reported that there was no relationship between functional capacity and respiratory functions [32]. Similarly, Ray et al. found that respiratory strength does not affect functional capacity [9]. However, Whetzel et al. reported a relationship between respiratory muscles strength and walking distance [10]. Functional capacity was assessed with 6MWT in the present study and we demonstrated from moderate to strong correlation between 6MWT and respiratory muscles strength. These inconsistent results may arise due to factors such as differences in subjects’ age and disability level selected, in statistical methods used in the studies. It was known that age affects MIP and MEP values [20]. Ray and colleagues’ study population’s age was higher than our study. With increasing age, confounding factors such as disability level [33] may affect the functional capacity and more severe problems may mask the minimal effect of respiratory muscle strength. Additionally, the studies by Savcı et al. [32] and Ray et al. [9] included patients with EDSS scores in the range of 1-6.5 while the present study included fully ambulatory patients with

EDSS scores 1- 4. Statistical analysis differences may also lead to controversial results in addition to demographic differences. Neither the studies by Savcı et al. nor that of Ray et al. remove the confounding effect of age on the relationship between functional capacity and respiratory muscle strength. In the present study partial correlation was performed to remove the effect of age in a similar way of the study of Whetzel et al. [10] and our results compatible with their results. As a result, it should consider that removing effect of age allows more reliable results to be obtained. Studies investigating the relationship between fatigue and respiratory muscle strength in MS patients are limited, and the results are contradictory. Ray et al. reported a weak to moderate relationship between fatigue and respiratory muscle strength [9]. Taveira et al. divided MS patients into two group according to fatigue level using modified FIS. They reported that there was no difference in respiratory muscle strength (MIP and MEP) between the two groups [12]. Similarly, we observed that fatigue was not associated with respiratory muscle strength. Fatigue in MS is a multifactorial and has a complex pathophysiology that cannot be explained by a single factor [34-35]. Ray et al. and Taverira et al. evaluated fatigue using Modified FIS, not FIS and FSS. Ray et al.’s study included methodological differences with our study in terms of age, gender and EDSS score while the study of Taverira et al. was more similar to our study in terms of age and EDSS. These factors like age, gender and disease severity might have affected our results. The degree of disability also is related to fatigue [35]. We might not have found a relationship between fatigue and respiratory muscle strength due to including patients with a low level of disability. The QoL is a multidimensional symptom like fatigue and it can be affected in MS patients as well as in all chronic diseases [36]. In present study, QoL of the patients was investigated with MSQoL-54, which is specific to MS, and it was observed that respiratory muscle strength interacted with its sub-parameters. In previous studies, it is seen that there is little emphasis on the direct relationship between respiratory muscle strength and quality of life. To our knowledge, there are a few studies on this subject in the literature. Muhtaroğlu et al. evaluated the quality of life with SF36, from which MSQoL-54 was developed. They showed that there was a relationship between QoL (physical function, physical role limitation, social function, emotional role limitation and energy sub-parameters) and respiratory muscle strength [13]. Köseoğlu et al. did not evaluate respiratory muscle strength but reported 157

doi: 10.5455/medscience.2020.09.9157

a relationship between pulmonary function tests and QoL [11]. Silverman et al. also investigated the relationship of respiratory muscle strength on QoL but evaluated it from the perspective of swallowing [37]. In our study, we found that the sub-parameters of QoL (emotional well-being, health perception, social function and health change) were related to respiratory muscle strength. In addition, there was the interaction between respiratory muscle strength and sexual function/satisfaction sub-parameters. Sexual dysfunction which is common even in patients with minimal disability, is one of the most common problems in MS patients [38]. In Turkey, 59.3% of women with MS have sexual problems [39] and it may affect the mental state of patients more than disease severity [40]. To our knowledge, the present study is the first research showing the relationship between respiratory muscle strength and poor quality of life caused by sexual dysfunction. Najafidoulatabad et al. [41] investigated the effect of yoga on sexual dysfunction in MS patients. They have implemented a program that also included breathing yoga (pranamaya) and reported that patientsâ&#x20AC;&#x2122; sexual dysfunctions decreased and quality of life improved. The researches reporting that pranamaya increased respiratory function [42-43], and our results suggested that sexual dysfunction in MS patients may be related to respiratory muscle strength. Further investigation of this relationship is warranted, and the results will contribute the MS literature by improving the training programs aimed ameliorating the quality of life of patients. Our results showed that respiratory muscle strength in MS patients decreased in the early stages of the disease even if there were no symptoms related to respiratory problems, and this decrease affected the functional capacity and quality of life in many ways. The present study had some limitations. Firstly, the number of patients was limited and the majority of patients had relapsing remitting type MS. Therefore, our study results may not represent the general MS population. Secondly, the presence of sexual dysfunction was not evaluated with any scale and was inferentially determined according to the values of a sub-parameter in the MSQoL-54. As a result, respiratory muscle strength decreases from the earliest period in MS patients and affects functional capacity. At the same time, weakness of these muscles negatively affects different dimensions of the quality of life. Therefore, it may be beneficial to evaluate respiratory muscle strength at early stage and if necessary to add exercises improving respiratory function in treatment programs for management MS. In addition, the present study demonstrated that respiratory muscle strength affects the quality of life related to sexual function. We think that the relationship between these functions should be investigated in more comprehensive studies. Acknowledgments No specific grants from any funding agency in the public, commercial, or not-forprofit sectors were received for this research. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports

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Ethical approval Ethical approval for the present study was obtained from Hacettepe University Non-Interventional Clinical Research Ethics Board. Ayla Fil Balkan ORCID: 0000-0002-2721-0222 Yeliz Salci ORCID: 0000-0002-3728-7194

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):160-3

Identification of chemoresistance-associated miRNAs in hypopharyngeal squamous cell carcinoma Elif Pala1, Tuba Denkceken2 1

SANKO University Faculty of Medicine, Department of Medical Biology, Gaziantep, Turkey 2 SANKO University Faculty of Medicine, Department of Biophysics, Gaziantep, Turkey Received 23 September 2019; Accepted 14 January 2020 Available online 28.02.2020 with doi: 10.5455/medscience.2019.08.9158

Abstract This study aimed to determine candidate miRNAs that could help to evaluate whether patients with hypopharyngeal squamous cell carcinoma (HSCC) would benefit from docetaxel, cisplatin, and 5-fluorouracil (TPF) induction chemotherapy. We downloaded the expression profiles of HSCC patients from the Gene Expression Omnibus database. miRNA profiles were analyzed via Principal Components Analysis (PCA), followed by Linear Discriminant Analysis (LDA). The Database Annotation for Visualization and Integrated Discovery tool was utilized for enrichment analysis; STRING and Cytoscape were used for network construction. We detected that hsa-miR15b-5p, hsa-miR-93-5p, and hsa-miR-130a-3p might act as crucial regulators in chemoresistance of HSCC, and they may play as prognosticators and therapeutic targets in the future. Keywords: HSCC, chemoresistance, component analysis, functional enrichment analysis, protein-protein interaction, miRNA-mRNA regulatory network

Introduction

Materials and Methods

Hypopharyngeal carcinoma (HPC) arises from a subsite of the upper aerodigestive tract, which accounts for 0.8-1.5% of head and neck tumors with poor prognosis [1]. Hypopharyngeal squamous cell carcinoma (HSCC) is a histologically dominant tumor subtype, often diagnosed in the advanced stage, and the 5-year overall survival for all stages is approximately 30%. Induction chemotherapy with docetaxel, cisplatin, and 5-fluorouracil (TPF) has been developed and is considered an option to total laryngectomy, and this treatment has significantly enhanced the outcomes in HSCC to sustain the normal physiological function of the larynx [2-4]. Understanding the genetic differences among patients sensitive and resistant to induction chemotherapy will contribute to the knowledge of the molecular basis of HSCC. Identification of these highly relevant gene biomarkers can help to prevent unnecessary medication and may allow higher expectations of the desired individualized treatment.

Collection and inclusion criteria of studies We searched the Gene Expression Omnibus (GEO) database (https:// www.ncbi.nlm. nih.gov/geo/) by using the following keywords: “hypopharyngeal squamous cell carcinoma” (study keyword), “Homo sapiens” (organism), “Expression profiling by array” (study type). The inclusion criteria were: (1) expression levels of tissues from the experimental group compared to the control group, (2) adequate information to perform the analysis. This study is the descriptive cross-sectional study and the GSE85608-GPL21572_ series_matrix.txt.gz microRNA expression profile was downloaded from the GEO database which consists of 12 docetaxel, cisplatin, and 5-fluorouracil (TPF)-sensitive patients (aged 56.3±9.68 years) and nine resistant controls (aged 59.2±12.42 years). Receiver Operating Characteristic (ROC) analysis with a discriminant function score produced an areas under the ROC curve (AUC) of 0.926 for separating chemosensitive from resistant samples, as seen in fig. 1. Minimal required sample size is calculated as 4 per group by using AUC value (0.926), Type I error (Alpha, Significance) value 0.05 (5%), Type II error (Beta,1-Power) value 0.20 (power is 80%) and null hypothesis value 0.5 [5]. This calculation shows that the number of the minimum sample size used in our study is sufficient.

*Coresponding Author: Elif Pala, SANKO University, Faculty of Medicine, Department of Medical Biology, Gaziantep, Turkey, E-mail: epala@sanko.edu.tr

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Data processing and Statistical analysis miRNA tissue expression profiles of 12 TPF-sensitive patients and nine resistant controls were downloaded (GSE85608) from GEO database. miRNA profiles were analyzed via Principal Components Analysis (PCA), followed by Linear Discriminant Analysis (LDA) [6, 7]. PCA was performed to reduce the number of predictor variables for the differentiation of chemosensitive/ resistant samples. Then LDA was used for separation while maximizing the variation between the groups and minimizing separation within each group. The miRNA tissue expression profiles were analyzed for the statistical analysis. In our study the entire data matrix of GSE85608 microRNA expression profile was [21x4603]. Firstly, we performed a PCA to reduce the dimension of observed variables into a relatively smaller number of components while maintaining as much information or variance. The PCA was applied to 4603 microRNA expression profiles of 21 centered and scaled (zero mean value and a standard deviation of one) data set. Whole data matrix “X” (P×M) contains the number of patients (P=21) and the number of microRNA expression profiles (M=4603). This matrix is separated into several principal components (PCs). The result of PCA is a product of PC scores “S” and PC loadings “L” matrices plus the residue “R”: S=X. L→X=S.L’+R=s1l’1+s2l’2+s3l’3+……snl’n+R where X: (P x M) initial data matrix (21x4603); S: Weight matrix, eigenvalue, score [s1, s2, s3…, sn]; L’: Eigenvector matrix, principle component factor (loading), variance; [l’1, l’2, l’3…., l’n]; Residual matrix (containing noise) and n is the number of computed PCs. Secondly, the most significant (p<0.05) components are determined for the differentiation of samples. Then these significant PCs are used as the input variables of LDA. To prevent overfitting, the crossvalidation was performed by using the “leave-one-out” technique. The AUC as well as the sensitivities and specificities for the optimal cut-points are calculated using the discriminant function scores which is obtained by LDA. All statistical analyses were done by using open source R Studio software program with the version of ‘1.1.456’ [8]. Target Prediction All miRNA names were standardized according to miRBase v.22 via miRNAmeConverter available in Bioconductor R-package [9]. Then, MultiMiR package was utilized to predict targets of miRNAs that include 14 databases. This package was used to predict targets of miRNAs by DIANA-microT, ElMMo, MicroCosm, miRanda, miRDB, PicTar, PITA and TargetScan databases with the criterion of primary score listed in top 35 [10]. Targets of each miRNA were obtained by minimum one validated and three predicted algorithms, and these genes were chosen for the following analysis. Functional Enrichment Analysis The Database Annotation for Visualization and Integrated Discovery (DAVID) was utilized for enrichment analysis [11]. We used the DAVID database to implement Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis on significant miRNA targets. The species was limited to “Homo sapiens” and the p < 0.05 cut-off was considered as significant. Protein-protein Interaction (PPI) Network Construction The targets were mapped by STRING with a confidence score>0.7 as a cut-off criterion to estimate the PPI information [12], and then interactions were viewed with Cytoscape [13]. The genes with a

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node degree>35 were considered as hub genes. miRNA-Hub Genes Network Construction miRNA-hub genes regulatory network was constructed. The miRNAs with a degree>5 were considered to play an essential role in discriminating chemosensitive/resistance samples. Results Identification of Differentially Expressed miRNAs (DEMs) PCA was performed by 1st finding the direction having the most significant variance (PC1: 21%), and after that finding following directions (PC2:8%, PC3:6%, PC4:6%, PC5-21 collectively provides 5% or less of variance however yet contributed significantly). The paired two-sample t-test on all component scores showed that there were two (PC6 and PC13) most significant (p<0.05) components for discriminating samples. The p-values of these components were calculated as 0.007476 for PC6 and 0.03598 for PC13. These two vital components were applied as the input variable of LDA. The cross-validation was conducted by using the leave-one-out technique to prevent over-fitting [14]. The Areas Under the ROC Curve (AUC) was computed, and the specificities and sensitivities for the optimal cut-points were determined with the discriminant function scores, which was acquired by LDA [15]. The classification based on the discriminant score gave a sensitivity of 100% and specificity of 91.7% in discriminating chemosensitive/resistant samples with an accuracy of 95.2% and AUC of 92.6% (Figure 1). Top 100 DEMs were obtained from PC6 and PC13 loading scores. Target Prediction MultimiR acquired 1108 target genes according to our criterion for further analysis. Functional Enrichment Analysis For 1108 targets, we listed the top 10 KEGG pathways, which revealed that targets were mostly enriched in cancer (Table 1). Table 1. Enriched KEGG pathways of top 10 differentially expressed genes obtained from DAVID TERM

COUNT

P-VALUE

Endocytosis

1.7e-9

Pathways in cancer

1.9e-8

Pancreatic cancer

4.2e-7

HTLV-I infection

3.0e-5

Melanoma

3.4e-5

PI3K-Akt signaling pathway

3.6e-5

FoxO signaling pathway

3.8e-5

Hepatitis B

4.4e-5

Proteoglycans in cancer

6.9e-5

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doi: 10.5455/medscience.2019.08.9158 Signaling pathways regulating pluripotency of stem cells

7.5e-5

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made 41 miRNA-hub gene pairs in the network. The relationship between miRNAs and hub genes are shown in Figure 3. miRNAs; hsa-miR-15b-5p, hsa-miR-93-5p, and hsa-miR-130a-3p are considered to be potential key miRNAs.

Figure 1. Receiver Operating Characteristic curve, comparing chemosensitive/ resistant samples

PPI network and identification of hub genes The 1108 targets were utilized to set the PPI network by STRING. Consequently, we examined the STRING results by using Cytoscape, and 28 genes in the PPI network were recognized as hub genes (Figure 2). These hub genes included UBC, EGFR, MAPK1, RAC1, PTEN, HSPA8, BTRC, PPP2CA, SMURF1, RBBP7, SMAD3, STAT3, ITCH, CDC27, TGOLN2, CCND1, UBE2D2, ACTR2, PIK3R1, RAB5A, CUL3, VEGFA, CUL2, UBE2B, CLTA, UBE2V1, ESR1, and CUL5.

Figure 3. miRNA-hub genes regulatory network. Blue corresponds to the hub genes and green to the miRNAs

Discussion MicroRNAs (miRNAs) are small non-coding oligonucleotides which are capable of negatively regulating expression of mRNAs by inhibiting protein translation [16]. In recent years, miRNA profiling data sets have increased rapidly with the development of high-throughput techn iques, paving the way for bioinformatics studies. In this study, we detected hsa-miR-15b-5p, hsa-miR-93-5p, and hsa-miR-130a-3p as crucial regulators in chemoresistance of HSCC by using multivariate statistical analysis and bioinformatics approaches.

Figure 2. PPI network of 28 hub genes

Construction of miRNA-hub genes regulatory network Twenty-eight hub genes and their corresponding ten miRNAs

hsa-miR-15b-5p was shown to be differentially expressed in head and neck squamous cell carcinoma and concluded that this miRNA might be a potential biomarker for individualized treatment in this disease [17,18]. In a study, the different miR expression profiles between laryngeal squamous cell carcinoma and the surrounding normal tissues were compared using miR array. Among differentially expressed miRNAs, miR-93 was upregulated [19]. In a multidrug resistance study, microarray analysis showed that miR-93 was downregulated in multidrug-resistant Hep2/v cells compared with Hep-2 cells [20] and also hsa-miR-130a-3p was shown to be relevant for a response to cisplatin in esophageal squamous cell carcinoma [21]. Moreover, hsa-miR-130a-3p was highlighted in hepatocellular carcinoma drug resistance [22,23], and in-vitro as well as in-vivo studies showed that overexpression 162

doi: 10.5455/medscience.2019.08.9158

of this miRNA promoted the invasion, migration, and proliferation of nasopharyngeal carcinoma cells [24]. Conclusion In conclusion, by using bioinformatics approach, we suggested that hsa-miR-15b-5p, hsa-miR-93-5p, and hsa-miR-130a-3p might act as crucial regulators in chemoresistance of HSCC, and they might serve as prognosticators and therapeutic targets in the future. Competing interests The authors declare that they have no competing interest.

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10. Ru Y, Kechris KJ, Tabakoff B, et al. The multiMiR R package and database: integration of microRNAâ&#x20AC;&#x201C;target interactions along with their disease and drug associations. Nucleic Acids Res. 2014;42:e133-e133. 11. Huang DW, Sherman BT, and Lempicki RA Systematic and integrative analysis of large gene lists using DAVID bioinformatics resources. Nat Protoc. 2008;4:44. 12. Szklarczyk D, Gable AL, Lyon D, et al. STRING v11: protein-protein association networks with increased coverage, supporting functional discovery in genome-wide experimental datasets. Nucleic Acids Res. 2019;47:607-13.

Financial Disclosure There are no financial supports

13. Shannon P, Markiel A, Ozier O, et al. Cytoscape: a software environment for integrated models of biomolecular interaction networks. Genome Res. 2003;13:2498-504.

Ethical approval No ethic approvell is needed to this research.

14. Brenning A and Lausen B Estimating error rates in the classification of paired organs. Stat Med. 2008;27:4515-31.

Elif Pala ORCID: 0000-0002-1690-3170 Tuba Denkceken ORCID: 0000-0002-4663-5410

15. Fawcett T An introduction to ROC analysis. Pattern Recogn. Lett. 2006; 27:861-74.

References

16. Ma L and Weinberg RA MicroRNAs in malignant progression. Cell Cycle. 2008;7:570-2.

Takes RP, Strojan P, Silver CE, et al. Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery. Head & Neck. 2012;34:270-281.

Pointreau Y, Garaud P, Chapet S, et al. Randomized trial of induction chemotherapy with cisplatin and 5-fluorouracil with or without docetaxel for larynx preservation. J NTL Cancer I. 2009;101:498-506.

Vermorken JB, Remenar E, Van Herpen C, et al. Cisplatin, fluorouracil, and docetaxel in unresectable head and neck cancer. N Engl J Med. 2007;357:1695-704.

Lian M, Shi Q, Fang J, et al. In vivo gene expression profiling for chemosensitivity to docetaxel-cisplatin-5-FU (TPF) triplet regimen in laryngeal squamous cell carcinoma and the effect of TPF treatment on related gene expression in vitro. Acta Otolaryngol. 2017;137:765-72.

20. Yin W, Wang P, Wang X, et al. Identification of microRNAs and mRNAs associated with multidrug resistance of human laryngeal cancer Hep-2 cells. Braz J Med Biol Res. 2013;46:546-54.

Goksuluk D, Korkmaz S, Zararsiz G, et al. easyROC: An Interactive Webtool for ROC Curve Analysis Using R Language Environment. The R Journal. 2016;8:213-230.

21. Lindner K, Eichelmann AK, Matuszcak C, et al. Complex Epigenetic Regulation of Chemotherapy Resistance and Biology in Esophageal Squamous Cell Carcinoma via MicroRNAs. Int J Mol Sci. 2018;19:499.

Abdi H and Williams LJ. Principal component analysis.WIREs Comp Stats. 2010;2:433-59.

22. Xu N, Shen C, Luo Y, et al. Upregulated miR-130a increases drug resistance by regulating RUNX3 and Wnt signaling in cisplatin-treated HCC cell. Biochem. Biophys. Res. Commun. 2012;425:468-72.

Lachenbruch PA and Mickey MR. Estimation of error rates in discriminant analysis. Technometrics. 1968;10:1-11.

RStudio Team (2016). RStudio: Integrated Development for R. RStudio, Inc., Boston, MA.

Haunsberger SJ, Connolly NM, and Prehn JH miRNAmeConverter: an R/ bioconductor package for translating mature miRNA names to different miRBase versions. Bioinformatics. 2016;33:592-3.

17. Ahmad P, Sana J, Slavik M, et al. MicroRNA-15b-5p Predicts Locoregional Relapse in Head and Neck Carcinoma Patients Treated With Intensitymodulated Radiotherapy. Cancer Genom Proteom. 2019;16:139-46. 18. Ramdas L, Giri U, Ashorn C, et al. miRNA expression profiles in head and neck squamous cell carcinoma and adjacent normal tissue. Head Neck. 2009;31:642â&#x20AC;&#x201C;54. 19. Cao P, Zhou L, Zhang J, et al. Comprehensive expression profiling of microRNAs in laryngeal squamous cell carcinoma. Head Neck. 2013;35:7208.

23. Li B, Huang P, Qiu J, et al. MicroRNA-130a is down-regulated in hepatocellular carcinoma and associates with poor prognosisMed. Oncol. 2014;31:230. 24. Chen X, Yue B, Zhang C, et al. MiR-130a-3p inhibits the viability, proliferation, invasion, and cell cycle, and promotes apoptosis of nasopharyngeal carcinoma cells by suppressing BACH2 expression. Biosci Rep. 2017;37:BSR20160576.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):164-9

The relationship between stress response after trauma with anxiety and depression levels of syrian children Oguz Emre1, Aysegul Ulutas1, Ramazan Inci2, Burcu Cosanay3 Inonu University, Faculty of Health Sciences, Department of Child Development, Malatya, Turkey 2 Batman University, School of health, Department of Nursing, Batman, Turkey 3 Mus Alparslan University, Department of Health Services, Programme of Child Development, Mus, Turkey 1

Received 12 November 2019; Accepted 03 February 2020 Available online 07.03.2020 with doi: 10.5455/medscience.2019.08.9159

Abstract Witnessing many painful events such as war and systematic violence adversely affects children’s mental health and development. Refugee children are the most at-risk group with the incidence of Post Traumatic Stress Disorder. The aim of this study upon working group of refugee children victims of war was to investigate the relationship between post-traumatic stress responses and anxiety and depression levels of children living in Turkey. This descriptive study was designed according to relational survey model. The sample of the study consists of 224 Syrian children who were randomly selected among the children living in Turkey. In the research, “Revised Child Anxiety and Depression Scales Child Version (RCADS-CV)” and Child The Child Posttraumatic Stress Disorder Reaction Index (CPTS-RI) ”data collection tools were used. To analyze the study data, Pearson Product Moment Correlation coefficients and frequency and percentage were used as descriptive statistical methods. As a result of the study, a positive, high and significant relationship was found between the total post-traumatic stress response levels and anxiety and depression levels of children (p <.05). Keywords: Refugee children, childhood trauma, depression and anxiety

Introduction Migration, which is as old as the history of humanity, has caused an increasing number of refugees and asylum seekers in the international arena as a result of war and similar conflicts in recent years. United Nations High Commissioner for Refugees report shows that 65.6 million people have been displaced worldwide due to persecution, conflict or human rights violations that have reached a record high level in the last decade [1]. Children constituting 31% of the global population accounts for 51% of all displaced persons by main force [1,2]. In particular, about seven million Syrians who have been forced to leave the country due to the civil war in Syria since 2011 constitutes the most recent immigrant group [3]. At least half of the refugees from Syria are children of the age group 0-18. This immigration, which is compulsory by families and children, has the same meaning in itself. Migration is a change of place where they are forced to live all or part of their future life [4]. This process can be defined as

*Coresponding Author: Oguz Emre, Inonu University, Faculty of Health Sciences, Department of Child Development, Malatya, Turkey, E-mail: oguz.emre@inonu.edu.tr

the families and children who have very good living conditions in their own countries and suddenly begin to enter into psychological problems and collapses in which they find themselves in troubles and distresses. Stress and collapse are already expected and usual [5]. However, what needs to be done after this is to provide assistance by experts in various fields to prevent psychological crises and to take steps to improve the process. Nevertheless, owing to the fact that it is reported that a certain proportion of the refugees who have migrated to a country have gone to a certain proportion in 17 years even in the presence of peace in their country, these children, who will become adults of the future, will continue to undergo significant changes in the course of the country if the tragedy is not sustained. [6]. Traumatic events such as war and migration, which refugees have to experience, are often associated with stress factors in displacement, deterritorialization, migration and resettlement processes [7]. The most affected group of these stress factors is unaccompanied children who migrate alone without parents or adults. Refugee children constitute the group at greater risk of exposure to the effects of war (violence, torture, death, famine, forced migration, etc.) than the general population [8, 9]. In addition, children experience severe injuries and deaths during and after war or migration with their closest relatives, other relatives and acquaintances such as friends and neighbors, and these events leave traces that are difficult to erase. 164

doi: 10.5455/medscience.2019.08.9159

These experiences are sometimes due to ethnic backgrounds and sometimes the things they cannot determine such as religion and language by themselves. It is a pity that children have always been at the center of these events, but they have never been considered and exploited as much [10]. When the studies in the literature are examined, social communication disorders, loss of social communication, crisis and psycho-social difficulties, traumas and effects that occur in children due to negative experiences such as war and forced migration are seen with stress disorder in addition to depression and anxiety. The frequency of emotional symptoms is reported. The most common post-traumatic stress disorder (PTSD) in children under 14 years of age [11] In a systematic review of the studies on the mental health of refugees and asylum seekers, the prevalence of post-traumatic stress disorder (PTSD) among refugee and asylumseeker children is 20% to 84% higher in European countries [12]. Due to the forced migration, 45% of the refugee children in Turkey are PTSD and that children who have been exposed to war-related traumatic events (violence, witnessing violence, rape, abuse, etc.) developed PTSD a few years after their migration have been detected, and the findings of a study based on these results a Syrian refugee camp in Turkey were found to be consistent with [13]. These conditions known as childhood trauma are considered as the general name of physical abuse, sexual abuse, psychological abuse, physical neglect and emotional neglect in individuals. If we open this definition then; damaging physical, emotional and mental development or disallowing is regarded as exploitation while feeding, housing, maintenance and education are considered as negligence (www.multeciler.org.tr). Even though child and adolescent health experts argue that more attention should be paid to the mental health of young migrants and refugees, studies to date have generally focused on issues such as education, physical health and infectious diseases of refugees. The reason for this is shown as the difficulty of applying psychometric tools during a highly variable situation in cases of mass migration or natural disasters. In addition, forced migration from such natural factors makes it difficult to access even the basic survival needs (food, shelter, etc.) in a safe way, while it is difficult to prioritize mental health needs. Research on refugee children has identified posttraumatic stress disorder as the most common problem followed by depression. Refugee children also tend to have a higher level of behavioral or emotional problems, including aggression and other emotional disorders [14]. The aim of this study is to investigate the effects of war and immigration on children, as the studies on the mental health of refugee children gain importance day by day. Upon trying to look at the information and other aspects that are not in the studies within the literature, the findings and results will be discussed and various suggestions will be made for the next generation. The aim of this study was to investigate the relationship between post-traumatic stress responses and anxiety and depression levels of children living in a refugee camp. For this general purpose, answers are sought to the following questions: • What are the post-traumatic stress response levels of children? • Is there a meaningful relationship between post-traumatic stress response levels and anxiety and depression levels of children?

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Materials and Methods Research Model This descriptive study was designed with relational survey model. In the relational screening method, it is possible to infer the causeeffect relationship between the variables and complex methods [15]. Population and Sample The study population consists of 1350 children living in a refugee camp in the province of Malatya, Turkey. Selected by the criterion sampling method from the study population, the sample consists of 224 children in the 13-16 age group, who are victims of war and who have been forced to migrate. Demographic information about the children in the study group is presented in Table 1. When Table 1 is analyzed, it indicates that 50% of children are girls and 50% are boys; 71.4% are in the 16 age group; 62.5% have 5 or more siblings; 97.8% of the mother is alive; 91.5% of his father is alive. Table 1. Demographic Information on Children n

Female

112

Male

112

Gender

Age Age 13

7.6

Age 14

13.4

Age 15

7.6

Age 16

160

71.4

1 Sibling

2.2

2 Siblings

4.5

3 Siblings

12.9

4 Siblings

17.9

≥5 Siblings

140

62.5

Number of Siblings

Mother alive or not Dead

2.2

Alive

219

97.8

Dead

8.5

Alive

205

91.5

Total

224

100

Father alive or not

Data Collection Tools The General Information Form contains questions about the age, sex, number of siblings and whether or not the child’s parents are alive. Posttraumatic Stress Response Scale for Children: The posttraumatic stress response scale (CTSS-TÖ) for children was developed by Pynoos et al. [16] in order to evaluate the stressors that occur after a specific trauma situation in children and adolescents. Each item of this 20-item Likert-type semi-structured 165

doi: 10.5455/medscience.2019.08.9159

scale scores between 0 and 4 according to the severity of the symptom. A high score indicates that the child is highly affected by the trauma experienced. Pynoos et al. [22] conducted the first application of the scale on children who were exposed to sexual harassment, physical abuse and a nuclear accident, and then the scale was revised and applied to children who had experienced this trauma in an armed conflict and the scale was finalized. ÇTSS-TÖ was revised by Pynoos & Nader [23] and the scoring was finalized. In the validity study, the criterion validity was found to be .91 between the data obtained from the scale and the clinical diagnosis according to DSM III-R criteria [24]. The Turkish adaptation and validity-reliability study of the scale was conducted by Erden et al. [24]. The Anxiety and Depression Scale in Children-Refurbished (ÇADÖ-Y): The scale developed by Spence [19] to evaluate depression and anxiety disorders in children based on DSM-IV diagnostic criteria was revised by Chorpita et al. [20]. It has been finalized as a 5-point Likert-type scale with 47 items. The subdimensions included social phobia (9 items), separation anxiety (7 items), generalized anxiety disorder (6 items), major depression (10 items), and obsessive compulsive disorder (6 items). The questions created to determine the level of anxiety and depression of children are asked to be marked as 0 = never, 1 = sometimes, 2 = frequently, 3 = always 4 degrees. The Turkish adaptation and validity-reliability study of the scale was conducted by Görmez et al. [21].

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Data Analysis To analyze the study data, Pearson Product Moment Correlation coefficients and frequency and percentage were used as descriptive statistical methods. The compatibility of the scale scores of the scales to normal distribution was analyzed by KolmogorovSmirnov (n> 50) test and parametric tests were applied since the variables were distributed normally. Cronbach’s Alpha coefficients were calculated for reliability analysis of the scales. Statistical significance level (�) was taken as 5% in the calculations and SPSS (IBM SPSS for Windows, Ver.24) package program was used for the calculations. According to the reliability analysis of the answers given to the scale questions; The Cronbach’s Alpha value of the Posttraumatic Stress Response Scale for Children was 0.82 and the Cronbach’s Alpha value of the Anxiety and Depression Scale in Children was calculated as 0.95. Results When Table 2 is examined, we can see “general descriptive statistics belonging to scale scores”. According to this, in the scale study conducted on 224 children, the mean of the RCADS-CV scores were 102.5, and the mean of the CPTS-RI scores were 46.4. The scores obtained from the RCADS-CV scale ranged between 74 and 163. The scores obtained from the CPTS-RI scale ranged from 20 to 92.

Table 2. The distribution of scales scores SAD

OCD

GAD

MDD

RCADS-CV

CPTS-RI

Mean

14.5268

20.1607

13.9286

17.9821

14.6429

21.2902

102.5313

46.4063

Median

14.0000

20.0000

14.0000

17.0000

14.0000

21.0000

101.0000

44.5000

Std. Dev.

3.59985

3.75972

2.99091

4.34495

2.82480

4.10956

14.85261

13.62009

Minimum

9.00

10.00

7.00

12.00

9.00

13.00

74.00

20.00

Maximum

45.00

38.00

22.00

34.00

26.00

36.00

163.00

92.00

Separation anxiety disorder (SAD), Panic disorder (PD), Revised Child Anxiety and Depression Scales Child Version (RCADS-CV) Social phobia (SP), Generalized anxiety disorder (GAD), The Child Posttraumatic Stress Disorder Reaction Index (CPTS-RI) Obsessive-compulsive disorder (OCD), Major depressive disorder (MDD) Table 3. Descriptive statistics and correlation analysis findings on variable and subdimensions 1

.27*

.33**

.27**

.51**

.34**

.27**

.31**

.28**

.39**

.44**

.38**

.30**

.44**

.46**

.70**

.64**

.56**

.75**

.63**

.76**

.46**

.36**

.39**

.56**

.47**

.55**

.69**

Maximum

45.00

38.00

22.00

34.00

26.00

36.00

163.00

92.00

**p<.01; *p<.05; N=224 1-Separation anxiety disorder (SAD), 2- Social phobia (SP), 3-Obsessive-compulsive disorder (OCD), 4-Panic disorder (PD), 5- Generalized anxiety disorder (GAD), 6. Major depressive disorder (MDD) 7- Revised Child Anxiety and Depression Scales Child Version (RCADS-CV), 8-The Child Posttraumatic Stress Disorder Reaction Index (CPTS-RI)

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When Table 3 is examined; correlation analysis findings related to variables are seen. A positive, high and significant relationship was found between the post-traumatic stress response levels and anxiety and depression scores (r=.69; p<.01). There was a positive, moderate and significant relationship between the total posttraumatic stress response levels of the children and the anxiety and depression subscale scores of Panic Disorder (PD) (r=.56; p<.01) and Major Depression Disorder (MDD) (r=.55; p<.01). There was a positive, weak and significant relationship between Social Phobia (SP) subscale and Separation Anxiety (SAD) (r=.27; p<.05). Obsessive Compulsive Disorder (OCD) subscale and Separation Anxiety (SAD) (r=.33; p<.01) and Social Phobia (SP) (r=.27; p<.01) revealed a positive, significant and weak relationship. Panic Disorder (PD) and Separation Anxiety (SAD) were positive, moderate and significant; Social Phobia (SP) (r=.51; p<.01) and Obsessive Compulsive Disorder (OCD) (r=.27; p<.01) subscales revealed a positive, significant and weak relationship. There was a positive, significant, weak relationship among the General Anxiety Disorder (GAD) subscale and Social Phobia (SP) (r=.31; p<.01), Separation Anxiety (SAD) (r=.27; p<.01), Obsessive Compulsive Disorder (OCD) (r=.28; p<.01) and Panic Disorder (PD) (r=.39; p<.01). There was a positive, significant and moderate relationship among Major Depression Disorder (MDD) sub-dimension and Separation Anxiety (SAD) (r=.44; p<.01), Panic Disorder (PD) (r=.44; p<.01) and Generalized Anxiety Disorder (GAD) (r=.46; p<.01). When Figure 1 is analyzed, the distribution of post-traumatic stress response levels of children is seen. That 1.3% of children had none, 32.6% had mild, 49.1% had moderate, 17% had severe post-traumatic stress response has been determined.

Figure 1. Distribution of post-traumatic stress response levels of children

Discussion The so-called Arab Spring, the anti-regime protests that broke out in Syria in 2011, created one of the biggest human crises in the world [22]. People with their families were forced to emigrate to neighboring countries to escape war, persecution and violence. The ongoing war and violence in Syria have caused many tragedies and problems on Syrians.Children and adolescents are the most vulnerable group [23].

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In this study; the fact that 1.3% of children had mild, 32.6% had moderate, 49.1% had severe, 17% had very severe post-traumatic stress response has been determined. In another study in which the sample included 105 unaccompanied refugees, the prevalence of psychological disorders was investigated. The most common discomfort was 42% depression, 35% behavior disorder and 32% Posttraumatic Stress Disorder [24]. In the study on refugee children who were victims of war, a positive, high and significant relationship was found between the total score of post-traumatic stress response levels and anxiety and depression levels of children (p <.05). This result is similar to the research results. According to the results of the World Health Organization’s (WHO) survey of Syrian Refugees in 2015, the vast majority of refugees have directly been experiencing the violence of war. Approximately 70% of the respondents stated that they lost a relative, more than 50% were in the middle of the war, and 50% lost their homes [25]. Adverse events experienced during escape and migration and their exposure to a traumatic event affect people’s mental health and psychology negatively [26]. Refugees and asylum-seekers constitute the risk group for Post-Traumatic Stress Disorder due to their negative effects during war or escape [27,28]. Similarly, Systematic Violence causes high post-traumatic stress and then triggers post-traumatic stress disorder [29]. Physical violence and negative experiences gained in war increase the risk of anxiety, stress and depression [30]. In a study conducted with Bosnian refugees; there was a positive relationship between the amount of exposure to war and anxiety and stress levels [31]. After trauma, the most common disorders in children are sleep and anxiety disorders [32]. Another finding of the study revealed that there was a positive, moderate and significant relationship between the total posttraumatic stress response levels and anxiety and depression scale subscale scores of Panic Disorder (PD) and Major Depression Disorder (MDD). In other words, that the refugees fleeing the war are exposed to violence and various stressful situations in their country of origin has been causing severe psychiatric damage on them [10]. Traumatic events experienced by adults also affect the child’s mental health [33]. Negative life experiences during the war are damaging children’s mental health and development in the long run [34]. Researches on refugee children in recent years have emphasized that children experience sleep disturbance, stress and various psychological disorders due to traumatic events [35]. In a qualitative study conducted with 55 children aged 11 to 17 in the refugee camp in Germany, it is stated that the current psychological stress in exile is high in addition to past psychological stress. Family-related problems in exile have been found to be highly associated with current mental health problems [36]. In a retrospective study conducted in Germany, psychological disorders of unaccompanied refugee children were investigated. It was found that 56 (75%) of 75 children participated in the study had psychological disorders. The most common disorders are posttraumatic stress disorder and depressive episodes [37]. It is known that refugees have problems in exchanging healthy information about social and cultural integration and asylum processes. Researches conducted in war zones state that children’s mental health is bad due to violence and similar negative experiences and they should be treated [27]. Therapy methods and intervention programs are developed and implemented for refugee children 167

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who experience post-traumatic stress and helplessness [38]. While pedagogical professional approaches by traumatized children are important for teachers in the countries of migration [39], teachers’ knowledge and skills should be increased in their approach to these children [40]. Through the Provincial Directorates of Family, Labor and Social Services, it is recommended to identify the children who are victims of war and who are experiencing trauma and to improve their quality of life with psychotherapy. The public policy makers in Turkey should aim to raise child welfare to higher levels by establishing specialized centers for war-victim children, who are the adults of the future, and by employing professionals in these centers.

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J Nervous Mental Disease 2007;195:288–97. 12. Curtis P, Thompson J, Fairbrother H. Migrant children within Europe: A systematic review of children’s perspectives on their health experiences. Public Health. 2018;158:71-85. 13. Sirin S, Rogers-Sirin L. The educational and mental health needs of Syrian refugee children. Migration Policy Institute, Washington DC, 2015. 14. Henley J, Robinson J. Mental health issues among refugee children and adolescents. Clin Psychologist. 2011;15:51-62. 15. Fraenkel JR, Wallen NE. How to design and evaluate research ineducation,Seventh Edition, New York: McGraw-Hill Companies, 2011.

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

16. Pynoos RS, Frederick C, Nader K, et al. Life threat and posttraumatic stress in school-age children. Arch Gen Psychiatry. 1987;44:1057-63.

Financial Disclosure There are no financial supports

17. Pynoos RS, Goenjian A, Tashjian M, et al. Post-traumatic stress reactions in children after the 1988 Armenian earthquake. British J Psychiatry. 1993;163:239-47.

Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki. Oguz Emre ORCID: 0000-0001-6810-3151 Aysegul Ulutas ORCID: 0000-0002-6497-6534 Ramazan Inci ORCID: 0000-0002-6855-4574 Burcu Cosanay ORCID: 0000-0002-8337-3851

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Canada’s 2016 record high level of resettlement praised by UNHCR. Geneva, Switzerland: http://www.unhcr.org/news/press/2017/4/58fe15464/ canadas-2016-record-high-level resettlement-praised-unhcr.html access date 22.00.2019

Santiago AM, Smith RJ. Community practice with immigrant and refugee populations: responding to a growing human rights crisis. J Community Practice. 2019;27:1-4

18. Erden G, Kılıç EZ, Uslu R, et al. Çocuklar için travma sonrası sress tepki ölçeği: Türkçe geçerlilik, güvenilirlik ön çalışması. Çocuk ve Gençlik Ruh Sağlığı Dergisi. 1999; 6(3): 143-49. 19. Spence SH. A measure of anxiety symptoms among children. Behav Res Ther. 1999;36:545-66. 20. Chorpita BF, Yim L, Moffitt C, et al. Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behav Res Ther. 2000;38:835- 55. 21. Gormez V, Kılınçaslan A, Orengul AC, et.al. Psychometric properties of the Turkish version of the Revised Child Anxiety and Depression Scale–Child Version in a clinical sample. Psychiatry Clin Psychopharmacol. 2017;27:8492. 22. Buhmann CB, Nordentoft M, Ekstroem M, et al. Long-term treatment effect of trauma-affected refugees with flexible cognitive behavioural therapy and antidepressants. Psychiatry Res. 2000;264:217-23. 23. Sierau S, Nesterko Y, Glaesmer H. Herausforderungen im Fluchtprozess unbegleiteter Jugendlicher. Kindheit und Entwicklung. 2019;28:139-46.

Alaoui KEM, Scruby L. Posttraumatic Stress Disorder Among Refugees. J Nurse Practitioners. 2019;15;339-32.

Goldin S, Levin L, Persson LÅ, et al. Child war trauma: a comparison of clinician, parent and child assessments. Nordic J Psychiatry. 2003;57:173-83.

Chung MC, AlQarni N, Al Mazrouei M, et. al. The impact of trauma exposure characteristics on post-traumatic stress disorder and psychiatric co-morbidity among Syrian refugees. Psychiatry Res. 2018;259:310-5.

Fazel M, Reed RV, Panter-Brick C, et al. Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors. Lancet. 2012;, 379: 266–282.

Kirmayer LJ, Narasiah L, Munoz M, et.al. Common mental health problems in immigrants and refugees: General approach in primary care. Canadian Med Association J. 2011;183:959-67.

27. Ruf M, Schauer M, Elbert T. Prävalenz von traumatischen Stresserfahrungen und seelischen Erkrankungen bei in Deutschland lebenden Kindern von Asylbewerbern. Zeitschrift für klinische Psychologie und Psychotherapie. 2010;39:151-60.

Wilson RM, Murtaza R, YB. Pre-migration and post-migrationdeterminants of mental health for newly arrived refugees in Toronto. Canadian Issues: Immigrant Mental Health, Summer. 2010;45–50.

28. Neuner F, Kurreck S, Ruf M, et al. Can asylum-seekers with posttraumatic stress disorder be successfully treated? A randomized controlled pilot study. Cognitive Behaviour Therapy. 2010;39:81-91.

10. Kılınç G, Yıldız, E, Harmancı P. Toplumsal Travmatik Olaylar ve Aile Ruh Sağlığı. Turkiye Klinikleri Psychiatric Nursing-Special Topics. 2017;3:182-8.

29. Hensel-Dittmann D, Schauer M, Ruf M, et.al. Mental health of detained asylum seekers. Lancet. 2016;362:1721-3.

11. Bean T, Derluyn I, Eurelings-Bontekoe E, et al. Comparing psychological distress, traumatic stress reactions, and experiences of unaccompanied refugee minors with experiences of adolescents accompanied by parents. The

30. Cardozo BL, Talley L, Burton A, etal. Karenni refugees living in Thai– Burmese border camps: traumatic experiences, mental health outcomes, and social functioning. Social Sci Med. 2004; 58:2637–44.

24. Sierau S. Psychische Belastungen unbegleiteter junger Flüchtlinge sindhoch. Fortschr Neurol Psychiatr. 2019;87:407-8. 25. Handicap İnternational Kriegstraumata: eine tickende Zeitbombe für Gesellschaften im Wiederaufbau. https://handicap-international.de/de/ neuigkeiten/kriegstraumata-einetickende-zeitbombe-fur-gesellschaften-imwiederaufbau access date 20.08.2019. 26. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365:1309–14.

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31. Begic S. Mcdonald, WT. The Psychological effects of exposure to wartime traumain bosnian residents and refugees: implications for treatment and service provision. Int J Ment Health Addiction. 2006;4:319– 29.

36. Gavranidou M, Niemiec B, Magg B, et al. Traumatische Erfahrungen, aktuelle Lebensbedingungen im Exil und psychische Belastung junger Flüchtlinge. Kindheit und Entwicklung. 2008;17:224-31.

32. Winklhofer C. Flucht Und Trauma im pädagogischen Kontext. Eine Broschüre zur Unterstützung von Pädagoginnen und Pädagogen im Umgang mit Kindern und Jugendlichen mit Fluchterfahrung. Medieninhaber und Herausgeber: Pädagogische Hochschule Salzburg Stefan Zweig, 2017.

37. Walg M, Fink E, Großmeier M, et al. Häufigkeit psychischer Störungen bei unbegleiteten minderjährigen Flüchtlingen in Deutschland. Zeitschrift für Kinder-und Jugendpsychiatrie und Psychotherapie. 2016; 44:1-9.

33. Ruf-Leuschner M, Roth M, Schauer M. Traumatisierte Mütter –traumatisierte Kinder? Eine Untersuchung des transgenerationalen Zusammenhangs von Gewalterfahrungen und Traumafolgestörungen in Flüchtlingsfamilien. Zeitschrift für Klinische Psychologie und Psychotherapie. 2014;43:1-16. 34. Nelson CA. Carver LJ. The effects of stress and trauma on brain and memory: A view from developmental cognitive neuroscience. Dev Psychopathol. 1998;10:793–809. 35. Asefaw F, Bombach C. In der Schweiz lebende Minderjährige mit Fluchterfahrungen. Swiss Arch Neurol Psychiatry Psychotherapy. 2018;169:171-80.

38. Dixius A, Möhler E. Ein neues Therapie-Konzept validiert die besonderen Bedürfnisse geflüchteter Kinder und Jugendlicher: START. Psychotherapie Forum. 2017;22:76-85. 39. Lanfranchi A. Kinderaus Kriegsgebieten ineuropäischen Einwanderungsländern Trauma, Flucht, Schule und Therapie. Symposium 11„Kultur und Trauma“. V. Europäisches Kongress für Familientherapie und Systemische Praxis, Berlin 1.10.04, 2004 40. Ellerbrock B, Petzold HG Traumatisierte Kinder. Einsatz der Traumapädagogik in der Kita. Kindergarten Heute. 2014;9:8-14.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):170-4

Stress and recurrent aphthous stomatitis Isil Cakmak Karaer1, Ayca Urhan2, Ismail Reyhani3 1 Malatya Training and Research Hospital, Ministry of Health , ENT Clinic, Malatya, Turkey Ministry of Health, Malatya Training and Research Hospital, Clinic of Biochimestry, Malatya, Turkey 3 Inonu University Faculty of Medicine, Department of Health Services, Programme of Child Development, Mus, Turkey 2

Received 25 December 2019; Accepted 02 February 2020 Available online 03.03.2020 with doi: 10.5455/medscience.2019.08.9160

Abstract Recurrent aphthous stomatitis (RAS) is a commonly-encountered oral lesion. The aim of this study was to identify the levels of stress, anxiety and depression in patients with RAS .Fourty (40) patients with RAS and 40 age-matched controls were enrolled in this study. Blood and salivary levels were analyzed electrochemiluminescence technique. The Beck Depression Rating Scale (BDRS) and Beck Anxiety Scale (BAS), Perceived Stress Scale (PSS), and State-Trait Anxiety Inventory (STAI-S and STAI-T) were applied to all participants. There was no statistically significant differences levels between two groups regarding to BDRS, BAS, PSS, STAI-S and STAI-T level. Blood cortisol levels were statistically significantly higher in patients with RAS than controls (12.45 ± 0.74 µg/dL vs. 9.8± 0.68,respectively,p=0.01), wheras there was no statistically significant difference between women with RAS than controls regarding to salivary cortisol levels (0.33± 0.03 µg/dL vs. 0.34± 0.03, respectively. Patients with RAS have not higher depression and anxiety levels compared to the control. Keywords: Aphthous stomatitis, anxiety, stress, depression, free cortisol, salivary cortisol

Introduction Recurrent aphthous stomatitis (RAS) is a painful situation occurring as oral mucosal ulcers which negatively affect quality of life. It has been reported that the prevalence of RAS iaround20% [1]. Classically, self-limiting ulcers are observed in non-keratinizing oral mucosa. After 24-48 hours of prodromal findings of pain and burning, the clinical scene begins to progress [2]. There are three clinical subtypes based on the shape and spread of the ulcers: minor, major and herpetiform RAS [3]. In the literature, though many factors have been shown as a cause of RAS such as genetics, nutrition, local trauma, allergies, endocrine disease, changes in oral microbiota (disruption of flora), and quitting smoking, the definite cause is not fully known [4-6]. The general opinion is that RAS is triggered by stress and anxiety [7].

*Coresponding Author: Isil C. Karaer, Malatya Training and Research Hospital, Hastane street no:44, postal code:44623 Department of Otolaryngology, Malatya, Turkey, E-mail: isilkaraer@gmail.com

The Beck depression rating scale (BDRS) and Beck anxiety scale (BAS) are tests commonly used around the world to determine the presence and severity of anxiety and depression [8-10]. To measure for anxiety levels, Spielberger’s state-trait anxiety inventory (STAI-S and STAI-T) comprises the STAI-T providing a general view of personality constructs and the STAI-S assessing anxiety in specific situations. The perceived stress scale (PSS) is the most widely used psychological instrument for measuring the perception of stress. It is a measure of the degree to which situations in one’s life are appraised as stressful [11]. Cortisol is released from the adrenal cortex and is accepted as a stress marker; another name for it is the stress hormone. In humans, stress and anxiety levels can be identified with free blood and salivary cortisol levels. The literature shows that salivary cortisol is more valuable than free cortisol in blood as a stress indicator [12]. In addition to, blood is invasive to collect and may be painful when compared to saliva. In adition to, the sampling is easier than blood sa . The aim of this study was to determine whether a association 170

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between between RAS and the levels of depression, anxiety, stress, blood cortisol and salivary cortisol. Materials and Methods A prospective case–control study was carried out in the Department of Otolaryngology, Malatya Training and Research Hospital. Data were collected between September 2016 and September 2017 after obtaining informed consent from the subjects. A total of 80 patients were included in the study. Study population The study involved two groups. Group 1 was the RAS group, which comprised 40 patients (16 males and 24 females) with a mean age of 34.7±2 (min 15- max 63) years(y). The control group comprised 40 patients (14 males and 26 females) with a mean age of 36.08±2.1 (min 15-max 62) y. All study participiants had minor RAS form (surficial, oval ulcers in buccal mucosa, smaller than 10 mm, localized to the tongue and pharynx). Only patients with RAS complaint with incidence of at least two per month during at least two years were included in the study. The exclusion criteria is major and herpetiform RAS , cigarette smoking smokers, those using any medication like steroids or oral contraceptives, with systemic and immunological disorders (such as Behçet disease) , any vitamin deficiency or anemia. The controls comprised individuals with no active RAS and no history of RAS, who were healthy with no systemic disease and no medication use. Psychoanalytic Tests Beck Depression Rating Scale (BDRS) and Beck Anxiety Scale (BAS), Perceived Stress Scale (PSS), and State-Trait Anxiety Inventory (STAI-S and STAI-T) were applied to all study participants. Study partipiants were given information about the study protocol and provided informed consent before being given the form prepared by the researchers and requested to complete it fully. In this way, the sociodemographic characteristics of cases were determined. With the aim of determining the anxiety levels of cases, the Spielberger State-Trait Anxiety Inventory (STAI-T) and Spielberger Perceived Stress Scale (STAI-S) were used, each scala comprising 20 questions [8]. For both scales, 4 answer choices were present with weight varying from 1 to 4. The scales included 2 types of statement; direct or plain statements and inverse statements. The state anxiety scale includes 10 inverse statements, while the trait anxiety scale includes 7 inverse statements. Points for direct and inverse statements are collected separately and the total weighted points for inverse statements are subtracted from the total weighted points obtained from direct statements. This number has a fixed value added, previously determined as 50 for the state anxiety scale and 35 for the trait anxiety scale. The value is the individual’s anxiety points which determine the anxiety level. With the aim of determining the depression levels of cases, the Beck Depression rating scale (BDRS) was used. The BDRS is a selfassessment scale comprising 21 items which measures symptoms seen in depression. Each question has four answer choices with weight degrees from 0 to 3. According to cut-off points of 17 for the scale, those with points above this value are assessed as being at risk of clinical depression [9]. The Basel Beck Anxiety scale

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(BAS) was developed by Beck et al. with the aim of determining the incidence of anxiety symptoms experienced by individuals and is a self-assessment scale. It comprises 21 items with Likert-type responses and points from 0-3 [10,11]. Salivary and Serum Cortisol analysis All patients had blood and saliva samples taken during the active period of the disease. Salivary and serum samples of study participants were obtained in the early morning (9 to 10 a.m.). Saliva samples were collected by special saliva tubes (Salivette Cortisol, Sarstedt, Sevelen, Switzerland).All samples were collected at least 8-10 hours fasting. At the time of saliva collection, the couples were warned to avoid drinking, eating, and tooth brushing in the first 30 min, and avoid drinking milk or coffee in the first 60 min after waking up.. All saliva samples were stored at -80 °C until analysis. Salivary and serum cortisol levels were analyzed by the electrochemiluminescence technique (Cobas 6000, E601 analyzer, Roche Diagnostic, Germany). Cortisol levels were expressed as microgram per deciliter (µg/dL). The measurement ranges are 0.054-63.4 μg/dL according to the manufacturer’s protocol. Statistical analysis All analyses were conducted using SPSS 15.0 (SPSS® for Windows 15.0, Chicago, USA). The data were distributed not normally according to the one-sample Kolmogorov–Smirnov test. The variables were expressed as the mean ± SD. Comparisons of all parameters were carried out using the Mann–Whitney U test. Multiple comparisons were carried out using Spearman’s test. A two-tailed p<0.05 was considered statistically significant. Results The mean age of the patients with RAS was 34.7±2.06 (min 15max 63) years(y), wheras the mean age of controls was 34.2± 2.5 (min 15-max 62) y. When the mean ages of patients with RAS were compared with controls, there was no statistically significant difference (p=0.61). The mean BDRS points was 14.7±1.6, in patients with RAS and mean 11±1.3, in controls (p=0.187). BAS points were mean 15.1±1.9, in Group RAS and mean 10±1.7, in the controls (p=0.106). The PSS points were mean 19.2±1.05, in Group RAS and mean 17.5±1.05, in the controls(p=0.390). The STAI-S points were mean 39.5±1.49, in Group RAS and mean 37.9±1.4, in the controls (p=0.461). The STAI-T points were mean 47±1.2, in Group RAS and mean 46.4±1.5, in the controls(p=0. 760). Between both groups, there were no statistically significant differences identified for BDRS, BAS, PSS, STAI-S and STAI-T test results. Laboratory and psychoanalysis findings for both groups are presented in Table 1. The mean free blood cortisol value was 12.45 ± 0.74 µg/dL in group RAS, while the mean free blood cortisol values were 9.8± 0.68 µg/dL, in controls. The mean salivary cortisol value was 0.33± 0.31 µg/dL, in group RAS. The mean salivary cortisol value was 0.34± 0.35 µg/dL, in controls (Figure 1 and 2). There was a statistically significant difference in the free cortisol values in group RAS and controls (p=0.011). On the contrary,there was no statistically significant difference between patients with RAS and the controls regarding to salivary cortisol levels (p=0.82). There was not statistically correlation free cortisol and salivary cortisol level between psychoanalytic tests. 171

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Table 1. Clinical characteristics , laboratory profile and Psychoanalytic Tests results of study participants SAD

OCD

34.7 ± 2.0

36.08 ±2.1

0.61

24/16(60%/40%)

26 /14 (%65/%35)

Free cortisol (µg/dL )

12.4± 0.74

9.8 ± 0.6

0.011*

Salivary cortisol (µg/dL)

0.33± 0.03

0.34± 0.03

0.827

BDRS

14.7± 1.6

11 ± 1.3

0.187

BAS

15.1± 1.9

10 ± 1.7

0.106

PSS

19.2± 1.05

17.5 ± 1.04

0.390

STAI-S

39.5± 1.49

37.9 ± 1.4

0.461

STAI-T

47± 1.20

46.4 ± 1.5

0.760

Age(y) Female/Male

Beck Depression Rating Scale ( BDRS ), Beck Anxiety Scale (BAS), Perceived Stress Scale (PSS), State-Trait Anxiety Inventory (STAI-S and STAI-T) results shown that mean± standard deviation , * p<0.05

Discussion In this study, there was no statistically significant difference between BDRS, BAS, PSS, STAI-S and STAI-T value in both groups.. When the patients with RAS compared to controls, there was no statistically significant difference between any of the psychoanalytic test results.The blood cortisol levels of patients with RAS was statistically significant higher than controls. However, there was no statistically significant difference between two groups regarding to salivary cortisol levels.

Figure 1. Blood Free cortisol levels (µg/dL) in patients with Recurrent Aphthous Stomatitis (RAS) and in control group

Figure 2. Salivary cortisol levels (µg/dL) in patients with Recurrent Aphthous Stomatitis (RAS) and in control group

It is considered that RAS activation is associated with stress and anxiety, with more frequent recurrence in stressful situations [13-15]. Gallo et al. applied a psychoanalytic test created by the Psychology Institute of Sao Paulo University (Symptoms of Stress List; SSLVAS questionnaire) to RAS patients. Compared to the controls , patients with RAS were found to experience higher psychological stress in the acute period. [16] Zadik et al. compared patients with aphthous stomatitis without RAS history with patients with RAS they found that patients with RAS had higher both anger and anxiety level [17]. A study by Huling et al. applied the Recent Life Changes Questionnaire (RLCQ) with mental and physical stressor components to 160 patients with RAS . This study found that patients with experienced RAS attack when faced with mental stress rather than physical stress. However, they stated the presence of stress did not affect the duration of active period of RAS [7]. Similarly, Keennan et al. applied the Recent Life Changes Questionnaire (RLCQ) to patients with RAS .they stated that mental stressors were more effective on RAS activation than physical stressors; however, the stress severity did not affect the duration and frequency of RAS [18]. Kandagal et al. monitored 278 patients with anxiety and 398 patients with depression. In this study, the Hamilton anxiety and depression scale were applied. The patients’ results were compared with 676 controls. In the 6-month follow-up duration, 20% of patients with anxiety and 9% of patients with depression experienced RAS. The RAS rate in the control group was stated to be 5%. In conclusion, they stated that anxiety and depression had a definite place in the etiology of RAS [19]. Contrary to this study , the study by Varkal et al. applied the STAI-S, STAI-T and Beck depression inventory to RAS patients. The STAI-S test results were higher for patients 172

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with RAS; however, there was no difference identified in terms of depression among patients with RAS [20]. In aggrement with this study, other studies found no significant association between depression and RAS [12,13].

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

A study by Karthikeyan et al. investigated the blood, salivary and urinary cortisol levels in 30 patients with RAS and 30 patients with oral lichen planus . The blood, salivary and urinary cortisol levels were higher in patients with RAS than controls [21]. AlbanidouFarmaki et al. found that Patients with RAS had higher both blood and saliva cortisol levels than controls [22]. However, Valle et al. found no statistically significant difference between patients with RAS and controls regarding to salivary cortisol levels [23]. A study by Nadendla et al. investigated the salivary cortisol and Hamilton anxiety scale points. They identified both salivary cortisol levels and anxiety levels in patients with RAS were higher compared to the controls [24]. Another study compared the salivary cortisone levels, Hamilton anxiety rating scale (HARS) and Hamilton depression rating scale (HDRS) and compared psychoanalytical test results with the control group. The results of the study did not identify a statistically significant difference between salivary cortisol levels and HARS results in RAS patients compared to the control group. However, the HDRS index in RAS patients was found to be higher than the control group. In this study, only depression levels were found to be high in RAS patients [25]. McCartan et al. studied two groups. The first group comprised 12 RAS patients with oral lesions which did not respond to vitamin treatment. The second group comprised 12 patients with RAS diagnosis who responded to vitamin treatment. The salivary cortisone levels, HARS and HDRS psychometric analyses were compared in patients in these two groups. In conclusion, the first group of patients who did not respond to treatment had much higher both cortisone levels and anxiety levels compared to the other group [12]. However, in the literature there are publications stating there is no correlation between stress levels and anxiety with RAS. These authors stated that psychological factors had no effect on the etiology and severity of RAS [26-28].

Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki.

The strong aspects of this study are that all blood and saliva samples taken from patients with RAS were taken in the active RAS period and from 9-10 AM. Psychoanalytic tests were again applied in the active period. The laboratory findings of all patients were normal and no anemia or vitamin deficiency was identified. Patients were chosen from the minor RAS group. All examinations were performed by the same otolaryngologist. Different to previous studies, broader psychoanalysis was performed with the BDRS, BAS, PSS, STAI-S and STAI-T. Psychoanalytical tests were assessed by the same specialist psychologist blind to the study. A limitation of the study is that salivary cortisol was only assessed once. Conclusions This study identified that the idea that RAS patients have higher depression levels, higher stress perception levels and greater anxiety was not correct compared to a control group. Identification of high blood cortisol levels in RAS patients may be due to pain or sympathetic activation. The results of this study found that the place of stress, anxiety and depression in RAS etiology is suspect. Further studies with larger numbers of cases will be beneficial.

Financial Disclosure There are no financial supports

Isil Cakmak Karaer ORCID: 0000-0002-9429-2248 Ayca Urhan ORCID: 0000-0002-50359711 Ismail Reyhani ORCID: 0000-0002-2573-0996

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10. Beck AT, Epstein N, Brown G et al. An inventory for measuring clinical anxiety: Psychometric properties. J Consulting Clin Psychol.1988;56:893-7. 11. Kim HJ, Park EH. Diagnostic efficiency of BDI in a clinical setting: comparison among depression, anxiety, psychosis and control group. Int J Innov Managd Technol. 2010;1:502-6. 12. McCartan BE, Lamey PJ, Wallace AM. Salivary cortisol and anxiety in recurrent aphthous stomatitis. J Oral Pathol Med 1996;25:357‑9. 13. Soto Araya M, Rojas Alcayaga G, Esguep A. Association between psychological disorders and the presence of Oral lichen planus, Burning mouth syndrome and Recurrent aphthousbstomatitis. Med Oral. 2004;9:17. 14. Cohen L. Etiology, pathogenesis and classifications of aphthous stomatitis and Behçet’s syndrome. J Oral Pathol. 1978;7:347-52. 15. Dhopte A, Naidu G, Singh-Makkad R et al. Psychometric analysis of stress, anxiety and depression in patients with recurrent aphthous Stomatitis-A cross-sectional survey based study . J Clin Exp Dent. 2018;10:1109-14. 16. Gallo C B, Mimura MA, Sugaya NN. Psychological stress and recurrent aphthous stomatitis. Clinics (Sao Paulo) 2009;64:645–8. 17. Zadik Y, Levin L, Shmuly T et al. Recurrent aphthous stomatitis: Stress, trait

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Salivary cortisol determination in patients from the Basque Country with recurrent aphthous stomatitis. A pilot study. Med Oral Patol Oral Cir Bucal. 2013;1:207-11. 24. Nadendla LK, Meduri V, Paramkusam G et al. Relationship of salivary cortisol and anxiety in recurrent aphthous stomatitis. Indian J Endocrinol Metab. 2015;1:56-9. 25. Polat C, Düzer S, Ayyıldız H et al. Association Between Anxiety, Depression, and Salivary Cortisol Levels in Patients with Recurrent Aphthous Stomatitis Turk Arch Otorhinolaryngol. 2018;56:166-9. 26. Andrews VH, Hall HR. The effects of relaxation/imagery training on recurrent aphthous stomatitis: a preliminary study. Psychosom Med. 1990;52:526-35. 27. Zwiri AM. Anxiety, Depression and Quality of Life among Patients with Recurrent Aphthous Ulcers. J Contemp Dent Pract. 2015;16:112. 28. Sherman JJ, Barach R, Whitcomb KK, et al. Pain and pain-related interference associated with recurrent aphthous ulcers. J Orofac Pain. 2007;21:99-106.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):175-9

Comparison of gadoxetic acid and gadobenate dimeglumine, liver-specific contrast agents used in magnetic resonance imaging in differential diagnosis of liver masses Mehmet Akcicek1, Serkan Unlu1, Mehtap Ilgar1, Tamer Baysal2 2

1 Malatya Training Research Hospital, Department of Radiology, Malatya, Turkey Istanbul Kartal Dr. Lutfi Kirdar Education and Research Hospital, Department of Radiology, Istanbul, Turkey

Received 25 November 2019; Accepted 27 December 2019 Available online 02.03.2020 with doi: 10.5455/medscience.2019.08.9161

Abstract To compare Gadoxetic acid and Gadobenate dimeglumine in the detection and characterization of liver masses. In this study, 59 lesions in 28 patients are included in which were dynamic MRI that had been used Gadoxetic acid (Gd-EOB-DTPA) and Gadobenate dimeglumine (Gd-BOPTA). Observers recorded the liver lesions and adjacent parenchymal signal intensities (SI) in precontrast, arterial and hepatocyte phase by using the ROIs for the quantitative analysis. All statistical analyzes were performed with SPSS 22 software. p <0.05 was considered significant. In the cases of hemangiomas Gd-BOPTA applied, the SI of the lesions increased by 7.46% in the transition to the arterial phase, and 74.6% in the transition to the hepatocyte phase. In the cases of Gd-EOB-DTPA applied, the SI of the lesions increased by 16.01% in the transition to the arterial phase, and 99.76% in the transition to the hepatocyte phase. Compared two agents in the arterial and the hepatocyte phases there were no statistically significant differences. In the cases of metastases Gd-BOPTA applied, the SI of the lesions increased by 28.10% in the transition to the arterial phase, and 90.48% in the transition to the hepatocyte phase. In the cases of Gd-EOB-DTPA applied, the SI of the lesions increased by 12.68 % in the transition to the arterial phase, and 47.72% in the transition to the hepatocyte phase. Compared two agents in the hepatocyte phase the p-value was 0.006 and found a statistically significant difference. The difference in parenchymal-lesion contrast is more prominent for metastatic liver lesions in the hepatocellular phase in patients administered Gd-EOB-DTPA. Keywords: Gadoxetic acid, gadobenate dimeglumine, contrast agents, liver metastasis, liver hemangiomas

Introduction Intravenous contrast agents on liver MRI improve the contrast between the lesion and the liver, facilitating the detection and characterization of disease [1]. Firstly, Gadopentetate dimeglumine (Gd-DTPA) has been approved for clinical use; its practical use has increased, and new agents have been produced [2]. The ideal contrast medium to be used in liver MRI should be an agent with a strong magnetic effect, low side effects and biodistribution differentiation [3]. The contrast agents have been used in liver MRI can be grouped into five main categories: nonspecific extracellular gadolinium chelators, hepatocyte-specific contrast agents, reticuloendothelial system-specific contrast agents, blood pool agents and combined contrast agents [4]. Gadolinium

*Coresponding Author: Mehmet Akcicek, Malatya Training and Research Hospital, Department of Radiology, Malatya, Turkey E-mail: mmakcicek@gmail.com

chelates are the most commonly used agents [4,5]. All contrast agents except superparamagnetic iron oxides that are used clinically in liver MRI act by shortening the T1 and T2 durations of the liver parenchyma. The liver signal is increased in T1weighted sequences (T1W) because of the shortening of T1 time in gadolinium- and manganese-containing agents [1,6]. In recent years, hepatocyte-specific contrast agents have been developed for lesion characterization. Compared with classical gadolinium chelates, these agents increase the contrast between the lesion and the liver [6,7]. Gadoxetic acid is a hepatocyte-specific agent with gadolinium that has been commonly used in clinical practice [8,9]. In many studies, the efficacy of this contrast agent in detecting focal liver lesions due to high hepatocyte specificity was compared with that of nonspecific gadolinium chelates [10]. This study compared Gadoxetic acid disodium (Gd-EOB-DTPA) and Gadobenate dimeglumine (Gd-BOPTA) agents, which are both extracellular and hepatocyte-specific gadolinium chelates, in detecting and characterizing of liver masses. 175

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Materials and Methods The study was carried out at Istanbul Kartal Dr. Lutfi Kırdar Education and Research Hospital Radiology Department. This study received approval from the hospital ethics committee. Contrast-enhanced dynamic MR images had been performed at the hospital imaging center in two years were investigated retrospectively. The patients’ images were selected in which the gadolinium-based contrast agents Gd-EOB-DTPA and Gd-BOPTA had been administered and masses had been detected in the liver. A total of 59 lesions were identified as hemangiomas and metastases in 28 patients under follow-up who met these criteria. Except for hemangiomas and metastases we did not detect any other lesions. Two groups were formed according to the contrast media used, and the contrast ratios were evaluated in the obtained images. Studies that were not complete for any reason, images with artifacts and the examinations in which liver lesions had not been detected were not included. MRI examination of all patients was performed using a 1.5 T MRI device (Siemens Avanto, Germany) using an 8-channel phased array coil. Routine pre-contrast upper abdominal images, coronal T2W, axial T2W, axial fat-suppressed T2W and T1W, axial T1W in-phase/out-of-phase sequences and pre-contrast DWI images had been obtained. Then IV contrast agents had been administered, and axial fat-supressed T1W images had been taken in the early (0 s, 25 s, 60 s, and 90 s), late (5 m) and hepatocyte (15 m for GdEOB-DTPA, 60 m for Gd-BOPTA) phases. The contrast medium had been administered at the manufacturers’ recommended dose of 0.1 ml/kg (0.025 mmol/kg Gd-EOB-DTPA; 0.05 mmol/kg GdBOPTA) as indicated in the package inserts, followed by 20 ml of serum at 2 ml/sec with an automatic pump injector system. Spectral Adiabatic Inversion Recovery (SPAIR) was used as the fat suppression technique in all sequences.

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significant at P < 0.05. As the data distribution was not normal and the variance homogeneous, to calculate enhancement in the arterial and hepatocyte phases as a percentage (%), the nonparametric Mann-Whitney U test was applied. Results Gd-BOPTA had been used on 9 patients who had a total of 23 lesions. Eight lesions were hemangiomas and the others were metastases. Half of 36 lesions in 19 patients who had been administered Gd-EOB-DTPA were hemangiomas and the others were metastases. In the dynamic contrast-enhanced MRI series, the difference in signal intensity (SI) from second 0 to the arterial phase and from second 0 to the hepatocyte phase were calculated in cases of hemangiomas. Eight hemangiomas in which had been administered Gd-BOPTA as a contrast agent in MRI were evaluated. The average SI in the transition to the arterial phase was calculated as 7.46% in this group. The median value was 0.78%. On the other hand, 18 hemangiomas were also evaluated in which Gd-EOB-DTPA had been used. The average SI in the transition to the arterial phase was calculated as 16.01% in this group. The median value was 8.80%. The difference between the two groups in the transition to the arterial phase in hemangioma cases was not statistically significant (P = 0.437; Figure 1 and 2). The average SI in the transition to the hepatocyte phase was calculated as 74.60% in the first group, and the median value was 60.05%. The average SI in the transition to the hepatocyte phase was calculated as 99.76% in the second group, and the median value was 96.38%. The difference between the two groups in the transition to the hepatocyte phase in the hemangioma cases was not statistically significant (P = 0.505; Figure 1).

All images were transferred to the picture archiving and communications system workstation at a resolution of 2,048 × 2,060 pixels and evaluated randomly by two experienced radiologists. Radiologists were blinded to the contrast agent used and recorded the degree of enhancement of the liver lesion and parenchyma of the same or adjacent segment by measuring the ROI (region of interest) on the pre-contrast, arterial and hepatocyte phases images. Observers described each lesion according to size and localization to avoid confusion during data analysis in the case of patients with multiple lesions in the same segment. Additionally, in evaluations of the parenchyma, vascular structures were not measured. As ROIs were measured in homogenous locations at heterogeneous lesions, intratumoral necrosis or hemorrhage was excluded from this field. To protect against a partial volumetric effect, 59 lesions larger than 1 cm in diameter and visible in all sequences in 28 patients were used. Radiologists evaluated each case independently, for cases with measurement differences they re-evaluated together and agreed jointly. All statistical analysis was performed with the SPSS 22 (Statistical Package for Social Sciences) program. Differences were considered

Figure 1. The enhancement ratios in hemangiomas in which Gd-BOPTA and GdEOB-DTPA had been administered.

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Figure 2. A 50-year-old female patient who had had a radical nephrectomy because of a malignant neoplasm in the left kidney. Dynamic MR images applied Gd-BOPTA. a. pre-contrast b. arterial phase c. hepatocyte phase. The signal intensity of both the hemangioma in segment 7 and the liver paranchyma were calculated by measuring the respective ROIs.

The average differences in SI in the transition to the arterial and hepatocyte phases for metastatic lesions were also calculated. In patients with metastases had been administered with Gd-BOPTA, the SI of 15 metastatic lesions were increased by an average of 28.10% in the arterial phase, and the median value was calculated as 27.62%. In the group had been administered with Gd-EOBDTPA, the SI of a total of 18 metastatic lesions were found to increase by an average of 12.68% in the arterial phase shift, and the median value was calculated as 7.47%. The difference in percentage increment of the SI in the arterial phase between metastases cases which had been administered with Gd-BOPTA or Gd-EOB-DTPA was not statistically significant (P = 0.112; Figure 3). The signal SI of the metastatic lesions in Gd-BOPTA-administered patients increased by an average of 90.48% in the hepatocyte phase transition, and the median value was calculated as 93.50%. The metastatic lesions in Gd-EOB-DTPA-administered patients showed a 47.72% increase in the hepatocyte phase transition, and the median value was 34.38%. The difference in percentage increase of SI in the hepatocyte phase transition between metastasis cases administered with Gd-BOPTA or Gd-EOB-DTPA was statistically significant (P = 0.006; Figure 3 and 4).

Figure 3. The enhancement ratios in metastasis in which Gd-BOPTA and Gd-EOBDTPA had been administered.

Figure 4. Gd-EOB-DTPA enhanced dynamic MRI images of a 64-year-old male patient followed-up for lung cancer a. pre-contrast b. arterial phase c. hepatocyte phase. The signal intensity of metastatic lesions in segment 4 and liver paranchyma were calculated by measuring the respective ROIs.

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The increase of liver parenchyma SI in the hepatocyte phase as a percentage were also calculated in all patients. In 9 cases had been administered Gd-BOPTA, the parenchymal SI in the hepatocyte phase increased by 54.04%, and the median value was 58.14%. In 19 cases had been used Gd-EOB-DTPA, the increase of parenchymal SI in the hepatocyte phase was calculated as 80.63%. The median value was 67.48%. The difference in the increase of SI of hepatic parenchyma in the hepatocyte phase between two agents was not statistically significant (P = 0.157; Figure 5).

Figure 5. Percentage increases in SI values of the liver parenchyma in the hepatocyte phase in cases of Gd-BOPTA and Gd-EOB-DTPA administration

Discussion Optimal detection of liver lesions can alter the patientâ&#x20AC;&#x2122;s treatment protocol and, in some cases, prevent costly procedures such as unnecessary laparotomy [4,6]. Intravenous contrast materials given in liver MRI facilitate the detection and characterization of diseases by increasing the contrast between the lesion and the liver [4,11]. Gadolinium chelates developed for this purpose are the most commonly used agents [1,5,9]. In recent years, hepatocyte-specific contrast agents have been developed to provide additional lesion characterization. These agents increase the contrast between the lesion and the liver compared with classical gadolinium chelates [6,7]. These agents may be used in the pre-operative evaluation of patients under consideration for curative liver resection [12]. Gd-EOB-DTPA is a hepatobiliary specific gadolinium agent that has been used in clinical practice. The ability to take hepatobiliary phase images 10â&#x20AC;&#x201C;20 minutes after contrast injection is a significant advantage whereas images in the hepatocyte phase are taken between the first and third hours in the use of Gd-BOPTA, another gadolinium-based hepatobiliary specific contrast agent [8,13]. Previous studies have shown that Gd-EOB-DTPA is well-tolerated and non-reactive and has a minor side-effect ratio [14,15]. Our study reported no serious side effects in the patients. Gd-EOB-DTPA is given in low doses compared with Gd-BOPTA, and the majority is excreted by biliary excretion. This facilitates its use especially in patients at risk for nephrogenic systemic fibrosis [8,16]. In many studies, the effectiveness of this contrast agent, due to its

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high hepatocyte specificity, in detecting focal liver lesions was compared with that of nonspecific gadolinium chelates [17*19]. In this study, we compared Gd-EOB-DTPA and Gd-BOPTA, both extracellularly distributed and as a part of hepatocyte-specific gadolinium chelates, in detecting and characterizing liver masses. In a study in which quantitative analysis was performed, it was shown that the contrast enhancement of intra-abdominal solid organs and the aorta in the arterial phase was higher with GdDTPA administered [10]. That is, on dynamic MRI, the contrast enhancement of the abdominal solid organs and aorta in the arterial phase and that of the portal vein and inferior vena cava in the portal phase were found to be less with Gd-EOB-DTPA than with GdDTPA [10]. Liver parenchyma has a strong contrast enhancement because of the high rate of biliary excretion of Gd-EOB-DTPA, and the diagnostic accuracy with a high contrast noise ratio (CNR) increases when detecting lesions such as HCC. However, this is similar for MRI applied Gd-BOPTA [8]. A prospective study of 22 lesions in 18 HCC patients by Park and colleagues showed that dynamic contrast-enhanced MR scans with Gd-BOPTA and Gd-EOB-DTPA had similar diagnostic accuracy, sensitivity and positive predictive values [8]. In a retrospective study of Park and colleagues in 47 patients with HCC lesions, because of the hypointense properties of these lesions in the hepatocyte phase, Gd-EOB-DTPA contrast studies were superior to Gd-BOPTA in the detection of HCC [20]. Intravascular enhancement of Gd-EOB-DTPA is less likely due to the recommended dose difference between Gd-BOPTA and GdEOB-DTPA [21]. In a prospective study of ten healthy volunteers by Brismar et al., Gd-BOPTA 0.1 mmol/kg and Gd-EOB-DTPA 0.025 mmol/kg were applied, and the contrast enhancement between the liver parenchyma and hepatic artery, as well as between the portal vein and middle hepatic artery was measured as an intensity. In conclusion, Gd-BOPTA showed higher contrast enhancement in the arterial and portal phases compared with Gd-EOB-DTPA, and there was no difference in liver parenchymal enhancement in the late phase [22]. We found an increase in the signal intensities of the liver parenchyma in the hepatocyte phase with both agents was not found to be statistically significant. Huppertz reported in a meta-analysis that the hepatocyte phase of Gd-EOB-DTPA enhanced MR examinations did not provide an additional benefit in the differential diagnosis of metastases, hemangiomas, and cysts, three types of lesions that appear hypointense at this phase because they do not show selective enhancement of hepatocytes. On the other hand, the hepatocyte phase is highly prevalent in the differential diagnosis of metastases and FNH or adenomas [21]. In our study, when the contrast ratios of Gd-BOPTA and Gd-EOB-DTPA were compared in metastases in the hepatocyte phase transition from second 0, the difference in percentage increase of the signal intensities between two agents was statistically significant. In contrast, there was no significant difference between hemangioma cases with Gd-BOPTA and GdEOB-DTPA. Since hemangiomas do not contain hepatocytes like metastases, we would expect them to have less contrast with Gd-EOB-DTPA as in metastases in the hepatocellular phase. However, we believe that the absence of statistically significant differences may have been due to the contrast medium pooling in hemangiomas.

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Conclusion In the detection and characterization of liver masses, the difference in parenchymal-lesion contrast is more prominent for metastases in the hepatocellular phase in patients administered Gd-EOBDTPA. Given this result, Gd-EOB-DTPA may be preferred in the MRI of liver hemangiomas and metastases because of its lower dosage, lower risk of nephrogenic systemic fibrosis and shorter time to reach the hepatocyte phase. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports Ethical approval This study received approval from Dr Lütfi Kırdar Kartal Training and Research Hospital ethics committee by number 89513307/1009/208. Mehmet Akcicek ORCID: 0000-0002-0232-1284 Serkan Unlu ORCID: 0000-0001-7535-0812 Mehtap Ilgar ORCID:0000-0001-9064-8123 Tamer Baysal ORCID: 0000-0001-8902-2043

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10. Tamada T, Ito K, Sone T, et al. Dynamic contrast-enhanced magnetic resonance imaging of abdominal solid organ and major vessel: comparison of enhancement effect between Gd-EOB-DTPA and Gd-DTPA. J Magn Reson Imaging. 2009;29:636-40. 11. Filippone A, Blakeborough A, Breuer J, et al. Enhancement of liver parenchyma after injection of hepatocyte specific MRI contrast media: a comparison of gadoxetic acid and gadobenate dimeglumine. J Magn Reson Imaging. 2010;31:356-64. 12. Albiin N. “MRI of focal liver lesions.” Current medical imaging reviews 8.2. 2012;107-16. 13. Morana G, La Torre E, Fuser M, et al. Optimal imaging of focal liver lesions. Imaging in Medicine. 2010;2:497–518. 14. Endrikat J, Schwenke C, Vogtlaender K, et al. Safety profile of gadoxetate disodium in elderly patients (≥ 65 years). Acta Radiologica. 2018;59:81-8. 15. Endrikat JS, Dohanish S, Balzer T, et al. Safety of gadoxetate disodium: results from the clinical phase II–III development program and postmarketing surveillance. J Magn Reson Imaging. 2015;42:634-43.

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18. Zech CJ, Herrmann KA, Reiser MF, et al. MR imaging in patients with suspected liver metastases: value of liver-specific contrast agent Gd-EOBDTPA. Magn Reson Med Sci. 2007;6:43-52. 19. Caraiani CN, Dan M, Fenesan DI, et al. Description of focal liver lesions with Gd-EOB-DTPA enhanced MRI. Clujul Med. 2015;88:438. 20. Park G, Kim YK, Kim CS, et al. Diagnostic efficacy of gadoxetic acid enhanced MRI in the detection of hepatocellular carcinomas: comparison with gadopentetate dimeglumine. Br J Radiol. 2010;83:1010-6. 21. Huppertz A. Gadoxetic acid-enhanced MRI compared with unspecific extracellular contrast media for differential diagnosis of metastasis and benign liver lesions. EJCMO. 2010;1-7. 22. Brismar TB, Dahlström N, Edsborg N, et al. Liver vessel enhancement by Gd-BOPTA and Gd-EOB-DTPA: a comparison in healthy volunteers. Acta Radiol. 2009;50:709-15.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):180-5

Functional evaluation of bilateral arthroereisis of subtalar joint and simultaneous gastrocnemius lengthening in symptomatic flexible flatfoot in children Zafer Atbasi Guven Hospital, Department of Orthopedics and Traumatology, Ankara, Turkey Received 24 December 2019; Accepted 11 February 2020 Available online 02.03.2020 with doi: 10.5455/medscience.2019.08.9162

Abstract The aim of this study was to report the radiological and pedobarographic results of 10 children’s 20 feet with symptomatic flexible flat foot, who were treated with gastrocnemius lengthening with arthroereisis of subtalar joint. A total of 10 children’s 20 feet (5 boys and 5 girls between 9-14-year-old) with painful feet due to the flatfoot were treated in our clinic between August 2016 and December 2018. Bilateral gastrocnemius lengthening and arthroereisis of subtalar joint was performed simultaneously. Radiological evaluation was performed by measuring calcaneal pitch angle and Meary’s talusfirst metatarsal angles, pedobarographic evaluation by static and dynamic plantar heel and forefoot pressure data. The mean calcaneal pitch angle increased from 8° ± 0.93° preoperatively to 16.5° ± 1.14° postoperatively, and the mean Meary’s talus-first metatarsal angle decreased from 7.5° ± 1.14°preoperatively to 0.5° ± 0.51° postoperatively. The mean heel peak pressure and the forefoot peak pressure ascended from 11.5 ± 1.14 (N/cm2) and 10.5 ± 1.14 (N/cm2) preoperatively to 17.5 ± 1.14 (N/cm2) and 15.5 ± 1.14 (N/cm2) postoperatively, respectively. Clinical evaluation revealed that 9 patient had painful feet, while 1 patient had discomfort since the implant had been inserted.Arthroereisis of subtalar joint with simultaneous gastrocnemius lengthening provides painful feet and seems to be an effective, simple and safe solution for symptomatic flexible flatfoot in pediatric patients. Keywords: Flatfoot, pediatric, subtalar joint, arthroereisis, gastrocnemius lengthening

Introduction Management of flat foot treatment is still a challenge for orthopedic surgeons because it is a common and generally physiological process that usually requires observation and follow-up due to its asymptomatic nature at the pediatric population. Flexible flatfoot (FFF) is the most common form and the major abnormal biomechanical changes include valgus malalignment of the calcaneus, plantar deviation of the talus and medial longitudinal arch collapse occurring during weight-bearing. However, in symptomatic cases this process can lead to subjective symptoms such as foot and ankle pain with postural difficulties [1]. Furthermore, additional equinus pathology (isolated gastrocnemius or gastro-soleus tightness) combined with FFF may aggregate pain along the medial side of the foot, heel, calf, knee or low back during gait phases and make daily activities difficult, which sometimes extent to walking disability in children [2]. Although there is still controversy on the surgical indications and treatment

*Coresponding Author: Zafer Atbasi, Guven Hospital, Department of Orthopedics and Traumatology, Ankara, Turkey E-mail: zatbasi@yahoo.com

modalities, surgical intervention is recommended when the child is complaining about excessive foot pain after 8 years of age [3]. The diagnosis is also based on parental warnings about child’s unwillingness of walking or contributing athletic activities due to foot pain [4,5]. Surgical management of symptomatic FFF includes various options: soft tissue procedures (tendon transposition, Achilles/gastrocnemius lengthening, spring ligament repair), osteotomy and bony procedures (medializing calcaneal osteotomies, lateral column lengthening osteotomies) arthrodesis and arthroereisis [5,6]. The main goal of these procedures is to restore proper alignment between talus and calcaneus, and better results are obtained with osteotomies, bony procedures and arthroereisis compared to soft tissue procedures [7]. With increasing interest in foot and ankle sub-specialty and minimally invasive procedures, arthroereisis became popular and widely accepted. However, the necessity of implant removal is still a negative aspect of the procedure, and most of the current studies focus on overcoming this problem by developing new bio-absorbable implants and evaluating their effects on correction [6,8,9]. On the other hand, there is no comparative study investigating biomechanical effects of this procedure on foot plantar pressures yet. 180

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The aim of this study is to investigate the alterations of foot biomechanics and plantar pressures utilizing pedobarography and radiographic measurements in pediatric population who had undergone simultaneous gastrocnemius lengthening and arthroereisis procedure due to symptomatic flat foot with tight heel cord. Materials and Methods This retrospective study included 20 feet of 10 children (5 male, 5 female) who underwent bilateral gastrocnemius lengthening and simultaneous arthroereisis procedure for symptomatic flat feet between August 2016 and December 2018. Children between 9-14 years old with idiopathic, flexible, symptomatic FFF and gastrocnemius/gastrosoleus tightness (positive Silverskiöld test) that had not responded to adaptive footwear, orthotics or physiotherapy were included to our study. Exclusion criteria included post-traumatic, neurological or neuromuscular disorders, presence of joint hyper laxity, foot synostosis and clubfoot sequelae. Study protocol was approved by the Institutional Review Board and conducted in accordance with the principles of the Declaration of Helsinki. Physical Examination The diagnosis was based on clinical history and physical examination

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and was documented by radiographs and pedobarography. All patients were carefully examined preoperatively and at follow-up visits postoperatively by the same surgeon. Clinical diagnosis was based on increased hindfoot valgus position at rest and during tiptoe standing test while restricting the dorsiflexion of the ankle joint in neutral varus/valgus position. Radiographic Assessment The radiographic assessment included weight-bearing antero posterior (AP) and lateral (L) radiographs of the feet preoperatively and 6 weeks postoperatively. On radiographs, Meary’s talar-first metatarsal angle and calcaneal pitch angle were measured (Figure 1). Additional computed tomography or magnetic resonance imaging studies were performed when the presence of a coalition was suspected, and the patient was excluded from the study if present. Pedobarographic Measurement The pedobarographic assessment included plantar heel and forefoot (2-5 metatarsophalangeal joints and phalanges) pressures preoperatively and 6 weeks postoperatively. Footprint enlargement ratio (degree of plantar collapse) was evaluated using Viladot’s classification ([0] (Figure 2,3).

Figure 1. Preoperative a) Anteroposterior and b,c) lateral radiographs of the flatfoot of a 10- year old boy. Calcaneal pitch angle and Meary’s angle was improved postoperatively d) Anteroposterior and e,f) lateral radiographs of the foot after surgical correction

Figure 2. Footprint enlargement ratio according to Viladot (10)

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Two masks of plantar foot pressures including heel and forefoot peak pressures were analyzed with the pedobarograph (footscan7ÂŽ, RSscan International NV, Belgium) and were recorded as static and dynamic pressure data (Figure 4). Dynamic measurements were performed while the child was walking at natural speed.

Figure 3. a) Preoperative and b) postoperative image of foot of 10-year-old girlSurgical technique

All children were placed supine on the operating table under general anesthesia. A tourniquet was applied on the thigh for a bloodless and adequately exposed surgical field for the gastrocnemius

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lengthening procedure. The foot and the leg were prepared in usual sterile fashion, and local anesthetic was applied to the incision sites for postoperative pain control. After inflation of tourniquet, a longitudinal 6-7 cm incision somewhat medial to the midline at the middle of the calf was performed. After subcutaneous dissection, Z-shaped incision at the aponeurosis of the gastrocnemius muscle was made. With controlled passive dorsiflexion of the foot, elongation of the gastrocnemius was obtained. After that, a 2 cm oblique skin incision was made over the tarsal sinus approximately 1-1.5 cm distal to the tip of the lateral malleolus. Blunt dissection to the location of the tarsal sinus is carried out and soft tissues within were ransected to create a soft tissue pocket for the insertion of the guide wire and trial sizer. Inadequate soft tissue transection compromises proper placement as well as the size of trials. The guide wire in the tarsal sinus canal should be in the configuration of distal-lateral to proximal-medial (Figure 5). In-line cannulated trial sizer from small to large were inserted into the canal over the guide wire and appropriate size is selected by evaluating talotarsal mechanism until reaching the optimal hindfoot valgus which is considered < 5 degrees. After fluoroscopic assessment, proper size titanium cone-shaped implant was placed into the canal and plain radiographs were obtained to evaluate the position of the implant (Figure 6). After wound irrigation, hemostasis, closure and dressing a short leg soft cast was applied with the ankle in neutral position. Statistical Analysis Statistical analysis was performed using the IBM SPSS for Mac version 23.0 software (IBM Corp., Armonk, NY, USA). Descriptive data were expressed in mean Âą standard deviation (SD), number and frequency. Paired samples t test was used to compare preoperative and postoperative calcaneal pitch angle, Mearyâ&#x20AC;&#x2122;s angle, heel peak pressure and fore foot peak pressure. The interim analysis was performed by an independent statistician blinded for the treatment allocation. A p value of <0.05 was considered statistically significant.

Figure 4. a) Preoperatively printed out and b) postoperative static and dynamic pedobarographic measurements of 12-year-old girl with symptomatic flatfoot. Loading of plantar foot is shifted to laterally after surgery

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Figure 5. a) Anteroposterior and lateral view of the guide wire and screw placement into the sinus tarsi in direction of distal-lateral to proximal-medial, b) Neutral position of the heel after proper size implantation of subtalar correction screw (not varus/valgus), c) Intraoperative fluoroscopic images of correct placement of guide-wire and screw.

Of the 10 patients (20 feet), there were 5 (50%) females and 5 (50%) males with a mean age of 11.4±1.46 years. The mean follow-up period was 24 months. Applied implant diameters were between 7-10 mm. Patients’ demographic data, radiologic and pedobarographic results are presented in Table 1. The mean calcaneal pitch angle of 8°±0.93° preoperatively increased to 16.5°±1.14° postoperatively (p<0.001). On the other hand, the mean Meary’s angle of 7.5°±1.14° preoperatively decreased to 0.5° ± 0.51° postoperatively (p<0.001). The mean heel peak pressure of 11.5±1.14 (N/cm2) preoperatively increased to 17.5±1.14 (N/cm2) postoperatively and the fore foot peak pressure of 10.5±1.14 (N/cm2) preoperatively increased to 15.5±1.14 (N/cm2) postoperatively (p<0.001 for both) (see Table 2).

Figure 6. Cannulated arthroereisis titanium implant. Results

Table 1. Patients’ demographic data, radiologic and pedobarographic results Nu

Gender (Female/ Male)

Age (Year)

Screw diameter (mm)

Calcaneal pitch angle (degree) Right

Left

Meary’s angle (degree) Right

Heel peak pressure (N/cm2)

Left

Right

Fore foot peak pressure (N/cm2)

Left

Right

Left

9.5

PO:preoperative PT:postoperative

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Clinically, children’s abilities to participate in athletic activities had deteriorated according to their parents’ observations. 9 patients (18 feet) (90%) reported that their feet were significantly pain free. On the other hand, one patient (2 feet) (10%) reported minor discomfort since the implant had been inserted. In addition, their parents reported significant decrease of wear on the soles of their shoes.

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values, while the calcaneal pitch angle was within the near-normal values. Pedobarographically, medially increased center of pressure was moved to laterally in all feet with an improvement in terms of forefoot and heel pressures. Preoperatively, 10 feet was Viladot’s grade 4 and 10 feet was Viladot’s grade 3. Postoperatively, 18 feet was improved to Viladot’s grade 2 and 2 feet was improved to Viladot’s grade 3. The rate of foot print improvement is listed in Table 3.

Radiologically, Meary’s angle was improved within normal

Table 2. Comparison of radiological and pedobarographic parameters Preoperative Parameter

Postoperative p*

Minimum

Maximum

Mean±SD

Minimum

Maximum

Mean ± SD

Calcaneal pitch angle (degree)

9.5

8±0.93

16.5±1.14

<0.001

Meary’s angle (degree)

7.5±1.14

0.5±0.51

<0.001

Heel peak pressure (N/cm2)

11.5±1.14

17.5±1.14

<0.001

Fore foot peak pressure (N/cm2)

10.5±1.14

15.5±1.14

<0.001

*paired samples t test Table 3. CDegree of plantar collapse measured using Viladot’s classification preoperatively and postoperatively (n=20 feet in 10 children) Viladot’s Classification 0

Preoperatively

0 (0%)

10 (50%)

Postoperatively

0 (0%)

18 (90%)

2 (10%)

0 (0%)

All patients were discharged at the postoperative first day with a short leg soft cast. Casts were removed at the 6th week postoperatively and patients were encouraged full weight bearing as tolerated. Full foot and ankle ROMs were recorded before and after surgery. None of the patients experienced major intraoperative or postoperative complications during follow-up; there was no infection, deep vein thrombosis or implant-related problems. No patient was lost during follow-up. None of the implants were removed during 24 months follow-up. Discussion In this study, we evaluated the alterations of the foot pressures and radiographic changes in the patients with symptomatic FFF and tight heel cord after simultaneous gastrocnemius lengthening and arthroereisis procedure. Our results suggest that this procedure yields statistically significant improvement at the dynamic pedobarographic measurements including mean heel peak and mean forefoot peak pressures as well as the radiological measurements including calcaneal pitch and Meary’s angle. FFF is a common problem in children which usually does not require treatment [11]. Only %5 of the children with FFF have symptoms of plantar foot pain and muscle fatigue with increased physical activity due to dynamic functional changes at the lower extremities [12]. Regarding flatfoot biomechanics, the walking

pressure mostly tends to distribute medially including medial arch, medial of the hindfoot and first metatarsal head [13]. Pedobarographic evaluation, which shows the plantar pressure alterations at the foot is useful to determine the abnormal walking pattern [12,14]. In addition, the lack of radiation exposure to the children is another benefit of this evaluation. Normative data for dynamic plantar pressure measurements by pedobarographic technique was reported in several studies to define the healthy foot while comparing to flatfoot deformity [15,16]. Furthermore, numerous surgical corrective techniques have been introduced for symptomatic flatfoot [17]. Expected results with the corrective techniques may be explained as lateral shifting of foot pressures. In a dynamic pedobarographic study by Matheis et al. they reported significant changes in medial to lateral shifting on forefoot and midfoot in terms of walking peak pressure and percentage of body weight [18]. In their comparative study of intraoperative plantar pressure evaluation by pedobarographic device, MacMahon et al. concluded that greater medial plantar pressures moved to the lateral side of the foot, especially forefoot, after corrective surgery [19]. Our study includes preoperative dynamic pedobarographic evaluation of foot the forefoot and heel peak pressures. While higher peak pressures of forefoot was localized on the first metatarsophalangeal joint and phalanx preoperatively, it was found higher on 2-5th metatarsophalangeal joints postoperatively. On the other hand, lower preoperative heel peak pressures during walking increased and closed to the normative data after surgical correction, which is consistent with literature. With regard to surgical 184

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corrective techniques, arthroereisis stands out as a less invasive technique with the advantage of restricting the subtalar joint movement without any particular damage [17]. This periodically popularized technique has been nearly abandoned recently due to implant related complications and the necessity of implant removal which is considered as the most common complication [20]. In a recent study, Saxena et al. reported an implant removal rate of 22.1% in 100 patients; however, the study population consists of patients older than 18 years old. It is also emphasized that the implant diameter more than 11 mm would be a risk factor for implant removal [21]. In our study, arthroereisis was applied to children under 14 years old and implant diameter was smaller than 11 mm for all cases, which is consistent with the literature. Furthermore, in weight-bearing radiographs, the mean calcaneal pitch angle was increased to near-normal ranges and Meary’s angle had been corrected to the straight line between midline axis of the talus and first metatarsal compared to convex downward position, those values were found statistically significant. On the other hand, arthroereisis procedure was performed with concomitant gastrocnemius lengthening for all cases in our study; addressing the underlying equinus deformity correction with gastrocnemius lengthening would provide better outcomes in children with FFF deformity. We concluded that the satisfying changes on foot biomechanics were obtained with this combined procedure. Numerous studies about arthroereisis procedure evaluated the implant types, alteration of foot biomechanics, complications of implants and walking patterns; however, there is no currentdata about the plantar pressure distribution in children after this procedure. The results of our study showed significant increases in both the heel and forefoot peak pressures (p<0.05),coinciding with the postoperative results of previous studies [13,18]. Nonetheless, there are some limitations to our study. First, there is no control group thus limiting the strength of the current analysis. Second, our cohort is the set of consecutive patient series in a highly specific patient group of a single surgeon in the first decade of his practice. Third, the study population is small due to the low incidence symptomatic FFF. A larger sample size might be better for detecting the prevalence of implant related complications after this procedure. And lastly, the mean follow-up period of this study is 24 months, which may be relatively short for a flatfoot series; therefore, further studies are needed to elucidate the longterm outcomes of this technique. Conclusion In conclusion, our study results suggest that arthroereisis procedure in combination with gastrocnemius lengthening in symptomatic FFF can yield promising short-term results if it remains faithful to the surgical technique of stabilizing subtalar joint. However, we recommend large-scale and long-term, prospective, clinical studies to confirm the efficacy and safety of this technique. Financial Disclosure There are no financial supports Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki.

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References 1.

Caravaggi P, Lullini G, Berti L, et al. Functional evaluation of bilateralsubtalar arthroereisis for the correction of flexible flatfoot in children: 1-year followup. Gait Posture. 2018;64:152-8.

Herring JA. Tachdjian’s Pediatric Orthopaedics. 5th Edn. Elsevier, Philadelphia 2013.

Roth S, Sestan B, Tudor A, Ostojic Z, Sasso A, Durbesic A. Minimal invasive calcaneostop method for idiopathic flexible per planovalgus in children. Foot Ankle Int. 2007;28:991–5.

Mosca VS. Flexible flatfoot in children and adolescents. J Child Orthop. 2010;4:107-21.

Faldini C, Mazzotti A, Panciera A, et al. Bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot. Musculoskelet Surg. 2018;102:11-9.

Viladot Voegeli A, Fontecilla Cornejo N, Serrá Sandoval JA, et al. Results of subtalar arthroereisis for posterior tibial tendon dysfunction stage IIA1. Based on 35 patients. Foot Ankle Surg. 2018;24:28-33.

Arangio GA, Salathe EP. A biomechanical analysis of posterior tibial tendon dysfunction, medial displacement calcaneal osteotomy and flexor digitorum longus transfer in adult acquired flat foot. Clin Biomech (Bristol, Avon). 2009;24:385-90.

Fernández de Retana P, Alvarez F, Viladot R. Subtalar arthroereisis in pediatric flatfoot reconstruction. Foot Ankle Clin. 2010;15:323-35.

Schon LC. Subtalar arthroereisis: a new exploration of an old concept. Foot Ankle Clin. 2007;12:329-39.

10. Jerosch J, Schunck J, Abdel-Aziz H. The stop screw technique-a simple and reliable method in treating flexible flatfoot in children. Foot Ankle Surg. 2009;15:174-8. 11. Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. 1999;7:44-53. 12. Lin CJ, Lai KA, Kuan TS, Chou YL. Correlating factors and clinical significance of flexible flatfoot in preschool children. J Pediatr Orthop. 2001;21:378-82. 13. Ledoux WR, Hillstrom HJ. The distributed plantar vertical force of neutrally aligned and pes planus feet. Gait Posture 2010;15:1-9. 14. Dziuba A, Szpala A. Foot kinematics in gait of children with cerebral palsy (CP). Acta Bioeng Biomech. 2008;10:3-6. 15. Alvarez C, De Vera M, Chhina H, Black A. Normative data for the dynamic pedobarographic profiles of children. Gait Posture. 2008;28:309-15. 16. Liu XC, Thometz JG, Tassone C, Barker B, Lyon R. Dynamic plantar pressure measurement for the normal subject: Free-mapping model for the analysis of pediatric foot deformities. J Pediatr Orthop. 2005;25:103-6. 17. Ford SE, Scannell BP. Pediatric flatfoot: pearls and pitfalls. Foot Ankle Clin. 2017;22:643-56. 18. Matheis EA, Spratley EM, Hayes CW, Adelaar RS, Wayne JS. Plantar measurements to determine success of surgical correction of Stage IIb adult acquired flatfoot deformity. J Foot Ankle Surg. 2014;53:562-6. 19. MacMahon A, Hillstrom HJ, Do HT, Chan JY, Deland JT, Ellis SJ. In Vivo Plantar Pressures in Adult-Acquired Flatfoot Compared to Control Using an Intraoperative Pedobarographic Device. HSS J. 2017;13:136-45. 20. Ortiz CA, Wagner E, Wagner P. Arthroereisis: what have we learned? Foot Ankle Clin. 2018;23:415-34. 21. Saxena A, Via AG, Maffulli N, Chiu H. Subtalar arthroereisis implant removal in adults: a prospective study of 100 patients. J Foot Ankle Surg. 2016;55:500-3.

Zafer Atbasi ORCID: 0000-0002-5837-7367

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):186-90

The relationship between spiritual well-being and hopelessness levels of substance users Pinar Soylar, Ufuk Dogan Firat University, Health Sciences Faculty, Department of Nursing, Elazig, Turkey Received 14 October 2019; Accepted 25 November 2019 Available online 03.03.2020 with doi: 10.5455/medscience.2019.08.9163

Abstract This study was carried out to investigate the effect of the spiritual well-being of the individuals diagnosed with substance use disorder on their level of hopelessness. The sample of this study consisted of 256 patients who were hospitalized with the diagnosis of substance use disorder in an alcohol and druc addcition treatment center (ADATC) between October 1, 2018 and April 1, 2019. Patients who did not accept to participate in the study and repeated hospitalizations were excluded. The study was carried out with remaining 201 patients. Data were collected using Sociodemographic Information Form, the Spiritual Well-being Scale and the Beck Hopelessness Scale. Mann Whitney U, Kruskal Wallis test and Spearman Correlation analyses were used in the evaluation of the data. The mean age of the participants was 28.59±8.54 and all participants were male. The total score of the participants from the Spiritual Well-being Scale was 109.89±15.88, and from the Beck Hopelessness Scale was 7.33±5.30. In the study, a negative relationship was found between spiritual well-being and hopelessness levels of the patients (p<0.01). There was a negative relationship between patients’ spiritual well-being scores and the number of applications to the inpatient treatment center (p<0.01). There was a positive relationship between patients’ Beck hopelessness scores and the number of applications to the inpatient treatment center (p<0.05). There was a weak negative relationship between patients’ Beck hopelessness scores and their age (p<0.05). As the level of spiritual well-being increased, hopelessness level decreased. It is recommended to provide counseling and care services to increase the patient’s spiritual well-being. Keywords: Spiritual care, spirituality, hopelessness, drug addiction, substance use disorder

Introduction Substance abuse is an important public health problem affecting the individual and his/her environment in terms of biopsychosocial aspects [1]. Substance abuse is defined as an euphoric condition that occurs when a psychoactive substance affects the central nervous system after ingestion or withdrawal of the substance from the body, but the desire to use the substance continuously despite the occurrence of certain disorders [2]. World Health Organization (WHO) defines substance abuse as a strong desire and need to obtain and use the substance, the tendency to increase the dose used, high sensitivity towards the physical and psychological effects of substance after withdrawal, and the substance becoming the most important thing in a person’s life [3]. Substance abuse, which threatens human and public health is affected by many factors in development process, is not expected

*Coresponding Author: Pinar Soylar , Firat University, Health Sciences Faculty, Department of Nursing, Elazig, Turkey E-mail: psoylar@gmail.com

to be successful only through medical interventions during the treatment phase. In addition to medical interventions, one of the support and rehabilitation programs is spiritual care. Spirituality has proven to be effective in preventing drug addiction and reducing returns to drug use [4,5]. Spirituality is an effort to understand and accept the one’s relationships with itself and the people around it, its position in the universe and what life means [6]. It is known that spirituality has a positive effect on questioning the health and illness behaviors of the people, adapting to the changes, gaining the ability to overcome the problems, finding the healing power and hope again [7,8]. Hope is the belief of individuals in achieving any goal they wish to realize in their later lives. The belief that one can get rid of the bad situation and take positive steps in life is the most beneficial aspect of hope. Hope is a psychological factor that will help the person in his or her efforts to improve his/her mental state and get rid of negative health problems [9]. In a study with occupational groups working in the field of drug addiction and stated that spiritual well-being was effective in increasing the percentage of success in the treatment process. They also claimed that the treatment providers’ determining the mental health status of the addicts during the course of treatment and 186

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providing therapeutic care for them would contribute positively to the treatment process [10]. It is a very challenging and difficult process for substance abuse to get rid of addiction. They need to decide to change to get rid of addiction. The addicted individual may have difficulty in deciding to change or may give up his/her decision after some time. One of the factors that will affect this situation is self-belief and being hopeful to give up substance [11]. It is thought that the hope factor is useful in setting goals for the later lives of the patients, in finding ways to find the way out and in reaching these goals, and it also affects the success of the treatment [12]. This study was carried out to examine the relationship between the spiritual well-being of the individuals diagnosed with substance abuse and their hopelessness levels. Materials and Methods Study Design This descriptive study was carried out with adult male individuals (no female patients) who were diagnosed with substance use disorder and treated as inpatients in Alcohol-Drug Addiction Treatment Center (ADATC), Elazığ between September 1, 2018 and February 1, 2019. The number of patients who applied to the ADATC for inpatient treatment was obtained from the records for previous years and estimated as approximately 600 patients in a year. The study was conducted between October 1, 2018 - April 1, 2019, for 6 months, and thus, approximately 300 patients were expected to participate. However, fewer patients applied to the center compared to previous years and 246 patients were admitted to the hospital. Of those who applied, 18 were recurrent patients and 27 individuals did not agree to participate in the study. Therefore, the sample was composed of 201 patients. The sample size was found 20 after post hoc power analyses (the significance level was 0,05, correlation coefficient between two scales was 0,65, the power of representing the population %80). Data Collection Tools Data were collected using “Sociodemographic Information Form”, “Spiritual Well-being Scale (SWB)” to determine the status of spiritual well-being and using “Beck Hopelessness Scale (BHS)” to determine the levels of hopelessness. Sociodemographic Information Form Sociodemographic Information Form consists of 10 items which were prepared according to the literature to measure the characteristics of patients (age, education, marital status), characteristics of substance use disorder (duration, type, age of onset, number of hospitalization) and family characteristics (parents’ being together). Spiritual Well-Being Scale (SWB) The scale, developed by Ekşi H. et al. in 2017 and Turkish validity and reliability was performed, was developed as a way of assessing how well adults’ lives align with their values and their understanding of ultimate meaning in personal, social, environmental, and transcendental terms. The scale composed

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of 29 items and 3 dimensions (harmony with nature, anomie and transcendence). The scale is 5-point Likert type as “1=Not applicable to me at all”, “2=Not applicable to me”, “3=Somewhat applicable to me”, “4=Quite applicable to me”, “5=Completely applicable to me”. It includes questions such as how assuring it is to adhere a divine power, how harmonious it is with nature and how much it makes sense of life. As a result of the answers given to the scale, the lowest possible score from the scale is 29 and the highest is 145. In the scale, the questions related to the anomie (3,7,11,15,19,23,26) were scored reverse. It is concluded that the higher the total score obtained from the scale, the higher the level of spiritual well-being of individuals [13]. Beck Hopelessness Scale (BHS) The Beck Hopelessness Scale was developed by Beck et al. in 1974 to reveal the sense of hopelessness in quantitative data [14]. Turkish adaptation and validity-reliability studies were performed by Seber et al. The scale consists of 20 items, 11 of which are positive and 9 of which are negative. For positive questions, yes answer is 1 point and no answer is 0 point. For negative questions, yes answer is 0 point and no answer is 1 point. The lowest possible score from the scale is 0 and the highest is 20 points. The total score of individuals constitutes the hopelessness score. The higher the scores, the higher the level of hopelessness of the individual [15]. Statistical Analysis Kolmogorov Smirnov test was used to check the normal distribution of continuous variables. Spearman Correlation analysis was used for correlations between numerical variables and Mann Whitneu U and Kruskal Wallis test were used for comparison of independent groups. SPSS for Windows version 22.0 was used for statistical analysis. Analyzes were evaluated at 95% confidence interval and p<0.05 significance level. Ethical Considerations Ethical approval was obtained from the Non-Interventional Ethics Committee of Fırat University Faculty of Medicine and the written permission was obtained from Elazığ Provincial Health Directorate. The purpose, content and their voluntary involvement in the study were explained to participants verbally and the ‘Informed Consent Form’ was read and their approval was taken. Results The sociodemographic characteristic of the 201 patients was presented in Table 1. 42.3% of the patients were in the 24-29 age group in our study, 60.2% were single, 53.2% were primary school graduates, 67.2% worked in a job, 70.6% of their parents were together and at least one of the parents of 21.9% was not alive (Table 1). In the evaluation of the descriptive characteristics of the patients with substance use disorder, it was found that the most commonly used substance was heroin with 46.3% while it was determined that more than one stimulant substance was used with 33.8%. 48.3% of the patients used substances for one to five years while 32.8% of them used substances for six to ten years. It was found 187

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that 47.8% started using substance earlier than 18 years old while 39.3% of them started between 19 and 25 years old. It was further determined that 39.3% of the patients applied to an inpatient treatment center for the first time while 60.7% of them went through treatment before and applied at least for the second time (Table 2).

Characteristics

Marital status

Educational level

Working condition

The Status of Parents

Table 3. The mean scores of spiritual well-being and beck hopelessness scale

201

100.0

Spiritual Well-Being Scale Beck Hopelessness Scale Beck Hopelessness Scale

18-23

27.4

42.3

30 and above Married

61 80

30.3 39.8

Single

121

60.2

Literate

13.4

Primary Education

107

53.2

Secondary Education

31.3

University

2.0

Working

32,8

Not working

135

67.2

Divorce

7.5

Married Couple

142

70.6

Dead

21.9

Table 2. Descriptive characteristics of patients regarding subctance use Characteristics

The mean score of the participants from the spiritual well-being scale was 109.89±15.88, and the mean score from the beck hopelessness scale was 7.33±5.30 (Table 3).

28.59±8.54 24-29

Age Groups

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Scale

Table 1. Sociodemographic characteristics of patients

Age X±SS

Substance used

Obtainable Min-Max Scores

Received Min-Max Scores

X ± SS

29-145

62-143

109,89±15,88

0-20

7.33±5.30

The negative relationship between SWB and BHS indicated that as patients’ spiritual well-beings increased, their hopelessness levels decreased (r=- 0.696). While there was a negative significant relationship between patients’ SWB and the number of applications to the inpatient treatment center (r = -0.248), there was a positive significant relationship between patients’ BHS and the number of applications to the inpatient treatment center (r= 0.173) (Table 4). Table 4. The correlation between total mean scores of the spiritual well-be¬ing scale, beck hopelessness scale, age and the number of hospitalization SWBS

BHS

Number of Hospitalization

Age

Beck Hopelessness Scale (BHS)

r = -0,696**

Number of Hospitalization

r = -0,248**

r = 0,173*

r = -0,134

r = 0,217**

r = 0,085

Scale Spiritüel Well-Be¬ing (SWBS)

Heroin

46.3

Age

Multiple drugs

33.8

SWBS: Spiritual well-being scale, BHS: Beck Hopelessness Scale **p<0,01, *p<0,05 r = Correlation Coefficient

Marijuana

9.0

Alcohol

7.5

Ecstasy

3.5

1-5 year

48.3

6-10 year

32.8

11-15 year

10.0

16 and above

9.0

18 under

47.8

19 – 25

39.3

26 – 35

10.4

36 and above

2.5

First

39.3

2-4

47.3

5-7

10.0

7 and above

3.5

Substance use time

Substance onset age

Number of hospital admissions

Discussion In the evaluation of patients’ sociodemographic characteristics, it was determined that the rate of single individuals who substance abuse was higher than the married individuals. In a study conducted with patients with substance use disorder in our country, the rate of married and single individuals was in parallel with findings of our study [16]. When Turkish Monitoring Center for Drugs and Drug Addiction (TUBIM) data for 2011 (59.5%), 2012 (60.62%) and 2013 (61.49%) were examined, it was found that substance abuse was more common among single individuals [17-19]. In the investigation of the education level of patients, it was determined that almost half of them (53.2%) were primary school graduates. Many studies in the literature reported that the level of education of individuals who substance abuse was low [20-23]. In our study, the mean age of the patients was 28.5±8:54. In TUBIM, 2015, the patients receiving treatment were mostly between the ages of 20-29 [24]. In another study conducted in the center where we did our study, it was seen that the majority of patients were between the ages of 18-29 [20]. In another study, in the evaluation of the data for previous years in a treatment center, the mean age of patients was found as 27.5±12.68 [24]. It can be stated that the mean age in our study is similar to those in other 188

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studies in the literature. The most commonly used substances in our study were heroin, then multiple stimulants, cannabis, alcohol and pill-ecstasybonsai, respectively. In a study conducted in our country, it was reported that the most commonly used substances were heroin, mixed substance and alcohol, respectively [16]. According to the European Drug Report and TUBIM reports, the most consumed substance was cannabis [18,19,25,26]. In another study conducted in the center in 2015 where our study was conducted, the most commonly used substances were multiple stimulants and heroin, respectively [21]. In our study, the percentage of substance abuse under age 18 was found to be 47.8%. In a previous study that was similar to our study, it was observed that onset of substance abuse under the age of 18 was 37.1% [18]. In another study, it was observed that onset of substance abuse under the age of 18 was 28.3% [23]. This may indicate that onset of substance abuse has decreased to earlier ages.

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found statistically significant results between psychiatric patients’ spiritual well-being and age [36]. In conclusion, it was determined that the spiritual well-being of patients with substance use disorder was above the average and their level of hopelessness was below the average. As the spiritual well-being increased, hopelessness scores decreased. Accordingly, it was concluded that hope, which is one of the important factors for the treatment of patients, was significantly related to spiritual well-being. To increase the spiritual well-being of the patients, it is important to provide spiritual counseling and spiritual care services before, during and after the treatment, and to include initiatives to increase spiritual well-being in the holistic nursing care plans. During the rehabilitation process, the consultancy service of the health team in order to strengthen the communication between the family and the patient and to resolve conflicts will contribute to the spiritual well-being of the patients.

Total BHS mean scores of patients in our study were found to be low. In the literature, studies reported that the hopelessness levels of patients with substance use disorder were low [23,27]. In a study conducted that with patients diagnosed substance abuse, 59% of heroin addicts were hopeless and in the comparison of hopelessness levels of healthy individuals and heroin addicts, it was found that heroin addicts were more hopeless than healthy individuals [28]. The fact that the majority of the individuals participating in our study is young may be the reason for the low level of hopelessness.

This study was conducted in only one hospital therefore our results should not represent for all substance user and also city. This was the limitation of our study. Due to first study in literature it is believed that the study will be leading for further studies with a large sample.

In our study, spiritual well-being of individuals diagnosed with substance use disorder was found to be higher than average. In studies in the literature, it was observed that substance abuse had spiritual tendencies and these tendencies were perceived as a protective factor in the purification phase of substance abuse [10,29,30]. In a study conducted in many countries including Turkey, it was mentioned that the tendency to patients with substance use disorder was higher in individuals with low spiritual well-being [29,31]. In a study conducted among students abroad, it was found that the students who used substance had less spiritual well-being than the students who did not use [32].

Ethical approval An approval from the Firat University Health Sciences Non-Invasive Clinical Trials Ethics Committee and the legal permission from the institution where the study was carried out were obtained to conduct the study (App. No: 2018/13-12).

Kulaksızoğlu B, Kara H, Özçelik Ö, et al The use of naltrexone implants for the treatment of opioid addiction: a retrospective study. Anatol J Psychiatr. 2019;20:133-8.

In our study, a statistically significant negative relationship was found between the levels of hopelessness and spiritual well-being of patients with substance use disorder and treated as inpatient. As the spiritual well-being of patients with substance use disorder increased, their hopelessness levels decreased.

Yüksel E. What does it mean; drug addiction? practices and discussions on basic concepts of drug-based work. Anadolu University Facult Communication Sci J Int Referee. 2017;25:39-64.

Yorgancıoğu A, Esen A. Cigarette addiction and physicians. Thoracic J. 2000;1:90-5.

Koenig et al. reviewed approximately many studies on religion and well-being and found that at least 80% of these studies had negative significant results related to hopelessness [33]. In their study with alcohol addicts, emphasized that the distress, hopelessness and existential problems of the dependent individuals improved with the improvement of their spiritual status [34].

Kurtuluş, S. Care and spiritual social services on the axis of spirituality. Bilim Alanları. 2015; 6-7

Saraçoğlu AD. Dezavantajlı gruplar–psiko-sosyal ve manevi bakım. akademik platform. J Islamic Res. 2016;3:89-93.

Çetinkaya B, Sebahat A, Azak A. Spiritual care and nursing. ADU J Med Faculty. 2007;8:47-50.

Narayanasamy A. Spiritual coping mechanisms in chronically ill patients. Br j Nurs. 2002;11:1461-70.

Karagül AR. Spiritual care, meaning, significance, method and training “The Case of the Netherlands’. Religious Studies, 2012;15:7-25.

No significant difference was found between spiritual well-being and age in our study. Since there was no study examining age and spirituality in substance abuse during the study period, other patient groups were discussed. In a study conducted with oncology patients, no significant difference was found between the age and total well-being scores of the patients [35]. However, a study

Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports

Pinar Soylar ORCID: 0000-0003-1565-2100 Ufuk Dogan ORCID: 0000-0002-1345-5261

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10. Altundaş M, Öztürk E, Arıkın S. Providing moral support with team work in drug addiction treatment. TJSS. 2019;3:195-207. 11. Ögel K. Alkol ve Madde El Kitabı. http://www.ogelk.net/Dosyadepo/gpktp8. pdf. access date 11.09.2019 12. Kavradım S, Özen Z. Kanser tanısı alan hastalarda umut. Current Approaches in Psychiatry. 2014;6:154-64. 13. Halil E, Selami K. Spiritual well-being: Scale development and validation. Spiritual Psychology and Counseling. 2017;2:73-88. 14. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol, 1974;42:861-5. 15. Gülten S, Dilbaz N, Kaptanoğlu C, et al. Umutsuzluk ölçeği: Geçerlilik Vegüvenirliği. Kriz Dergisi, 1993;1:139-42. 16. Asan Ö. Sociodemographic and Clinical Features of Patients with Alcohol and Substance Use Disorders in a Specialized Unit. J Dependence. 2015;16:1-8. 17. Türkiye Uyuşturucu ve Uyuşturucu Bağımlılığı İzleme Merkezi: Ankara, Türkiye. 2013 Emcdda Ulusal Raporu. http://www.sck.gov.tr/oecd/2013%20 T%C3%BCrkiye%20Uyu%C5%9Fturucu%20Raporu.pdf access date 09.09.2019. 18. Türkiye Uyuşturucu ve Uyuşturucu Bağımlılığı İzleme Merkezi: Ankara, Türkiye. 2011 Emcdda Ulusal Raporu. http://www.narkotik.pol.tr/ kurumlar/narkotik.pol.tr/Arsiv/TUBIM/Documents/TURKIYE%20 UYUSTURUCU%20RAPORU%202011.pdf access date 14.09.2019. 19. Türkiye Uyuşturucu ve Uyuşturucu Bağımlılığı İzleme Merkezi: Ankara, Türkiye. 2012 Emcdda Ulusal Raporu. http://www.sck.gov.tr/oecd/2012%20 T%C3%BCrkiye%20Uyu%C5%9Fturucu%20Raporu.pdf access date 16.09.2019. 20. Kübra Al. Alkol-Madde Bağımlısı Bireylerde İçselleştirilmiş Damgalama ve Benlik Saygısı: Elazığ Ruh Sağlığı ve Hastalıkları Hastanesi Amatem Örneği :Yüksek lisans tezi, :Fırat üniversitesi, Elazığ,2018. 21. Karakaş SA, Ersöğütçü F. Social Functioning and Self-Esteem of Substance Abuse Patients Arch Psychiatr Nurs. 2016;30:587-92. 22. Türkiye Uyuşturucu ve Uyuşturucu Bağımlılığı İzleme Merkezi: Ankara, Türkiye. 2012 Emcdda Ulusal Raporu file:///C:/Users/AnkaBiLisim/ Downloads/Documents/TURKIYE%20UYUSTURUCU%20RAPORU%20 2016.pdf.

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23. Gökhan O. Alkol ve Madde Bağımlılığı Tedavisi Gören Bireylerde Algılanan Sosyal Destek ve Umutsuzluk Düzeyi Arasındaki İlişkinin İncelenmesi. Yüksek Lisans Tezi,Haliç Üniversitesi, İstanbul, 2016. 24. Hakan KA, et al. Retrospective Analysis of Sociodemographic Characteristics of Inpatients at Kayseri Research and Training Hospital AMATEM Clinic. J Psychiatr Neurol Sci. 2017;30:251-7. 25. Avrupa Uyuşturucu ve Uyuşturucu Bağımlılığı İzleme Merkezi. Avrupa Uyuşturucu Raporu. 2017 http://www.emcdda.europa.eu/system/files/ publications/4541/TDAT17001TRN.pdf access date 16.09.2019. 26. Türkiye Uyuşturucu ve Uyuşturucu Bağımlılığı İzleme Merkezi: Ankara, Türkiye. Emcdda Ulusal Raporu 2013. http://www.sck.gov.tr/oecd/2013%20 T%C3%BCrkiye%20Uyu%C5%9Fturucu%20Raporu.pdf 27. Büşra DA. Madde Kullanım Bozukluğu Tedavisi Gören Bireylerin Duygusal Zekâ, Depresyon Ve Umutsuzluk Düzeyleri Arasındaki İlişkinin Değerlendirilmesi. Yüksek Lisans Tezi , Üsküdar Üniversitesi, İstanbul, 2018 28. Ayşe KO. Suicide Ideation, Planning and Attempt of Heroin Dependent Patients. J Dependence. 2003;4:101-4. 29. Abbas S, et al. Recovery based on spirituality in substance abusers in Iran. Glob J Health Sci. 2014;6:154-62. 30. Orhan G. Madde bağımlılığı ve din: HİGED Örneği. The Turkish Journal on Addictions. 2018;5:37-54. 31. Heinz AJ, et al. A focus-group study on spirituality and substance-abuse treatment. Subst Use Misuse. 2010;45:134–53. 32. Debnam K, et al. The role of stress and spirituality in adolescent substance use. Substance Use Misuse. 2016;51:733-41. 33. Koenig H, King D, McCullough M. Handbook of religion and health. New York, ABD: Oxford University Publisher; 2001. 34. Kenneth H, Terence SI. An existential model of flourishing subsequent to treatment for addiction: The importance of living a meaningful and spiritual life. Illness Crisis & Loss. 2009;17:125-47. 35. Gülnaz AT. Onkoloji Hastalarında Manevi İyiliğin Umut Ve Depresyonla İlişkisi.Yüksek Lisans Tezi, Atatürk Üniversitesi, Erzurum, 2018. 36. Abdurrezzak GÜ. Psikiyatri Hastalarının Manevi İyilik Düzeyleri İle Tedaviye Uyumları Arasındaki İlişki. Yüksek Lisans Tezi, İnönü Üniversitesi, Malatya, 2018.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):191-6

A new approach for green synthesis and characterization of Artemisia L. (Asteraceae) genotype extracts -Cu2+ nanocomplexes (nanoflower) and their effecitve antimicrobial activity Ayse Baldemir Kilic1, Cevahir Altınkaynak2, Nilay Ildiz3, Nalan Ozdemir4, Vedat Yilmaz5, Ismail Ocsoy5 2

1 Erciyes University, Faculty of Pharmacy, Department of Pharmaceutical Botany, Kayseri, Turkey Nevsehir Haci Bektas Veli University, Avanos Vocational School,Department of Plant and Animal Production, Nevsehir, Turkey 3 Erciyes University, Faculty of Pharmacy, Department of Pharmaceutical Microbiology, Kayseri, Turkey 4 Erciyes University, Faculty of Science, Department of Chemistry, Kayseri, Turkey 5 Erciyes University, Faculty of Pharmacy, Department of Analytical Chemistry, Kayseri, Turkey

Received 27 September 2019; Accepted 20 October 2019 Available online 07.03.2020 with doi: 10.5455/medscience.2019.08.9165

Abstract In this study, we have demonstrated the fabrication of novel organic-inorganic nanobio-antimicrobial agents called “nanoflowers” (NFs) and elucidate the increase in the antimicrobial activity of NFs. This is the first report that the NFs were formed of plant extracts as the organic components and copper (II) ions (Cu2+) as the inorganic component. The Artemisia L. (Asteraceae) methanol extracts from three genotypes including A. absinthium L. (Aa), A. vulgaris L. (Av) and A. ludoviciana Nutt. (Al) were selected in the NF synthesis. The effect of the plant extract concentrations on the morphology of NFs was examined. Most regular and uniform flower-shaped morphologies were observed when a concentration of 0.1 mg mL-1 plant extract was used in the synthesis of NFs. The syntesized NFs were characterized with several techniques such as scanning electron microscopy (SEM), Fourier transform infrared spectrometer (FT-IR), energy-dispersive X-ray (EDX) and X-ray diffraction analysis (XRD). The NFs exhibited much antimicrobial activity against the pathogens even at low concentrations compared to the extracts. The MICs and MBCs values for NFs were found to be range between 0.4 to 40 μg mL-1 and 40 to 400 μg mL-1 while those values for Aa, Av and Al extracts were ranged from 500-2000 μg mL-1 and 1000-4000 μg mL-1 for the studied pathogens, respectively. Keywords: Artemisia extracts, hybrid nanoflower, inhibitory property, bacterial and fungal pathogens.

Introduction The development of nanomaterials has provided many multifunctional versatile tools used in scientific and technical fields [1-3]. Various colloidal nanomaterials (NMs), such as metallic or polymeric, have been synthesized and characterized using several techniques [4-8]. Among the NMs, the biocompatible molecules (DNA, protein, enzyme and plant extract) integrated nano or micro sized materials have been commonly used in last two decades due to much biocompatibility and very less environmental toxicity [913].

*Coresponding Author: Nilay Ildiz, Erciyes University, Faculty of Pharmacy, Department of Pharmaceutical Microbiology, Kayseri, Turkey E-mail: nilaygucluer@yahoo.com

The plant extracts have been receivied considerably much attention in NMs synthesis compared to other biomolecules owing to their quite less price, high stability, lack of contamination risk and easy preparation. Up to now, researchers have intensively used various plant extracts as reducing and capping agent in the synthesis of metallic NMs. In typical synthesis, certain amount of plant extract and metal salt are accordingly mixed in aqueous solution and incubated under stirring at various temperatures for different periods of time. The plant extracts are mainly composed of natural chemicals, such as flavonoids and polyphenols. The oxidation of those of which induces the reduction of metal ion and eventual formation of metallic nanomaterials [14-19]. Rather than conventional plant extract based metallic NMs synthesis, we were inspired from an encouraging breakthrough discovered by Zare and co-workers in 2012 for prepration of protein-inorganic nanoflowers (NFs) [20,22]. In several reported 191

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works, protein, enzyme and amino acid were successfully utilized as organic component and some metal ions were used as inorganic component in the formation of flower-shaped nanostructures. However, to the best of our knowledge, plant extracts have not been previously involved in synthesis of organic-inorganic hybrid nanostructures [22-30]. Artemisia L. species are medicinal and aromatic herbs in the Asteraceae family, which has a long history of use in culinary traditions [31]. They have been actively used in various purposes, such as coughs and colds, chills, stomatchache, dry dyspepsia, purgative effect; tea, poultice, inhale (vapours from boiling leaves); insect repellent [32]; a vermifuge, in the treatment of chronic fevers and for inflammation of the liver, as an antispasmodic and antiseptic [33,34]. Herein, for the first time, a simple and rational approach is reported for the preparation of novel organic-inorganic nanobio agents called “nanoflowers” (NFs) and elucidate the increase in the antimicrobial activity of NFs. The NFs were formed of plant extracts as the organic component and copper (II) ions (Cu2+) as the inorganic component. The extract of Artemisia from three different genotypes including Artemisia absinthium L. (Aa), A. vulgaris L. (Av) and A. ludoviciana Nutt. (Al) were selected in the NF synthesis. The effects of the plant extracts and Cu2+ concentrations on the morphology of NFs were systematically examined. The antimicrobial activities of Aa, Av and Al extracts and NFs synthesized from extracts were evaluated against bacterial and fungal pathogens. Materials and Methods Chemicals and reagents Copper sulfate pentahydrate, methanol, phosphoric acid, dimethyl sulphoxide (DMSO) and other chemicals were purchased from Sigma-Aldrich. NaCl, KCl, Na2HPO4, KH2PO4, HCl and NaOH were used to prepare phosphate buffer saline solution (PBS, pH 7.4). Coomassie brilliant blue G-250 were used for buffer solution and prepared using ultrapure water. Preparation of extracts Artemisia species were obtained from Zeytinburnu Medicinal Plant Garden, Istanbul, Turkey. Herba of Artemisia spp. were washed several times with deionized water and dried at room temperature. Aa, Av and Al herbs were powdered using a blender. 100 g of the each plant powder was added into 500 mL onenecked flask containing 250 mL methanol and incubated at room temperature (RT: 25 ºC) for 1 day under stirring. After incubation, the each solution was filtered through a Whatman filter paper No. 1 to collect the extract. This step was repeated twice using the same procedure. The extracts were evoporated under vacuum at 40 ºC and stored at -20 ºC for further use. Preparation of Aa, Av and Al-Cu2+hybrid nanoflowers The extracts incorporated-Cu2+ NFs were prepared according to previously reported method with some modifications [23-28]. Birefly, a volume of 0.35 mL CuSO4 solution (120 mM) was separately mixed with Aa, Av and Al extracts (concentrations increasing from 0.1 and 0.5 mg mL-1) into 50 mL of 10 mM PBS (pH 7.4) The mixtures were vigorously shaken for 30 s to make them homogeneous and then left without disturbing at +4°C for 3 days incubation. The greenish precipitates appeared at the bottom of the solution were washed by centrifugation at 10.000 rpm for

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15 min at least 3 times. Finally, the collected NFs were dried under vacuum at 50°C for overnight and stored for futher characterization and use. The supernatant of each mixture was kept for Bradford protein assay. Characterization of plant extract incorporated nanoflowers The morphologies of the NFs were examined using ZEISS model EVO LS10 scanning electron microscope (SEM). The elemental analysis of the NFs was undertaken by energy-dispersive X-ray (EDX) (ZEISS EVO LS10) to determine weight and atomic percentage of Cu2+ in the NFs. The infrared spectra of the NFs were recorded using a Fourier Transform Infrared Spectrometer (FT-IR) (Perkin Elmer Spectrum 400). The 20 mg of NFs was also used for X-ray Diffraction Analysis (XRD) (BRUKER AXS D8). The encapsulation yield of Aa, Av and Al NFs was determined to be ~58%, ~68% and ~48%, respectively via Bradford protein assay using an UV-vis spectrophotometer (HITACHI) [35]. Antimicrobial study The bacterial strains (E. coli ATCC 35218, S. typhi ATCC 14028 P. aeruginosa ATCC 27853 C. albicans ATCC 10231 and S. aureus ATCC 25923) were obtained from Medical Microbiology Laboratory, Faculty of Medicine, Inonu University culture collection. The minimum inhibitory concentration (MIC) and mimimum bactericidal concentration (MBC) values of both the extracts (Aa, Av and Al) and NFs (Aa, Av and Al NFs) were determined via broth microdilution method based on Clinical Laboratory Standards Institute (CLSI) [36,37] guidelines protocole modified by Bazargani and coworkers [38] The MIC assays were carried out in 96-well microtitre plates in triplicate at a two fold serial dilution of the tested materials from 500 µg mL-1 to 4000 µg mL-1 for the extracts and from 0.4 µg mL-1 to 400 µg mL-1 for the NFs. The inoculum concentration for the MIC and MBC tests was standardized by using the optical density of the bacterial suspension to a turbidity according to spectrophotometric absorbance. The bacterial suspensions (5×105 CFU mL-1) were added in each well. Appropriate antibacterial agent and Mueller Hinton Broth (MHB) + bacterial suspension were used as positive control while MHB served as negative control. The plates were then incubated at 37 0C for 16 to 20 h. After incubation, the plates were visually examined for bacterial growth. No visible growth was observed in each well, then the samples were subcultured on sterile Mueller hinton agar (MHA) plates to determine the MBC value. The plates were then incubated at 37 0C for 24 h. The well containing the lowest concentration with no visible bacterial growth was taken as the MIC value. This is further validated by addition of 3-(4,5-dimethyl2-thiazolyl)-2,5-diphenyl-2H tetrazolium bromide (MTT) to the wells. 0.2 mg/mL of 4 μL MTT was added to wells and they were incubated at 25 0C for 15 minutes. The pink appeared in the wells was considered as a positive meaning active bacterial growth, while wells with colourless solution were reprepsentetive of negative for bacterial growth. The well containing the lowest concentration of the colourless solution was interpreted as the MIC. The MBC was interpreted as lowest concentration showing no visible growth on agar subculture [38]. Both the extracts and the NFs were also used to determine their minimum fungicidal concentration (MFC) values via the broth microdilution method according to CLSI, 2008 guidelines [36]. A 192

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mixture of L-glutamine and sodium bicarbonate-free RPMI 1640 broth containing 0.2 % (m/v) glucose was used as media. The pH of the media was adjusted to pH 7.0 by using a solution of 0.165 mol L-1 morpholinepropanesulfonic acid (MOPS). Mc Farland 0.5 inoculum was prepared in 0.85% (m/v) NaCl aqueous solution. Amphotericin B and dimethyl sulfoxide (DMSO) were used as a positive control and a negative control, respectively. Each experiment was performed in duplicate and repeated three times. The plates were examined visually. Sabaraud dextrose agar (SDA) was used to determine the MFC values. Result Characterization of Aa, Av and Al-Cu2+hybrid nanoflowers Images of Aa, Av and Al NFs were generated by the SEM. The elemental composition of each NF was analyzed by EDX. The crystal structure and chemical structure of NFs were characterized using XRD and FT-IR spectroscopy, respectively.

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The presence of Cu metal in NF was analyzed by the EDX as shown in Figure 2a, The diffraction peaks in the NFs corresponding to Cu3(PO4)2 nanocrystals were almost consistent with the JCPDS card (00-022-0548) as presented in Figure 2b, 2c and 2d. The FTIR spectrums of the only extract and the NFs are illustrated in Fig. 3a and 3b, respectively. The absorption bands (in Figure 3b) at 559, 1032 and 1150 cm−1 in the the NFs were attributed to P–O and P=O vibrations, indicating the existence of phosphate groups (PO43- ) [39]. It is worthy to mention that molecules in the extracts were packed in the NFs with different conformations, which increase localized molecules concentration in the extract and may lead to strong and shifted vibration peaks. The vibration bands of –NH2 groups were at 1595 cm−1 and 1627 cm−1, for extracts and the NFs, respectively. The stretching bands of –CH2 and –CH3 groups in the extract Al were at 2850 and 2918 cm−1. The adsorption bands at 1675 cm−1 and 3232 cm−1 were assigned to carbonyl (>C=O) and hydroxyl (–OH) groups from the compounds in the extract, respectively.

The NFs were formed by the combination of each extract with Cu2+ ions in PBS buffer. Although all NFs were quite spherical, Aa and Av NFs were much uniform and monodispersed compared to Al NFs. The potential reason can be attributed to contents of each extract. Interestingly, the NFs were formed using 0.1 mg mL-1 of each extract (Figure 1a, 1c and 1e). However, no NFs were formed when 0.5 mg mL-1 extracts were used (Figure 1b, 1d and 1f). The sizes of Aa and Av NFs were around 11±1 μm and 8±1 μm (Figure 1a and 1a), while the size of Al NF was determined in the range of 2 μm and 10 μm (Figure 1e). These differences showed that the content and concentrations of the extracts can be the key point for formation and controlling the size of the NFs.

Figure 2. a) EDX analysis of Cu metal in the NFs, b-d) XRD of pattern of AI NFs, Aa NFs and Av NFs. Aa: A. absinthium; Av: A. vulgaris; AI: A. ludoviciana, NFs: Nanoflowers

Figure 1. a-b) Aa 0.1 mg and 0.5 mg, c-d) Av 0.1 mg and 0.5 mg, e-f) Al 0.1 mg and 0.5 mg Aa: A. absinthium; Av: A. vulgaris; Al: A.ludoviciana

Figure 3. FT-IR spectra of extract AI (a) and the extract AI-Cu2+ hybrid nanoflower (b). AI: A. ludoviciana

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Evaluation of antimicrobial activity of Aa, Av and AlCu2+hybrid nanoflowers According to literature, Artemisia spp. containing various active molecules (phenolic compounds, essential oil) have high antibacterial and antifungal activity. Previous report revealed that Artemisia spp. did not exhibited any antimicrobial effect to Gram negative bacteria but showed moderate and strong activity against Gram posititive bacteria and fungi [40-44]. Park et al. [45] used the A. capillaris Thunb. extract as reducing agent to synthesis the silver nanoparticles (Ag NPs) and to improve the antimicrobial activity against several Gram negative and Gram positive bacterial strains. Some studies demonstrated that the green synthesis of AgNPs using Artemisia extracts and found them as effective antimicrobial agents towards pathogenic bacteria, such as Staphylococcus aureus, Bacillus cereus, Acinetobacter baumannii, and Pseudomonas aeruginosa [46]. In this study, antimicrobial activities of the NFs and extracts of three Artemisia genotype (Aa, Av, Al) and were tested against standard pathogens using the broth microdilution method. Subsequently MIC, MBC and MFC values were determined. The NFs showed excellent antimicrobial acitivity against bacteria and fungi even at very low concentrations (Figure 4,5). The MIC and MBC values for NFs were between 0.4 to 40 μg mL-1 and 40 to 400 μg mL-1 while those values for Aa, Av and Al extracts were 500-2000 and 1000-4000 μg mL-1 for bacterial pathogens, respectively. The extracts did not show any antibacterial activity towards E. coli, S. typhi and P. aeruginosa at 4000 μg mL-1. According to these results, the NFs have very promising antimicrobial properties compared to the extracts.

Figure 5. MIC and MBC values (µg/ml) of nanoflowers (NFs). Aa: A. absinthium; Av: A. vulgaris; AI: A. ludoviciana MIC: Minimum inhibitory concentration: MBC: Minimum bactericidal concentration

Discussion Several plant extracts were used for extracellular synthesis of silver nanoparticles and they can selectively inhibit growth of the Gram negative and Gram positive and they can be considered an interesting versatile biotechnological resource due to their antimicrobial activity [47-50]. The resistance of Gram negative bacteria to plant extract and essential oil have been associated to hydrophilic outer membrane that may block the penetration of hydrophobic compounds into target bacterial cell membrane [51]. The NFs as amphipathic hybrid nanomaterials can attach Gram positive and Gram negative bacteria outer membrane and they may show antibacterial activity. In addition, the NFs exhibited much higher antibacterial activity against Gram positive bacteria than Gram negative. Conclusion In this work, we have successfully firstly produced to synthesize the three Artemisia genotypes (Aa, Av, Al) extracts-metal ion NFs with very narrow size distribution, high production yield, and also demonstrated their excellent inhibitory property. Differences of the antimicrobial activities of the NFs and extracts may be related to due to the varied amounts of plant extracts of main molecules (proteins, flavonoids, polyphenol) contained in the Aa, Av and Al extracts. Importantly, the NFs exhibited dramatically enhanced antimicrobial activities towards standard bacterial (E. coli, S. typhi, P. aeruginosa and S. aureus) and fungal pathogens (C. albicans) compared to extracts. The results suggest that green sytnthesis of the NFs present promising a great potential for development of eco-friendly antimicrobial agents for especially nasocomial human pathogens.

Figure 4. MIC and MBC values (μg/ml) of Artemisia sp. extracts (Aa, Al, Av). Aa: A. absinthium; Av: A. vulgaris; Al: A. ludoviciana MIC: Minimum inhibitory concentration, MBC: Minimum bactericidal concentration

Acknowledgements The authors would like to thank Zeytinburnu Medicinal Plant Garden due to provide to plant materials. This manuscript was partially presented as an oral presentation at the DRD-2019 symposium.

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doi: 10.5455/medscience.2019.08.9165 Competing interests The authors declare that they have no competing interest. Financial Disclosure This work was supported by the Scientific Research Projects Coordination Unit of Erciyes University [Project number: THD-2016-6590]. Ethical approval No ethic approvell is needed to this research. Ayse Baldemir Kilic ORCID: 0000-0003-2473-4837 Cevahir Altinkaynak ORCID: 0000-0003-0082-8521 Nilay Ildiz ORCID: 0000-0002-3799-856X Nalan Ozdemir ORCID: 0000-0002-8930-5198 Vedat Yilmaz ORCID: 0000-0001-6194-6527 Ismail Ocsoy ORCID: 0000-0002-5991-3934

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Medicine Science International Medical Journal

Medicine Science 2020;9(1):197-200

Mitral annular calcification is associated with postexercise heart rate recovery Vahit Demir1, Siho Hidayet2, Yasar Turan1 1 Bozok University Faculty of Medicine, Department of Cardiology, Yozgat, Turkey Inonu University Faculty of Medicine, Department of Cardiology, Malatya, Turkey

Received 10 January 2020; Accepted 02 Febuary 2020 Available online 08.03.2020 with doi:10.5455/medscience.2020.09.9176 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract Mitral annular calcification (MAC) is a chronic, degenerative disease characterized by accumulation of calcium and lipid in the fibrous ring of the mitral valve. Heart rate recovery index (HRR) calculated after treadmill exercise test is a predictor of autonomic dysfunction and cardiovascular mortality. The aim of this study was to investigate the relationship between MAC and HRR parameters. 64 patients with MAC (mean age 54.9±5.8, 40 males) and 44 healthy controls (mean age 55.1±6.5, 28 males) were included in the study. All subjects in the MAC group and control group underwent basal 12-lead electrocardiography, echocardiography, and treadmill exercise test at a target rate determined by age. HRR indices were calculated from the maximal heart rate by subtracting the heart rate at the 1st, 2nd and 3rd minutes of the recovery period. Baseline demographic and laboratory data were similar in both groups. Compared with healthy controls, individuals with MAC had decreased HRR at 1 (HRR1), 2 (HRR2), and 3 (HRR3) minutes [16.9 ± 4.5 vs. 19.2 ± 3.9, p = 0.009; 33.9 ± 4.6. 36.2 ± 5.1, p = 0.019; 49.6 ± 7.1. 52.4 ± 6.1, p = 0.035; respectively]. These results show that heart rate recovery after exercise is impaired in individuals with MAC. Given the independent prognostic value of HRR, these findings can be evaluated in terms of symptomology of autonomic dysfunction in people with MAC. Because HRR is a simple and inexpensive method, it may be useful in identifying high-risk patients, especially in individuals with MAC. Keywords: Heart rate recovery, Mitral annular calcification, Treadmill exercise test

Introduction Mitral annular calcification (MAC) is a chronic degenerative change of the mitral valve which is more common in women and increases with age. It does not require treatment unless valve dysfunction and/or embolic complications develop. MAC is a noninflammatory pathology of the mitral valve diagnosed by echocardiography [1]. The incidence increases with age and end-stage renal disease [2]. MAC is a benign character and is a common finding in surgical operations and autopsy series as well as incidental detection in cardiovascular imaging (echocardiography) studies. MAC develops as a result of calcification in the basal section of the mitral valve leaflets and annulus. The posterior mitral annulus is affected more frequently than the anterior annulus. Calcifications usually accumulate irregularly and cluster. Sometimes it is seen as nodular calcification involving the valves and subvalvular structures. As the annular calcification progresses, sinus node disease, atrioventricular block and branch blocks may

*Coresponding Author: Siho Hidayet, Inonu University Faculty of Medicine, Department of Cardiology, Malatya, Turkey E-mail: shhidayet@hotmail.com

be observed due to the neighboring conduction system between the interventricular septum and anulus [3]. Many studies have shown that MAC is associated with atherosclerotic diseases such as carotid artery disease and coronary artery disease [4]. MAC is associated with an increase in total and cardiovascular mortality [1,5]. An exercise treadmill test is a widely used and important test in the diagnosis and follow-up of cardiovascular diseases. Several parameters are routinely derived from this test and are used to assess cardiovascular events and mortality risk [6]. Exercise treadmill test, exercise capacity, chronotropic response determination, heart rate recovery (HRR) and ventricular ectopic beat level can be determined. It is an important advantage that these parameters are reliable, reproducible and easily measured. HRR is an important indicator of autonomic activity that reveals a decrease in heart rate after a gradual exercise [7]. HRR; It is defined as the difference between the maximum heart rate during exercise and the heart rate during the recovery phase. HRR is an important and complex indicator of cardiac autonomic function that reflects the balance of sympathetic-parasympathetic effects and the interaction of each other with regulating heart rate [8]. It has an important prognostic value in normal population as well as those with cardiac disease. It also provides prognostic information for all-cause death, cardiacrelated death and sudden death risk [7,9,10]. A better understanding 197

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The aim of this study was to investigate the differences between HRR parameters and Treadmill exercise testing in patients with MAC detected by transthoracic echocardiography.

Statistical analysis Shapiro wilk test was used to evaluate the distribution of normality of continuous variables. Statistical analysis of the clinical data between the two groups was evaluated by Student’s t test for normally distributed parameters and Mann Whitney U test for those without normal distribution. Chi-square test was used for categorical variables. SPSS 20 (SPSS/IBM, Chicago, IL, USA) software was used for the analysis and p value of less than 0.05 was considered statistically significant.

Material and Methods

Results

of the pathophysiological mechanism of the relationship between decreased HRR and increased mortality will contribute to the development of strategies to improve HRR and improve survival. Studies have shown that both MAC and impaired HRR are associated with increased cardiovascular (CV) risk factors.

Study population The study was conducted at the Department of Cardiology, Faculty of Medicine, Bozok University. Between June 2017 and November 2019, 64 consecutive patients with a sinus rhythm in the 40-65 age range with a mitral valve area greater than 2.5 cm2 and a transmitral mean gradient of less than 2 mmHg were included in the study. The control group consisted of healthy subjects in the same age and sex group without mitral annular calcification on echocardiography. All control subjects had normal physical examination and echocardiographic findings. Coronary artery disease, moderatesevere valvular heart disease, history of acute rheumatic fever, prosthetic valve, left ventricular systolic dysfunction (ejection fraction <50%), advanced lung disease, pulmonary hypertension, chronic or acute infective disease, patients with dysrhythmia, those with electrolyte imbalance and those with disability to perform stress testing were excluded from the study. Exercise test abnormalities and those who did not complete the test were also excluded. Baseline demographic characteristics and clinical data were recorded. Body mass index (BMI) was calculated as (kg/ m²). Standard 12-lead surface electrocardiography (ECG) was performed to all subjects at rest using the device (Nihon Kohden, Tokyo, Japan. Blood samples were taken after twelve hours of fasting. Written informed consent was obtained. Ethical approval was obtained by the local ethics committee (Approval no:2017KKAEK-189-2017.08.24).

The study was carried out with 108 subjects between the ages of 40-65 years. The subjects were divided into two groups as MAC and control. The MAC group consisted of 64 subjects (40 males and 24 females), and the control group consisted of 44 males (28 males and 16 females). Demographic, clinical and biochemical characteristics of individuals with MAC and control group are summarized in Table 1. The resting heart rate and arterial blood pressures of the two groups were within normal range and there was no significant difference between the two groups. Appropriate records of the stress test according to the Bruce protocol were successfully obtained for all subjects. Resting heart rate, maximum heart rate, exercise duration, and maximal METs values were similar between the groups (Table 2). The HRR1 was significantly lower in the MAC group than in the control group (16.9±4.5 and 19.2±3.9, respectively; p=0.009). Likewise, the HRR2 (33.9±4.6 and 36.2±5.1, respectively; p=0.019), HRR3 (49.6±7.1 and 52.4±6.1, respectively; p=0.035), were significantly lower in the MAC group (Figure1). Table 1. Baseline clinical and laboratory parameters Variables

MAC (n=64)

Control (n=44)

P value

Age, years

54.9 ± 5.8

55.1 ± 6.5

0.800

24/40

16/28

0.645

Echocardiographic assessment Echocardiographic examinations of the participants were performed with Philips Affiniti 50 echocardiography device (Philips Healthcare, Netherlands). Patients were placed in left lateral decubitus position during echocardiographic examination. Measurements were performed from parasternal short-and longaxis views and apical two/four chambers conventionally. MAC is defined as an echocardiographic structure in M-mode or 2-dimensional (parasternal-apical) images, seen as an echogenic band that is thicker than 1 mm thick at the base of the mitral leaflets and does not change along the systole and diastole [11].

Gender (Female/Male)

Exercise Stress Test Protocol In the study, maximum exercise test was done by treadmill in Bruce protocol. The highest heart rate during the test (220 - age), the target was to reach at least 85% of the heart rate calculated by age [6]. After reaching maximal heart rate, an active recovery period was started at 1.5 MPH and 2.5 slopes. Continuous electrocardiogram monitoring was performed during the test and recovery period and data on symptoms, heart rate and blood pressure were recorded. HRR1, HRR2 and HRR3 values were calculated by subtracting the heart rate values at the first, second and third minutes after exercise from the maximum heart rate reached during the exercise. The metabolic equivalent 1 MET is expressed as (equivalent to 3.5 mL of oxygen uptake per kilogram per minute).

Body Mass Index (kg/m )

24.3 ± 2.4

24.5 ± 2.3

0.612

SBP (mmHg)

131.1 ± 19.5

128.3 ± 16.8

0.454

DBP (mmHg)

80.9 ± 14.6

79.3 ± 8.2

0.495

Hypertension, n (%)

38 (59)

23 (54)

0.638

Diabetes mellitus, n (%)

26 (41)

17 (40)

0.988

24 (41)

23 (54)

0.121

118.6 ± 39.8

117.6 ± 37.7

0.888

Smoking, n (%) Serum Glucose (mg/dL) Hemoglobin, (g/dL)

14.5 ± 1.4

14.3 ± 1.5

0.346

Serum Creatinine (mg/dL)

0.93 ± 0.29

0.89 ± 0.18

0.432

AST(U/L)

21.9 ± 8.3

25.8 ± 17.7

0.293

ALT(U/L)

24.3 ± 11.6

25.6 ± 19.1

0.673

Total Cholesterol (mg/dL)

185.1 ± 38.7

189.9 ± 45.1

0.405

Triglycerides (mg/dL)

158.7 ± 78.4

173.3 ± 90

0.379

High-density lipoprotein (mg/dL)

43.4 ± 15.6

40.6 ± 10.3

0.318

Low-density lipoprotein (mg/dl)

114.5 ± 37.1

117.5 ± 36.1

0.678

Expressed as Mean ± Standard Deviation or as Percentage (%), p values were compared by Student’ T-test or chi-square test as appropriate, p<0.05 significant. SBP: Systolic blood pressure, DBP: Diastolic blood pressure, ALT: Alanine aminotransferase, AST: Aspartate aminotransferase, HDL: High-density lipoprotein, LDL: Low density lipoprotein

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Figure 1. Comparison of HRR indices between the MAC and control groups

Table 2. Comparison of treadmill exercise test parameters MAC (n=64)

Control (n=44)

P value

Maximal METs

10.7 ± 1.9

10.9 ± 1.8

0.376

Resting heart rate (beat/min)

69.2 ± 9.9

68.8 ± 10.1

0.826

Exercise duration (minutes)

9.4 ± 2.3

9.3 ± 1.9

0.770

Variables

Maximum heart rate (beat/min)

159.6 ± 15.9

163 ± 12.7

0.246

HRR1(beat/min)

16.9 ± 4.5

19.2 ± 3.9

0.009

HRR2 (beat/min)

33.9 ± 4.6

36.2 ± 5.1

0.019

HRR3(beat/min)

49.6 ± 7.1

52.4 ± 6.1

0.035

Expressed as Mean ± Standard Deviation or as Percentage (%), p<0.05 significant. METs: Metabolic equivalent, HRR1: First minute heart rate recovery, HRR2: Second minute heart rate recovery, HRR3: Third minute heart rate recovery

Discussion The main objective of this study was to show how HRR changes in individuals with MAC compared to normal healthy subjects. In patients with MAC, HRR parameters were significantly impaired (decreased) compared to controls. This is the first study in the literature to evaluate the relationship between the presence of MAC and HRR in individuals of similar age and similar risk factors for cardiovascular disease. In previous studies, risk factors such as age, DM, HT and obesity, which are risk factors for atherosclerotic heart disease, have been shown to be risk factors for MAC [2,5]. Mitral annular calcification is closely associated with cardiovascular diseases such as coronary artery disease, carotid and aortic atherosclerosis, heart failure and stroke [4]. The imbalance in calcium and phosphorus metabolism, which leads to an increased risk of atherosclerosis, plays an important role in MAC formation, along with an unknown pathophysiology [2]. The relationship between experimentally induced systemic artery atherosclerosis and accumulation of fatty plaques on the ventricular side of posterior mitral leaflets has been demonstrated [3]. In the light of this information, MAC is thought to be a form or symptom of atherosclerosis because it has pathological findings similar to that of atherosclerotic lesions and its close association with risk factors for atherosclerosis. In a study

of Boon et al. The incidence of hypertension, hyperlipidemia and DM was found to be significantly higher in MAC patients than in the control group [12]. Similarly, in the Framingham Heart Study; The incidence of DM, HT and obesity was found to be significantly higher in MAC patients than in the control group [5]. There is a complex relationship between various intrinsic, neural and humoral factors that control the slowing of heart rate after exercise [13,14]. However, autonomic nervous system mediated responses, particularly parasympathetic reactivation, are major determinants for HRR. Delayed HRR after exercise is an indicator of decreased parasympathetic activity [15] and is associated with increased long-term mortality [5,10]. Since our study was performed cross-sectionally, it is not appropriate to make this judgment in individuals with MAC in terms of long-term mortality and prognosis. However, long-term studies with people with MAC will inform us about this. In our study; Although the incidence of cardiovascular risk factors were similar and relatively high in both groups, the reason for the lack of a statistically significant difference between them may be due to the small sample size and the inclusion of people older than 65 years. Arrhythmia and conduction disorders can be seen in patients with MAC. Both the severity and prevalence of ventricular arrhythmias have been shown to increase in patients with MAC. However, in the literature, there is not enough data about the procedures to identify patients with MAC at high risk for arrhythmic events. Increased sympathetic and decreased parasympathetic activity is associated with an increased risk of sudden death and ventricular arrhythmia [16]. Therefore, it is important to evaluate autonomic functions in identifying high-risk patients for sudden death. Analysis of HRR parameters is one of the inexpensive and noninvasive methods that can be used to evaluate cardiac autonomic functions [7,8]. The combination of sympathetic withdrawal and parasympathetic reactivation after exercise regulates HRR. In one study, abnormal HRR response was an important indicator of impaired autonomic function, and increased mortality in patients with decreased HRR was more likely to be due to cardiac autonomic dysfunction than underlying coronary artery disease [6,17]. In our study, it was shown that there was 199

doi: 10.5455/medscience.2020.09.9176

a significant decrease in HRR1, HRR2 and HRR3 in individuals with MAC. These findings suggest that the decrease in HRR is may be one of the predictors of increased cardiac death in people with MAC.

Fox CS, Vasan RS, Parise H, et al. Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study. Circulation. 2003;107:1492-1496.

Desai MY, De la Pena-Almaguer E, Mannting F. Abnormal heart rate recovery after exercise as a reflection of an abnormal chronotropic response. Am J Cardiol. 2001;87:1164-9.

Lauer M, Froelicher ES, Williams M, et al. Exercise testing in asymptomatic adults: a statement for professionals from the American heart association council on clinical cardiology, subcommittee on exercise, cardiac rehabilitation, and prevention. Circulation. 2005;112:771-6.

Chacko KM, Bauer TA, Dale RA, et al. Heart rate recovery predicts mortality and cardiovascular events in patients with type 2 diabetes. Med Sci Sports Exerc. 2008;40:288-95.

Van de Vegte YJ, van der Harst P, Verweij N. Heart rate recovery 10 seconds after cessation of exercise predicts death. J Am Heart Assoc. 2018;7:e008341.

Limitations Our study presents some limitations. Our study is a single center and the number of subjects is relatively low. Adults consisted of both MAC and control groups. Therefore, further studies are needed to investigate whether the results of our study can be applied to young and old population. Conclusion Looking at the relationship between HRR and MAC; HRR can be used as an indicator to identify patients at higher risk for atherosclerotic burden and arrhythmia in individuals with MAC. Closer follow-up of arrhythmia and risk of sudden cardiac death can be arranged in individuals with MAC and decreased HRR. However, multicenter, large-scale, randomized and prospective studies are required to clarify this hypothesis. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval The study was approved by Presidency of T.C. Bozok University Ethics Committee. Vahit Demir ORCID: 0000-0001-8349-6651 Siho Hidayet ORCID: 0000-0002-4103-9345 Yasar Turan ORCID: 0000-0002-2796-899X

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Medicine Science International Medical Journal

Medicine Science 2020;9(1):201-4

Changes in thiol/disulfide homeostasis in patients with chronic kidney disease Ibrahim Solak1, Ibrahim Guney2, Seher Mercan1, Ozcan Erel3, Salim Neselioglu3, Cigdem Damla Cetinkaya4, Mehmet Ali Eryilmaz5 University of Health Sciences, Training and Research Hospital, Department of Family Medicine, Konya, Turkey 2 University of Health Sciences, Training and Research Hospital, Department of Nephrology, Konya, Turkey 3 Yildirim Beyazıt University, Ankara Ataturk Training and Research Hospital, Department of Biochemistry, Ankara, Turkey 4 University of Health Sciences, Training and Research Hospital, Department of Biochemistry, Konya, Turkey 5 University of Health Sciences, Training and Research Hospital, Department of General Surgery, Konya, Turkey 1

Received 23 September 2019; Accepted 19 November 2019 Available online 07.03.2020 with doi:10.5455/medscience.2019.08.9168 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract Thiol/disulfide homeostasis (TDH) is a new marker of oxidative stress. In this study, we would like to determine the changes in TDH in hemodialysis (HD) patients with chronic kidney disease (CKD). This cross-sectional study was conducted in the Nephrology Clinic of Konya Training and Research Hospital. A total of 197 individuals including 75 HD patients, 41 end stage renal disease (ESRD) patients (having stage 3-5 CKD but not receiving hemodialysis), and 81 healthy controls were enrolled in the study. Serum native thiol, total thiol, and disulfide levels were measured with a new method developed by Erel and Neselioglu. It was determined that there was a statistically significant difference in the mean age, body mass index (BMI), modification of diet in renal disease (MDRD), and creatinine level between the three groups (p<0.001). It was shown that there was a statistically significant difference in native thiol and total thiol levels and disulfide/native thiol, disulfide/total thiol, and native thiol/total thiol ratios between the three groups, whereas there was no statistically significant difference in disulfide level between the three groups. Consequently, our study found that TDH shifted more towards the left (disulfide side) and oxidative stress was higher in both HD (markedly) and CKD groups when compared to the control group. Keywords: Hemodialysis, chronic kidney disease, oxidative stress, thiol/disulfide homeostasis

Introduction Oxidative stress is defined as a disturbance in the prooxidants– antioxidants balance in favor of the former, thus leading to a potential damage to the cells and organs [1]. The most common comorbid conditions during hemodialysis (HD) treatment are infections, cardiovascular diseases, amyloidosis (due to β2-microglobulin accumulation), and malnutrition. These diseases are considered to be side effects of long-term HD. Oxidative stress and microinflammation are accepted as the main causes of these comorbid conditions. There are two main reasons for increased oxidative stress in HD patients. The first reason is that free radical production occurs for improving the biocompatibility of HD treatment. The second reason is that antioxidant levels decrease [2]. Oxidative stress significantly contributes to the morbidity and mortality of HD patients [3,4]

*Coresponding Author: Ibrahim Solak, University of Health Sciences, Training and Research Hospital, Department of Family Medicine, Konya, Turkey E-mail: isolaktr@yahoo.com

Oxidative stress is present in the early stages of chronic kidney disease (CKD) and increases in more advanced stages of CKD. Oxidative stress plays a central role in the pathophysiology of uremia and cardiovascular complications of CKD. However, the stage where oxidative stress begins to develop during the progression of CKD is unknown [5,6]. Thiol groups are important antioxidants. Intracellular thiols, including glutathione and thioredoxin present in millimolar concentrations within cells, are very important for preserving a highly reduced intracellular environment. Extracellular thiols also constitute an important component of antioxidant defense. The plasma protein-reduced thiols (located primarily on albumin) are depleted in HD patients and are thus not able to participate in antioxidant defense [7]. Previous studies have used various parameters to determine oxidative stress and to assess its severity in HD and CKD patients [8-10]. Thiol/disulfide homeostasis (TDH) is a marker of oxidative stress. In many inflammatory diseases, increased production of proinflammatory cytokines is associated with increased levels of oxidative stress mediators [11,12]. 201

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TDH has vital importance. One side of this double-sided balance has been measurable since 1979, but today a new method, developed by Erel and Neselioglu, can measure levels of both variables separately and additively and can evaluate both individually and holistically. The aim of this study was to determine the changes in TDH in HD and CKD patients. Material and Methods This cross-sectional study was conducted in the Nephrology Clinic of Konya Training and Research Hospital. The study was approved by the Ethics Committee of KTO Karatay University Faculty of Medicine (2017/002). All individuals were informed about the study design. Participants who agreed to take part in the study gave written informed consent in accordance with the World Medical Association’s Declaration of Helsinki. Those who were not between the ages of 18 and 65 years old, who did not smoke cigarettes, who had cardiovascular diseases (such as acute coronary syndrome, myocarditis, left ventricular dysfunction, and heart failure), who had chronic inflammatory autoimmune diseases, who received antioxidant drugs (such as angiotensin-converting enzyme inhibitors, beta-blockers with antioxidant properties, and antioxidant vitamin preparations), who were diagnosed with diabetes mellitus, who had chronic liver failure or acute renal failure, who were diagnosed with cancer, and who had Parkinson’s disease or Alzheimer’s disease were excluded from the study [13]. Patients who received HD treatment for at least 3 months were included in the HD group. Patients who had predialysis stage 3-5 CKD were included in the CKD group. The abbreviated MDRD estimate [14] of kidney function was calculated as 175×plasma creatinine-1.154×age-0.203 ( ×0.742 if female; ×1.21 if black). The body mass index (BMI) was calculated by dividing weight in kilograms by the square of height in meters (BMI = kg/m2). Laboratory Analysis Blood samples were taken from the patients and the controls into serum separator tubes. Sera were obtained by centrifugation at 1500×g for 10 min. The samples were immediately put in the freezer at −80°C. The same process was applied to all specimens. When the study was completed, the samples were sent to the

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biochemistry laboratory of Ankara Ataturk Training and Research Hospital to measure thiol/disulfide homeostasis parameters. Total thiol (-SH+-S-S-) consists of reduced and native thiols. Thiol/disulfide homeostasis tests were performed using a novel automatic and spectrophotometric method developed by Erel and Neselioglu. The principle of the thiol/disulfide measurement method is the reduction of dynamic disulfide bonds (–S–S–) to functional thiol groups (–SH) by a reductant solution (10 μL), sodium borohydride (NaBH4). The unused NaBH4 remnants are completely removed by formaldehyde. So this prevents further reduction of 5,5′-dithiobis-2-nitrobenzoic acid (DTNB) as well as any disulfide bonds resulting from the reaction with DTNB. Total thiol content in the samples were determined by using a modified Ellman reagent after the reaction with DTNB. The disulfide parameter is a value which can be calculated automatically as half of the native thiol content and total thiol content. After the determination of the main parameters (native thiol, total thiol, and disulfide values), disulfide/total thiol percent ratios, disulfide/ native thiol percent ratios, and native thiol/total thiol percent ratios were calculated [15]. Statistical methods Statistical analyzes were performed with SPSS software V21.0 (Statistical Package for the Social Sciences, IBM Corp., Armonk, NY). Numbers, percentages, means, and standard deviations were used for data presentation. The Shapiro-Wilk test was used to examine if the data were normally distributed. The Paired samples t-test was used if the data were normally distributed. The Wilcoxon signed-rank test and Kruskal–Wallis test were used if the data were not normally distributed. All analyzes were performed as two-sided hypotheses with a 5% significance level and a 95% confidence interval. Results A total of 197 individuals including 75 HD patients, 41 ESRD patients (having stage 3-5 CKD but not receiving hemodialysis), and 81 healthy controls were enrolled in the study. The sociodemographic features of the participants are shown in Table 1. It was determined that there was a statistically significant difference in the mean age, BMI, MDRD, and creatinine level between the three groups (p<0.001). Plasma levels of TDH parameters in the three groups are shown in Table 2.

Table 1. Sociodemographic and laboratory features of three groups HD n=75(%)

CKD n=41(%)

Control n=81(%)

Female

40(53.3)

34(82.9)

57(70.4)

Male

35(46.7)

7(17.1)

24(29.6)

Mean±SD

44.75±12.54

48.82±10.54

46.71±8.95

<0.001

BMI (kg/m )

24.39±4.73

29.76±5.66

31.19±6.42

<0.001

Creatinine (mg/dL)

7.22±2.16

2.78±1.26

0.90±0.11

<0.001

MDRD(mL/min/1.73 m2)

8.44±2.96

25.35±11.98

91.56±10.07

<0.001

Age

Age (year) 2

p 0.003

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Table 2. Plasma thiol/disulfide levels of three groups HD n=94 Mean±SD

CKD n=67 Mean±SD

Control n=102 Mean±SD

Native thiol (μmol/L)

245.65±52.13

247.76±40.86

375.09±63.18

<0.001

Total thiol (μmol/L)

274.34±58.00

270.82±45.38

403.02±63.04

<0.001

Disulfide (μmol/L)

14.34±11.02

11.52±6.68

13.96±6.62

0.155

Disulfide/native thiol (%)

6.08±5.34

4.69±2.68

3.87±2.05

0.007

Disulfide/total thiol (%)

5.09±3.47

4.18±2.16

3.52±1.70

0.007

Native thiol/total thiol (%)

89.80±6.95

91.62±4.33

92.94±3.41

0.007

Native thiol level was found to be highest in the control group and to be lowest in the HD group. There was a statistically significant difference in native thiol level between the three groups (p<0.001). Total thiol level was found to be highest in the control group and to be lowest in the HD group. There was a statistically significant difference in total thiol level between the three groups (p<0.001) Disulfide level was found to be highest in the HD group and to be lowest in the CKD group. There was no statistically significant difference in disulfide level between the three groups (p=0.155). Disulfide/native thiol ratio was found to be highest in the HD group and to be lowest in the control group. There was a statistically significant difference in disulfide/native thiol ratio between the three groups (p=0.007). Disulfide/total thiol ratio was found to be highest in the HD group and to be lowest in the control group. There was a statistically significant difference in disulfide/total thiol ratio between the three groups (p=0.007). Native thiol/total thiol ratio was found to be highest in the control group and to be lowest in the HD group. There was a statistically significant difference in native thiol/total thiol ratio between the three groups (p=0.007). Discussion Patients with uremia due to renal failure are at a higher risk of morbidity and mortality than nonuremic patients. Many factors are responsible for this increased risk. Oxidative stress and formation of reactive oxygen species seem to play an important role. Both experimental and clinical studies have demonstrated that there is an increase in oxidation state due to disease progression and that it relates to clinical complications in the context of different renal injury models [2]. In this study, we tried to show the changes in oxidative stress in HD and CKD patients by TDH. As a member of the antioxidant cascade, thiol group eliminates reactive oxygen species (ROS), and thus the measurement of total thiol level can be used to assess oxidative status [16]. Ates et al. [17] determined that total thiol level was lower in CKD patients than in healthy controls. In our study, total thiol level was found to be lowest in the HD group, followed respectively by the CKD and control groups. There was a statistically significant difference in total thiol level between the three groups.

Native thiol capacity was shown to decrease linearly by application of oxidation process [15]. Previous studies revealed that serum thiol levels decreased in CKD patients [18, 19]. This decrease can be due to two reasons: decreased protein uptake and loss of amino acids through proteinuria (1) and transformation of thiols to disulfides by oxidation (2) [17]. Ates et al. [17] determined that native thiol level was lower in CKD patients than in healthy controls. In our study, native thiol level was found to be lowest in the HD group, followed respectively by the CKD and control groups. There was a statistically significant difference in native thiol level between the three groups. Ates et al. [17] determined that disulfide level was lower in CKD patients than in healthy controls. In our study, disulfide level was found to be lowest in the CKD group, followed respectively by the control and HD groups. However, there was no statistically significant difference in disulfide level between the three groups. The thiol–disulfide equilibrium provides rapid and dynamic regulation, generates redox signaling, and occupies a central place as a target of oxidative stress. This feature makes serum disulfide/ thiol ratio useful as a clinical measure of oxidative stress [15]. Ates et al. [17] found that there was no statistically significant difference in disulfide/native thiol, disulfide/total thiol, and native thiol/total thiol ratios between the CKD and healthy control groups. In our study, disulfide/native thiol and disulfide/total thiol ratios were found to be highest in the HD group, followed respectively by the CKD and control groups. There was a statistically significant difference in disulfide/native thiol and disulfide/total thiol ratios between the three groups. In our study, native thiol/total thiol ratio was found to be lowest in the HD group, followed respectively by the CKD and control groups. However, there was no statistically significant difference in native thiol/total thiol ratio between the three groups. Ateş et al. [20] reported that there was a positive correlation between oxidative stress and age and that native thiol level decreased with age. Babaoglu et al. [21] also indicated that there was a negative correlation between age and total and native thiol levels. This information shows us that oxidative stress may increase with age and that thiol/disulfide homeostasis may shift towards disulfide side. In our study, there was a statistically significant difference in the mean age between the three groups. Although the HD group had the lowest median age, oxidative stress was found to be highest in this group. 203

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Studies have revealed that adipose tissue formation is associated with increased levels of inflammation and oxidative stress and antioxidant levels decreased in obese individuals [22]. Sögüt et al. [23] reported that TDH shifted more towards disulfide side (decreased total and native thiol levels, increased disulfide level) in obese individuals when compared to normal-weight individuals. In our study, the fact that the control group had highest BMI could explain that disulfide levels did not differ between the three groups. If there was no difference between in BMI between the three groups in our study, the other groups would have higher levels of oxidative stress when compared to the control group. Conclusion Consequently, our study found that TDH shifted more towards the left (disulfide side) and oxidative stress was higher in both HD (markedly) and CKD groups when compared to the control group. More comprehensive studies will show that different strategies to reduce oxidative stress in HD and CKD patients can prevent the development of additional diseases due to oxidative stress in these patient groups. Competing interests The authors declare that they have no competing interest. Financial Disclosure This study was funded by the research fund of Konya Training and Research Hospital. Ethical approval The study was approved by the Ethics Committee of KTO Karatay University Faculty of Medicine (2017/002). Ibrahim Solak ORCID: 0000-0001-5311-0631 Ibrahim Guney ORCID: 0000-0002-1646-2811 Seher Mercan ORCID: 0000-0002-4066-2928 Ozcan Erel ORCID: 0000-0002-2996-3236} Salim Neselioglu ORCID: 0000-0002-0974-5717 Cigdem Damla Cetinkaya ORCID: 0000-0002-6052-4645 Mehmet Ali Eryilmaz ORCID: 0000-0002-5280-3943

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10. Tayebi Khosroshahi H, Vaziri ND, Abedi B, et al. Effect of high amylose resistant starch (HAM‐RS2) supplementation on biomarkers of inflammation and oxidative stress in hemodialysis patients: a randomized clinical trial. Hemodialysis Int. 2018. 11. LeGrand A, Fermor B, Fink C, et al. Interleukin‐1, tumor necrosis factor α, and interleukin‐17 synergistically up‐regulate nitric oxide and prostaglandin E2 production in explants of human osteoarthritic knee menisci. Arthritis & Rheumatism: Official J Am College Rheumatol. 2001;44:2078-83. 12. Horton JW. Free radicals and lipid peroxidation mediated injury in burn trauma: the role of antioxidant therapy. Toxicology. 2003;189:75-88. 13. Solak I, Cetinkaya C, Gederet Y, et al. Effects of smoking on thiol/disulfide homeostasis. Eur Rev Med Pharmacol Sci. 2017;21:2477-82. 14. Levey AS, Coresh J, Greene T, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006;145:247-54. 15. Erel O, Neselioglu S. A novel and automated assay for thiol/disulphide homeostasis. Clinical Biochemistry. 2014;47:326-32. 16. Bal C, Büyükşekerci M, Koca C, et al. The compromise of dynamic disulfide/ thiol homeostasis as a biomarker of oxidative stress in trichloroethylene exposure. Human & Experimental Toxicology. 2016;35:915-20. 17. Ateş İ, Özkayar N, Yılmaz FM, et al. Oxidative stress level in patients with chronic kidney disease. Ortadogu Med J. 2018;10. 18. Prakash M, Upadhya S, Prabhu R. Protein thiol oxidation and lipid peroxidation in patients with uraemia. Scand J Clin Lab Invest. 2004;64:599604.

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20. Ates I, Kaplan M, Inan B, et al. How does thiol/disulfide homeostasis change in prediabetic patients? Diabetes Res Clin Pract. 2015;110:166-71.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):205-6

Patient involvement in disease management: A holistic approach in clinical pharmacy Aygin Bayraktar-Ekincioglu Hacettepe University, Faculty of Pharmacy, Department of Clinical Pharmacy, Ankara, Turkey Received 30 September 2019; Accepted 05 November 2019 Available online 03.03.2020 with doi:10.5455/medscience.2019.08.9169 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract Clinical pharmacy is one of the specialized areas of pharmacy profession which demands scientific and comprehensive therapeutic knowledge, extensive clinical experience and skills, and collaboration with other healthcare professionals as well as the patients in disease management. The concepts of patient involvement and patient empowerment, patient self-management and patient engagement in health care settings are explored in many studies. The PubMed search undertaken in March 2019 by using the keywords of ‘patient involvement,’ ‘disease management,’ and ‘clinical pharmacy’ revealed 581 publications, of those 268 were published in the last five years and 95 were review articles. Another search made by using the words of ‘patient empowerment’ and ‘clinical pharmacy,’ and the results were even increased to 735 articles. A patient-centered approach is the cornerstone of the provision of clinical pharmacy services in chronic disease management. The patient’s ability in problem-solving can be enhanced through teaching general skills and providing access to appropriate counseling or supervision. Therefore, patients become responsible for many issues, such as describing their symptoms and expressing their concerns properly, using specific self-management practices, and applying preventative approaches in their disease management. During the disease management process, roles and responsibilities of healthcare professionals and patients should be specified, and patients become less severely incapacitated by disease consequences, well-informed about their condition and medications, and have higher self-esteem to improve their condition or prevent their condition becoming worse. Keywords: Clinical pharmacy, patient empowerment, disease management

Introduction Clinical pharmacy is one of the specialized areas of pharmacy profession among health disciplines that demands scientific and comprehensive therapeutic knowledge, extensive clinical experience and skills, and collaboration with other healthcare professionals as well as the patients in disease management. The principles of clinical pharmacy rely on the philosophy of pharmaceutical care and focus on taking responsibility in the provision of care to the patients to improve health-related outcomes. The aims of clinical pharmacy activities to develop and promote the rational and appropriate use of drugs and medicinal products and devices and to improve patient’s quality of life. By the provision of pharmaceutical care, a clinical pharmacist performs individual patient’s needs assessment by planning clinical activities (Plan), implementing the activities for identified problems (Do), acting according to the pharmaceutical care plan (Act), and assessing the

*Coresponding Author: Aygin Bayraktar-Ekincioglu, Hacettepe University, Faculty of Pharmacy, Department of Clinical Pharmacy, Ankara, Turkey E-mail: aygin@hacettepe.edu.tr

outcomes of activities (Check). To identify individual drug-related problems for a patient and to find appropriate solutions to solve the problems, it is inevitable to involve the patients in the care process [1-4]. It is appreciated that a concept of ‘health’ consists of the physical, intellectual, emotional, and social well-being of a person, which can be maintained through a multidisciplinary and holistic approach in the provision of care for the patients. Material and Methods There have been many studies in the literature that explored the concept of the involvement of the patient and patient empowerment, patient self-management and patient engagement in health care settings. The PubMed search was undertaken in March 2019 by using the keywords of ‘patient involvement,’ ‘disease management’, and ‘clinical pharmacy’ revealed 581 results, of those 268 were published in the last five years, and 95 were review articles. Once the words of ‘patient empowerment’ and ‘clinical pharmacy’ used, the results were even increased to 735 articles. The search can be expanded by using the keywords as ‘self-care,’ ‘self-management,’ and ‘patient participation.’ 205

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Results A patient-centered approach is the cornerstone of the provision of clinical pharmacy services in chronic disease management, which demands responsibilities from the patients in shared decision making, monitoring of drug therapy, and adherence to the therapy to achieve definite outcomes. The studies showed that health-related outcomes such as control of diabetes, better physical functioning in rheumatic disease, pain control, correct use of inhalers, enhanced adherence, or any preventive activities had been achieved by the involvement of patients in various chronic disease management. Discussion Patient involvement has been interpreted as a holistic approach to individuals taking more control over their health independently through their experience of health and illness and it begins with an understanding of the process where a patient can function by his/herself in the maintenance and promotion of health, disease prevention, awareness, treatment, and care of illness and adaptation to limited daily living activities. It originates from a need for a better understanding of their symptoms and builds on patient’s self-enablement, their relationships with health care professionals, and the availability of resources in the community. Therefore, the patient’s role in this process is to engage him/ herself with the maximum feasible amount of self-management through the provision of knowledge and facilitation by health care professionals [5]. As the disease progresses, management strategies change according to patients’ needs, their understanding of their therapy, their ability to engage in the partnership, and the availability of financial resources. Effective chronic disease management can be achieved by the establishment of a partnership process based on shared understandings and taken actions, which requires inquiry, interpretation, learning, and negotiation. Provision of information regarding self-care, disease management, and drug therapy is crucial to ensure patient’s involvement, which is pre-requisite for participation. Long term experiences with diseases ground expertise in self-care and require commitments to be actively involved in disease management. Therefore, engaging patients with self-care activities would achieve successful outcomes (such as sustaining symptoms or positive physiological indicators) in disease management in chronic illness. As a part of disease management, drug treatment is intended to alleviate symptoms rather than cure disease in chronic conditions. It is, therefore, an important issue for patients to use their medication as prescribed. Patients sometimes require self-management skills in the use of medicines, which enable them to comply with a regimen, interpret the effects of medication, recognize side effects,

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seek medical advice, and prompt a change in a treatment program when necessary. The patient’s ability in problem-solving can be enhanced through teaching general skills and providing access to appropriate counseling or supervision. Therefore, patients become responsible in seeking advice at the right time, describing their symptoms and expressing their concerns properly, differentiating different stages of disease-while acquiring an understanding and interpreting disease patterns, using specific self-management practices, and applying preventative approaches in their disease management. It becomes crucial for health care professionals to understand the patient’s willingness to involve in disease management and how to overcome any barriers. There is a challenge for the health systems which initiate a shift in chronic disease management towards the encouragement of patients to enable them to take an increasingly more active role in their care and a need for training of health care professionals to maintain and foster patients’ self-management abilities in clinical settings. Therefore, it is assumed that definition of roles and responsibilities would achieve improved disease management where patients are expected to manage specific aspects of their disease effectively; become less severely incapacitated by disease consequences; able to access health and social care services, wellinformed about their condition and medications and have higher self-esteem in order to improve their condition or prevent their condition becoming worse. Financial Disclosure All authors declare no financial support. Ethical approval No ethic approvell is needed to this research. Aygin Bayraktar-Ekincioglu ORCID: 0000-0002-3481-0074

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Cipolle RJ, Strand LM, Morley PC, Eds. Pharmaceutical Care Practice: The patient-centred approach to medication management service. 3rd edition. USA McGraw-Hill Education LCC. 2012;10-35.

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Graffigna G et al. Patient Engagement: a consumer-centered model to innovate healthcare. Chapter 2: Giving (Back) a Role to Patients in the Delivery of Healthcare Services: Theoretical Roots of Patient Engagement. In: Graffigna G, Barello S, Triberti S, eds. Berlin De Gruyter Open. 2015;14-23.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):207-11

The investigation of the effect of NAD, H2O2 and weak magnetic field on the antibacterial mechanism of isoniazid (INH) that first line antibiotic against M. tuberculosis agent Selami Gunal1, Kadir Batcioglu2, Esra Erdogan1 1

Inonu University Faculty of Pharmacy, Department of Pharmaceutical Microbiology, Malatya, Turkey Inonu University Faculty of Pharmacy, Department of Pharmaceutical Biochemistry, Malatya, Turkey

Received 25 September 2019; Accepted 20 November 2019 Available online 07.03.2020 with doi: 10.5455/medscience.2019.08.9171

Abstract Tuberculosis is an infectious disease, which is caused by the Mycobacterium tuberculosis complex. This disease leads to up to 1.3 million deaths out of more than eight million cases every year. A prodrug called isoniazid has been proven to be effective and widely used in the treatment of infections caused by tuberculosis. Despite its use for more than six decades clinically, the action mechanism of this prodrug is yet to be elucidated. INH action agains mycobacteria requires catalase−peroxidase (KatG) function, and IN-NAD adduct formation is catalyzed in vitro by M. tuberculosis KatG under a variety of conditions. Low-intensity EMF (Electromagnetic Field) has been used in therapeutic practices in addition to its use in telecommunication systems and food protection. EMF is used in medicine and food industries especially for its bactericidal effects. In this study, we aimed to investigate the effects of weak magnetic field application and the addition of NAD and H2O2 on the action mechanism of isoniazid. We added H2O2 and NAD individually and together, to the different groups at varying concentrations. Also, one experimental group was exposed to a 5mT, 50Hz magnetic field for 4 to 5 hours per day (total of 45 hours in 10 days). The agar proportion method was used to evaluate the results. It was determined that the addition of 100 μM NAD and H2O2 together increased the effectiveness of isoniazid to some extent. However, the application of a weak magnetic field did not change the effectiveness of the drug. Keywords: Mycobacterium tuberculosis, Isoniazid, Magnetic Field, NAD, H2O2

Introduction According to the WHO 2018 Tuberculosis Report, millions of people continue to get sick every year with tuberculosis. It is estimated that fatalities related to tuberculosis have reached 1.3 million among HIV negative people and 300000 among HIV positive people in 2017. It is evaluated that approximately 1.7 billion people, 23 percent of the world’s population, carry tuberculosis [1]. Tuberculosis is an infectious disease caused by bacilli called Mycobacterium tuberculosis complex. In addition to factors such as increasing and spreading of multi-drug resistant strains and coinfection with HIV, the long-term, combined, complex, expensive treatment regimen of tuberculosis and the inability to provide adequate patient compliance makes the control of the disease increasingly difficult [2]. Isoniazid, which is a prodrug, is an isonicotinic acid hydrazide and is a widely used and effective drug in the treatment of tuberculosis.

*Coresponding Author: Esra Erdogan, Inonu University Faculty of Pharmacy, Department of Pharmaceutical Microbiology, Malatya, Turkey E-mail: eczesraerdogan@gmail.com

The isonicotinic acid radical formed by KatG dependent isoniazid activation is oxidized by NADH to form the covalent bond compound of INH-NADH. The NADH/NAD ratio is extremely important for maintaining the viability of the bacterium and it also affects the susceptibility of mycobacteria to isoniazid. The reduction of NAD in the environment causes isoniazid resistance. In oxidative phosphorylation, NADH dehydrogenase enzyme forms NAD by NADH oxidation [3,4]. WHO accepts ICNIRP (International Commission on NonIonizing Radiation Protection) when it comes to the effects of nonionizing radiation and IARC (International Agency for Research on Cancer) when it comes to cancer. In June 2001, IARC announced that electromagnetic fields (ELF) formed near energy transmission (high voltage) lines could be carcinogenic. ELF magnetic fields have been accepted as “Possibly Carcinogenic” (Group-2B) in the WHO classification of cancer [5]. The electromagnetic field affects the ion transport systems, membrane potential and ions related cellular response, especially in the cell membrane. Thus, it affects many cell functions such as cell growth and differentiation, apoptosis, DNA synthesis, RNA transcription, protein expression and phosphorylation, lipid reoxidation, ATP synthesis, hormone production, antioxidant 207

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enzyme activities, and metabolic activity [6-9]. This study aims to demonstrate the role of NAD, and H2O2 added to the environment in varying concentrations in isoniazid susceptible and resistant strains of M.tuberculosis, and at the same time, to determine the possible effects of 5mT, 50Hz weak magnetic field application on the efficacy of the drug. Materials and Methods In the first stage of the experiment, five groups (40 samples in total) were studied with four susceptible (H37Rv) and four resistant (H37Ra) strains total of 8 samples in each group for ten days. Cultivation was done in MD7H9 liquid media. Mc Farland turbidity was set to 0.5 (1x106 CFU/mL) and 0.2µg/ml of INH was added to each tube.

3. Group: For each of the eight samples, 100µL of H2O2 prepared as 1mM per day, was added for ten days. Hence, H2O2 was obtained in the 10μM final concentration in the test tube. 4. Group: NAD was added to achieve a 10µM final concentration. 5. Group: H2O2 and NAD were added together for ten days to ensure that both H2O2 and NAD were present at the 10µM final concentration. The agar proportion method was used. At the end of 10 days, 10µL was taken from each tube (from a total of 40 tubes) and were cultured by being taken with sterile loops into the Middlebrook 7H10 solid media, in which antibiotics were added and was previously prepared. The experiment was terminated to count the colonies formed in the plates that were kept in the incubator for 14 days. In the second stage of the experiment, four groups were prepared which included five liquid media (MD7H9) each. ATCC H37Rv susceptible strains were cultured on these. They were exposed to H2O2 and NAD for 12 days such that their final concentrations were 50, 100, 150 and 200µM. To evaluate again by agar proportion method, the experiment was terminated to count the colonies by culturing on solid media (MD7H10). Result As the results of the normal distribution test, which is the first statistical evaluation, did not conform to the normal distribution, Kruskal Wallis Variance Analysis and Mann Whitney U tests, which are non-parametric statistics tests, were used in the analysis. When all the groups were evaluated by performing Kruskal Wallis variance analysis in more than two-group comparisons and a statistically significant difference was found between the groups (p <0.05), the Mann Whitney U test was performed to determine which groups caused the difference.

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Table 1. Effects of every 10 µM H2O2 and NAD on susceptible and resistant strains

GROUPS

Control 2

10 µM H2O2

1. Group (Control 1 group): It was incubated in the absence of any treatment. 2. Group: 8 samples with four susceptible and four resistant strains were exposed to a magnetic field of BDC = 4.95 (± 0.02) mT, for 45 minutes every day for 4.5 hours in total. The room temperature was kept at 23 ± 20C.

10 µM NAD

10 µM H2O2 +10 µM NAD

SUSCEPTIBLE STRAIN H37Rv ATCC 27294 (colony numbers)

RESISTANT STRAIN H37Ra ATCC 25177 (colony numbers)

a 17

a 83

b 16

b 82

c 17

c 84

d 18

d 83

a 18

a 82

b 16

b 84

c 15

c 83

d 16

d 83

a 15

a 84

b 15

b 81

c 14

c 82

d 16

d 81

a 83

b 82

c 82

d 83

Table 2. The effects of susceptible and resistant strains of 45 hours 5mT magnetic field application on colony numbers

GROUPS

Control 1

Magnetic Field

SUSCEPTIBLE STRAIN H37Rv ATCC 27294 (colony numbers)

RESISTANT STRAIN H37Ra ATCC 25177 (colony numbers)

a 14

a 83

b 16

b 81

c 15

c 84

d 15

d 80

a 16

a 80

b 15

b 81

c 15

c 82

d 15

d 81

While the addition of H2O2 and NAD individually or combined in resistant strains did not affect colony numbers (p> 0.05), the addition of 10µM H2O2 and NAD, when added together, inhibited bacterial growth significantly by enhancing the efficiency of isoniazid dramatically in susceptible strains (p <0.05). We then tested the dose-dependent effect by adding different concentrations of H2O2 and NAD only to susceptible strains. When we compared the four experimental groups, in which H2O2 and NAD were added, such that their final concentrations were 50, 100, 150, and 200 µM, we found that the most effective concentration was achieved by adding 100µM H2O2 and NAD together. In this concentration, the growth of isoniazid-susceptible bacilli was more strongly inhibited as compared to others (p <0.05) 208

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Table 3. Colony numbers obtained by the addition of H2O2 and NAD

GROUPS

SUSCEPTIBLE STRAIN H37Rv ATCC 27294 (colony numbers) a 17 b 16

Control Group 2

c 17 d 17 e 18 a 14

Figure 3. 10 Effects of 10 µM H2O2 and NAD on resistant strains

b 16 50 µM H2O2 +50 µM NAD

c 14 d 14 e 14 a 7 b 7

100 µM H2O2 +100 µM NAD

c 7 d 8 e 7

150 µM H2O2 +150 µM NAD

200 µM H2O2 +200 µM NAD

a 10 b 9 c 9 d 10 e 10 a 12 b 13 c 15 d 14

Figure 4. The combined addition of H2O2 and NAD at different concentrations affects the colony numbers of susceptible strains

Discussion In the literature, studies are showing that the magnetic field increases cell membrane permeability [10]. Also, it is known to alter the activities of enzymes that catalyze the oxy-reduction reactions and contain metal ions in the active center [11,12]. In a study conducted by Fojt et al., they reported that exposure to 10 mT, 50 Hz magnetic field for an hour did not cause any morphological changes on the surface and in the form of both bacillus (Escherichia coli) and coccoid (Paracoccus denitrificans) shaped bacteria [13]. Another study conducted by the same research team found that there was a decrease in the number of colonies when 50mT, 50Hz electromagnetic field exposure of different bacterial strains (Escherichia coli, Leclercia adecarboxylata, Staphylococcus aureus) was compared to the control groups [14]. In another study conducted by Fojt et al., the effects of electromagnetic field exposure of 7.1mT, 50Hz and 24 minutes on the viability of sulfate-reducing bacteria were investigated, and it was shown that the number of colonies decreased by 15% compared to the control group after exposure [15].

Figure 1. Our experimental setup

Figure 2. Effects of 10 µM H2O2 and NAD on susceptible strains

Cellini et al. found that the exposure to 50 Hz and 0.1, 0.5, 1.0 mT magnetic fields for up to 2 hours changed the morphology of E.coli and transformed their form from bacilli to cocci. In culture, atypical bacilli were also found along with cocci. Also, the 50Hz electromagnetic field is thought to act as a stress factor in bacteria by inducing phenotypic and transcriptional changes [16]. In a study conducted by Strasak et al., it was found that 2.7-10mT, 50 Hz exposure had a negative effect on the proliferation of E. coli, and duration and intensity of increased magnetic field caused a bactericidal effect by reducing colony formation ability and oxidoreductive activity of bacteria [17].

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In a study conducted by Segatore et al., Escherichia coli and Pseudomonas aeruginosa bacteria were exposed to 2mT, 50Hz electromagnetic field for 24 hours, and their growth and antibiotic susceptibilities were evaluated. As a result, there were no significant differences in antibiotic susceptibility and growth rates in both bacteria when compared to control groups. In the presence of different class antibiotics (kanamycin, amikacin, ampicillin, cefazolin, ceftazidime, ceftriaxone, mocsalactam and levofloxacin) with different effect mechanisms, the effects of electromagnetic field on the antibiotic susceptibility of both bacteria were tested and no significant change was observed in the minimum inhibition concentrations. According to the study, in the absence of antibiotics, bacteria can recognize the electromagnetic stimulation and regulate their physiological conditions accordingly, and potential cumulative effects may occur when exposed to both sub-inhibitory concentration antibiotics and very-low-frequency electromagnetic fields [19]. According to our comprehensive literature review, there is no such study investigating the possible effects of the magnetic field on the growth potential of M. tuberculosis. In this context, our study is the first study investigating the effect of magnetic field on M. tuberculosis. The unique cell wall structure of M. tuberculosis containing mycolic acid may have made bacilli more resistant to the potential effects of the magnetic field. Or the bacteria may have developed a metabolic adaptation to very long exposure. Even though different microorganisms are exposed to the same magnetic field, it is known that they are affected due to their different biological and molecular structures. The effects of the very lowfrequency electromagnetic field are very diverse, depending on the cell type, exposure time, intensity, and frequency of the magnetic field. These studies show that different magnetic field intensity, frequency and exposure times can have very different effects on different bacilli and strains. Different from these studies, in our study, we investigated M. tuberculosis, which has a very different cell wall structure. Low permeability and hydrophobicity of the cell walls of mycobacteria makes bacteria resistant to harmful compounds and makes the usage of some useful metabolites difficult. Also, mycobacteria which have a slow growth rate due to their low elongation rate of the nucleic acid chain, are divided into two in 18-24 hours. Due to the low growth rate of M. tuberculosis, we applied a magnetic field to the bacteria for a longer duration as compared to other studies. In conclusion, no significant change was observed when the colonies were counted, compared with the control group (p> 0.05). In their study, Argyrou et al. showed in vivo that the increased NAD addition increased the INH-NAD levels which are effective forms of the drug [20]. Zhao et al., in their study, showed in vivo the effect of NAD and NADH addition, in the presence and absence of additional peroxide, on the rate of formation of INHNAD compound with isoniazid. In the experiment conducted without the addition of H2O2, NADH was more effective in forming compounds than NAD. While NAD was 5 times more effective than NADH when slow-flowing H2O2 was added to the medium. InhA enzyme activity was observed with experiments performed with the addition of 200μM H2O2 and slow-flowing H2O2 with both wild type katG and S315T strains. It was observed that slow-flowing H2O2 addition was more effective in lowering

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the activity of the enzyme. In the study conducted with the wildtype strain, it was determined that the addition of 200μM H2O2 significantly decreased the enzyme activity [21]. In another in-vivo study by Cade et al., it was found that isoniazid-resistant strains with different mutations exhibit very different oxidant-specific reactivities. According to the study, the wild-type strain with the addition of 400μM H2O2 produces much more INH-NADH products, while the lower peroxide addition causes less product formation. The product formed without the addition of peroxide is extremely low compared to the product formed with the addition of peroxide. These rates were found to be quite different in strains with different mutations [22]. Conclusion In our study, we determined that the application of a magnetic field to susceptible and resistant strains in the in-vitro environment did not change the efficiency of isoniazid. At the same time, in the experimental groups with different concentrations of H2O2 and NAD, the best efficacy was determined where 10μM H2O2 and NAD were added together to the susceptible strains. Then, we added H2O2 and NAD together into only susceptible strains in different concentrations and we found that the most effective concentrations were obtained by adding 100μM H2O2 and NAD together to the susceptible strains. New studies are needed to make isoniazid, which is widely used in the treatment of tuberculosis, more effective. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval We made in-vitro study. We worked only with bacteria. We did not work with the patient sample Esra Erdogan ORCID: 000-0003-1626-6033 Selami Gunal ORCID: 0000-0002-4752-5176 Kadir Batcioglu ORCID: 0000-0001-6623-2287

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World Health Organization, Global Tuberculosis Report. Executive summary 2018, http://www.who.int/tb/publications/global_report/ GraphicExecutiveSummary.pdf?ua=1 2018.

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Winder F 1960 Catalase and peroxidase in mycobacteria. Am Rev Respir Dis. 81:68-78.

Awasthy D, Ambady A, Narayana A, et al. Roles of the two type II NADH dehydrogenases in the survival of Mycobacterium tuberculosis in vitro. Gene. 2014;550:110-6.

International Agency for Research on Cancer (IARC). IARC monographs on the evaluation of carcinogenic risk to humans, 2002, vol 80.

Cifra M, Fields JZ, Farhadi A.Electromagnetic cellular interactions. Prog Biophys Mol Biol. 2011;105:223-46.

Ciejka E, Kleniewska P, Skibska B, et al. Effects of extremely low frequency magnetic field on oxidative balance in brain of rats. J Physiol Pharmacol. 2011;62:657-61.

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Goraca A, Ciejka E, Piechota A. Effects of extremely low frequency magnetic field on the parameters of oxidative stress in heart.J Physiol Pharmacol. 2010;61:333-8.

Mostafa RM, Moustafa YM, Ali FM, et al. Sex hormone status in male rats after exposure to 50 Hz, 5 mTesla magnetic field. Arch Androl. 2006;52:3639.

10. Saunders RD, Jefferys JG. A neurobiological basis for ELF guidelines. Health Phys. 2007;92:596-603. 11. Batçıoğlu K, Öztürk İÇ, Atalay S, et al. Investigation of time dependent magnetic field effects on superoxide dismutase and catalase activity: an in vitro study. JBPC. 2002;2:1-5. 12. Batçıoğlu K, Doğan M, Uyumlu AB, et al. Investigation of a weak magnetic field effect on the in vitro catalytic activity of adenosine deaminase and xanthine oxidase.Gen. Physiol. Biophys. 2011;30:410-4. 13. Fojt L, Klapetek P, Strasak L, et al. 50 Hz magnetic field effect on the morphology of bacteria. Micron. 2009;40:918-22. 14. Fojt L, Strasak L, Vetterl V, et al. Comparison of the low-frequency magnetic field effects on bacteria Escherichia coli, Leclerciaadecarboxylata and Staphylococcus aureus. Bioelectrochemistry. 2004;63:337-41. 15. Fojt L, Strasak L, Vetterl V. Extremely-low frequency magnetic field effects

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on sulfate reducing bacteria viability. Electromagn Biol Med. 2010;29:17785. 16. Cellini L, Grande R, Di Campli E, et al. Bacterial response to the exposure of 50 Hz electromagnetic fields. Bioelectromagnetics. 2008;29:302-11. 17. Strasak L, Vetterl V, Smarda J. Effects of low-frequency magnetic fields on bacteria Escherichia coli. Bioelectrochemistry. 2002;55:161-4. 18. Segatore B, Setacci D, Bennato F, et al. Evaluations of the effects of extremely low-frequency electromagnetic fields on growth and antibiotic susceptibility of escherichia coli and pseudomonas aeruginosa. Int J Microbiol. 2012:587293. 19. Argyrou A, Vetting MW, Blanchard JS. New insight into the mechanism of action of and resistance to isoniazid: Interaction of Mycobacterium tuberculosis enoyl-ACP reductase with INH-NADP. J Amn Chemical Society. 2007;129:9582-3. 20. Zhao XB, Yu H, Yu SW, et al. Hydrogen peroxide-mediated isoniazid activation catalyzed by Mycobacterium tuberculosis catalase-peroxidase (KatG) and its S315T mutant. Biochemistry .2006;45:4131-40. 21. Cade CE, Dlouhy AC, Medzihradszky KF, et al. Isoniazid-resistance conferring mutations in Mycobacterium tuberculosis KatG: catalase, peroxidase, and INH-NADH adduct formation activities. Protein Sci. 2010;19:458-74.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):212-5

Preparation of sumac extract loaded microemulsion-alg microcomposites Fadime Nulufer Kivilcim1, Seval Cing Yildirim2, Ahmet Gultek1 Inonu University, Art and Science Faculty, Department of Chemistry, Malatya, Turkey 2 Inonu University, Art and Science Faculty, Department of Biology, Malatya, Turkey

Received 01 October 2019; Accepted 25 November 2019 Available online 08.03.2020 with doi: 10.5455/medscience.2019.08.9172

Abstract Our skin is the largest organ that covers our body against the external environment and it is in constant contact with microorganisms compared to our other organs. The bacterial infection does not develop easily on our skin due to many protective factors. However, bacterial infections occur when there is a deterioration in any of these protective mechanisms. Therapeutic plants and spices are widely used as antibacterial agents for dermatological use. In this study, it is aimed to prepare a microemulsion loaded with bioactive sumac extract and to test bioactivity of microalgae (Chlorella sp.) commonly used in cosmetic formulations by using an innovative approach. The microcomposites prepared by this method are expected to have a better effect on fat, bacteria and toxins on the surface of skin. Sumac fruit (Rhus coriaria), which is used as a spice, was extracted by using ethanol in Soxhlet apparatus. Algae-microcomposites were prepared with different amounts of sumac extract (1%, 2% and 3% (w/v). Excess of ethanolic extract of sumac fruit was mixed in 3 ml oleic acid for 72 hours at 37Â°C and and the insoluble fraction was removed by centrifugation. Tween 80 was added to the solution as a surfactant and PEG-400 was added as a co-surfactant at 2: 1 ratio into the solution. While the mixture was stirred at the medium intensity on the magnetic stirrer, pure water was added dropwise over solution until a homogenous clear solution was obtained. The bioactivity tests of the microcomposites were carried out using gram-positive Staphylococcus aureus and gram-negative Escherichia coli bacteria which are generally found on the skin surface. Microcomposites containing 2 % and 3 % sumac extract showed bioactive properties by inhibiting the growth of S. aureus and E. coli bacteria. Keywords: Microalgae, sumac fruit, Rhus, antibacterial, dermatologic

Introduction Therapeutic plants and spices derived from natural sources play an important role in health care. Due to flavonoids, vitamins, essential oils and minerals that they contain, these plants are widely used in medicine and cosmetic industries. Among these therapeutic plants, sumac, Rhus coriaria L. (Anacardiaceae) is a wild edible medicinal plant that grows in tropical regions of the world. Sumac shows an excellent bioactive effect due to its rich antioxidant, vitamin, fatty acid and mineral content. Also, it shows antioxidant, antibacterial, antifungal, antiviral and antimicrobial properties [1]. Microalgae are unicellular, photosynthetic organisms that play a key role in aquatic ecosystems and grow in freshwater as well as in marines. Microalgae are a unique reservoir of bioactive compounds and produce secondary metabolites that are required

*Coresponding Author: Fadime Nulufer Kivilcim, Inonu University, Art and Science Faculty, Department of Chemistry, Malatya, Turkey E-mail: nilufer.kivilcim@inonu.edu.tr

for cellular metabolism. These secondary metabolites include phenolic compounds, carotenoids, tannins, alkaloids, flavonoids and numerous other compounds which have cosmetically importance. Microalgae used in cosmetic products have recently gained interest in the treatment of skin problems such as anti-aging and pigment disorders [2-4]. Our skin is the largest organ that covers our body against the external environment and it is in constant contact with microorganisms compared to our other organs. Despite this intense microorganism contact, the bacterial infection does not develop easily on our skin due to many protective factors. However, bacterial infections occur when there is a deterioration in any of these protective mechanisms. The most common deteriorations are caused by gram-positive bacteria, streptococci and staphylococci [5]. Aqueous and ethanolic extracts of sumac exhibit a strong antibacterial effect against gram-positive and gram-negative bacteria such as Staphylococcus aureus, Bacillus cereus, Escherichia coli, Salmonella typhi, Proteus vulgaris, and Shigella flexneri [6]. Staphylococcus aureus and Escherichia coli 212

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start to grow intensively when the protective factor against the microorganism changes with alteration of eating, cleaning and dressing habits [7]. In cosmetic industry and literature, algae are commonly used for dermatological and medical purposes. However, there is no commercial product and scientific data in the literature on microemulsions of sumac penetrated into algae. Nanosystems such as microemulsions (ME) and nanoemulsions (NE) offer considerable opportunities for targeted drug delivery to and via the skin. ME and NE are stable colloidal systems composed of oil and water, stabilized by a mixture of surfactants and cosurfactants, that have received particular interest as topical skin delivery systems [8]. There is a considerable effort to manipulate their formulation and characteristics to achieve optimal bioavailability and minimal skin irritation. This includes incorporation of chemical penetration enhancers, thus reduced skin blockage and increased permeation are established. Macroemulsions are often referred as ‘coarse’ or opaque emulsions due to their relatively large droplet sizes causing a turbid solution. Microemulsions are transparent, monophasic, optically isotropic and thermodynamically stable colloidal dispersions consisting of oil, water, surfactant and co-surfactant. The droplet size of the microemulsions ranges between 10-100 nm. [9-11]. The aim of this study is to synthesize bioactive microcomposite suitable for dermatological use by combining the unique properties of sumac (Rhus spp.) and algae (Chlorella sp.). The bioactive sumac extract was loaded into the microemulsion to achieve a better skin penetration. Materials and Methods Algae Production As shown in figure 1, 5 % of the algae cultures were incubated in Bold’s Basal medium (BBM) under aseptic conditions. 200 mL algae production medium were transferred into 500 mL flasks. Chlorella spp. was cultured for 15 d at 22°C under a 12-hour photoperiodic conditions at a light intensity of 5000 lux (Figure 1).

Figure 1. Photograph of the algae production unit. Chlorella spp. was incubated for 15 d at 22°C under 12-hour photoperiod conditions at a light intensity of 5000 lux

Sumac Extraction The pericarp portion of the sumac was ground in the grinder. 10 g of milled sumac was placed in the soxhlet extraction apparatus. Extraction was carried out by using ethanol and excess ethanol was evaporated using a rotary evaporator.

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Perparation of Microemulsion 3 mL of oleic acid was added to the ethanolic extract of the sumac fruit and stirred at 37 ° C for 72 hours and the insoluble fraction was removed by centrifugation. Tween 80 as a surfactant and PEG400 as a co-surfactant was added into this solution at 2: 1 weight ratio. While stirring the mixture on a magnetic stirrer, distilled water was added dropwise until a homogeneous clear solution was obtained (Figure 2B). Since the particle size of the microemulsions was smaller than the wavelength of visible light, obtained mixture was transparent, not opaque, unlike conventional emulsions.

Figure 2. Perparation of microemulsion: Emulsion (A), Microemulsion (B).

Preparation of Microcomposites At this stage of the study, dry algae biomass and microemulsions containing different amounts of bioactive sumac extract were mixed and the microcomposite was prepared (Table 1). Table 1. Composition of microcomposite with antimicrobial agent Treatment Algae-Microcomposite (AMC)

Composition Algae (w/v) , PEG (v/v), Tween-80 (v/v) 1

AMC + Sa (1% (w/v))

AMC + S (2% (w/v))

AMC + S (3% (w/v))

a 1

S: Sumac Concentrations were measured as dry-bases of algae

Antimicrobial Activity of Sumac extract loaded microemulsionalg microcomposites Typical skin bacterial contaminants used in this study were Escherichia coli and Staphylococcus aureus. E. coli and S. aureus were grown on nutrient broth at 37°C. Before measuring the antimicrobial activity of microcomposites, 0.1 mL of cultures were transferred to new broth medium and grown for 1 d. The microcomposites were fragmented into 1.2 cm diameter under aseptic conditions and the pieces were placed on nutrient agar plates, which had been previously seeded with 0.1 mL of inoculumn containing approximately 104-105 CFU/mL of S. aureus and E. coli. The plates were incubated at 37°C for 24 h. The diameter of the inhibitory zone surrounding microcomposites pieces was measured. The experiment was done in triplicates. Result Microemulsions containing PEG, Tween 80 and sumac extract at different concentrations (1%, 2% and 3% weight ) were prepared. Algae were added to the prepared microemulsions to 213

doi: 10.5455/medscience.2019.08.9172

form microcomposites. Sumac extract loaded microemulsion-alg microcomposites were synthesized for antimicrobial activity tests. Inhibition effect of Sumac extract at various concentrations is given in Table 2. The results showed a strong inhibitory effect at given concentrations except for 1 % sumac. In addition, the antibacterial effect of sumac against S. aureus is higher than that of E. coli. Table 2. The effect of sumac extract loaded microemulsion-alg microcomposites against microorganisms S. aureus

E. coli

Without

+++

Values were expressed as mean of 3 analysis. -, not detected; +, diameter of inhibition zone was < 1 cm; ++, diameter of inhibition zone was 1-2 cm; +++, diameter of inhibition zone > 2 cm M1: AMC + S (1% (w/v)) M2: AMC + S (2% (w/v)) M3: AMC + S (3% (w/v))

Figure 3 shows the antibacterial results of the samples containing 2% and 3% sumac extract in the microcomposites. While the inhibition zone diameter of the microcomposite containing 2% sumac extract against E. coli was less than 1 cm, the inhibition zone diameter at a concentration of 3% was about 2 cm. The maximum inhibition diameter was obtained in microcomposite containing 3% sumac extract against S. aureus.

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properties [12, 13]. Algae have recently attracted attention in the treatment of various skin problems [14]. Microemulsion is an emulsion preparation method and its usage in medical applications is becoming widespread since it carries the bioactive cargo to its target effectively. In this study, the extract of sumac fruit was loaded in algae microemulsion and microcomposite and its antibacterial activity was investigated. Hydrophilic species can be obtained by extraction of sumac with water and n-hexane. A more comprehensive bioactivity can be obtained by extracting both hydrophilic and hydrophobic species with the ethanolic extract. Therefore, the ethanolic extract of sumac was preferred in this study. The most important difference that separates microemulsion from macroemulsion is that the macroemulsion becomes turbidity after mixing has stopped, while the microemulsion becomes clear. Therefore, it can be understood which system is used without carrying out further analysis. In this study, it was determined that the microemulsion was prepared since the mixture was transparent as shown in Figure 2B without further analysis techniques. Oils having antimicrobial effect in spices are usually hydroxyl group containing phenol compounds and have important antifungal, antibacterial and antioxidant properties. These phenolic compounds destroy the phospholipid layer in the cell membrane, increasing the permeability of this layer, and thus the substances inside the cell leak from the cell or the enzyme system of the bacteria is disrupted. In this case, microorganism inhibition occurs [15]. Sumac is known to exhibit antibacterial effect [16]. However, it is important to show that similar effect is observed with algae in microemulsion. Also the ratio of sumac extract in the microcomposite is highly determinant in the antibacterial effect. Experimental results show that microcomposites containing 2% and 3% sumac extract show strong antibacterial effect. The formation of an inhibitory zone depends on the diffusion of the antimicrobial compound into culture media and growth rate of microorganisms. These parameters are influenced by the physiological state of the culture, the chemical structure and the cross-linking level of the micro-composite [17]. The antimicrobial activities of cellulose-based micro-composites containing nisin / natamycin against S. aureus, L. monocytogenes and Penicillium spp. Although nisin-containing cellulose microcomposite had no antimicrobial effect on S. aureus due to the very slow diffusion rate from micro composite to surface, neomycin containing films showed high antimicrobial effect [18]. Conclusion

Figure 3. Photographs of antimicrobial activity of microemulsion-alg microcomposites against S. aureus (containing % 2 Sumac extract (A), % 3 Sumac extract (B) and E. coli (containing % 2 Sumac extract (C), % 3 Sumac extract (D)

Discussion Sumac has a remarkable bioactive effect due to its rich and different antioxidant, vitamin, fatty acid and mineral content compared to all other spices. This spice has antioxidant, antibacterial, antifungal, antiviral, antifibrogen, hypoglycemic and antimicrobial

It was determined that the algea-microcompositions prepared by microemulsion of sumac extracts have strong antibacterial effect against Staphylococcus aureus and Escherichia coli bacteria. Since microemulsions provide better skin penetration, algaemicrocomposites prepared by this method can be used in later stages in dermatological applications. Competing interests The authors declare that they have no competing interest. Financial Disclosure There are no financial supports. Ethical approval No ethic approvell is needed to this research.

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Fadime Nulufer Kivilcim ORCID: 0000-0002-6017-5326 Seval Cing Yildirim ORCID: 0000-0001-7163-9512 Ahmet Gultek ORCID: 0000-0002-4980-1568

10. Mc Clements DJ, Jafari SM. Improving emulsion formation, stability and performance using mixed emulsifiers: A review. Adv Colloid Interface Sci. 2018;251:55–79.

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McClements DJ, Gumus CE. Natural emulsifiers-Biosurfactants, phospholipids, biopolymers, and colloidal particles: Molecular and physicochemical basis of functional performance. Adv Colloid Interface Sci. 2016;234:3–26. Zhiping DA, Xuebin M, Xiumei T, et al. Preparation and properties of microemulsion detergent with linear medium chain fatty alcohols as oil phase. J Molecular Liquids. 2016;223:805–10.

12. Abu-Reidah IM, Jamous RM, Ali-Shtayeh MS. Phytochemistry, pharmacological properties and industrial applications of Rhus coriaria L (Sumac). Jordan J Biol Sci. 2014;7:233-44. 13. Gabr SA, Alghadır AH. Evaluation of the biological effects of lyophilized hydrophilic extract of Rhus coriaria on myeloperoxidase (MPO) activity, wound healing, and microbial infections of skin wound tissues. Hindawi Evid Based Complement Alternat Med. 2019;14:1-14. 14. Patil L, Kaliwal BB. Microalga Scenedesmus bajacalifornicus BBKLP-07, a new source of bioactive compunds with in vitro pharmacological applications. Bioprocess Biosyst Eng. 2019;42:979-994. 15. Moreira MR, Ponce AG, Valle CE, et al. Inhibitory parameters of essential oils to reduce reduce a food born pathogen. Food Sci Technol. 2005;38:56570. 16. Elhugessein EAA, Kurtulbaş E, Bilgin M, et al. Screening of the most consumed beverages and spices for their bioactive non-nutrient contents. J Food Measurement Caracterization. 2018;12:2289-301. 17. Çağrı A, Üstünol Z, Ryser ET. Antimicrobial, mechanical, and moisture barrier properties of low ph whey protein-based edible films containing p-aminobenzoic or sorbic acids. Food Microbiol Safety. 2001;66:865-70. 18. Santos Pires AC, Soares NFF, Andrade NJ, et al. Development and evaluation of active packaging for sliced mozzarella preservation. Packag Technol Sci. 2008;21:375-83.

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Medicine Science 2020;9(1):216-20

Evaluation of the applications of traditional and complementary medicine in the perspective of family medicine in a tertiary referral center Mehmet Kayhan1, Erdal Dilekci2 1

Abant Izzet Baysal University, Faculty of Medicine. Department of Family Medicine, Bolu, Turkey Abant Izzet Baysal University, Department of Physical Medicine and Rehabilitation, Bolu, Turkey

Received 07 Febuary 2020; Accepted 04 March 2020 Available online.07.03.2020 with doi:10.5455/medscience.2020.09.9175 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract To evaluate the clinical and demographic characteristics of the patients who apply to Traditional and Complementary Medicine (TCM) center. The medical charts of patients, who were admitted to AIBU Izzet Baysal Physical Therapy and Rehabilitation Training and Research Hospital, TCM centre, from September 2018 to August 2019, were retrospectively reviewed. Only patients over the age of 18 were included in the study. 879 (84.4%) of the patients were female, 163 of them were (15.6%) male. 44 (4.2%) patients in the 18 - 24 age group, 137 (13.1%) patients in the 25 - 34 age group, 223 (21.4%) people in the 35 - 44 age group, 287 (27.5%) patients in the 45 - 54 age group, 205 (19.7%) patients were in the 55-64 age group, and 146 (14.0%) patients were in the age group 65 and over. Mean age of the patients was 48.64 ± 13.86 (19-87). 365 (35.0%) of TCM applications were made in spring, 266 (25.5%) in winter, 223 (21.5%) in summer and 188 (18.0%) in autumn. In this study, the most preferred TCM applications are acupuncture (48.1%), ozone therapy (34.3%) and mug treatment (13%), respectively. Determining by whom, in which age group and in which period of the year are more preferred TCM applications, which have been increasingly used in recent years, may prevent problems that may develop during the service delivery process. Keywords: Acupuncture, alternative medicine, hirudotherapy, traditional medicine

Introduction According to the World Health Organization (WHO), traditional medicine has a long history, which has been practiced for centuries. Traditional medicine is a whole of knowledge, skills and practices based on theory, beliefs and experiences specific to different cultures, which are used for protection from physical and mental illnesses, treatment of many diseases and maintaining health [1,2]. On the other hand, alternative medicine is a term that includes conventional medical practices and methods of treatment whose effect has not been scientifically proven, and is used synonymously with the term complementary medicine or traditional medicine in some countries [3, 4]. The terms “complementary medicine” or “alternative medicine” are used synonymously with traditional medicine in some countries.

*Coresponding Author: Mehmet Kayhan, Abant Izzet Baysal University, Faculty of Medicine. Department of Family Medicine, Bolu, Turkey E-mail: dr.mehmetkayhan@gmail.com

These definitions refer to different health practices, which are not a part of the country’s own tradition and are not integrated into the existing health system [5]. Some societies refer to modern medicine supportive therapies as “complementary medicine” and non-medical practices as “alternative medicine”. Others define any scientifically unproven treatment intervention as “alternative medicine”. Today, the common usage of all medicine supportive therapies in Turkey is “traditional and complementary medicine (TCM)”. This concept gained a new meaning in the “Regulation on Traditional and Complementary Medicine Practices” published by the Ministry of Health in October 2014. In this regulation, purpose, scope and legal basis were clearly demonstrated. In this regulation, the characteristics and education levels of healthcare practitioners, the characteristics of health institutions and which methods can be applied in which disease were explained in detail. Furthermore, TCM applications other than acupuncture such as apitherapy, phytotherapy, hypnosis, leech practice, homeopathy, chiropractic, cup practice, larva practice, mesotherapy, prolotherapy, osteopathy, ozone practice, reflexology and music therapy were also defined in this regulation for the first time. Today, patients’ desire to take more control and responsibility 216

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in their own treatment, efforts to achieve therapies that reduce symptoms, the high cost of current treatments have increased the interest in complementary and alternative therapies [6â&#x20AC;&#x201C;9]. The national complementary and center of alternative medicine (NCCAM) defined TCM as products, applications and health care systems, which are not considered as part of traditional medicine [10]. Complementary and Alternative Medicine practices are widely used worldwide, especially in the elder people and the children with chronic disease. The frequency of its use is increasing in chronic diseases such as cancer, HIV infection, multiple sclerosis, rheumatological diseases and asthma [11-13]. According to NCCAM, TCM applications for health management can be offered in at least two basic functions: 1) Treating the current disease, 2) Preventing a certain disease. The number of studies on the effectiveness and safety of TCM applications, which are preferred for the treatment, have been increasing [14-16].

patients (50.3%), followed by mug (hacamat) treatment to 380 patients (36.5%). Ozone therapy was applied to 332 patients (31.9%) and hirudotherapy (leech) to 144 patients (13.8%) (Table 2). Table 1. Clinical and demographic characteristics of the patients

Gender

Age groups (years)

It is important to know how often and for what purpose traditional and alternative practices are used in society. Herein, we aimed to evaluate the demographic and clinical characteristics of the patients referred to TCM center. Material and Methods The medical charts of patients, who were admitted to AIBU Izzet Baysal Physical Therapy and Rehabilitation Training and Research Hospital, TCM center, from September 2018 to August 2019, were retrospectively reviewed. Only patients over the age of 18 were included in the study. Demographic and clinical characteristics including age, gender, treatment, the time of the initial appointment were recorded. Collected data were analyzed by SPSS version 15.0 program. We used percentage (%) and number (n) for descriptive data. We also performed Chi-square test to evaluate categorical variables. Descriptive statistics of variables are expressed as number and percentage. Since one participant in our study can receive treatment more than once, the ratio of the number of treatments to the total number of participants can yield over 100%. A p value less than 0.05 was considered as statistiscally significant. Bonferroni post hoc test was applied to avoid type 1 error. The statistical significance limit for post hoc analysis was determined as 0.33% (p <0.0033). Abant Izzet Baysal University, Local ethic committee approved the present study. Results A total of 1042 patients, 879 (84.4%) of the them were female, 163 of them were (15.6%) male. 44 (4.2%) patients in the 18 - 24 age group, 137 (13.1%) patients in the 25 - 34 age group, 223 (21.4%) people in the 35 - 44 age group, 287 (27.5%) patients in the 45 - 54 age group, 205 (19.7%) patients were in the 55-64 age group, and 146 (14.0%) patients were in the age group 65 and over. Mean age of the patients was 48.64 Âą 13.86 (19-87). 365 (35.0%) of TCM applications were made in spring, 266 (25.5%) in winter, 223 (21.5%) in summer and 188 (18.0%) in autumn (Table 1). The most common treatment was acupuncture applied to 524

Med Science 2020;9(1):216-20

Season

Number (n)

Percentage (%)

Female

879

84.4

Male

163

15.6

18 - 24

4.2

25 - 34

137

13.1

35 - 44

223

21.4

45 - 54

287

27.5

55 - 64

205

19.7

65 and above

146

14.0

Spring

365

35.0

Winter

266

25.5

Summer

223

21.5

Autumn

188

18.0

Table 2. Distribution of the treatment methods Number (n)

Percentage (%)

Acupuncture

524

50.3

Mug treatment

380

36.5

Ozone therapy

332

31.9

Hirudotherapy

144

13.8

760 (72.9%) patients received single therapy, 228 (21.9%) received double therapy, 52 (5.0%) triple therapy, and two (0.2%) quadruple therapy. In the analysis to evaluate the effect of gender, age groups and seasonal characteristics of the patients on the choice of treatment method, a statistically significant relationship was found between the gender and the application of acupuncture treatment (p <0.001). Acupuncture treatment was applied to 469 (53.4%) of women and 55 (33.7%) of men. Furthermore, there was a statistically significant relationship between gender and ozone therapy (p <0.05). 292 (33.2%) of women and 40 of men (24.5%) were treated with ozone therapy. No statistically significant relationship was detected between the gender and cup treatment or hirudotherapy (p> 0.05) (Table 3). 217

doi: 10.5455/medscience.2020.09.9175 Table 3. The treatments the participants received according to their gender

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Table 4. The treatments the participants received according to their age-group

ACUPUNCTURE

ACUPUNCTURE Applied

GENDER

number(n)

Non-applied

percentage (%)

number(n)

469

53.4

410

46.6

Male

33.7

108

66.3

0.004 MUG TREATMENT

Female

312

35.5

567

64.5

Male

41.7

58.3

0.130 OZONE THERAPY

Female

292

33.2

587

66.8

Male

24.5

123

75.5

0.029

Non-applied

number (n)

percentage (%)

number (n)

number (%)

18 - 24

81.8

18.2

25 - 34

61.3

38.7

35 - 44

109

48.9

114

51.1

45 - 54

140

48.8

147

51.2

55 - 64

47.8

107

52.2

65 and above

39.0

61.0

percentage (%)

Female

Applied

AGE GROUPS (years)

0.005 MUG TREATMENT

18 - 24

34.1

65.9

25 - 34

32.8

67.2

35 - 44

40.4

133

59.6

45 - 54

108

37.6

179

62.4

55 - 64

35.1

133

64.9

65 and above

34.2

65.8

0.703

HIRUDOTHERAPY

OZONE THERAPY

Female

117

13.3

762

86.7

18 - 24

18.2

81.8

Male

16.6

136

83.4

25 - 34

24.8

103

75.2

35 - 44

31.4

153

68.6

45 - 54

32.8

193

67.2

When the treatments in different age groups were evaluated, we determined a statistically significant relationship between acupuncture and hirudotherapy application (p<0.05). Acupuncture treatment was applied to 36 (81.8%) patients in the 18 - 24 age group and 29 patients (19.9%) in the 65 and older group. There was no statistically significant difference in terms of cup treatment or major treatment in the different age groups (p> 0.05) (Table 4).

55 - 64

34.6

134

65.4

65 and above

37.7

62.3

18 - 24

9.1

90.9

A statistically significant difference was found between the ages of 18 - 24 and 35 - 44, 45 - 54, 55 - 64 and over 65 in terms of acupuncture application frequency (p <0.0033). We also found a statistically significant difference in the frequency of acupuncture application between the 25 - 34 age group and the 65 and over age group (p <0.0033). A statistically significant difference was found between 35 - 44 age group and 55 - 64 and 65 age group and above in terms of frequency of hirudotherapy application (p <0.0033) (Table 5)

25 - 34

13.9

118

86.1

35 - 44

6.7

208

93.3

45 - 54

14.6

245

85.4

55 - 64

17.1

170

82.9

65 and above

19.9

117

80.1

0.269

0.740 HIRUDOTHERAPY

0.005

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Featherstone et al. and Erci et al revealed that female patients often preferred TCM methods [26,27]. Similarly, we observed that the female patient often preferred TCM methods (84.4%), especially acupuncture and ozone therapy.

Table 5. Post hoc analysis of the different age groups ACUPUNCTURE

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HIRUDOTHERAPY

AGE GROUPS (years)

18 - 24 / 25 - 34

0.012304

18 - 24 / 25 - 34

0.407754

18 - 24 / 35 - 44

0.000061

18 - 24 / 35 - 44

0.507171

18 - 24 / 45 - 54

0.000043

18 - 24 / 45 - 54

0.322276

18 - 24 / 55 - 64

0.000040

18 - 24 / 55 - 64

0.186213

18 - 24 / 65 and above

0.000001

18 - 24 / 65 and above

0.098253

25 - 34 / 35 - 44

0.021616

25 - 34 / 35 - 44

0.024461

25 - 34 / 45 - 54

0.015616

25 - 34 / 45 - 54

0.804626

25 - 34 / 55 - 64

0.014149

25 - 34 / 55 - 64

0.426806

25 - 34 / 65 and above

0.000180

25 - 34 / 65 and above

0.179327

35 - 44 / 45 - 54

0.982400

35 - 44 / 45 - 54

0.004931

35 - 44 / 55 - 64

0.824218

35 - 44 / 55 - 64

0.000871

35 - 44 / 65 and above

0.063234

35 - 44 / and above

0.000140

45 - 54 / 55 - 64

0.830947

45 - 54 / 55 - 64

0.462896

45 - 54 / 65 and above

0.054355

45 - 54 / 65 and above

0.164752

55 - 64 / 65 and above

0.103167

55 - 64 / 65 and above

0.504645

Discussion WHO states that more than three-quarters of the world’s population rely on complementary and alternative health approaches and recommends traditional and complementary therapies, especially in chronic diseases [17,18]. The use of traditional and complementary medicine (TCM) applications; 42.1% in the United States, 48.2% in Australia, 49.3% in France, 70.4% in Canada, 71% in Chile, 70% in China, 40% in Colombia and around 80% in African countries [19,20]. In a study of 5,882 individuals from seven geographical regions in Turkey, TCM utilization rate was found to be 60.5% [21]. In a study from Eskişehir, it was reported that 60% of individuals use various complementary and alternative therapies. Yavuz et al reported that 87% of breast cancer patients used TCM applications. [22,23]. The rate of use of TCM in individuals applying to the family health center in Kayseri was 65.8% [24]. Since the present study is retrospective and only TCM center applications are evaluated, we have no data regarding the usage rates of TCM applications. In order to determine the knowledge, attitudes and behaviours of future physicians on this subject, 276 students studying at Düzce University Faculty of Medicine were surveyed online and the top 3 best known TCM methods were observed as follows: acupuncture (77.5%), mug application (73.5%) and phytotherapy (67.3%) [25]. In this study, the most preferred TCM application was acupuncture (48.1%), ozone therapy in the second frequency (34.3%) and cup therapy (13%) in the third frequency.

Oktar et al., in a study involving 446 patients and conducted in Eskişehir Osmangazi University Health Practice and Research Hospital, reported that the individuals aged 45-64 often preferred TCM methods [28], similar to the present study. Furthermore, we found that acupuncture application was preferred more frequently in the 18-24 age group and hirudotherapy in the group of patients over 65. The present study found that TCM methods was generally applied in spring. However, no studies evaluated the effect of seasons on use of TCM methods up to today. The prerequisite for providing adequate and effective service to the public is to have information about the educational status, expectations, social, economic and health status of the public. Therefore, it is important for the healthcare professionals to know such characteristics of the public they will serve in increasing the efficiency of the service provided. The fact that physicians question whether their patients are using TCM in a judgmental and nonaccusatory environment, the increased knowledge of the benefits, harm, drug interactions, infection risks of TCM applications will contribute to increasing confidence in modern medicine and physician. For example, it has been reported that acupuncture is effective in the treatment of chemotherapy-induced vomiting and anxiety in smoking cessation, and group music therapy is useful in the treatment of chronic schizophrenia, Parkinson and Alzheimer’s diseases [29,30]. Conclusion In conclusion, the present study demonstrated that most of patients, who were aged from 45 to 54, admitted to TCM center for commonly acupuncture in mostly spring. The knowledge obtained from this study may raise the clinical familiarity for the specialists who work a family medicine center. In the present study, the retrospective and the single-centre design are important limiting factors. Further well-designed, prospective and multicentre studies should be conducted. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki. Mehmet Kayhan ORCID:0000-0001-7493-5165 Erdal Dilekci ORCID:0000-0001-7507-2808

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Medicine Science 2020;9(1):221-6

Assessment of the clinical and sociodemographic characteristics of children and adolescents who are sent to an affiliated university hospital for forensic psychiatric examination Yusuf Ozturk1, Burcu Rahsan Erim2 Bolu Abant Izzet Baysal University, Department of Child and Adolescent Psychiatry, Bolu, Turkey 2 Bolu Abant Izzet Baysal University, Department of Psychiatry, Bolu, Turkey

Received 27 December 2019; Accepted 22 January 2020 Available online 07.03.2020 with doi:10.5455/medscience.2019.08.9166 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract This study aimed to investigate the socio-demographic data, the reason and frequency of forensic application, and the presence of additional mental disorders in children and adolescents who applied for a forensic psychiatric examination to an affiliated university hospital. Pediatric psychiatry files of the patients who applied to Abant İzzet Baysal Mental Health and Diseases Policlinic outpatient clinic of Bolu Abant İzzet Baysal University between 2016-2018 were screened retrospectively and the data were evaluated in SPSS 22.0. The mean age of 117 patients included in the study was 14.86 ± 3.37, 54(46.2%) were female and 63(53.8%) were male. The most common reason for being sent is the claims within the scope of evaluation and health measures in terms of perceiving the legal meaning and consequences of the crimes committed with 33 applications. There was a statistically significant difference between males and females in terms of forensic assessment. At least one psychiatric diagnosis was made in 69.1% of the cases and the most common diagnosis was mental retardation. Dissemination of regional studies of forensic assessment and identification of differences by the province may contribute to the more efficient and functional use of resources. In addition to contributing to the improvement programs to be made after forensic assessments, pre-crime is also of value in terms of identifying the causes of crime, especially in children and adolescents. Keywords: Child and adolescent, psychiatry, forensic assessment

Introduction In Turkey, individuals who have completed the age of 11 but not entered the age of 16 are legally considered a juvenile, while those that have entered the age of 16 but not completed the age of 18 are considered children [1,2]. According to the Declaration of the Rights of the Child, every individual under the age of 18 is considered a child [3], and therefore, involvement of individuals under the age of 18 in a crime for any reason and their display of behaviors that require prosecution in the judicial system related to this is considered as juvenile crime [4,5]. While the history of juvenile crime may be traced back very long, it has been on the agenda more frequently with the recent increase in Turkey.

*Coresponding Author: Yusuf Ozturk, Bolu Abant Izzet Baysal University, Department of Child and Adolescent Psychiatry, Bolu, Turkey E-mail: yusuf26es@hotmail.com

According to the data of the Turkish Statistical Institute (TÜİK) on children involved in crime for the year 2017, 107 thousand 984 children under the age of 17 were involved in 25 different criminal activities. The number of children who were brought to security institutions for any reason increased by 5 in a thousand in comparison to 2016 and reached 335 thousand 242. The highest rate was reported for the age range of 15-17. 66% of the children who arrived at or were brought to security units were male. It was reported that children arrive at security institutions mostly as victims. According to the 2017 Penitentiary Institution Statistics published at the end of 2018 by TÜİK, based on the ages of entrance into penitentiary institutions as convicts, the number of those who were children (age group of 12-17) increased by 109.4% in comparison to the previous year and reached 2 thousand 56. The number of those who were children at the time of committing a crime increased by 28.3% in comparison to the previous year and reached 11 thousand 805 [6]. The exponential increase in the number of children directed to crime in Turkey is an indicator of the priority of this problem.

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The differences in the reasons that direct children to crime and their physiological status are among the main reasons for the distinction between adult crime and juvenile crime. Legal systems have divided the active duration of crime into two as children and adults and subjected adults and children to different punishment, prosecution and enforcement practices. On the one hand, they have aimed to remove the child from criminal law, while on the other hand, they have aimed to rehabilitate the child for their actions rather than punishing them [1,7,8]. Additionally, the decision on the United Nations Guidelines for the Prevention of Juvenile Delinquency that is known as the Riyadh Guidelines underlined that the main issue is the prevention of crime for prevention of juvenile crime, and education, the family and the society were emphasized [9]. It is not possible to explain juvenile crime by a single cause. Several factors such as the male gender, deficiencies in coping and social support, intellect, decrease in self-esteem, domestic violence, and adaptation problems, migration, absence at school, presence of emotional irregularities such as restlessness and anger, cruel emotions towards people, low intelligence levels, history of attention deficit and hyperactivity disorder, presence of antisocial behavior patterns, exposure to neglect and abuse in childhood, frequent replacement of the primary caregiver and inconsistent or strict disciplinary practices against the child have been reported as risk factors for criminal behavior in childhood and adulthood [10-16]. While children involved in crime are evaluated during the forensic psychiatric examination, indifference to adults, with the principle of no harm first, it is aimed to assess the child or the adolescent based on their developmental level and characteristics and minimize secondary traumas [5,10]. Another difference to adults is that children-adolescent cases that are sent for examination by judicial units do not only consist of children and adolescents involved in crime. Forensic mental and spiritual assessment may be requested due to other reasons such as being a victim of a crime, custody, adoption, early marriage, and protection-precaution. Additionally, the modern approach to juvenile crime brought by the ‘Child Protection Law’ is concerned with not that the child commits a crime but that they are pushed to it by others. This approach assumes the main principle of not seeing the child as a criminal who commits a crime but considering that they are pushed to it, therefore considering the child to be in the position of a victim of the crime they have committed and bringing about the concept of a juvenile pushed to crime. According to the Article 31/1 of the Turkish Criminal Law (TCK), the minimum age where the criminal liability of children starts was accepted as 12. As children reach a certain mental, moral and intelligent maturity in their natural development process, they reach a capacity of making a mistake after the age of 12, but they still cannot be prosecuted as adults are. In the Turkish Criminal Law, children at the ages of 12-18 are subjected to gradually decreased sentences. According to the Article 31/3, children at the ages of 15-18 are protected from prison time by a reduction of their sentence, while this reduction amount is higher in children at the ages of 12-15 [5]. A significant difficulty in forensic examination of children comes from the fact that there are not enough experts in this field. Forensic psychiatry education, which is included within adult psychiatry

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education based on the means of institutions, is unfortunately not usually found within child and adolescent psychiatry education [11]. Additionally, considering the numbers of child and adolescent psychiatrists in Turkey, the difficulty in the assessment of forensic cases becomes clearer. For this reason, child and adolescent cases are frequently assessed by adult psychiatrists. This study aimed to reveal gender-based and possible regional differences and contribute to the literature on the topic by examining the sociodemographic data (gender, age, education), forensic application reasons and frequencies and additional mental disorders of children and adolescents that are requested by judicial units to be examined and reported in the years 2016-2018 by the Child and Adolescent Psychiatry Polyclinic at the Bolu Abant İzzet Baysal University Hospital which serves a broad geographical region as it is not only affiliated but also a regional hospital. Material and Methods This is a cross-sectional and retrospective study. The study included the results of 117 cases that applied for forensic examination at the Child and Adolescent Psychiatry Polyclinic (CAPP) of the Bolu Abant İzzet Baysal Mental Health Research and Training Hospital affiliated with the Faculty of Medicine at Bolu Abant İzzet Baysal University between the dates of January 2016 and January 2018. The inclusion criteria were planned as having made an application primarily to CAPP for forensic examination, being under the age of 18, having come for forensic examination with mother or father, not having a chronic medical disease (epilepsy, cerebral palsy, etc.), having received psychometric assessment for intelligence evaluation and having complete data on the assessments on file. The exclusion criteria were determined as having been directed by the Department of Forensic Medicine for forensic examination consultation, having a chronic medical disease, not having come to the assessment with mother or father and missing data to be used in the study. During the studied period, 207 cases under forensic evaluation applied to CAPP at the Bolu Abant İzzet Baysal Mental Health Research and Training Hospital. Among these cases, 40 were excluded as they were consulted by the Department of Forensic Medicine, 17 were excluded because they were evaluated without parent supervision, 10 were excluded due to chronic medical diseases, 11 were excluded as they did not attend intelligence evaluation, 12 were excluded as they had missing data in their files, and the study included 117 cases. The psychiatric diagnoses of the cases were made clinically based on the DSM-V criteria. Forensic assessment interviews were conducted by the child and adolescent psychiatrists. The intelligence levels of the cases were assessed using the Wechsler Intelligence Scale for Children-Revised (WISC-R). WISC-R was administered by psychologists who were trained to perform this test in all cases aged 6-16 years for forensic evaluation. The test took between 45 minutes and one and a half hours. Ethical approval of the study was obtained from the Abant İzzet Baysal University Clinical Studies Ethics Board (Date: 09.07.2018, Number: 227). All protocols of the study were implemented in compliance with the Declaration of Helsinki and the local laws and directives. WISC-R: The test was developed in 1949 by Wechsler. It was 222

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revised in 1974 and took the name of WISC-R. The Turkish standardization and validity studies were conducted in 1988 by İskender Savaşır and Nesrin Şahin [17]. The test which is applied to individuals in the age range of 6–16 takes 90-100 minutes to complete. It consists of 12 subtests that measure different mental functions and include verbal and performance skills.

was analyzed by the Kolmogorov-Smirnov method. As the data complied with normal distribution, paired-samples were analyzed by student’s t-test. P-values of smaller than 0.05 were considered significant.

Statistical Analysis The data obtained in the study were statistically analyzed by using the Statistical Package for the Social Sciences (SPSS 18.0). Some sociodemographic and clinical categorical data of the case and control groups were analyzed by frequency and percentage values. Quantitative variables were summarized as either arithmetic means and standard deviations or medians and inter-quartile ranges depending on the presence of outliers and assumptions of normality. The classified categorical variables were compared by using the cross-tabulated chi-squared test (with Yates and Fisher corrections when needed). Firstly, the distribution of the data

The mean ages of the 117 cases that were included was found as 14.86±3.37. 54 of the cases (46.2%) were female, while 63 (53.8%) were male. In terms of attendance to school, 44 cases (37.6%) were not attending school, 67 (57.3%) were attending school, and 6 (5.1%) had not ever started school. There was no statistically significant difference between the males and the females in terms of past psychiatric treatment and family psychiatric history, while the number of hospitalizations and cases of multiple diagnoses were significantly higher among the males. Table 1 shows the comparison of cases in terms of their sociodemographic and clinical characteristics based on gender.

Results

Table 1. Comparison of sociodemographic and clinical data in terms of gender Parameters

Girl(n:54)

Boy(n:63)

test

Age(year)

15.01±3.21

14.73±3.51

t=-0.46

0.647

Yes

35(%71.4)

32(%50.8.)

16(%38.84)

28(%44.4)

x2=2.73

0.255

Never started

3 (%6.1)

3 (%4.8)

Past treatment

6 (%11.1)

12 (%19.0)

x2=1.41

0.307

Number of hospitalizations

1 (%2.0)

8 (%15.4)

x2=4.81

0.028

14 (%25.9)

19 (%30.2)

x2=0.25

0.612

No diagnosis

17 (%31.5)

17 (%27.0)

One

25 (%46.3)

17 (%27.0)

x2=12.48

0.014

Two

12 (%22.2)

19 (%30.2)

0 (%0.0)

10 (%15.8)

School Attendance

Family History Number of Diagnoses

More than two

The most frequent reason for sending the cases for forensic examination was by 28.2% (n = 33) for “whether or not the capacity of perceiving the legal meaning and outcomes of the act and directing behaviors has developed by the on TCK 31” and for assessments regarding health precautions. Based on the genders of the cases, the girls were sent the most frequently for health precautions by 38.8% (n=19), while the boys were sent the most frequently for TCK 31 by 49% (n=24). While the girls were never requested to be examined based on TMK (Turkish Civil Code) 432, the boys were also not sent for assessment due to marriage. Table 2 shows the comparison of the forensic examination reasons

of the cases based on their genders. Regarding the diagnoses, 34 cases (29.1%) did not receive a diagnosis, 42 (35.9%) received only one diagnosis, and 41 (35.0%) received multiple diagnoses. The most frequently observed psychiatric diagnosis was “mental retardation” by 34.7% (n = 40). According to the mental limitations of the cases, 13 cases had “borderline mental retardation”, 25 had “mild mental retardation”, and 2 cases had “severe mental retardation” diagnoses. Table 3 shows the distribution of the diagnoses of the cases. 223

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Table 2. Distribution of reasons for judicial evaluation by gender Reasons for Judicial Evaluation

Girl n (%)

Boy n (%)

Reputation to Declaration

2 (3.7)

0 (0.0)

Mentally ill / weak

1 (1.9)

1 (1.6)

11 (20.4)

23 (36.5)

TCC 432

0 (0.0)

8 (12.7)

Marriage

3 (5.6)

0 (0.0)

Health Precaution

19 (35.2)

14 (22.2)

Psychiatric examination

7 (13.0)

10 (15.9)

More than one

11 (20.4)

7 (11.1)

TPC 31

Test

x2=19.26

0.014

TCC=Turkish Civil Code, TPC= Turkish Penal Code

Table 3. Diagnostic distribution of cases Diagnosis

Mental Retardation

34.7

Attention Deficit and Hyperactivity Disorder

21.4

Behavioral Disorder

14.5

Major Depressive Disorder

10.3

Conduct Disorder

8.5

Substance Use Disorder

8.5

Posttraumatic Stress Disorder

5.1

Acute Stress Disorder

2.6

Specific Learning Disorder

0.8

Reactive Attachment Disorder

0.8

Autism Spectrum Disorder

0.8

Psychiatric examination

7 (13.0)

10 (15.9)

More than one

11 (20.4)

7 (11.1)

TCC=Turkish Civil Code, TPC= Turkish Penal Code

Discussion This study investigated children and adolescents who applied to the forensic child and adolescent psychiatry polyclinic of an affiliated university hospital within two years. 53.8% of the entire sample and 67.7% of the 34 cases who were pushed to the crime were males. At the time of visitation, 66.3% were continuing their education (Table 1). While the literature shows that most children who are pushed to

crime are male [10,17] and adolescents [10,18,19], it reveals the highest frequency of committing the crime at the age range of 1418 [6,10,18-20]. While there was no significant difference in age between the male and female cases in our study, the mean age was found as 14.86 ± 3.37, which was in agreement with the literature. On the other hand, the male-female ratio, education statuses and reasons for forensic examination in the sample revealed different ratios to those in several regional studies that were understood to have been conducted with similar designs. 67.3% of the cases in this study were sent for health precautions and evaluation of understanding the legal meaning of the crime they committed. In a study that examined cases that visited CAPP at Karadeniz Technical University, it was found that approximately 89% of the cases were sent for evaluation in terms of their understanding of the legal meaning of their crime, 91.7% were male, and 84% of all cases were students at the time of visitation [18]. In another study which retrospectively examined the mental disorder diagnoses, intelligence levels and sociodemographic characteristics of children and adolescents at the ages of 6-18 who were sent to the Child Psychiatry Polyclinic of Sakarya Research and Training Hospital for forensic reports, it was determined that 86.3% of the children pushed to crime were male, only 58.8% of the sample were continuing their educations that were suitable for their age, 81% of abuse cases and 100% of early marriage cases were female, and 62% of the abused children and only 15.4% of the early married ones could continue their education [14]. A study that retrospectively examined 4 years of file records of children and adolescents that were requested to be reported on in terms of criminal liability at the Department of Child and Adolescent Mental Health and Diseases at the Faculty of Medicine at Pamukkale University found that 91.3% of the cases were male, and the mean length of education of the children was found as 7.62±1.60 (0-10) years [12]. In a sample in Eskişehir consisting of children pushed to crime at the Forensic Medicine Branch Office, it was seen that 78.6% of the cases were male, and 9.5% had never had any education [19]. 224

doi: 10.5455/medscience.2019.08.9166

In a study that retrospectively examine the file data of 272 children and adolescents that were sent to the Department of Forensic Medicine and Child and Adolescent Mental Health and Disease at the Adnan Menderes University Hospital and CAPP at the Aydın State Hospital in 12 months for forensic report preparation, 57.7% of the cases were male, and 54% were found to be children pushed to crime. Being pushed to the crime was significantly more frequent among males while being victims of sexual abuse was significantly more frequent among females [20]. In studies conducted in Turkey some of which are reported above, it is seen that males have dominated the samples. However, in our sample, the males constituted only 53.8%. The ratios similar in this sense were reported only in one study that was carried out in the province of Aydın [20]. However, as the number of cases sent for assessment regarding sexual abuse was high in their sample, and females were dominant in this group, the dominance of males in number was not clear. In this study, on the other hand, no case was admitted about sexual abuse. For this reason, our results may indicate a significant regional difference. According to the education data of TÜİK [21], as Bolu was among the provinces in Turkey with the highest net rates of schooling in the academic year of 2016-2017, the 66.3% continuation rate in education in our study may be relatively higher than other regions based on the province, and additionally, the noticeably low rate in comparison to the results of a study at KTU [1] may need to be interpreted as a regional difference that needs to be separately considered. When the reasons for forensic applications were examined based on gender, no statistically significant difference was found (Table 2). While health precautions, marriage, and consideration of testimony were frequent among the assessment of the girls, being pushed to crime and psychiatric assessment reasons were higher among the boys. Another result of our study was that there was a significant difference between the genders in terms of multiple diagnoses and hospitalization. 8 of the 9 cases who were hospitalized due to psychiatric reasons were male. While there was no significant gender difference among the cases that did not have any diagnosis, the males were dominant among the ones that received multiple diagnoses. These two findings were in parallel with each other. This situation may also be linked with the finding that more male children were sent for assessment of being pushed to crime and psychiatric assessment. Sexual assault is a sociological problem that affects individuals in all age groups, while several studies have shown that most children, especially adolescent girls and MR individuals are exposed to sexual assault [12,22-25]. In studies that have been conducted in Turkey, substantial differences in the range of 54.9-89% may be noticed in the ratios reported on the victimhood of sexual abuse. Based on reasons for forensic examination, while there was no case of sexual abuse in our study, there were only 3 cases related to assessment due to marriage, but as the diagnoses of dissociative disorder, acute stress disorder and posttraumatic stress disorder which are frequently associated with trauma constituted 16% of the group that received diagnoses, and in addition to this, as the most frequently encountered group among the ones that received diagnoses consisted of MR cases, this result should be investigated in detail. This situation may be related to that every unit works

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only with the cases that are directed to them, the fact that cases that were sent to Forensic Medicine were not included in the study or consultation was not requested for psychiatric assessment in these cases. In a study that was carried out by Emergency Medicine and Forensic Psychiatry Departments where forensic cases that visited the emergency services in 4-years were retrospectively examined, it was determined that traffic accidents, intoxication, assaultphysical violence, and sexual abuse were more frequent in the 0-17 age group. Moreover, it was reported that the ratio of victims of sexual abuse under the age of 18 was lower than the literature [26]. When this result is evaluated together with the finding of no case in our study sent for assessment in terms of sexual abuse, it may be concluded that these cases are being directed to the Department of Forensic Medicine, and post-harassment examination has a lower prevalence in the province of Bolu. However, whether the reason is the method of sample selection or that there were no forensic applications, neglection of sexual abuse cases is a highly significant issue in terms of mental health problems in the future. The most frequently made diagnosis in the cases in this study was determined as “mental retardation” (MR). This was also different from the results of similar regional studies. A study in Sakarya reported lower rates of MR and the dominance of posttraumatic stress disorder (PTSD) [11]. However, the fact that there was no case application due to sexual abuse in our study may be determined in this sense. In assessments at Pamukkale University with a similar design and by using WISC-R and clinical interviews, it was determined that 65.4% of the cases had a normal level of intelligence. 26.8% had borderline mental capacity, and 7.8% had MR [12]. These ratios were lower than the findings of our study. Although the combination of MR and crime, especially repeated crime, is a wellknown situation [12,27,28], the high rates need to be considered as a regional difference in this sense. On the other hand, regional statistics on MR could not be accessed. Epidemiological studies to be conducted on this issue may prove significant in terms of rates of being pushed to crime. This study also had some limitations. At first, our study was planned as a cross-sectional and retrospective study. Secondly, the psychiatric diagnoses of the cases were made clinically. Third, the cases were not categorized based on types of crime. It is believed that conducting prospective, longitudinal studies with semistructured interviews and by separating types of crime on cases that arrive at the child and adolescent mental health and disease clinics for forensic assessment will be guiding for future studies. Despite the limitations of our study, our study emphasizes regional differences and the fact that both university and state hospital data are being evaluated are the strengths of the study. Conclusion Making such regional studies prevalent and determining differences based on provinces may contribute to more efficient and functional usage of resources. Moreover, in addition to contributing to rehabilitation programs to be organized after forensic assessments, this also carries significance in terms of determining the reasons that push especially children and adolescents to the crime before 225

doi: 10.5455/medscience.2019.08.9166

a crime occurs. The combination of ‘MR and children pushed to crime” in our region was noteworthy in terms of the results of the study. This result may provide a significant contribution in efforts to prevent being pushed to crime in the region. For this reason, the results of studies that cover all forensic assessment centers and rehabilitation institutions in different regions may provide significant contributions in this matter. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval This study was approved by the Institutional Ethics Committee and conducted in compliance with the ethical principles according to the Declaration of Helsinki. Yusuf Ozturk ORCID:0000-0002-3412-9879 Burcu Rahsan Erim ORCID:0000-0003-4145-8969

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13. Oldehinkel AJ, Hartman CA, De Winter AF, et al. Temperament profiles associated with internalizing and externalizing problems in preadolescence. Dev Psychopathol. 2004;16:421-40. 14. Loeber R, Pardini D. Neurobiology and the development of violence: common assumptions and controversies. Phil Trans R Soc. 2008;363:24912503. 15. Farrington DP. Predictors causes and correlates of male youth violence. M Tonry, M Moore (Eds.), Youth Violence, Chicago: University of Chicago Press, 1998, p.421-75. 16. Barkley RA, Fischer M, Smallish L, et al. Young adult follow-up of hyperactive children: antisocial activities and drug use. J Child Psychol Psychiatry. 2004;45:195- 211. 17. Savaşır I, Şahin N. Wechsler Çocuklar İçin Zeka Ölçeği (WISC-R). Ankara Türk Psikologlar Derneği, 1995. 18. Göker Z, Hesapçıoğlu ST, Sarp KS, et al. Evaluation of psycholegal subjects admitted to K.T.U child and adolescent psychiatry department at last two years. J Forensic Med. 2006;20:1-5. 19. Şen S, Karbeyaz K, Toygar M, et al. Sociodemographic evaluation of children pushed into crime in Eskisehir. J Forensic Med. 2012;26:146-55.

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Çopur EÖ, Ulutaşdemir N, Balsak H. Çocuk ve suç. Hacettepe Univ Fac Heal Sci J 2015;1:120-4.

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İçli T. Kriminoloji. Ankara, Bizim Büro Press,2001.

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10. Baysan Arabacı L, Taş G. Dragging factors in juvenile delinquency, mental health problems, and nursing care. J Psychiatr Nurs. 2017;8:110-7. 11. Ayaz M, Ayaz AB, Soylu N. Psychiatric evaluation of child and adolescent forensic cases. J Clin Psy. 2012;15:33-40.

22. Tittle CR, Ward DA, Grasmick HG. Gender, age and crime deviance: A challange to self-control theory. J Res Crime Delinq. 2003;40:426-53. 23. Bayındır N, Özel A, Köksal E. The demography of juvenile deliquency: A sample of the city of Kütahya. Turkish Journal of Police Studies. 2007; 95108. 24. Akduman GG, Akduman B, Cantürk G. Investigation of the some personal and familial characteristics of juvenile delinquency. Türk Pediatri Ars. 2007;42:156-61. 25. Uğur N, Türkcan S, Geyran P. Adli psikiyatride çocuk ve ergen suçları. Dusunen Adam. 1994;7:20-4. 26. İlçe A, Erkol MH, Alpteker H, et al. Retrospective analysis of forensic case reports who had applied to the emergency service in the city centre of Bolu. Abant Med J. 2018;7:68-75. 27. Bircan S, Bacanlı F. Ergenlerin duygusal zekalarının çatışma eğilimlerine ve suç davranışlarına etkisi. M.Ü. Atatürk Eğitim Fakültesi Eğitim Bilimleri Dergisi. 2005;22:61-82. 28. Glancy GD, Ash P, Bath EP, et al. AAPL Practice Guideline for the Forensic Assessment. J Am Acad Psychiatry Law 2015;43:3-53.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):227-30

Neutrophil to lymphocyte ratio of patients who underwent bilateral versus unilateral unicompartmental knee arthroplasty Nihat Demirhan Demirkiran1, Ramadan Ozmanevra2 1

Kutahya University of Health Sciences, Department of Orthopedics and Traumatology, Kutahya, Turkey 2 University of Kyrenia, Dr.Suat Gunsel Hospital Karakum, Department of Orthopedics, Kyrenia TRNC Received 20 December 2019; Accepted 27 Febuary 2020 Available online 08.03.2020 with doi:10.5455/medscience.2019.08.9177 Copyright ÂŠ 2020 by authors and Medicine Science Publishing Inc.

Abstract In recent years, the neutrophil-to-lymphocyte ratio (NLR) has emerged as a sensitive index of systemic inflammation. NLR predicts serious complications, such as pulmonary embolism or cardiovascular disease risk. Our study aims to compare the inflammation rate of bilateral simultaneous UKA versus unilateral UKA by using NLR. The medical records of 27 patients who underwent unicompartmental knee arthroplasty were reviewed retrospectively. The patients were divided into two groups. Group 1 consisted of 10 patients who underwent bilateral simultaneous UKA (bUKA), whereas group 2 consisted of 17 patients who underwent unilateral UKA (uUKA). Preoperative and postoperative 1st hour blood chemistries were performed and results were extracted from the electronic database. The neutrophil-to-lymphocyte ratio (NLR) was calculated from the absolute neutrophil and lymphocyte counts. The mean preoperative and postoperative NLR and the difference in NLR between the preoperative and postoperative 1st hour was calculated. The mean preoperative NLR was 2.13 (0.51-4.54), and the mean postoperative NLR was 7.06 (0.50-15.33) in the uUKA group. NLR was significantly higher in the postoperative 1st hour (p=0.001). In the evaluation of the bilateral group (bUKA), the mean NLR was calculated as 1.61 preoperatively and 9.38 postoperatively. Hence, there was a statistically significant difference (p=0.001). The mean difference in NLR was 7.77 in Group 1 and 4.92 in Group 2. Although the increase in NLR was higher in Group 1, no statistically significant difference was found (p=0.547). Our findings revealed similarly increased rates of NLR in the bilateral and unilateral UKA groups. Our study may suggest that bilateral simultaneous application of UKA is a safe procedure in terms of NLR-associated complications. Keywords: Neutrophil to lymphocyte ratio, unicompartmental, knee arthroplasty

Introduction Total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) are proven procedures for the treatment of advanced gonarthrosis. There has been significant debate about the safety of bilateral total knee arthroplasty since it was first described [1-3]. It was shown that bilateral simultaneous TKA has the advantage of not increasing the rate of perioperative complications [4]. However, some studies have reported increased perioperative complication rates, including pulmonary embolism and major cardiac events [5,6]. UKA has a quicker functional recovery than TKA and has advantages such as smaller incision and less blood loss [7].

*Coresponding Author: Nihat Demirhan Demirkiran, Kutahya University of Health Sciences, Department of Orthopedics and Traumatology, Kutahya, Turkey E-mail: drdemirhandemirkiran@gmail.com

Numerous studies have compared the safety of simultaneous versus staged unicompartmental knee arthroplasty [8-11] or simultaneous bilateral versus unilateral UKA [12]. In recent years, the neutrophil-to-lymphocyte ratio (NLR) has emerged as a sensitive index of systemic inflammation. NLR predicts serious complications, such as pulmonary embolism or cardiovascular disease risk [13]. Deviations in the NLR are also apparent with contrasting arthroplasty procedures, suggesting that the NLR could serve as an indicator for systemic inflammation [14]. Complete blood cell count is one of the simplest and most readily available tests in clinics. It reports the absolute neutrophil count (ANC) and absolute lymphocyte count (ALC). The neutrophil-tolymphocyte ratio (NLR), calculated by dividing the ANC by the ALC, can serve as an index of systemic inflammatory response in critically ill patients [15]. Also, the neutrophil-to-lymphocyte ratio (NLR) is developing as a clinical tool that predicts venous thromboembolism risk [13,16,17]. Our study aims to compare the inflammation rate of bilateral simultaneous UKA versus unilateral UKA by using NLR. 227

doi: 10.5455/medscience.2019.08.9177

Material and Methods The medical records of 27 patients who underwent unicompartmental knee arthroplasty were reviewed retrospectively (Zimmer Biomet, OxfordÂŽ Partial Knee, Biomet UK Limited). The patients were

Med Science 2020;9(1):227-30

divided into two groups. Group 1 consisted of 10 patients who underwent bilateral simultaneous UKA (bUKA) whereas Group 2 consisted of 17 patients who underwent unilateral UKA (uUKA) (Figure 1, 2).

Figure 1. Postop X-ray of a patient who underwent bilateral simultaneous unicompartmental arthroplasty (bUKA)

Figure 2. Postop X-ray of a patient who underwent unilateral unicompartmental arthroplasty (uUKA)

The surgeries were performed between 2016 and 2019. All surgeries were performed by the same surgeon at the same hospital. Cefazolin (1 gr.) and tourniquet were applied in all surgeries. Combined spinal-epidural anaesthesia was performed on both uUKA and bUKA groups. A minimally invasive oblique medial parapatellar approach was used as the surgical technique. No blood transfusions were performed perioperatively. Low molecular weight heparin was used to prevent thromboembolic events after surgery. No complications were observed in any surgery. The following data were collected: age, gender, comorbidities, mean surgical time, neutrophil to lymphocyte ratio, and early complications. Preoperative and postoperative 1st hour blood chemistries were

performed and results were extracted from the electronic database. The neutrophil-to-lymphocyte ratio (NLR) was calculated from the absolute neutrophil and lymphocyte counts. The mean preoperative and postoperative NLR and the difference of NLR between preoperative and postoperative 1st hour was calculated. The mean difference was evaluated for both groups. The mean, standard deviation, median lowest, highest, frequency and ratio values of the descriptive statistics were used (Table 1). The Mann-Whitney U test was used for statistical analyses. The statistical analysis was performed using SPSS 22.0. A p-value lower than 0.05 was considered statistically significant. 228

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Range

Minimum

Maximum

Mean

Std. Deviation

Group 1 (bUKA)

23.84

-0.11

23.73

7.7730

8.21290

female. The mean age of Group 1 was 60.7 (55-67), while for Group 2 it was 61.41 (54-68). In the bUKA group, three patients had diabetes mellitus and two patients had hypertension. In the uUKA group, two patients had hypothyroidism, three patients had hypertension, while one patient had diabetes mellitus.

Group 2 (uUKA)

13.70

-0.74

12.96

4.9276

4.50627

The mean surgical time was 49.8 minutes for the bilateral procedures and 28.29 minutes for the unilateral ones (Table 2).

Table 1. The descriptive statistics of the NLR increase

*N: number of patients

Results Group 1 consisted of 10 patients and all patients were female. In Group 2, only 1 patient was male, while all other 16 patients were

The mean preoperative NLR was 2.13 (0.51-4,54), and the mean postoperative NLR was 7.06 (0.50-15.33) in the uUKA group. NLR was significantly higher in postoperative 1st hour (p=0.001). In the evaluation of the bilateral group (bUKA), the mean NLR was calculated as 1.61 preoperatively and 9.38 postoperatively. There was a statistically significant difference (p=0.001) (Table 3).

Table 2. Demographic features of the patients Bilateral UKA (Group 1)

Unilateral UKA (Group 2)

Number(N) (female:male)

10 (10:0)

17 (16:1)

Mean age (years) (range)

60.7 (55-67)

61.41 (54-68)

10:10

8:9

49.8 (45-55)

28.29 (23-35)

7.7730

4.9276

Side (R:L) Mean surgical time (min.) (range) Mean NLR increase (pre-post 1st h.)

The mean difference in NLR was 7.77 in Group 1 and 4.92 in Group 2. Although the increase in NLR was higher in Group 1, no statistically significant difference was found (p=0.547) (Table 1). Table 3. The comparison of preoperative and postoperative 1st hour NLR. Preop NLR

Postop 1st h. NLR

p value

Group 1 (bUKA)

1.6150

9.3880

.001

Group 2 (uUKA)

2.1394

7.0671

.001

Discussion Unicompartmental knee arthroplasty (UKA) is a good option for isolated medial compartment osteoarthritis, even for overweight and obese patients [18]. UKA presents many advantages like short anaesthetic time and reduced length of hospital stay in comparison to TKA [19-22]. Prolonged hospital stay leads to increased morbidity/mortality and significant financial loss [23]. In addition, the rate of infection due to arthroplasty conducted in summer is reported to be higher than other seasons [24]. Simultaneous bilateral surgery is superior to the two-staged procedure as it reduces costs, length of hospital stay and rehabilitation time [8,11]. However, bilateral procedures cause massive blood loss, longer operative times, and increased complication for both TKA [25-28] and UKA [29]. In our study, bUKA was about 20 minutes longer than uUKA and no complications were observed in either group. In the literature, there are many studies that have reported the

p value

0.547

relationship between the neutrophil lymphocyte ratio (NLR) and systemic inflammation [13,14,16,17]. The NLR is a ratio between the absolute neutrophil and lymphocyte counts and it is accepted as a marker of systemic inflammation. In many studies, it was concluded that NLR can be used as a clinical tool for venous thromboembolism (VTE) [13,16,17]. Previous studies have focused on cardiac disease mortality by using NLR [13,30,31]. Knee arthroplasty is known as an independent risk factor for developing VTE [32-34]. In their investigation, Barker et al. [14] concluded that NLR increase is greater in TKA compared to UKA and may be a predictor for VTE after TKA. In our study, there was a higher NLR increase in the bUKA group compared to the uUKA group. Although this increase was not statistically significant. There are two major limitations of preliminary study. First of all, the groups consisted of a small number of patients and also, the study was designed retrospectively. Conclusion Our findings revealed similarly increased rates of NLR in the bilateral and the unilateral UKA groups. Our study may suggest that bilateral simultaneous application of UKA is a safe procedure in terms of NLR and systemic inflammation. In the light of data obtained from further studies to be performed on larger patient series, bUKA may be preferred to uUKA as the increase in inflammation could be similar. Further studies on this subject can encourage surgeons to perform bilateral surgeries for appropriate patients without additional complications. 229

doi: 10.5455/medscience.2019.08.9177 Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval Ethical approval was obtained (University of Kyrenia, 2019/18). Nihat Demirhan Demirkiran ORCID: 0000-0002-0724-9672 Ramadan Ozmanevra ORCID: 0000-0003-0515-4001

References 1.

Dennis DA. Debate: bilateral simultaneous total knee arthroplasty. Clin Orthop Relat Res. 2004;428:82-3.

Med Science 2020;9(1):227-30

17. Ghaffari S, Nadiri M, Pourafkari L, et al. The predictive value of total neutrophil count and neutrophil/lymphocyte ratio in predicting in-hospital mortality and complications after STEMI. J Cardiovasc Thorac Res. 2014;6:35–41. 18. Polat AE, Polat B, Gürpınar T, et al. The effect of morbid obesity (BMI ≥ 35 kg/m2) on functional outcome and complication rate following unicompartmental knee arthroplasty: a case-control study. J Orthop Surg Res. 2019;14:266. 19. Laurencin CT, Zelicof SB, Scott RD, et al. Unicompartmental versus total knee arthroplasty in the same patient. A comparative study. Clin Orthop Relat Res. 1991;273:151–6. 20. Pandit H, Jenkins C, Barker K, et al. The Oxford medial unicompartmental knee replacement using a minimally-invasive approach. J Bone Joint Surg (Br). 2006;88:54–60.

Parvizi J, Rasouli MR. Simultaneous-bilateral TKA: double trouble - affirms. J Bone Joint Surg Br. 2012;94:90-2.

Sculco TP, Sculco PK. Simultaneous-bilateral TKA: double trouble - opposes. J Bone Joint Surg Br. 2012;94:93-4

21. Rougraff BT, Heck DA, Gibson AE. A comparison of tricompartmental and unicompartmental arthroplasty for the treatment of gonarthrosis. Clin Orthop Relat Res. 1991;273:157–64.

Hersekli MA, Akpinar S, Ozalay M, et al. Comparison between single- and two-staged bilateral total knee arthroplasty operations in terms of the amount of blood loss and transfusion, perioperative complications, hospital stay, and cost-effectiveness. Acta Orthop Traumatol Turc. 2004;38:241–6.

22. Cross MB, Berger R. Feasibility and safety of performing outpatient unicompartmental knee arthroplasty. Int Orthop. 2014;38:443–7.

Bullock DP, Sporer SM, Shirreffs Jr TG. Comparison of simultaneous bilateral with unilateral total knee arthroplasty in terms of perioperative complications. J Bone Joint Surg Am. 2003;85-A:1981–6.

Hart A, Antoniou J, Brin YS, et al. Simultaneous bilateral versus unilateral total knee arthroplasty: a comparison of 30-day readmission rates and major complications. J Arthroplasty. 2016;31:31–5.

Lombardi AV Jr, Berend KR, Walter CA, et al. Is recovery faster for mobilebearing unicompartmental than total knee arthroplasty? Clin Orthop Relat Res. 2009;467:1450–7. Berend KR, Morris MJ, Skeels MD, et al. Perioperative com-plications of simultaneous versus staged unicompartmental knee arthroplasty. Clin Orthop Relat Res. 2011;469:168–73. Ma T, Tu YH, Xue HM, et al. Clinical outcomes and risks of single-stage bilateral unicompartmental knee arthroplasty via oxford phase III. ChinMed J (Engl). 2015;128:2861–5.

10. Akhtar KS, Somashekar N, Willis-Owen CA, et al. Clinical out-comes of bilateral single-stage unicompartmental knee arthroplasty. Knee. 2014;21:310–4. 11.

Chen JY, Lo NN, Jiang L, et al. Simultaneous versus staged bilateral unicompartmental knee replacement. Bone Joint J. 2013;95-B:788–92.

12. Romagnoli S, Zacchetti S, Perazzo P, et al. Onsets of complications and revisions are not increased after simultaneous bilateral unicompartmental knee arthroplasty in comparison with unilateral procedures. Int Orthop. 2015;39:871–7. 13. Kayrak M, Erdogan HI, Solak Y, et al. Prognostic value of neutrophil to lymphocyte ratio in patients with acute pulmonary embolism: a retrospective study. Heart Lung Circ. 2014;23:56–62. 14. Barker T, Rogers VE, Henriksen VT, et al. Is there a link between the neutrophil-to-lymphocyte ratio and venous thromboembolic events after knee arthroplasty? A pilot study. J Orthop Traumatol. 2016;17:163–8. 15. Zahorec R. Ratio of neutrophil to lymphocyte counts—rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001;102:5–14. 16. Erturk M, Cakmak HA, Surgit O, et al. The predictive value of elevated neutrophil to lymphocyte ratio for long-term cardiovascular mortality in peripheral arterial occlusive disease. J Cardiol. 2014;64:371-6.

23. Duman Y, Sevimli R. Investigation of the Presence of Pantone-Valentine Leukocidin in Staphylococcus aureus Strains Isolated from Orthopedic Surgical Site Infections. Mikrobiyol Bul. 2018;52:340-7. 24. Sevimli R, Aslanturk O, Ertem K, et al. An investigation of infection rate and seasonal effect level in total joint replacement cases. Med Sci. 2018;7:210-3. 25. Levy YD, Hardwick ME, Copp SN, et al. Thrombosis incidence in unilateral vs. simultaneous bilateral total knee arthroplasty with compression device prophylaxis. J Arthroplasty. 2012;28:474–8. 26. March LM, Cross M, Tribe KL, et al. Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA. Osteoarthr Cartil. 2004;12:400–8. 27. Memtsoudis SG, Ma Y, González Della Valle A, et al. Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology. 2009;111:1206–16. 28. Ritter MA, Harty LD, Davis KE, et al. Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty. A survival analysis. J Bone Joint Surg Am. 2003;85:1532–7. 29. Chan WCW, Musonda P, Cooper AS, et al. One-stage versus two-stage bilateral unicompartmental knee replacement: a comparison of immediate post-operative complications. J Bone Joint Surg (Br). 2009;91-B: 1305–9. 30. Horne BD, Anderson JL, John JM, et al. Which white blood cell subtypes predict increased cardiovascular risk? J Am Coll Cardiol. 2005;45:1638–43. 31. Shah N, Parikh V, Patel N, et al. Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the national health and nutrition examination surveyIII. Int J Cardiol. 2014;171:390–7. 32. Mantilla CB, Horlocker TT, Schroeder DR, et al. Risk factors for clinically relevant pulmonary embolism and deep venous thrombosis in patients undergoing primary hip or knee arthroplasty. Anesthesiology. 2003;99:552– 560. 33. Pedersen AB, Mehnert F, Johnsen SP, et al. Venous thromboembolism in patients having knee replacement and receiving thromboprophylaxis: a Danish population- based follow-up study. J Bone Joint Surg Am. 2011;93:1281–17. 34. Brookenthal KR, Freedman KB, Lotke PA, et al. A meta-analysis of thromboembolic prophylaxis in total knee arthroplasty. J Arthroplasty. 2001;16:293–300.

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Medicine Science International Medical Journal

Medicine Science 2020;9(1):231-3

Investigation of colorectal cancer distribution in Mardin province Aydin Aytekin Van Yuzuncu Yil University, Faculty of Medicine, Department of Medical Oncology, Van, Turkey Received 13 January 2020; Accepted 12 February 2020 Available online 08.03.2020 with doi: 10.5455/medscience.2020.09.9179

Abstract Colorectal cancers are the third most common tumors both in the world and in Turkey. Its frequency may vary according to geographical regions, environmental conditions and feeding habits. This study aimed to investigate the distribution of CRC patients admitted to Mardin State Hospital Medical Oncology Outpatient Clinic according to age, sex, diagnosis and stage. The records of patients admitted to Mardin State Hospital Medical Oncology Clinic between 2014-2018 were reviewed retrospectively. Patients over 18 years of age were included in the study. Gender, diagnosis and disease stages of the patients were recorded. A total of 1208 patients were examined. 160 colorectal cancer patients (13.2%) were detected. 74 (46.3%) of the patients were female and 86 (53.8%) were male. The male / female patient ratio was 1.16 / 1. While the median age of the whole group was 57 (19-93), the median age of the women was 57.78 (24-86) and the median age of the men was 56 (19-93). The ratio of colon cancer / rectal cancer in men was 54/32 (62.8 / 37.2%), whereas it was 44/30 (59.5 / 40.5%) in women. There was no difference in the age of the groups according to the diagnosis of colon and rectal cancer and gender (p = 0.37 and p = 0.59). There was no difference between the groups when the diagnoses and stages were compared by gender (p = 0.66 and p= 0.18). When the application stage was examined in all groups, the least application was in stage 1, and the most common application was in stage 4. 32 patients (20%) were over 70 years old and 19 (11.9%) were over 75 years old. The number of patients â&#x2030;¤49 years and 50-64 years were 51 (31.9%) and 64 (40%), respectively. This study includes the first CRC data of Mardin province. CRC patients in Mardin are diagnosed at a younger age and in an advanced stage. Since diagnosis and treatment methods are not sufficient in Mardin, patients are mostly diagnosed outside the province. Therefore, the number of patients is limited. Nevertheless, the statistics will be the first to guide future studies. Keywords: Colon cancer, rectal cancer, distribution, Mardin, Turkey

Introduction Cancer is a major health problem in almost every country in terms of mortality and morbidity rates. Today, it is the second leading cause of death worldwide after cardiovascular diseases [1]. According to the United States (USA) cancer database, colorectal cancer (CRC) is the third most common type of cancer in men and women. In addition, CRCs are the third most common cause of cancer-related deaths [2]. It is more common in European and US countries, and more rarely in Asian and African countries [3]. According to Turkey Cancer Statistics 2013 data, CRC is the third most common type of cancer in women after breast cancer and thyroid cancer and also the third most common cancer type in men after lung and prostate cancers [4]. According to Globocan 2012 Data, published by International Agency for Research on Cancer

(IARC) [5], CRC is the third most common cancer type in men, in the World, the European Union (EU) (28 countries), the United States and Turkey. In Women, it is the second most common cancer type in World and EU and the third most common cancer type in the USA and Turkey. Risk factors for colorectal cancer have been identified and its incidence increases in older age. More than 90% of colorectal cancer is diagnosed after the 50s. Studies with large case series found peaks in the 7th decade [6]. The incidence increases in both sexes with age and is the most common cancer in both sexes, over 75 years of age [7]. This study aimed to investigate the distribution of CRC patients admitted to Mardin State Hospital Medical Oncology Outpatient Clinic according to age, sex, diagnosis and stage. Materials and Methods

*Coresponding Author: Aydin Aytekin, Van Yuzuncu Yil University, Faculty of Medicine, Department of Medical Oncology, Van, Turkey E-mail: aytekxx@gmail.com

The records of patients admitted to Mardin State Hospital Medical Oncology Clinic between 2014-2018 were reviewed retrospectively. Patients over 18 years of age were included in the study. Gender, diagnosis and disease stages of the patients were 231

doi: 10.5455/medscience.2020.09.9179

recorded. Comparisons were made according to sex and colonrectum cancer diagnosis. Statistical analysis was performed using SPSS version 20.0 software. Chi-Square or Fisher Exact tests were used to compare categorical variables. Parametric variables with normal distribution were compared with Student’s t-test of independent groups. Parametric variables and ordinal variables that did not fit into the normal distribution were compared using the Mann-Whitney U test. p values less than 0.05 were considered statistically significant. Results A total of 1208 patients were examined. 160 colorectal cancer patients (13.2%) were detected. Of these patients, 98 were colon (61.2%) and 62 were rectum (38.8%). 74 (46.3%) of the patients were female and 86 (53.8%) were male. The male / female patient ratio was 1.16 / 1. While the median age of the whole group was 57 (19-93), the median age of the women was 57.78 (24-86) and the median age of the men was 56 (19-93). The median age of colon cancer patients was 56.67 (20-93), while the median age of patients with rectal cancer was 57.03 (19-86). While the female / male ratio was 44/54 (44.9% / 55.1%) in colon cancer patients,

Med Science 2020;231-3

this ratio was 30/32 (48.4% /%51.6) in patients with rectal cancer. Colon cancer / rectal cancer ratio in men was 54/32 (62.8% / 37.2%), whereas it was 44/30 (59.5% / 40.5%) in women. The ratio of colon cancer / rectal cancer was 31/21 (59.6% / 40.4%) at age 50 and under. There was no difference between the groups according to the diagnosis of colon and rectal cancer (p = 0.37). In addition, the ages of the two groups were similar according to gender (p = 0.59). There was no difference between the groups when the diagnosis and stages were compared according to gender (p = 0.66 and p = 0.18). In all groups (female, male, colon cancer, rectum cancer, total), when the application stage was examined, the least applications were in stage 1 and the most common ones were in stage 4 (Table 1). When the patients were divided into four groups as ≤49 years, 50-64 years, 65-79 years and ≥80 years, the number of patients was 51 (31.9%), 64 (40%), 36 (22.5%) and 9 (5.6%), respectively. In men these rates were 27 (31.4%), 40 (46.5%), 16 (18.6%) and 3 (3.5%); in women this rates were 24 (32.4%), 24 (32.4%), 20 (27%), and 6 (8.1%), respectively. There were 32 (20%) patients over 70 years and there were 19 (11.9%) patients aged 75 years and over. Discussion

Table 1. Disease Stage distribution according to sex and diagnosis Group/Stage

Stage 1 (n,%)

Stage 2(n,%)

Stage 3(n,%)

Stage 4(n,%)

Total

Female

4.1

33.8

35.1

Male

11.6

23.3

32.6

Colon Cancer

7.1

29.6

33.7

Rectal Cancer

9.7

25.8

30.6

33.9

All Group

8.1

28.1

33.8

160

Among all cancers, the incidence of colorectal cancers is approximately 9 %. This rate varies between countries and races. It is more common in European countries and the United States, and more rarely in Asian and African countries [3]. In the Mardin study, the CRC rate was 13.2%. There are different results in the distribution of colorectal cancers according to gender in the literature. Although it has been reported to be seen in close proportions in both sexes, in a study Boyle et al. reported that colorectal cancers as 1.1 times higher in males than females [8]. The lifetime probability of CRC diagnosis is 5.0 % in men and 4.7% in women. While the male to female ratio is 1.1 at the age of 0-49, it is 1.4 at the age of 50-79, 1.2 at the age of 80 and over [9]. The reason for this high rate in men is not fully understood, but it has been suggested that changes in the screening test habits over 50 years and older or may be due to etiological factors with complex interactions of sex hormones and risk factors exposures [10,11]. In the Mardin study, the male-female ratio was 1.16 and was similar to the literature. Similar to the Mardin study, the rate of males and females was found to be 1.16 in a study included 123 patients by Yalçın et al., in Samsun and its surroundings [12]. In this study, the median age of male patients was 62.82 and female patients was 62.21. In the Mardin study, the median age was 56 years for men and 57.78 years for women. In a study conducted

by Gürsoy et al. with 250 patients with CRC in Kayseri and its region, the ratio of male to female was found to be 1.3 / 1 [13]. In the study of 69 patients conducted by Özgören et al. in Van and its surroundings, the male / female ratio was reversed and the female / male ratio was 1.3 / 1 [14]. In this study, median age was found to be 48.3 in males and 47 in females. The Mardin study and this study indicate that CRCs occur at a younger age in Eastern and Southeastern Anatolia. Metastasis is detected at the time of diagnosis in 25% of colorectal cancer (CRC), while metastasis develops in the disease process in approximately 50% of patients [15,16]. In the Mardin study, the rate of metastatic patients in the whole group was 33.8%. Approximately 60% of cases and 70% of deaths occur at age 65 and over. Approximately 30% of cases and more than 40% of deaths occur in women aged 80 and over; 20% of cases and 30% of deaths occur in men in 80 and over [9]. The rate of patients over 70 years of age in Mardin is 20% and the rate of patients aged 75 and over is 11.9% . As a results, the rate of elderly patients is very low according to the literature. In the Mardin study, 51% of the patients were diagnosed at age 49 and under .In addition, the rate of patients in the 50-64 age range was 40%. In a study conducted 232

doi: 10.5455/medscience.2020.09.9179

by Yalcin et al. [12] , 82.1% of cases were identified in 51 years and over. In this study, the rate of rectal cancer was 33.3% in men and 40.4% in women, whereas in the Mardin study, this rate was 37.2% for men, 40.5% for women and 38.8 % for all group. In the USA, this rate was reported as 28% for rectal cancer in all groups [9, 17]. According to the study of Siegel et al., [9] rectal cancer percentage was 28% in the whole group, while it was 31% in men and 24% in women. In one study, it was reported that the rate of rectal cancer under the age of 50 ranged from 36-40% (in women and men) [18]. In the Mardin study, this rate was 40.4%. In the study of Siegel et al., [9] patients were evaluated in 4 groups as age 49 and under, age 50-64, age 65-79 and age 80 and above; patient rates were detected as 10-32-39% and 19% in males and 10-25-3529% in females, respectively. In the Mardin study, these rates were 31.4-46.5-18.6 and 3.5% in males, respectively; 32.4-32.4-27 and 8.1% of women, respectively and the patients were diagnosed at a younger age.

References

Med Science 2020;231-3

Jemal A, Clegg LX, Ward E, et al. Annual report to the nation on the status of cancer, 1975–2001, with a special feature regarding survival. Cancer: Interdisciplinary Int J Am Cancer Society. 2004;101:3-27.

American CS. Cancer Facts and Figures 2011. Atlanta. 2011.

Fund WCR, Research AIfC. Food, nutrition, physical activity, and the prevention of cancer: a global perspective: Amer Inst for Cancer Research; 2007.

Gültekin M, Boztaş G. Türkiye kanser istatistikleri. Sağlık Bakanlığı, Türkiye Halk Sağlığı Kurumu. 2014;43.

Ferlay J, Soerjomataram I, Ervik M, et al. Cancer incidence and mortality worldwide: IARC CancerBase. GLOBOCAN 2012 v10. 2012;11.

Haggar FA, Boushey RP. Colorectal cancer epidemiology: incidence, mortality, survival, and risk factors. Clin Colon Rectal Surg. 2009;22:191-7.

Although rectal tumors are detected at the localized stage and colon tumors are detected at a higher stage, the 5-year overall survival rate is slightly higher in rectal tumors compared to colon tumors (67% vs. 64%) [19]. The localize stage rate at diagnosis 43% in rectal tumors and 38% in colon tumors. The localized stage rate in all groups (CRC) is 39% [19]. In the Mardin study, the rate of the local stage (stage 1 and 2) was 35.5% in rectal cancers, while it was 36.7% in colon cancers, and there was no difference between the two groups in terms of stages. The local stage rate in the whole group was 36.2% and these results are close to the literature.

Edwards BK, Howe HL, Ries LA, et al. Annual report to the nation on the status of cancer, 1973–1999, featuring implications of age and aging on US cancer burden. Cancer. 2002;94:2766-92.

Boyle P, Leon ME. Epidemiology of colorectal cancer. British Medical Bulletin. 2002;64:1-25.

Siegel R, DeSantis C, Jemal A. Colorectal cancer statistics, 2014. CA: A Cancer J For Clin. 2014;64:104-17.

According to a study including 2003-2009 USA data, colorectal cancer stage distribution was examined and CRC stage rates detected as at localized stage 40%, regional: 36%, distant: 20%, unstaged 5% and these rates were 38-37-21-4% for colon cancer and 44-33-18-6% for rectal cancer, respectively [20]. In the Mardin study, patients examined as stages 1,2,3 and 4 and stage rates were 8.1-28.1-30-33.8% in the whole group (CRC):, 7.1-29.6-29.633.7% in colon cancer, and 9.7-25.8-30.6-33.9 % in rectal cancer. In other words, while localized stage (1-2) was approximately 36%, the regional stage was 30%, distant metastasis was around 33% and distant metastasis rates were higher in Mardin than in the present study [20].

11. Meissner HI, Breen N, Klabunde CN, et al. Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiology and Prevention Biomarkers. 2006;15:389-94.

Conclusion This study includes the first CRC data of Mardin province. CRC patients in Mardin are diagnosed at a younger age and in an advanced stage. Because of diagnosis and treatment methods are not sufficient in Mardin, patients are mostly diagnosed outside the province. Therefore, the number of patients is limited. Nevertheless, the statistics will be the first to guide future studies. Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval In this retrospective study, local ethics committe approved the study. Aydın Aytekin ORCID:0000-0002-7001-3945

10. Murphy G, Devesa SS, Cross AJ, et al. Sex disparities in colorectal cancer incidence by anatomic subsite, race and age. Int J Cancer. 2011;128:1668-75.

12. Yalçın BM, Turan E, Yücel İ, ve ark. İlk kez tanı konan kolorektal kanser hastalarının epidemiyolojik özellikleri. Türkiye Aile Hekimliği Dergisi. 2012;16:169-77. 13. Gürsoy Ş, Özlem E, Canöz Ö, ve ark. Kayseri ve yöresinde kolon kanserlerinin özellikleri. Akademik Gastroenteroloji Dergisi. 2003;2. 14. Özgören E, Kisli E, Aydın M, ve ark. Kolorektal kanserlerde tedavi yaklaşımlarımız. Van Tıp Dergisi. 2001;8:124-7. 15. Labianca R, Beretta GD, Kildani B, et al. Colon cancer. Critical Reviews In Oncology/Hematology. 2010;74:106-33. 16. Sundermeyer ML, Meropol NJ, Rogatko A, et al. Changing patterns of bone and brain metastases in patients with colorectal cancer. Clin Colorectal Cancer. 2005;5:108-13. 17. Health NIo. Surveillance, epidemiology, and end results (SEER) program SEER* stat database: incidence-SEER 9 regs research data, Nov 2016 Sub (1973-2014). National Cancer Institute, D, Surveillance Research Program. 2017. 18. Siegel RL, Miller KD, Fedewa SA, et al. Colorectal cancer statistics, 2017. CA: A Cancer J For Clin. 2017;67:177-93. 19. Howlader N. Noone AM, editor;, Krapcho M, editor., et al. eds. SEER Cancer Statistics Review, 1975–2013. Bethesda, MD: National Cancer Institute; 2016. 2017. 20. Howlader N. Noone aM, Krapcho M, et al (eds). sEER Cancer statistics Review, 1975-2010, National Cancer Institute. Bethesda, MD. 2013.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):234-40

Comparison of retrograde intrarenal surgery, mini percutaneous and super mini percutaneous in the treatment of <2cm renal lower pole stones Recep Eryilmaz, Rahmi Aslan, Kasim Ertas, Arif Mehmet Duran, Kerem Taken Van Yuzuncu Yil University, Faculty of Medicine, Department of Urology, Van, Turkey Received 18 December 2019; Accepted 08 March 2020 Available online 09.03.2020 with doi: 10.5455/medscience.2019.08.9180

Abstract Renal lower pole stones are a common disorder in the community. In this study, we aimed to compare Retrograde intrarenal surgery (RIRS), Mini PCNL(percutaneous nephrolithotomy) and Super Mini PCNL treatments in the treatment of lower pole stones. Patients who had lower pol renal stones with <20 mm stone sizes were enrolled in the study. Preoperatively, renal stone and kidney characteristics were evaluated renal ultrasonography, intravenous pyelography and/or non-contrast abdominal computed tomography (CT). RIRS, Mini PCNL and Super Mini PCNL surgery methods were performed. Holmium laser and pneumatic lithotriptor were used for stone lithotripsy. The mean age of the patients in the RIRS group was 35 ± 5.23 years, the mean age in the Mini PCNL group was 38.3 ± 6.47 years and the mean age in the Super Mini PCNL group was 34.12 ± 3.56 years. RIRS were performed in 43 patients, Mini PCNL 37 patients and Supper Mini PCNL 35 patients.Stone free in RIRS was 74.3% Mini PCNL was 93.3% Super Mini PCNL was 94.6 %. According to clavien dindo classification postop grade2-3 complication , in RIRS was 4,6% Mini PCNL was 8,1% .But no grade2-3 complication was seen in Super Mini PCNL group. Hospital stay of RIRS was 1.59± 2.03 mini pnl was 3.73±1.76 and Super Mini PCNL was 2.3±1.55.Cost analysis respectively ,RIRS group, $801.52 ± 25.32; Mini PCNL group, $698.33 ± 22.37; Super Mini PCNL group,$703.13±62. In lower pole stones, RIRS is minimally invasive and have less hospital stay.Stone free rates were higher in Mini PCNL and Super Mini PCNL than RIRS. Super Mini PCNL has short hospital stay and less postoperative complication rate than Mini PCNL. RIRS is more expensive than Mini PCNL and SMP. Keywords: Lower pol stone,treatment,RIRS,mini PCNL,supper mini PCNL

Introduction Urolithiasis is the most common urological benign disease and its prevalence rate has increased worldwide in the past decades. At present, the prevalence rate of urolithiasis varies from 1 to 20% [1]. Recently, the incidence of urolithiasis has increased due to various factors. These factors are geographic, climatic, genetic and nutritional. Urolitiasis is one of the leading urological diseases that need to be treated [2]. The prevalence of kidney stone is increasing and the optimal treatment of symptomatic lower-pole renal calculi (LPC) remains quite challenging. Hence, current treatment modalities for 1–2 cm LPC continue to be contested the European Association

*Coresponding Author: Recep Yilmaz, Van Yuzuncu Yil University, Faculty of Medicine, Department of Urology, Van, Turkey E-mail: recepuro@hotmail.com

of Urology (EAU) guidelines shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and retrograde intrarenal surgery (RIRS) are recommended treatment options for 1–2 cm LPC [3]. SWL is the least invasive treatment modality to treat renal stones; however, it is the least efective in the management of lower pole renal stones. Endoscopic procedures such as PCNL and RIRS are preferred in methods of renal stone therapy [2]. PCNL and RIRS have taken the place of SWL for treatment of kidney stones as a result of development of minimally invasive techniques and instruments in the last years. Each procedure has its own advantages and disadvantage. Mini-PCNL and RIRS are procedures that are preferred for minimally invasive treatment due to their negligible stone-free and complication rates [4]. The current EAU guidelines for urolithiasis recommend SWL as the initial treatment for renal stones smaller than 2 cm, except for the lower pole stones with unfavorable risk factors [5]. Over recent years, the introduction of miniaturized PCNL 234

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techniques such as Miniperc, super mini percutaneous (SMP), and Ultra-miniperc has further expanded the indications for management of renal stones by percutaneous techniques [6]. Miniaturized PCNL (mini-PCNL), defined as a PCNL involving the use of smaller nephroscopes [7]. can be performed effectively to manage kidney stones with high stone free rates and low complications [8]. The new tecnic for kidney stones, SMP is safe, feasible, and effective for managing renal calculi of <3 cm, with the advantages of a small percutaneous tract, less blood loss, high efficacy in stone clearance, improved visual field, short operation duration, and ease of operation [9]. In this study, we aimed to compare RIRS, mini PCNL and SMP in terms of postoperative complications, preoperative and postoperative hemoglobin levels, residual stone, inserted catheter, operation time and hospital stay in the treatment of renal lower pole stones smaller than 2 cm. Materials and Methods Study population After obtaining ethical approval from the faculty ethics committee the patients who underwent RIRS, mini-PCNL and SMP for lower pol kidney Stones <2cm, between January 2017 and April 2019 were retrospectively analyzed in our tertiary academic center. All patients were treated with 3 sessions of ESWL before surgery. However, the renal lower pole stones were not broken. After that, patients underwent surgical treatment. Since all the stones we intervened were lower calix stones, intravenous pyelography (IVP) was requested before surgery. Mini or super Mini PCNL was performed in patients with narrow pole angle in IVP. RIRS was performed in patients with comorbidity and not narrow lower pole angle. Routine DJ stents were not placed in patients before RIRS procedure. Only 6 patients underwent DJ stents prior to RIRS. DJ stent was inserted to these patients because the ureteral access sheath could not be sent to ureter. Patients who had lower pol renal stones with <20 mm stone sizes were incluted in the study. Stone sizes were calculated as the sum of maximal diameters of all stones. Patients below 18 years age and with multiple renal stones were excluded. This study was performed by two surgeon. Patients were evaluated renal ultrasonography, intravenous pyelography and/or non-contrast abdominal computed tomography (CT) in preoperatively. Demographic characteristics of the patients were age, sex, body mass index(BMI) and stone size. Laboratory tests were hemoglobin measurements, serum creatinine level, platelet counts, and coagulation screening tests in preoperative. Urine was sterilized before surgery and consent form was obtained from all patients. Study design This study is a comparative and retrospective study, our study was performed in a tertiary hospital. RIRS was performed in 43 patients, mini PCNL was performed in 37 patients and super mini PCNL was performed in 35 patients. These three surgical techniques were compared in terms of the treatment of renal lower pole stones <20mm, operation times, postoperative complications, catheter insertion, preoperative and post hemoglobin levels and blood transfusion.

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SURGICAL TECHNIQUES RIRS Technique RIRS surgery were performed under general anesthesia and after that were located at the lithotomy position. Passive dilatation was performed primarily with 8-9,8 french Ureterorenoscopy (URS). 6-7,5 french URS were performed in cases that could not be passed with 8-9,8french URS. Then, two hydrophilicy guide wire (0.035-inch) were plased to the renal pelvis with ureteroscope. Under fluoroscopy, the 11F ureteral access sheath was placed on the ureter. We used a ﬂexible ureterorenoscope ( Flex Hawk, Germany). Kidney stones were fragmented using a Ho YAG laser (272 μm,wolf, Germany). Mini-PCNL Technique Mini PCNL was performed under general anesthesia. In the lithotomy position, the 5f open end ureter catheter was inserted into the ureter with rigid ureteroscope. Then, the patient was placed in prone position and access was obtained from the lower pole of the kidney with 18 needles under fluoroscopy. A 0.035mm hydrophilic guidewire was inserted into the renal pelvis. Primarily, 10F-14F-16F dilators were used ,respectively.Next, we inserted a 16-F sheath and introduced a rigid 14-F nephroscope. The stone fragmentation was performed using a Ho:YAG laser (365-μm fibre; energy 1.5 Jd; frequency 10 Hz). A 12-F nephrostomy tube was inserted into the calyceal system at the end of the procedure. Two days after the surgery, the nephrostomy tube was removed. After 3 week, double j stent (DJ) was removed with local anesthesia. Super Mini PCNL Tecnique Super-mini-percutaneous nephrolithotomy was performed under general anesthesia in lithotomy position. A 5- F open- end ureteric catheter was placed under ureteroscopic guidance into the renal pelvis in all patients. Then the patient was turned to prone position. Percutaneous access was performed under fluoroscopy. Tract dilatation was performed with facial dilators up to 14 F. Next a 14F sheath was introduced into the pelvicalyceal system and 12-F rigid nephroscope was used for remove the renal stones. 272 μm holmium laser was used for stone fragmantation.The level of lazer energy 1.5 jd and frequency 10 hz. In case of pelvic perforation or residual stone, 26 / 4.8 dj was inserted. In the routine prosedure, 5f ureter catheter was inserted and this catheter was removed on postoperative first day. 10-f nephrostomy was performed in bleeding cases and in the presence of clinically significant residual stones. Nephrostomy tube was removed postoperative first day. Cost analysis The cost of each procedure was calculated and noted according to the invoices that were obtained from the hospital. Cost analysis was carried out both in TL and US$. Statistical Analysis Descriptive statistics for continuous variables in our study; Mean, Standard Deviation, expressed as Minimum and Maximum values; For categorical variables, they are expressed as Number and Percentage. Independent T-test was used to compare group means in terms of continuous variables Chi-Square test was used to determine the relationship between groups and categorical variables. Statistical significance level was taken as p <0.05 in the calculations and SPSS (ver.23) statistical package program was used for the calculations. 235

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Results The mean age of the patients in the RIRS group was 35 ± 5.23 year,in the Mini PCNL group was 38.3 ± 6.47 year and in the Super Mini PCNL group was 34.12 ± 3.56 year. The mean stone size was 13.44 ± 3.97 mm in the RIRS group, 16.7 ± 5.1mm in the Mini PCNL group and 15.3 ± 4.32 mm in the SMP group. Average operation time in RIRS 80 ± 25.15 minute, in Mini PCNL67.93 ± 20.05 minute and in SMP 65.32 ± 21.53 minute. Stone free rate was 56.4% in the RIRS group, 80.0% in the Mini PCNL group and 81.3% in the SMP group. Length of hospital stay was 1.59 ± 2.03 day in the RIRS group, 3.73 ± 1.76 day in the Mini PCNL group

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and 2.3 ± 1.55 day in the SMP group. According to clavien dindo classification, complications of grade2 and above were seen in 2 cases in RIRS and 3 cases in Mini PCNL. Postoperative grade2 and above complications were not observed in the SMP group. Preoperative and demographic findings of the patients are shown in table 1, operative and postoperative findings of RIRS and Mini PCNL are shown in table 2, operative and postoperative findings of RIRS and Super Mini PCNL are shown in table 3 and operative and postoperative findings Mini PCNL and Super Mini PCNL are shown in table 4. The operative and postoperative findings of all three groups are shown in table 5.

Table 1. Preoperative and demographic parameters in study groups

Variable

RIRS group

Mini-PCNL group

Super Mini PCNL

Number of patients

Gender male/female

26/17

21/16

20/15

Side left/right

24/19

18/19

22/14

Stone size (mm)

13.44±3.97

16.7 ± 5.1

15.3±4.32

Stone localization

Lower pole

lower pole

BMI (kg/m2)

25.7±3.21

26.11±2.64

24.83±3.41

40/3

36/1

35/0

Stone opacity (opaque / nonopaque)

Table 2. Intraoperative and postoperative parameters and surgical complications in study groups of RIRS and Mini PCNL. Variable

RIRS

Mini-PCNL

P value

80±25.15

67.93 ± 20.05

P=0.033

Stone free

56.4%

80.0%

P=0.027

<4mm residue

17.9%

13.3%

P=0.043

>4mm residue

22.6%

6.7%

P=0.013

DJ catheter

74.4%

33.3%

P=0.032

Ureter catheter

25.6%

66.7%

P=0.034

1.59± 2.03

3.73±1.76

P=0.023

Grade 0

p>0.05

Grade I

P=0.031

Grade II

P=0.045

Grade III

p>0.05

Grade IV/V

Preoperative Hb (g/dL)

14.76± 1.75

12.94± 1.68

p>0.05

Postoperative Hb (g/dL)

14.57± 1.74

11.91± 1.46

P=0.037

5.4%

P=0.039

$801.52 ± 25.32

$698.33 ± 22.37

P=0.011

Operative time (min)

Catheter status (%)

Hospital stay (day) No. of Clavien complications

Blood transfusion Cost

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Table 3. Intraoperative and postoperative parameters and surgical complications in study groups RIRS and Super PCNL. Variable

RIRS

Super Mini-PCNL

P value

80±25.15

65.32±21.53

P=0.038

Stone free

56.4%

81.3%

P=0.023

<4mm residue

17.9%

14.33%

P>0.05

>4mm residue

22.6%

4.27%

P=0.017

DJ catheter

74.4%

35.2%

P=0.015

Ureter catheter

25.6%

64.8%

P=0.022

1.59± 2.03

2.3±1.55

P>0.05

Grade 0

P>0.05

Grade I

P>0.05

Grade II

P=0.042

Grade III

P=0.042

Grade IV/V

Preoperative Hb (g/dL)

14.76± 1.75

13.57±1.23

p>0.05

Postoperative Hb (g/dL)

14.57± 1.74

13.25±1.11

p>0.05

$801.52 ± 25.32

$703.13±62

Operative time (min)

Catheter status (%)

Hospital stay (day) No. of Clavien complications

Blood transfusion Cost

P=0.011

Table 4. Intraoperative and postoperative parameters and surgical complications in study groups of Mini PCNL and SMP Variable

Mini-PCNL

Super Mini PCNL

67.93 ± 20.05

65.32±21.53

Stone free

80.0%

81.3%

<4mm residue

13.3%

14.33%

>4mm residue

6.7%

4.27%

DJ catheter

33.3%

35.2%

Ureter catheter

66.7%

64.8%

3.73±1.76

2.3±1.55

Grade 0

Grade I

P<0.05

Grade II

P<0.05

Grade III

P<0.05

Grade IV/V

Preoperative Hb (g/dL)

12.94± 1.68

13.57±1.23

Postoperative Hb (g/dL)

11.91± 1.46

13.25±1.11

P<0.05

5.4%

P<0.05

Operative time (min)

P Value

P<0.05

Catheter status (%)

Hospital stay (day)

P<0.05

No. of Clavien complications

Blood transfusion

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Table 5. The operative and postoperative findings of all three groups Variable

RIRS

Mini-PCNL

Super Mini PCNL

P value

80±25.15

67.93 ± 20.05

65.32±21.53

P=0.033

Stone free

56.4%

80.0%

81.3%

P=0.027

<4mm residue

17.9%

13.3%

14.33%

P=0.043

>4mm residue

22.6%

6.7%

4.27%

P=0.013

DJ catheter

74.4%

33.3%

35.2%

P=0.032

Ureter catheter

25.6%

66.7%

64.8%

P=0.034

1.59± 2.03

3.73±1.76

2.3±1.55

P=0.023

Grade 0

p>0.05

Grade I

P=0.031

Grade II

P=0.045

Grade III

P=0.042

Grade IV/V

Preoperative Hb (g/dL)

14.76± 1.75

12.94± 1.68

13.57±1.23

p>0.05

Postoperative Hb (g/dL)

14.57± 1.74

11.91± 1.46

13.25±1.11

P=0.037

5.4%

P=0.039

$801.52 ± 25.32

$698.33 ± 22.37

$703.13±62

P=0.011

Operative time (min)

Catheter status (%)

Hospital stay (day) No. of Clavien complications

Blood transfusion Cost

The total cost for lower pol Stones <2cm in the RIRS group was comparable to that in the Mini and Super Mini PCNL under the Turkish healthcare system. However, in the RIRS group, it was higher than the mini and Super Mini PCNL(RIRS group, $801.52 ± 25,32; Mini PCNL group, $698.33 ± 22,37; Super Mini PCNL group,$703,13±62; US$1 = 5.8 TL). Discussion RIRS has increasingly been used for moderately sized kidney stones in recent years [10,11]. However, this technique has limitations such as low success rate in the lower calyx, necessity of using ureteral access sheath, necessity of placing DJ stent in case of failure due to inability to gain access in the first session and requirement of a second session, and longer duration of the surgical period as the stone size increases [12]. RIRS is considered an acceptable treatment for kidney lower pol calculi but not a first-line treatment for calculi of 1.0-2.0 cm in diameter [13]. Although flexible URS is a minimally invasive procedure, complications such as subcapsular hematoma may occur. After that RIRS subcapsular renal hematoma represents a rare but potentially serious complication. The elevated intrarenal pressures and long time of operation play an important role in subcapsular hematoma etiology [14]. In our study, RIRS was performed in 43 patients with renal lower pole stones. Stone free rate was 74.3% in patients who underwent

RIRS. When we compared RIRS with Mini PCNL or Super Mini PCNL, it was observed that DJ stent placement, operation time and residual stone retention rates were high but preoperative and postoperative hemoglobin values, length of hospital stay and postoperative pain rates were lower in RIRS (p <0.05) In one patient who underwent RIRS, postoperative subcapsular hematoma developed and then this hematoma was evacuated with percutanous catheter. SMP was more effective than RIRS for treating 1-2 cm LPC in terms of a better stone free rate(SFR) and lesser auxiliary procedure rate. The complications and hospital stay were comparable. RIRS has the advantage of less postoperative pain. The SFR after a single treatment was significantly higher in the SMP group than in the RIRS group (91.2% vs 71.2%) [15]. This was probably due to the favourable location and angulation of the lower calyx of the kidney for SMP puncture, meaning that percutaneous access could be achieved directly in line with the target stones in the lower pole [16]. In study of Atassi et al. A total of 160 patients were included and randomized to the two procedures RIRS and SMP. Although stone parameters were comparable among the two groups (15 vs. 14.3 mm), postoperatif 1-day and 3-month SFR were significantly higher in SMP (day1: SFR 91.2 vs. 71.2%,; 3 months: 93.8 vs.82.5%, There were no significant differences in operating time, hospital stay, and complication rates between the groups [17].

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According to the available literature, RIRS and SMP were compared studies. Stone free rate in RIRS is from 65% to 92% RIRS known as that low-risk surgical procedure in treating small renal stones. However, The success of RIRS in renal lower pole stones is low. Especially if the lower calyx angle is narrow, the success of RIRS is further reduced. Other disadvantages, If the ureter is not large enough, dilatation is necessary then this extends the process, RIRS has high cost, In large stones, multiple sessions may be required, risk of ureteric damage, and DJ stent insertion rate is high. Recently, in the comparative randomized and prospective studies of RIRS and SMP, SMP had higher SFR than RIRS and was more effective in the treatment of renal pole stones smaller than 2 cm. Complications were comparable in both treatment modalities, however, there was less postoperative pain in the RIRS. This study showed that SMP is an effective and safe method that could be an alternative to RIRS, especially in the treatment of lower pole Stones [18]. In this study, stone free rates postoperatif one month were higher in patients who underwent SMP than patients with RIRS respectively (95,6% vs74,3%) and also the operation time is lower in SMP than RIRS (p<0.05). As the literature is given, it is difficult to return to the lower pole with RIRS. In SMP, it is easier to reach the lower pol stone because it is entered directly from the lower pol of kidney. The complication of PCNL is related to large tract size. If we decrease PCNL size,morbidity rates is decrease too. It is a modified Mini- PCNL technique using a miniaturised scope through a smaller, 10–14 F nephrostomy tract. With the newly designed irrigationsuction sheath, the critical limitations of new miniaturised PCNL, poor irrigation and challenging stone extraction were completely addressed. Several studies have suggested that SMP is highly effective and safe for moderate- sized Stones [19]. In present study, when we compared the patients who underwent mini PCNL with Super Mini PCNL, postoperative hemoglobin drop, postoperative complication, dj stent placement and hospital stay were less in SMP group than Mini PCNL group (p<0.05). The operation time was similar in both groups. As it is understood from this, when the tract number decreases the complication rates decrease. In patients who were treated ‘tubeless’ following PCNL, the hospital stay was reduced significantly. In study of Shah et al. 94.8% the patients did not require a nephrostomy tube after SMP, and 67.5% did not require a nephrostomy tube or double J stent following SMP. This may explain why the mean hospital stay was similar in the SMP and RIRS groups [20,21]. In this study, 91.3% of patients who underwent SMP had no nephrostomy. Also, DJ stent was not present in 64.8% of patients. Only the ureter catheter was inserted in these patients and the ureteral catheter was removed on the postoperative 1st day. In particular, the hospital stay of SMP patients without nephrostomy was similar to that of RIRS patients. The mean of hospital stay in RIRS and SMP was 1.59 ± 2.03 vs 2.3 ± 1.55 respectively. Smaller renal access sheaths were initially introduced for pediatric patients, but increasingly gained popularity in adults, as well. Procedures were performed with small instruments tend to be associated with significantly lower bleeding rates, while the

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operation times tend to be significantly longer. Stone-free (SF) rates are comparable in Mini PCNL and standard PCNL procedures [22]. In our study, blood transfusion was decreased, as the number of channels decreased. No blood transfusion to any of our patients in SMP group but 5,4% patients of Mini PCNL were done blood transfüzyon. No significant difference was found in terms of operation time. Stone free rates in SMP and Mini PCNL groups were similar. In the study of Bağcı et al., the cost was significantly higher in the RIRS group than in the mini PCNL group [23]. Chung et al. compared RIRS, SWL, PCNL and open surgery in terms of cost. As a result of comparison, it is shown that the RIRS is more expensive than the others [24]. In our study, RIRS, Mini PCNL and SMP were compared in terms of cost analysis and RIRS was found to be more costly than Mini PCNL and SMP. Therefore, it is appropriate to consider the cost when planning surgery for kidney stones. Limitations The low number of our patients may have resulted in lower complication rates. In addition, lack of pediatric patients is the shortcomings of our study. Conclusion As a result, when we compare SMP with Mini PCNL , SMP is a safer method than Mini PCNL. On the other hand, when we compare SMP with RIRS, we found that SMP is as safe and effective as RIRS. However RIRS is more costly than SMP in the treatment of lower pole of kidney stones smaller than 2 cm. Therefore SMP can be an alternative to RIRS. 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 2019 / 02-05, date 01,02,2019 Approval was obtained from the ethics committee of the yuzuncu yil university. Recep Eryilmaz ORCID: 0000-0002-4506-8784 Rahmi Aslan ORCID: 0000-0002-4563-0386 Kasim Ertas ORCID: 0000-0003-4300-1399 Arif Mehmet Duran ORCID: 0000-0002-9990-1516 Kerem Taken ORCID: 0000-0002-4370-4222

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10. Karatag T, Buldu I, Inan R, Istanbulluoglu MO. Is micropercutaneous nephrolithotomy technique really efficacicous for the treatment of moderate size renal calculi? Yes. Urol Int. 2015;95:9-14. 11. Karakan T, Kilinc MF, Doluoglu OG, et al. The modified ultra-mini percutaneous nephrolithotomy technique and comparison with standard nephrolithotomy: a randomized prospective study. Urolithiasis. 2017;45:20913. 12. Resorlu B, Unsal A, Gulec H, Oztuna D. A new scoring system for predicting stone-free rate after retrograde intrarenal surgery: the “resorlu-unsal stone score” . Urology. 2012;80:512-8. 13. Li MM, Yang HM, Liu XM, et al. Retrograde intrarenal surgery vs miniaturized percutaneous nephrolithotomy to treat lower pole renal stones 1.5-2.5 cm in diameter World J Clin Cases. 2018;6:931-5.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):241-5

Demographic, clinic, and genetic characteristics in 149 children diagnosed with familial mediterranean fever Elif Guler Kazanci1, Muhammet Furkan Korkmaz2, Vefik Arica3, Ahmet Ibrahim Kurtoglu3 1

Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Department of Pediatric Hematology, Bursa, Turkey 2 Yuksek Ihtisas Training and Research Hospital, University of Health Sciences,Department of Pediatrics, Bursa, Turkey 3 Mustafa Kemal University, Faculty of Medicine, Department of Pediatrics, Hatay, Turkey Received 28 November 2019; Accepted 14 January 2020 Available online 09.03.2020 with doi: 10.5455/medscience.2019.08.9181

Abstract Familial Mediterranean fever (FMF) is a hereditary disease characterized by recurrent attacks of fever, peritonitis, pleuritis and/or synovitis. In this study, we retrospectively evaluated demographic, clinical findings, and genetic features in 149 children (63 male/86 female) with FMF. The mean age of the patients at the time of diagnosis was 6.44 Âą 3.21 years. A positive family history for FMF was present in 26%, and 8% of the patients had consanguinity between the parents. The frequency of family history of FMF was found to be higher in patients diagnosed under 10 years of age (p=0.038). Frequencies of the most frequent symptoms observed in cases during episodes were abdominal pain (95%), fever (68%), and arthralgia/arthritis (23%). Genetic analysis revealed that 16% of the patients had homozygous mutations, 32% had heterozygous mutations, and 38% had compound heterozygous mutations, while no mutations were detected in 21 (14%). There were mutant genes in 218 alleles, the most frequently observed were R202Q (48%), M694V (24%), and E148Q (17%). Patients with non-R202Q compound heterozygous mutation had higher frequency of high fever, CRP (C-reactive protein) levels, and fibrinogen levels during the episodes (p=0.006, p=0.001, and p=0.042, respectively). Thus, our study showed that R202Q mutation appeared to have no significant disease-causing and clinical effects, while mutations at exon 10 were associated with increased severity of symptoms as well as elevated levels of acute phase reactants. Further studies with larger FMF populations may shed more light on the role of these mutations in the pathogenesis of FMF. Keywords: Familial Mediterranean fever, MEFV gene mutation, children, clinical manifestations

Introduction Familial Mediterranean Fever (FMF) is a chronic periodic inflammatory disease characterized by recurrent fever and polyserositis episodes. Although the etiology and pathogenesis of FMF are uncertain, immune mechanisms are thought to play a major role. The most important feature that distinguishes FMF from other chronic inflammatory diseases is the complete normalization of the patient between inflammatory episodes [1,2] However, in some studies conducted in recent years, elevated levels of cytokines and inflammatory markers during episode-free periods suggest that subclinical inflammation continues. [3-5].

*Coresponding Author: Muhammet Furkan Korkmaz, Yuksek Ihtisas Training and Research Hospital, University of Health Sciences,Department of Pediatrics, Bursa, Turkey, E-mail: korkmazmfurkan@gmail.com

This disease occurs mainly in Turkish, Arab, Armenian, Jewish and other Mediterranean ethnic groups. Based on the data provided by the Turkish FMF Study Group, the incidence of the disease is 1/1000 and the carrier rate is as high as 1/5 [6]. In the studies, M694V mutation was found most frequently in Turkish populations as in other races [7,8]. It is stated that more than 160 mutations in the MEFV gene cause this disease. However, M694V, V726A, M680I, M694I and E148Q mutations account for 74% of all FMFrelated mutations. [9]. In the studies, it was found that there was a relationship between the type of mutation and the age of onset of clinical findings and the severity of the disease. Clinical findings were more severe in patients with homozygous MEFV gene mutation [10]. Furthermore, although some studies have reported correlations between genetic characteristics and the severity, course, and prognosis of FMF, the data on this issue are not clear. In this study, the demographic, clinic, and genetic characteristics as well as the treatment response in 149 Turkish pediatric patients diagnosed with FMF in two different centers are presented. 241

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Materials and Methods

sequencing method (Illumina device).

In this study, medical records of 149 FMF patients between 0 and 18 years of age followed up at two tertiary centers between January 2018 and June 2019, i.e. Department of Pediatrics, Bursa Yüksek İhtisas Training and Research Hospital and Department of Pediatrics, Research and Application Hospital, Medical Faculty of Hatay Mustafa Kemal University were retrospectively analyzed after obtaining the approval of local ethics committee, (2011KAEK-25-2019/09-11).

For data analysis SPSS (Statistical Package for Science Studies) version 21.0 statistic software pack was used. Categorical variables were expressed with n (%), while mean ± standard deviation and median (min-max) values were used for continuous variables with or without normal distribution, respectively.

Demographic data, family history, use of medication, and gene mutations were recorded in all patients, as well as the age at disease onset, episode frequency, accompanying symptoms, complete blood count, CRP (C-reactive protein), ESR (Erythrocyte sedimentation rate), and fibrinogen levels. Venous blood samples of 2 to 5 mL obtained from each patient were transferred to medical genetic laboratory in EDTA tubes at 18-24 ℃ for genetic analysis. MEFV gene-related mutations were screened at the Medical Genetics Center of both hospitals using the next generation

The chi-square test or Fisher’s exact test were used to compare the frequency of qualitative variables. In cases where the prerequisites of parametric tests could not be fulfilled for some variables, MannWhitney U test was used for two-group comparisons and Kruskal Wallis tests for multiple group comparisons. In all tests, p <0.05 was considered statistically significant. Results The mean age of 149 patients included in the study was 8.12 ± 3.48 years (range: 1-16 y). Of these, 63 (42%) were male and 86 (58%) were female. The mean age of the patients at the time of diagnosis was 6.44 ± 3.21 years, with 75% of the patients having a disease onset earlier than 10 years of age (Table 1).

Table 1. Demographic and clinical data of Familial Mediterranean fever cases Parameters Sex (M/F), n (%)

FMF* cases n=149

Age ≤10 n=111

Age >10 n=38

P-value

63/86 (42/58)

44/67

19/19

0,6

Age (years), mean ± SD**

8,12 ± 3,48

6,46 ± 2,15

12,94 ± 1,62

0,02

Age at diagnosis, mean ± SD

6,44 ± 3,21

4,96 ± 2,04

10,73 ± 1,82

<0.001

Number of attacks in the last year, median (min-max)

3 (0-10)

3 (0-9)

3 (0-10)

0,9

FMF in family history, n (%)

39 (26)

34 (23)

5 (3)

0,038

Consanguineous marriage, n (%)

12 (8)

10 (7)

2 (1)

0,6

12 (0-84)

24 (0-60)

0,054

Colchicine usage time (months), median (min-max) *: Familial Mediterranean fever, **: standard deviation

The median value for the frequency of episodes in the last year was 3 days (0-10 days). A positive family history for FMF was present in 26%, and 8% of the patients had parents with consanguineous marriage. The median duration of colchicine use was 12 months (0-84 months), with a median dosage of 1 mg/day (0-4 mg/day). When the demographic and clinical data of the patients were analyzed statistically, the frequency of family history of FMF was found to be higher in patients diagnosed under 10 years of age (p=0.038). Abdominal pain (95%), fever (68%) and arthralgia / arthritis (23%) were frequently observed when the patients were evaluated for accompanying symptoms during the episode (Table 2). When mutation analysis results of our patients were examined, 24 (16%) patients had homozygous, 48 (32%) patients had heterozygote and 56 (38%) patients had compound heterozygous mutations, while no mutations were detected in 21 (14%) patients. As a result of this study, mutant genes were detected in 218 alleles. The most common alleles were R202Q (48%), M694V (24%), and E148Q (17%). The mutation analysis results of the cases are

shown in Table 3. In order to examine the effect of R202Q, which is the most common mutation in our study, on clinical and laboratory results, the data of patients were compared in three groups as R202Q homozygote, R202Q / M694V and non-R202Q compound heterozygote (Table 4). The frequency of fever, CRP and fibrinogen levels during the episode was higher in patients with non-R202Q compound heterozygous mutations (p=0.006, p=0.001, p=0.042, respectively). Table 2. Clinical symptoms of the patients during an episode Symptoms

n (%)

Abdominal pain

141 (95)

Fever

101 (68)

Arthralgia/arthritis

34 (23)

Nausea and vomiting

32 (21)

Chest pain

18 (12)

Myalgia

12 (8)

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Heterozygous for one mutation

Homozygous for one mutation

Compound heterozygous

Mutation

n (%)

R202Q/-

21 (14)

E148Q/-

9 (6)

M694V/-

8 (5)

V726A

3 (2)

P369S/-

3 (2)

A744S/-

2 (1)

M680I (G/C)/-

1 (1)

R761H/-

1 (1)

R202Q/R202Q

16 (10)

E148Q/E148Q

5 (3)

M694V/M694V

3 (2)

R202Q/M694V

31 (21)

R202Q/E148Q

10 (7)

M680I (G/C)/V726A

3 (2)

E148Q/M694V

3 (2)

E148Q/P369S

3 (2)

M694V/V726A

2 (1)

E148Q/V726A

1 (1)

E148Q/R202Q/M694V

1 (1)

E148Q/M694V/V726A

1 (1)

M694V/M680I (G/C)

1 (1)

In this study, patients followed up at two tertiary care centers with a diagnosis of FMF were retrospectively analyzed in terms of demographic, clinic, and genetic characteristics. FMF is an autosomal recessive systemic inflammatory disorder commonly occurring in our geographical area that is associated with diagnostic challenges [11]. There is no specific laboratory test for diagnosis, and currently, clinical and family history are the most important tools for diagnosis [12]. FMF is mainly childhood disease, and is usually diagnosed within the first 10 years of life. In a study by Sohar et al. [13], the age of onset of clinical findings was before 10 years of age in 65% of the patients and before 20 years of age in 90% of the patients. BenChetrit et al. [11] reported first occurrence of symptoms within the first 10 years of life in approximately 50% of patients with FMF, while only 2% of the patients had a disease onset after 30 years of age. In the current study, the mean age of the patients at the time of diagnosis was 6.44 ± 3.21 years, with 75% of the cases having a disease onset before 10 years of age. In most published reports, FMF has been reported to affect both genders at similar rates. In a multi-center study conducted in our country, the female / male ratio was reported as 1.2 to 1 [6]. Similarly in our study, the female / male ratio was found to be 1.3 / 1.

Mutation (+)

128 (86)

Mutation (-)

21 (14)

Total

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Discussion

Table 3. Distribution of Mediterranean fever gene Genotype

As with all autosomal recessive diseases, consanguineous marriages are associated with an increased likelihood of mutant alleles in FMF [14]. Eight percent of our patients had parents with consanguineous marriage, while 26% had a positive family history for FMF. In our study, the incidence of family history of FMF was found to be higher in patients diagnosed under 10 years of age.

149 (100)

Table 4. Relationship between genotype, clinical and laboratory findings in patients Parameters

R202Q Homozygous N=16

R202Q/M694V N=31

Non R202Q CH N=13

P-value

Sex (M/F), n

7/9

9/22

4/9

0,5

Age (years)*

7,8 ± 2,8

8,5 ± 3,6

6,8 ± 3,6

0,3

Age at diagnosis* Number of attacks in the last year** FMF in family history, n

5,7 ± 3,1

6,9 ± 3,5

5,8 ± 2,9

0,5

3 (1-8)

3 (0-9)

3 (2-10)

0,7

0,5

Consanguineous marriage, n Colchicine usage time (months)** Abdominal pain, n

0,1

12 (0-36)

12 (0-60)

12 (0-48)

0,06

0,07

Fever, n

0,006

Arthralgia/arthritis, n

0,4

Hb (g/dL)*

12,8 ± 1,7

12,5 ± 1,4

12,5 ± 1,5

0,7

WBC (x109)*

7,6 ± 2,5

8,8 ± 2,8

8,2 ± 2,6

0,5

303000 ± 88000

313000 ± 98000

320000 ± 83000

0,9

3,3 (0-3,3)

3,3 (0-54,9)

35 (3,3-100)

0,001

5 (2-20)

5(0-69)

17 (3-52)

0,064

203 (0-342)

318 (0-681)

350 (126-2228)

0,042

Platelet count (/μL)* CRP (mg/L)** ESR (mm/saat)** Fibrinojen (mg/dL)**

Abbreviations: CH: Compound heterozygous, Hb: Hemoglobin, WBC: White blood count, CRP: C-reactive protein, ESR: Erythrocyte sedimentation rate *: mean ± standard deviation, **: median (min-max)

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Recurrent abdominal pain with fever is the most common symptom in FMF disease. Although these typical findings are seen in different populations and races in different frequencies, arthralgia/ arthritis, chest pain, joint pain and erysipelas-like rash may also be observed in patients [15]. Based on the data from the Turkish FMF Study Group, the most common symptoms included abdominal pain (93%) and fever (92%). Also, in our study, abdominal pain (95%) and fever (68%) were the most common symptoms in accordance with the literature. In recent years, significant advances have been achieved in understanding the molecular basis of FMF and supporting diagnosis through emerging molecular genetic methods. The number and type of mutations in the MEFV gene that play a role in the etiology of FMF cases vary among populations. Among the most common mutations, M694V, M680I, V726A and M694I are located on exon 10, while E148Q mutation, which is frequently observed, is located on exon 2. No mutation is detected in approximately 20% of patients [16,17]. The most frequently identified mutant alleles in our study were R202Q (48%), M694V (24%), and E148Q (17%), with 14% of the patients having no mutations. The most frequently detected mutation in FMF patients is known to be the M694V mutation [17]. Until now, the mutations most frequently identified in Turkish patients include M694V, M680I, V726A and M694I [14]. These mutations at exon 10 may coexist with amyloidosis and may lead to a more severe clinical presentation, while the mutations of M148Q and R202Q in exon 2 have a controversial role in the etiology of FMF [18,19]. While Ozturk et al. [20] found no association between heterozygous R202Q mutations and FMF, they also showed that the clinical manifestations may emerge when it co-occurs with other diseasecausing mutations. On the other hand, Yiğit et al. [21] recommended routine examination of R202Q mutations, as these mutations may lead to FMF when they are in the homozygous form. Again, Çankaya et al. [22] showed that the presence of R202Q mutations may lead to clinical FMF. The most frequently detected mutation in FMF patients is known to be the M694V mutation [17]. M694V, M680I, V726A and M694I are the most common mutations reported in AAA patients in our country so far [14]. It is thought that these mutations caused by exon 10 may cause a more severe clinical presentation with amylodosis. It is controversial that mutations such as E148Q and R202Q caused by exon 2 cause disease [18,19]. While Ozturk et al. [20] found no association between heterozygous R202Q mutations and FMF, they also showed that the clinical manifestations may occur in association with other disease-causing mutations. However, Yigit et al. [21] suggested that R202Q may also cause disease in homozygous forms and should be included in routine molecular examination. Similarly, Çankaya et al. [22] showed that FMF disease may occur in some patients in the presence of R202Q mutation. Giaglis et al. [23] reported a 9.2% R202Q homozygous polymorphism in FMF patients in the Greek population and 0.7% in healthy subjects. Yiğit et al. [21] observed heterozygous and homozygous R202Q polymorphism in 59.6% and 14.7% of Turkish patients, respectively. In the current study, R202Q mutation was detected as 14% heterozygous, 21% homozygous and 29% compound heterozygous. When comparing the data of

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patients to examine the effect of R202Q on clinical and laboratory results, the frequency of fever, CRP and fibrinogen levels during episode was higher in patients with non-R202Q compound heterozygote mutation than patients with R202Q. Accordingly, our study supports the hypothesis that R202Q does not have diseasecausing effects as suggested by some previous studies. The most important limitations of this study are the limited number of patients and the small number of mutations that can be examined and the retrospective nature of the study. Conclusion In conclusion, although M694V gene mutation was reported to be the most common mutation in previous studies in our country, R202Q mutation was the most common type of mutation in our study. However, our study showed that R202Q had no significant effect on disease-causing and clinical effects, whereas mutations at exon 10 could increase the frequency of symptoms and elevate acute phase reactant levels during episode. We believe that the effects of mutations on FMF patients will be further elucidated in future studies with larger series. 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 Research and Application Hospital, Medical Faculty of Hatay Mustafa Kemal University were retrospectively analyzed after obtaining the approval of local ethics committee, (2011-KAEK-25-2019/09-11). Elif Guler Kazanci ORCID: 0000-0003-0910-1142 Muhammet Furkan Korkmaz ORCID: 0000-0001-5440-7955 Vefik Arica ORCID: 0000-0002-2080-4677 Ahmet Ibrahim Kurtoglu ORCID: 0000-0001-8581-5652

References 1.

Abraham G. Hereditary Periodic Fever Syndromes. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF (eds): 18th edition. Nelson Textbook of Pediatrics, WB Saunders Co, Philadelphia, 2007;1029-34.

Livneh A, Langevitz P, Zemer D, et al. The changing face of Familial Mediterranean fever. Semin Arthritis Rheum. 1996;26:612-27.

Kıraz S, Ertenli I, Arici M, et al. Effects of colchicine on inflammatory cytokines and selectins in Familial Mediterranean fever. Clin Exp Rheumatol. 1998;16:721-4.

Duzova A, Bakkaloglu A, Besbas N, et al. Role of A- SAA in monitoring subclinical inflammation and in colchicine dosage in Familial Mediterranean fever. Clin Exp Rheumatol. 2003;21:509-14.

Lachmann HJ, Sengul B, Yavuzşen TU, et al. Clinical and subclinical inflammation in patients with Familial Mediterranean fever and in heterozygous carriers of MEFV mutations. Rheumatology (Oxford). 2006;45:746-50.

Tunca M, Akar S, Önen F, et al. Familial Mediterranean fever (FMF) in Turkey: results of a nationwide multicenter study. Medicine (Baltimore). 2005;84:1-11.

Chen X, Fischel-Ghodsian N, Cercek A, et al. Assessment of pyrin gene mutations in Turks with Familial Mediterranean fever (FMF). Human Mutation. 1998;11:456-60.

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Bakkaloglu A. Familial Mediterranean fever. Pediatric nephrology (Berlin, Germany). 2003;18:853-9.

Akin H, Onay H, Turker E, et al. MEFV mutations in patients with Familial Mediterranean fever from the Aegean Region of Turkey. Mol Biol Rep. 2010;37:93-8.

17. Barut K, Sahin S, Adrovic A, et al. Familial Mediterranean fever in childhood: a single-center experience. Rheumatology International. 2018;38:67-74.

10. Yılmaz R, Ozer S, Ozyurt H, et al. Familial Mediterranean fever gene mutations in the iner northern region of Turkey and genotype-phenotype correlation in children. J Paediatr Child Health. 2009;45:641-5.

18. Tchernitchko D, Legendre M, Delahaye A, et al. Clinical evaluation of a reverse hybridization assay for the molecular detection of twelve MEFV gene mutations. Clinical Chemistry. 2003;49:1942-5.

11. Ben-Chetrit E, Levy M. Familial Mediterranean fever. Lancet. 1998;351:65964.

19. Ozen S, Besbas N, Bakkaloglu A, et al. Pyrin Q148 mutation and familial Mediterranean fever. QJM: Monthly J Association Physicians. 2002;95:3323.

12. Çağlar A, Özçelik G, Akıncı N. Genotype – phenotype correlation in pediatric patients with Familial Mediterranean Fever. İzmir Dr. Behçet Uz Çocuk Hast. Dergisi. 2018;8:144-50. 13. Sohar E, Gafni J, Pras M et al. Familial Mediterranean fever. A survey of 470 cases and review of the literature. Am J Med. 1967;43:227-53. 14. Turkish FMF study group. Familial Mediterranean Fever in Turkey: results of a nationwide study. Medicine. 2005;84:1-11. 15. Yavuz S, Selçuk Duru N, Elevli M. Relationship among clinical, laboratory findings, disease severity scores and genetic mutations in patient with Familial Mediterranean fever. Med Bull Haseki. 2018;56:58-64. 16. Soylemezoglu O, Kandur Y, Duzova A, et al. Familial Mediterranean fever

with a single MEFV mutation: comparison of rare and common mutations in a Turkish paediatric cohort. Clinical and Experimental Rheumatology. 2015;33:S152-5.

20. Oztürk A, Ozçakar B, Ekim M, et al. Is MEFV gene Arg202Gln (605 G>A) A disease-Causing Mutation? Turk J Med Sci. 2008;38:205-8. 21. Yiğit S, Karakuş N, Taşlıyurt T, et al. Significance of MEFV gene R202Q polymorphism in Turkish Familial Mediterranean fever patients. Gene. 2012;506:43-5. 22. Çankaya T, Bora E, Torun Bayram M, et al. Clinical significance of R202Q alteration of MEFV gene in children with Familial Mediterranean fever. Arch Rheumatol. 2015;30:1-6. 23. Giaglis S, Papadopoulos V, Kambas K, et al. MEFV alterations and population genetics analysis in a large cohort of Greek patients with Familial Mediterranean fever. Clin Genet. 2007;71:458–67.

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ORIGINAL RESEARCH

Medicine Science International Medical Journal

Medicine Science 2020;9(1):246-50

Barbaloin attenuates ischemia reperfusion-induced oxidative renal injury via antioxidant and anti-inflammatory effects Ayhan Tanyeli̇1 , Mustafa Can Guler1, Ersen Eraslan2, Fazile Nur Eki̇nci̇ Akdemi̇r3, Omer Topdagi4, Elif Polat5, Tuncer Nacar1 Ataturk University, Faculty of Medicine, Department of Physiology, Erzurum, Turkey 2 Bozok University, Faculty of Medicine, Department of Physiology, Yozgat, Turkey 3 Agri Ibrahim Cecen University, High School of Health, Department of Nutrition and Dietetics, Agri, Turkey 4 Ataturk University, Faculty of Medicine, Department of Internal Medicine, Erzurum, Turkey 5 Ataturk University, Faculty of Medicine, Department of Biochemistry, Erzurum, Turkey 1

Received 29 August 2019; Accepted 21 October 2019 Available online 28.02.2020 with doi:10.5455/medscience.2019.08.9182 Copyright © 2020 by authors and Medicine Science Publishing Inc. Abstract The goal of this research is to find out the protective effects of barbaloin on kidney injury by ischemia-reperfusion. In this research, the rats were allocated into four groups. Study groups are programmed as; sham control, ischemia-reperfusion, ischemia reperfusion+DMSO and ischemia reperfusion+barbaloin. When the study was completed, various oxidative stress parameters like total oxidant status, total antioxidant status, oxidative stress index, myeloperoxidase, and cytokine levels such as tumor necrosis factor-α and interleukin-1β were measured in all groups. Oxidant and inflammatory parameters increased, and antioxidant parameters decreased in the ischemia reperfusion group, but antioxidant parameters increased while oxidant and inflammatory parameters decreased in the treatment group. These results have shown us that barbaloin has a protective effect against oxidative renal injury caused by ischemia-reperfusion. Keywords: Barbaloin, Ischemia-Reperfusion, Kidney, Oxidative stress, Cytokines

Introduction Acute kidney injury (AKI) could be induced by various conditions, including kidney ischemia, exposure to toxic substances, obstruction of urinary tracts, and severe inflammation [1]. Renal ischemia-reperfusion (I/R) injury, a widespread reason for AKI [2], may occur due to several surgical operations such as cardiac surgery, renal transplantation and vascular surgery [3,4]. As a widespread clinical syndrome, renal I/R injury results in a high rate of complications and death [5]. Renal, I/R injury pathophysiology mechanisms are complex and involve several signaling pathways that are associated with the interaction of apoptosis-related factors, inflammatory cytokines/chemokines, ROS, and oxidative stress [6,7]. Free radicals induced by oxidative stress play a critical role in I/R pathophysiology [8]. When the mitochondrial respiratory chain is dysfunctional during the ischemic phase, this leads to ROS production, and the reperfusion phase enhances this production

[9]. Lipid peroxidation is the most detrimental feature of ROS. Malondialdehyde (MDA), as a lipid peroxidation end-product, much more exacerbates the cell damage [10]. The ratio of total oxidant status (TOS) to total antioxidant status (TAS) is called an oxidative stress index (OSI), and it reflects the balance between oxidative and antioxidative systems [11]. In AKI (induced by I/R), the inception and improvement of kidney dysfunction and tubular injury are associated with infiltrating inflammatory cells [12]. Myeloperoxidase (MPO) is secreted by activated neutrophils and takes the role of catalyzing hypochlorous acid and chloride anion formation. For this reason, MPO activity is preferred for the evaluation of neutrophil activation [13]. Inflammation constitutes a major part of I/R pathogenesis by way of playing a key role for cytokines, particular cells and adhesion molecules [14]. I/R is responsible for the upregulation of inflammatory pathways such as tumor necrosis factor-α

*Coresponding Author: Ayhan Tanyeli̇ , Ataturk University, Faculty of Medicine, Department of Physiology, Erzurum, Turkey E-mail: ayhan.tanyeli@atauni.edu.tr

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(TNF-α) and interleukin-1β (IL-1β) [15,16]. Although important developments about understanding ischemic AKI pathogenesis, in the last decades, there is still supportive therapy instead of curative approaches [17]. Barbaloin(10-β-D-glucopyranosyl-1,8-dihydroxy3(hydroxymethyl)-9(10H)-anthracenone), the primary active ingredient in aloe has gained increasing attention [18]. Barbaloin is a specific extract of aloe and has been determined to have several pharmacological effects such as anti-inflammatory, free radical scavenging, antiviral, and antibacterial properties [1822]. Barbaloin attenuated inflammation, oxidative stress and thus prevented liver injury induced by alcohol in mice experimental models [23]. Different agents with anti-inflammatory, antioxidant and radical scavenging properties have been reported in alleviation or elimination of I/R injuries [24-26]. We searched the effects of barbaloin on several cytokine levels and oxidative stress parameters in bilateral renal I/R applied rats. Material and Methods Laboratory conditions and Drugs This study was fulfilled in Atatürk University Experimental Animal Research and Application Center, Atatürk University Faculty of Medicine Department of Physiology. The present work has also been confirmed by Atatürk University Experimental Animals Local Ethics Committee. All rats were kept in a laboratory environment a 12-night/12-day, with a humidity of 55 % and a mean temperature of 21 degrees. Experimental animals were fed with standard pellet feed and water. However, all rats were starved before 12 hours from the experiment. For sacrification, 10 mg/kg i.p. xylazine hydrochloride (Rompun®, Bayer, Istanbul) and 60 mg/kg, i.p. ketamine (Ketalar®, Pfizer, Istanbul) were used. Barbaloin was supplied by Sigma-Aldrich Co, USA. Groups and Ischemia-Reperfusion Model In the present study, 32 Wistar albino male rats were weighed (220240 g) and randomly divided into four groups. In group I, the back region was shaved and cleaned. Also, the back region was opened with an incision under the anesthesia and closed again without the I/R model and any medication application. In group II, the incision area was cleaned with povidone-iodine. Bilateral renal arteria and veins were held with atraumatic microvascular clamp for 1 hour. Later, allowing blood circulation for 24 hours by opening the clamps in the reperfusion period. Incision closed with silk 3/0 suture. When the reperfusion ended, renal tissues were removed. In group III, DMSO purchased from Sigma Aldrich Co. DMSO was administered by oral gavage for one week before the experiment and the latest dose was applied 30 minutes before reperfusion. In group IV (I/R + 20 mg/kg barbaloin), barbaloin was performed to rats via oral gavage for one week before the experiment, and the latest dose was applied 30 minutes before reperfusion as mentioned in the previous study [27]. Later, as described in group II, the I/R model was established. All procedures were performed under anesthesia of xylazine hydrochloride and ketamine. Finally, when the experiment ended, renal tissues were washed and kept frozen until the biochemical analysis. Biochemical Analysis of Renal Tissues After the tissues have been homogenized, all biochemical analyses were made in the homogenized tissues. In renal tissue samples,

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MDA level to define lipid peroxidation status due to the method presented by Ohkawa et al, were measured [28]. The results were given as µmol/g protein. It was analysed using the superoxide dismutase (SOD) activity specification protocol detected by Sun et al [29]. SOD activity results of tissue samples were given as U/ mg protein. MPO activity of the kidney tissue was measured using a method improved by Bradley et al [30]. The results of MPO activity tissue were presented as U/g protein. TOS measurement was made with commercially available kit (Rel Assay Diagnostics). TAS value was evaluated with the commercial kit (Rel Assay Diagnostics, Gaziantep, Turkey). TAS and TOS results were presented as nmol/L. The ratio of TOS to TAS was accepted as the OSI. OSI value was detected as follows: OSI = [(TOS, μmol H2O2 equivalent/L)/(TAS, mmol Trolox equivalent/L) × 10]. OSI has been proposed. TNF-α and IL-1β levels were determined with the commercially available kit (Elabscience, Wuhan, China). Following bilateral renal I/R, proinflammatory cytokine levels obtained from renal homogenate were determined by enzymelinked immunosorbent assay (ELISA, BioTEK Powerwave XS Winooski, UK). Statistical Analysis All results were presented as mean ± SD. The statistical significance was analyzed using the Student’s t-test. The difference was considered statistically significant at P < 0.05. The statistical analyses were performed using the SPSS 20 Program. Results It was determined that TOS and OSI values increased while TAS values decreased in I/R and I/R+DMSO groups compared to the sham group. However, it has been observed that TAS value increased, but TOS and OSI values decreased significantly due to barbaloin treatment (Table 1; p<0.05). MDA and MPO levels were increased, whereas SOD activity was significantly decreased in I/R and I/R+DMSO groups compared to the sham group. Table 1. Mean±SD results of TAS (mmol/L), TOS (µmol /L) and OSI activities all experiment groups Parameters/Groups

TAS (mmol/L)

TOS (µmol /L)

OSI

Sham

2.70±0.19

6.11±0.50

0.22±0.02 a

I/R

1.43±0.14 a,b

8.44±0.91 a,b

0.59±0.08 a,b

I/R+DMSO

1.38±0.13 a,b

8.52±0.77 a,b

0.61±0.06 a,b

I/R+Barbaloin

2.53±0.19

6.59±0.67

0.26±0.02 b

: The significance relationship at the level of p<0.05, represents a meaningful relationship between groups with the same letters a,b

Table 2. Mean ± SD results of MDA (µmol/g protein), MPO (U/g protein) and SOD (U / mg protein) activities of all experimental groups Groups/ Parameters

MPO

TOS (µmol /L)

OSI

Sham

39068.98±4602.39 a

73.07±5.62 a

615.94±68.28 a

I/R

81058.63±7297.27 a.b

131.15±7.30 a,b

302.18±17.79 a,b

I/R+DMSO

83375.31±8366.29 a,b

132.91±8.47 a,b

298.09±16.54 a,b

I/R+Barbaloin

41259.91±1846.15 b

76.77±4.16 b

552.68±33.92 b

: The significance relationship at the level of p<0.05, represents a meaningful relationship between groups with the same letters a,b

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On the contrary, it was observed that these results changed significantly due to barbaloin treatment (Table 2; p<0.05). It was also found that TNF-α and IL-1β levels increased in I/R and I/R+DMSO groups and decreased significantly with barbaloin treatment. (Table 3; p<0.05). Table 3. Mean ± SD results of TNF-α (pg/mg protein) and IL-1β (pg/mg protein) levels of all experimental groups Parameters/Groups

TNF-α (pg/mg protein)

IL-1β (pg/mg protein)

Sham

22061.77±1967.07 a

24241.29±2701.64 a

I/R

43504.51±4249.33 a,b

59772.61±3840.21 a,b

I/R+ DMSO

43704.82±3380.27 a,b

61645.57±4383.07 a,b

I/R+ Barbaloin

22608.58±1918.31

25695.86±2397.31b

: The significance relationship at the level of p<0.05, represents a meaningful relationship between groups with the same letters a,b

Discussion Renal I/R injury has a key role in ischemic acute renal failure (ARF). ARF may occur after kidney transplantation and shock. It may lead to morbidity and also mortality with a high rate [31]. Oxidative stress is indispensable for the inception and improvement of renal I/R injury [32]. Many antioxidant enzymes, including SOD and glutathione peroxidase (GPx), have ROS scavenging properties that provide protection against renal I/R injury [33]. GPx, SOD, glutathione reductase and catalase (CAT) perform against ROS and its destructive effects. All these protective molecules form TAS [34]. As described by Erel, we preferred to measure serum TOS value instead of seperately measurement of oxidant molecules [35]. OSI much more reflects oxidative status than TOS or TAS level [36]. When there is an overaccumulation of oxidative agents, renal detoxification capacity may be insufficiant. This situation results in lipid peroxidation and cellular membrane damage [37]. Reperfusion phase increases MPO and MDA levels. This much more injures renal tissue and decreases antioxidant levels [38]. During I/R injury response, neutrophil accumulates and inflammation occurs. MPO may demonstrate neutrophil activity and accumulation [39]. Inflammation exacerbates tubular necrosis and inflammation arises from the inflammatory mediators produced by damaged tubular cells [40]. Following renal I/R, leukocyte infiltration to parenchyma is observed. Inflammatory mediators such as TNF-α, interleukin-1 (IL-1), interleukin-8 (IL-8) and interleukin-6 (IL-6) allows targeting and adhesion of leukocytes to related damaged blood vessel endothelium. Leukocytes play role in ROS production, raise in vascular wall permeability and lysosomal enzyme secretion [41]. TNF-α is well known as one of the key cytokines mediating inflammatory responses [42]. TNF-α is an initiator factor for inflammatory response. IL-6 and IL-1 are major inflammatory factors take action on tissue damage mediating [43]. During I/Rinduced renal injury, IL-1α levels are at maximum level in 24 h [44]. Therefore, we preferred ischemia (1 hour)/reperfusion (24 hours) model to guarantee the damage model. Even with progresses in diagnosis and treatment methods, ischemic acute renal failure is a major and common clinical problem [45]. In literature reviews, there is no study about barbaloin in renal I/R and our study is of original quality. However, there are several studies showing the antioxidant and anti-inflammatory properties

Med Science 2020;9(1):246-50

of barbaloin that support the results of this study. In the present study, reduction of TNF-α, IL-1β levels in renal I/R model in rats by barbaloin, suggesting that barbaloin decreased I/R-induced renal injury. Barbaloin has been reported to have a myocardial protective effect in a rat model of myocardial I/R injury [27]. Barbaloin has been reported to reduce the levels of intracellular ROS and proinflammatory cytokines (TNF-α, IL-1β and IL-6) and prevented lipopolysaccharide-induced acute lung injury [46]. Barbaloin pretreatment has been shown to alleviate myocardial ischemia reperfusion injury by antioxidant and antiinflammatory effects [47]. Barbaloin has been reported to have antiviral activity [20] and anti-inflammatory [48] property and may be used as a potential candidate for an alternative for antimicrobial. Barbaloin demonstrated protection against liver injury induced by alcohol throughout alleviation of oxidative stress and inflammation [23]. In parallel with these studies, in our study, antioxidant and antiinflammatory properties of barbaloin have been shown in renal I/R model in rats. In I/R group, SOD and TAS decreased while OSI, MDA, MPO, TOS, TNF-α and IL-1β levels increased and barbaloin treatment reversed these levels. We assessed oxidative stress in the renal tissue to investigate the possible mechanisms of the protective effect of barbaloin against I/R-induced renal injury and observed oxidative stress decreased with barbaloin. To make effective changes in the clinical management of I/R, the pathogenesis of I/R-induced organ damage should be better understood for the development of therapeutic strategies. Clearly observed in I/R studies is that inflammation, oxidative stress suppression can provide significant contributions to the treatment of I/R. In current study, inflammation, oxidative stress pathways are suppressed by barbaloin and this promise hope in the treatment of I/R. Conclusion Barbaloin protects against I/R-induced renal injury with its antioxidants and anti-inflammatory properties. We have indicated that treatment with barbaloin reduces renal damage in experimental animals exposed to I/R model. Moreover, further researches are necessary for explaining the other protective mechanism on I/Rinduced renal tissue damage. Acknowledgement We would like to thank all participants for contributing in the present survey and also thanks to Kardelen Erdoğan and Yaylagülü Yaman, undergraduates of Atatürk University Nursing Faculty, for their effort, help and support during the experiment. Competing interests The authors declare that they have no competing interest. Financial Disclosure The authors received no financial support for this study. Ethical approval Ethical permission related to the study was obtained from the Ataturk University Experimental Animals Local Ethics Committee with the decision number 60 on 25.03.2019

Ayhan Tanyeli ORCID: 0000-0002-0095-0917 Mustafa Can Guler ORCID: 0000-0001-8588-1035 Ersen Eraslan ORCID: 0000-0003-2424-2269

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doi: 10.5455/medscience.2019.08.9182 Fazile Nur EkiĚ&#x2021; nciĚ&#x2021; Akdemir ORCID: 0000-0001-9585-3169 Omer Topdagi ORCID: 0000-0002-9690-4447 Elif Polat ORCID: 0000-0003-0042-4084 Tuncer Nacar ORCID: 0000-0002-9287-7170

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Available online at www.medicinescience.org

ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):251-4

Antioxidant and anti-lipoxygenase activities of Cydonia oblonga Mehmet Berkoz Van Yuzuncu Yil University, Faculty of Pharmacy, Department of Biochemistry, Van, Turkey Received 18 September 2019; Accepted 12 December 2019 Available online 07.03.2020 with doi: 10.5455/medscience.2019.08.9174

Abstract The present studies are focused to explore the antioxidant and anti-lipoxygnease activities in crude extract, aqueous and organic fractions (ethyl acetate, chloroform, butanol) of dry fruit of Cydonia oblonga. For determining the antioxidant activity; total phenolic content and 1,1-diphenyl-2-picryl-hydrazil (DPPH) radical scavenging assay were performed in the aqueous and organic fractions of C. oblonga. In our study, phenolic content revealed that crude extract has highest phenolic content followed by ethyl acetate fraction. The results of DPPH radical scavenging activity showed IC50 values of crude extract as 61.4 μg/mL, chloroform and aqueous 67.4 and 55.5 μg/ mL, respectively, which are well comparable with butylatedhydroxyanisol (BHA) standard, which showed IC50 as 44.2 μg/mL. In addition, crude extract appeared to be the prominent inhibitor of lipoxygenase. The results suggests that the extract and different fractions of dry fruit of C. oblonga exhibits significant antioxidant and free radical scavenging activities/capacity which might be associated with the presence of main phytochemicals like flavonoids, phenols and tannins. Besides that, all these extract and fractions have well enough lipoxygenase inhibitory potential. As a result, we can claim that the presence of the scavenger molecules in the dry fruit of C. oblonga may attribute health benefits by providing the protective effects during the progressive stages of different acute and chronic disorders. Keywords: Cydonia oblonga, crude extract, aqueous fraction, organic fractions, antioxidant activity, anti-lipoxygnease activity

Introduction Antioxidant compounds are an important factor in health protection. Moreover, they reduce the risk of chronic diseases such as heart diseases and cancer. Free radicals are molecular species, containing one or more unpaired electrons and are highly reactive. They are formed by regular metabolism during oxygen utilization, to burn food for energy. Their development occurs endlessly within the body as a result of both enzymatic and non-enzymatic reactions. These reactive oxygen species (ROS) are dangerous for vital cell components like fatty acids, proteins, nucleic acids and carbohydrates [1]. Non-enzymatic antioxidant defense system is composed by a range of compounds such as a tocopherol (Vitamin E), β-carotene, sodium ascorbate (Vitamin C) and phenolic compounds which are widely found in medicinal plants. The main function of the antioxidant defense system is to inhibit or reduce damages caused by free radicals and reactive oxygen species.

*Coresponding Author: Mehmet Berkoz, Van Yuzuncu Yil University, Faculty of Pharmacy, Department of Biochemistry, Zeve Campus, Van, Turkey, E-mail: mehmet berkoz@yahoo.com

These damages are related to a number of chronic diseases, including cancer and some cardiovascular and neurodegenerative diseases. Phenolic compounds are derived from secondary plant metabolism and are essential for plant growth and reproduction. Flavonoids, xanthones, phenolic acids, tannins and tocopherols are the most common natural source of phenolic antioxidants [1]. Phytomedicine explored so far for phenolics found to have antioxidants activities and have been exploited to decrease the risk of cancer and heart ailments. The traditional medicinal plants have also been proven to cause inhibition of the biological enzymes for example lipoxygenase, cholinesterase and tyrosinase. The plants polyunsaturated fatty acids are converted by enzymes lipoxygenase into bioactive metabolites, which are eventually involved in inflammatory and immune responses. This occurs due to the formation of the leukotrienes (LTs). The approaches which cause inhibition of lipoxygenase isoforms and/or their bioactive metabolites can be valuable in the dealing with asthma, allergic rhinitis, rheumatoid arthritis, psoriasis, and cancer [1]. Antioxidant and radical scavenging properties of plants are subject to intensive research. The aim of the present study was to screen the antioxidant activities of some commonly available plants and fruits. Several medicinal plants in Turkey flora, which 251

doi: 10.5455/medscience.2019.08.9174

possess pharmacological properties are partly identified. One such medicinal plant used since ancient time is Cydonia oblonga commonly known as quince. Its vast medicinal, pharmacological and antimicrobial properties were reported and well explained in folkloric medicine and greatest medicinal value, however, has been attributed to its fruit [2,3]. Through in vitro and in vivo studies it is pointed out that Cydonia oblonga is a major source of accepted antioxidants, which might be supportive in controlling the progress of various oxidative stresses in the body thus have a good potential to use in various progressive inflammatory diseases, to use as a protective agent in hepatic and heart disorders [4]. Phytochemical screening of C. oblonga discovered the occurrence of alkaloids, cardiac glycosides, terpenoids, saponins, tannins, flavonoids, and steroids [5]. Scientific literature reflected that almost all parts of this plant except dry fruit were used to isolate several active principles like sterols, triterpenes, and tannins [6]. The present studies are focused to explore the total phenolic content, DPPH- radical scavenging and lipoxygnease inhibition activity in crude extract, aqueous and organic fractions (ethyl acetate, chloroform, butanol) of dry fruit of C. oblonga. Materials and Methods Chemicals 1,1-diphenyl-2-picryl-hydrazil (DPPH) & all solvents were procured from Roche Diagnostics, Mannheim, Germany. DMSO, potassium hexacyanoferrate [K3Fe(CN)6], F-C reagent, sodium carbonate (Na2CO3), butylatedhydroxyanisol (BHA), Ferric chloride, trichloroacetic acid (TCA) were purchased from MP Biomedicals (France). Lipoxygenase sodium dihydrogen phosphate, linoleic acid, tween 20, baiclein were purchased from Sigma. Plant material The dry fruit of C. oblonga was procured from Van Province, Turkey and recognized by Prof. Dr. Ali Aslan from Van Yuzuncu Yil University, Faculty of Pharmacy, Department of Pharmacology. Method Subsections Preparation of plant extract The dry fruit of C. oblonga (approximately 3 kg) was cleaned of dust particle and other adulterants by manual examination and picking and then thickly grounded. The coarse milled stuff was covered with 7 L methanol:water (70:30) mixture at room temperature (23-25ºC) for 72 hrs with intermittent shaking. It was first filtered through muslin cloth and then through Whatman No.1 filter paper, thrice; filtrate was pooled and then concentrated under reduced pressure at 40ºC on rotary evaporator. The resulting dark brown colored semi-solid mass (13.26%) was named as crude extract and stored at 4ºC until use. Half of the crude extract was used for further fractionation. For preparation of different fractions crude extract was mixed with 100 mL of water and 200 mL of ethyl acetate in a separating funnel and left for 24 hours. Next day aqueous and ethyl acetate layers were collected separately. Ethyl acetate layer was evaporated to obtain ethyl acetate fraction while aqueous layer was again treated with 200 mL of chloroform and then 200 mL of butanol in the similar manner as mentioned above to obtain chloroform, butanol and aqueous soluble fractions. The crude extract and fractions were stored at 4ºC in air tight bottles

Med Science 2020;9(1):251-4

for further studies [7]. Estimation of total phenolics Total phenolic content of extracts and various fractions of C. oblonga was measured by Folin-Chiocalteu reagent according to the method described by Hazra et al. [8] with some amendment. The extracts were diluted with distilled water to obtain the readings inside the standard curve range of 0.0 to 600 μg of gallic acid/mL. A mixture was obtained my adding 250 μL of gallic acid, 1 mL of distilled water, 250 μL of Folin-Chiocalteu reagent in a test tube. After mixing, it was kept standing for 5 min at room temperature. Then, 7% sodium carbonate aqueous solution (2.5 mL) and distilled water were added to make up the volume to 6 mL. The mixture was kept in an incubator for 90 minutes. The absorption of the subsequent blue color solution produced, was measured at 725 nm by spectrophotometer. The results were calculated as mg of gallic acid (Standard) equivalents (GAE)/g of extract by means of an equation from the standard gallic acid graph. Three readings were noted for each extract. DPPH radical scavenging assay The free radical scavenging activity was measured by method describing by Iqbal et al., [9] using 1,1-diphenyl-2-picryl-hydrazil (DPPH) as free radical. The solution of DPPH of 0.3 μM was prepared in ethanol. Each sample (5μL) (of different percentages) was mixed with 95μL of DPPH solution in ethanol, incubated at 37ºC for 30min. The absorbance at 515 nm was measured by ELISA plate reader (VersaMax, Molecular Devices LLC, California, USA) and percent radical scavenging activity was determined. BHA is used as standard. DPPH scavenging effect (%) = Ac – As/Ac × 100 where; Ac = Absorbance of control (DMSO treated) and As = Absorbance of sample. Lipoxygenase inhibition assay 5-lipoxygenase activity was analyzed by the method of Tappel [10] with slight modifications. A total volume of 200 μL containing 160μl of KH2PO4 buffer (100mM, pH 8.0), 10μl test compound (extract and fractions), and 20 μL purified lipoxygenase solution (130 units per well) were mixed and pre-read at 234 nm by ELISA plate reader (VersaMax, Molecular Devices LLC, California, USA). The mixture was pre-incubated at 25°C for 10 minutes. The reaction was originated by the addition of 10 μL substrate solution (linoleic acid 0.5 mM, 0.12% tween 20). The absorbance was noted every 15 min at 234 nm for any change in absorbance. Baicalein was used as a positive control. The IC50 values were determined at 0.5, 0.25, 0.125, 0.0625, 0.0313, 0.015 mg dilutions. All extracts assays carried out in triplicate. The radical scavenging activity was calculated by the equation: Inhibition (%) = (Absorbance of control - Absorbance of test solution/Absorbance of control) × 100 Results Total phenolic content revealed that crude extract has highest phenolic content followed by ethyl acetate fraction. Total phenolic compounds behave as key constituents because of their hydroxyl groups, which bestow scavenging ability (Table 1). 252

doi: 10.5455/medscience.2019.08.9174 Table 1. Total phenolic content of extracts and various fractions of C. oblonga Fraction

Total phenolic content (mgGAE/g)

Crude extract

367

Aqueous

115.3

Ethyle acetate

Chloroform

244.9

Butanol

123.4

The results of DPPH radical scavenging activity showed IC50 values of crude extract as 61.4 μg/mL, chloroform and aqueous fractions were 67.4 and 55.5 μg/mL, respectively, which are well comparable with BHA standard which showed IC50 as 44.2 μg/mL. While butanol and ethyl acetate posses less antioxidant potential as compared to other fractions but, however the fruit has good antioxidant activities (Table 2). Results in Table 2 showed that all fractions along with crude extract appeared to be the prominent inhibitor of lipoxygenase. The effect of various fractions and extract on lipoxygenase inhibition challenge was very profound. Table 2. IC50 values of extracts and fractions of dry fruit of Aeglemarmelos L. DPPH Scavenging IC50 μg/ml± SD

Lipoxygenase Inhibition IC50 μg/ml± SD

Crude extract

61.4± 0.12

99.3±0.84

Aqueous extract

55.5±0.40

101.8±1.2

Ethyl Acetate

110.7±0.71

227.3±1.89

Chloroform

67.4±0.63

102.4±0.95

Butanol

93.6±0.59

207±3.5

BHA

44.6±0.05

N.D.

22.6±0.02

Fraction

Baicalein

(SD: Standart deviation, N.D.: not determined)

Discussion The aim of the present study was to screen indigenous plants, especially which are commonly used, to identify antioxidant ability and enzyme inhibition capacity. Most bioactive food constituents are derived from plants; this study is therefore an essential research tool to further elucidate the potential health effects of phytochemical antioxidants in diet. Due to unpleasant effects of synthetic drugs, which are commonly used against oxidative damage, it is wise and advisable to use herbal antioxidants as food supplements and traditional medicines. Therefore, globally interest is developed towards green medicines because herbs are good source of many vital nutrients required to run life healthy and smoothly [11,12]. The results of this study confirmed that crude extract has highest phenolic content followed by ethyl acetate fraction and it is well reported that majority of natural antioxidants are polyphenol in nature which confer their scavenging ability [13]. The phytochemical content and antioxidant activities among the extracts can be compared if the density of the extracts are similar. Extract with high density may show higher phytochemical content and higher activity than low density extract. Therefore, all extracts

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in the present study should be prepared in similar density [11-13]. DPPH free radicals dissolve in methanol and show absorption at wavelength 515 nm. Antioxidant will transfer the hydrogen to DPPH, which will be stable. Colors of DPPH would be changed from purple to yellow when the free radicals are scavenged by antioxidant. FRAP reagent is ferric (III) chloride which is combined with 2,4,6-Tris(2-pyridyl)-s-triazine (TPTZ) in acetate buffer of pH 3.6. Reduction potential of Fe (III)/Fe (II) is 0.77 V. Antioxidant with reduction potential lower than 0.77 V will reduce Fe (III) to Fe (II). Blue color complex of Fe (II)-TPTZ shows absorption at λ515 nm. The amount of Fe (III) is reduced to Fe (II) and then forms Fe (II)-TPTZ, related to intensity of blue color. Sample with IC50 or EC50 lower than 50 μg/mL can be classified as very strong antioxidant, 50-100 μg/mL as strong, 101-150 μg/ mL as medium and greater than 150 μg/mL as weak antioxidant [11-13]. Determination of antioxidant activities by DPPH method is presented by IC50 DPPH, the concentration of extract (antioxidant sample) that can scavenge free radical DPPH 50% and figured by decreasing absorbance of DPPH after adding extract. IC50 DPPH can be determined using regression linear equation of calibration curve of each extract. In the present research, DPPH scavenging activity of dry fruit of C. oblonga were evaluated using its crude and aqueous extracts, ethyl acetate, chloroform, and butanol fractions. Aqueous extract of C. oblonga dry fruit showed the highest antioxidant activity by DPPH assay, which had the lowest IC50 of DPPH scavenging activity (55.5 μg/mL). Crude extract of C. oblonga dry fruit also exhibits strong antioxidant activity. Also, chloroform and butanol fractions of C. oblonga dry fruit show strong antioxidant activity. But, ethyl acetate fraction of C. oblonga dry fruit shows medium grade antioxidant activity. IC50 of DPPH scavenging activity of ascorbic BHA was found as 44.6±0.05 μg/mL. It means that antioxidant potential of BHA is around 2.5 times antioxidant potential of ethyl acetate fraction of C. oblonga dry fruit by DPPH assay. Lipoxygenase inhibition activity showed that all fractions along with crude extract appeared to be the prominent inhibitor of soybean lipoxygenase. The effect of various fractions and extract on lipoxygenase inhibition was very profound. It is evident from IC50 values in Table 2 that crude extract, aqueous and chloroform fractions have good lipoxygenase inhibition potential (99, 101 and 102 μg/mL), respectively. The important role of the 5-lipoxygenase pathway in carcinogenesis is vital as inhibition of the 5-lipoxygenase pathways clearly has chemo preventive effects on various cancers [14]. We observed in our study that all fractions and crude extract of C. oblonga strongly inhibit lipoxyganase and have potential of scavenging of DPPH radical, this can be assumed that the components present in fractions and extract may block the cascade process of arachidonic acid metabolism by inhibiting lipoxygenase and may serve as strong scavenger of free radicals to save cellular organs. Conclusion The results suggest that the extract and different fractions of dry fruit of C. oblonga exhibits significant antioxidant and free radical 253

doi: 10.5455/medscience.2019.08.9174

scavenging activities/capacity which might be associated with the presence of main phytochemicals like flavonoids, phenols and tannins. All these extract and fractions have good enough lipoxygenase inhibitory potential. Therefore the presence of the scavenger molecules in the dry fruit of C. oblonga may attribute health benefits by providing the protective effects during the progressive stages of different acute and chronic disorders.

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Erturk AG, Erturk O, Ayvaz MC, et al. Screening of phytochemical, antimicrobial and antioxidant activities in extracts of some fruits and vegetables consumed in Turkey. CBU J Sci. 2018;14:81-92.

Stojanović BT, Mitić SS, Stojanović GS, et al. Phenolic profiles and metal ions analyses of pulp and peel of fruits and seeds of quince (Cydonia oblonga Mill.). Food Chem. 2017;232:466-75.

Acknowledgment The author would like to thank Prof. Dr. Ali Aslan for recognizing of Cydonia oblonga.

Yaqeen Z, Naqvi NH, Sohail T, et al. Screening of solvent dependent antibacterial activity of Prunus Domestica. Pak J Pharm Sci. 2013;26:409-14.

Financial Disclosure Financial support for this study was provided by the researcher.

Hazra B, Biswas S, Mandal N. Antioxidant and free radical scavenging activity of Spondiaspinnata. BMC Complement Altern Med. 2008;8:63.

Iqbal L, Lateef L, Ali S, et al. Antioxidant activities of tetraketones derived from 5, 5 dimethylcyclohexane-1, 3- dione. J Chem Soc Pak. 2007;29:51-4.

Ethical approval No ethic approvell is needed to this research. Mehmet Berkoz ORCID: 0000-0003-4219-8054

References

10. Tappel AL. Method of Enzymology, Vol 5. Academic Press. New York, 1962, 539-42. 11. Ahmad M, Imran H, Yaqeen Z, et al. Pharmacological profile of Salvadora Persica. Pak J Pharm Sci. 2011;24:323-30.

Fleschin S, Fleschin M, Nita S, et al. Free radical mediated protein oxidation in Biochemistry. Roun Biotechnol Lett. 2000;5:479-95.

12. Rehman A, Fatima N, Imran H, et al. Nutritional and toxicological evaluation of Grewiaasiatica (Phalsa) powder used as a summer drink. J Chem Soc Pak. 2013;35:320-3.

Reddy VD, Padmavathi P, Paramahamsa M, et al. Amelioration of alcoholinduced oxidative stress by Emblicaofficinalis (Amla) in rats. Ind J Biochem Biophys. 2010;47:20-5.

13. Wojdylo A, Oszmianski J, Czemerys R. Antioxidant activity and phenolic compounds in 32 selected herbs. Food Chem. 2007;105:940-9.

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Ashraf MU, Muhammad G, Hussain MA, et al. Cydonia oblonga M., A medicinal plant rich in phytonutrients for pharmaceuticals. Front Pharmacol. 2016;7:163.

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ORIGINAL ARTICLE

Medicine Science International Medical Journal

Medicine Science 2020;9(1):255-60

ERCC1 and XRCC1 single nucleotide polymorphisms can guide treatment decision in patients with metastatic non-small cell lung cancer Mustafa Karaagac1, Mehmet Artac1, Caglayan Geredeli1, Melek Karakurt Eryilmaz1, Mahmut Selman Yildirim2, Tuba Akkuloglu2, Ali Inal3, Abdurrahman Isikdogan3, Hakan Bozcuk4, Ahmet Demirkazik4 Necmettin Erbakan University, Meram Medical Faculty, Department of Medical Oncology, Konya, Turkey Necmettin Erbakan University, Meram Medical Faculty, Department of Medical Genetics, Konya, Turkey 3 Dicle University, Medical Faculty, Department of Medical Oncology, Diyarbakir, Turkey 4 Ankara University, Medical Faculty, Department of Medical Oncology, Ankara, Turkey

Received 03 October 2019; Accepted 31 December 2019255 Available online 13.03.2020 with doi: 10.5455/medscience.2019.08.9184

Abstract Results from studies in several cancers on single nucleotide polymorphisms (SNPs) suggest that DNA repair capacity may have prognostic implication for disease recurrence, survival, and responses to treatment. This study aimed to evaluate the potential prognostic value of SNPs as biomarkers in patients with metastatic non-small cell lung cancer (mNSCLC) treated with platinum. Analysis of SNPs from peripheral blood cells was performed by polymerase chain reaction. Excision repair cross-complementing group 1 (ERCC1)-Asn118Asn, excision repair cross-complementing group 2 (ERCC2)-Lys751Gln, X-ray repair cross-complementing group 1 (XRCC1)-Arg399Gln, and tumor protein 53 (TP53)-Arg72Pro polymorphisms were evaluated in conjunction with clinical and pathological parameters, and survival. The median progression-free survival (PFS) and overall survival (OS) of 145 patients were 5.1 months and 30.9 months, respectively. In the univariate analysis ERCC1 genotype, XRCC1 genotype, and Eastern Cooperative Oncology Group Performance Status (ECOG-PS) were significant parameters for OS. In the multivariate analysis ERCC1 genotype, XRCC1 genotype, and ECOG-PS retained their significance. The median OS was 45.2 months for the ERCC1 normal (CC) and heterozygote (CT) genotypes, and 25.5 months for the ERCC1 mutant (TT) genotype. The median OS was 31.4 months for the XRCC1 normal (AA) and heterozygote (AG) genotypes, and 23.1 months for the XRCC1 mutant (GG) genotype. The median OS was 30,7 months for ECOG-PSâ&#x2030;¤ 1 and 10.2 months for ECOG-PSâ&#x2030;Ľ 2. ERCC1 and XRCC1 genotypes, and ECOG-PS independently predicted OS in mNSCLC patients. Additional studies are needed for the further evaluation of potential prognostic SNPs in mNSCLC. Keywords: Biomarker, lung cancer, platinum, single nucleotide polymorphism, survival

Introduction Lung cancer is the second most common cancer and is the main cause of cancer death among both men and women. Although lung cancer is a molecularly heterogeneous group of diseases and new treatment methods are available, the 5-year survival rate in advanced disease is still 6% [1,2]. The treatment of lung cancer remains challenging. Platinum, the main component of cytotoxic chemotherapy (CT) used in the treatment of lung cancer, damages the DNA and causes the death of tumor cells [3]. However, platinum response rates are less

*Coresponding Author: Mustafa Karaagac, Necmettin Erbakan University, Meram Medical Faculty, Department of Medical Oncology, Konya, Turkey, E-mail: mustafakaraagac55@hotmail.com

than 30% in patients with metastatic non-small cell lung cancer (mNSCLC) [4]. The efficacy of platinum regimens is limited due to drug resistance. A thorough understanding of the mechanisms of resistance and the identification of new biomarkers for more accurate prognostic and predictive assessment is necessary for personalized cancer treatment and may emphasize the possibility of patient-tailored platinum-based CT for mNSCLC [5,6]. Accumulating results from the studies on single nucleotide polymorphisms (SNPs) in several cancers as well as NSCLC suggest that DNA repair capacity may have prognostic implication for disease recurrence, survival, and responses to platinum-based CT, but the results are controversial [7-9]. In this study, we aimed to evaluate the potential prognostic value of SNPs consisting of excision repair cross-complementing group 1 (ERCC1), excision repair cross-complementing group 2 (ERCC2), X-ray repair cross-complementing group 1 (XRCC1) and tumor 255

doi: 10.5455/medscience.2019.08.9184

protein 53 (TP53) in mNSCLC patients treated with platinumbased chemotherapy. Materials and Methods This was a multicenter, cross-sectional, and retrospective study. In this study, we recruited 145 patients with mNSCLC who were treated with platinum at the Medical Oncology Departments of Necmettin Erbakan University, Ankara University, Akdeniz University, and Dicle University between April 2010 and July 2012. Data on age, gender, comorbidities, pathological diagnosis, previous treatments such as neoadjuvant and/or adjuvant chemotherapy, date of disease progression and date of death of patients were recorded. Patients were followed up every three months after completion of treatment to evaluate survival. Ethical approval The study was performed according to the Declaration of Helsinki and approved by the Ethics Committee of the Meram Medical School of Selcuk University and also performed with the financial support of the Scientific Research Project of Selcuk University (Project no.: 11102028). Eligibility Age between 18 to 80 years, having pathologically proven mNSCLC with radiologically measurable disease, being treated with platinum-based CT regimens (dose concerning the National Comprehensive Cancer Network guidelines for CT), allowing informed consent for genetic analysis were the eligibility criteria. DNA analysis A ten mL of a peripheral venous blood sample by the nursing staff was obtained from each patient for DNA analysis. All of these blood samples taken from participating centers were sent to Meram Medical Faculty Department of Genetics. High Pure Polymerase Chain Reaction (PCR) Template Preparation Kits (Roche Diagnostics, Mannheim, Germany) were used for DNA isolation. After DNA isolation each sample was stored for PCR analysis. Polymerase chain reaction analysis PCR analysis was performed with the Roche Light Cycler 480 II real-time PCR system (Roche Molecular Systems, Inc.). The polymorphisms of codon 118 (rs11615) of ERCC1, codon 751 (rs13181) of ERCC2, codon 399 (rs25487) of XRCC1, and codon 72 (rs1042522) of TP53 were genotyped. Each PCR reaction (20 µL) contained 200 ng of DNA template, 200 µM of dNTP, 1 unit of Taq DNA polymerase, and 200 µM of primers, as well as 1.5 mM of MgCl2. The PCR conditions were one cycle of 10 min at 95 ºC; 45 cycles of 10 s denaturation at 95 ºC; 10 s hybridization at 60 ºC for ERCC1, ERCC2, and XRCC1; or 58 ºC for TP53 and 15 s elongation at 72 ºC. Following PCR amplification, the results were classified as normal, heterozygote, or mutant with melting curve analysis. Genotyping was done blind, and a random 5% of the samples were repeated to validate the genotyping procedures. Two authors independently reviewed all genotyping results. Statistical analysis Primary statistical analysis has included descriptive statistics of the patients as age, gender, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), histological subtypes, the status

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of neoadjuvant CT, subtypes of the surgical procedure, the status of adjuvant CT, first-line CT regimens for metastatic disease. All patients underwent overall survival (OS) and progression-free survival (PFS) analysis. Statistical analysis was performed by using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA). Univariate and multivariate Cox regression analyses and Kaplan Meier survival curves subjected to log-rank testing were utilized for the survival analyses. Forward likelihood ratio was used for the multivariate selection process. A p-value <0.05 was required for statistical significance. Results Characteristics of patients A total of 145 patients were enrolled in this study. There were 126 males and 19 females. The median age was 60 years (range 34-79). The ECOG-PS of 99 patients was 0-1, while the ECOGPS of the remaining 46 patients was 2 or more. There were 64 cases of adenocarcinoma, 55 cases of squamous cell carcinoma, and 26 cases of the other histological subtypes. All patients received platinum-based CT as the first line for metastatic disease Demografhic and cilinical parameters of patients were shown in Table 1. [Table 1 near here] Table 1. Demographic and clinical parameters of patients (n=145) (100%)

Characteristics Age (years), median (range)

60(34-79) Gender, n (%) Male Female

126(86.9) 19(13.1)

≤1 ≥2

99(68.2) 46(31.8)

Adenocarcinoma

64(44.1)

Squamos cell carcinoma

55(37.9)

Others

26(18.0)

Yes

13(9.0)

136(91.0)

Lobectomy

30(20.7)

Pneumectomy

3(2.1)

Yes

23(15.9)

122(84.1)

Cisplatin+Gemcitabine

44(30.3)

Carboplatin+Paclitaxel

33(22.8)

Cisplatin+Docetaxel

21(14.5)

Other Platinum-based regimens

47(32.4)

ECOG-PS, n (%)

Histological subtype, n (%)

Neoadjuvant CT, n (%)

Surgery subtype (if done), n (%)

Adjuvant CT, n (%)

First line CT for metastatic disease, n (%)

ECOG-PS; Eastern Cooperative Oncology Group Performance Status CT; Chemotherapy

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Gene polymorphisms ERCC1 was 25.1 % in CC, 52.8 % in CT heterozygosity, and 22.1 % in TT mutant alleles. ERCC2 was 23.1 % in CC, 52.8 % in CT heterozygosity, and 24.1 % in TT mutant alleles. XRCC1 polymorphism was 34.4, 41.0, and 24.6 % in AA, AG heterozygosity, and GG mutant alleles, respectively. TP53 was 14.4 % in CC, 48.2 % in CG heterozygosity, and 37.4% in GG mutant alleles. Gene polymorphisms and survival outcomes The median PFS and OS were 5.1 months (95% confidence interval (CI), 4.3-5.8) and 30.9 months (95% CI, 28.2-33.6), respectively. In the univariate analysis for OS, ERCC1 genotype (hazard ratio (HR), 0.26; 95% CI, 0.12-0.57; p=0.001), XRCC1 genotype (HR, 0.37; 95% CI, 0.16-0.83; p=0.01), and ECOG-PS (HR, 5.25; 95% CI, 1.45-19.04; p=0.01) were significant parameters. Therefore, multivariate analyzes were performed, and ERCC1 genotype (HR, 0.36; 95% CI, 0.14-0.92; p=0.03), XRCC1 genotype (HR,

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0.37; 95% CI, 0.14-0.98; p=0.04), and ECOG-PS (HR, 4.80; 95% CI, 1.22-18.87; p=0.02) retained their significance. In univariate analysis, there was no significant difference in PFS according to age, gender, number of metastatic organs, ERCC1, ERCC2, XRCC1, TP53, and ECOG-PS (Table 2). [Table 2 near here] The median OS was 45.2 months (95%CI, 25.3-65.0) for the ERCC1 normal (CC) and heterozygote (CT) genotypes, and 25.5 months (95%CI, 9.5-41.5) for the ERCC1 mutant (TT) genotype (p<0.01) (Figure 1). [Figure 1 near here] The median OS was 31.4 months (95%CI, 20.1-42.7) for the XRCC1 normal (AA) and heterozygote (AG) genotypes, and 23.1 months (95%CI, 20.0-26.3) for the XRCC1 mutant (GG) genotype (p=0.01) (Figure 2). [Figure 2 near here] The median OS was 30,7 months (95%CI, 26.4-35.1) for ECOGPS â&#x2030;¤ 1 and 10.2 months (95%CI, 3.4-16.9) for ECOG-PSâ&#x2030;Ľ 2 (p<0.005) (Figure 3). [Figure 3 near here]

Table 1. The predictors of PFS and OS OS (univariete)

Characteristics

PFS (univariete)

OS (multivariete)

Age (years), median (range)

p value

Age

1,01

0,40

1,00

0,82

Gender

0,70

0,57

1,36

0,22

Number of metastatic organs

1,60

0,30

1,01

0,96

ERCC1

(Asn118Asn)

0,26

0,001*

0,84

0,43

ERCC2

(Lys751Gln)

0,88

0,80

0,79

0,35

XRCC1

(Arg399Gln)

0,37

0,01*

1,30

0,20

1,31

0,69

1,10

0,70

TP53

(Arg72Pro)

p value

0,36

0,03*

0,37

0,04*

ECOG-PS 5,25 0,01* 3,49 0,62 4,80 0,02* FS; Progression free survival, OS; Overall survival, HR; Hazard ratio, ERCC1: Excision repair cross-complementing group 1, ERCC2: Excision repair crosscomplementing group 2, XRCC1: X-ray repair cross-complementing group 1, TP53: Tumor protein 53, ECOG-PS; Eastern Cooperative Oncology Group Performance Status *;statistically significant (p value<0,05)

Figure 1. The overall survival with respect to ERCC1 genotypes

Figure 2. The overall survival with respect to XRCC1 genotypes 257

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Figure 3. The overall survival with respect to ECOG-PS Discussion This was the first study investigating the prognostic role of SNPs in patients with mNSCLC in Turkish cohort. In this study, we demonstrated that ERCC1 and XRCC1 gene polymorphisms and ECOG-PS predicted OS in mNSCLC patients, but ERCC2 and TP53 were not significant in this regard. Although many newer treatment methods that target mutations and rearrangements in oncogenes are available and have excellent clinical benefit and minimum toxicity, the majority of patients with mNSCLC are not appropriate for these drugs due to the lack of target mutations or rearrangements in these oncogenes [10]. Currently, platinum-based CT is still the primary treatment modality for most of the patients with mNSCLC. But, the platinum response rate is not high in patients with advanced NSCLC [4]. The efficacy of platinum regimens is limited due to drug resistance. Decreased accumulation of platinum, increased drug inactivation, enhancement of tumor cellsâ&#x20AC;&#x2122; tolerance to platinumâ&#x20AC;&#x2018;DNA adducts, and enhancement of the repair of the damaged DNA by nucleotide excision repair (NER) pathway which consists of many polypeptides, including ERCC1 and ERCC2 are thought to be the cause of this critical problem [11,12]. Explaining the mechanisms of resistance and the identification of prognostic and predictive biomarkers are necessary for personalized treatment of mNSCLC. ERCC1 plays a critical role in the NER pathway and simplifies the excision of damaged DNA, and thus, can be used as a prognostic biomarker to reestablish the therapeutic sensitivity to platinum-based agents in chemoresistant patients [5,6,13,14]. Also, ERCC2, where the gene product has ATP-dependent helicase activity, participates in NER [15]. SNPs, which have been shown to induce amino acid changes such as Asp312Asn and Lys751G1n, have been identified in some exons of ERCC2 [16]. Several studies demonstrated the relationship between ERCC2 SNPs and platinum activity in many different types of cancer, but the relationship between ERCC2 levels and treatment results in patients treated with platinum-based CT is still controversial

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[17-19]. Kang et al. demonstrated that upregulation of ERCC1 in metastatic lymph nodes was a poor prognostic factor in N1 patients but not in N2 patients who underwent surgical resection followed by platinum-based adjuvant CT [20]. In several studies, it has been demonstrated that the suppression of ERCC1 can regenerate or increase platinum sensitivity and the low level of ERCC1 was associated with significantly improved OS in lung cancer patients treated with platinum-based CT [21-23]. Olaussen et al. demonstrated that ERCC1 expression is a possible marker for the effect of postoperative adjuvant CT in patients with resected tumors. Adjuvant platinum-based CT was reported to be beneficial for survival in ERCC1-negative patients, but no benefit was observed in ERCC1-positive patients [22]. In another study, Geredeli et al. evaluated ERCC1 and ERCC2 polymorphisms in surgically treated NSCLC patients, and an increase in relapse-free survival (RFS) was observed, but was not statistically significant [24]. Kalikaki et al. showed that ERCC1 polymorphic variants were independent prognostic factors for improved OS and ERCC1 genotype was significantly associated with response to platinumbased treatment in advanced NSCLC patients treated with platinum-based CT [25]. On the other hand, Yin et al. performed a meta-analysis in patients who received platinum-based treatment and demonstrated that the rate of ERCC1 and ERCC2 polymorphisms did not have a predictive or prognostic value for RFS and OS [26]. Besides all these, in this study, we evaluated the association between ERCC1 and ERCC2 polymorphisms and survival in mNSCLC treated with platinum-based CT. So here we showed that the median OS was longer for the ERCC1 normal and heterozygote genotypes, and shorter for the ERCC1 mutant genotype and it was statistically significant. These results confirmed the positive data related to ERCC1 in the literature and revealed that platinum-based CT may be more benefical in patients with ERCC1 normal and heterozygote genotypes. And, for the first time, these results showed that ERRC1 had a prognostic role also in the Turkish cohort. However, unlike ERCC1, we demonstrated no significant difference between ERCC2 polymorphism and survival in mNSCLC. XRCC1 is another protein involving NER and a member of the base excision pathway in DNA repair paths. XRCC1 gene polymorphism is associated with suboptimal DNA repair, and as a result of this inadequate process, the tumors may become more biologically aggressive [16,27]. XRCC1 T-77C polymorphisms are associated with increased risk of NSCLC [28]. Kim et al. showed that non-mNSCLC patients with AA homozygous variants of XRCC1 gene polymorphism had better survival rates [29]. Besides, the polymorphisms of XRCC1 399 and XRCC3 241 have been reported to be a prognostic factor in survival [25,30,31]. However, Yao et al. examined XRCC1 polymorphism in advancedstage NSCLC patients, but no statistically significant correlation was observed [32]. Also, Gurubhagavatula et al. demonstrated that XRCC1 variant alleles were associated with short-term survival in NSCLC patients treated with platinum-based CT [33]. Moreover, XRCC1 was found not to be associated with prognosis and survival in another study on T-77C polymorphism [7]. In this study, we also evaluated the relationship between XRCC1 polymorphism and survival in mNSCLC. So here we demonstrated that the median OS was shorter in XRCC1 mutant genotype and it was statistically significant. This result suggested that polymorphism of XRCC1 may play an essential role as a prognostic marker in the survival 258

doi: 10.5455/medscience.2019.08.9184

of mNSCLC patients and should be considered as a predictive marker for treatment outcome of platinum-based CT. As in lung cancer, the most commonly mutated gene in cancer is the TP53 tumor suppressor gene, which, as a result of these mutations, has acquired oncogenic properties to promote invasion, metastasis, proliferation and cell survival [34,35]. Many studies have demonstrated that TP53 mutations have a potential prognostic role for disease recurrence and shorter survival in non-mNSCLC [36-38]. Although Fukuyama et al. demonstrated that the NSCLC patients with TP53 mutations had a worse prognosis in earlystage cases, there was no statistically significant difference when advanced-stage cases or all patients were considered [39]. To the best of our knowledge, few studies in the literature investigated the relationship between TP53 polymorphism and prognosis and survival in patients with mNSCLC. In this study, we evaluated the relationship between TP53 polymorphism and survival in mNSCLC and found no statistically significant difference. This result is consistent with the current literature. Performance status is one of the most critical criteria in the choice of treatment in patients with mNSCLC and is an independent predictor of poor prognosis in patients with advanced or mNSCLC receiving CT [40-42]. Also, we demonstrated that a good ECOGPS was statistically significant on prolonged survival. Conclusion We showed that ERCC1 and XRCC1 gene polymorphisms and ECOG-PS are prognostic markers in survival and should be considered as predictive markers for the treatment decision of patients with mNSCLC. Our results may provide insight and guidance on prospective studies of the assessment of potential predictive and prognostic biomarkers in patients with mNSCLC.

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10. Shea M, Costa DB, Rangachari D. Management of advanced non-small cell lung cancers with known mutations or rearrangements: latest evidence and treatment approaches. Ther Adv Respir Dis. 2016;10:113-29. 11. Rosell R, Tarón M, O’Brate A. Predictive molecular markers in non-small cell lung cancer. Curr Opin Oncol. 2001;13:101-9. 12. Simon GR, Sharma S, Cantor A, et al. ERCC1 expression is a predictor of survival in resected patients with non-small cell lung cancer. Chest. 2005;127:978-83.

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

13. 13. Marteijn JA, Lans H, Vermeulen W, et al. Understanding nucleotide excision repair and its roles in cancer and ageing. Nat Rev Mol Cell Biol. 2014;15:465-81.

Financial Disclosure The study was approved by the Ethical Board of the Meram Medical School of Selcuk University and performed with the financial support of the Scientific Research Project of Selcuk University (Project no: 11102028)

14. He L, Wang X, Liu K, et al. Integrative PDGF/PDGFR and focal adhesion pathways are downregulated in ERCC1-defective non-small cell lung cancer undergoing sodium glycididazole-sensitized cisplatin treatment. Gene. 2019;691:70-6.

Ethical approval The study was performed according to the Declaration of Helsinki and approved by the Ethics Committee of the Meram Medical School of Selcuk University and also performed with the financial support of the Scientific Research Project of Selcuk University (Project no.: 11102028).

15. Lainé JP, Mocquet V, Bonfanti M, et al. Common XPD (ERCC2) polymorphisms have no measurable effect on nucleotide excision repair and basal transcription. DNA Repair (Amst). 2007;6:1264-70.

Mustafa Karaagac ORCID: 0000-0003-4533-0620 Mehmet Artac ORCID: 0000-0003-2335-3354 Caglayan Geredeli ORCID: 0000-0002-3982-7465 Melek Karakurt Eryılmaz ORCID: 0000-0003-2597-5931 Mahmut Selman Yildirim ORCID: 0000-0002-3986-5517 Tuba Akkuloglu ORCID: 0000-000-2398-65517 Ali Inal ORCID: 0000-0002-7451-2786 Abdurrahman Isikdogan ORCID: 0000-0002-7451-2786 Hakan Bozcuk ORCID: 0000-0001-7809-1721 Ahmet Demirkazik ORCID: 0000-0002-2917-7999

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39. 39. Fukuyama Y, Mitsudomi T, Sugio K, et al. K-ras and p53 mutations are an independent unfavourable prognostic indicator in patients with non-smallcell lung cancer. Br J Cancer. 1997; 75: 1125-1130.

28. Hao B, Miao X, Li Y, et al. A novel T-77C polymorphism in DNA repair gene XRCC1 contributes to diminished promoter activity and increased risk of non-small cell lung cancer. Oncogene. 2006; 25:3613-20.

40. Hoang T, Xu R, Schiller JH, et al. Clinical model to predic survival in chemonaive patients with advanced non-small-cell lung cancer treated with third-generation chemotherapy regimens based on eastern cooperative oncology group data. J Clin Oncol. 2005;23:175-83.

29. Kim M, Kang HG, Lee SY, et al. Comprehensive analysis of DNA repair gene polymorphisms and survival in patients with early stage non-small-cell lung cancer. Cancer Sci. 2010;101:2436-42. 30. Liao WY, Shih JY, Chang GC, et al. Genetic polymorphism of XRCC1 Arg399Gln is associated with survival in non-small-cell lung cancer patients treated with gemcitabine/platinum. J Thorac Oncol. 2012;7:973-81. 31. de las Peñas R, Sanchez-Ronco M, Alberola V, et al. Polymorphisms in DNA

41. Trapé J, Montesinos J, Catot S, et al. A prognostic score based on clinical factors and biomarkers for advanced non-small cell lung cancer. Int J Biol Markers. 2012;27: e257-62. 42. Gong J, Xu L, Li Z, et al. A Clinical prognostic score to predict survival of advanced or metastatic non-small cell lung cancer (NSCLC) patients receiving first-line chemotherapy: a retrospective analysis. Med Sci Monit. 2018; 24: 8264-71.

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Medicine Science 2020;9(1)261-4

Evaluation of drug permeability methods recommended by health authorities Tugba Gulsun, Selma Sahin Hacettepe University Faculty of Pharmacy, Department of Pharmaceutical Technology, Ankara, Turkey Received 05 September 2019; Accepted 23 December 2019 Available online 07.03.2020 with doi: 10.5455/medscience.2019.08.9173

Abstract The oral route is the most preferred route for drug administration because of patient compliance. Following oral administration, a drug has to cross several biological barriers before reaching the systemic circulation by transcellular or paracellular transports. Oral drug absorption and bioavailability are influenced by the physicochemical, formulation and physiological variables. Oral absorption of drugs is controlled by dissolution from the dosage form, and permeability across the gastrointestinal membrane. Rate limiting step in absorption is the permeability for compounds with low permeability, and dissolution for compounds with low solubility. According to Food and Drug Administration (FDA) Biopharmaceutics Classification System (BCS)-based biowaiver guidance and European Medicines Agency (EMA) Guideline on the Investigation of Bioequivalence, permeability class of a drug substance can be determined using different methods. The aim of this study was to evaluate the methods in detail recommended by FDA and EMA for determination of permeability of drugs. We surveyed the literature as to the pros and cons of the methods recommended by the health authorities for assessment of permeability. In general, a single method is sufficient for determination of permeability. When a single method fails to demonstrate a permeability classification, two different methods may be used. Keywords: Permeability, Food and Drug Administration (FDA), Biopharmaceutics Classification System (BCS), oral absorption, European Medicines Agency (EMA)

Introduction Dosage forms are administered by various routes such as oral, buccal, rectal, sublingual, topical, transdermal, inhaler, vaginal, ophthalmic, intradermal, intramuscular, intravenous [1]. Among these routes, the oral route is the most preferred route for drug administration [2] because it is painless, safe, and cheaper than the other routes, and is self-administered by the patients. When a drug administered as a solid dosage form (e.g. tablets, capsules) by oral route, initially, it disintegrates into solid particles, and then these particles dissolve in the gastrointestinal fluids, and finally permeate from the gastrointestinal tract into systemic circulation [3, 4]. Drug absorption, and hence bioavailability are influenced by the physicochemical (e.g. particle size, salt forms, crystal forms, polymorphism, pH, pKa, complexation), formulation (e.g. process

*Coresponding Author: Selma Sahin, Hacettepe University Faculty of Pharmacy, Department of Pharmaceutical Technology, Ankara, Turkey, E-mail: sahin.selma@gmail.com

parameters, excipients, preparation methods) and physiological (e.g. intestinal motility, gastric emptying, gastric flow rate, absorption surface area, interindividual differences) parameters [5]. Following oral administration, a drug has to cross several biological barriers before reaching the systemic circulation. Transport across the cell membranes are classified as transcellular and paracellular transports [6]. The transcellular transport takes place by several mechanisms including passive diffusion, carriermediated transport (e.g. facilitated diffusion and active transport) and vesicular transport (e.g. endocytosis, phagocytosis). On the other hand, paracellular transport in which drug diffuses through the aqueous pores at the tight junctions between the intestinal enterocytes is the minor route for absorption and controlled by the tight junctions between the epithelial cells. Oral absorption of drugs is controlled by two main parameters namely dissolution of drug from the dosage form and the permeability of dissolved drug across the gastrointestinal membrane [7]. Rate limiting step in absorption is the permeability for compounds with low permeability, and dissolution for compounds with low solubility.

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The Biopharmaceutics Classification System (BCS) is a scientific framework for classifying drug substances based on their aqueous solubility and intestinal permeability. According to the BCS, drugs substances are classified into four groups: Class I with high solubility and high permeability; Class II with low solubility and high permeability; Class III with high solubility and low permeability; Class IV with low solubility and low permeability [8]. According to the FDA BCS-guidance, a drug substance is defined as highly soluble when the highest dose strength of the drug is soluble in 250 mL or less of aqueous media over the pH range of 1-6.8 at 37±1°C. In the absence of evidence suggesting instability in the gastrointestinal tract, a drug substance is considered to be highly permeable when the systemic bioavailability or extent of absorption in human (fa) is determined to be 85% or more of an administered dose based on a mass balance determination or in comparison to an intravenous reference dose [9]. According to the EMA and FDA guidelines, immediate release dosage forms of BCS Class I and III compounds are subject to a BCS-based biowaiver given that all recommended criteria (For Class I: high solubility and high permeability for drug substance, rapid in vitro dissolution rate (>%85 in 30 min) for test and reference products; For Class III: high solubility and limited absorption for drug substance; very rapid in vitro dissolution rate (>85% in 15 min) for test and reference drug products; no change in excipients that might affect bioavailability) are met [9,10]. According to FDA BCS-based biowaiver guidance, permeability class of a drug substance can be determined using different methods such as pharmacokinetic studies in human (mass balance or absolute bioavailability studies), and intestinal perfusion approaches (in vivo intestinal perfusion studies in humans, in vivo or in situ intestinal perfusion studies using suitable animal models, in vitro permeation studies using excised intestinal tissues, in vitro permeation studies across a monolayer of suitable cultured epithelial cells) [9]. In general, a single method is sufficient for

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determination of permeability when the absolute bioavailability is ≥ 85%, or the administered drug excreted unchanged in urine is ≥ 85%, or when ≥ 85% of the administered drug is recovered in urine as parent and metabolites. Before determination of the permeability class of a drug, suitability of a permeability method should be validated by using model drugs in the range of zero, low (fa< 50 %), moderate (fa=50 – 84 %), and high (fa ≥ 85 %) absorption [9] According to FDA guideline, sufficient number of model drugs should be used for the method validation to characterize high, moderate and low permeability, and also assay should be performed in replicates for reliable permeability results. Examples of model drugs recommended for determination of suitability of a permeability method were given in Table 1. After demonstrating suitability of a method, permeability of a drug can be determined using internal standards (a low and a high permeability model drug included in the perfusion fluid or donor fluid along with the test drug substance), and a fluid volume marker (a zero permeability compound such as PEG 4000) [9]. According to EMA guidance, reliable human investigations should be performed to justify complete drug absorption. For this purpose, data obtained from absolute bioavailability or massbalance studies are recommended to be used to support the claim [10]. The aim of this study was to evaluate the methods in detail recommended by FDA and EMA for determination of permeability of drugs. For this purpose, different permeability methods were obtained from the guidance and literature. PubMed, Google Scholar and Web of Science search engines were used for the literature search from 1980 to 2019 using the keywords permeability determination methods, permeability from Caco-2 cells, in vivo and in situ intestinal perfusion, in vitro permeability, intestinal permeability, human intestinal perfusion, in vivo permeability, in situ permeability.

Table 1. List of model drugs recommended for determination of suitability of a permeability Zero permeability

Low permeability (fa< 50 %)

Moderate permeability (fa=50 – 84 %)

High permeability (fa≥ 85 %)

Polyethylene glycol 4000

Sulpiride

Ranitidine

Minoxidil

Lucifer yellow

Nadolol

Enalapril

Disopyramide

Inulin

Enalaprilat

Terbutaline

Caffeine

Lactulose

Acyclovir

Creatinine

Phenytoin

Polyethylene glycol 400

Atenolol

Naproxen

Chlorothiazide

Hydrochlorothiazide

Carbamazepine

Lisinopril

Metformin

Propranolol

Mannitol

Amiloride

Metoprolol

Famotidine

Furosemide

Theophylline

Foscarnet

Chlorpheniramine

Antipyrine

Fluorescein isothiocyanate dextran (MW≥3000)

Ketoprofen where fa is the extent of absorption in human

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doi: 10.5455/medscience.2019.08.9173 Table 2. Examples of model drugs for permeability assay method validation from Caco-2 cells [16-19]. Drug

Fa % (% fraction dose absorbed in humans)

Acetaminophen

100

Acetylsalicylic acid

100

Amiloride

Antipyrine

100

Aspirin

100

Atenolol

Caffeine

100

Carbamazepine

Chlorothiazide

Chlorpheniramine

Citalopram

Coumarin

100

Dexamethasone

100

Digoxin

Diltiazem HCl

Disopyramide

85.3

Famotidine

FITC-Dextran

Furosemide

Hydrochlorothiazide

Ibuprofen

100

Indomethacin

100

Ketoprofen

100

Labetalol

Lisuride

100

Mannitol

Metoprolol

Nadolol

Naproxen

Nicardipine

100

PEG 4000

PEG 900

Phenytoin

Pindolol

Propranolol

100

Ranitidine

Sulfasalazine

Theophylline

100

Verapamil

100

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Results and Discussion Mass balance studies using unlabeled, stable isotopes or a radiolabeled drug substance can be used to demonstrate the extent of absorption of a drug. The number of subjects is critical in this method for a reliable estimate of the extent of absorption [11]. The other most important parameter is the formation of metabolite. When the data obtained from mass balance studies are to be used to support complete absorption, it must be ensured that metabolites are formed after absorption. In this regard, EMA recommends that “when referring to total radioactivity excreted in urine, it should be ensured that there is no degradation or metabolism of the unchanged drug substance in the gastric or intestinal fluid. Phase 1 oxidative and Phase 2 conjugative metabolism can only occur after absorption (i.e. cannot occur in the gastric or intestinal fluid). Hence, data from mass balance studies support complete absorption if the sum of urinary recovery of parent compound and urinary and fecal recovery of Phase 1 oxidative and Phase 2 conjugative drug metabolites account for ≥ 85 % of the dose” [10]. Absolute bioavailability studies compare the bioavailability of the drug in systemic circulation following non-intravenous administration with the bioavailability of the same drug following intravenous administration. When the absolute bioavailability of a drug is ≥ 85%, additional data to document drug stability in the GI fluid is not necessary. However, such studies are expensive, requires preclinical toxicity test to confirm tolerable safety, and also potential problems due to solubility limitations [12]. The basic principle of perfusion experiments in humans (such as open and semi-open perfusion methods, well-stirred model, triple lumen tube method, multi-lumen tube method) is that the absorption is calculated from the disappearance rate of the drug from the perfused segment. In the open and semi open methods, the parallel tube model is applied as the concentration will decrease in an exponential fashion along the perfused segment. The well stirred model is the most applicable for regional perfusion techniques using the balloon approach. Also, in the triple lumen method entering perfusion solution and gastrointestinal fluids are mixed in a mixing segment, and at the distal end of the mixing segment a sample is taken which is considered to be the inlet concentration of the test segment. The absorption is then calculated from a second outlet sample taken at the end of the test segment. In the multilumen tube method, proximal contamination problem was avoided by using an occluding balloon proximal to the test segment. A separate tube ending aboral to the balloon provides continuous drainage and avoid proximal leakage into the test segment. All these methods are useful for generating knowledge about the direct in vivo membrane transport. However, low recovery of the nonabsorbable volume marker, and higher perfusion flow rates are the major drawbacks of these methods [13]. In vivo models (direct or indirect approach) are also developed for permeability experiments. In the direct method, the drug levels in blood or urine is determined as a function of time. When the measurement of drug concentration in blood or urine is difficult or not possible, studies can be done by indirect method. In this method, pharmacological response of drug is related to amount of the drug in body [14]. The other methods for permeability determination are the in situ 263

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intestinal perfusion studies using suitable animal models, in vitro permeation studies using excised human or animal intestinal tissues such as Ussing-chamber technique and cell culture studies are considered appropriate for passively transported drugs [9]. These methods are more rapid and easy than the other methods, provide insights into segmental differences, and requires fewer compounds. Although Caco-2 cells are derived from human colon adenocarcinoma cells, Caco-2 cells have morphological similarity to human small intestinal enterocytes, they are polarized with an apical brush border, tight intercellular junctions, and several active transporters. Therefore, Caco-2 cells are approved by the guidelines, and commonly used in permeability determination studies [15]. Examples of model drugs for permeability assay method validation across Caco-2 cells were given in Table 2 [1619]. Additionally, in situ models offer more realistic results than in vitro techniques due to animal’s blood supply remains intact.

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 No ethic approvell is needed to this research. Tugba Gulsun ORCID:0000-0001-9359-276X Selma Sahin ORCID:0000-0001-5736-5906

References 1.

Hirota J, Shimizu S. Routes of Administration in The Laboratory Mouse. Second Edition. Academic Press, USA, 2012;709-725.

Kayaalp SO. Rasyonel Tedavi Yönünden Tıbbi Farmakoloji (c. 1). Nüve Matbaası, Ankara, 1981.

Hannan PA, Khan JA, Khan A, et al. Oral dispersible system: A new approach in drug delivery system. Indian J Pharm Sci. 2016;78:2-7.

Löbenberg R, Amidon GL, Ferraz HG, et al. Mechanism of gastrointestinal drug absorption and application in therapeutic drug delivery. Therapeutic Delivery Methods: A Concise Overview of Emerging Areas. Beom-Jin Lee

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Future Science Ltd Unitec House, 2 Albert Place, London, 2013;8-22. 5.

Horter D, Dressman JB. Influence of physicochemical properties on dissolution of drugs in the gastrointestinal tract. Adv Drug Deliv Rev. 2001;46:75-87.

Hillyer JF, Albrecht RM. Gastrointestinal persorption and tissue distribution of differently sized colloidal gold nanoparticles. J Pharm Sci. 2001; 90:192736.

Lin L, Wong H. Predicting oral drug absorption: Mini review on physiologically based pharmacokinetic models. Pharmaceutics. 2017;9:41.

Amidon GL, Lennernas H, Shah VP, et al. A theoretical basis for a biopharmaceutic drug classification: the correlation of in vitro drug product dissolution and in vivo bioavailability. Pharm Res. 1995;12:413-20.

U.S. Department of Health and Human Services Food and Drug Administration. Guidance for Industry Waiver of In Vivo Bioavailability and Bioequivalence Studies for Immediate-Release Solid Oral Dosage Forms Based on a Biopharmaceutics Classification System Guidance for Industry. https://www.fda.gov/downloads/Drugs/Guidances/ucm070246.pdf access date 22.07.2019

Conclusion Oral bioavailability of systemically acting compounds can be limited by dissolution and permeability. For permeability limited absorption, use of the most suitable method for determination of permeability across the intestines is very important to obtain reliable results. In general, a single method may be sufficient: when the absolute bioavailability is ≥ 85%, or when ≥ 85% of the administered drug is excreted unchanged in urine, or when ≥ 85% of the administered drug is recovered in urine as parent and metabolites with evidence indicating stability in the GI tract. When a single method fails to demonstrate a permeability classification, two different methods may be used. If conflicting results are obtained from different types of studies, human data replace in vitro or animal data.

10. European Medicines Agency. Guideline on The Investigation of Bioequivalence. https://www.ema.europa.eu/en/documents/scientificguideline/guideline-investigation-bioequivalence-rev1_en.pdf access date 25.07.2019 11. Penner N, Klunk LJ, Prakash C. Human radiolabeled mass balance studies: Objectives, utilities and limitations. Biopharm. Drug Dispos. 2009;30:185203. 12. Lappin G, Rowland M, Garner RC. The use of isotopes in the determination of absolute bioavailability of drugs in humans. Expert Opin. Drug Metab Toxicol. 2006;2:419-27. 13. Ewe K, Wanitscke R, Staritz M. Intestinal Permeability Studies in Humans. In: TZ Csáky, eds, Pharmacology of Intestinal Permeation II. New York: Springer-Verlag. 1984;535-71. 14. Dahlgren D, Roos C, Sjogren E, et al. Direct In vivo human intestinal permeability (Peff) determined with different clinical perfusion and intubation methods. J Pharm Sci. 2015;104:2702–26. 15.

ICH guideline M9 on Biopharmaceutics Classification System Based Biowaivers. https://www.ema.europa.eu/en/ich-m9-biopharmaceuticsclassification-system-based-biowaivers access date 10.12.2019

16. Lentz KA, Hayashi J, Lucisano LJ, Polli JE. Development of a more rapid, reduced serum culture system for Caco-2 monolayers and application to the biopharmaceutics classification system. Int J Pharm. 2000; 200:41-51. 17. Bock U, Flötotto T, Haltner E. Validation of cell culture models for the intestine and the blood-brain barrier and comparison of drug permeation. LTEX. 2004;21:57-64. 18. Volpe DA, Faustino PJ, Ciavarella AB, et al. Classification of drug permeability with a Caco-2 cell monolayer assay. Clin Res Regul Aff. 2007;24:39-47. 19. Volpe DA. Application of method suitability for drug permeability classification. AAPS J. 2010;12:670-8.

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Medicine Science 2020;9(1):265-9

Evaluation of preparation methods for orally disintegrating tablets Yagmur Akdag1, Tugba Gulsun1, Nihan Izat1, Meltem Cetin2, Levent Oner1, Selma Sahin1 1

Hacettepe University Faculty of Pharmacy Department of Pharmaceutical Technology, Ankara Turkey Ataturk University Faculty of Pharmacy, Department of Pharmaceutical Technology, Erzurum, Turkey

Received 04 September 2019; Accepted 12 December 2019 Available online 07.03.2020 with doi: 10.5455/medscience.2019.08.9167

Abstract Oral disintegrating tablets (ODT) are orally administered solid dosage forms commonly used in pediatric and geriatric patients with difficulty in swallowing. The lack of need for water during the use of ODTs is another advantage that increases patient compliance. Many methods are used for the production of ODTs such as direct compression (DC), freeze-drying (FD), spray drying, 3-D printing, melt granulation, phase transition process, molding, sublimation, mass extrusion, cotton candy process. Since the ODTs produced are aimed to disintegrate and dissolve rapidly, and consequently act quickly, the production method parameters need to be optimized in line with the critical product parameters. In this study, the most widely used manufacturing methods (especially DC and FD) for ODT and in vitro quality control tests of ODT are evaluated. Keywords: Orally disintegrating tablets, direct compression, freeze drying, spray drying, disintegration, dissolution

Introduction Oral route is the commonly preferred drug administration route, because it is easy to administer, comfortable, safe to apply, and provides high patient compliance [1]. ODTs are solid dosage forms with fast disintegration and dissolution characteristics, and can be used without any need for water [2]. ODTs are mainly preferred by patients with swallowing difficulties [3]. ODT formulations usually contain superdisintegrants, flavoring agents, sweetener, surface active agents, binder, coloring agents, lubricant and filler as excipients. There are various ODT preparation methods including DC, FD, spray drying, 3-D printing, melt granulation, phase transition process, molding, sublimation, mass extrusion, cotton candy process [4]. In this study, the most widely used manufacturing methods (especially DC and FD) for ODT and in vitro quality control tests of ODT are evaluated. Direct Compression Method DC method is a convenient method if the flowability and

*Coresponding Author: Selma Sahin, Hacettepe University Faculty of Pharmacy Department of Pharmaceutical Technology, Ankara Turkey, E-mail: sahin.selma@gmail.com

compressibility of the bulk powder is suitable. The formulation can be developed by using conventional excipients and improving the powder characteristics by granulation techniques and adding glidants. ODT formulations are designed to disintegrate in the mouth quickly. Therefore, a disintegrant/superdisintegrant or their combination (e.g. sodium starch glycolate, crospovidone, AcDi-Sol®) is the main excipient in the formulation. Currently, in the market there are ready-to-use ODT excipients (Ludiflash®, Parteck ODT®, Disintequik™ ODT, PROSOLV® ODT G2) mostly contain the filler, binder and disintegrant/superdisintegrant together, and show great flow performance to be directly compressed. The compression force must be optimized to obtain tablets in suitable hardness and friability that do not adversely affect the disintegration rate in the mouth. Considering the oral disintegration, hydrophobic excipients (e.g. stearic acid and its salts) are generally avoided. It is possible to produce ODTs with high mechanical strength and stability by DC method with low cost and short processing time. However, compared to the FD methods, directly compressed ODTs are tend to disintegrate slowly and show decreased dissolution rate [4-7]. Gulsun et al. [1] developed furosemide ODT formulations using microcrystalline cellulose, hydroxypropylcellulose, aspartame, sodium stearyl fumarate for direct compression method. It was reported that furosemide ODTs disintegrated within 15 seconds and had a friability of less than 1%.

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Spray Dried Excipient Based Method DC method may also be performed by spray drying of the active substances and excipients. Spray dried excipients have porous structure, and show better flow properties as they have a spherical shape [8]. This method can also be used for taste masking by encapsulating the active substance into the microsphere. The spray-dried excipient based method is a valuable and important technique to improve the characteristics such as disintegration time, dissolution of ODT prepared by DC method. Tanimura et al. [9] produced the spray-dried composite particles of erythritol and porous silica, and used DC method to prepare ODTs with sufficient tensile strength and acceptable disintegration time (<30 s). Freeze Drying Method In FD method, active substances and suitable excipients are suspended or dissolved to form a stable suspension/solution. The obtained mixture is equally distributed into blisters and frozen at -20ºC. Afterwards, the lyophilization procedure is applied under the recommended pressure and temperature conditions (0.44 mbar and−55°C) to obtain freeze dried ODTs. In this method, the critical materials are antifoaming such as simethicone, and matrix forming agents such as gelatin and sodium alginate. According to the properties of the matrix forming excipients, the disintegration, and thus dissolution properties of the ODTs might vary. This method is appropriate for heat sensitive drugs, and low dose drug since it is dissolved/dispersed in the mixture. Although, the hardness and friability of ODTs prepared by FD method are less than that of the ODTs prepared by DC method, they are produced in the final package and enough tablet strength can be achieved. Moreover, ODTs prepared by FD method show faster disintegration and increased dissolution rate than the ODTs prepared by DC method [5, 6]. Gulsun et al. [5] developed terbutaline sulfate-containing ODTs using DC and FD methods, and obtained that the disintegration times of ODTs prepared by DC and FD methods were approximately 3 min and 11s, as respectively . Molding Molding is categorized in two methods (compression molding and heating molding), and includes wetting, dispersing or dissolving, tablet compression and evaporation of the remaining solvents [10]. Hydrophilic excipients are used to achieve maximum solubility. Tablets prepared by compression molding have very porous structure due to removing the solvents by drying [11], and have low mechanical strength due to the tablet compression is performed with low pressure [12]. In heating molding method, a suspension of the drug with watersoluble sugar such as xylitol, agar, mannitol, lactose, sucrose is prepared. Agar solution is used as a binder. This mixture is then added to the blisters. Agar solution is solidified at room temperature to obtain a gel form, and finally dried under vacuum at about 30 °C [13]. There are several patents describing the molding method [14,15]. Sublimation Sublimation is a process in which water passes directly from its solid state to vapor without becoming liquid [13]. Volatile

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components such as urea, camphor, ammonium carbonate, ammonium bicarbonate and hexamethylene-tetramine are widely used to form a porous matrix are used in the sublimation method. Then, it is mixed with other excipients and compressed with low pressure. Koizumi et al. [16] manufactured porous tablets using a subliming material (camphor) and mannitol. As a result, the ODTs with approximately 30% porosity were obtained, and the ODTs rapidly dissolved (15 s) in saliva. Phase Transition Method Orally disintegrating tablets can be prepared by combining low and high melting point sugar alcohols (such as mannitol, erythritol, and sorbitol), and providing phase transition during production. The ODTs are obtained by heating to a temperature between the melting points of these sugar alcohols and then cooling. The content of low melting point sugar alcohol and the heating process may affect the properties of ODTs such as hardness and disintegration time. The hardness of the tablets increases by the heating process [17]. Kuno et al. [18] formulated the ODTs by phase transition method using lactose as a high melting point saccharide and xylitol as the low melting point sugar alcohol. They also evaluated the effect of the type of lubricants (talc, sodium stearyl fumarate, and magnesium stearate) on the characteristics of ODTs. As a result, talc was shown to be the most suitable lubricant for preparing ODTs by this method. Mass Extrusion Method This technology involves softening of a blend of active substance(s) and the other ingredients with a mixture of polyethylene glycol and ethanol, and then the expulsion of this soft mass through a syringe or extruder to form a cylindrical shape, which are used to prepare tablets [11]. Patil et al. [19] developed tramadol hydrochloride containing ODT using mass extrusion method to mask the bitter taste of drug. The blend of tramadol hydrochloride and Eudragit E100, which was used a taste masking agent, was softened by ethanol, and then extruded using a syringe. Afterwards, ODTs were prepared using the obtained taste-masked granules, various superdisintegrants (croscarmellose sodium, crospovidone, sodium starch glycolate) and other excipients (diluents and lubricant) by DC method. The fastest disintegration was observed for the ODTs containing crospovidone. Cotton Candy Method With fast melting and spinning, polysaccharides or saccharides form a matrix called a floss. The resulting matrix is partially recrystallized to improve flow properties and sustainability. After milling the floss matrix, it is mixed with the active substance and excipients, and then compressed [20]. There are many patents describing the cotton candy process [21,22]. Nanocrystal Technology Nanocrystal technology is based on reducing the particle size to nanoscale. The nanocrystals obtained by milling are stabilized to prevent agglomeration by physical adhesion on the surface of the inert material. The tablets prepared by this method disintegrate very quickly. In addition, the solubility, absorption rate and 266

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bioavailability of ODTs are also increased [4].

Wetting Time and Water Absorption Capacity

Lai et al. [23] prepared piroxicam-containing nanocrystal formulations using high pressure homogenization technique and poloxamer 188 as stabilizer. Then, they used the prepared formulation and the other ingredients (xanthan gum, maltodextrins, and PEG 4000) to obtain ODTs by FD method. The ODTs containing nano-sized piroxicam had a higher piroxicam dissolution rate compared to untreated piroxicam-containing ODTs.

Water absorption is an important parameter for ODTs, since these tablets generally disintegrate by swelling. According to the widely used simple method [1, 29-32], a glass petri dish containing 6 mL water (with/without a dye) and a filter paper are required to perform the test. Pre-weighed tablet is placed on the filter paper, and the time required for complete wetting of the tablet is recorded. Water absorption capacity is calculated using the following equation [33]:

Oral films/wafers In this method, water soluble film forming polymer (e.g. hydroxyl propylcellulose, sodium alginate, pullulan, hydroxypropyl methylcellulose, carboxy methylcellulose, polyvinyl alcohol), drug and taste masking agents are dissolved in a nonaqueous solvent. After evaporation of the solvent, a film is formed [24]. Liew et al. [25] were developed taste-masked oral disintegrating film formulation containing donepezil (as active ingredient) and polymeric bases such as polyethylene glycol, crospovidone, hydroxypropyl methylcellulose, lactose monohydrate, and corn starch. They found that the mean in vitro disintegration time of the oral disintegrating film was 44 s, and the oral disintegrating film was stable for at least 6 months at 40°C and 75% relative humidity. Lai et al. [26] developed quercetin nanocrystal-containing ODT, using glycerin (plasticizer) and maltodextrins (film forming material) to enhance oral bioavailability of quercetin. The aim of this study was to evaluate different methods in terms of ODT production and quality control parameters. Quality Control Tests of Manufactured ODTs In this context, the thickness, diameter, hardness, friability, wetting time, water absorption ratio, disintegration time and dissolution rate of ODTs are often determined. Thickness, Diameter and Hardness of ODTs Thickness (n=20), hardness (n=10) and diameter (n=20) are determined to evaluate batch-to-batch uniformity of produced ODTs. The hardness of ODTs is an important characteristic which has to be obtained over 5 kg (49.04 N) for uncoated tablets to maintain their mechanical stability. However, it should be adjusted optimally to avoid reduced disintegration and dissolution rates which are also key parameters for ODT preparations and aimed to be improved [27]. Friability of ODTs Friability indicates the weight loss of ODTs due to abrasion and loss of fine particles from tablet surface because of poor cohesion among the tablet ingredients [27,28]. If the percentage weight loss of uncoated tablets is less than 1%, the tablets pass the friability test [28]. To evaluate friability, 20 tablets are rotated at 25 rpm for 4 minutes. Friability (%) is calculated using the following equation: % Friability = [(W1-W2) /W1]x100 where, W1= Weight of tablet before test, W2 = Weight of tablet after test

Water absorption capacity=[(Ww-Wd )/Wd]x100 Ww: weight of wet ODT; Wd: weight of dry ODT. Disintegration Study In disintegration test, ODTs (n=6) are placed in tubes of the basket-rack assembly and the assembly is moved up and down in 1000 mL of distilled water at 37 ± 2°C. Disintegration time is determined according to European Pharmacopoeia 8.2, ODTs should disintegrate within 3 min [28]. Dissolution Study Dissolution test conditions (apparatus, rate, dissolution media and volume, time intervals for sampling) for the compound of interest are generally obtained from mainly the pharmacopeia. The dissolution test is performed using a dissolution testing device. Since ODTs are expected to disintegrate rapidly, frequent samples should be taken at the first time points of the dissolution study. Results and Discussion Thickness, Diameter and Hardness The standard deviations of thickness, diameter and hardness values are required to be low as an indicator of uniform ODTs. On the other hand, freeze drying method has no compression procedure and therefore, ODTs tend to have weaker strength, and achievement of uniform thickness values is challenging as compared to directly compressed tablets. In our previous study, it was reported that the hardness values of terbutaline sulfatecontaining ODTs prepared by DC method using Ludiflash® and Parteck ODT® as ready-to-use tableting excipients were 173.03 N and 212.58 N, respectively. However, the hardness of terbutaline sulfate-containing ODTs prepared by FD method was less than 20 N [5]. In another study, it was aimed to optimize a freeze dried ODT matrix for multiparticulate delivery by means of matrix content with a central composite face centered design. It was demonstrated that increasing the gelatin and alanine concentrations was the most effective approach. Considering the other parameters, the formulation was optimized and the hardness of the formulation was recorded as 17.22 ± 0.74 N [34]. Friability Friability is used as an indicator of physical strength of ODTs. Friability of uncoated tablets is required to be less than 1% [33]. The freeze-dried ODTs are more fragile than the directly compressed ODTs, and thus, it is more difficult to maintain in tablet form [4]. However, since the freeze-dried tablets fill the blister chamber precisely, they do not move during transport, which reduces the possibility of breaking tablets from production to consumption.

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Water Absorption, Disintegration and Dissolution ODTs are usually expected to rapidly absorb water, swell and disintegrate. Therefore, water absorption capabilities of ODTs are considered as an indicator of their disintegration ability. However, it was observed that lyophilized tablets do not swell but disintegrate very rapidly [5]. Freeze dried ODTs have very low disintegration time, therefore, their dissolution rate tends to be higher than the other ODTs such as direct compressed, spray dried [7,35]. According to European Pharmacopoeia 8.2, ODTs should disintegrate within 3 min [33]. Dissolution studies of ODTs are performed in accordance with dissolution databases in Pharmacopoeia or FDA. The selected manufacturing method and excipients may affect the dissolution rate. For example, freeze dried ODTs have very low disintegration time, hence their dissolution rate is very fast [7,35]. Elkhodairy et al. [31] were prepared flutamide containing ODTs by superdisintegration, effervescence and sublimation approaches. Two-fold increase in the superdisintegrant content decreased the disintegration times from 46 to 38 s. The combination of effervescence approach and superdisintegrant addition resulted faster disintegration (22 s), however, dissolution rate was not altered. The major increase in the dissolution rate (73.12 to 96.99% after 15 min) was achieved by the preparation of solid dispersion of the active compound with PEG6000. Conclusion In conclusion, ODTs can be prepared by several techniques and the use of variety of excipients. The suitable preparation method should be selected according to the specifications of the active pharmaceutical ingredient, the properties of excipients, target patient population and intended disintegration time enabling the effective 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. Ethical approval No Ethical approval is needed for thisresearch Yagmur Akdag ORCID: 0000-0003-4139-9815 Tugba Gulsun ORCID: 0000-0001-9359-276X Nihan Izat ORCID: 0000-0001-7378-9100 Meltem Cetin ORCID: 0000-0003-4009-2432 Levent Oner ORCID: 0000-0002-6510-7680 Selma Sahin ORCID: 0000-0001-5736-5906

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10. Bandari S, Mittapalli RK, Gannu R. Orodispersible tablets: An overview. Asian J Pharm Sci. 2014;2:2-11. 11. Hannan P, Khan J, Khan A, et al. Oral dispersible system: A new approach in drug delivery system. Indian J Pharm Sci. 2016;78:2. 12. Dey P, Maiti S. Orodispersible tablets: A new trend in drug delivery. J Nat Sc Biol Med. 2010;1:2. 13. Kakar S, Singh R, Kumar S. Orodispersible tablets: an overview. MOJ Proteomics Bioinform. 2018;7:180-2. 14. Van Scoik KG. Solid pharmaceutical dosage in tablet triturate form and method of producing same. Google Patents; 1992. 15. Hirsh J, Midha K, Hirsh M, Lo W-Y. Pharmaceutical composition for compressed annular tablet with molded triturate tablet for both intraoral and oral administration. Google Patents; 2005. 16. Koizumi K-i, Watanabe Y, Morita K, et al. New method of preparing highporosity rapidly saliva soluble compressed tablets using mannitol with camphor, a subliming material. Int J Pharm. 1997;152:127-31. 17. Kuno Y, Kojima M, Ando S, et al. Evaluation of rapidly disintegrating tablets manufactured by phase transition of sugar alcohols. J Controlled Release. 2005;105:16-22. 18. Kuno Y, Kojima M, Nakagami H, et al. Effect of the type of lubricant on the characteristics of orally disintegrating tablets manufactured using the phase transition of sugar alcohol. Eur J Pharm Biopharm. 2008;69(3):986-92. 19. Patil MG, Kakade SM, Pathade SG. Formulation and evaluation of orally disintegrating tablet containing tramadol hydrochloride by mass extrusion technique. J Appl Pharm Sci. 2011;1:178. 20. Shukla D, Chakraborty S, Singh S, et al. Mouth dissolving tablets I: An overview of formulation technology. Sci Pharm. 2009;77:309-26. 21. Myers GL, Battist GE, Fuisz RC. Process and apparatus for making rapidly dissolving dosage units and product therefrom. Google Patents; 1999. 22. Chivers TE. Process for making candy floss. Google Patents; 1971. 23. Lai F, Pini E, Angioni G, et al. Nanocrystals as tool to improve piroxicam dissolution rate in novel orally disintegrating tablets. Eur J Pharm Biopharm. 2011;79:552-8. 24. Kumar RS, Yagnesh TNS. Oral dissolving films: an effective tool for fast therapeutic action. J Drug Deliv Ther. 2019;9:492-500.

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Medicine Science 2020;9(1):270-3

Hunting for molecules in schizophrenia through omics technologies Ceren Acar Inonu University, Department of Molecular Biology and Genetics, 44280, Malatya, Turkey Received 23 September 2019; Accepted 25 November 2019 Available online 07.03.2020 with doi: 10.5455/medscience.2019.08.9170

Abstract Schizophrenia is a complex mental disorder that affects 1% of the population worldwide with ~80% heritability rate. This mental disorder has dramatic impacts not only on the patients but also on the society as well. Unfortunately our knowledge about the molecular mechanisms underlying the disease is limited. To understand the pathological mechanisms that lead to disease phenotype we need to use genomics, transcriptomics, epigenomics, proteomics, metabolomics like approaches with newly developed technologies. These approaches will also help scientist to find out new diagnostic tools that can be used as biomarkers in a complex disease like schizophrenia or personalized therapy strategies. It is possible to map the molecular changings in disease and healthy state with the help of the OMICS based technologies. This review sheds light on these OMICS based approaches to hunt the biomarkers that can be used as diagnostic tools for schizophrenia and other mental disorders or to figure out the candidate molecules for new treatment options. Keywords: Schizophrenia, OMICS, biomarker, genomics, proteomics, metabolomics

Introduction Schizophrenia is complex and debilitating disorder with both positive and negative symptoms and cognitive disturbances as well [1]. It affects 1% of the worldwide population and it imposes domestic and global burden of morbidity and mortality [2]. This disorder has ~80% heritability rate and this shows the importance of genetics in the aetiology of the disease [1]. Eventhough several reports can be found on the databases related with the candidate molecules for schizophrenia, the molecular architecture of the disease can not be established well. The advancements in the technology that is used in research area open new doors for the scientist to understand more of the molecules and their interactions that are responsible for the disease phenotypes. It is not enough to find out the candidate molecules in complex disease, their interactions with other molecules and the consequences of these interactions should be understood well in order to get a molecular profile for the disease at the systems level. To understand these relations OMICS technologies are employed. Especially when we think about the etymology of the word OMICS which is derived from

*Coresponding Author: Ceren Acar, Inonu University, Department of Molecular Biology and Genetics, 44280, Malatya, Turkey E-mail: ceren.acar@inonu.edu.tr

Sanskrit â&#x20AC;&#x153;OMâ&#x20AC;? meaning completeness and fullness which fullfills the term OMICS well [3]. In the present review the efforts to find out candidate molecules for schizophrenia and interactions in different areas of OMICS are discussed. Genomics-Epigenomics The neurobiology leading to schizophrenia is poorly understood and as a result of this there is no objective measurement or a lab test that supports clinical diagnosis. The research in the molecular genetics area has increased our understanding the mechanisms of schizophrenia in recent years and let us see more of the molecular architecture of the disease and find therapeutic targets. The first study that focuses on the molecular markers of schizophrenia was published in Nature in 1988 [4]. In that 31 years we expanded our knowledge a lot with the advancements in the techniques. During that period many genome-wide association studies were performed and many genes were found to be candidates. But schizophrenia is a complex disease and there are no singular causal schizophrenia genes but many. So maybe it is the accumulation and interaction of the variants that leads to disease state [2]. So not only the genes and their interactions but also the epigenetic conditions are responsible for the pathology underlying the disease. Genetic structure of complex disorders are characterized by 270

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genome-wide association studies (GWAS). When a search is run for the keywords GWAS in schizophrenia more than 16000 published reports are found in the networks. The latest GWAS study published in this year in Nature Neuroscience reported that more than 100 schizophrenia loci have been identified. But still there is a big question mark on the biology of the disease. So by using multi-omics data and gene networks Wang et al tried to figure out the risk genes in GWAS loci [5]. With their method they predicted 104 network derived risk genes. Here we only gave the examples of genomic marker studies for schizophrenia but as mentioned earlier there are thousands of GWAS or individual SNP studies to find the available biomarkers for schizophrenia including our group’s reports [1,6]. In a large study which includes 36989 cases and 113075 individuals in 108 loci 128 common variants were reported to be accounting for a modest disease risk [7]. The genes involved were related with glutamatergic neurotransmission, synaptic plasticity, voltage gated calcium channels and dopamine receptor (DRD2). On the other side application of epigenetic data for diagnosis is comparing to genomics is a new and promising area. The studies on that subject focusing on DNA methylation and histone modification patterns or from time to time on small non-coding RNAs. For each, different technological approaches like next generation sequencing (NGS), microarrays, ChIP-Chip/ChIP-Seq, qPCR, RNA Seq are used to analyze the difference between the healthy and the disease states [8]. Related with epigenomics in different studies more than one thousand differentially methylated regions were identified. Some of these regions were also overlapping with the genomics data as well [7, 9]. Still genomics and epigenomics based studies are the hot topics in mental disease research in order to find right type of biomarker for diagnosis and better treatment targets. Transcriptomics When molecular architecture studies are considered DNA data is not the only material that can be used, RNA and protein levels which is derived from that DNA should be taken into account as well. In the last decades transcriptomics and proteomics studies are taking leading roles in OMICS innovations in neuroscience. Transcriptome can be defined as the full set of mRNA molecules expressed by an organism or it is also possible to define the term as mRNA transcripts produced in a particular cell or tissue type. Belgard et al stated that “understanding the concept of a transcriptome is key to understanding modern biology” [10]. We know that not all the RNAs are expressed in all cell types or not every gene is expressed at the same level, so the amounts are different in different cells in different times. So in transcriptomics studies gene activity of the biological system is tried to be solved, how the genes are expressed, in what conditions they are expressed and when they are expressed, in what conditions they are silenced are the questions that need to be answered. One handicap of these transcriptomics research in mental disorders is to get the right type of tissue to analyze. So mainly

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blood transcriptomics is on the table or post mortem brain samples are also used in some of the studies. So inflammation related genes’ or immune response related genes’ expression profiles are examined mainly from blood samples. For example in a study done by Gardiner et al in 2013, 114 cases of schizophrenia or schizoaffective disorder vs 80 healthy controls were reported. Their results pointed 6 genes (EIF2C2, EVL, DEFA4, S100A12, PI3 and MEF2D) that showed validated expression changes. On the other side by using post mortem prefrontal cortex samples of 45 schizophrenia subjects vs 46 healthy controls, two genes (NOTCH 2 and MT1X) turned out to be associated with schizophrenia. Also in another study by Perez-Santiago et al the expressions of BAG3, C4B, EGR1, MT1X, NEUROD6, SST and S100A8 were found to be altered in schizophrenia. These results were from a meta analysis conducted on data from microarray studies of dorsolateral prefrontal cortex of 107 patients and 118 healthy individuals [9]. When RNA is taken into account we need to talk about small noncoding RNAs which take part in regulation of gene expression or gene silencing. In Pubmed there are 337 miRNA and schizophrenia papers are reported and in PubMed Central 3749 reports are found with the same keywords. So many miRNA target related with schizophrenia are shown as biomarkers for the disease and the researches are stilll going on [11]. Proteomics As it is mentioned previously in the text it is not enough to work on DNA in order to figure out the molecular events in particular systems both RNA and proteins and other metabolic products should be characterized both in normal and disease states. If the proteins are the focus of research we need to talk about proteomics studies. As can be understood from the term proteomics it is the large scale analysis of proteins expressed in a given biological system [12]. The current research in the area is going on three main subejcts which are protein expression states both in qualitative and quantitative levels, posttranslational modifications and proteinprotein interactions. The techniques that are used in the proteomics area are mainly Two Dimensional Gel Electrophoresis (2DGE) and Mass Spectrometry (MS) bu also yeast two hybrid studies are employed for interaction mappings or individual blotting studies are also used for proteins. In the case neuroproteomics it is difficult to get the samples as much as needed. Most of the time just like the situation with mRNAs the sampling is done from post mortem tissue. This brings the ethical and technical concerns. Since the inaccesibility of the central nervous system tissue in order to find a way scientists use blood associated cellular and molecular markers in the diseases of brain. And for their convenience antibody based assays are used a lot for identifying the blood based biomarkers [13]. As an example for this type of research in schizophrenia and depression subjects BDNF levels turned out to be reduced. For another example to that our group’s report in which we studied the levels of some inflammatory factors in patients with treatment resistant schizophrenia. In that study we checked the effect of electroconvulsive therapy on some inflammatory factors like IL-4, TGF-β, MPO and NF-κB and we have seen that the anti-inflammatory response such as the levels of IL-4 and TGF-β was increasing but this did not affect the levels of MPO and NF-κB activation [14]. 271

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Metabolomics

technology [20].

Metabolomics is the comprehensive analysis of metabolites in a biological specimen [15]. It is thought that disease, drugs, or toxins cause perturbations in the concentrations and fluxes of endogenous metabolites involved in key cellular pathways [16]. Previously small number of metabolites were used to diagnose complex metabolic diseases or certain monogenic diseases but current metabolomics technologies have the capability to test huge number of metabolites. So this gives us the ability to characterize the metabolite profile both in normal and disease states.

Discussion and Conclusion

In literature there are several reports found to figure out metabolic signature of schizophrenia. In these studies comparison of healthy and patient subjects or pre-post treatment metabolic profiles are checked. In a study performed with 122 schizophrenia patients pre- and post treatment serum samples were analyzed and 14 water soluble metabolites were identified which include amino acids, carnitines, polar lipids and an organic acid. In that study it is revealed that the amino acids and lysophosphatidylcholines (LysoPC) were increased, on the contrary the four carnitinesoleoylcarnitine, L-palmitoylcarnitine, linoleyl carnitine, and L-acetylcarnitine- were decreased post-treatment [17]. A case control study from the same group showed that four amino acids and derivatives (cysteine, GABA, glutamine and sarcosine) were higher in patients comparing to healthy subjects on the opposite seven other amino acids and derivatives (arginine, L-ornithine, threonine, taurine, tryptophan, methylcysteine, and kynurenine) were lower in schizophrenia subjects [18]. Previous studies have also shown that abnormal lipid metabolism was also seen in schizophrenia patients. In the light of that Yang et al investigated the serum fatty acid patterns in 110 schizophrenia patients and 109 normal controls. In that study it is reported that monounsaturated fatty acids and ꞷ-6 polyunsaturated fatty acids were significantly increased in schizophrenia patients [19]. It is possible to increase the examples to the metabolomics studies in schizophrenia and when one searches in PubMed there are 49 reports that are published from different parts of the world. They serve good information to point out new candidate biomarkers for schizophrenia. But of course these data should be evaluated with bioinformatic tools as well to interpret the right type of biomarkers for the diagnosis of mentioned disease. Cellomics-Connectomics It is known that nervous system has most significant cellular diversity [20]. How this diversity has an impact on the cause of mental disorders is a problem to be solved. To find a way out the cell types and their functions should be clarified in the first place. OMICS approaches are good tools to characterize these cells at the molecular level in detail. Each cell type has its own expression profile to do its normal function. But single cell profiling won’t help us to understand the complex events that are happening in our brains, we need to understand how these diverse cells are communicating with each other and how this communication is disrupted in the case of disease. So cellomics and connectomics studies are aiming to understand the cellular and molecular architecture of the brain both in normal and in unhealthy states. Different imaging techniques are used to characterize the cells and their connections in brain networks. This is the new rising area of this branch of science with the help of the advancements in

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Here the summary of the impact of OMICS technologies in mental disorders like schizophrenia is discussed. The data obtained from these types of studies unlock new information to understand more about the underlying mechanisms that leads to schizophrenia. OMICS derived markers will be helpful for the precise diagnosis of the disease, for preventive medicine and target new therapy strategies against certain molecules that are playing roles in the molecular pathology of the disease. Acknowledgments This study was the subject of the invited talk in “International Multidisciplinary Symposium on Drug Research and Development- DRD 2019,” and the author would like to thank the organizing committee for their invitation. Financial Disclosure The financial support for this study was provided by the investigators themselves. Ethical approval No ethic approvell is needed to this research. Ceren Acar ORCID:0000-0003-1842-9203

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10. Belgard TG and Geschwind DH, Transcriptomics. In: The OMICS Applications in Neuroscience. Oxford University Press, 2014 .p. 63-72. 11. Schizophrenia and miRNA https://www.ncbi.nlm.nih.gov/ pmc/?term=miRNAs%20in%20schizophrenia 12. Trinidad JC. Proteomics. In: The OMICS Applications in Neuroscience. Oxford University Press. 2014 .p. 155-81.

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13. Jaeger PA, Villeda SA, Berdnik D, et al. Focused Plasma Proteomics for the study of brain aging and neurodegeneration. In: The OMICS Applications in Neuroscience. Oxford University Press 2014;183-91.

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18. Cao B, Wang D, Brietzke E, et al. Characterizing amino-acid biosignatures amongst individuals with schizophrenia: a case-control study. Amino Acids. 2018; 50(8):1013-1023.

15. Clish CB. Metabolomics: an emerging but powerful tool for precision medicine. Cold Spring Harb Mol Case Stud. 2015;1: a000588

19. Yan X, Sun L, Zhao A, et al. Serum fatty acid patterns in patients with schizophrenia: a targeted metabonomics study. Transl Psychiatry. 2017;7:e1176.

16. Lindon JC, Holmes E, Nicholson JK. So, whatâ&#x20AC;&#x2122;s the deal with metabonomics? Anal Chem. 2003;75:384A-391A. 17. Cao B, Jin M, Brietzke E, et al. Serum metabolic profiling using small

20. Dougherty J. Cellomics: Characterization of Neural Subtypes by HighThroughput Methods and Trasngenic Mouse Models. In: The OMICS Applications in Neuroscience. Oxford University Press. 2014 .p. 195-219.

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Medicine Science 2020;9(1):274-7

Plasmapheresis as treatment for patients with severe hypertriglyceridemia Okan Sefa Bakiner Baskent University School of Medicine Adana Hospital, Department of Internal Medicine, Ankara, Turkey Received 09 February 2020; Accepted 21 February 2020 Available online 09.03.2020 with doi: 10.5455/medscience.2020.09.9183

Abstract Severe hypertriglyceridemia (SHGT) occurs when triglyceride values exceed 1,000 mg/dl which places patients at considerable risk of acute pancreatitis. Treatment of SHGT includes lipid lowering approches and dietary interventions. Insulin infusion is considered to decrease triglyceride levels in patients who display SHTG related acute pancreatitis. Plasmapheresis is an effective method and an extracorporeal process which may be used both in urgent and in selective cases. Plasma exchange and double cascade filtration are methods of plasmapheresis used in SHTG and possible following acute pancreatitis. In this article effect and mechanisms of plasmapheresis on SHTG and related acute pancreatitis will be discussed. Keywords: Severe hypertriglyceridemia, acute pancreatitis, therapeutic apheresis

Introduction Abbreviations Hypertriglyceridemia (HTG), triglyceride (TG). The Adult Treatment Panel (ATP), severe hypertriglyceridemia (SHTG), acute pancreatitis (AP), high density lipoprotein (HDL), low density lipoprotein ( LDL), very low density lipoprotein (VLDL), free fatty acids (FFA),Hypertriglyceridemia related pancreatitis (HTGP), lipoprotein lipase (LPL) , lipoprotein apheresis (LA), American Society for Apheresis (ASFA), Therapeutic plasma exchange (TPE) double membrane filtration (DFP). The Role of Hypertriglycemia on Pancreatitis Hypertriglyceridemia (HTG) is prevalent between 16 and 65 years of age for 18.6% and 4.2% for men and women respectively. The Adult Treatment Panel (ATP) III guidelines has described normal triglyceride (TG) concentration <150mg/dL (<1.6mmol/L), borderline-high TG as 150 to 199mg/dL (1.6â&#x20AC;&#x201C;2.2mmol/L), high TG as 200 to 499mg/dL(2.2â&#x20AC;&#x201C;5.6mmol/L), and very high TG as>500mg/dL (>5.6mmol/L) [1]. Severe hypertriglyceridemia (SHTG) in patients with TG > 1.000 mg/dL (11.2mmol/L) should TG > 1,000 mg/dL is 5%, and with levels > 2.000 mg reaches to be alarming. The risk of acute pancreatitis (AP) in patients with

*Coresponding Author: Okan Sefa Bakiner, Baskent University School of Medicine Adana Hospital, Department of Internal Medicine, Ankara, Turkey, E-mail: okansefabakiner@gmail.com

10-20% [2]. AP due to SHTG is associated with high mortality and morbidity covering 10% of affected individuals. Also, TG values less than 1.000 mg / dl are associated with high risk of premature cardiovascular disease. Even back in 1953 patients having myocardial infarction were shown to have high TG levels [3]. Recent studies show that high TG levels is a predictor of cardiovascular and all-cause mortality as well as the cardiovacular risk (4]. TG plays a major role in the atherosclerotic process by cholesterol- rich lipoprotein particles. Number of atherogenic particles increase, leading to dysfunctional high density lipoprotein (HDL) cholesterole and low density lipoprotein( LDL) cholesterole and the patientbecomes vulnerable to oxidative modification, all of which increase total cardiovascular risk. Besides, those patients display markedly higher plasma fibrinogen and clotting factor Xc concentration which propel them to a more prothrombotic state [5]. SHTG is found to be a common cause of AP following gallstones and alcohol [2]. Breakdown of TG into free fatty acids (FFA) by the enzyme pancreatic lipase causes lipotoxicity and leads to a systemic inflammatory response and AP. Pancreatic lipase hydrolyses TG and FFA gets released and induces free radical damage and diminish blood flow to pancreas because of hyperviscosity. Chylomicrons in SHTG can obstruct capillaries of pancreas and cause pancreatic iscemia and release of pancreatic lipase. Concentration of FFA increases, endothelial cells get damaged and a cascade of deleterious conditions show up like conversion of trypsinogen to trypsin, activation of zymogen and inflammatory cells, and release of cytokines that further mediate local inflammatory responses. The breakdown of TG to FFA by 274

doi: 10.5455/medscience.2020.09.9183

pancreatic lipase induces a severe toll-like receptor 2 and 4 which mediate inflammatory response after pancreatic autodigestion maybe another cause of HTG related pancreatitis (HTGP) [6]. The flow of events lead to hemorrhage, edema and finally pancreatic necrosis. Whats more; as the mediators go into the circulation, bacteremia, acute respiratory distress syndrome, renal failure and gastrointestinal hemorrhage may develop. Systemic schock and death may follow after systemic inflammatory response develops reaching mortality rates of 20% to 30% [7]. The severity of AP is assessed by The Ranson, Apache II, and Glasgow scores. Causes of HTG is divided into primary disorders (genetic) and secondary disorders (due to other diseases). According to Fredericksonâ&#x20AC;&#x2122;s classification type l,lV and V dyslipidemia is generally associated with SHTG [8]. Secondary causes of SHTG are, most common obesity, uncontrolled diabetes mellitus, alcohol, pregnancy, and drugs. Recent data shows that unsaturated fatty acids derived from the pancreas or surrounding environment by the release of enzymes cause local and systemic complications in AP. In obese patients intrapancreatic and visceral fat tissue are associated with obesity which may be an explanation for increased risk of severe AP in the obese group [9]. Management of Severe Hypertriglyceridemia The accepted management of SHTG consists of dietary limitations, and lipid-lowering drugs such as fibrates, nicotinic acid, and omega-3 fatty acids. Alcohol restriction, weight loss, regular exercise and control of additional endocrinopathy (such as diabetes mellitus and hypothyroidism) are important measures for the treatment of SHTG. Drugs with TG enhancing effects must be avoided. Insulin infusion helps decrease triglyceride leves although no standart guideline for it is not yet present. Insulin treatment activates lipoprotein lipase (LPL) which leads to degradation of chylomicron particles. SHTG often comes up in diabetic patients with poor glucose control; therefore aggressive insulin treatment is important both for lowering blood glucose and activating LPL. But it has been proved that its use is not limited to diabetic patient group [10]. Heparin stimulates endothelial LPL into blood circulation, but that treatment is still under debate because it only provides a transient rise in LPL and later result in LPL deficiency. Therefore it is not recommended as a solo-treatment for HTGP [11].

Med Science 2020;9(1):274-7

Therapeutic Apheresis for Severe Hypertriglyceridemia and Related Acute Pancreatitis Since first being reported by by Betteridge et al. in 1978, plasmapheresis for lowering TG levels has been a therapeutic choice [12]. Initaiting a therapy with lipoprotein apheresis has some indications and these are: 1. Homozygous Familial Hypercholesterolemia, 2. Severe hypercholesterolemia and cardiovascular disease, 3. Elevated lipoprotein (a) level with a progress of the cardiovascular disease. SHTG is not counted as an officially indication. Apheresis is an effective and a safe method and can also be considered for cases of AP which do not respond to other medical approaches. This treatment is also advised by the American Society for Apheresis (ASFA) for hyperlipidemic acute pancreatitis with lack of existing evidence to manage efficacy of the treatment to determine the risk / benefit and cost / benefit ratio. Currently this treatment is registered in the III category of the ASFA and is being used in AP with satisfying results [13]. A method of therapeutic apheresis is therapeutic plasma Exchange (TPE). Quick clearance of macromolecular lipids by this method is an important difference. LPL; which plays a key role in the pathogenesis of SHTG is desuppressed by the mechanism of action of this method. The plasme milieu at a pancreatic capillary level is delipidated and function of LPL becomes effective. Studies have shown that unsaturated fatty acids in AP to be causes for local and systemic complications [14]. During an episode of AP, pancreatic lipase is released and presence of excess TG in SHTG provides extra substrate as unsaturated fatty acids that increases the risk of severe AP. As a result; removal of excess TG is a considerable option to decrease the severity of SHTG related AP. Following plasmapheresis a reduction of 40-80% in TG is associated with relief of pancreatitis symptoms. Apheresis for HTG generally lowers TG concentrations by 60-70% per session [15]. The formula to calculate the removal rates of cholesterol and triglyceride during the process is (pre-plasmapheresis concentrationâ&#x20AC;&#x201C;postplasmapheresis concentration)/ pre-plasmapheresis concentration [16]. In a multycenter case series study 17 patients who had not responded to conventional medical therapy (fat-free diet plus pharmacological interventions) underwent TPE. Two hundred seventeen sessions

Table 1. Indications and contraindications of plasmapheresis in patients with SHTG ( According to The Apheresis Applications Committee of the American Society for Apheresis (ASFA) (13)

Indication

Procedure

Recommendation