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Medicinski Glasnik
Official Publication of the Medical Association of
Zenica-Doboj Canton
Bosnia and Herzegovina
Editor-in-chief
Selma Uzunović
Zenica, Bosnia and Herzegovina
MANAGING EDITOR
Tarik Kapidžić
Zenica, Bosnia and Herzegovina
Editors
Adem Balić, Tuzla, Bosnia and Herzegovina
Dubravka Bartolek, Zagreb, Croatia
Branka Bedenić, Zagreb, Croatia
Asja Čelebić, Zagreb, Croatia
Josip Čulig, Zagreb, Croatia
Filip Čulo, Mostar, Bosnia and Herzegovina
Jordan Dimanovski, Zagreb, Croatia
Branko Dmitrović, Osijek, Croatia
Ines Drenjančević, Osijek, Croatia
Harun Drljević, Zenica, Bosnia and Herzegovina
Davorin Đanić, Slavonski Brod, Croatia
Lejla Ibrahimagić-Šeper, Zenica, Bosnia and Herzegovina
Tatjana Ille, Belgrade, Serbia
Vjekoslav Jerolimov, Zagreb, Croatia
Mirko Šamija, Zagreb, Croatia
Sven Kurbel, Osijek, Croatia
Snježana Pejičić, Banja Luka, Bosnia and Herzegovina
Belma Pojskić, Zenica, Bosnia and Herzegovina
Besim Prnjavorac, Tešanj, Bosnia and Herzegovina
Asja Prohić, Sarajevo, Bosnia and Herzegovina
Velimir Profozić, Zagreb, Croatia
Radivoje Radić, Osijek, Croatia
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Suad Sivić, Zenica, Bosnia and Herzegovina
Sonja Smole-Možina, Ljubljana, Slovenia
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MEDICINSKI GLASNIK
Official Publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina
Volume 12, Number 1, February 2016
Free full-text online at: www.ljkzedo.com.ba, and www.doaj.org (DOAJ, Directory of Open Access
Journals)
REVIEW
1
Cystic fibrosis: model of pathogenesis based on the apical membrane potential
Beatrica Kurbel, Saša Rapan, Sven Kurbel
7
The assessment of acid-base analysis: comparison of the “traditional” and the “modern” approaches
Jasna Todorović, Jelena Nešovic-Ostojić, Aleksandar Milovanović, Predrag Brkić, Mihailo Ille, Dušan
Čemerikić
19 Clonus: definition, mechanism, treatment
Ismail Boyraz, Hilmi Uysal, Bunyamin Koc, Hakan Sarman
Original
article
27 Human dental pulp mesenchymal stem cells isolation and osteoblast differentiation
Moustafa Alkhalil, Amer Smajilagić, Amira Redžić
33 Inflammatory cytokine gene polymorphism profiles in Turkish patients with ulcerative colitis
İlhami Gök, Fahri Uçar, Orhan Ozgur
40 False-positive 18-fluorodeoxyglucose positron emission tomography–computed tomography (FDG
PET/CT) scans mimicking malignancies
Zehra Yasar, Murat Acat, Hilal Onaran, Akif Ozgül, Erhan H. Dincer, Erdogan Cetinkaya, Nurdan A.
Korkmaz
47 Human West Nile virus infection in Bosnia and Herzegovina
Sead Ahmetagić, Jovan Petković, Mirsada Hukić, Arnela Smriko-Nuhanović, Dilista Piljić
52 Incidence and etiological agents of genital dermatophytosis in males
Asja Prohić, Mersiha Krupalija-Fazlić, Tamara Jovović Sadiković
57 Surgical therapy for pilonidal sinus in adolescents: a retrospective study
Tamer Sekmenli, Ilhan Ciftci
61 Impacts of education level and employment status on health-related quality of life in multiple
sclerosis patients
Selma Šabanagić-Hajrić, Azra Alajbegović
68 Importance of Herrings classification in predicting the outcome of aseptic necrosis of the femoral
head
Žarko Dašić, Miroslav Kezunović, Goran Pešić, Vesna Bokan, Mira Jovanovski
73 A retrospective review of 139 major and minor salivary gland tumors
Marija Trenkić Božinović, Dragan Krasić, Vuka Katić, Miljan Krstić
79 Effects of hormone replacement therapy on depressive and anxiety symptoms after oophorectomy
Danijela D. Ðoković, Jelena J. Jović, Jelena D. Ðoković, Marinela Ž. Knežević, Slavica DjukićDejanović, Dragana I. Ristić-Ignjatović
86 Mechanical prosthetic valve disease is related with an increase in depression and anxiety disorder
Yasemin Turker, Kurtulus Ongel, Mehmet Ozaydin, Yasin Turker, Funda Yildirim Bas, Mehmet Akkaya
93 Emotional profile and risk behaviours among tattooed and non-tattooed students
Matea Zrno, Maja Frencl, Dunja Degmečić, Ivan Požgain
99 The effect of anger management levels and communication skills of Emergency Department staff on
being exposed to violence
GozdeYildiz Das, Ilknur Aydin Avci
Letter to
Editor
105
Retraction
107
Occurrence and morphological characteristics of cataracts in patients treated with general steroid
therapy at the Cantonal Hospital Zenica
Jasmin Zvorničanin, Edita Zvorničanin
Increased counts and degranulation of duodenal mast cells and eosinophils in functional dyspepsiaa clinical study
Shijun Song, Yan Song, Haishan Zhang, Gaiqin Li, Xiaopei Li, Xiaohong Wang, and Zhen Liu
Medicinski Glasnik is indexed by MEDLINE, EMBASE (Exerpta Medica), EBSCO, Scopus, and Directory of Research Journals Indexing (DRJI)
REVIEW
Cystic fibrosis: model of pathogenesis based on the apical
membrane potential
Beatrica Kurbel1, Saša Rapan2, Sven Kurbel3
Department of Anesthesiology, Zagreb University Hospital, Zagreb, 2Department of Orthopedic Surgery and 3Department of Internal
Medicine, University Hospital, Osijek; Croatia
1
ABSTRACT
Corresponding author:
Saša Rapan
School of Medicine,
University Josip Juraj Strosmayer,
J. Huttlera 4,
31000 Osijek, Croatia
Phone: +385 31 512 800;
A simple model of cystic fibrosis (CF) is proposed, based on the
apical membrane (ApM) potential. The ApM of epithelial cells
is highly permeable to sodium and activation of CFTRs makes it
permeable to chloride. Calculated ApM potentials of cells with activated cystic fibrosis transmembrane conductance regulators (CFTRs) are between the sodium and chloride Nernst values and thus
allow rapid absorption of both ions in exocrine glands. In CF patients the potential is near the sodium Nernst value and thus more
salt is left in the ducts. Simulation predicts that the sodium driving
force increases more than 3.5 times if the ApM permeability for
Cl- increases from 5-94% of the sodium permeability. In pancreatic ductal cells basolateral sodium bicarbonate cotransporters
(pNBC1) allows influx of bicarbonates with sodium. Bicarbonates
are exchanged for intraductal chloride by anion exchanger 1 (AE1)
in the ApM. Activated CFTRs let some chloride to leak back to
ducts, followed by water that dilutes ductal proteins. Replenished
intraductal chloride allows more bicarbonate secretion. In CF patients, pancreatic water and bicarbonate secretion is limited by the
intraductal chloride pool.
Key words: membrane potential, cystic fibrosis, pNBC1, AE1
Fax: +385 31 512 833;
E-mail: [email protected]
Original submission:
21 August 2014;
Revised submission:
23 November 2014;
Accepted:
21 December 2014.
Med Glas (Zenica) 2015; 12(1):1-6
1
Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
This paper on electrophysiological aspects of cystic fibrosis is based on the previous paper about
importance of chloride (Cl-) membrane traffic
and Donnan effect of cytoplasmic proteins (1).
Cystic fibrosis (CF) is an inherited disease caused by dysfunctional chloride channels, cystic
fibrosis transmembrane conductance regulator
(CFTR) in various epithelial cells (2). Since this
disease is often diagnosed by measuring increased negativity of the transepithelial potential,
calculating the basolateral and apical membrane
potentials by using the Goldman’s equation calculators seemed suitable for the model of pathogenesis (3,4).
BASIC ASSUMPTIONS BEHIND THE PROPOSED
MODEL
The model of cystic fibrosis pathogenesis presented here uses several assumptions.
An example: the resting potential in neurons is
near the potassium Nernst potential and traffic of
K+ is opposed by a strong electric force. Traffic
of ions across the membrane is intensive during
the action potential.
The apical membrane (ApM) of epithelial cells faces the ductal lumen. Due to presence of
ENaCs, ApM is highly permeable to sodium
and activation of CFTRs makes it permeable to
chloride. Except in some kidney cells, ApMs of
various epithelial cells are probably less permeable to potassium than their basolateral membrane
(BlM). This means that the actual ApM potential
depends mainly on Na+ and Cl- entering the cell
along their concentration gradients. Since these
two ions have very different Nernst values, the
expected intermediary membrane potential would allow both ions to enter with ease.
The CFTR is among other regulators of the ductal pancreatic cell function: anion exchanger 1
(AE1), responsible for the exchange of chloride
for bicarbonate (HCO3-), sodium-hydrogen antiporter 1 (NHE-1), encoded by the SLC9A1 gene,
pNBC1 that imports two bicarbonate ions and
one sodium (Na+) in the cell (5).
In normal individuals and in CF patients transepithelial potential is negative. Since the outer epithelial surface consists of closely arranged apical
membranes, this potential has to be related to the
actual potential of apical membranes, although
the measured transepithelial potential is probably
smaller than the actual ApM potential.
Dysfunctional CFTRs in patients with cystic fibrosis affect several organs and tissues. Genes
for all these structures of ion traffic are variably
expressed in all epithelial cells affected by cystic
fibrosis (6,7), but high expressions of CFTR and
pNBC1 genes seem unique for pancreas.
THE PROPOSED ELECTROPHYSIOLOGICAL
MODEL OF THE APICAL MEMBRANE POTENTIAL
Membrane ion traffic is governed by electric fields, concentration gradients and ion specific
membrane permeability. All cell membranes act
as diffusion bottlenecks and if ions accumulate
near the membrane, their electric charges alter
diffusion of other ions (5).
If a membrane allows only one ion to diffuse
along its concentration gradient the diffusion will
continue until the membrane reaches the Nernst
value of that ion. Further ion traffic depends on
Brownian kinetic that washes away ions near the
membrane.
Cell membranes are permeable to more than one
ion and the actual membrane potential is calculated by the Goldman equation (3,4). Cells permeable to potassium (K+) and chloride ions normally
2
have membrane potential somewhere between
the respective Nernst values.
Table 1 shows model predictions of the apical
membrane potentials in cells with and without
functional CFTRs. The Goldman’s equation calculators (3,4) are used to simulate transepithelial
voltage in normal ducts with increased Na permeability through ENaCs, and high Cl- permeability through activated CFTRs. For the 1st, basolateral column values of the generic cell setting
in the calculator (3) were used. Sodium and potassium permeability values were interchanged in
the remaining two columns that show the apical
membrane potentials. Without functional CFTRs
(3rd column with low chloride permeability) the
apical membrane potential is so near the sodium
Nernst value that diminished sodium traffic depends on Brownian mediated diffusion of cations
away from the apical membrane. With functional
CFTRs (2nd column with chloride permeability
that is 94% of sodium permeability), the apical
membrane potential is in the middle between the
Kurbel et al. Membrane potential model of cystic fibrosis
Table 1. Simplistic model of ion traffic of epithelial cells of normal individuals and patients with cystic fibrosis, calculated by
Goldman’s equation (3,4)
Parameters of Goldman’s equation
Basolateral membrane
PNa+
5
[Na+]out
145
[Na+]in
15
PK+
100
Potassium
[K+]out
4.5
[K+]in
120
PCl10
Chloride
[Cl-]out
116
[Cl-]in
20
ENa
+60.6
Nernst potentials
EK
-87.7
(mV)
ECl
-47.0
VDF,Na
-121.09
Electrochemical
VDF,K
+27.22
driving force (mV)
VDF,Cl
-13.53
VDF,Na ratio of Na+ traffic: activated CFTRs / non-activated CFTRs
Goldman’s equation results (mV)
-60.5
Predicted potential between intraductal content & IF (assumed to be
0 mV) IF-(apical-basolateral)
Sodium
Comments
Apical membrane permeability in epithelial cells
Epithelium with cAMP activa- Epithelium without cAMP activated
ted CFTRs
CFTRs, as in CF patients
100
145
15
5
4.5
120
94
116
20
+60.6
-87.7
-47.0
-54.40
+93.91
+53.16
+6.2
100
145
15
5
4.5
120
5
116
20
+60.6
-87.7
-47.0
-15.28
+133.03
+92.28
3.56
+45.3
-66.7
-105.8
Na+ and Cl- both easily cross low influx of Na+ due to membrane
both K+ and Cl- easily cross since
since the apical membrane
potential close to the Na+ Nernst
the basolateral potential is intermepotential is intermediary to their value and almost no Cl- or K+ influx
diary to their Nernst values
Nernst values
due to low permeability
Cl- and Na+ Nernst values, so the electric field is
allowing the maximal traffic of these two ions.
The model predicts that permeability values of
sodium and chloride need to be almost equal to
allow the maximal influx of these ions through
the apical membrane. Predicted potential difference between intraductal content and interstitial fluid (IF) is also calculated. It is assumed that
this potential is the source of the measured negative transepithelial potential and, as expected,
potential is more negative in epithelial cells with
dysfunctional CFTRs.
Apical membranes of epithelial cells are highly
permeable to sodium (ENACS), and probably
some potassium. Permeability to Cl- through CFTRs depends on activation by cAMP (5). Chloride that enters through functional CFTRs maintains an intermediary apical membrane potential
that allows rapid absorption of both ions (Table
1). In this way, activation of CFTRs modulates
salt absorption in various exocrine glands.
Epithelial cells in exocrine glands of patients
with cystic fibrosis are in a specific situation.
Their apical membranes cannot modulate the
Cl- permeability via CFTRs and only the small
potassium permeability keeps the membrane potentials from hitting the sodium Nernst value that
would further compromise Na+ diffusion. When
the ApM is compared with the IF potential of 0
mV, a more negative difference can be predicted
in these patients (Table 1), leading to more negative intraductal potentials. Altered permeability
to chlorine makes the apical membrane potential so high that this reduces sodium transport and
more salt is left in the ducts. Based on simulation in Table 1, the sodium driving force increases
more than 3.5 times if the apical membrane permeability for Cl- increases from 5 to 94% of the
sodium permeability.
The remaining question is why respiratory tract
mucosa is the most damaged epithelial tissue in
cystic fibrosis patients when similar transepithelial potentials are found in sweat glands and
in salivary glands without much damage. A plausible explanation is that it is a consequence of
the failed salt reabsorption from the evaporating
fluid that covers respiratory mucosa. Each day a
normal adult exhales some 400 mL of pure water,
and near one half of it comes from the respiratory
airways. The only way to prevent accumulation
of hypertonic residues after evaporation is quickly to reabsorb salt before evaporation. This desalinization is done via combined action of ENACs
and CFTR in normal individuals. In CF patients
this process is compromised and some minerals
from 150 to 200 ml of evaporated IF similar fluid
3
Medicinski Glasnik, Volume 12, Number 1, February 2015
remain on mucosal surfaces after water evaporation. The hypertonic ductal content forces some
water to remain in ducts due to osmosis and this
salty microenvironment is prone to infection and
biofilm formation by respiratory bacteria (8).
The presented model interpretation of CFTR
function in pancreatic ductal cells is complex.
Basolateral membranes in these calls contain
pNBC1 that carries two bicarbonate ions with
sodium, and each action allows three osmotically and electrically active particles to enter the
ductal cell. Excess sodium is taken away by Na+/
K+ pumps but the faith of bicarbonates is variable. Bicarbonates can interact with intracellular
H+ ions and form carbonic acid that can interact
with carboanhydrase and leave the slightly more
alkaline cell as CO2. Alternatively, bicarbonates
can leave the cell in exchange for intraductal
Cl- via AE1 structures in the apical membrane.
Due to this trade, the overall sum of chloride and
bicarbonates concentrations in the ductal content
remain almost the same until secretion of bicarbonates is stimulated through opening of CFTRs
in the apical membrane.
The AE1 action is probably bidirectional, as is
described in erythrocytes during the chloride
shift (5). This means that bicarbonates leave the
cell if intraductal Cl- is higher than the cytoplasmic level. Nevertheless, when the pool of intraductal Cl- is exhausted, the AE1 stops and both
bicarbonate and chloride levels in pancreatic
ducts and in ductal cells become similar, meaning
that without replenishing of the ductal Cl- pool,
pancreatic juice is limited in the bicarbonate content and thus in the enzymatic activity.
Normally, due to various stimuli, intracellular
cAMP opens CFTRs on the apical membrane
and some influxed Cl- leak back to ducts, thus
allowing more bicarbonates to be secreted by
AE1. The consequence is that the sum of Cl- and
bicarbonates increases during the bicarbonate
secretion. This is in concordance with the report
that pancreatic secretion in two dogs shows more
than a 100-fold variation (9), while concentrations of sodium and of potassium were independent of secretory rates. At low secretory rates,
bicarbonate levels dropped to values equal to, or
lower than plasma concentration, while the concentration of chloride varied inversely with that
of bicarbonate.
4
It is here proposed that by returning the influxed
Cl- ions, the CFTRs add some water to the ductal content, since Cl- and bicarbonates are both
osmotically active and this added water dilutes proteins secreted by acinar pancreatic cells,
allowing the diluted and highly alkaline juice to
leave pancreas. In patients with CF, the model
predicts that the basal secretion produces juice
with limited concentration of bicarbonates until the ductal chloride pool is so exhausted that
Cl- concentration is near the cytoplasmic level.
This interpretation suggests that accumulated
intracellular excess of bicarbonates cannot leave
to the duct due to AE1 function failure, and this
can lead to cellular alkalosis, via carboanhydrase action. It is well known that cellular alkalosis
increases Donnan effect of cytoplasmic proteins
due to increased number of protein-bound charges in alkaline pH. The model predicts that this
might block further influx of bicarbonate ions
via pNBC1, despite the sodium gradient and increased affinity for cations by the Donnan. This
means that the ion traffic across the ductal cell
apical membrane would be halted until the ductal
chloride pool is replenished by the acinar cells.
This interpretation is in concordance with reports
that the defect in agonist-stimulated ductal bicarbonate secretion in patients with CF is predominantly due to decreased NBC-driven bicarbonate
entry at the basolateral membrane, in the absence
of functional CFTR (10). The consequence is that
without CFTRs pancreas lacks cAMP modulated
secretion of bicarbonates, chloride and water
needed to dilute proteins in the pancreatic juice
below the dangerous concentration of enzyme
activation within the gland.
POSSIBLE EXTRAPOLATIONS OF THE PRESENTED MODEL
Simplistic electrophysiological model of CF
changes in ion traffic in various cells presented
here clearly suggest that ion traffic is seriously
altered in CF patients who are homozygous for
the mutation. The remaining question is what can
be expected in heterozygous individuals without
evident CF. Their phenotype needs to carry some
survival advantage that allowed the CF mutation
to spread in European nations. Estimated mutation incidences range from 1:200 in northern Sweden, 1:143 in Lithuanians, 1:38 in Denmark to
Kurbel et al. Membrane potential model of cystic fibrosis
high values in Italy, France, Switzerland, British
Isles, Germany and Greece (11,12). On the other
hand, Saamis and Finnish have the lowest rates
in Europe (13), while the highest incidences have
been found in some disparate locations such as
Ireland, Romania, Slovakia and Bulgaria (14).
It is certain that the overall information is blurred
by continuous human migrations during the last
50 Ky. This period is crucial due to the estimate
that the most common CF linked mutation is possibly no more than 52 Ky old (15).
The model presented here is possibly related to
the CF incidence interpretation proposed by M.
Lubinsky (16) that involves complex interactions
between climate, pathogens and human physiology. The climate factors that are considered are
temperature, latitude and altitude, the probable
pathogen is tuberculosis while the physiological mechanisms involve vitamin D availability
and arterial hypertension. The basic idea is that
altered Cl- transport suppresses tuberculosis and
alleviates the risk of hypertension caused by salt
ingestion. On the other hand, low vitamin D availability, due to scarce sun exposure, increases the
chances for tuberculosis and hypertension. This
vitamin D and CFTR mutation link is based on
the distribution of CF mutations with a high incidence among people from northern latitudes with
low vitamin D levels in food and low insolation,
except among Inuits, who have rich vitamin D sea
food diet. On the other hand, cold climate, high
altitude and vitamin D deficiency can all increase
risk of arterial hypertension that becomes a very
strong selective pressure during pregnancy. Thus,
the heterozygote individuals for the CF mutation
might have been more resistant to hypertension
in this setting due to increased salt losses.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATION
Competing interest: none to declare
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Shumaker H, Amlal H, Frizzell R, Ulrich CD 2nd,
Soleimani M. CFTR drives Na+-nHCO-3 cotransport
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Wennberg C, Kucinskas V. Low frequency of the
delta F508 mutation in Finno-Ugrian and Baltic populations. Hum Hered. 1994; 44:169-71.
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Farrell PM. The prevalence of cystic fibrosis in the
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Wiuf C. Do delta F508 heterozygotes have a selective advantage? Genet Res 2001; 78:41-7.
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5
Medicinski Glasnik, Volume 12, Number 1, February 2015
Model mehanizma oštećenja u cističnoj fibrozi temeljen na
apikalnom membranskom potencijalu duktalnih stanica
Beatrica Kurbel1, Saša Rapan2, Sven Kurbel3
Klinika za anesteziologiju, Klinički bolnički centar Zagreb, Zagreb, 2Odjel za ortopediju i 3Klinika za unutarnje bolesti, Klinički bolnički
centar Osijek, Osijek; Hrvatska
1
SAŽETAK
U radu je prikazan jednostavni model oštećenja u bolesnika s cističnom fibrozom (CF), temeljen na
membranskom potencijalu apikalne membrane (APM) duktalnih stanica koja je normalno vrlo propusna za natrij, a u slučaju aktivacije CFTR kanala postaje propusna za klorid. U modelu izračunati APM
potencijali stanica s normalnom aktivnošću CFTR kanala pokazuju vrijednosti između Nernstovog potencijala natrija i Nernstovog potencijala klora, što znači da oba iona prolaze s lakoćom i apsorbiraju se
iz vodova egzokrinih žlijezda. U bolesnika s CF-om, izračunati apikalni membranski potencijal je blizu
Nernstove vrijednosti za natrij, što znači da električno polje priječi apsorpciju natrija a time i više soli
ostaje u vodovima žlijezda. Simulacija predviđa da pokretačka snaga apsorpcije natrija raste više od 3,5
puta, ako se APM propusnost za klor povećava u rasponu od 5% do 94% propusnosti za natrij. U stanica vodova gušterače, bazolateralne membrane sadrže natrij/bikarbonata kotransporter (pNBC1) koji
omogućuje prolaz bikarbonata zajedno s natrijem. Bikarbonati se razmjenjuju za intraduktalni klorid
preko anionskog izmjenjivača 1 (AE1) na apikalnoj membrani. Aktivni CFTR kanali dozvoljavaju povrat klorida iz stanice nazad u vodove pankreasa. Klorid prati voda koja razrjeđuje sadržaj u vodovima.
Recirkuliranje klorida u vodove omogućuje veću sekreciju bikarbonata. U bolesnika s cističnom fibrozom, sekrecija bikarbonata i vode je ograničena intraduktalnom količinom klorida koja se ne obnavlja
kroz CFTR.
Ključne riječi: membranski potencijal, cistična fibroza, pNBC1, AE1
6
REVIEW
The assessment of acid-base analysis: comparison of the
“traditional” and the “modern” approaches
Jasna Todorović1, Jelena Nešovic-Ostojić1, Aleksandar Milovanović2, Predrag Brkić3, Mihailo Ille4,
Dušan Čemerikić1
Department of Pathological Physiology, 2Insitute of Occupational Health, 3Department of Medical Physiology, 4Department of Surgery;
School of Medicine, University of Belgrade, Belgrade, Serbia
1
ABSTRACT
Corresponding author:
Jelena Nešović Ostojić
Department of Pathological Physiology,
School of Medicine
Dr. Subotića 1/II, 11000 Belgrade, Serbia
Phone: +381 11 2685 282;
Fax: +381 11 2685 340;
E mail: [email protected]
Three distinct approaches are currently used in assessing acid-base
disorders: the traditional - physiological or bicarbonate-centered
approach, the base-excess approach, and the “modern” physicochemical approach proposed by Peter Stewart, which uses the
strong ion difference (particularly the sodium chloride difference)
and the concentration of nonvolatile weak acids (particularly albumin) and partial pressure of carbon dioxide (pCO2) as independent variables in the assessment of acid-base status. The traditional approach developed from the pioneering work of Henderson
and Hasselbalch and the base-excess are still most widely used
in clinical practice, even though there are a number of problems
identified with this approach. The approach works well clinically
and is recommended for use whenever serum total protein, albumin and phosphate concentrations are normal. Although Stewart’s
approach has been largely ignored by physiologists, it is increasingly used by anesthesiologists and intensive care specialists, and is
recommended for use whenever serum’s total protein, albumin or
phosphate concentrations are markedly abnormal, as in critically
ill patients. Although different in their concepts, the traditional and
modern approaches can be seen as complementary, giving in principle, the same information about the acid-base status.
Key words: acid-base balance, anion gap, strong ion difference,
bicarbonate, base excess, nonvolatile weak acids, strong ion gap
Original submission:
03 September 2014;
Revised submission:
21 November 2014;
Accepted:
18 December 2014.
Med Glas (Zenica) 2015; 12(1):7-18
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Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
Historically, two different conceptual approaches have been evolved among clinicians and
physiologists for interpreting acid-base phenomena. The “traditional” or bicarbonate-centered
approach relies qualitatively on the HendersonHasselbalch equation, whereas the “modern” or
strong ion approach utilizes either original Peter
Stewart equations or its simplified version derived by Peter Constable (1,2). The strong ion and
bicarbonate-centered approaches are qualitatively identical even in the presence of non-bicarbonate buffers. The “traditional” approach for interpreting acid-base disorders developed from the
pioneering work of Henderson and Hasselbalch
is still the most widely used in clinical practice.
One of the advantages of this approach is that it
is relatively easy to understand and to apply in
clinical situations (3). The strong ion model offers a novel insight into the pathophysiology of
mixed acid-base disorders and is mechanistic (4).
The newest approach has steadily gained acceptance especially among critical-care physicians
and anesthesiologists (5,6). In this review we
will discuss the advantages and disadvantages of
Stewart’s method of acid-base balance compared with traditional bicarbonate-based approach,
what will help better understanding in the complexity of acid-base balance.
THE “TRADITIONAL” APPROACH
In the early 1900s sufficient laboratory and
observational evidence had been accumulated to
define the influence of carbon dioxide on pH and
to suggest a role for serum bicarbonate in characterizing acid-base disorders. Henderson recognized that carbon dioxide and bicarbonate were key
elements of carbonate mass action, as shown by
his famous equilibrium equation (7). Hasselbalch
reformulated this equation by introducing the negative logarithmic pH notation and by applying
Henry’s law to generate the pCO2 term. A buffer
is substance that has ability to bind or release hydrogen ions (H+) in solution, thus keeping the pH
of the solution relatively constant despite the addition of considerable quantities of acid or bases
(8). Bicarbonate is the most important buffer in
biological system at constant pCO2, and Henderson-Hasselbalch equation provides a simple relationship among the respiratory parameter pCO2,
8
the non-respiratory parameter bicarbonate, and
overall acidity parameter, pH (9). But a change
in bicarbonate concentration does not reflect the
total amount of non-carbonic acid or base, because there are non-bicarbonate buffers, especially
albumin and hemoglobin (10). Even more important is the fact that bicarbonate concentration is
not independent of variation in pCO2. As pCO2
increases carbonic acid is buffered by non-bicarbonate buffers and the bicarbonate concentration
increases. An elevated bicarbonate concentration
may therefore erroneously be interpreted as a metabolic alkalosis when respiratory acidosis is the
cause (11). So, this equation lists pCO2 and bicarbonate as independent predictors of pH while,
in fact, these variables are interdependent. Consequently, this equation merely serves as a description of a patient’s acid-base state but does not
provide insight into the mechanism of the patient
s acid base disorder (12,13).
The traditional approach to clinical acid-base interpretation (bicarbonate-centered approach) is
based on Lowry-Bronsted theory, wherein acids
are defined as substances capable of donating
protons, and the centrality of the bicarbonate
buffer system in whole body acid-base homeostasis, given that it is composed of a volatile
and nonvolatile buffer pair. Two bicarbonatecentered approaches evolved: the comparative
∆HCO3/∆pCO2 approach (14) and the base excess (BE) approach (15).
The comparative ∆HCO3/∆pCO2 approach
Qualitatively, this approach starts with the
assumption that the components of the HCO3CO2 equilibrium reaction are in equilibrium with
non-bicarbonate buffers (albumin, phosphate, hemoglobin) (3).
Two bicarbonate-centered approaches evolved:
the comparative ∆HCO3/∆pCO2 approach (14)
and the base excess (BE) approach (15).
The ∆HCO3/∆pCO2 approach has been criticized (2,11) for being qualitative in nature and
incapable of quantifying acid or base loads that
result in metabolic acid-base disorders. In particular, because body compartments consist of
multiple buffers, it is argued that HCO3 buffer is
only one of several buffers that were protonated
by an H+ load (16). Therefore, the ∆HCO3 would underestimate the actual total body acid bur-
Todorović et al. Assessment of acid-base analysis
den as, for example, in a patient with keto-acidosis (17). Additional criticism is the fact that
a component of the change in the HCO3 is due
to a shift in the HCO3-CO2 equilibrium reaction
as a result of the compensatory ventilatory response (altered pCO2) that occurs in patients with
metabolic acid-base disturbances (18). Moreover, the compensatory ventilatory induced alteration in the pCO2 causes a change in renal
NH4 and HCO3 and titrate-able acid excretion.
This results in a further change of the [HCO3]
(which is independent of the acid-base load and
independent of the change due to the shift in the
HCO3-CO2 equilibrium reaction) (19, 20). Finally, a disadvantage is that the ∆HCO3/∆pCO2
ratio expected in acute respiratory acid-base
disorders depends on the number of proton binding sites on non-bicarbonate buffers (albumin,
hemoglobin, phosphate) (2). Thus, the bicarbonate concentration may be used as a screening
parameter of a non-respiratory acid-base disturbance when respiratory disturbances are taken
into account (2).
One possibility to solve this problem is to measure the bicarbonate concentration at a standard
condition (when pCO2 is 40 mm Hg) - value that
we call standard bicarbonate, or to use the sum
of bicarbonate and non-bicarbonate buffer anions – value that we call buffer base (changes in
pCO2 would not affect the buffer base concentration as the rise in bicarbonate concentration
associated with a rise in pCO2 is matched with a
fall in concentration of other buffer anions) (11).
Disagreement about the best parameter to describe acid-base balance in the body has dominated
this area of physiology for more than three decades (19). The Henderson-Hasselbalch equation
does not satisfactorily explain why the apparent
value of pK1 in plasma depends on pH, protein
concentration and Na+ concentration as well as
the fact that only a non-linear relationship exists
between log pCO2 and pH in vivo (markedly in
acidic plasma) (2, 21). So, this equation (especially ∆∆HCO3/∆pCO2 ratio) is criticized because
of its qualitative nature and impossibility to quantify the acid or base excess that exists in acid
base balance disorders (20). So, this approach
can only be accurately applied to human plasma
at approximately normal pH, protein concentration, and Na+ concentration (22).
Base excess (BE) approach
Dissatisfactions with the Henderson-Hasselbalch
approach prompted Singer and Hastings to propose in 1948 that plasma pH may be determined
by two independent factors, pCO2 and net strong
ion charge as the difference between all of the
cations (termed total base) and anions (termed
total fixed acid). They introduced the concept of
buffer base (BB), (23) as the sum of all plasma
buffer anions, i.e. bicarbonate plus the non-volatile weak acid buffers (albumin, phosphate)
(3,24). These parameters (standard bicarbonate
and buffer base) suggested as measures of metabolic acid-base disturbance are now obsolete.
It is shown that a change in buffer base corresponds to a change in the metabolic component
of acid-base balance, and yields the base excess
(BE) methodology (25-28). Base excess is traditionally calculated from Van Slyke equation
as developed by Siggard-Anderson (29). In the
late 1950s, Siggaard-Andersen and colleague, at
a fixed temperature and partial pressure of carbon
dioxide, measured the plasma bicarbonate concentration and compared the difference between
this value and a reference (30). When corrected
by a constant, this difference yields the base excess (BE) as a more sensitive measure of metabolic
imbalance. Clinically, this base excess represents
the amount of acid per unit volume that must be
added to achieve a normal pH (27). Blood base
excess was introduced to replace plasma [HCO3]
with a measure of the metabolic component that
is independent from the respiratory component,
and incorporates the effect of hemoglobin as a
buffer (30). Base excess represents the amount
of acid or alkali that must be added to 1l of oxygenated blood exposed in vitro to a pCO2 of 40
mm Hg to achieve the average normal pH of 7.40
(30). Acid is required when blood pH is higher
than 7.40 (positive BE or base excess), whereas alkali is needed when blood pH is lower than
7.40 (negative BE or base deficit). Under normal
conditions, the average blood BE is zero (11).
Criticism of this method followed soon (18, 31,
32). For example, the laboratory BE value represents the net effect of all metabolic acid-base abnormalities. Therefore, the effect of coexisting metabolic acidosis and alkalosis may lead
to falsely suggest that no acid-base abnormality
exists. Furthermore, this BE does not propose
9
Medicinski Glasnik, Volume 12, Number 1, February 2015
an etiology for the acid-base disorder once an
abnormality is discovered (33). During in vitro
blood titration, any CO2 –induced increase in
plasma concentration of bicarbonate is attended
by an equivalent decrease in the anionic charge
of non-bicarbonate buffers (mainly hemoglobin).
This comes from the binding of H+ released from
carbonic acid, and as a result blood base excess
remains constant. Base excess becomes controversial because in vivo base excess is altered by
purely respiratory changes. This occurs because
blood freely exchanges ions with interstitial fluid, which contains little or no protein buffer. Therefore, as PaCO2 changes in vivo, whole blood
base excess changes measurably as bicarbonate
and other ions equilibrate between blood and the
interstitial space. Thus, primary PaCO2 change in
living organism causes base excess to move in
the opposite direction, despite demonstrable in
vitro CO2 invariance. When the PaCO2 is varied
in vivo as a result of hypoventilation or hyperventilation, blood base excess does not remain
constant because a concentration gradient for bicarbonate develops between blood and interstitial
compartment. Accordingly, bicarbonate is removed from the plasma into the interstitial fluid in
hypercapnia resulting in a negative base excess,
whereas bicarbonate is added to plasma from the
interstitial fluid in hypocapnia causing positive
base excess (1,5,34). When the pCO2 is varied in
vivo by CO2 inhalation or hyperventilation, not
only blood but all extracellular fluid is equilibrated with the new pCO2. When pCO2 increases
pH tends to decrease more in the poorly buffered
interstitial fluid than in the well buffered blood.
H+ therefore tends to diffuse from the interstitial
fluid into the blood where they are buffered in
the erythrocytes. This addition of H+ to the blood
is registered as a fall in whole blood base excess, while the plasma base excess rises slightly.
The actual ionic movements involve a diffusion
of bicarbonate ions from the erythrocytes to the
plasma and interstitial fluid in exchange for chloride ions. However, the base excess of the total
extracellular fluid remains constant, during acute
pCO2 changes in vivo. It is not possible to obtain
a sample of average extracellular fluid (including
erythrocytes). However, a blood sample diluted
threefold (1 + 2) with its own plasma may serve as a model of extracellular fluid. This pitfall
was addressed by introducing the extracellular
10
base excess or standard base excess by Siggaard-Andersen (11), as a measure of the metabolic
component that is modeled by diluting the blood
sample threefold with its own plasma or estimated by using the blood base excess at a hemoglobin concentration of 50 g/l. Thus, standard
base excess or extracellular base excess is modeled from the existing PaCO2 and pH, at a hemoglobin concentration of approximately 50 g/l,
to replicate the mean extracellular hemoglobin
concentration and does appear to have acceptable
CO2 invariance in vivo, although it is less than
perfect. The base excess equation was modified
to standardize the effect of hemoglobin on CO2
titration in order to improve the accuracy of the
base excess in vivo. Base excess of such model
of the extracellular fluid may be calculated using
the Van Slyke equation and now it represents the
most relevant measure of a metabolic acid-base
disturbance. Standard base excess is therefore roughly the corrective dose of sodium bicarbonate
in mmol per liter of extracellular fluid. Currently,
many blood gas analyzers calculate standard base
excess from measured pH, pCO2 and hemoglobin. Modern pH-blood gas analyzers calculate
the extracellular base excess and present the result with the same ease as they present the actual
bicarbonate concentration. Determination requires an arterial blood sample and a modern pH
blood gas analyzer. Total CO2 (bicarbonate) measured in venous plasma using an electrolyte analyzer or multi-purpose chemical analyzer may be
used as screening parameter in patients without
respiratory disorders. Base excess is numerically
identical with the delta buffer base of Singer and
Hastings: the change in buffer base from the value at pH 7.4 and pCO2 40 mm Hg. However,
standard base excess still yields results that are
slightly unstable as pCO2 changes. Furthermore,
the equation assumes normal concentration of
non-bicarbonate buffers (albumin and phosphate), and when albumin or phosphate is decreased,
a common scenario in the critically ill patients,
standard base excess will result in even more
instability (4,11,23,35). Even that standard base
excess became (and remains) an optional computation that could be printed by most commercial
blood gas analyzers, Bill Schvartz and Arnold
Relman in Boston 1967 continued to advocate
for the use of the actual bicarbonate concentration in assessing a metabolic component of acid-
Todorović et al. Assessment of acid-base analysis
base status. Discussions in letters to the editors
of several journals were called “the great transAtlantic acid-base debate” by John Bunker, and
Boston and Copenhagen school were unreconciled (4,11,23,35). So, in a traditional approach the
metabolic component of acid-base physiology is
based on the analysis of plasma concentrations of
bicarbonate and standard base excess. Both are
usually used in clinical practice and their calculations are included in all blood gas analyzers.
Despite these complexities, the comparative
∆HCO3/∆pCO2 and BE approaches evolved historically as two alternative “bicarbonate-centered” approaches for diagnosing clinical acid-base
disturbances (2,36).
The anion gap method
An additional diagnostic contribution in assessing metabolic component of acid-base analysis, the anion gap method, was eventually
introduced. The anion gap is defined as the difference between unmeasured plasma anions
and the unmeasured plasma cations. A normal
anion gap is 12±4 mmol/l. Since normally the
total unmeasured anions exceed the total unmeasured cations, there is an anion gap. Under normal conditions, the bulk of the serum anion gap
(approximately 80%) is due to the sum of the anionic charges on circulatory proteins (albumin is
the most abundant of circulating proteins). The
charge on albumin at pH 7.4 contributes ~66%
of the total net charge calculated by the anion
gap, with the remainder composed of phosphate, urate, lactate, ketone bodies, and sulfate (37).
Usually proteins behave as anions, contributing
about 13 mmol/L to the unmeasured anion pool
(pH-independent protein charge is 3.7 mmol/L,
pH-dependent protein charge is 10.3 mmol/ L,
pH-dependent phosphate charge is 1.0 mmol/L,
the net protein charge of human plasma = 3.7 +
10.3 – 1.0 = 13 mmol/L) (37). Therefore, changes
in the concentration of serum albumin would be
expected to alter the serum anion gap. For each
10 g/L decrement in the serum concentration of
albumin, the serum anion gap was decreased by
2.5 mmol/L, and needed to be corrected to compensate for abnormal albumin concentrations
(thus, for example, significant ketoacidosis, could be missed in a diabetic patient with hypoalbuminemia): corrected anion gap = observed anion
gap – 0.25 x ([normal albumin g/L] - [abnormal
albumin g/L]), (38). This corrected anion gap can
unmask an organic acidosis that was previously
undetected in the setting of hypoalbuminemia
(33). So, changes in the anionic effect of albumin
will alter both the anion gap and the base excess.
The presence of organic acid (XAH), which
dissociates to form the anionic species XA while consuming bicarbonate results in increased
unmeasured anions (UA) and a subsequently increased anion gap. Therefore, an increase in the
calculated anion gap compared to the institutional reference, suggests the presence of an organic
metabolic acidosis. Thus, when anion gap acidosis exists, the increase in the anion gap should
qualitatively mirror the fall in bicarbonate. Disruption of this expected relationship is indicative
of certain mixed acid-base disorders (39). The
small size of the anion gap is most likely to result from a reduced concentration of the normal
“unmeasured anion” albumin in critically ill patients. Globulins do not have a significant charge
contribution compared to albumin since their pKa
is much greater than plasma pH (Ka is the effective equilibrium dissociation constant for plasma
weak acids). As myeloma proteins have isoelectric points >7.4 they become positively charged
in the serum and behave as cations. In this way
they may lead to a reduced anion gap by creating
an excess of positively charges ions. That has to
be counterbalanced by an increase in anions, mainly chloride. This explains why in about 30% of
myeloma or gammapathies the anion gap could
be <3 mmol/l (40).
THE “MODERN” APPROACH
In late 70s and early 1980s Peter Stewart proposed that the generalized Arrhenius definition of
acid (substance that, when dissolved in water,
produces increased concentration of H+) with
Naunyn’s ideas (acid-base status was partly determined by electrolytes, particularly sodium
- base forming and chloride - acid forming), is
more useful to outline physiology than the Bronsted-Lowry definition (acid-donate proton, base
acceptor of proton), (41). In 1978 Stewart questioned the traditionally accepted approach used
to analyze acid-base chemistry. He modeled a
solution which contained a complex mixture
of ions of constant charge over the physiologi-
11
Medicinski Glasnik, Volume 12, Number 1, February 2015
cal pH range (Na+, K+, Ca2+), nonvolatile proton
donor/acceptors which transfer H+ within the
physiological pH range (albumin, phosphate, hemoglobin, metabolizable organic compounds),
and the volatile bicarbonate-CO2 buffer system
composed of CO2, HCO3, H2CO3, and CO32-.
According to requirements of electro neutrality,
the law of conservation of mass and certain equilibrium constants, Stewart solved a fourth-order
polynomial equation for calculating the H+ concentration. His analysis did not depart from the
traditional approach to acid-base chemistry as a
result of the equations that are derived. Pivotal
to the Stewart formulation was the categorization
of certain species as being dependent or independent variables in relationship to their purported
role in determining and modifying the H+ concentration of solution. At first, H+, OH-, HCO3,
and CO32- were categorized as dependent variables (the mass balance of these species in a solution or specific body fluid compartment could
not per se affect the H+ concentration). Finally,
he contended that H+ concentration was a function of three variables: strong ion difference (SID)
(the difference in the net charge of fixed cations
and anions fully dissociated in solution), partially dissociated weak acids (albumin, phosphate)
(ATOT), and the partial pressure of carbon dioxide (pCO2) of the solution (2). According to the
principle of electro neutrality, SID is balanced of
the weak acids (albumin, phosphate) and CO2.
Therefore, SID can be defined either in terms of
strong ions or in terms of the weak acids and CO2
offsetting it. Of note, the SID defined in terms of
weak acids and CO2, termed as the effective SID
and is identical to the buffer base term coined by
Singer and Hastings over half a century ago. So,
changes in standard base excess also represent
changes in SID (42).
Stewart hypothesized that water dissociates into
H+ and OH- to a greater or a lesser extent when
(SID), (ATOT ) or pCO2 change. Aqueous solutions contain a virtually inexhaustible source of
H+. Although pure water dissociates only slightly
into H+ or OH-, electrolytes and CO2 produce
powerful electrochemical forces that influence
water dissociation. SID has a powerful electrochemical effect on water dissociation, and hence
on H+ concentration. As SID becomes more positive, H+, a “weak cation”, decreases - (and pH
12
increases) in order to maintain electrical neutrality. Strong ions cannot be created or destroyed
to satisfy electro neutrality but H+ ions are generated or consumed by changes in water dissociation (30). This method emphasizes the role
of water dissociation as a proton source and the
association of water to consume protons as the
driving force behind changes in blood pH. The
relative balance of plasma positive and negative charges, including those on serum proteins,
most notably albumin, drives water dissociation
and association by the law of mass action (43).
Stewart approach puts water dissociation at the
center of the acid-base states of body fluids. pH
of a body fluid is a function of water dissociation
modified by pCO2, other weak acids and certain
electrolytes (5,44). To date there have been no
empirical observations that confirm water dissociation as the mechanism whereby (SID), (ATOT)
or pCO2 affect pH. Thus, the disadvantage of Siggaard-Andersen approach is that it implies adding or introducing H+ to the solution, which is
impossible. The more general Stewart’s approach
explains the acid base variations over more valuable physical basis. This physicochemical approach can be helpful in understanding mechanisms
barely understandable using traditional approach (45). The Stewart approach is a very general
physicochemical method that uses charge and
mass balance to deduce an expression for proton
concentration. Similarly, the base excess method
is another very general physicochemical approach, but one that uses proton balance to calculate
changes in proton concentration by using the Van
Slyke equation (46).
Thus, Stewart challenged the traditional bicarbonate-based method of diagnosis and treating
acid-base disorders and proposed an approach
based primarily on charge differences between
strong cations and anions. He suggested that
three independent factors, the pCO2, the strong
ion difference, and the total non-volatile weak
acid concentration may be used to analyze the
causes of acid-base disorders. These three factors control other variables including hydrogen
ion concentration and bicarbonate concentration
which are dependent variables. Increases in pCO2
and total weak acid concentration increase acidity. Decreases in strong ion difference increase
acidity. This approach may better explain the me-
Todorović et al. Assessment of acid-base analysis
chanism of acid-base physiology and disorders
than the Henderson-Hasselbalch approach (44).
On the basis of Stewart’ s definition H+ and bicarbonate are dependent variables whose concentrations are determined by three independent variables, namely SID, pCO2 and ATOT. SID therefore
can be calculated as the difference between fully
dissociated cations and anions which do not participate in proton transfer reactions (aprote ions neither donate or accept H+) and by the principle
of electro neutrality this difference is equal to the
sum of bicarbonate and the non-bicarbonate anions, which represent total charges contributed of
all non-bicarbonate buffers, primarily, albumin
and phosphate, and in whole blood, hemoglobin.
SID is, therefore, the same as buffer base concept
introduced by Singer and Hastings more than 5
decades ago.
“Apparent SID” and “effective SID”
When abnormal anion is present, a gap will
appear between SID calculated by the difference between strong ions (the so-called “apparent
SID”) and calculated by the addition of bicarbonate and non-bicarbonate buffers (so called “effective SID). This difference, named strong anion gap (SIG), is a marker for the presence of an
abnormal anion (23). The SIG indicates the presence of unmeasured strong anions if its value is
positive, the normal value of the SIG is zero. The
SIG is similar in concept to the anion gap, once
the latter has been corrected for anionic contribution of albumin and phosphate (3). A positive
SIG value represents unmeasured anions (such as
ketoacids, urate, sulfate, citrate, pyruvate, acetate
and gluconate) that are present in the blood.
Apparent SID is referred to as “apparent” (SIDa) with the understanding that some unmeasured
pp
ions might be also present. It represents the difference between the charge of measured strong cations (sodium, potassium, calcium, magnesium)
and strong anions (chloride, lactate, sulfate, ketoacids, nonesterified fatty acids and many others)
that are completely dissociated in biological solutions. Currently, (SID) is routinely measured
from [Na+] + [K+] + [Ca2+] + [Mg2+] - [Cl-] - [lactate-]. It is always positive in plasma and in healthy humans - its value is 40 to 42 mmol/L, while
it is often quite different in critically ill patients.
The effective SID (SIDeff) represents the effect of
the corrected pCO2 and the weak acids, albumin
and inorganic phosphate, on the balance of electrical charge in plasma, where HCO3 is in mmol/L,
albumin in g/l and phosphate in mmol/L. All the
independent variables are present in millimolar
concentrations and their interaction with water
dictates the amount of free H+, the concentration
of which is in order of nanomoles.
The difference between the calculated apparent
SID and effective SID constitutes the strong ion
gap, SIG. In healthy humans, the SIG should be
“theoretically” equal to zero (electrical charge
neutrality). If this is not the case, there must be
unmeasured charges to explain this ion gap. A
positive SIG value represents unmeasured anions
(such as ketoacids, urate, sulfate, citrate, pyruvate, acetate and gluconate) that are present in the
blood and account for the measured pH, the measured levels of strong and weak ions, and the
need to maintain electro neutrality (46). Unlike
the classic parameters used to calculate the anion gap, in calculating SIG, the effect of albumin,
phosphate and lactate is “subtracted out”. Therefore, SIG compared with the anion gap is caused
by shorter list of unmeasured ions including ketone bodies, sulfate and uraemic anions (2).
Calculating the effective SID takes into account
the role of weak acids (carbon dioxide, albumin
and phosphate) in the balance of electrical charges of plasma water (47). Once weak acids are
qualitatively taken into account, the difference
between apparent and effective SID should be
zero, unless there are unmeasured charges (anions). Such charges are then described by the
strong ion gap, SIG (SIG = apparent SID – effective SID). Bicarbonate is considered separately because this buffer system is an open system
in arterial plasma. Rapid changes in pCO2 and
hence arterial bicarbonate concentration can be
rapidly induced through alteration in respiratory
activity. In contrast, the non-bicarbonate buffer
system is a closed system containing relatively fixed quantity of buffers. Nonvolatile buffer
ion (A-) represents a diverse and heterogeneous
group of plasma buffers consisting primarily of
dissociable imidazole and α-amino groups on
plasma proteins with a smaller contribution from
phosphate-containing weak acids and citrate.
On the basis of information stated above, plasma
contains three types of charged entities: SID+,
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Medicinski Glasnik, Volume 12, Number 1, February 2015
HCO3 and A-. The requirement for electro neutrality dictates that at all times [SID+] equals the
sum of [HCO3] and nonvolatile [A-], such that
[SID+] - [HCO3] - [A-] = 0. (The dissociation reaction for a weak acid-conjugate base-pair, HA
and A-, is HA =H++A-) (48).
Partially dissociated weak acids (albumin, phosphate), (ATOT)
Plasma proteins provide the major contribution
to ATOT, and therefore, plasma protein concentration independently affects acid-base balance.
One major departure from the traditional approach is classification of acid-base disorders as a
result of alteration in ATOT. ATOT, representing all
non-bicarbonate buffers pairs (HA + A-), is made
up of charges contributed primarily by serum
proteins (mainly albumin) with phosphate and
other buffers playing a minor role. The sum of
[HA] and [A-] (called ATOT by Stewart) therefore
remains constant through conservation of mass.
The normal value of the total negative charges on
plasma non-bicarbonate buffers is [ATOT] = [A-albu] + [A-globulin] + [A-phosphate] = 16.6 mmol/L (49).
min
On the basis of this classification, an increase in
serum protein would result in metabolic acidosis
while a decrease would cause metabolic alkalosis. Siggaard-Andersen and Fogh-Andersen have
suggested that changes in protein concentration
should not be considered as acid-base disorders,
and have considered the Stewart approach problematic in that regard (11). Dissatisfaction with
the Henderson-Hasselbalch approach prompted
Singer and Hastings to propose in 1948, that plasma pH was determined by two independent factors, pCO2 and net strong ion charge, equivalent
to the strong ion difference (SID+). Stewart later
proposed that third variable, the total plasma concentration of nonvolatile weak acids (ATOT), also,
exerted an independent effect on plasma pH.
Thus, by combining equations for conservation
of charge, conservation of mass, and dissociation
equilibrium reactions, Stewart developed a polynomial equation, relating H+ concentration [H+]
to three independent variables (pCO2, [SID+] and
[ATOT]) and five constants (48). These three independent variables may change the hydrogen
concentration in water (i.e. the acid-base equilibrium). The strong ion difference is regulated by
the kidney, weak acid concentration primarily by
14
liver, and pCO2 by lung (48). An independent variable is defined as one that influences the system
but is not influenced by the system. The term system refers to any single aqueous compartment
(i.e. plasma).
The Stewart’s approach states that pH is primarily determined by several “independent variables” (which change primarily and independently
of one another: by pCO2, strong ion difference
(SID) and nonvolatile weak acids). This physicochemical approach might identify altered individual component of complex acid-base abnormalities and provide insights to their underlying
mechanisms (35).
The relation between strong ion difference (SID)
and standard base excess (SBE)
The SIDa must be counterbalanced by an equal
and opposing charge termed the effective strong
ion difference (SIDe) (normal approximately -40
to -42 mmol/L). The SIDe negative charge principally stems from the dissociated moieties of
plasma proteins (-78% albumin) and phosphate
(-20%). The sum of these weak acids is known as
ATOT since they exist in a dissociated form (A-), as
well as an associated form (AH). When the SIDa
and SIDe are equal the plasma pH is exactly 7.4
at a pCO2 of 40 mm Hg. Bicarbonate is dependent variable and does not determine the pH (47).
According to the principle of electro neutrality,
SIDa is balanced of the weak acids and CO2, such
that SID can be defined either in terms of strong
ions (SIDa) or in terms of the weak acids and CO2
(SIDe) offsetting it. Of note, the SID defined in
terms of weak acids and CO2, which has been subsequently termed the effective SID is identical
to the buffer base term coined of Singer and Hastings over half a century ago. So, changes in the
standard base excess also represent changes in
SID. The difference in electrical charge between
strong cations and strong anions is called strong
ion difference. In normal plasma this amount is
about 42 mmol/L. Indeed, to reach the electro
neutrality, 42 mmol/l of negative charged ions,
are required. These are basically the bicarbonate
(HCO3) and negative charged form of weak acids
(A-), primarily albumin plus an extremely small
amount of hydroxyl (OH-). The sum of [HCO3] +
[A-] which equals the strong ion difference was
called “buffer base” by Singer and Hastings, and
Todorović et al. Assessment of acid-base analysis
later by Siggaard-Andersen. Indeed, a big difference between the traditional approach (SBE)
and the Stewart’s approach is that the first considers what happens inside buffer base domain.
As an example, in the traditional model (SBE)
the normal buffer base (42 mmol/l, as the normal
[SID]) may decrease for 10 mmol/L if the (A-)
and (HCO3) are consumed by adding 10 mmol/L
of H+. In this case the actual buffer base is 32
mmol/L and the difference between the actual buffer base and the ideal buffer base is equal to -10
mmol/L, and is called base excess.
In the Stewart model the same problem is considered from another point of view. If a strong
ion is added to the system the ratio between
strong cations and strong anions will change. As
an example, by adding 10 mmol/l of lactate the
strong ion difference decreases from 42 mmol/L
to 32 mmol/L. The “space” available for A- and
HCO3 and OH- decreases, indeed part of A- will
become AH, part of HCO3 will become H2CO3
and part of OH- will become H2O. As the product
of H+ and OH- is constant, a decrease of OH- will
correspond to an increase of H+. i.e. acidosis (45).
So, the disadvantage of standard base excess
approach is that it implies adding or introducing
H+ to the solution, which is impossible. The more
general Stewart’s approach explains the acid-base variations on a more valuable physical basis.
So, the physicochemical Stewart’s approach can
be helpful in understanding mechanisms barely
understandable using traditional approach.
“The mystery” of dilutional acidosis during repletion of extracellular fluid deficit can be better
explained by the modern approach. The mechanism is obviously not bicarbonate dilution as explained by the traditional approach (otherwise why
would the proton donors not be diluted at the same
time?). Therefore, from Stewart’s perspective an
alternative explanation for dilutional acidosis needed to be developed. His mechanistic explanation
is based on strong ions and the maintenance of
electro neutrality. It was believed that positive or
negative charges (i.e. changes of the concentrations of strong ions) influence the dissociation of
water (50). In the context of dilutional acidosis,
this means dilution of plasma (which has a positive SID of 39 mmol/l) by water or another solution
with SID of zero decreases the SID, i.e. diminishes
the surplus of positive charges. However, the de-
crease in SID demands compensation by a positive
charge. This is suggested by increased water dissociation with generation of a positively charged
H+. This newly generated H+ then causes acidification of the solution, i.e. dilutional acidosis (50).
Interestingly, hypertonicity makes solutions more
acidifying, as more water is drained from the intracellular space, which ultimately contributes to the
final equilibrium (51).
Changes in SID, SIG and ATOT in acid base disorders
Respiratory disorders, in the modern approach as
in the traditional approach, are due to change in
pCO2, whereas metabolic disorders are due to alterations in either SID or ATOT. SID is decreased
in metabolic acidosis and increased in metabolic
alkalosis. By calculating SIG, one can further classify metabolic acidosis. In hyperchloremic metabolic acidosis both effective and apparent SID
decreases equally, as the increase in chloride is
counterbalanced by an equal decrease in the bicarbonate concentration. SIG therefore remains at or
near zero. In anion gap metabolic acidosis, apparent SID does not change (as chloride concentration is unchanged), but effective SID decreases (as
a result of a decrease in bicarbonate concentration) and SIG therefore becomes positive, reflecting
high levels of unmeasured anions such as lactate
and ketoanions (52). One major departure from
the traditional approach is classification of acidbase disorders as a result of alteration in ATOT. On
the basis of this classification, an increase in serum
protein would result in metabolic acidosis and a
decrease, metabolic alkalosis (23).
CONCLUSION
Three distinct approaches are currently used in
assessing acid-base disorders, the traditional or
physiological approach pioneered by Van Slyke,
the base-excess method, developed by Astrup,
and the physicochemical approach, proposed by
Stewart. The last and newest approach has steadily gained acceptance especially among criticalcare physicians and anesthesiologists (5).
The “traditional” approach to interpreting acid-base disorders developed from the pioneering work
of Henderson and Hasselbalch and is still most widely used in clinical practice. An advantage of this
approach is that it is relatively easy to understand
and to apply in common clinical situations (3).
15
Medicinski Glasnik, Volume 12, Number 1, February 2015
We conclude that the physiological or traditional
approach remains the simplest, most rigorous, and
most serviceable approach to assessing acid-base
disorders. Clinically, the traditional approach is
intuitive in nature and is supported by a large body
of robust empirical observations.
The true relevant acid-base quantities are the arterial pH, the arterial pCO2, and the extracellular base
excess. Determination requires an arterial blood
sample and a modern pH blood gas analyzer. Total CO2 (bicarbonate) measured in venous plasma
using an electrolyte analyzer or multipurpose chemical analyzer may be used as screening parameter
in patients without respiratory disorders (101).
The strong ion model offers a novel insight into
the pathophysiology of a mixed acid-base disorders and is mechanistic (4). The traditional
approach should be abandoned only if proponents of Stewart’s approach could provide clear
empirical observations supporting its superiority
as a clinical tool in diagnosis and treating patients
with acid-base disorders.
The dependence of pK’1 (carbonic acid) on pH
and protein concentration is a major anomaly for
the Henderson-Hasselbalch equation because the
dissociation constant for equilibrium reactions
should not be influenced by changes in reactants
(hydrogen ion activity = pH) or by anything else
(including protein) except temperature and ionic
strength, the latter being determined primarily by
the sodium concentration. The change in [SID+]
from normal is equivalent to the base excess value assuming a normal, nonvolatile buffer ion
concentration (normal albumin, globulin and
phosphate concentrations) (1).
If serum total protein, albumin and phosphate
concentrations are approximately normal, then
acid-base status should be evaluated using blood
pH, pCO2 and extracellular base excess concentration, which is the traditional Henderson-Hasselbalch approach. The presence of unidentified
anions should be investigated by calculating anion gap. If albumin concentration is abnormal, the
anion gap can be corrected based on the albumin
concentration, as this corrected anion gap can
unmask an organic acidosis that was previously
undetected in the setting of hypoalbuminemia.
However, if serum total protein, albumin and
phosphate concentrations are markedly abnormal, as in critically ill patients, then acid-base
status should be evaluated using blood pH, pCO2,
measured [SID+] and ATOT. The presence of unidentified strong ions should be investigated by
calculating the SIG. Traditional approach works
well clinically and is recommended for use whenever serum total protein, albumin and phosphate concentrations are normal. Although Stewart’s
approach has been largely ignored by physiologists, it is increasingly used by anesthesiologists
and intensive care specialists, and is recommended for use whenever serum total protein, albumin or phosphate concentrations are markedly
abnormal, as in critically ill patients.
Although different in their concept, the traditional and modern approaches can be seen complementary giving, in principle, the same information about the acid-base status.
FUNDING
This work was supported by grants 175081 from
the Ministry of Education, Science and Technological Development of the Republic of Serbia.
TRANSPARENCY DECLARATION
Competing interests: None to declare.
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49. Matousek S, Handy J, Rees SE. Acid-base chemistry
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Acido-bazne analize: poređenje „tradicionalnog“ i „modernog“
pristupa
Jasna Todorović1, Jelena Nešović-Ostojić1, Aleksandar Milovanović2, Predrag Brkić3, Mihailo Ille4,
Dušan Čemerikić1
1
Institut za patološku fiziologiju, 2Institut za medicinu rada, 3Institut za fiziologiju, 4Hirurgija; Medicinski fakultet Univerziteta u Beogradu,
Beograd, Srbija
SAŽETAK
Danas se koriste tri posebna pristupa u proceni acido-baznih poremećaja: tradicionalni ili fiziološki
ili bikarbonatni pristup, metoda baznog ekcesa i „moderni“ fizikalno-hemijski pristup predložen od
Stewarta koji koristi razliku glavnih jona (naročito natrija i hlorida), koncentraciju neisparljivih slabih
kiselina (osobito albumina) i parcijalni pritisak ugljen dioksida (pCO2) kao nezavisne varijable u analizi
acido-baznog statusa. Tradicionalni pristup kojeg su predložili Henderson i Hasselbalch i metoda baznog ekcesa, uprkos brojnim nedostacima, još uvek su najšire korišćeni u kliničkoj praksi. Ovaj pristup
se naročito preporučuje u kliničkoj praksi kada su koncentracije ukupnih proteina, albumina i fosfata u
serumu normalne. Iako je Stewartova metoda bila uglavnom ignorisana od strane fiziologa, nju sve više
primenjuju anesteziolozi i lekari intenzivne nege prilikom lečenja teško bolesnih pacijenata kod kojih su
koncentracije ukupnih proteina, albumina i fosfata u serumu poremećene. Iako različite u svom konceptu, tradicionalna i moderna metoda mogu se posmatrati kao komplementarni pristupi koji upotpunjuju
informisanost o acido-baznom statusu.
Ključne reči: acido-bazna ravnoteža, anjonski zjap, razlika glavnih jona, bikarbonati, bazni eksces,
neisparljive slabe kiseline, zjap glavnih jona
18
REVIEW
Clonus: definition, mechanism, treatment
Ismail Boyraz1, Hilmi Uysal2, Bunyamin Koc1, Hakan Sarman3
Physical Medicine and Rehabilitation, Abant Izzet Baysal University, Bolu, 2Neurology, Akdeniz University Hospital, Antalya, 3Orthopeadics Department, Abant Izzet Baysal University, Bolu; Turkey
1
ABSTRACT
Corresponding author:
Ismail Boyraz
Physical Medicine and Rehabilitation
Hospital, Abant Izzet Baysal University
Aibu Ftr Hospital Karacasu,
Bolu 14100Turkey
Phone: +90 505 469 17 28;
Fax: +90 374 262 91 90;
E-mail: [email protected]
Clonus is involuntary and rhythmic muscle contractions caused by
a permanent lesion in descending motor neurons. Clonus may be
found at the ankle, patella, triceps surae, wrist, jaw, biceps brachii.
In general, clonus may occur in any muscle with a frequency of
5-8 Hz and the average period of oscillations of the ankle clonus
is approximately 160–200 ms. Plantar flexion (PF) comprises 45%
of the period, dorsifleksion (DF) comprises 55% of the period.
The first beat is always longer, with the time shortening in continuing beats and becoming stable in the 4th or 5th period. The exact
mechanism of clonus remains unclear. Two different hypotheses
have been asserted regarding the development of clonus. The most
widely accepted explanation is that hyperactive stretch reflexes in
clonus are caused by self-excitation. Another alternative explanation for clonus is central generator activity that arises as a consequence of appropriate peripheral events and produces rhythmic
stimulation of the lower motor neurons. The durations of clonus
burst were found longer than the durations of Soleus medium-latency reflex (MLR). There is a similarity in their nature, although
the speed and cause of the stretch of triceps surae differ in the
MLR and the clonus, and there is a sufficient period of time for
group II afferents and for other spinal mechanisms to be involved
in the clonus, together with Ia afferents. Clonus can be treated by
using baclofen, applying cold, botox or phenol injections.
Key words: botulinum toxin, spasticity, upper motor disorder, gait
disorder
Original submission:
04 September 2014;
Revised submission:
22 December 2014;
Accepted:
05 January 2015.
Med Glas (Zenica) 2015; 12(1):19-26
19
Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
Clonus is involuntary and rhythmic muscle contractions caused by a permanent lesion in descending motor neurons and it is usually considered
to be a result of oscillations in the group Ia spinal
stretch reflex (Figure 1). Clonus is accompanied
by spasticity and other findings of reflex excitability (1). Spasticity is defined as an increased resistance to stretching caused by disorders
involving the upper motor neurons, and clonus
is characterized by exaggerated brain stem and
spinal reflexes resulting in increased muscle tone
and involuntary spasms. Although closely linked,
clonus is not seen in all patients with spasticity
(2).Clonus does not occur if the muscle is excessively hypertonic (2). Any mechanism or pharmacological drug suppressing increased reflexes
and muscle tone is also prone to block the clonus
(2). Severe clonus can interrupt sleep and prevent
the transfer capability of the patient and result in
fatigue that can decrease work performance of an
individual (3). It can also interfere with the posture and gait of the patient (4). Clonus can also
occur in normal individuals. The plantar flexion
power is low in normal individuals (5). Clonus
may be found at the ankle, patella, triceps surae,
wrist, jaw, biceps brachii (6-8). Jaw jerk is due to
supranuclear lesion of the trigeminal nerve and
it may occur in Amyotrophic Lateral Sclerosis
(6).Wrist clonus in patients with hemiplegia was
notably described in lectures published in 1883
by the French neurologist Jean-Martin Charcot,
who called the phenomenon “provoked trepidation”, the patients, on raising the paralyzed arm,
often experience trembling similar to that which
Figure 1. Ankle clonus Soleus rectified EMG and position of the
ankle are displayed superimpose. Soleus muscle activity can
be seen after ankle dorsiflexion
20
occurs in the lower limb under like circumstances (7). But the wrist-phenomenon, provoked
or spontaneous, is much more uncommon. In
general, clonus may occur in any muscle with a
frequency of 5-8 Hz and the average period of
oscillations of the ankle clonus is approximately
160–200 ms (9). Plantar flexion (PF) comprises
45% of the period, and dorsiflexion (DF) comprises 55% of the period (9). It has been shown that
the duration of the dorsiflexion was 88.63±10.83
ms, and the duration of the PF was 71.75±6.73
ms (9). The DF and PF comprised 55.17±3.9%
and 44.83±3.9% of one clonus beat, respectively
(9). The first beat is always longer, with the time
shortening in continuing beats and becoming
stable in the 4th or 5th period. Measured the refractory period only in the triceps surae muscle
is 90-100 ms. This period may differ for other
muscle groups with different central stretch reflex organizations, thereby resulting in different
maximum clonus frequencies (9). In order to
reach an understanding of clonus, it is essential
to consider not only reflex path length but also
muscle contraction and relaxation times, muscle
load, muscle spindle activity and central excitability, all of which play a role in clonus (7,9).
Dimitrijevic et al. have shown that clonus occurred in the presence of a lesion involving a large
portion of the lateral corticospinal tract(2). This
observation was based on the histopathological
evaluation of specimens from patients with a lesion in the central nervous system (CNS). They
reported that the frequency of clonus was constant in each muscle and the frequency of clonus did not show a tendency toward a change
over time (2). Rapid onset exteroceptive stimulations in sufficient intensity can induce clonic
discharge in the muscle and not only via type Ia
afferent fibers (9). Painful stimuli and cold are
the leading cutaneous stimuli giving rise to and
sustaining clonus. The cutaneous stimulation
of the unaffected side can also produce clonus.
The stimulations causing polysynaptic flexor or
extensor reflexes are susceptible to produce clonus via nonspecific descending facilitations produced by the “Jendrassik” maneuver. The stimuli
activating these pathways can stop clonus (5).
Clonus may even occur in the absence of any movement in the extremity. The amplitude of clonus
induced and sustained by stretch can decrease
and become attenuated over time. Cutaneous sti-
Boyraz et al. Clinical aspect of clonus
mulation triggered by scratching skin over the
muscle will provide sufficient input to the spinal
cord to maintain the amplitude of clonus (2). Bernhard and Therman showed that proprioceptive
inputs generated with the movement of the limbs
trigger rhythmic discharges from the motor units
in decerebrate cats (10).
Gottlieb and Agarwal showed that pharmacological agents increasing the discharge from
stretched muscle fibers could produce clonus in
healthy individuals. They reported that clonus in
normal individuals shares common features with
those in spastic patients and possesses a limited
band of frequency, and it is independent from the
loading on the extremity (11).Struppler observed
these findings using iv succinylcholine injection,
and Marsden, Meadows, and Hodgson used IV
adrenalin injections (12,13).
CLONUS MECHANISM
The exact mechanism of clonus remains unclear. Two different hypotheses have been asserted
regarding the development of clonus. The most
widely accepted explanation since the pioneering studies by Denny-Brown (1928-1929) is that
hyperactive stretch reflexes in clonus are caused
by self-excitation (14). Szumski et al. observed
that a few beats of clonus occurred after tendon
tap in the wrist flexors and clonus was sustained
by the “Jendrassik” maneuver. They concluded
that the spindles involved in clonus were abnormally sensitive and dynamic fusimotor neurons
were important motor neurons involved in eliciting clonus (2). Szumski and Hagbarth showed
the discharge of Ia afferent fibers before clonic
bursts on electromyographi (EMG) and these
discharges were not activated during muscle contraction. They concluded that muscle spindles
were stretched during muscle relaxation and repeated oscillatory movement elicited EMG activity (5). Janell et al. reported that clonus would
not be elicited if reflex responses were not generated against a stretch (3). Rack et al. observed
that the frequency of soleus EMG activity could
be regulated by loading and loaded oscillatory
movements in spastic patients, and they concluded that self-sustaining oscillation of stretch
reflex pathway resulted in clonus. In spastic subjects, motoneuron firing threshold may decrease
to a level in which the spindle afferent output eli-
cited during muscle lengthening is now sufficient
to reach threshold for motoneuron firing (16).
This shift in threshold can be thought of as an
effective increase in the feedback gain since the
same amount of afferent input in the spastic case
will result in higher motoneuron activation than
in a normal threshold level (17,18). According to
control theory, instability may arise in a system
with a high feedback gain and significant delays,
conditions both present in the ankle muscles of
spastic subjects (13). Hidler et al have clearly
shown that both movement frequency and EMG
burst frequency can be altered, and so we can
only speculate that the loads used in the mentioned studies were not sufficient to perturb the system onto a different limit cycle orbit (19). Clonus was of shorter duration when more muscles
were activated. In contrast, clonus was persistent
when EMG activity was largely confined to the
synergistic triceps surae muscles (20).
Iansek found a linear relationship between the
frequency of clonus and the distance between
spinal cord and the muscle. Mathematically, reflex oscillation latency was found to be predominant in determining frequency, and if there
was a central spinal pacemaker, it would predict
the frequency of clonus regardless of the length
of the reflex pathway (21). The findings that are
parallel to pure peripheral self-re-excitation mechanisms are preferably coupled with high reflex
arc gain (shift in threshold of motoneuron activation). Possible factors involved in the regulation
of clonus frequency are length of reflex arc; the
frequency of clonus can increase with the decrease in activation latency of la afferent fibers; factors such as the mass and viscosity of the muscles
can affect the frequency of clonus by changing
the activity latency of spindle relaxation (21).
The idea that central mechanisms may be involved was not adopted in observations where clonus was attributed to peripheral mechanisms. The
frequency of clonus changed by changing the
mechanical load on the joint. The rhythmic oscillations occurring in stretched muscles in some
animal preparations are assumed to be analogous
to clonus, and these oscillations were inhibited
by the blockade of peripheral afferent fibers (22).
Unsuccessful utilization of the signals from
muscle spindles and Golgi tendon organs complicates imaging and regulation of muscle length
21
Medicinski Glasnik, Volume 12, Number 1, February 2015
and power and autogenic reflex pathways play a
major role in motor control in humans (4,23,24).
The stretch reflex is a primary autogenic reflex
and the negative feedback arc is the first line of
active resistance when the body interacts with the
environment. In normal conditions, the gains in
reflex pathways were shown to be minimal. The
functional behavior of the reflexes changes significantly with increasing excitability of motor
neurons. It is believed that clonus with rhythmic
or oscillatory contractions could occur in distal
limbs where there is a change in the excitability
of CNS associated with concurrent neurological
disorders and when there is an increased tendency toward instability (2,4,23).
Hidler et al. hypothesized the coexistence of
both conditions for the occurrence of clonus: reflex pathway delay (involving distal extremity
muscles, displaying slow twitch properties), and
increasing motor neuron excitability (decrease in
motor neuron excitability threshold). These two
phenomena disrupt the stability of motor neurons. The high incidence of orderly motor unit
recruitment in human skeletal muscles that, due
to spinal trauma, are under no voluntary control from higher centers suggests that spinal systems also dominate the stereotyped excitation
of human motoneurons during clonus. Thus, any
changes in spinal neuron excitability, synaptic
inputs, or muscle properties due to injury were
appropriate to preserve an orderly pattern of
motor unit recruitment, as found during voluntary contractions of muscles innervated from the
level of injury (12,13). Orderly recruitment of
motor units during clonus is ordered by size of
unit excitability. Afferent activity from the previous contraction and the level of spinal excitation
were adequate to recruit most of the units during
every contraction but were insufficient to increase their firing rates. None of these peripheral or
spinal factors were sufficient to markedly disrupt
the recruitment order of pairs of motor units during clonus (4).
The reason for this lengthened delay in spasticity
may be the sensitivity of muscle spindles or changes in the passive features of the muscle. Increase
of viscoelasticity of passive tissues enlarges the
clonus receptive area (shaded); that is, it increases the amount of combinations of motor unit
pool threshold and gain that will result in clonus
22
(24).Cook et al. showed that ankle dorsi-flexor
remained reactively silent during the emergence
of clonus, and the blockade of the peroneus communis nerve did not affect the amplitude and
duration of oscillation (25).
The character of the input-output relationship in
motor neurons can be defined by the Gaussian
cumulative distribution function. Accordingly,
the synaptic current scale is linearly correlated
with the spindle firing rate. The functional pattern of motor neurons is determined by both
motor unit recruitment and modulation rate. The
single major reason for the delay in the generation of the monosynaptic reflex arc is neural conduction time in the reflex pathway. The delays in
the “negative feedback” pathway possess a destabilizing effect on the behavior of the system.
The frequency of oscillation decreases with increasing conduction delay (1).
Another reason for the delay in the reflex pathway
is the contractile features of the muscle. These
delays are caused by Ca dynamics, myofilament
cross bridges, elasticity of the muscle fibers, and
tendon compliance. In pathological conditions,
slow-twitch muscle fibers can be replaced by
fast-twitch muscle fibers. The input-output behavior in the muscle is similar to that in low pass
filtering. Low pass filtering in the muscle or the
delays in the reflex pathway due to conduction
delays will affect reflex stability (24).
It is believed that clonus and spasticity share a
common pathway; therefore, their co-occurrence
on most, if not all, occasions is not surprising.
The neuroaxial lesions such as stroke or spinal
cord injury result in a net inhibition in segmental neurons. The balance of synaptic input to
the motor neurons would change in favor of net
excitation. It was reported that the muscle was
continuously active due to on-off signal during
rotational movement, and high tonic activity can
be responsible for this condition. The oscillatory
behavior observed in clonus is similar to closed
arc oscillations seen in negative feedback control
encompassing high feedback gains accompanied
by significant delays.
Hagbarth et al. recorded medial gastrocnemius
Ia afferent muscle spindle discharges during clonus caused by the stretch before muscle stretch
and not during muscle activation. While spindle
activity is expected during muscle stretch, the
Boyraz et al. Clinical aspect of clonus
observation of muscle spindle activation in medial gastrocnemius is not surprising during clonus
elicited by fast stretch of PF; however, it was suggested that this would not be proven if spindle
activation directly elicited or maintained clonus.
No positive correlation was found between the
number and frequency of power and spindle discharges following clonic EMG bursts. They reported that hyperexcitability of the stretch reflex
is not centrally related for certain (26).
If repeated muscle stretch and the resulting
muscle spindle activation elicit clonus, tibialis
anterior muscle spindle activity and subsequent
EMG activity should have been formed in a pattern following the activity of medial gastrocnemius. Hagbarth et al. did not record this from the
tibialis anterior (26). Janell et al. suggested that
the synchronous discharge of muscle spindle afferents of antagonistic muscles would be unlikely
during DF-PF of the ankle joint, although muscle
spindle activation was not measured directly (3).
When synchronous activation of plantar flexors
and tibialis anterior during clonus was demonstrated, the inconsistency with the origin of the
stretch reflex was not taken into consideration.
Cook et al reported tibialis anterior EMG activity synchronous with PF that could not be eliminated by tibialis anterior nerve blockade, and
they concluded that the observed tibialis anterior
EMG activity could have been caused by crossconvergence due to PF (27). In addition, successive plantar-dorsiflexion EMG was not observed
during clonus. They concluded that antagonistic
activity was not necessary to elicit clonus and it
was attributed to the repeated reflex stretch of
plantar flexors. According to the results of the
stimulation data, the investigators ruled out tibialis anterior and supported repeated stretch reflex
as the cause of clonus (l). Cook et al. provided
alternative explanations, suggesting that the activity observed in tibialis anterior was not caused
by plantar flexors, but may have been caused by
incomplete nerve blockade (19).
Hidler and Rymer observed tibialis anterior EMG
activity synchronous with soleus and medial gastrocnemius activity during clonus, and they
attributed tibialis anterior EMG activity to shortening reaction. The shortening reaction is defined as the EMG response in the shortened muscle
commonly observed in patients with Parkinson’s
disease. The shortening reaction in the ankle has
been rarely observed in patients with first motor
syndrome (12%) and the rate was uncommonly
compared to disabled subjects (23).
Attempts have been made to change the frequency of clonic oscillatory burst patterns in order
to test the stretch reflex and central oscillatory
theories. If clonus correlates with the stretch,
externally applied motion frequency affects the
frequency of clonus. Rack et al. observed rhythmic EMG activity with various frequencies in
response to ankle loading (16). Hidler and Rymer
reported that the increase in the applied moment
loading produced a greater stretch on the plantar flexors, and this resulted in early EMG response with higher frequency (1). It was reported
that clonus could be re-established (reset) with
the stimulation of the soleus H-reflex in the time
frame between two successive clonic beats (28).
Peripheral events are estimated to regulate afferent output, and such observations are commonly
reported. On the other hand, there is no sufficient
evidence to suggest that clonic EMG was only
caused by the recurrent stretch reflex. The observation of oscillatory EMG activity in the absence
of synchronous repetitive peripheral inputs supports the role of oscillatory neurons in the spinal cord that can be activated by many afferent
events (19).
Another alternative explanation for clonus is central generator activity that arises as a consequence of appropriate peripheral events and produces
rhythmic stimulation of the lower motor neurons
(9). Walsh reported that clonic EMG frequencies
of plantar flexors remained unchanged (14). In
their study, Dimitrijevic et al. evaluated clonus
EMG records, ankle angle, and pressure applied
to the soles, and they investigated whether the
silent period between two beats of clonus was
caused by loading on the spindles or by the central refractory period (2). The attempts failed to
change the frequency of clonus. The refractory
period was approximately 100 msec and the excitatory period was approximately 60 msec, and
accordingly cyclic changes in centrally regulated
excitability constitute the basis for clonus and
determine its frequency. They indicated that periodicity could be modified only for a short period
by Ia inputs while transforming from the refractory period to excitatory period (2). According
23
Medicinski Glasnik, Volume 12, Number 1, February 2015
to Dimitrijevic, the central generator is a transistor providing a functional organization, and it is
made up of segmental reflex activity influenced
by peripheral, propriospinal, suprasegmental mechanisms, proprioceptive volleys from the limb,
and the movement of the muscle and parts of the
limb. The features of the central generator include cyclic, regular activation at a fixed phase (2).
Brune and Schenck examined H-reflex volleys
between two clonic bursts and reported a refractory period between EMG bursts. They attributed the cessation of motor neuron activity at the
beginning of the silent period to the refractory
state of the motor neurons with the inhibition of
Renshaw cells after firing and lack of stimulation from spindle afferents at the rest of the period (29). Strupler, Burg, and Erbel suggested
that recurrent inhibition produced by Renshaw
cells and autogenic inhibition by Golgi afferents
played a role in the refractory phase of the motor
neurons and not only spindle unloading (30). Nathan measured the refractory period only in the
triceps surae muscle (90-100 ms). He proposed
that this period may differ for other muscle groups with different central stretch reflex organizations, thereby resulting in different maximum
clonus frequencies (31). Wachholder and Altenburger showed that the latency of the first clonic beat was same as the stretch reflex. This time
relationship did not persist in sustained clonus.
Therefore, they expressed that clonus was triggered by the stretch and rhythmic discharge was
maintained by the central factors (32).
The characteristic feature of clonus is synchronous motor discharge. It was reported that synchronous discharge occurred despite the input
from asynchronous spindles to the clonus, muscle geometry, and the contribution of peripheral
muscle factors such as the relaxation rate of the
muscle (31). This indicates that the reflex is rigidly controlled over time and in the spatial extent
in the motor unit pool. It was asserted that the
discrepancy between peripheral factors and synchronized motor unit response indicates that central mechanisms play a major role (3,5). It was
reported that peripheral input is essential for the
re-activation of cyclic bursts and the overall activity is controlled by spinal mechanisms. The
intermittent discharge of clonus is suggested to
be caused by the periods of refractoriness, which
24
is due to the inhibition of motor neurons and/or
interneurons. The prolonged period of refractoriness is caused by Renshaw cells.
The results of Janell et al.and Walsh support the
interaction between many peripheral events and
central mechanisms to elicit clonus (3,33). Despite the lack of an input that would produce a stretch in the muscles, bilateral clonic EMG activity
was prominent in the proximal and distal limbs
in the standing position without bearing weight.
Clonus has been observed in the hamstring muscles following the development of clonus in the
vastus medialis, vastus lateralis, and rectus femoris muscles while loading in the standing position
and clinically after clonus in the ankle. The coactivation of the muscles between the limbs may
have played a role after spinal cord injury, but
the co-activation of antagonistic muscles in the
same limbs also point to the convergence of the
interneurons. A synchronous and bilateral muscle
stretch in agonist and antagonist muscles seems
unlikely (3).
TREATMENT OF CLONUS
Clonus can be treated by using baclofen, applying cold, botox or phenol injections (7, 9, 3437). Several studies in the literature have reported that centrally active antispastic drugs do not
have significant effects on clonus; however, some
studies have shown that baclofen has more dramatic effects than other drugs. Tizanidine selectively blocks group II pathways, which have a role
in spasticity but has no effect on clonus (38-41).
In a study by Bassett and Lake on patients with
upper motor neuron lesions, spasticity and clonus
both decreased with the application of wet towels
wrapped in crushed ice and with submergence in
cold water (42). Measurable functional improvement has been reported in association with decreased spasticity after cold application. Knutsson
who studied the kinematics of spastic gait before
and after cold application, reported that a decrease in spasticity of antagonistic spastic plantar
flexors paralleled an increase in the late oscillation phase during dorsiflexion (43). Hedenberg on
the other hand, tested upper extremity functions
of patients with hemiplegia before and after submergence in cold water and after cold application
and noted significant improvements in functional
capacities (44). Dimitrijevic et al. reported no
Boyraz et al. Clinical aspect of clonus
changes in clonus frequencies with cold application (2). Miglietta showed that the longer the
period of cold application, the longer it took for
clonus to recur. The average periods of recurrence of clonus observed after 10, 20, and 30 minutes of cold application were 28 (range, 15 to 45
minutes), 48 (range, 10 minutes to 2 hours), and
85 minutes (20 minutes to 6 hours), respectively
(40,45). Cold application induced prolonged inhibitory effects on clonus. In response to cryotherapy, Boyraz et al. showed persistence of H and T
reflexes with prolonged latencies, as well as decreases in the stimulation threshold and H/M ratio, but with a marked inhibitory effect on clonus.
There is a persistence of ankle clonus inhibition
even after a cooled muscle has returned to body
temperature. This phenomenon could be explained by an increase in the threshold of the nerve fiber and/or a relatively prolonged refractory period. The prolonged effect of the cold supports the
presence of spinal neuroplasticity and adaptation
in individuals with neurologic impairments (35).
Thevenon showed that clonus affected the first
metatarsal, since it was selectively triggered by
extension of the first metatarsophalangeal joint.
To treat clonus, they applied injecting botulinum
toxin into the peroneus muscles but failed. To
stop clonus through selective neurotomy of the
gastrocnemius and soleus, Thevenon performed
neurotomy of the branches of the superficial fibular nerve that innervated the peroneus brevis
and peroneus longus. After the surgery, clonus of
the first metatarsal was no longer observed (35).
Botulinum toxin has a role in treating ankle clonus in neurological patients, where it interferes
in gait and may improve walking speed and level
of dependence on others (33). The treatment of
clonus and spasticity may be obtained by using
centrally and peripherally effective mechanisms
simultaneously.
Clonus was considered to be a common presentation of the intrinsic oscillation of the spinal neural network after a reduction in sensorial input
related to loading and chronic loss of supraspinal input. The spinal networks can be activated
by numerous stimulations including interventions during voluntary movements, nociceptive
synapses, and cutaneous synapses. Due to the
presence of limited motor pools to elicit voluntary movements after severe spinal cord injury,
the attempts mostly result in generalized motor
patterns. In most cases with spinal cord injury,
chronic unloading occurs not only as a result of
the absence of supraspinal input, but also due to
a lack of stepping and standing. Synchronous oscillatory motor output could be a re-organization
of the neural network as a response to chronically
changing afferent and supraspinal inputs, and
therefore the same stimulus before injury did not
cause the activation of the entire network. It must
be investigated as to whether repetitive afferent
information regarding stepping would re-modify the clonic motor firing pattern. Better results
in the treatment of clonus and spasticity may be
obtained by using centrally and peripherally effective mechanisms simultaneously.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATION
Competing interest: none to declare.
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ORIGINAL ARTICLE
Human dental pulp mesenchymal stem cells isolation and
osteoblast differentiation
Moustafa Alkhalil1, Amer Smajilagić1, Amira Redžić2
Department for Oral and Cranio-Maxillo-Facial Surgery, Hamad Medical Corporation, Doha, Qatar, Weill Cornell Medical College, Doha,
Qatar 2Institute for Biology and Human Genetic, School of Medicine University of Sarajevo , Sarajevo, Bosnia and Herzegovina
1
ABSTRACT
Aim This study was focused on the isolation and characterization of mesenchymal stem cells (MSCs) from human dental pulp
(DPSC).
Corresponding author:
Amer Smajilagić
Department for Oral and
Cranio-Maxillofacial Surgery,
Hamad Medical Corporation
P. B. 3050, Doha, Qatar
Phone: +974 4439 7346;
Fax: +974 4439 7362;
Email: [email protected]
Original submission:
10 September 2014;
Revised submission:
22 September 2014;
Methods The study was performed in the Department for Oral
and Cranio-Maxillo- Facial Surgey Hamad Medical Corporation,
Doha, Qatar and Weill Cornell Medical Colleague Doha, Qatar,
in period 2010-2011. Dental pulp was extracted from premolars
and third molars of 19 healthy patients. The pulp was digested in
a solution of 3 mg/mL collagenase type I and 4 mg/mL dispase for
1 hour at 37C. After filtration, cells were cultured in Dulbecco’s
Modified Eagle Medium (DMEM Low Glucoses) with 20% Fetal
Bovine Serum (FBS), 2mM L-glutamine and antibiotics (100 U/
mL penicillin, 100 ug/mL streptomycin) at 37 °C under 5% CO2.
Cultures were treated with osteoinductive medium for differentiation MSC in to the osteoblast cell line. Staining with Alizarin
red were used for the detection of the osteoblast production and
calcification new formed tissue.
Results On the total of three out of 19 patients it was possible
to isolate DPMSCs after 2 to 3 weeks: in one patient it was not
possible to expand MSCs because of infection, and in other two
patients positive Alizarin red staining reaction showed osteogenic
differentiation capability and strong mineralization in vitro.
Conclusion The main advantage of using DPSC is absence of
morbidity. MSCs could be isolated noninvasively from teeth,
routinely extracted in the clinic and discarded as medical waste.
Standardization of clinical and laboratory protocols for DPMSCs
isolation and team work coordination could lead to significantly
improved result.
Key words: regenerative medicine, bone, tissue engineering, osteoblast
Accepted:
29 October 2014.
Med Glas (Zenica) 2015; 12(1):27-32
27
Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
MATERIALS AND METHODS
Tissue engineering is an interdisciplinary field
that applies the principles of engineering and
life sciences toward the development of biological substitutes that restore, maintain, or improve tissue function or a whole organ. Those
involved in regenerative medicine place more
emphasis on the use of Stem Cells to produce
tissues (1). Stem cells have two main properties: pluripotency, e.g. formation of all ectoderm,
endoderm and mesoderm cells layers, and self
renewal (2,3). Depending on the origin there are embryonic stem cells and somatic stem
cells which include mesenchymal stem cells,
hematopoietic stem cells and neural stem cells.
Mesenchymal stem cells (MSCs) are able to differentiate into the different cell types such as
osteoblast, chondroblast myoblast, adipoblast
and even beta- pancreatic cells (4). These cells
could be isolated from the variety of tissues and
expanded in vitro. Such produced MSC may
have the use as valuable tools for regenerative
medicine (5,6). Mesenchymal stem cells of human origin were isolated and have been used for
the preclinical studies and clinical trials (7,8).
The most common source is bone marrow (911), fat tissue (12,13) and umbilical cord blood
(14-16). However, isolation of the MSCs from
those sources is performed by aspiration and
is often an invasive and painful procedure for
donors, associated with morbidity. Umbilical
cord cells are only available immediately after
the delivery so they have limited availability.
Because of those disadvantages, identification
of other sources for MSCs isolations is of great
importance (17).
For isolation of human dental pulp mesenchymal
stem cells (DPMSCs), the extracted teeth of the
total of 19 patients treated at the Department for
Oral and Cranio-Maxillofacial Surgery, Hamad
Medical Corporation, Doha, Qatar were used.
In collaboration with the Laboratory for Stem
Cells Research Weill Cornel Medical College,
Doha, Qatar, the study was performed in the period 2010-2011. All patients were healthy based
on documented evidence found in their medical
files. All patients or their legal representatives
signed an informed consent form, following the
guidelines approved by the Ethic Committee of
the Medical Research Center, Hamad Medical
Corporation, Doha, Qatar.
This study is focused on the isolation and characterization of MSCs from human dental pulp (DPSC)
(18). An important issue is presented indicating
that there is a significant diversion in the MSCs isolation protocols from different tissues (19), which
makes it difficult to compare results between laboratories and verify success of clinical trials.
The aim of this study was isolation and cultivation of MSCs from the human dental pulp as a
future model for regenerative medicine application with the intention of establishing unique and
effective clinical and laboratory protocol, characterization and differentiation in the osteoblast
cells phenotype.
28
All removed teeth used in the study were intact
and medically indicated for the extraction, either
for orthodontic reasons or causing health problems. Teeth were removed using local anesthesia
with 2% xylocain/adrenaline, under standard conditions, and after the removal they were cleaned
with 70% alcohol swab topically. Extracted teeth
were placed into the sterile plastic tubes, and tubes
were put into ice, stored between 0-4 °C, for 6-18
hours overnight. This time delay was necessary
whilst waiting for transportation to the stem cell
laboratory and isolation procedures. All the teeth
had fully developed roots and using Luers forceps,
in the laboratory the roots were separated from the
crown. After the separation an extirpation needle
was used to remove dental pulp.
After extirpation pulp tissues were digested in a
solution contest from 4 mL of DMEM/low Glc,
100U/mL penicillin, 100 ug/mL streptomycin,
and 3 mg/mL enzymes collagenase type I and 4
mg/mL dispasae for 60 minutes et 37 °C. Then,
cells were digested in the media and centrifuged
for 10 min at 1200 rpm. The pellet was washed
twice in PBS, resuspended in to the 6 mL cell
culture medium and placed in T25 flasks. The
flasks were incubated in 5% CO2 at 37 °C. The
medium was changed twice weekly. The cells
cultivate medium were contest of: DMEM/Low
Glc with 20% fetal bovine serum (FBS) 2 mM
L-glutamine, 100U/mL penicillin and 100 ug/
mL streptomycin. When the cells in 24 well
plate reached 50-60% confluency, the medium
in each flask was replaced using fresh osteogenic differentiation media contest: ascorbic
Alkhalil et al. h-MSCS
acid 50 ug/mL, b-Glycerol phosphate 10 mM,
Dexamethason 10-7 in DMEM/low Glu and
10% FBS, 2mM L-glutamine, 100U/mL penicillin and 100ug/mL streptomycin. Osteogenic
medium was changed twice weekly, and after 2
weeks the cells were differentiated and stained
with 2% Alizarin, for the detection of osteoblast
production and calcification.
The Alizarin method for the staining was performed according the procedure: washing the
cells 2x with PBS, 10 min with 70% ice cold
ehanol, washing with distilled H2O, application 10 min Alizarin red at RT, 5 times washing with distilled H2O, add PBS and after 15
minute checking under a microscope to see the
calcification.
RESULTS
Dental pulps were extirpated from the extracted
teeth, respectively for each individual patient
from the total of 19 patients included in study (6
males, 13 females), for the purpose of isolation
and cultivation of MSCs. In 16 of them permanent premolars teeth were extracted, according
to orthodontist indication in therapeutic purpose,
and in the other three patients permanent molars
were extracted due to health reasons. The average age of the patients was 13 years (range 9-22
years). From the total of 19 patients, it was possible to detect and isolate MSCs in three of them.
The MSCs were detected by visualization colonies on electronic microscope and their specific
spherical like cluster shape (Figure 1).
dental pulp isolation
The time between extirpation pulp tissue and
DPMSCs isolation was variable. In one patient
time the duration between isolation and detection
of MSCs was 7 days, on another it took 13 days,
and on the third 24 days.
Two patients were females and one patient was
male (average age of 13 years).
After visualization, colonies started to grow rapidly in the cell media. After isolation in one
patient, an infection appeared and destroyed all
the cells. The other two patients (one male, one
female) dental pulps were extirpated from the
extracted premolars, and showed DPMSCs isolation after 2 weeks, colonies were expanded
and when they reached confluences 50-60% they
were exposed to the osteogenic differentiation
media for next two weeks (Figure 2).
A)
B)
Figure 2. A) Expanded stem cells in culture, single pulp extracted premolar tooth, day 24 after isolation on male patient; B)
Expanded stem cells in culture, single pulp extracted premolar
tooth, day 30 after isolation on female patient. On both isolated
cultures, cells are adherent, elongated in spindle shape with
thin expansion (phase contrast microscopy) (Mehteb M, 2010)
Figure 1. Colonies of the aggregated stem cells on the 13th day
of culture in a 13-year old male patient, isolated from single
dental pulp of the removed premolar tooth. Cells were adherent and formed aggregates. In total 7 colonies of stem cells
were detected (Mehteb M, 2010)
Two weeks after the exposure to osteoinductive
factors, Alizarin red staining of DPMSCs culture demonstrated positive reaction. Long term
growth cultures of DPMSCs (between 4-6 weeks)
29
Medicinski Glasnik, Volume 12, Number 1, February 2015
in vitro, demonstrated the capacity to form Alizarin red-positive mineralization nodules with high
levels of calcium (Figure 3).
response and no ethical dilemma that we have in
embriogenic stem cells research. For example, as
supplement for bone grafting in conventional surgery, or for use in any clinical situations where the
regenerative process is damaged (22).
In systematic diseases, such as osteoporosis, therapies are mostly oriented towards suppression
osteoclast function but no one or very few are
oriented towards osteoblast proliferation (23).
Figure 3. Adherent layers of cultured DPMSCs are shown (with
Alizarin Red staining as a measure of calcium accumulation after induction with Ascorbic acid 50ug/ml, b-Glycerol phosphate
10mM, Dexamethason 10-7 in DMEM/low Glu and 10% FBS,
2mM L-glutamine), capacity to form Alizarin Red-positive condensed nodules with high levels of calcium (Mehteb M, 2010)
DISCUSSION
Human tissues have different potential for regenerative properties. It appears that stem cells and
their biology may play an integral role in that
regenerative process. Multipotent mesenchymal
stem cells (MSCs) were first discovered by Friedenstein 1976 (9), who isolated them from bone
marrow. Based on this protocol, MSCs from other tissues were searched for isolation and cultivation. Several loci within human body were
isolated as a source for the MSCs isolation: bone
marrow, cartilage tissue, fat tissue, and umbilical
cord blood (11, 13-15, 20). However, accessibility can be limiting. Mesenchumal stem cells from
dental tissue were isolated by Gronthoss 2000
(18) from the pulp tissue. Those cells showed
capability to differentiate into the osteoblasts,
odontoblasts, adipocytes, and neural cells (21).
The results of this study have shown ability of ex
vivo expanded human DPMSCs taken from permanent teeth to differentiate into osteoblasts and
produce in vitro a mineralized bone like tissue,
detected by using a specific calcium deposit staining Alizarin red, similar to some of the previous
research (18,19,21).
The aim of this study was to isolate (from each individual) DPMSCs as autologous cells model, potential clinical tools which can be used as alternative to conventional medicine, free of any immune
30
Comparing with isolation from other sources of
MSCs, DPMSCs are easily accessible tissue resource (24). Most important advantage of this
MSCs source is absence of morbidity and no
need for additional surgical procedures. Harvesting process of donor tissue is done when a
patient comes to have a tooth removed for health
or therapeutic reasons, and instead of throwing
tooth in the garbage, it should be placed in the
process of MSCs isolation and cultivation. Such
isolated DPMSCs could be also cryo-preserved
and stored for future treatment of that person
if required (25). Comparing with DPMSCs, an
umbilical cord blood and amniotic fluid are limited MSCs sources, as they are available only
after delivery (25)
Dental pulp as MSCs source offers multiple opportunities for their isolation throughout life.
Some research indicates that the DPMSCs are
detectable in humans up to the age of 30 years,
which is in accordance with results of this study
where the average age of successful isolations
was 13 years (26-28). Some investigations show
that stem cells can be obtained from the dental
pulps of subjects between 30 and 45 years of
age using specific antibodies for stromal stem
cells (29). Our results also indicate that h-DPMSCs possess high proliferation ability and great
potential for isolation of large numbers of cells,
suggesting that they are a useful source for stem
cell–based therapy.
In conclusion, individual autologous stem cells
from dental pulp were isolated in only three out
of 19 patients, and in two of them osteoblast cells line and calcification tissue were produced.
Main disadvantages of this study include the
low rate of the DPMSCs isolation and a long
time period between pulp tissue isolation and
DPMSCs visualization and cultivation. Our findings suggest the main reason for such results
was the long time between tooth extraction and
Alkhalil et al. h-MSCS
pulp tissue extirpation for DPMSCs isolation.
Probably, the overnight delay of more than 10
hours could lead to the MSCs and other cells
dying. Even that result of 15% successful isolation in such conditions indicates that dental
tissue is a great potential reservoir of stem cells,
with a high rate of survival.
Improvement in the standardization of clinical
and laboratory protocols, and better coordination and team work could significantly improve
this process.
dental pulp isolation
FUNDING
This research was supported by the Medical
Research Office, Hamad Medical Corporation,
Doha, Qatar (Project Project No: 8121/08 “Mesenchymal Stem Cells Isolations and Cultivation
as Experimental Bone Tissue Engineering System“) and Qatar, Doha, Weill Cornel Medical
School, Laboratory for Stem Cells Research and
Senior Researcher Mehteb Meleki.
TRANSPARENCY DECLARATIONS
Competing interest: none to declare.
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ORIGINAL ARTICLE
Inflammatory cytokine gene polymorphism profiles in Turkish
patients with ulcerative colitis
İlhami Gök1, Fahri Uçar2, Orhan Ozgur3
Department of Bioengineering, Faculty of Engineering & Architecture, Kafkas University Kars, 2Departments of Medical Biology &
Genetics, School of Medicine, Akdeniz University, Antalya, 3Divisions of Gastroenterology, School of Medicine, Karadeniz Technical
University, Trabzon; Turkey
1
ABSTRACT
Aim To investigate IL-1α, IL-1β, IL-1R , IL-4RA, TGF-β, TNF-α
and IFN-γ, genes polymorphism in Turkish patients with ucerative
colitis (UC).
Methods An analysis was carried out at Trabzon Karadeniz Technical University
Medicine Faculty Gastroenterology polyclinics between March
2005 and May 2011 on 51 patient with UC (cases) and 100 healthy
individuals (controls). PCR-SSP and cytokine gene panel (Helderberg kits) based techniques for analysis of gene polymorphisms
were used.
Corresponding author:
İlhami Gök
Department of Bioengineering,
Faculty of Engineering & Architecture,
Kafkas University
36100 Kars, Turkey
Phone: + 90 474 225 12 79;
Fax: +90 474 225 12 82;
E-mail: [email protected] Original submission:
28 October 2014;
Revised submission:
18 December 2014;
Results Changes in allelic frequencies of each of the investigated eight cytokine genes polymorphisms in patient with ulcerative colitis were found. Among the allelic genes analyzed here,
the highest statistically significant change was observed in the position TNF-α -308 G/A (339.7%). The following increases were
observed in IL-IR mspa T/C variation (179.4%), IFN-γ 5644A/T
variation (77.4%), and in IL-1β -511T/C SNPs (35.9% ). In other
analyzed genes, allelic changes were found to be decreasing for
TGF- β codon10C / T (-71.9%), IL4RA + 1902G / A (-47.3 %),
and for IL- 1α -889T / C (-37.7%). The lowest negative change
(-25.9%) was observed in the allele frequency in IL- 1β 3962T /
C (p<0.000). In addition, there were changes in genotypic frequencies investigated seven gene polymophic site and only one of
cytokine gene IL-1β 3962TT/TC/CC was not changed.
Conclusion Genes polymorphism is not itself the only determining factor for clinical diagnoses. However, it can be used in the
clinical diagnosis of UC in order to determine the low level or high
level variations in cytokine gene polymorphisms.
Key words: colitis, ulcerative, cytokines, genetic polymorphisms,
PCR-SSP, Turkey
Accepted:
05 January 2015.
Med Glas (Zenica) 2015; 12(1):33-39
33
Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
Today, ulcerative colitis (UC), which as a common disease, brings serious problems particularly such as risk of developing toxic megacolon
and colon cancer in developed countries, as well
as in regions with high level of well-being (1).
Although it can be seen at any age, it is rather
known as a disease of young adults, and does
not discriminate on gender (2). The prevalence
of UC in normal population is 8-15.7% and the
incidence 1.5 -25/100 000. The incidence in the
20-30 age group is 7-11/100,000, and the prevalence more than 15% in those over the age
of sixty (1-3). Many environmental factors are
involved in the pathogenesis of UC, but disease-related multifactorial genes have not yet been
fully identified (4). In order to clarify the exact
cause of UC inflammation, the genotypic level
of cytokine genes should be studied indifferent
population and we should increase UC samples.
Field research on autoimmune diseases has been
performed but data regarding the results are conflicting (4-6). The genes that encode proinflammatory cytokines could be activated in an important phase of relationships of autoimmune factors
with the genes which might be susceptible to UC
as in other genetic factors, contribution of mediator molecules to the functioning of the genes
(5). It manages the changing level of transcription and translation in cytokine gene, and detecting
the autoimmune response by cells may promote
inflammation or can act as a trigger for inflammation (6). In this context, interleukin-1 receptor antagonist (IL-1RA) and interleukin-1 (IL-1)
gene family that functions at opposite effects as
regulator proinflammatory have come to the fore
in the relationship between polymorphic genes
and alleles especially in patients with UC (7-8). It
can regulate the relationship with UC disease, the
formation of IL-IRA in different parts of the gene
encoding the allelic polymorphisms by these
findings. Identification of a polymorphic region
variable can modify the frequency of allele one
and allele two with the number of repetitions (9).
Also, the two alleles of the gene IL-IRA can affect
(GM-CSF)-stimulated monocytes as colony-stimulating factor for in vitro production of granulocytes (10). A close connection of IL-1 gene family
with another gene is known as IL-IRA encoding
the endogenous gene antagonist (11-12). Proteins
34
encoded by the genes interleukin-1 alpha (IL-1α)
and interleukin-1 beta (IL-1β ) are known to play
a role in UC formation. The causes of substantially individual differences of in vivo production of
cytokines is that IL-1 protein domains are managed as hereditary (13). Another comment T cells
differentiation in the formation of inflammation is
synergistic participation of IL-1α production on
polymorphisms (14). So far, the studies conducted in patients with UC have been considerable
and there are conflicting results about the relationship between cytokine polymorphisms and the
disease (15). Also, promoter regions of cytokine
gene as inflammation trigger can be held responsible for the formation of inflammation (16). A
common emphasis in linkage disequilibrium of
autoimmune diseases as UC, alleles of the genes
encoding IL-1α include existing heterogeneous
polymorphic region (17). Conflicting results were
found between disease groups with gene IL-1RA
and healthy controls (18). Therefore, IL-1α, gene
polymorphism, either alone or in combination
with IL-lRA can be tested by including in the pathogenesis and by method cross-matching alleles
and genotypes in patients with UC by IL-IRA genotype frequency analyses (19).
Environmental agents that cause activation of inflammation in patients with UC, especially nuclear antigens, auto-reactive B cells and T cells can
accelerate the formation of autoantibodies and
may cause different immune response in different
tissues (20). Basically, as the functioning of cytokine genes is variable, antagonist relationship was
observed among IL-1α, tumor necrosis factor alpha (TNF-α), transforming growth factor (TGF-β)
and interferon gamma (IFN-γ) (21). However,
cytokine production varies during the stage of the
disease (22). In UC animal models, TH1 cytokines vary as predominate at the onset of disease and
then unstable in clinical stage in favor of the TH2
(19-21). The presence of different histone peptide
stimulates T lymphocytes in patients with UC during clinical stage and can affect the stages of the
disease. Then, at a certain point in time, Th1 cytokines are secreted, and in later periods, Th2 cytokine secretion comes to the fore (22). Most studies
have shown higher TNF-α in UC patients and that
secretion is high during illness (23). However, different research groups have observed that TNF is
at normal and low levels in patients (8). In additi-
Gök et al. Cytokine genes in ulcerative colitis
on, levels of IFN-γ have been identified as variable
in patients, IFN- γ gamma levels vary depending
on affected organ (6). Cytokine TGF-β at plasma
levels in immune regulation systems were reduced in patients with UC (3,15). In recent years, the
evidence gathered is that cytokine production is
under genetic control. Polymorphisms which have
the promoter and coding region in most cytokine
genes are associated with the level of cytokine
production (24). In this sense, accepted cytokines
are cytokine genes as TGF-β, TNF-α, IFN polymorphisms and the IL-1, IL-4RA genes (8,18).
Conflicting results and allele differences between
populations and genetic variability are emphasized
in observations in patients with UC (10). Among
them, TNF-α 308 A/G polymorphism is associated
with autoimmune diseases at a high rate (21,22).
TNF-α production is considerably higher in Colombia populations with UC susceptibility (24).
The aim of this study is to investigate various polymorphisms genes IL-1α, IL-1β, IL-1, IL-4RA,
TGF-β, TNF-α and IFN-γ in Turkish population
patients with UC by genomic techniques.
PATIENTS AND METHOD
Patients and genomic DNA extraction
This research was conducted among the Black
Sea Region population which geographically
corresponds to the northern Turkey. Fifty-one
individual cases in the study were selected from
the patients applying to the Farabi Hospital Gastroenterology (School of Medicine), Karadeniz
Technical University polyclinics as to whom the
inflammatory bowel diagnosis was set, and 100
healthy individuals as control group (one patient
controlled with two healthy individuals).
The inflammatory bowel disease diagnosis was
determined using the physical examination, radiological, endoscopic, and pathological test criteria according to signs and symptoms of the patients. The classifications of cases (UC) were made
according to the settlement of the lesions in the
digestive organs and behavior type of the illness
in the inflammatory bowel patients. From each of
51 UC patients and 100 healthy individuals included to the study, 8 mL blood was taken to the
EDTA tube. From the peripheral blood samples,
the DNA isolation was conducted with the method of Salting-Out (25).The optical density of the
concentration of DNA obtained in this stage was
read in the spectrophotometer (Shimadzu, Japan)
in 260 nm wave length. The isolated DNA samples were kept at -80oC. The genomic analyses
were completed in Farabi Hospital Hematology
Department tissue typing Laboratory School of
Medicine, Karadeniz Technical University.
PCR-SSP genotyping
PCR-SSP cytokine gene panel (Cytokine Kits, Heiderlberg, Germany for the determination of the
cytokine gene polymorphisms was used in the determination of 16 polymorphic varieties of 7 different cytokines: interleukin-1alpha (IL-1α), interleukin-1beta (IL- 1β), interleukin-1reseptor (IL-1R),
interleukin-4 anti-receptor (IL- 4RA), tumor growth
factor beta (TGF-β), and tumor necrosis factor alpha (TNF-α) and interferon gamma (IFN-γ). The
Cytokine Kits gene is composed of 3 different subcomponents with the primers. For the PCR-SSP
amplification of each individual, the master-mix
and DNA mixture having total volume of 521.3 mL
Genomic DNA (50-300 ng/mL) and Taq Pol (5U/m
L) was prepared. The prepared master mixes were
slightly mixed in the vortex and were distributed to
16 wells in the plate with the final volume being 10
m L for each patient. For the following ones given
for the cytokine genes, the beginning denaturation
was amplified at 94oC for 2 min, denaturation was
amplified at 94oC for 10 sec, annealing-extension
was amplified at 65oC for 1 min 10 cycles, the final
denaturation was amplified at 94oC sec, annealing
was amplified at 61oC for 50 sec, the extension was
Table1. Heidelberg Cytokine genotyping CTS-PCR-SSP Tray Kit
Cytokine genes
Corres- Specific Size of
Alleles specificity ponding am- PCR amand positions
Alleles/ plicon plification
genotype (bp)
(bp
Interleukin-1a
T at pos -889
Interleukin -1a
C at pos -889
Interleukin -1b
T at pos +3962
Interleukin -1b
C at pos +3962
Interleukin -1b
C at pos -511
Interleukin -1b
T at pos -511
Interleukin -1R T at pos mspa111100
Interleukin -1R C at pos mspa111100
Interleukin
G at pos +1902
-4RA
Interleukin
A at pos +1902
-4RA
Transforming
T At pos kodon 10
growth factor -b
Transforming
C at pos kodon 10
growth factor -b
Tumor necrosis
T at pos - 308
factor -a
Tumor necrosis
A at pos -308
factor -a
Interferon - γ
A at pos UTR5644
Interferon -γ
T at pos UTR5644
T
C
T
C
C
T
T
C
220
220
340
340
220
220
300
300
440 bp
440 bp
440 bp
440 bp
440 bp
440 bp
440 bp
440 bp
G
140
440 bp
A
140
440 bp
TC
80
440 bp
C
200
440 bp
Gg
110
440 bp
Ag
110
440 bp
A
T
280
280
440 bp
440 bp
pos, Bases G, C, T, A at position corresponding genotype or alleles
35
Medicinski Glasnik, Volume 12, Number 1, February 2015
amplified at 72oC for 30 sec, 30 cycles and hold was
amplified at 4oC in indefinite PCR cycle programme (26). For the implementation of the amplified
PCR products in the electrophoresis, 2% agarose
gel was prepared. The samples were executed at
75V, 50 A for 35 minutes by being loaded to 16 well
gel for each patient. The results were examined in
the transilluminator at UV and the wells having double bands from the samples available in each well
were accepted as positive and photographed. The
changes in the cytokine gene polymorphisms of the
patients were determined as a result of the comparison with the control groups within information
provided in the chart in the Cytokine Kits system
analysis as given in Table 1. In total, we studied 16
allelic locations of 8 different polymorphic regions
of 7 cytokine genes in UC
Statistical Analysis
Allelic frequencies of all cytokine genes were
estimated by allele counts and expressed as a percentage, Chi-square test (χ2 ) with Yates correction, Odd’s ratio, and relative risk. Frequencies
were also tested for Hardy-Weinberg equilibrium
(HWE) by calculating allele frequencies using
the Pearson’s Chi-square test (χ2 ) with 1° freedom. Findings were considered significant with
two-tailed Fisher’s exact tests (p<0.001).
RESULTS
From the 51 patients, 27 (53%) were females and
24 (47%) were males, with the age ranging from
18 to 69 (mean 49.3 years). Of 100 healthy controls, 47 (47%) were females and 53 (53%) were
males, with the age ranging from 18 to 65 (mean
Table 2. Demographic characteristics and clinical features of
patients with ulcerative colitis (UC) and healthy controls
Clinical findings
Sex (males/ females) (No of
patients)
Age (years)
Course of the diseases (years)
mean (range)
Disease location (distal part/
total colitis) (No of patients)
Disease severity (mild/severe)
(No of patients)
Ulcerative colitis
(n=51)
Controls
(n=100)
24/27
53/47
(43.9)18-69
39.1 (18-65)
2.3 (1-8)
negative
36/15
negative
41/10
negative
39.1 years). Evolution of the disease was 1-8 years. Distal colitis was present in 36 (70.5%) patients, and 15 (29.5%) patients were without distal
colitis. According to clinical course of disease, in
41(42%) patients mild form was diagnosed, 10
(30%) patients were with severe continual activity. None of the patients received treatment with
cyclosporine or infliximab (Table 2).
In total, 8 sites of 16 different polymorphic regions of seven cytokine genes in UC patients were
analyzed. Of the 8 sites examined, a total of all 8
(100%) sites in the UC patients showed the changes in allele frequencies compared to the control
group with statistically significant differences.
Among the allelic genes analyzed here, the highest statistically significant change was observed
in the position TNF-α -308 G/A (339.7%). The following increases were observed in IL-IR mspa
T/C variation (179.4%), IFN-γ 5644A/T variation
(77.4%), and in IL-1β -511T/C SNPs (35.9% ).
In the other analyzed genes, allelic changes were
found to be decreasing for TGF- β codon10C / T
(-71.9%), IL4RA + 1902G / A (-47.3 %), and for
IL- 1α -889T / C ( -37.7%). The lowest negative
change (-25.9%) was observed in the allele frequency in IL- 1β 3962T / C (p<0.000) (Table 3).
Table 3. The allele frequencies of cytokine polymorphisms in ulcerative colitis (UC) patients and controls
Cytokine
IL-1-α
-889
IL-1-β
3962
IL-1-β
-511
IL-1R
mpsa 111100
IL-4RA
1902
TGF-β
Codon 10-2
TNF-α
-308
IFN-γ
36
Position
UTR5644
Alleles
No (%) of patients
with ulcerative colitis (n=51)
No (%) of healthy
controls (n=100)
C
T
C
T
C
T
C
T
A
G
C
T
A
G
A
T
55 (53.92)
47 (46.08)
44 (43.14)
58 (56.86)
54 (52.94)
48 (47.06)
37 (36.27)
65 (63.73
45 (44.12)
57 (55.88)
54 (52.94)
48 (47.06)
35 (34.31)
67 (65.69)
55 (53.92)
47 (46.08)
32 (32)
68 (68)
30 (30.00)
70 (70.00)
67(67.00)
33 (33.00)
79 (79.00)
71 (21.00)
20 (20.00)
80 (80.00)
12 (12.00)
88 (88.00)
87 (87.00)
13 (13.00)
77 (77.00)
23 (23.00)
p
0.002
0.053
0.042
0.000
0.000
0.000
0.000
0.001
Odd ratio
2.487
1.547
1.770
1.312
0.554
0.753
0.151
0.422
3.158
1.664
8.250
2.318
0.078
0.343
0.350
0.621
95% CI
1.402
1.178
0.991
1.004
0.313
0.576
0.081
0.315
1.687
1.288
4.025
1.797
0.038
0.255
0.190
0.478
4.410
2.030
3.162
1.715
0.980
0.985
0.284
0.565
5.910
2.150
16.908
2.990
0.159
0.461
0.641
0.805
Gök et al. Cytokine genes in ulcerative colitis
Table 4.The genotypes frequencies of cytokine polymorphism in ulcerative colitis (UC) patients and controls
Genotype distribution
Cytokine
Position
IL-1-α
-889
IL-1-β
-511
IL-1-β
3962
IL-1R
mpsa 111100
IL-4RA
1902
TGF-β
Codon 10-2
TNF-α
-308
IFN-γ
UTR5644
Genotypes
No (%) of patients with ulcerative colitis (n=51) No (%) of controls (n=100)
TT
TC
CC
TT
TC
CC
TT
TC
CC
CC
TT
TC
GG
GA
AA
CC
TC
TT
GG
GA
AA
AA
AT
TT
For the genotypic polymorphisms of eight gene
regions examined, there were statistically significant changes in seven genes: interleukin-1alpha
(IL-1α), interleukin-1reseptor (IL-1R), interleukin-4 anti-receptor (IL- 4RA), tumor growth factor beta (TGF-β),and tumor necrosis factor alpha
(TNF-α) and interferon gamma (IFN-γ). There
was one gene only with no changes in gene region, IL-1β 3962TT/TC/CC. In other regions, a
statistically significant change compared to the
control group was observed (p<0.001) (Table 4).
DISCUSSION
In the last 10 years, in order to determine the UC
epidemiological and genetic aspects, several surveys were carried out in Turkey with the participation of 1107 inflammatory bowel diseases (IBD)
patients in different cities (27). In these studies,
the incidence of UC in Turkey was determined as
4.4/100,000. It is emphasized that UC incidence in
Turkey is lower than that in North and West Europe (Norway and England, 30/100,000) (6,11),
and it is at a level closer to that in the Middle East
countries, e. g., the prevalence of 4.1/100,000 in
population of Lebanon (22). In the present study,
cytokine genes were studied by genomic analyses
in which the variation of polymorphic sites was at
the allelic level (28). Accordingly, for the genetic
polymorphisms investigated for all cytokine gene
sites most susceptible to the disease, highest rate
was observed in TNF-α -308 → G in UC patients
17 (0.333)
13 (0.255)
21 (0.412)
16 (0.314)
16 (0.314)
19 (0.373)
18 (0.353)
22 (0.431)
11 (0.216)
6 (0.118)
20 (0.392)
25 (0.492
16 (0.314)
25 (0.49)
10 (0.196)
23 (0.451)
8 (0.157)
20 (0.392)
23 (0.451)
21 (0.412)
7 (0.137)
10 (0.196)
35 (0.686)
6 (0.118)
46 (0.462)
44 (0.435)
10 (0.102)
11 (0.108)
44 (0.442)
45 (0.448)
49 (0.490)
42 (0.420)
9 (0.090)
62 (0.624)
5 (0.045)
33 (0.331)
64 (0.640)
32 (0.320)
4 (0.040)
2 (0.052)
21 (0.211)
77 (0.774)
1 (0.069)
23 (0.226)
76 (0.756)
59 (0.592)
36 (0.355)
5 (0.052)
p
0.0003
0.0079
0.0648
0.0001
0.0001
0.0001
0.0001
0.0002
compared to controls, and minor changes at allelic level in 3962T → C, IL-1β, and IL-1β -511T
→ C . In our research, it was determined IL-1β
gene alleles between 54% and 69% in UC patients,
and same gene alleles between 30% and 70% in
controls. In the research of Latino et al. (2013) in
the Italy population, TGF 1 gene - 511 polymorphism “T” allele frequencies have been shown as
between 0.26 and 0.46 of all UC patients. The
T allele frequency was between 0.30 and 0.35 in
controls (21).
In the analysis of Weersma et al. from the Netherlands in 2007, in the analysis of the IL-1 gene, it
has been found that polymorphism rates in healthy
individuals was 6%-57% and 7.4-42% in UC patients ( 28). In our results, IL-1 gene codon polymorphisms “T” allele frequencies were found in
23%-58 % in the control group and 15% -77% in
UC patients. In this sense, our rate of TGF-1 gene
is observed higher than that of the European rate.
The clinical presentation of a very different courses of UC, which is a chronic disease, can bring
along uncertainty in the diagnosis of the disease.
Also, genes and regulatory environmental agents
showing multifactorial inheritance can affect the
course of UC (13,29). Environmental impact-induced cytokine genes may be unstable in protein
synthesis in reducing or increasing direction (15).
Stimulated monocytes can be shown as reason
for criteria for the production of protein in the ILlα gene. Therefore, the cytokine gene is included
37
Medicinski Glasnik, Volume 12, Number 1, February 2015
within the specific allele determining factor (30).
In IL-1α allele frequencies there were similarities
between Turkish and the Netherlands populations
for healthy controls, but we could not compare
them with the frequency in same gene of Caucasian populations (26-28). A European research
group has shown no statistically significant difference between patients and healthy controls in
UC genotypic frequencies. They were reported
as inflammation and inflammatory periods in patients with UC, and it is suggested that the detection of the polymorphism in the Netherlands population is widely studied whereas other genetic
technology like gene sequencing is not. (4) It will
be required to conduct additional studies using
other genetic technologies like gene sequencing.
According to Ferguson et.al (6) the TNF-α polymorphisms were defined by a G to A substitution. A significant decrease in the frequency of
the TNF-α A allele was observed in UC patients
compared with further controls in our study. Opposite to Ferguson et al, we observed that the
TNF-α gene G to A alelles were increased (17)
Yamamoto-Furusho et al. (2011) investigated
proinflammatory cytokines genes (IL-1 β and
IL-R), and they found a decreasing frequency
of genotypes in UC patients as compared with
healthy controls (2,4), which is similar with the
results of the presented study.
In the regulation of intestinal inflammation, it
is known that IL-1α can be effective, it can be
predicted that changes in cytokine polymorphisms can lead to an imbalance in certain parts of
the intestinal mucosal (23). Thus, the effect of
cytokines, which are heteromorphic may be due
to inflammatory reaction (22,30). The presence
of the receptor of IL-RA and IL-1α gene in the
intestinal tract is important to determine the location and functioning of that gene (31). Strong
arguments should be obtained to examine the
function of the IL-lα and IL-1RA and we need
to have reliable data in order to strongly express
biological activity and their ability to induce the
formation of the UC (31,32).
In this study, in order to indicate the relationship
between cytokines and UC disease, our opinion
becomes predominant if carrier position of allelic variants, both IL-lα and IL-1RA is in the same
genes. Although in the interpretation of the data,
p-values are not higher in ​​UC patients comparing
to healthy controls, we can assume that intestinal
inflammation is genetically determined by imbalances in the functioning of genes. In different functional studies, even if subgroups of UC patients
defined by cytokines IL-α and IL-1RA, genotypes
are clinically heterogeneous, we believe that the
findings can contribute to the diagnosis and treatment of the UC. Furthermore, determination of
cytokine gene polymorphisms in UC, helps us
with clinical diagnosis of cancer, autoimmune diseases and other multifactorial genetic disorders.
FUNDING
We are grateful to the Karadeniz Technical University Scientific Research Project unit (Trabzon,
Turkey. Grant No: 22.114.001.11) for financial
support to this study.
TRANSPARENCY DECLARATION
Competing interests: none declared.
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39
ORIGINAL ARTICLE
False-positive 18-fluorodeoxyglucose positron emission
tomography–computed tomography (FDG PET/CT) scans
mimicking malignancies
Zehra Yasar1, Murat Acat2, Hilal Onaran3, Akif Ozgül3, Erhan H. Dincer4, Erdogan Cetinkaya3, Nurdan A.
Korkmaz5
1
Department of Chest Diseases, School of Medicine, Abant Izzet Baysal University, Bolu, Turkey, 2Department of Chest Diseases,
School of Medicine, Karabuk University, Karabuk, Turkey, 3Pulmonary Division, Yedikule Chest Diseases and Surgery Teaching and
Research Hospital, Istanbul, Turkey, 4Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, MN,
USA,5Department of Nuclear Medicine, School of Medicine, Abant Izzet Baysal University, Bolu, Turkey
ABSTRACT
Aim 18-Fluorodeoxyglucose (FDG) positron emission tomography–computed tomography (PET/CT) is an imaging modality that
is often used to help differentiate benign from malignant pulmonary lesions and it has been shown to be more efficacious than
conventional chest computed tomography (CT). However, some
benign lesions may also show increased metabolic activity which
can lead to false-positive PET findings. We aim to illustrate false
positive findings of PET scan that simulate lung cancer in a variety
of diseases.
Corresponding author:
Zehra Asuk Yasar
Department of Chest Diseases,
Abant Izzet Baysal University
School of Medicine
Gölköy Yerleşkesi,Gölköy-Bolu, Turkey
Phone: +3742534656;
Fax: + 3742534615;
Original submission:
08 September 2014;
Revised submission:
25 December 2014;
Accepted:
08 January 2015.
Med Glas (Zenica) 2015; 12(1):40-46
40
Methods Patients referred to Yedikule Chest Diseases and Surgery Teaching and Research Hospital with increased FDG uptake
for which histological results were available over a 2-year period
(2013-2014) were reviewed. Seven patients with false-positive
PET/CT findings were reported in this study.
Results The majority of lesions showing increased metabolic
activity were due to malignant diseases. However, increased 18
F-FDG uptake was also seen in benign lesions such as active pulmonary inflammation or infection, granulomatous processes and
fibrotic lesions.
Conclusion. The integration of clinical history, morphologic findings of lesions on the CT component, and metabolic activities of
PET/CT scan can help reduce false interpretations. Interventional
procedures may be needed for tissue confirmation for differential
diagnosis.
Key words: false –positive, FDG, PET scan, mimicking malignancies
Yasar et al. Falsely FDG-PET positive pulmonary lesions
INTRODUCTION
Fluorine-18 fluoro-2-deoxyglucose (18F-FDG)
positron emission tomography combined with
computed tomography (PET/CT) is a useful test
to evaluate malignancies (1). Mechanism of 18FFDG uptake in malignant tissues depends on the
metabolic activity of the lesion, e.g. the extent of
uptake is proportional to the number of malignant
cells and their proliferative activity (1,2). Malignant lesions have been shown to have elevated
expression of the glucose transporter (GLUT1) and tend to have increased metabolic activity
evidenced by increased FDG uptake (2). Notwithstanding the controversial views, SUVs of 2.5 or
greater have been used as a cutoff value indicative
of malignancy (1-3). However, inflammatory diseases may also show increased uptake of 18F-FDG
and cause false-positive PET scan results, necessitating further investigations to rule out malignant
conditions (3,4). The rationale underlying this belief is that activated macrophages and neutrophils
in inflammatory tissue use glucose as an energy
source for chemotaxis and phagocytosis, whereas
fibroblasts use glucose for proliferation (3).
The aim of this study was to describe benign lung
lesions with increased 18F –FDG uptake that simulate malignancies at series of seven cases, and
their imaging characteristics that may help in differentiating them from malignant metastases.
PATIENTS AND METHODS
This study retrospectively analyzed seven patients in order to describe false-positive 18F-FDG
uptake increase according to PET/CT scans and
to review the diagnosis and management of the
patients with increased uptake on PET/CT scan.
This study included 7 patients with suspected
lung cancer (patients with pulmonary lesions of
ambiguous nature) who were referred to Yedikule Chest Diseases and Surgery Teaching and Research Hospital clinic over 2 years (2013-2014).
The presented data were collected from patients’
records: patient’s age and sex, clinical features on
presentation, results of investigations including
X-ray, CT, PET/CT, treatment and outcome.
There were three women and four men, in the age
between 27 and 78 years.
The metabolic activity of the lesions determined
by the chest CT were evaluated for F-18 FDG
PET/CTF-18 FDG uptake. The patients underwent
18F-FDG PET/CT examination using a multidetector CT integrated high-resolution PET/CT scanner (Biograph, Siemens Medical Solutions, USA
Inc.). They fasted for 6 h before receiving an intravenous injection of 296-555 MBq of 18F-FDG.
The PET/CT acquisitions started 60 min after tracer injection. The PET scan (6–7 fields of view,
3 min/field) and low-dose non-enhanced CT scan
were acquired from the skull to the mid-thigh (5).
As a limit value for lesions suspected of neoplastic
nature, SUVmax higher than 2.5 was accepted.
In case of hypermetabolic lesions, histological or cytological examinations of the material
obtained from biopsies (CT-guided fine needle aspiration cytology, FNAC), endobronchial ultrasound-guided transbronchial aspiration
(EBUS-TBNA),video-assisted thoracic surgery
(VATS) biopsy and lobectomy, were diagnosed.
RESULTS AND DISCUSSION
Case 1: Pulmonary tuberculosis and tuberculous
lymphadenopathy
A 57-year-old female presented with dyspnea,
cough and weight lost on exertion. She has a
20-pack-year smoking history and continues to
smoke. Family history is positive for her father
with lung cancer who was heavy smoker. There
is history of loss of appetite. Physical examination is normal. Laboratory data revealed normal
blood count, erythrocyte sedimentation rate
(ESR) rate 33/1h. The sputum smear was
negative for acid fast bacillus (AFB) testing. A
chest X-ray done for evaluation of dyspnea and
cough on exertion revealed mediastinal enlargement, and there was heterogeneous density at the
right upper lobe (RUL). The CT chest revealed a
patchy consolidation in the right upper lobe and
also hilar, mediastinal lymph node enlargement.
The 18F-FDG PET/CT scan showed increased
uptake in parenchymal right upper lobar lesion
(peak standardized uptake value [SUV] = 3.9)
and in mediastinal, hilar lymph node (peak SUV
= 6.5) (Figure1). Given the patient’s high risk
based on tobacco use and family history of lung
cancer, fiberoptic bronchoscopy was performed
and no endobronchial lesion was found. EBUSTBNA biopsy of mediastinal and hilar lymph
nodes was performed. Pathology of both lymph
41
Medicinski Glasnik, Volume 12, Number 1, February 2015
nodes revealed chronic inflammation with granulomatous formation, no evidence of malignancy.
Mycobacterium tuberculosis was demonstrated
in bronchoalveolar lavage and was sus­ceptible to
all the tested anti-tuberculous agents.
Tuberculoma is one of the most well-known
diseases that show intense FDG uptake. Active
granulomatous processes such as tuberculosis
have been reported to accumulate FDG (1-4, 6).
In tuberculosis, granulomatous lesions are mainly composed of lymphocytes and macrophages,
which use 18F-FDG as an energy source (7).
Activated inflammatory cells have markedly increased glycolysis. The hexose monophosphate
shunt is stimulated by phagocytosis, with increases of 20-30 times that of baseline values, which
is the cause of high FDG uptake (6). Tuberculous
lymphadenopathy can be understood in the same
manner as tuberculoma in the lung parenchyma.
Figure 1. Tuberculous lymphadenitis in a 57-year-old woman.
In the mediastinal window setting, axial transverse CT scan
shows lymph node enlargement (left). Increased 18F-FDG uptake is observed in lesion on PET image (peak standardized
uptake value = 6,5) (right) (Yedikule EAH, 2013)
Case 2: Sarkoidosis
A 27-year-old nonsmoking male presented with a
1-month history of cough, weight loss and increasing shortness of breath. He had no history of fever,
night sweats, chest pain, palpitation, arthralgia or
skin rash. There was no history of allergy or systemic disease. On admission, he was afebrile with
a respiratory rate of 22. The physical examination
was unremarkable. Chest radiograph on admission showed mediastinal enlargement and bilateral
millimetric nodules in the upper and middle lung
zone. The laboratory tests including the complete
blood count, biochemical and tumor markers were
within normal limits. The CT chest revealed hilar,
mediastinal lymph node enlargement and numerous millimetric-dimensional parenchymal nodules
predominantly viewed in the upper and middle
zone. Heterogeneous and numerous milimetric
hypodense areas with unclear borders seen in liver
parenchyma and spleen. Quanti FERON Gold blo-
42
od test for tuberculosis was negative. The sputum
smear was negative for AFB. Malignancies were
suspected clinically and PET-CT scan was done for
diagnosis. On PET-CT, mediastinal lymph nodes,
paranchimal nodules and liver and spleen showed
fluorodeoxyglucose (FDG) uptake with a maximum standardized uptake value (SUVmax) of 2.2,
4.8 and 8.8 both liver and spleen, respectively (Figure 2). Since malignancy could not be excluded by
PET-CT scan, EBUS-TBNA biopsy of mediastinal
and hilar lymph nodes was performed. Pathology
of both lymph nodes revealed chronic inflammation with granulomatous formation, no evidence of
malignancy. After that, steroid therapy was proposed and the patient’s complaints regressed.
Sarcoidosis is a chronic multisystem disorder.
It can be characterized in affected organs by an
accumulation of T lymphocytes and mononuclear phagocytes, noncaseating epithelioid granulomas, and derangements of the normal tissue
architecture (8). The etiology is unknown, but it
is thought to be caused by exaggerated cellular
immune responses (8). Pathologically, the first
manifestation of the disease is an accumulation of mononuclear inflammatory cells, mainly
CD4+ T helper 1 lymphocytes and mononuclear
phagocytes, in the affected organ. This inflammatory process is followed by the formation of
granulomas, aggregates of macrophages and their progeny, epithelioid cells, and multinucleated
giant cells (8). Actively granuloma-forming parenchymal lesions or nodes show increased 18FFDG uptake because activated lymphocytes and
macrophages contribute to increased glucose use
in the corresponding lesions (9).
Figure 2. Sarcoidosis in 27- year-old man: in the lung window
setting, axial transverse CT scan shows small millimetric nodules (left). Increased 18F-FDG uptake is observed in lesion
on PET image (peak standardized uptake value = 4.8) (right)
(Yedikule EAH, 2013)
Case 3: Pulmonary actinomycosis
A 56-year-old woman was admitted with the complaints of intermittent cough with blood-tinged
sputum for 2 years, fatigue and weight loss. She
smoked cigarettes 1 pack a day for over 20 years.
Yasar et al. Falsely FDG-PET positive pulmonary lesions
Respiratory examinations found no cervical lymphadenopathy, musculoskeletal disorder or other abnormalities. The remainder of her physical exam
was unremarkable. Laboratory data revealed normal blood count, ESR, C-reactive protein (CRP),
and renal and liver functions. Sputum examinations (three consecutive samples) were negative
for acid-fast bacilli, malignant cells, or fungal elements. The contrast-enhanced computerized tomography (CT) showed a speculated mass, 14.17mm
in diameter, in the right lower lobe, which was
highly suspected as a malignancy. The FDG PET/
BT revealed a hypermetabolic lesion over the right
lower lobe of the lung, with a maximum SUV of
5.2 which favors a malignancy (Figure 3). Bronchoscopy revealed normal airways and mucosa
and bronchoalveolar lavage was negative for malignant cells or fungal elements. CT-guided FNAC
was done from the right lung mass lesion. The smears were prepared and stained with haematoxylin
and eosin, periodic acid Schiff (PAS), and Giemsa
stains. The smears revealed radiating filamentous
colonies of Actinomyces in a background of neutrophilic exudates; PAS stain also showed Actinomyces colonies, resulting in the confirmation of the
diagnosis of pulmonary actinomycosis. The patient
was treated with intravenous penicillin for a month
and then given oral penicillin for six months. The
patient responded well to the treatment.
Pulmonary actinomycosis is a rare bacterial lung
disease and causes lung cavities, lung nodules, and
pleural effusion (10). Radiographic and clinical
features of pulmonary actinomycosis varied and
could mimic a wide spectrum of benign and malignant diseases (11). Mabeza et all. reported that
up to 25% of cases with thoracic actinomycosis
were initially misdiagnosed as malignancy (12). In
general, high uptake on FDG PET suggests that
the nodule contains active and proliferative lesions
such as lung cancer, infiltration tumor, tuberculoma, and pulmonary mycosis (13).
Figure 3. Pulmonary actinomycosis in a 56- year-old woman:
axial transverse CT scan shows a spiculated mass, 14.17mm
in diameter, in the right lower lobe (left). Increased 18F-FDG
uptake is observed in lesion on PET image (peak standardized
uptake value = 5.2) (right) (Yedikule EAH, 2013)
Case 4: Reumatoid nodules
A 65-year-old woman with a history of rheumatoid arthritis (RA) presented with dyspnea on exertion. The RA was diagnosed 16 years earlier and
has been treated with salisilazosülfapiridin and
prednisolon since the time of diagnosis. She has
a 15-pack-year smoking history. Family history
is positive for lung cancer. There is history of loss
of appetite and weight over a period of 6 months.
Physical examination including joint examination is normal except for decreased breath sounds.
Laboratory data revealed normal blood count,
ESR,CRP, and renal and liver functions. The CT
chest revealed a 23.15 mm noncalcifiednodule
in the right lower lobe and bilateral millimetric
nodules. The 18F-FDG PET/CT scan showed
moderately increased uptake with a maximum
SUV of 4.3 in the right lower lobe (RLL) nodule
(Figure 4). Subsequent VATS biopsy of the right
lower and middle lobe nodules was performed.
Pathology of both nodules revealed chronic inflammation with necrotizing granulomatous formation consistent with rheumatoid nodules and
no evidence of malignancy. Fungal and acid-fast
bacilli stains and cultures were negative.
Figure 4. Reumatoid nodule in 65- year-old woman: axial
transverse CT scan shows 23.15 mm non-calcified nodule
in the right lower lobe (left).Increased 18F-FDG uptake is
observed in lesion on PET image (peak standardized uptake
value = 4.3) (right) (Yedikule EAH, 2013)
Reports of the use of PET and PET/CT in extraarticular RA are limited to subcutaneous nodules,
lymph nodes, and the lung (14,15). Gupta et al.
described a patient with RA found to have mild
increased uptake in pulmonary nodules on PET
scan (16). Histological examination of these nodules revealed the presence of rheumatoid nodules. On the other hand, Rodr´ıguez et al. described two patients with RA in whom pulmonary
nodules showed increased SUV on 18F-FDG
PET scan (17). Biopsy of the nodules demonstrated bronchogenic carcinoma developing wi-
43
Medicinski Glasnik, Volume 12, Number 1, February 2015
thin preexisting rheumatoid nodules. Clinicians
need to keep in mind that rheumatoid nodules can
have increased activity on PET scan in the management of lung nodules in rheumatoid arthritis.
Case 4: Anthracosilicosis
A 78-year-old asymptomatic man was admitted
to our hospital for evaluation of an abnormal shadow on chest roentgenogram. He has 45-packyear smoking history and did not have history of
industrial exposure. On admission, physiological
and laboratory examinations, including tumor
markers, were within normal limits. Chest X-ray
showed an abnormal mass in right middle field of
the lung and mediastinal enlargement. Chest CT
revealed an approximate 1.8cm sized mass in the
right middle lob, and enlarged mediastinal lymph
nodes. The FDG-PET showed high uptake with a
maximum SUVmax 9.1 in hilar and mediastinal
nodes and 1.5 in the RML mass lesion which favors a malignancy. Since malignancy could not
be excluded by PET-CT scan, EBUS-TBNA biopsy of mediastinal and hilar lymph nodes was
performed. Pathological findings showed that
contained polarizable material suggestive of silica with focally contained fine anthracotic pigments, and negative for malignancy.
The silicosis with anthracotic pigments in mediastinal lymph nodes might be caused by inhalation
of irritant dusts and attendant distortion of local
lymphatic vessels (18). One clinicopathologic
form of this reaction is fibrosis, while the other
form consists of aggregates of particle-laden
macrophages with minimal or no accompanying
fibrosis, a reaction that is typically seen with
inert dusts such as iron, tin, and barium (18). The
FDG-PET studies have revealed increased uptake in pneumoconiosis and progressive massive
fibrosis. Some of this uptake is perhaps related
to the presence of inflammatory cells such as macrophages, as well as fibroblasts (19).
Case 5: Vanishing tumor
A 75 -year-old man with operated sigmoid colon
tumor presented with cough of several days’ duration but reported no chest pain, dyspnea, fever,
or hemoptysis. He also had hypertension. There
was a 60 pack-year smoking history, but no alcohol or illicit drug use. A chest radiograph obtained during evaluation demonstrated homogeno-
44
us densities in the right hemithorax. Laboratory
studies were remarkable for a normal leukocyte
count, a hemoglobin level of 10 g/dL. The CT
scan (mediastinal windows) reveals homogenous, spherical density within the right lower lobe.
The opacity is surrounded by a pleural rim and
lie along the expected location of the oblique
fissure. Malignancies were suspected and PETCT scan was done for diagnosis. The FDG PET/
BT revealed a hypermetabolic lesion over the
right lower lobe of the lung of the patient, with
a maximum SUV of 8-10 which favors a malignancy. Since malignancy could not be excluded
by PET-CT scan, CT-guided biopsy was planned
for diagnosis. While carrying out this procedure, we recognized that the lession had regressed.
An echocardiogram obtained and demonstrated
left ventricular hypertrophy and mild systolic
dysfunction; there was no pericardial effusion.
The patient responded well to diuretic treatment.
Vanishing tumor refers to the transient localized
collection of pleural fluid in the interlobar fissures,
usually in association with congestive heart failure from various causes (20). Vanishing tumor is a
phenomenon predominantly occurring in the right
hemithorax (21). The pathogenesis of vanishing
tumors involves the adhesion and obliteration of
the pleural space due to pleuritis, thus preventing
the free accumulation of fluid (21). In this setting,
whenever hydrostatic and/or oncotic forces produce fluid at the pleural surface beyond the resorptive ability of the pleural lymphatics, a localized
pleural effusion that is recognized as a vanishing
tumor may result. This hypothesis is supported by
the finding of adhesive pleuritis at autopsy in cases
of known vanishing tumors (22,23).
Case 6: Aspergillosis
A 68-year-old man operated for ampullary carcinoma 2 years before presented with cough of
several days’ duration. He also had hypertension.
There was a 40 pack-year smoking history, but
no alcohol use. Chest CT revealed an irregularly
shaped lung nodule approximately 11.17mm in
diameter in the right upper lobe. The FDG uptake at PET showed that the SUVmax was 5.4.
Radiologists did not diagnose the nodule as an
aspergilloma. The pathological examination of
the FNAC was negative for malignant cells, and
the cultures were negative by bronchoscopic
Yasar et al. Falsely FDG-PET positive pulmonary lesions
examinations. Because lung cancer was strongly
suspected, video-assisted thoracic surgery was
performed. An upper lobe wedge resection was
performed, including the tumor in the right upper
lobe. In the specimen, the tumor was necrotic and
a pathological examination during operation had
shown no evidence of malignancy. The final pathological examination showed the presence of an
aspergilloma. The postoperative evolution was
therefore favorable.
Recently, FDG-PET accumulation in cases of
pulmonary aspergillosis mimicking lung cancer
was reported (24), and in the three cases reported
in that study, the FDG uptake during PET scans
showed an SUVmax ranging from 4.0 to 8.3 suggesting a tendency for high FDG accumulation
in 10 cases.
Case 7: Pulmonary nocardiosis
A 35-year-old male presented with cough and
expectoration with episodes of haemoptysis for
2 years. He took an antitubercular treatment for
six months. With antitubercular treatment fever
had subsided but the amount of sputum and haemoptysis had continued. Two months ago he
referred to a general physician with low grade
fever associated with productive cough and received some medication without any improvement. His condition became worse. Chest x-ray
showed infiltrations in right upper lobe with
cavity formation and CT revealed the presence
of areas of consolidation with air bronchograms
and cavitary lesions containing air and infiltration beginning from the apical segment lying to
anterior segment of right lower lobe. The FDG
PET/BT revealed a hypermetabolic lesion over
the right upper lobe of the lung of the patient,
with a maximum SUV of 5.9-7.1 which favors
a malignancy (Figure 5). So due to findings he
Figure 5. Pulmonary nocardiosis in 35- year-old man: axial
transverse (mediastinal windows) CT scans reveals cavitary
lesions in anterior segment of right lower lobe (left). Increased
18F-FDG uptake is observed on PET image (peak standardized uptake value =5.9-7.1) (right) (Yedikule EAH, 2013)
received ceftazidim and ciprofloxacin. But he
had no improvement in respiratory symptoms.
Several sputum samples were collected and
tested for the presence of acid-fast bacilli, but
all smears were negative. The patient then underwent bronchoscopy and aspirated material
was negative for tuberculosis, fungi (including
Pneumocystis jirovecii), and malignancy. The
FNAC was done from the right lung lesion. Aspirated material was negative for tuberculosis
and malignancy. Because of progressive worsening of clinical status, right upper lobectomy
was performed. On gram staining, the organism appeared as gram-positive, beaded, coccoid,
thin branching filaments. Modified Ziehl-Neelsen staining showed many branching acid-fast
bacilli, consistent with the morphology of Nocardia species. The patient was started on trimethoprim-sulfamethoxazole and improved
remarkably both clinically and radiographically.
Pulmonary nocardiosis is an infection caused
by gram-positive aerobic bacilli belonging to
genus Nocardia. Pulmonary nocardiosis occurs
through inhalation and most often affects patients presenting with immunosuppression due
to AIDS, neoplasia, as well as kidney or bone
marrow transplantation (25). The diverse radiological manifestations of pulmonary nocardiosis reflect its ability to cause both suppurative
and granulomatous infection (8). Actively granuloma-forming parenchymal lesions or nodes
show increased 18F-FDG uptake because activated lymphocytes and macrophages contribute to increased glucose use in the corresponding lesions (9).
In conclusion, metabolic imaging with FDGPET is beginning to play an important role in
the management of malignancies. However,
benign and malignant lesions may have
overlaps. Benign focal lung lesions can simulate lung cancer with increased 18F-FDG
uptake. The integration of clinical history,
morphologic findings of lung parenchymal
lesions on the CT component, and metabolic
activities on the PET component of integrated
PET/CT can help reduce false interpretations.
Interventional procedures may be needed for
lesions showing increased 18F FDG uptake on
PET for tissue confirmation irrespective of their morphology on CT.
45
Medicinski Glasnik, Volume 12, Number 1, February 2015
We must keep in mind that not all increased 18FFDG uptakes should be considered malignant.
These cases exemplify the need of clinicians to
exercise clinical and critical thinking skills to
consider the broad diagnostic possibilities of
lung lesions presenting as a malignancy.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATION
Competing interests: None to declare
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LF, Sobrinho AB, da Cunha AL, Santos AC. Extraarticular inflammatory sites detected by F-18 FDG
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ORIGINAL ARTICLE
Human West Nile virus infection in Bosnia and Herzegovina
Sead Ahmetagić1, Jovan Petković1, Mirsada Hukić2, Arnela Smriko-Nuhanović1, Dilista Piljić1
1
Clinic for Infectious Diseases, University Clinical Centre Tuzla, Tuzla, 2 International Burch University, Sarajevo; Bosnia and Herzegovina
ABSTRACT
Aim To describe the first two cases of West Nile virus (WNV)
neuroinvasive infections in Bosnia and Herzegovina.
Methods At the Clinic for Infectious Diseases of the University
Clinical Centre Tuzla, Bosnia and Herzegovina (B&H), specific
screening for WNV infection was performed on patients with neuroinvasive diseases from 1 August to 31 October 2013. Serum
samples were tested for the presence of WNV IgM and IgG antibodies using enzyme-linked immunosorbent assay (ELISA); positive serum samples were further analyzed by detection of WNV
nucleic acid of two distinct lineages (lineage 1 and lineage 2) in
sera by RT-PCR.
Corresponding author:
Arnela Smriko-Nuhanović
Clinic for Infectious Diseases,
University Clinical Centre Tuzla
Trnovac bb, 75 000 Tuzla,
Bosnia and Herzegovina
Phone: +387 35 303 326;
Fax: +387 35 303 480;
E-mail: [email protected]
Original submission:
Results Three (out of nine) patients met clinical criteria, and two
of them had high serum titre of WNV specific IgM antibodies (3.5
and 5.2). Serum RT-PCR testing was negative. Conformation by
neutralization testing was not performed. Both cases represented
with encephalitis. None of these cases had recent travel history in
WNW endemic areas, or history of blood transfusion and organ
transplantation, so they represented autochthonous cases.
Conclusion Although there were no previous reports of flavivirus
infections in B&H, described cases had high titre of WNV specific
antibodies in serum, and negative flavivirus-vaccination history,
they were defined as probable cases because recommended testing
for case confirmation was not performed. The West Nile virus
should be considered a possible causative pathogen in this area,
probably in patients with mild influenza-like disease of unknown
origin and those with neuroinvasive disease during late summer
and early autumn.
Key words: neuroinvasive infections, encephalitis, flaviviruses
14 August 2014;
Revised submission:
24 October 2014;
Accepted:
18 December 2014.
Med Glas (Zenica) 2015; 12(1):47-51
47
Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
The genus Flavivirus comprises 53 viruses, and
many of them are human pathogens of concern. In
Europe, many flaviviruses are endemic (West Nile,
Usutu, tick-borne encephalitis viruses) or occasionally imported (dengue, yellow fever viruses) (1).
West Nile virus (WNV) is transmitted in an avian
cycle by ornithophilic mosquitoes, chiefly of the
genus Culex. Mammals can also be infected, but
are considered dead end hosts because viraemia is
generally too low to infect mosquitoes (2). West
Nile virus was first identified in the West Nile district of Uganda in 1937 in a woman who presented with a mild febrile illness (3). During the next
decades, the virus spread through Africa and Asia.
It was first described in Europe in the 1960s when
seropositive animals or virus isolates were reported in France, Portugal and Cyprus (4). West Nile
virus has historically been considered less pathogenic in humans than dengue virus or yellow fever virus; however, more virulent genotypes have
emerged since 1998. Isolates from Israel (1998),
Hungary (2003), or North America (1999) belonging to the Israeli-American cluster of WNV lineage 1a are highly pathogenic in birds and mammals,
and lineage 2 viruses have caused an increasing
number of WNV outbreaks in Europe since 2008
(2). In Europe, WNV has mainly been reported in
central and south-eastern Europe, regions in which
WNV infections and virulence have recently increased, and the implicated viruses have spread to
new areas, including Bulgaria and Greece in 2010,
Albania and Macedonia in 2011, and Croatia, Serbia, and Kosovo in 2012 (1,2,5). The first laboratory-confirmed cases of the West Nile virus neuroinvasive infection in Croatia were diagnosed in
September 2012 in three eastern Croatian counties,
although specific antibodies to West Nile virus in
humans, horses, and European brown bears have
been previously detected (6-9). Also, in Serbia first
outbreak of West Nile virus infection was reported
in humans in August to October 2012, and evidence of detected virus activity in horses, wild birds
and mosquitos (10-12). There are no reports of
WNV or other flaviviruses activities in humans or
animals in Bosnia and Herzegovina.
PATIENTS AND METODS
At the Clinic for Infectious Diseases University
Clinical Centre Tuzla, Bosnia and Herzegovina
48
(B&H), specific screening for WNV infection was
performed on patients with neuroinvasive diseases
with negative CSF bacterial cultures and negative
serological tests for other common causes of bacterial, viral or protozoan meningitis and/or encephalitis (rubella, measles, mumps, varicella-zoster
viruses, adenovirus type 3, Epstein-Barr, herpes
simplex virus-1, herpes simplex virus-2, cytomegalovirus, coxackie B, coxsackie A7, echovirus
type 7 viruses, Treponemaa pallidum, Borrelia
burgdorfer sensu stricto, Borrelia garinii, Borrelia afzelii, Haemophilus influenza, Listeria monocytogenes 1/2a and 4b, Toxoplasma gondii) from
1 August to 31 October 2013. There was no data
about specific WNV screening performed before
in medical centres in B&H. The study had been
approved by the Research Ethics Committee of the
University Clinical Centre Tuzla.
Case definition
The case definition and case classification were
established according to European Union case
definitions for West Nile fever (13). Persons with
fever (≥37.5 °C) and meningitis and/or encephalitis were included. Meningitis was defined as
presence of fever, clinical signs of meningeal inflammation (including headache, nuchal rigidity,
Kernig’s sign or Brudzinski signs, photophobia
or phonophobia), and the presence of cerebrospinal (CSF) pleocytosis (>5 leucocytes/mm3),
elevated protein levels (>0.45 g/L; normal range
0.15-0.45 g/L) and normal (2.6-3.1 mmol/L, 5060% serum glucose levels) or mildly decreased
(2.4-2.6 mmol/L) CSF glucose level. Encephalitis was defined as the presence of fever, encephalopathy (decreased or altered level of consciousness, lethargy or personality change) and/or
focal neurological signs (weakness, cranial nerve palsy), seizures or movement disorders (tremor, parkinsonisam, ataxia), and the presence of
CSF pleocytosis (>5 leucocytes/mm3), elevated
protein levels (>0.45 g/L), and normal (2.6-3.1
mmol/L, 50-60% serum glucose levels) or mildly
decreased (2.4-2.6 mmol/L) CSF glucose level.
Laboratory criteria for a probable case were the
presence of WNV-specific antibody response in
serum (IgM or IgM and IgG). Laboratory criteria
for a case conformation were isolation of WNV
from blood or CSF, detection of WNV nucleic
acid in blood or CSF, WNV specific antibody
Ahmetagić et al. Human WNV infection in B&H
response (IgM) in CSF, WNV IgM high titre and
detection of WNV IgG, and conformation by neutralisation.
Serology and molecular tests
Serum samples were tested at the Institute of
Clinical Microbiology, University Clinical
Center of Sarajevo, for the presence of WNV
IgM and IgG antibodies using the West Nile Virus IgM Capture DxSelectTM ELISA and West
Nile Virus IgG DxSelectTM ELISA kits (Focus
Diagnostics, Cypress, California, USA). Serum
samples, which tested positive in the ELISA,
were further analyzed by detection of WNV
nucleic acid of two distinct lineages (lineage 1
and lineage 2) in sera by RT-PCR. Results were
confirmed at the Institute of Microbiology and
Immunology, Medical Faculty University of
Ljubljana, Slovenia. Diagnostic tests for WNV
isolation from blood, specific CSF testing
(WNV isolation, specific antibody response, or
detection of nucleic acid), and conformation by
neutralization were not performed.
Patient data
Patient’s demographic characteristics (age, sex,
region of residence), travel history, blood transfusions, transplants, and vaccination status,
comorbidity, presenting symptoms and signs,
clinical findings, hematology and blood biochemistry analysis, CSF cell count and biochemical
analysis were recorded, along with serology and
molecular diagnostic tests results, as well as the
outcome at hospital discharge.
RESULTS
During the period 01 August to 31 October 2013
only three patients (out of nine) met clinical criteria, and two of them were identified as probable cases according to the case definition (Table
1); conformation by neutralization testing was
not performed.
Table 1. Results of serology and molecular testing of two
patients with neuroinvasive West Nile virus infection
Day of samSample
IgM ELISA IgG ELISA
Case
pling after
RT-PCR
type
(titre)
(titre)
illness onset
1
Serum
20
Positive (3.5) Positive (2.2) Negative
2
Serum
12
Positive (5.2) Negative (0.27) Negative
First case had onset of symptoms at the beginning
of August, and second case at the beginning of September 2013. None of these cases had recent travel
history in areas where WNV was endemic, nor the
history of blood transfusion and organ transplantation, and had negative flavivirus-vaccination
history (demographic characteristics and comorbidities are shown in Table 2). They were both represented with encephalitis (self-reported symptoms
and clinical signs are shown in Table 3).
Table 2. Demographic characteristics and comorbidities of
two patients with neuroinvasive West Nile virus infection
Age
Case
Sex
(years)
1
84
2
68
Male
Immunosuppression Hyper- Other chronic
including tension
illness
diabetes
Vertigo
Tuzla
No
Yes
Chronic bronchitis
City
area
Female Kladanj
No
Yes
Hypertensive
heart disease
Table 3. Self-reported symptoms and clinical signs of two
patients with neuroinvasive West Nile virus infection
Signs and symptoms
Fever ≥ 37.5 °C
Neurological manifestation
Fatigue
Consciousness impairment
Rash
Case 1
+
+
+
+
+
Case 2
+
+
+
+
-
+, present; -, absent;
Neurological manifestation, including neurological
deficit and consciousness impairment were recorded on day 10 after symptom onset in both cases.
Neurological manifestations in case 1 included
horizontal nystagmus, positive Romberg’s sign,
positive Kernig’s sign, neck and extremities
muscle stiffness with lively deep tendon reflexes,
and urine retention. In this case qualitative (confusion, disorientation) and quantitative (somnolence) consciousness impairment were present,
and mood changes in form of anxiety.
Neurological manifestations in case 2 included
ataxia, horizontal nystagmus, positive Romberg’s
sign, nuchal rigidity, and diminished deep tendon
reflexes, with qualitative (confusion, disorientation) and quantitative (somnolence) consciousness
impairment, and incoherent speech.
Cerebrospinal fluid analysis results of these two
cases are shown in Table 4.
None of these patients developed respiratory failure requiring mechanical ventilation. Both patients recovered by the time they were discharged,
case 2 had complete recovery, and case 1 still had
49
Medicinski Glasnik, Volume 12, Number 1, February 2015
mild horizontal nystagmus, positive Romber’s
sign and urine retention.
Table 4. Cerebrospinal fluid analyses results of 2 patients
with neuroinvasive West Nile virus infection
Parameter
WBC (per mm3)
WBC differential
Protein (g/L)
Glucose (mmol/L)
Normal value/range
<5
No predominance
<0.45
2.6-3.1 mmol/L
Case 1
136
60% L
1.55
3.3
Case 2
960
62% N
1.45
2.7
WBC, white blood cells; L, lymphocytes; N, neutrophiles;
DISCUSSION
Taking in consideration that large WNV outbreaks happened in Eastern Croatia (6) and Serbia
(10) in 2012, we analyzed appearance of the human neuroinvasive disease in B&H, performing
a screening for patients hospitalized throughout
summer and autumn 2013 for WNV infection
with the aim to investigate presence of the virus
in this location. Although only patients with neuroinvasive disease were tested, of whom two
were positive, we assumed that there were more
patients with WNV infection who had influenzalike febrile illness who were not tested, or who
did not seek medical help due to the symptoms
being too mild or were treated in primary care.
This is a single-center study at regional level, and
a large study at state level should be planned so
that the incidence rates can be calculated.
Both presented patients had clinical signs of encephalitis that could not be distinguished from
the patients with encephalitis with a different etiology (14), but large sample case-control studies
might reveal specific characteristic of encephalitis due to WNV infection (14).
Serological diagnosis of flavivirus infections is
complicated by the antigenic similarities among
the Flavivirus genus because most flavivirus antibodies are directed against the highly immunogenic envelope protein, which contains both flavivirus cross-reactive and virus-specific epitope (1).
Serological assay results should thus be interpreted with care and confirmed by comparative neutralization test using a panel of viruses known to
REFERENCES
1.
50
Beck C, Jimenez-Clavero MA, Leblond A, Durand
B, Nowotny N, Leparc-Goffart I, Zientara S, Jourdain E, Lecollinet S. Flavivirus in Europe: Complex
circulation patterns and their consequences for the
diagnosis and control of West Nile Disease. Int J Environ Res Public Health 2013;10:6049-83.
circulate in Europe (1,15). Although there have
been no previous reports of other flavivirus infections in B&H, the cases presented in this report had high titre of WNV specific antibodies
in serum, and had negative flavivirus-vaccination
history, and accordingly, they were defined as
probable because we were not able to perform
recommended testing for case conformation.
Knowledge of flavivirus diversity at the local level is essential before rigorous serological surveys can be undertaken (1). Veterinary and entomologic investigations related to WNV and other
flaviviruses have not been performed in B&H, so
we can only assume from the published regional
data (6-12) the circulating pattern of the virus in
this area. Systematic research is needed to understand epidemiology and ecology of WNV in
B&H. It is very important to develop a project to
detect WNV in mosquitoes in urban regions and
near rivers in various parts of the state, as well as
surveillance of human cases.
Considering the vectors and recent floods, a number of public health measures can be undertaken
(intensifying activities to reduce the number of
mosquitos in environments using insecticide, destroying mosquito habitat, systematic extermination of larvae and adult form of larvae and adult
form of mosquitoes, education of the population on
how to avoid or decrease the risk of being bitten by
potentially infected mosquitoes through posters, leaflets, television, and newspapers) (16). These actions should help avoid outbreaks of human WNV
infection and raise awareness of healthcare providers about emergence of the virus in B&H. In patients with mild influenza-like disease of unknown
origin and those with neuroinvasive disease during
late summer and early autumn, WNV should be
considered a possible causative pathogen.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATION
Competing interests: None to declare.
2.
3.
Reiter P. West Nile virus in Europe: understanding the present to gauge the future. Eurosurvaill
2010. http:www.eurosurveillance.org/ViewArticle.
aspx?Articleid=19508. (3 Jun 2014)
Sithburn KC, Hughes TP, Burke AW Paul JH. A neutropic virus isolated from the blood of a native of
Uganda. Am J Tro Med 1940; 20:471-92.
Ahmetagić et al. Human WNV infection in B&H
4.
Murgue B, Murri S, Triki H, Deubel V, Zeller H.
West Nile in Mediterranean basin:1950-2000. Ann
N Y Acad Sci 2001; 951:117-26.
5. Nowotny N, Bakonyi T, Weissenbock H, Seidel B,
Kolodziejek J, Sekulin K, Lussy H. West Nile virus
infection in Europe – general features. Medica Sciences 2013; 39:123-4.
6. Merdić E, Perić L, Pandak N, Kurolt IC, Turić N, Vignjević G, Stolfa I, Milas J, Bogojević MS, Markotić
A. West Nile virus outbreak in humans in Croatia,
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7. Madić J, Huber D, Lugović B. Serologic survey for
selected viral and rickettsial agents of brown bears
(Ursus arctos) in Croatia. J Wildl Dis 1993; 29:572-6.
8. Madić J, Savini G, Di Gennaro A, Monaco F, Jukić
B, Kovac S, Rudan N, Listes E. Serological evidence
for West Nile virus infection in horses in Croatia. Vet
Rec 2007; 160:772-3.
9. Barbić L, Listeš E, Katić S, Stevanović V, Madić J,
Starešina V, Labrović A, Di Gennaro A, Savini G.
Spreading of West Nile virus infection in Croatia.
Vet Microbiol 2012; 159:504-8.
10. Popović N, Milošević B, Urošević A, Poluga J, Lavadinović L, Nedelijković J, Jevtović D, Dulović
O. Outbreak of West Nile virus infection among
humans in Serbia, August to October 2012. Euro
Surveill 2013. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20613 (11 July 2014)
11. Petrović T, Blazquez AB, Lupulović D, Lazić G, Escribano-Romero E, Fabijan D, Kapetanov M, Lazić
S, Saiz J. Monitoring West Nile virus (WNV) infection in wild birds in Serbia during 2012: first isolati-
12.
13.
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aspx (10 October 2013)
Sejvar JJ. Clinical manifestations and outcomes
of West Nile virus infection. Viruses 2014; 6:606-23. Sambri V, Capobianchi MR, Cavrini F, Charrel R,
Donoso-Mantke O, Escadafal C, Franco L, Gaibani
P, Gould EA, Niedrig M, Papa A, Pierro A, Rossini G, Sanchini A, Tenorio A, Varani S, Vázquez A,
Vocale C, Zeller H. Diagnosis of West Nile virus human infections: overview and proposal of diagnostic
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Radivojević S, Maris S, Ljubić B, Obrenović J. First
detection of West Nile fever in human population in
the territory of Belgrade. Proceedings Third International Epizootiology Days and XV Serbian Epizootiology Days, Niš/Serbia, May 8-11 2013. Faculty of
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vet.bg.ac.rs/uploads/file/seminari_simpozijumi/Epizootioloski.dani.2013.ZBORNIK.pdf (20 April 2014)
Humana infekcija virusom Zapadnog Nila u Bosni i Hercegovini
Sead Ahmetagić1, Jovan Petković1, Mirsada Hukić2, Arnela Smriko-Nuhanović1, Dilista Piljić1
1
Univerzitetski klinički centar Tuzla, Tuzla, 2International Burch University, Sarajevo; Bosna i Hercegovina
SAŽETAK
Cilj Prikazati prva dva slučaja neuroinvazivne infekcije uzrokovane virusom Zapadnog Nila (WNV) u
Bosni i Hercegovini (BiH).
Metode U Klinici za infektivne bolesti Univerzitetskog kliničkog centra Tuzla (BiH), u periodu od 1.
avgusta do 31. oktobra 2013. godine, kod pacijenata kojima je postavljena dijagnoza neuroinvazivne
infekcije provedena su specifična testiranja na WNV infekciju. Uzorci seruma testirani su na prisustvo
specifičnih WNV IgM i IgG antitijela pomoću enzimsko-imunološkog testa (ELISA), a pozitivni uzorci
seruma su dalje testirani ispitivanjem prisustva WNV nukleinske kiseline za dvije različite linije (linija
1 i linija 2) pomoću RT-PCR-a.
Rezultati Samo tri pacijenta (od ukupno devet) zadovoljavala su postavljene kliničke kriterije, od kojih
su dva imala visoke titrove WNV specifičnih IgM antitijela (3,5 i 5,2) u serumu. RT-PCR testovi iz istog
seruma bili su negativni. Potvrdni test neutralizacije nije urađen. Oba slučaja imala su kliničku sliku
encefalitisa. Pacijenti nisu boravili u područjima gdje je virus Zapadnog Nila endemičan, niti su primali
transfuzije krvi ili transplantaciju organa, tako da predstavljaju autohtone slučajeve.
Zaključak Iako nije bilo ranije prijavljenih flavivirusnih infekcija u BiH, u oba slučaja su u serumu
nađena specifična WNV antitijela u visokom titru i u oba slučaja nije bilo prethodne vakcinacije protiv
flavivirusa; oba slučaja su ostala nepotvrđena jer nije provedeno preporučeno testiranje za potvrdu
slučaja. Virus Zapadnog Nila je prisutan u ovoj regiji te ga uvijek treba razmotriti kao potencijalnog
patogena u pacijenata sa simptomima blage influence nepoznatog porijekla ili neuroinvazivne bolesti
koji se javljaju u kasno ljeto i ranu jesen.
Ključne riječi: neuroinvazivne infekcije, encefalitis, flavivirusi
51
ORIGINAL ARTICLE
Incidence and etiological agents of genital dermatophytosis in
males
Asja Prohić, Mersiha Krupalija-Fazlić, Tamara Jovović Sadiković
Department of Dermatovenerology, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Aim To determine the incidence and etiological agents of dermatophytosis of male genitalia in Sarajevo area, Bosnia and Herzegovina, during a 5-year period (2009-2013).
Methods A total of 313 male patients with confirmed dermatophyte infection elsewhere in the body was analyzed. All samples
(skin scrapings and hairs) were treated with lactophenol to detect
a possible presence of fungal elements and then cultured on Sabouraud glucose agar. Dermatophytes species were identified based
on macroscopic and microscopic morphology.
Corresponding author:
Asja Prohić
Department of Dermatovenerology,
University Clinical Center Sarajevo
Bolnička 25, 71000 Sarajevo,
Bosnia and Herzegovina
Phone: +387 33 298 136;
Fax: +387 33 297 801;
E-mail: [email protected]
Original submission:
14 October 2014;
Accepted:
24 October 2014.
Med Glas (Zenica) 2015; 12(1):52-56
52
Results Dermatopyte infection of penis and/or scrotum was confirmed by positive cultures in 17 (5.4%) patients, of which four
had lesions on the penis alone, five had lesions on scrotum and
eight patients had lesions on both penis and scrotum. Majority
of patients, 12 (70.0%) belonged to the age group 21-40. Fifteen
patients (88.2%) had associated foci of dermatophyte infection,
but the inguinal area was most frequently affected, in 10 (66.6%)
patients. Microsporum canis was the most frequent dermatophyte
found on culture, in 10 (58.8%) patients.
Conclusion Dermatophytosis of male genitalia is a rare entity,
occurring more often in young males and the main causative species is Microsporum canis.
Key words: tinea, male genitalia, incidence, etiology
Prohić et al. Dermatophytosis of the male genitalia
INTRODUCTION
RESULTS
Dermatophyte (tinea) infections of penis and scrotum are relatively rare compared with those involving the inguinal area (1). The infection usually
extends from the inguinal area to the scrotum and
uncommonly to the penis, but rarely occurs on the
glans or prepuce (2). Different factors such as occlusive clothing, systemic diseases and a reservoir
of dermatophytes at any other body site are considered to contribute to the occurrence of infections,
which mainly affect young males (1,3,4).
The incidence of tinea in males is traditionally
considered to be very low (4-6). On the other
hand, some studies report it as quite common (79). Moreover, there are different results regarding
the causative dermatophyte species in this particular body site in males (4,7,9)
These controversial opinions regarding the rarity
of this entity incited us to undertake an investigation to find out incidence and etiological agents
of male genitalia in individuals with dermatophytosis of the skin in population of Sarajevo region, Bosnia and Herzegovina.
Among 313 male patients who attended the Department of Dermatovenerology, University Clinical
Center Sarajevo, Bosnia and Herzegovina, with dermatophytosis elsewhere in the body, KOH preparations of the skin scraping from the lesions showed
mycelia of dermatophyte in 17 (5.4%) patients.
PATIENTS AND METHODS
During a five-year period (2008-2013), clinical
presence of dermatophytosis of the penis and/
or scrotum has been studied in 313 male patients
who reported the Department of Dermatovenerology, University Clinical Center Sarajevo, Bosnia
and Herzegovina, with dermatophytosis elsewhere
in the body. The samples were taken from a prominent border of the lesions and examined in the
Mycological Laboratory of the Institute of Microbiology, Parasitology and Immunology, Sarajevo
University Clinical Center.
No patient gave any history of diabetes, tuberculosis or any other immunosuppressive condition
in the recent past.
Mycological examination consisted of direct microscopy and culture identification of causative
agents.
All scrapings were examined in 10% potassium
hydroxide (KOH) solutions directly under the
microscope and cultivated on Sabouraud glucose
agar with added chloramphenicol and cycloheximide. The cultures were incubated at 27o C for up
to 6 weeks and observed weekly for evidence of
growth. The identification of dermatophytes was
based on their macroscopic and microscopic characteristics of the colonies (10).
The causative dermatophyte species was identified by positive cultures in 17 (5.4%) patients.
Microsporum (M.) canis was the most frequent
dermatophyte isolated, in 10 (58.8%), followed
by Epidermophyton (E.) floccosum, in five (29.4)
and Trichophyton (T.) mentagrophytes var. interdigitalis in two (11.8%) patients.
Majority of the patients with positive culture findings , 12 (70.0%) belonged to the age group 2130 years, followed by 31-40 years age group, three
(17.7%) patients. No patients belonged to age group below 10 or above 51 years of age (Table 1).
Table 1. Age distribution of patients with genital dermatopytosis
Age group (years)
0-10
11-20
21-30
31-40
41-50
51 and above
No (%) of patients
0
1 (5.8)
12 (70)
3 (17.7)
1 (5.8)
0
Of the 17 patients with positive culture findings, penile dermatophytosis was found in four
(23.5%) patients, scrotal lesions in five (29.4%)
patients, both penile and scrotal lesions in eight
(47.0%) patients. None of the patients had lesions
on the glans or prepuce. Wives of the six married
patients (35.3%) were examined and found to be
free from genital infection.
Solitary involvement of the penis or scrotum without the involvement of the crural region or any
other regions was found in two (11.8%) patients.
Fifteen (88.2%) patients showed tinea infection
at other anatomical sites of whom ten (66.7%)
patients presented with tinea cruris, four (26.7)
with tinea unguium and one (6.7) patient with tinea pedum (Table 2).
Table 2. Sites of involvement in patients with genital dermatopytosis
Site of the lesion
Penis
Scrotum
Penis and scrotum
Other sites of dermatophytosis
Solitary genital involvement
No (%) of patients
4 (23.5)
5 (29.4)
8 (47.0)
15 (88.2)
2 (11.8)
53
Medicinski Glasnik, Volume 12, Number 1, February 2015
DISCUSSION
Dermatophytosis of male genitalia has been regarded as a rare entity since its first description in
1860 by Ferdinand Ritter von Hebra (1816–1880),
a founder of the Vienna School of Dermatology
(11). So far the same opinion has been supported
by many other investigators (4-6). A study conducted in Italy has shown low frequency because
the authors reported nine cases of male tinea genitalis over a period of fifteen years (4). In another
study from India, of 2200 patients with confirmed
dermatophytosis, approximately 1% had penile
involvement (8). Some authors attributed rarity of
the genital involvement to capric acid and some
fungistatic serum factor and sebum (12).
Contrary to this, some studies from different researchers showed that dermatophytosis of male
genitalia is quite common, particularly from tropical countries, where the reported incidence was
21% (7). Similarly, Gupta and Banerjeer reported
six cases of dermatophytes of male genitalia in a
short period of three months (9).
Our observation shows an incidence of 5.4% of
all examined patients to be a relatively rare entity. The low incidence in our study, but also in
aforementioned studies, may be due to difference
in climate and socioeconomic condition. Climate
plays an important role and the higher incidence of the infection in the tropics has been noted
during the rainy season of a year when humidity
was more than 95% (7). The low incidence could
be also attributed to the fact that the disease could
go unnoticed because the clinical manifestations
are slight and healing is often spontaneous (9).
In this study most of the patients with penile and/
or scrotal dermatophytosis (70.37%) belonged
to the age group 21-40, which is in concordance with the majority of the studies, which found
that young males were most susceptible to the
dermatophyte infection of genital region (7,13).
Surprisingly no patients belonged to age group
below 10 or above 50 years of age which was
also abserved by Pandey et al. (14) and Vora et
Mukhopadhyay (7). Further investigations are
required particularity in this age group.
The presence of tinea infection at other anatomical
sites may serve as a reservoir of infection. Especially tinea cruris, tinea pedis and toenail onychomycosis are common sources of infection of male
54
genitalia (7,8,14,15). In our study, the lesions situated on penis and scrotum were preceded by dermatophytosis in inguinal area in 58.8% patients,
which indicates that the infection probably started
in the crural region and spread later to the genitalia.
Glans penis involvement is considered even rarer
(16), whereas dermatophytosis of the prepuce has
not been reported in the literature. In our case series, none of the patients had lesions on glans and/or
prepuce, which supports earlier reports.
Solitary involvement of the penis or scrotum without the involvement of any other regions was
found in 11.8 % males, which indicates the possibility that penis and scrotum may be infected
with dermatophytosis de novo without involvement of any other area (2,6,17).
Our study has confirmed zoophilic dermatophyte M. canis as being the most common species
isolated from genital area. However, most studies reported T. rubrum as a common pathogen
(4,7,9,15,17,18), although E. floccosum and T.
mentagrophytes var. interdigitale have also been
isolated from the genital region (4,7,17). High isolation rate of M. canis from the genital
region (58.8%) correlates with the high frequency of this species in our population in general
(19). In the last fifteen years, an increasing incidence of zoophilic dermatophytes, especially M.
canis has been observed in many regions in Europe (20). Generally, the prevalence of M. canis
in our population is one of the highest in Europe
(90.4) (20) and is comparable only with rates reported from Italy (90.5) (21), Grace (84.5%) (22)
and Spain (63.5%) (23). The high prevalence of
this dermatophyte species can be attributed to the
increase in the number of domestic animals particularly cats living outside homes and consequently an increase in the phenomenon of animals
stray and semistray (24). Presumably stray cats
are the major reservoir and carriers of M. canis.
It is widely accepted that dermatophytes are keratinophilic in nature and they invade their host by
enzymatic digestion of keratin. This can explain
the rarity of tinea infections on male genitalia,
since anatomically the glans penis and inner surface of the prepuce are covered with non-keratinized epithelium. Overweight, occlusion, high
moisture, inadequate hygiene, diabetes, previous
antibiotic treatment and immunosuppression are
common predisposing factors.
Prohić et al. Dermatophytosis of the male genitalia
In tinea of the genital region individual treatment
approach is needed, considering both local and
systemic susceptibility factors. Topical antifungal treatment is usually sufficient in acute infections. In many cases, systemic treatment with either azoles or terbinafin may be needed in cases of
widespread dermatophytic infection (25).
To conclude, our results suggest that dermatophytosis of male genitalia with an incidence of
5.4% is rare mycotic infection of this particular
body site. The infection affects more often young
males, occurring more often on the penis and scrotum at the same time. Zoophyte species M. canis is
the most frequently isolated dermatophyte.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATION
Competing interests: None to declare
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30-year survey of paediatric tinea capitis in southern
Spain. J Eur Acad Dermatol Venereol 2011; 25:170-4.
24. Proverbio D, Perego R, Spada E, Bagnagatti de Giorgi G, Della Pepa A, Ferro E. Survey of dermatophytes
in stray cats with and without skin lesions in Northern
Italy. Vet Med Int 2014; 2014:565470.
25. Pires CA, Cruz NF, Lobato AM, Sousa PO, Carneiro
FR, Mendes AM. Clinical, epidemiological, and therapeutic profile of dermatophytosis. An Bras Dermatol 2014; 89:259-64.
55
Medicinski Glasnik, Volume 12, Number 1, February 2015
Incidenca i etiološki agensi genitalne dermatofitije kod
muškaraca
Asja Prohić, Mersiha Krupalija-Fazlić, Tamara Jovović Sadiković
Klinika za kožne i spolne bolesti, Klinički centar Univerziteta u Sarajevu, Sarajevo, Bosna i Hercegovina
SAŽETAK
Cilj Utvrditi incidencu i etiološke agense genitalne dermatofitoze kod muškaraca na području Sarajeva,
u petogodišnjem periodu (od 2009. do 2013. godine).
Metode Analizirano je ukupno 313 muškaraca s potvrđenom dermatofitnom infekcijom druge lokalizacije. Svi uzorci (ljuske s kože i dlake) preparirani su u laktofenolu radi otkrivanja eventualno prisutnih
gljivičnih elemenata i zatim kultivirani na Sabouraud glukoza agaru.
Rezultati Dermatofitna infekcija penisa i/ili skrotuma potvrđena je pozitivnom kulturom kod 17 (5,4%)
pacijenata, od kojih je četiri imalo promjene samo na penisu, pet na skrotumu, dok je njih osam imalo
promjene na penisu i skrotumu. Većina pacijenata, 12 (70%), pripadala je dobnoj skupini od 21 do
40 godina. Petnaest (88,2%) pacijenata imalo je dermatofitnu infekciju druge lokalizacije, od kojih je
najčešće bilo zahvaćeno ingvinalno područje, 10 (66,6%). Microsporum canis bio je najčešće izolirani
specijes u kulturi, 10 (58,8%).
Zaključak Dermatofitoza muških genitalija je rijetka pojava, češće prisutna kod mlađih muškaraca, a
glavni uzročnik je Microsporum canis.
Ključne riječi: tinea, genitalije muškarca, incidenca, etiologija
56
ORIGINAL ARTICLE
Surgical therapy for pilonidal sinus in adolescents: a retrospective
study
Tamer Sekmenli, Ilhan Ciftci
Department of Pediatric Surgery, School of Medicine, Selcuk University, Konya, Turkey
ABSTRACT
Aim To investigate optimal surgical management of pilonidal sinus (PS) in pre-adolescent and adolescent periods in which it is
less common.
Methods A retrospective study based on 25 adolescent patients
with PS disease that were treated at the Department of Pediatric
Surgery, Selcuk University, Konya, Turkey, between 2010 and
2013 was conducted.
Corresponding author:
Ilhan Ciftci
Selcuk Universitesi Tip Fakultesi
Cocuk Cerrahisi A. D. Konya, Turkey
Phone: +90 33 22 415 000;
Fax: +90 33 22 412 184;
E-mail: [email protected]
Results Among 25 patients with PS disease 17 (68%) were males
and eight (32%) females, with a mean age of 16.08 ± 1.2 years.
According to the body mass index (BMI), 17 (68%) of the cases
were in the normal range, 4 four (16%) of each were overweight, and obese, respectively. Twenty cases (80%) were managed
with total excision and primary closure, while five (20%) cases
underwent Limberg flap repair. Four patients were managed with
the Limberg procedure due to very large sinuses, while a single
patient underwent the procedure due to a recurrence following primary repair.
Conclusion Factors that predispose patients to developing PS include an above average BMI, significant body hair, and prolonged
time in a seated position. Elevated BMI as a risk factor for PS is a
growing concern given the rise in obesity. Although there are various treatment modalities, total excision and primary closure has
demonstrated successful outcomes.
Key words: hair, surgery, adolescent, follow-up
Original submission:
30 September 2014;
Revised submission:
04 November 2014;
Accepted:
17 December 2014
Med Glas (Zenica) 2015; 12(1):57-60
57
Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
RESULTS
Pilonidal sinus (PS) was first described in 1883
by Mayo, and further characterized by Hodges in
1880 (1,2). Pilonidal disease is an acquired skin
condition that develops in the sacrococcygeal
area or other hair-bearing areas, and is characterized by an epithelialized tract (the sinus) generally
containing hair (3,4). Although PS can occur at
any age, it is known to be less common during
the pre-adolescent and adolescent periods (5).
Pilonidal disease can have a dramatic impact on
activities of daily living and quality of life (5). In
the past, it was thought to be a congenital skin disease, but it is now considered to be an acquired
condition that results from burrowing of loose
hair shafts into vulnerable skin (5). Although pilonidal disease is not uncommon in adolescents,
there are very few publications concerning PS in
this age group.
Adolescents with pilonidal disease who presented between January 2010 and June 2013, were
evaluated. Seventeen (68%) patients were males
and eight (32%) were females, with a mean age
of 16.08 ± 1.2.
There is an ongoing debate regarding the optimal
surgical management of PS. Various approaches
to treatment have been suggested, ranging from
conservative, nonsurgical treatments, to extensive resections (1,6,7). There is no clear evidence
to identify the best method, and the majority of
the literature pertains to children (6,7). The fact
that there are multiple surgical procedures in use
suggests that the optimal technique remains to be
determined (6,7).
The aim of this study was to describe our experience with PS in adolescents with specific attention to complications and management strategies.
PATIENTS AND METHODS
Adolescents patients who were treated for PS at
the Pediatric Surgery Department, Selcuk University Medicine Scholl Hospital between January 2010 and June 2013 were retrospectively
analyzed.
Patients were categorized according to sex, age,
body mass index (BMI), amount of body hair,
and daily duration of sitting.
Patients were managed with either excision and
primary closure or Limberg flap repair. Patients
who presented with infected PS were treated 7
to 10 days with antibiotics after drainage, if necessary. The degree of hirsutism was quantified
using the Ferriman-Gallwey scale and prolonged
sitting was defined as four or more hours per day.
58
According to the BMI, 17 (68%) patients were in
the normal range (average BMI 24.8), four (16%)
were considered overweight (average BMI 28.2),
and four (16%) were classified as obese (average
BMI 31).
Regarding body hair, 12 (48%) patients had a
moderate amount, while 13 (52%) had a high degree of body hair. Eighteen (72%) patients reported spending four or more hours a day in a seated
position.
Twenty (80%) patients were managed with total
excision and primary closure, while five (20%)
underwent Limberg flap repair. The Limberg procedure was chosen for five patients: four had particularly large sinuses and one had a recurrence
after initially being managed with primary repair.
No recurrences have been identified in follow-up.
DISCUSSION
Pilonidal disease is a common, acquired disease that mainly affects active young adults and
adolescents (2). This study is limited to sacrococcygeal pilonidal pathology although the disease
process can occur elsewhere, particularly around
the finger webbing in hair dressers and shearers
and breasts of wool handlers in shearing sheds
(2). Hair (wool) insertion is the essential cause
of the disease (5). The peak incidence of pilonidal disease is in 15–24 years of age (2). Studies
have shown that 38% of PS patients have a family history of pilonidal disease. Caucasians get PS
more frequently than other races (8).
In our study 50% of patients had normal body
weight and 37% were overweight. Patients with
a high body mass index have an increased risk of
recurrence after surgery (9). Weight excess may
be a risk factor for PS (10,11). It is notable that
one patient in our study who had a recurrence after primary closure was overweight. Patients with
repeated local trauma and occupations that require prolonged sitting have a higher prevalence of
pilonidal disease (10). Of our patients, 68% had
normal BMI, the daily sitting rate of more than
Sekmenli et al. Pilonidal sinus in adolescents
four hours was 72%, and more than half of the
patients in our series had a high degree of body
hair. As the whole patient series in this study
consisted of students sitting for extended periods
while studying, time seated is considered to be
a risk factor. Prolonged local trauma for PS has
been shown to be a risk factor (12).
ned as it does not require the creation of flaps.
There are several advantages to primary closure.
The procedure is easy to perform and does not
require significant experience. As such, it can
be performed quickly. In addition, there is little
postoperative pain, early wound healing, and an
early return to normal activities.
Three factors are thought to combine in the pathogenesis of PS: loose hair, some force causing
penetration of hair into the skin, and vulnerability
of the skin to insertion of the hair at the natal cleft
(13). One hair penetrating the dermis may create
an environment in which other hairs can penetrate
more easily. The resulting foreign body reaction
develops into PS (13). Lifestyle changes may address the first two factors. Hair removal may help,
and weight loss results in a natal cleft that is not
as deep and has less friction (13). One study demonstrated successful management of pilonidal
disease on an outpatient basis, because hospital
admissions were decreased by 78% when patients
began instituting a conservative strategy that emphasized hygiene and meticulous shaving (14).
Two of the major complications that can occur
after primary closure are wound site infection
and wound dehiscence. Neither of these complications, however, occurred in our patient series.
The average healing period of PS was 40-60 days
following excision or marsupialization and leaving the site completely open. During this period,
dressing changes should be performed regularly
with the defect expected to heal with granulation
tissue. In this case, the result has a poor cosmetic
appearance.
There are different treatment approaches, and although medicine treatment is an option, it is not
preferred as it takes a long time and its efficacy
is hard to establish (14). In medicine therapy for
PS the use of phenol has been proposed in the
literature (15,16). A disadvantage of using phenol
is prolonged treatment. Surgical intervention is
initially aimed at removing pits and sinuses, and
debriding any infected tissue by excision (17).
One large series of 78,924 American soldiers
during the Second World War reported hospitalization time of 55 days, mainly due to complications resulting from a wide excision (18). This
is because wide excision typically results in large
defects that require healing by secondary intention. This resulted in an open wound that was,
theoretically, susceptible to further invasion by
loose hairs (13). We have used the technique of
en bloc excision of the sinus or sinuses with the
surrounding healthy tissue down to the presacral
fascia and primary closure of the wound. It is an
uncomplicated technique that can be easily lear-
When flap methods are compared with primary
closure, considerable cosmetic scar tissue develops in the gluteal area. This was demonstrated
in the study in which the Limberg flap method
was used and displeasure regarding the cosmetic
outcome was expressed and considered to be a
significant disadvantage (19).
In conclusion, until now, the etiology of pilonidal disease has not been clarified although it has
been discussed in many studies (1,2,10,11). In
this study, excessive hair growth, obesity, and
prolonged sitting have increased the incidence
of PS. Adolescents with these risk factors ought
to be examined routinely. In surgical treatment,
the benefits of primary closure include ease of
performance, minimal postoperative pain, early
wound healing, and early return to work, with
acceptable recurrence rates. Thus, excision and
primary closure may be the preferred approach in
adolescents with PS.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATION
Competing interests: None to declare
59
Medicinski Glasnik, Volume 12, Number 1, February 2015
REFERENCES
1.
Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin N Am 2010;
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2. Lee PJ, Raniga S, Biyani DK, Watson AJ, Faragher
IG, Frizelle FA. Sacrococcygeal pilonidal disease.
Colorectal Dis 2008; 10:639-50.
3. Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir
M. Limberg flap procedure for pilonidal sinus disease: results of 353 patients. Langenbecks Arch Surg
2008; 393:185–9.
4. Ersoy E, Devay AO, Aktimur R, Doganay B,
Ozdoğan M, Gündoğdu RH. Comparison of the
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5. Hull TL, Wu J. Pilonidal disease. Surg Clin N Am
2002; 82:1169.
6. Daphan C, Tekelioglu MH, Sayilgan C. Limberg flap
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Ferahkose Z. Rhomboid excision and Limberg flap
for managing pilonidal sinus: long-term results in
411 patients. Colorectal Dis 2008; 10:945-8.
8. de Parades V, Bouchard D, Janier M, Berger A. Pilonidal sinus disease. J Visc Surg. 2013; 150:237-47.
9. Varnalidis I, Ioannidis O, Paraskevas G, Papapostolou D, Malakozis SG, Gatzos S, Tsigkriki L, Ntoumpara M, Papadopoulou A, Makrantonakis A, Makrantonakis N. Pilonidal sinus: a comparative study
of treatment methods. J Med Life 2014; 7:27-30.
10. Sakr M, El-Hammadi H, MoussaM, Arafa S, Rasheed M. The effect of obesity on the result of Karydakis technique for the management of chronic pilonoidal sinus. Int J Colorectal Dis 2003; 18:36-9.
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11. Arda IS, Güney LH, Sevmiş S, Hiçsönmez A. High
body mass index as a possible risk factor for pilonidal sinus disease in adolescents. World J Surg 2005;
29:469-71.
12. Søndenaa K, Andersen E, Nesvik I, Søreide
JA.Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis 1995;
10:39-42.
13. Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg 1992; 62:385.
14. Armstrong JH, Barcia PJ. Pilonidal sinus disease. The conservative approach. Arch Surg 1994;
129:914.
15. Girgin M, Kanat BH. The results of a one-time
crystallized phenol application for pilonidal Sinus disease. Indian J Surg 2014; 76:17-20.
16. Gulpinar K, Pampal A, Ozis SE, Kuzu MA. Nonoperative therapy for pilonidal sinus in adolescence:
crystallised phenol application, ‘report of a case’.
BMJ Case Rep 2013; 3:2013.
17. Petersen S, Koch R, Stelzner S, Wendlandt TP,
Ludwig K. Primary closure techniques in chronic pilonidal sinus: asurvey of the results of different surgical approaches. Dis Colon Rectum 2002;
45:1458–67.
18. Abramson D. Outpatient management of pilonidal
sinuses: Excision and semiprimary closure technique. Milit Med 1978; 143:753.
19. Eryılmaz, R, Sahin M, Alimoglu O, Daşıran F. Surgical treatment of sacrococcygeal pilonidal sinus
with the Limberg transposition flap. Surgery 2003;
134:745-49.
ORIGINAL ARTICLE
Impacts of education level and employment status on healthrelated quality of life in multiple sclerosis patients
Selma Šabanagić-Hajrić, Azra Alajbegović
Department of Neurology, Clinical Center of the University of Sarajevo
ABSTRACT
Aim To evaluate the impacts of education level and employment
status on health-related quality of life (HRQoL) in multiple sclerosis patients.
Corresponding author:
Selma Šabanagić-Hajrić
Department of Neurology,
Clinical Center, University of Sarajevo
Bolnička 25, 71000 Sarajevo,
Bosnia and Herzegovina
Phone: +387 33 29 73 54;
Fax:+387 33 29 78 21;
E mail: [email protected]
Original submission:
08 September 2014;
Revised submission:
07 October 2014;
Methods This study included 100 multiple sclerosis patients treated at the Department of Neurology, Clinical Center of the University of Sarajevo. Inclusion criteria were the Expanded Disability
Status Scale (EDSS) score between 1.0 and 6.5, age between 18
and 65 years, stable disease on enrollment. Quality of life (QoL)
was evaluated by the Multiple Sclerosis Quality of Life-54 questionnaire (MSQoL-54). Mann-Whitney and Kruskal-Wallis
test were used for comparisons. Linear regression analyses were
performed to evaluate prediction value of educational level and
employment status in predicting MSQOL-54 physical and mental
composite scores.
Results Full employment status had positive impact on physical
health (54.85 vs. 37.90; p<0.001) and mental health (59.55 vs.
45.90; p<0.001) composite scores. Employment status retained its
independent predictability for both physical (r2=0.105) and mental
(r2=0.076) composite scores in linear regression analysis. Patients
with college degree had slightly higher median value of physical
(49.36 vs. 45.30) and mental health composite score (66.74 vs.
55.62) comparing to others, without statistically significant difference.
Conclusion Employment proved to be an important factor in predicting quality of life in multiple sclerosis patients. Higher education level may determine better QOL but without significant predictive value. Sustained employment and development of vocational
rehabilitation programs for MS patients living in the country with
high unemployment level is an important factor in improving both
physical and mental health outcomes in MS patients.
Key words: QOL, physical health, mental health
Accepted:
22 October 2014.
Med Glas (Zenica) 2015; 12(1):61-67
61
Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
Multiple sclerosis (MS) is a chronic and unpredictable neurological disease varying from a
mild course with minimal disabilities to a rapidly progressing or fluctuating course resulting in
severe disabilities (1). The associations between
employment status and the incidence and prevalence of chronic diseases and mortality have been
previously discussed (2-4). Evidence regarding
whether two different pathways, employment–
health status or health status–employment, actually do exist in the chronically ill patients has been
described in an extensive review by Clougherty
(2). Based on the current literature, employment
status is analyzed in relation to disease-specific,
therapeutic, psychosocial and socioeconomic
factors with special emphasis on the vocational
status of MS patients (5). On cognitive testing,
unemployed individuals performed significantly
worse on measures assessing information processing speed, verbal learning and memory and
executive functioning (6). While the physical disability is well recognized in MS patients, it does
not necessarily reflect all aspects which patients
should consider as important once in their life.
Although fatigue, depression, and physical disability are usually experienced aspects of MS patients, it is also documented that cognitive, emotional, and psychological functions contribute to
their quality of life (QoL) (7). Today, the Neurology Quality-of-Life Measurement Initiative
is a standardized approach based on extant items
used for measuring QoL across common neurologic conditions, including multiple sclerosis, for
both adults and children (8,9). Using QoL measures may provide clinicians with the information
regarding the general health status of MS patients
who might otherwise go unrecognized with high
recommendations for using them in clinical practice (10). Several questionnaires have been developed to evaluate aspects of health related quality
of life (HRQoL) in MS patients. There is a distinction between studies using generic HRQoL
inventories, and the studies with disease specific
instruments, such as the Multiple Sclerosis Quality of Life-54 questionnaire (MSQoL-54), which
comprises the SF-36 and 18 additional MS specific items (11). A large number of studies have demonstrated that patients with MS have a poorer
HRQoL than persons from the general populati-
62
on, as MS occurs in people during the peak years
of employment (12,13). The disease significantly
impacts the ability to remain in the workforce
with data suggesting high rates of unemployment
and early retirement in MS patients (14,15). Considering that employment is a central aspect of
one’s standard of living or for forming relationships, of individuals’ personality and self-esteem,
loss of paid work is associated with financial, social and mental health implications for patients
and their families, leading to a significant decline
of patients’ quality of life (QoL) (16-18). Data
indicates that majority of US MS patients (90%)
were employed before the diagnosis, and about
60% continued to work at the time of the diagnosis (13). Only 20-40% of patients with MS, however, remain employed following the diagnosis
(19,20). It is shown that onset of early retirement
was about three years after receiving a diagnosis
of multiple sclerosis at an average age of 38 years
(21) and rates of early retirement due to MS are
about 40% (22,23). Previous studies showed that
unemployed patients reported low scores in some
HRQoL domains, such as physical role limitation, physical function, and emotional limitation
(24). In addition, education seems to have some
impact on HRQoL. High school or college graduates had higher physical health composite scores
than patients with a low educational level (25).
The aim of this study was to evaluate the effects
of education level and employment status on
HRQoL in MS patients at different stage of the
disease treated at the Clinical Center of the University of Sarajevo, Bosnia and Herzegovina. A
purpose of the study was to evaluate importance
of sustained employment and development of vocational rehabilitation programs for MS patients
living in the country with high unemployment
level. This is the first study of this type conducted in Bosnia and Herzegovina. The results are
expected to provide important information to medical professionals and people from an immediate environment how to best participate in treating
and taking care for persons with MS.
PATIENTS AND METHODS
Study design
This independent, observational, cross-sectional
study included 100 consecutive patients with
Šabanagić-Hajrić et al. Education and employment on QoL in MS
multiple sclerosis treated at the Department of
Neurology, Clinical Center University of Sarajevo, Bosnia and Herzegovina, during the period
January 1st to July 15th 2005. Inclusion criteria
for the study were: clinically defined diagnosis
of MS according to previously published recommendations (26), Expanded Disability Status
Scale (EDSS) score between 1.0 and 6.5 (27), 18
years of age or older and patients who were able
to give written informed consents. Exclusion criteria were cognitive deterioration (Mini Mental
Status Test Score <26) (28), and the presence of
any acute somatic or neurological disease.
cs were summarized. The Linkert method was
adopted to assemble MSQoL-54 scale scores and
the raw scores were transformed into 0-100 scales. Mann-Witney and Kruskal Wallis tests were
used for comparisons between sociodemographic and clinical characteristics and QOL scores.
Linear regression analyses were performed to
evaluate prediction value of educational level
and employment status in predicting MSQOL-54
physical and mental composite scores, with a significance level of p<0.05.
Having evaluated the protocol the Ethics Committee of the Clinical Center of the University
of Sarajevo gave an ethical consent to have the
study the performed. Each patient gave an informed written consent for use of the results obtained for publication before the enrollment.
The mean age of patients at enrolment was
39.88+/- 10.03 years; 69 (69%) patients were
females and 31 (31%) were males. The majority of patients, 64 (64%) were married. The
mean disease duration at enrolment was 9.39+/7.30 years. The majority of patients, 72 (72%)
had relapsing-remitting MS at the time of enrolment, 25 (25%) had secondary progressive
type while only three (3%) patients had primary
progressive type of the disease.
Instruments
Patients reported their QoL using a self-administered questionnaire. The disease-specific Multiple Sclerosis Quality of Life-54 (MSQoL-54) questionnaire developed by Vickrey et al. was used
(11); it was translated and adapted to the Bosnian
language (29). This questionnaire consists of 18
MS-specific dimensions and ratings for overall
QoL (MS-18 module), in addition to the generic
QoL features of the Short-Form 36-Item Health
Survey Questionnaire (SF-36) (30) to obtain the
MSQoL in reference to the following domains:
physical health composite score (PHCS), mental
health composite score (MHCS), physical function (PF), role limitation-physical (RP), emotional wellbeing (EWB), mental health (MH),
role limitation-emotional (RE), bodily pain
(BP), energy (EN), health perception (HP), social function (SF), change in health (CH), health
distress (HD), cognitive function (CF), sexual
function (SxF), satisfaction with sexual function
(SSxF), and overall quality of life (OQoL). The
MSQoL-54 item results are transformed linearly
to 0-100 scores, and final scores are calculated by
averaging items within the scales.
Statistical analyses
Statistical analyses were performed for patients
satisfying all the inclusion criteria. Demographic parameters and other baseline characteristi-
RESULTS
Table 1. Multiple Sclerosis Quality of Life questionnaire
(MSQOL)-54 scores according to employment status
Median value of physical health composite score (25th-75th percentile)
Employed
Unemployed
(n=38)
(n=62)
60.00
30.00
Physical function
(28.75-85.00)
(10.00-55.00)
Role limitations75.00
0.00
physical
(0.00-100.00)
(0.00-25.00)
Role limitations
100.00
33.33
emotional
(33.33-100.00)
(0.00-66.67)
80.83
54.17
Pain
(52.92-95.00)
(31.67-76.67)
Emotional well72.00
60.00
being
(52.00-84.00)
(44.00-65.00)
56.00
48.00
Energy
(42.00-68.00)
(32.00-60.00)
50.00
30.00
Health perceptions
(33.75-65.00)
(15.00-50.00)
75.00
50.00
Social function
(54.17-91.67)
(25.00-66.67)
82.50
70.00
Cognitive function
(70.00-95.00)
(53.75-80.00)
72.50
40.00
Health distress
(53.75-86.25)
(20.00-60.00)
Overall quality
58.35
50.00
of life
(50.00-73.35)
(36.65-60.00)
100.00
66.70
Sexual function
(62.49-100.00)
(33.00-91.68)
Satisfaction with
50.00
50.00
sexual function
(50.00-75.00)
(25.00-50.00)
25.00
25.00
Change in health
(25.00-50.00)
(0.00-50.00)
Physical health
66.70
39.47
composite score
(42.07-81.98)
(24.71-54.53)
Mental health
72.60
45.33
composite score
(55.96-84.13)
(37.08-65.11)
MSQQOL-54
domain
p
0.001
<0.001
<0.001
0.002
0.001
0.014
<0.001
<0.001
<0.001
<0.001
0.001
0.002
0.001
0.017
<0.001
<0.001
63
Medicinski Glasnik, Volume 12, Number 1, February 2015
The mean EDSS score of all patients at enrolment
was 3.57+/-1.73. In terms of education, 67 (67%)
of patients had a high school degree, 23 (23%)
had a college degree while only 10 (10%) had
primary education.
Regarding occupation, 38 (38%) patients were
employed, six (6%) were students, 25 (25%) patients were unemployed, and 31 (31%) retired.
Employed patients scored significantly higher than
unemployed patients in all MSQOL-54 domains
(Table 1). Employed patients had statistically significant higher median value of physical health
composite score (66.70 vs. 39.47; p<0.001) and
mental health composite score (72.60 vs. 45.33;
p<0.001) comparing to unemployed patients.
Patients with college degree scored better than
those with secondary and primary education in
most domains, e.g. role limitations emotional,
body pain, emotional well-being, health perceptions, social function, cognitive function, health distress, overall quality of life, satisfaction with sexual function, change in health-CH, physical health
composite score-PHCS, mental health composite
Table 2. Multiple Sclerosis Quality of Life questionnaire
(MSQOL)-54 scores according to education level
score-MHCS, but without statistically significant
difference (p>0.05). Patients with secondary and
primary education scored better than the group
with college degree only in sexual function domain, also without statistically significant difference
(p>0.05) (Table 2). Patients with college degree
had slightly higher median value of physical health composite score (49.36 vs. 45.30) and mental
health composite score (66.74 vs. 55.62) comparing to unemployed patients, without statistically
significant difference (p>0.05).
Stepwise linear regression analysis examining
the prediction value of demographic and clinical characteristics of all patients in predicting
MSQOL-54 physical and mental health composite scores is shown in Table 3. Employment status
proved its independent predictability of physical health composite score, PHCS (r2=0.105)
and mental health composite score, MHCS
(r2=0.076).
Table 3. Stepwise linear regression analysis: predictors of
quality of life on the MSQOL-54
MSQOL-54
MSQOL-physical
Median (25th-75th percentile)
MSQOL-54 domain
Physical function
Role limitationsphysical
Role limitations
emotional
Pain
Emotional well-being
Energy
Health perceptions
Social function
Cognitive function
Health distress
Overall quality of life
Sexual function
Satisfaction with
sexual function
Change in health
Physical health
composite score
Mental health
composite score
64
High school
degree
(n=23)
35.00
(20.00-65.00)
0.00
(0.00-75.00)
Primary and sep
condary school
(n=77)
40.00
0.130
(20.00-65.00)
0.00
0.170
(0.00-50.00)
66.67
(0.00-100.00)
33.33
(0.00-100.00)
68.33
(40.00-100.00)
72.00
(52.00-76.00)
52.00
(36.00-64.00)
45.00
(25.00-55.00)
66.67
(33.33-83.33)
80.00
(65.00-95.00)
65.00
(35.00-75.00)
55.00
(40.00-68.35)
70.86
(45.64-100.00)
50.00
(25.00-75.00)
25.00
(25.00-50.00)
49.36
(32.38-70.93)
66.74
(47.39-80.29)
63.33
(39.17-85.00)
60.00
(46.00-68.00)
52.00
(34.00-60.00)
40.00
(20.00-55.00)
58.33
(33.33-75.00)
70.00
(55.00-85.00)
55.00
(25.00-75.00)
50.00
(43.33-65.85)
83.35
(41.43-100.00)
50.00
(25.00-75.00)
25.00
(25.00-50.00)
45.30
(31.72-67.46)
55.62
(39.96-72.12)
0.115
0.112
0.099
0.221
0.240
0.242
0.061
0.108
0.232
0.120
0.171
0.253
0.131
0.102
MSQOL-mental
Significant predictors
Eta squared
R2
Presence of pain
EDSS
Sphincteric disorders
Employment status
Disease type
Patient age
Presence of pain
Disease type
Employment status
EDSS
0.287
0.271
0.186
0.105
0.104
0.063
0.139
0.087
0.076
0.074
0.827
0.598
Eta squared, correlation ratio; EDSS, enabled disability status scale;
R2, coefficient of determination;
DISCUSSION
The age and employment status of patients in this
study is consistent with the fact that MS often
strikes young adults and working people at the
top of their careers and that increasing disability
makes finding a job becomes more difficult (31).
According to the literature, 67% of those diagnosed with MS for less than 5 years change job status, and 45% switch to a different field; approximately 21% of patients with MS for less than 5
years are unemployed, versus 92% of those with
MS for at least 30 years (32).
Patients with multiple sclerosis with good selfrated health are more likely to be employed, even
after adjusting for age, gender, education, functional disability, disease duration, depression and
Šabanagić-Hajrić et al. Education and employment on QoL in MS
anxiety (33). Studies with similar percentage of
employed patients to this study showed statistical significant influence of employment on both
physical and mental health composite scores
(1,11). Employed patients in this study scored
significantly higher than unemployed patients in
all MSQOL-54 domains. In other studies with higher level of employment, employed patients did
not scored significantly better in health perception and emotional well-being (18), and did not
score significantly better in mental health domains at all (34). Those findings implicate higher influence of unemployment on mental health in this
study that could be partially explained by poor
mental health status among unemployed patients.
Results from German study showed that in patients with minor motoric impairment, depressive
symptoms seem to have a major impact on employment status (5). The lack of flexible working
hours, inability to have flexible resting times at
work, lack of understanding from colleagues and
employers, as well as the personal attitude were
main non-disease-specific reasons for early retirement (5).
Greater physical and cognitive disability, progression of disease, longer disease duration, and
older age are considered to be the factors associated with unemployment (35). Other studies
on employment in MS have shown that those
patients who remain employed have better selfreported quality of life (1,36). Being employed
was also positively associated with physical
HRQOL (37) with findings that for MS patients,
regardless of disability level, increased physical
activity is related to better HRQOL in terms of
energy, social functioning, mental and physical
health (38). The results of this study clearly suggest the importance of sustained employment
after the MS diagnosis. The condition of being
employed with a social role and salary seems to
improve the QoL of patients diagnosed with MS.
Employment rate among patients with MS is variable, and can partly depend on economic status
of different countries, as demonstrated by previous studies (24, 39-41).
Majority of patients in this study had a high school and college degree, which is in accordance
with data from the literature indicating that more
than 50% of MS patients have high school and
college degree, while less than 5% have primary
education only (42). In this study there was no
statistically significant difference in HRQOL
between patients with different educational level, although the patients with college degree
scored better than those with secondary and primary education in most domains except in sexual function. This could be partially explained
by stronger awareness of the disease and better
coping ability with the challenges of a chronic
disease among the patients with higher education
level but still not significant and with no independent predictability in the group of patients
with low employment rate. In an Italian study,
educational level was shown to be a significant
and independent predictor for the physical health
composite score, pain, mental health composite
score, physical health, role limitation - physical,
cognitive function, social function, role limitation – emotional domains of the MSQoL-54 (18).
Less education was proved to be negatively associated with mental HRQOL in other studies that
were done in different countries (33,43). Taking
these findings into account, a neurologist should
encourage a patient to sustain from his/her usual activity, either employment or studying. The
clinician should stress the assertion that patients
who continue working or studying have a better
QoL (44). Mean scores for pain, role limitation
– emotional, and social function domains of the
MSQoL-54 were generally not clinically different among 185 patients with MS, as well as in
the US population as a whole (44). Results from
different studies have shown effects that coping
skills of MS patients have on social and emotional adjustment and emphasized the need to provide better information to the MS patients about the
nature and evolution of multiple sclerosis.
In conclusion, sustained employment and development of vocational rehabilitation programs
for MS patients living in the country with high
unemployment level is an important factor in improving both physical and mental health outcomes in MS patients.
FUNDING
No specific funding was received for this study
TRANSPARENCY DECLARATIONS
Competing interests: none to declare
65
Medicinski Glasnik, Volume 12, Number 1, February 2015
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Utjecaj stupnja obrazovanja i statusa zaposlenosti na kvalitet
života oboljelih od multiple skleroze
Selma Šabanagić-Hajrić, Azra Alajbegović
Neurološka klinika, Klinički centar Univerziteta u Sarajevu
SAŽETAK
Cilj Evaluirati utjecaj stupnja obrazovanja i statusa zaposlenosti na kvalitet života oboljelih od multiple
skleroze.
Metode U ispitivanje je uključeno 100 pacijenata s dijagnosticiranom multiplom sklerozom koji su
liječeni na Neurološkoj klinici Kliničkog centra Univerziteta u Sarajevu. Kriteriji za uključenje bili su
skor Proširene skale stupnja onesposobljenosti (EDSS) između 1,0 i 6,5, dob između 18 i 65 godina, te
stabilni tok bolesti. Kvalitet života je evaluiran uz pomoć upitnika kvaliteta života oboljelih od multiple
skleroze (MSQoL-54). Mann-Whitneyev i Kruskal-Wallisov test su korišteni za usporedbe. Linearna
regresiona analiza korištena je za procjenu signifikantnih prediktora fizičkog i mentalnog zbirnog skora
kvaliteta života (MSQOL-54).
Rezultati Zaposleni pacijenti imali su više zbirne skorove fizičkog (54,85 vs. 37.90; p<0,001) i mentalnog zdravlja (59,55 vs. 45,90; p<0,001). Zaposlenost se potvrdila kao neovisni prediktivni faktor
fizičkog (r2=0,105) i mentalnog (r2=0,076) zbirnog skora kvaliteta života. Pacijenti koji imaju visoko
obrazovanje imali su nešto veće srednje vrijednosti fizičkog (49,36 vs. 45,30) i mentalnog zbirnog skora
(66,74 vs. 55,62) kvaliteta života u usporedbi s ostalim, ali bez statističke značajnosti.
Zaključak Zaposlenost se pokazala kao značajan faktor pozitivnog utjecaja na kvalitet života oboljelih
od multiple skleroze. Viši stupanj obrazovanja može utjecati na bolji kvalitet života, ali bez značajne
prediktivne vrijednosti. Zadržavanje statusa zaposlenosti i razvoj profesionalnih rehabilitacionih programa za pacijente oboljele od multiple skleroze koji žive u zemlji s visokim stupnjem nezaposlenosti
jeste važan faktor u poboljšanju njihovog kako fizičkog, tako i mentalnog zdravlja.
Ključne riječi: kvalitet života, fizičko zdravlje, mentalno zdravlje
67
ORIGINAL ARTICLE
Importance of Herrings classification in predicting the outcome
of aseptic necrosis of the femoral head
Žarko Dašić1, Miroslav Kezunović1, Goran Pešić1, Vesna Bokan2, Mira Jovanovski3
Clinic for Orthopedics and Traumatology, 2Center for Physical Medicine and Rehabilitation; Clinical Center Podgorica, 3Montenegro
Ministry of Health; Podgorica, Montenegro
1
ABSTRACT
Aim To highlight the importance of values of the ​​Herring’s classification in the treatment planning of Legg-Calve-Perthes disease
(LCPD).
Method The charts of 14 patients in a period of 4 years (20042008) were retrospectively reviewed. Inclusion criteria was unilateral LCPD and contralateral healthy hip. The patients were divided into three Herring groups according to radiographic images
(A, B and C). For all patients the acetabulum/head index (AHI)
was determined. Corresponding author:
Žarko Dašić
Clinic for Orthopedics and Traumatology,
Clinical Center Podgorica
Ljubljanska bb, Podgorica, Montenegro
Phone: +382 20 242 684;
Fax: +382 20 412 359;
E-mail: [email protected]
Results The youngest patient was 4.9 years and the oldest 9.11
years; male patients were dominant (male:female 11:3). The right
hip side was more affected comparing to the left one (8:6). The
distribution of patients in Herring groups was three in the Group
A, six in the Group B and five patients in the Group C. The AHI
index was lowest in the group C. Patients in the group C were
treated surgically.
Conclusion Herrings classification predicts patients with extensive changes and suggests what kind of treatment should be applied. Key words: Perthes disease, Herring’s classification, treatment
Original submission:
16 June 2014;
Revised submission:
05 November 2014;
Accepted:
20 November 2014.
Med Glas (Zenica) 2015; 12(1):68-72
68
Dašić et al. Herrings classification
INTRODUCTION
Since Legg-Calve-Perthes-disease (LCPD) is a
chronic disease, it has a characteristic cyclic flow.
Perthes disease is not only an aseptic necrosis of
the bone, but also subchondral fracture, which leads to deformities of the head and neck of the femur (1,2). The disease occurs in three pathological
stages: the initial stage, the stage of fragmentation
and the reparation stage. Definite changes in the
proximal femur in this disease depend on several
factors that influence the course of the disease (3).
Out of these, the most important are patient age,
degree of involvement of the epiphysis, sex, containment of the head within the acetabulum, premature closure of the growth zones, changes in the
metaphysis, increased body weight and prolonged
restriction of movement in the hip (1,3,4).
Deformity that occurred as final outcome of the
LCPD caused altered morphology of the hip and
related conditions for the emergence of early degenerative hip changes (osteoarthritis).
A significant number of methods (2,3,5,6) for
evaluating the results of LCPD treatment are
described: Heyman and Heradon (calculated
epiphysis index, head and neck index, acetabulum index and acetabulum-head index), Mose
(estimated AP and lateral radiographs, which
are made in Lowenstein’s position), Catterell’s
classification in 4 stages and one of the last modern classifications by Herring which consists
in determining the side (lateral) collapse of the
epiphysis in the process of fragmentation of the
containment of the head within the acetabulum in
the final stage of the disease.
According to Stolberg, there are three types of
congruency between the femoral head and the
acetabulum: spherical congruency, non-spherical
congruence and non-spherical incongruence (710). Spherical congruence does not cause degenerative changes; non-spherical congruence leads to
degenerative changes at a later age, and non-spherical incongruence to early degenerative changes
in the hip joint, before the end of the fifth decade
(11). Montenegro is an area with disorders of the
hip joint during childhood, highly represented.
Good diagnosis and adequate treatment are conditions for full functional recovery. The importance
of Herring classification has not been studied in
this area and this study can serve as a further contribution to clinical practice.
The aim of this study was to highlight the importance of ​​Herring’s classification values in the
treatment planning and outcome of Legg-CalvePerthes disease.
PATIENTS AND METHODS
A retrospective analysis of X-ray images in 14
patients treated at the Clinic for Orthopedics and
Traumatology of the Clinical Center Podgorica,
Montenegro, in the period from 2004 to 2008 was
conducted. All patients had unilateral occurrence
of the LCPD and all patients were at the stage of
complete restitution of the disease. X-rays of the
pelvis at the final stage of the fragmentation of the
disease with definite changes in the proximal femur
were analyzed. Inclusion criteria were healthy contra lateral hip as healthy material for comparison.
Image analysis of the fragmentation phase included a division and definition of the three pillars
of the femoral head; the determination of the collapse degree of the lateral pillar (determined by
measuring the distance h (the distance between
the epiphysis cracks and the highest point of the
epiphysis in the lateral column). This distance
was determined in both: the diseased and the healthy opposite hip, and it was expressed in mm.
According to Herring’s classification (12,13) patients were divided into 3 groups. In the Group
A (Herring A) lateral pillar height of the affected
hip was identical with the height of the lateral pillar of the healthy hip, in the Group B (Herring
B) lateral pillar of the affected hip reached a height of more than 50% of the healthy hip, and in
the G group C (Herring C) the height of the lateral pillar of the affected hip was less than 50% of
the height of the lateral pillar of the healthy hip.
Evaluation of the head containment within the
acetabulum was performed by determining the
acetabulum/head index (AHI) and the HeymanHerndon index: the ratio between horizontal diameters of the head covered by acetabulum and
horizontal diameter of the head.
The study was approved by the Ethics Committee of the Clinic for Orthopedics and Traumatology, Clinical Center Podgorica.
RESULTS From the total number of 14 patients, three
(21.42%) were females and 11 (78.58%) were
69
Medicinski Glasnik, Volume 12, Number 1, February 2015
males. The youngest patient was 4.9 and the oldest one was 9.11 years of age (Table 1).
According to the localization of the LCPD the
right hip dominated in eight (57.14 %) patients. The highest number of patients with LCPD
were in the age group 6-8 years, eight patients
(57.14%), while the smallest representation of
LCPD was in the age group of 5 years, one patient (7.14%) (Table 1).
Table 1. Patients with Legg-Calve-Perthes disease (LCPD)
according to sex, localization and age distribution
Gender
Males
Females
Total
No (%) of patients
Total
Age distribution
Right
0-5
6-8
9-11
7
11
1
6
4
(50.01) (78.58) (7.14) (42.85) (28.57)
1
3
2
1
(7.14) (21.42)
(14.28) (7.14)
8
14
1
8
5
(57.15)
(100) (7.14) (57.15) (35.71)
Side
Left
4
(28.57)
2
(14.28)
6
(42.85)
The largest representation of LCDP was in males
on the right hip at the age of 6-8 years.
According to the Herring classification in the group A there were three (21.43%) patients, in group B six (42.86%) and in group C five (35.71%)
patients; gender distribution was approximately
uniform, A: B: C for males was 3: 4: 4 (Table 2).
Table 2. Distribution of patients according to Herring groups
Herrings classification Group
A
B
C
Total
No (%) of patients
Males
Females
Total
3 (21.43)
0
3 (21.43)
4 (28.57) 2 (14.29) 6 (42.86)
4 (28.57)
1 (7.14) 5 (35.71)
11 (78.57) 3 (21.43)
14
Evaluation of the head containment within the
acetabulum showed the AHI value in group A of
0.8, in the group B 0.7, and in the group C 0.6
(Figure 1).
Figure 1. Acetabulum/Head Index and Heyman-Herndon index
according to Herring groups
70
DISCUSSION
For the disease evaluation and treatment planning
examination (14), the presence of (containment)
of the femoral head within the acetabulum is an
important factor. Calculation and determination
of AHI (acetabulum-head-Herndon Hayman index) derives from the need to timely detect and
assess risk patients, in order to plan their treatment and to start it on time (15,16). Treatment
started timely avoids the risk of pronounced
changes in the proximal femur, and thus significantly reduces non-spherical incongruence (17).
Measurement of the epiphyseal collapse of the
diseased hip in the studied patients showed significant differences compared with measurements of the same parameter of the healthy
hip in all three groups classified according to
Herring. Park et al. (18) suggested highest reliability of the Herring classification stating that
patients who are older than 8 years and belong
to group A, may be considered for surgical
treatment. In our study, group A (three males)
with AHI of 0.8 were treated conservatively.
The results of this study showed that the AHI
in patients’ decreased from group A to group C,
and that the containment of the femur head was
smallest when the degree of the epiphysis collapse was higher.
In group B there were six patients with AHI index 0.7, and in group C five patients had AHI index 0.6. This difference between groups suggests that the Herrings classification in predicting
the outcome of treatment of LCPD has a basis,
since the group (group A) patients with AHI index 0.8 had the smallest changes in the lateral
column of the fragmentation stage and that in
group (group C) patients with AHI index 0.6,
changes were the biggest. Patients from group C
were treated as high- risk patients and an active
surgical treatment was engaged for them to achieve good results. In the prospective multicenter
Herring et al. study (17) the lateral pillar classification and age of onset of the disease strongly
correlated with the outcome of the treatment of
LCPD. Patients in groups B and C had a better
outcome with operative treatment and the age of
eight years. In our study, according to the age
of disease onset, more than half of the patients
were in the group 6-8 years, which correlates
with the results of Herring (17). Recent studies
Dašić et al. Herrings classification
show that the Herring classification is significant in predicting the outcome of treatment in
children under six years of age (19). Examination of the degree of collapse of the outer epiphysis pillar and the containment of the
head in the acetabulum was biggest in group C,
where the collapse of the epiphysis was most pronounced, in group B it was moderate, while in the
group A it was least pronounced, and accordingly, the patients in group C were candidates for
active surgical treatment. Patients in the Herring
groups A and B were treated conservatively. A limitation of this study is the small number of
patients; larger number of patients would enable
comparison of Herring groups of different ages.
There is no single method of treatment of Perthes
disease. The results of this study indicate that the
application of Herring’s classification provides
an appropriate division of patients with Perthes
disease. Herrings’ classification provides a good
estimate of the degree of change in the epiphysis
and adequate distribution of patients into three
groups. Also, it evaluates patients with extensive
changes and poor prognosis, thus indicating the
need of adequate treatment.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATION
Competing interests: None to declare.
REFERENCES
1.
Stulberg S D, Cooperman DR, Wallensten R. The
natural history of Legg – Calve - Perthes Disease. J
Bone Joint Surg Am 1981; 63: 1095-108.
2. Catterall A, Pringle J, Byers PD, Fulford GE,
Kemp HBS, Dolman CL, Bell HM, McKibbin B,
Ralis Z, Jensen OM, Lauritzen J, Ponseti IV, Ogden
J. A review of the morphology of Perthes Disease. J
Bone Joint 1982; 64:269-75.
3. Salter RB. The present status of surgical treatment
for Legg-Calve-Perthes disease. J Bone Joint Surg
Am 1984; 66:961-6.
4. Ippolito E, Tudisco C, Farseti P. Long-term prognosis of Legg – Calve – Perthes Disease developing
during adolescence. J Pediatr Orthop 1985; 5:625-6.
5. Cristensen F, Soballe K, Ejsted R, Luxhøj T. The
Catterall classification of Perthes`s disease: an assessment of reliability. J Bone Joint Surg Am 1986;
68:614-5.
6. Ippolito E, Tudisco C, Farseti P. The long-term prognosis of unilateral Perthes Disease. J Bone Joint
Surg Am. 1987; 69:243-50.
7. Kollitz KM1, Gee AO. Classifications in brief:
the Herring lateral pillar classification for LeggCalvé-Perthes disease. Clin Orthop Relat Res 2013;
471:2068-72.
8. Mukherjee A, Fabry G. Evaluation of the prognostic
indices in Legg – Calve – Perthes Disease: statistical
analysis of 116 hips. J Pediatr Orthop 1990; 10:1538.
9. Wenger DR, Ward WT, Herring JA. Current concepts review: Legg – Calve – Perthes Disease. J
Bone Joint Surg Am 1991; 73:778-88.
10. Urlus M, Stoffelen D, Fabry G. Hinge abduction in
avascular necrosis of the hip: diagnosis and treatment. J Pediatr Orthop 1992; 1:67-71.
11. Crutcher JP, Staheli LT. Combined osteotomy as a
salvage procedure for severe. J Pediatr Orthop 1992;
12:151-6.
12. Herring JA, Neustadt JB, Williams JJ, Early JS,
Browne RH. The lateral pillar classification of Legg
– Calve – Perthes Disease. J Pediatr Orthop. 1992;
12:143-50.
13. Herring JA, Williams JJ, Neustadt JB, Early JS. Evolution of femoral head deformity during the healing
phase of Legg – Calve – Perthes Disease. J Pediatr
Orthop 1993; 13: 41-5.
14. Ritterbush JF, Shantharam SS, Gelinas C. Comparison of Lateral Pillar Classification and Catterall Classification Legg – Calve – Perthes Disease. J Pediatr
Orthop 1993; 13:200-2.
15. Schepers A, Robertson AF. Legg-Calvé-Perthes disease. The results of a prospective clinical trial comparing the outcomes of surgery and symptomatic
treatment for patients presenting at age 5 years or
younger. SA Orthop J 2011; 10:67-77.
16. Sales de Gauzy J, Kerdiles N, Baunin C, Kany J,
Darodes P, Cahuzac JP. Imaging evaluation of subluxation in Legg-Calvé-Perthes disease: magnetic
resonance imaging compared with the plain radiograph. J Pediatr Orthop 1997; 6:235-8.
17. Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part II: Prospective multicenter study
of the effect of treatment on outcome. J Bone Joint
Surg Am 2004; 86: 2121-34.
18. Park MS, Chung CY, Lee KM, Kim TW, Sung KH.
Reliability and stability of three common classifications for Legg-Calvée-Perthes disease. Clin Orthop
Relat Res 2012; 470:2376-82.
19. Gent A, Antapur P, Mehta RL, Sudheer VM, Clarke
NM. Predicting the outcome of Legg-Calve-Perthes’
disease in children under 6 years old. J Child Orthop
2007; 1: 27–32.
71
Medicinski Glasnik, Volume 12, Number 1, February 2015
Značaj Herringove klasifikacije u predviđanju ishoda aseptičke nekroze
glave butne kosti
Žarko Dašić1, Miroslav Kezunović1, Goran Pešić1, Vesna Bokan2, Mira Jovanovski3
1
Klinika za ortopediju i traumatologiju, 2Centar za fizikalnu medicinu i rehabilitaciju; Klinički centar Podgorica3, Ministarstvo zdravlja;
Podgorica, Crna Gora
SAŽETAK
Cilj Ukazati na značaj vrijednosti Herringove klasifikacije u planiranju liječenja Legg-Calvé-Perthesove bolesti (LCPB).
Metode Retrospektivnom studijom je obuhvaćena grupa od 14 ispitanika, u periodu od četiri godine
(2004-2008.). Uključujući kriteriji bili su unilateralna LCPB i kontralateralni zdravi kuk. Analizom
radiografskih snimaka ispitanici su podijeljeni u tri Herringove grupe (A, B i C). Kod svih ispitanika je
određen acetabulum/head index (AHI).
Rezultati Najmlađi ispitanik imao je 4,9 godina, a najstariji 9,11 godina; u polnoj strukturi muški pol je
dominirao (muškarci:žene, 11:3). Desna strana je bila češće zahvaćena u odnosu na lijevu (8:6). Zastupljenost pacijenata u Herringovim grupama bila je tri pacijenta u grupi A, šest u grupi B i pet pacijenata
u grupi C. AHI indeks bio je najmanji u grupi C. Pacijenti iz grupe C su operativno liječeni.
Zaključak Herringova klasifikacija omogućava prepoznavanje pacijenata s opsežnim promjenama i
sugeriše vrstu liječenja.
Ključne riječi: Perthesova bolest, Herringova klasifikacija, liječenje
72
ORIGINAL ARTICLE
A retrospective review of 139 major and minor salivary gland
tumors
Marija Trenkić Božinović1, Dragan Krasić2,3, Vuka Katić2, Miljan Krstić2,4
Ophthalmology Clinic, University Medical Center, 2University of Niš, School of Medicine, 3Clinic of Maxillofacial Surgery, 4Institute of
Pathology, University Medical Center; Niš, Serbia
1
ABSTRACT
Aim To describe demographic and histomorphological characteristics of 139 patients with epithelial salivary gland tumors in the
Southeastern Serbia population.
Methods A total number of 139 patients with epithelial tumors
arising in major and minor salivary glands in the period 20102012 was evaluated. After standard tissue proceeding, the routine
haematoxylin-eosin (HE) and histochemical alcian blue-periodic
acid-Schiff (AB - PAS) methods were used for histomorphological
examination.
Corresponding author:
Marija Trenkić Božinović
Department of Ophthalmology,
University Medical Center
Dr. Zorana Djindjica 48, 18000 Niš, Serbia
Phone +381 18 4232 367;
Fax: +381 18 4534545;
E-mail: [email protected]
Results Among 139 patients, 102 (73.38%) had benign, and 37
(26.62%) malignant tumors. The majority of tumors were localized in the parotid gland, in 117 (84.17%) patients. Among benign tumors there were 50 (49.02%) pleomorphic adenoma, 48
(47.06%) Warthin’s tumor, two (1.96%) myoepithelioma, and two
(1.96%) oncocytoma. In the group of malignant tumors the most
common was mucoepidermoid carcinoma, in 12 (32.43%) patients, carcinoma ex pleomorphic adenoma in six (16.22%), adenoid cystic carcinoma in five (13.51%), and oncocytic carcinoma in
three (8.11%) patients.
Conclusion Benign tumors were more common than malignant
ones, with predominance of pleomorphic adenoma. Malignant tumors are less common than benign in the large salivary glands,
and more common in the minor salivary glands. Histochemical
AB-PAS method helps in the diagnosis of mucinous salivary gland
carcinoma.
Key words: benign, carcinoma, epidemiology, histopathology.
Original submission:
31 July 2014;
Revised submission:
30 October 2014;
Accepted:
16 December 2014.
Med Glas (Zenica) 2015; 12(1):73-78
73
Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
were used for histomorphological examination.
Salivary gland tumors can show a striking range of morphological diversity among different
tumor types and sometimes within an individual
tumorous mass. In addition, hybrid tumors, dedifferentiation and propensity for some benign
tumors to progress to malignancy can confound
histopathological interpretation. These features,
together with the relative rarity of a number of
tumors (1), can sometimes make diagnosis difficult. There is some geographic variation and
among different ethnic groups according to the
place of residence (2-5). Therefore, the global
annual incidence, when all salivary glands tumors were considered, varied from 0.4–13.5 cases per 100.000 population (6). The frequency of
malignant salivary neoplasm range from 0.4–2.6
cases per 100.000 population (7). Between 64%
and 80% of all primary tumors occur in the parotid gland, 7%–11% in the submandibular glands,
and 9%–23% occur in the minor glands (6,8).
Females are more frequently affected (2). The
mean ages of patients with benign and malignant
tumors is 46 and 47 years, respectively (3,9).
The results were statistically analyzed using descriptive and quantitative analysis, the arithmetic mean (X) and standard deviation (SD). The
difference in the average values ​​was calculated
using the t- test for two independent samples. The
association between the two marks was measured
using the χ2 test. The Pearson’s rank correlation
test was used to determine a relation between the
associated parameters. The threshold for statistical significance was taken at p ≤ 0.05.
The aim of this study was to investigate both demographic and histomorphological characteristics of epithelial salivary gland tumors of 139 patients over a period of three years, and to compare
findings with results of other studies. The purpose of this paper is to contribute to more accurate
diagnosis of a lesion of salivary glands.
PATIENTS AND METHODS
The study included 139 patients with epithelial
salivary gland tumors arising in the major and
minor salivary glands, selected from the medical files of the University Hospital, Department
of Maxillofacial Surgery, and the Institute of Pathology of the University Medical Center Niš,
Serbia, from the beginning of 2010 to the end of
2012. The following parameters were analyzed:
patient age and gender, distribution of tumors in
relation to malignancy (benign or malignant), as
well as the localization in salivary glands (minor
glands, parotid gland, submandibular glands, sublingual glands).
After standard tissue proceeding, routine haematoxylin-eosin (HE) and histochemical alcian
blue-periodic acid-Schiff (AB - PAS) methods
74
RESULTS
During the span of 3 years, 139 cases of salivary
glands tumors were diagnosed. Among these, 73
(52.52%) patients were females (56 benign and 17
malignant), and 66 (47.48%) were males (46 benign and 20 malignant); 102 (73.38%) were benign
and 37 (26.62%) malignant tumors (Tables 1-3).
The mean age of the patients was 51.2 ± 13.97 years for benign tumors, and 58.97 ± 10.35 years for
malignant tumors. In the group of benign tumors,
the youngest patient was a 16-year-old female
with pleomorphic adenoma in the right parotid
gland. The oldest patient was 80-year-old male
with pleomorphic adenoma of the left parotid
gland. In the series of malignant tumors, the youngest patient was also female, 43-year old, with
mucoepidermoid carcinoma of the right submandibular gland. The oldest patient was a 81-yearold male, who was diagnosed with adenoid cystic
carcinoma of the right submandibular gland.
Localization of tumors in the major (parotid, submandibular and sublingual glands) and minor salivary glands is presented in Table 1.
Examining the correlation between types of tumors (benign or malignant) and their localization in the salivary glands (minor glands, parotid
gland, submandibular glands, sublingual glands)
a statistically significant difference was found
(p<0.0001 ) (Table 1).
Table 1. Distribution of tumors in the salivary glands
No (%) of patients
Type of
tumor
Minor
glands
Parotid
gland
Subman- Sublindibular gual
Total
glands glands
3
97
2
(2.94%) (95.10%) (1.96%)
11
20
6
Malignant
(29.73%) (54.05%) (16.22%)
14
117
8
Total
(10.07%) (84.17 %) (5.76 %)
Benign
0
0
0
p
102
(73.38%)
37
<0.0001
(26.62%)
139
Trenkić Božinović et al. Major and minor salivary gland tumors
Table 2. Histological types and other characteristics of benign salivary gland tumors
Gender
Male
Female
14 (28.0)
36 (72.0)
30 (62.5)
18 (37.5)
1 (50.0)
1 (50.0)
1 (50.0)
1 (50.0)
46 (45.1) 56 (54.9 )
Type of tumor
Pleomorphic adenoma
Warthin’s tumor
Myoepithelioma
Oncocytoma
Total
No (%) of patients
Localization
Type of salivary gland
Right
Left
Parotid Submandibular Sublingual
25 (50.0)
25 (50.0)
47 (94.0)
1 (2.0)
0
29 (60.42) 19 (39.58) 47 (97.92)
1 (2.08)
0
1 (50.0)
1 (50.0)
2 (100.0)
0
0
2 (100.0)
0
1 (50.0 )
0
0
57 (55.88) 45 (44.12) 97 (95.1)
2 (1.96)
0
The most frequent tumors originated from the
parotid gland (97 benign and 20 malignant), followed the submandibular gland (2 benign and 6
malignant) and minor salivary glands (benign 3
and malignant 11). The majority of tumors, both
benign and malignant, was localized in the parotid gland, 117 (84.17%). The most frequent
tumors in minor salivary glands were malignant,
11 (78.57%). Benign lesions were localized in
parotid gland, in 97 (95.10%) patients (69.78%
of all tumors), and only 20 (54.05%) malignant
lesions (14.39% of all tumors) were localized in
the parotid gland. No tumor was implicated from
sublingual mayor salivary gland.
There was no statistically significant association
between tumor type and gender (p>0.05). Patients with malignant tumors were significantly older than patients with benign tumors (p<0.05). In
Minor
2 (4.0)
0
0
1 (50.0)
3 (2.94)
Total
50 (49.02)
48 (47.06)
2 (1.96)
2 (1.96)
102
both, benign and malignant tumors, there was no
significant difference considering the localization
(right/left) (p>0.05 ).
Among 102 (73.38%) benign tumors, there were
50 (49.02%) pleomorphic adenoma, 48 (47.06%)
Warthin’s tumor, and myoepithelioma and oncocytoma, two (1.96%) of each (Table 2). The maA)
B)
Table 3. Histological types and other characteristics of malignant salivary gland tumors
No (%) of patients
Type of salivary gland
Total
Type of
SubSublintumor (Ca) Male Fimale Parotid mandiMinor
gual
bular
Gender
Mucoepidermoid
7
5
7
4
(58.33) (41.67) (58.33) (33.33)
Ca ex PA
2
4
4
2
(33.33) (66.67) (66.67) (33.33)
0
Adenoid
cystic
3
2
(60.0) (40.0)
0
0
5
5
(100.0) (13.51)
Oncocytic
2
1
2
(66.67) (33.33) (66.67)
0
0
1
3
(33.33) (8.11)
Myoepithelial
1
1
(50.0) (50.0)
0
0
0
2
2
(100.0) (5.41)
Cystadeno
2
(100.0)
0
0
0
2
2
(100.0) (5.41)
Squamous
cell
1
1
2
(50.0) (50.0) (100.0)
0
0
0
2
(5.41)
0
0
0
2
(5.41)
1
(100.0)
0
0
0
1
(2.70)
1
(100.0)
0
0
0
1
(2.70)
1
1
(100.0) (100.0)
0
0
0
1
(2.70)
0
11
(29.73)
37
Basal cell
adeno
0
Mucinous
adeno
1
(100.0)
Salivary
duct
1
(100.0)
Small cell
type
0
Total
0
0
2
2
(100.0) (100.0)
0
0
20
17
20
6
(54.05) (45.95) (54.05) (16.22)
Ca, carcinoma
0
C)
1
12
(8.34) (32.43)
0
6
(16.22)
D)
Figure 1. A) Pleomorphic adenoma: epithelial cells arranged in
strands in mucoid background (HE, x 200); B) Warthin’s tumor:
double-layered columns of cells with intervening lymphoid tissue (HE, x 200); C) Myoepithelioma: clear cell variant with
mucoid surrounding stroma (AB- PAS, x 200); D) Oxyphilic adenoma: large polyhedral cells with finely granular cytoplasm;
colagenous stroma is minimal – PAS positive (AB- PAS, x 300)
(Katić, V, 2014)
75
Medicinski Glasnik, Volume 12, Number 1, February 2015
jority of the benign tumors were located in the
parotid glands, in 97 (95.10%) cases.
The most common histological types (overall
prevalence was 62.16%, e.g., 23 cases) were mucoepidermoid carcinoma which were reported in
12 (32.43%) cases, carcinoma ex pleomorphic
adenoma in six (16.22%) cases, adenoid cystic
carcinoma in five (13.51%) cases, followed by
oncocytic carcinoma, in three (8.11%), myoepithelial carcinoma in two (5.41%), cystadenocarcinoma in two (5.41%), squamous cell carcinoma
in two (5.41%), basal cell adenocarcinoma in two
(5.41%) cases. Small cell carcinoma, salivary duct
carcinoma, and mucinous adenocarcinoma were
uncommon, in one (2.70%) case each, respectively. Most of the tumors in the minor salivary glands
were malignant, 11 (78.57%) (Table 1 and 3).
The most common histologic appearance of benign and malignant tumors is presented in Figure
1 and 2.
A)
B)
C)
Figure 2. A) Mucoepidermoid carcinoma: both solid and multicystic pattern, with syalomucin in cystic component (AB-PAS,
x 200); B) Carcinoma ex pleomorphic adenoma: poorly differentiated adenocarcinoma (HE, x 200); C) Adenoid cystic carcinoma: multiple cystic spaces filled with acid mucin (AB- PAS,
x 250) (Katić, V, 2014)
76
DISCUSSION
This paper describes the epidemiological and
histomorphological features of 139 epithelial
tumors of the salivary glands, with reference to
their surgical treatment. Our results are similar to
other reports in relation to age, sex and localization of the tumors (2,9,10).
In this series, the most common benign tumor
was pleomorphic adenoma, localized mostly in
the parotid glands, mostly affecting women. Pleomorphic adenoma is a benign tumor, but recurrence appears very often (10). Recurrences can
be explained by the growth of the tumor around
the facial nerve, which complicates its surgical
extirpation (11,12), or they arise as complications of multicentric growth of pleomorphic adenoma (1). The recurrence increases the risk to
malignant alteration of pleomorphic adenoma
(11,13). Warthin’s tumor was more common in
our series, localized in the parotid gland without
malignant alteration. In some reports, this is one
of rare variants of epithelial salivary gland tumors (14). The discrepancy in the frequency could be explained by geographical, racial factors,
as well as aggravated differential diagnosis with
metastatic adenocarcinoma tumors in the lymph
nodes, that is induced by its mixed lymphoid glandular structure (3,4,15-17).
Cancers of the salivary glands are less common
than benign forms in this study. A higher incidence of malignant tumors, compared to the results
of other authors (14,18), could be explained by
the profile of patients treated in our institution of
tertiary level, as pointed out by the others (19).
The microscopic pattern of malignant salivary
gland tumors is sometimes very similar to benign tumors, therefore, the differentiation is difficult (6,8,20). The specific criteria of malignancy
include anaplasia, infiltration of the capsule to
surrounding tissue or the absence of a capsule,
multiple foci of necrosis and hemorrhage, lymphangio invasion, as well as perineural invasion
inside the tumor. The most important characteristic of malignant tumor is the involvement of
the regional lymph nodes, that we found in our
malignant salivary gland tumors (7).
According to the results of this study, the most
common was mucoepidermoid carcinoma, reported in 12 cases. Contrary to the literature that
Trenkić Božinović et al. Major and minor salivary gland tumors
mucoepidermoid carcinoma is frequently located
in the minor salivary glands (20), we have found that the mucoepidermoid carcinoma is more
frequently presented in the parotid gland and
submandibular glands. Carcinoma ex pleomorphic adenoma was second in frequency, which is
directly related to the long-standing pleomorphic
adenoma and its recurrences. Inexplicable manifestation of metastasizing benign mixed tumor
with local or distant metastasis ( “metastasizing
pleomorphic adenoma”) has been described in
the new WHO histological classification of tumors of the salivary glands (1). Differential diagnosis of the metastatic adenocarcinoma of
surrounding organs from primary salivary gland
adenocarcinoma is very difficult (21,22). Due to
these characteristics, it is emphasized that pathognomonic finding of primary adenocarcinoma of
the salivary gland is the presence of polymorphic
adenoma or healthy salivary gland tissue in its
vicinity (23). Adenoid cystic carcinoma reported
in this study was localized in the small salivary
glands, oncocytic carcinoma in the parotid glands, and in the minor salivary glands. In terms of
localization and frequency, this is in accordance
with data from the literature (24,25).
Other cancers, myoepithelial carcinoma, cystadenocarcinoma, squamous cell carcinoma and basal
cell carcinoma were far less frequently found in
this study. Myoepithelial carcinoma and cystadenocarconoma were discovered in the minor salivary glands, while squamous and basal cell adenocarcinoma were found in the parotid gland (5,25).
In conclusion, this study is the first epidemiological study on salivary gland tumors performed on
the population from Southeastern Serbia, based
on the 2005 WHO tumor classification. The findings of this study contribute significantly to the
awareness of clinical and pathological features
of salivary gland tumors in our region and can
improve our understanding of significant differences in the global distribution of salivary gland
tumors which have been reported. Although, the
reason for these differences remains unclear, further investigations specifically searching for the
possible causes, are greatly encouraged.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATIONS
Conflict of interest: none to declare.
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14. Mejía-Velázquez CP, Durán-Padilla MA, GómezApo E, Quezada-Rivera D, Gaitán-Cepeda LA.
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Retrospektivni pregled 139 tumora malih i velikih pljuvačnih
žlezda
Marija Trenkić Božinović1, Dragan Krasić2,3, Vuka Katić2, Miljan Krstić2,4
Klinika za očne bolesti, Klinički centar Niš, 2Medicinski fakultet, Univerzitet u Nišu, 3Klinika za maksilofacijalnu hirurgiju, Niš, 4Institut za
patologiju, Klinički centar Niš; Niš, Srbija
1
SAŽETAK
Cilj Opisati demografske i histomorfološke karakteristike 139 slučajeva epitelijalnih tumora pljuvačnih
žlezda u populaciji jugoistočne Srbije.
Metode Analizirano je 139 pacijenata s epitelnim tumorima malih i velikih pljuvačnih žlezda operisanih na Klinici za maksilofacijalnu hirurgiju u Nišu, u periodu od 2010. do 2012. godine. Posle standardne obrade tkiva za histomorfološko ispitivanje korišćena je rutinska hematoksilin-eozin (HE) metoda
i histohemijska AB-PAS metoda.
Rezultati Studija je obuhvatila 139 slučajeva, odnosno 102 (73,38%) benigna tumora i 37 (26,62%)
malignih lezija. Većina tumorâ bila je lokalizovana u parotidnim žlezdama, u 117 (84,17%) slučajeva.
Među benignim tumorima bilo je 50 (49,02%) slučajeva pleomorfnog adenoma, 48 (47,06%) Warthinovog tumora i po dva slučaja (1,96%) mioepitelioma i oncocitoma. U grupi malignih tumora najčešći je
bio mukoepidermoidni karcinom, u 12 (32,43%) slučajeva, carcinoma ex pleomorphic adenoma u šest
(16,22%), adenoidni cistični karcinom u pet (13,51%) i oncocitic carcinoma u tri (8,11%) slučaja.
Zaključak Benigni tumori pljuvačnih žlezda su češći nego maligni, uz dominaciju pleomorfnog adenoma. Maligni tumori su se ređe od benignih javljali u velikim pljuvačnim žlezdama, a češće su bili
lokalizovani u malim pljuvačnim žlezdama. Histohemijska AB-PAS metoda pomaže u dijagnozi mucinoznih karcinoma pljuvačnih žlezda.
Ključne reči: benigni, maligni, epidemiologija, histopatologija.
78
ORIGINAL ARTICLE
Effects of hormone replacement therapy on depressive and
anxiety symptoms after oophorectomy
Danijela D. Ðoković1,2, Jelena J. Jović3, Jelena D. Ðoković1, Marinela Ž. Knežević1, Slavica DjukićDejanović1,2, Dragana I. Ristić-Ignjatović1,2
School of Medicine, University of Kragujevac, 2Psychiatric Clinic, Clinical Center Kragujevac; Kragujevac, 3Department of Preventive
Medicine, University of Prishtina-Kosovska Mitrovica, Kosovska Mitrovica; Serbia
1
ABSTRACT
Aim To assess the effect of hormone replacement therapy on postoperative depression and anxiety symptoms.
Corresponding author:
Jelena J. Jović
Department of Preventive Medicine,
University of Prishtina-Kosovska
Mitrovica, Kosovska Mitrovica; Serbia
Anri Dinana BB, Kosovska Mitrovica
38220, Serbia
Phone: +381 28498296;
Fax: +381 28498298
E-mail: jovic.jelena@gmail
Original submission:
15 April 2014;
Revised submission:
17 June 2014;
Accepted:
24 October 2014.
Methods In observational prospective study 80 women divided
into two groups were evaluated: women who received estrogen
and androgen replacement therapy after hysterectomy with bilateral oophorectomy before onset of menopause (35-45 years old)
and a control group that consisted of perimenipausal women (4555 years old). Hormone replacement therapy began one week after surgery. The severity of depression and anxiety was evaluated
through the use of Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale. Subjects from the study group were
interviewed right after the surgical treatment, one, two and three
months later. Subjects from the control group were interviewed
only once.
Results The women who underwent surgery had a statistically significantly higher score in Hamilton Depression Scale (p<0.001)
and Hamilton Anxiety Scale (p=0.002) compared to the control
perimenopausal women. There was a significant reduction of
depressive and anxiety symptoms during hormone replacement
therapy. Statistically significant difference in depressive score
was found immediately after one month of hormone replacement
therapy (first week/one month later: p=0.0057). Statistically significant difference in anxiety score appeared three months after
the introduction of hormone therapy (first week/one month later:
p=0.309; first week/two months later: p=0.046; first week/three
months later: p<0.001). Level of serum luteinizing hormone was
in correlation with depressive and anxiety score.
Conclusion Estrogen-androgen replacement therapy may reduce
the risk of psychiatric disorders developing in women with bilateral oophorectomy (indication for hysterectomy with oophorectomy was leiomyomata uteri).
Keywords: hysterectomy, mood disorders, women health, HAMD,
HAMA
Med Glas (Zenica) 2015; 12(1):79-85
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Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
In women with surgically removed uterus and
ovaries before natural menopause, there is a sudden and drastic decrease in levels of ovarian hormones in the circulation which causes surgical
menopause. Women who experienced this menopause have increased morbidity. They have a
higher risk of developing cardiovascular (1), neurological (2,3) and psychiatric diseases (4,5) and
osteoporosis (6) compared to referent population.
Study of Rocca 2009 found that bilateral oophorectomy performed before the onset of menopause is associated with an increased long-term risk
of depressive and anxiety symptoms, especially
at younger age (4).
The pattern of psychiatric disorder development
is multifaceted. The possible role of hormone
deprivation in occurrence of psychiatric symptoms in this population is not clear. The association between oophorectomy and increased risk of
depressive and anxiety symptoms development
may be explained by deficit in ovarian hormones
and by the disruption of hypothalamic–hypophysal–ovarian axis (7). However, this association
may be due to some undergoing psychological
factors. Whether the abrupt onset of hormone
imbalances will affect and how it will affect the
mental and physical health of women depends on
many factors (indications for surgery, mental and
physical health of women before the operation,
her sexual function, specific surgical procedure,
age, marital status, socio-economic status, parenting) (8). The effect of the hormone does not
cause behavior changes, but the likelihood of response to stimuli (9).
It is known that hysterectomy only leads to the
development of depressive and anxiety symptoms (10-12). However, results of some studies
are inconsistent with these findings because there
no association was found between surgical treatment and psychological symthoms (13,14) or
any data that would imply that an intervention
may improve psychological health (15,16). In
most researches, it is not precise what the secretory function of ovary was.
Also, age specific data are limited although some
researches show that women who had undergone hysterectomy in young age had more severe
psychological reaction (13).
80
Altough there are many preclinical studies regarding the role of testosterone in depression
and anxiety disorders, there are very few clinical
studies on this subject (17). On the other hand,
it is a known fact that women are twice as prone to anxiety disorders and depression than men.
It is possible that sexual hormones are some of
the key factors in the discrepancy between men
and women, which leads to the possible role of
testosterone and its possible protective benefits
against anxiety and depression (18).
The aim of our study is to determine whether
hysterectomy with bilateral oophorectomy and
consequent ovarian hormone disruption leads to
an increase of anxiety and depression, and if it is
possible eliminate or reduce those symptoms by
hormone substitution therapy. The purpose of our
research is to better understand these issues and
improve mental health of women.
PATIENTS AND METHODS
Patients
This observational prospective study was conducted during a two-year period at the Clinic of
Gynecology and Obstetrics of the Clinical Centre
Kragujevac, Clinic of Psichiatry of the Clinical
Centre Kragujevac and Dispensary for Women of
the Primary Health Care Centre Kragujevac.
It evaluated 80 women who were divided into
two groups: women who received estrogen and
androgen replacement therapy after hysterectomy with bilateral oophorectomy before onset of
menopause, and the control group that consisted
of women in perimenopause. The first group included 40 women who were 35-45 years old. The
control group included 40 women aged 45-55.
Most of the women finished high school. Majority were from urban environments while 16.78%
were from rural environments; 52 women were
married, eight were single and 20 were divorced.
By comparing the socio-demographic characteristics, (except for the age) no statistically significant difference between the two groups in any of
the categories was found (p>0.001).
The indication for hysterectomy with oophorectomy was leiomyomata uteri. The inclusion
criteria was age between 35-45 for the clinical
and 45-55 for the control group, no hormone therapy for one year prior, body mass index (BMI)
Đoković et al. Hormone therapy after oophorectomy
<33kg/m2. The women with mental retardation,
with known or suspected history of breast carcinoma, any malignant disease in the last 5 years,
severe liver or renal disease, thromboembolic
history or treatment with liver enzyme inducing
medications or those that could have affected
bone metabolism were excluded. Women did not
use any antidepressants and anxiolytics. A written informed consent was obtained in all cases.
The study was approved by the Ethics Committee of Faculty of Medical Sciences Kragujevac.
Methods
The severity of depressive and anxious symptoms
was evaluated with the hetero-administered Hamilton Depression Rating Scale (HAM-D 21) (19) and
Hamilton Anxiety Rating Scale (HAM-A) (20). In
all patients diagnosis was confirmed by two experienced psychiatrists based on DSM-IV critera for
depression/anxiety. Hormone replacement therapy
began one week after the surgery. The therapy included estradiol valerianate-dehydroepiandrosterone enanthate at a 1:50 ratio (Gynodian Depo).
Subjects from the study group were interviewed
during the first week after surgery and then again
during follow-up visits when they received hormonal therapy, four times in total. Subjects from the
control group were interviewed only once. Blood
was taken for analysis from patients on the same
day the psychiatric interview was conducted.
Statistical methods
Data were expressed as mean ± standard deviation. The Kolmogorov-Smirnov test was used for
testing variables normality. Because of non-normal distribution of data the statistical significance
between the study groups was assessed by using
the non-parametric Kruskal-Wallis Tests (three or
more categories) and Mann-Whitney Tests (two
categories). Wilcoxon Test was used to estimate
if there were statistically significant differences
among repeated measurements in the group with
hormone substitution therapy. Linear correlation
was used to examine relation between blood hormone level and HAMD and HAMA score. Statistical significance of p <0.001 was used.
RESULTS
Eighty women divided into two groups were
evaluated: women who received estrogen and an-
drogen replacement therapy after hysterectomy
with bilateral oophorectomy due to leimyomas
and the referent group of perimenopausal women. The first group included 40 women who were
35-45 years old (mean age of 42±6.9). Control
group included 40 women who were 45-55 years
old (mean age of 53±7.1).
The women who had undergone surgery had a statistically significant difference in HAMD (p<0.001)
and HAMA (p=0.002) score compared to women
with physiological perimenopause (Table 1). It is
apparent that women who had surgically undergone hysterectomy with bilateral oopherectomy had
significantly more depressive symptoms than perimenopausal women. Anxiety symptoms were also
more drastic in that group of women.
Table 1. Hamilton Depression Rating Scale (HAMD) and
Hamilton Anxiety Rating Scale (HAMA) scores in women who
underwent hysterectomy with bilateral oophorectomy and
perimenopausal women
HAMD/HAMA
HAMD score
HAMA score
Hysterectomy with oop- Perimenopausa
horectomy* (n= 40)
(n= 40)
(mean± SD)
(mean± SD)
16.10 ± 4.74
38.00 ± 11.78
10.75 ± 3.71
29.00 ± 13.00
p
<0.001
0.002
*first week after surgery; SD, standard deviation
Scores of depression (HAMD scale) in the first
week (1), one month (2), two months (3) and
three months (4) after the surgical procedure are
shown in Table 2. Hormone replacement therapy
began in the first week after the procedure, e.g.,
when the first interview with the subjects was
conducted. Statistically significant difference in
depressive score immediately after one month of
hormone replacement therapy (the first week/one
month later: p=0.0057) was found; the depressive score significantly reduced each month.
Table 2. Hamilton Depression Rating Scale (HAMD) score in
women in the study group at different time intervals after the
surgical procedure
HAMD scores during
different time intervals*
1-2
1-3
1-4
2-3
2-4
3-4
Xsr ± SD
Xsr ± SD
16.10 ± 4.74
(n= 40)
16.10 ± 4.74
(n= 40)
16.10 ± 4.74
(n= 40)
15.62 ± 4.67
(n= 40)
15.62 ± 4.67
(n= 40)
14.42 ± 4.17
(n= 40)
15.62 ± 4.67
(n= 40)
14.42 ± 4.17
(n= 40)
13.05 ± 3.56
(n= 40)
14.42 ± 4.17
(n= 40)
13.05 ± 3.56
(n= 40)
13.05 ± 3.56
(n= 40)
p
0.0057
0.0000
0.0000
0.0001
0.0000
0.0003
*first week (1), one month (2), two months (3), three months (4);
SD, standard deviation
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Medicinski Glasnik, Volume 12, Number 1, February 2015
Figure 1. Correlation between serum level of LH and HAMD score HAMD, Hamilton Depression Rating Scale; LH, luteinizing hormone
Scores of anxiety (HAMA) in the first week (1),
one month (2), two months (3) and three months
(4) after the surgical procedure were shown
in Table 3. The anxiety score was reduced one
month after the hormone replacement therapy.
Statistically significant difference in anxiety
score appeared three months after the start of hormone therapy (after the subjects received the 3rd
dose of the therapy) (first week /one month later:
p=0.309; first week /two months later: p=0.046;
first week /three months later: p<0.001).
Table 3. Hamilton Anxiety Rating Scale (HAMA) score in
women in the study group at different time intervals after the
surgical procedure
HAMA scores during
different time intervals*
1-2
1-3
1-4
2-3
2-4
3-4
Xsr ± SD
Xsr ± SD
38.00 ± 11.78
(n= 40)
38.00 ± 11.78
(n= 40)
38.00 ± 11.78
(n= 40)
37.55 ± 10.99
(n= 40)
37.55 ± 10.99
(n= 40)
36.90± 10.10
(n= 40)
37.55 ± 10.99
(n= 40)
36.90± 10.10
(n= 40)
28.27 ±8.30
(n= 40)
36.90± 10.10
(n= 40)
28.27 ±8.30
(n= 40)
28.27 ±8.30
(n= 40)
p
0.3092
0.0461
0.0000
0.1815
0.0000
0.0000
*first week (1), one month (2), two months (3), three months (4);
SD, standard deviation
The Pearsons linear correlation test showed existence of strong negative correlation between the
level of serum luteinizing hormone and HAMD
and HAMA score (Figures 1, 2).
DISCUSSION
Menopause is a universal and irreversible part
of the overall aging process as it involves a
woman’s reproductive system. It is the final menstrual period which is diagnosed after 12 months
of amenorrhea and is characterized by a myriad
of symptoms that may include changes from regular, predictable menses, vasomotor and urogenital symptoms and sleep and mood dysfunction
(21,22). Hormonal changes and clinical symptoms occur over a period leading up to menopause. This period is termed the climacteric or
perimenopause or menopausal transition and it
characteristically begins years before menopause, typically occurring between the ages of 45
and 55, with median age at inception of perimenopause 47.5 years (21-23). Until recently, perimenopause was not recognized as a period with
a higher risk for new or repeated depression. It
Figure 2. Correlation between serum level of LH and HAMA score HAMA, Hamilton Anxiety Rating Scale; LH, luteinizing hormone
82
Đoković et al. Hormone therapy after oophorectomy
is still unclear whether and to what extent changes in estrogens, progesterone and androgens that
occur in menopause period influence psychological status in women.
The first important result of this study was the finding of a difference in HAMD and HAMA score
between women who underwent surgery and the
control group of perimenopausal women. Previous
studies show that women who underwent hysterectomy with bilateral oophorectomy had more pronounced psychiatric symptoms (4,5,7). In the studies of women undergoing natural menopause an
increase in depressive symptoms was demonstrated, generally revealed during perimenopause with
a decrease in risk during postmenopausal years (5).
Very interesting finding of this study is the indication of moderate depression according to average
HAM-D value found in the control group, which
was in line with some of the other researches (24).
Previous research suggests that the estrogen deficiency caused by bilateral oophorectomy may be
the initial step in a chain of causality that determines an increased long-term risk of depression or
anxiety (4). Although the precise mechanisms are
still unknown, depression during perimenopause
is likely to occur due to the influence of estrogen to
actions of serotonin and norepinephrine. A decline
in estrogen concentrations may decrease levels of
these hormones and thus contribute to depression
(25,26). The hormonal changes induced by premenopausal bilateral oophorectomy are different
from those occurring during natural menopause
(27-29). In natural menopause, as well as after
menopause, the ovary leads testosterone production. In widespread tissues and organs including
the brain, testosterone is aromatized into estrone
and estradiol, the most potent estrogen. Bilateral
oophorectomy before menopause results not only
in an abrupt drop in levels of circulating estrogen
but also an abrupt drop in levels of circulating testosterone and in a disruption of the hypothalamicpituitary-ovarian axis with an increased release of
the gonadotropins luteinizing hormone and follicle stimulating hormone (27-29)
According to the correlation between hormonal
status and score of depression and anxiety was
found in this study, it is a question if deteriorated
mental health in hysterectomized and oophorectomized women could be attributed only to hormonal abruption. These results can be explained
by losing uterus and ovary as symbols of femini-
nity and maternity in woman’s life, which leads
to psychological problems (28,29).
The loss of the uterus and scarring after surgery
may result in impairment of body image, which
includes the perception of a loss of femininity
and vitality (33,34). Impairment of body image
has been found in oophorectomized women (35).
Conserving their uterus may be important for gender identity, sexuality, marital relations, and selfesteem for many women in our population (36).
A statistically significant decrease in depression
and anxiety across post surgical time period has
been found in this study. The scores for depression decreased significantly earlier (after first measure) and moved in a positive direction during the
time compared to the anxiety score which did not
change considerably for longer time (it decreased significantly after three months). Cohen 2011
showed that anxiety and depression after hysterectomy were highest in the immediate post-operative period and decreased significantly over the
period of eight weeks (37).
The results of this study have shown a correlation
between the level of serum luteinizing hormone
and score of depression and anxiety; the levels of
LH had a negative correlation with the levels of
depression and anxiety in the investigated groups of women. Similar results were obtained in
a study (38) showing that psychiatric disorders
should be considered in polycystic ovarian syndrome women in which significantly higher LH
level has been found in the investigated group as
compared to the control group.
The main finding of this study is that postoperative estrogen therapy in combination with androgen therapy may decrease anxiety and depression in women who underwent hysterectomy with
oophorectomy. There are some studies which
examined the effect of estrogen replacement therapy on anxiety and depressive symptoms in such
women, but results are inconsistent. The study of
Rocca et al. (2008) found that the treatment with
estrogen in women who are 50 years old and underwent bilateral oophorectomy at younger age
did not modify the risk (4). Nathorst-Böös et al.
(1993) reported less anxiety and depression and
more well-being in oophorectomized women
who received estrogen replacement therapy (39).
There are two important mechanisms by which
estrogen influences depression and depressivelike behavior: interactions with neurotrophic
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Medicinski Glasnik, Volume 12, Number 1, February 2015
factors and influence on the serotonergic system
(40). On the other hand, there are almost no studies that examine the effect of combined estrogenandrogen on anxiety and depressive symptoms.
One of the shortcomings of this study is that
the levels of hormones were determined solely
on the basis of morning blood samples. Another
shortcoming is that we did not have a group of
women who underwent an operation, and who
did not have a hormonal therapy. Furthermore,
the control and clinical group were not compatible in terms of age. Therefore, there is a possibility that difference in the levels of depression
and anxiety between these groups, in that case,
would be much higher. All this should be taken
into consideration in the future research.
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84
Even though our results show that appropriate
hormone therapy can have a considerable effect
on anxiety and depression in women with hysterectomy and bilateral oophorectomy, it is necessary to continue research in this field. It is also
necessary to reduce the limitations of our study
in future research.
FUNDING
Hereby authors would like to express gratitude to
the Grant N°175014 and 175007 of Ministry of
Science and Technological Development of The
Republic Serbia, out of which this study was partially financed.
TRANSPARENCY DECLARATION
Competing interest; none to declare.
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Efekti hormonske supstitucione terapije na simptome
depresivnosti i anksioznosti kod žena posle uklanjanja jajnika
Danijela D. Ðoković1,2, Jelena J. Jović3, Jelena D. Ðoković1, Marinela Ž. Knežević1, Slavica DjukićDejanović1,2, Dragana I. Ristić-Ignjatović1,2
Medicinski fakultet, Univerzitet u Kragujevcu; 2Klinika za psihijatriju, Klinički centar Kragujevac, Kragujevac; 3Katedra za preventivnu
medicinu, Medicinski fakultet, Univerzitet u Prištini, Kosovska Mitrovica; Srbija
1
SAŽETAK
Cilj Proceniti uticaj efekata hormonske supstitucione terapije na postoperativne simptome depresije i
anksioznosti.
Metode U opservacionoj prospektivnoj studiji pratili smo 80 žena, podeljenih u dve grupe: žene pre
početka menopauze (od 35 do 45 godina starosti) koje su posle operativnog uklanjanja materice i jajnika dobijale supstitucionu terapiju estrogena i androgena, i perimenopauzalne žene (starosti od 45 do
55 godina) koje su činile kontrolnu grupu. Hormonska supstituciona terapija započeta je nedelju dana
nakon hirurške intervencije. Depresivnost i anksioznost je procenjivana Hamiltonovom skalom depresivnosti i Hamiltonovom skalom anksioznosti. Ispitanice iz studijske grupe intervjuisane su neposredno
posle operacije, te mesec, dva i tri meseca kasnije. Ispitanice iz kontrolne grupe intervjuisane su samo
jedanput.
Rezultati Operisane žene, u poređenju s perimenopauzalnim ženama, imale su statistički značajno više
skorove na Hamiltonovoj skali depresivnosti (p<0.001) i Hamiltonovoj skali anksioznosti (p=0.002).
Tokom primene hormonske supstitucione terapije došlo je do značajne redukcije simptoma depresivnosti i anksioznosti. Statistički značajna razlika u depresivnosti ustanovljena je mesec dana nakon početka
hormonske terapije (prva nedelja/mesec dana kasnije: p=0.0057). Statistički značajna razlika u pogledu
anksioznosti utvrđena je tri meseca nakon početka hormonske terapije (nedelja/mesec dana kasnije:
p=0.309; nedelja/dva meseca kasnije: p=0.046; nedelja/tri meseca kasnije: p<0.001). Nivo luteinizirajućeg hormona bio je u korelaciji sa skorovima depresivnosti i anksioznosti.
Zaključak Estrogen-androgen supstituciona terapija može smanjiti rizik od razvoja simptoma depresivnosti kod žena kojima su uklonjeni jajnici (indikacija za histerektomiju s adneksektomijom bio je
benigni miom materice).
Ključne reči: histerektomija, poremećaji raspoloženja, žensko zdravlje, HAMD, HAMA
85
ORIGINAL ARTICLE
Mechanical prosthetic valve disease is related with an increase
in depression and anxiety disorder
Yasemin Turker1, Kurtulus Ongel2, Mehmet Ozaydin3, Yasin Turker4, Funda Yildirim Bas5, Mehmet
Akkaya6
Family Medicine Center, Duzce, 2University of Katip Celebi, Faculty of Medicine, Department of Family Medicine, İzmir, 3University of
Suleyman Demirel, Faculty of Medicine, Department of Cardiology, Isparta, 4Duzce University, Faculty of Medicine, Department of Cardiology, Duzce, 5University of Suleyman Demirel, Faculty of Medicine, Department of Family Medicine, Isparta, 6Bezm-i Alem University,
Faculty of Medicine, Department of Cardiology, Istanbul; Turkey
1
ABSTRACT
Aim Patients with organic disease can present with psychiatric
symptoms. We hypothesized that since patients with prosthetic
heart valve require frequent hospital followup and are at higher
risk for complications, the incidence of depression and anxiety is
higher in these patients.
Methods This cross-sectional study prospectively studied 98
consecutive patients with mechanical prosthetic heart valve. All
patients fulfilled prosthetic heart valve evaluation form, Beck
Depression Inventory (BDI) and Hamilton Anxiety Scale (HAS).
Complete blood count, basic metabolic panel and echocardiogram
results were collected for all the patients.
Corresponding author:
Yasemin Turker
Family Health Center Duzce Provincial
Directorate of Health, No. 3,
Düzce, Turkey
Phone: +90 505 654 61 70;
Fax: +90 380 542 13 87 ;
E-mail: [email protected]
Original submission:
02 July 2014;
Revised submission:
18 August 2014;
Accepted:
28 August 2014.
Med Glas (Zenica) 2015; 12(1):86-92
86
Results Using the BDI, there were 26 patients (27%) with no depression, 20 (20%) with mild depression, 38 (39%) with moderate, 4 (4%) with severe and 10 (10%) patients with very severe
depression. Avarege score was 18.3±11.4 on BDI and 19.1±11.1
on HAS. The depression level was positively associated with prothrombin time (p<0.001) and international normalized ratio (INR)
level (p<0.001). Hamilton Anxiety Scale was significantly correlated with comorbidities (r: 0.344; p=0.002), blood transfusion (r:
0.370; p<0.001), obesity (r: 0.319; p=0.007) and Beck Depression
Scale was correlated with comorbidities (r: 0.328; p=0.002), in patients with prosthetic heart valve disease.
Conlusion Patients with prosthetic heart valve have higher prevalence of depression and higher scores of anxiety and depression. Early recognition and appropriate treatment of depression and
anxiety may decrease the morbidity in prosthetic heart valve disease. Besides, use of new oral anticoagulant agents that do not need
INR check, could decrease anxiety and depression in the future.
Keywords: anxiety, depression, heart valve diseases, comorbidities, prothrombin time, international normalized ratio.
Turker et al. Valve disease and depression and anxiety
INTRODUCTION
Patients with organic disease can present with
psychiatric symptoms. Depression is the most common psychiatric disorder accompanying organic
disorders and is a significant clinical syndrome affecting both mortality and morbidity in those patients (1). Among the patients with organic disorders, the prevalence of major depression was found
to be 5-10% in inpatients and 9-16% in outpatients
(2). Patron et al. found that 48% patients were depressed any time during their life after cardiac surgery (e.g. heart valve surgery, coronary artery bypass graft) (3). Mechanical prosthetic heart valves
are commonly used nowadays for the treatment of
heart valve diseases with proven utility for increasing life expectancy and quality of life. Patients
with prosthetic heart valves constitute 28% of the
population with heart valve disease and they need
to take anticoagulation therapy lifelong and international normalized ratio (INR) level check at
regular intervals. Besides, these patients may develop structural heart disease over time (4).
We hypothesized that since patients with prosthetic heart valve require frequent hospital followup and are at higher risk for complications, the
incidence of depression and anxiety is higher in
these patients.
PATIENTS AND METHODS
Study design
The study was designed as cross-sectional and the
patients with mechanical prosthetic heart valve,
aged 18 or older, who were admitted to the Cardiology Outpatient Clinic, University of Suleyman
Demirel, Faculty of Medicine, between March
2008 and August 2009, were consecutively enrolled. With a tolerance of 5% error, assuming alpha
0.05 and beta 0.20, it was found that 100 patients
would be sufficient to detect a significant difference. Patients with mental retardation were excluded
and all patients gave informed written consents.
All patients completed prosthetic heart valve
evaluation form, Beck Depression Inventory
(BDI) and Hamilton Anxiety Scale (HAS). In
prosthetic heart valve evaluation form the data
including patient’s age, gender, type of prosthetic
valve, procedure date, need for repeated procedure, smoking status, comorbidities (hypertension, obesity, diabetes, chronic renal failure),
history of bleeding, transfusion, cerebrovascular
accident, myocardial infarction, congestive heart failure, pulmonary disease or gastrointestinal
disease were collected. Patients’ recent complete
blood count, basic metabolic panel and echocardiogram results were collected too.
Beck Depression Inventory
The Beck Depression Scale (BDS) is one of the
most common scales used for assessment of
mood disorders and depression, created by Aeron
Beck in 1961 (5). It consists of 21 questions, 15
for emotional and 6 for somatic symptoms and filled by the patient. In BDS, scoring ranges from
0-3 on each question. The total score is calculated
by summation of all the patient’s responses, so
the maximum possible sum is a score of 63. Higher scores on the scale indicate a greater level of
depressive symptoms, BDS 0-11 indicates no depression, 12-26 mild depression, 17-29 moderate
depression, 30-39 severe depression and above
40 indicates very severe depression (5).
Hamilton Anxiety Scale
The Hamilton Anxity Scale measures the severity
of anxiety level and symptom distribution. It is a
14-item test including mood and somatic symptoms administered by an interviewer. Each item
is rated on a five-point Likert-type scale ranging
from 0-4, so the sum of the score range is between 0-56. The patients must complete the test
within 72 hours from the admission (6).
The study protocol was approved by the Ethics
Committee of Suleyman Demirel University and
all subject signed written consent forms.
Statistical analysis
Measured values are reported as mean ± standard
deviation (minimum-maximum values). Oneway ANOVA, Kruskal Wallis, chi-square test and
student test were used to compare group differences where appropriate. Spearman correlation test
was used to identify correlation between continuous variables. Differences were considered significant at a p value of < 0.05.
RESULTS
In the study 98 patients (54% males, n=53) with
prosthetic heart valve presenting to Cardiology
Outpatient Clinic were enrolled. The past dura-
87
Medicinski Glasnik, Volume 12, Number 1, February 2015
tion of the surgery for heart valve was 7.89 ± 5.7
years (1-25 year) before they were included into
the study (Table 1). According to the BDS, there
were 26 (27%) patients with no depression, 20
(20%) with mild depression, 38 (39%) with moderate, four (4%) with severe and 10 (10%) patients with very severe depression. Avarege score
was 18.3 ± 11.4 on BDS and 19.1 ± 11.1 on HAS.
Table 1. Characteristics of study participants
Characteristic
Number
Age, years
Gender (male)
AVR
MVR
AVR and MVR
Beck Depression Inventrory
No depression
Mild depression
Moderate depression
Severe depression
Very severe depression
Hamilton Anxiety Scale
Cerebrovascular accident
CHF
COAH
Gastrointestinal bleeding
Epistaxis
Gingival bleeding
Blood transfusion
Hypertension
Diabetes mellitus
Obesity
Arrhythmia
Atrial fibrillation
Atrial flutter
Premature atrial contraction
Premature ventricular contraction
No (%) of patients/value at
current visit
98
53.6±10.9
54 (54.5)
10 (10%)
75 (77)
13 (13)
18.3±11.4
26 (27)
20 (20)
38 (39)
4 (4)
10 (10)
19.1±11.1
3 (3)
2 (2)
2 (2)
4 (4)
19 (19.4)
15 (15.3)
8 (8)
29 (30)
8 (8%)
9 (9)
26 (26.5)
19 (19.4)
1 (1)
5 (5)
1 (1)
AVR, aort valve replacement; MVR, mitral valve replacement;
COAH, chronic obtructive pulmanary disease; CHF, congestive heart
failure
Of those 98 patients, eight (8%) were 33-40, 31
(31%) 41-50, 36 (37%) 51-60, 13 (13%) 61-70
and 10 (10%) were 71-80 years of age. A comparison of patients by age groups did not show difference for either BDS (p=0.520) or HAS (p=0.469).
Medical history of the patients was significant for
cerebrovascular accident in three (3%) patients,
congestive heart failure and chronic obstructive
pulmonary disease in two (2%) patients each.
Four patients had gastrointestinal bleeding, 19
had epistaxis and 15 patients had gingival bleeding after the surgery. Eight patients had received blood transfusion due to anemia or bleeding.
Among the cardiac risk factors, hypertension was
present in 29 (30%) patients, diabetes mellitus
88
in eight (8%) and obesity in nine (9%) patients.
Arrhythmia was detected in 26 patients, 19 had
atrial fibrillation, one had atrial flutter, five had
premature atrial contraction and one had premature ventricular contraction.
Table 2 showed the comparison between depression level on BDS and patients complete blood count (CBC), coagulation parameters, fasting
glucose, renal function test and echocardiographic findings. The depression level was positively
correlated with prothrombin time and INR level. Prothrombin time was longer than expected
in patients with mild and moderate depression
(36±12.4 vs. 39±11.7, respectively), whereas it
was shorter than expected in patients with very
severe depression (21.8±8.2) (Table 2). Patients
with severe depression were also found to have
lower than expected INR levels (Table 2). However, BDS was not significantly correlated with
prothrombin time (p=0.446) and INR (p=0.919)
(in correlation analysis).
Table 2. Comparison between depression level and laboratory
and echocardiographic data
Depression level
Paremeters
Hb
(g/dL)
Glucose
(mg/dL)
PT
(sec)
INR
BUN
(mg/dL)
Cr
(mg/dL)
EF (%)
LA
(mm)
No
Mild Moderate Severe
(n = 26) (n = 20) (n = 38) (n = 4)
12.6 ±
1.6
108 ±
71
27.5 ±
8.6
2.64 ±
0.7
21.5 ±
6.1
0.9 ±
0.1
60.3 ±
7.9
44.9 ±
5.9
13.1 ±
1.6
90 ±
11
36 ±
12.4
3.19 ±
1.06
17.2 ±
3.3
0.8 ±
0.2
54.5 ±
11.5
44.5 ±
3.5
12.5 ±
1.0
93 ±
9.3
39 ±
11.7
3.3 ±
0.99
21.1 ±
6.4
0.9 ±
0.2
58.4 ±
7.9
46.3 ±
6.2
13.3 ±
1.3
96 ±
1.7
28.5 ±
4.04
2.09 ±
0.1
17 ±
6.9
1±
0.08
62.5 ±
2.8
47 ±
2.3
Very
severe
(n = 10)
13 ±
1.2
108 ±
19.7
21.8 ±
8.2
2.5 ±
0.41
18.6 ±
4.6
0.7 ±
0.3
58 ±
7.1
41.2 ±
4.9
p
0.462
0.474
<
0.001
<
0.001
0.535
0.212
0.187
0.110
EF, ejection fraction; Hb, hemoglobin; INR, international normalized
ratio; LA, left atrium diameter; PT, prothrombin time; Cr, creatinine
The depression levels were also compared with
patients’ demographic and clinical features (Table 3). Patients with comorbidities accompanying prosthetic heart valve had more advanced
degree of depression (p=0.005). Similary, chronic gastrointestinal disease was correlated with
very severe stage of depression (p=0.001). Other
parameters did not show significant difference.
Patients with chronic diseases accompanying
prosthetic heart valve were more depressive
according to BDS (22.5 ± 13.3 vs. 14.9 ± 7.9;
Turker et al. Valve disease and depression and anxiety
Table 3. Comparison between depression level and demographic and clinical features
No (%) of patients with depression level
Very
No
Mild Moderate Severe
Paremeters
severe
(n = 26) (n = 20) (n = 38) (n = 4)
(n = 10)
Gender (male) 15 (58) 13 (65) 18 (47) 3 (75) 4 (40)
Smoker
1 (4) 3 (15)
0
0
2 (20)
Comorbidities 8 (30.7) 8 (40) 17 (44.7) 2 (50) 10 (100)
Heart Failure
2 (7.6) 1 (5) 3 (37.5)
0
0
Arrhythmia
6 (23.07) 7 (35) 7 (18.4) 2 (50) 4 (40)
DM
2 (7.6) 1 (5)
3 (7.8)
0
2 (20)
Obesity
2 (7.6)
0
5 (13.1)
0
2 (20)
HT
4 (15.3) 5 (25) 12 (31.5) 2 (50) 6 (60)
CVA
0
0
3 (7.8)
0
0
Bleeding
7 (29.9) 10 (50) 19 (50)
0
2 (20)
GIS disease
0
0
0
0
2 (20)
Repeat surgery 2 (7.6) 4 (20) 4 (10.5)
0
0
p
0.523
0.058
0.005
0.873
0.385
0.657
0.338
0.090
0.308
0.070
0.001
0.436
GIS, gastro intestinal system; DM, diabetes mellitus; HT, hypertansion; CVA, cerebrovascular disease
p = 0.001) and more anxious according to HAS
(23.2 ± 11.7 vs. 15.0 ± 9.4; p = 0.001) than patients without comorbidities. The presence of
hypertension was associated with higher scores
for both depression (24.9 ± 10.2 vs. 16.7 ± 10.6;
p = 0.01) and anxiety (24.9 ± 10.2 vs. 16.7 ±
10.6; p = 0.01). There was no significant difference between patients with and without diabetes
for depression (p=0.272) and anxiety (p = 0.842).
Gender difference, history of repeat procedure,
cerebrovascular accident, congestive heart failure and smoking status were also not in correlation
to depression and anxiety.
History of bleeding by itself was not associated
with depression and anxiety. However, while depression score was not different between patients
with and without blood transfusion (p=0.235)
Table 4. Comparison between type of heart valve surgery and
clinical and laboratory data
Paremeters
HAS
BDS
BDS level
No depression
Mild depression
Moderate depression
Severe depression
Very severe depression
Gender (male)
Age, years
Comorbidities
PT (sec)
INR
No (%) of patients/value
AVR
MVR
AVR and
(n=10)
(n=75) MVR (n=13)
21.8 ± 5.3 19.5 ± 11.6
21.8 ± 5.3 18.2 ± 11.8
0
4 (40)
4 (40)
0
2 (20)
9 (90)
61.0 ± 12
4 (40)
30.7 ± 9.4
2.6 ± 0.6
14.6 ± 7.2
14.5 ± 9.4
22
4
14
2
27
7
4
0
8
0
37 (49.3)
8 (61.5)
53.5 ± 10 49.0 ± 12.4
35 (46.7)
6 (46.2)
32.2 ± 10.7 34.3 ± 8.5
2.9 ± 0.8
3.0 ± 0.7
P
0.208
0.293
0.302
0.052
0.028
0.593
0.679
0.599
AVR, aortic valve replacement; BDS, Beck Depression Scale; HAS,
Hamilton Anxiety Scale; INR, international normalized ratio; MVR,
mitral valve replacement; PT, prothrombin time
due to anemia or bleeding, patients with transfusion history were more anxious (32 ± 4.2 vs. 17.9
± 10.8; p < 0.001). Similarly patients with obesity were more anxious than non-obese ones (27.77
± 7.83 vs. 18.24 ± 11.09; p=0.014).
Patients with arrhyhthmia had similar depression
scores compared to the patients without arrhythmia. Although the difference did not reach
statistical significance, patients with arrhythmia
tended to be more anxious than those without it
(22.7 ± 12.7 vs. 17.8 ± 10.2; p=0.054). The presence of gastrointestinal disease in the patients
was correlated with both high depression (45 ±
10.0 vs. 17.8 ± 10.8; p=0.001) and anxiety (39 ±
10.0 vs. 18.7 ± 10.8; p=0.01) scores.
The Hamilton Anxiety Scale was significantly
correlated with comorbidities (r: 0.344; p=0.002),
blood transfusion (r: 0.370; p<0.001), obesity (r:
0.319; p=0.007) and the Beck Depression Scale (r:
0.660; p<0.001) in patients with prosthetic heart
valve disease. The Beck Depression Scale was
correlated with comorbidities (r: 0.328; p = 0.002)
in patients with prosthetic heart valve disease.
The Hamilton Anxiety Scale was not significantly
correlated with PT (p=0.423) and INR (p =0.789).
The type of heart valve surgery were aortic valve
replacement (AVR) for 10 (10%) patients, mitral
valve replacement (MVR) for 75 (77%) patients
and both AVR and MVR for 13 (13%) patients.
Table 4 showed the comparison between type
of heart valve surgery and clinic and laboratory
data. There were no significant differences in
HAS, depression level and BDS between ARV,
MVR and AVR and MVR.
DISCUSSION
In the present study, the level of depression and
anxiety in patients with prosthetic heart valve
and its relationship with the demographic and
clinical features was investigated. A significant
association between depression level and prothrombin and INR levels was found. The level of
depression was more severe in patients having
comorbidities and gastrointestinal disease. Besides, hypertensive patients were more anxious and
depressive compared to non-hypertensive ones.
Patients who had blood transfusion and obesity
were more anxious.
Chronic diseases are long-term diseases that may
cause psychiatric problems in their course (7-9).
89
Medicinski Glasnik, Volume 12, Number 1, February 2015
Depression and anxiety disorder are the most common psychiatric diseases occurring in patients with
somatic diseases and they usually coexist (10).
Worsening in the quality of life, functional disability and direct biological effects of organic diseases
are the main reasons for development of depression
(11). Several studies have reported increased prevalence of depression and anxiety in patients with
chronic disease as compared to patients without
chronic disease (12-16). It was determined that patients undergoing heart operation experienced such
physical and psychological problems as decrease
in appetite, sleep disturbances, fatigue and activity intolerance, anxiety and depression within six
months of being discharged (17). In our study, 27%
of the patients with prosthetic heart valve did not
have depression measured by the Beck Depression
Inventory. In a study done by Bahar et al., age was
reported to be correlated with higher anxiety and
depression scores (15). On the contrary, Munir et
al. found that majority of patients with anxiety and
depression were aged between 20-49 years (18). In
the present study, we did not find significant difference in neither the Beck Depression Inventory nor
Hamilton Anxiety Scale by patient’s age.
Female gender has been shown to be a risk factor
for the development of depression. Some studies
have demonstrated that women have higher average depression scores than males (19-20). Gilmour et al. found that females with depression
had a higher risk for the development of heart
disease while males did not (21).
The relationship between psychiatric disorders and
irritable bowel syndrome has been subject of interest for a long time (22). It has been shown that patients with irritable bowel syndrome have a higher
incidence of depression and anxiety disorder (23).
In addition, patients with depression have also
been reported to have higher incidence of gastorinteestinal disease (24). Coexistance of depression
and irritable bowel syndrome has been attributed
to increased sympathetic activity. Our results are
in accordance with previous studies, showing that
patients with gastrointestinal diseases were more
depressive and anxious. These patients were also
more likely to be in “very severe depression group”
in the Beck Depression Inventory groups.
This study demonstrated a significant relationship
between the depression levels and the prothrombin time and INR levels. Longer prothrombin time
90
than expected in patients with mild and moderate
depression was found, whereas it was shorter than
expected in patients with severe depression. Additionally, INR levels were lower than expected in
the very severe depression group. These findings
may indicate that patients with more depression
and anxiety have lower sense of responsibility to
protect themselves from possible complications
that may occur due to prosthetic heart valve disease. It is reasonable to think that these patients do
not have regular prothrombin time and INR check
and hence cannot reach target values.
In the present study, the prevalence of depression
and anxiety was higher in patients with comorbidities accompanying prosthetic heart valve disease.
Besides, the level of depression was more severe in
these patients compared to patients without comorbidities. Patients with chronic diseases are known
to be more depressive and anxious (13,15,16). Since the study participants had chronic heart disease,
comorbidities with this challenging heart problem
make them more depressive and anxious.
A meta-analysis reported a significantly higher risk
for the development of hypertension in patients
with high psychological stress levels. Moreover, it
was claimed that this risk is comparable to wellknown risk facors for the development of hypertension such as obesity and lack of physical activity (25). Supporting the literature, patients with
hypertension in this study were more depressive
than without hypertension using the Beck Deprerssion Inventory. The Hamilton Scale anxiety scores
were also higher in patients with hypertension.
Patients requiring blood transfusion following
bleeding or due to anemia experienced intense
anxiety in this study. Since patients with prosthetic heart valve need frequent follow-ups over a
long period of time, the need for admission to the
hospital for blood transfusion probably makes
them more aggressive and anxious.
Several studies have demonstrated high prevelance of depression and anxiety in patients with
obesity (26,27) pointing that in obese individuals, impaired body image and body dissatisfaction were observed, which might contribute to
the development of anxiety and depression in
this population. However, no correlation was reported between obesity and a level of anxity and
depression. In our study, there was no difference
in respect to depression between obese and non-
Turker et al. Valve disease and depression and anxiety
obese patients whereas obese patients were found
to feel more anxious.
Prevalence of anxiety and depression is very common in patients with ischemic heart disease
(28). Persistent symptoms of anxiety and depression increased substantially the risk of death in
patients with ischemic heart disease (29). Patients
with organic disease with major depressive disorder have longer in-hospital stays, fail to comply
with treatment of the disease and medication they
are prescribed, and have increased mortality and
morbidy rates. Similar correlation is also found in
patients with anxiety. Van Hout et al. reported that
presence of anxiety disorder increases mortality in
men, however, mortality in women is not increased (30). Garfield et al. reported that anxiety disorders, major depressive disorder, and co-occurring
anxiety and major depressive disorder are associated with incident heart failure in large cohort (31).
The depression and anxiety scores were not significantly different among the prosthetic valve
type in this study. Relatively lower depression and
anxiety detection in patients with both AVR and
MVR may be associated with their younger age.
Ther are several limitations of the present study.
The number of patients across the different de-
pression categories is unbalanced (only four patients in severe depression), therefore, a more
balanced sample size across the depression categories would potentially allow for more robust
comparison between these groups. The other limitation of study was that there was no control
group of healthy individuals. Finally, patients did
not have pre-surgery measurements of depression and anxiety level to compare the difference
between pre and post surgery changes.
In conclusion, it is crucial to identify depression
and anxiety disorders of the patients with mechanical prosthetic valve disease, which can play an
important role in treatment planning, and helps
physicians predict the indication for treatment modalities and good long-term outcomes. Early recognition and appropriate treatment of depression
and anxiety may decrease the morbidity in prosthetic heart valve disease. Besides, use of new oral anticoagulant agents that do not need INR check, could decrease anxiety and depression in the future.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATIONS
Competing interest; none to declare.
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9. Gagnon LM, Patten SB. Major depression and its
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10. Hirschfeld RM. The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care. Prim Care Companion J Clin
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11. Kılıcoglu A. Risk factors and etiology of depression
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12. Ozmen E, Taşkin EO, Ozmen D, Demet MM. Which
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15. Bahar A, Tutkun H, Sertbas G. The determination of
the level of anxiety and depression of old people who
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16. Romao AP, Gorayeb R, Romao GS, Poli-Neto OB,
dos Reis FJ, Rosa-e-Silva JC, Nogueira AA. High
Levels of Anxiety and Depression have a Negative
Effect on Quality of Life Women with Chronic Pelvic
Pain. Int J Clin Pract 2009; 63:707-11.
17. Jaarsma T, Kastermans M, Dassen T, Philipsen H.
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19. Güz H, Yaman MA, Dilbaz N. Frequency of depression and psychiatric symptoms in elderly population with physical illness. Türkiye’de Psikiyatri 2007;
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20. Yakar T, Baran A, Güngör S, Altinsoy B, Yalcinsoy
M, Can G, Akkaya E. The factors affecting Beck depression scale in asthmatic patients. Tuberk Toraks
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21. Gilmour H. Depression and risk of heart disease. Health Rep 2008; 19:7-17.
22. Creed F, Guthrie E. Psychological factors in the irritable bowel syndrome. Gut 1987; 28:1307-18.
23. Lydiard RB. Irritable bowel syndrome, anxiety, and
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25. Ruthledge T, Hogan BE. A quantitative review of
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Hebebrand J. Rates of psychiatric disorders in a clinical study group of adolescents with extreme obesity
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29. Doering LV, Moser DK, Riegel B, McKinley S, Davidson P, Baker H, Meischke H, Dracup K. Persistent
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Association of anxiety disorders and depression with
incident heart failure. Psychosom Med 2014; 76:12836.
ORIGINAL ARTICLE
Emotional profile and risk behaviours among tattooed and
non-tattooed students
Matea Zrno1, Maja Frencl2, Dunja Degmečić 1,2, Ivan Požgain1,2
School of Medicine, University of Osijek ‘’Josip Juraj Strossmayer‘’, 2 Department of Psychiatry, University Hospital Centre; Osijek,
Croatia
1
ABSTRACT
Aim To determine differences in emotional profile and frequencies of certain risk behaviours between tattooed and non-tattooed
students.
Methods One hundred students fulfilled personality assessment
(trust, timid, depressive, distrust, aggressive, gregarious, controlled, uncontrolled) and questionnaire of socio-demographic data
that also included some questions about possession of tattoo
(time, place, motive) and about certain risk behaviours (court punishment, consummation of alcohol, psychoactive substances and
cigarettes).
Corresponding author:
Maja Frencl
Department of Psychiatry, University
Hospital Centre Osijek,
Huttlerova 4, 31000 Osijek, Croatia
Phone: +385 31 511 799;
Fax: +385 31 512 225;
E-mail: [email protected]
Original submission:
Results The total number of 35 (out of 100) students had a tattoo,
and 67 wished to have a tattoo. There was no statistically significant difference in emotional profile between tattooed and nontattooed individuals, yet the differences were detected when the
group of subjects who wanted a tattoo and those who did not want
a tattoo were compared. Higher result on the aggression scale of
and lower on control scale was gained by those with the wish for
tattooing. Students with bigger tattoos (23) showed higher score
on depression scale. Students in the tattooed group more frequently abused drugs and committed traffic offences compared to the
students in non-tattooed group.
Conclusion Results of this research as well as previous research
show that the presence of a tattoo could be a rough indicator for
possible emotional problems and risk behaviour, which could have
significant implications in preventing these behaviours. Future
studies are required on a larger and more representative sample as
well as to clarify why young people decide to be tattooed.
Key words: tattooing, personality, drug abuse, traffic offences
08 September 2014;
Revised submission:
29 October 2014;
Accepted:
04 December 2014.
Med Glas (Zenica) 2015; 12(1):93-98
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Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
Main assumption in the theory of personality is
that characteristics of personality are partly genetically predisposed and are manifested as individual differences in cognitive, emotional and
behavioural functioning in different time and
situations (1). Personality is manifested through behaviour, therefore researching connections
between specific behaviour, emotions and personality characteristics can help in predicting the
appearance of certain behaviours (1). This can be
especially useful in the research of risk behaviours because of the prevention and treatment plans.
Through history in most cultures tattooing had a
negative meaning. Common attitude is that tattooed persons are ”different” and that they have a
certain pathology in personality (2-11).
There are also some stereotypes connected to
tattooing. People can perceive tattooed males as
more dominant which means more attractive, and
tattooed females as less healthy compared to nontattooed (2,3), more sexually promiscuous and
heavier drinkers than non-tattooed females (3).
Researches showed that a differences in personality between tattooed and non-tattooed individuals
have existed. Studies found tattooed persons more
extroverted, with a greater need to be unique and
more prone to adventurous behaviours as compared to non-tattooed individuals (4). They also
showed a more positive attitude towards tattoos
in comparison with non-tattooed individuals. According to that research it is assumed that tattooing has become a sign of self-expression used by
individuals to differ more from others (4). There
are many studies conducted worldwide which
show connection between tattooing and risk and
violent behaviours. A few new studies (5-9) show
that tattooing is connected with high-risk behaviours. Tattooed young people drink more alcohol drinks (5,6,7) and more frequently (6), use
psychoactive substances more frequently (6,7),
have higher incidence of school throw-outs (6),
practice more insecure sexual intercourses (6,7),
while suicidal behaviors and suicidal ideation
were not related to tattoo status among university students (7). These differences occurred not
only in young population, but in the population
through the lifespan also (8). Tattooed students
were also significantly more often depressed (6).
94
Higher impulsivity, adventurism and risk behaviours in tattooed soldiers with PTSD were found
(9), and more tattooed patients were diagnosed
with antisocial personality disorder (10) compared to the non-tattooed.
Non-psychiatric population study showed that tattooed individuals more often had unconventional
sexual relationships, they were more extroverted,
more prone to adventurist/risk behaviour and that
they had less consciousness than non-tattooed individuals (11). Bender et al.(12) showed that impulsiveness has an indirect relationship to suicidal
behavior, and that this relationship is mediated by
painful and provocative events that include tattooing as well. Nevertheless, there are also researches that show that nowadays tattooing is only the
expression of fashion and is not connected with
higher rate of risk behaviour and personality
differences (13,14). The motivation for different body modifications like tattooing and piercing was found in expressing self-consciousness,
identity, and a wish to demonstrate autonomy and
thereby to control one’s own body (15).
Although tattooing is planetary popular today
and it does not stigmatize individuals as much as
it used to, there is still an open question if there is
connection between tattooing and different kind
of disturbed or high-risk behaviour, and if tattooing can be a certain predictor of such behaviour.
The aim of the study was to determine the differences in emotional profile and frequencies of
certain risk behaviour between individuals with a
tattoo and those without it. As having tattoo can
be a rough indicator of emotional and behavioural problems, we hypothesized that students with
a tattoo were more prone to emotional problems
and risk behaviours. EXAMINEES AND METHODS
The study was conducted among students of Josip Juraj Strossmayer University of Osijek. One
hundred students were included (37 males, 63
females) between 19 and 30 years of age. Mean
age was 23.05 years (SD=2.53). Students participated in the research on voluntary basis, they
were invited by an advertisement on information
board of a few faculties.
From the total number of 100 students, two
(2%) were first year students, 38 (38%) second
year, 18 (18%) third year, 10 (10%) fourth year,
Zrno et al. Tattoing: emotional profile and risk behaviour
15 (15%) fifth year, eight (8%) sixth year students, and nine (9%) students were at the point
of finishing their study.
and one (2.9%) had 6 tattoos. Considering the
size of the tattoo, 12 (34.3%) had small tattoos,
23 (65.7%) had medium or large tattoos.
Socio-demographic questionnaire was designed
for this study and it included questions about age,
sex, faculty and year of the study, eventual court
punishment, consummation of alcohol, psychoactive substances and cigarettes, existence of a tattoo, wish for a tattoo and questions about the tattoo
(place, motive, time of tattooing). In the second
part of the study participants fulfilled Emotions
Profile Index (PIE) assessment, which was supervised by a licensed psychologist. Participants
completed questionnaires anonymously and voluntary, in groups or individually, in presence of the
skilled person, and were allowed to ask questions
and get additional explanations relating to questionnaire completeness. Written consent was obtained from the subjects for collecting the data and
publication of the study. This study was approved
by the Ethical Committee of School of Medicine,
J.J. Strossmayer University of Osijek.
More than half of the students, 18 (51.4%), responded that love for tattoos was their motivation
to have it, personal connection with the motive of
the tattoo was declared by five (14.3%), a moment
decision was stated by three (8.6%), two (5.7%)
had it done for memories, two (5.7%) because
their close persons told them to do it, one (2.9%)
out of curiosity, one (2.9%) because of wish to
have the tattoo seen by everyone, one (2.9%) student said he/she did it for love. The remaining
two students had different reasons like: a song,
nothing, feeling that everyone has something, life
road etc. Most of the subjects had their tattoos
made at the age between 18 and 21, 16 (45.7%).
The majority of the students, 31 (88.6%), were
not sorry for having a tattoo, while four (11.4%)
affirmed that they were sorry.
Assessment PIE is designed for measurement
of emotionality of participants according to the
Plutchik multidimensional model of emotions
(16). The theory assumes existence of 8 basic
dimensions of emotions: Trust, Timid, Depressive, Distrust, Aggressive, Gregarious, Controlled,
and Uncontrolled. Assessment PIE is composed
of 62 questions which are pairs of expressions for
characteristics of personality (total of 12), and the
task for the participants was to choose which one
of the two words describe him/her better (16).
Results were presented as frequencies and percentages (for descriptive variables), means and
standard deviations (for numerical variables).
Furthermore, independent samples t-test was
performed for testing differences in emotional
dimension between tattooed and non-tattooed
students, and Chi-square was performed for testing differences in frequencies of certain risk
behaviours. In cases where expected frequency
was lower than 5, Fisher exact test was used. Results were considered statistically significant on
the level of risk equal to or less than 5% (p<0.05).
RESULTS
In the observed group (n=100), 35 (35%) had
tattoo: six (17.1%) of them had 2 tattoos, two
(5.7%) had 3 tattoos, two (5.7%) had 5 tattoos,
There was no statistically significant difference
in the distribution of the dimensions of emotions between the groups of tattooed and non-tattooed subjects.
From the total number of subjects, 67 (67%)
wished to have a tattoo. There was statistically
significant difference in the distribution of the
dimensions of emotions between those with andwithout a wish for tattooing. Statistically significant difference resulted in the distribution of
dimension ‘’Controlled’’ between those two groups (p=0.05). Students who had a wish to tattoo
had lower result on scale ‘’Controlled’’ (M=15.9;
SD=4.04) compared to those who had no wish to
tattoo (M=17.67; SD=4.11). Statistically significant difference resulted in the distribution of the
dimension ‘’Aggressive’’ (t=2.29; p<0.05). Students with the wish to tattoo had a higher result
on the scale ‘’Aggressive’’ (M=11.09; SD=5.77)
compared to those without the wish for tattooing
(M=8.36; SD=5.13).
A statistically significant difference (p=0.02)
in the personality dimension ‘’Depressive’’
between students with small tattoo (n=12) and
those with medium or big tattoo (n=23) was
found. Students who had medium or big tattoos had higher score on the scale ‘’Depressive’’
(M=7.74; SD=3.01) than those with small tattoos (M=5.00, SD=3.25) (Table 1).
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Medicinski Glasnik, Volume 12, Number 1, February 2015
Table 1. Mean and standard deviation of participants’ answers on dimensions of aggression, control and depression
considering wish for tattoo and size of tattoo
Dimension of emotions
Aggression
Control
Depression
Groups
M (SD)
With wish
Without wish
With wish
Without wish
Big tattoo
Small tattoo
11.09 (5.77)
8.36 (5.13)
15.93 (4.04)
17.67 (4.11)
7.74 (3.01)
5.00 (3.25)
M=Mean, SD=Standard deviation
More tattooed students reported to use drugs
(p<0.05) and have traffic offenses (p<0.05) than
the non-tattooed ones. In the results distribution
consummation of alcohol, cigarettes, other offenses (domestic violence, disturbing public peace,
crime) there was no statistically significant difference in the frequency distribution between tattooed and non-tattooed students (Table 2).
Table 2. Frequencies of specific risk behaviours in two groups
of subjects
Risk behaviour
Answer
Yes
Punishment for traffic
offence
No
Yes
Drug abuse
No
No (%) of students
With tattoo Without tattoo
5 (14.7)
0
29 (85.3)
66 (100)
19 (55.88)
14 (21.21)
15 (44.12)
52 (78.79)
DISCUSSION
From the total number of students who participated in the study, 35% had a tattoo, and 67% had a
wish for tattoo in the future. In the western civilization, the number of tattooed persons is growing
(13, 17) possibly because of the promotion of the
tattoos by celebrities in music, film industries, resulting in the transfer of tattooing from the edge
of society to the main stream.
No statistically significant difference occurred in
dimensions of emotions between the two groups,
but differences were found between the students
with/without a wish to tattoo. It seems that students who wish to tattoo are more aggressive
and have less control than students without a
wish to tattoo. It is proposed that students with
a wish to tattoo can be considered as the group
of tattooed (they are still too young and financially dependent, but will have a tattoo done in
the future); both groups have the same attitudes
towards tattoos. Moreover, a significant difference in emotional profile between the groups with
and without a wish for tattoo were found, which
is in concordance with the results of the previous
96
researches (4,9). However, it is important to notice, contrary to the findings of Tate and Shelton
(14), that some differences in emotional dimensions found in our study emerged as important.
Although in Tate and Shelton study differences
in personality between tattooed and non-tattooed have emerged, mean scores for those variables fell within the range of standardized norms.
In the presented study mean scores of tattooed
students were either above (for Aggression) or
below the average (for Control). That indicates
some emotional problems in tattooed students
that are not negligible.
The size of the tattoo was also connected with
the differences in the student’s emotional profile
in this study, students with a big tattoo were more
depressed than those with a small tattoo. Similar
results were detected in other studies too, where
tattooed persons (males) were more depressed
than non-tattooed (7).
Furthermore, results of this research have shown
that more tattooed compared with non-tattooed
are involved in risk behaviour, such as consummation of drugs and traffic offences, but it was
not confirmed that tattooed students drink alcohol
more often than non-tattooed, like in some other
studies (5-8). This could be explained by the fact
that a 4-point scale for measuring frequency of
drinking alcohol used in this questionnaire is not
appropriate for this population. Both groups of
students mostly answered that they occasionally
drank alcohol. So the findings in this study just
partly confirmed previous findings about tattoos
and risk behaviour (5-8).
Regarding the choice of the tattoo place we can
conclude that our subjects wanted to have a possibility to hide the tattoo, showing that there is
still stigma about tattoos. Hands were the most
frequently used place for tattooing (31%) followed by the back (24%). Those are the places
where tattoo is visible but also can be hidden. In
one study, 68% of tattooed subjects admit that
they hide their tattoos in special occasions, such
as exams, certain festivities, and the main reason
for that behaviour is because they consider them
inappropriate (17).
In this study 89% of the tattooed students were
not sorry because they had a tattoo. New research among American population showed that
14% of tattooed persons want to have it removed
Zrno et al. Tattoing: emotional profile and risk behaviour
because they were too young when they made
a tattoo (21%), they did not like to be marked
for the rest of the life (19%) and did not like it
any more (18%) (18). The results in this study
are not the same, probably because young population was investigated, so their first tattoo was
not made long time ago, at the age between 18
and 21 (45.7%). Our results are similar to those
of the study of Aslam and Owen (19), but in their
study one third of subjects regreted their tattoos.
Considering that fact and a short period from the
tattooing in which they could feel regret, our results are expectable.
The act of tattooing is rather painful, maybe
persons who have tattoos are considered braver,
more special, more capable compared to the nontattooed, and therefore this courage leads them
to risk behaviours. According to the interpersonal theory of suicide, impulsive people often
do painful and provocative things and have more
capability for self-harm and over time they get
accustomed to pain, which gives them more capability to suicidal behavior if they ever desire
it (20). Maybe stable personality or just current
immaturity of those who decide to have a tattoo
is the reason, because later in their life they regret for this act. Most young people have tattoos
done in the adolescent age, which is marked with
emotional instability and less capacity for the anticipation of consequences later in life.
To summarize, based on the results from our and
other studies, although tattoos have become planetary popular and do not stigmatize individuals
as in the past, they still carry and lead to some
risk behaviour and possible markers of those behaviours, respectively. The presence of a tattoo
in a person could be a rough indicator for possible risk behaviour, like drug abuse and traffic
offences, and also for emotional problems like
aggression and lack of behavioural control. This
could have significant implications in therapeutic interventions and prevention. A similar study
had not been performed in Croatia before and this
one gives some interesting insights into tattooing, emotional profile and risk behaviours in this
region. Future studies should be done on a larger
and more representative sample, which will include young people with or without finished high
school who are not going to the college. Also, it
would be interesting to include in the study the
population of broader age scale. Reasons for the
tattooing should be determined with more details,
with the aim to discover whether this behaviour
has deeper meaning or is it just a part of fashionable behaviour.
FUNDING
No specific funding was received for this study.
TRANSPARENCY DECLARATION
Competing interests: None to declare
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12. Bender TW, Gordon KH, Bresin K, Joiner Jr TE. Impulsivity and suicidality: The mediating role of painful and provocative experiences. J Affec Disorders
2011; 129: 301-7.
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13. Preti A, Pinna C, Nocco S, Mulliri E, Pilia S, Petretto
DR, Masala,C. Body of evidence: Tattoos, body piercing and eating disorders symptoms among adolescents. J Psychosom Res 2006; 61:561-6
14. Tate JC, Shelton BL. Personality correlates of tattooing and body piercing in a college sample: The kids
are alright. Pers Indiv Differ 2008; 45:281-5.
15. Stirn A, Oddo S, Peregrinova L, Philipp S, Hinz A.
Motivation for body piercing and tattoos: the role of
sexual abuse and the frequency of body modification. Psychiat Res 2011; 190: 359-63.
16. Plutchik R, Kellerman H. Emotions profile index
manual (PIE). Jastrebarsko: Naklada Slap, 2000.
17. DeMello M. Not just for bikers anymore: Popular
representation of American Tattooing. J Pop Cult
1995; 29:37-52
18. American Academy of Dermatology. Tattoos and
body piercings. http://www.aad.org/media-resources/stats-and-facts/prevention-and-care/tattoos-andbody-piercings (25 November 2012).
19. Aslam A, Owen CM. Fashion change but tattoos are
forever: time to regret 2013. Brit J Dermatol 2013;
169:1364-6.
20. Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner Jr. TE. The Interpersonal
theory of suicide. Psychol Rev 2010; 117:575-600.
Profil emocija i rizična ponašanja kod tetoviranih i netetoviranih
studenata
Matea Zrno1, Maja Frencl2, Dunja Degmečić1,2, Ivan Požgain1,2
1
Medicinski fakultet, Sveučilište J. J. Strossmayera u Osijeku, 2Klinika za psihijatriju, Klinički bolnički centar Osijek, Osijek, Hrvatska
SAŽETAK
Cilj Utvrditi postoji li razlika u emocionalnom profilu i u kojim dimenzijama između tetoviranih i netetoviranih studenata, te ispitati učestalost javljanja određenih rizičnih ponašanja kod ove dvije skupine
ispitanika.
Metode U istraživanju su sudjelovali studenti koji su ispunili upitnik o ličnosti (povjerljivost, bojažljivost, depresivnost, nepovjerljivost, agresivnost, društvenost, kontroliranost, nekontroliranost) i
učestvovali u anketi posebno osmišljenoj za ovo istraživanje, a koja je uključivala sociodemografska
pitanja, pitanja o tetovažama (posjedovanje, želju za posjedovanjem, dob tetoviranja, lokaciju tetovaže,
motiv), te učestalosti rizičnih ponašanja (sudsko kažnjavanje, konzumiranje alkohola, droge i cigareta).
Rezultati Od ukupnog broja studenata, 35 (od ukupno 100) ih je imalo tetovažu, a 67 ih je imalo želju
za tetoviranjem. Nisu pronađene statistički značajne razlike u emocionalnom profilu između tetoviranih
i netetoviranih, ali su utvrđene razlike u agresivnosti i kontroliranosti između studenata sa željom za tetoviranjem i onih koji nemaju takve želje. Studenti s većim tetovažama (23) pokazali su veću depresivnost od onih s malim i srednjim tetovažama. U odnosu na rizična ponašanja, kod tetoviranih ispitanika
utvrđena je češća zloporaba droga i kažnjavanje za prometne prekršaje.
Zaključak: Postojanje tetovaže kod osobe mogao bi biti grubi indikator za mogućnost postojanja
emocionalnih problema i rizičnog ponašanja što može imati implikacije u prevenciji takvih ponašanja.
Potrebna su daljnja istraživanja na većem i reprezentativnijem uzorku.
Ključne riječi: tetoviranje, osobine ličnosti, zloporaba droga, prometni prekršaji
98
ORIGINAL ARTICLE
The effect of anger management levels and communication skills
of Emergency Department staff on being exposed to violence
GozdeYildiz Das1, Ilknur Aydin Avci2
School of Health, Amasya University, Amasya, 2Nursing Department, Samsun School of Health, Ondokuz Mayis University, Samsun;
Turkey
1
ABSTRACT
Aim To determine the effect of anger management levels and communication skills of emergency department staff on their frequency of being exposed to violence.
Methods This cross-sectional study was conducted in the Training
and Research Hospital, Istanbul, Turkey between 11 April and 15
October 2013 by using a questionnaire including descriptive features, anger management scale, and communication skills scale applied to 283 health personnel working in children and adult
emergency department clinics.
Corresponding author:
Ilknur Aydin Avci
Nursing Department, Samsun School of
Health, Ondokuz Mayis University
Atakum Kurupelit, Samsun, Turkey
Phone: +90 505 203 1286;
Fax:+90 362 457 6020;
Email: [email protected]
Results Statistically significant differences were found between
the health workers’ ages and their anger control levels, marital status and anger-in and anger control levels, working position and
anger-in levels, and between anger-in, anger-out and anger control
levels based on their level of education. Statistically significant differences were also found between age and communication levels
based on the personnel’s working position. Statistically significant
difference between the anger-in subscale of health personnel based
on their state of being exposed to violence was found (78.4% of
the health workers had been exposed to violence).
Conclusion In the in-service programs of institutions, there should
be trainings conducted about anger management and effective communication techniques so that the health personnel can be aware
of their own feelings and express anger in a suitable way
Key words: anger management, communication, patients
Original submission:
18 August 2014;
Revised submission:
09 October 2014;
Accepted:
22 October 2014.
Med Glas (Zenica) 2015; 12(1):99-104
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Medicinski Glasnik, Volume 12, Number 1, February 2015
INTRODUCTION
Anger, which has an important place among feelings, is generally related to familial, work-related,
health related and legal problems. Anger is a negative mood state which varies in terms of intensity and continuity and associated with a sense of
emotional elevation and being exposed to a wrong
behavior (1). Anger is also related to an emotional
reaction to restrictions, strains and intense stressors within the working environment (2).
It is obvious that human health is under the physical and psychological effect of many-sided stresses which are related to working life. One of the
most important sources of stress caused by working life is the relationships among people (3).
It has been reported that a stressful working environment, not asking for ideas within the organizational process, absence of common goals and
presence of rivalry among organizations cause
nurses to become more inclined to conflict and to
experience intense feelings of anger (2).
Within the hospital environment, nurses frequently come across verbal anger expressions from
patients and generally perceive these as a threat
and thus, they experience anger either directly, by
getting angry with the patient and reflecting this
anger in their behaviors, or indirectly by getting
away from the patient (4). Deterioration in nurses’ health will cause loss of workforce, economic loss for the organization and the country, an
increase in accidents and risk for the healthcare
workers or patients for whom they are offering
service. Thus, it is very important to determine
the risks which are related to the working conditions of nurses and to eliminate these risks or to try
to minimize them. It is important to develop nurses’ skills to deal with the feelings of anger and to
channel the energy felt directly anger and to use
this energy to increase the quality of care (5,6).
Hospital environment causes healthcare workers
to violate boundaries and privacy. During the critical period caused by illness, the patient needs to
belong to and connect to a person. Thus, it is very
important that the patient can reach and trust his/
her doctor, nurse and other workers (7). Most of
the time, patients and their relatives are in fear
and anxiety since they do not know what to do.
Because they think that their condition is more
urgent than others’ and because the necessity of
100
triage is not adopted by the society, they have an
expectation of immediate treatment. This situation often causes conflict between the emergency
department staff and relatives of the patient (8).
Communication skills have an important place
in nursing services. While providing service to
patients and healthy people, nurses should expect
to understand these people and to be understood
by them. Healthy communication skills will help
nurses to develop their interpersonal relationships and this will in turn cause an increase in the
satisfaction of the people that they are providing
service for. Thus, health professionals should
have effective communication skills in order to
perform this important mission (9).
Deterioration of the health workers’ physical and
psychological health will cause loss of workforce, a decrease in care, treatment and efficiency,
economic loss for the organization and the country and risk for the people or patients for whom
they are offering service. Thus, the risks which
are caused by the working conditions of health
workers should be determined and eliminated.
While the studies done in this field have so far
been oriented towards the reason of increasing
violence regarding emergency staff, this study
aims to determine the effect of anger management levels and communication skills of emergency department staff on their frequency of exposure to violence.
EXAMINEES AND METHODS
This cross sectional study was conducted in the
Training and Research Hospital Provincial Directorate of Health, Istanbul, Turkey, in the period between11 April and 15 October 2013.
The research group of the study consisted of 238
health personnel working at the Pediatric and
Adult Emergency Clinics of the Training and
Research Hospital. All the personnel working
in these units were voluntarily included in the
study: 107 nurses, 113 doctors and 63 other health personnel (laboratory technicians, radiology
technicians, emergency technicians).
Data collection
The data was collected through a question form
of descriptive characteristics, trait anger and anger management inventory and communication
skills questionnaire.
Das et al. Anger management and communication skills
The question form which was prepared by the researchers contained 19 questions: the individual
and occupational descriptive characteristics of
the health personnel, their exposure to violence
in the emergency service and their anger, communication and behavior styles.
Trait Anger and Anger Expression Inventory
Trait Anger and Anger Expression Inventory is
a self evaluation inventory that measures anger
and anger expression. It was developed by Spielberger in 1983 (10) and its validity and reliability for Turkey were made by Özer in 1994
(11). The inventory has two main subscales,
S1-Anger and Anger-Style, respectively. The
inventory has a total of 34 items. The items do
not measure the absence of anger, but they measure the presence of anger. Scoring of the scale
is as follows:”Almost never” (1), “Sometimes”
(2), “Often” (3) and “Almost always” (4). In the
S1 scale, total score was obtained by adding up
the scale interval scores of each item. The first 10
questions of the inventory included the items measured trait anger, 24 remaining items were about
anger expression; 8 of these items are related to
anger-out expression (be reflected out of anger),
while 8 items are related to anger-in (be reflected in himself/herself of anger) expression and 8
items are related to anger-control.
Alpha reliability coefficient of the inventory of
0.77 was used.
Communication Skills Inventory
Communication skills inventory is a 5-point Likert scale inventory developed by Ersanli and
Balci in 1998 was used, in order to evaluate the
communication skills level of individuals (12).
Cronbach Alpha coefficient which was measured
to determine the internal consistency of the inventory was 72. The scale was scored as always
5, never 1. The scale has a total of 45 items and
the highest possible score was 225, while the
lowest possible score was 45.
Alpha reliability coefficient of the scale of 0.82
was used.
The health personnel individually completed the
question form, trait anger and anger management
inventory and communication skills inventory
and they filled in the forms by themselves.
Data analysis
Descriptive analysis was used for the comparison
of quantitative data, Student t Test was used for
the comparison of normally distributed parameters, One-way Anova test was used for intergroup
comparisons, and Tukey HSD test was used for
the determination of groups which caused difference. Pearson Correlation analysis was used for
the evaluation of inter-parameter relationships.
Ethical principles of the study
The study was approved by the Ondokuz Mayis
University Ethics Committee and the permission
was taken also from Istanbul Provincial Directorate of Health and the Training and Research
Hospital. Only health personnel who accepted to
participate voluntarily were included in the study.
RESULTS
Descriptive characteristics of the participants
The participants’ age varied between 19-50 years,
with a mean age of the participants being 29.23±5.94
years; 44.5% (n=126) of the participants were males, and 55.5% (n=157) were females.
Participants (n=107) were nurses, 39.9 % (n=113)
were doctors, 9.9% (n=28) were emergency medicine technicians and 12.3 % (n=35) were technicians (radiology or laboratory).
With regard to marital status, 56.2% (n=159)
of the health personnel were single, and 43.8 %
(n=124) were married. High school graduates had
16.3% (n=46) of the personnel, 19.8% (n=56)
had two-year degree, 45.2% (n=128) were doctors, while 18.7% (n=53) were postgraduates.
While 25.1% (n=71) of the participants had children, 74.9% (n=212) did not have children. The
time spent in the occupation ranged between 0.10
and 26 years, with the mean of 6.26±5.21 years,
and the time spent in the emergency department
was between 0.10 and 26 years, with the mean
of 4.43±3.99 years; 38.9% (n=110) of the health
personnel were willing to work at the emergency
department while 61.1 % were unwilling.
Violence related features
Large majority of the participants, 78.4% (n=222)
had been exposed to violence within the time
they worked in the emergency department: 64.9
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Medicinski Glasnik, Volume 12, Number 1, February 2015
% (n=144) had been exposed to verbal violence,
and 9.5 % (n=21) had been exposed to physical
violence, 22.5 % (n=50) had been exposed to both
verbal and physical violence, 2.3% (n=5) had been
exposed to all verbal, physical and sexual violence
and 0.9 % (n=2) had been exposed to both verbal
and sexual violence.
Nine percent of the participants (n=20) had been
exposed to violence by patients, 48.2% (n=107)
by patients’ relatives, 34.2% (n=76) by both patients and patients’ relatives, and 8.3% (n=19) had
been exposed to violence by the hospital administration (mobbing).
Eleven percent (n=31) of the health personnel
stated that they got angry frequently, and 42.4%
(n=120) stated that they had a training for anger
and anger management (Table 1).
Table 1. Reasons for the participants’ exposure to violence
(n=222)
Reason
Being late in treating a patient because of having too
many patients
Patients forcing the personnel to see a doctor although their situation is not urgent
Not letting in relatives to the intervention room
Referring a patient to another hospital
Patient relatives’ reactions to the intervention
Number (%) of
participants
92 (41.44)
49 (22.07)
44 (19.81)
25 (11.26)
12 (5.40)
Anger related features
Statistically significant differences were found
between the anger-in levels of the health personnel
regarding their levels of education (p<0.01). The
participants who had graduate degree had a higher
level of anger-in comparing to others. Statistically
significant differences were also found between
the anger-out level of the health personnel regarding their level of education (p<0.05). The
participants who had undergraduate degree had
a high level of anger-out. Statistically significant
differences were found between the anger control
level of the health personnel regarding their level
of education (p<0.01). The participants who had
graduate degree had a higher level of anger control comparing to others. Statistically significant
differences were not found between the trait anger
level of the health personnel regarding their level
of education (p>0.05) (Table 2).
102
Table 2. Evaluation of the trait anger and anger style inventory scores of the health personnel by their levels of education
Inventory score (Mean±SD)
Two-year UnderTrait anger /
High school
Graduate
degree
graduate
anger style
(n=107)
(n=35)
(n=113)
(n=28)
Trait anger
17.67±3.93 18.28±4.67 18.09±3.79 17.64±4.49
level
Anger-in
14.63±2.88 14.52±3.27 15.70±3.04 16.51±3.89
Anger-out 13.56±2.67 14.45±3.49 14.88±3.30 13.77±3.03
Anger
19.48±4.42 21.28±4.51 21.06±4.13 23.39±6.13
control
p
0.802
0.003
0.046
0.001
their mental communication skills and mental
communication levels (p=0.009), their behavioral communication skills and behavioral communication levels (p=0.045), and between their
general communication skills and general communication levels (p=0.02) (it found increasing
by the age). Difference was not found between
the health personnel’s age and their emotional
communication skills (p=0.081) (Table 3).
Table 3. Relationship between the age of the health personnel
and scores from communication skills scale
Scores of communication
subscale
Mean
SD
Mental communication
54.07
5.17
Behavioral communication
56.43
5.70
Emotional communication
50.89
5.50
General communication
161.48
14.09
Communication skill
Age
R
0.155
0.119
0.104
0.138
p
0.009
0.045
0.081
0.020
SD, standard deviation; R, Pearson Correlation Coefficient
The relationship between the participants’ anger
levels and their communication skills
No statistically significant relationship was found
between the general communication scores and anger-out of the health personnel, while statistically
significant relationship was found between health
personnel trait anger, anger-in scores, and anger
control scores (p=0.000, p=0.000 and p=0.000,
respectively). It was found that as their general
communication skills increased, health personnel
trait anger, anger-in and anger-out levels decreased
while their anger control levels increased (Table 4).
Table 4. Relationship between the health personnel’s anger control scale scores and their general communication skills scores
Trait anger / anger style
Scores of anger
control subscales
Mean
SD
17.98
4.12
Anger-in
15.45
3.30
Communication related features
Anger-out
14.37
3.22
Statistically significant difference was found
between the health personnel’s mean age and
Anger control
21.29
4.81
Trait anger level
General
communication
R
p
R
p
R
p
R
p
SD, standard deviation; R, Pearson Correlation Coefficient
-0.324
0.000
-0.301
0.000
-0.036
0.558
0.466
0.000
Das et al. Anger management and communication skills
DISCUSSION
In this study, 64.9 % of the participants were found to have been exposed to verbal violence while
9.5 % to physical violence, 22.5 % to both verbal
and physical violence and the rest of examinees
had been exposed to all verbal, physical and sexual violence. Similar results were shown by Crilly
et all. stating that 61% nurses were sworn at, 10%
pushed, 3% of each hit or kicked (18).
There are many reports about recorded violence
among health workers at emergency departments
(13-17). Behnam et al. found out that 75% of the
health workers have been exposed to verbal violence and 21% to physical violence (13). Kowalenko et al. reported 48.1% of women and 51.9
% of men among emergency physicians had been
exposed to workplace violence, most commonly
to verbal violence (74.9%) (14). Wu et al. found
out that 11% of the health workers had been exposed to physical violence, 26% to verbal violence and 1% to sexual violence (15), Canbaz et
al. (2008) found 59.6 % of the health care workers had been exposed to verbal violence while
19.6% had been exposed to physical violence
(16). There is a lot of stress and workload in the
emergency service. At the same time, emergency service is also a very stressful place with lots
of anxiety for patients and their relatives. Thus,
emergency department attending physicians who
have high anger management and communication problems may have tendency to violence in
this environment.
It has been found that 30-89% of health workers exposed to violence by patients, 9-82% to
patient’s relatives (14,19,20). The findings of
this study are in parallel with the findings of In
Kitaneh and Hamdan’ study showing that 20.8%
and 59.6% health professionals were exposed to
physical and non-physical violence, respectively (21). All this data show that even though
the type and kind of violence to health workers
vary, violence that can be caused by patients or
patient relatives seems to have become a part of
working life.
There are many studies describing the reasons
of health workers exposed to violence such as
misunderstandings, medical reasons, patients
and their relatives did not like the treatment, too
waiting for too long, patient deaths, insufficient
number of personnel, and late treatment of patients (10,15,19,20,22). The findings of the study
are similar to those studies.
In a study by Rosenstein and O’Daniel which
was conducted with 1500 nurses showed that as
the anger level of the nurses increased, they had
difficulties in concentration and communication,
the problems among the team, about information
exchange e.g., relationships in the work places
had been negatively affected (23). Communication is a very important factor in anger management. The results of this study showed that healthcare workers with bad communication have
higher anger levels.
As the education level of the participants increased, the mean of anger management and the
mean of anger-in among health personnel increased. In Balkaya’s study with 756 healthcare
workers which aimed to develop multi-dimensional anger inventory, it was found that high
school graduates were more inclined to experience more anger problems in their interpersonal
relationships when compared with primary education or university graduates (24). The findings
of the study are in concordance with the findings
of this study.
According to the results of this study, behavioral control increases with age. This study found
a statistically significant positive relationship
between the participants’ age and their general
communication skills and it was determined that
as healthcare workers aged, their general communication skills level increased. This situation
can be explained by the fact that as health workers get older, they will have a better knowledge
from their experience and information and that
they can more easily turn these into theoretical
application. In this study, as the health workers
get older, mental and behavioral communication
skills increase while emotional communication
skills decrease. Kaya et al. did not find a relationship between 41-45 year old nurses and communication skills although their communication
skills scores were the highest (25).
In conclusion, in the in-service programs of
institutions, training should be conducted about anger management and effective communication techniques so that the health personnel
can be aware of their own feelings and express anger in a suitable way, and the reasons of
103
Medicinski Glasnik, Volume 12, Number 1, February 2015
violence and aggressiveness toward the health
personnel should be researched and solutions
should be developed. Similar studies should be
made more extensively within the country.
FUNDING
This study was supported by Ondokuz Mayis
University Scientific Research Fund
TRANSPARENCY DECLARATION
Competing interest: none to declare
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LETTER TO EDITOR
Occurrence and morphological characteristics of cataracts in
patients treated with general steroid therapy at the Cantonal
Hospital Zenica
Jasmin Zvorničanin1, Edita Zvorničanin2
1
Eye Clinic, University Clinical Centre Tuzla, 2Institute of Public Health Tuzla Canton; Tuzla; Bosnia and Herzegovina
Dear Editor,
We read with interest the article by Čerim et al. regarding the occurrence and morphological characteristics
of cataracts in patients treated with general steroid therapy (1). Similar to the results of previous studies, the
authors found that the use of corticosteroids is associated with a higher incidence of cataract development
and posterior subcapsular (PSC) cataract as most prevalent morphological type (2).
Older age and heredity are the most important risk factors associated with different types of cataracts
and females are at increased risk of cortical cataract (2,3). Myopia (≤ −1.0 D) and elevated intraocular
pressure are also associated with an increased risk of nuclear and PSC cataracts (3). The major causal
external risk factors influencing cataract formation include: smoking, excessive UV-B exposure, diabetes mellitus (DM) and steroidal treatment (2,3). There is also a significant relationship between the risk
of cataracts and delivered corticosteroid dose (4). Lower monthly household income, lower education,
hypercholesterolemia, hypertension and DM are independent risk factors for the development of any
cataract type, while older age and DM are independent risk factors for the development of pure PSC (5).
Elevated body mass index (BMI) and rapid weight gain may also increase the risk for age related cataract, especially PSC cataract (3,6). Other risk factors for PSC development also include hypertension,
the use of amiodarone, thiazide diuretics, aspirin and vitamin E (2).
For these reasons, we would kindly ask the authors to perform the correlations for age, gender, BMI, length
and regimen of steroid use, cumulative steroid dose, the use of other systemic drugs, DM duration, spherical equivalent and intraocular pressure changes, with cataract occurrence and morphology between the
groups. Without this information it would be difficult to hypothesize the direct steroid induced cataractogenesis, especially in the group on the steroid therapy >4 years, where all patients had iatrogenic diabetes.
In these patients, it is the indirect impact of steroids on body metabolism that might initiate the cataractogenesis. These findings will significantly contribute to the paper’s scientific value and contribution.
Overall, we agree with Čerim et al. that general steroid therapy remains the important risk factor for
cataract development and all patients should have regular ophthalmological control examinations. Other systemic risk factors such as BMI, DM, smoking history, duration of basic systemic disease and
corticosteroid dose should be carefully monitored too.
Corresponding author:
Jasmin Zvorničanin
Eye Clinic, University Clinical Center Tuzla
Trnovac bb., 75000 Tuzla,
Bosnia and Herzegovina
Phone: +387 61 134 874;
fax: +387 35 250 474;
E-mail: [email protected]
Med Glas (Zenica) 2015; 12(1):105-106
105
Medicinski Glasnik, Volume 12, Number 1, February 2015
References:
1.
2.
3.
106
Čerim A, Dizdarević A, Pojskić B. Occurrence and
morphological characteristics of cataracts in patients
treated with general steroid therapy at Cantonal Hospital Zenica.Med Glas (Zenica) 2014; 11:295-9.
Robman L, Taylor H. External factors in the development of cataract. Eye (Lond) 2005; 19:1074-82.
Chang JR, Koo E, Agrón E, Hallak J, Clemons T,
Azar D, Sperduto RD, Ferris FL 3rd, Chew EY;
Age-Related Eye Disease Study Group. Risk factors
associated with incident cataracts and cataract surgery in the Age-related Eye Disease Study (AREDS):
AREDS report number 32. Ophthalmology 2011;
118:2113-9.
4.
5.
6.
Weatherall M, Clay J, James K, Perrin K, Shirtcliffe
P, Beasley R. Dose-response relationship of inhaled
corticosteroids and cataracts: a systematic review
and meta-analysis. Respirology 2009; 14:983-90.
Rim TH, Kim MH, Kim WC, Kim TI, Kim EK. Cataract subtype risk factors identified from the Korea
National Health and Nutrition Examination survey
2008-2010. BMC Ophthalmol 2014; 14:4.
Ye J, Lou LX, He JJ, Xu YF. Body mass index and
risk of age-related cataract: a meta-analysis of prospective cohort studies. PLoS One 2014; 9:e89923.
RETRACTION
Increased counts and degranulation of duodenal mast cells and
eosinophils in functional dyspepsia- a clinical study
Shijun Song, Yan Song, Haishan Zhang, Gaiqin Li, Xiaopei Li, Xiaohong Wang, and Zhen Liu
The above article published in Medicinski Glasnik online on 26 June 2014 by the Medical Association
of Zenica-Doboj Canton (http://www.ljkzedo.com.ba/index.php/u-sljedecem-broju) and in Volume 11,
Issue 2, pages 276-282, has been retracted by agreement between the authors, the journal Editor-in-Chief, Professor Selma Uzunović, and the Medical Association of Zenica-Doboj Canton.
The reasons for this retraction are as follows:
The work reported in the paper was about the role of duodenal eosinophils and mast cells in the pathogenesis of functional dyspepsia. Most of the experiments were carried out by a former member of the
authors’ team named Yuan Haipeng, who has left the team for more than two years. A high proportion of
data in the paper had been reported in the doctoral dissertation of Yuan Haipeng in 2012, and the paper
was published without the knowledge or permission of Yuan.
Besides the data previously reported in the doctoral dissertation of Yuan Haipeng, the authors calculated
the other data in the paper before the submission. However, it has come to the authors’ attention that
they had made quite a few mistakes due to a loss of the original data, which was not described in details
in the dissertation.
REFERENCE
Shijun Song, Yan Song, Haishan Zhang, Gaiqin Li, Xiaopei Li, Xiaohong Wang, Zhen Liu. Increased
counts and degranulation of duodenal mast cells and eosinophils in functional dyspepsia- a clinical
study. Med Glas (Zenica) 2014; 11(2):276-82.
Med Glas (Zenica) 2015; 12(1):107
107

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