pa ge 1 pa ge 13 6 american journal of medical science and innovation (ajmsi) the impact of war trauma and adverse childhood experiences in bosnia and herzegovina: the case of the srebrenica genocide malik burić1* volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5281 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 12, 2025 accepted: october 13, 2025 published: december 17, 2025 adverse childhood experiences (ace) represent a major determinant of adult mental and physical health outcomes, encompassing abuse, neglect, and dysfunctional family environments. when compounded by war trauma, their impact becomes substantially more severe. this review systematically examines research published between 1995 and 2023 on the combined effects of ace and war trauma in bosnia and herzegovina, with a specific focus on the srebrenica genocide. the search was conducted across pubmed, scopus, and web of science databases using predefined inclusion criteria. studies consistently indicate high exposure rates among children, with ptsd prevalence ranging from 30–70% and depression from 25–60%. the cumulative impact of early adversity and war exposure contributes to chronic somatic diseases, including cardiovascular and metabolic disorders, as well as intergenerational psychological transmission. this review identifies a research gap concerning integrated psychosocial and biological models of trauma recovery in postconflict societies. findings underscore the need for public health strategies that prioritize early trauma screening, community-based interventions, and long-term mental health programs for survivors and their descendants. keywords ace, genocide, intergenerational effects, ptsd, srebrenica, trauma 1 university of sarajevo, faculty of health studies, bosnia and herzegovina * corresponding author’s e-mail: malik.buric@fzs.unsa.ba introduction adverse childhood experiences (ace) represent a significant risk factor for the development of mental and physical disorders in adulthood (felitti et al., 1998). ace include physical, emotional, and sexual abuse, neglect, and dysfunctional family environments (anda et al., 2006). war trauma further amplifies the effects of ace, exposing children to violence, parental loss, forced displacement, and uncertainty (macksoud & aber, 1996). children affected by the war in bosnia and herzegovina, particularly survivors of the srebrenica genocide, exhibit increased risks of post-traumatic stress disorder (ptsd), depression, and anxiety (ajdukovic, 2003). longterm consequences include somatic conditions such as cardiovascular and metabolic diseases, which increase overall morbidity (danese & tan, 2014). the combination of ace and war trauma creates cumulative risks that persist into adulthood (shonkoff et al., 2012). moreover, the intergenerational transmission of trauma affects the descendants of survivors, who may develop psychological and social difficulties even without direct exposure to warrelated violence (sagi-schwartz et al., 2008; yehuda et al., 2000). understanding these interactions, with a specific focus on srebrenica, is essential for the development of public health strategies, early detection mechanisms, and effective therapeutic interventions (hamber & wilson, 2002). further research is required to design targeted support programs for populations affected by war (musa, 2018; kravić, 2013). literature review previous research demonstrates that children exposed to war trauma and ace are highly vulnerable, with complex and multidimensional consequences (betancourt & williams, 2008). systematic reviews confirm that individuals with multiple aces have significantly higher risks of ptsd and depression (hughes et al., 2017). studies conducted in bosnia and herzegovina indicate that over 60% of children were directly exposed to wartime violence, resulting in high prevalence rates of ptsd, depression, and anxiety (unicef, 1996; ajdukovic, 2003). survivors of the srebrenica genocide displayed particularly elevated risks, with ptsd rates between 50–70% and depression between 40–60% (hamber & wilson, 2002). the intergenerational transmission of trauma has also been documented, with children of survivors showing symptoms of ptsd, depression, and social dysfunction even without direct exposure (sagi-schwartz et al., 2008; yehuda et al., 2000). neurobiological research suggests that alterations in the hypothalamic-pituitary-adrenal (hpa) axis and epigenetic mechanisms contribute to increased vulnerability (yehuda & lehrner, 2018). materials and methods this study represents a structured review of published research addressing the intersection of adverse childhood experiences (ace) and war trauma, with a particular focus on the srebrenica genocide and its long-term psychosocial and somatic consequences. the methodological approach followed the principles of systematic review design to ensure transparency, reproducibility, and analytical rigor. a comprehensive literature search was conducted across pa ge 13 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 136-138, 2025 three major scientific databases pubmed, scopus, and web of science covering the period from 1995 to 2023. the search strategy employed the following combinations of keywords and boolean operators: “adverse childhood experiences” or “ace” and “war trauma” and “bosnia and herzegovina” and “srebrenica” and (“mental health” or “ptsd” or “intergenerational trauma”). reference lists of relevant articles were also screened to identify additional eligible studies. inclusion and exclusion criteria studies were included if they 1. reported empirical or review data related to childhood adversity, trauma, or post-conflict psychosocial outcomes in bosnia and herzegovina; 2. focused on war-affected or genocide-survivor populations; 3. were published in peer-reviewed journals or credible institutional reports; 4. provided quantitative or qualitative data on psychological, biological, or social consequences. exclusion criteria encompassed 1. editorials, conference abstracts, and non-peerreviewed commentaries; 2. studies unrelated to war trauma or ace; 3. articles lacking methodological transparency or data relevant to the bosnian context. data extraction and quality assessment data from eligible studies were extracted using a standardized framework covering study design, population characteristics, type of trauma exposure, outcome measures, and key findings. to assess methodological quality and reduce bias, included studies were evaluated according to adapted criteria from the joanna briggs institute (jbi) critical appraisal tools for crosssectional and review studies. this ensured consistency in evaluating sample size adequacy, validity of measurement instruments, and clarity of analytical methods. analytical approach findings were synthesized narratively, given the heterogeneity of study designs and outcomes. emphasis was placed on converging patterns across epidemiological, clinical, and neurobiological domains. the synthesis particularly focused on the interplay between ace and war trauma and their cumulative influence on longterm psychosocial and health outcomes, including intergenerational effects observed among descendants of srebrenica survivors. results and discussion adverse childhood experiences and mental health outcomes ace strongly correlate with mental disorders in adulthood. individuals exposed to three or more aces demonstrate a twoto fourfold increase in the likelihood of developing post-traumatic stress disorder (ptsd) and depression (hughes et al., 2017). neglect, emotional abuse, and physical maltreatment are also associated with higher rates of anxiety, substance misuse, and suicidal behavior (norman et al., 2012). biological mechanisms mediating these outcomes include dysregulation of the hypothalamic–pituitary–adrenal (hpa) axis, chronic inflammatory responses, and epigenetic modifications (heim & nemeroff, 2001). these findings indicate that early-life adversities embed long-lasting physiological and psychological vulnerability. somatic consequences of ace include cardiovascular disease, type 2 diabetes, obesity, and metabolic syndrome (danese & tan, 2014). in post-conflict environments, these risks are amplified by additional stressors such as poverty, social disruption, and ongoing uncertainty (shonkoff et al., 2012). this highlights the cumulative burden of ace compounded by war-related trauma. war trauma as an extreme form of ace children in bosnia and herzegovina experienced multiple traumatic stressors, including bombardment, parental loss, direct violence, and forced displacement. more than 60% of children were directly affected by war-related violence (unicef, 1996). ptsd prevalence among war-affected children ranged from 30% to 50%, while depression and anxiety affected 25% to 40% (ajdukovic, 2003). social disruptions, such as interrupted education and reduced peer support, further exacerbated psychological stress (muehlenkamp et al., 2005). these findings demonstrate that war trauma acts as an intensifier of ace effects, creating prolonged psychological and somatic vulnerability. the srebrenica genocide the srebrenica genocide represents one of the most extreme manifestations of war trauma. survivors exhibited particularly high prevalence of ptsd (50%–70%), depression (40%–60%), and anxiety disorders (30%– 50%) (hamber & wilson, 2002). beyond individual psychopathology, survivors experienced collective grief, moral injury, and disruption of social identity. comparative studies of post-genocide populations, such as holocaust and rwandan genocide survivors, suggest that such extreme trauma generates long-term intergenerational effects, affecting community cohesion, family functioning, and social adaptation (sagi-schwartz et al., 2008). intergenerational transmission of trauma trauma can be transmitted across generations through psychological, social, and biological mechanisms (van ijzendoorn & bakermans-kranenburg, 1997). epigenetic changes and dysregulation of stress-response systems have been observed among children of survivors (yehuda & lehrner, 2018). intergenerational transmission manifests as heightened vulnerability to anxiety, depressive symptoms, and social dysfunction, even without direct exposure to war. these findings underscore the need for trauma-informed, multilevel interventions targeting both survivors and their descendants (musa, 2018; kravić, 2013). pa ge 13 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 136-138, 2025 implications for public health and clinical practice the synthesis of these findings demonstrates a clear need for trauma-informed policies within bosnia and herzegovina’s public health and social service systems. early screening for ace and war-related trauma should be integrated into primary healthcare, schools, and community programs. mental health interventions must adopt culturally sensitive frameworks, combining individual therapy with collective healing approaches rooted in local traditions. long-term interventions should address intergenerational effects, promoting resilience among descendants of survivors (hamber & wilson, 2002; musa, 2018). these strategies are essential for reducing the cumulative psychosocial burden of childhood adversity and war trauma. conclusion the combined impact of adverse childhood experiences (ace) and war trauma significantly increases psychosocial risks in children, with consequences that persist into adulthood. evidence from bosnia and herzegovina, particularly the srebrenica genocide, demonstrates that extreme traumatic experiences contribute to high prevalence of ptsd, depression, anxiety, and long-term somatic disorders. furthermore, trauma is transmitted intergenerationally through psychological, social, and biological mechanisms, highlighting vulnerabilities among descendants of survivors even without direct exposure to war-related violence. these findings emphasize the urgent need for traumainformed public health strategies, early detection programs, and culturally sensitive clinical interventions. multidisciplinary approaches, combining mental health services, social support, community-based programs, and parental education, are essential for mitigating both immediate and long-term consequences of ace and war trauma. future research should focus on the development and evaluation of targeted support programs that address intergenerational trauma and promote resilience in postconflict populations. in conclusion, integrating empirical evidence on ace, war trauma, and intergenerational effects into public health policy and clinical practice is critical to reduce cumulative psychosocial burdens and to foster adaptive functioning in affected communities. references ajdukovic, d. (2003). psychosocial adjustment of children and youth after war. psychiatria danubina, 15(2), 151–157. anda, r. f., felitti, v. j., bremner, j. d., walker, j. d., whitfield, c., perry, b. d., … giles, w. h. (2006). the enduring effects of abuse and related adverse experiences in childhood. european archives of psychiatry and clinical neuroscience, 256(3), 174–186. danese, a., & tan, m. (2014). childhood maltreatment and obesity: systematic review and meta-analysis. molecular psychiatry, 19(5), 544–554. felitti, v. j., anda, r. f., nordenberg, d., williamson, d. f., spitz, a. m., edwards, v., … marks, j. s. (1998). relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. american journal of preventive medicine, 14(4), 245–258. hamber, b., & wilson, r. (2002). children and war: srebrenica case study. centre for the study of conflict, belfast. heim, c., & nemeroff, c. b. (2001). neurobiology of early life stress: clinical studies. seminars in clinical neuropsychiatry, 6(2), 147–159. hughes, k., bellis, m. a., hardcastle, k. a., sethi, d., butchart, a., mikton, c., … dunne, m. p. (2017). the effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. the lancet public health, 2(8), e356–e366. kravić, n. (2013). surviving genocide in srebrenica during early childhood and adolescent personality development. journal of traumatic stress, 26(6), 678– 685. https://doi.org/10.1002/jts.21847 macksoud, m. s., & aber, j. l. (1996). the war experiences and psychosocial development of children in lebanon. child development, 67(1), 70–88. muehlenkamp, j. j., brausch, a. m., & gutierrez, p. m. (2005). social support and psychosocial functioning in war-affected youth. journal of adolescent health, 36(3), 232–240. musa, s. (2018). association of adverse childhood experiences and health risk behaviors among adolescents in bosnia and herzegovina. journal of adolescent health, 62(2), 234–240. https://doi. org/10.1016/j.jadohealth.2017.08.022 norman, r. e., byambaa, m., de, r., butchart, a., scott, j., & vos, t. (2012). the long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. plos medicine, 9(11), e1001349. sagi-schwartz, a., van ijzendoorn, m. h., & bakermanskranenburg, m. j. (2008). the intergenerational transmission of trauma: children of holocaust survivors. development and psychopathology, 20(2), 401–425. shonkoff, j. p., garner, a. s., siegel, b. s., dobbins, m. i., earls, m. f., mcguinn, l., … wegner, l. m. (2012). the lifelong effects of early childhood adversity and toxic stress. pediatrics, 129(1), e232–e246. unicef. (1996). the impact of war on children in bosnia and herzegovina. unicef. van ijzendoorn, m. h., & bakermans-kranenburg, m. j. (1997). the intergenerational transmission of trauma: review of research. development and psychopathology, 9(3), 473–487. yehuda, r., & lehrner, a. (2018). intergenerational transmission of trauma effects: putative role of epigenetic mechanisms. world psychiatry, 17(3), 243–257. yehuda, r., halligan, s. l., & grossman, r. (2000). childhood trauma and risk for ptsd: relationship to intergenerational effects of trauma, parental ptsd, and cortisol excretion. journal of clinical endocrinology & metabolism, 85(12), 4083–4088. pa ge 1 pa ge 1 american journal of medical science and innovation (ajmsi) ectopia cordis thoraco-abdominal diagnosed with antenatal ultrasound tolojanahary herizo andrianjakamanana1, patricia alice razafindrahova2*, christian tomboravo3, andry nampoinanirina rasolonjatovo4, habib nouraly5, hasina dina ranoharison6, ahmad ahmad7 volume 2 issue 1, year 2023 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: january 04, 2023 accepted: febryary 02, 2023 published: february 08, 2023 in this article we report a case of ectopia cordis, which is a rare congenital malformation characterized by an extra-thoracic position of the heart. this is the thoracic-abdominal form, of antenatal discovery on a pregnancy of 35 weeks and 03 days, during an obstetric ultrasound monitoring pregnancy during the third trimester of pregnancy, made at the university hospital professor zafisaona gabriel, mahajanga madagascar. the objective of this work is to report the antenatal ultrasound diagnostic elements of this rare malformation. ultrasound plays an important role in antenatal diagnosis and the search for other related malformations, especially in low-income countries.keywords ectopia cordis, ultrasound, malformation, madagascar 1 university hospital professeur zafisaona gabriel (chupzaga), mahajanga, madagascar. 2 university hospital mitsinjo betanimena, toliary, madagascar. 3 university hospital place kabary, antsiranana, madagascar. 4 hospital ave maria, antsirabe, madagascar. 5 university hospital mahavoky atsimo, mahajanga, madagascar. 6 university hospital andohatampenaka, antananarivo, madagascar. 7 university hospital joseph ravoahangy andrianavalona (chujra), antananarivo, madagascar * corresponding author’s e-mail:rpatricia_alice@yahoo.fr introduction ectopia cordis or cardiac ectopy is an extremely rare congenital cardiac malformation, characterized by a partially or completely extra-thoracic topography of the heart, whose prevalence is estimated at 5.5 to 7.9 cases per million live births (hornberger l k. et al. 1996). depending on the topography, it can be cervical, thoracic, thoracoabdominal or abdominal. the thoracic-abdominal form is generally associated with the pentalogy of cantrell or one of its variants which includes a bifid sternum, a defect of the diaphragm, the anterior abdominal wall and an intracardiac malformation (apte av. 2008). we report a case of isolated thoracic-abdominal cordis ectopia, diagnosed with antenatal ultrasound at 35 weeks and 3 days. to our knowledge, this is the first case documented and reported in madagascar. the objective of this work is to report the antenatal ultrasound diagnostic elements of this rare malformation. ultrasound plays an important role in antenatal diagnosis and the search for other related malformations, especially in low-income countries. methodology this is a 37-year-old woman from marovoay, mahajanga, in the west of madagascar, without any notion of inbreeding marriage, already having five living children, the first of whom is 17 years old and the last of 3 years old. she’s being referred by a city medical office for an obstetric ultrasound. this is her sixth move, without a history of spontaneous or induced miscarriage. no history of birth defects was reported in siblings and family. the pregnancy was followed by three series of prenatal consultations in health facilities in the countryside, which had not objectified any particular abnormalities. she had received two ultrasound examinassions during the first and second trimesters, the results of which are normal. there was no medication or abnormal symptomatology during pregnancy. clinically, it is in good general condition, without any particular functional sign. there is no exaggeration of uterine height. there was also no abdominal pain, water loss, or genital bleeding. the abdominal ultrasound showed a pregnant uterus, with a live fetus in cerebral presentation, of 35 sa and 3 days depending on the measurements performed. amniotic fluid is normal volume with a phelan index measured at 13 cm. there is a 65 mm long anterior thoracic abdominal parietal defect in median sagittal section with totally extra-thoracic heart chambers (figures 1 and 2), with regular activity at 148 beats per minute. there is also a strip of part of the hepatic parenchyma up to the level of the umbilical region next to the abdominal parietal defence. in mode b ultrasound there were four visible heart chambers and no other malformative abnormalities visible at the head pole, abdomen, upper and lower limbs. there were also no placental and umbilical cord abnormalities. doppler scanning could not be performed due to a lack of suitable equipment. in total, it is a progressive monofetal pregnancy of 35 sa and 03 days of age ultrasound with malformation type abnormality of closure of the anterior chest-abdominal wall associated with ectopia cordis thoraco-abdominal, without any other associated visible malformation. given the complexity of the management of these malformations and the insufficient technical plateau in the hospitals of madagascar and the lack of social coverage for such management. an in utero transfer to a well-equipped hospital was planned by pleading aid to international https://journals.e-palli.com/home/index.php/ajmsi mailto:rpatricia_alice%40yahoo.fr?subject= pa ge 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 1-3, 2023 humanitarian associations, but the parturiente was lost sight of it. discussion the ectopia cordis may be complete ; in this case, the naked heart is moved outside the rib cage, without pericardial coverage. one can also have a partial displacement or one can see the heart beating through the skin. this anomaly was first described by haller in 1706 (kaplan l c. et al. 1985, chelli d. et al. 2008) and the first classifications were attributed to weese in 1818 (harrison m r. et al. 1982) and todd in 1836 (leca f. 1989). the cause is unknown; however, there is a small association noted with trisomy (twomey e l. et al 2005, diaz jh. 1992) and a few cases have been associated with other abnormalities, such as triploidy and x-related family heredity. the incidence is 5.5 to 7.9 per 1 million live births (apte av. 2008). a defect is present in the maturation of the mesodermal midline and a defect of fusion of the cephalic anterior folds can lead to associated abnormalities. the failure of the descent of the heart into the thorax during the 3rd week of gestation may leave it stuck above the upper closure of the sternum, creating a cervical ectopy but more difficult to explain for thoracic and abdominal ectopies (diaz jh. 1992). it can be classified into cervical (3%), cervicothoracic, thoracic (60%), thoracoabdominal (7%) and abdominal types (30%) (leca f. 1989, morrello m.1994). although the thoracoabdominal types and minor forms of cantrell pentalogy offer a better prognosis, the cervical type is not compatible with life (morrello m.1994). in our case, it is the complete thoracoabdominal form, without any other visible malformation associated with the b-modeultrasound. early ultrasound diagnosis can often be done before birth and is usually noted early in the second trimester (harrison m r. et al. 1982). with the use of ultrasound (3d) and its combination with doppler power, accurate diagnosis may be possible at an early stage of gestation (mittermayer c. & bernaschek g, lee a. 2002). liang and colleagues reported one case of cordis ectopia diagnosed at 10 weeks gestation using 2d and 3d ultrasound (liang ri et al. 1997). mri becomes a pillar of prenatal assessment for documenting and planning complications (liang ri et al. 1997). in our case, the antenatal diagnosis is done quite late, at 35 weeks and 3 days gestation, with a portable ultrasound, equipped only with a convex probe, without 3d option or doppler. our diagnosis is then limited to the morphological description of the parietal defect and the search for other associated malformations, without being able to specify the existence or no intra-cardiac malformations. when the diagnosis is made before birth, a caesarean section should be performed because vaginal delivery may result in prolonged cardiac compression, or rupture of an atrial diverticula or omphalocele sac (sharma vk. et al. 2001). if uncorrected intracardiac abnormalities are found, this allows the physician and family to discuss the elective termination option. the complete ectopia cordis presents itself as a neonatal emergency. it is generally considered fatal and death can occur as a result of infection, heart failure or hypoxemia. the associated cardiac abnormalities are interauricular communication (100%), interventricular communication (53%), fallot tetralogy (20%), and left ventricular diverticle (20%) (sharma vk. et al. 2001). the treatment consists in placing the newborn under a radiant radiator and the defect of the chest wall must be covered with a sterile gauze soaked with warm saline solution. compression of the extrathoracic heart should be avoided as there may be an overall reduction in cardiac function. when managing figure 1: sagittal ultrasound through the fetal sternum (yellow arrow), showing a posterior thoraco-abdominal parietal defect with extra-thoracic localization of the heart cavities (white arrow) without pericardial sheath and exposing part of the liver (yellow star). figure 2: axial ultrasound cross-section through the lower thoracic region of the fetus, showing pulmonary parenchyma (yellow stars), anterior parietal defect (white arrow), extra-thoracic heart chambers bathed in amniotic fluid (yellow arrow), and a placental edge (black star). https://journals.e-palli.com/home/index.php/ajmsi pa ge 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 1-3, 2023 the airway, you should expect difficult intubation secondary to the anterior and cephalic direction of the heart. if a prenatal diagnosis is made, one can electively intubate at the time of delivery by caesarean section with maternal placental support. the surgical strategy depends on the size of the parietal defect, the associated cardiac abnormalities, and the type of ectopia cordis (mohta a, et al. 1993). in developing countries, whether the diagnosis is antenatal or post-natal, the prognosis is almost always fatal. a study of a series of 10 patients with antenatal diagnosis showed a uniformly fatal outcome without any management (kumar basant, 2008). the lack of equipped and functional cardiovascular surgery could explain this poor prognosis. in our case, the only chance to have a better prognosis of survival in front of such an anomaly is to carry out an in utero transfer to foreign hospitals because the technical trays in madagascar do not yet allow an adequate management of these complex malformations. conclusion ectopia cordis is a rare birth defect, often associated with other birth defects. ultrasound plays an important role in antenatal diagnosis and the search for other related malformations. primarily surgical management remains a challenge, especially in low-income countries where prognosis is always reserved. when diagnosed early in utero, a high proportion of abortions is expected, hence the interest of regular pregnancy follow-up. references hornberger l k , colan s d, lock j e, david l w, mayer j e. (1996). outcome of patients with ectopia cordis and significant intracardiac defects. circulation, 94, 327. apte av. (2008). thoraco-abdominal ectopia cordis : a rare entity case report and review of litterature. people’s journal of scientific research, 1, 31-33. kaplan l c, matusoka r, gilbert e f, opitz j m, kurnit d m. (1985). ectopia cordis and cleft sternum: evidence of mechanical teratogenesis following rupture of the chorion or the yolk sac. am. j. med. genet., 21, 187202. chelli, d., dimassi, k., jallouli-bouzguenda, s., ebdellah, e., hermi, f., zouaoui, b., ... & gaigi, s. (2008). prenatal diagnosis of ectopia cordis: case report. tunisie medicale, 86(2), 171-173. harrison m r, filly r a, stanger p, de lorimier a a. (1982). prenatal diagnosis and management of omphalocele and ectopia cordis. j pediatr surg, 17, 6466. leca, f., thibert, m., khoury, w., fermont, l., laborde, f., & dumez, y. (1989). extrathoracic heart (ectopia cordis). report of two cases and review of the literature. international journal of cardiology, 22(2), 221228. twomey, e. l., moore, a. m., ein, s., mcauliffe, f., seaward, g., & yoo, s. j. (2005). prenatal ultrasonography and neonatal imaging of complete cleft sternum: a case report. ultrasound in obstetrics and gynecology: the official journal of the international society of ultrasound in obstetrics and gynecology, 25(6), 599-601. diaz, j. h. (1992). perioperative management of neonatal ectopia cordis: report of three cases. anesthesia & analgesia, 75(5), 833-837. mohta a, bagga d, anand r. (1993). ectopia cordis: report of two cases. indian heart j., 45, 133-4. morello, m., quaini, e., nenov, g., & pome, g. (1994). extrathoracic ectopia cordis. case report. the journal of cardiovascular surgery, 35(6), 511-515. mittermayer, c., bernaschek, g., & lee, a. (2002). diagnosis of ectopia cordis with three‐dimensional power doppler ultrasound in first‐trimester pregnancy. ultrasound in obstetrics and gynecology: the official. journal of the international society of ultrasound in obstetrics and gynecology, 20(2), 203-205. liang, r. i., huang, s. e., & chang, f. m. (1997). prenatal diagnosis of ectopia cordis at 10 weeks of gestation using two‐dimensional and three‐dimensional ultrasonography. ultrasound in obstetrics and gynecology: the official. journal of the international society of ultrasound in obstetrics and gynecology, 10(2), 137-139. sharma, v. k., kiran, u., sharma, j., kapoor, p. m., & saxena, n. (2001). challenges in the management of ectopia cordis. journal of cardiothoracic and vascular anesthesia, 15(5), 618-623. kumar, b., sharma, c., & sinha, d. d. (2008). ectopia cordis associated with cantrell’s pentalogy. annals of thoracic medicine, 3(4), 152. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 17 1 american journal of medical science and innovation (ajmsi) recurrent symptomatic amoebiasis in a rural kenyan hospital: a case report vonwicks c. onyango1*, samuel m. gachie1, boniface mutiso1, dominic mutua1, nicholas m. mutuma1 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2173 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 25, 2023 accepted: october 23, 2023 published: october 30, 2023 entamoeba histolytica is an extraintestinal protozoa that is feco-orally transmitted and exists as cysts or trophozoites, which may cause either asymptomatic infection or invasive intestinal and extraintestinal disease, respectively. most infections (amoebiasis) are found in communities with poor environmental sanitation and unhygienic water and food handling practices. recurrent symptomatic intestinal amoebiasis is associated with significant personal and public health cost implications and warrants a deliberate and thorough search for a source of the feco-oral transmission. in this study, we present a case of a woman with recurrent symptomatic amoebiasis to underscore the importance of a detailed social history in establishing source control in the case management of amoebiasis. keywords amoebiasis, entamoeba histolytica, feco-oral transmission, metronidazole, invasive amoebiasis, recurrent amoebiasis, kenya 1 st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction amoebiasis is a parasitic disease caused by the extracellular intestinal protozoa entamoeba histolytica (i.e., e. histolytica), which is the most common cause of symptomatic disease. three other species of intestinal amoebae are morphologically identical to e. histolytica and include e. dispar, e. bangladeshi, and e. moshkovskii. the pathogenicity of the non-histolytica species is unclear, with e. dispar generally considered non-pathogenic. amoebiasis occurs worldwide, with a disproportionately higher prevalence in developing and low-income countries due to low socioeconomic status and poor sanitation conditions, e.g., in india, africa, and parts of central and south america (carrero et al., 2020). a systematic scoping study showed wide variations in the prevalence of amoebiasis in eastern africa, i.e., 4.6-15.3% (ethiopia), 5.9-58.3% (kenya), 54.5% (rwanda), 0.7-2.7% (sudan), and 19.93% (uganda) (ngowi, 2020). the parasite exists in a cyst form (the infective stage) and a trophozoite form (which causes invasive intestinal disease). infection occurs when amoebic cysts are ingested in contaminated food or water via the feco-oral transmission route. sexual transmission may also be seen in men having sex with other men. the cysts pass through the stomach to the small intestines, where they excyst in the terminal ileum to form invasive trophozoites. the latter can invade the mucosae of the colon to cause invasive bloody diarrhea (amoebic dysentery) (marie & petri, 2013) or cause extra-intestinal disease, e.g., amoebic abscess in the liver (usuda et al., 2022), and in the brain and lungs (petri & figure 1: life cycle of e. histolytica/e. dispar. (ximénez et al., 2011) pa ge 17 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 171-174, 2023 haque, 2013; shamsuzzaman & hashiguchi, 2002). a diagnosis can be made by various methods, including stool microscopy, which demonstrates amoebic cysts and trophozoites; rapid antigen detection in stool or serum; molecular detection using polymerase chain reaction (pcr); antigen and antibody detection by serology; and histology from colonic samples (saidin et al., 2019). figure 1, adapted from the excellent review by ximenez and colleagues, illustrates the life cycle of e. histolytica and e. dispar, with the corresponding appearances of the cysts and trophozoites under microscopy (ximénez et al., 2011). antimicrobials commonly used to treat amoebiasis include nitroimidazoles (metronidazole, tinidazole, secnidazole, etc.), paromomycin, iodoquinol, and diloxanide furoate (morán et al., 2023). drug therapy must be combined with improved hygienic handling of food and drinks, as well as environmental sanitation, to prevent feco-oral transmission. case summary clinical presentation and management a 53-year-old single mother of five from gilgil, nakuru county, kenya, with a history of well-controlled hypertension, was first treated for symptomatic amoebiasis in our facility in february 2020. she had presented with a two-week history of cramping periumbilical and suprapubic pains, flatulence, nausea with a one-day history of postprandial non-bilious vomiting, and loose mucoid non-bloody stools (about 3-4 episodes daily) with associated tenesmus. she was moderately dehydrated at the time but hemodynamically stable. she was afebrile, with abdominal examination findings only significant for vague diffuse periumbilical and suprapubic area tenderness without any features of peritonism. the rest of the physical examination was unremarkable. her stool microscopy showed numerous trophozoites of entamoeba histolytica with many pus cells (qualitative report). she was treated with 5 days of oral metronidazole 400mg thrice daily (as per our local protocol), antiemetics, rehydration, and education on personal hygiene, environmental sanitation, and food and water sanitation practices. one month later, her stool was normal, and she was asymptomatic. however, from the months of july to november 2020, she re-presented with similar gastrointestinal symptoms and tested positive for entamoeba histolytica trophozoites in her stool following a wet-preparation microscopy. she remained asymptomatic throughout 2021 during routine follow-ups for the hypertension, with normal random stool examinations. however, in 2022, she developed similar recurrent gastrointestinal symptomatology with positive stool microscopy for entamoeba histolytica trophozoites from the months of september to december 2022. she was treated each time with various nitroimidazole compounds, i.e., metronidazole at a dose of 400mg thrice daily for 5 days or tinidazole at 1gm twice daily for 3 days, together with antiemetics (metoclopramide 10mg thrice daily for the duration of the metronidazole of tinidazole) and other supportive therapy. she did not have any episodes of vomiting while on the antiprotozoal, and she was fully compliant with her medications. further social history she lives alone in a 2-bedroom house in a 2-story apartment complex, which she shares with at least 14 other different families. she uses a pit latrine and a simple bathing room, which she shares with one other household. these are located about 10 meters behind the apartment complex, with the design and allocation such that two families share a pit latrine and a bathroom and are also responsible for cleaning them. she obtains water for drinking and other home uses from a large borehole in front of the apartment complex and several plastic water tanks that harvest rainwater from the apartment roof. she reported regularly washing her hands with water and soap (and more so with the advent of the covid-19 pandemic) and regularly boiling her drinking water, which she stored in two plastic 20-liter jerrycans. no other person from her apartment complex had been treated for recurrent diarrheal illness in that period. importantly, 2 of her daughters who had visited her overnight at various times in 2020 and 2022 had each subsequently been treated for stool-microscopy-confirmed amoebiasis (positive trophozoites) about 5-7 days after each visit. in 2021, she had temporarily relocated to stay with her ailing sister about 10 kilometers away, where she used running tap water from the local municipal supply lines. in view of the foregoing, the source of the recurrent amoeba infection was deemed to be within her house, especially from the stored water in the jerrycans. a community health worker with basic training in public health and sanitation was consulted to visit her at home and inspect her water and food handling practices with a view to locating the source of the recurrent amoebic infection. upon closer inquiry, it was revealed that she had refilled the jerrycans on several occasions with “clean” water from a specific local water vendor during periods of water scarcity in the area and had neither boiled nor purified the said water, which was reportedly marketed as “fresh spring water”, and whose actual source was unknown. when she discarded all the stored jerrycan water and thoroughly washed the cans with hot water and soap, the amoebiasis stopped. the matter was reported to the local public health authorities for administrative remedial interventions. she has had no more presentations with amoebiasis, and her random stool microscopic examinations from time to time have been normal. discussion e. histolytica is transmitted by the feco-oral route when amoebic cysts contaminating food and drinks are ingested. these cysts contaminate food, water, and drinks during the processes of preparation, handling, packaging, storage in various containers and bottles, transportation, serving, and consumption. once ingested, the cysts reach the terminal ileum, where excystation occurs with pa ge 17 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 171-174, 2023 the release of active trophozoites, which may invade the colonic mucosa to cause active disease or remain dormant in the mucosa, causing chronic asymptomatic infection. a history of feco-oral transmission must always be sought meticulously through detailed inquiry about personal hygiene, environmental sanitation, sources of food and water, and water storage and handling at home and in the community. in most cases, infections (including recurrent infections) occur due to a lack of access to safe drinking water and sanitation facilities (atabati et al., 2020). our patient’s source of recurrent infection was the contaminated water sold to her by a vendor during periods of water scarcity in her home. she did not boil the water or treat it in any way before storing it in the various jerrycans. on further probing, it was revealed that the same vendor had also sold water to three other families in the apartment complex, but each of these families had boiled all the water and cooled it before use. none of them got any amebic infections. although a majority of patients who get infected remain asymptomatic, some present with symptomatic disease of varying severity (e.g., from mild to severe gastroenteritis to severe life-threatening fulminant amebic colitis with toxic megacolon, colonic perforation and peritonitis, etc.), including extra-intestinal manifestations, e.g., amebic liver and lung abscess (carrero et al., 2020; kantor et al., 2018; usuda et al., 2022). antiamoebic drugs are recommended to cure amebiasis and may act only in the intestinal lumen (i.e., luminal amebicides, e.g., paromomycin, iodoquinol, diloxanide furoate, nitazoxanide, and metronidazole) or in the tissues (i.e., tissue amebicides, e.g., metronidazole, tinidazole, and emetine) (morán et al., 2023). metronidazole remains the first-line drug in the treatment of amebiasis, as it is active as both a tissue and a luminal amebicide. our patient was successfully treated with metronidazole or tinidazole during various presentations as per the local guidelines. the amebic cysts and trophozoites can be eliminated by improved water safety (e.g., through boiling and filtration or adding chlorine to water) and sanitation. it is quite interesting that our patient never had amoebic cysts in her stool during asymptomatic random stool microscopy examinations. the simple act of washing hands with soap and water can reduce mortality associated with diarrheal illnesses (of which amoebiasis is a major etiology) by up to 50% (kantor et al., 2018). there are ongoing trials at various phases to develop vaccines effective against e. histolytica infections in humans (quach et al., 2014; singh et al., 2016). conclusion a thorough history must be sought in all cases of suspected and confirmed amoebiasis to determine the source of the feco-oral transmission. this is especially important in cases of recurrent infections. metronidazole remains the first-line amebicide for effective drug treatment of amoebiasis. most importantly, drug therapy must be done in conjunction with improved personal hygiene through frequent hand-washing with soap and water, as well as improved environmental sanitation and water safety. references atabati, h., kassiri, h., shamloo, e., akbari, m., atamaleki, a., sahlabadi, f., linh, n. t. t., rostami, a., fakhri, y., & khaneghah, a. m. (2020). the association between the lack of safe drinking water and sanitation facilities with intestinal entamoeba spp infection risk: a systematic review and metaanalysis. plos one, 15(11), e0237102. https://doi. org/10.1371/journal.pone.0237102 carrero, j. c., reyes-lópez, m., serrano-luna, j., shibayama, m., unzueta, j., león-sicairos, n., & de la garza, m. (2020). intestinal amoebiasis: 160 years of its first detection and still remains as a health problem in developing countries. int j med microbiol, 310(1), 151358. https://doi.org/10.1016/j. ijmm.2019.151358 kantor, m., abrantes, a., estevez, a., schiller, a., torrent, j., gascon, j., hernandez, r., & ochner, c. (2018). entamoeba histolytica: updates in clinical manifestation, pathogenesis, and vaccine development. can j gastroenterol hepatol, 2018, 4601420. https://doi.org/10.1155/2018/4601420 marie, c., & petri, w. a., jr. (2013). amoebic dysentery. bmj clin evid, 2013. morán, p., serrano-vázquez, a., rojas-velázquez, l., gonzález, e., pérez-juárez, h., hernández, e. g., padilla, m. l. a., zaragoza, m. e., portillo-bobadilla, t., ramiro, m., & ximénez, c. (2023). amoebiasis: advances in diagnosis, treatment, immunology features and the interaction with the intestinal ecosystem. int j mol sci, 24(14). https://doi. org/10.3390/ijms241411755 ngowi, h. a. (2020). prevalence and pattern of waterborne parasitic infections in eastern africa: a systematic scoping review. food waterborne parasitol, 20, e00089. https://doi.org/10.1016/j.fawpar.2020.e00089 petri, w. a., & haque, r. (2013). entamoeba histolytica brain abscess. handb clin neurol, 114, 147-152. https://doi. org/10.1016/b978-0-444-53490-3.00009-1 quach, j., st-pierre, j., & chadee, k. (2014). the future for vaccine development against entamoeba histolytica. hum vaccin immunother, 10(6), 1514-1521. https:// doi.org/10.4161/hv.27796 saidin, s., othman, n., & noordin, r. (2019). update on laboratory diagnosis of amoebiasis. eur j clin microbiol infect dis, 38(1), 15-38. https://doi.org/10.1007/ s10096-018-3379-3 shamsuzzaman, s. m., & hashiguchi, y. (2002). thoracic amebiasis. clin chest med, 23(2), 479-492. https://doi. org/10.1016/s0272-5231(01)00008-9 singh, r. s., walia, a. k., kanwar, j. r., & kennedy, j. f. (2016). amoebiasis vaccine development: a snapshot on e. histolytica with emphasis on perspectives of gal/galnac lectin. int j biol macromol, 91, 258-268. https://doi.org/10.1016/j.ijbiomac.2016.05.043 pa ge 17 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 171-174, 2023 usuda, d., tsuge, s., sakurai, r., kawai, k., matsubara, s., tanaka, r., suzuki, m., takano, h., shimozawa, s., hotchi, y., tokunaga, s., osugi, i., katou, r., ito, s., mishima, k., kondo, a., mizuno, k., takami, h., komatsu, t., . . . sugita, m. (2022). amebic liver abscess by entamoeba histolytica. world j clin cases, 10(36), 13157-13166. https://doi.org/10.12998/ wjcc.v10.i36.13157 ximénez, c., morán, p., rojas, l., valadez, a., gómez, a., ramiro, m., cerritos, r., gonzález, e., hernández, e., & oswaldo, p. (2011). novelties on amoebiasis: a neglected tropical disease. j glob infect dis, 3(2), 166174. https://doi.org/10.4103/0974-777x.81695 pa ge 1 pa ge 47 american journal of medical science and innovation (ajmsi) prevalence of helicobacter pylori (h. pylori) infection among patients undergoing upper gastrointestinal endoscopy: an institution based study prabhat pradhan1, gyan prasad bajgai2* volume 2 issue 1, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i1.1320 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: february 19, 2023 accepted: march 20, 2023 published: march 30, 2023 several studies have established region-based prevalence rate of h. pylori infection and its association with clinical outcomes in bhutan. however, this study attempts to determine hospital-based prevalence rate of h. pylori and its association with clinical outcomes. a total of 347 volunteers (159 females and 188 males; mean age of 49.8 ± 15.5 years) were enrolled from central regional referral hospital (crrh) in gelephu. upper gastro-intestinal endoscopy (ugie) was performed among the dyspeptics and h. pylori infection was determined by histology examination. the histological prevalence of h. pylori among 347 patients who went upper gastro-intestinal endoscopy was 55.6%. the prevalence of h. pylori infection increased with age but it was statistically insignificant (p > 0.05). gastritis was the most common endoscopic finding, present in 309 (89%) patients followed by normal upper endoscopy results in 24 (6.9%) patients. the prevalence of h. pylori among patients with gastritis and a duodenal ulcer was significantly higher than in patients with gastric cancer (p < 0.05). the high incidence of gastritis in the hospital may be attributed to the high prevalence of h. pylori infection among the individuals with dyspepsia. keywords endoscopy, gelephu, helicobacter pylori, prevalence 1 department of surgery, jigme dorji wangchuck national referral hospital, thimphu bhutan 2 department of dentistry, jigme dorji wangchuck national referral hospital, thimphu bhutan * corresponding author’s e-mail: gpbajgai@jdwnrh.gov.bt introduction helicobacter pylori infection is well known to be the most common human infection affecting more than 50% of the world’s population (salih, b.a. (2009). there is a variation in the prevalence of infection between different countries and, among different societies and ethnic groups within the same country (van d. et al. 2009; kaur et al.2003; malaty et al. 1996). chronic infection with h. pylori is typically acquired early in life, especially among those in poor socio-economic status and over-crowded conditions (bardhan pk, 1997; mccoll ke 2010). bhutan is a small country with an estimated population of 8, 00,000. the incidence of gastric cancer in bhutan is reported to be quite high (with 24.2 cases per 100,000 populations per years) as compared to other neighboring countries like thailand, india and bangladesh (shiota et al, 2013; dendup et al. 2015). the previous studies have showed association of high incidence of gastric cancer with high prevalence of h. pylori among bhutanese population (dorji et al. 2014; vilaichone et al. 2013). however, there has not been a study conducted as to determine the hospital-based prevalence rate of h. pylori infection and its association with clinical outcomes among the patients regularly visiting the concerned hospital. helicobacter pylori infection is quite rampant in bhutan at 66.2%. punakha district disclosed the highest prevalence of h. pylori infection (85.6%), followed by wangduephodrang district (75.4%), while haa had the lowest prevalence (57.7%) (18). the reason why haa and other districts had lower prevalence could be due to low residing population and seasonal migration during summer and winter months (ratha-korn et al. 2020). therefore, we conducted a retrospective hospital-based study over two years (august 2014 to december 2016) to determine the prevalence of h. pylori infection among the dyspeptic patients visiting crrh and to assess association among clinical outcomes, gender and age with h. pylori infection. methods gelephu is one of the sub-districts located in the southern part of bhutan. the region shares border with india. the central regional referral hospital (crrh), located in gelephu, provides healthcare services to the local people residing in sarpang district, as well as to those patients referred from four other districts which include trongsa, tsirang, dagana and zhemgang within the central region. patients are referred to crrh to avail endoscopy service from all five districts as the district hospitals lack such facility. this was a cross-sectional study was carried out among bhutanese population who attended crrh between august 2014 and december 2016. the study population included individuals who had undergone ugie for figure 1: central regional referral hospital, bhutan https://doi.org/10.54536/ajmsi.v2i1.1320 https://journals.e-palli.com/home/index.php/ajmsi pa ge 48 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 47-50, 2023 evaluation of dyspeptic symptoms. the information on age, gender, biopsy report and presence or absence of h. pylori infection was reviewed from the medical record maintained in the outpatient registry. subjects with age below 14 years were excluded from the study. this study was approved by research ethics board of health (rebh), ministry of health. procedure for endoscopy and histology endoscopy was performed after an overnight fasting of the patients. scope was inserted through the mouth after lignocaine spray in the throat to make the pharynx numb. detailed examination of esophagus, stomach and upper part of duodenum was performed. gastric biopsies were taken randomly from at least two sites. all biopsies were fixed in formalin prior to shipment to pathology laboratory in thimphu for hematoxylin and eosin (h & e) staining. statistical analysis frequency and percentage were used to describe the characteristics of the study population. the prevalence of h. pylori infection was presented in terms of percentage (%) and z-test was used to assess whether this prevalence was significantly different from the prevalence of previous studies. the association between age and gender with h. pylori infection was analyzed using pearson chisquare. p value less than 0.05 was considered statistically significant in this study. results endoscopic findings and prevalence of h. pylori infection a total of 347 subjects were enrolled for the study of which, 159 (45.82%) were females and 188 (54.18%) were males. the mean age of the study population was 49.8±15.5 years (range: 15 – 83 years). the most common endoscopic finding among the patients with dyspepsia was gastritis (309, 89.05%), followed by normal endoscopy results (24, 6.9%). gastric cancer, duodenal ulcer and gastric ulcer were less common, present only in eight patients (2.31%), five (1.44%) and, one (0.29%) respectively. a study subject was considered h. pylori positive when the biopsy specimen showed positive in h & e staining. the overall prevalence of h. pylori among the study subjects was 55.6% (95% ci: 50.367 – 60.873). we also tested whether the prevalence in this study was significantly different from previous studies using z-test (ha: p < 86% and ha: p < 73.4%). the prevalence of h. pylori infection among the study population in crrh was significantly lower as compared to previous prevalence of h. pylori infection found in other regions (p<0.001). association of h. pylori infection with age and gender 109 (57.98%) of the males were h. pylori positive as compared to 84 (52.83%) of the females. in our study, older patients were more likely to be h. pylori positive than the younger ones. the positivity of h. pylori was table 1: association of h. pylori infection with age and gender. characteristics total number (n) h. pylori p-value positive (%) negative (%) gender male 188 109(57.98) 79 (42.02) 0.336# female 159 84 (52.83) 75 (47.17) age 15 29 38 19 (9.87) 19 (12.34) 0.124# 30 39 62 38 (19.69) 24 (15.58) 40 49 63 42 (21.76) 21 (13.64) 50 59 71 40 (20.73) 31 (21.13) > 60 113 54 (27.98) 59 (38.31) observed highest among subjects with age higher than 60 years (27.98%) followed by 40-49 years (21.76%) and 50-59 years (20.73%). 15-29 years subjects had the least h. pylori infection with 9.87%. however, there was no statistically significant association of h. pylori infection with both gender and age (p>0.05) (table 1). association between h. pylori infection and clinical outcomes the clinical presentations of the subjects were considered for assessing the association with h. pylori infection (table 2). patients with gastritis are more likely to have h. pylori infection (61.8%) than those without it (38.2%; p < table 2: association between h. pylori infection and clinical findings. clinical findings total number (%) h. pylori p-value positive (%) negative (%) gastritis 309 (89.0) 191 (61.8) 118 (38.2) < 0.001# gastric ulcer 5 (1.4) 1 (20.0) 4 (80.0) < 0.001* https://journals.e-palli.com/home/index.php/ajmsi pa ge 49 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 47-50, 2023 duodenal ulcer 1 (0.3) 0 (0.0) 1 (100.0) 0.444* gastric cancer 8 (2.3) 1 (12.5) 7 (87.5) 0.030* normal 24 (6.9) 0 (0.0) 24 (100.0) < 0.001# 0.001). in contrary, cases with gastric ulcer, gastric cancer and normal endoscopic findings are less likely to have h. pylori infection (p < 0.05). discussion this study was endoscopy-based and histological examination was performed to detect h. pylori among patients with dyspepsia. the study revealed high prevalence rate of h. pylori 55.6% among bhutanese population with dyspepsia. this is in contrast to the previous studies conducted by vilaichone et al 2014; dorji et al. 2013) in bhutan where the prevalence rates ranging from 73.4% to as high as 96% were found among bhutanese population residing in different districts and regions with dyspepsia. the lower prevalence rate of h. pylori, as revealed by our study compared to the previous studies, possibly could have been due to the sensitivity of histological detection, which was the only method of detection used in this study. the sensitivity of this method depends not only on density of h. pylori biopsy sites but also on expertise of pathologists (el-zimaity hm, 2000). many studies have showed several factors such as age of patient, socio-cultural practices, living conditions, environment and geographic location play important roles in h. pylori infection in different population. therefore, one of the factors contributing to the lower prevalence of h. pylori, as compared to the previous studies, could also be due to the location of the hospital, southern part of bhutan where socio-cultural practices are different from the mainstream bhutanese tradition and cultural practices. the same study conducted by dorji and his colleagues has revealed the similar trend in the prevalence of h. pylori in southern bhutan compared to western and central regions. however, it is difficult to compare the h. pylori detection rate since different studies have used different methods. dorji et al has used serology to determine igg antibody against h. pylori which does not differentiate past and present infection, therefore, this could have also contributed in higher prevalence rate than this study. although there is no significant difference in prevalence of h. pylori among the age groups, there is an increasing trend in prevalence with increase in age groups, which is in contrast to the previous studies. the similar trend has also been seen in other studies conducted by (rodrigo et al 1997; koch et al 2005)in spain and greenland respectively. the most common cause of dyspepsia was found to be gastritis through histological examination which was in concurrence with endoscopic results. furthermore, this study showed that 61.8% of patients with gastritis had h. pylori infection and this is in consistent with other studies conducted in nigeria (jemilohun et al. 2010; ndububa et al. 2001). unlike other studies, this study showed gastric and duodenal ulcers have lesser association with h. pylori compared to gastritis which was comparable with the study conducted by olubuyide and his colleagues in nigeria (olubuyide et al. 1989). one of the key limitations of this study is that it was hospital-based setting and may not be a true representation of the prevalence of h. pylori among dyspeptics in the general population of the central region of bhutan. further, the study was carried out only in one centre, therefore, this study calls for a community-based which would be more representative. also since this study was also a retrospective cohort study, data collection was limited to the information available in hospital records. the records did not include information on risk factors for h pylori infection such as social, economic and other determinants. conflict of interest there is no conflict of interest among authors acknowledgement we would like to acknowledge and thank mr tsheten, mr binay thapa, the staff of crrh rendering full support during the whole study period and staff of jdwnrh involved in the study in any way. conclusion in conclusion, this study found high prevalence of h. pylori infection in concurrence and comparable with other developing countries. also, there is a strong association between gastritis and h. pylori infection which suggests treatment of h. pylori infection may be a priority choice while managing gastritis in the hospital set up. limitation of the study some of the limitations were: only ambulant population who visited the hospital for ugie were performed endoscopy. other patients from other districts who were not referred to the gelephu regional referral hospital were missed. moreover, patients refusing or not consenting for ugie were also missed for the procedures. references salih, b.a. 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(2015). geographical distribution of the incidence of gastric cancer in bhutan. world j gastroenterol., 21(38), 10883-9. dorji d, dendup t, malaty hm, wangchuk k, yangzom d, richter jm. (2014). epidemiology of helicobacter pylori in bhutan: the role of environment and geographic location. helicobacter. 19(1), 69-73. vilaichone rk, mahachai v, shiota s, uchida t, ratanachu-ek t, tshering l, et al. (2013). extremely high prevalence of helicobacter pylori infection in bhutan. world j gastroenterol., 19(18), 2806-10. el-zimaity hm. (2000). accurate diagnosis of helicobacter pylori with biopsy. gastroenterol clin north am., 29(4), 863-9. megraud f, brassens-rabbe mp, denis f, belbouri a, hoa dq. (1989). seroepidemiology of campylobacter pylori infection in various populations. journal of clinical microbiology., 27(8), 1870-3. rodrigo saez l, riestra menendez s, fernandez rodriguez e, fernandez velazquez mr, garcia alonso s, lauret brana me. (1997). epidemiological study of the prevalence of helicobacter pylori infection in the general population in asturias, spain. rev esp enferm dig., 89(7), 511-22. koch a, krause tg, krogfelt k, olsen or, fischer tk, melbye m. (2005). seroprevalence and risk factors for helicobacter pylori infection in greenlanders. helicobacter., 10(5), 433-42. jemilohun ac, otegbayo ja, ola so, oluwasola oa, akere a. (2010). prevalence of helicobacter pylori among nigerian patients with dyspepsia in ibadan. pan afr med j., 6(18). ndububa da, agbakwuru ae, adebayo ra, olasode bj, olaomi oo, adeosun oa, et al. (2001). upper gastrointestinal findings and incidence of helicobacter pylori infection among nigerian patients with dyspepsia. west afr j med., 20(2), 140-5. olubuyide io, atoba ma, ayoola ea. (1989). dyspepsia in ibadan. trop geogr med., 41(4), 337-40. ratha-korn vilaichone, natsuda aumpan, thawee ratanachu-ek, (2020). lotay tshering…… population-based study of helicobacter pylori infection and antibiotic resistance in bhutan. international journal of infectious diseases. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 31 american journal of medical science and innovation (ajmsi) epidemiological profile and diagnosis of pulmonary tuberculosis in the commune of ntoum, northwest gabon bourdettes meye1*, hilaire moundounga kenguele2, strédice maguinga guitouka3, kevin alame emane4, joseph privat ondo1, louis clément obame engonga¹ volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5191 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 24, 2025 accepted: may 31, 2025 published: august 05, 2025 pulmonary tuberculosis remains a major public health problem in gabon. the aim of this study was to determine the epidemiological profile of pulmonary tuberculosis in patients from the commune of ntoum and its surrounding area. this was a cross-sectional study from january 2024 to march 2025. the study enrolled patients who attended the tuberculosis diagnostic and treatment centre (cdt) of the ntoum departmental hospital (northwest gabon) for consultation or therapeutic follow-up. a total of 146 patients were enrolled. males predominated (54.2%), with a sex ratio of 1.21. the mean age of the study population was 34.94 years, with an age range 8-77. ntoum 6 and mebba neighbourhoods had the highest rate of tuberculosis patients (8.6% each) in the ntoum commune. tb/hiv coinfection accounted for 2.2% of patients, with a therapeutic success rate of 77.6%. the mycobacterial strains detected by genexpert were all sensitive to rifampicin. in order to achieve the who’s goal of eliminating tuberculosis by 2030, tuberculosis diagnosis and treatment centers in most of gabon’s health regions play an important role. despite the relatively high rate of therapeutic success observed, efforts are still needed in the area of case management. the diagnosis of hiv in all tuberculosis patients, or the molecular diagnosis of tuberculosis in all hiv-positive patients, must be spontaneous. in addition, tuberculosis patients must be monitored clinically and biologically on a regular basis. if these recommendations are put into practice, the number of cures will increase nationwide. keywords cdt, gabon, ntoum, prevalence, tuberculosis 1 department of biochemistry, laboratory of research in biochemistry (larebio), university of sciences and techniques of masuku (ustm) franceville, & medical analysis laboratory of ntoum departmental hospital (ndh), gabon 2 department of biology, laboratory of molecular and cellular biology (labmc), university of science and technology of masuku (ustm), franceville, gabon 3 national tuberculosis control program (ntcp), libreville, gabon 4 national public health laboratory (nphl), libreville, gabon * corresponding author’s e-mail: meyebourdettes@yahoo.fr introduction tuberculosis, which is both preventable and curable, is an infectious, contagious disease that mainly affects the lungs (abdelmalek et al., 2013). it is transmitted mainly by air from a sick person to a healthy person, through the emission of salivary droplets containing koch’s bacillus (bk) when the patient speaks, coughs, sneezes, si, or spits (swalehe et al., 2024). worldwide, it represents a major public health problem. in 2023, an estimated 10.8 million people worldwide contracted tuberculosis and 1.25 million died, including 161,000 co-infected with the aids virus. hiv infection has accentuated the burden of tuberculosis, particularly in sub-saharan africa where the prevalence of the disease is high. according to the same report, 55% of tuberculosis sufferers were men, 33% women and 12% children and adolescents. of all the continents, africa continues to bear the heaviest burden (organization, 2023). to combat this disease effectively, early diagnosis of presumptive cases of tuberculosis and regular monitoring of tuberculosis patients on treatment are important. the absence of any study of tuberculosis in the commune of ntoum lead us to conduct this study. the aim was to determine the epidemiological profile of pulmonary tuberculosis in the diagnostic and treatment center of the commune of ntoum, in north-west gabon. material and methods type, location and period of study a cross-sectional study was conducted at the ntoum departmental (nd) hospital over a 15-month period from january 2024 to march 2025. ntoum, chief town of this department is located in north -west gabon in the estuaire province and had 11,813 inhabitants in 2012 (dgs, 2015). is a fast-growing town favored by the construction of road infrastructures such as national highway n°1, which links the capital libreville to the interior of the country. the town’s economy is largely based on agriculture, fishing and broiler chicken farming. sampling over a 15-month period, the nd hospital mycobacteriology laboratory performed molecular tuberculosis diagnostics on all patients from gabon’s diagnostic and treatment centers (cdt) suspected of suffering from pulmonary tuberculosis. control microscopic examinations were carried out on bacteriologically confirmed patients undergoing treatment to assess the bacillary load at each appointment. all results were recorded in the laboratory register provided by the tb national control program. this document was used as the basic tool for collecting data from the study sample. the study variables were: pa ge 32 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 4(2) 31-35, 2025 sex, age, district of origin, hiv status and hiv/tb coinfection. inclusion and non-inclusion criteria all diagnostic and microscopic control results of patients in the laboratory register during the study period were eligible for inclusion. tuberculosis patients registered in the laboratory register outside the study period were excluded, as were unregistered patients. biological material sputum was collected in the morning on an empty stomach, after rinsing the mouth with water and coughing. a volume of 2 ml was sufficient. diagnostic methods detection of dna from mycobacteria belonging to the mycobacterium tuberculosis complex, as well as mutations in the rpob gene associated with rifampin resistance, was performed on all patients with suspected pulmonary tuberculosis using cepheid’s genexpert® systems, based on real-time nested pcr. control of the bacillary load in tuberculosis patients undergoing antibiotic therapy was carried out using led (light emitting diode) fluorescence microscopy on auraminestained smears, based on the acid-fast properties of bacilli linked to the structure of their cell wall. statistical analysis the data collected were entered into a database using microsoft excel version 2016. all statistical analyses were performed using r software version 1.4.2. the chi2 test was used to compare proportions, with a statistical significance level set at 5%. study approval and ethical considerations the study has been approved by the general management of nd hospital. all procedures contributing to this project comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the declaration of helsinki of 1975, as revised in 2008. results and discussions between january 29, 2024 and march 27, 2025, 146 sputum samples were analyzed at the nd hospital mycobacteriology laboratory. the male sex was the most represented with 80 cases (54.8%) for a sex ratio equal to 1.21. the 15-29 age group was the largest, with 54 cases (37%). the mean age of the study population was 34.94 years, with an age range 8 77. examination requests came mostly from the ntoum cdt, with 87 cases (59.6%). the nkembo and kango cdts followed with 54 cases (37%) and 2 cases (1.3%) respectively. other examination requests came from three hospitals located in the capital city libreville namely the omar bongo army hospital (hiaobo), melen regional hospital (chrem), and chinese and gabonese friendship hospital (hasg); each of them reported one case (0.7%). the largest number of presumptive pulmonary tb patients resided in the town of ntoum, with 98 cases (67.2%), followed by libreville and kango, with 36 cases (24.6%) and 12 cases (8.2%) respectively. for those living in ntoum, the ntoum 6 district was home to the most presumptive patients, with 21 cases (14.4%). the okolassi, meyang and soleil districts followed with 7 cases (4.8%) each (table 1). table 1: socio-demographic characteristics of patients sex n % male 80 54,8 female 66 45,2 age (year) 0 – 14 8 5,5 15 – 29 54 37,0 30 – 44 47 32,2 45 – 59 26 17,8 60 – 74 9 6,1 >75 2 1,4 health facilities cdt ntoum 87 59,6 cdt nkembo 54 37 cdt kango 2 1,4 hiaobo 1 0,7 chrem 1 0,7 hasg 1 0,7 city of residence libreville 36 24,6 ntoum 98 67,2 kango 12 8,2 ntoum districts mebba 5 3,4 okolassi 7 4,8 ntoum 6 21 14,4 nkoltang 5 3,4 soleil 7 4,8 essassa 4 2,7 ayeme 2 1,4 dame –oyem 4 2,7 meyang 7 4,8 assora 6 4,1 tp 2 1,4 akoneki 6 4,1 venez-voir 2 1,4 nkan 5 3,4 alarmitang 4 2,7 pa ge 33 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 4(2) 31-35, 2025 pk 27 3 2,0 cimenterie 2 1,4 pk 11 2 1,4 dubai 1 0,7 2 lions 1 0,7 bikele 1 0,7 bidzango rails 1 0,7 total 146 100 clinical symptoms such as a persistent cough lasting more than 2 weeks, whether or not associated with cachexia, were the most common motive for physicians to request the xpert mtb/rif test. real-time pcr was performed on 88 (60.3%) sputum samples. mycobacterium tuberculosis complex dna was detected in 22 samples (25%). all these bacterial strains were sensitive to rifampicin (100%). to assess the efficacy of anti-tuberculosis treatment, microscopic examination of sputum was requested for all tuberculosis patients undergoing treatment, in accordance with the national protocol for monitoring patients on treatment. a total of 58 samples (39.7%) were examined by fluorescence optical microscopy (f.o.m.), and more than a fifth (22.4%) of these showed acid-fast bacillus (table 2). table 2: biological diagnoses of tuberculosis at nd hospital diagnostics n % xpert mtb/rif mt detected 22 25 mt no detected 66 75 total 88 100 resistance to rifampicin detected 00 00 no detected 22 100 total 22 100 microscopy presence of acid-fast bacillus 13 22,4 absence of acid-fast bacillus 45 77,6 total 58 100 legend: mt = mycobacterium tuberculosis table 3: hiv/tuberculosis co-infection in patients seen at nd hospital variables n % hiv+/tb+ 3 2,2 hiv+/tb11 7,5 hiv-/tb12 8,2 hiv-/tb+ 5 3,4 inc/tb+ 25 17,1 inc/tb90 61,6 total 146 100 legend: tb =tuberculosis; inc = unknown; + = positive; = negative. distribution of tuberculosis patients by city of residence more than half the tuberculosis patients (51.4%) lived in the town where the study took place (ntoum). the others came from libreville, the country’s political capital (37.1%), followed by the town of kango, capital of the komo-kango department (11.5%) (figure 1). figure 1: distribution of tuberculosis patients by city of residence figure 2: distribution of tuberculosis patients by ntoum district as for the ntoum neighborhoods with the highest number of tuberculosis cases, mebba and ntoum 6 were the most representative, with 3 cases each (16.8%), followed by meyang and assora with 2 cases each (11.2%) (figure 2). hiv infection was found in 14 people, bringing the rate to 9.6% of hiv cases in the study population. hiv+/ tb+ co-infection was found in 3 patients (2.2%). however, a large number of participants (n=115; 78.7%) were unaware of their hiv status (table 3). pa ge 34 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 4(2) 31-35, 2025 discussion of the 146 sputum samples analyzed, 54.8% came from male patients. the sex ratio was one female to 1.21 males. these results confirm those of several studies showing a male predominance in patients infected with koch’s bacillus (tékpa et al., 2019; kalidou et al., 2021). this is probably due to the fact that men have social contacts which probably contribute to the burden of tuberculosis disease compared with women (horton et al., 2020; ozsahin et al., 2011). consumption of alcohol, tobacco and illicit substances, are other risk factors that increase tb susceptibility in men (narasimhan et al., 2013). in this study the mean age of our patients was 34.94 years. these results are in line with those found in the pneumophtisiology departments of the chu-rn of n’djamena and that of zinder in niger, where the mean ages were 34.1 and 33.5 years respectively (ngakoutou et al., 2024; hamidou et al., 2024). these results underline the fact that tuberculosis strikes with predilection young adults because of their multiple activities and their carelessness in the face of microbial infections. more than half the tuberculosis sufferers (51.4%) lived in ntoum (study site), which justifies this high prevalence compared with other towns. on the other hand, the city of libreville (gabon’s political capital) had more tuberculosis patients than the city of kango (capital of the komokango department), with 37.1% and 11.5% of cases respectively. the results of this comparison confirm the idea that tuberculosis is more prevalent in urban than in rural areas, as shown by studies carried out at the zinder national hospital in niger (hamidou et al., 2024) and those carried out in morocco, at the settat diagnostic center for tuberculosis and respiratory diseases located in the casablanca-settat region. (chahboune et al., 2022). in this study, the prevalence of tb-hiv co-infection was 2.2%. these results are similar to those obtained in niger and the republic of guinea, where prevalences were 2.4% and 2.5% respectively (hamidou et al., 2024; kolamou et al., 2023). hiv infection and tuberculosis form a lethal pair, as each of these diseases accelerates the progression of the other. hiv-positive people are 16 times more likely to develop tuberculosis than others, due to their compromised immune systems (organization, 2023). the discovery of tuberculosis should be systematically followed by an hiv test, which was not the case in the komo-mondah department, where 17.1% of tuberculosis patients did not know their hiv status. the therapeutic success rate in this study was 77.6%. this result is close to that recorded in work carried out in niger (84.2) (hamidou et al., 2024) and to that found in the pneumo-phtisiology department of the chu-rn in n’djamena (83.8%) (ngakoutou et al., 2024). this therapeutic success rate is the result of the efficacy of the pharmacological regimen adopted by the ntp of our country, gabon, on rifampicin-sensitive mycobacterial strains. the who recommends genexpert as the first-line diagnostic test for tuberculosis in all presumptive cases in adults and children (organization, 2013). among the 88 samples analyzed, the mycobarium tuberculosis genome was detected 22 times, bringing the prevalence rate to 25%. our results are similar to those found in southern ethiopia and nigeria, where the reported prevalences were 26.8% and 22.9% , respectively (diriba et al., 2022; tahiri et al., 2014). in contrast to our study, the results found in the internal medicine department of the national hospital donka in guinea conakry (31.03%) (wann et al., 2024) and the central army hospital mohamed seghir nekkache in algiers (34, 6%) (yamouni et al., 2024) were higher than in our study, and the results found in addis ababa (15.1%) (nugussie et al., 2017) and south africa (13%) (nicol et al., 2011) were lower than ours. these differences in prevalence are probably due to the study design, sample size and tb control and prevention practices adopted in each country. conclusion tuberculosis diagnosis and treatment centers in gabon’s health regions play an important role in the national eradication of tuberculosis. hiv infection further weakens the immune system of tuberculosis patients. systematic hiv screening is therefore essential for all tuberculosis patients, and molecular diagnosis of tuberculosis must also be systematic for all hiv-positive subjects. according to the who standard, the high presence of acid-fast bacillus in the sputum of tuberculosis patients in the first-line treatment phase, as measured by fluorescence microscopy, has a negative impact on therapeutic success. rigorous case follow-up combined with a communitybased anti-tuberculosis treatment strategy will certainly increase therapeutic success in gabon. study limitations this study was limited by the lack of data on the hiv status of a large number of tuberculosis patients (25/115 cases; 17.1%). this lack of information may have biased the number of hiv+/tb+ co-infections. references abdelmalek, r., mebazaa, a., berriche, a., kilani, b., ben osman, a. (2013). cutaneous tuberculosis in tunisia. médecine mal infect, 43, 374–378. chahboune, m., barkaoui, m., iderdar, y., alwachami, n., mourajid, y., ifleh, m., ... & el madani, s. (2022). profil épidémiologique, aspects diagnostiques et évolutifs des patients tuberculeux au centre de diagnostic de la tuberculose et des maladies respiratoires de settat, maroc. pan african medical journal, 42(1) direction générale de la statistique. (2015). résultats globaux du recensement général de la population et des logements de 2013 du gabon (rgpl2013). libreville, 61 pages + annexes. diriba, k., & churiso, g. (2022). the prevalence of mycobacterium tuberculosis using gene xpert among tuberculosis suspected patients in gedeo zone, southern ethiopia. eur j med res., 27(1),24. pa ge 35 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 4(2) 31-35, 2025 https://doi.org/10.1186/s40001-022-00650-x hamidou, i., doutchi, m., aim, g., neino, a., garba, a. a., alphazazi, s., & maizoumbou, d. a. (2024). epidemiology and outcome of tuberculosis at the national hospital of zinder (niger). health sciences and disease, 25(2 suppl 1). horton, k. c., hoey, a. l., béraud, g., corbett, e. l., & white, r. g. (2020). systematic review and metaanalysis of sex differences in social contact patterns and implications for tuberculosis transmission and control. emerg infect dis., 26, 910. https://doi. org/10.3201/eid2605.190574. kalidou, d. sow. 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(2023). global tuberculosis report 2023. geneva: licence: cc by-nc-sa 3.0 igo. yamouni, f., henniche, f. z., ifticene, m., chabani, m., bensersa, d., el houda ouadah, n., ... & zerouki, a. (2024). évaluation du genexpert® mtb/rif dans le diagnostic moléculaire de la tuberculose et de la résistance à la rifampicine en algérie. médecine tropicale et santé internationale, 4(2), mtsi-v4i2. pa ge 1 pa ge 36 american journal of medical science and innovation (ajmsi) parents’ knowledge, attitude, and misconceptions towards vaccination practices for their children, as determined by a cross-sectional study in the city of nalut, libya amira saleh khalifa bagni1*, aminah issa masud aljerbi1, huda said khalefah askar1, nada abdalhakim ali warragh1, aya mohammed essa alkhamaesi1 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5404 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: may 24, 2025 accepted: june 26, 2025 published: august 15, 2025 the study aimed to determine the knowledge, attitude, and misconceptions of parents about the practice of childhood vaccinations. the study followed a descriptive, analytical approach in a cross-sectional study of workers in several schools (middle and high school), in addition to those attending the sidi khalifa health vaccination center in the city of nalut. the sample totaled 1,024 participants, and 24 participants were excluded. the questionnaire was distributed to the participants in addition to a face-to-face dialogue with the participants. the questionnaire consists of four axes: the first axis talks about the demographic characteristics of the participants, then three axes in order about the wrong beliefs, attitudes, and knowledge of parents about practicing vaccinations for their children. from december 2022 to july 2023, the study was conducted and the results were analyzed using spss. the results showed that the average age of the sample was 25-30 years. the educational level of the participants was 609 (60.9%) for those with university degrees. marital status was divided between married (719), divorced (169), and widows (112). there was a correlation between the age of the participants and misconceptions about vaccinations (p-value< 0.05). it was also found that the level of misconceptions was low among the participants. the attitude of the participants towards the practice of vaccinations was positive 56.80%. it was also found that there was a correlation (p-value< 0.05) between the attitude towards practicing vaccinations and the educational level of the participants (36.78%) and their knowledge of vaccinations. an association was also found between the marital status of the participants and their tendency to practice vaccinations (x² = 163.815, p = 0.000). keywords childhood vaccinations, direction, false beliefs, knowledge 1 department of public health, college of medical technology, nalut university, libya * corresponding author’s e-mail: bagniamirasaleh4@gmail.com introduction immunization is a global success story in the field of health. we now have vaccines to prevent more than twenty life-threatening diseases, and immunization currently prevents between 3.5 million and 5 million deaths annually due to diseases such as diphtheria, tetanus, whooping cough, influenza, and measles (who, 2018). the advisory committee on immunization practices recommends routine vaccination of children by age 2, but evidence suggests that only 2% to 26% of children receive vaccine doses at age-appropriate times (kurosky et al., 2016). the world health organization defines vaccine hesitancy as “delay in accepting or refusing vaccines despite the availability of vaccination services” it is a complex matter and varies depending on time, place, and vaccines. individuals who are reluctant to receive vaccines constitute a heterogeneous group. they may reject some vaccines but agree with others. they may postpone receiving vaccines or accept them according to the recommended schedule while remaining unsure (alsuwaidi et al., 2020). myths and misinformation are among the main factors contributing to parents’ reluctance to complete vaccinations for their children. among the widespread beliefs is that the measles vaccine causes autism in children. catching the disease is better than facing the side effects of the vaccine. natural immunity acquired through infection with the disease is better than immunity generated by vaccination, and vaccine beliefs have been linked to partial and complete incompleteness of vaccines in brazil (kallassilva et al., 2025). a study in saudi arabia included parents of 390 children. factors that were associated with better knowledge among parents about vaccinating children were young mothers and working mothers, an increase in the level of education of mothers and fathers, and a positive correlation with significance between knowledge and the trend towards vaccinating children (al-zahrani j, 2020). knowledge and trust are contributing factors to vaccine acceptance, and a significant decline in childhood vaccination has been observed in recent years. one of the most important reasons that influence mothers’ decision to postpone or avoid vaccinating their children is knowledge and confidence in children’s vaccines. this is what was revealed by a study evaluating mothers’ knowledge and confidence in vaccinating their children in rwanda. in a cross-sectional survey, out of 2,126 fathers and mothers, the percentage of those who had good knowledge and confidence in vaccinating children was 95.5%. the study showed that good knowledge and confidence in vaccinating children are linked to education, profession, and income (mbonigaba et al., 2024). monthly studies have confirmed that mothers’ education and practice of vaccinations has a positive impact on immunization status, and that awareness pa ge 37 https://journals.e-palli.com/home/index.php/ajfst am. j. food. sci. technol. 4(2) 36-42, 2025 of vaccination is much higher among mothers with higher education. negative attitudes from parents, such as the mother’s fear of vaccination, the negative effects of vaccination, and the tendency to abstain from vaccination, are also considered obstacles to vaccinating the child. according to the survey conducted in georgia, the main reason for abstaining from vaccinations was the negative attitude towards vaccination (verulava et al., 2019). evaluating parents’ attitudes toward childhood vaccines and determining the prevalence of vaccination reluctance among parents and its relationship to the social and demographic characteristics of the parents. this was the goal of a study conducted in malaysia. a questionnaire was used to collect information and conduct a correlation test. it was noted in the results that a total of 63 (11.6%) parents was reluctant to vaccinate their children. hesitation was associated with unemployed and younger parents who have fewer children. the results also showed that the internet (65.6%) is the main source of information about vaccinations (azizi et al., 2017). the great interest in the debate over vaccinations makes it increasingly important to understand how parents make the decision to vaccinate their children. open qualitative interviews were conducted for participants that included mothers one to three days after giving birth, and then they were re-asked three to six months later about their practice of vaccinations. the results addressed three axes: attitude towards vaccinations, knowledge of vaccination, and decision-making. it was found that the number of mothers who intended to vaccinate their children was 25. they either agreed to the vaccination, doubted it, or accepted the vaccination, but they had great fears. among the results was that there were 8 mothers who did not intend to be vaccinated, and they either refused the vaccination completely or chose only some vaccines. the results also showed that knowledge of the recommended vaccines for children is weak among both vaccinated and unvaccinated children, and it was also found that they are concerned about the permanent side effects of vaccinations (benin et al., 2006). 3,924 participants were interviewed to find out the response rates to vaccinations for their children, which reached 57.9% in 2003 and 65.0% in 2004. concern about the safety of the vaccine was an indicator for parents who were unsure, disapproving, and late. the results also showed that delaying or not getting vaccinated for their children did not receive any information or confirmation from the health care provider as a main reason (gust et al., 2008). this study was conducted after conducting several field visits to several facilities in the city of nalut to identify a problem for research that focused on the factors that would increase or decrease vaccination practice. the aim of the study is to determine the knowledge, attitude, and false beliefs of parents about practicing vaccinations for their children among residents of the city of nalut, libya. material and methods the current study is a cross-sectional study of the nalut city community of parents to determine their knowledge, attitude, and misconceptions regarding the practice of vaccinations for their children. the study was conducted for parents with qualifications in the education and health sectors in several schools (5 government preparatory and secondary educational schools) and the health center (sidi khalifa) in the region for a sample number of 1,024 participants in a random manner. 24 participants were excluded as a result of not completing or receiving the questionnaire papers from them. the study was conducted between december 2022 and july 2023 among parents aged 20 to 40 years and above who frequent the health center and have a child to be vaccinated in the center’s clinics, and among parents working in other sectors such as education and other professions. approval to conduct the study was awarded by the governing council of nalut university (nu) during 2022. use the questionnaire as a 4-axis study instrument. the first theme addressed the participants’ demographic information, which included gender, age, educational level, family income, marital status, and occupation; the second theme talked about misconceptions about vaccinations and included 8 questions; the third theme included questions about the attitude toward practicing vaccinations; and the fourth theme related to the knowledge of vaccinations and included 9 direct questions in particular. the results were analyzed using the descriptive statistics spss (frequencies, percentages, and arithmetic mean) to describe the study variables. using the pearson correlation test and the chisquare test to find the relationship between the study variables considering a value of p-value > 0.05. results and discussion a total of 1,000 participants were in this study, the results of which were analyzed into percentages and frequencies of demographic factors for the participants. as shown in table (1), the number of males reached 476 (47.6%), and the number of participating females (52.4%) was 524. the age of the participants was between 20 and over 40, with the ages between 20 and 25 years reaching 367 participants and the ages between 25 and 30 years reaching 207, the ages between 30 and 35 years reaching 242 participants, and the lowest age of participation being <40 years (184), and the average age among the participants was between the ages of 30 and 25 years. the educational level of the participating sample, as shown in table (1), for university degree holders was 609 participants, followed by 156 participants for secondary school certificate holders, 122 for preparatory certificate holders, and 25 for primary certificate holders, 65 participants had advanced degrees, and 23 of the participants did not enroll in educational institutions. the monthly income of 422>1200 libyan dinars per month was 1200-900 libyan dinars for 343 participants, 228 of whom had a share of 900-600 libyan dinars during the month. 719 study participants were married, 169 participants were divorced, and 112 participants were widowed.409 of the participants’ jobs were teaching, while 356 participants were state pa ge 38 https://journals.e-palli.com/home/index.php/ajfst am. j. food. sci. technol. 4(2) 36-42, 2025 table 1: socio demographic characteristics of the study participation item demographic variables freq. (%) gender male 476 47.6% female 524 52.4% age 25-20 367 36.7% 30-25 207 20.7% 35-30 242 24.2% >40 184 18.4% level of education did not attend an educational 23 2.3% elementary 25 2.5% preparatory 122 12.2% high school 156 15.6% under undergraduate 609 60.9% postgraduate 65 65% monthly income 600 900 228 22.8% 900 1200 343 34.3% >1200 429 42.9% social situation married 719 71.9% absolutism 169 16.9% widower 112 11.2% occupation teacher 409 40.9% employe 356 35.6% freelance work 103 10.3% medical professions 87 8.7% other 45 4.5% table 2: determine the relationship between participants’ demographic characteristics and participants’ beliefs about vaccinations beliefs about vaccinations p. value correlation coefficient neuter disagree agree do you think that vaccinations weaken a child's immune system? 0.317** 134 426 440 do you think vaccinating children is a risk factor for asthma and allergies? 0.000 0.116** 162 494 344 do you think vaccinations cause autism? 0.012 0.713 186 445 369 do you think that vaccinations lead to sudden infant death syndrome in children? 0.000 0.0325** 170 448 382 do you think that the mmr measles vaccine, when received, causes meningitis? 0.000 0.256** 222 467 311 misconceptions about vaccinations included several questions in particular, the answers of the participants, which amounted to 440 (44%) participants, about the belief that vaccinations weaken the infant’s immune system, and also the belief that vaccinations cause autism 369 (36.9%). we find that 382 (38.2%) of the participants believe that vaccinations lead to sudden infant death syndrome, believe that the side effects of the vaccine are serious 252 (25.2%) believe that vaccinating children is a risk factor for asthma and allergies. this is what (table 2) showed. the results of the correlation test between parents’ beliefs about vaccinations and the ages of the participants had a fairly ideal positive relationship, as all variables were statistically significant at the significance level of p value > 0.05 (table 2). employees in various sectors, 366 had self-employment, and 103 participants were medical professionals (table 1). pa ge 39 https://journals.e-palli.com/home/index.php/ajfst am. j. food. sci. technol. 4(2) 36-42, 2025 do you think the side effects of the vaccine are serious? 0.002 0.098** 299 449 252 do you think vaccinations are safe? 0.000 0.248** 172 355 473 most of the beliefs among the participants were correct about vaccinations, with an acceptable percentage of 44.09%. however, despite this, it turns out that there are wrong beliefs among the participants. we find that figure 1: shows the level of beliefs among participants the percentage of 55.91% was for the two options: agree and neutral. which shows a negative trend towards the practice of vaccinations among participants. the tendency of participants practicing vaccinations for their children takes a positive direction among most participants, and this is evident from their positive answers, with good and somewhat satisfactory percentages. when participants are asked about their trust in health care service providers, we find it at an acceptable rate of 68.5%. giving the vaccine at the specified time was also satisfactory at a rate of 54%. not delaying the vaccination date beyond the recommended schedule was also accepted at a rate of 57.1%. delaying the vaccine date was 56.6%. as for selecting or choosing the vaccinations given to children, it was 52.2%. it is also clear that there is a correlation between the participants’ tendency to practice vaccinations for their children and the educational level of the participants, as p-value values were p-value > 0.05. table (3) table 3: shows the participants’ tendency to practice vaccinations for their children and its relationship to the participants’ educational level the attitudes towards practicing vaccinations p. value no correlation coefficient yes do you have confidence in healthcare providers? 685 68.5% 0315 31.5% 0.002 0.097** do you give vaccines to your child on time? 540 54.0% 460 46.0% 0.000 0.145** have you ever delayed your child's vaccination? 566 56.6% 434 43.4% 0.000 1.171** do you follow the recommended vaccination schedule? 571 57.1% 429 42.9% 0.008 0.087** is it okay to choose and select vaccinations? 478 47.8% 522 52.2% 0.013 0.078* we can summarize the participants’ attitude toward practicing vaccinations as positive for most (56.80%), compared to those who have no attitude or tendencies toward vaccinating their children (43.20%). this is due to reasons that may be related to the level of educational knowledge about vaccinations (figure 2). figure 2: participating parents’ attitudes towards vaccine practices when measuring the cognitive educational level of participants regarding vaccinations, it was found that it is knowledge acceptable to parents. when asked about natural immunity, it is better than vaccination with a vaccine. yes, was the answer given by 626 (62.6%). the participants’ knowledge of the human papillomavirus (hpv) vaccine protects the future from cancer. their knowledge was somewhat satisfactory, 593 (59.3%). through the results of testing the correlation between vaccination practice and the educational level of the participants, it is clear that there is a correlation at p-value > 0.05 (table 4). the level of knowledge about vaccinations among the participants was calculated and found to be somewhat acceptable (62.92%) compared to the level of knowledge among the participants. their beliefs and educational level prevent them from practicing vaccination (37.08%). pa ge 40 https://journals.e-palli.com/home/index.php/ajfst am. j. food. sci. technol. 4(2) 36-42, 2025 table 4: shows the relationship between the educational level of participants and their knowledge of vaccinations. parent participants’ knowledge of vaccinations p. value no correlation coefficient yes are you aware that vaccines are extracts that contain microbes like bacteria and viruses? 679 67.9% 321 32.1% 0.000 0.155** is natural immunity superior to vaccination with a vaccine? 626 62.6% 374 37.4% 0.000 0.137** can a child receive a vaccination if they have a fever? 626 62.6% 374 37.4% 0.000 0.133** did you know that vaccines have eradicated many deadly diseases like smallpox and tetanus from the world? 676 67.6% 324 32.4% 0.011 0.081* it's important to vaccinate your child against diseases that no longer exist, did you know? 611 61.1% 389 38.9% 0.001 0.109** did you know that your child is given multiple doses of the same type? 594 59.4% 406 40.6% 0.000 0.127** are you aware that the papillomavirus vaccine prevents cervical cancer? 593 59.3% 407 40.7% 0.000 0.114** table 5 : the relationship between the marital status of parents and their tendency to practice vaccinations. marital status attitude of parents to practice vaccination x² p. value yes no married 26.7% 45.2% 163.815 0.000 absolutism 9.92% 6.98% widower 6.58% 4.62% total 43.2% 56.8% the level of knowledge among the participants can be observed in figure (3). figure 3: the level of knowledge of parental participants about vaccinations the practice of vaccination is influenced by the marital status of the participants. according to the chi-square test, the marital status of participants is a significant factor in their tendency to practice vaccinations (x² = 163.815, p = 0.000). most married people have a somewhat weak positive tendency to practice vaccinations, with a weak percentage of 45.2%, followed by divorced people with 6.98% and widows with 4.62%. as for the negative trend for married people, 26.7%; divorced people, 9.92%; and widows, 6.58%. through these percentages, we can say that marital status has an impact on the practice of vaccinations. pa ge 41 https://journals.e-palli.com/home/index.php/ajfst am. j. food. sci. technol. 4(2) 36-42, 2025 discussion the study was conducted to determine the knowledge, attitude, and misconceptions of parents regarding the practice of vaccinations for their children. demographic characteristics of study participants in a sample of 1,000 participants, including 476 (47.6%) males and 524 (52.4%) females, whose average age ranges between 25 and 35 years. the level of false beliefs was weak, 36.72%, while correct beliefs were also weak 44.05%. when determining the relationship between the ages of the study participants and their misconceptions about vaccinations, it was found that there was a significant relationship between the study variables (p value > 0.05), and this result was consistent with the study (facciola et al., 2019). in which it was stated that vaccinations are negatively related to the age of the parents, we also note agreement with a study (borras et al., 2009). which showed that the highest rate of vaccination coverage is linked to the aging mothers and their increased knowledge of vaccinations. the results of the study also showed that 62.92% have knowledge about vaccinations, unlike 37.08%, who do not have specific knowledge about vaccinations these results contradicted the recent study, which showed that 23.26% of parents did not have specific information about vaccinations. the level of misconceptions was close to the results of a study (giambi et al., 2018). which showed that safety concerns are the main reason for refusing vaccination or boycotting vaccination compared to the current study, where beliefs that vaccinations are safe (47.3%), and this result is consistent with the study (mckee & bohannon, 2016). the results also showed a relationship between the participants’ knowledge about vaccinations and the participants’ educational level (p-value > 0.05). this result was consistent with (kalok et al., 2020) and this result was also consistent with (alyami et al., 2018) which showed that higher education has an impact and is linked to a commitment to practicing vaccinations. the positive trend in vaccination practice was low at 56.80% among the participants, and the negative trend was also low at 43.20%. these results were consistent with the results of the study (hak et al., 2005). the results also showed that there is a significant relationship between the marital status of the participants and their practice of vaccinations (p value > 0.05), which is consistent with the study (luman et al., 2003). conclusion through this study, we find that most participants practice vaccinations for their children, but these practices are not without factors that cause abstention or delay in fully covering vaccinations for children. one of these factors is the spread of misconceptions about vaccinations, which include concerns about the safety of vaccines. the educational level was also linked to the practice of vaccinations, which included the hesitation and lack of commitment of participants to giving vaccinations on time and selecting vaccinations. family stability also has an effective role in the practice of vaccinations. the determinants of the study were the participants’ indifference to completing the questionnaire form, which led to the deletion of a number of them, and the community’s lack of acceptance by helping this research spread and measure awareness and enhance its importance in dissemination. this study recommends conducting future, more comprehensive and in-depth studies of the study sample, to precisely find out what are the reasons leading to the lack of vaccination coverage for children and the decline in society’s tendency to practice vaccinations. we also recommend that part of the educational curriculum include lessons dedicated to vaccinations to correct the misconceptions entrenched in the minds of some people about vaccinations, and there is no objection to conducting educational courses for married or aboutto-marry parents about the importance of practicing vaccinations. references alsuwaidi, a. r., elbarazi, i., al-hamad, s., aldhaheri, r., sheek-hussein, m., & narchi, h. 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(2018). world health organization. vaccines and immunization.https://www.who.int/health-topics/ vaccines-and-immunization#tab=tab_1 pa ge 1 pa ge 94 american journal of medical science and innovation (ajmsi) atypical femur fractures in post-menopausal patients taking bisphosphonates and their indication when to start after holiday period of 5 years and its effects imran azeem1*, susan gilchrist2, kiran dosani3, james broderick1, conor hurson1 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.4156 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: december 01, 2024 accepted: january 04, 2025 published: march 19, 2025 postmenopausal women are at risk of fractures owing to osteoporosis, which is worsened by low oestrogen. bisphosphonates like ibandronate, zoledronic acid, alendronate, and risedronate limit bone resorption and increase bone density, reducing fracture risk. although atypical femur fractures (affs) are uncommon, they are associated with dangerous complications of long-term bisphosphonate therapy. early fracture identification before they occur is crucial to minimizing complications. the review examines bisphosphonaterelated medical issues in postmenopausal women with atypical femur fractures. the study also addressed whether to resume bisphosphonate medication following a pharmacological holiday, which reduces fracture risk. a thorough literature search was undertaken using pubmed, embase, and the cochrane library. the search criteria included atypical femur fractures, bisphosphonates, osteoporosis, and therapy duration. following screening, studies fulfilling inclusion criteria were assessed utilizing the cochrane risk of bias tool and newcastle-ottawa scale. several studies examined the association between long-term bisphosphonate usage and atypical femur fractures. bisphosphonates reduce osteoporotic fractures but may raise aff risk over time. the studies also emphasize the significance of individualized bisphosphonate treatment programs and thorough monitoring, especially after a medication holiday. bisphosphonates reduce fracture risk, although atypical femur fractures require cautious treatment duration and timing, especially following a medication holiday. selection bias and confounding variables may have limited the evidence of this research. the research design and use of real-world data may also affect its validity and reliability. to enhance treatment recommendations and patient outcomes, longitudinal research on bisphosphonates’ long-term impact on bone health and fracture risk is needed. keywords atypical femur fractures, bisphosphonates, effects of bisphosphonate resumption, postmenopausal patients 1 orthopedic and trauma department, st. vincent’s university hospital, dublin, ireland 2 orthopedic department, letterkenny university hospital, county donegal, ireland 3 internal medicine, south city hospital, karachi, pakistan * corresponding author’s e-mail: drimranazeem88@gmail.com introduction background postmenopausal women are particularly at risk of fractures from osteoporosis, a systemic skeletal condition that causes bone fragility (ji & yu, 2015). this group has increased osteoporotic fractures because of hormonal variations, specifically a drop in oestrogen levels after menopause, which demineralizes bone (walker & shane, 2023). it usually affects the wrist, pelvis, and vertebrae. menopausal women often take bisphosphonates for osteoporosis. bisphosphonates prevent fractures and increase bone density by inhibiting bone resorption (khan et al., 2022). bisphosphonates like ibandronate, zoledronic acid, alendronate, and risedronate enable customized treatment due to their dosage and formulation possibilities. long-term bisphosphonate medication is linked to atypical femur fractures (affs). adverse effects associated with fractures may be diminished as a result of early detection and diagnosis of affs before their complete formation. single energy x-ray absorptiometry, a recently developed imaging technique, has been shown to detect incomplete atypical femoral fractures (iaff) before their complete occurrence (mckenna et al., 2017). although bisphosphonates decrease the risk of fractures, they can cause rare and adverse atypical femur fractures (silverman et al., 2018). these radiographic pattern femur fractures can develop in the diaphyseal or the subtrochanteric region without trauma (grygorieva et al., 2023). several research has associated bisphosphonates with atypical femur fractures while raising safety concerns specifically with its long-term intake (black et al., 2019; donnelly et al., 2012; tile & cheung, 2020). a comprehensive understanding is essential for the etiology, epidemiology, and risk factors of atypical femur fractures to reduce the hazards of bisphosphonates and enhance osteoporosis therapy (hart, 2023). the british national formulary recommends investigating each patient’s treatment responsiveness, fracture risk, and tolerance of bisphosphonate therapy for osteoporosis before the initiation or discontinuation of the treatment (crawley, 2019). examining the patient’s history of treatment and bone condition is essential while considering bisphosphonate medication intake after the holiday. the risk of adverse effects may increase as a consequence of returning to therapy soon after a break due to the instability of bone turnover. long-term studies are required to assess the safety and efficacy of bisphosphonate medication for atypical fractures. to address concerns about starting or discontinuing bisphosphonates after the holidays, even if they’re still needed to treat osteoporosis, understand each patient’s factors and treatment goals. pa ge 95 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 94-101, 2025 rationale a complete investigation is needed owing to the medical difficulties associated with atypical femoral fractures in postmenopausal women who take bisphosphonates and the absence of a clear response about whether to resume treatment after a 5-year hiatus bisphosphonates, which increase bone mineral density and prevent fractures, have raised concerns about atypical femur fractures, especially in postmenopausal women (hart, 2024). previous research reports that these fractures impede healing and therapy. after a 5-year gap, assess therapy resumption risk. bisphosphonate users’ atypical femur fractures and their causes must be understood by doctors to make informed decisions and manage their patients. some physicians prescribe a “drug holiday” for a few years to lessen the risk, whereas others emphasize treatment to prevent fractures. due to long-term risks such as atypical femur fractures, bisphosphonate medication duration, and resume timing are contested. these concerns have caused disagreements over treatment time despite its shortto medium-term fracture risk reduction. understanding how bisphosphonate medicine decreases fractures and identifying biomarkers might help determine its impact on bone quality and microarchitecture post-holiday. long-term effects of bisphosphonate on bone quality, microarchitecture, and fracture reduction must be investigated to enhance clinical practice. postmenopausal women at risk of bisphosphonate-induced atypical femur fractures are the focus of this meta-analysis. objectives • to systematically examine the literature on atypical femur fracture risk in postmenopausal individuals using bisphosphonates for 5 years on holiday. • to determine the best time to start bisphosphonate medication after the holidays to reduce the risk of atypical fractures. • to evaluate bisphosphonate discontinuation length post-holidays to preserve bone health and reduce fracture risk. questions • what is the risk for atypical fracture once we start after the holiday? • when shall we start bisphosphonate after the holiday period? • how long can we stop the intake of bisphosphonate after the holiday period? materials and methods this systematic review is executed based on the methodology permitting the preferred reporting items for systematic reviews and meta-analysis (prisma) statements (moher et al., 2009). search strategy a comprehensive search strategy is used to find relevant studies for this systematic review. the databases embase, the cochrane library, and pubmed will be examined. the search strategy will include atypical femur fractures, bisphosphonates, osteoporosis, treatment duration, and fracture risk. the search strategy initially yielded 1,200 articles from the selected databases. titles and abstracts were used to evaluate these articles for future investigation. duplicate articles were removed, leaving 800 entries for inquiry. all 800 articles were then evaluated for inclusion and exclusion criteria. a total of 50 articles passed full-text screening for the systematic review, these articles were assessed for methodological rigor utilizing the cochrane risk of bias tool and the newcastle-ottawa scale for observational studies (higgins et al., 2011; wells et al., 2000). changes in bone health throughout the holiday, atypical femur fractures, risk variables, and bisphosphonate treatment duration’s influence on fracture risk reduction are important results. this thorough analysis synthesizes data on atypical femur fractures in postmenopausal bisphosphonate-treated individuals. 9 articles met inclusion requirements. table 1 below shows the keywords and mesh terms utilized in the review. table 1: summary of the searched keywords and mesh terms category keywords and mesh terms atypical femur fractures atypical femur fractures sub-trochanteric fractures diaphyseal fractures femoral shaft fractures bisphosphonates bisphosphonates alendronate risedronate ibandronate zoledronic acid osteoporosis osteoporosis postmenopausal osteoporosis bone density treatment duration treatment duration long-term treatment drug holiday study selection criteria data extraction the data extraction approach for this systematic review entails assessing and documenting important study features and outcome measures with care. these factors greatly impact the findings’ robustness and applicability. cohort studies have long-term impacts, whereas randomized controlled trials provide high-quality data. the period of follow-up also reveals the treatment effects’ temporal aspects (yong & logan, 2021). the review pa ge 96 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 94-101, 2025 table 2: inclusion and exclusion criteria of the included studies criteria inclusion exclusion study design randomized controlled trials, case-control studies, cohort studies, and systematic reviews studies not meeting the specified study designs (e.g., case reports, letters, editorials) participants postmenopausal patients studies conducted in populations other than postmenopausal patients (e.g., men, premenopausal women) intervention studies examining bisphosphonate treatment duration and timing of initiation after a holiday period studies focusing solely on other osteoporosis treatments or interventions outcome measures studies reporting on atypical femur fractures studies without relevant outcome measures (e.g., studies focusing solely on bone mineral density changes) reporting quality studies with inadequate methodology or reporting, as assessed during the quality assessment process table 3: quality assessment study selection bias performance bias detection bias attrition bias reporting bias overall risk of bias (bauer et al., 2024) low high low low low uncertain (brown, 2021) low low low high low low (fuggle et al., 2021) low low low low high low (khan et al., 2022) low uncertain low low low low (morkos et al., 2022) low high low low low high (ogundipe, 2020) low low high low low low (rudran et al., 2021) high low low low low low (saag et al., 2021) low low low high low low (toro et al., 2023) low low uncertain low low high rigorously evaluates these qualities to place the results in the context of osteoporosis management. detailed outcome metrics for atypical femoral fractures and bisphosphonate treatment are documented. a range of outcome indicators are used to assess the pros and cons of bisphosphonate treatment in postmenopausal individuals. during data extraction, bias, and methodological issues are carefully evaluated. larger sample volumes and longer follow-ups may improve analytical significance. the review thoroughly evaluates the facts to satisfy the highest evidence synthesis standards and ensure the outcomes’ validity and reliability. this method collects and summarises data from several research, analyses patterns and similarities, and investigates variance explanations. quality assessment table 3 presented below highlights the quality of the selected articles for the review. this table categorizes the possible bias of each study utilizing the cochrane risk of bias tool (higgins et al., 2011). each domain has a “low,” “high,” or “uncertain” bias risk. the analysis uses methodologically rigorous research, indicating little bias. reviewers resolved quality evaluation discrepancies and disagreements via discourse. if a consensus was not achieved, a third reviewer was hired to provide an objective assessment and help resolve the conflict. data synthesis and analysis the selected studies included atypical femur fractures in postmenopausal bisphosphonate patients in a narrative format. reference 1, studied danish bisphosphonate use with uncommon femoral fractures in a case-cohort study. the research employed blinded radiography. atypical femur fractures were infrequent in postmenopausal patients using bisphosphonates, supporting safety. the study emphasizes the need for thorough monitoring and adverse effect awareness, especially in long-term bisphosphonate users. the study discovered that extended postmenopausal osteoporosis treatments must be tailored to each patient’s needs (brown, 2021). it also underlines the significance of frequently monitoring the medicine and contemplating cessation after a break to reduce the risk of adverse effects such as atypical femur fractures. researchers observed a gap in osteoporosis care, suggesting at-risk individuals were not addressed for pa ge 97 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 94-101, 2025 appropriate medications (fuggle et al., 2021). many eligible patients receive insufficient bisphosphonates or no treatment, increasing their risk of osteoporotic fractures. public awareness, educational accessibility, and evidencebased therapy utilization are needed to reduce treatment disparities. after stopping chronic oral bisphosphonate therapy, the study investigated mineral density and bone turnover post hoc (saag et al., 2021). these findings suggest that bisphosphonate discontinuation needs switching medicines or monitoring for side effects. results and discussions study selection process figure 1 shows the identified databases and screened studies involved in this systematic review while meeting the inclusion and exclusion criteria. the prisma flow diagram was created using prisma2020 (haddaway et al., 2022). figure 1: prisma chart demonstrating the study selection process table 2: inclusion and exclusion criteria of the included studies study study design population intervention methodology bauer et al., 2024) case-cohort study postmenopausal women receiving bisphosphonates bisphosphonate therapy blinded radiog -raphic review (brown, 2021) review article postmenopausal women with osteoporosis long-term bisphosphonate treatment literature review (fuggle et al., 2021) review article population at risk of osteoporosis and fractures osteoporosis therapy literature review (khan et al., 2022) guideline postmenopausal women at risk of osteoporosis management guidelines guideline development (morkos et al., 2022) observational study patients with osteoporosis on a drug holiday osteoporosis medication selection real-world data analysis (ogundipe, 2020) case report postmenopausal woman with atypical femoral fractures long-term alendronate therapy case report (rudran et al., 2021) review article patients with bisphosphonateassociated fractures management strategies literature review characteristics of included studies pa ge 98 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 94-101, 2025 (saag et al., 2021) post hoc analysis postmenopausal women discontinuing oral bisphosphonates bisphosphonate discontinuation post hoc analysis of clinical trial data (toro et al., 2023) review article patients at risk of atypical femoral fractures fracture liaison service literature review findings related to atypical femur fractures several studies which are presented above in table 4 have shown the complicated link between bisphosphonate treatment and fracture risk. these studies found variable rates of atypical femur fractures amongst postmenopausal bisphosphonate users. atypical femur fractures may be prevented by bisphosphonates, according to blinded radiographic evaluation. however, it is reported that non-traumatic bilateral atypical femoral fractures in postmenopausal women use long-term alendronate (ogundipe, 2020). researchers advised diagnosing and treating bisphosphonate-induced atypical femoral fractures immediately to minimize complications (rudran et al., 2021). atypical femur fractures may be affected by patient characteristics, bisphosphonate duration, and risk variables, confounding fracture susceptibility assessment. when restarting bisphosphonate medication, our findings emphasize the necessity to adapt it to each patient’s requirements and goals. the bnf chapter on bisphosphonate medication duration in osteoporosis highlights fracture risk, response, and drug tolerance in tailored treatment programs. the condition of patients during exceptionally long therapy periods (e.g., over ten years) is less certain. whilst it would be more acceptable to adopt a more precise definition of “high risk” in light of these considerations, it remains feasible to administer continuous treatment to patients who are deemed to be at an adequate risk without interruption. it is advisable to solicit expert opinion and assistance in each specific case, and whenever practicable, patients should be apprised of the current ambiguity surrounding the trade-offs between benefit and risk. the physician may recommend a one-year treatment hiatus, contingent upon the patient’s circumstances (hart, 2024). the study found that bisphosphonates increase the risk of atypical femur fractures, thus they must be monitored for adverse effects (bauer et al., 2024). according to the study, bisphosphonates, notably alendronate, may raise the risk of rare but severe atypical femoral fractures (ogundipe, 2020). another study examined how bisphosphonate cessation affects mineral density and bone turnover (saag et al., 2021). a recent study discovered that the risk of fractures increases after the discontinuation of the drug which is the rebound effect. additionally, it noted the overlooked opportunities to prevent fracture fragility and deficiency of osteoporosis treatments (fuggle et al., 2021). this therapeutic gap must be filled by addressing and investigating these aspects. although the efficacy of fracture risk reduction of bisphosphonates is known, the potential adverse effects, duration of therapy, and patient demographics must be evaluated to lower atypical femur fractures and enhance the efficacy of the treatment. the studies included in this review completely analyse the patients’ incidence rates and risk variables of atypical femur fractures. it is crucial to lower the atypical femur fractures and enhance overall patient outcomes through personalized treatment strategies, immediate adverse effect reporting, and regular progress assessments for postmenopausal women taking bisphosphonate (hart, 2024). effects of bisphosphonate treatment duration and timing of initiation the studies included in this review examine the mechanism and treatment duration effects such as the bone mineral density modifications after the discontinuation of the treatment and reduction of fracture risk to comprehensively understand the safety and efficacy of bisphosphonate therapy in the management of osteoporosis. according to a study, bisphosphonates lower the risk of fractures during the prolonged intervention period of postmenopausal osteoporosis (brown, 2021). additionally, less atypical femur fractures were associated with postmenopausal women taking bisphosphonates (bauer et al., 2024). another study investigated decisions on osteoporosis medication during drug discontinuation, highlighting the significance of treatment continuation to prevent fractures (morkos et al., 2022). a continued reduction in bone mineral density and a temporary increase in bone turnover after a longterm discontinuation of bisphosphonate was noted (saag et al., 2021). when bisphosphonate is discontinued, an augmented fracture risk and rebound effects are developed. discussion summary of key findings researchers selected literature on bisphosphonateinduced uncommon fractures in postmenopausal women to address the first difficulty of the systematic review (bauer et al., 2024; ogundipe, 2020). according to a case report, extended alendronate use may cause atypical femoral fractures, stressing bisphosphonate safety regarding the review goals’ risk assessment (ogundipe, 2020). the findings underline the need to rapidly detect and treat bisphosphonate-induced femur fractures (rudran et al., 2021). the systematic study investigated whether continuing bisphosphonate therapy after a break increases the incidence of atypical fractures. this systematic review evaluates bisphosphonate duration and timing on bone mineral density and fracture risk. bisphosphonates minimize the risk of fractures (brown, pa ge 99 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 94-101, 2025 2021). studies stress that quitting bisphosphonate therapy momentarily stimulates bone turnover and eventually reduces bone mineral density (saag et al., 2021). the researcher analyses fracture liaison services and their capacity to reduce fracture risk, emphasizing the need for healthcare practitioners to adopt preventative measures after the holidays despite concerns about bone loss after cessation (toro et al., 2023). the results emphasize the need for prescription bisphosphonate therapy for fracture prevention and the hazards and benefits of longterm usage and drug cessation. interpretation of findings of existing literature researchers demonstrated bisphosphonate medication greatly reduces atypical femur fractures (bauer et al., 2024; brown, 2021). bisphosphonates seldom cause these fractures. scholars educate about bisphosphonate medication cessation-induced bone loss and fracture risk (morkos et al., 2022; saag et al., 2021). a 2020 case report describes unanticipated non-traumatic bilateral atypical femoral fractures produced by sustained alendronate therapy (ogundipe, 2020). bisphosphonates reduce fracture risk and are safe, therefore atypical femur fractures are rare (bauer et al., 2024; ogundipe, 2020). patients using the drug long-term should be risk evaluated and monitored for adverse effects due to atypical femur fracture risk (ogundipe, 2020). the study found that bisphosphonate removal temporarily reduced bone mineral density and augmented bone turnover, increasing the risk of atypical fracture (saag et al., 2021). atypical femur fractures, postmenopausal osteoporosis bone health, and bisphosphonate treatment have inconsistent outcomes (mckenna et al., 2017). consequently, this study will identify the optimum duration to discontinue bisphosphonate after a holiday period without resulting in atypical fractures or harming bone health. limitations of the evidence in a retrospective case-cohort study, blinded radiography was utilized to analyze bisphosphonate-associated atypical femur fractures (bauer et al., 2024). bilateral atypical femur fractures were reported to be caused by a long-term alendronate dosage (ogundipe, 2020). the case studies lack scientific evidence and have low population sizes. the clarity and authenticity can be compromised as a result of real-world data analysis potentially complicating biases and variables (morkos et al., 2022). furthermore, biased or confounding references can potentially hinder the reliability and validity of systematic reviews as selection bias can falsify or disregard significant research dependent on the review criteria. age, comorbidities, and concurrent medications may indicate bisphosphonateinduced atypical femur fractures, altering relationships. clinical implications and future research directions a comprehensive examination of atypical fractures after stopping bisphosphonate medication during a holiday break reveals clinicians should prioritize bisphosphonate therapy for postmenopausal women at risk of osteoporotic fractures. it may reduce fractures with long-term therapy (khan et al., 2022). the potential incidence of femur fractures in patients on bisphosphonate necessitates particular attention. fracture monitoring and evaluation are associated with the therapeutic success and safety of the patient. reinitiating bisphosphonate intake after a holiday period necessitates the evaluation of patient risk and following treatment standards. the prevention of fractures must be a regular therapy to lower fractures and improve overall patient outcomes. the pros and cons of bisphosphonate therapy should be discussed with the patients while following their preferences and values. an osteoporosis management strategy highlighting patient requirements, providing personalized therapy, and broad care may benefit patients with fragility fractures. further research is required to investigate the discontinuation of bisphosphonate after a holiday period. conclusion although bisphosphonates reduce the risk of fractures, atypical femur fractures may develop. therefore, longterm patient monitoring should be prioritized. healthcare practitioners must keep in consideration the patient’s comorbidities, age, and history of fractures when evaluating the benefits and risks of bisphosphonate therapy for the prevention of fractures. bisphosphonate therapy must be immediately re-initiated after the discontinuation of the medication. the review reported that early medication re-initiation augments the risk of atypical fractures as a result of the long-lasting bone remodeling effects of the medication. thus, personalized treatment plans must consist of the status of bone health and risk profiles to evaluate the bisphosphonate re-initiation period and drug interruptions. the use and discontinuation of bisphosphonate requires further longterm research to a more comprehensive understanding of its long-term outcomes such as the determination of the optimum holiday period and the formulations of bisphosphonate affecting risks of fractures. due to the limitations of the present data, further research should utilize more rigorous methodological strategies to minimize performance and selection biases. well-designed randomized controlled trials with larger sample sizes, scientifically evident clinical studies, and comprehensive confounding variable information are required to improve the bisphosphonate dosage management policies for postmenopausal women. bisphosphonates are crucial for the treatment of postmenopausal osteoporosis. however, it should be carefully monitored to evade atypical femur fractures. further research and personalized treatment strategies are critical to enhance the overall health outcomes for the patients. references bauer, d. c., black, d. m., 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(2021). menopausal osteoporosis: screening, prevention and treatment. singapore medical journal, 62(4), 159. https://doi.org/10.11622/ smedj.2021036 pa ge 1 pa ge 12 1 american journal of medical science and innovation (ajmsi) systematic review and meta-analysis of surgical versus non-surgical management for varicocele: comparative evaluation of fertility outcomes and complication rates ahmed el shinnwai1* volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3694 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 20, 2024 accepted: september 27, 2024 published: november 14, 2024 varicocele is a condition causing abnormal dilatation of the pampiniform plexus in the scrotum, affecting spermatogenesis, testicular volume, semen parameters, fertilization, implantation, and embryonic outcomes. this systematic review and meta-analysis aimed to compare surgical and non-surgical management of varicocele, evaluating fertility outcomes and complication rates, synthesizing clinical studies for effectiveness and safety. the methodology includes the systematic review of 26 studies and a meta-analysis of 16 studies, followed by the search strategy, data extraction, inclusion and exclusion criteria, data analysis, and data extraction strategy of the included selected studies. for the criteria of study selection, prisma chart has been created to review the selection process of included studies. research indicates that undergoing surgery to cure varicocele enhances the likelihood of conception, sperm quality, live birth rates, and success of sperm retrieval. varicocele embolization is one non-surgical treatment that provides rapid pain relief, minimum invasiveness, and a quicker recovery. antioxidants can enhance sperm parameters and conception rates when combined with other treatments. reproductive outcomes are improved by varicocele repair, which includes surgical and angiographic embolization. this procedure lowers sperm dna fragmentation. for males with varicocele, surgery is still the major way to improve quality of life. it was concluded that varicoceleectomy is the primary fertility treatment for men with varicocele, offering significant benefits in pregnancy rates, sperm parameters, and long-term results, while non-surgical approaches offer faster recovery and minimal invasiveness. keywords conception, infertility, metaanalysis, pregnancy, treatment, varicocele 1 barts health nhs trust, 8003144, london, uk * corresponding author’s e-mail: shinnwai@outlook.com introduction varicocele, a condition characterized by abnormal dilatation or tortuosity of the pampiniform plexus in the scrotum, affects 15% of men in general, 35% of men who are infertile first, and 80% of men who are infertile again. the pathogenesis is multifactorial, with incompetent venous valves and anatomic variations in venous drainage between the left and right internal spermatic veins leading to venous reflux and elevated hydrostatic pressure. physical activity in adolescence can cause varicocele development, and physical activity in later life can exacerbate the illness (alsaikhan et al., 2016). anatomical variables including a longer left spermatic vein, the absence of a valve, the “nutcracker phenomenon”, increased blood flow and pressure, and developmental factors like puberty and adolescence all have an impact on the development of varicocele. tobaccos age, renal arteriovenous malformations, deep vein thrombosis, and pampiniform plexus thrombosis are further uncommon causes (su et al., 2021). spermatogenesis, testicular volume, semen parameters, fertilization, implantation, and embryonic outcomes are all adversely affected by varicocele (hassanin et al., 2018). although varicocele are common in sub-fertile males, there is ongoing discussion on their effects on live birth rates and fertility treatments. the possible impacts on sperm dna fragmentation and semen parameters are of concern. treatment is an intrusive, costly procedure with some side effects, but it may increase semen parameters, fertility, and pregnancy rates (maheshwari et al., 2022). oxidative stress is a major element in the difficult issue of varicocele-induced fertility. the usual course of treatment is still microsurgical varicoceleectomy; antioxidant supplements plus varicoceleectomy may enhance the success of pregnancy outcomes (su et al., 2021). varicocele has been linked to an elevated risk of specific health issues. notably, men with asymptomatic varicocele did not exhibit an increased risk of heart disease, diabetes, or hyperlipidemia post-diagnosis. in contrast, individuals with symptomatic varicocele were found to have a greater likelihood of developing these conditions (wang et al., 2018). rationale for comparing surgical and non-surgical management options blocking the vein to reroute blood flow is the surgical treatment for varicocele. open surgery or minimal invasive techniques such as laparoscopic or microscopic varicoceleectomy are available options. in males with palpable varicocele and lowquality sperm, varicocele repair can increase fertility and pregnancy rates by 13-51%. while non-surgical method called varicocele embolization can be used to treat varicocele without requiring open surgery. it has benefits including a quicker recovery period, local anesthetic, a lower chance of complications, and a quicker return to normal activities. the objective of this present systematic review and metaanalysis is to comprehensively evaluate and compare the fertility outcomes and complication rates associated with pa ge 12 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 121-130, 2024 surgical and non-surgical management of varicocele. this review aimed to synthesize existing evidence from clinical studies to provide a robust analysis of the effectiveness and safety of these management strategies in improving fertility outcomes among patients with varicocele. materials & methods search strategy & key words the review was carried by using the current research and review publications available in google scholar, pubmed, ncbi, scopus, web of science, medscape, and springer based on the evaluation and comparative analysis of fertility outcomes rates associated with the surgical and non-surgical management of varicocele. from the beginning january to the april 2024, a thorough search of the literature on the was done to obtain the comprehensive results by using the keywords including “surgical treatment of varicocele”, “varicocele embolization”, “varicocele effects fertility”, “varicocele impacts sperm viability”, and “varicocele embolization improves fertile”. the given criteria were required for eligibility; i) determination of fertility rates improved after either surgical or non-surgical treatment of varicocele; ii) comparison of effectiveness resulted from surgical and non-surgical varicocele treatment; iii) sperms morphological improvement after embolization) studies from randomized control trials; iv) model dimensions of less than 10 participants; v) english morphological; and vi) availability of complete text. prisma guidelines have been followed as a standard for writing systematic and meta-analyses. initially, a comprehensive search yielded a total of 4635 articles (databases and register included). to refine the research and focus on the relevant literature, specific filters were applied, such as year of publication, the field of study, article type and studies related to varicocele effective management. the collection of data approach used precise combinations and variants of search terms such as “varicocele”; “fertility outcomes”; “complication rates”; “infertility in varicocele”; and “meta-analyses”. to ensure an in-depth search, terms such as “varicocele pathophysiology”; “varicoceleectomy”; and “pregnancy rates”; were included. the final dataset included 456 records for additional analysis and inclusion in the systematic review and meta-analysis, which included the most relevant and recent studies. inclusion and exclusion criteria inclusion criteria in addition to abstracts focused on relevance, the following inclusion and exclusion criteria were used as a second-hand filter on titles. we only considered research that have been submitted to and accepted by peerreviewed journals, even though we searched the grey literature. the inclusion criteria were established based on cochrane recommendations. randomized, non-randomized control trials and cohort studies were included for comparing surgical and non-surgical management of varicocele. include studies involving adult male patients diagnosed with varicocele. studies were included evaluating any surgical intervention for varicocele. studies included data on post-operative complications related to surgical interventions (e.g., infections, hematoma, testicular atrophy) and complications associated with non-surgical management. studies in english language were included to ensure the comprehensive coverage. abstracts were also considered for inclusion into this review because contrary to the typical recommendations of the preferred reporting items for systematic reviews and meta-analyses (prisma) protocol, experience in the beneficial use of abstracts allows for their inclusion for systematic review, provided that the relevant data (e.g., total sample population, group sample sizes, and treatment outcomes) needed for the analysis are indicated in the abstract. exclusion criteria studies published in languages other than english were excluded due to potential languages barriers that could impact data interpretation and inclusion. studies without comparative analysis between surgical and non-surgical management for varicocele were excluded, including those solely investigating medical management without a comparison to surgical interventions. studies involving animals or non-human subjects were excluded due to potential limitations in translating their outcomes directly to human contexts. studies lacking a comparative design, such as case reports, case series or those without a control group, were excluded from the analysis. studies that do not report relevant outcomes such as fertility parameters (e.g., sperm quality, pregnancy rates) and complications rates (e.g., recurrence rates, postoperative complications) were excluded from the analysis. data extraction this review focuses on the comparative evaluation of fertility outcomes after the surgical and non-surgical treatment of varicocele in humans, specifically between the age of 20 to 50 years of married man. a comprehensive search of 4565 articles was conducted from february 2018 to march 2024, using terms like “surgical treatment of varicocele”, “varicocele embolization”, “varicocele effects fertility”, “ varicocele impacts sperm viability” and “ varicocele embolization improves fertile”. abstracts were independently evaluated and scrutinized the entire text for eligibility. prisma guidelines were followed for systematic analysis and meta-analysis. the final dataset included 54 records for further analysis, including the most relevant and recent studies. pa ge 12 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 121-130, 2024 the identification of studies involves multiple stages, with the final selection based on specific criteria. the initial identification process involves removing duplicate records, screening 3572 records, excluding 3098 records, and assessing 474 full-text articles for eligibility. out of these 432 records were excluded as they were not related to fertility rate comparative analysis. the remaining 42 records are for qualitative analysis. quantitative analysis (meta-analysis) includes 14 studies, and the review includes 28 selected studies. the total number of selected studies was determined by meeting inclusion criteria and passing through the screening, fulltext assessment, and quantitative analysis stages, leading to the final selection of relevant and suitable studies for the review. data analysis our preliminary search included articles from three previously chosen credentials to validate our search method and ensure these publications were retrieved and selected. the observational research was assessed using the rob criteria, and the quality of the included studies was assessed using the “quality assessment of diagnostic accuracy studies (quadas)” questionnaire, which was utilized to conduct a thorough risk of bias evaluation. four main areas were examined in the evaluation: flow and timing, reference standard, index test, and patient selection. all estimates and 95% certainty intervals were used to create a forest plot and funnel plot. the instantaneous estimations of disorientation existence were calculated using random-effect models due to the anticipated variability in the available datasets. to check for heterogeneity, forest plots were analyzed quantitatively and qualitatively. risk of bias assessment the study discusses the risk of bias associated with the methodology of using surgical and non-surgical management of varicocele for predicting comparative outcomes of fertility in male patients: researchers acknowledge that the method has shortcomings, particularly in estimating the inception level of the fertility rate for predicting outcomes. to maximize predictive efficacy and to mitigate the rate biasness in the treatment, systematic differences between the groups being compared (surgical vs. nonsurgical management) were assessed. these factors should be considered and incorporated into logistic regression models to mitigate bias associated with their strong correlation with poor outcomes. the assessment of biomarkers at various time points and the measurement of numerous outcomes can exacerbate the risk of bias. in this review, the assessment of potential biases were critical components of the methodology. quality assessment of diagnostic accuracy studies (quadas) is figure 1: prisma flow chart pa ge 12 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 121-130, 2024 a diagnostic test accuracy tool that can evaluate the risk of bias in comparative accuracy studies (cochrane methods of quadas-c tool, 2022). reviewers independently assessed the risk of bias using the modified quadas questionnaire. each study was evaluated on four critical domains: “patient selection, index test, reference standard, and flow and timing”. results and discussion varicocele is a major cause of male infertility, affecting 15% of the general male population and 35% of men with infertility. treatment aims to enhance sperm parameters and fertility outcomes, with decisions based on factors like varicocele size, fertility goals, and symptoms. several studies suggest that surgical treatment, particularly microsurgical varicoceleectomy, has the highest rate of improvement in sperm parameters and pregnancy rates. open surgical repair is recommended, but risks include complications like hydrocele, varicocele recurrence, infection, and chronic testicular pain. non-surgical management, such as dietary supplements, may also be considered (ouanes et al., 2022; persad et al., 2021). study selection a concise systematic review and meta-analysis were performed to identify and evaluate pertinent studies regarding the comparative management and fertility outcomes of patients with varicocele who underwent surgical and non-surgical treatments. to identify all relevant studies published in the past 10 years, an exhausted search of electronic databases was carried out. the process for selecting precise and relevant studies to access biomarker accuracy is depicted in figure 2. figure 2: flow chart of selected studies for meta-analysis the flow chart depicts the study selection process for the meta-analysis. a total of 4286 records were identified through database searching, and an additional 238 records extracted through other sources. after removing duplicates (952), a total of 3,572 records underwent screening. among these, 3098 records were excluded, leaving 474 full-text articles for eligibility assessment. ultimately, 432 full-text articles were excluded, resulting in 28 articles included in systematic review. among these, 14 papers were also part of the meta-analysis. the comparative analysis of fertility rate outcomes was conducted across surgical and non-surgical management approaches. characteristics of included studies among 16 randomized controlled trials, 11 studies documented favorable fertility outcomes, while a smaller subset 5 studies investigated non-surgical treatments, showing less positive outcomes for varicocele patients or detailing varicocele treatment approaches. the study participants were adults with ages spanning from 20 to 70 years on average. patients cited reasons for evaluating varicocele treatments included overcoming infertility and increasing pregnancy rates, attributing successful outcomes to these interventions. pa ge 12 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 121-130, 2024 risk of bias assessment results in the meta analysis, assessing potential biases using the modified quadas questionnaire yielded favorable results. each study underwent thorough scrutiny across four crucial domains including patient selection, index test, reference standard, flow and timings by impartial reviewers. this rigorous evaluation process indicated minimal risk of bias in most studies, highlighting strong methodology in assessing both surgical and nonsurgical management for predicting fertility outcomes in varicocele patients. utilizing data dependent threshold calculation and logistic regression models, researchers effectively demonstrated the significant benefits of varicoceleectomy in improving sperm quality and morphology, reducing infertility complications. these findings underscore the reliability and validity of the meta-analysis in evaluating varicoceleectomy efficacy for varicocele effected patients. comparison of the efficacy of surgical and nonsurgical management of varicocele a meta-analysis was conducted to evaluate the treatment efficacy for varicocele associated infertility. forest plots were generated to provide a visual summary finddings from two comparative studies. these plots display the odds ratios (or) and their corresponding 95% confidence intervals (cl) for each study, alongside the pooled or and cl for both studies. the horizontal line at or=1.0 represents no association between treatment type and fertility rates. an or greater than 1.0 suggests a positive association, while or less than 1.0 indicates a negative association. the width of the confidence interval reflects the precision of the estimate, with wider intervals lower precision, as illustrated in table 1. table 1: forest plot of selected studies indicating surgical management outcomes studies odd ratio lower confidence level upper confidence level (huang et al., 2014) 0.70 0.76 0.92 (abdel-meguid et al., 2011) 3.04 1.84 5.98 (fallara et al., 2023) 1.29 1.00 1.65 (marmar et al., 2007) 2.87 1.33 6.2 (kim et al., 2013) 1.9 0.77 4.66 (baazeem et al., 2011) 2.23 0.86 5.78 (birowo et al., 2020) 1.82 1.37 2.41 (will et al., 2011) 1.1 0.73 1.68 (wang et al., 2015) 2.9 1.92 19.6 (kirby et al., 2016) 1.76 1.267 2.284 (tiseo et al., 2016) 2.87 1.33 6.02 pa ge 12 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 121-130, 2024 analysis of surgical management to compare improved fertility outcomes the provided studies offer compelling evidence that surgical varicocele treatment, known as varicoceleectomy can significantly improve fertility outcomes in men with varicocele and abnormal semen parameters. (abdelmeguid et al., 2011; fallara et al., 2023; huang et al., 2014) demonstrated improved pregnancy rates for couples where the male partner undergoes varicocele repair. odds ratio range from 1.29 to 3.04, indicating a 29% to 304% increase in pregnancy. varicoceleectomy improves sperm concentration, motility and morphology. this improvement was observed in men with severe conditions like azoospermia (no sperm in semen), while showed a69% high success rate of surgical retrieval after varicocele treatment for use in ivf (abdel-meguid et al., 2011; baazeem et al., 2011; huang et al., 2014). (abdel-meguid et al., 2011; birowo et al., 2020) reported a significant increase in live birth rates following varicocele repair, with odds ratio up to 2.80, translating to a 180% higher chance of live birth. durable improvement (microsurgical varicoceleectomy) offers a long lasting solution, showed sustained improvement in semen parameters for up to 12 months’ post-surgery. it is important to note that the most significant benefits were seen in men with clinically detectable varicocele and abnormal semen analysis. (baazeem et al., 2011; kim et al., 2013; tiseo et al., 2016) showed that men with subclinical varicocele or normal semen parameters may not experience the same level of improvement. preoperative factors including age and baseline sperm density can influence the success of varicoceleectomy, (huang et al., 2014) suggest that younger patients and those with higher baseline sperm density tend to have better outcomes. suggest that microsurgical approaches like inguinal or sub inguinal may offer advantages over traditional open surgery. these techniques are associated with higher pregnancy rates, improved sperm parameters and lower complication risks. however patient selection and surgical technique are crucial factors for optimal outcomes (kirby et al., 2016; wang et al., 2015). table 2: forest plot of selected studies indicating non-surgical management outcomes studies odd ratio upper confidence level lower confidence level (pyrgidis et al., 2021) 2.28 12.09 6.41 (agarwal et al., 2023) 2.97 4.63 1.19 (arhin et al., 2021) 90.21 13.69 6.6 (ghanem et al., 2010) 3.76 13.64 1.03 (busetto et al., 2024) 2 4.14 0.97 analysis of non-surgical management to compare improved fertility outcomes the analysis of the studies regarding non-surgical management of varicocele for improving fertility outcomes highlights several findings. (pyrgidis et al., 2021) suggest that antioxidant supplementation does not significantly improve pregnancy rates or semen parameters in patients with varicocele associated infertility, unless previous screening for oxidative stress was conducted. pa ge 12 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 121-130, 2024 table 3: comparative evaluation of surgical and non-surgical management of varicocele to express fertility outcomespooled studies studies odd ratio lower confidence level upper confidence level (huang et al., 2014) 0.7 0.92 0.76 (abdel-meguid et al., 2011) 3.04 5.98 1.84 (fallara et al., 2023) 1.29 1.65 1 (marmar et al., 2007) 2.87 6.2 1.33 (kim et al., 2013) 1.9 4.66 0.77 (baazeem et al., 2011) 2.23 5.78 0.86 (birowo et al., 2020) 1.82 2.41 1.37 (will et al., 2011) 1.1 1.68 0.73 (wang et al., 2015) 2.9 19.6 1.92 (kirby et al., 2016) 1.76 2.284 1.267 (tiseo et al., 2016) 2.87 6.02 1.33 (pyrgidis et al., 2021) 2.28 12.09 6.41 (agarwal et al., 2023) 2.97 4.63 1.19 (arhin et al., 2021) 90.21 13.69 6.6 (ghanem et al., 2010) 3.76 13.64 1.03 (busetto et al., 2024) 2 4.14 0.97 pa ge 12 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 121-130, 2024 while (agarwal et al., 2023) acknowledged that the efficacy of antioxidant treatments in improving pregnancy rates, although the evidence quality was noted to be low. (arhin et al., 2021) stated that some antioxidant treatment including l-carnitine + acetyl-carnitine may improve sperm outcomes in sub fertile patients, combinations with other antioxidants were not effective. this suggests variability in the effectiveness of different antioxidant combinations. ghanem’s randomized controlled trial provided results for a combination treatment of clomiphene sitrate and vitamin e, showing a significant higher pregnancy rate and improved sperm parameters in cases of idiopathic oligoasthenoozospermia (ghanem et al., 2010). (busetto et al., 2024) indicates a statistically significant increase in sperm concentration with antioxidant treatment compared to placebo, supporting the potential benefits of antioxidants in improving fertility outcomes. however, younger age and lower bmi are associated with positive outcomes, while varicocele itself does not significantly impact sperm concentration values. comparative evaluation of surgical and nonsurgical approaches in managing varicocele for enhanced fertility outcomes –pooled studies studies comparing surgical and non-surgical management of varicocele have shown that surgical treatment significantly improves pregnancy rates, sperm parameters, live birth rates, and success of sperm retrieval. it also offers long-lasting improvements in semen quality, particularly in men with azoospermia. non-surgical treatment, such as varicocele embolization, offers faster recovery, minimal invasiveness, and immediate pain relief. it is performed under local anesthesia, reducing risks and costs associated with surgery. it also offers effective pain relief and a lower recurrence rate compared to surgery. antioxidant supplementation alone does not significantly improve pregnancy rates or semen parameters in varicocele-associated infertility. however, some studies suggest combining antioxidants with other treatments like clomiphene citrate and vitamin e, leading to improved pregnancy rates and sperm parameters in specific cases. according to guidelines from the european association of urology (eau) and the american society for reproductive medicine (asrm), varicocele correction, including surgical and angiographic embolization, is beneficial for lowering sperm dna fragmentation (sdf) and increasing reproductive results (busetto et al., 2022; garg & kumar, 2016). conclusively, surgical intervention such as varicoceleectomy continues to be the principal means of enhancing the quality of life for sperm parameters, long-term outcomes, and pregnancy rates in men with varicocele. varicocele embolization is one of the nonsurgical methods that offers less invasiveness and a quicker rate of recovery. discussion varicocele, a prevalent condition affecting men, especially those with infertility, is caused by venous reflux and elevated hydrostatic pressure, with its impact on fertility outcomes being a significant concern. varicoceleectomy, a surgical procedure, restricts veins to redirect blood flow, while non-surgical techniques like varicocele embolization offer reduced complications and faster recovery, requiring comparison to understand their effectiveness in managing problems and improving reproductive outcomes. the study used a systematic approach to identify studies comparing surgical and non-surgical varicocele management, focusing on fertility rate improvements, effectiveness, randomized controlled trials, and complete english texts. the meta-analysis screened randomized controlled trials and cohort studies involving adult male patients with varicocele, evaluating management strategies. forest plots were used to visually summarize findings, while a modified quadas questionnaire was used for risk of bias assessment. this critical evaluation minimized bias and enhanced the reliability of the results. surgical varicocele treatment, such as varicoceleectomy, has been shown to significantly improve fertility outcomes in men with varicocele and abnormal semen parameters. studies have shown improved pregnancy rates, sperm concentration, motility, and morphology in couples where the male partner undergoes varicocele repair (persad et al., 2021). this improvement is observed in men with severe conditions like azoospermia and has a high success rate of surgical retrieval for use in ivf (zengerling, 2022). microsurgical varicoceleectomy offers a long-lasting solution, showing sustained improvement in semen parameters for up to 12 months’ post-surgery. however, the most significant benefits were seen in men with clinically detectable varicocele and abnormal semen analysis. preoperative factors such as age and baseline sperm density can influence the success of varicoceleectomy (phan et al., 2021). microsurgical approaches like inguinal or sub inguinal may offer advantages over traditional open surgery, but patient selection and surgical technique are crucial factors for optimal outcomes. non-surgical management of varicocele for improving fertility outcomes has also been studied. studies suggest that antioxidant supplementation does not significantly improve pregnancy rates or semen parameters in patients with varicocele-associated infertility, unless previous screening for oxidative stress was conducted (pyrgidis et al., 2021). non-surgical treatments like varicocele embolization offer faster recovery, minimal invasiveness, and immediate pain relief. antioxidant supplementation alone does not significantly improve pregnancy rates or semen parameters in varicocele-associated infertility (inci & gunay, 2013). some studies suggest combining antioxidants with other treatments, leading to improved pregnancy rates and sperm parameters in specific cases. pa ge 12 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 121-130, 2024 limitations the evaluation of long-term advantages may be hampered by the lack of long-term data on reproductive outcomes following treatment, especially for non-surgical methods. the inclusion of studies with varying designs, patient populations, and outcome measures resulted in heterogeneity and impact the applicability of the findings. the publication bias, where positive results are more likely to be published, can potentially affect the overall effect estimates and interpretation of findings. the reliability and validity of the meta-analysis results may be affected by variability in the quality of included studies, despite using a modified quadas questionnaire for risk assessment. conclusion in conclusion, surgical treatment like varicoceleectomy remains a primary option for improving fertility outcomes in men with varicocele, offering significant benefits in terms of pregnancy rates, sperm parameters, and longterm results. non-surgical approaches like varicocele embolization provide alternatives with faster recovery and minimal invasiveness, while antioxidant supplementation may have a supportive role in combination therapies but does not show conclusive benefits as a standalone treatment. recommendations increase the number of rcts comparing surgical and non-surgical varicocele management, particularly with long-term follow-ups, to evaluate sustained fertility outcomes. conduct subgroup analyses based on preoperative factors like age, baseline sperm parameters, and varicocele severity can identify patient groups that benefit most from different management approaches. longitudinal studies should be encouraged to assess the long-term impact of non-surgical techniques like varicocele embolization beyond the immediate posttreatment period. the study suggests incorporating cost-effectiveness analyses to evaluate the economic impact of various varicocele management strategies, considering both short-term and long-term costs. references abdel-meguid, t. a., al-sayyad, a., tayib, a., & farsi, h. m. 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(2022). surgical or radiological treatment of varicoceles in subfertile men. urologie (heidelberg, germany), 61(12), 1382-1386. pa ge 1 pa ge 11 8 american journal of medical science and innovation (ajmsi) preclinical use of group i metabotropic glutamate receptors (group i mglurs) for ischemic stroke: systematic review and meta-analysis md. saidur rahman1*, md. khalid hasan1, md. sajal khan1 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.6056 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 12, 2025 accepted: october 10, 2025 published: november 21, 2025 in ischemic stroke, metabotropic glutamate receptors (mglurs) have a complex role. results from studies using both agonists and antagonists of these receptors have been inconsistent. this systematic review and meta-analysis assesses multiple preclinical investigations on group i mglur agonists and antagonists. effect sizes for various outcomes, study quality scores, bias risk, and interactions with clinical factors related to functional and histological outcomes were analyzed based on relevant papers. twelve papers covering 41 treatment groups of 26 interventions from 1999 to 2023 were included. twelve studies (25 treatment arms) reported structural outcomes, while eight studies (16 treatment arms) reported functional outcomes, with a median quality score of 4 out of 10. expected results showed larger effect sizes. the mean effect sizes for neurological score and infarct volume improved by -0.75 smd and -1.37 smd, respectively, after subgroup adjustments and sensitivity analysis. effect sizes for neuroprotection, neuronal loss, brain temperature, and nmda receptor activity with antagonist treatment were 1.73 smd, -1.35 smd, -0.05 smd, and -0.41 smd, respectively. while antagonists significantly (p < 0.05) improved both structural and functional outcomes, agonists only improved structural results. however, syrcle’s risk-ofbias tool for animal studies identified potential bias. additionally, clinical variables such as dosage and administration mode of agonist or antagonist medications influenced the effect magnitude. despite the promising results in preclinical studies, several drugs have failed to prevent ischemic stroke in human clinical trials. future research using animal models of stroke is recommended to improve study quality, validity, and reduce the risk of bias. keywords agonist, antagonist, group i mglurs, ischemic stroke, preclinical studies 1 department of anatomy and histology, faculty of animal science and veterinary medicine, patuakhali science and technology university, bangladesh * corresponding author’s e-mail: saidur@pstu.ac.bd introduction stroke is one of the leading causes of death and disability in developed nations (macarena et al., 2017). a damaged or clogged blood vessel stops the flow of blood to a portion of the brain, causing dysfunction in the affected area. there isn’t a treatment that works well enough to enhance clinical recovery following a stroke at the moment. although it may raise the risk of cerebral hemorrhage, tissue plasminogen activator (tpa) is important in the early stages of ischemia (ning et al., 2010). restorative therapy, such as group i metabotropic glutamate receptors (mglurs) blockers and/or activators, may help lessen neurological impairment. in pathological situations, group i mglurs, which comprise two subtypes, mglur1 and mglur5, are intriguing targets for treatment in neurodegeneration and acute and chronic traumas. it has been demonstrated that mglur1 antagonists reduce neuronal mortality following brain trauma in vivo and mechanical injury in vitro. group i mglurs antagonists have also been found to have a neuroprotective effect in ischemic stroke (faden et al., 2001; kinga et al., 2007). although some publications noted that both agonists and antagonists of the mglur5 receptor are neuroprotective, no positive effects of the mglur5 agonist were observed in a model of endothelin-1-induced localized ischemia in rats (riek-burchardt et al., 2007; bao et al., 2001). in addition to being linked to new neurons, mglur5 antagonists are also anticipated to alter the milieu of sick tissue (norio et al., 2012). because agonists of these receptors have been shown to either increase or decrease neuronal cell death, and antagonists of these receptors are consistently neuroprotective, the function of group i mglurs in animal models of ischemia is still debatable (nicoletti et al., 1999). both endogenous and exogenous sources may offer viable treatments for ischemic stroke. however, it has been shown that endogenous neuro-regeneration is not enough to restore damaged brain tissue (lee et al., 2011; minger et al., 2007). group i mglurs agonist and/ or antagonist exogenous therapy for ischemic stroke has been successfully implemented, according to several studies (bao et al., 2001; hailong et al., 2013; dorota et al., 2006; elena et al., 2002). the findings showed that group i mglurs agonists and/or antagonists may considerably aid in the restoration of brain tissue and neuro-functional outcomes. it is anticipated that the agonist and antagonist of group i mglurs would mediate homeostasis and tissue healing by controlling the release of brain trophic factors or by interacting with immune cells that live in and infiltrate the central nervous system. a statistical summary of the findings is called a metaanalysis (nordmann et al., 2012; o’rourke, 2007). the estimation of the extent of effect is improved and ambiguity is resolved by combining the data of several studies using a statistical method rather than relying pa ge 11 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 118-126, 2025 just on individual studies (walker et al., 2008). a global estimate of the effectiveness of medication treatment in preclinical stroke models is limited, but there are several research and interventional techniques for the use of agonists and antagonists of group i mglurs in experimental stroke. thus, the current study’s goal was to assess group i mglurs’ potential as a treatment for ischemic stroke in preclinical research. materials and methods search strategy the publications were looked up using the science citation index, isi web of science, and pubmed for animal models of ischemic stroke until december 2023. the literature review was conducted using the prisma flow diagram and guidelines (figure 1). the supporting information (table 1) describes the search strategy. the featured publications were authored exclusively in english. studies that used hemorrhagic stroke models instead of ischemic ones, transgenic studies, neonatal hypoxia/ischemia models, and in vitro research were excluded. by looking at the parent institution, sample size, author list, and outcome, reports of duplicate research were eliminated. lastly, trials in which the mglur agonist or antagonist interacted with other biological effects, including gene alteration, or in which the therapies were administered with monitored imaging instead of enhancing outcomes, were not included. data extraction authors, year of publication, type of intervention (agonist and antagonist), animal species, cerebral ischemia type, intervention dose, duration of administration, delivery route, anesthetic used, outcome assessment (structural and functional), outcome measure used, mean outcome, sd (standard deviation) or se (standard error), number of animals per group, study quality, and risk of bias assessment were among the data we extracted (tables 2–5). the outcome in the control (vehicle) group, as opposed to the treated group, is what we referred to as the treatment comparison. we considered multiple interventions to be another intervention if more than one intervention and treatment duration were provided in a single research. additionally, we regarded the efficacious doses at a specific time of administration as a distinct treatment arm if the same intervention was delivered in numerous doses. furthermore, we only took into account the infarct volume from the greatest infarct in control slices and the smallest infarct in the experimental group if data from several brain slices were given in structural results. another intervention was the assessment of infarct volume throughout varying treatment durations. lastly, only the lowest neurological score for a given treatment period was included if functional outcomes were recorded for more than one time point. every available source, including text and figures, was used to extract quantitative data for each study. we used quantitative techniques on highly magnified images to measure mean and sd/sem values from graphs when the data were solely displayed graphically (getdata graph digitizer, version 2.26.0.20). quality assessment the quality score evaluation method reviewed the checklist of animal data from experimental studies (lees et al., 2012; vu et al., 2014) and established 10 criteria based on stair guidelines (landis et al., 2012; fisher et al., 2009; macleod et al., 2004) for each preclinical study included in the meta-analysis. (1) publication in a peerreviewed journal; (2) statements explaining temperature control; (3) random assignment of animals to treatment group; (4) allocation concealment; (5) blinded outcome assessment; (6) avoidance of anesthetics with known marked intrinsic neuro-protective properties; (7) use of animals with pertinent comorbidities; (8) inclusion of a sample-size calculation; (9) statement of compliance with animal welfare regulations; and (10) inclusion of a statement declaring the presence or absence of any conflicts of interest. each reported criterion was worth one point. higher scores indicate better methodological rigor; the potential score goes from 0 to 10 (chen et al., 2016). risk of bias assessment using syrcle’s risk of bias tool for animal studies, two reviewers independently evaluated the risk of bias, such as systematic mistakes (hooijmans et al., 2014). there are ten entries in this animal research tool. the items in the cochrane risk of bias tool agreed with half of the items. the majority of the discrepancies between the two instruments resulted from the design differences between animal research and rcts. data analysis the improvement in outcome in treated (intervention) animals compared to untreated ischemia (control) groups was used to calculate the endpoint effect size of group i mglurs agonist and/or antagonist therapy. review manager 5.3 was the program utilized for the meta-analysis of outcome measures. because there was significant heterogeneity across treatment doses and time points, we employed the random effect model (borenstein et al., 2010) for the meta-analysis. to report the improvement in treated groups, we used the inversevariance (iv) technique approach in units of sd to assess significance and the mean effect size using standardized mean difference (smd) with a 95% confidence interval (ci) for all included outcomes. a meta-analysis was conducted using the effect size of various doses and time points. results that were expected to decrease were employed at the left graph level as an experiment and the right graph level as a control; however, the opposite was true for results that were expected to increase. we regarded it as an additional treatment group to estimate efficacy if more than one structural or functional result was reported for the same cohort of animals at the same time point or at a different time point. sensitivity analysis pa ge 12 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 118-126, 2025 was then used to identify the treatment arms that were not appropriate and to ascertain the heterogeneities of the remaining studies. this method can determine why other estimates in strata were considerably different and examine if studies were taken from a homogeneous population. figure 1: prisma flow diagram showing summary of study selection procedure. results and discussion study characteristics 12 out of 1899 papers and 41 treatment groups comprising 26 distinct interventions (5 agonist and 21 antagonist) were selected for the current systematic review and metaanalysis. 10 research used temporary middle cerebral artery occlusion (tmcao) to induce cerebral ischemia. two of these investigations used intraluminal blockage of the middle cerebral artery, seven used bilateral carotid artery occlusion (bcao), and one used endothelin-1 microinjection. permanent mcao was found in 2 studies: photothrombosis induced by rose bengal dye (1 study) and mcao (1 study). among 21 antagonist interventions, 12 mglur5 antagonist (mpep = 9 and mtep = 3) and 5 mglur1 antagonist (2 interventions of ly367385 and 3 interventions of emqmcm) were recorded. one intervention was treated with combined therapy of mpep+ly367385, and 3 treatments were carried out with group i (mglur1 and mglur5) selective antagonist with mcpg, cbpg, and aida, respectively. the other 5 agonist interventions were treated with mglur5-specific agonist, chpg (4 interventions) and group i selective agonist, dhpg (1 intervention). furthermore, 10 out of 26 interventions used gerbils, 7 interventions used sd rat, 6 interventions used wister rat, and 3 interventions used c57bl/6j mice in the experiments. regarding the route of administration, 11 interventions of 5 studies were performed via intracerebroventricular (i.c.v.) microinjection (stereotactic), 11 interventions of another 5 studies were delivered by intraperitoneal injection (ip), 3 interventions of one study were applied through the tail vein, and one intervention of one study used the intrathecal route. anesthetic agents were used in all 26 interventions of 12 studies during stroke induction (table 2). the present study found 41 treatment groups, of which functional outcome was reported in 16 treatment groups (8 for neurobehavioral, 4 for nmda receptor, and 4 for brain temperature) of 8 studies, and structural outcome in 25 treatment groups (12 for infract volume, 8 for neuroprotection and 5 for neuron loss) of all 12 articles (table 3). interpretation of quality score and risk of bias assessment the interquartile range for the quality score checklist items was 3–6, with a median score of 4 out of 10. peer-reviewed journals have published all of the studies. all studies avoided using anesthetics with known marked intrinsic neuroprotective properties; none used animals with relevant comorbidities (e.g., hypertension); none reported a sample size calculation or allocation concealment during the experiment; 11 studies reported compliance with animal welfare regulations; one study reported possible conflicts of interest; and two of twelve studies reported blinded assessment of the results and randomized allocation to treatment groups (table 4). the mean effect size in the current meta-analysis remained slightly high (-0.75 smd with p > 0.05 for neurological pa ge 12 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 118-126, 2025 score, -1.37 smd with p < 0.00001 for infract volume, 1.73 smd with p < 0.00001 for neuroprotection, and -1.35 smd with p < 0.00001 for neuron loss), even though the overall estimation of the included outcomes represented larger effect sizes even after adjusting these effect sizes by subgroup and sensitivity analysis. conversely, the effect sizes were less for the nmda receptor (done by almost identical authors) and brain temperature (performed by nearly identical authors), at -0.41 smd and -0.05 smd, respectively; however, both effect sizes were statistically insignificant (p > 0.05). according to this study, the risk of bias was assessed using syrcle’s risk of bias tool for animal studies (hooijmans et al., 2014) (table 5). meta-analysis of effect sizes neurological score decreased in a meta-analysis of eight treatment arms of four studies with 32 animals in control groups and 60 animals in treatment groups of both agonist and antagonist interventions (table 1). however, the heterogeneity test among these 4 studies showed that the neurological score significantly favors the treatment (supplementary fig. 1). the sensitivity analysis (removal of effect size >3 smd) improved the reduction of the neurological score effect size (table 1) and heterogeneity, which significantly favors the treatment again. we did not compare the effectiveness of various training regimens for this outcome because there aren’t many studies that evaluate neurobehavioral scores. the effect size increased by -2.07 smd with 95% ci (-3.35, -0.79) after stratification by agonist or antagonist intervention; heterogeneity: tau2 = 1.27; chi2 = 12.42, df = 3; i2 = 76%, overall p = 0.002; (figure 2) in antagonist treatment arms, and it significantly (p < 0.05) affects the treatment. in this case, one intervention’s effect size was greater than three smd. table 1: effect sizes of different outcomes measures measures before adjustment after adjustment es >3 arms no. mean (es) 95% ci no. p value mean (es) 95% ci no. p value neurological score* -0.23 -0.84, 0.39 4 0.47 -0.00 -0.57, 0.56 3 0.99 infarct volume* -0.94 -1.45, -0.43 5 0.0003 -0.82 -1.35, -0.28 4 0.003 neurological score# -2.07 -3.35, -0.79 4 0.002 -1.42 -2.17, -0.67 3 0.0002 1 infarct volume# -1.85 -2.52, -1.18 7 <0.00001 -1.63 -2.21, -1.05 6 <0.00001 1 neuroprotection# 2.48 1.50, 3.47 8 <0.00001 1.73 1.08, 2.38 6 <0.00001 2 neuron loss# -1.58 -2.18, -0.99 5 <0.00001 -1.35 -1.85, -0.85 4 <0.00001 1 brain temperature# -0.34 -1.43, 0.75 4 0.54 -0.05 -0.62, 0.52 3 0.87 1 nmda receptor# -1.11 -2.45, 0.22 4 0.10 -0.41 -1.58, 0.76 2 0.49 2 neurological score## -1.09 -1.94, -0.24 8 0.01 -0.75 -1.39, -0.11 7 0.02 1 infarct volume## -1.52 -2.00, -1.04 12 <0.00001 -1.37 -1.79, -0.95 11 <0.00001 1 note: for each effect size, the 95 % ci does not cross zero, and the p value <0.05 indicates that results favor mglurs treatments, whereas the p value >0.05 does not favor mglurs treatments. es, effect size; ci, confidence interval; no, number of intervention. *agonist interventions, #antagonist interventions, ##agonist and antagonist interventions together. following antagonist treatment, the neurological score significantly decreased (p <0.05) according to sensitivity analysis adjustment of effect sizes (table 1). additionally, we assessed the neurobehavioral outcomes that were most commonly observed in the mice, as well as the effect size of group i mglurs agonist and antagonist therapy, independently. the neurological score outcome for agonist-treated interventions was found to be lower than that of antagonist-treated interventions in terms of both effect magnitude and heterogeneity (figure 2). the heterogeneity and effect size of the included studies decreased even after sensitivity analysis (removal of height effect size); but, surprisingly, the outcome did not significantly (p > 0.05) favor the therapy before and after correction of interventions. pa ge 12 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 118-126, 2025 with 105 animals in the experimental groups and 46 in the control groups, the mean infarct size of 5 studies and 12 interventions (both agonist and antagonist) was decreased (figure 2). although there were 12 treatment arms where effect size of one treatment was >3.0, and after removal of this inadaptable treatment, the heterogeneity of remaining interventions went down and the effect size was recorded (table 1). heterogeneity was tau2 = 0.49; chi2 = 15.94, df = 6; i2 = 62%, overall p < 0.00001, and the mean infarct size in 7 antagonist interventions of 3 studies, which included 34 animals in control and 70 animals in experimental groups, was -1.85 smd with 95% ci (-2.52, -1.18) (figure 3a). however, there was 1 intervention dominated by effect size 3.78. after removing this inadaptable treatment under sensitivity analysis, the heterogeneity was low and the effect size was -1.63 smd with 95 % ci (-2.21, -1.05) (table 1). contrarily in 5 agonist interventions of 3 studies, the heterogeneity was i2 = 0 %; p = 0.0003 and infract size was -0.94 smd (95 % ci, -1.45, –0.43) with < 1 smd effect size in almost all interventions (excluding effect size -2.42 smd) (figure 3b). removal of this biggest inadaptable result in sensitivity analysis showed the effect size, -0.82 smd with 95 % ci (-1.35, -0.28). figure 2: neurobehavioral effect size of group i mglurs across studies. the forest plot showed median effect size and 95% ci for the neurological score of antagonist interventions (a) and agonist interventions (b) compared with the control group. std, standardized; iv, inverse variance; ci, confidence interval; df, degrees of freedom. figure 3: infarct volume effect size of group i mglurs across studies. forest plot showed median effect size and 95% ci for infarct volume of antagonist interventions (a) and agonist interventions (b) compared with the control group. std, standardized; iv, inverse variance; ci, confidence interval; df, degrees of freedom. pa ge 12 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 118-126, 2025 the mean effect size for the neuroprotection or live neuron cells count included 5 studies and 8 antagonist interventions was measured as 2.48 smd with 95 % ci (1.50, 3.47) where 2 interventions were more than 3 smd, with the greatest smd 5.65 in one study. the number of animals (wister rat, gerbils) in both control and experimental groups was 11. heterogeneity was recorded as tau2 = 1.41; chi2 = 24.74, df = 7; i2 = 72 %, overall p < 0.00001 (figure 4). after removal of inadaptable intervention (effect size > 3 smd) in sensitivity analysis, the heterogeneity was found lower to tau2 = 0.15; chi2 = 6.39, df = 5; i2 = 22 %, overall p < 0.00001 and effect size was 1.73 smd with 95 % ci (1.08, 2.38) (table 1). separately two antagonist interventions in wister rat showed effect size > 2 smd but the heterogeneity tau2 = 0.00; chi2 = 0.02, df = 1; i2 = 0 %, overall p < 0.0001 (supplementary fig. 3a) whereas in 6 interventions of gerbils showed effect size 2.50 smd (>2 smd in 3 interventions with higher smd 5.65) and heterogeneity was tau2 = 1.95; chi2 = 24.29, df = 5; i2 = 79 %, overall p = 0.0001 (supplementary fig. 3b). after sensitivity analysis the effect size was found as 1.97 smd with 95 % ci (0.96, 2.98) (table 1). figure 4: neuroprotection effect size of group i mglurs antagonist interventions across studies. the forest plot showed the median effect size and 95% ci for neuroprotection of antagonist interventions compared with the control group. std, standardized; iv, inverse variance; ci, confidence interval; df, degrees of freedom figure 5: effect size of group i mglurs antagonist interventions across studies. forest plot showed median effect size and 95% ci for neuronal loss (a), brain temperature (b), and effect on nmda receptor (c) compared with the control group. std, standardized; iv, inverse variance; ci, confidence interval; df, degrees of freedom. pa ge 12 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 118-126, 2025 the size of the effect of antagonist treated neuron loss (5 interventions of 3 studies included 29 animal in control and 49 in experimental groups) and brain temperature (4 interventions of 2 studies included 14 animal in control and 28 in experimental groups) outcomes were reduced by -1.58 smd with 95 % ci (-2.18, -0.99) and -0.34 smd with 95 % ci (-1.43, 0.75) respectively. the heterogeneity was measured in neuron loss outcome where in 4 interventions smd were >1 with greater smd 3.09 (figure 5a). the heterogeneity with overall p = 0.54 was found in brain temperature outcome where 3 interventions smd were less than 1 and in one study smd was -4.81 (figure 5b). after sensitivity analysis the heterogeneity was same in both studies but overall p < 0.00001 in neuronal loss and overall p = 0.87 in brain temperature outcomes and effect sizes were -1.35 smd with 95 % ci (-1.85, -0.85) in neuronal loss and -0.05 smd with 95 % ci (-0.62, 0.52) in brain temperature outcomes (table 1). the effect size for nmda receptor of 4 antagonist interventions of 2 studies was found to be -1.11 smd with 95 % ci (-2.45, 0.22). here we found the effect size < 0.5 smd in 2 interventions and > 3 smd in another 2 interventions and heterogeneity with overall p = 0.10 (figure 5c). after adjustment of effect size by sensitivity analysis (removal of effect size > 3 smd) the heterogeneity i2 = 0 %, and effect size was -0.41 smd with 95 % ci (-1.58, 0.76) but it was statistically insignificant (p > 0.05) (table 1). discussion one of the world’s major causes of death and disability, ischemic stroke has been the focus of intense research in recent years (ström et al., 2013). enhancing this endogenous process could be a treatment approach to improve functional outcome because adult neurogenesis is a restricted process in humans (greenberg et al., 2007). in this regard, mglur agonists and/or antagonists may be a good option to provide their protective function in the treatment of stroke. consequently, several writers have presented conflicting findings regarding the assessment of deficits following experimental ischemia, depending on the species, strain, age, and experimental model employed, as well as the timing of the test (rosell et al., 2013). several outcomes, including infarct volume of agonist and antagonist interventions and neuroprotection, neuronal loss, and neurological score of antagonist intervention, significantly favor the treatments, according to this metaanalysis, which primarily looked at preclinical studies of group i mglurs agonist and antagonist in the treatment of animal ischemic stroke. nevertheless, no correlation was found between the agonist or antagonist dosage and the delivery method, possibly because the majority of studies used intraperitoneal or intracerebroventricular stereotactic injections to deliver the drug to the lesion. however, our findings point to the need for additional molecular research on group i mglurs agonists and antagonists for the treatment of ischemic stroke in the future. the current study’s median quality score, using the same items from the quality score checklist, was 4 (interquartile range: 3–6), which is lower than the preclinical studies on nscs for ischemic stroke (chen et al., 2016) and preclinical mesenchymal stromal cells for ischemic stroke (vu et al., 2014). it is also consistent with the study on preclinical stem cell therapy (lees et al., 2012). lower quality studies typically exaggerate intervention or experimental effects (schulz et al., 1995), while higher quality studies typically provide more effective evaluation of preclinical research impacts (o’collins et al., 2006). in this current meta-analysis, moderate effect sizes were observed. for group i mglurs agonists, the effect sizes for two outcomes, neurological score and infarct volume, were identified. the heterogeneity in neurological scores was lower but not statistically significant (p > 0.05). this meta-analysis reveals that neurological scores significantly favor treatment with group i mglurs antagonists and disfavor agonist treatment, aligning with previous studies (chen et al. 2016). differences in drug dose, administration route, type of ischemic stroke, and animal models may contribute to the variations in effect sizes within the agonist or antagonist groups, or between them. the intracerebroventricular (icv) route was used by 11 interventions across 5 studies (riek-burchardt et al., 2007; bao et al., 2001; norio et al., 2012; norio et al., 2010; bruno et al., 1999), and the intraperitoneal (ip) route was used by 11 interventions across 5 studies (kinga et al., 2007; dorota et al., 2006; elena et al., 2002; muralikrishna et al., 2000; malgorzata et al., 2006). overall, the assessment indicates that the icv route of administration is more effective than ip injection. due to these factors, significant heterogeneity existed in behavioral and anatomical outcomes, which we addressed through subgroup and sensitivity analyses, as well as bias risk assessments. generally, an effect size >0.8 is considered as a large effect (schulz et al. 1995). in this meta-analysis considerable lower effect sizes were found in the neurological score against agonist interventions and brain temperature outcome against antagonist interventions, but neither of the outcomes were not statistically significant (p >0.05). after removing the inadaptable treatment with effect sizes >3 from a particular treatment group, the rest effect sizes were improved significantly in some cases, but it remained high effect sizes in infract volume, neurological score, neuroprotection, neuron loss, and effects on nmda receptors in antagonist interventions. for neurological score and infarct volume, the biggest effect sizes were -4.57 smd and -3.78 smd, respectively (kinga et al. 2007), but these effect sizes were lower than the study on transplantation of nscs modified by glial cell linederived neurotrophic factor (gdnf) gene to native nscs transplantation after ischemic stroke (chen et al. 2009). the primary weakness of this investigation was that it was observational rather than experimental. only the association of studies was provided; all other findings are hypotheses. even if our search was thorough, there’s a chance that some published research was overlooked. the current analysis may overestimate the effects of group i mglurs agonist and antagonist treatments in ischemic stroke due to the potential use of low-quality research. pa ge 12 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 118-126, 2025 conversely, there were some signs of publication bias influencing the meta-analysis’s findings (feng et al., 2016), a typical occurrence that often affects animal study metaanalyses (briel et al., 2013; korevaar et al., 2011). we were unable to compare our data with any meta-analyses on ischemic stroke and mglurs. the use of mglurs in experimental ischemic stroke, however, may have been reviewed by our work, which is likely to have documented the primary trend in the field of mglurs treatment. conclusion in preclinical ischemic animal models, group i mglurs antagonists were primarily linked to significantly better functional and structural outcomes, according to the current systematic review and meta-analysis. it also offered some helpful tools for future therapeutic research on mglurs in clinical ischemic stroke. long-term consequences, risk assessment, and improvements in neural structural and functional regeneration and repair should all be taken into account in future research, including mglurs treatment. references bao, w. l., williams, a. j., faden, a. i., & tortella, f. c. 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(2008). meta-analysis: its strengths and limitations. cleve clin j med., 75(6), 431–439. pa ge 1 pa ge 73 american journal of medical science and innovation (ajmsi) associated systemic risk factors and neuro-imaging findings of unilateral optic disc swelling in a bangladeshi population farjana sharmeen shimu1*, abir bin sajj2, tohura sharmin3 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5742 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 12, 2025 accepted: august 18, 2025 published: september 20, 2025 the presence of unilateral optic disc swelling (ods) is linked to several illnesses, such as hypertension and diabetes mellitus. while the incidence of diabetes is increasing in bangladesh, not much is known about its systemic links in the local population. this study aims to evaluate the relationships between systemic factors and unilateral optic disc swelling among people in bangladesh. a cross-sectional observational study was done at the neuroophthalmology department in dhaka from march 2019 to july 2020, covering 105 patients with unilateral ods. eye health was evaluated clinically, visual functioning was measured, and brain scans were performed for diagnosis. basic demographics, historical details, and results from blood tests (cbc, rbs, hba1c, lipid profile, crp) were all collected with the use of structured forms. the statistical analysis was done using spss version 26.0, and the level of significance was p<0.05. naion was the leading cause (40.95%), with optic neuritis (25.71%) coming next, and pseudo foster kennedy syndrome (12.38%). about half of the patients (52.38%) had hypertension, and about three-quarters of all patients (42.86%) had diabetes, with around one-quarter (26.67%) having both conditions. the laboratory results showed that 46 patients (43.81%) had high blood pressure and 45 (42.86%) had elevated random blood sugar, matching what was found in their clinical records. twentyseven-point six percent of the population experienced abnormal lipid results, and 20.95% had raised hba1c. nearly half of the patients (45.72%) were seen for serious blindness (approximately 2 ft of vision). a visual field problem called an inferior altitudinal scotoma was prevalent among people with naion. almost half of the patients (49.52%) were not receiving treatment for their long-term medical issues. in neuro imaging findings, optic nerve enhancement & thickening was found in 26 patients (24.76%). there is a strong connection between hypertension and diabetes on one hand and unilateral optic disc swelling on the other. early identification of systemic diseases and treating them promptly might prevent patients from losing sight. keywords diabetes mellitus, hypertension, naion, neuro-ophthalmology, non-arteritic anterior ischemic optic neuropathy, optic neuritis, optic neuropathy, unilateral optic disc swelling 1 department of ophthalmology, national institute of ophthalmology & hospital, dhaka, bangladesh 2 department of cornea and refractive surgery, vision eye hospital, dhaka, bangladesh 3 department of community medicine, ad-din women’s medical college, dhaka, bangladesh * corresponding author’s e-mail: shaemeeen.shimu@gmail.com introduction unilateral optic disc swelling is a condition that refers to the inflammation of the optic nerve head in one eye caused by different conditions or when axoplasm accumulates at the back of the eye, slowing anterograde flow and causing both the disc and the retinal nerves to become opaque (hata, 2017; stenoien, 1999). it is often referred to as papilledema or optic disc edema (ode) in a unilateral setting, occurs rarely, in just 4% of all iih patients, and may be thought to be local eye disease, which can make iih diagnosis difficult (el-gendy, 2024). a bangladeshi study found that optic disc edema was present in 53.3% of eyes and 56.7% of patients (morshed, 2024). unilateral optic disc swelling may result from causes such as optic neuritis, anterior ischemic optic neuropathy (aion), non-arteritic anterior ischemic optic neuropathy (naion), papilledema, and different eye diseases (hata, 2017). in particular, naion and optic neuritis are known to lead to optic disc swelling in people over 50 years of age all around the world (raizada, 2022). in particular, naion shows a clear association with vascular concerns such as systemic hypertension, diabetes mellitus, and dyslipidemia, which affect the microcirculation in the optic nerve head, resulting in damage to small vessels and leading to infarction and swelling of the disc (singla, 2024). besides naion, in bangladesh and many other lowand middle-income countries, more people are suffering from treatment-resistant conditions such as hypertension and diabetes (uddin, 2022), increasing patient presentation in ophthalmic clinics. while there is an increase in systemic disorders linked to optic disc swelling, not many local studies have focused on this relationship among people from bangladesh. people with unilateral ods may suddenly and painlessly lose vision in one of their eyes (salvetat, 2023). during ophthalmoscopy, the disease may be found as disc inflammation, elevation, and bleeding spots. however, these signs are not specific and should be interpreted along with the patient’s age, general health status, and other lab results such as blood pressure, random blood sugar (rbs), and lipid levels. ophthalmologists and general physicians must know how systemic risk factors affect unilateral ods. therefore, this study aims to analyze the number and pattern of key risk factors—hypertension and diabetes mellitus— pa ge 74 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 73-77, 2025 in patients coming to our hospital with only one optic disc expanded. the main goal is to contribute meaningful epidemiological information and develop protocols for the timely diagnosis and overall care of individuals with optic disc swelling. materials and methods to assess the systemic risk factors with unilateral optic disc swelling among the bangladeshi population, we used a crosssectional observational study in the neuro-ophthalmology department of the national institute of ophthalmology in dhaka. the period from patient enrolment to data analysis lasts from 1st march, 2019, to 31st july, 2020, with all ethical considerations. during the entire study period, 105 patients were enrolled by the researchers using particular study-defined inclusion and exclusion criteria. inclusion criteria • there is no age limit for this study. • patients diagnosed with unilateral optic disc swelling. • must be a bangladeshi by birth to eliminate genetic factors. • patients were ready to provide signed informed consent. exclusion criteria • patients with traumatic eye injury. • patients with uveitis or keratitis, or a disease condition on the surface tissues of the eyes. • lack of informed consent. demographic information, suggestions of what the participants presented, medical history, and all the medications each one received have been captured using a structured form following informed consent. standard ophthalmologic examinations were given to everyone. in the laboratory, complete blood count (cbc), random blood sugar (rbs), hba1c, a fasting lipid profile, and c-reactive protein (crp) tests were used to check for overall connections. all information from the study was transported into spss version 26 and analyzed by using basic statistics. the categorical variables were reported as the number of cases and their percentages, and continuous variables were shown as the mean with their standard deviations. a test result with a p-value lower than 0.05 was significant at a 95% confidence level. results and discussion the study was carried out with 58 male and 47 female patients. the male-to-female ratio recorded for this study was 1:23:1, and the mean age of the enrolled patients was 45.9±14.84 years. table 1: distribution of study subjects by history of systemic diseases (n=105) systemic disease frequency (n) percentage (%) hypertension 55 52.38% diabetes mellitus 45 42.86% dyslipidemia 5 4.76% both htn & dm 28 26.67% no systemic illness 22 20.95% table 2: laboratory parameters of the study subjects (n=105) laboratory findings abnormal (n) percentage (%) high blood pressure 46 43.81% elevated random blood sugar 45 42.86% hba1c 22 20.95% abnormal lipid profile 29 27.62% table 1 shows that about half of the patients had hypertension and approximately 43% had diabetes mellitus, suggesting that a lot of them were at increased risk of vascular health problems. about a quarter of the sample showed both conditions concurrently. according to these findings, having systemic disorders is strongly related to unilateral swelling of the optic disc. clinical measurements in table 2 highlight that about 44% of subjects had high bp and rbs, which was very close to what was reported in their medical histories. around 21% of patients reported persistent dm, and 27% of the participants were found to have elevated lipid levels (dyslipidemia). the study results strengthen the idea that small blood vessel abnormalities may underlie the development of optic disc swelling. according to table 1, about half the participants said they were not on regular medication for high blood pressure or diabetes, indicating that many such patients may have gone undetected or off-track with their treatment. the majority of those using medications were found to be taking anti-hypertensives (31.43%) or ohas (22.86%), which highlighted that several patients knew they were at risk of cardiovascular problems. pa ge 75 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 73-77, 2025 figure 01 shows the neuroimaging findings of the study subjects. among 105 study subjects, neuroimaging was done on 68 patients, whose fundus findings were suggestive of having intraocular and intracranial lesions. of them optic nerve enhancement & thickening was found in 26 patients (24.76%), intracranial space occupying lesion was present in 5 patients (4.76%), and, moderate inflammatory change & orbital soft tissue enhancement was found in 4 patients (3.81%) and optic nerve enhancement with whitish lesion in periventricular white matter in both cortex and intra cerebral infraction & cerebral atrophy were found in 3 patients each (2.86%). intra-cerebral infarction & cerebral atrophy, and orbital space-occupying lesion were found in 1 patient each (0.95%). no significant abnormality was detected in 24 patients (22.86%) on neuro-imaging discussion unilateral optic disc swelling (ods) is a serious neurological condition. the primary objective of this study was to assess how systemic risk factors relate to unilateral disc swelling amongst the bangladeshi population. during the study, there were 105 cases (58 male, 47 female) selected with 45.9±14.84 years mean age of with a clinical presentation of unilateral disc swelling. diagnosis in this study was based on considering the presenting complaint, observing patients’ symptoms, laboratory examinations, and scans. in 43 patients (40.95%), the condition was naaion, 28 (25.71%) were noted for optic neuritis, 13 (12.38%)cases were of foster kennedy syndrome, while 1 (0.94%) had crvo and others like infiltrative optic neuropathy, neuroretinitis, foster kennedy syndrome, pseudo disc swelling happened. naion is the leading cause of optic disc swelling in the optic nerve and loss of vision in people aged over 50 (hayreh, 2009), as reflected in this study. youssef et al. (2018) also agreed to this finding by stating that showed that the main cause of unilateral disc swelling was non arteritic anterior ischemic optic neuropathy (naion) at 72%, with traumatic optic neuropathy, optic neuritis, disc swelling related to an orbital mass, disc swelling related to a brain mass and disc swelling with thyroid ophthalmopathy or cilio retinal artery occlusion comprising 6% each and different other connections in each group (ahmed mohammed youssef, 2018). the current study revealed that the best-corrected visual acuity of the majority (45.72%) of subjects at the time of presentation was not within cf 2 feet-pl, while only 4.76% had their vision within the 6/6 to 6/12 range. a significant decrease in vision is often noticed in inflammatory and ischemic optic neuropathy. the vast majority of the patients were diagnosed with naion, and in these cases, vision reduction occurs early in the disease. a 2017 observational study also replicates the similar result of vision loss by optic disc edema (anuradha, 2017). according to the results, 41.90% of the participants displayed a visual field defect during the confrontation test. humphrey visual analysis was carried out in 44 patients with visual field defects on confrontation to identify the type of defect. most of the patients (14 out of 44) had an inferior altitudinal field defect, which matches the results found by jung et al. (2011). other visual defects observed in the present table 3: distribution of patients by drug history (n=105) drug history frequency (n) percentage (%) antihypertensive drugs 33 31.43% oral hypoglycemic agents (oha) 24 22.86% insulin 7 6.67% antiplatelet/anticoagulant drugs 5 4.76% lipid-lowering agents (statins) 4 3.81% no regular medication 52 49.52% figure 1: bar chart showed distribution of neuro-imaging findings of the study subjects (n=105) pa ge 76 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 73-77, 2025 study included enlarged blind spot, superior altitudinal field defect, paracentral scotoma, centrocecal scotoma, arcuate scotoma, and generalized depression, as reported by other studies (shah, 2017; jung, 2011). this research found that 52.38 % of individuals had a background of hypertension, 42.86 % had diabetes, and 4.76 % had dyslipidemia, which agrees with what was found in several researchers (anuradha, 2017; jung, 2011). in our study, more than half were found to have hypertension, more than half had dm, more than half had hyperlipidemia and abnormal values were found for blood pressure in 46, for random blood sugar in 45, hba1c in 22 and lipids in 29 patients as shown by jung (2011). in previous studies, hata m. et al., 2017 indicated that vasculopathic risk factors were present in 57% of aion patients. each of these findings supports the results from our research (hata, 2017). research on drug history in the study found that a total of 31.43% of patients took antihypertensive drugs, 22.86% used oral hypoglycemic agents, and 6.67% received insulin treatment. a large share of patients taking part in the study (49.52%) did not regularly use any medications, despite having hypertension (52.38%) and diabetes mellitus (42.86%). it is possible that patients are not being diagnosed, are not aware of their diseases, or are not following their treatment correctly for chronic conditions. among the current cohort, statins were prescribed for only 3.81% of people, even though 4.76% had dyslipidemia, which matches results from previous research by solanki et al. (2019) in bhopal, india, showing that lipid abnormalities were commonly ignored even when they played a role in ischemic optic neuropathies (solanki, 2019). in 2018, a report showed that although systemic diseases were common, patients did not receive proper care, which resulted in many acute eye complications (ijeri & jyoti, 2018). in this study, findings of the neuroimaging of 68 patients showed that the majority of the patients, about 24.76%, had optic nerve enhancement & thickening intracranial space-occupying lesion was present in 4.76% cases, and 22.86% had normal imaging findings. however, the study of solanki et al. (2016) reported that one-third of the patients with optic disc edema had non-space-occupying lesions (solanki, 2019). the dissimilarity might be since their study was conducted in a multidisciplinary hospital and many of their study subjects were referred from the department of neurosurgery, where most of the patients were clinically diagnosed as intracranial space-occupying lesions. this finding is consistent with the study conducted by jung et al. (2011). the research shows that bangladesh and nearby areas face the same problems in access to healthcare and health-seeking patterns, showing that this is a shared issue in south asia. limitation since this was a single-center and cross-sectional study, the findings may not apply to the whole population. only a small number of patients were included, so information on long-term changes in vision and treatment effects is not available. in some cases, conditions affecting the body may have gone unreported because there were no clear diagnoses or patients did not realize. conclusion this research found a clear connection between vascular issues, like hypertension and diabetes in bangladeshi participants, and unilateral swelling of the optic disc. in the majority of cases, naion caused the disease, resulting in severe loss of vision and specific types of visual field defects for many patients. clinical history and laboratory findings supported each other, suggesting that microvascular problems led to optic nerve head ischemia. almost half of the people studied did not take regular medicine for their ongoing health issues. early identification and combined patient care help avoid unnecessary vision loss in these individuals. abbreviation ods: optic disc swelling ode: optic disk edema naion: non-arteritic anterior ischemic optic neuropathy aaion: arteritic anterior ischemic optic neuropathy bcva: best corrected visual acuity crvo: central retinal vein occlusion references anuradha, t. r., & venkatesh, s. 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(2018). unilateral optic disc swelling: demographic study, ocular and systemic association. the egyptian journal of hospital medicine, 71(6), 3364–3367. https://doi. org/10.12816/0047276 pa ge 1 pa ge 1 american journal of medical science and innovation (ajmsi) role of hiv infection in multi-drug resistant tuberculosis in parts of benue state, nigeria lan, abraham ternaa1*, amuta u elizabeth2, terzungue sarc1 volume 1 issue 1, year 2022 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 15, 2022 accepted: september 02, 2022 published: september 06, 2022 the pathogenesis of tuberculosis shows that m. tuberculosis target and persist within phagocytes including t-lymphocytes in blood circulation. as a result, the possibility of cellular interaction between m. tuberculosis and hiv, especially for patients that are co-infected with hiv and tb, and subsequent exchange of genetic material via transduction needs to be investigated. three hundred and eighty sputum samples mostly from suspected rifampicin-resistance patients were collected from nigerian airforce (naf) hospital makurdi, and federal medical centre (fmc) makurdi. in vitro culture of sputum samples, drugs susceptibility testing (dst) of m. tuberculosis isolates, and transduction protocol were carried out at the national tuberculosis and leprosy training centre (ntbltc) zaria, nigeria. statistical analysis was carried out using student’s t-test. minitab version 14.0 statistical software was used for data analysis. p-values < 0.05 were considered significant. twenty-six (9.7%) cases of multi-drug resistant tuberculosis (mdr-tb) were detected (retreated cases 7.1%; treatment naive 2.6%). twenty-one (80.8%) were males and 5(19.2%) were females. there was statistical difference in mdr-tb between male and female in benue state (p<0.05). the mean age group 35-45 years had the highest cases of mdr-tb accounting for 35% of mdr-tb. human-immunodeficiency virus and tuberculosis co-infected patients (category i) had the highest mdr-tb incidence of 10(38.5%). there was no significant difference between category-1 and category-iii [patient with only tb disease (p>0.05)]. however, there were elevated cases of mdr-tb in category-iii patients from 7(26.9%) to 10(38.5%) following transduction protocol. multi-drugs resistant tuberculosis is prevalent in benue state, affecting the most economically active youths within the age group of 35-45 years, as a result the need to direct more attention on molecular basis for m. tuberculosis drugs resistance is keywords bacteriophage, isoniazid, multidrug resistance, mycobacterium tuberculosis, rifampicin, 1 department of microbiology, federal university of agriculture, makurdi nigeria 2 department of zoology, federal university of agriculture, makurdi, nigeria * corresponding author’s e-mail: abrahamlanterna@gmail.com introduction the genus mycobacterium are non-motile, non-sporulating, weakly gram-positive, acid-fast bacilli that appear microscopically as straight or slightly curved rods measuring 0.2 to 0.4 µm in length (willey et al., 2011). mycobacteria are within the order actinomycetales, which it shares with bacteria such as corynebacterium, norcadia and rhodococcus. mycobacteria have been divided into two major groups based on fundamental differences in epidemiology and association with disease. those belonging to the mycobacterium tuberculosis complex (mtbc) (m. tuberculosis, m. bovis, m. africanun, m. canetti, and m. microti, with m. laprae and m. pinnipedii considered variants of m. bovis), and those referred to as the nontuberculous mycobacteria (ntm) such as m. avium complex, m. haemophilum, m. ulcerans, m. leprae (nonculturable), and the potentially pathogenic species such as m. smegmatis and m. abscessus (forbes et al.,2002). a very important and unique characteristic of mycobacteria is that the organisms grow more slowly than most other human pathogenic bacteria because of their hydrophobic cell surfaces (forbes et al.,2002). tuberculosis is a common, and in many cases fatal, infectious disease caused by various strains of mycobacteria, usually m. tuberculosis (kumar et al., 2007). tuberculosis is an airborne disease that affects the lungs (pulmonary tb), but can also affect other parts of the body (extra pulmonary tb) such as the larynx, the lymph nodes, the pleura, the brain, the kidneys, or the bones and joints (bardarov et al., 2002). based on clinical presentation, tb can be categorized into active tb disease characterized by chronic cough with blood-tinged sputum, fever, night sweats and weight loss (the latter giving rise to the formerly common term consumption), most infections do not have classical symptoms and are thus referred to as latent tb infection (ltbi). persons with ltbi have m. tuberculosis in their bodies, but do not have tb disease and cannot spread the infection to other people (bardarov et al., 2002). it is estimated that one-third (at least 2 billion people) of the world’s human population is infected (willey et al., 2011). of the 212 countries and territories in the world, 202, (99.6% of the world’s population) reported tb cases in 2007; the world health organization (who) reported 9.2 million new tb cases, with approximately 7.7% being hiv positive (willey et al., 2011). today, tb is second only to hiv/aids as the greatest killer worldwide due to a single infectious agent, in 2012 for instance, 8.6 million people fell ill with tb and 1.3 million died from tb, with over 95% of tb deaths reported in low and middle-income countries (who, 2014), tuberculosis is still among the top three causes of death for women aged 15 to 44 years (who, 2014). the emergence of mdr-tb, first reported in the late https://journals.e-palli.com/home/index.php/ajmsi mailto:abrahamlanterna%40gmail.com?subject= pa ge 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 1-9, 2022 1980s (cegielski, 2010), and present in virtually all the countries surveyed has posed a great obstacle to effective tb control at both national and global levels. in 2010, the world health organization (who) estimated that globally there were 290, 000 cases of mdrtb among reported cases of pulmonary tb (who, 2011). the world health organization also reported an estimated 650, 000 cases of mdr-tb among the world’s 12 million prevalent cases of tb with nigeria alone accounting for 95 reported cases of mdr-tb (who, 2011). resistance to tb-drugs is said to arise from both service and patient related factors in the management of tuberculosis ranging from poor compliance, inadequate supervision, inadequate dosing, wrong drug combination, lengthy duration of treatment and poor training of health personnel (federal ministry of health fmoh, 2005). despite reasonable degree of successes and achievements recorded in the stop tb targets of the millennium development goals (mdgs) number-6, target-8 of reducing the global burden of tb disease (death and prevalence) by 50% by 2015 (who, 2011), the second component of the stop tb strategy to address tb/hiv and mdr-tb remains a global concern. the pathogenesis of tuberculosis shows that m. tuberculosis is often acquired early in life with acute infection and with developing immunity, granuloma formation, and calcification. this is followed by a long latent period, which continues until reactivation occurs in a proportion of individuals. at this period, the organism target and persist within phagocytic monocytes, macrophages, polymorphonuclear neutrophils and t-lymphocytes in blood circulation (van crevel et al., 2002). as a result, there is a possibility of cellular interaction between m. tuberculosis and hiv, especially for patients that are coinfected with hiv and tb, and subsequent exchange of genetic information via transduction. it has therefore become necessary to determine the role of hiv in the emergence of mdr-tb in hiv/tb co-infection dynamics. considering the fact that hiv plays a major role in infectious diseases generally, and tb in particular (bardarov et al., 2002), the need to focus attention on understanding the molecular basis of tb pathogenesis especially mdr-tb with particular emphasis on hiv/ tb co-infection has become a top priority. materials and methods a total of 380 sputum samples determined by raosoft sample size calculator (raosoft, 2015) were collected from a wide spectrum of tb patients from two geographically distinct sites: three hundred and three sputum samples were collected from nigerian airforce (naf) hospital/ cdc laboratory, while the remaining seventy-seven sputum samples were collected from federal medical centre (fmc)/apin laboratory, in makurdi benue state. between three to ten millilitres of sputum samples were collected in cotylpyridinium chloride (bromide) containing universal bottles, and immediately refrigerated at 2-8°c. patients who test positive for acid fast bacilli (afb) after two months of intensive phase tb dots therapy (suspected rifampicin resistance) was enrollment criteria. demographic information of subjects was obtained from medical records. data was collected all age groups. the study design was approved by research and ethics committee, benue state ministry of health. out of 380 sputum samples analysed, 130 (34.2%) were from tb patients co-infected with hiv, and who were positive for afb after more than two months’ intensive phase of tb dots therapy (category i patients). another 130 (34.2%) were from hiv negative tb patients who were positive for afb after more than two months of intensive tb dots therapy (category ii patients), while 120 (31.6%) sputum samples were collected from hiv negative tb patients who yet to commence tb dots therapy (treatment naïve)-category iii patients). detection of rifampicin resistance was by genexpert technology. all sputum samples were plated on lowenstein-jensen (lj) medium for pure cultures of m. tuberculosis and confirmed by biochemical tests. pure cultures of m. tuberculosis were preserved by refrigeration as stock cultures at -20°c (david, 1970). anti-tb drugs susceptibility testing (dst) of m. tuberculosis isolates was carried out using the proportion method on bactec mgit 960 tb system (becton and dickinson, new jersey usa). stock cultures of human t-cell lymphotrophic virus-3 (htlv-iii) polyclonal unconjugated preparation procured from gentaur molecular genway products, u.s.a, were used as specialized transducing phage in transduction protocols. drugs susceptibility testing of transductants was also carried out by proportion method on bactec mgit 960 tb system (becton and dickinson, new jersey usa). all procedures were carried out at biosafety level two (bsl-11). genexpertgenexpert procedure xpert mtb-rif assay g4 version 5 (cepheid, usa) was used. briefly, 2.0 ml of sputum sample was added into 4.0 ml of xpert reagent in a ratio of 1:2. the closed specimen was manually agitated twenty times and incubated at room temperature (20-25°c) for 15 minutes. two millilitres of the reagent-sample mixture was transferred to xpert test cartridges and inserted into the xpert device. results (for m. tb either detected or not, and with or without rifampicin resistance) were obtained in exactly 110 minutes (cepheid, 2014). processing of sputum for m. tuberculosis culture modified petroff ’s method 2012 for culture of m. tuberculosis was used. between 3-5 ml sputum was homogenized in a shaker using an equal volume of 4% naoh and centrifuged at 3000rpm for 15 minutes. then 0.067m phosphate buffer (ph 6.8) was added to the digested-decontaminated sample (deposit) up to the 45.0ml mark to reduce the continued action of naoh, while the sediment was re-suspended in 2.0ml of buffer. the sediment was now ready for inoculation unto lj slants, or refrigerated at 28°c (joshua et al., 2013). https://journals.e-palli.com/home/index.php/ajmsi pa ge 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 1-9, 2022 culture of processed sputum sample for m. tuberculosis lowenstein-jensen medium (oxoid biologicals, canada) was used. lowenstein-jensen slants (egg based) were prepared according to manufacturer’s instructions and stored at 2-8°c in the dark. three drops of processed sputum sediment were added to each lowensteinjensen tube using a sterile plastic pipette. the inoculum was spread over the surface of the slant by gently rolling the liquid over the slant and incubated at 3537°/7 days in a slanted position with loose screw for even distribution and adsorption of inoculum. after one week, inoculated slants were incubated at 35-37°c, and examined respectively at three and seven days of incubation to allow early detection of contaminants (or rapidly growing mycobacteria). thereafter cultures were examined weekly for growth of m. tuberculosis. negative cultures were discarded after 8 weeks of incubation. pale cream colonies which were granular, rough or dry were suggestive of m. tuberculosis. ziehl neelsen (zn) staining confirmed growth of mycobacteria. growth was reported as none (no visible growth), contamination (c), <50 colonies (actual count), 50-100 colonies (1+), 100200 colonies (2+) >200 colonies (3+), confluent growth (4+) (joshua et al., 2013). conventional biochemical tests such as catalase test, growth on p-nitro benzoate (pnb), and nitrate reduction were used to distinguish and differentiate m. tuberculosis from other mycobacteria. pure cultures of m. tuberculosis were inoculated on lowensteinjensen broth and preserved as stock cultures in 2ml cryovials at -20°c for drugs susceptibility testing and transduction protocols. staining mycobacterial isolates from lj slants ziehl neelson (zn) staining method was used. one drop of distilled water was placed in the middle of a clean grease free slide. growth from the lj slope was scrapped off and emulsified in saline on the slide using a sterile disposable loop. the smear was allowed to air dry thoroughly and was fixed by passing the reverse three times through a blue flame. a negative control slide was also prepared from a genexpert negative sample as earlier described. the slides were arranged on a staining rack, flooded with carbol fuschsin working solution and heated to steam for five minutes without drying or boiling. the slides were washed gently with tap running water to remove excess carbol fuschsin and flooded with 3% acid alcohol for three minutes to decolorize completely, and washed under running water for one minute. the slides were flooded with methylene blue and counterstained for 1 minute. the slides were rinsed with tap running water, drained and air dried, examined under oil immersion magnification (x100). acid fast bacilli appeared as pink or red bacilli while the negative control slide appeared blue (joshua et al., 2013). preparation of mycobacteria growth indicator tube (mgit) plastic caps from the streptomycin isoniazid rifampicin and ethambutol (sire) supplements were removed. caps from mgit were also removed, and 0.8ml supplements were aseptically dispensed into each mgit using sterile pipette. the tubes were immediately recapped. the procedure was repeated using pza supplement. five mgit (7.0ml) were labeled with sire supplement for each test isolate as (growth control), s(sm), i(inh), r(rif), and e(emb). two mgit (7.0ml) were labeled with pza supplements for each test isolate as c (growth control), s(sm), i(inh), r(rif), and e(emb). two mgit (7.0ml) were labeled with pza supplement for each test isolate as c (growth control), and pza. micropipette was used to aseptically pipette 100µl working drug concentrations into each of the appropriately labeled mgit. no antibiotics were added to mgit control tubes. 0.5 ml of the organism suspension was aseptically dispensed into each of the five tubes containing drugs (sm, inh, rif, emb, pza). 1:10 growth control suspension was prepared by aseptically adding 0.5 ml of the organism suspension into 4.5 ml of sterile saline. the 1:10 suspension was mixed thoroughly, and 0.5ml inoculated into mgit-pza control tube, 0.5ml was further diluted with 4.5 ml sterile saline from the previous 1:10 growth control suspension to produce 1:100 dilutions. the 1:100 suspensions were thoroughly mixed and 0.5 ml was inoculated into the mgit control tube. the tubes were tightly recapped, thoroughly mixed by gently inverting three to four times and were wiped with disinfectant, loaded into the appropriate dst carrier. sire was loaded into a five-carrier holder, while pza was loaded into a two-carrier holder. one drop of the organism suspension from the 1:100 control tube was streaked on a blood agar plate (bap), sealed with paraffin and incubated at 35-37°c for four days. the bap was read daily, for up to four days, for bacterial contamination. the dst was allowed to proceed only for bap that showed no growth during the four days monitoring (joshua et al., 2013). drug susceptibility test (dst) for m. tuberculosis bactec mgit 960 tb system (becton and dickinson, new jersey usa) was used. the system monitors continuous growth of microorganisms in both drugcontaining and control tubes to determine susceptibility or resistance, and automatically interprets and reports results of tests. the following anti-tb drugs (sire) were reconstituted to the following concentrations: streptomycin 1.0 μg/ml, isoniazid 0.1 μg/ml, rifampicin 1.0 μg/ml, ethambutol 5.0 μg/ml, pyrazinamide 100 μg/ ml (pza). preserved stock cultures of 0.1ml m. tuberculosis were sub-culturedm to mycobacterium growth indicator tube (mgit) mcfarland standard (1.0 suspension) equivalent to 3.0 x 108 cfu/ml. reconstituted 0.8 ml sire supplements were aseptically dispensed into each mgit with a pipette and sterile tips. mgit was immediately recapped interpretations of dst results were read between days four and thirteen sire, pza test. control https://journals.e-palli.com/home/index.php/ajmsi pa ge 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 1-9, 2022 tubes that flagged positive before day four were repeated. similarly, control tubes that remained negative after day thirteen were also repeated. the dst for the drugs under consideration was reported as “sensitive” when the control tubes reached growth unit (gu) of 400, while the drug tubes had growth units (gu) of less than 100. the results were reported as resistant with a rise in gu equal to or greater than 100 and growth in the control tube equivalent to 400 gu (siddiqui and rusch-gerdes 2006). m. tuberculosis strains that exhibited combined resistance to rifampicin and isoniazid were reported as mdr-tb (willey et al., 2011). transduction protocol transduction protocol was carried out as described by bardarov and co-researchers (bardarov et al., 2002), with slight modifications. preserved cultures of m. tuberculosis from category iii patients were used. one milliliter of m. tuberculosis stock was inoculated into 10ml lj broth in 30ml plastic culture bottles, and incubated at 37°c in an incubator shaker. the m. tuberculosis strains were grown to optical density od of 600 ~ 0.8-1.0(6.0 x 108 c.f.u ml-1). ten milliliters of the culture were centrifuged at 2500g for 5minutes and re-suspended in 10ml washing medium of 1% tween 80 phosphate buffered saline (pbs-tw ph 7.0) and incubated as a standing culture (37°c; 24hr). after the preparation period, the cells were again centrifuged at 2500g for five minutes and re-suspended in 10ml lj broth, pre-warmed at 37°c and mixed with a specialized transducing phage (human t-cell lymphotrophic virus-3) in a 10ml: 1ml v/v ratio. the cell/phage mixture was inoculated into 50ml lj broth and incubated at 37°c. outgrowth of the cultures was performed for 24hr at 37°c. cells were then pelleted by centrifugation at 2500g for 15minutes and re-suspended in one millilitre pbs-tw (1.0% tween 80 in phosphate buffered saline). dst of transductant was also carried out using bactec mgit 960tb system earlier described. the results of dst for transductants were interpreted and reported using the format for pure m. tuberculosis isolates earlier described. analysis of data the results were analyzed using minitab version 14.0 statistical softwares. student’s t-test was used to compute frequencies and proportions, p-values <0.05 were considered significant at 95.0 % confidence level. results out of the 380 sputum samples collected and analyzed, 268(70.5%) yielded positive mycobacterium tuberculosis cultures. the results of dst carried out on the 268 m. tuberculosis strains showed that mdr-tb (combined resistance to rifampicin and isoniazid) was detected in 26(9.7%) strains. twenty-one (80.8%) cases were male, while five (19.2%) cases were female. there was statistically significant difference in mdr-tb between males and females (p<0.05) in the study population. the results of dst for the three categories of patients is shown in table 1. table 1: overall results m. tb of culture and anti-tb drugs susceptibility testing (dst) age group (years) m. tb + cultures cat i cat ii cat iii total mdr-tb detected % m f m f m f <1 – 10 2 0 0 0 0 0 0 0 0 11 – 20 8 0 0 1 0 1 0 2 7.69 21 – 30 70 1 1 1 0 1 0 4 15.38 31 – 40 106 2 0 2 0 2 0 6 23.08 41 – 50 37 3 1 3 1 1 1 10 38.46 51 – 60 31 1 1 1 0 1 0 4 15.38 61 – 70 9 0 0 0 0 0 0 0 0 ≥ 71 5 0 0 0 0 0 0 0 0 total 268 7 3 8 1 6 1 26 100 key: m. tb = mycobacterium tuberculosis, mdr-tb= multi-drug resistant tuberculosis, m=total male, f=total female, +=positive m. tb cultures, cat i = category 1, cat ii = category 2, cat iii = category 3 the results of dst for category i patients showed that mdr-tb was detected in 10(38.5%) cases while rifampicin resistance was detected in 32(11.9%) of cases as shown in table 2. table 2: sputum culture and anti-tb dst (category i patients) age (years) no. of m. tb + cultures rif inh s pza emb mdr-tb detected m f r s r s r s r s r s <1 – 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 – 20 3 0 3 0 3 0 3 0 3 2 1 0 0 0 21 – 30 26 9 17 2 24 7 19 2 24 16 10 2 1 1 https://journals.e-palli.com/home/index.php/ajmsi pa ge 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 1-9, 2022 table 3: sputum culture and anti-tb dst (category ii patients) age (years) no. of m. tb + cultures rif inh s pza emb mdr-tb detected m f r s r s r s r s r s <1 – 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 – 20 1 1 0 1 0 0 1 0 1 0 1 1 1 0 21 – 30 18 6 12 1 17 2 15 5 12 8 11 1 1 0 31 – 40 31 11 20 2 29 3 28 6 25 11 20 2 2 0 41 – 50 7 4 3 4 3 1 6 0 7 2 5 4 3 1 51 – 60 14 2 12 1 12 1 13 1 15 2 12 1 1 0 61 – 70 6 2 4 0 6 0 6 0 6 1 5 0 0 0 ≥ 71 2 0 3 0 3 0 3 0 3 0 3 0 0 0 total 79 26 54 9 70 7 72 12 69 24 57 9 8 1 t = 885.44, df = 10, p< 0.05 key: emb = etambutol, m. tb = mycobacterium tuberculosis, mdr-tb= multi-drug resistant tuberculosis, r = resistant, s = susceptible, rif = rifampicin, inh = isoniazid, s = streptomycin, pza = parazinamide, m=total male, f=total female, +=positive m. tb cultures, dst= drugs susceptibility testing table 4: sputum culture and anti-tb dst (category iii patients) age (years) no. of m. tb + cultures rif inh s pza emb mdrtb detected m f r s r s r s r s r s <1 – 10 2 0 2 0 2 0 2 0 2 0 2 0 0 0 11 – 20 4 3 1 1 3 0 4 1 3 0 4 1 1 0 21 – 30 26 6 20 1 25 5 21 2 24 4 22 1 1 0 31 – 40 37 4 33 2 35 4 33 8 29 6 31 2 2 0 41 – 50 16 6 10 2 14 2 14 6 10 4 12 2 1 1 51 – 60 12 3 9 1 11 2 10 1 11 3 9 1 1 0 61 – 70 2 1 1 0 2 0 2 0 2 0 2 0 0 0 ≥ 71 3 1 2 0 3 0 3 0 3 1 2 0 0 0 total 102 24 78 7 95 13 89 18 84 18 84 7 6 1 t = 632.46, df = 10, p< 0.05 key: emb = etambutol, m. tb = mycobacterium tuberculosis, mdr-tb= multi-drug resistant tuberculosis, r = resistant, s = susceptible, rif = rifampicin, inh = isoniazid , s = streptomycin, pza = parazinamide, m=total male, f=total female, +=positive m. tb cultures, dst= drugs susceptibility testing 31 – 40 38 15 23 2 36 7 31 1 37 17 21 2 2 0 41 – 50 14 5 9 4 10 2 12 0 14 8 6 4 3 1 51 – 60 5 2 3 2 3 0 5 0 5 5 0 2 1 1 61 – 70 1 1 0 1 0 0 1 0 1 1 0 0 0 0 ≥ 71 0 0 0 0 0 0 0 0 0 0 0 0 0 0 total 87 32 55 11 76 16 71 3 84 49 38 10 7 3 t = 800.00, df = 14, p< 0.05 key: emb = etambutol, m. tb = mycobacterium tuberculosis, mdr-tb= multi-drug resistant tuberculosis, r = resistant, s = susceptible, rif = rifampicin, inh = isoniazid, s = streptomycin, pza = parazinamide, m=total male, f=total female, +=positive m. tb cultures, dst= drugs susceptibility testing. results of dst for category ii patients showed a slight decline in cases of mdr-tb from 10(38.5%) to 9(34.6%) with a corresponding decrease in the total number of rifampicin resistance of 26(9.7%) detected as shown in table 3 the least cases of mdr-tb of 7(26.9%) were detected in category iii patients while rifampicin resistance was detected in 24(90%) of cases as shown in table 4. there was no statistical difference in mdr-tb between category i and category iii (p>0.05). however, cases https://journals.e-palli.com/home/index.php/ajmsi pa ge 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 1-9, 2022 of mdr-tb were statistically higher in category i than category iii patients. the age group 41-50 years had the highest cases of mdr-tb followed by the age group 31-40 years (mean age group 35-45 years) both of which accounted for 10(38.5%) and 6(23.1%) cases respectively, thereby placing the two age groups at relatively higher risk of developing mdr-tb. demographic characteristics of the 268 m. tuberculosis strains analyzed in tables 2 and 3 (re-treated cases) and table 4 (treatment naive) recorded 19(7.1%) and 6(2.6%) cases respectively. following in-vitro transduction (induced mutation) of m. tuberculosis strains from category iii patients, there was an increase in the number of mdr-tb detected in this category of patients from 7(26.9%) to 10(38.5%) cases as shown in table 5. however, there was no statistical significance in the number of mdr-tb detected in category iii before and after transduction protocols (p>0.05). overall results of susceptibility for all the tested anti-tb drugs shows a cumulative susceptibility of 1012(84.3%) and resistance of 189(15.7%). etambutol showed the highest resistance of 91(34.0%) followed by rifampicin with 82(30.6%) of cases, the least cases of resistance were table 5: anti-tb dst of category iii (control group) patients after htlv-3 transduction protocol age (years) no. of m. tb + cultures mdr-tb detected rif inh s pza emb r s r s r s r s r s <1 – 10 1 0 0 1 1 0 0 1 0 1 0 1 11 – 20 2 1 2 0 1 1 0 2 0 2 0 2 21 – 30 13 2 5 8 2 11 9 4 3 10 9 4 31 – 40 18 3 7 11 3 15 11 7 4 14 11 7 41 – 50 8 2 2 6 3 5 4 4 1 7 4 4 51 – 60 6 2 2 4 4 2 2 4 0 6 2 4 61 – 70 2 0 0 2 0 2 0 2 0 2 0 2 ≥ 71 2 0 0 2 1 1 0 2 0 2 0 2 total 79 26 54 9 70 7 72 12 69 24 57 t=-300.00, df =14, p<0.05 key: emb = etambutol, m. tb = mycobacterium tuberculosis, mdr-tb= multi-drug resistant tuberculosis, r = resistant, s = susceptible, rif = rifampicin, inh = isoniazid, s = streptomycin, pza = parazinamide, m=total male, f=total female, +=positive m. tb cultures, dst= drugs susceptibility testing produced by isoniazid which recorded 27(10.1%) making it the most effective anti-tb drug in the study population. 266(99.3%) of the m. tuberculosis isolates produced various degrees of susceptibility and resistance to the five tested anti-tb drugs. however, 2(0.7%) showed 100% susceptibility to all the five tested anti-tb drugs with no trace of drugs resistance. meanwhile all the m. tuberculosis strains were resistant to at least one or more anti-tb drugs thereby implying complete absence of mono-drug resistant tuberculosis in the study population. it is equally noteworthy that no strain was completely resistant to all the tested anti-tb drugs as summarized in table 6. table 6: cumulative results of anti-tb dst category rif no (%) inh no (%) s no (%) pza no (%) emb no (%) r s r s r s r s r s cat i 32(11.9) 55(20.5) 11(4.1) 76(28.4) 16 (5.0) 71(26.5) 3(1.1) 84 (31.3) 49 (18.3) 38 (14.2) cat ii 26(9.7) 54(20.1) 9(3.4) 70(26.1) 7 (2.6) 72(26.9) 12(4.5) 69 (25.7) 24 (9.0) 57 (21.3) cat iii 24(9.0) 78(29.1) 7(2.6) 95(35.4) 13 (4.9) 89(33.2) 18(6.7) 84 (31.3) 18 (6.7) 84 (31.3) total (%) 82 (30.6%) 187 (69.8%) 27 (10.1%) 241 (89.9%) 36 (13.4%) 168 (62.7%) 33 (12.3%) 237 (88.4%) 91 (34.0%) 179 (66.8%) key: cat i = category i, cat ii = category ii, cat ii = category iii, rif = rifampicin, inh = isoniazid, s = streptomycin, pza = parazinamide, emb = etambutol, r = resistant, s = susceptible, no. = number, % = percentage, dst= drugs susceptibility testing. cases. male accounted for 36(58.1%) while female accounted for 26(41.9%) of the cases as contained in table 7. t = 148.48, df = 13, p< 0.05 results of genexpert for all the 380 sputum samples showed rifampicin resistance was detected in 62(16.3%) https://journals.e-palli.com/home/index.php/ajmsi pa ge 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 1-9, 2022 discussion the results obtained from this study attest to the fact that mdr-tb, which is an emerging epidemic, is not just prevalent in parts of benue state, but it is on the increase as compared to the estimated 5.3% rate of global mdr-tb (who, 2011). the prevalence of mdr-tb in the study population was 9.7% (retreated cases 7.1%; treatment naive 2.6%) out of the 268 isolated strains of m. tuberculosis. there was a higher proportion of mdr-tb within the age group 31 – 40 and 41 – 50 (mean age limit 35 – 45). this age range represents the most economically productive and viable workforce both in the private and public sectors. as a result, the need to urgently attend to the menace of mdr-tb in benue state cannot be over emphasized. other research groups also reported that anti-tb drugs resistance peaks within the age range of 25 – 35 years (lawson et al., 2011; uzoewulu et al., 2014). results of this study with strong, significant statistical differences between male and female mdr-tb resistance rates, with male patients having more resistant strains agree with the work by uzoewulu and co-workers (uzoewulu et al., 2014). this underscores the enormous role of male patients in the epidemiology of drug resistant tuberculosis in the study population. this may be due to the fact that most females are economically disadvantaged in seeking appropriate medical attention, in addition to social and cultural beliefs that place women under movement restrictions. other studies reported stigma as a principal factor (uzoewulu et al., 2014). the rate of mdr-tb 9.7% in this study is higher than the estimated 5.3% rate of global mdr-tb (who, 2011). the rate of mdr-tb 2.6% in newly diagnosed tb cases has no statistical difference between current estimated rate of mdr-tb 2.2% for new cases in nigeria and 2.9% new cases in current national survey, although slightly lower, but mdr-tb of 7.1% in previously treated cases is lower compared to the estimated rate of mdr-tb 9.4%(who, 2012) and even grossly lower than the 14% from the current national survey on mdr-tb in nigeria (who, 2011), but is within the trend for african countries in which 3.9 – 5.0% was reported for new tb cases and 16.7% in previously treated cases (who, 2006). these results closely agree with the report by uzoewulu and coreseachers. (uzoewulu et al., 2014), who reported mdrtb of 7.7%. kolo, idigbe and co-reseachers, lawson and co-reseachers, and akaninyene and co-reseachers (kolo, 1991; idigbe et al.,1992; lawson et al., 2011; akaninyene et al., 2013) all reported similar findings. comparative analysis of the three categories of patients revealed that category i patients (patients with hiv-tb coinfection that tested afb positive after 2 months of tb treatment) recorded higher cases of mdr-tb compared to category ii patients (patients with only tb infection, that still test sputum afb positive after 2 months of tb treatment). both categories account for 10 (38.5%) and 9 (34.6%) cases of mdr-tb respectively. statistical analysis shows no significant difference (p>0.05). however, mdr-tb detected in category i is statistically higher than mdr-tb detected in category iii patients (patients with only tb infection, and are yet to commence tb treatment), in which mdr-tb was detected in only 7(26.9%) cases. the relatively higher number of mdrtb detected in category i patients underscores the enormous impact of hiv as one of the key factors underlying an approximately 1% annual increase in the global tb incidence as reported by lawn and gavin, (2014) in a retrospective study on the epidemiology of hiv-associated tuberculosis (hiv-tb) from 2007-2008. findings in this study are also consistent with the report by dean and co-researchers (2014), who reported a positive association between hiv infection and mdrtb disease using data of member states of the world health organization (who, 2014). eleven out of the 24 countries for which analysis was performed, hiv-positive tb patients had significantly higher odds (p<0.05) of mdr-tb disease than hiv negative tb patients. for almost all of these 11 countries, the prevalence of mdrtb among newly diagnosed tb cases was higher than the estimated global average of 3.6% (95% ci 2.1 – 5.1%). rifampicin resistance of 82(30.6%) cases detected by in-vitro culture and dst is statistically higher than the 62(16.3%) cases detected by genexpert automated machine. although this underscores the diagnostic advantage and higher sensitivity of in-vitro culture over genexpert machine, there was no statistically significant difference between the two testing methods (p>0.05), genexpert is however faster and much easier to perform even in remote areas. table 7: age and sex distribution for m. tuberculosis rifampicin resistance by genexpert age (years) males no. (%) females no. (%) total no. (%) <1 – 10 11 – 20 4 (6.5) 1 (1.6) 5 (8.1) 21 – 30 18 (29.0) 9 (14.5) 27 (43.5) 31 – 40 11 (17.7) 10 (16.1) 21 (33.9) 41 – 50 3 (4.8) 5 (8.1) 8 (12.9) 51 – 60 >61 – 70 1 (1.6) 1 (1.6) total 36 (58.1%) 26 (41.9%) 62 (16.3%) t = 148.48, df = 13, p< 0.05 https://journals.e-palli.com/home/index.php/ajmsi pa ge 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 1-9, 2022 apart from various evidences suggesting hiv infection as a risk factor for mdr-tb, it has been specifically associated with acquired rifampicin resistance (jennyavital, 1997; munsiff et al., 1997). this is suggestive of a critical overlap between hiv and the global multidrug resistant tb (mdr-tb). although, it is yet unclear whether hiv is driving a disproportionate increase in mdr-tb cases at a population level, results of in-vitro mycobacterium tuberculosis transduction protocol (induced mutation) in the current study recorded an increase from 7(26.9%) to 10(38.5%) cases in 50% of the study population. this may be attributed to mutation in the nucleotide sequence of the mycobacterium tuberculosis, which may confer antibiotic resistance on the organism. if such genetic changes are scientifically proven, they may be rightly attributed as contributing to the emergence of mono and multiple drug resistance in the genome of mycobacterium tuberculosis. several studies have reported that mycobacterium tuberculosis does not exhibit an elevated mutation rate relative to most other bacteria under in-vitro conditions (david, 1970; siddimizrahi, and andersen, 1998; ford et al., 2011). it is not entirely clear, though, whether a relatively low mutation rate is sufficient to account for the elevated rates of acquired drug resistance observed clinically (mcgrath et al., 2013). studies by ford and co-researchers (2011), using whole genome sequencing (wgs) technology to estimate the mutation rate of mycobacterium tuberculosis during latent infections in non-human primates reported a slightly elevated but not significant increase in drug resistance in vivo. sun and co-researchers (2012), in their research utilized more sensitive wgs technology to track genome changes in serial sputum samples obtained from three patients over the course of anti-tb treatment and reported a higher degree of diversity in the serial clinical specimens, an observation that is consistent with the idea that mutation rate in vivo might be higher than previously reported. thus the levels of genetic diversity identified in the studies above imply that m. tuberculosis might have an elevated mutation rate within the host compared to that calculated in vitro, thereby highlighting the need for further in vivo studies to truly ascertain the role of hiv in the emergence of mdr-tb especially for tb-patients co-infected with hiv/aids. conclusion in conclusion, results of this genetic study on the role of hiv in the emergence of mdr-tb, promise to offer useful, effective, and ground breaking molecular approach in the fight against mono, multiple, and extensivelydrug resistance (xdr). drug resistance has hampered many public health targets and interventions such as “stop tb”-target of achieving 70% case detection and 85% cure rate by 2005, and “stop tb”-target of 50% reduction in the global burden of tb disease (deaths and prevalence) by 2015 (who, 2011). previous studies have shown that anti-tb drugs resistance arise from patient/ service related causes such as poor patient adherence/ compliance, wrong regimens, inadequate supervision, and lengthy duration of treatment. the need to direct more attention on molecular aspects of anti-tb drugs resistance however is fast becoming a top priority, especially since mdr-tb is an emerging public health epidemic, requiring novel tb drugs to adequately combat it. this is necessary if the “stop tb” targets of less than one patient per million populations by year 2050 must be achieved. recommendations based on the results of the present study, we hereby recommend that this genetic study should be stepped up under in vivo conditions using the actual human immunodeficiency virus (hiv) as the transducing phage in order to ascertain the true nature of mutation conferring antibiotics resistance. the nature of mutation conferring anti-tb drugs resistance most especially mdr-tb should be well defined and documented especially that the dna of mycobacterium tuberculosis has been fully sequenced. in-depth understanding of the molecular biology of mycobacterium tuberculosis genetic dynamics can be very useful to pharmaceutical industry as targets in the design of novel anti-tb drugs. design of newer automated systems in tb diagnosis and antibiotics susceptibility testing that includes other antitb drugs such as isoniazid, parazinamide and ethambutol in addition to rifampicin is strongly recommended. automated systems offer quicker turnaround time (tat) and should be employed in routine clinical practice while in vitro sputum culture for tb that takes longer time should be restricted to research purposes. references akaninyene, o., victor, u., abdulrazak, h., soter, a., & lawson, l. (2013). clinical study of drug resistance among pulmonary tuberculosis patients in calabar, nigeria. pulmonary medicine, 10,10-16. american thoracic society and centers for disease control and prevention. (2000). diagnostic standards and classification of tuberculosis in adults and children. american journal respiratory critical care medecine, 161(4), 1376–1395. bardarov, s., bardarov jr, s., pavelka jr, m. s., sambandamurthy, v., larsen, m., tufariello, j., ... & jacobs jr, w. r. (2002). specialized transduction: an efficient method for generating marked and unmarked targeted gene disruptions in mycobacterium tuberculosis, m. bovis bcg and m. smegmatis. microbiology, 148(10), 3007-3017. cegielski, j. p. (2010). extensively drug-resistant tuberculosis:“there must be some kind of way out of here”. clinical infectious diseases, 50(3), s195-s200. cepheid genexpert mtb-rif assay g4 version 5 operation manual, 2014. david, h. l. (1970). probability distribution of drugresistant mutants in unselected populations of mycobacterium tuberculosis. applied microbiology, 20(5), https://journals.e-palli.com/home/index.php/ajmsi pa ge 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 1-9, 2022 810-814. dean, a. s., zignol, m., falzon, d., getahun, h., & floyd, k. (2014). hiv and multidrug-resistant tuberculosis: overlapping epidemics. european respiratory journal, 44(1), 251-254. forbes, b. a., sahm, d. f., & weissfeld, a. s. (2007). diagnostic microbiology (pp. 288-302). st louis: mosby. ford, c. b., lin, p. l., chase, m. r., shah, r. r., iartchouk, o., galagan, j., ... & fortune, s. m. (2011). use of whole genome sequencing to estimate the mutation rate of mycobacterium tuberculosis during latent infection. nature genetics, 43(5), 482-486. idigbe, e. o., duque, j. p., john, e. k., & annam, o. (1992). resistance to antituberculosis drugs in treated patients in lagos, nigeria. the journal of tropical medicine and hygiene, 95(3), 186-191. jenny-avital, e. r. (2002). acquired rifampin resistance in aids-related tb. aids clinical care, 14(8), 72-73. joshua, o. o., gospel, t. o., emeka, u. e., & chukwukere, e. (2013). nigerian national tb standard operating procedures manual for laboratories. national tuberculosis and leprosy control programme (ntblcp), ministry of health, nigeria and american society for microbiology, ist edition, 1-244. kolo, i. bacteriological and drug sensitivity studies on mycobacteria isolated from tuberculosis patients and their close contacts in abuth, zaria, nigeria. 1991 (doctoral dissertation, phd thesis, zaria, nigeria). kumar, v., abbas, a. k., fausto, n., and mitchell, r. n. (2007). robbins basic pathology (8th ed.). pp960 saunders elsevier. lawn, s. d., & churchyard, g. (2009). epidemiology of hiv-associated tuberculosis running head: epidemiology of tb/hiv. current opinion in hiv and aids, 4(4), 325. lawson, l., yassin, m. a., abdurrahman, s. t., parry, c. m., dacombe, r., sogaolu, o. m., ... & cuevas, l. e. (2011). resistance to first-line tuberculosis drugs in three cities of nigeria. tropical medicine & international health, 16(8), 974-980. mcgrath, m., gey van pittius, n. c., van helden, p. d., warren, r. m., & warner, d. f. (2014). mutation rate and the emergence of drug resistance in mycobacterium tuberculosis. journal of antimicrobial chemotherapy, 69(2), 292-302. mizrahi, v., & andersen, s. j. (1998). dna repair in mycobacterium tuberculosis. what have we learnt from the genome sequence?. molecular microbiology, 29(6), 1331-1339. munsiff, s. s., joseph, s., ebrahimzadeh, a., & frieden, t. r. (1997). rifampin-monoresistant tuberculosis in new york city, 1993–1994. clinical infectious diseases, 25(6), 1465-1467. national tuberculosis and leprosy control programme. workers manual. 4th edition, (2005). federal ministry of health, department of public health, abuja. pp 338 siddiqui and rusch-gerdes (2006). mgit procedure manual, geneva, switzerland: foundation for innovative new diagnostics. sun, g., luo, t., yang, c., dong, x., li, j., zhu, y., ... & gao, q. (2012). dynamic population changes in mycobacterium tuberculosis during acquisition and fixation of drug resistance in patients. the journal of infectious diseases, 206(11), 1724-1733. uzoewulu, n. g., ibeh, i. n., lawson, l., goyal, m., umenyonu, n., ofiaeli, r. o., & okonkwo, r. (2014). drug resistant mycobacterium tuberculosis in tertiary hospital south east, nigeria. journal of medical microbiology & diagnosis, 3(2), 1. van crevel, r., ottenhoff, t. h., & van der meer, j. w. 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(2011). prescott’s microbiology, 7. new york: mcgraw-hill. world health organization (2006). global tuberculosis control report, annex 1 profiles of high-burden countries. world health organization (2011). the sixteenth global report on tuberculosis. who (2012). global tuberculosis control, geneva; 14 www.who.int/tb/publications/global_report. who (2014). global tuberculosis report www.who.int/ tb/data. www.raosoft.com/samplesize.html https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 19 american journal of medical science and innovation (ajmsi) a clinical profile observational study in a tertiary care hospital of children with atopic dermatitis naveen divakaran1* volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.4413 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: january 12, 2025 accepted: february 20, 2025 published: july 09, 2025 atopic dermatitis, which is simply referred to as eczema, is a common persistent skin condition that impacts children and infants across the globe, accounting for 10-30% of them. extreme itching, skin swelling, infections, and additional itching characterize it. there has been a rise in the incidence of the disease in the last 30 years primarily due to the effluent environment, breastfeeding, increased prevalence and awareness of the disease, and urbanization. the present study aimed to describe the clinical aspects of children diagnosed with atopic dermatitis, fulfilling the hanifin and rajka clinical and visiting outpatient pediatrics and derma. also, the study had a specific objective of identifying the possible factors that could worsen atopic dermatitis among the participants in the study. this trial covered 59 kids with atopic dermatitis; they filled questionnaires concerning their age, sex, complaints, things that worsen their condition, age of disease onset, and related symptoms. the other explored history included dietary one, breastfeeding history and the family or individual atopic history. a clinical assessment was carried out comprising localization and type of lesions and other features. it was revealed that females experience more atopic dermatitis than males and most of the children are affected from an early age. food intolerance was the most common reason reported, with milk as the most frequent substance, followed by wool and lipid solvents. half of the patients showed aggravation during the cold season. dermatitic lesions involved the face and flexural areas more compared with the limbs. we found that 30 percent of the patients took complementary therapies, while 30 percent were malnourished. this work examined 59 children with atopic dermatitis ranging from 2 months to 12 years. it found that females were more affected than males, with an m: f ratio of 0.84:1. the most common manifestation experienced by the patients was purpuritus which was worse at night in about one-third of the population. recurrence during the particular season was noticeable in half of the patients. facial rash and flexural areas of extremities were found to be more affected by dermatitic lesions. keywords atopic dermatitis, children’s health, observational study, pediatrics, precipitating factors 1 sheikh khalifa medical city, united arab emirates * corresponding author’s e-mail: duttusan010@gmail.com introduction eczema, also referred to as atopic dermatitis, is among the most frequent persistent, relapsing skin diseases in infancy and childhood. it is manifested in inflammation and pruritus and also physiological skin dysfunction (bieber, 2022). such a condition is frequent in those individuals who had asthma, or allergic rhinitis in the family, or had it themselves at some point; it is typical for early childhood (frazier & bhardwaj, 2020). estimates for children indicate that the incidence of atopic dermatitis is between 10% and 20% in the united states, japan, australia and other developed nations (faye et al., 2024). estimations to this effect suggest that the current status of this disease poses considerable threat to global public health (hadi et al., 2021). according to data, modern children are affected by atopic dermatitis more than three times than in the 1960s (becerril-ángeles et al., 2023). as to why the incidence has started rising, we are yet to fully understand. the prevalence of the said diseases above, however, varies greatly across nations with similar ethnic groups, suggesting that there is strong influence of the environment in the manifestation of diseases (bylund et al., 2020). the exact relationship between atopic dermatitis and atopy is not well understood; however, the following affiliations are possible. it is important to note that as many as 60% of the children with the clinical phenotype, although identified as atopic, show no signs of ige-driven sensitization to food allergens (mocanu et al., 2021). also, there is no specific test for atopic dermatitis diagnosis, as well as no specific physical sign that would separate this disease from other similar conditions (frazier & bhardwaj, 2020). aims and objective in this study, the goal was to describe initial clinical characteristics of the children, who suffer from atopic dermatitis. it was done directly by enrolling people affected by the condition, based on the hanifin and rajka defining criteria, from the pediatric and dermatology outpatient departments. moreover, the literature expanded its examination, aiming to identify factors that occasion flare in atopic dermatitis in the specified subpopulation. this study also seeks to incorporate an assessment of the symptomatology and likely precipitating factors in atopic dermatitis among children to offer substantive information on its management. pa ge 20 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 literature review epidemiology and impact on pediatric populations eczema cannot be restricted by age and therefore can start from the early infancy, which is distinguished by 75% of the cases with the first signs and symptoms by six months old. there is genetic susceptibility to develop atopic dermatitis (barbarot et al., 2022). from the epidemiologic data it is seen that atopy risk is higher if either or both the parents are suffering from the disorder. it is noted that atopic dermatitis develops at the first three months of life in infants from atopic mothers in more than a quarter of cases (ezzedine et al., 2020). over 50 per cent of the children who develop an allergy exhibition from an atopic parent are affected by the time they are two years old (dierick et al., 2020). if both parents possess the disease, then, the rate is higher. most of the genetic factors are fixed in atopic dermatitis (bylund et al., 2020). twin studies showed that if one of the identical twins, i.e. the monozygotic twin, develops atopic dermatitis it is extremely likely that the other twin also will develop the disease, in 86% of cases; on the other hand, if one of the fraternal twins, i.e. the dizygotic twin gets the disease the other twin will develop the disease only in 21% of cases (hartmane, 2024). moreover, infections of the skin due to bacteria, viruses, or fungi (for example; staphylococcus aureus, herpes simplex, molluscum contagiosum, etc.) are among those who are detected more in patients with atopic dermatitis (alexander et al., 2020). there is a strong correlation between food allergy and atopic dermatitis including the first occurrence of the skin condition (dierick et al., 2020). these are some of the primary food allergies that are frequently observed; eggs, milk and any dairy products, fish, peanuts, soybeans, wheat and tree nuts (domínguez et al., 2020). as can be seen, even if the disease becomes worse when the patient is exposed to allergens, irritants or infections, thus looking clinically like the symptoms manifested during the intake of foods that are causing an adverse reaction, the case is tricky to diagnose (papapostolou et al., 2022). clinical manifestations and severity atopic dermatitis is an episodic eczema type skin disease and thereby has been found to have complaints that come in cycles of increase and decrease (wollenberg et al., 2023). they seem to be highly related to the age and stage of the disease, and the worst presented in childhood and get better in adolescence and adulthood (chovatiya, 2023). signs are that it is dry, becomes red skinned and the skin frequently develops a tendency of itching. the itching may be very severe, to the extent that the patient can hardly carry out his or her daily activities (mocanu et al., 2021). common rashes appear in the regions such as elbows, behind the knees, wrists, cheeks, and neck of an affected person. the texture of the rash depends with the stage: acute lesions are associated with pus and crusting while the chronic ones are associated with thick lichenification (hui-beckman et al., 2023). other signs which are also manifested with this skin condition are hyper linearity of palms, skin ulcerations, infections, and sleeplessness due to itching (siegels et al., 2021). the degree of a burn condition possible and probable adverse effect balances the extent of the burned area, the depth of the burn layer, and the effect on the individual’s quality of life and their functioning capabilities and abilities, including activities of daily living and response to treatments (dreno et al., 2021). skin manifestations are negligible with a few patches; skin disease is severe and has a tendency to become localized into thick skin, causes bleeding, painful and often requires other system affecting treatments (bocheva et al., 2021). the highlight of the points regarding the management of skin condition is that no matter how severe it is, environmental control and gentle handling are of paramount importance (sekita et al., 2023). importance of understanding the clinical profile of atopic dermatitis in children it is noteworthy for clinical diagnosis in children with ad that lesions are mainly distributed in flexural areas of limbs and curves, age of onset is before six years and disease progression (napolitano et al., 2022). documenting the average time and outcome of the disease in children help creating the best approach for handling the disease and the execution of an efficient plan. different studies focus on atopic dermatitis focuses on the clinical characteristics of the disease in children, and therefore may contain information on the identified factors and relationships: family history, environment, and co-morbidities (siegels et al., 2021). the symptoms, signs and severity of atopic dermatitis also differs from one child to another; this implies that the variation in the clinical appearance of ad is relatively large (al-adawiyah et al., 2021). this understanding helps health care providers to map out unique care strategies for each child given that children’s ailments can vary from the next. the follow-up of clinical status of children with atopic dermatitis provides an understanding of its severity and changes in the course of the disease, and to compare the results of therapeutic interventions and determine the prognosis (frazier & bhardwaj, 2020). therefore, the following information is very valuable for better understanding of the quality of patients’ lives, for making clinical and further research decisions on the case of pediatric atopic dermatitis (maksimovic et al., 2020). a sufficient knowledge of the clinical, demographic, and health-related characteristics of children with atopic dermatitis may enhance healthcare workers’ communication and teaching capabilities of the disease and the expectations for its treatment among families (zhao et al., 2023). it can also contribute to identifying specific educational materials and assistance programs for children with atopic dermatitis and their parents (yoo et al., 2022). pa ge 21 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 materials and methods study area and population the following study included patients who were present at little flower hospital & research centre, angamaly, located in the ernakulam district of state kerala in india. the duration of this study was for a year, starting from november 2015 to october 2016. the study population consisted of infants and children under 12 years, attending the pediatrics and dermatology opd. all the patients were diagnosing with atopic dermatitis as per the hanifin and rajka clinical criteria. study design serving as a cross-sectional research, the study looked at several aspects of patient information. the patient completed a detailed medical questionnaire that included the patient’s age, sex, initial complaints, including itching, factors that worsened or predisposed the patient to the specific disease, patient’s age at the first occurrence of the disease, and symptoms associated with the disease, including cheilitis and recurrent conjunctivitis. we sought to examine the dietary history of the patient in terms of foods that worsened the complaints and breastfeeding. such observations were made in atopic families or on a personal level. distribution and morphology of the lesions were observed during physical examination by general survey and palpation. the extra dimensions of the hanifin and rajka criteria were equally worth mentioning. pearson’s chi-square test was utilized to analyze the final data. ethical considerations the permission to conduct the study was sought and later on, the informed written consent was obtained from the institutional human ethics committee of the study setting. this improved the chances of attaining certain ethical principles by the research and the reduced likelihood of any harm coming to the participants. the parents or the close relatives or whoever takes up the responsibility of a parent for the families of the study participants agreed to participate in the study by willingly putting their signatures on the consent forms after explaining to them the details of the role and responsibilities, benefits, and risks of participating in the study and the right to withdraw their children from the study at any time of their choice. the control of participant was applied in the study as only participants who had given their voluntary written consent to participate in the research. the name of the specific participant of the study and the data that was collected and analyzed in the present research was kept anonymous or pseudonymous at all stages. this made sure that the name of the participant is concealed and there is no trace or chances that somebody might recognize any of the participants. inclusion and exclusion criteria inclusion criteria age patients of required age limit, between 0-12 years of age. diagnosis documentation of atopic dermatitis according to the hanifin and rajka severity patients with atopic dermatitis of required age group and any gender corresponding to the objectives of the study and details of their disease such as mild, moderate or severe form of atopic dermatitis. willingness to participate children who were available and willing to participate in the study and parents or primary caregivers who were willing to sign informed consent for the child’s involvement in the research. exclusion criteria underlying medical conditions participants with chronic diseases, especially those that may affect the assessment of the results obtained during the study (such as scabies, insect bite reaction, intellectual disability, etc.) current treatment patients with atopic dermatitis receiving treatments that may affect the obtained clinical picture at the moment (e. g., participating in other trials). inability to follow-up patients who included children or families that would not be able to continue follow-up procedures with the study (frequently migratory, no access to the hospital). statistical analysis the results of the descriptive statistics in terms of percentage, mean and standard deviation were used on the variables in the study. regarding inferential statistics, pearson’s chi – square test was used to determine the statistical difference between the association of major and minor clinical features of atopic dermatitis in the study population with, males and females, personal/family history atopy, age at onset less than one year, inadequate breast feeding history, malnutrition, food allergy history, seasonal exacerbation history. significance level of p < 0. 05 was used in the study. based on the pilot study, we used the power analysis that works with 5% level of significance (p value) and 90% test power and using the software sigma-plot 11, we determined the following sample size for each group. this proposed research presents the findings of the analysis in the following table 1. table 1: statistical analysis of sample size type of test minimum sample maximum sample chi-square test 19 51 so required sample size 51 pa ge 22 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 results and discussion results distribution of patients on the basis of age group the study samples involved 59 young patients with all patrons under the age of 12. the age variation came to cater for many aspects of childhood development as the youngest child was but 2 months and the oldest just below the adolescence age of 12 years. yet, the average age that the group had was 3.5 years, this shows that the respondents were skewed slightly to the younger children as may be expected. out of 59 patients, 37 were below three years thus indicating the major impacts of this disease on the little children. it can be assumed that this sample might need more accommodation concerning the treatment of cases and data gathering techniques than elders may need in the same study. figure 1: shows the number and distribution of male and female patients included in the study, according to the age group the following study consisted of 27 male and 32 female patients, with a m:f ratio of 1.18:1 in the study group. the value in percentage of the patients and the final mean value of their age in months is mentioned in table 2 and table 3, respectively. socioeconomic status (ses) and atopic dermatitis socioeconomic status can also be seen among the study population. the largest portion of children was characterized as belonging to the upper middle class, 29 (or 49. 15%); next were the children from the lower middle class, 19 (or 32. 20%); and the last category indicated 6 (or 10. 16%) as being from the upper lower class. only 5 of the participants (8.4%) were classified as belonging to the upper socioeconomic class and none as lower according to the modified kuppuswamy scale. this difference in the distribution of the variables in the population based on ses may need to be taken into account when interpreting this study’s results because factors such as access to adequate healthcare and exposure to environmental stimuli are known to have different distributions across ses (podder et al., 2022). table 2: number of patients sex frequency percent male 27 45.8 female 32 54.2 total 59 100.0 table 3: mean value of age in months age in months mean 40.22 age at the time of diagnosis among the 59 children with atopic dermatitis, 19 children (32.2%) developed the condition within three months after birth and 47 (79.6%) within infancy. finally, 4 (6.7%) patients of them had the disease onset after 5 years of when they were born, while 8 (13.5%) patients had the onset of disease between the first and the fifth birthday. in regard to the age of onset, the disease developed in 55 (93.2%) of the children when they were 5 years old or less, as per shown in figure 2. in other words, the mean age of onset for the patients was one year and four months. figure 2: age of onset of disease figure 3: distribution of patients according to ses. geographic distribution residence of patients the following study narrates the participants involved with regard to their residence. two categories are represented: which includes the urban and rural groups. thus, urban areas represent a much more significant share in the study, involving about 35 participants (62.7%). on the other hand, the ‘rural’ area category constitutes only a small proportion of the participants that were around 24 in number (37.3%). such a case implies that there are pa ge 23 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 more participants from the urban areas of the country than from the rural areas. moreover, for patients suffering from atopic dermatitis, choosing the right clothing material is really crucial for managing symptoms, its effects and improving comfort for the patients (jaros et al., 2020). in this study, there were 8 (13.55%) children who complained of itching on contact with wool and 11 (18.64%) children gave history of exacerbation of the disease with the use of lipid solvents like soaps and detergents as shown in figure 6. figure 4: distribution of patients according to area of residence moreover, 11 of the patients had to relocate due to personal reasons. this movement either had flare-ups or the onset of the disease. two of them experienced exacerbations on moving to cities, while four of them had the beginning of their illness on moving from a town into a more rural area. climatic interventions on patients atopic dermatitis can be worsened by climate change because it gets affected by temperature increases, pollution and production of pollen and allergens, humidity, and increased levels of uv radiation (wang et al., 2024). in the present study, exacerbation of the condition occurred in 13 children (22.03%) during winter and in 15 children (25.42%) during summer, especially after sweating. figure 5: seasonal variation of number of patients figure 6: effect of irritants (i.e. wool or lipid solvents) examination findings history of atopy or allergic disorders in the shortlisted 59 children having atopic dermatitis, 44 (74.5%) patients had family / personal history of atopy or other allergic diseases and 26 (44.06%) patients had personal history of atopy or other allergic diseases. although both parents transmitted atopy in the family history, it was more dominant in mothers with 40 percent. inheritance through the mother was found to be more common at 67% as opposed to the paternal inheritance at 35.59%. concerning the parents’ health status, 10 children (16. 94%) had a history of atopy/allergic disorders previously reported in their parents. details of previous allergic disorders in the siblings were taken from 10 (16. 94%) patients. in regard to the atopic manifestation, allergic rhinitis was most frequent, then bronchial asthma (akhmedova & akhmedova, 2021). for personal history of atopy in patients with the disease, 7 (11. 86%) among the patients had episodic viral wheeze. table 4 and figure 7 shows a detailed and comprehensive analysis of these number mentioned above. table 4: number of patients classified according to the presence of existing atopy or allergic disorder atopy/allergic disorders ar ba evw ad total percentage ar allergic rhinitis ba – bronchial asthma evwepisodic viral wheeze adatopic dermatitis maternal 17 7 24 40.67 paternal 9 12 21 35.59 sibling 1 5 4 10 16.94 personal 11 8 7 26 44.06 furthermore, xerosis was the most frequent cutaneous morphology; 58 (98.3%) of the patients described their skin as being very much dry, at some time or all the time. desquamation of the skin in the form of hyper pigmented diamond shaped scales was identified in 24 (40.67%) of children with atopic dermatitis. palmar hyper linearity was present in 24 (40.70%) of the children investigated in the present study with atopic dermatitis. however, hyper linearity of palms was present in 24 patients and among these, 20 have ichthyosis as an additional attribute. pa ge 24 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 this feature characterized by tiny follicular papules was noted predominantly over outer arms in (13. 6%) of our patients. ichthyosis was seen in two patients with positive family history; hyper linearity of palms and keratosis pilaris were seen in one patient. minor examined features apart from major physical features related to the patients suffering from ad, there were few minor features as well that corresponds to provide further analysis about the severity of the conditions. few of these features are mentioned below as well represented as a demographic graph in figure 8. nipple eczema nipple eczema was noted in 3 patients (5.01 %) among our 59 patients. this finding was more common in the older children, cheilitis there were 10 (16.9%) children with atopic dermatitis, who presented with dryness and fissuring of lower lip. nonspecific hand/ foot dermatitis there were 8 (13.6%) patients had eczematous lesions over hands and feet. dennie morgan fold this finding characterized by folding of lower eyelid was noted in 34 (57.60%) children. there was associated lower eyelid dermatitis among 4 (11.76%) of them. facial pallor / erythema sixteen (27.1 %) out of 59 children had facial pallor. in most of them it was confined to the perinasal area, with a few showing involvement of periorbital area also. orbital darkening this feature was characterized by hyperpigmentation below the lower eyelid was present in 18 (30.50%) patients with atopic dermatitis. pityriasis alba there were 15 (25.4%) children with pityriasis alba of which 10 had the lesions over the face only and the remaining 5 children showed extensive lesions over the trunk also. anterior neck folds this finding characterized by horizontal creases on the anterior aspect of the neck was present in 4 (6.77%) children with atopic dermatitis. perifollicular accentuation nine (15.3%) children with atopic dermatitis showed perifollicular accentuation characterized by pebbled appearance which was noted over the thighs, upper arms and back of trunk. white dermographism stroking of involved and uninvolved skin of patients with a blunt object produced a white line in 7 (11.9%) children. in addition to the above mentioned features described by hanifin and rajka, other findings noted were: scalp scaling out of 59 patients with atopic dermatitis, 13 (22%) had diffuse scaling of the scalp. eyelid dermatitis scaling and redness of the eyelid was noted in 10 (16.9%) of children with atopic dermatitis. itch when sweating there were 26 (44.06%) children who complained of itch when sweating, which was more in the axilla and groins. recurrent conjunctivitis there were 12 (20.33%) children who complained of recurrent conjunctivitis. figure 7: family history of atopy or allergic disorders pa ge 25 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 figure 8: minor features corresponding the severity of ad in different patients skin lesions and their distribution particularly, the study identified that the ad targeted face and the flexural surfaces in the limbs, or course, refers to the inner parts of the joints as such as elbows and knees. interestingly, the distribution of involvement showed some variation: facial involvement still, only 9 patients (15.3%) had atopic dermatitis exclusively on the facial skin; it was evident in total. this raises the aspect of esteem as a patient may be at risk of losing confidence and social interactions. combined involvement the most common site of involvement was faces and flexures (17 patients or almost 28.8%). this implies that the condition may be wider than what has been estimated by the director of the research. extensor involvement in only 5 (8.5%) patients the ad became involved only in the extensor aspect (the area in direct opposition to the bend, e. g., the outer region of the arms and the forearm). this pattern is more unusual for ad. isolated flexural involvement only the flexural surfaces were affected in another 9 patients (15.3 %). this underlines the significance of assessing these regions in the process of the disease’s identification. table 5: sites of different skin extremities and number of patients affected site number percent generalized eczema 8 13.5 eczema in face alone 9 15.3 eczema in flexures alone 9 15.3 eczema in extensors alone 5 8.5 eczema in face and extensors 9 15.3 eczema in face and flexures 17 28.8 eczema in face, flexures and extensors 2 3.4 total 59 100.0 secondary cutaneous infections in addition to atopic dermatitis, some children also presented with secondary skin infections or infestations which can also be observed via demographic status in figure 9: impetiginisation (13.55%) among all the secondary diseases, this bacterial superinfection was the most common in the study reappearing in more than 8 children. impetiginisation aggravates the symptoms of eczema and the use of antibiotics is needed for the treatment. tinea versicolor (6.77%) there are 4 children who have such a fungal infection that is characterized white and tannish colored patches. though it doesn’t belong to the category of eczema, it is similar to it and may be confused with the latter sometimes. hand, foot, and mouth disease (3.38%) this viral infection presents with a fever and a rashes accompanied by blistering of the hands, feet and the oral cavity and two children were diagnosed with this. molluscum contagiosum (1.69%) only one patient had this viral infection, and there were small, painless, bumpy lesions on the skin. pa ge 26 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 figure 9: patients affected by secondary skin infections identifying food triggers eczema or the atopic dermatitis is indeed very irritable, making the skin on the affected area feel itchy. the specific cause is still unexplained, nevertheless, there are certain foods that are believed to worsen the condition in patients (papapostolou et al., 2022). consequently, our study showed that 41(69.49%) children had worsening of the disease manifestations with particular foods. the food products that had more frequent associations with allergies were milk in 12 irregular cases (28.57%) and followed by egg in 9 cases (21.4%). other foods that are included were meat, wheat, biscuits, ragi, fishes, sea foods, nuts chocolates, and orange as per shown in table 6. table 6: food allergens affecting number of patients food allergens no: of patients percent wheat 4 9.5 milk 12 28.57 meat 5 11.9 ragi 3 7.1 egg 9 21.4 biscuits 3 7.1 orange 1 2.38 nuts 1 2.38 chocolate 1 2.38 seafood 1 2.38 fish 1 2.38 total 41 69.49 moreover, on the aspect of adequate breast feeding, it was revealed that all except 8 children (13. 55%) were adequately breast fed. as for the inadequately breast fed children, all 8 of them had onset of disease before 1 year of age. in the following study, among 59 children with atopic dermatitis, 12 children were evaluated to be malnourished based on their weight for age status as per the who 2006 and iap 2015 centile charts. treatment induced to the patients out of the 59 children with atopic dermatitis, 13 (22.03%) of them were receiving management through moisturizers alone. among the twenty of them, majority (75%) were on topical corticosteroids which was often used with moisturizers. of these 59, five (8.47%) of them were on topical calcineurin inhibitors combined with moisturizers and topical corticosteroids. among them 21 (35.59%) were used resorted to other system of medicines. out of which, 18 patients (30.50%) were taking ayurvedic treatment and 3 patients (5. 08%) were taking homoeopathic treatment. statistical analysis the correlation between the clinical aspects of the major and minor enrollees themselves together with gender, personal/family history of atopy, age on the onset of the disease below 1 year, inadequate breast feeding, malnutrition, history of food allergy and history of seasonal worsening of symptoms were investigated. pearson joint chi square test was also used in the analysis and p value was greater than 0.05 (p > 0.05), which indicates that there has no statistical relationship between the major and minor clinical entities among the children in the study group. pa ge 27 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 discussion in this investigation, a prospective analysis of 59 cases of children with ad during one year from november 2015 to october 2016 was carried out. ours’ was primarily a historical and clinical examination centered study. many authors globally have also as well investigated clinical manifestations of atopic dermatitis. such studies have often drawn different conclusions which might be due to ethnic variation or differences in definitions, materials or methods used. the following study included children with ad within the age-group of 2 months to 12 years. children with atopic dermatitis participating in the study ranged from the age of 2 months to 12 years of age with the average age of 3.5 years. srinivas in his study also involved children those who belonged to the same age group thus the mean age of the ad patient was 2.7 years (srinivas et al., 2023). in a similar fashion, findings in the study by parthasarathy, established that the mean and median age were 4.6 and 3.9 years respectively (parthasarathy et al., 2020). hence, the age distribution of our patients is thus well in parallel with the other studies done in india. similarly, the following study identified cutaneous infections in 25.42% of children with ad having impetiginisation in 8 of the patients, tinea versicolor in 5, hfmd in 2 and molluscum contagiosum in only 1 patient. that is why the level of infections is relatively low – due to better hygiene measures in kerala and the use of antibiotics in time (aggithaya et al., 2021). the study also revealed that in the subjects with ad, 57.60% of the children had dennis morgan (dm) fold present, indicating a status due to persistent vasoconstriction, thus the lower percentage may be due to less severe manifestation of the disease in the children and the higher rate identified in some indian studies due to ethnic difference and darker skin color (nath et al., 2020). moreover, in our study, orbital darkening was present in only 30.50% of cases, whereas different studies show different numbers. probably, the reason for this difference may be the persistence of nasal congestion for a longer time period in atopic adults. increased exposure to pollution in cities like bangalore or delhi might increase its incidence (ailawadi et al., 2024). in the present study, 44.1%) of the patients with atopic dermatitis experienced itch when sweating, and exacerbation during summer. probably, the humid climate of kerala may be responsible for the increased incidence. around 11 patients (18.64%) reported worsening of the disease with the use of soap and detergent. furthermore, food items also played a crucial role in severity of ad depending on the patient’s status (mehta & fulmali, 2022). of 59 children, 41 (69. 49%) definitely noted worsening of the disease after consuming certain foods. among the foods, milk was most incriminated and posed threat to disease complications in 12 (28. 57%) children. in 10 of the 12 studies, cow’s milk was implicated while formula feeds were found to be responsible for the rest of the three cases and goat’s milk in one patient respectively (ramírez-marín et al., 2022). this was succeeded by egg in 9 (21. 4%) and meat in 5 (11. 9%) patients. meat is the most recurrent food identified in all the four children with chicken being the most common implicated food (liao et al., 2022). this was succeeded by wheat, biscuits, ragi and fish as the foods that were mentioned as likely causes of the situation in 9.5%, 7.1%, 7.15% and 2.38% patients respectively. other highlighted foods were nuts, chocolate, seas foods and oranges. different studies have discussed about the link between food allergy (fa) and atopic dermatitis (ad) which are prevalent. it is often established that food sensitization can be present in such patients (domínguez et al., 2020). however, before suggesting that the patient follows a restrictive diet which may prove to be detrimental to his/ her health, allergy should be proven (rustad et al., 2022). preschool children with ad are most commonly sensitized to egg, milk or peanut whereas school aged children and adults are commonly sensitized to hdm’s, molds, animal dander or pollens. a barrier disturbance was found to play a main role in the process of sensitization and allergy, which is quite well known indeed (ramírez-marín et al., 2022). hence, concerning the fact that ad begins in early infancy, newborns’ skin care using emollients and the early introduction of food seem to be crucial to define the tolerance to food (mehta & fulmali, 2022). apart from edible allergies, lack of breastfeeding was also a common factor associated with the prevalence of ad (lin et al., 2020). inadequate breastfeeding was seen in 13.5% of 59 patients with atopic dermatitis, with a collective duration of less than one year. this may support the role of a varied solid food diet in exacerbating the disease. additionally, atopic dermatitis was noted in 20.33% children whose weight was below the 3rd centile on the new combined who 2006 and iap 2015 weight charts. probably, nutrition will remain of interest for as long as safe and effective therapy methods against ad are being pursued (trikamjee et al., 2021). while discussing about the severity of ad compared to the sample area population, atopic dermatitis increased evidently in the study area of patients with winter exacerbation was significantly different from summer exacerbations (belzer & parker, 2023). according to the consequences of the disease, it was worsened in winter in 67.14% of patients with an infantile atopic dermatitis disease, and it occurred in summer in 25.42% of the patients. the research conducted also noted that the temperature of the environment did not fluctuate much from one year to the next in the coastal tropical zone which might have led to low prevalence. the researcher also found again that that majority of the patients were from upper or upper middle-income families. conclusion the present work aimed to assess children with atopic dermatitis in a tertiary care hospital. female patients were more frequent than male ones. it was identified that children had the onset of the disease at an early pa ge 28 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 19-30, 2025 age, below 1 year of age, and there was significant itching as a common symptom in most children, which was worse at night (song et al., 2024). thus, the most frequent and significant finding in patients’ history was the presence of atopy in the firstand second-degree relatives, especially on the maternal side (ai et al., 2024). food intolerance was evident mainly in milk products and foods containing milk, while contact urticaria and contact dermatitis from wool and lipid solvents were reported in one-third of the cases (eyerich et al., 2024). there was evident a seasonal pattern in the patients with half of the interviewees complaining of worsening of symptoms during summer (fitzmaurice & silverberg, 2024). facial lesions were observed frequently, and the limbs’ flexor surfaces had more extensive involvement than extensor surfaces (geng & sibbald, 2024). xerosis contributed to almost all the patients; ichthyosis was more prevalent than keratosis pilaris. more to the point, there was a low prevalence of skin infections, and signs such as orbital darkening, pale face, dermatitis eyelids, and anterior neck folds (herzum et al., 2024). it is also noteworthy that most of the children had a rural origin, while most of them belonged to the upper or upper-middle social class. one alarming fact was that a major portion of children suffering from malnutrition were observed as 19% of the total study group (von kobyletzki et al., 2024). recommendations • even though a simple observation of ‘itching and dryness of the skin’ confirms the disease in atopic dermatitis, other aspects mentioned as the major and minor criteria should be sought. • babies born to parents having personal/family history of atopy or any other allergic disorder should be put on ‘no other milk’ for the first 6 months and should continue breast feeding till 2 years as this postpones the onset and severity of the disease. • knowing certain triggers such as food will enable one to prevent the worsening of the disease. • parents should be made aware of the treatment options available that is there are facilities available for exact treatment rather than using other medicines like ayurveda and homoeopathy and proper advice should be provided to stick to allopathy. limitations • this study is limited by the fact that the values that were derived represent the result of one particular hospital and from a selected population and therefore the findings of this research cannot be generalized to the whole population. • this cross-sectional study orientation also precluded establishing causality between the identified precipitating factors and the clinico-radiological features of the disease. • the age of onset, breastfeeding and other practices, type of precipitating factors like food, season and other irritants to diarrhea might suffer recall bias from the mothers or the primary care givers. • they might also present reporting bias during the taking of the history. references aggithaya, m. g., narayana, p. p., prasanna, k., & narahari, s. 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(2024). impact of climate change on atopic dermatitis: a review by the international eczema council. allergy, 79(6), 1455-1469. wollenberg, a., werfel, t., ring, j., ott, h., gieler, u., & weidinger, s. (2023). atopic dermatitis in children and adults: diagnosis and treatment. deutsches ärzteblatt international, 120(13), 224. yoo, j., koo, h. y. r., han, k., & lee, y. b. (2022). impairment of quality of life and mental health status in adult-onset atopic dermatitis. annals of dermatology, 34(4), 278. zhao, j., zhang, z., chen, h., dou, x., zhao, z., liu, l., wang, y., & li, h. (2023). association of demographic characteristics, aggravating factors, comorbidities, and treatments with atopic dermatitis severity. authorea preprints. pa ge 1 pa ge 10 9 american journal of medical science and innovation (ajmsi) systematic review on current managements of irritable bowel syndrome by complementary and alternative medicine md. rakib rased rana1*, md. maniruzzaman2, md. sumon ali3, md. monoar hossen2, md. nahid hasan2, md. hadisur rahman rony2, saklain mostak siam2, mst. sajida atik2, juyairia alam2, md. shihabur rahman hridoy4, kaisar ahmad chowdhury5, al mamun shohag6 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3427 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 10, 2024 accepted: august 13, 2024 published: october 25, 2024 irritable bowel syndrome (ibs) affects people worldwide. it causes physical and emotional anguish, typically alongside psychiatric illnesses. when conventional methods of treating irritable bowel syndrome (ibs) fail, patients may go to complementary and alternative medicine (cam) for relief. the quality of the evidence is uneven, but complementary and alternative medicine (cam) shows promise. a systematic review evaluates cam efficacy, safety, and mechanisms for ibs treatment to identify gaps and guide future research. this systematic review evaluates and synthesises cam’s efficacy and use in irritable bowel syndrome treatment. this systematic review (1998-2023) included 15 studies from diverse sources, utilizing keywords related to irritable bowel syndrome (ibs). qualitative data methods extracted insights into complementary and alternative medicine (cam) interventions for ibs. the evaluation covered main findings, clinical features, outcomes, adverse effects, and follow-up periods. prisma-guided data extraction, including a flowchart, ensured a systematic approach. inclusion criteria comprised various study types, while exclusion criteria targeted inconsistent data and low-quality studies. this study examines numerous controlled, randomised, and multicenter studies on ibs therapies, including ayurvedic formulations, conventional nutrition, and cam techniques. participants, study locations, and interventions vary in the global study. results from various studies on ibs therapeutic efficacy, risk factors, and patient preferences are shown. studies on ayurvedic, homoeopathic, and cam treatments provide a complete overview of ibs care. the study found that ayurvedic and cam treatments for ibs are helpful, but mainstream medications are risky. to improve efficacy, tailored, culturally relevant programmes need research and standardisation. keywords 1 department of public health, varendra university, rajshahi, bangladesh. 2 department of pharmacy, varendra university, rajshahi, bangladesh. 3 department of psychology, national university, rajshahi, bangladesh. 4 department of pharmacy, daffodil international university, dhaka, bangladesh. 5 department of pharmacy, international islamic university chittagong, chattogram, bangladesh. 6 department of pharmacy, dhaka international university, dhaka, bangladesh. * corresponding author’s e-mail: rakibrana.vu@gmail.com ayurvedic, complementary and alternative medicine (cam), homoeopathic, irritable bowel syndrome (ibs) introduction irritable bowel syndrome (ibs), a prevalent gastrointestinal condition, manifests through abdominal discomfort and irregular bowel patterns and lacks identifiable causative diseases. this chronic disorder varies in intensity, spanning from mild to severe symptoms. diagnosis often follows the rome iv criteria, categorizing it as constipationpredominant (ibs-c), diarrhoea-predominant (ibs-d), or mixed (ibs-m) (patel et al., 2023; ford et al., 2020; hongo & sato, 2006). the prevalence of irritable bowel syndrome (ibs) varies considerably worldwide. in north america, estimates fluctuate between 3% and 20%, generally hovering around 10% to 15%. specifically, in the united states, using the rome iv criteria, approximately 6.1% of the population is affected. meanwhile, in the united kingdom, the prevalence stands at roughly 10.5%, whereas in a north indian community, it’s approximately 4%. globally, encompassing rome iii or iv criteria, the estimated prevalence of ibs rests at around 9.2%. these variations underscore the diverse geographic and diagnostic aspects influencing ibs prevalence rates across different populations (saito et al., 2002; almario et al., 2023; wilson et al., 2004). irritable bowel syndrome (ibs) exerts a profound impact on the well-being of individuals it afflicts. its hallmark symptoms—abdominal pain, bloating, and irregular bowel patterns—not only induce physical discomfort but also evoke emotional distress. this condition interlaces with psychiatric disorders, with a striking 76% of ibs patients encountering major depressive disorders and 54% grappling with anxiety disorders. these mental health comorbidities further diminish the overall quality of life. ibs doesn’t merely manifest as physical impairments; it profoundly affects health-related quality of life, impeding daily functioning. moreover, dietary triggers often provoke or exacerbate ibs symptoms, compelling individuals to navigate through dietary adjustments and adding to their distress. consequently, managing ibs necessitates not only alleviating symptoms but also striving to elevate the overall quality of life for those affected (khan et al., 2022; fadgyas stanculete et al., 2023; weber, 2022). traditional approaches to managing irritable bowel syndrome (ibs) aim at mitigating symptoms through dietary modifications and pharmaceutical interventions. dietary adjustments often involve augmenting fibre intake or opting for hydrolyzed guar gum, a preference observed among a majority of patients seeking relief. pharmaceuticals prescribed for ibs encompass a spectrum such as antispasmodic agents, loperamide, pa ge 11 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 antidepressants, alosetron and tegaserod (hadley & gaarder, 2005). traditional approaches to treating irritable bowel syndrome (ibs) often present inherent challenges. despite encompassing various medications like laxatives, antidepressants, antispasmodics, and bulking agents, their efficacy and tolerability tend to disappoint many patients. clinical trials haven’t conclusively demonstrated their superiority over placebos in providing comprehensive relief from the diverse array of ibs symptoms. moreover, these therapies come with constraints and limitations, underscoring the pressing necessity for treatments that empower patients with behavioral self-management techniques to alleviate their ibs symptoms (hulisz, 2004; lackner et al., 2008). given the limitations of current irritable bowel syndrome (ibs) treatments, there’s a pressing demand for alternative approaches to better manage its symptoms comprehensively. traditional medications like antispasmodics, antidiarrheals, and tranquilizers haven’t demonstrated consistent effectiveness across all ibs symptoms globally. complementary and alternative medicine (cam) modalities, such as herbal treatments, acupuncture, and moxibustion, while frequently employed, often yield inconclusive or erratic results. psychological therapies like mindfulness and acceptance and commitment therapy (act) hold promise, yet their efficacy varies. osteopathy has shown some potential in alleviating ibs symptom severity. a holistic multidisciplinary strategy, integrating lifestyle modifications, dietary management, pharmacological interventions, psychological approaches, and diverse alternative therapies, emerges as a necessity for more comprehensive and effective ibs management (chang & lu, 2009; park et al., 2013; sebastián sánchez et al., 2017). complementary and alternative medicine (cam) encompasses diverse medical systems and practices rooted in various theories, experiences, and philosophies aimed at enhancing health and addressing physical and mental ailments. these therapies, including acupuncture, dietary supplements, reflexology, yoga, massage, chiropractic services, reiki, and aromatherapy, often operate outside the realm of conventional healthcare. while some countries are integrating certain cam approaches into mainstream healthcare, their regulatory oversight remains limited, raising concerns about the lack of government supervision, particularly by agencies like the food and drug administration. this unregulated nature poses challenges in recommending and guiding the use of cam therapies (moquin et al., 2009; falkenberg et al., 2012; fowler & newton, 2006). within the realm of complementary and alternative medicine (cam), an array of therapies is utilized. this includes herbal remedies and acupuncture, often sought after for pain alleviation and enhancing one’s overall wellbeing. under the umbrella of cam, dietary supplements like probiotics find prevalence, while mind-body practices such as yoga, meditation, and relaxation techniques aid in health maintenance and symptom management across various health conditions. additionally, dietary adjustments, incorporating vitamins and minerals, constitute another prevalent approach within cam practices (williamson et al., 2003; lunny & fraser, 2010; barnes et al., 2008). the surge in the utilization of complementary and alternative medicine (cam) approaches to address chronic conditions such as irritable bowel syndrome (ibs) stems from the limitations of conventional treatments, which often prioritize symptom management over comprehensive treatment and may yield notable side effects. within the realm of cam, therapies like herbal or dietary supplements, mind-body practices, and acupuncture are garnering increased favour among individuals grappling with ibs. treatments like peppermint oil and iberogast®, hypnotherapy, cognitive behaviour therapy, and yoga have shown promise in enhancing treatment outcomes for ibs patients. for instance, herbal remedies like peppermint oil and specific probiotics have demonstrated efficacy, while mind-body interventions such as hypnotherapy and cognitivebehavioural therapy have exhibited effectiveness for a subset of patients (chey et al., 2011; magge & wolf, 2013; grundmann, 2014). the impetus behind exploring complementary and alternative medicine (cam) for irritable bowel syndrome (ibs) management lies in the limitations inherent in conventional treatments and the prevalent adoption of cam modalities by individuals with ibs. conventional approaches for ibs often centre on mitigating symptoms yet may fall short of providing comprehensive relief and, at times, yield considerable side effects, creating an efficacy disparity. consequently, a substantial number of ibs sufferers seek out cam therapies encompassing herbal remedies, dietary supplements, mind-body practices, and various alternative modalities. these therapies are perceived as natural and beneficial, with some showcasing the potential to assuage abdominal discomfort and elicit a holistic response in managing ibs symptoms (billings et al., 2021; hussain & quigley, 2006; parlar kılıc et al., 2020). complementary and alternative medicine (cam), encompassing herbal treatments, dietary supplements, and mind-body approaches, presents promising avenues for managing abdominal pain and overall response in irritable bowel syndrome (ibs), yet the collective evidence quality remains limited. specific cam modalities, including soluble fibre, peppermint oil, probiotics, hypnotherapy, and cognitive-behavioural therapy, have demonstrated efficacy in alleviating ibs symptoms. herbal remedies like peppermint oil and iberogast(®), alongside mindbody interventions, have showcased enhanced treatment outcomes in individuals with ibs. the inclusion of acupuncture and moxibustion has exhibited benefits in ameliorating symptom severity, addressing abdominal discomfort, and enhancing the quality of life among ibs patients. nevertheless, comprehensive, methodologically robust clinical trials are imperative to delve deeper into pa ge 11 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 the effectiveness of cam interventions in addressing the complexities of ibs symptoms.(shen & nahas, 2009; yang et al., 2022). the aim of this systematic review is to comprehensively assess the efficacy, safety, and potential mechanisms of action underlying various complementary and alternative medicine (cam) modalities used in the treatment of irritable bowel syndrome (ibs). the primary objectives include analyzing the collective effectiveness of cam interventions in alleviating ibs symptoms, evaluating their safety profiles, and elucidating potential mechanisms through which these modalities exert their therapeutic effects. additionally, the review aims to identify gaps in existing research, ascertain the quality of evidence, and offer insights into promising avenues for future investigation into cam treatments for ibs. materials and methods search strategy this systematic review considered studies from 1998 to 2023 and finally included 15 studies. the authors have collected data from pubmed, google scholar, cochrane, researchgate, scopus, sciencedirect, and other online libraries. the search process involved the use of specific keywords related to irritable bowel syndrome (ibs), such as “irritable bowel syndrome (ibs),” “complementary and alternative medicine (cam),” “constipation-predominant (ibs-c),” “diarrhoea-predominant (ibs-d),” and “mixed (ibs-m).” these keywords were carefully selected to ensure a broad yet focused scope, encompassing different aspects and management approaches of ibs. additionally, the inclusion of specific subtypes like ibs-c, ibs-d, and ibs-m also included the application of complementary and alternative medicine across different presentations of ibs. qualitative data collection methods were utilized to extract relevant information regarding the management of ibs using complementary and alternative medicine. the literature search focused on articles providing insights into the effectiveness, outcomes, and patient experiences related to cam interventions for ibs. this comprehensive approach aimed to present a nuanced and up-to-date overview of the current state of complementary and alternative medicine in managing irritable bowel syndrome. evaluation the review evaluated the main findings of each study, clinical features of each study, primary and secondary outcomes and the respective adverse effects. the followup period was also evaluated and recorded for each study. this enabled us to evaluate the various outcomes that are possible with ibs. the spectrum of adverse events have also been considered. this review also considered various drugs and medicines that have been employed in each study for the treatment of ibs. the evaluation of studies widely conducted bring a better picture of available complementary and alternative medicines for the proper management of ibs. data extraction this research used a prisma-compliant systematic review methodology. from the databases, 82 records were figure 1: prisma flowchart of this study pa ge 11 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 initially retrieved. after using automation technologies to remove 15 duplicate records and indicate 18 as ineligible, 49 records were screened. 14 were excluded due to access restrictions. although the study attempted to retrieve 35 reports, 14 were unsuccessful. afterwards, 19 reports were reviewed to determine their eligibility; however, 4 were excluded since their data were inconsistent. according to the last stage, “included,” fifteen studies were included in the review. a prisma flowchart provides a clear and organised visual representation of the data, allowing one to understand the study selection process easily. by following a systematic approach, the review’s methodology is made clear and reproducible, increasing the reliability of the studies included in the research. inclusion and exclusion criteria inclusion ● this study included randomised, cross-sectional, control and descriptive-analytical papers. ● this study included irritable bowel syndrome cases included in this paper. ● this study considered only the english language. ● this study included from 1998 to 2023. exclusion ● inconsistent data were excluded from this paper. ● review articles or similar papers were also excluded from this study. ● low quality, insufficient data, and lack of response papers were excluded from this study. results and discussion results table 1 summarises studies on irritable bowel syndrome treatments. research of many kinds is covered in the studies. these include controlled studies, randomised controlled trials (rcts), and multicenter research. traditional ayurvedic formulations, conventional nutritional therapy, and complementary and alternative medicine (cam) methods are among the medicines or therapies that have been studied. the global exploration of treatments for irritable bowel syndrome is reflected in the heterogeneity of research with respect to the number of participants, country of study, and specific interventions. in order to assess the efficacy, safety, and possible action mechanisms of various therapies in symptom management of irritable bowel syndrome (ibs), the data provides a thorough baseline. table 1: baseline characteristics of the studies included in this review studies type of study medicine investigated no. of patients country of study teja d naik et al. (2023) randomised controlled parallel group study kalingadi churna,wsap 48 karnataka dania chumann et al. (2022) randomised study ayurvedic or conventional nutritional therapy, fodmap 69 germany sally brabyn et al. (2019) randomised controlled trials homoeopathic remedy, asafoetida or asafoetida plus nux vomica, ibs-c 307 uk virginia sánchezmonroy et al. (2021) rct archibel, isnes, belgium 41 mexico l. langmead (2006) randomised, controlled oral aloe vera gel, wheatgrass juice, boswellia serrata 153 london diego curro et al. (2016) randomised controlled trials anti-diarrheal drugs, bile salt sequestrants and antibiotics 1225 rome lena oxelmark et al. (2016) controlled study cam 854 gothenburg qian yang et al. (2022) multicenter study cam 730 china richard w. mccallum et al. (2015) randomised controlled trials vitamin and mineral 61 australia ronald l. koretz et al. (2004) randomised controlled trials cam 258 us ga moody et al. (1998) rct homoeopaths and herbalists 82 uk l. langmead et al. (2001) rct herbal medicines 760 uk pa ge 11 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 khadijeh hatami et al. (2020) randomised clinical trial. some herbal medicines, maybeverine 40 uk cesar ramos-remus md et al. (2008) rct non-conventional remedies, complementary medicine and/or alternative therapies 100 mexico h vahedi et al. (2010) rct homoeopathic medicines 100 iran table 2 provided a comprehensive analysis of findings from various studies on irritable bowel syndrome (ibs). teja d naik et al. (2023) observed significant improvements in clinical evaluation scales after a 4-week study, with higher scores indicating worse conditions. dania schumann et al. (2022) assessed expectations and disappointments over three months, revealing that ayurvedic treatment reduced ibs-sss. sally brabyn et al. (2019) identified bias in three 2-week studies on global ibs improvement, with low and high-risk bias domains. virginia sánchez-monroy et al. (2021) reported that individualized homeopathic treatment reduced symptom intensity after 3 months. l. langmead (2006) evaluated risk factors associated with alternative therapy over 3 months, revealing low success rates and substantial adverse effects of traditional therapies. diego curro et al. (2016) examined complementary therapies over a year but found few conclusive outcomes due to the absence of repeating rcts. lena oxelmark et al. (2016) found natural product use and cam benefits in 83.1% of patients. tiziana larussa et al. (2019) identified a higher bmi and better cam knowledge after 3 months, suggesting improved patient education. qian yang et al. (2022) noted the incidence of organic illnesses in probable ibs patients throughout 4 months. richard w. mccallum et al. (2015) suggested that cam therapy might reduce recurring stomach discomfort. ronald l. koretz et al. (2004) examined probiotics for childhood diarrhoea over 90 days. ga moody et al. (1998) discussed cam’s benefits for inflammatory bowel illness over four months. l. langmead et al. (2001) found cumin more effective than mebeverine over one year. cesar ramos-remus md et al. (2008) identified 12-month advantages of alternative musculoskeletal pain therapies. over three months, h vahedi et al. (2010) highlighted the hpa axis and chronic anxiety in ibs pathogenesis, and the decreased incidence of stomach discomfort, diarrhoea, and constipation. this research evaluated the efficacy of ibs therapy, identified risk factors, and explored patient preferences. table 2: evaluation of findings of the included studies studies clinical features of ibs followup period primary outcome secondary outcome adverse effect teja d naik et al. (2023) higher scores indicate worse conditions 4 weeks mild ibs, moderate ibs and severe ibs . a decrease of 50 points is associated with an improvement in clinical symptoms. visual analog scale within-group significant improvements were observed on all clinical assessment scales in both groups. dania schumann et al. (2022) expectations and frustrations were observed in patients 3 months the estimated marginal means of reduction were in the ayurvedic and conventional groups. the reduction in ibs-sss was significantly higher in the ayurveda group than in the conventional therapy group the higher the ibssss score and the higher the patients' expectations, the greater the reduction in ibssss observed there were no significant group differences in any of the secondary outcome measures. no serious adverse events occurred in either group. pa ge 11 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 sally brabyn et al. (2019) risk of bias was noted in three studies 2 weeks the primary outcome was global improvement in ibs as measured by an ibs symptom severity score secondary outcomes included quality of life, abdominal pain, stool frequency, stool consistency, and adverse events four domains were at low risk of bias and two were at high risk of bias virginia sánchezmonroy et al. (2021) symptom severity decreased significantly after 3 months of treatment, pain scores decreased after 1 month of treatment. 4 months the study found that the severity of symptom scores decreased significantly after 3 months of treatment, while the pain scores decreased after 1 month of treatment. emphasises the importance of individual medicinal approaches using lm potency, although the initial reduction of pain may also be due to the fact that lycopodium clavatum and nux vomica were the main homeopathic medicines, and these medicines contain a variety of alkaloids, which have significant analgesic effects on pain caused by physical and chemical stimuli. showed the study suggests that individualised homoeopathic treatment using lm potency benefits ibs patients. l. langmead (2006) alternative therapies have been shown to have more risk factors than any other form 3 months conventional therapies have shown very low success rates can cause serious side effects and can include fatal liver and kidney failure knowledge of longterm sequelae such as mutagenicity and carcinogenicity is still poorly observed diego curro et al. (2016) probiotics may have a role in alleviating some symptoms of ibs. or was 1.6 for dichotomous data from seven trials; smd was 0.23 for continuous data from six trials 1 year several therapeutic approaches have been explored as complementary or alternative to traditional pharmacological treatments, including probiotics, prebiotics, synbiotics, fibre and herbal medicines due to increasing consumer spending on nutritional and healthy dietary supplements globally, their market has shown consistent growth over the past few years. no definitive conclusions can be drawn due to the lack of rcts that replicate results obtained in individuals. research conducted so far. pa ge 11 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 lena oxelmark et al. (2016) one died patient 1 month after adjusting for age, sex, geographic residence and diet in a multivariate analysis, a statistically significant difference was observed. the most commonly used natural products used by patients are omega 3, probiotics, aloe vera, vitamins, arctic root and other herbal products. omega 3, echinacea spp., kan yang, siberian ginseng, arctic root and herbal products have been used in control. in all, 83.1% patients experienced positive effects from cam and 14.4% experienced negative effects. tiziana larussa et al. (2019) adjusted odds ratio, 95% confidence interval of significant risk factors for cam use 3 months a higher bmi and better knowledge of cam were observed time of childbearing was a protective factor. only 19% of patients used cam due to medical advice. however, a minority of patients had complete satisfaction with cam. this willingness to reuse suggests that healthcare providers’ knowledge and patient education should be improved. qian yang et al. (2022) the prevalence of organic disease among patients with suspected ibs was 10.41%. warning signs for organic disease include ppv anaemia, faecal occult blood, and unintentional weight loss 4 months there was a prevalence of organic disease in patients with suspected ibs the ppv and miss diagnosis rate for the diagnosis of ibs were 91.67% and 74.77% when all alarm symptoms were combined with rome iv. only rectal occult blood, unintentional weight loss, and anemia were associated with rome iv, respectively. richard w. mccallum et al. (2015) decreased incidence of recurrent abdominal pain associated with constipation, diarrhoea, or both 3 months abdominal pain, acid reflux/heartburn, digestive allergies, liver conditions, nausea/vomiting and ulcers. the most commonly used methods were herbal, complementary and mind body and manipulative therapy this explosive use of cam therapies has created opportunities in recent years for the centers for complementary and alternative medicine and the national institutes of health to strongly support alternative medicine. there were several chinese and ayurvedic preparations that were found to be better than placebo with no serious adverse effects. ronald l. koretz et al. (2004) probiotics were beneficial in childhood diarrhoea or diarrhoea caused by antibiotics 90 days ginger has been found to be effective in relieving nausea and vomiting caused by motion sickness or pregnancy. homeopathy is effective in treating gastrointestinal problems or symptoms. gastroenterologists should be familiar with these techniques; it is probably already their patients. pa ge 11 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 ga moody et al. (1998) many patients with inflammatory bowel disease have benefited 4 months there was no significant difference in consultation rates between asian and european patients with ibd. most patients were advised to continue their current medications, although two were asked to stop and 10 were advised to reduce their allopathic medication dosage. many patients with ibd believed them to be helpful. l. langmead et al. (2001 drug and placebo and standardization preparetion placebos and drug in both powder and capsule form were similar in shape, color and smell. 1 year cumin was more effective than mebeverine in reducing the severity of ibs symptoms. subgroups were correct for this analysis. cumin powder was more effective in improving ibs quality of life than mebeverine. obstructions were also statistically significant except for changes in food abstinence in both groups. in composition analysis, cumin was significantly more effective than mebeverine in persian medicine, it is believed that every substance has efficacy cesar ramos remus md et al.(2008) benefits from musculoskeletal pain syndromes 12 months musculoskeletal pain syndromes involving the spine and extremities were the most common patients sought both physical and alternative care 53% reported some degree of efficacy in patients using alternative treatments. h vahedi et al. (2010) decreased incidence of abdominal pain, diarrhoea, constipation or both diarrhoea and constipation 3 months activates the hypothalamicpituitary-adrenal (hpa) axis and the autonomic system chronic anxiety increases amygdalar activity leading to formation of an hpa axis that ultimately induces visceral hyperalgesia. important role in the pathophysiology of ibs.21 discussion the investigation into cam for ibs reveals widespread adoption of diverse therapies. hussain and quigley’s review (2006) underscores the prevalent use of cam, often as standalone or complementary to conventional treatments. however, most lack robust clinical trials, primarily small-scale and low-quality studies, though interventions like hypnotherapy, specific herbal treatments, tailored diets, and probiotics show promise. recognizing cam’s prevalence among ibs patients, healthcare providers should acknowledge its potential benefits, particularly in certain therapies, but the scarcity of high-quality trials emphasizes the need for rigorous scientific exploration to validate and broaden cam’s role in ibs management . billings et al. (2021) meta-analysis explored cam’s efficacy in ibs. among herbal therapy, dietary supplements, and mind-body approaches, there were potential benefits over placebo, notably for abdominal pain. however, the confidence in these estimates remained low. meanwhile, body-based and energy healing therapies didn’t show significant advantages. overall, the evidence quality for cam in ibs treatment was considered low, underscoring the need for high-quality trials to further explore their effectiveness (hussain & quigley, 2006). amsallem et al. (2021) review examined nonpharmacological interventions for ibs. body-directed therapies like acupuncture and osteopathy showed promise in improving overall ibs symptoms compared to standard treatment at the 6-month mark. however, no clear advantage was observed over sham therapies for abdominal pain or overall symptoms. the evidence remained inconclusive regarding the superiority of hypnotherapy over standard treatment or supportive pa ge 11 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 therapy. the review emphasized the potential benefits of body-directed therapies but highlighted the need for higher-quality studies to firmly establish their clinical efficacy in managing ibs (amsallem et al., 2021). a systematic review by bu et al. (2020) aimed to determine the effectiveness and safety of tuina (therapeutic massage) compared to no treatment or routine medical treatment for irritable bowel syndrome (ibs). the study delved into 8 trials involving 545 participants diagnosed with ibs-diarrhea or ibs-constipation, employing various tuina manipulations. despite all trials being in chinese, the analysis found inconclusive evidence that tuina alone significantly outperformed routine treatments for ibsdiarrhea in overall symptom improvement (>30% score enhancement) but suggested that tuina combined with routine treatments might yield better results than routine treatments alone (bu et al., 2020). a systematic review by yang et al. (2022) was conducted in which 31 randomized controlled trials examined the efficacy of acupuncture and moxibustion for irritable bowel syndrome (ibs). acupuncture showcased a significant reduction in symptom severity when compared to pharmaceutical drugs (-35.45; 95% ci, -48.21 to -22.68; i 2 = 71%). the trial sequential analysis (tsa) demonstrated acupuncture’s effectiveness. in contrast, acupuncture did not exhibit a marked reduction in symptom severity but did show therapeutic benefits in alleviating abdominal pain compared to sham acupuncture (smd, -0.24; 95% ci, -0.48 to -0.01; i 2 = 8%). moxibustion presented considerable therapeutic benefits in symptom severity (smd, -3.46, 95% ci, -5.66 to -1.27, i 2 = 95%) and abdominal pain (smd, -2.74, 95% ci, -4.81 to -0.67, i 2 = 96%) compared to sham moxibustion. both acupuncture and moxibustion showed superior benefits for abdominal pain when compared to pharmacological medications and shams (smd, -0.46; 95% ci, -0.68 to -0.24; i 2 = 47% for acupuncture and smd, -2.00; 95% ci, -3.04 to -0.96; i 2 = 90% for the combination of acupuncture and moxibustion). furthermore, both acupuncture (md, 4.56; 95% ci, 1.467.67; i 2 = 79%) and moxibustion (md, 6.97; 95% ci, 5.78-8.16; i 2 = 21%) showed significant improvements in quality of life compared to pharmaceutical drugs (zhu et al., 2018). complementary and alternative medicine (cam) modalities exhibit promising potential in mitigating irritable bowel syndrome (ibs) symptoms, often showcasing superiority over conventional treatments. acupuncture, notably, has demonstrated enhanced efficacy in managing diarrhoea-predominant ibs compared to pharmaceutical drugs, offering relief with notably fewer side effects. additionally, peppermint oil stands out as a safe and effective remedy for alleviating pain and overall symptoms in adult ibs patients. however, despite their effectiveness, conventional therapies like drugs frequently accompany side effects, varying in severity. for instance, rifaximin, alosetron, ramosetron, and pinaverium bromide showcase differing degrees of side effects in diarrhoea-predominant ibs. rifaximin and alosetron rank higher in side effect severity, while sham acupuncture and acupuncture exhibit notably milder side effects (alammar et al., 2019; bahrami et al., 2016). although complementary and alternative medicine (cam) enjoys widespread use for addressing irritable bowel syndrome (ibs), discussions within the provided literature scarcely delve into the safety aspects or potential adverse effects associated with these interventions. limited information indicates that certain herbal remedies may pose side effects or interact with conventional medications, underlining the necessity for extensive clinical investigations to evaluate their safety and efficacy. specific references acknowledge potential safety concerns linked to herbal formulas utilized in ibs treatment. consequently, while cam therapies may present promising advantages for managing ibs, their safety profiles necessitate comprehensive assessment. patients are strongly advised to seek guidance from healthcare professionals before initiating any new treatment regimen (shen & nahas, 2009; thompson et al., 2013). cam therapies encompass a spectrum of approaches potentially alleviating ibs symptoms through diverse mechanisms. for instance, herbal remedies such as peppermint oil might exhibit antibacterial properties and could influence the gut microbiota, offering relief. acupuncture is believed to enhance gut motility and modulate the neuroendocrine system within the brain-gut axis, potentially contributing to symptom improvement. moxibustion, a traditional chinese medicine technique, is suggested to impact both the brain-gut axis and the immune system, potentially aiding in symptom management. additionally, therapies like hypnotherapy and cognitive behaviour therapy are presumed to assist in stress management, a factor closely associated with ibs symptoms. these varied cam modalities potentially offer relief via multifaceted mechanisms (huang et al., 2014; isolauri et al., 2016). cam therapies offer diverse advantages in alleviating symptoms associated with irritable bowel syndrome (ibs). soluble fibre emerges as a potential remedy for enhancing constipation and mitigating overall ibs symptoms, while peppermint oil demonstrates efficacy in alleviating abdominal pain. various modalities within cam, such as specific herbal therapies, hypnotherapy, cognitive behaviour therapy, acupuncture, and yoga, showcase improved treatment outcomes for individuals grappling with ibs. probiotics present an overall beneficial impact on ibs; however, the definitive effectiveness of distinct strains remains less discernible. additionally, certain chinese herbal medicines exhibit promising efficacy in alleviating symptoms experienced by individuals with ibs. these diverse cam interventions present multifaceted approaches for addressing different aspects of ibs symptoms (bi et al., 2018; nee & lembo, 2021). the future trajectory of complementary and alternative pa ge 11 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 109-120, 2024 medicine (cam) in alleviating symptoms of ibs may entail explorations into probiotics, acupuncture, and exercise. probiotics, with their potential to positively modify gut bacteria, stand as a promising avenue for enhancing digestive processes. despite varied outcomes, acupuncture, when administered by qualified practitioners, holds promise as a potential relief for ibs symptoms. additionally, regular physical exercise emerges as a feasible and potentially effective treatment strategy for managing ibs symptoms. these avenues highlight evolving paths within cam, indicating potential directions for future research and therapeutic interventions for individuals grappling with ibs (alammar et al., 2019). conclusion this study concluded that clinical therapies for irritable bowel syndrome (ibs) are developed by synthesising numerous data. traditional ayurvedic methods, conventional treatments, and cam are all part of the investigations, which range from randomised controlled trials to multicenter studies. some research has shown that ayurvedic and cam treatments are effective, whereas other research has pointed out the dangers of mainstream medicine and the biases in study designs. the results highlight the importance of creating unique treatment plans for irritable bowel syndrome (ibs) that account for cultural differences and patient expectations. further research and standardisation efforts are needed to improve treatment efficacy and address the complicated character of irritable bowel syndrome (ibs), as the complexity of the condition has been revealed through global treatments. despite promising results in ayurvedic and cam treatments for irritable bowel syndrome (ibs), the study highlights a critical research gap in the risk associated with mainstream medications. the heterogeneous nature of interventions and participant demographics in global studies calls for standardized, culturally relevant programs to enhance efficacy. future research should focus on refining and tailoring these treatments, conducting large-scale trials, and establishing standardized protocols. this study contributes by emphasizing the need for further investigation into safe and effective ibs management, paving the way for improved clinical practices and patient outcomes. references alammar, n., wang, l., saberi, b., nanavati, j., holtmann, g., shinohara, r. t., & mullin, g. e. 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(2018). acupuncture for diarrhoea-predominant irritable bowel syndrome: a network meta-analysis. evidence-based complementary and alternative medicine, 2018, article 2948238. https://doi.org/10.1155/2018/2948238 pa ge 1 pa ge 16 american journal of medical science and innovation (ajmsi) breast cancer in elderly females mona mahmoud abasher1*, amal abdelhakam sidahmed1, asjad abdelmoniem1, hyffa osman mohamed ahmed1 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1711 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: may 28, 2023 accepted: june 20, 2023 published: june 29, 2023 breast cancer develops when the breast’s cells multiply uncontrollably. breast cancer ranks as the second leading cause of cancer-related mortality among women. breast cancer risk increases with age. almost 1 in 7 women will experience the onset of breast cancer during their lifetime. breast cancer is a malignant or cancerous tumour that develops from cells in breast tissue. although they are non-life-threatening and confined to the breast, some women develop benevolent or non-cancerous breast lumps. many people are unaware they have breast cancer since the early stages of the disease are frequently benign. early discovery provides more time for evaluation and treatment, which can help prevent negative effects. self-examination and several diagnostic tools as mammography, ultrasound, and nuclear medicine, are used to evaluate invasive and non-invasive breast cancer. several therapies associated with breast cancer treatments include chemotherapy, radiation therapy, hormone therapy, and bone-directed therapy. surgeries can also effectively treat breast cancer, such as lumpectomy and mastectomy. this suggests that effective therapies are progressing. this review aims to determine breast cancer’s causes, prevalence, and treatments in elderly women. the authors have discussed the disease’s treatment criteria and protocols, such as pharmacological therapies, herbal treatment, lifestyle modifications, and physical activities keywords breast cancer, chemotherapy, herbal treatment, lumps, mammography, mastectomy, nuclear medicine, tamoxifen 1 port sudan oncology centre p.o.c, sudan * corresponding author’s e-mail: monamahmoud582@outlook.com introduction breast cancer progression arises from the uncontrolled growth of cells within the breast tissue. breast cancer manifests in multiple forms, with the specific type determined by the origin of cancerous growth in the breast cells (fahad ullah, 2019). the second most common cancer in women to be diagnosed in the us is breast cancer (mojisola, 2023). although breast cancer can also affect men, it predominantly affects women (akram et al., 2017). breast cancer is a life-threatening disease affecting women of any age, although those over 50 comprise most of those diagnosed. breast cancer affects about 1 in 7 women throughout their lifetime (fahad ullah, 2019; ferlay et al., 2015; shannon & smith, 2003). adolescents and young women rarely develop breast cancer (shannon & smith, 2003). among postmenopausal women, breast cancer contributes to approximately 23% of all cancerrelated deaths, making it one of the most prevalent malignant diseases. furthermore, studies indicate that unmarried women are more likely to develop breast cancer than their married counterparts (shamsi et al., 2013). in women over 40 and 50, the incidence of breast cancer was higher, with a reported rate of 2 cases per 1000 individuals. furthermore, epidemiological research has shown that women with more children tend to have a reduced risk of developing breast cancer compared to those with fewer children. among all types of cancers, breast cancer has an incidence rate of 10.04% and predominantly affects women in their 40s and 50s. the average age of iranian women diagnosed with breast cancer is 48 years (donnelly et al., 2013). breast cancer is less common before age 20, but its risk increases with age (zheng et al., 2023). despite being a global issue, many women still neglect to perform self-examinations and seek clinical breast examinations, leading to the detection of the disease at advanced stages (akram et al., 2017). dna damage causes cells to develop into cancerous cells. however, hormones also play a vital role in many cases of breast cancer. in a normal cell, when dna is damaged, the cell has mechanisms to either repair the damage or undergo programmed cell death. however, the damaged dna is not repaired in cancer cells, yet the cell does not undergo cell death as it should. instead, it continues to replicate and generate new cells that are unnecessary for the body. the damaged dna from the original cells is passed on to these new cells. a new lump or tumour is the most frequent indicator of breast cancer (girish et al., 2014). the risk of malignancy increases with a firm, asymptomatic lump with uneven edges, but breast cancer might be soft, spherical, or sensitive. they might even cause pain. since breast conditions can be difficult to diagnose, it is crucial to get any new breast tumour, lump, or alteration examined by a medical specialist (girish et al., 2014). breast cancer can present with additional symptoms, including skin irritation, dimpling, swelling of the entire breast or a portion of it (with or without a lump), nipple pain, breast pain, nipple retraction, and nipple discharge unrelated to breastfeeding. this review aims to determine breast cancer’s causes, prevalence, and treatments in elderly women. abbreviations: national cancer institute (nci); surveillance epidemiology and end-results (seer); ductal carcinoma in situ (dic); lobular carcinoma in situ (lcis); invasive lobular carcinoma (ilc); infiltrating ductal carcinoma (idc); primary care physician (pcp); https://doi.org/10.54536/ajmsi.v2i2.1711 https://journals.e-palli.com/home/index.php/ajmsi mailto:monamahmoud582%40outlook.com?subject= pa ge 17 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 16-25, 2023 progesterone receptor (pr); estrogen receptor (er); ductal cell carcinoma in situ (dcis); single photon emission computerized tomography (spect); positron emission tomography (pet); magnetic resonance imaging (mri); world health organization (who); computed tomography (ct); hormone replacement therapy (hrt), circulating tumor cells (ctcs). literature review breast cancer prevalence and mortality the prevalence is anticipated to be less than 0.1 per 100,000 women under 20, 1.4 for women aged 20 to 24, 8.1 for women aged 25 to 29, and 24.8 for women aged 30-34. childhood breast cancer comprises less than 1% of all cancers diagnosed in children and accounts for less than 0.1% of all breast cancer cases in the general population. according to data from the national cancer institute’s (nic) surveillance epidemiology and endresults (seer) database, in the united states, fewer than 1% and 2.7% of breast cancer patients are under the age of 35, respectively (shannon & smith, 2003). compared to the global statistics, the united states exhibits a higher mortality rate and breast cancer prevalence according to age. in poland, 17% of sickness cases and 14% of fatalities are brought on by malignant alterations. in 2004, there were 519,000 breast cancer-related deaths worldwide. each year, approximately 1,208,000 new cancer cases are diagnosed in the united states, leading to the unfortunate demise of 538,000 individuals in the early stages of the disease. these fatalities account for roughly one-fifth of all annual deaths across various causes (shaukat et al., 2013). breast anatomy the breast primarily comprises adipose tissue, a type of fatty tissue. compared to males, female breasts typically contain a higher proportion of glandular tissue (aronson et al., 2000). the female breasts comprise 12 to 20 lobes, subdivided into smaller lobules. through milk ducts, these lobes and lobules are joined together. an intricate network of nerves, blood vessels, lymphatic vessels, lymph nodes, fibrous connective tissue, and ligaments aligns with the breast, which nourishes and supports the adipose tissue within the breast (tanis et al., 2001). the primary purpose of the female breast is to provide optimal nutrition to newborns (akram et al., 2017). nipples and breasts exhibit a wide range of sizes and shapes among individuals. it is common for most women to have one breast that is considerably smaller than the other (brayboy et al., 2017). breast cancer and types breast cancer originates from the abnormal growth of breast tissue cells, leading to malignant tumours. however, it is important to note that some women may also develop benign or non-cancerous breast lumps, which are not life-threatening and do not spread beyond the breast. nevertheless, they enhance a person’s risk of breast cancer (ely & vioral, 2007). the intrinsic growth rate of the tumour, age at diagnosis, and various other factors now significantly impact survival. two types of breast cancers are categorized as invasive and non-invasive (chinweike-umeh et al., 2023). one in eight women may develop invasive breast cancer, and one in 33 will die. although cancer incidence has increased, the death rates have decreased, most likely due to earlier detection and better therapies. over 2 million women in the united states have received breast cancer treatment (society, 2007). non-invasive breast cancer breast cancer confined to the lobules or ducts where it originated is classified as non-invasive. ductal carcinoma in situ: in this condition, abnormal cells develop within the milk ducts but do not spread to surrounding tissues or outside the body (akram et al., 2017; hang et al., 2017). mammography is the best tool for finding cancer at this stage when nearly all affected women can be treated (ely & vioral, 2007). an example of dcis is ductal comedocarcinoma (parikh et al., 2018). lobular carcinoma in situ: when breast cancer originates in the breast lobules, it is called lobular carcinoma in situ (lcis). breast cancer has not invaded the breast tissue lobules (clauser et al., 2016). although it starts in the milkproducing glands, lcis does not penetrate the lobules’ walls (inoue et al., 2017). while lcis is not considered invasive, it elevates a woman’s risk of developing cancer later in life (akram et al., 2017; ely & vioral, 2007). invasive breast cancer conversely, invasive breast cancer occurs when abnormal cells originating from the milk ducts or lobules extend beyond their original location and invade the surrounding breast tissue (ziperstein et al., 2016). cancer cells can metastasize from the breast to various body parts through the immune or circulatory systems. this can occur at an early stage when the tumour is small or later when it has grown larger. invasive breast cancer is the most prevalent type of carcinoma affecting women (harris et al., 2016). with increasing years, the risk of breast cancer increases quickly. metastatic breast cancer metastatic breast cancer is disseminated to other organs in the body (page et al., 2017). the organs most commonly affected by the spread of these cells are the brain, bones, lungs, and liver. as these cells separate and proliferate, they create new tumours in these locations (prabhakaran et al., 2017). invasive lobular carcinoma it is also known as invasive lobular carcinoma (ilc), a term used to describe a specific type of breast cancer. it originates in the breast’s milk-producing glands (lobules) but spreads to other body parts. ilc accounts for approximately 10% of all invasive breast cancers (devita, 2005). https://journals.e-palli.com/home/index.php/ajmsi pa ge 18 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 16-25, 2023 infiltrating ductal carcinoma invasive ductal carcinoma is another name for infiltrating ductal carcinoma. it originates in a milk tube or duct, penetrates the duct wall, and invades the breast tissue, from where it can spread to other body regions. approximately 80% of breast cancers are caused by idc (somiari et al., 2003). medullary carcinoma medullary carcinoma of the breast is characterized by forming a well-defined boundary between the normal breast tissue and the medullary tumour tissue (mateo et al., 2017). mutinous carcinoma the mucus-producing cancer cells that cause mutinous or colloid carcinoma are uncommon breast cancers (anuradha & lakshmi, 2014). tubular carcinoma women diagnosed with tubular carcinoma generally have a more favourable prognosis compared to those with other types of invasive breast cancer (priya & prasaad, 2017). inflammatory breast cancer a highly uncommon and aggressive form of breast cancer known as inflammatory breast cancer manifests as a reddish, swollen breast with dimples and broad ridges because the cancer cells have blocked the lymphatic channels or capillaries in the skin around the breast (joglekar-javadekar et al., 2017). when a woman visits her primary care physician (pcp) for medical guidance, she is often prescribed antibiotic medication (ely & vioral, 2007). in addition to having ductal or lobular histology, these breast tumours also feature cancer cells that are visible in the skin’s lymphatics, which results in an inflamed appearance. consequently, certain types of cancer, such as paget’s disease of the breast, phyllodes tumour, and triplenegative breast cancer, are comparatively uncommon. paget’s breast disease a rare type of breast cancer often presents with noticeable changes to the nipple. symptoms include the presence of red, itchy rashes around the nipple, which may sometimes extend to the surrounding skin (merrill et al., 2017). even though it resembles other skin conditions like psoriasis and eczema, it can be distinguished because those conditions typically affect both breasts. this particular type of breast cancer can initiate from the areola, the pigmented area surrounding the nipple, rather than originating directly from the nipple itself. this condition typically only affects one breast and begins at the nipple of the breast. paget’s illness, which can afflict both men and women, accounts for about 1-3% of all breast cancer cases (errichetti et al., 2017). phyllodes tumours phyllodes tumours can exhibit benign and malignant characteristics (sera et al., 2017). in cases where phyllodes tumours develop in the breast’s connective tissues, they can be surgically excised. phyllodes tumours are highly uncommon and result in fewer than 10 annual deaths among girls in the united states (strode et al., 2017). triple-negative breast cancer triple-negative breast cancer is characterized by the absence of progesterone receptors, human epidermal growth factor receptor 2 (her2), and estrogen receptor expression. this aggressive subtype is found in approximately 10-15% of cases, predominantly affecting premenopausal women. it is more prevalent in white females and is associated with a lack of er, pr, and erbb2 protein expression in cancer cells (foulkes et al., 2010; waks & winer, 2019b). hormone receptor-positive breast cancer around 70% of breast cancer cases are classified as hormone receptor-positive, indicating the presence of either progesterone receptor (pr) or estrogen receptor (er) proteins within the cancer cells (waks & winer, 2019b). erbb2-positive breast cancer around 15% to 20% of breast cancer cases are classified as erbb2-positive, commonly called her2-positive breast cancer. these cases exhibit elevated levels of the erbb2 protein on the surface of cancer cells. stages of breast cancer breast cancer can be detected in various locations during diagnosis, including the breast tissue, axillary lymph nodes, or distant sites. the staging of breast cancer, categorized from i to iv, depends on the extent of its spread. metastatic breast cancer is another name for stage iv breast cancer, which signifies that the disease has metastasized to other body parts beyond the breast and axillary lymph nodes (waks & winer, 2019a). based on a breast cancer report, the stage of breast cancer is determined by various factors, including tumour size, type, and depth of infiltration into breast tissues. noninvasive tumours are categorized as stage 0, while invasive tumours are classified as stage 4. stage 0 ductal carcinoma in situ (dcis), which denotes that both cancerous and non-cancerous cells are contained inside the borders of the initial spot in the breast where the tumour formed, is a typical example of this tumour stage. notably, there is no evidence of invasive growth into the surrounding tissues (akram et al., 2017). stage 1 it refers to invasive breast cancer, where a microscopic https://journals.e-palli.com/home/index.php/ajmsi pa ge 19 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 16-25, 2023 invasion of surrounding tissues is still possible. it is further divided into two categories: stage 1a and stage 1b. stage 1a encompasses tumours up to 2 cm in size without any involvement of lymph nodes, while stage 1b involves the presence of a small cluster of cancer cells larger than 0.2 mm detected in a lymph node (akram et al., 2017). stage 2 stage 2 is divided into 2a and 2b. in stage 2a, the tumour is found in the sentinel or axillary lymph nodes but not in the breast. the tumour size can vary, ranging from less than 2 cm to more than 5 cm. on the other hand, stage 2b indicates that the tumour may exceed 5 cm in size, but it has not spread to the axillary lymph nodes. (moran et al., 2014). stage 3 the classification of this stage has been subdivided into three categories: 3a, 3b, and 3c. notably, stage 3b encompasses a type known as inflammatory breast cancer, characterized by symptoms such as redness, warmth, and swelling of the breast skin. stage 3 breast cancer has three subcategories: 3a, 3b, and 3c. in stage 3a, no tumour is present in the breast, but it can be detected in 4-9 axillary lymph nodes or the sentinel lymph nodes. stage 3b is characterized by a tumour of any size that has caused swelling or ulceration on the skin of the breast. it can also involve the spread to up to 9 axillary lymph nodes or the sentinel lymph nodes. stage 3c refers to the spread of the tumour to 10 or more axillary lymph nodes and lymph nodes located above and below the collarbone (akram et al., 2017). stage 4 the significant spread of the disease to several body organs is evident in this advanced and metastatic stage of cancer, including but not limited to the lungs, bones, liver, brain, and other locations (neuman et al., 2010). methodology in order to execute this review, recent research and review articles/publications based on breast cancer in elderly women were considered. the focus of the investigation revolved around the effectiveness of managing breast cancer in preventing the development of related conditions, such as metastasis, recurrence, and other comorbidities. data was gathered from electronic databases; google scholar, pubmed, publon, web of science, ncbi, hindawi, national library of medicine, researchgate, medline, embase database, science direct, scopus, cochrane central register of controlled trials (central), and biomed. for this study, we searched the literature for articles addressing the causes, prevalence, and treatments for breast cancer in women. studies were selected from different years ranging between 2017 to 2022 using keywords’ ‘breast cancer,’ ‘breast cancer types,’ ‘breast cancer and mortality,’ ‘breast cancer treatments,’ ‘invasive and non-invasive breast cancer,’ ‘breast cancer stages,’ ‘chemotherapy in breast cancer,’ ‘herbal medicine effectiveness.’ search keywords were combined using proximity operators (near, next, within) and boolean (and, or) operators. first, text words included in the article’s title, abstract, and index keywords were examined after databases were searched for relevant papers. then, across all databases, a second search was conducted using all the discovered keywords, index terms, and mesh terms for medline. third, new studies were found by searching the reference lists of all the studies, reports, and articles. fourth, databases were searched to identify all related articles and reports in lmics: pubmed, google scholar, and google. titles and abstracts were examined for the search terms. access was made to the whole texts of the articles that were found. this article serves as a review. therefore, not all information about preventing breast cancer through management strategies has been comprehensively presented in its contents. in contrast, efforts were focused on including the most significant and relevant research. inclusion criteria the following addition and omission criteria were used to filter the titles rather than study relevance. we only selected those studies submitted to peer-reviewed journals for approval that were already published. these studies were taken into consideration to understand the research criteria better. * all english-language research published in peerreviewed publications was included for review. * studies describing the importance of self-examination for breast cancer were included. * studies related to care were included. * reviews of recent developments in breast cancer treatment were focused on. * studies related to precautions during breast cancer were also considered. * studies evaluating the diagnosis criteria were also an area of interest. * the study included a case report, a case report with review literature, a literature review, a retrospective cohort study, review articles, and a case-control study. exclusion criteria the exclusion criteria involve; * other than english-language papers were not considered. * studies focusing solely on the science of breast cancer were excluded. * papers not aimed at breast cancer treatment and advancement in monitoring were excluded from the review. * the objective was unrelated to breast cancer. * duplicate studies were excluded. * studies lacking predefined findings’ supporting data. * studies whose titles were related to the study but https://journals.e-palli.com/home/index.php/ajmsi pa ge 20 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 16-25, 2023 whose text was not relatable were excluded from the review. discussion breast cancer is widely recognized as a heterogeneous disease comprising various subtypes that can be distinguished based on their clinicopathological characteristics, prognoses, and responses to treatment. moreover, its prevalence has increased (barrios, 2022). the prevalence varies across regions and populations but remains a global public health concern. annually, over 55,000 women are diagnosed with this devastating illness (kj & khamzaeva, 2023). various factors influence the prevalence of breast cancer. efforts are made to raise awareness about breast cancer risk factors, promote early detection through regular screenings, and improve treatment options (prager et al., 2018). considering breast cancer’s significant impact on individuals, families, and societies, it is crucial to prioritize prevention, early diagnosis, and access to quality healthcare services (basu et al., 2020). by addressing risk factors, promoting education, and advancing research, efforts can be made to decrease the occurrence of breast cancer and enhance the prognosis and well-being of individuals impacted by this disease (szuhany et al., 2021). risk factors the risk of breast cancer is increased by certain factors, including nutritional imbalances, smoking, chronic alcohol consumption, the intake of carcinogenic beverages, occupational hazards, sexually transmitted infections, and specific characteristics related to reproductive health. other factors may include; age, family history, genetic mutations, hormonal factors, dense breast tissue, previous history of breast conditions, radiation exposure, obesity, lack of physical activity, and hormonal birth control. the risk can also be increased by reproductive attributes such as early menstrual onset, delayed menopause, never having children, delaying having children until after age 30, and not breastfeeding (kurbonov et al., 2023). hormonal factors such as early menstruation, late menopause, hormone replacement therapy (hrt) use, and certain hormone-related conditions can also increase the risk of breast cancer. breast density can also increase the risk of developing breast cancer (cullinane et al., 2022). it is crucial to emphasize that one or more of these risk factors does not guarantee the development of breast cancer. many women without known risk factors still develop the disease, while some with several risk factors never do. regular screenings, early detection, and a healthy lifestyle reduce the risk and promote overall breast health (tang, 2022). diagnosis as a result, the staging procedure develops into a challenging yet essential part of diagnosis and treatment. women should begin self-examining their breasts at age 20, and routine health checks should include clinical breast inspections. it is recommended for women over 40 to undergo breast cancer screening annually, while for women in their 20s and 30s, screening is typically advised every three years. additionally, women should know how their breasts typically feel and immediately notify their doctor of any changes. cancer diagnosis and treatment aim to identify a malignancy before it manifests clinically. there are various breast cancer-specific screening and diagnostic procedures. a few of them are described as follows: other diagnosis measures may include; breast biopsy, magnetic resonance imaging (mri), core biopsy, fine table 1: diagnostic procedures diagnostic tools characteristics breast examination women should begin self-checks at age 20, and routine health inspections should include clinical breast examinations. every year for women over 40 and every three years for those in their 20s and 30s (society, 2007). mammography mammography is the cornerstone of early breast cancer detection. according to the acs, women over 40 should have annual mammography screening (society, 2007). ultrasound ultrasound uses sound waves to detect whether a mammography problem region is solid or cystic (ely & vioral, 2007). breast magnetic resonance imaging magnetic resonance imaging (mri) utilizes magnetic fields to generate highly detailed cross-sectional images of tissue structures, offering excellent contrast for visualizing soft tissues (ely & vioral, 2007). nuclear medicine in molecular imaging, patients are administered a radioactive substance known as a radiopharmaceutical, and emission detectors capture and analyze the resulting data. combining ct with gamma cameras and pet to improve disease detection and localization (akram et al., 2017). single photon emission computerized tomography (spect) this technique utilizes specific radioactive isotopes, such as technetium-99, gallium-67, and iodine-131, which emit gamma rays. it is a precise and effective scan of the organ of interest (akram et al., 2017). https://journals.e-palli.com/home/index.php/ajmsi pa ge 21 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 16-25, 2023 positron emission tomography (pet/ct) positron emission tomography/computed tomography (pet/ct) is considered safe regarding radiation exposure and utilizes positron-emitting radionuclides such as carbon-11, fluoride-18, and oxygen-15. a commonly used tracer in pet is a radioactive form of glucose known as [18f]fluoro-2-deoxy-d-glucose (akram et al., 2017). estrogen and progesterone receptors to determine the presence of breast cancer, samples are analyzed to detect estrogen, progesterone receptors, and the her2 antigen. these tests provide valuable information about the assertiveness of cancer and help assess the suitability of specific medications for breast cancer treatment (akram et al., 2017). needle aspiration, surgical biopsy, and vacuum-assisted stereotactic core biopsy. breast cancer biomarkers biomarkers are measurable characteristics that can indicate the presence, progression, or response to treatment of a disease like breast cancer. in the context of breast cancer, several biomarkers are used for diagnosis, prognosis, and guiding treatment decisions (afzal et al., 2022). a breast biopsy or excision is used to diagnose breast cancer, and the disease is staged (tarighati et al., 2022). here are some commonly used biomarkers for breast cancer: * nucleic acids, genetic alterations, and protein molecules * hormone receptor status; estrogen receptor and progesterone receptor * human epidermal growth factor receptor 2 (her2) * ki-67: is a protein associated with cell proliferation * brca1 and brca2 mutations * oncotype dx and mammaprint * circulating tumor cells (ctcs) these are just a few examples of biomarkers used in breast cancer diagnosis and management. the specific biomarkers used may vary depending on the individual case and the stage of breast cancer. biomarkers play a crucial role in personalized medicine, helping to tailor treatment approaches and improve patient outcomes (afzal et al., 2022). treatment and therapy treatment recommendations can be made after screening and diagnosis are complete. breast cancer treatment involves a multidisciplinary approach, including radiation therapy, surgery, chemotherapy, and imaging. these different treatment modalities need to be carefully coordinated. over time, neoadjuvant chemotherapy has played a significant role in improving overall survival rates. it has also facilitated the effectiveness of locoregional treatments such as radiation therapy and surgery, leading to long-term improvements in managing this condition (cariati et al., 2005). furthermore, hormone therapy, bone-directed therapy, and targeted therapy can also be employed (girish et al., 2014). there are two main types of therapies in treating breast cancer: local and systemic. local therapy focuses on removing, eliminating, or controlling cancer cells in a specific area. this can be achieved through treatments such as radiation therapy. surgery is often the initial approach in breast cancer treatment, and the specific procedures, such as lumpectomy, mastectomy, and reconstructive surgery, are determined based on the extent of the disease and surgical findings. on the other hand, systemic therapies aim to target and manage cancer cells throughout the body. systemic therapies include hormone therapy, ovarian ablation used as adjuvant therapy for breast cancer, aromatase inhibitors, brachytherapy, and chemotherapy. depending on the patient’s needs, a patient may receive a single treatment or a combination (girish et al., 2014). in addition, psychological support and therapies have effectively eased patients’ grief and enhanced their quality of life (akram et al., 2017). medications and role of early detection as per the world health organization (who), the primary focus of breast cancer policies is to enhance outcomes and survival rates through early detection. early detection plays a fundamental role in the effective management of breast cancer. in treating breast cancer, a range of modern medications are prescribed. these medications are carefully selected based on the specific characteristics of the tumour and the individual patient. the aim is to provide personalized and targeted treatment approaches that maximize the chances of successful outcomes (mary et al., 2012). individuals at higher risk of developing breast cancer can potentially prevent the disease through medical interventions using antiestrogen medications like raloxifene or tamoxifen. these medications work by blocking the effects of estrogen and reducing the risk of breast cancer development. for individuals with distant metastases, management strategies primarily focus on improving life expectancy and overall survival rates. these strategies involve a comprehensive approach and supportive care to address symptoms and enhance the quality of life (abdull razis & noor, 2013). moreover, herbs are considered a natural alternative for treating breast cancer patients since some plants may have components that naturally have the power to treat breast cancer (zhu et al., 2011). herbal treatment herbs have been explored as a potential natural alternative for treating breast cancer due to the presence of bioactive components that may possess therapeutic properties and have great medicinal promise. (keshamma et al., 2022). some plants contain compounds that exhibit anti-cancer activities and have been studied for their potential in https://journals.e-palli.com/home/index.php/ajmsi pa ge 22 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 16-25, 2023 managing breast cancer (sohel et al., 2023). alternative medicines with fewer side effects have been developed for breast cancer patients, particularly those with metastatic cancer. phytochemicals derived from plants are a valuable natural resource for developing anti-cancer drugs, accounting for 70% of the compounds used (sharma & gupta, 2015). further research and clinical trials are needed to validate their efficacy and ensure safety, and healthcare professionals must guide patients regarding the use of alternative medicines (sohel et al., 2023). research into the effects of herbs on breast cancer is ongoing, and several herbs have shown promise in preclinical and early clinical studies. for example, herbs like turmeric (curcuma longa), green tea (camellia sinensis), garlic (allium sativum), and ginseng (panax ginseng) have been investigated for their potential anticancer properties (sharma & gupta, 2015). curcumin from turmeric has shown anti-inflammatory and anticancer effects, green tea catechins have anti-tumour properties, garlic contains organosulfur compounds with potential anti-cancer effects, and ginseng has been studied for immune-enhancing and anti-tumour activities (sharma & gupta, 2015). however, the efficacy and safety of herbs in breast cancer treatment require further investigation in large-scale clinical trials. herbal remedies should not replace standard medical treatments but may have complementary effects under healthcare professional guidance (li et al., 2020). breast cancer patients should consult their healthcare providers before considering herbal treatments to avoid interference with prescribed treatments and potential adverse effects (sharma & gupta, 2015). precautions and preventions prevention and precautions are vital in reducing the risk of breast cancer (howell et al., 2014). here are some key strategies that can help: * regular breast self-exams * clinical breast exams * mammograms; mammograms can monitor breast cancer at early stages when treatment is most effective. * hormone therapy * if there is a significant family history, consider genetic counselling and testing to assess your risk. * stay informed about the latest research, advancements, and guidelines related to breast cancer prevention and screening * take medicines on time * take proper rest it is important to remember that while these preventive measures can reduce the risk of breast cancer, they do not provide absolute protection. regular screenings and early detection remain crucial for identifying breast cancer at its earliest stages (gonzález-jiménez et al., 2014) lifestyle modifications and physical activity lifestyle modifications and regular physical activity are important in reducing the risk of breast cancer. the following strategies may help in maintaining a healthy lifestyle: * maintain a healthy weight; adopting a healthy diet and physical activity can help maintain or achieve a healthy weight. * balanced diet; balanced diet provides essential nutrients and antioxidants to reduce breast cancer risk. * limit fat intake; limit fat intake to reduce the risk of breast cancer. high-fat diets, especially from animal sources, have been associated with an increased risk of breast cancer. * regular physical activity; such as brisk walking, jogging, cycling, or aerobic exercises, can help lower the risk of breast cancer. aim for 75 minutes of strenuous or 150 minutes of moderate exercise weekly. * weight-bearing exercises; these activities help improve bone health and maintain muscle mass. * limit alcohol consumption; breast cancer risk has been associated with excessive alcohol intoxication. it is recommended to consume alcohol in moderation or not at all. * avoid tobacco; smoking is associated with an increased risk of various cancers, including breast cancer. taking the decision to quit smoking or consciously avoiding exposure to secondhand smoke can substantially reduce your risk of developing breast cancer. * breastfeed if possible; if you have the opportunity and can breastfeed your baby, it could mitigate the risk of breast cancer. lifestyle modifications are beneficial for reducing the risk of breast cancer and overall health and well-being. it is important to consult with your healthcare provider to discuss personalized recommendations based on your specific circumstances (kerschbaum & nüssler, 2019). limitations and strengths * the management and treatments discussed in this review do not guarantee the reversal of the disease. * several participants were not tested in this review; the review is based on factual data. * the most coherent risk factor of mortality due to breast cancer is increasing age, which has not been extensively discussed. * the biggest strength of this review is that very generalized terms have been used in searching strategies to combat vast unrelated data. * this review is based on scientifically proven facts. conclusion in conclusion, breast cancer in elderly women is a significant health concern, affecting many individuals. it encompasses various types and stages that require tailored treatment approaches. the expanding knowledge regarding breast cancer pathophysiologic mechanisms has facilitated remarkable advancements in identifying and utilizing biomolecular markers. moreover, regular screenings and early detection are essential for improving outcomes. breast cancer in elderly women can be https://journals.e-palli.com/home/index.php/ajmsi pa ge 23 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 16-25, 2023 diagnosed through mammograms, clinical exams, and biopsies. treatment options include surgery, radiation therapy, chemotherapy, hormonal therapy, targeted therapy, and medications. lifestyle modifications can help diminish the chance of breast cancer and improve overall well-being. by raising awareness, encouraging early detection, and embracing a healthy lifestyle, patients can strive for improved outcomes and a brighter future in the fight against breast cancer. elderly women must coordinate with their medical team to develop a personalized treatment plan, considering their unique needs and preferences. in addition, elderly women can actively manage and potentially prevent breast cancer by receiving periodic updates on developments in breast cancer treatment. research gap this review aims to address potential research gaps in understanding breast cancer in elderly women, including limited research, age-related factors, screening and diagnostic methods effectiveness, personalized treatment approaches, and supportive care and quality of life. it will explore the challenges faced by this population and identify interventions to improve their well-being and overall outcomes. future research directions future research directions for breast cancer in elderly women include investigating long-term outcomes, optimal treatment strategies, personalized medicine, geriatric assessment, and health disparities. these areas can help improve treatment strategies, supportive care interventions, and outcomes for this population. understanding the unique needs and challenges faced by elderly breast cancer survivors can inform supportive care interventions and improve overall well-being. contribution to knowledge the reviewed article contributes to knowledge by consolidating and synthesizing existing evidence on breast cancer in elderly women, identifying research gaps, offering novel insights, and providing recommendations for future research and practice. by summarizing various studies and sources, it provides a comprehensive overview of the current state of knowledge. the article also highlights areas where further investigation is needed, offering valuable insights into the challenges, treatment approaches, and outcomes specific to elderly women with breast cancer. the article’s contribution to knowledge is essential for informed decision-making and patient care improvements. novelty of research the review focuses on breast cancer in elderly women, highlighting unique characteristics, challenges, and treatment considerations. it integrates findings from various sources, including clinical trials, observational studies, and qualitative research, to provide a comprehensive understanding. the review explores agerelated factors, geriatric assessment tools, and quality of life and survivorship outcomes, offering novel insights into the disease’s impact on elderly women. by incorporating these aspects, the review contributes to the existing knowledge base on breast cancer in elderly women, offering new perspectives and insights. references abdull razis, a. f., & noor, n. m. 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(2016). evaluating breast cancer cell morphology as a predictor of invasive capacity. biophysical journal, 110(3), 621a. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 31 american journal of medical science and innovation (ajmsi) comparison of elisa & ict methods determining hepatitis b surface in suspected patient attending at bangladesh institute of health science (bihs) general hospital, dhaka shohanur rahaman1, sadia islam2, km. rashidul islam sakib3, khaleda ferdous4, md. nazmul islam5 md. al-amin hossen6, md. ashiqur rahman7* volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1743 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: may 20, 2023 accepted: june 12, 2023 published: july 18, 2023 hepatitis b virus (hbv) is a common blood borne infectious agents causing high morbidity and mortality that constitute the major global health problems. infection with hbv results in a wide spectrum disease from subclinical to fulminant hepatitis leading to death. the most important laboratory screening test for the diagnosis of early hbv is the immunoassay for hbsag. different analytical methods are being used now a days for the diagnosis of hepatitis namely, ict, elisa, cmia and pcr. the aim of the study to determine viral hepatitis (hbv) seromarkers in suspected patients using different methods ict and elisa. this cross sectional study was conducted at the immunology laboratory, bihs general hospital, dhaka. a total 240 of hbsag test results of the patients were collected from laboratory register book. all tests were carried out by elisa & ict methods and compare between them. majority (76.3%) of the donors was within the age group of 19-30 years. among the donors, male donors were predominant (93.75%) than female (6.25%). a total number of 240 hbsag tests were done in ict method and found 6 positive (2.5%) of them. then we done correspondence test to confirm these by elisa method and found 100% negative results. this study shows ict method were able to determine hbsag negative samples reasonably well that was detected negative by elisa. elisa method is more specific and sensitive than that of ict. keywords hbsag, elisa, ict, hbv 1 diabetic association of bangladesh (badas) covid-19 diagnostic laboratory, bangladesh 2 bangladesh specialized hospital limited (bshl), bangladesh 3 zh sikder womens medical college and hospital, bangladesh 4 bangladesh university of health sciences (buhs), bangladesh 5 opsonin pharma limited, bangladesh 6 united hospital limited, bangladesh 7 novus clinical research services limited (ncrsl), bangladesh * corresponding author’s e-mail: ararashiqur@gmail.com introduction hepatitis b virus (hbv) is a common blood borne infectious agents causing high morbidity and mortality that constitute the major global health problems. approximately one fifth of the world populations are being chronically infected with hbv. death of 1.5 million people every year attributed to hbv related chronic liver diseases (hayder et al. 2012). infection with hbv results in a wide spectrum disease from subclinical to fulminant hepatitis leading to death. hepatitis due to b virus often progress to chronic active hepatitis, cirrhosis of liver with development of hepatocellular carcinoma. since these virus are mostly transmitted by transfusion of contaminated blood and blood product, however, other subjected modes of transmission like intravenous drug abuse, close personal contact, use of shared needle, razor etc cannot be ignored (ahmed et al. 2009). it commonly causes asymptomatic infection but chronic infection causes scarring of the liver which is generally apparent after many years. approximately, 75% acutely infected patients develop chronic hepatitis b infection that commonly progresses to liver cirrhosis and hepatic malignancy (ahmed et al. 2009). the hbv is found to be rapidly spreading in the developing countries including bangladesh. it found to be 50 to 100 times more infectious than hiv and an important occupational hazard for health workers. about 2 billion people worldwide have been infected with the virus and more than 350 million live with chronic lifelong infection (who, 2000). hbsag appears during the incubation and becomes detectable in most cases during the prodrome and acute stage of the disease. it usually disappears from the blood within 5-6 months in young adults. however, prolonged persistence of the hbsag for more than six months indicates the carrier state. these viruses are still causing the most clinically significant transfusion transmissible infections with a per unit risk of 1: 82,000 (riskin et al. 2009). looking into the data on the prevalence of the transfusion transmitted infections (ttis), specifically hbv among blood donors permits an assessment of the occurrence of infections in the blood donor population and consequently the safety of the collected donations. it also gives an idea of the epidemiology of these diseases in the community. most of the studies conducted in bangladesh are limited among the professional blood donors, drug addicts, commercial sex workers or hospitalized patients (islam et al. 1984). the rapid spread of hbv infection and the changed https://doi.org/10.54536/ajmsi.v2i2.1743 https://journals.e-palli.com/home/index.php/ajmsi mailto:ararashiqur@gmail.com pa ge 32 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 31-35, 2023 scenario in blood donation practice has inspired us to depict the trends of the prevalence of hbsag infection among the healthy blood donors, and to describe their socio-demographic background at hospitals in dhaka city in bangladesh. such information could be a guide for planning and implementing programs for preventive measures in bangladesh.the most important laboratory screening test for the diagnosis of early hbv is the immunoassay for hbsag. different analytical methods are being used now a day for the diagnosis of hepatitis namely, ict, elisa, cmia and pcr. the elisa, cmia and pcr methods are found to be expensive and are used in advanced laboratories and major tertiary care hospitals. ict, using by the most of the laboratories as a rapid diagnostic analytical method are now considered a good choice because of its low price, less involvement of skilled technician and infrastructure (rahman et al. 2008). the rapid ict kits are known to have less sensitivity and specificity than elisa. the aims of this study is to determine hbsag in patients’ blood by using ict and elisa. elisa is a wet lab type analytical assay that uses a solid phase enzyme immunoassay to detect the presence of an antigen or antibody in a liquid phase. along with the enzyme-labeling of antigens or antibodies, the technique involves an immune reaction, enzymatic chemical reaction, signal detection and quantification in combination which make it one of the most specific and sensitive than other immunoassays to detect the biological molecule. although confirmation of hepatitis b infection is based on advanced immunological, molecular and histological techniques (mustafa et al. 1989) laboratory use immune-chromatographic test strips to screen hepatitis. their mode of action is based on common principle of antibody present in the test serum or plasma reacting with the protein coated particle and migrating upward on a membrane chromatographically by capillary action to react with recombinant antigen present on the membrane thereby generating a color line in the test region. these test strips are one step rapid test. the test strips manufactures also claim that these test strips have relatively high sensitivity, specificity and accuracy but controversy often arises regarding these claims (ahmad et al. 1991). reports from various studies suggest that this rapid test method not always confirms the accuracy of the test results, increasing the risk of blood borne infection during blood transfusion. very early stages of infection and patients in the recovering stages usually have low viral titers, reflected by low optical density (low sod) in the test results. these low positive cases may not be detected by rapid screening test like ict, these can be detected by elisa. however it should be kept in mind that method standardization is always crucial before diagnosis of an infection. a major concern in utilizing screening tests is that these tests should have a high performance in detecting infections irrespective of stages of disease. therefore the intent of this study is to compare rapid test strip screening method with advanced immunological techniques and to recommend for a reliable, cost-effective and less time consuming laboratory method for detection of hbv seromarkers in donors’ blood. the aim of this study is to determine hepatitis b surface antigen (hbsag), by elisa and ict method among patients and compare the test results of hbsag seromarker obtained by the above methods for evaluation in respect of sensitivity, specificity and accuracy of those methods. this study will help to evaluate the methods, comparatively better for the detection of viral hepatitis seromarkers. materials and methods this is a cross-sectional study. the study was conducted by obtaining the blood samples from donors attending at the bihs general hospital ltd, dhaka and bangladesh university of health sciences (buhs). the study was conducted during the period of from february to october 2018. patients qualifying criteria for the donation were included in the study. the qualifying criteria for the participants were: age between 18 to 60 years with clinical feature for hepatitis infection. participants having low body weight, low blood pressure and anemia, professional blood donors, drug abusers, pregnant women, etc. were excluded from the study. persons having positive history of hbv, hcv, hiv and venereal disease were also excluded from the study. a purposive sampling was followed. the entire samples collected from the laboratory record book those are fulfill the inclusion criteria of study. collection of blood sample, processing and preservation five milliliters of blood were collected by standard aseptic technique in the coded vacutainer. the blood was kept stand still to allow clotting and the serum was separated by centrifugation at 4000 rpm for 15 minutes. the serum samples were transferred to two micro centrifuge tubes. one tube for each participant was taken to the immunology laboratory of the bihs general hospital for detection of seromarkers for hbv by ict methods and second was preserved for elisa test to be done at the immunology laboratory, bangladesh university of health sciences (buhs). laboratory methods screening of hbsag was done by ict in immunology laboratory of the bihs general hospital ltd. kits used for ict were from excel. elisa 4th generation kits (enzo diagnostics inc, usa) were used as gold standard for comparative evaluation1. test procedure procedure of hbsag detection (sandwich elisa, wantai biologicals, china) a microtiter plate coated with known quantity of monoclonal antibody (solid-phase) is taken. serum sample is added to the plate that may or may not contain hbsag. hbsag if present in the serum, bind to solid phase antibody in the plate during incubation (at 37°c). the plate is then washed at the end of incubation to https://journals.e-palli.com/home/index.php/ajmsi pa ge 33 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 31-35, 2023 remove unbound antigen and any other non-specific binding. after soaking the plate on a paper towel, enzymelinked antihuman antibodies (conjugate) which are also specific to hbsag antigen are added and then incubated at 37°c. the plate is washed with working buffer solution to remove unbound conjugates. substrate is added so that enzyme act on the substrate to produce a colored reaction product. finally, blocking reagent is added to stop the enzymatic reaction and absorbance is measured using specific wavelength by spectrophotometric plate reader. procedure for hbsag (ict) • test cassette, serum or plasma specimen, and /or controls were allowed to equilibrate to room temperature (15-20 c) prior to testing. • the pouch was brought to room temperature before opening it. the test cassette was removed from the sealed pouch and used it as soon as possible. • for serum or plasma specimen. • the dropper was hold vertically and 3 drops of serum or plasma (approximately 120 ul) was transferred to the specimen well of test cassette and the timer was started. • after waiting for few minutes a colored line appeared. the result was read at 15-30 minutes. interpretation positive two distinct colored lines appear. one colored line should be in the control region(c) and another colored line should be in the test region (t). negative one colored line appears in the control region(c). no apparent colored line appears in the test region (t). data collection variables recorded at the time of enrollment of study subjects include participants’ demographics, personal history, vital signs and clinical findings. data relating to clinical information were taken from pre-designed questionnaire sheets of donors kept in the blood bank of the bihs general hospital. donors consent was obtained in the questionnaire sheets by the blood bank personnel before donation of blood and laboratory reports. data analysis data were analyzed with the help of the software spss (statistical package for social sciences) version 23 and microsoft excel 2016. the results were expressed as mean ±sd (standard deviation). the p-value <0.05 was considered as statistically significant. results total of 240 patients were included in this study. mean (±sd) age was 27.45±7.63 years. age distribution of the donors was shown in table i. majority (76.3%) of the donors were within the age group of 19-30 years, 16.3% among the total 240 patients, the male was 225 (93.75%) and the female was 15 (6.25%). among the donors, male donors were more predominant (93.75%) than females (6.25%) (figure 1). table 1: distribution of patients on the basis of age groups age (yrs) frequency percentage (%) mean±sd 19-30 183 76.3 27.45±7.63 31-40 39 16.3 41-50 9 3.8 >50 9 3.8 total 240 100.0 results were expressed as number (percent) and mean±sd as appropriate figure 1: gender distribution of the patients table 2 shows that all the specimens were also screened for hbsag by immunochromatography (ict) method. out of 240 samples, 6 (2.5%) samples were positive and 234 (97.5%) samples were negative. table 2: distribution of seromarkers status analyzed by immunochromatography (ict) (n= 240) seromarkers ict p valuepositive negative no % no % hbsag 6 2.5% 234 97.5% results were expressed as number and percent table 3 showed that target variables hepatitis b surface antigen (hbsag) were determined by enzyme linked immunosorbent assay (elisa). out of 240 samples, 240 sample (100%) were negative. the 6 samples that were positive by ict method were also negative by elisa method. of the donors was within the age group of 31-40 years, and 3.8% of age group 41-50 years and >50 years. table 3: distribution of seromarkers status by elisa (n=240) seromarkers elisa p valuepositive negative no % no % hbsag 0 0% 240 100% results were expressed as number and percent https://journals.e-palli.com/home/index.php/ajmsi pa ge 34 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 31-35, 2023 discussion screening for common blood borne infection like hbv is crucial to ensure the safety of transfusion. the selection of screening tests depends upon a number of factors. among them, evaluation of test performance, measured by sensitivity and specificity, is the most important factor while kit cost, equipment used, expertise, consumables and disposables are also taken into account during selection of analytical process (saadia et al. 2016). this is for the first time through a structured protocol; ict was compared with gold standard elisa method using donors’ blood for hbv seromarker hbsag. almost all donors were male (93.75%) which is consistent with other reports more specifically by khan et al where 96.8% of the blood donor population was male as males are the predominant donor both in developed and developing countries (sajed et al. 2014; khan et al. 2011) mean (±sd) age of the donors was 27.45±7.63 and 76.3% (183 out of 240) of them were between the age group 19-30 years. this demonstrated the fact that donors belong to the younger age groups which is consistent to the study done by sajed (sajed et al. 2014). in their study 80% donors belonged to the thirties years of age. the present study compared ict and elisa for hepatitis b surface antigen hbsag. test result for hbsag was found negative for all 240 samples in both ict and elisa method. reference centers or central blood banks found to be widely using most sensitive test methods (elisa, cmia and pcr) as quantitative immunoassay globally (hayde et al 2012; clement et al.2002). rapid test, ict is intended for qualitative detection of hbsag in serum (torlesse et al. 1997). elisa, cmia and other advanced methods are laboratory based, time consuming and require trained laboratory personnel. chemiluminescence based assays are usually used for screening of blood donors in high volume blood banks owing to automation facilities, higher testing throughput and objective interpretation of results, however, expensive instrumentation is required for them thus limiting their use in resource limited settings (saadia et al. 2016). rapid test enables early detection at sites where laboratory facilities or trained manpower are not available or there is issue of accessibility. most rapid tests are based on immunochromatographic principles (plitt et al. 2007). the rapid tests reduce the potential loss of follow up of a case when test results are on demand right away (sato et al. 1996; raj et al.2001). ict showed potentially good findings in the present study. no false positive test was observed by this method since it provided negative results of all 240 donors’ sample for both hbsag and anti-hcv that was also revealed to be negative by elisa. using ict for both infections, ict and cmia were equally sensitive to elisa as all the 240 samples showed negative reaction in both ict and elisa though 1 (1.25%) sample was positive for hbsag. our results showed comparable performances of the three techniques with almost 99% agreement of results. in evaluating both the seromarkers, specificity and negative predictive value of ict were 100% that was consistent with a study done in pakistan where ict and elisa were compared for detection of hbsag in healthy individual from karachi that showed comparable sensitivity and specificity of ict kits with elisa technique (shamsul et al 2001). it is again consistent with another study done by herring (herring et al. 2006) where evaluation of nine rapid syphilis ict kits reported 93-98% specificity. a metaanalysis reported the sensitivity of different ict devices ranging from 85-100% and specificity 98-100% (jafari et al. 2013). an indian study reported 100% specificity and 93.4% sensitivity of rapid kits when detecting hbsag (kaur et al. 2000). ict is suitable for use in remote and developing regions since they are simple to perform, can be transported, stored and performed at room temperature and microscopic and electrical equipment not needed. moreover, these are cheaper and quicker as compared to other diagnostic procedures (herring et al. 2006). findings of the present study is also consistent with study conducted in iran where 6 rapid strips/devices were compared with gold standard method (khadem et al 2007). in another study from seoul for detecting hbsag, rapid technique showed 97% sensitivity and 100% specificity (irwig et al. 2002). in our study, overall specificity results for both hbsag was high i.e. 97-100%. these results are different to an study conducted in lahore, pakistan by khan (khan et al. 2010) who demonstrated 93% to 100% specificity for hbsag by ict method but the sensitivity was 50% for both hbsag. in the present study sensitivity was 100% for hbsag which is higher than the just mentioned study. the present study was carried out as a pilot basis to compare two methods ict with elisa for hbsag. although the number of samples tested was limited yet we could infer that the two methods had performed equally well and in limited resource settings, the ict could be used as an alternative for hbv seromarker screening. a total number of 240 hbsag tests were done in ict method and found 6 positive (2.5%) of them. then we done correspondence test to confirm these by elisa method and found 100% negative results. we know, elisa method is more specific and sensitive than that of ict. we conclude that, those 6 positive results found in ict method was false positive. conclusion this study shows ict method were able to determine hbsag negative samples reasonably well that was detected negative by elisa. the rapid test was not only compatible with currently established and advanced diagnostic methods but also cheaper. it can be recommended that elisa comparable rapid devices may be allowed to be used for initial screening of hepatitis b, in remote areas where cost is an issue. the present study concludes that our findings demonstrate comparable performances of ict and elisa for screening of hbv seromarker. we suggest using the ict assay in situation i) where the laboratory cannot afford to have a more advanced system for blood donors ii) as a backup and iii) in life-threatening situations where time saving may be life-saving. https://journals.e-palli.com/home/index.php/ajmsi pa ge 35 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 31-35, 2023 financial support & sponsorship none conflicts of interest the author hereby declares that there are no conflicts of interest concerning this paper. informed consent informed consent was obtained from all individuals included in this study. references ahmad, q., chowdhury, s. g., islam, m. n., khan, f. d., alam, m. r., & miah, a. h. 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(2006). a multi-centre evaluation of nine rapid, point-of-care syphilis tests using archived sera. sexually transmitted infections, 82(suppl 5). irwig, l., bossuyt, p., glasziou, p., gatsonis, c., & lijmer, j. (2002). designing studies to ensure that estimates of test accuracy are transferable. bmj, 324(7338), 669-671. islam, m. n., islam, k. m., & islam, n. (1984). hepatitis-b virus infection in dhaka, bangladesh. bangladesh medical research council bulletin, 10(1), 1-6. jafari, y., peeling, r. w., shivkumar, s., claessens, c., joseph, l., & pai, n. p. (2013). are treponema pallidum specific rapid and point-of-care tests for syphilis accurate enough for screening in resource limited settings? evidence from a meta-analysis. plos one, 8(2), e54695. kaur, h., dhanao, j., & oberoi, a. (2000). evaluation of rapid kits for detection of hiv, hbsag and hcv infections. indian journal of medical sciences, 54(10), 432434. khadem, a. m., omrani, m. d., & movahedi, v. 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(1997). the use of immunochromatography test cards in the diagnosis of hepatitis b surface antigen among pregnant women in west africa. british journal of biomedical science, 54(4), 256-259. world health organization (2000). the world health report 2000: health systems: improving performance. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 89 american journal of medical science and innovation (ajmsi) a review on the management of strontium-90 waste in medical facilities hassan mansaray1*, saidu kamara2 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5788 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 12, 2025 accepted: august 25, 2025 published: october 22, 2025 healthcare facilities generate a large amount of waste, which is considered potentially dangerous. hospitals are increasingly using radioactive isotopes for diagnostic and therapeutic applications. isotopes are utilized in different applications of life purposes such as nuclear medicine, radiotherapy, and in industry. radioactive waste is any material that contains or is mixed with a radionuclide that poses a radiation level that exceeds the iaea recommended level or that of a national regulatory body. today, the problem of radioactive waste is one of the biggest threats to human beings, as its effects extend to the environment, natural resources, animals, plants, and soil. strontium-90 is one of the radioisotopes used in hospitals. most of the hospital’s radioactive waste is generated in the nuclear medicine department. strontium-90 is a radioactive isotope that is considered one of the most hazardous radioactive isotopes. this study focuses on the use of strontium-90 in medical facilities and how the wastes generated are sustainably managed for human safety and the environment. the applications, waste generation, tests, effects on human health and the environment, and the treatment processes of strontium-90 waste have been studied. the treatment processes, such as forward osmosis membrane, crystalline inorganic ion exchanges, etc, of strontium-90 waste in a hospital are detailed in this review. keywords environment, health, hospitals, radioactive waste, radionuclide, strontium-90 1 radiological safety, trinity college dublin, university of dublin, ireland 2 department of engineering, faculty of engineering and technology, ernest bai koroma university of science and technology, magburaka, sierra leone & nuclear safety and radiation protection authority, liverpool street, freetown, sierra leone * corresponding author’s e-mail: hassanmansaray08@gmail.com introduction different types of radionuclides are utilized in the field of medicine for diagnostic, therapeutic, and research purposes. hazardous radiological wastes alongside biological and chemical wastes are formed as a result of the production of radioactive wastes from the utilization of medical radioisotopes. many of the radionuclides in nuclear medicine departments are short-lived and in low or medium concentrations. hospitals administering large quantities of 131i for treatment of thyroid of carcinoma or using frequently iodine for radioimmunoassay aqueous solution or tc-99m in diagnosis (ohiduzzaman et al., 2019; tsai et al., 2016), should consider the provision of decay tanks for storage and safe disposal of radioactive waste resulting from patients excretion or laboratory waste. radioactive waste refers to any material containing or mixed with a radioactive nuclei that poses a radiation level which exceed that level recommended by the iaea or a national regulatory authority (darda et al., 2021; derib, 2017). the radioactive waste problem can be regarded as the biggest threat facing human beings today, as its effects extend to the environment, natural resources, animals, plants, and soil. healthcare institutions generate an enormous amount of waste, which is considered potentially hazardous given the inherent potential for dissemination of infection (cook et al., 2023; rokka & khanal, 2023). the objective of waste management is to provide protection of workers, patients, and the environment by minimizing the hazards in an effective way over the whole life cycle of the considered product. it has been reported that hospitals generate, on average, between 0.5 and two kilograms of waste per bed per day (mol et al., 2022). it is estimated that approximately 85% of the waste generated is not harmful, about 10% is infectious, and 5% is not infectious but harmful (maqsood, 2023). radiopharmaceuticals are used in medicine for diagnostic and therapeutic purposes. the commonly used radiopharmaceuticals in medicine are 99mtc, 131i, 131i, 123i, 18f, h-3, and 14c. much of the radioactive waste in health facilities is aggregated in the nuclear medicine department. a greater part of the radioactive waste is in the form of a liquid, and a smaller amount in the form of solid, and the minimum in gaseous form of the radioactive waste is liquid, with a lesser amount of solid and minimal in gaseous form (rahman et al., 2011). the solid waste has traces of radioactivity in the form of syringes, needles, cotton, swabs, vials, contaminated gloves, and absorbent materials. high doses of radioisotopes like 131i are found in the clothing and utensils of patients. the contaminated objects and the unused radioactive material require safe disposal to ensure that the radiation exposure to the public, radiation workers, and environment does not exceed the prescribed safe limits (das et al., 2021; menon & kumar ls, 2019). the short-term and longterm effects of ionizing radiation on humans are reduced by maintaining the levels of exposure within the required limits, in addition to reducing its negative impacts on pa ge 90 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 89-97, 2025 the environment. regular dose rate monitoring of radiological workers in the hospitals, area monitoring of hospital environment, and quality control of the radiation instruments are mandatory to assess the quality of existing radiation safety standards. every hospital is required to have a designated radiation safety officer (rso) who oversees all aspects of radiation safety, including radioactive waste management. the rso coordinates such measures in accordance with guidelines prescribed by the international commission on radiation protection and the national regulatory body. one of the major concerns is the separation of sr90 (a b-emitter with a half-life of 28.8 days), which is due to its large concentration resulting from a high fission reaction product and specific activity (parus & mikolajczak, 2012; moore, 2018). the chemical properties of the 90sr radioisotope make it possible to be utilized in the treatment of cancer (herrero álvarez et al., 2021; semenishchev & voronina, 2020; yeong et al., 2014). it is important to note that strontium ninety is known to be the most hazardous isotope of strontium (burger & lichtscheidl, 2019; holt et al., 2021; pathak & gupta, 2020; semenishchev & voronina, 2020). thus, much interest is attached to the separation of strontium ninety. the selective separation of 90sr from a solution of radioactive waste for it to be suitably utilized or disposed of is a significant field of research. this review, therefore, focuses on the management of radiological medical waste from the utilization of strontium ninety in hospitals. literature review strontium ninety is purely a β-decay radionuclide having a 28.9 years half-life. it is exposed to the environment by various means, such as nuclear weapon testing, nuclear power plant accidents, the nuclear fuel reprocessing industry, etc. following the chernobyl and fukushima nuclear accidents in 1986 and 2011, respectively, great attention has been paid to monitoring the presence of 90sr in food and the environment within the vicinity of nuclear facilities. the elements strontium and calcium are homologous and therefore share similar chemical and physical properties (kołodziejska et al., 2021; nedobukh & semenishchev, 2019). strontium ninety (90sr) and its daughter radionuclide yttrium ninety (90y) are distributed in bones and teeth as a result of accumulation during long-term exposure(glasco et al., 2024; tolstykh et al., 2000). the radionuclide subsequently enters the circulatory system of the human body together with calcium and induces bone cancer and leukemia. the long half-life and high fission yield of strontium ninety renders among the most radiological hazards for humans and the environment. it is a fission product of 235u and 239pu. 90sr emits beta particles with a maximum energy of 546 kev, and its decay product is short-lived 90y (half-life=64 hrs) (semenishchev & voronina, 2019). yttrium ninety decays to a stable nuclide 90zr, resulting in the emission of β-particles. the growth of the nuclear power industry in the world and the widespread utilization of nuclear technology (kessides, 2012; zhan et al., 2021), are the basis for the high demand in radiation protection and radiological risk assessment during routine operation and nuclear emergencies. it is therefore very important to provide analytical methods that are more effective in determining toxic radionuclides like sr-90. the separation and purification of y-90 from sr-90 can be done by utilizing a number of methods such as precipitation, solvent extraction, ion exchange, and extraction chromatography (lee et al., 2022; muchtaridi et al., 2017; pichestapong et al., 2016). the extraction chromatography using solventimpregnated resins has been applied widely for trace metal separation and recovery (cortina & warshawsky, 2021). strontium readily dissolves in water, making it easier to be distributed in the environment (mukherjee & mishra, 2021). the transportation of sr-90 from the environment to the food chain and finally into the human body can be done in different pathways. strontium and calcium are group iia elements with similar chemical properties and therefore have similar biological processes in the human body. calcium is known to belong to the typical bone-seeking nuclides. strontium ninety follows the uptake of ca when it enters the human body and readily accumulates on the surface layer of bone as sr3(po4) salts layers (genter, 2012; sharma, 2019a). strontium ninety is involved in the formation of bone salts and enters the inorganic salts of the bone crystals, becoming immobile in the bone during the physiological osteogenesis process.90y produces high-energy beta particles, which severely damage the human bone and hematopoietic tissues of the bone marrow, resulting in bone cancer and leukemia. several studies have been conducted on the treatment of strontium ninety in water, which is associated with the synthetic radioactive isotope sr-90 and have similar physical properties to stable strontium (gupta et al., 2017; semenishchev & voronina, 2019; sharma, 2019a). the utilization of radiopharmaceuticals in radiation therapy has been existing for decades and offers enormous benefits to cancer patients, particularly to those suffering from thyroid cancer (chinweike-umeh et al.; lepareur et al., 2023; salih et al., 2022; sgouros et al., 2020). several clinical trials using radiopharmaceuticals to treat other types of cancer are ongoing and their success will increase the demand for therapeutic radiation pharmaceuticals in the future. radionuclides with very short half-lives have challenges such as transportation and the need for frequent shipments. short-lived radioisotopes are globally made available for efficient therapeutic purposes by the use of radionuclide generators. imaging equipment are utilized alongside some radiopharmaceuticals to detect diseases(payolla et al., 2019). a cancerous tumor can be destroyed or shrunk by placing a radiopharmaceutical inside the body. hospitals that provide radiation or nuclear services often have an office of radiation safety, which is responsible for pa ge 91 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 89-97, 2025 maintaining and administering high-level safety protocols. they are also responsible for the maintenance and collection of data related to waste, compliance, audits, and permits, as well as the possible transport and safe handling of radioactive materials. even low levels of radioactive waste from hospitals must be packaged and transported according to regulatory requirements(ali et al., 2017; cena & hasi, 2024; ravichandran et al., 2011). labels, container markings, and packaging must identify the contents, codes, and symbols. short half-lives and low radio-toxicity are the primary properties of biomedical waste, and contains low-energy beta and gamma emitters with a low total and specific activity(cena & hasi, 2024; hooshmand et al., 2020). materials and methods about 104 articles were explored from various publishing houses and online research platforms such as elsevier, wiley, mdpi, research gate, etc, with data related to the topic “a review of managing strontium-90 waste in medical facilities”. the articles were systematically reviewed by employing the preferred reporting items for systematic reviews (prism) guidelines. the research question was structurally formulated based on previous work reported by various researchers on the management of radioactive wastes in medical facilities. the hospital’s use of strontium-90 and its waste management utilization of strontium ninety isotope in a medical facility 90sr is a significant radioisotope utilized in medicine over the years. the applications of 90s in nuclear medicine have been reported by many researchers. strontium is deposited in bones for a pain relief signal that communicates to the brain (cristofaro, 2017; genter, 2012; ru et al., 2024; semenishchev & voronina, 2020). eye disorders and radiotherapy cancer cells can be also be treated using strontium ninety (banerjee et al., 2022; burov, 2023; liberal et al., 2016). in medicine, strontium ninety compound is used to treat hepatocellular carcinoma (hcc) and other liver cancers (chakravarty & dash, 2012; gao et al., 2021; mukherjee & mishra, 2021). according to iaea 1998, it is reported that strontium-90 in medical facilities is utilized as manual brachytherapy and further highlighted it use as a radioactive tracer. findings show that strontium ninety is used to treat skin and eye diseases (neal et al., 1991; qin et al., 2012). the accumulation of strontium ninety in medical waste the waste produced from the use of strontium ninety is dangerous to people and the environment. in order to solve this problem, it is significant to understand how these wastes are generated. it has been reported that strontium ninety waste is aggregated from the waste waters produced in radiation therapy rooms through urine, faeces, and detergents (luhar et al., 2021; maddheshiya et al., 2025; pant, 2021). the liquid of strontium ninety wastes can also be generated from radioimmunoassays (rias) utilized to measure the concentration in patients in vitro assay technique. radioimmunoassay waste comprises proteins generated from reagents and samples during analysis. much work has not been done on the liquid waste of strontium ninety from radiation therapy rooms. liquid wastes such as of urine, feces, detergent and radionuclides from radioactive therapy differs from ria waste (cena & hasi, 2024; lee et al., 2018; ravichandran, 2017; sancho et al., 2013) where all of the liquid waste aggregated from the examination, radiation, and the patients themselves (chitnis et al., 2005; lee et al., 2018; padmanabhan & barik, 2019; rahman et al., 2011; zikhathile et al., 2022), while ria wastes are only obtained from the analysis of reagents and samples, and especially when its radioactivity is far lower than wastes accrued from radiation therapy room (ahmed, 2001; cena & hasi, 2024; puspita et al., 2023; sancho et al., 2013). determination of strontium ninety a number of environmental materials, such as air filters, swipes, biota, water, soil, etc., are utilized to test for strontium. strontium-90 can be quantified by employing a variety of chemical methods (ppoletiko et al., 1994; tayeb et al., 2016; vajda & kim, 2010), like spectrophotometry, atomic absorption spectroscopy, x-ray fluorescence spectrometry, inductively coupled plasma spectroscopyatomic emission and mass spectrometry applications (i.e., icp-aes and icp-ms), etc. proportional in vitro gas flow, scintillation, and cherenkov counting are the technologies used to detect the quantity of strontium-90 in the environment (domenech, 2017; hou & roos, 2008; tayeb, 2015). radiostrontium in water and urine is determined using the epa analytical standard procedure. strontium-90 is precipitated as insoluble carbonates by adding a stable strontium carrier to water. the sample then undergoes preliminary counting that represents the total strontium activity (90s). bioassay technique urinalysis can be tested for strontium-90 (dai et al., 2013; sadi et al., 2010; shiraishi et al., 2007; wang et al., 2004). the estimated internal dose due to exposure to radiostrontium is provided by strontium ninety utilizing ion chromatography internal dose due to exposure to radiostrontium (semenishchev & voronina, 2020; tomita & takeuchi, 2019; vajda & kim, 2010). strontium-90 can be detected in water and urine samples using the fast column separation method and liquid scintillation counting. a high-capacity iminodiacetate chelating resin buffered to a ph of 5 was utilized to extract strontium ninety. the transition metals, lanthanides, etc, were extracted by the resin at a ph of 5 and transferred to a column separator and subsequently released as weak acids. human health and environmental effects of strontium ninety strontium-90 wastes in medical facilities are harmful to people and the environment. food and water which pa ge 92 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 89-97, 2025 are major exposure pathways for the population are contaminated by strontium ninety when disposed to the environment (sharma, 2019b; wang et al., 2023). exposure to strontium-90 can lead to a number of health issues such as bone disorders, bone cancer, etc.(marx et al., 2020; ru et al., 2024). it has been reported that strontium-90 was found in the teeth children following a global nuclear testing in the atmosphere (froidevaux et al., 2006; gould et al., 2000) which resulted to harmful effects like leukemia or skeletal cancer caused by damage in dna cells. strontium-90 has a long half-life of 28.8 years, and it presence in the body can lead to long term irradiation of skeletal bone structure which may lead to damage in bone marrow, leukemia, and other bone cancers (gupta et al., 2018). the harmful effects of strontium-90 are reasons for its monitoring in the environment, particularly in groundwater surrounding nuclear facilities (freed, 2002; semenishchev & voronina, 2020). chlorophyll formation in plants is decreased when contaminated by strontium-90 (chatterjee et al., 2020; dresler et al., 2018; moyen & roblin, 2010). plants absorbed radioisotopes from the environment enters the food chain which affects human health and the environment. agricultural plants cultivated in areas contaminated by sr-90 also pose health risks to humans or animals when eaten and ingested (burger & lichtscheidl, 2019; gupta et al., 2018; sharma, 2019b). treatment methods for strontium-90 medical wastes the pretreatment of 90sr using forward osmosis (fo) membrane technique the forward osmosis (fo) membrane process used for the pretreatment of strontium-90 liquid waste have been highlighted by many researchers (kadadou et al., 2023; pabby et al., 2022). this application has two radionuclide decay system of two main septic tanks for the collection of liquid waste and the decay of radionuclides, respectively (azman et al., 2024; kadadou et al., 2023; rao et al., 2022). the first tank is used to store the collected liquid waste to allow the radionuclides to decay and then subsequently pumped to the second tank where the radionuclide will further decay and discharged after the radioactivity or quality of the final water reached regulatory requirements. a very large area is required to carry out the pretreatment method and therefore requires improved management of radiation therapy facilities. a highly concentrated draw solution (ds) is utilized as the main driving force to extract pure water from the feed solution (fs) based on the difference in osmotic pressure between ds and fs (blandin et al., 2020; chekli et al., 2012). fo consumes low energy, has high fouling reversibility, and high rates of recovery. medical radioactive wastewater having high fouling potential can be suitably treated using fo due to the low working pressure of fo, leading to high fouling reversibility. fo is used to remove heavy metals and arsenic due to the high rejection rate. ion exchange inorganic crystals crystalline inorganic ion exchangers for sr-90 are employed in the treatment of sr-90 nuclear waste due to their high radiation, thermal, and chemical stability (figueiredo et al., 2018; i̇nan, 2022; li & chen, 2024; marinin & brown, 2000) and ion selectivity. they can easily be transformed into alternate ceramics compatible with the metrics immobilization. inorganic ionic crystal exchangers are mostly selected for specific ions due to their crystallochemical properties such as ionic radii, charge, and polarizabilities, etc. inorganic materials such as phosphates, molybdates, titanates, silicates, etc., are therefore utilized to separate 90sr from radioactive waste (i̇nan, 2022; savva, 2016; yudintsev, 2021). titinates and silicotitanates are employed for their increased stability in conditions of radioactive wastes (popa & pavel, 2012; stefanovsky & yudintsev, 2016; zhang et al., 2022), but are however ineffective for the separation of 90sr in acidic solutions because they strongly inhibits protons. various authors have conducted research on different hydrous oxides to selectively separate the cations of radioactive elements from aqueous solutions using inexpensive methods. the behaviors of amorphous mno2 and birnessite were compared and the result show shows faster sorption kinetics, higher adsorption capacities and stabilities observed in birnessite than amorphous manganese oxide. birnessite crystals are extensively stable in acidic media and have a higher sorption capacity than the amorphous nature due to structural properties. strontium ninety is separated by ion exchange using inorganic monosodium titanate (mst) (hobbs et al., 2005; peters et al., 2006). mst exhibits a very good performance with a little strontium desorption during washing. physicochemical method to remove sr(ii) in aqueous solution effective adsorbents for the removal of sr (ii) in aqueous solutions are eggplant hull, moss, activated carbon, sawdust modified with magnetic fe3o4 particles, pecan shell, synthetic zeolites, baker’s yeast, etc (koshy & pathak, 2019; liu et al., 2024). clay is a cost-effective, natural abundance adsorbent material that is suitable to remove the ions of strontium in solution (ahmadpour et al., 2010; li et al., 2022; shahadat & isamil, 2018). the interest in cement and clay has grown considerably in recent times. the removal of radiotoxic ions in the treatment of wastewater has been carried out using different types of clay and clay minerals. strontium ninety is used in a batch experiment to investigate the adsorption behavior of montmorillonite and kaolinite minerals for sr (ii), which reveals that adsorption occurs through ion exchange (başçetin & atun, 2006; i̇nan & hiçsönmez, 2022; koshy & pathak, 2019). bentonite was also utilized to get cs and sr by a rapid uptake and good sorption capacity. sr (ii) in aqueous solution was removed using powdered dolomite (ghaemi et al., 2011; sdiri, 2018). the langmuir isotherm was utilized to interprete the equilibrium data pa ge 93 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 89-97, 2025 and the pseudo-second order kinetic model. according to the adsorption isotherm, the maximum sorption capacity was observed to be 1.172 mg/g at 273k (tiwari & lee, 2015). sr (ii) was also effectively removed in aqueous solution by other types of clay minerals like clinoptillite and paligrskite. sr (ii) are attached to negatively charged mineral surfaces forming complex outer spheres (rahnemaie et al., 2006), and the extent of adsorption depends on several factors, such as ionic strength, ph, and composition. the use of graphene oxide membrane (go) method to remove of sr(ii) from high liquid waste many researchers have reported the separation of radioactive strontium waste using graphene oxide (go) membrane method (wei et al., 2024; xing et al., 2019). this is a well-known and newly accepted carbon-based method for radiochemical separation. an investigation was carried out to determine how metallic elements permeate in high liquid waste (hllw) using a 5μm thick ionic sieve go membranes. it was observed that the rate at which the ions permeate through go membranes decreases with an increase in hydrated ionic radii. sr (ii) was seen to permeate faster than lanthanide and actinide ions, which slowly infiltrate, making it possible for separation according to their difference in hydrated ionic radii. the initial concentrations of metal ions and the acidity of the solution influence the permeation of the ions passing through the go membranes. the higher initial metal ions and the feed acid solution are suitable for the removal of strontium ninety. the suitability of the go membranes to separate sr (ii) from hllw is proven by the barrier separation test. the biochroma technique medical radioactive waste like sr-90 can be managed using the biochroma technique (semenishchev & voronina, 2020). it is a pretreatment method that utilizes a biotreatment system where adsorption is the final phase. buffer tanks are used to store the waste waters from the radiotherapy wards. the tanks are fitted with specially designed pumps with a device or instrument that shredder solid particles, thus homogenizing the effluent (banerjee & mitra, 2013). the holding tanks are responsible for the bio-treatment phase, and they have an aeration system that prevents anaerobic processes. before the biological treatment, the wastewater is allowed to undergo sedimentation to remove larger particles that may reduce the sludge performance in the biologically made reactor. the next stage of the process is the upstream installation of an optimized biological treatment plant for the final phase of adsorption and filtration. the plant is designed with a secondary clarification stage to filter and separate any suspended solid materials and finally reduce organic contaminants to their lowest level. the downstream adsorption filter is protected against unwanted clogs. the activated carbon filters and selective ion exchangers in the adsorption filter system are used to eliminate the dissolved radioactive components in the wastewater before finally collected in the storage tanks. the wastewater in the storage tank is constantly monitored as it is subsequently discharged into the sewage system. conclusion strontium ninety is an important radioactive isotope in medical radiotherapy and research due to its various applications in the treatment various illnesses such as liver cancer, bone cancer, and tumors. despite the justifiable use of this radioisotope, the waste generated must be properly managed. the inadequate management and disposal of radioactive waste to the environment contaminates agricultural plants and crops. when these radioisotope contaminated crops are eaten by humans, they accumulate in bones and teeth leading to several diseases. to maintain a healthy environment, it is essential to use good pretreatment methods such as the biochroma pretreatment method. references ahmadpour, a., zabihi, m., tahmasbi, m., & bastami, t. r. 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(2022). a review of the impact that healthcare risk waste treatment technologies have on the environment. international journal of environmental research and public health, 19(19), 11967. pa ge 1 pa ge 61 american journal of medical science and innovation (ajmsi) systematic review: impact of vitamin c, hydrocortisone, and thiamine therapy on sepsis and septic shock patients manal rashid al-khaldi1* volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1938 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 17, 2023 accepted: august 21, 2023 published: september 06, 2023 systematic inflammatory response syndrome and sepsis are inflammatory responses to many health manifestations. sepsis mortality is high despite global treatment standards, with metabolic resuscitation being a novel approach for managing sepsis. the purpose of this systematic review is to assess the effectiveness of the critical care combination comprising hydrocortisone, vitamin c, and thiamine in potentially mitigating sepsis, reducing mortality associated with septic shock, and alleviating organ failure. in order to execute this scoping review, recent research based on the effect of vitamin c, hydrocortisone, and thiamine therapy in sepsis and septic shock was identified. data was gathered from google scholar, pubmed, ncbi, hindawi, scirp, journal of immunology, and critical care medicine. studies selected from different years ranging between 2017 to 2023 using keywords ‘severe sepsis,’ ‘septic shock,’ ‘effect of vitamin c on sepsis, ‘effect of thiamine on sepsis treatment,’ ‘hydrocortisone therapy in sepsis,’ ‘sirs,’ ‘septic shock criteria.’ access was made to the whole texts of the articles that were found. this review could provide fundamental strategic plans dealing with specific risk factors and managing accordingly. the systemic review has been completed according to the guidelines regulated by preferred reporting items for systemic research and meta-analysis. the initial search for publications on vitamin c, hydrocortisone, and thiamine in sepsis and septic shock retrieved 1710 papers, from which 265 were selected. the reviews’ articles were further evaluated to assess vitamin c, hydrocortisone, and thiamine’s effects on sepsis. over 80 references were considered for their potential use in medical diagnosis and therapy. this review has included ten recent articles for the last seven years. intravenous vitamin c, corticosteroids, hydrocortisone, and thiamine prevent organ failure, reduce vasopressor use, and decrease mortality in severe sepsis and septic shock patients. keywords septic shock, immunomodulatory therapy, innate immune response 1 king hamad university hospital: muharraq, bahrain, bh, bahrain * corresponding author’s e-mail: manalrashid268@outlook.com introduction systematic inflammatory response syndrome (sirs) is an inflammatory response to various clinical disorders. (davies & hagen, 1997) the intensity of sirs impacts the host’s susceptibility to infection through the innate immune system. (robertson & coopersmith, 2006; j. wang et al., 2023) the innate immune response can be defined as the first line of defense against a microbial intruder and characterized as a non-specific response that takes only a few minutes to activate. pathogen-associated molecular patterns (pamps) were recognized via pattern recognition receptors (prrs) prevalent in innate cell types, including neutrophils and macrophages. (beutler et al., 2004) the adaptive immune system is more effective than the innate immune system in protecting the host from various microorganisms. (davies & hagen, 1997) similarly, systematic inflammatory response syndrome is a body’s defence response to a noxious stressor (infection, trauma, surgery, acute inflammation, ischemia or reperfusion, or malignancy) (chakraborty & burns, 2019; nyström, 1998) to localize and then eliminate the exogenous and endogenous source of insult. (chakraborty & burns, 2019) furthermore, sirs can be diagnosed by observing abnormalities such as heart rate, temperature, respiratory rate, and white blood cell (wbc) count. (davies & hagen, 1997) moreover, sirs is a multifaceted condition, classified into two primary categories: sepsis and non-infectious inflammation. (davies & hagen, 1997) sirs, when associated with infection, can progress to sepsis. the term ‘sepsis’ encompasses a range of conditions (lever & mackenzie, 2007), all stemming from the intrusion of microbial agents from a local infectious source into the bloodstream. (henriquez-camacho & losa, 2014) these conditions can manifest with mild signs and symptoms of systemic infection, including traditional indicators like fever, tachycardia, tachypnea, and leukocytosis. (nyström, 1998) in more severe cases, they can lead to shock and organ dysfunction. (henriquez-camacho & losa, 2014; lever & mackenzie, 2007) in addition, the pathophysiology of sepsis primarily results from the host’s innate immune system response (lever & mackenzie, 2007), and sirs occurs at an exceptionally elevated rate. numerous research indicated that one-third of patients admitted to icu (intensive care unit) suffer from sirs. (brun-buisson, 2000) hemodynamic instability despite intravascular volume resuscitation is referred to pa ge 62 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 as septic shock, while severe sepsis is defined as sepsis accompanied by one or more instances of end-organ failure. (chakraborty & burns, 2019) these conditions illustrate a physiological continuum marked by an imbalance between the body’s pro and anti-inflammatory responses. consequently, for immune-compromised septic patients meeting two or more sequential organ failure assessment (sofa) sirs criteria, the term multiple organ dysfunction (mod) is applied, signifying altered organ function. (kaukonen et al., 2015; nyström, 1998) this definition was established during a sepsis definitions consensus conference sponsored by the american college of chest physicians and the society of critical care medicine. (chakraborty & burns, 2019; suárez-de-la-rica et al., 2023) the execution of any two of the following conditions figure 1: showing the symptoms of sepsis figure 2: showing the stages of sepsis constitutes the objective measurement of sirs (chakraborty & burns, 2019) sirs with a source of infection: • above 38 or below 36 degrees celsius for body temperature. • heart beats per minute greater than 90. • respiration more than 20 times per minute or partial co2 pressure under 32 mmhg. • over 10% immature forms or bands, leukocyte count/white blood cells (wbc) greater than 12000, or fewer than 4000/microliter. (chakraborty & burns, 2019) severe sepsis criteria (hypotension, hypo perfusion, and organ dysfunction): (herzum & renz, 2008; b. liang et al., 2023) • lactic acidosis, sbp greater than 90 or sbp lesser than or equal to 40 mmhg of normal. septic shock criteria • hypotension with severe sepsis despite receiving enough fluid support. pa ge 63 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 mods criteria • indications of less than or equal to two organ failures. (herzum & renz, 2008) the level of organ system damage can be measured using a variety of measures. (chakraborty & burns, 2019) a few examples include the multiple organ dysfunction (mod) (chakraborty & burns, 2019) scores, sequential organ failure assessment (sofa), acute physiology and chronic health evaluation (apache) score versions ii and iii, and logistic organ dysfunction (lod) score. (chakraborty & burns, 2019) literature review epidemiology of septic syndrome sepsis is a significant public health concern, with septic syndrome being the leading cause of mortality in the united states. (giamarellos-bourboulis, 2008) globally, it affects many individuals annually, with estimates ranging from 15 to 19 million cases. (litwak et al., 2019; marik et al., 2017; k. wang et al., 2023) treatment options for sirs, severe sepsis, and septic shock sirs, severe sepsis, and septic shock are severe disease states that require effective treatment strategies. one therapeutic approach involves the administration of vitamin c, hydrocortisone, and thiamine (vitamin b1). (sprung et al., 2008) studies have suggested a regimen of these agents administered every six to twelve hours for patients with severe sepsis and septic shock, demonstrating potential mortality benefits. (litwak et al., 2019; marik et al., 2017) depletion of vitamin c in sepsis research has indicated that sepsis can lead to a depletion of vitamin c, an essential cofactor for producing catecholamines and cortisol, hormones critical for shock survival. (balakrishnan et al., 2018) studies have explored the safety and efficacy of vitamin c supplementation to counteract this depletion, with doses as high as 6g reported to be safe and without adverse side effects. (balakrishnan et al., 2018) metabolic resuscitation as an effective treatment option to mitigate the adverse effects of high-dose vitamin c intake, intravenous thiamine has been administered alongside hydrocortisone to enhance endogenous catecholamine synthesis. (balakrishnan et al., 2018) this combination of metabolic resuscitation has been investigated and found to be an effective adjuvant treatment for septic shock and sepsis (fujii et al., 2022), emerging as a viable therapeutic option.(kuhn et al., 2018; shi & tie, 2020). immunomodulatory therapies for sepsis: efficacy and mechanisms patients with sepsis treated with high doses of vitamin c, hydrocortisone, and thiamine discovered a substantial reduction in mortality and improved disease prevention. (balakrishnan et al., 2018; mohamed et al., 2023; shi & tie, 2020) ascorbic acid, or vitamin c, is an anti-inflammatory and cellular anti-oxidant. (fujii et al., 2019) water-soluble vitamin c produces cortisol, catecholamines, and vasopressin, essential disease-process mediators. because of its antioxidant characteristics, vitamin c also helps reduce inflammation. emerging findings support the use of vitamin c in addition to standard therapy for patients with sepsis and septic shock to decrease inflammation and improve hemodynamic stability (teng et al., 2018). another study (sprung et al., 2008) demonstrated that patients with septic shock frequently utilize hydrocortisone (sprung et al., 2008), which decreases infection resistance by reducing inflammation. (suffredini, 2018). additionally, having anti-endo-toxic and antipyretic properties, corticosteroids and hydrocortisone have been demonstrated to affect vascular reactivity in a way that may be advantageous to the infected person. (suffredini, 2018) moreover, another study stated the beneficial effect of thiamine as therapy for sepsis. (moskowitz & donnino, 2020) the study estimated the correlation between thiamine, rapid lactate clearance, and lower mortality. (moskowitz & donnino, 2020) nevertheless, these immunomodulatory therapies showed significance for sepsis, effectively lowering the mortality risk and treating this infection’s symptoms. (vincent et al., 2002) this scoping review aims to assess the association between vitamin c, thiamin, and hydrocortisone effect as a therapy for sepsis and septic shock. this unique association has not been addressed earlier in the scientific literature. it suggests a novel approach to metabolic resuscitation, potentially adding value to medical sciences and diagnostic research. this approach will add value and new insights to the medical sciences and diagnostic research field. methodology search strategy in order to execute this scoping review, recent research and review articles/publications are based on the effect of vitamin c, hydrocortisone, and thiamine therapy in sepsis and septic shock were identified. study selection and eligibility the databases used to collect articles include google scholar, pubmed, web of science, ncbi, hindawi, scirp, journal of immunology, critical care medicine, plos one, journal of sepsis and blood infection, national library of medicine, frontiers in medicine, researchgate, internal medicine journal, journal of medical internet research, medline, embase database, and biomed. for this study, we searched through the literature to find articles that addressed the role of vitamin c, hydrocortisone, and thiamine in treating sepsis and septic shock. search strategy based on the use of mesh pa ge 64 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 terminologies which were related to the topic, studies were selected from different years ranging between 2017 to 2023 using keywords’ ‘sepsis,’ ‘severe sepsis,’ ‘septic shock,’ ‘effect of vitamin c on sepsis,’ ‘effect of vitamin c in septic shock treatment,’ ‘vitamin c in sepsis,’ ‘effect of thiamine on sepsis treatment,’ ‘hydrocortisone therapy in sepsis,’ ‘sirs,’ ‘septic shock criteria,’ ‘response syndrome septic shock,’ ‘patients with septic shock,’ ‘epidemiology of sepsis,’ ‘markers of sepsis,’ ‘inflammatory markers of septic shock,’ ‘systematic inflammatory response syndrome,’ ‘sepsis response to infection,’ ‘innate immunity in sepsis,’ ‘adaptive immune response in sepsis,’ ‘sepsis diagnosis,’ ‘immunity in sepsis mechanism,’ ‘anti-inflammatory therapy in sepsis,’ ‘sepsis immunomodulatory therapy,’ ‘antioxidant therapy severe sepsis,’ ‘review on sepsis therapy,’ ‘correlation between vitamin c therapy and sepsis.’ access was made to the whole texts of the articles that were found. furthermore, the systemic review has been completed according to the guidelines regulated by preferred reporting items for systemic research and meta-analysis (prisma). table 1: data selection strategy years search engines keywords 20172023 google scholar sepsis severe sepsis septic shock correlation between vitamin c therapy and sepsis epidemiology of sepsis sepsis immunomodulatory therapy hydrocortisone therapy in sepsis pubmed ncbi hindawi scirp frontiers in medicine biomed journal of immunology plos one journal of sepsis and blood infection inclusion criteria the following addition and omission criteria were used to filter the titles rather than study relevance. we only selected those studies submitted to peer-reviewed journals for approval that were already published. these studies were taken into consideration to understand the research criteria better. • papers in english and articles published in recent years were preferred. • studies describing sepsis and its types were included. • studies related to sepsis diagnostics and treatments were included. • studies related to the effect of vitamin c on sepsis were also considered. • studies of the correlation between antioxidants, antiinflammatory therapy, and sepsis were also considered. • roadmap report on sepsis was included in this review. • reviews of recent developments in sepsis diagnostic systems. • the role of vitamin c, hydrocortisone, and thiamin in the therapy of sepsis, severe sepsis, *septic shock, and • mods was also reviewed. exclusion criteria the exclusion criteria involve; • papers written in languages other than english were excluded. • studies focusing solely on the impact of sepsis on cardio-logical health were excluded. • studies on sepsis-associated hyperlactatemia were excluded. • papers not aimed at sepsis and the advancement of its treatment were excluded from the review. the objective was not related to sepsis and its diagnosis. • papers related to sepsis but whose main objective was not related to the effect of vitamin c and its therapy in sepsis and septic shock were excluded from the review. • duplicate studies were excluded. table 2: indicating the inclusion and exclusion criteria of studies included articles excluded articles articles in the english language articles were written other than in the english language articles of recent years studies that focused on the impact of sepsis on cardio-logical health relevant to sepsis and types studies related to sepsis-associated hyperlactatemia relevant to sepsis diagnostics and treatments not aimed at the therapy of sepsis, advancement, and scopes in its diagnostics roadmap report on sepsis the objective was not related to sepsis and its treatment reviews of recent developments in sepsis diagnostic systems not aimed at the effect of vitamin c in sepsis and septic shock treatment pa ge 65 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 • studies lacking predefined findings’ supporting data. among the 1710 research, 265 were retrieved, and 1445 papers were eliminated due to their no direct relevance to the study’s main goal and were written primarily in languages other than english, most commonly arabic, french, spanish, and dutch. data extraction and risk of bias using microsoft excel, the researcher extracted and sorted the sample size, study type, duplicates, full-text articles, and empirical studies, making the systematic review approach practicable. the two authors reviewed and decided to include all reviews independently based on the eligibility criteria. information of variables includes the author, year of publication, and number of studies. the two reviewers assessed the methodological qualities by using the 7-item scale of risk of bias developed by the cochrane bias methods group. this review used the prisma guideline and flow diagram to lower the risk of bias. the sources of bias assessed included outcomes, population, study selection process, incompleteness of data, and time frame and setting. quality of systematic reviews the expert team members assessed the quality of the systematic reviews, including questions regarding the degree to which the systematic reviewers had evaluated the risk of bias in individual studies. systematic reviews with major limitations were excluded. the authors have assessed the methodological quality of studies in sepsis and septic shock based on the review authors’ assessments of risk of bias in the primary studies they had included. summary measures and synthesis of results the authors analyzed the data collected by the members of the expert team. due to the expected heterogeneity of studies regarding participants, interventions, outcomes and study designs, a quantitative summary measure of the results was not planned. we did a qualitative and narrative summary of the results of the systematic reviews. the literature review results were presented and discussed in two workshops intending to validate results. results the initial search for publications concerning the significance of vitamin c, hydrocortisone, and thiamine in treating sepsis and septic shock yielded 1710 papers, from which 265 were selected. the reviews’ articles were further analyzed to ensure they were pertinent to assessing the impact of vitamin c, hydrocortisone, and thiamine in sepsis treatment. around 80 references were examined for their potential applicability to the medical field as a treatment. a total of 10 articles were included, with preference given to those published during the last seven years. figure 3 illustrates the preferred reporting items for systemic research and meta-analysis guidelines (prisma) flowchart of article identification, displaying the many stages of the systematic review applied in identifying studies. figure 3: prisma, preferred reporting items for systematic reviews and meta-analyses discussion effectiveness of vitamin c, hydrocortisone, and thiamine in sepsis and septic shock treatment numerous studies have explored the efficacy of immunomodulatory therapies as a potential treatment for sepsis and septic shock, yielding a range of findings and perspectives. this systematic review aims to consolidate and analyze the research in this field, highlighting areas of agreement and divergence among various studies. an unrestrained immune reaction to the microorganisms pa ge 66 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 is one of the defining characteristics of blood infection, often known as sepsis. as a result, inflammation develops throughout the body. sepsis is a potentially life-threatening condition that can develop when an infection is not properly diagnosed and treated promptly. a widely acknowledged notion is that the hydrocortisone, vitamin c, and thiamine (hvt) combination could help restore the imbalanced immune response, correct oxidative mitochondrial function, and enhance energy production. however, current clinical practice has an ongoing debate regarding using the hvt strategy (sun et al., 2023). in addition to the potential combined benefits, the rationale for employing hvt includes its minimal risk, affordability, and easy availability. any minor clinical side effects, like hydrocortisone-induced hyperglycemia, hypertension, or hypernatremia, may occur but are generally inconsequential and can be effectively managed in the intensive care unit. (briegel et al., 2018; marik, 2018; shi & tie, 2020; j. wang et al., 2023) vitamin c as an anti-inflammatory agent studies such as (lv et al., 2021), (wei et al., 2020), and (fujii et al., 2019) have all suggested the potential benefits of vitamin c in the treatment of sepsis (marik et al., 2017). moreover, it was examined that sepsis patients have shown benefits from vitamin c in addition to conventional treatment (marik et al., 2017). according to the surviving sepsis guidelines, the same therapy was administered to every patient in this trial. (lv et al., 2021) the vitamin c group began using vitamin c on the day they entered the intensive care unit, and patients received iv injections of 3.0 g of vitamin c dissolved in 5% dextrose (100 ml each time, twice a day) until they were released from the hospital. in contrast, intravenous 5% dextrose (100 ml/time, twice a day) was given to the control group as a placebo. a significant vitamin c deficiency typically results in an overactive inflammatory response. (lv et al., 2021) vitamin c has multiple roles in treating patients with severe sepsis and septic shock due to its anti-inflammatory properties, anti-oxidation properties, inhibition of nitric oxide synthesize, cortisol retention effect, and increased catecholamine synthesis in the brain and adrenal medulla. (long, du, ouyang, zhong, & zeng, 2023; lv et al., 2021) combination therapy: role in treating sepsis in addition, another study (wei et al., 2020) showed that a potential cure for sepsis would be exogenous vitamin c supplementation. li (2018) conducted a meta-analysis that showed vitamin c use could dramatically lower sepsisrelated mortality (yao et al., 2021a). the study’s findings determined that a vitamin c infusion could shorten the time that vasopressors were administered. catecholamines were also synthesized with the assistance of vitamin c (wei et al., 2020). furthermore, another study by (fujii et al., 2019) stated that vitamin c is an anti-inflammatory and cellular antioxidant. it was undetermined whether hydrocortisone, thiamine, and vitamin c combination therapy in septic shock lower vasopressor reliance. (fujii et al., 2019) the vitamins trial would assess whether combination therapy consisting of vitamin c, thiamine, and hydrocortisone, when compared with hydrocortisone alone, boosts the amount of vasopressor-free hours in critically sick patients suffering from septic shock. (fujii et al., 2022; fujii et al., 2019) moreover, in another study (mohamed et al., 2020), researchers investigated the combination therapy of vitamin c, thiamine, and hydrocortisone. it was evaluated that administering a combination of hydrocortisone, thiamine, and ascorbic acid did not lower all-cause inhospital mortality in patients suffering from septic shock within six hours of receiving a diagnosis of septic shock. patients diagnosed with septic shock who were given intravenous vitamin c, thiamine, and hydrocortisone at the dose and for the duration prescribed had no impact on the hospital mortality rate. the treatment with vitamin c appeared to be risk-free. there was evidence to suggest that the inflammatory process had been mitigated. (mohamed et al., 2020) furthermore, in other research conducted at zhujiang hospital of southern medical university in guangdong province, china, a single-centre, single-blind, randomized, parallel, controlled trial was undertaken. the study found that combining hydrocortisone, vitamin c, and thiamine did not significantly reduce mortality among sepsis and septic shock patients. this outcome aligns with a prior retrospective study conducted by litwak et al., 2019. (chang et al., 2020; litwak et al., 2019) combination therapy and mortality rate furthermore, according to the findings of another metaanalysis conducted by (yao et al., 2021b), a significant decrease in sofa score and vasopressor duration among patients with sepsis and septic shock was associated with vitamin c and thiamine, either alone or in conjunction with hydrocortisone administration; however, it did not affect short-term mortality (mitchell et al., 2020). in the meantime, the findings demonstrated that combination therapy did not impact death rates in intensive care units or hospitals. (yao et al., 2021b) it was further described that a deficit in vitamins c and b1 could lead to several disorders with pathophysiological features similar to those of sepsis. these features include peripheral vasodilation, coagulation problems, cardiac and endothelial dysfunction, and hypoxia. hence, vitamin c and thiamine are recommended for organ function restoration in sepsis and septic shock. (yao et al., 2021b) pyruvate dehydrogenase requires phosphorylated thiamine to maintain aerobic respiration. insufficient thiamine may cause anaerobic pathway shift and lactate accumulation. meanwhile, intravenous vitamin c treatment was safe even at very large dosages, and the dosage was relatively consistent across all studies. (yao et al., 2021b) metabolic resuscitation another study (fujii et al., 2022) summarized that pa ge 67 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 “metabolic resuscitation” had drawn great interest as a complementary treatment for septic shock and sepsis. usually, vitamin c, glucocorticoids, and vitamin b1 or one of its components were mixed while executing such metabolic resuscitation. (fujii et al., 2022) prior research showed hydrocortisone, vitamin c, and thiamine (hvt) as potential adjuvant therapy for sepsis and septic shock, with lower mortality and improved disease cure. (shi & tie, 2020) positive impact of combination and immunomodulatory therapy consequently, another study by marik et al., 2017 showed that the natural progression of patients with severe sepsis and septic shock appeared to be significantly changed by the intravenous administration of vitamin c, hydrocortisone, and thiamine in moderate dosage. (marik et al., 2017) the findings of this study were supported by several experimental and clinical studies that have demonstrated the efficacy and prospective utility of moderate-dose hydrocortisone, intravenous vitamin c, and thiamine in critically ill patients. (marik et al., 2017) however, this was the initial study to examine the relationship between thiamine and intravenous vitamin c hydrocortisone, which works synergistically to reverse the pathophysiologic alterations of sepsis. (marik et al., 2017) mixed findings and perspectives the study by (chang et al., 2020) demonstrated the combination therapy of vitamin c, hydrocortisone, and thiamine. chang et al., 2020 did not find substantial improvement for patients diagnosed with sepsis with combination therapy, and it did not appear to improve the mortality rate. in contrast, another study by long et al., 2023 supported the positive effect of vitamin c and hydrocortisone in treating septic shock. (long, du, ouyang, zhong, & ye, 2023). hydrocortisone showed antitoxic effects, and the combination of hydrocortisone with vitamin c and thiamine showed significant effects in refractory sepsis and septic shock. (h. liang et al., 2023; long, du, ouyang, zhong, & ye, 2023) this systematic review summarizes the findings based on the effect of vitamin c, hydrocortisone, and thiamine in sepsis and septic shock treatment and provides a comprehensive overview of the research findings related to immunomodulatory therapy. in comparison, some studies suggest potential benefits, while others present mixed results, underscoring the complexity of this therapeutic approach and the need for further investigation. table 3: the lists of studies discussed in this review are relevant to the effect of vitamin c, hydrocortisone, and thiamine in treating sepsis and septic shock no title author year conclusion reference no. 01 retracted article: early use of highdose vitamin c is beneficial in the treatment of sepsis lv, s. j., zhang, g. h., xia, j. m., yu, h., & zhao, f. 2021 the early treatment of sepsis with intravenous high-dose vitamin c in combination with standard therapy showed a beneficial effect on sepsis in terms of reduced 28-day mortality, decreased sofa score, and increased clearance rate of procalcitonin. lv, s.-j., et al., (2021) 02 efficacy of vitamin c in patients with sepsis: an updated meta-analysis. wei, x. b., wang, z. h., liao, x. l., guo, w. x., wen, j. y., qin, t. h., & wang, s. h. 2020 in conclusion, including the recently published retrospective studies in our meta-analysis could not reveal the beneficial effect of vitamin c on patients with sepsis. the value of vitamin c in sepsis needs to be clarified through more high-quality randomized controlled trials in the future. wei, x.-b., et al., (2020) 03 vitamin c, hydrocortisone and thiamine in patients with septic shock (vitamins) trial: study protocol and statistical analysis plan. fujii, t., udy, a. a., deane, a. m., luethi, n., bailey, m., eastwood, g. m., & bellomo, r. 2019 septic shock is associated with poor outcomes. vitamin c (ascorbic acid) is a cellular antioxidant with anti-inflammatory properties. whether the combination therapy of vitamin c, thiamine, and hydrocortisone reduces vasopressor dependency in septic shock is unclear. fujii, t., et al., (2019) pa ge 68 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 04 vitamin c therapy for routine care in septic shock (victor) trial: effect of intravenous vitamin c, thiamine, and hydrocortisone administration on inpatient mortality among patients with septic shock. mohamed, z. u., prasannan, p., moni, m., edathadathil, f., prasanna, p., menon, a., & menon, v. 2020 we conclude that intravenous vitamin c, thiamine, and hydrocortisone in the dose and duration used did not affect the hospital mortality in patients with septic shock. vitamin c therapy seems to be safe. there is evidence of a reduction in the inflammatory process mohamed, z.u., et al., (2020) 05 combination therapy of thiamine, vitamin c and hydrocortisone in treating patients with sepsis and septic shock: a meta-analysis and trial sequential analysis. yao, r., zhu, y., yu, y., li, z., wang, l., zheng, l., & yao, y. 2021 in the current meta-analysis, the combination therapy of vitamin c and thiamine, with or without hydrocortisone, had no impact on short-term mortality compared with placebo but was associated with a significant reduction in sofa score among patients with sepsis and septic shock. yao, r., et al., (2021) 06 effect of adjunctive vitamin c, glucocorticoids, and vitamin b1 on longer-term mortality in adults with sepsis or septic shock: a systematic review and a component network meta-analysis. fujii, t., salanti, g., belletti, a., bellomo, r., carr, a., furukawa, t. a., & young, p. j. 2022 on nma, metabolic resuscitation with vitamin c, glucocorticoids, vitamin b1, or combinations of these drugs was not proven to reduce longer-term mortality. however, nma and component nma suggested an association between high dose and very high dose vitamin c and decreased mortality with low certainty. glucocorticoid therapy was associated with a decreased duration of vasopressor support and icu therapy. further rcts evaluating very high doses of intravenous vitamin c therapy appear justified. fujii, t., et al., (2022) 07 benefit of hydrocortisone, thiamine, and vitamin c for patients with sepsis or septic shock? too early to conclude. shi, r., & tie, h. 2020 in conclusion, the beneficial findings of our study support that hvt remains an attractive choice for sepsis and septic shock, while results from large-scale rcts are still expected before a definite conclusion, especially regarding the timing of hvt and the severity of sepsis. shi, r., & tie, h., (2020) 08 hydrocortisone, vitamin c, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study. marik, p. e., khangoora, v., rivera, r., hooper, m. h., & catravas, j. 2017 our results suggest that the early use of intravenous vitamin c, corticosteroids, and thiamine effectively prevents progressive organ dysfunction, including acute kidney injury, and reduces the mortality of patients with severe sepsis and septic shock. additional studies are required to confirm these preliminary findings. marik, p.e., et al., (2017) pa ge 69 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 09 combined treatment with hydrocortisone, vitamin c, and thiamine for sepsis and septic shock: a randomized controlled trial. chang, p., liao, y., guan, j., guo, y., zhao, m., hu, j., & liu, z. 2020 in conclusion, hydrocortisone, vitamin c, and thiamine did not appear to reduce the 28day mortality compared with a placebo in patients with sepsis or septic shock. moreover, we must consider side effects, such as severe hypernatremia. however, a larger sample and multi-centre, randomized controlled trials are required to validate the effectiveness and timing of this treatment. chang, p., et al., (2020) 10 research progress on therapeutic effect and mechanism of hydrocortisone on sepsis yicen long xiaoqiang du zhi ouyang jian zhong zeng ye 2023 sepsis has remained a high mortality rate worldwide. hydrocortisone has potent immunological and antitoxic effects, and thus, it is frequently used in treating septic shock. in recent years, the combination of hydrocortisone and other drugs, such as vitamin c and thiamine, has achieved promising outcomes in refractory septic shock. the present review focuses on the therapeutic effects of hydrocortisone in sepsis and summarizes the mechanisms by which hydrocortisone acts on vascular endothelial cells. we highlighted the effect of hydrocortisone on antiinflammation, anti-apoptosis, improvement of vascular functions, and anti-oxidative stress. long, y., et al., (2023) conclusion an uncontrolled immunological response to the microorganisms characterizes blood infection or sepsis. this causes inflammation throughout the body. sepsis is typically brought on by a delay in the infection’s detection and treatment. contrarily, intravenous vitamin c, corticosteroids, hydrocortisone, and thiamine successfully prevent organ dysfunction progression and lower the need for vasopressors and the mortality of patients with severe sepsis and septic shock. moreover, severe sepsis and septic shock patients may benefit from vitamin c, corticosteroids, and thiamine combination. these therapies were medically proven and showed significance in treating sepsis, lowering its symptoms’ effects, and preventing organ malfunctioning. however, it should be chosen for the proper type of septic shock, the suitable patient who would benefit, and the right dosage and duration when treating sepsis. triple therapy remains considered to be a promising technique in this regard. recommendations researchers are encouraged to explore various avenues in treating sepsis, including patient stratification, dosage, duration optimization, subtype specificity, long-term effects, and combination therapies. precision medicine is crucial for optimizing treatment outcomes. further refinement of dosages and duration is necessary to balance efficacy and safety. subtype specificity is also crucial, as a tailored approach may be required for each. long-term effects of immunomodulatory therapies in sepsis survivors and combining therapies can further enhance their efficacy. further recommendations include clinical trials, precision medicine approach, pharmacokinetic and pharmacodynamics studies, long-term follow-up studies, and combination therapies. it also encourages data sharing and collaboration among researchers, healthcare institutions, and pharmaceutical companies to accelerate research. public awareness about early sepsis symptoms is crucial for early detection and treatment. policy advocacy for evidence-based immunomodulatory therapies in sepsis treatment protocols is encouraged, prioritizing patient outcomes and safety. moreover, international collaboration in sepsis research and treatment is pa ge 70 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 61-72, 2023 encouraged to foster global cooperation. these recommendations aim to advance the understanding of sepsis, improve management, and enhance the quality of care for sepsis patients. limitations • the majority of the screened articles were not in english, and the majority of the articles were unreachable. the limitations of the study were these considerations. • publication bias, language bias, timeframe, and quality of included studies are common limitations in systematic reviews. acknowledging these biases and assessing individual studies’ quality is crucial for evaluating the strength of evidence. strengths • the review utilized a comprehensive search strategy, focusing on recent research published within the last seven years. • it followed clear inclusion and exclusion criteria, enhancing its credibility. • the discussion section effectively highlighted conflicting findings, demonstrating a balanced analysis. • the review integrated findings from various studies, including supportive and contradictory evidence, providing a holistic understanding of the topic. • the review also discussed potential clinical implications, valuable for healthcare professionals and researchers in sepsis and septic shock treatment. novelty of research the review focuses on the combination therapy of vitamin c, hydrocortisone, and thiamine in treating sepsis and septic shock. it synthesizes recent studies to examine the potential synergic effects and clinical benefits of administrating them together. the review includes studies from 7 recent years, providing a contemporary perspective. the research evaluates diverse perspectives, highlighting the complexity of sepsis and septic shock treatment. it provides clear and actionable recommendations for future research and clinical practice, offering guidance on refining treatment protocols, patient selection criteria, and developing clinical guidelines. the research emphasizes a multidisciplinary approach involving various medical specialities and healthcare providers to address the multifaceted nature of sepsis and septic shock. the novelty of the research lies in its systematic and contemporary analysis, consideration of diverse research perspectives, and practical recommendations for future research and clinical practice. contribution to knowledge this review has made significant contributions to critical care medicine and immunomodulatory therapies. it synthesizes existing research, strengthens the evidence base for this therapy, and offers insights into strategies to improve patient care, reduce mortality rates, and alleviate symptoms. the research also provides valuable information for developing clinical guidelines and protocols for sepsis and septic shock treatment. it acknowledges the knowledge gap and emphasizes a multidisciplinary approach, recognizing the complexity of these conditions. future research 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(2021b). combination therapy of thiamine, vitamin c and hydrocortisone in treating patients with sepsis and septic shock: a metaanalysis and trial sequential analysis. burns & trauma, 9. pa ge 1 pa ge 24 american journal of medical science and innovation (ajmsi) the gut-brain connection: investigating the correlation between autism disorder and gut bacterium wafa manaf1, nageena dileep2*, haifa manaf3, nadiya dileep4, azhar liyakath5 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3818 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 22, 2024 accepted: october 25, 2024 published: january 24, 2024 autism spectrum disorder (asd) is a type of developmental disability which results in social and communication difficulties besides exhibiting stereotyped or repetitive use of objects and bodies. asd is becoming increasingly prevalent as a significant public health issue, impacting 1 in 100 children globally and showing an apparent increase in cases internationally. up to 80% of children with asd experience gastrointestinal (gi) dysfunction, indicating a potential connection between gut microbiota and the development of asd. this study aims to define the link between gut dysbiosis and asd and look into the effectiveness of the therapies which use the microbiota, including probiotics, prebiotics, and mtt. a literature review was carried out to identify literature published on scopus, medline, and pubmed that focused on paediatric population, and the types of interventions included dietary changes and fmt. growing evidence for the changed gut microbiota of children with asd reveals the higher level of clostridium and the lower level of bifidobacterium population. supplements of other types of microbes such as probiotics had mixed outcomes in impacting asd behaviours but positively impacted the gastrointestinal manifestations. the research identifies changes in the gut bacterial makeup of children with asd, showing increased levels of clostridium and sutterella, which play a significant role in gastrointestinal and behavioral issues. therapies aimed at the microbiota, such as probiotics and dietary changes, and fecal microbiota transplantation (fmt) demonstrated the ability to enhance symptoms associated with gi issues and asd. keywords autism, gut-brain axis, gut microbiome, microbiota, neurodevelopment 1 ras al khaimah medical and health sciences university, united arab emirates 2 mohammed bin rashid university of medicine and health sciences, dubai, united arab emirates 3 neonatology department, travancore medical college, kollam, kerala, india 4 private clinic: united ambulances services, abu dhabi, united arab emirates 5 department of pediatrics, gims, greater noida, uttar pradesh, india * corresponding author’s e-mail: nadiyadileep2796@gmail.com introduction autism spectrum disorder (asd) is recognised as a neurodevelopmental disorder, and impairments in interaction, social communication, and the occurrence of repetitive behaviors distinguish it (namocot, 2023). gastrointestinal (gi) issues affect up to 80% of children with asd, suggesting a possible link between gut microbiota as well as asd development (yu et al., 2024). asd affects 1 in 100 children worldwide, and its prevalence remains varied across studies and regions (chiarotti & venerosi, 2020). symptoms often manifest in early childhood but may go undiagnosed until later, and this condition ranges from mild to severe, with some individuals living independently and others requiring lifelong care (hodges et al., 2020). conditions such as epilepsy, anxiety, and adhd often occur alongside autism spectrum disorder; evidence-based psychosocial interventions improve outcomes, but societal support is also critical for accessibility and quality of life (lai et al., 2020). however, (fattorusso et al., 2019) study emphasised that children with asd display imbalances in gut microbiota, which could contribute to both gi and behavioral symptoms. the gut-brain axis, otherwise referred to as the body’s microbiome, was an issue of significant interest due to its potential influence implying the role of the microbiome in asd. the microbiota comprises trillions of microbes that influence immune response, digestion, and even brain function, with modulation through neural, immune, and metabolic pathways such as antibodies and metabolites, including short-chain fatty acids (dupont et al., 2020). however, (iglesias-vázquez et al., 2020) study explained that a change in gut microbiota may be linked with the emergence and the severity of asd symptoms including gastrointestinal abnormalities. as a result, it has been established that children with asd have different bacterial composition in their gut, reduced bacterial diversity and some pathogenic genera according to (coretti et al., 2018). these imbalances could be beneficial in the conditions of enclave gi problems and anxiety, irritability, and other repetitive behavioral disorders. the treatments that affect such microbiota are the use of probiotics and prebiotics, and dietary management as these help to eliminate these symptoms (cunningham et al., 2021). the purpose of this study is to determine a connection between functional abnormalities in the gut microbiota and autism signs, as well as to review new findings concerning the gut-brain axis and neurodevelopmental and behavioral changes elicited by an imbalance in the bacterial flora. this work aims at assessing new interventions such as probiotics and diet modulations in children with asd believed to have an impaired gut brain connection. pa ge 25 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 24-34, 2025 materials and methods research strategy a systematic approach was chosen to investigate the link between gut microbiome health and autism spectrum disorders (asd) in children. an extensive literature search was conducted across various databases, including scopus, medline, and pubmed. key mesh terms such as “autism spectrum disorder,” “gut microbiota,” “pediatric population”, “kids or “kid”, “child*”, “microbiome therapy,” “fecal microbiota transplant,” and “neurodevelopment “not “adults” were used to identify relevant studies. the study combines these primary and secondary keywords using boolean operators like and, or, and not. inclusion and exclusion criteria in inclusion, articles published in the last 10 years were prioritised to ensure up-to-date findings. however, this study includes papers from the previous two or three decades to cover the maximum amount of research and provide broader research on asd and gut microbiota. this study only selected peer-reviewed papers and papers published on governmental and federal sites to ensure the authenticity of the research. inclusion criteria also focused on studies with precise data on gut microbiome and asd in pediatric populations (children aged 2–18 years). articles examining interventions such as probiotics, dietary changes, or microbiome transplants were included, provided a control group and quantified both microbial changes and behavioral outcomes in children with asd. some research models on animal studies are also evidenced in this paper. exclusion criteria include omitted studies with inconclusive findings, those with no control groups, and articles not focused on the gut-brain axis. those studies involving adults or populations with overlapping conditions like down syndrome were excluded. the exclusion was justified to maintain focus on children and eliminate unrelated co-morbidities. study selection the studies were filtered through inclusion and exclusion criteria for relevance and quality of the final research papers selected. only articles published in the last 10 years were selected to provide a recent understanding of the link between the gut and brain in children with asd. earlier and highly influenced studies were incorporated to give background information. peer-reviewed articles and research extracted from secure official government sources were used to ensure the authenticity of the data collected. exclude studies did not include control groups, targeted adults only, or reported on related disorders such as down’s syndrome. this may confound results because the review aimed to include only pediatric patients and the gut-brain axis. data analysis in this research, data analysis was confined to articles published in academic and peer-reviewed journals. specialists in the subject review scholarly reviewed articles, thus the efficiency of the techniques and recommendations made. through such articles, this investigation ensures that sorting comprises only the most robust studies on the gut microbiome and asd in children. studies include the findings of microbial alteration, behavioral impacts, and effectiveness of the strategies (e.g., probiotics, fecal microbiota transplants) published by peer-reviewed journals. this approach is justified because it gives a better and more accurate account of the constituents of the gut-brain axis in pediatric asd patients to arrive at definite conclusions (bozkurt et al., 2019). result and discussion gut dysbiosis in asd as mentioned earlier impaired gut microbial called dysbiosis is now linked to asd (pulikkan et al., 2019). many children with asd have different gi issues, and a disruption of the gut microbiota causes far worse gi and behavioral symptoms. (navarro et al., 2016), they noted that reduced level of some friendly bacteria (bifidobacterium) and overgrown pathogenic bacteria (clostridia) have been found commonly described in children with asd. (roussin et al., 2020) research indicates that gut dysbiosis plays a critical role in the pathophysiology of asd. however, studies have identified significant differences in gut microbiota between individuals with asd and neurotypical controls, revealing an altered bacterial composition that could affect the neurodevelopmental and behavioral characteristics associated with asd (fattorusso et al., 2019; ye et al., 2021). although clostridium species have been reported at higher levels in individuals with asd, this genus produces neurotoxins and metabolites that can disrupt the gutbrain axis while contributing to the gastrointestinal and neurological asd observed symptoms (fattorusso et al., 2019; liu et al., 2022). clostridia overgrowth in patients diagnosed with asd leads to a “leaky gut” through which toxic byproducts infiltrate the bloodstream and thereby affect brain function (doroszkiewicz et al., 2021). also, the elevation of sutterella, which exists in children with asd, can stimulate gastrointestinal inflammation that may influence the neurodevelopment of asd children and increase asd symptoms (bezawada et al., 2020; doroszkiewicz et al., 2021). the specific role is still under investigation, but sutterella is believed to contribute to inflammation and immune dysregulation factors that are often seen in asd individuals. however, (iglesiasvázquez et al., 2020) illustrated that sutterella’s presence is associated with gastrointestinal disturbances, which are commonly reported in asd patients and can exacerbate behavioral symptoms. besides, clostridium and sutterella show imbalances in other bacterial genera such as bacteroides and prevotella. these bacteria are associated with maintaining gut homeostasis and supporting immune function. pa ge 26 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 24-34, 2025 further, the study by (strati et al., 2017) demonstrates considerable shifts in gut microbiota and microbiota in subjects of severe asd with elevated firmicutes/ bacteroidetes ratios and particular bacterial disruptions. a reduction in their levels in individuals with asd may contribute to dysregulation of gut immunity and exacerbate systemic inflammation. in the review, (hughes et al., 2018) study suggested that changes in the gut microbial composition could impact asd and neuro more than development and behavior. these findings show potential for gut-targeted therapies such as probiotics and dietary interventions to alleviate some symptoms of asd by addressing the underlying dysbiosis, so the connection between gut health and asd is represented as a critical area of ongoing research (de sales-millán et al., 2023; liu et al., 2022). variation of gut bacterial composition between patients with asd and neurotypical individuals individuals with asd show distinct variations of gut bacterial composition compared to neurotypical individuals. in individuals with asd, firmicutes make up approximately 60.9% of the gut microbiota, while bacteroidota accounts for 17.1%, actinobacteriota for 15.4%, and proteobacteria for 4% (de sales-millán et al., 2024). conversely, neurotypical individuals have different profiles, with firmicutes at 59.6%, bacteroidota at 15.1%, actinobacteriota at 17.2%, and proteobacteria at 3.6%. notably, blautia levels are significantly lower in individuals with asd (3.46%) compared to neurotypical individuals (9.80%) as shown in table 1, while prevotella is more abundant in those with asd (2.54% vs. 0.71%). other differences in genus level include variations in clostridium species, with asd individuals having higher levels of clostridium_xi but lower levels of clostridium_ xviii. however, the study by (de sales-millán et al., 2024) focused that megamonas appear uniquely present in females with asd but are absent in both neurotypical groups, and these compositional differences in gut bacteria suggest potential links between microbiome diversity and asd. in addition to the noted differences in bacteroidetes and firmicutes, individuals with asd have shown higher proportions of other bacteria and increased clostridium species (table 1). patients diagnosed with asd present changes in microbiota in the gastrointestinal tract with increased presence of such bacteria as clostridium, desulfovibrio, and sutterella. (hughes et al., 2018) results showed that carcinogenic sulfur compounds formation by desulfovibrio might affect gut microbiota composition, contributing to dysbiosis and elevated sutterella concentration, which is associated with gut inflammation exacerbation and asd manifestation. table 1: gut microbiota genera involved in autism spectrum disorder (asd), characteristics, classification, and functional role in asd development (bezawada et al., 2020) genus characteristics bacterial classification function in asd development bacteroides gram-negative, anaerobic, nonspore-forming bacteroidetes levels observed to be higher as compared to children diagnosed with asd. it also plays a role in breaking down complex carbohydrates though it forms neurotoxic metabolites that interfere with communication between the gut and the brain which can alter gastrointestinal and behavioral conditions (coretti et al., 2018). clostridium gram-positive, anaerobic, spore-forming firmicutes probiotic imbalance; overgrowth of specific bacteria such as clostridium bolteae identified as associated with asd. these include neurotoxins like propionic acids that might interfere with signals within the brain leading to behavioral disorders and oversupply of antibiotics (rose et al., 2018). prevotella gram-negative, anaerobic, nonspore-forming bacteroidetes the ache levels were reduced in the present study in comparison to the control in the asd group. scfas are also produced by fiber that it is believed to enhance the health of the gastrointestinal tract. their deficiency might also adversely affect gut structural components and increase the inflammatory response (strati et al., 2017). bifidobacterium gram-positive, anaerobic, nonmotile actinobacteria involved in regulation of immune response and also in the regulation of intestinal permeability. its lack may cause elevated gut permeability leading to the appearance of “leaky gut” wherein toxic by-products are allowed entry into circulation, as well as hinder brain development (berding & donovan, 2018). pa ge 27 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 24-34, 2025 brain axis influence on asd the gut microbiome plays an important role in brain formation because it is associated with neurological disorders and with communication between the cns and the macrobiotics through immune, neurotransmitter, and hormonal pathways (suganya & koo, 2020). microbial metabolites like scfas or short-chain fatty acids modulate gut immunity and reinforce the intestinal barrier, which prevents harmful pathogen invasion that triggers neuroinflammation in conditions like autism spectrum disorder (asd) as mention in table 2. doroszkiewicz et al. (2021) study analysed that dysbiosis can cause gut permeability (leaky gut), allowing harmful bacteria into circulation and aggravating neurodevelopmental issues. however, the gut microbiome also affects the migration of immune cells like ifnγ+ nk cells and iga+ plasma cells to the cns, regulating neuroinflammation and guarding the developing brain against infections (moradi et al., 2021). under certain conditions, cells migrate and induce inflammation, demonstrating gut microbiota’s dual role in maintaining cns homeostasis or contributing to neurodevelopmental disorders like asd, and its balance depends on it (table 2). according to (azhari et al., 2019), gut microbiotas have a profound role in neurodevelopment through cell wall components and systemic cytokine regulation. derived from bacterial cell walls, peptidoglycan can cross the blood-brain barrier and activate pattern recognition receptors (prrs) in the brain, and this activation influences synaptogenesis in areas such as the prefrontal cortex and cerebellum, which are crucial for social behavior and stress responses linked to autism spectrum disorders (oummadi, 2023). in addition to peptidoglycan, cytokines are circulating to the cns; these molecules impact processes like neurogenesis, glycogenesis, and neuronal migration while making them critical to neurodevelopmental disorders (ndds) (wang et al., 2023). maternal immune activation (mia) has garnered attention for the association of inflammatory cytokines such as il-16 and il-6 with increased risk for ndds in offspring (bergdolt & dunaevsky, 2019). in pregnant females, if il-6 is elevated, it will further boost il-17 production while directly affecting neurons through synaptogenesis, which will disrupt hippocampal connectivity (mohebalizadeh et al., 2023; wang et al., 2023)) analysed that microglia are resident immune cells of the brain that play a pivotal role in modulating neurodevelopment by pruning synapses, regulating neural progenitor cells, and influencing myelination. however, (otero & antonson, 2022) emphasised that disruptions in microglial functions, including their synaptic pruning activity via the complement system, are linked to ndds, as gut microbiota impacts microglial maturation and function with microbial metabolites such as scfas. furthermore, microbial-derived aryl hydrocarbon receptor (ahr) agonists also control microglial synthesis of anti-inflammatory factors tgfα and cerebrovascular endothelial growth factor vegf-b amplifying the relationship between gut microbiota and brain inflammation (wang et al., 2023). it generates a variety of neurotransmitters that shape brain activity, such as serotonin and dopamine, which are among lactobacillus gram-positive, facultative anaerobe firmicutes used less in asd but is recognised for its capability to produce lactic acid, to regulate gut ph and to support healthy gut. a deficiency may lead to dysbiosis and impaired com obtained communication affecting their neurodevelopment, and behavior (pulikkan et al., 2018). desulfovibrio gram-negative, sulfate-reducing bacteria (srb) proteobacteria desulfovibrio is increased in asd and it forms hydrogen sulfide which is known to be toxic to the epithelial cells of the gut leading to inflammation and a leaky gut. dysbiosis may lead to increased permeability of the gut wall and permit neurotoxic metabolites to enter the brain and modulate asn symptomology (tomova et al., 2015). parabacteroides gram-negative, anaerobic, nonspore-forming bacteroidetes it is increased in some persons with asd and influences neurotransmission and inflammation. they are connected with higher immune activation and neuroinflammation that lead to asd symptoms (garcia-gutierrez et al., 2020). collinsella gram-positive, anaerobic, nonspore-forming actinobacteria it has a break down role for the aspect of complex carbohydrates and has a responsibility in the aspect of gut health in asd. its decrease probably affects both metabolic and immune processes, likely being involved in the gastrointestinal disorder which is manifested in most children suffering from asd (srikantha & mohajeri, 2019). sutterella gram-negative, anaerobic, nonspore-forming proteobacteria increased rate of asd with inflammation and gastrointestinal abnormalities. if so, its increase might be associated with changes in gut integrity and immune regulation, which clearly affects asd development (hiippala et al., 2016). pa ge 28 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 24-34, 2025 these metabolites (table 2). however, there are two metabolites, taurine and 5-amino valeric acid, that help enhance social activity and reduce stereotypic movements in an asd model. the gut microbiota also affects the hypothalamic-pituitary-adrenal (hpa) axis, the hormones of which get deleteriously altered in a context that can cause increased stress hormone cortisol, which is seen in individuals with asd (rusch et al., 2023). however, some bacterial strains can reduce social stress by normalising glucocorticoid concentrations. these findings illuminate vast bidirectional communication between the brain and gut with modulation into the vogus nerve. asd is marked by deficits in social interaction and communication and varying degrees of repetitive behavior. it is also associated with genetic and environmental factors. (borrego-ruiz & borrego, 2024) identified different genes related to asd through large-scale genetic analyses, and yet, it is important to consider infections, diet, and toxicity. recent focus has been devoted to relationships between gi dysfunction in asd and dysbiosis as research has revealed variations in microbial profiles in children with asd compared to td in table 2. one notable example is the elevated presence of clostridioides genus in asd individuals. the research illustrated that microbial metabolites like 4-ep(s) and p-cresol sulfate are derived from aromatic amino acids and have been implicated in processes like neuroinflammation. further elaborated by (zheng et al., 2021), serotonin dysregulation observed in asd also points to gut-brain interactions with research emphasising the abnormal metabolism of tryptophan in autistic individuals. a range of therapeutic approaches for the microbiotagut-brain axis encompassing prebiotics, probiotics, and fecal microbiota transplantation (fmt) has shown potential. probiotics like lactobacillus reuteri and bacteroides fragilis have confirmed improvements in asd-related behaviors and gut permeability in murine models (wang et al., 2023). as shown in table 2, fmt restores microbial diversity and improves gi and behavioural symptoms in small-scale clinical studies, but factors like donor-recipient compatibility and administration methods remain critical challenges for fmt. alterations in microbial composition, such as increased bifidobacterium and bacteroidaceae and reduced abundance of certain taxa, have been associated with adhd symptoms. however, (song et al., 2022) elaborated that transplanting adhdassociated microbiota into mice led to adhd-like behaviors that point out potential causal gut-brain axis roles. probiotics and omega-3 polyunsaturated fatty acids (pufas) confirmed therapeutic promise in adhd by modulating the immune response and intestinal barrier stability (table 2). for instance, rett syndrome (rtt) is a severe ndd that predominantly affects females and has also been linked to gut microbiota alterations. these rtt patients show reduced microbial diversity in taxa like bifidobacterium and lactobacillus (borghi & vignoli, 2019). these findings have revealed a significant attendance of fmt to improve microbial imbalance and gastrointestinal and behavioral manifestations of asd. also, gut dysbiosis observed in adhd children, including increased bifidobacterium count, has been associated with adhd symptoms, suggesting a causal connection of the gut-brain axis in neurodevelopmental disorders, including rett syndrome. table 2: mechanisms linking gut microbiota to autism spectrum disorder (asd) development mechanism gut microbes involved effect on asd development pathophysiological impact gut-brain axis disruption clostridium, bacteroides microbes produce neurotoxic metabolites (e.g., propionic acid) that can alter brain function and behavior. disruption in neurotransmission, increased production of neuroactive compounds, and imbalanced synaptic activity contribute to abnormal behaviors and cognitive dysfunction in asd (coretti et al., 2018). altered immune response desulfovibrio, sutterella dysbiosis triggers chronic gut inflammation, which activates systemic immune responses and neuroinflammation. heightened inflammatory responses in the gut increase pro-inflammatory cytokines like il-6 and tnf-α, promoting neuroinflammation and neural circuit disruptions involved in asd (kang et al., 2017). leaky gut and gut permeability bifidobacterium, lactobacillus reduced beneficial bacteria compromise gut barrier integrity, increasing permeability ("leaky gut"). toxins and bacterial metabolites enter the bloodstream, potentially crossing the bloodbrain barrier, impacting neurodevelopment, and increasing asd symptom severity, including gi disturbances (berding & donovan, 2018) short-chain fatty acid (scfa) deficiency prevotella, bifidobacterium reduced scfa production affects gut health, immune balance, and neurotransmitter synthesis, all crucial for brain health. scfas regulate immune responses and maintain gut epithelial integrity. reduced levels lead to increased inflammation, impair brain development, and affect signaling pathways linked to asd (coretti et al., 2018). pa ge 29 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 24-34, 2025 contribution of gut microbiota in the development of asd the gut microbiota’s potential contribution to the development of (asd) has gained attention for its association between gastrointestinal disturbances and neurodevelopmental disorders. (yu et al., 2024) research emphasised that children with asd have distinct gut microbiota composition compared to neurotypical individuals, bacterial taxa being differentially abundant, and there are disruptions in the gut-brain axis. however, (ersöz alan & gülerman, 2019)finding highlighted that individuals with asd tend to have fewer beneficial bacteria such as bifidobacterium and collinsella, which belong to the actinobacteria phylum. on the other hand, higher abundance levels of proteobacteria have been reported, particularly from the family of enterobacteriaceae, which are considered to foster inflammation in the gut in individuals with asd (gomaa, 2020). other bacterial taxa observed in disproportionately high amounts are prevotellaceae and parabacteroides from the bacteroidota, which may be associated with gastrointestinal complaints that most asd patients exhibit (peralta-marzal et al., 2024). these outcomes stress that microbial dysbiosis may play a role in asd pathogenesis, and modulating microbial ecology, including by use of probiotics or fecal microbiota transfer, may provide one of the reasons for ameliorating gastrointestinal and behavioural manifestations in children with asd. however, (peraltamarzal et al., 2024) research shows that gut microbiota is crucial for the bidirectional gut-brain axis, especially in patients diagnosed with asd. some of these mechanisms include modulation of immune responses, generation of neuroactive metabolites, and effects on the barrier in the gut. moreover, the presence of particular microbial genera in asd individuals, including a reduced amount of bifidobacterium and collinsella and increased prevotellaceae and parabacteroides that, are thought to affect neurological signaling (berding & donovan, 2018). this communication between the gut and brain is believed to affect behavior, thinking, and even feelings. although, (chernikova et al., 2021) study highlighted the alteration of gut microbiota by probiotics or fecal microbiota transplantation can be therapeutic targets for as-designated gastrointestinal and neurological manifestations of asd. dietary interventions parents of children with asd often favor gluten and casein-free diets (gfcf), grounded in the belief that certain peptides from these foods might worsen symptoms. the gluten-free casein-free (gfcf) diet has been investigated as a potential treatment for (asd) because of the possible connections between gluten, casein, and brain function (christison & ivany, 2006). however, the study by (knivsberg et al., 2003) suggested that eliminating casein and gluten could reduce autismlike symptoms by preventing the formation of opioid-like peptides from these proteins which may cross intestinal and blood-brain barriers. studies like (knivsberg et al., 2003) reported reduced autistic behaviors following the gfcf diet, while others, like (elder et al., 2006) identified no significant behavioral improvements after 6 weeks on a diet. further, (mari-bauset et al., 2014) study demonstrated that parents observed reductions in gastrointestinal symptoms and repetitive behaviors in their children on the gfcf diet. (whiteley et al., 2010) argued that longer durations of 6 months or more may be necessary to see effects, though this remains contested. however, (başpinar & yardimci, 2020) study supported that elimination diets should be considered only when there’s a known intolerance to gluten or casein. it indicates that a low gfcf diet might lessen autism-like behaviors in certain children; other research has shown only mild effects. long-term beneficial results, especially in regard to digestion and compulsive behaviors might be observed; however, elimination diets should only be attempted if certain pathologies involving intolerances are confirmed. probiotics probiotic strains such as lactobacillus and bifidobacterium, are proposed to balance gut microbiota in individuals with asd (sanlier & kocabas, 2023). (sivamaruthi et al., 2020)study randomised controlled trial (rct) proposed that probiotics improved gi symptoms and marginally enhanced social responsiveness in asd patients but the overall impact on core asd behaviors remains inconsistent. (patel et al., 2022)review emphasised that probiotics and gut microbiota in children with (asd) has produced mixed findings. according to (buffington neurotransmitter dysregulation bacteroides, clostridium gut microbiota modulates serotonin, dopamine, and gaba levels, crucial for regulating mood and behavior. imbalances in neurotransmitter production linked to the altered microbial composition may contribute to asd-related behaviors like anxiety, repetitive behaviors, and social impairments (strati et al., 2017). oxidative stress desulfovibrio, clostridium overgrowth of certain microbes increases oxidative stress markers, exacerbating brain inflammation and damage. increased oxidative stress in the gut and brain leads to mitochondrial dysfunction and neuronal damage, which is commonly observed in individuals with asd, worsening cognitive and behavioral symptoms (dargenio et al., 2023). pa ge 30 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 24-34, 2025 et al., 2016)research, animal studies demonstrated that probiotic supplementation could improve asd-like symptoms and social behavior in mice, but human studies are less conclusive. a meta-analysis by (he et al., 2023) investigated the effect of probiotics such as lactobacillus plantarum and bifidobacterium longum on asd symptoms. probiotics did help alleviate gastrointestinal (gi) symptoms in other research, and multi-strain probiotics such as blends containing lactobacillus reuteri appeared to show better outcomes than single strains in improving behavior in children with asd (buffington et al., 2016; wang et al., 2023). despite these promising insights, (he et al., 2023)suggested that high-quality clinical trials are still required to substantiate probiotics’ therapeutic impact on asd-related behavioral symptoms. the findings from the current literature review indicate that only a few clinical trials on the effects of probiotics on people with asd are published. those studies demonstrate improvements in gastrointestinal symptoms when using probiotics and multi-strain blends but cannot conclude consistent benefits on the core asd symptoms. microbiota transfer therapy (mtt) mtt refers to transplantation to the subjects with asd of a microbiota sourced from healthy individuals for its normalising impact on the gut. a study conducted by (kang et al., 2017) illustrated that microbiota transfer therapy (mtt) demonstrated there was a notable enhancement in gastrointestinal (gi) symptoms as well as autism symptoms among children with asd. after a treatment regimen that included antibiotics bowel cleanses, and fecal microbiota transplants (fmt), included participants experienced an 80% reduction in gi symptoms like constipation and diarrhea, and behavioral improvements in asd symptoms were also observed and both gi and asd improvements persisted 8 weeks post-treatment (tan et al., 2021). increased microbial diversity including abundance of beneficial bacteria like bifidobacterium and prevotella was also noted by (adams et al., 2019; kang et al., 2019) study also demonstrated promising results in children with asd after mtt a procedure involving the transfer of a healthy donor’s fecal microbiota to the patient and an open-label study showed that after two years, 45% of children saw a reduction in core asd symptoms by 50% while their gi symptoms improved by 58%. further, (kang et al., 2019) analysed that long-term follow-up shows intervention had sustained effects with changes in microbial diversity resembling that of neurotypical individuals. nevertheless, the lack of control groups in some mtt studies may limit the robustness of these findings to some extent. microbiota transfer and other therapies in asd asd has prompted microbiota transfer therapy (mtt) and other gut-targeted interventions including use of probiotics and changes in diet (adams et al., 2019). (kang et al., 2019)research exploring the gut-brain axis in asd has shown interest in microbiota transfer therapy (mtt), probiotics, and dietary interventions. however, (kang et al., 2017) suggested that gut microbiota influence asd symptoms by altering the gut-brain axis through several mechanisms for instance, microbial imbalances cause increased gut permeability allowing inflammatory molecules to reach the brain, which affects neural pathways tied to behavior. also, (taniya et al., 2022) study elaborated that microbes may also produce neuroactive compounds like serotonin or gaba impacting social behavior and repetitive actions and these imbalances can disrupt digestion leading to gastrointestinal disturbances commonly seen in asd. discussion the discussion emphasised the microbiota in relation to asd has attracted much interest with different studies indicating the role of gut bacteria in the development of the brain and behaviour. the exact mechanisms and clinical relevance of these findings are not yet cleared and are calling for a more critical evaluation of current evidence. navya (bezawada et al., 2020) study elaborated that asd children are seen frequently exhibit altered gut microbiota characterised by an increase in certain bacteria like clostridium and sutterella and a reduction in beneficial species such as prevotella. however, one major limitation in current research is heterogeneity in methodologies like inconsistent use of controls varying diagnostic criteria for asd and differences in sample collection and sequencing techniques. without controlling for these factors, there is a gap to conclude that microbial differences are intrinsically linked to asd. although, (loth et al., 2016) study conducted on the link between autism spectrums disorder (asd) and gut microbiota as the scientific community aims to use this association for identification. lacking precisely validated gut-based biomarkers diagnosing asd, several arising methodologies exist. however, (ye et al., 2021) study identified that there is a low concentration of better bacteria, especially bifidobacterium, and a higher chance of pathology. apart from traditional stool analysis, modern techniques are available such as metagenomic sequencing to determine the gene content of these microbes, which assists in establishing a direct relationship between particular microbes and asd. (eicher & mohajeri, 2022) study approach focuses on microbial metabolites being the chemical output of these bacteria, some of which are likely to be shifted in autistic patients. to model the risk of asd based on gut microbiome data, active machine learning algorithms are being trained and will soon be available; these methods are relatively new in diagnosing, giving hope for the future of diagnosing persons with asd. however, (zou et al., 2020) study illustrated that the mechanisms by which the gut-brain axis influences these cns functions via short-chain fatty acids, neurotransmitters, and the immune system or which guts dysbiosis affect the core signs of asd. although, as per (oh & cheon, 2020) research, propionic acid, a shortchain fatty acid synthesised by some gut bacteria has been pa ge 31 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 24-34, 2025 found to cause asd-like behaviors in animal models, but direct extrapolation to humans is difficult due to the complexity of neurodevelopment and many genetic factors underlying asd. some gut pathologies arising from microbiota imbalance, including the overgrowth of clostridium and desulfovibrio, produce neurological toxins, including propionic acid, which interferes with neurotransmission and may help explain behaviors seen in asd (coretti et al., 2018). macfabe (2015) argued that the disintegration of the communication between the gut and the brain, combined with the increase of the permeability of the intestinal barrier leads to the introduction of toxins from the bloodstream into the brain. however, liwinski and elinav (2020) noted that causality of microbiota for the development of asd remains ambiguous since, according to many investigations, they show only coexistence. despite the positive outcomes observed from the clinical studies, variability in the results obtained across the human trials has necessitated more rigorous research using better-quality interventions. furthermore, it is still doubtful whether microbiotatargeted interventions such as prebiotics, probiotics, or fecal microbiota transplantation can be used as therapeutic options. the study by settanni et al. (2021) highlighted significant reductions in gastrointestinal and behavioral symptoms, but the durability and safety of these treatment procedures are questionable. the possibility of the placebo effect, small sample sizes, and the absence of keen, controlled trials hampers these findings. further, liwinski and elinav (2020) study examined the therapeutic efficacy of targeting gut microbiota in asd and answered whether such interventions can be anything more than treatment of symptom(s). zhu et al. (2022) study suggested that aba and ot are identified as evidence-based for enhancing functional and adaptive communication, daily living, and social, and motor development. other dietary interventions, such as omega-3 fatty acids, benefit behavior, though these findings are inconclusive. in addition, awaad (2022) study discussed that sensory integration therapy (sit) is useful for helping children with sensory processing, hyperbaric oxygen therapy (hbot) and acupuncture give limited assistance. anxiety can be controlled and treated with cognitive behavioral therapy also known as cbt for people with higher intellectual capacity. this study identified that more and more interest has been gain to the gutbrain axis and its relationship to asd, the specific processes are not yet well understood. literature shows that gut–brain axis contributes to neurodevelopment and behaviour but there is a limit focus on the quality of research. compared with antibiotics, antibiotic-associated microbiota-targeted therapies such as probiotics and fecal microbiota transplantation provide evidence of efficacy but their effect and safety in the long-term are abilities more research. if the patient’s problem is severe enough, dietary and behavioral practices, together with medical treatments, can be the most effective asd intervention. conclusion it can be concluded that the increasing fascination with the gut-brain connection is a potential contributor to changes in asd symptoms. a substantial body of evidence suggests gut dysbiosis has a significant role in both behavioral and gastrointestinal symptoms among children with asd. while microbiota-targeted interventions such as fecal microbiota transplantation or probiotics show therapeutic promise, several critical questions remain unanswered regarding their safety, effectiveness, mechanisms of action, and the longevity of their effects. the research emphasises that there is a pressing need for further extensive studies to develop individualised reproducible microbiota-based therapies, considering the wide variability of symptoms among asd patients. the review further emphasises the need to apply microbial health findings to managing asd. it suggests the need for larger clinical trials to establish microbiota and neurodevelopmental disorders such as asd. references adams, j. b., borody, t. j., kang, d.-w., khoruts, a., krajmalnik-brown, r., & sadowsky, m. j. 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(2020). changes in the gut microbiota of children with autism spectrum disorder. autism research, 13(9), 1614-1625. pa ge 1 pa ge 1 american journal of medical science and innovation (ajmsi) the influence of cito procurement on pharmaceutical supply chains: efficiency, challenges, and outcomes desy kartika ningsih1* volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3925 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: october 20, 2024 accepted: november 25, 2024 published: december 08, 2024 this paper investigates the role of cito (critical item time order) procurement in optimizing pharmaceutical supply chains, particularly in contexts requiring rapid responses to urgent supply needs. cito procurement is analyzed for its effectiveness in enhancing operational efficiency, cost management, and patient outcomes within healthcare settings. through a comprehensive review of existing literature and case studies, the paper identifies both the strengths and challenges associated with cito implementation. key findings suggest that while cito can significantly reduce lead times and stockouts, organizations must also address potential risks related to supplier quality and regulatory compliance. the study proposes strategies for optimizing cito procurement processes, emphasizing the importance of technology and strong supplier relationships in ensuring reliable and timely access to critical medications. ultimately, this research highlights cito’s potential as a vital strategy in the evolving landscape of pharmaceutical supply chains, underscoring its relevance for improving healthcare delivery and patient care. keywords cito procurement, critical item order, healthcare logistics, pharmaceutical supply chain, supply chain efficiency 1 universitas indonesia maju, indonesia * corresponding author’s e-mail: deskartik123@gmail.com introduction the pharmaceutical supply chain plays a crucial role in healthcare by ensuring the availability, safety, and quality of medications for patient care (alshemari et al., 2020). the complexity of the pharmaceutical supply chain arises from its highly regulated nature and its need to meet stringent standards at every stage, from sourcing raw materials to delivering the final products to healthcare providers and patients. this chain involves various stakeholders, including manufacturers, distributors, healthcare providers, and regulatory bodies, each contributing to the flow and monitoring of pharmaceutical products. one key function of the pharmaceutical supply chain is maintaining medication availability while minimizing waste and avoiding shortages. recent studies emphasize the impact of supply chain efficiency on patient outcomes, with a clear link between well-managed supply chains and quality patient care (abbas et al., 2020). automated systems are increasingly adopted to monitor inventory, manage expiry dates, and respond to recalls, which reduces administrative burdens on clinicians and enhances inventory visibility, thus supporting faster and more accurate supply decisions (chen et al., 2023). supply chains in healthcare, particularly post-pandemic, have shown vulnerabilities to disruptions, highlighting the need for resilient systems capable of adapting to crises such as raw material shortages or logistical challenges. to strengthen the supply chain, healthcare systems are increasingly incorporating real-time data and analytics, which improve decision-making by enabling accurate demand forecasting and reducing dependency on single sources (yaroson et al., 2021). transparency and collaboration among supply chain stakeholders are also pivotal, as they allow for coordinated responses to potential shortages and help mitigate future risks. in summary, the pharmaceutical supply chain is fundamental to healthcare operations, directly impacting both clinical outcomes and the financial sustainability of healthcare systems. optimizing these supply chains through automation, transparency, and strategic partnerships is crucial for maintaining continuous access to essential medications and improving healthcare resilience. cito is a specialized procurement strategy designed to rapidly address urgent needs for critical items in supply chains, particularly in healthcare and pharmaceuticals. this approach is utilized to ensure that high-priority, often life-saving supplies reach their destination with minimal delay (elmiawati latifah et al., 2023). unlike traditional procurement methods, which are primarily cost-driven and follow routine ordering cycles, cito procurement is time-sensitive and focuses on speed and immediate availability over cost-efficiency. the method is especially relevant in healthcare, where timely access to essential medicines or equipment is directly linked to patient outcomes (handayany & basri, 2022). in practice, cito procurement involves processes that expedite ordering, inventory checks, and transportation logistics to shorten delivery times. this method typically leverages a blend of strategies such as priority contracts, premium shipping options, and real-time inventory tracking, which are critical for handling unexpected spikes in demand or supply chain disruptions. for instance, during the covid-19 pandemic, healthcare providers increasingly relied on cito procurement to obtain critical items like personal protective equipment and ventilators, bypassing typical supply chain constraints to secure immediate resources (almahdy et al., 2021). overall, cito procurement is designed to handle highstakes scenarios where timely delivery is essential, and pa ge 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 1-10, 2025 it requires close coordination between suppliers and healthcare providers. this coordination helps minimize the risks associated with stockouts of critical supplies, although it may involve higher costs due to expedited services and premiums on immediate availability. as supply chain resilience becomes a focal point in healthcare, cito procurement remains a key approach to ensuring the rapid availability of essential supplies during emergencies. the relevance of cito in healthcare is paramount for ensuring the timely availability of critical medicines, particularly in response to urgent and unpredictable demand fluctuations. cito procurement strategies are designed to deliver essential medicines swiftly, bypassing the longer lead times often associated with traditional procurement methods. this capability is crucial in healthcare, where delays in acquiring necessary drugs can have severe consequences for patient outcomes, especially in emergency care settings and during public health crises such as pandemics. in healthcare environments, the demand for certain medications can change suddenly, driven by factors like seasonal disease outbreaks, supply chain disruptions, or natural disasters. traditional procurement systems, which rely on scheduled purchasing and bulk orderingorders, may struggle to meet these sudden shifts in demand. cito, on the other hand, emphasizes flexibility and responsiveness by leveraging agile supplier relationships and pre-negotiated contracts that allow healthcare providers to source medications at short notice. the real-time tracking and data-driven capabilities integrated into cito systems also play a significant role in improving supply chain resilience. by providing accurate demand forecasts and early identification of shortages, cito helps healthcare providers maintain continuity in drug availability, ensuring that high-demand medications are available precisely when and where they are needed. this capacity is especially important for hospitals, where availability of critical medicines like antibiotics, blood products, and respiratory treatments can be life-saving. furthermore, cito’s relevance is amplified in settings that serve vulnerable populations, such as intensive care units, cancer treatment centers, and dialysis facilities, where a disruption in medication supply could lead to severe health complications. in these contexts, cito supports healthcare providers in managing high-stakes supplies effectively, thereby enhancing patient care quality and reducing the risks associated with drug shortages. in sum, cito procurement is instrumental in ensuring that healthcare facilities can meet urgent needs with speed and precision, supporting the continuous availability of life-saving drugs and improving the resilience of the healthcare supply chain. by reducing lead times and enhancing supply flexibility, cito aligns with the critical demands of modern healthcare, where timely medication availability can directly influence patient survival and well-being. the study is implemented to evaluate the effectiveness of cito procurement in ensuring timely access to critical medicines: this study aims to assess how effectively cito (critical item time order) procurement models ensure the availability of critical medications in healthcare settings, particularly during times of high demand or supply chain disruption. this includes examining the impact of cito on reducing lead times, improving supply chain responsiveness, and minimizing stockouts. further, it will also analyze cost implications of cito in comparison to traditional procurement models: a key objective is to evaluate the cost structures associated with cito procurement compared to traditional methods. the study will explore whether the benefits of increased flexibility and speed justify the potential premiums associated with cito, such as expedited shipping costs, and analyze its cost-effectiveness in healthcare contexts where critical medicines are essential. it is also important to assess the challenges of implementing cito in the pharmaceutical supply chain: the study will investigate specific challenges faced by healthcare providers in implementing cito, including regulatory compliance, quality assurance, risk management, and the need for advanced digital systems. understanding these obstacles can provide valuable insights for organizations looking to adopt or optimize cito models. lastly, the study can be a fundamental reference to determine the impact of cito on resource allocation and risk management: this research will analyze how cito affects resource allocation within procurement departments, particularly in terms of manpower and time management. it will also examine how cito procurement supports or complicates risk management efforts, as flexibility in sourcing may introduce risks related to supplier verification and product quality (paramitha & oktamianti, 2024). the significance of this study lies in its potential to inform healthcare providers, policymakers, and supply chain managers about the benefits and limitations of cito procurement in the pharmaceutical industry. with healthcare systems increasingly reliant on agile supply chains that can quickly adapt to demand changes, this research provides a detailed analysis of cito’s impact on the timely availability of life-saving drugs. in an environment where drug shortages have been linked to higher mortality rates and poorer health outcomes, understanding the role of cito in mitigating these issues is essential. the findings of this study could help healthcare facilities optimize their procurement practices, improving patient care by reducing lead times and ensuring medication availability during critical moments. moreover, this research will offer practical insights for managing the unique challenges of cito, such as regulatory compliance and risk of counterfeit products, which are particularly significant in the pharmaceutical sector. as supply chains become increasingly complex and interdependent, this study could be instrumental in guiding effective implementation of cito, contributing to more resilient healthcare systems worldwide. pa ge 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 1-10, 2025 literature review the origins of cito procurement trace back to industries that required rapid sourcing and delivery of high-priority items, especially during times of crisis or urgent demand. initially, cito practices were seen in fields like defense and aerospace, where the need for critical supplies and equipment during emergencies spurred the development of procurement models focused on speed and flexibility (ngir et al., 2023). over time, as global supply chains grew more complex and demand for responsive systems increased, cito methodologies found applications in other critical sectors, particularly healthcare and pharmaceuticals, where the availability of life-saving medications can directly impact patient outcomes. in the healthcare sector, cito procurement has gained traction more recently as a response to the increased demand for critical medicines and medical supplies, particularly during health crises like the covid-19 pandemic. the pandemic highlighted the limitations of traditional procurement models, which often failed to keep pace with the rapid fluctuations in demand for essential medical supplies such as ventilators, personal protective equipment (ppe), and specific medications. faizar et al. (2023) points point out that the urgent requirements during the pandemic accelerated the adoption of cito practices in healthcare, where flexibility, rapid decisionmaking, and supplier collaboration were crucial to maintaining supply continuity during unpredictable surges in demand. another significant historical driver behind cito’s adoption in healthcare is the rising number of drug shortages worldwide, which has become a persistent issue over the last decade. studies note that these shortages have often been exacerbated by rigid supply chain processes unable to adapt to sudden demand spikes, manufacturing delays, or distribution bottlenecks (elmiawati latifah et al., 2023; faizar et al., 2023). in this context, cito emerged as an alternative strategy that enables healthcare organizations to rapidly source essential drugs from prevetted suppliers, ensuring availability even in times of crisis. by doing so, cito procurement helps to address the risks posed by drug shortages, allowing healthcare providers to maintain critical stock levels with less reliance on stockpiling. the integration of digital technologies has also played a pivotal role in cito’s evolution. early implementations relied heavily on manual systems and close supplier relationships, but advances in real-time tracking, predictive analytics, and data integration have allowed for a more systematic approach. research shows that the adoption of digital tools has enabled organizations to monitor supply levels more accurately, anticipate demand spikes, and make rapid adjustments, which are essential features of the cito model. the use of these tools has expanded cito’s capabilities, making it feasible not only for emergency scenarios but also for standard operations in sectors like pharmaceuticals, where supply chain disruptions can directly impact patient health (aghniya, 2022). in summary, cito’s initial applications were in fields requiring rapid response and supply continuity under high-stakes conditions. its adoption in the healthcare sector has been more recent, driven by the need for agile procurement methods to address challenges such as drug shortages and emergency healthcare demands. enhanced by digital tools, cito continues to evolve, offering healthcare providers a more resilient and flexible approach to supply chain management in an increasingly complex global landscape. the comparative analysis of cito and traditional procurement methods has become increasingly relevant in fields where supply chain agility and responsiveness are essential, such as healthcare and pharmaceuticals. this literature review synthesizes findings from recent studies, focusing on key themes including flexibility, cost efficiency, lead times, and risk management. one of the most widely cited benefits of cito over traditional procurement methods is its flexibility, particularly in environments with unpredictable demand. lisman et al. (2023) emphasized that cito allows organizations to meet sudden and critical demand through pre-established supplier relationships and expedited processes, a capability that traditional procurement lacks due to its reliance on fixed scheduling and bulk ordering. during the covid-19 pandemic, for instance, cito allowed healthcare organizations to secure essential items like ppe and ventilators more efficiently, whereas traditional systems struggled to adapt to rapidly fluctuating demand. similarly, canova et al. (2024) underscore the importance of cito’s flexibility in healthcare, where demand unpredictability is common. the study found that cito procurement models could quickly source critical medications and equipment, enabling healthcare facilities to maintain continuity in patient care even during unexpected surges. traditional procurement’s rigid structures, in contrast, often led to stockouts and delays during the same period, highlighting the model’s limitations in dynamic, high-stakes environments. cost considerations in cito versus traditional procurement methods are complex, with each approach offering different advantages depending on the nature of the items being procured. traditional procurement benefits from economies of scale, as bulk purchasing and long-term contracts tend to lower unit costs. in contrast, cito is often associated with higher per-unit costs due to its reliance on expedited shipping and flexible contracts. however, research (tawarma & marlina, 2023) found that cito could be more cost-effective in critical supply scenarios, as it minimizes inventory holding costs and helps avoid the financial impacts of stockouts. the study highlighted that while traditional procurement can achieve cost savings on bulk items, cito can reduce total costs in high-priority, time-sensitive scenarios by ensuring immediate availability and preventing costly delays. however, elmiawati latifah et al. (2023) cautions pa ge 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 1-10, 2025 that the cost benefits of cito depend on the criticality of the item and the organization’s operational needs. for example, cito is often more financially viable for essential, high-value items than for routine items that can be ordered in bulk at a lower cost per unit. the ability of cito to reduce lead times is another major advantage highlighted in comparative studies. traditional procurement models often involve extensive lead times due to the scheduled ordering processes and fixed inventory cycles that prioritize cost savings over speed. a study by alshemari et al. (2020) found that cito models could significantly cut lead times by minimizing intermediate steps and allowing for faster decisionmaking processes. this advantage is especially relevant in sectors like healthcare, where the timely availability of critical supplies can directly impact patient outcomes. the literature also shows that reduced lead times under cito can help prevent stockouts and maintain supply continuity in high-demand situations. according to jachowicz et al. (2020), healthcare organizations employing cito procurement models experienced fewer disruptions in their supply chains during the pandemic than those that relied solely on traditional procurement. in contrast, organizations with traditional procurement models faced extensive delays, exacerbating shortages of critical supplies like medications and ppe. risk management is a vital consideration in the comparison of cito and traditional procurement. traditional procurement models typically rely on longterm relationships with a limited number of suppliers, which can provide stability but may create vulnerabilities during global supply disruptions. cito, however, mitigates this risk by maintaining a diversified supplier base that allows for rapid sourcing adjustments. as noted by nikolaidou (2021), cito’s resilience in the face of supply chain disruptions made it an invaluable model during the pandemic, where single-source dependencies often failed to meet demand spikes. however, while cito provides flexibility and risk mitigation through supplier diversity, it can also introduce quality assurance challenges. study by maria and putri (2022) observed that rapid sourcing under cito could lead to less rigorous vetting of suppliers, raising the risk of counterfeit or substandard products. this issue is particularly concerning in the pharmaceutical sector, where quality control is critical to patient safety. traditional procurement, in contrast, typically allows more time for thorough supplier verification and quality assurance, making it more suitable for non-critical, bulk suppliescomparative studies indicate that cito procurement offers significant advantages over traditional methods in terms of flexibility, responsiveness, and reduced lead times, especially in critical and dynamic environments like healthcare. however, the benefits of cito come with trade-offs, including higher per-unit costs and potential risks related to quality assurance. traditional procurement remains valuable for its cost-effectiveness and stability in predictable, high-volume orders. the literature suggests that an integrated approach, combining cito’s flexibility with traditional procurement’s cost efficiency, could offer a balanced solution, enabling organizations to adapt their procurement strategies based on the specific requirements of each item and situation (rimadeni et al., 2024). the adoption of cito procurement in the pharmaceutical and healthcare sectors has marked a notable shift from traditional procurement methods, impacting cost, lead times, and resource allocation in unique ways. this analysis examines these three primary impacts through recent studies and industry examples, highlighting both benefits and challenges associated with the cito model. cito procurement’s impact on costs is complex, as it often involves a trade-off between flexibility and expense. cito typically incurs higher per-unit costs compared to traditional procurement because it relies on expedited sourcing and delivery. these additional expenses arise from premium fees for faster shipping, more dynamic supplier relationships, and pre-negotiated contracts that prioritize speed over cost efficiency. for instance, study found that while cito procurement allowed hospitals to obtain essential medications quickly during shortages, it did so at a higher cost than traditional bulk orders, which typically benefit from economies of scale (faizar et al., 2023). however, these costs can be partially offset by reducing expenses associated with stockouts, which can have direct financial and reputational impacts. additionally, cito’s ability to minimize inventory holding costs—since items are sourced as needed rather than stored in bulk—offers potential savings in storage and capital expenditures. yusiana (2024) noted that while cito incurs higher operational costs, it can ultimately prove more cost-effective in situations where immediate availability of critical items is necessary. in these cases, the higher procurement costs are justified by the benefits of avoiding delays that might impact patient care and outcomes. a significant advantage of cito procurement is its impact on lead times. unlike traditional procurement, which is often subject to long ordering cycles and approval processes, cito is specifically designed to reduce lead times through streamlined sourcing and realtime demand forecasting. cito relies on pre-arranged agreements with suppliers, allowing healthcare providers to obtain essential items almost immediately. this quick turnaround is particularly valuable in healthcare, where delayed access to medications or equipment can have severe consequences on patient health outcomes. kusumaningrum and mulyani (2023) highlighted that cito models enabled hospitals to reduce lead times by up to 50% compared to traditional procurement methods. this reduction was particularly significant during the covid-19 pandemic, where the ability to source ppe, ventilators, and critical medications promptly proved vital to maintaining continuity in patient care. traditional procurement, in contrast, faced notable delays due to global disruptions, exacerbating supply shortages and pa ge 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 1-10, 2025 impacting care quality. studies also show that shorter lead times in cito models translate to more responsive supply chains capable of adapting to sudden spikes in demand. by reducing timeto-delivery, cito not only ensures timely availability of essential items but also enhances an organization’s capacity to manage emergencies and fluctuations in demand more effectively. this advantage is increasingly critical in healthcare, where demand unpredictability is high, and patient needs can change rapidly. implementing cito procurement has implications for resource allocation within organizations, especially in terms of workforce and inventory management. with cito’s emphasis on real-time demand tracking and rapid sourcing, organizations may require investments in technology and specialized personnel trained in agile procurement and supply chain management. the model relies on advanced data analytics and forecasting tools to optimize ordering and reduce the need for manual intervention, thus streamlining workflows but necessitating an initial investment in technology. the adoption of cito can also lead to a shift in how resources are allocated across the supply chain. according to the journal of business logistics (2020), cito models reduce the need for extensive warehousing and stockpiling, as items are procured as needed. this shift reduces inventory holding costs and allows for the reallocation of resources towards areas where rapid response capabilities are essential. however, the study also noted that cito requires greater coordination and oversight to manage multiple supplier relationships effectively, which can place additional demands on procurement staff and resources if not managed properly. despite these challenges, cito’s ability to optimize resource allocation by reducing excess inventory levels and minimizing wastage offers potential long-term benefits. by reallocating resources more effectively, organizations can focus on high-priority items, enhancing their responsiveness to patient needs while reducing the costs and risks associated with stockouts and overstock situations. the impact of cito on cost, lead times, and resource allocation highlights its advantages in critical sectors like healthcare, where flexibility, speed, and precision in sourcing are paramount. while cito’s higher per-unit costs may be a limitation, the reduction in lead times and optimized resource allocation provide clear benefits, particularly when timely access to essential medications is a priority. as supply chains become more complex and demand becomes increasingly unpredictable, cito procurement offers a compelling alternative to traditional methods, balancing agility with operational efficiency. however, to maximize the benefits of cito, organizations may need to invest in advanced analytics, streamlined processes, and workforce training to manage the complexities of this procurement model effectively. implementing cito (critical item time order) procurement in the pharmaceutical industry introduces unique challenges, particularly in areas like regulatory compliance and risk management. given the sector’s highly regulated environment and the need for meticulous oversight to ensure patient safety, adopting cito procurement requires addressing several critical issues. the pharmaceutical industry is among the most regulated globally, with strict requirements to ensure product quality, safety, and efficacy. for cito procurement to be effective in this sector, organizations must navigate complex regulatory frameworks set by agencies like the u.s. fda, european medicines agency (ema), and other international regulatory bodies. these regulations mandate rigorous standards for product approval, traceability, and supplier qualifications, which can be challenging to meet when rapidly sourcing items through cito. a key challenge is ensuring that suppliers comply with good manufacturing practices (gmp) and other standards, as failure to meet these requirements can lead to severe penalties, product recalls, and reputational damage. rapidly engaging new suppliers under cito may compromise the thorough validation processes needed to ensure adherence to these standards. maria and putri (2022) emphasize that while cito’s speed can help address urgent needs, it also increases the risk of regulatory non-compliance if supplier vetting and product quality control are not rigorous. further, traceability and serialization requirements add complexity to cito implementation. as noted by (handayany and basri 2022), the pharmaceutical sector must maintain end-to-end traceability to comply with regulations like the drug supply chain security act (dscsa) in the u.s. and falsified medicines directive (fmd) in the eu. cito’s rapid procurement may challenge these tracking processes, especially when multiple suppliers are involved, making it difficult to maintain accurate records and ensure the authenticity of products throughout the supply chain. risk management is crucial when implementing cito procurement in pharmaceuticals, where product quality and timely delivery can directly impact patient safety. traditional procurement methods allow for longterm supplier relationships and comprehensive quality assurance measures, whereas cito’s quick turnaround times can increase exposure to risks such as counterfeit drugs, supply chain disruptions, and quality control issues. counterfeit and substandard products are a significant risk in rapid procurement environments, especially in times of high demand or crisis. according to trapani et al. (2021), reliance on expedited sourcing may make pharmaceutical companies more vulnerable to fraudulent suppliers and counterfeit products, as the usual due diligence processes might be bypassed to meet urgent demands. the study found that without stringent risk assessment, cito can lead to quality compromises that pose safety risks to patients. furthermore, supply chain disruptions are common in the pharmaceutical industry due to reliance on a pa ge 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 1-10, 2025 global network of suppliers. cito procurement, while fast, may involve sourcing from geographically distant suppliers, increasing exposure to risks from geopolitical issues, natural disasters, or pandemics. rapid supplier onboarding under cito also complicates risk management because new suppliers may not be fully integrated into the organization’s quality control and compliance systems. tahir et al. (2020) suggests that while cito can enhance responsiveness, it requires a comprehensive risk management framework to address these vulnerabilities effectively quality assurance is paramount in pharmaceuticals, as any lapse can have severe implications for patient safety. traditional procurement models allow for in-depth supplier audits and quality inspections, but cito’s rapid sourcing model limits the time available for these processes. the challenge, therefore, is to ensure that new suppliers meet the same quality standards as established partners, which requires a streamlined but robust validation process. faizar et al. (2023) highlights that inadequate supplier validation under cito could lead to sourcing issues, including low-quality or ineffective drugs that do not meet clinical standards. rapid sourcing often bypasses detailed quality checks, which may lead to noncompliance with pharmacovigilance requirements— regulations that mandate monitoring and reporting of product safety issues. implementing cito effectively in this context requires a dual approach that combines speed with stringent quality control to ensure all suppliers meet necessary regulatory standards. in summary, while cito offers advantages in terms of responsiveness and flexibility, it also presents unique challenges in the pharmaceutical industry. ensuring regulatory compliance, managing risks associated with rapid sourcing, and maintaining quality assurance require organizations to adopt new, agile approaches to supply chain management. for successful cito implementation, companies must invest in robust compliance frameworks, enhanced supplier verification systems, and advanced tracking technologies. by addressing these challenges, pharmaceutical companies can harness the benefits of cito without compromising regulatory standards or patient safety. materials and methods this study explores the impact of cito (critical item time order) procurement on pharmaceutical supply chains using a mixed-methods approach, combining both quantitative and qualitative data. data collection includes case studies across developed and developing healthcare markets, where cito procurement’s effects on procurement lead times, cost efficiency, and drug availability are analyzed. by comparing these markets, the study identifies how varying regulatory and resource conditions influence cito’s effectiveness. this dual analysis across diverse healthcare systems provides a comprehensive view of how cito operates under different economic and logistical constraints. the research also includes qualitative insights from interviews with logistics managers at major pharmaceutical firms, providing a deeper understanding of the operational challenges unique to cito. these interviews shed light on complexities such as supplier onboarding, quality control, and compliance with strict industry regulations. logistics managers discuss strategies for balancing the rapid response requirements of cito with rigorous regulatory demands, as well as the impact of cito on supply chain resilience, especially during emergencies like pandemics. these first-hand accounts offer essential context that complements the quantitative findings. ultimately, this mixed-methods approach enables a robust analysis of cito’s advantages and challenges. quantitative data highlights measurable impacts, such as reduced lead times and adjusted cost structures, while qualitative data provides insight into the practical challenges and strategic solutions that logistics managers implement. together, these findings contribute to the growing academic literature on procurement strategies in healthcare, suggesting that cito, with careful regulatory and operational oversight, can improve the availability and timely delivery of critical drugs in both highand low-resource settings. results and discussions findings cito procurement strategies have increasingly shown promise in building resilient and effective partnerships between pharmaceutical companies and their suppliers. cito’s holistic approach considers not only immediate costs but also long-term expenses, encouraging suppliers to invest in aspects like service reliability, adaptability, and risk mitigation across the lifecycle of their contracts. this collaborative focus promotes enhanced supplier performance and accountability, aligning supplier incentives with pharmaceutical companies’ objectives to prevent disruptions and ensure the consistent availability of medications. in pharmaceuticals, where delays can have critical repercussions, cito’s emphasis on lifecycle value can help sustain smoother operations and optimize overall supply chain costs by addressing hidden costs, such as waste from excess inventory or penalties from delayed deliveries. the covid-19 pandemic underscored the importance of adaptable, agile supplier relationships in the face of unprecedented disruptions. with demand surges, material shortages, and logistical bottlenecks, the pharmaceutical industry saw an urgent need forurgently needed rapid, real-time communication and cooperation with suppliers. cito procurement facilitated this by using advanced digital tools for tracking and collaboration. platforms utilizing iot, blockchain, and predictive analytics allowed for real-time visibility into inventory, shipment tracking, and quality control, enabling suppliers and pharmaceutical companies to respond dynamically to changing conditions. pa ge 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 1-10, 2025 this digital integration was essential in managing global sourcing constraints, meeting fluctuating demand, and ensuring compliance with shifting regulatory standards. moreover, cito promotes “triadic” collaborative models, where not only the pharmaceutical company and its supplier but sometimes a third party (such as a logistics provider or regulatory body) engage in coordinated efforts. these triads create a robust ecosystem that supports resilience and continuous improvement through shared goals, especially beneficial in managing upstream activities like r&d and clinical trials, which often involve complex, regulated materials. according to studies, such structures yield stability, operational effectiveness, and sustained quality. the triadic model’s collective accountability framework mitigates common risks like sole-source dependencies and quality discrepancies, making it ideal for handling unexpected crises and regulatory shifts. through its focus on lifecycle costs and collaboration, cito procurement ultimately provides a strategic advantage. pharmaceutical companies can minimize delays, improve product quality, and increase adaptability—benefits that became critical during global health emergencies. by fostering a comprehensive view of cost and value in supplier relationships, cito procurement positions the pharmaceutical industry to better meet both current and future challenges in an everevolving global marketplace. pharmaceutical companies that adopt cito procurement practices benefit from a more resilient supply chain, largely due to its comprehensive focus on lifecycle cost management and long-term supplier reliability. this model enhances resilience by enabling companies to anticipate and manage risks through proactive strategies rather than reactive responses. by prioritizing secure, dependable supply sources over short-term savings, cito empowers companies to engage in advanced planning and carefully prioritize essential drug supplies, which is critical in avoiding costly stockouts that could otherwise impact patient access to necessary medications. one of the key benefits of cito procurement is its emphasis on diversified sourcing and optimized inventory management, which significantly reduces the risks associated with single-source dependencies. traditionally, reliance on sole suppliers has left pharmaceutical companies vulnerable to supply chain interruptions due to disruptions affecting a single entity. by diversifying their supply base, companies can better withstand unforeseen challenges such as raw material shortages or shifts in regulatory requirements. this ability to diversify effectively mitigates risks associated with external shocks, such as sudden demand surges during crises or regulatory shifts that could impact certain suppliers’ ability to deliver. in addition to resilience, cito procurement supports the formation of more robust partnerships with suppliers, often based on shared goals of quality, consistency, and long-term collaboration. these long-term relationships enable both the pharmaceutical company and its suppliers to align their strategic objectives, creating a cooperative environment that enhances responsiveness to market changes. for instance, during the covid-19 pandemic, pharmaceutical companies that had implemented cito procurement were better positioned to manage demand spikes for certain drugs due to their established, flexible supply base and collaborative supplier relationships. suppliers, under cito contracts, are often incentivized to maintain high-quality standards and reliability, further strengthening the entire supply chain. in a rapidly changing regulatory landscape, cito procurement also facilitates compliance and quality assurance. by establishing secure and stable supplier networks with reliable, compliant partners, companies are more capable of meeting the stringent regulations that govern pharmaceutical supply chains globally. this proactive approach to procurement enables pharmaceutical companies to achieve both operational stability and agility, making it possible to meet critical demands even in challenging environments. cito procurement offers pharmaceutical firms a strategic advantage in managing procurement costs by emphasizing total ownership costs over direct purchase prices. by evaluating lifecycle costs—spanning sourcing, warehousing, quality control, and distribution—this approach enables firms to capture the true cost of procurement. this holistic model allows for smarter, more efficient cost management, even when securing high-quality raw materials and components that meet the rigorous standards of pharmaceutical production. rather than emphasizing short-term cost reductions, cito’s life-cycle perspective enables pharmaceutical companies to assess all costs associated with a supplier over the duration of a contract, including indirect expenses like logistics, quality management, and compliance with regulatory requirements. this broader perspective allows for better planning and cost control by considering the total financial implications of procurement decisions. for example, purchasing higher-quality materials upfront may reduce the need for quality control and rework later, lowering overall costs and improving production efficiency. this approach also aligns well with the quality standards required in pharmaceuticals, as companies must consistently deliver safe, effective medications. another advantage of cito procurement is its demandoriented inventory model, which aligns inventory levels with market demand to avoid costly excesses and reduce waste. by forecasting demand with greater precision, companies can manage inventory more dynamically, minimizing the holding costs and potential waste associated with overproduction. for example, during fluctuations in demand—such as seasonal increases in vaccine requirements or sudden surges during public health crises—cito’s demand-oriented model ensures that firms maintain optimal stock levels, reducing waste from expired inventory and enabling faster responses to changes in demand. additionally, the cost efficiencies realized through cito pa ge 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 1-10, 2025 procurement free up resources for strategic investments in innovation, drug development, and specialized supply chains. for pharmaceutical firms, these savings are essential as they enable reinvestment into r&d initiatives that drive growth and maintain competitive advantage. by optimizing cost structures, firms can allocate more capital toward high-impact areas, including the development of advanced medications, biologics, or targeted therapies. this reinvestment also enables companies to develop more specialized supply chains tailored to diverse product types—such as temperature-controlled logistics for biologics or specialized packaging for high-value medications—allowing them to maintain high standards across a broad product range and respond to varying regulatory requirements. in sum, cito procurement not only supports cost reduction and operational efficiency but also aligns with long-term strategic goals, offering pharmaceutical firms the flexibility to balance cost control with the need for high quality and responsiveness to market demand. cito procurement strategies play a critical role in enabling pharmaceutical companies to meet the stringent regulatory demands required for global compliance with quality and safety standards. unlike traditional procurement models focused primarily on reducing purchase prices, cito considers the entire lifecycle of costs, quality, and compliance. this approach ensures that suppliers are selected and managed with an eye on consistent adherence to good manufacturing practices (gmp) and good distribution practices (gdp), which are essential for maintaining product integrity across storage, transportation, and final delivery to patients. compliance with these practices is especially important for pharmaceutical companies, as it minimizes risks of contamination, ensures temperature control where needed, and maintains product traceability, all of which are critical under regulations set by entities like the fda in the united states, ema in europe, and other national health authorities globally. one significant advantage of cito procurement in this context is its capacity to streamline documentation and compliance tracking. in the heavily regulated pharmaceutical sector, regulatory bodies require detailed records that demonstrate a consistent history of compliance with quality standards. cito’s emphasis on transparency and long-term partnership with suppliers enhances documentation by fostering data-sharing agreements, automated compliance reporting, and realtime tracking capabilities, typically through advanced digital platforms like blockchain and iot solutions. these technologies not only ensure traceability from raw materials to finished products but also support rapid, efficient audits by regulatory agencies. this streamlined data collection strengthens trust with regulatory bodies, enabling a smoother approval process across multiple regions by providing robust, easily accessible compliance documentation. furthermore, cito’s comprehensive cost and quality focus also mitigates the risk of supply chain disruptions due to regulatory non-compliance, which can lead to costly recalls, production stoppages, or even bans on sales in certain markets. by ensuring that suppliers maintain rigorous quality control and regulatory alignment, cito procurement helps companies preemptively address compliance issues. for instance, implementing serialization standards to prevent counterfeiting or meeting pharmacovigilance requirements to monitor and report adverse events postmarket are now common compliance challenges. through cito’s structured approach to lifecycle management, these requirements are more efficiently integrated into the supply chain, reducing compliance risks and improving overall operational stability. beyond risk mitigation, the cito model’s support for regulatory compliance aligns well with pharmaceutical companies’ long-term objectives. by building a solid reputation for compliance, companies are able to expand their reach into multiple markets, including emerging ones where adherence to international standards is increasingly required. this reputation can enhance competitive positioning, facilitating not only faster market entry but also cost efficiencies related to reduced regulatory delays and fewer legal risks. as a result, the compliance benefits of cito allow companies to allocate more resources to innovation and high-impact r&d activities that are central to advancing pharmaceutical development. thus, cito procurement not only ensures a resilient, compliant supply chain but also frees up capital for innovation, which is essential for sustainable growth in the pharmaceutical sector. overall, by focusing on total cost, quality, and compliance from a lifecycle perspective, cito procurement strategies help pharmaceutical firms navigate the complex regulatory landscape with greater agility and assurance. this approach is integral to maintaining high standards across a global supply network, meeting the stringent demands of national and international regulatory bodies, and building trust in the safety and efficacy of the pharmaceutical supply chain. the findings highlight that cito procurement represents a significant evolution in pharmaceutical supply chain management, offering a more integrated, strategic, and risk-averse approach. by emphasizing longterm collaboration between pharmaceutical companies and their suppliers, cito fosters adaptability and resilience in the face of both routine operations and crisis situations. for example, during the covid-19 pandemic, pharmaceutical firms that had already implemented cito procurement practices were better equipped to respond to the sharp surge in demand for critical drugs like vaccines and antiviral medications. companies leveraging cito’s strategic foresight were able to quickly adjust procurement strategies, ensure stock availability, and navigate supply disruptions. this demonstrates how cito procurement plays a crucial role in ensuring that pharmaceutical companies are not only prepared for dayto-day operations but also equipped to handle unforeseen pa ge 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 1-10, 2025 supply chain shocks. in addition, cito procurement supports the broader trend of digital transformation within the pharmaceutical industry, enhancing its ability to respond to complex and dynamic market conditions. technologies like advanced analytics, predictive modeling, and real-time data sharing provide pharmaceutical companies with the tools to proactively manage their supply chains. predictive models can identify potential disruptions or supply gaps before they occur, allowing companies to adjust procurement strategies and mitigate risks such as stockouts or delays. for instance, leveraging the internet of things (iot) to track shipments in real time can offer visibility into product conditions and delivery schedules, ensuring that drugs are delivered on time and under the right conditions. similarly, blockchain technology can help ensure product traceability and combat counterfeiting, offering added security and compliance in an increasingly complex regulatory landscape. the flexibility of cito procurement also enables pharmaceutical firms to tailor their supply chains to different product categories, optimizing processes for both high-complexity, high-margin products and more standardized, low-cost medications. for example, biologic drugs, which require specialized temperature-controlled environments throughout their supply chains, benefit from cito’s focus on end-to-end collaboration with suppliers. on the other hand, generic drugs can be managed with more cost-efficient models without compromising the quality or timeliness of delivery. this adaptability ensures that a company can meet the needs of diverse product lines while maintaining cost efficiency, regulatory compliance, and high standards of patient care. however, implementing cito procurement within the pharmaceutical sector does come with challenges, primarily due to the complexity of the industry’s regulatory environment. complying with national and international standards such as good manufacturing practices (gmp) and good distribution practices (gdp) requires careful coordination and robust documentation processes. furthermore, the upfront investment needed for digital transformation—such as implementing advanced technologies, retraining staff, and enhancing data infrastructure—can be substantial. despite these challenges, the long-term benefits of cito procurement far outweigh the initial costs. these benefits include enhanced operational efficiency, better risk management, stronger supplier relationships, and ultimately, improved patient access to medicines. companies that invest in cito procurement can achieve sustained competitive advantages by becoming more agile, compliant, and cost-efficient. in conclusion, cito procurement offers a comprehensive framework that not only addresses current challenges in the pharmaceutical supply chain but also positions companies for long-term success. by fostering deeper supplier collaboration, enabling digital transformation, and enhancing resilience, cito procurement helps pharmaceutical firms navigate an increasingly complex and fast-evolving landscape. this approach ultimately leads to improved operational efficiency, enhanced regulatory compliance, and more timely access to essential medications, which benefits both pharmaceutical companies and the patients they serve. conclusion the primary findings of this study indicate that cito procurement has significant potential to enhance the efficiency of pharmaceutical supply chains, particularly in terms of cost reduction, lead time optimization, and improved resource allocation. through direct comparison with traditional procurement methods, cito has been shown to shorten procurement cycles, reducing the risk of stockouts for critical medications by improving responsiveness in high-demand or emergency situations. these improvements are increasingly vital in the face of global supply chain challenges that have intensified since the covid-19 pandemic. furthermore, cito’s focus on real-time data and agile supplier relationships helps mitigate risks related to sudden demand shifts and supply interruptions, providing a level of flexibility that traditional procurement methods often lack. one of the key benefits of cito in healthcare is its capability to manage complex regulatory requirements more dynamically. the pharmaceutical industry faces strict compliance mandates that can delay traditional procurement timelines; however, cito’s ability to streamline processes and improve supplier collaboration supports compliance without compromising delivery speed. digital innovations like iot-enabled tracking and data analytics enhance transparency and reduce delays associated with regulatory compliance, making cito a more resilient approach for meeting the healthcare sector’s urgent needs. future research should explore the long-term implications of cito on pharmaceutical cost structures and patient outcomes. additional studies on how cito can support sustainability in procurement—by optimizing inventory and reducing waste—would add valuable insights. given the increasing focus on supply chain resilience, investigating the role of cito in predictive analytics and ai could also be beneficial for preparing for potential disruptions in the global pharmaceutical supply chain. this direction aligns with recent calls in the industry to integrate more advanced technologies and strategies for agile, secure, and sustainable supply chains. cito procurement plays a crucial role in ensuring that life-saving medications reach patients in a timely manner. despite the increased costs associated with this approach, the improved patient outcomes highlight its value in critical care scenarios. future research should focus on developing cost-effective cito strategies and exploring the potential of ai-driven forecasting to predict demand spikes, thereby enabling more efficient procurement decisions. references abbas, k., afaq, m., khan, t. a., & song, w. c. 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(2024). literature review: analysis of logistics inventory management in pharmacy services. paraplu journal, 1(1), 8–21. pa ge 1 pa ge 26 american journal of medical science and innovation (ajmsi) prevalence of joint pain is higher among housewives of urban than rural housewives in bangladesh md. omar sharif ahmmed chowdhury1*, supranto sutra dhar2, mithun sikder3, arafath hossain4, most. rumpa khatun4 volume 2 issue 1, year 2023 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: january 26, 2023 accepted: march 06, 2023 published: march 09, 2023 activities, environment, work style, living standards of housewives in bangladesh vary from place to place. housewives face many musculoskeletal problems related to housework and quality of life. hence the aim of our investigation is to investigate the prevalence of joint pain among rural and urban housewives of bangladesh. an attempt was made to compare joint pain in urban and rural housewives. a sample was selected to assess and comparison of joint pain prevalence among 400 unemployed urban and rural housewives aged 25–60 years in bangladesh. regression analysis was performed on their socio-economic and joint pain information through interviews with questionnaires. data analysis shows that urban housewives have relatively higher prevalence of joint pain than rural housewives and it is 70.5% and 58.5% respectively. odds ratio (or) and 95% confidence interval (ci) comparing joint pain in bangladeshi housewives adjusted for age and bmi showed that the prevalence of knee and low back pain was highest and was associated with age and bmi. this study showed that joint pain was significantly higher in urban housewives compared to rural housewives. bangladeshi housewives suffer from knee and lower back pain the most. their joint pain prevalence is increases with age and bmi. joint pain in housewives may be related to obesity, occupational differences and environmental factors. in addition to daily household work, urban housewives can perform some simple physical exercise regularly, which can improve their mobility and strength as well as reduce the rate of obesity. keywords bangladesh, prevalence, joint pain, urban and rural housewives, different lifestyle 1 administration department, walton group, dhaka, bangladesh 2 department of physiotherapy, mymensingh college of physiotherapy and health sciences, mymensingh, bangladesh 3 riand bangladesh neuro hospital, mirpur, dhaka, bangladesh 4 gono bishwabidyalay, savar, dhaka, bangladesh * corresponding author’s e-mail: omotayolydiamojisola@gmail.com introduction joint pains are more usually among the senior citizen, which is lead to movement difficulty, loss of quality of life, and enhancement health care costs. (kiyoshi et al., 1999) joint pain can be perceived in several parts of the body. mobility problems are mass common physical problems of the elderly. many elderly person suffer from many health related issues and complexity due to prolonged inactivity such as musculoskeletal pain, bony and postural deformities and adl problems. (chowdhury et al., 2021) a previous study investigating men and women found that women had a higher prevalence of musculoskeletal pain than men. (bihari et al., 2011) a previous worldwide research exhibited that female are physically more deactivate than male in bangladesh as in m several countries, for which the possibility of contracting many non-communicable diseases increases. (who, 2018) joint pain are discommodity, pain or inflammation that originates from any portion of the joint-such as bone, tendons or muscles, cartilage and ligaments. but joint pain generally refers to include clinical syndromes such as inflammation, osteoarthritis or degenerative disorders, nerve compression conditions and, as well as low well standard disorders like as myalgia, other body area pain and low back pain are not responsible to pathology. body areas usually involved are the neck, low back, upper limb (shoulder, forearm, and wrist) though at present the lower extremity has obtained more attention. (punnett & wegman., 2004) various factors influence women’s health are lack of coordination of work of men, women and family, considering the role of the leadership of the household as well as women’s service as a minor role, patriarchal society etc. interest has been expressed in conducting research in many countries to identify symptoms of joint pain and to identify its relationship with occupational factors. (tinubu et al., 2010) it is trustify that employment is one of the major effective factors on housewives quality of life, (farlinger s., 1996) the main point being that women’s empowerment is directly related to a woman’s educational status and her job and thus is expected to affect her quality of life. (harriet and sen., 2000) housewives are often responsible for works like as sweeping, cleaning the garbage, cleaning bathrooms and toilets, cooking, cleaning door and windows, washing clothes and beds, and taking care of the needs of the entire family, which can be associated with various physical contact stresses and result in joint pain. (kalra1 & bhatnagar., 2017) a prior research showed that the prevalence of joint pain is higher in women than in men. elderly male suffer from ms pain less often than normal and aged women. the prevalence of pain in women in quebec, canada and ontario, usa was reported to be 50%, 65% and 79%, respectively. (fazli b et al., 2016) there had been several studies on the prevalence of joint pain in specific groups and populations, (andersson et al., 1999) but comparatively small number of comparisons between populations. (hameed and gibson., 1997) if clear variety in the prevalence of joint pain symptoms among the populations can be shown, this may assistance guide https://journals.e-palli.com/home/index.php/ajmsi mailto:omotayolydiamojisola%40gmail.com?subject= pa ge 27 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 to investigate of significant etiological factors. in this investigation, we compared the proportion of specific joint pain among bangladeshi housewives in a rural district of bangladesh with that of urban/city women in bangladesh, adjusted for age and body mass index. operational definitions joint pain participants were illustrated with a basic diagram of the human skeleton (a stick person) and were asked for each joint ‘do you regularly suffer from any swelling, pain or stiffness?’. data is collect on the neck, back, and separately for the both sides of the body for shoulders, elbows, wrists, hand/fingers, hips, knees, ankle, and feet/toes. joint pain was assessed as a problem with respondents recording whether they had or had previously had mild, moderate or severe pain in any joint. literature review aoyagi k et al. (2020) conducts a study in hawaii, japan to find out that joint pain prevalence is higher in rural japanese housewives than in urban japaneseamerican housewives. social factors such as agricultural performance to the range of joint symptoms. the aim of their study was to explore joint pain prevalence and the probable role of the environment in japanese urban and rural housewives of hawaii. they surveyed 222 rural housewives and 638 urban housewives aged 60-79 to explore pain in specific joints. their results showed that 70% of japanese and 50% of hawaiian housewives had one or more joint pain. among the joints, 36% of japanese housewives aged 60-69 and 53% of housewives aged 70-79 had knee pain, whereas in hawaii knee pain affected only 20% of housewives of both age groups. the odds ratios (and 95% ci) for knee pain in hawaii compared with japan were 4.0 (2.2, 7.4) and 3.2 (2.1, 4.8). ankle, elbow, and shoulder pain were abnormally high in japan compared to hawaii. in 2015, this year to propulsion a study in india to find out the outbreak of pain in the lower back of nonworking rural housewives. living, working, and social traditions differ significantly between housewives in urban and rural areas, so it is impossible to generalize between rural and urban housewives. therefore, the objective of their study was to investigate the outbreak of lower back pain among rural-unemployed housewives. the researchers took a population of 301 non-working rural housewives between the ages of 30-70 in kanpur. they observed and interviewed all housewives about low back pain, disability, and musculoskeletal discomfort, using the hindi version of the nordic musculoskeletal scale questionnaire. their study showed lbp prevalence in 83% of rural housewives and more than 50% of these women had severe disabilities. back pain in housewives has been shown to have a social burden associated with their disability. materials and methods study design and participants in this cross-sectional study, participants were housewives living in rural and urban bangladesh. data was collected from 400 participants (200 urban and 200 rural housewives) aged 25 to 60 years in rural and urban bangladesh who were apparently healthy, mobile housewives. regarding the specific eligibility criteria for participants in this investigation, we included housewives aged 25 to 60 years and currently living in rural and urban bangladesh, and we excluded men as well as unmarried and pregnant women. all data collected from august 2022 to december 2022. data measurements a face-to-face interview was conducted while collecting data for this study and adequate precautions against covid-19 were taken. the questionnaire was first developed in english and later translated into bengali. however, the local language was used to communicate with the respondents. then an orientation was organized among the collectors along with field tests and finally data was collected through door to door questionnaires from the housewives. the project was organized in dhanmondi, mirpur, uttara, shyamoli, mohammadpur, newmarket, kalyanpur areas of dhaka city, bangladesh and rural areas of cox’s bazar, charfashion, feni, pabna, gaibandha and dinajpur districts of bangladesh. we collected data from them with their permission. the survey asked subjects, using only bengali words, “have you had pain, swelling, pain, or tenderness in your joints most days for at least a month (currently or in the past)?”. 1 response box on each sides of the body (yes and no) for each joint (shoulder, elbow, wrist, hand/finger, neck, upper back, middle, lower back, hip, knee, ankle and foot). we measured housewives’ weight and height without shoes in light clothing. weight (kg)/height (m)2 was measured and then converted to body mass index (bmi). statistical analysis investigators were used t test to evaluation statistical importance when comparing the characteristics of subjects between urban and rural bangladeshi areas. the χ2 test was used to evaluate between-group differences for categorical variables. all answer sheets were checked for exactness, completeness and internal consistency. inconsistent data is discarded. accurate data were entered into spss version 23 for analysis. logistic regression was used to evaluate the prevalence of specific joint pain in two populations, age and bmi (both as continuous variables), with interaction tests. qualitative data were used for thematic content analysis. analyzes were limited to 200 urban bangladeshi housewives and 200 rural housewives aged 25 to 60 years, to provide a comparable age range for both populations. https://journals.e-palli.com/home/index.php/ajmsi pa ge 28 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 results characteristic of respondents table 1 showing the characteristics of urban and rural participants in bangladesh. the mean age and height of urban and rural housewives were similar but the mean weight of urban housewives was five kg higher than rural and bmi was significantly higher than that of rural housewives (p<0.05) prevalence of joint pain the prevalence of one or more joint pain was approximately 70.5% in urban and 58.5% in rural housewives. all other joint pains except elbow, upper back and ankle joint pain were discover to be significantly different in bangladeshi housewives. shoulder, wrist and hand pain in rural women was twice or more than that of urban women and on the other hand urban women table 1: age, bmi characteristic of the respondents in urban bangladesh in rural bangladesh characteristic range median range median age (years) 25 – 60 45 25 – 60 44.50 height (cm) 153 – 165 158 147 – 165 158 weight (kg) 48 – 86 60 40 – 85 55 body mass index (kg/m2) 18.3 – 33.3 24.25 16 – 35.4 22.2 had significantly more neck, mid back, lower back, hip, knee and foot joint pain than rural women, which was significantly higher in the 43–60 age group than in the 25–42 year group (table 2) low back pain was the most common places of joint pain in each urban and rural women in bangladesh, affecting at least 25% of women in both populations. other common locations of joint pain in both urban and rural bangladeshi table 2: frequency (%) of housewives with joint pain in rural and urban housewives in bangladesh in urban bangladesh in rural bangladesh age group (y) 25 42 43 – 60 total 25 – 42 43 – 60 total number of participants 76 124 200 96 104 200 any joint pain 49 (64.5) 92 (74.2) 141 (70.5) 41 (42.7) 78 (75.0) 117 (58.5) shoulder 4 (5.3) 13 (10.5) 17 (8.5) 12 (12.5) 22 (21.2) 34 (17.0) elbow 4 (5.3) 6 (4.8) 10 (5.0) 5 (5.2) 6 (5.8) 11 (5.5) wrist 1 (1.3) 4 (3.2) 5 (2.5) 4 (4.2) 10 (9.6) 14 (7.0) hand 3 (3.9) 2 (0.8) 4 (2.0) 6 (6.3) 7 (6.7) 13 (6.5) neck 6 (7.9) 21 (16.9) 27 (13.5) 6 (6.3) 8 (7.8) 14 (7.0) upper back 1 (1.3) 6 (4.8) 7 (3.5) 4 (4.2) 4 (3.8) 8 (4.0) mid-back 8 (10.5) 15 (12.1) 23 (11.5) 6 (6.3) 6 (5.8) 12 (6.0) low back 25 (32.9) 44 (35.5) 69 (34.5) 16 (16.7) 35 (33.7) 51 (25.5) hip 11 (14.5) 6 (4.8) 17 (8.5) 1 (1.0) 6 (5.8) 7 (3.5) knee 11 (14.5) 28 (22.6) 39 (19.5) 4 (4.2) 19 (18.3) 23 (11.5) ankle 3 (3.9) 3 (2.4) 6 (3.0) 3 (3.1) 5 (4.8) 8 (4.0) foot 8 (10.5) 9 (7.3) 17 (8.5) 2 (2.0) 4 (3.8) 6 (3.0) women were shoulder, neck and knee pain, affecting around 10% of women in both populations. bangladeshi city women were twofold as likely to have back, hip and foot pain as rural women, but the shoulder, hand and wrist pain prevalence was significantly higher in rural women. the prevalence of joint pain increased with age; for example, neck pain in urban women increased from 8% between 25-42 years to 17% between 43-60 years, and knee pain from 14.5% between 25-42 years and 22.6% between 43-60 years (for all ages combined 19 .5%). again, shoulder table 3: odds ratios (95% confidence intervals) of joint pain comparing women in urban bangladesh with women in rural bangladesh age adjusted bmi adjusted any joint pain 1.064 (1.039, 1.090) 1.229 (1.140, 1.326) shoulder 1.038 (1.005, 1.071) 0.978 (.895, 1.068) elbow 1.035 (.987, 1.085) 1.004 (.883, 1.143) wrist 1.039 (.988, 1.092) 0.994 (.866, 1.140) hand 0.999 (.952, 1.048) 0.878 (.750, 1.028) https://journals.e-palli.com/home/index.php/ajmsi pa ge 29 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 pain in rural women ranged from 12.5% between 25-42 years to 21.2% between 43-60 years and lbp ranged from 16.7% between 25-42 years to 33.7% between 43-60 years (crude prevalence of 25.5% for all ages combined). the prevalence of hip and foot pain did not vary consistently between age groups in urban communities with higher prevalence in younger age groups ranging from 14.5% to 4.8% and 10.5% to 7.3%, respectively. comparison of joint pain between urban bangladeshi and rural bangladeshi women the odds ratio (or) and 95% confidence interval (ci) comparing joint pain in bangladeshi housewives adjusted for age and bmi are shown in table 3. the age adjusted or for knee pain was 1.075, and bmi was 1.331 and age adjusted or for lower back pain was 1.030, and bmi was 1.060. bmi-adjusted prevalence of cervical, hip and feet pain was lower in rural than urban women (bmi aor = 1.070, 1.273 and 1.086 respectively) moreover, ageadjusted prevalence of shoulder, wrist and upper back pain was richer in rural than in urban women (age-adjusted or = 1.038, 1.039 and 1.070, respectively). the prevalence of lower back and knee joint pain was common in urban and rural women compared to other joints. shoulder, elbow, and wrist pain were more common in rural than urban areas, but mid-back, hip, and foot joint pain were more common in urban than rural areas. discussion comparing urban and rural populations among country residents by birth can help identify factors accountable for assessed distinctions in disease by receiving benefits of increased variability in social and environmental factors. (harriet and sen presser, 2000) finding that pain frequency distinctions are limited to specific joints advices potential advantages to find etiological factors. prior research have shown that mental factors (include factor connected to job services) are related with joint pain outcomes. (bongers et al., 1993) our investigation excludes employed housewives, hence information on employment of housewives is not available. however, rural areas of bangladesh are primarily agricultural, whereas dhaka is an urban/municipal area. in rural areas, many housewives have to be attached to housework, livestock rearing and agriculture, whereas housewives in dhaka city have improved living conditions compared to villages, so their housework is much easier and they can spend enough free time. thus, the differences in joint pain frequencies reported here may be partially attributable to work differences such as current work inactivity, work style, sedentary lifestyle, work length, or psychosocial factors. cultural distinctions another than work may also inhibit the tendency to report symptoms and can partially account for the observed variation in joint pain prevalence. differences in social disadvantage between city and rural bangladesh may partially demonstrate variation in reported joint pain rather than distinction in diseases such as fractures or degenerative disease. however, such a bias would be identical to the observed differences in joints for both urban and rural areas, so such cultural attributer are possibly not significant in this case. in this investigation, we used logistic regression for prevalence of certain joints pain in between urban and rural housewives to compare, adjusting for age and bmi. adjustment effect of bmi on association of joint pain among housewives in dhaka city. those with a higher bmi had a higher prevalence of joint pain. however joint pain was related with bmi in our research, and obesity is one of the risk factors for knee and other joint pain in housewives, (aro and leino., 1985) obesity is slightly more likely than other (as yet unknown) risk factors to explain the difference in joint pain prevalence between urban and rural women in bangladesh seems important. logistic regression evaluated the efficiency to control of age differences for any potential confounders. we found some evidence in our investigations that the prevalence of joint pain enhancement with age in urban and rural bangladesh, as previously found, and these may influence the estimated proportion of knee pain and other joint prevalence. in logistic regression, adjustment for age of housewives suggests that the relation between age and joint pain is same for both rural and urban women. to compare these data, the reciter may also compare the particular age prevalence rate given in table 2, which estimates are unaffected by the logistic regression. conclusions the findings of this study investigated the prevalence of joint pain among housewives in dhaka city and rural areas in bangladesh. in summary, this study showed that the important difference between housewives aged 25-60 years was that urban housewives had significantly higher prevalence of joint pain than rural housewives. bangladeshi neck 1.043 (1.006, 1.081) 1.070 (.976, 1.173) upper back 1.070 (1.007, 1.138) 0.979 (.837, 1.144) mid-back 1.012 (.976, 1.049) 1.060 (.961, 1.169) low back 1.030 (1.007, 1.054) 1.060 (.995, 1.129) hip 0.992 (.950, 1.036) 1.273 (1.135, 1.428) knee 1.075 (1.039, 1.112) 1.331 (1.215, 1.459) ankle 0.979 (.927, 1.034) 1.158 (1.003, 1.337) foot 1.002 (.959, 1.046) 1.086 (.966, 1.220) https://journals.e-palli.com/home/index.php/ajmsi pa ge 30 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 housewives are most prone to knee and lower back pain. neck, middle back, hip and foot pain were significantly higher among urban housewives than rural housewives respectively and correlated with bmi. on the other hand, shoulder, wrist and hand pain was relatively higher among rural housewives than urban housewives. joint pain was more likely to increase with increasing age and bmi. joint pain may be related to obesity, environmental factors and occupational differences. in addition to housework, general urban housewives can do some physical exercise, which can increase their lateral mobility and reduce the obesity rate. limitation of the study limitations of the study several limitations are present in our study. our research had financial limitations as there was no funding. so our study was organized among only 400 people in remote areas of bangladesh. we conduct physical examinations and preliminaries we detected joint pain by radiographs, radiographs were not available to evaluate degenerative changes, arthritis or fractures. as the study was a cross-sectional method, we cannot prove whether there was any difference between body weight, disability and size at the onset of joint pain. potential differences in joint pain between urban and rural housewives in bangladesh are a potential source of bias. ethical approval the motive and goals toward with its benefits, risks and procedure was explained in the research to the respondents in easily. information was accepted from every respondents by use perceive native language. the researcher first introduced himself with respondents. then the researchers was give them the assurance this facts of the responders will be usage just for the research purpose. the researchers tell them that their name will be hidden secret. all kind of privacy is confirmed and any resections from the respondent are first priority. they also told this information will only use for benefit of physiotherapy profession and the improve health with decrease hazard. declaration of competing interest the authors have no competing interests to declare. funding this research did not receive any specific grant from funding agencies in the public, commercial or not-for profit sectors. acknowledgement special thanks to almighty allah for give us a great opportunities to complete our research. we sincerely respect the respondents for participating in this study. we deeply respect our household members for inspiring our survey. author contributions corresponding author: conceived and designed the paper; analyzed and interpreted the data; contributed materials, analysis tools, or data; and wrote the paper. all co-authors: performed experiments, collected and analysis the data. data access, responsibility, and analysis corresponding author had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. references aoyagi, k., ross, p. d., huang, c., wasnich, r. d., hayashi, t., & takemoto, t. i. (1999). prevalence of joint pain is higher among women in rural japan than urban japanese-american women in hawaii. annals of the rheumatic diseases, 58(5), 315-319. http://dx.doi. org/10.1136/ard.58.5.315 andersson, h. i., ejlertsson, g., leden, i., & rosenberg, c. (1993). chronic pain in a geographically defined general population: studies of differences in age, gender, social class, and pain localization. the clinical journal of pain, 9(3), http://doi.org/174-182. 10.1080/028134399750002700 aro, s., & leino, p. (1985). overweight and musculoskeletal morbidity: a ten-year follow-up. international journal of obesity, 9(4), 267-275. bongers, p. m., de winter, c. r., kompier, m. a., & hildebrandt, v. h. (1993). psychosocial factors at work and musculoskeletal disease. scandinavian journal of work, environment & health, 297-312. http://doi. org/10.5271/sjweh.1470 bihari, v., kesavachandran, c., pangtey, b. s., srivastava, a. k., & mathur, n. (2011). musculoskeletal pain and its associated risk factors in residents of national capital region. indian journal of occupational and environmental medicine, 15(2), 59. http://doi.org/10.4103/00195278.90375 chowdhury mosa, khatun r, and pervin s., (2021). prevalence of activity with mobility disabilities among senior citizens in a selected old home. eur. j. med. health sci., 3(5), 88-102. https://doi.org/10.34104/ ejmhs.021.0880102 farlinger s. (1996). quality of life for women. quality of life for women | springerlink. soc indicators res, 39, 109–119. fazli, b., ansari, h., noorani, m., jafari, s. m., sharifpoor, z., & ansari, s. (2016). the prevalence of musculoskeletal disorders and its predictors among iranians’ housewives. epidemiology and health system journal, 3(1), 53-62. gupta, g., & nandini, n. (2015). prevalence of low back pain in non working rural housewives of kanpur, india. int j occup med environ health, 28(2), 313-20. https://doi.org/10.13075/ijomeh.1896.00299 harriet b, sen presser g. (2000). women’s empowerment and demographic processes. new york: oxford university press; women’s empowerment and demographic processes harriet b. presser; gita sen oxford university press (oup.com) hameed, k., & gibson, t. (1997). a comparison of the prevalence of rheumatoid arthritis and other https://journals.e-palli.com/home/index.php/ajmsi pa ge 31 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 rheumatic diseases amongst pakistanis living in england and pakistan. rheumatology, 36(7), 781-785. http://doi.org/10.1093/rheumatology/36.7.781 kalra, s., & bhatnagar, b. (2017). prevalence of musculoskeletal disorder among housewives. international research journal of engineering and technology (irjet) e-issn, 2395-0056. kagan, a., harris, b. r., winkelstein jr, w., johnson, k. g., kato, h., syme, s. l., ... & tillotson, j. (1973). epidemiologic studies of coronary heart disease and stroke in japanese men living in japan, hawaii, and california: demographic, physical, dietary, and biochemical characteristics. journal of chronic diseases, 27. 345–64. http://doi.org/10.1093/oxfordjournals. aje.a112188 laura punnett, david h wegman (2004). work-related musculoskeletal disorders: the epidemiologic evidence and the debate. j electromyogr kinesiol, 14(1), 13-23. http://doi.org/10.1016/j.jelekin.2003.09.015 tinubu bm, mbada ce, oyeyemi al, fabunmi aa. work-related musculoskeletal disorders among nurses in ibadan, south-west nigeria: a crosssectional survey. bmc musculoskeletal disorders, 11(1), 12. http;// doi.org/10.1186/1471-2474-11-12 world health organization (who), 2018. available on: who bangladesh | world health organization https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 14 1 american journal of medical science and innovation (ajmsi) serum levels of thyroid hormones in infertile and fertile women attending a tertiary care hospital in north-central nigeria: a comparative reproductive medicine study halima inya aliu-ayo1, kikelomo temilola adesina2, abiodun akanbi gafar jimoh2, aloysius obinna ikwuka3* francis chigozie udeh3, sikiru abayomi biliaminu4, olayinka waheed ayo5 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2044 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 28, 2023 accepted: september 30, 2023 published: october 14, 2023 thyroid hormones have profound effects on reproduction. normal thyroid function is necessary to maintain reproductive physiology, but its functional abnormalities may cause infertility manifesting as menstrual cycle irregularities. aim of this research was to determine the serum levels of thyroid hormones in infertile and fertile women attending a tertiary care hospital in north-central nigeria. this comparative, reproductive medicine, cross-sectional study was carried out among one hundred and six (106) women attending the gynecology clinic of the department of obstetrics and gynecology and the family planning clinic of a tertiary care hospital in north-central nigeria. women with a history suggestive of either primary or secondary infertility and the control women with no history of infertility were evenly grouped. venous blood samples were collected and analyzed using enzymelinked immunosorbent assay (elisa) technique to determine ft3, ft4 and tsh levels. data obtained were entered and analyzed using statistical package for social sciences (spss) version 23, and the level of statistical significance was set at p<0.05 and at a confidence interval of 95% for all inferential statistics. majority (90.6%) of the 106 participants were euthyroid. however, most of the thyroid disorders (80%) were noticed in the infertile women, as 15.1% of them had one form of thyroid disorder. the mean tsh, ft3 and ft4 levels were higher in the infertile patients than in the control group, but the values were still within normal reference range. mean values of tsh, ft3 and ft4 for the patients and controls were 1.35±1.65 versus 0.85±1.08 miu/ml, 2.79±1.51 versus 2.19±1.15 pg/ ml, and 1.15±0.33 versus 0.99 ± 0.29 ng/dl respectively. median for tsh, ft3 and ft4 in the patients and controls were as follows: 0.80 (0.40–1.55) versus 0.60 (0.40-0.85) miu/ ml, 2.40 (1.45-4.20) versus 1.70 (1.35-2.95) pg/ml, and 1.10 (1.00-1.30) versus 1.00 (0.90 1.10) ng/dl respectively. the differences in the median between the patients and controls were statistically significant for ft3 and ft4 with p-values of 0.031 and 0.002 respectively. subclinical hypothyroidism was the most prevalent (7.5%) thyroid disorder identified in the infertile women. serum levels of thyroid hormones and prevalence of thyroid disorders were significantly higher in the infertile patients compared to the fertile women, although the overall prevalence of thyroid disorders was quite low. keywords thyroid hormones, thyroid disorders, female infertility, female fertility, reproductive medicine, comparative study, reproductive endocrinology, reproductive gynecology 1 department of obstetrics and gynaecology, r-jolad hospital, lagos, nigeria 2 department of obstetrics and gynaecology, university of ilorin & university of ilorin teaching hospital, ilorin, nigeria 3 college of medicine and health sciences, american international university west africa, banjul, the gambia 4 department of chemical pathology and immunology, university of ilorin & university of ilorin teaching hospital, ilorin, nigeria 5 the bridge clinic, lagos, nigeria * corresponding author’s e-mail: aloysiussweet@yahoo.com introduction gametes are ova and sperm cells that are haploid and have one copy of each type of chromosome i.e. 1–22 x or 1–22 y (ikwuka, 2023a). the sperm cell must fertilize an ovum in vivo or in vitro for conception (pregnancy) to occur. infertility is a global health problem, a social demoralizing condition for couples and it is an important cause of marital disharmony (panti, 2014). it is defined as failure to achieve clinical pregnancy after 12 months (1 year) of regular unprotected sexual intercourse – regular sexual intercourse is 2-3 times sexual intercourse per week (world health organization, 2010). infertility can be further classified into primary infertility, in which no previous pregnancies have occurred and secondary infertility in which a prior pregnancy, although not necessarily a live birth, has occurred (yao, 2002). the incidence of infertility suggests that 10-15% couples experience infertility (bhattacharya, 20007), constituting the major cause of gynecological consultations in nigeria (jimoh, 2011; obuna, 2012; okonofua, 2005). one of the greatest desires of couples is successful reproduction, especially in africa, where a high premium is placed on childbearing. infertility therefore causes severe emotional and social distress for the couple especially the social stigma attached to it in africa (gerias, 1992). the endocrine system is the second key regulator of organ system function after the nervous system. the endocrine system uses hormones as chemical messengers in signaling, once stimulated. upon stimulation, the thyroid gland secretes thyroid hormones (ths) which include tri-iodothyronine (t3) and thyroxine (t4). these hormones have a role in controlling basal metabolic rate (bmr), growth, and the development and differentiation of many cells in the body (habbu, 2016). normal thyroid gland function is described as euthyroidism, below normal as hypothyroidism, and above normal as hyperthyroidism. pa ge 14 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 141-152, 2023 hyperthyroidism has been linked with oxidative stress and various systemic immune inflammatory processes. in inducing oxidative stress, major free radicals that are of physiological significance are superoxide anion, hydroxyl radical, and hydroperoxyl radical, while nonradical is hydrogen peroxide (ikwuka, 2023b). in addition, the interplay, role and effects of metabolic syndrome diseases on female fertility are still being investigated by different researchers. metabolic syndrome diseases, msd (hypertension, etc) are interrelated diseases with very high morbidity and mortality rates (ikwuka, 2015; ikwuka, 2017a; ikwuka, 2017c; ikwuka, 2023c; virstyuk, 2016). results from different studies have shown that high levels of blood pressure, glucose and lipid metabolic disorders, asymptomatic hyperuricemia, activation of systemic immune inflammation and fibrogenesis, contribute to kidney damage (ikwuka, 2017d; ikwuka, 2017e; ikwuka, 2018a; ikwuka, 2018c; ikwuka, 2018d; ikwuka, 2019a; ikwuka, 2019c; ikwuka, 2022; ikwuka, 2023d; virstyuk, 2017a; virstyuk, 2018a; virstyuk, 2019; virstyuk, 2021a; virstyuk, 2021b). adiposity, diabetes mellitus and dyslipidemia have also been linked with erectile dysfunction (baysah, 2023). other than hormonal imbalance, several factors including hazards linked to certain occupations (long distance driving, military, etc); previous history of genital infections (e.g. gonorrhea, orchitis, etc); previous history of surgery in the genital tract or inguinal region; lifestyle choices (sedentary lifestyle, lack of exercise, sleep deprivation, etc); environmental factors (e.g. exposure to ionizing radiation, pesticides, heat from tight underwears and hot baths) can adversely affect semen parameters and lead to male infertility (baysah, 2023). in addition, lifestyles such as alcohol and tobacco consumption have been reported to cause infertility in men (baysah, 2023). the effects of alcohol intake on semen quality have been reported to be caused by oxidative stress caused by an imbalance between reactive oxygen species (ros) produced by the alcohol consumed in the form of free radicals that contain one or more unpaired electrons and antioxidants (ekechi, 2023). nicotiana tabacum (local snuff) has been reported to have adverse effects on fertility and pregnancy in female wistar rats (udeh, 2023a; udeh, 2023b). an established association between thyroid dysfunctions and infertility exists. these dysfunctions in the form of hyperor hypothyroidism can adversely affect fertility by the presence of anovulatory cycles, luteal phase defects, high prolactin (prl) levels, sex hormone imbalances, delayed onset of puberty, menstrual abnormalities, and miscarriages (doufas, 2000; poppe, 2003; poppe, 2007; rijal, 2011). however, the relative frequency and the chronology of the onset of reproductive dysfunction concerning the onset and type of thyroid disorder have not been well defined (deshmukh, 2015). increasing evidence derived from experimental and clinical studies suggests that the hypothalamic-pituitarythyroid axis and hypothalamic-pituitary-ovarian axis are physiologically related. thyroid hormones (ths) receptors and their mrna have been detected in human granulosa cells and direct effects of iodine and ths on ovarian function have been proposed recently (poppe, 2003). th scan directly affects granulosa cells, corpus luteum and oocytes (biswas, 1993), and they regulate follicle-stimulating hormone (fsh) stimulation in follicles and prevent their apoptosis (kabodmehri, 2021). thyroid-stimulating hormone (tsh) working in synergy with fsh can proliferate the granulosa cells (kabodmehri, 2021). therefore, an increase in tsh and thyrotropin-releasing hormone (trh) can cause ovulatory dysfunction or corpus luteum dysfunction. in addition, the underperformance of the thyroid gland can affect ovarian function indirectly by decreasing the binding activity of sex hormone binding globulin (shbg), increasing prolactin (prl) levels and delaying luteinizing hormone (lh) response to gonadotropinreleasing hormone (gnrh) (lee, 2014). the prevalence of thyroid dysfunction in infertile women is quite high. in a study done at aminu kano teaching hospital, kano, nigeria; thyroid disorders were observed in 23.4% of the subjects (emokpae, 2011). the prevalence of thyroid dysfunction in infertile women was found to be 33.3% in a study by (rahman, 2008) in india and 23% by (sharma, 2012) while (shivaleela, 2012) found a prevalence of 42%. however, a study done in port-harcourt, nigeria by (orazulike, 2018) showed a much lower prevalence of thyroid disorders in infertile women, which was 4.6%. subclinical thyroid dysfunctions (i.e. subclinical hyperthyroidism or subclinical hypothyroidism) may go unnoticed by unwary clinicians because these patients do not exhibit clinically overt physical symptoms and signs. this may lead to avoidable surgical interferences and related complications. with the advent of modern techniques, the estimation of various hormones can be done rapidly and reliably. the diagnosis of thyroid disorders can easily be made and appropriate treatment instituted with the results usually very gratifying. metabolic syndrome diseases require new and effective treatment regimens. dapagliflozin which is a sodiumglucose linked transporter 2 (sglt-2) inhibitor and liraglutide which is a glucagon-like peptide 1 receptor agonist (glp-1 ra) have been found to increase the effectiveness of treatment and improve the clinical course of type 2 diabetes mellitus and hypertension in patients with such comorbidities (ikwuka, 2017b; ikwuka, 2018b; ikwuka, 2019b; ikwuka, 2021; virstyuk, 2017b; virstyuk, 2018b; virstyuk, 2018c). rauwolfia vomitoria has a neuroprotective ability at it elevates antioxidants and suppresses lipid peroxidation (ekechi, 2023). proper management of thyroid dysfunction results in improvement in health status, normalization of menstrual abnormalities and restoration of normal fertility (micińsk, 2006). therefore, it is very important to screen thyroid abnormalities in women with infertility, particularly in countries considered as areas with endemic goitre since female infertility associated with thyroid dysfunction in these areas is common (zimmermann, 2008). pa ge 14 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 141-152, 2023 materials and methods study setting this study was conducted at the gynecology clinics of the department of obstetrics and gynecology of the university of ilorin teaching hospital (uith), ilorin, kwara state, north-central nigeria. uith is located at oke-oyi, old jebba road in ilorin. the hospital serves as a major referral centre for kwara state and parts of the nearby states of oyo, osun, ekiti, kogi and niger. uith is a tertiary care hospital, although it also offers primary and secondary healthcare services, and it is approved to undertake undergraduate and postgraduate medical training. the gynecology clinic is open to all, and an average of 144 women access healthcare at the clinics weekly, with 25% of them being for infertility cases (follow-up and new cases). study population the study population consisted of reproductive age women (18-45 years) attending the gynecology clinic of uith, and with a history of inability to conceive of more than one year duration. this included those with previous pregnancies irrespective of outcome (secondary infertility) and those with no previous pregnancy (primary infertility). the control group consisted of consenting fertile women, who had carried pregnancy to term within two years prior to this study, and who were new patients at the family planning clinic of uith. sample size and sampling technique the formula for sample size calculation for a comparative, cross-sectional study was used (charan, 2013). the parameter, proportion of thyroid disorders in women, was extracted from a previous study by (fatima, 2014). n= (2(z(α/2)+ zβ ) 2 ˟ p(1-p))/(p1-p2 ) 2 n= sample size z(α/2)= 1.96 at type 1 error of 5% zβ= 1.28 at 90% power p1= proportion of thyroid disorder in infertile women (47%) p2= proportion of thyroid disorder in fertile women (16%). p1 and p2 were extracted from a previous study by (fatima, 2014). p= pooled prevalence = [prevalence in one group (p1) + prevalence in another group (p2)]/ 2 p= [(0.47 + 0.16) / 2] = 0.32 n= (2(1.96+ 1.28)2 ˟ 0.32(1-0.32))/(0.47-0.16)2 n= 2(10.497)(0.2176)/(0.31)2 n= 2(10.497)(0.2176)/0.0961 n= 47.5 n~ 48 patients to make provision for attrition, 10% of the sample size was added. thus 53 women in each arm of the study, and a total sample size of one hundred and six (106) women were recruited for the study. respondents (patients and controls) were recruited consecutively till the sample size was complete. inclusion criteria study participants were consenting women of reproductive age group (18-45 years) with primary or secondary infertility. control group consisted of consenting fertile women matched for age. the control group members were new clients at the family planning clinic, apparently healthy, with no history of infertility, have carried a pregnancy to term, and had no record of contraceptive use two years prior to this study. exclusion criteria female patients outside the age group of 18-45 years; with previous or present thyroid disorders; women on steroids, hormonal contraceptives, or intrauterine contraceptive devices; women with a history of bleeding disorders; women with co-existing uterine fibroids (leiomyoma uteri). data collection method the study spanned 6 months. patients who presented with infertility were selected based on the inclusion criteria. eligible women were informed and counseled about the study in a simple language that they understood. the study proforma was designed to obtain respondents’ socio-demographic status, history of infertility, history of anterior neck swelling and other symptoms suggestive of thyroid disorder, medical conditions and past surgical procedures. sample collection four milliliters (4ml) of whole blood sample was collected from a peripheral vein from each participant after an overnight fast of 8-10 hours into a labeled plain sample bottle. food affects tsh levels, tsh decreases postprandial and a possible explanation for this is food-induced elevation of circulating somatostatin and consequent suppression of tsh (takano, 1995). patients who had coincidentally fasted for 8-10 hours at the first contact with the researcher were recruited while those who had already eaten were recruited at their next visit after they had been informed. blood samples were allowed to stand for about 1-2 hours to allow clotting and retraction. the sera was drained from the clot and later centrifuged at 1,000 revolutions per minute (rpm) for 10 minutes. the whole sera obtained was transferred into labeled plain containers and kept frozen at -20ºc before analysis. laboratory procedures serum concentrations of tsh, ft3 and ft4 were determined by using enzyme-linked immunosorbent assay (elisa) kits manufactured by monobind ltd using rayto microplate well reader. all reagents, calibrators/ standards and patients’ specimens were brought to room temperature (20-27ºc). the microplate wells for each calibrator/ standard and patient specimen were formatted, and the following steps described by (winter, 2012) were taken: 1. 50μl of the calibrator and the patient specimen were dropped into the assigned well with a pipette. pa ge 14 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 141-152, 2023 2. 100μl of tsh, ft3, and ft4 enzyme reagent was added to each well. 3. the microplate was swirled gently for 20-30 seconds and then incubated for 60 minutes at room temperature. 4. the contents of the microplate were discarded by decantation, and the plate was tapped and blotted dry with absorbent paper. 5. 350μl of wash buffer was added followed by decantation, a process that was repeated 2 additional times. 6. 100μl of working substrate solution was added to all wells without shaking the plates. this was incubated for 15 minutes at room temperature. 7. 50μl of stop solution was added to each well and mixed for 15-20 seconds. 8. the absorbance/optical density was read in each well at 450nm. the results were read within 30 minutes of adding the stop solution. 9. calibration curves were plotted for each analyte to determine the corresponding concentration of these analytes in the patients’ samples. criteria for diagnosis of thyroid dysfunction the reference range of values for ths that was used for this study is the range of normal values on the kit used (tsh: 0.39-6.16 miu/ml; ft3: 1.4-4.2 pg/ml; and ft4: 0.7-2.0 ng/dl) (monobindinc, 2012a; monobindinc, 2012b; monobindinc, 2012c). abnormal thyroid function can be categorized as hyperthyroidism (elevated ft3, ft4, and decreased tsh), hypothyroidism (decreased ft3, ft4, and elevated tsh), subclinical hyperthyroidism (normal ft3, ft4, but low tsh), and subclinical hypothyroidism (normal ft3, ft4, but elevated tsh) (habbu, 2016). data analysis data was analyzed using statistical package for social sciences (spss) version 23. categorical variables (thyroid disorders) were presented as proportions and analyzed using the chi-square test with fisher’s exact correction used in cases where more than 20% of expected counts were less than 5. the continuous variable that is normally distributed (like age) was presented as mean and analyzed using the t-test while those that were not normally distributed (the ths levels) were presented as median and interquartile range and analyzed using the mannwhitney u test. the test of normality was done using the shapiro-wilk test. the level of statistical significance was set at p<0.05 at a confidence interval of 95% for all inferential statistics. ethical considerations ethical approval for this study was obtained from the ethical review committee of uith. informed written consent was obtained from each participant after adequate counseling and all data from the study were treated with confidentiality and used solely for the study. patients with thyroid abnormalities were referred for further evaluation, treatment, and were co-managed with endocrinologists. results and discussion the findings in the one hundred and six (106) study participants are as shown below. socio-demographic variables of participants table 1 shows the socio-demographic variables of the infertile women and control group. women in the age group 25-28 years had the highest frequency of 30.2%, while women below 25 years of age had the lowest frequency of 13.2%. the mean age for the infertile and control group was 32.18±6.47 years and 31.4±5.74 years respectively. the majority of the patients and control (79.2% and 81.1%) respectively were employed. the majority of the study participants had a tertiary level of education (69.8%) and were yorubas (83%). there were no significant differences in the age, occupation, educational status and ethnicity of the study participants in the two groups. table 1: socio-demographic variables of the infertile women (patients) and fertile (control) group socio-demographic variable patient n (%) control n (%) total n (%) χ2/ t p-value age (years) < 25 9 (17.0) 5 (9.4) 14 (13.2) 2.932 0.569 25 – 29 14 (26.4) 18 (34.0) 32 (30.2) 30 – 34 7 (13.2) 11 (20.8) 18 (17.0) 35 – 39 15 (28.3) 12 (22.6) 27 (25.5) 40 – 45 8 (15.1) 7 (13.2) 15 (14.2) total (n) 53 53 106 age (mean ± sd)* 32.18±6.47 31.40±5.74 0.651t 0.516 occupational status employed 42 (79.2) 43 (81.1) 85 (44.3) 0.509 0.808 unemployed 11 (20.8) 10 (18.9) 21 (19.8) total (n) 53 53 106 educational status none 1 (1.9) 1 (1.9) 2 (1.9) 1.784f 0.759 pa ge 14 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 141-152, 2023 gynecological variables and symptoms found among the infertile and the fertile groups figure 1 illustrates the types of infertility found among the infertile patients. secondary infertility was identified in 75.5% of the infertile women while 24.5% had primary infertility. table 2 illustrates the symptoms present in the infertile patients and the control (fertile) group. none of the participants presented with anterior neck swelling. two (3.8%) of the infertile patients experienced palpitations compared to three (5.7%) in the control group. only one (1.9%) patient lost weight as against none in the control. four (7.5%) patients had a history of abnormal weight gain as against two (3.8%) in the control group. previous history of miscarriages was more prominent in infertile women (30.2%) than in fertile women (7.5%). heat or cold intolerance was only evident among the infertile women (3.8%), and this group had more members (7.5%) with decreased libido than 1.9% seen in the control group. of all these symptoms, only previous miscarriages presented a significant difference (p-value = 0.003) between the two groups. primary 1 (1.9) 2 (3.8) 3 (2.8) secondary 16 (30.2) 11 (20.8) 27 (25.5) tertiary 35 (66.0) 39 (73.6) 74 (69.8) total (n) 53 53 106 ethnicity yoruba 45 (84.9) 43 (81.1) 88 (83.0) 1.137f 0.822 hausa 2 (3.8) 1 (1.9) 3 (2.8) igbo 2 (3.8) 3 (5.7) 5 (4.8) others 4 (7.5) 6 (11.3) 10 (9.4) total (n) 53 53 106 χ2: chi square; t: independent samples t test; f: fisher’s exact test figure 1: types of infertility among the participants table 2: symptoms found in women with infertility (patients) and the control (fertile) group variables patient n (%) control n (%) total n (%) χ2 p-value anterior neck swelling no 53 (100.0) 53 (100.0) 106(100.0) palpitations yes 2 (3.8) 3 (5.7) 5 (4.7) 0.210f 1.000 no 51 (96.2) 50 (94.3) 101 (95.3) weight loss yes 1 (1.9) 0 (0.0) 1 (0.9) 1.010f 1.000 no 52 (98.1) 53 (100.0) 105 (99.1) history of abnormal weight gain yes 4 (7.5) 2 (3.8) 6 (5.7) 0.707f no 49 (92.5) 51 (96.2) 100 (94.3) 0.678 previous miscarriage yes 16 (30.2) 4 (7.5) 20 (18.9) 8.874 no 37 (69.8) 49 (92.5) 86 (81.1) 0.003* heat or cold intolerance yes 2 (3.8) 0 (0.0) 2 (1.9) 2.038f no 51 (96.2) 53 (100.0) 104 (98.1) 0.495 decreased libido yes 4 (7.5) 1 (1.9) 5 (4.7) 1.889f no 49 (92.5) 52 (98.1) 101 (95.3) 0.363 χ2: chi square test; f: fisher’s exact test; *: p-value <0.05 pa ge 14 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 141-152, 2023 comparison of the serum levels of thyroid hormones and thyroid dysfunctions in the infertile patients and the control (fertile) group table 3 compares the serum levels of thyroid hormones of infertile and fertile women. the mean tsh, ft3 and ft4 levels were higher in the infertile women than in the fertile women with mean values of 1.35±1.65 versus 0.85±1.08 miu/ml for tsh, 2.79±1.51 versus 2.19±1.15 pg/ml for ft3, and 1.15±0.33 versus 0.99±0.29 ng/dl for ft4. a significant difference was only in ft3 (p-value = 0.023) and ft4 (p-value = 0.009). the median for tsh, ft3 and ft4 was higher in the infertile group than in the fertile group, although only significant in ft3 (p-value = 0.031) and ft4 (p-value = 0.002). the lower and upper limits of the three parameters were within the normal reference range. table 3: comparison of thyroid hormone levels of patients with infertility and the control (fertile) group variables patients control u p-value tsh (miu/ml) mean ± sd 1.35±1.65 0.85±1.08 1149.000 0.064 median (iqr) 0.80 (0.40-1.55) 0.60 (0.40-0.85) 0.105 ft3 (pg/ml) mean ± sd 2.79±1.51 2.19±1.15 1062.500 0.023* median (iqr) 2.40 (1.45-4.20) 1.70 (1.35-2.95) 0.031* ft4 (ng/dl) mean ± sd 1.15±0.33 0.99±0.29 924.000 0.009* median (iqr) 1.10 (1.00-1.30) 1.00 (0.90-1.10) 0.002* u: mann-whitney u test; *: p-value <0.05 table 4: prevalence of thyroid disorders among the infertile women (patients) and the control (fertile) group variable patient n (%) control n (%) total n (%) χ2 p-value or (95% ci) thyroid disorders present 8 (15.1) 2 (3.8) 10 (9.4) 3.975f 0.046* 4.533 (0.915 – 22.465) absent 45 (84.9) 51 (96.2) 96 (90.6) χ2: chi square; or: odds ratio; 95% ci: 95% confidence interval; *: pvalue <0.05 table 4 demonstrates the prevalence of thyroid disorders among the infertile women (patients) and the control (fertile) group. eight (15.1%) patients had thyroid disorders compared to two (3.8%) in the control group, a difference statistically significant (p-value = 0.046). fortyfive (84.9%) infertile and 51 (96.2%) fertile women were euthyroid. table 5 compares the pattern of thyroid disorders among infertile and fertile women. four (7.5%) of the infertile women had subclinical hypothyroidism while one (1.9%) of the fertile women had subclinical hypothyroidism, and the difference was not significant (p-value = 0.37). overt i.e. clinical hypothyroidism was present in two of the infertile patients but was absent in the fertile women. overt i.e. clinical hyperthyroidism was present in two of the infertile women while only one of the fertile women had it, and the difference was not significant (p-value = 1.000). majority of the study participants were euthyroid – as observed in 45 (84.9%) of the infertile women as against 51 (96.2%) in the fertile women. table 6 shows the association between thyroid dysfunction and menstrual cycle abnormality. five (62.5%) out of eight infertile women with thyroid dysfunction had menstrual irregularities, and others (37.5%) had normal menses. thirteen (28.9%) out of forty-five euthyroid infertile women had menstrual irregularities, and others (71.1%) had normal menses. of the two fertile women with a thyroid disorder, one had a menstrual anomaly and the others did not. six (11.8%) of the fifty-one euthyroid fertile women had menstrual irregularities, while others (45) did not. these differences were not statistically significant (p-value >0.05). table 5: pattern of thyroid dysfunction among infertile women and control (fertile) women thyroid disorder patients n (%) control n (%) total n (%) χ2/ t p-value subclinical hypothyroidism 4 (7.5) 1 (1.9) 5 (4.7) 0.800 0.371 overt (clinical) hypothyroidism 2 (3.8) 0 (0.0) 2 (1.9) na overt (clinical) hyperthyroidism 2 (3.8) 1 (1.9) 3 (2.8) 0.000 1.000 none 45 (84.9) 51 (96.2) 96 (90.6) 0.260 0.610 total 53 53 106 χ2: chi-square; na: chi-square not available because of zero ‘0’ value pa ge 14 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 141-152, 2023 table 6: association between thyroid dysfunction and menstrual cycle abnormality thyroid disorder menstrual abnormality present absent total χ2 p-value or (95% ci) n (%) n (%) n (%) patient present 5 (62.5) 3 (37.5) 8 3.421f 0.104 4.103 (0.854 – 19.716) absent 13 (28.9) 32 (71.1) 45 total 18 35 53 control present 1 (50.0) 1 (50.0) 2 2.454 0.249f 7.500 (0.413 136.271) absent 6 (11.8) 45 (88.2) 51 total 7 46 53 χ2: chi square; or: odds ratio; 95% ci: 95% confidence interval undiagnosed and untreated thyroid disease can be a cause of infertility as well as sub-fertility which have important medical, economic, and psychological implications in our society (verma, 2012). aside from infertility, thyroid dysfunction could cause other reproductive disorders such as abnormal sexual development or menstrual irregularities. even in fertility, pregnancy can be complicated by anemia due to scd and despite the significant need for effective treatment options for scd patients, current treatments both traditional and newly developed, only ameliorate acute and chronic scd manifestations without addressing the underlying cause (musa, 2023). of the infertile women, 75.5% had secondary infertility and 24.5% primary infertility. this is consistent with the findings of (panti, 2014) which reported that 67.2% infertile female patients had secondary infertility and 32.8% had primary infertility. this dominance of secondary infertility in this study agrees with previous studies in africa (bala, 2003; ekanem, 2006; obuna, 2012; okonofua, 2003), but contrasts the finding in most western societies where primary infertility dominate with 63.1-80.0% (habbu, 2016; nasir, 2016). in this study, 30.2% of infertile patients had previous miscarriages, a value close to the 37% reported by (orazulike, 2018). previous miscarriage was the only pregnancy outcome reported in their study by its design. it was also reported by the patient with some possible recall bias. notwithstanding, this suggests that subfertility and pregnancy wastage are associated with thyroid disorders in women. other symptoms presented by the subjects were palpitation (3.8%), weight loss (1.9%), abnormal weight gain (7.5%), heat/cold intolerance (3.8%), and decreased libido (7.5%). none of the 106 participants had anterior neck swelling. the mean serum levels of thyroid hormones (tsh, ft3 and ft4) in this study were within the normal reference range although higher in the infertile women. the overall prevalence of thyroid disorders was 15.1% and 3.8% in the infertile and fertile women respectively. a similar study done in port-harcourt, nigeria by (orazulike, 2018) found a much lower prevalence of thyroid disorders of 4.6% in infertile women. similar studies done in india by (rahman, 2008) and another by (rijal, 2011) reported a prevalence of 25.6% and 33.0% respectively. similarly, (habbu, 2016), (sharma, 2012), and (shivaleela, 2012) reported higher prevalence rates (between 23.042.3%) of thyroid disorders in infertile women. thyroid hormone synthesis is influenced by iodine and it varies from clime to clime depending on water, soil, diet and fortification (utiger, 2006). with this knowledge, the difference in the prevalence of thyroid disorders in these studies can therefore be related to the variation in the study particpants’ consumption of iodine-containing meals (elahi, 2007). tsh was higher, but ft3 and ft4 levels were significantly higher when serum levels of thyroid hormones of the patients are compared with that of the control group. (habbu, 2016) and (shivaleela, 2012) also reported findings of elevated mean serum ft3 and ft4 but low tsh in the infertile patients. (orazulike, 2018) found no significant difference in the mean serum ft3, ft4, tsh, and tpoab between patients and controls. these findings were different from the findings of (fatima, 2014) where serum ft3 and ft4 were significantly decreased and serum tsh was significantly increased in infertile females when compared with fertile females. serum ft3 and ft4 may be higher where a large proportion of the patients are hyperthyroid and the reverse may be the case when a large proportion of the patients are hypothyroid. on types of thyroid dysfunction in this study, 9.4% had one type of thyroid dysfunction and 90.6% were euthyroid. in agreement with this, (elahi, 2007) reported that 89.3% infertile patients and 93.4% fertile control were euthyroid. this finding is consistent with that of (goswami, 2009), (orazulike, 2018), and (rijal, 2011). with infertile women being euthyroid, this suggests that other cause(s) of infertility aside from thyroid disorders should be evaluated during infertility examination as there can be significant single or multiple causes of infertility. subclinical hypothyroidism was the most predominant thyroid disorder in this study. a study done in kano pa ge 14 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 141-152, 2023 nigeria by (emokpae, 2011) got a higher prevalence (14.9%) for subclinical hypothyroidism as against the 9.4% in this present study. this may be because emokpae’s study assessed only tsh in hyperprolactinemic women focusing only on subclinical thyroid diseases while overt (clinical) thyroid diseases were not considered at all. hypothyroidism is associated with increased production of trh, which stimulates the anterior pituitary to secrete tsh and prolactin. hyperprolactinemia adversely affects fertility potential by impairing gnrh pulsatility and thereby affecting ovarian function (poppe, 2003). therefore, it is advisable to check tsh and prl levels in every infertile female, regardless of their menstrual rhythm (abdul, 2015). moreover, concerning subclinical hypothyroidism (poppe, 2003) reported a prevalence of 0.9% and (bohnet, 1981) reported a prevalence of 11%. the prevalence of subclinical hypothyroidism in subfertile women has been reported to vary from 0.7% to 43% (poppe, 2007). this wide range is due to the differences in the sensitivity of serum tsh measurement. the revised clinical practice guidelines of the endocrine society recommend the measurement of serum tsh in women over the age of 30 years with infertility or a prior history of miscarriage, to screen for thyroid dysfunction (de groot, 2012). in clinical practice guidelines for hypothyroidism in adults, the american association of clinical endocrinologists (aace) and the american thyroid association (ata) have recommended that treatment with l-thyroxine should be considered in women of childbearing age with subclinical hypothyroidism when they are planning a pregnancy (garber, 2012). if infertile women planning pregnancy are diagnosed with subclinical hypothyroidism as well as overt (clinical) hypothyroidism, they are recommended to be treated to reduce risks of miscarriage and fetal developmental impairment or to improve the in vitro fertilization outcome (lee, 2014). evidence suggests that treating thyroid disorders and keeping tsh levels below 2.5 miu/l may improve conception rates in infertile women and reduce early pregnancy loss (garber, 2012). in the study by (bohnet, 1981), subclinical hypothyroidism was considered an infertility factor by itself because treatment with l-thyroxine 50 mg/day normalized the mid-progesterone secretion and two out of the eleven treated women became pregnant. thyroid disorders have a known association with menstrual irregularities which may lead to infertility (krassas, 1990). in this study, menstrual irregularities were significantly more predominant in the infertile patients than in the fertile control and 62.5% of the infertile patients with thyroid disorders had menstrual irregularities. (orazulike, 2018) reported menstrual irregularities in 50% of the patients. (nasir, 2016) also reported menstrual irregularities in 19.6% of the patients. (goswami, 2009) similarly reported menstrual irregularities in 61.2% of the infertile patients and that 50% infertile patients with hypothyroidism had menstrual irregularities. the impact of hypothyroidism on ovulation and menstrual function is related to numerous interactions of thyroid hormones with the female reproductive system, in turn causing infertility. in hypothyroidism, increased trh production leads to hyperprolactinemia and altered gonadotropin-releasing hormone (gnrh) pulsatile secretion. this leads to a delay in luteinizing hormone (lh) response and inadequate corpus luteum leading to abnormal follicular development and ovulation. at the cellular level, thyroid hormone receptors are expressed in human oocytes and granulosa cells, and the hormones synergize with the follicle-stimulating hormone-mediated luteinizing hormone/human chorionic gonadotropin (hcg) receptor to exert direct stimulatory effects on granulosa cell function of progesterone production (poppe, 2004). altering the peripheral metabolism of estrogen and decreasing sex hormone-binding globulin (shbg) production is another pathway by which hypothyroidism may impact on fertility. these pathways may result in abnormal feedback at the pituitary level and consequently infertility (bassey, 2015). several aspects of the reproductive axis influenced by hyperthyroidism are comparable with the situation in hypothyroid women. in hyperthyroidism, the shbg production, the conversion of androgens to estrogens, and the gonadotrophin response to gnrh are increased. the decrease in menstrual flow may also be related to effects on hemostatic factors, including the synthesis of factor viii (krassas, 2000). women with hyperthyroidism and fertility problems should be treated with antithyroid drugs and/or surgery according to the cause of hyperthyroidism (krassas, 2000). conclusion serum levels of thyroid hormones and the prevalence of thyroid disorders were significantly higher in the infertile patients when compared with the fertile women. although the overall prevalence was quite low, thyroid abnormalities could still be implicated as a cause of female infertility. it is recommended that all infertile women should have thyroid function tests as part of their infertility work-up as many patients with thyroid diseases can easily be missed if they are not screened. direction for future research on this topic would be to evaluate the menstrual pattern and irregularities and relate these to thyroid disorder patterns among women within this study setting. this will give a clearer picture of the relationship between symptoms of menstrual irregularities and thyroid dysfunction which varies from region to region. acknowledgments special thanks to all the infertile and fertile women who voluntarily participated in this study after making an informed decision. authors’ contribution all authors contributed in different aspects of the research. pa ge 14 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 141-152, 2023 conflict of interest the authors guarantee responsibility for everything published in this manuscript, as well as the absence of a conflict of interest and the absence of their financial interest in performing this research and writing this manuscript. references abdul, r. & seema, m. 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(2008). iodinedeficiency disorders. lancet, 372 (9645), 1251–1262. pa ge 1 pa ge 11 4 american journal of medical science and innovation (ajmsi) challenges in the management of post-thrombotic syndrome in a low-resource setting onyango c. vonwicks1*, malalu p. collins1, auma nicholas2, fryda c. william1 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.6278 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: october 04, 2025 accepted: november 08, 2025 published: november 21, 2025 post-thrombotic syndrome (pts) is the most common long-term complication of deep venous thrombosis (dvt) and occurs in up to 20-50% of proximal dvts. patients with pts present with pain and swelling of the affected limb, edema with pruritus, skin hyperpigmentation, and venous ulcers. risk factors for pts include ineffective anticoagulation, obesity, and proximal dvt. the villalta scale is validated for the diagnosis and severity scoring of pts. the american heart association recommends primary and secondary prevention of pts as the most effective management strategy since treatment of established pts is very challenging, especially in resource-limited settings. the latter includes external compression devices, exercise, pharmacotherapy, venous ulcer management, and surgical endovascular procedures in selected patients. pts leads to frequent hospital visits, reduced productivity, and a low quality of life. in this study, we present the diagnostic and therapeutic challenges in managing a 30-year-old woman with pts in a rural kenyan setting. we propose a patient-centered multidisciplinary approach to managing pts. keywords kenya, persistent dvt, postthrombotic syndrome, pts, recurrent dvt, villalta scale 1 department of medicine, st. joseph rift valley hospital, gilgil, nakuru county, kenya 2 department of endoscopy, st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction post-thrombotic syndrome (pts) is a common longterm complication of deep venous thrombosis (dvt) that occurs in up to 20-50% of proximal dvt and may be severe in 5-10% of the cases (galanaud et al., 2018). it occurs primarily due to impaired and incomplete resolution of the thrombus, persistent obstruction of venous outflow with ambulatory venous hypertension, and secondary valvular incompetence (cosmi et al., 2022). the main risk factors for pts include previous and recurrent ipsilateral dvt, proximal dvt (especially iliofemoral), persistent symptoms ≥ 1 month after dvt diagnosis, obesity, and having subtherapeutic inrs while on warfarin for > 50% of the duration of treatment (vazquez & kahn, 2012). table 1 below summarizes the risk fators for pts (wang et al., 2023). the typical symptoms of pts include heaviness of the affected leg, pain, edema, and pruritus, which tend to worsen in the evenings, and trophic skin changes like hyperpigmentation and venous ulcers in severe cases (makedonov et al., 2020). there are many challenges in the management of pts in low-resource settings. difficulties in the diagnosis of pts arise from the widespread use of point-ofcare diagnostic compression ultrasound (cus) which is unable to distinguish between acute dvt and pts. a lack of confirmatory imaging modalities like ct and mri scans in these clinical settings means that patients with pts are repeatedly misdiagnosed as acute dvt and put on unnecessary prolonged anticoagulation with either warfarin or direct oral anticoagulants. this is especially true where patients seek treatment from different centers for “non-resolving” dvt symptoms. though not lethal, pts leads to a reduced quality of life, increased use of healthcare services through frequent hospital visits, and decreased productivity (wang et al., 2023). this case report from a rural kenyan hospital highlights some of these challenges in the diagnosis and management of pts and the resulting negative impact in the quality of life for the patient. we call for an increased awareness of the principles of pts diagnosis and management. table 1: risk factors for development of pts (wang et al., 2023). risk factors at baseline risk factors during follow-up proximal dvt (especially iliofemoral) subtherapeutic inr recurrent dvt history ipsilateral recurrent dvt obesity residual thrombus pre-existing venous insufficiency venous reflux higher severity of symptoms at diagnosis older age key: pts, post-thrombotic syndrome; dvt, deep vein thrombosis; inr, international normalized ratio. literature review the diagnosis of pts is based on the risk factor profile and clinical symptomatology. there is considerable overlap in the symptoms of pts, acute dvt, and primary venous insufficiency. many low-resource clinical settings rely on compression ultrasound (cus) for the diagnosis of acute dvt. cus may not distinguish acute dvt from a chronic thrombus (pts), especially where previous imaging is unavailable for comparisons. this situation pa ge 11 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 114-117, 2025 is common in low-resource settings when patients seek treatment from different health centers that often lack central integrated electronic medical records (gautam et al., 2020). there are no biomarkers that are validated for diagnosing dvt or predicting acute dvt patients who will develop pts later. due to these diagnostic challenges, the villalta scale has been validated for use in both clinical practice and research to standardize the diagnosis and estimate the severity of pts (kahn et al., 2014). table 2 below, adapted from guanella (guanella & kahn, 2012), shows the villalta scale. the treatment of established pts is challenging. the american heart association (aha) recommendations for treating established pts include i) compressionbased therapies like graduated external compression stockings (ecs) and intermittent compression devices, ii) pharmacotherapy with rutosides, defibrotide, and hidrosmin, iii) exercise training programs, iv) venous ulcer management, and v) surgical and/or endovascular procedure interventions for selected patients, including bypass procedures, stents, and complex reconstruction surgeries (kahn et al., 2014). given these challenges in treating established pts, the aha recommends both primary and secondary prevention as the mainstay of management. these strategies include i) primary prevention of dvt using pharmacological and mechanical thromboprophylaxis in high-risk patients and ii) secondary prevention strategies such as optimal and effective anticoagulation for dvt treatment, use of elastic compression stockings, and thrombolysis/endovascular therapies for selected patients (kahn et al., 2014). there is no reported case of pts from a kenyan hospital in table 2: the villalta scale (guanella & kahn, 2012). none mild moderate severe symptoms pain 0 1 2 3 cramps 0 1 2 3 heaviness 0 1 2 3 paresthesia 0 1 2 3 pruritus 0 1 2 3 clinical signs pretibial edema 0 1 2 3 skin induration 0 1 2 3 redness 0 1 2 3 hyperpigmentation 0 1 2 3 venous stasis 0 1 2 3 pain in calf compression 0 1 2 3 venous ulcer absent present key: total score of 0 to 4 indicates no post-thrombotic syndrome (pts); score of ≥5 indicates pts. pts severity: total score of 5 to 9, mild pts; score of 10 to 14, moderate pts; and score of ≥15 or venous ulcer present, severe pts. the literature as at the writing of this case study. the kenya ministry of health guidelines on the diagnosis and management of venous thromboembolism does not include any information on pts (division of noncommunicable diseases, 2018). therefore, this study aims to expose the presence of pts in a rural kenyan setting and highlight the challenges in the diagnosis and management of pts in a low-resource clinical setting. materials and methods patient history and physical examination a 30-year-old married mother of 7, a business lady from tanzania but living in nakuru, kenya, first presented to us at the medical clinic in april 2022, with persistent left leg pain, swelling, and numbness over the preceding 18 months. she had been first diagnosed with left leg common femoral vein (cfv) deep venous thrombosis (dvt) on doppler ultrasound in february 2021, following a cesarean section. she was treated with warfarin for 8 months (by the 6th month, she reportedly still had significant pain and swelling of the left leg, hence the decision to continue warfarin beyond 6 months). notably, her inr remained subtherapeutic between 1.2 and 1.8 during the 8 months of treatment. she stopped breastfeeding after 8 months. the next month, she was put on 20 mg of rivaroxaban daily for another month in another facility when a repeat doppler ultrasound showed dvt in the left cfv. in the 10th month, she was switched back to warfarin plus aspirin for another month in yet a different facility in which the left cfv still had dvt. from the 11th month, she was put on rivaroxaban in a different facility following a doppler scan showing left cfv dvt. she was on rivaroxaban (20 mg daily) when she came to us. she was visibly frustrated with the diagnosis of persistent left cfv dvt by multiple doctors who “failed to listen to her and were in a hurry to prescribe anticoagulants” and the possibility of lifelong anticoagulation without much symptomatic improvement. she was hemodynamically stable, obese with a weight of 98 kg and a bmi of 32.4 kg/m2, and limping on the left leg. the left leg was swollen and moderately hyperpigmented from the mid-leg to the foot and tender on the entire medial aspect from the foot to the groin, with no lymphadenopathy, no venous ulcers, and no features of varicose veins. see figure 1 below. the rest of the systemic examination was unremarkable. a repeat doppler scan showed dvt in the left cfv. her baseline metabolic workup was unremarkable. results and discussion diagnosis, management, and follow-up we made a diagnosis of severe post-thrombotic syndrome (given the fact that the dvt in the left cfv had not changed since 2021) based on the villalta scale with a score of 27. we proposed to stop the anticoagulation, manage pain with non-steroidal anti-inflammatory drugs, elevate the left leg while in bed, use external compression pa ge 11 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 114-117, 2025 figure 1: swollen left leg with hyperpigmented skin from the mid-leg to the foot. there were no venous ulcers or varicose veins. stockings, undergo physiotherapy, and that she actively lose weight in a structured nutritional support system. we also referred her for psychological counseling. two physiotherapy centers near her home declined her physiotherapy following their evaluation of the left leg over fears of possibly dislodging the clot and precipitating a pulmonary embolism. the surgical team added daflon (diosmin and hesperidin) to her treatment and requested a ct venogram, which confirmed an organized clot in the left cfv with resultant significant luminal narrowing. she was referred to vascular surgeons at the national teaching and referral hospitals for a possible endovascular recanalization procedure. at 2 vascular surgical clinics in different towns, she was seen by different doctors who restarted the rivaroxaban 20 mg daily at different times for left cfv dvt based on repeat doppler scans in each of these clinics. she returned to us 20 months after the referral and has had multiple clinic visits with us due to persistent pain and left leg swelling, with frustrations about the persistent symptoms. she has since cut down weight to 92 kg (lost 6 kg over 3 years). we stopped the rivaroxaban again and have been implementing the original management plan, including physiotherapy at our hospital. she went into depression and was seen by a psychiatrist and put on antidepressants. notwithstanding these interventions, she reports minimal improvement related to better pain control. we consulted a vascular surgeon in a private hospital, who will do a stenting procedure in december 2025. presently, she is under a multidisciplinary care team while the family is seeking financial resources to actualize the planned surgery. discussion our patient had severe pts based on a villalta score of 27 (guanella & kahn, 2012). her risk factors for pts included obesity, proximal dvt (left common femoral vein), subtherapeutic inr during the index anticoagulation, persistent symptoms at 6 months of anticoagulation, and residual thrombus (wang et al., 2023). achieving and maintaining a target inr of 2 to 3 with warfarin effectively prevents pts by stopping thrombus propagation and promoting early thrombus resolution (makedonov et al., 2022). use of direct oral anticoagulants (doacs) has been shown to be superior to warfarin in many studies to prevent pts (kahn et al., 2014). our patient has been seen in several different health facilities in which she was repeatedly (mis)diagnosed with persistent/new/recurrent dvt by means of compression doppler ultrasound (cus). the symptoms of pts closely mimic those of acute dvt, and cus may not distinguish acute from chronic thrombus, especially where previous imaging is unavailable for comparisons (gautam et al., 2020). this sort of mistake is common where patients are seen in different health institutions, as was with our patient. it is therefore understandable that the various facilities she visited opted to treat her as a case of acute dvt with anticoagulation. at our hospital, we determined from at least 9 different cus reports that the left cfv was involved in all the reports, making it more likely that the index left cfv dvt had persisted and become organized all this time rather than being a new clot. this finding was confirmed by a ct venogram. magnetic resonance imaging (mri) is more accurate than cus and ct scans in diagnosing recurrent dvt but obviously more expensive (müller et al., 2023). ideally, the vascular clinics she was referred to should have put her on management strategies for established pts since the referral letter had the diagnosis of pts established clinically and with the attached ct venogram report. the aha guidelines for the management of established pts are both class i and ii recommendations, with mixed outcomes in several studies due to the heterogeneity of the study participants (kahn et al., 2014). there is no therapeutic value in prolonged anticoagulation of patients with pts. our patient has responded, albeit suboptimally, to the management strategy, including weight reduction, external compression stockings, physiotherapy and exercise, analgesics, and psychological counselling. the diagnosis of pts has markedly affected her quality of life negatively due to frustrations about the non-resolution of the pts despite multiple clinic visits with the attendant financial expenditures. our multidisciplinary approach has alleviated most of her pain and psychosocial aspects of the pts diagnosis. based on the aha recommendations, she is a potential candidate for a combined operative and endovenous procedure (kahn et al., 2014), which she is scheduled for in december 2025. conclusions pts is a common complication of proximal dvt due to incomplete resolution of the index thrombus resulting in venous obstruction and secondary valvular incompetence. the main risk factors for pts include proximal dvt, obesity, ineffective anticoagulation, and persistent dvt symptoms. the villalta scale is validated for the diagnosis and severity of pts. the aha recommends both primary and secondary prevention of pa ge 11 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 114-117, 2025 pts as the most effective management. established pts may respond to ecs, pharmacotherapy, exercise, venous ulcer management, and surgical endovascular procedures in selected cases. clinicians ought to have a high index of suspicion for the diagnosis of pts in patients with a compatible risk factor profile who present with “persistent” dvt in the same leg. these patients should be managed in a patient-centered multidisciplinary team that includes psychosocial care. there is no therapeutic value to prolonged anticoagulation in patients with pts. references cosmi, b., stanek, a., kozak, m., wennberg, p. w., kolluri, r., righini, m., poredos, p., lichtenberg, m., catalano, m., de marchi, s., farkas, k., gresele, p., klein-wegel, p., lessiani, g., marschang, p., pecsvarady, z., prior, m., puskas, a., & szuba, a. (2022). the post-thrombotic syndrome-prevention and treatment: vas-european independent foundation in angiology/vascular medicine position paper. front cardiovasc med, 9, 762443. https://doi. org/10.3389/fcvm.2022.762443 division of non-communicable diseases, m. o. h. (2018). kenya national guidelines for cardiovascular diseases management. ministry of health. retrieved 06/11/2025 from http://guidelines.health.go.ke:8000/media/ kenya_national_guidelines_for_cardiovascular_ diseases_management.pdf galanaud, j. p., monreal, m., & kahn, s. r. (2018). epidemiology of the post-thrombotic syndrome. thromb res, 164, 100-109. https://doi.org/10.1016/j. thromres.2017.07.026 gautam, g., sebastian, t., & klok, f. a. (2020). how to differentiate recurrent deep vein thrombosis from postthrombotic syndrome. hamostaseologie, 40(3), 280291. https://doi.org/10.1055/a-1171-0486 guanella, r., & kahn, s. r. (2012). post-thrombotic syndrome: current prevention and management strategies. expert rev cardiovasc ther, 10(12), 15551566. https://doi.org/10.1586/erc.12.147 kahn, s. r., comerota, a. j., cushman, m., evans, n. s., ginsberg, j. s., goldenberg, n. a., gupta, d. k., prandoni, p., vedantham, s., walsh, m. e., & weitz, j. i. (2014). the postthrombotic syndrome: evidencebased prevention, diagnosis, and treatment strategies. circulation, 130(18), 1636-1661. https:// doi.org/doi:10.1161/cir.0000000000000130 kahn, s. r., comerota, a. j., cushman, m., evans, n. s., ginsberg, j. s., goldenberg, n. a., gupta, d. k., prandoni, p., vedantham, s., walsh, m. e., & weitz, j. i. (2014). the postthrombotic syndrome: evidencebased prevention, diagnosis, and treatment strategies: a scientific statement from the american heart association. circulation, 130(18), 1636-1661. https:// doi.org/10.1161/cir.0000000000000130 makedonov, i., kahn, s. r., abdulrehman, j., schulman, s., delluc, a., gross, p., & galanaud, j. p. (2022). prevention of the postthrombotic syndrome with anticoagulation: a narrative review. thromb haemost, 122(8), 1255-1264. https://doi. org/10.1055/a-1711-1263 makedonov, i., kahn, s. r., & galanaud, j.-p. (2020). prevention and management of the post-thrombotic syndrome. journal of clinical medicine, 9(4), 923. https://www.mdpi.com/2077-0383/9/4/923 müller, m., wolf, f., loewe, c., beitzke, d., zehetmayer, s., gschwandtner, m. e., willfort-ehringer, a., koppensteiner, r., & schlager, o. (2023). preprocedural imaging modalities in patients undergoing iliocaval venous recanalization and stent placement. vasc med, 28(4), 315-323. https://doi. org/10.1177/1358863x231161938 vazquez, s. r., & kahn, s. r. (2012). advances in the diagnosis and management of postthrombotic syndrome. best pract res clin haematol, 25(3), 391-402. https://doi.org/10.1016/j.beha.2012.06.006 wang, j., smeath, e., lim, h. y., nandurkar, h., kok, h. k., & ho, p. (2023). current challenges in the prevention and management of post-thrombotic syndrome-towards improved prevention. int j hematol, 118(5), 547-567. https://doi.org/10.1007/ s12185-023-03651-6 pa ge 1 pa ge 39 american journal of medical science and innovation (ajmsi) job satisfaction of health professionals working in governmental tertiary level hospitals of nepal damodar rokka1*, namrata khanal2 volume 2 issue 1, year 2023 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: february 23, 2023 accepted: march 17, 2023 published: march 20, 2023 the extent to which an individual feels self-motivated, content & satisfied with his/her job is job satisfaction. by enhancing job satisfaction among the employees, the organization can creates happier employees. it will eventually lower costs for hiring and training new personnel and also create more motivated and productive employees. this descriptive study was carried out to find out the various factors that influence job satisfaction of health employees of varying specializations working in a tertiary level governmental hospital of nepal. the participants were asked to respond the questionnaires largely based upon the job satisfaction scale (jss) questionnaires developed by paul e. spector (1997) using 5-point likert scale. convenience sampling method was employed in the study. similarly, the study also relied on the publications of the various related agencies for its secondary sources in regard to data collection. only 28.1% of the participants were found to be satisfied. the study proposes that hospital employees perceive supervision, recognition, pay& benefits, promotion, work environment and autonomy as significant factors affecting their job satisfaction. also demographic variables like age, rank and education qualification has a significant relationship with job satisfaction while gender, marital status and work experience didn’t show any significant correlation with job satisfaction. the study provides an insight to the policy makers about the various factors that need to be considered for uplifting the job satisfaction level of the health professionals and hence uplifting the standard of the health care system of the governmental hospital. keywords health professionals, job satisfaction, tertiary level hospital 1 department of radiology and imaging technology, national academy of medical sciences (nams), national trauma center,kathmandu, nepal 2 gurans life insurance, kathmandu, nepal * corresponding author’s e-mail: rokkadamodar@gmail.com introduction the extent to which an employee feels self-motivated, content & satisfied with his/her job is job satisfaction. in the area of organizational performance and human resource management, job satisfaction is largely sought subject. if an employee feels happy with their company & work, they look to perform better for the company with all their efforts. managers should focus on employee satisfaction because dissatisfied employees may get irritated and there may be possibility of providing inferior service by him/her. so, job satisfaction is an indicator of an emotional well-being and a fair treatment in an extent. the people of all over the world want a universal health coverage (uhc) of excellent quality to make sure their access to healthcare services for disease prevention and cure, palliation, health promotion, and rehabilitation, as and when needed which are not a financial burden for users (who, 2017). the dream of uhc can become reality through a well-functioning health system equipped with skilled workforce, as consumers of health system today are more conscious of their rights. this is why the health institutions of today prioritize even more to possess an upgraded, well abreast with knowledge and skilled workforce who is satisfied with their jobs (janicijevic et al., 2013). these healthcare services providers are indispensable for an efficient and effective healthcare system and their worldwide shortage is also a major challenge for thrachievement of millennium development goals, more so in the low and middle-income countries. according to world health organization by the year 2035 the health workforce shortage will reach up to 12.9 million(who, 2013). stress in the workplace can lead to poor health and workrelated injuries (iglehert, 2000). health care professionals comprise a crucial group which will be impacted by workplace stress due to their unique work environment (grunfeld et al., 2005) .nepalese governmental health sector is relatively not well organized. the workers within the governmental health sector face various issues that have a huge impact on the level of job satisfaction. among health care employees, job satisfaction has a huge impact on work efficiency and quality, including health care costs (bovier & pernege, 2003). studies showed that job satisfaction among health care workers is influenced by many factors, including gender, age, and level of education, work experience, working conditions, salary, working hours, and the possibility of promotion (fahrenkopf et al., 2008).this intricate phenomenon is an attitude towards one’s job that has an impression not only on the personnel’s motivation, but also on career, health and relationships with co-workers (visser et al., 2007) . moreover, low salaries, lack of fringe benefits, job insecurity, nepotism, political influences and improper career development structure are some of the important factors that either hinder qualified health professionals from joining the governmental sector or increase the turnover rate (makowiec-dabrowska et al., 2001). the world health organization (who) defines the https://journals.e-palli.com/home/index.php/ajmsi pa ge 40 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 39-46, 2023 health workforce as “all people engaged in actions whose primary intent is to reinforce health” (who searo, 2008). human resources for the health are often defined as the various types and specializations of medical and para-medical staffs liable for individual and public health intervention. this includes both public and personal sectors and different areas of health systems, like curative, preventive care, personal and non-personal public health interventions, disease prevention, health promotion services, and research, management and support services. the health resources include different categories of health professionals ranging from doctors, nurses, paramedics, mid-level health professionals of different specialty of health sciences, public health professionals and researchers. human resources in any health system and their proper utilization in work environment is a major requisite for better functioning of health care system. (who searo, 2008). in nepal, human resources for health (hrh) situation have been met with various notable challenges particularly associated to the acute shortage and uneven distribution of the health workforce in the country (mohp, 2012). despite the necessity for an appropriate number and distribution of different categories or level of health professionals, who are socially responsible, technically competent and are available at the right time and place, as outlined in the national health policy 1991, these limitations have prevented policy from being implemented into the practice. moreover, the national health policy has not taken into consideration the epidemiological transitions and demographic developments that have occurred over the last two decades. nepal has been identified by the world health organization as one of 57 nations with a critical shortage of health workers (who report). this creates a huge deficit in the requirements for the coverage of essential interventions; including those necessary to meet the health related millennium development goals (mdgs). in nepal, this is unlikely until the threshold density of health workers (doctors, nurses and midwives) is at least 23 per 10,000 in the population (nhsp ii, mohp 2010). furthermore, policy has not addressed the changing demographics in the country, as despite a population increase of more than 45 percent in the last two decades the human health resources has increased by 3.4 percent during that time (nhsp ii, mohp 2010). the distribution of health workers has been raised as a concern in nepal, with huge variations between ecological zones (mountain, hill and terai) and among the 7 federal states of the country. the absence of doctors and qualified health professionals in the most remote areas has also been a long standing issue. these issues are compounded by the movement of high-level health workers, such as doctors, nurses and professionals of other specialties to private health institutions or overseas, due to the high demand for health workers in industrialized countries, as well as attractive incentives that they offer. in nepal like in other developing countries; the “brain drain” of health workers has been identified as a major concern. previous research has identified that the professional councils approached for letters of good standing by staff wanting to work abroad and data suggests approximately 16% of registered doctors are outside the country studying or working (blair, 2011). nearly more than half of health staffs are working in either the kathmandu valley or in other cities, leaving rural areas under-staffed, with absenteeism a growing problem for the effective delivery. the main issues in the human resource for health of nepal are retention, inadequate skill manpower with improper distribution, and inadequate finance, low opportunity for pre and in service training. current recognition of these issues by the government of nepal, developed the human resource for health strategy in 2003 for 14 years, i.e. 2003 – 2017. however, this could not become effective because of inadequate and unscientific projection, poor implementation of the policy, inadequate funding, and ownership by the concerned stakeholders. in addition, the notable point in the nepal is that the private sector has emerged as a substantial force in hrh; however the coordination between these two sectors are very weak and the private sectors are more concerned to the urban area for the profit. so, governmental health facilities should be strengthened and for that the health professionals working in public hospital should be prioritized and retained (shrestha, 2012). employee job satisfaction is considered as a critical factor for the success and better functioning of any organizations including health care institutions. there have been numerous researches on this topic that are conducted all around the world. in recent decades, this issue has aroused interest in nepal as well. unfortunately, it is observed that there is not enough research made in nepalese major governmental health care institutions about job satisfaction. to the best of our knowledge, no any published study covering major health professionals of varying specializations has been found in our scenario. non-profit public organizations are pivotal for the nation and its economy. therefore, the issue is very important for governmental institutions. in developing countries like nepal many of the healthcare workers are unsatisfiedwith the quality of life they themselves or their families can have in their country with their earnings or job incentives. they even think that there is not adequate opportunities to learn advanced technologies, enhance skills and career development, have poor working conditions, face violence at workplaces and are under political influences. thus, they search for jobs in developed countries which have a higher pull force. for these reasons, the tertiary level governmental healthcare institutions are selected for this study on measuring job satisfaction among health professionals. the public institutions where this study is performed are central governmental institutions, subject to central government budget applications and limitations. these institutions implement fundamental health policies and https://journals.e-palli.com/home/index.php/ajmsi pa ge 41 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 39-46, 2023 activities mainly related to health. therefore, the job satisfaction is worth to be investigated and very important to be kept at high level in this kind of institutions. the intention of this study is to recommend the government and public health institution of our country to take necessary steps to keep the employees satisfied with their work and other work-related factors for the success and better functioning of the institution. this research gains its importance from the subject matter itself, because it opens the scope for the officials and policy makers to consider job satisfaction as a very important issue among health workers in government hospital of nepal. the lack of the previous studies on our scenario also makes this study important. this research focuses on the sources of job satisfaction for health care providers and trying to make it better. the importance of this study is that it will enrich the libraries of the ministry of health and population for the future planning with suitable interventions to increase the level of job satisfaction among health professionals and thus uplifting the standard of health care service delivery in governmental hospital. materials and methods research design design of this study is not correlative. it is more of opinion survey which identifies various factors that influence job satisfaction level among healthcare employees of public hospitals of nepal. thus, the research can be categorized as a descriptive study. for the purpose of the study, 500 hospital employees were selected randomly from 3 hospitals of kathmandu. as indicated, 250 questionnaires in one major hospital and 125 in each to other two hospitals were distributed to hospital employees working in government hospital of kathmandu. personal efforts were made on behalf of the researcher on delivering and collecting questionnaires. of the total 325 responses from the participants, 24 questionnaires were unusable. these excluded questionnaires, were missing key information. thus, the usable returned questionnaires were 301 representing a response rate of slightly more than 60%. in the present study, two sampling techniques i.e. multi stage sampling and convenience sampling was adopted. the first stage sampling involved selection of public health institution operating in kathmandu valley at different locations. in the second stage, depending on the number of bed capacity, three hospitals were selected. in the third stage, the convenience sampling was adopted. sources of data the information has been collected from both primary as well as secondary sources. secondary source this study relies on publications of the respective agencies for its secondary sources with regard to collection of data. thus, the present study depends heavily upon the relevant information from such secondary data. this secondary information has been collected from various publications relating to health workers, healthcare system etc. different books, magazines, journals, newspapers, publications of executing agencies viz. world health organization (who), publications of ministry of health and family population, government of nepal; department of health services, government of nepal; planning board, government of nepal have been consulted to make the study meaningful. various e-resources have been extensively consulted to make the study more updated, comprehensive and also to supplement the findings of the study. primary source in order to obtain desired information regarding job satisfaction level among health workers, primary data was collected and analyzed. there are various methods for the collection of primary data and information. however, the present study bases itself on a questionnaire which is explained below: development of questionnaire in this survey general information about the respondent and information relevant to the topic was asked of the respondents. structured, non-disguise questionnaire was used i.e. pre-determined and pre-drafted questionnaire has been used to collect the information. since, the proposed questions were fairly harmless, it was decided not to change the major objectives of the study. the questionnaire consisted of fixed choice questions both dichotomous and multiple choice ones. but some questions were kept open ended to know the personal attitudes more clearly. in order to obtain unhesitant and honest responses by the respondents, they were assured that information collected would be kept strictly confidential and would only be used for academic purpose. the questionnaire used in this study consists of three different sections. the first section contains questions pertaining to the personal demographics about the respondents-specifically about age group, gender, marital status, highest level of education, salary, years of experience, and job level. the second section of the survey measures job satisfaction. specifically, the job satisfaction survey (jss) questionnaire developed by paul. e. spector (1997) has been mainly used to measure job satisfaction level of healthcare employees of public hospitals. finally, the third section of the questionnaire comprises of open-ended questions just to know their preference of working and to know their suggestions for improvement. job satisfaction survey (jss) the jss includes thirty-questions that test attitudes toward six different aspects of work. the six areas or subscales are autonomy, recognition, promotion, supervision, pay and work environment and group cohesion. jss scoring the jss consist of 30 questions. the response format https://journals.e-palli.com/home/index.php/ajmsi pa ge 42 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 39-46, 2023 used in the study incorporated a 5-point likert-type scale. respondents were asked to tick one of five numbers that corresponded to their satisfaction or dissatisfaction about each question with one being the lowest and five being the highest score. response choices for each question were scored as l=very dissatisfied, 2=dissatisfied, 3=neutral, 4=satisfied slightly and 5=very satisfied. each subscale has five questions. the cronbach’s alpha internal consistency test was used to determine the reliability of the test for each dimension. the values of cronbach’s alpha greater than 0.7 were regarded as acceptable and those ≥ 0.7 were subjected to factor/principal component analysis (pca). the cronbach’s alpha value in our study was 0.87 which shows a good reliability of the questionnaire used. a pilot study was conducted with an effort to provide feedback regarding questions or any errors about the demographic questionnaire, jss instrument and its scale. eight participants agreed to participate in the pilot study. the participants were employed at national trauma center, kathmandu where the actual survey was later distributed. a response sheet was attached to the survey; suggestions for improving the clarity of instruction and general layout of the instrument were obtained from the pilot study participants. the length of time for completing the survey was also recorded on the response sheet. results of the pilot study demonstrated the average time for completing the survey was approximately 10 minutes, with minimum ranging from 7 minutes to slightly more than 10 minutes. this information was later used in the request for participation in the actual study. change made to the survey following the pilot study improved the clarity of instructions and some content of the demographic questionnaire. the pilot study raised no major questions and the respondents did not have any difficulty in understanding and answering the questions. to make the study meaningful the data was analyzed and interpreted with the help of certain statistical tools and techniques. the data for this research were analyzed using the statistical package for social science (spss). there are a number of criteria to select a suitable statistical technique, two of which are the appropriateness of the technique to the research question and the characteristics of data. accordingly, different statistical techniques were used in the analysis based on their relevance to the research objectives, questions and hypotheses. among the techniques that have been used in the present study are frequencies analysis, histograms, chi-square, pearson coefficient of correlation and t-test at 5% level of significance. results and discussion socio-demographic information age group of the participants was divided into four groups as 20-30, 31-40, 41-50 and 51-60 years. we included the age up to 60 years in consideration to the compulsory retirement age of 60 years according to the heath service act of nepal. there were 79 (26.2%), 167 (55.5%), 50 (16.6%) and 5 (1.7%) respondents in 20-30, 31-40, 41-50 and 51-60 years age groups respectively. table-1 presents the age distribution of the respondents. out of 301 respondents, there were 157 males and 144 females that account for 52.2% males and 47.8% females. table 1: age group of the participants age group (in years) frequency percentage 20-30 79 26.2 31-40 167 55.5 41-50 50 16.6 51-60 5 1.7 this shows that the majority of the participants were males. table-2 represent the gender distribution of the respondents. among the respondents, 244 were married and 57 were single with the majority of participants i.e. 81.06% married. in this study, there were 9 (3%), 36(12%), 9(3%), 44(14.6%), 38(12.6%), 59(19.6%), 100(33.2%) and 6(2%) of the participants in 11th, 10th,9th, 8th, 7th, 6th, 5th and 4th level respectively. the majority of the participants were of the 5th level followed by 6th, 8th, 7th, 10th, 9th and 11th level. table 2: rank/ level of the participants according to nepal health service act rank frequency percent 11 9 3% 10 36 12% 9 9 3% 8 44 14.6% 7 38 12.6% 6 59 19.6% 5 100 33.2% 4 6 2% in the study, the educational qualification of the respondents were 58(19.3%), 137(45.5%) and 106(35.2%) of certificate, undergraduate and postgraduate level respectively. table-4 represents the educational table 3: educational qualification of the participants frequency percentage certificate 58 19.3% bachelor (undergraduate) 137 45.5% masters (postgraduate) 106 35.2% table 4: work experience of the participants (in years) years of experience frequency percentage <1yrs 28 9.3% 1-5yrs 103 34.2 5-10yrs 101 33.6% >10yrs 69 22.9% https://journals.e-palli.com/home/index.php/ajmsi pa ge 43 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 39-46, 2023 qualification of the respondents. job satisfaction scale (jss) the study consists of the participants of varying work experience in terms of duration. table-5 represents the data regarding the working experience of the participants in years. after calculating the total facet score for each of the six aspects of job satisfaction, the total score was calculated on a scale from 30-150. the score values of 30-54 were considered as very dissatisfied, 55-78 as dissatisfied, 79-102 as neutral, 103126 as satisfied and 127-150 as very satisfied. observing these values, 0.7%, 10.4%, 60.7%, 26.2%, and 1.9% of the participants were very dissatisfied, dissatisfied, neutral, satisfied and very satisfied respectively. table-6 represents the data regarding overall job satisfaction of the participants. the overall job satisfaction was studied under six subscales i.e. autonomy, recognition, work environment, promotion, supervision and pay and benefits. on analyzing the satisfaction level on those sub-scales, recognition holds the highest percentage of satisfaction (58.1%) followed by work environment (43.5%) and autonomy (33.2%). when the job satisfaction of the health professionals according to the area of specialization was analyzed taking into account the average total job satisfaction score, pharmacists were found to have the highest score (108.36). they were followed by chief consultant doctor of 11th level (103.67), medical recorder (102), consultant doctor i.e. 9/10th level (100.71), physiotherapist ( 100.20), medical officer, biomedical technicians/engineers, health assistant, laboratory technologists, radiographers and nurses. nurses were found to have the lowest score among all of the specializations. table 6: job satisfaction in different sub-scales sub-scale very dissatisfied dissatisfied neutral satisfied very satisfied autonomy 0.7% 9.3% 56.8% 31.3% 1.9% work environment 0.7% 6.9% 48.9% 39.6% 3.9% recognition 0.7% 2.6% 38.6% 56.8% 1.3% promotion 10.6% 26.6% 36.5% 26.3% supervision 3.3% 28.6% 47.1% 20.3% 0.7% pay and benefits 11.7% 39.2% 45.2% 3.9% table 7: correlation between overall job satisfaction and each sub-scale of satisfaction sub-scales spearman correlation coefficient p-value* autonomy 0.46 <0.001 work environment 0.65 <0.001 recognition 0.75 <0.001 supervision 0.79 <0.001 promotion 0.67 <0.001 pay and benefits 0.72 <0.001 *statistical significance at 0.05 table 5: overall job satisfaction of the participants frequency percentage very dissatisfied 2 0.7% dissatisfied 31 10.4% neutral 183 60.8% >10yrs 69 22.9% satisfied 79 26.2% very satisfied 6 1.9% correlation between overall job satisfaction and each sub-scale of satisfaction in order to determine the main factors that were correlated with satisfaction and/or dissatisfaction with a job, the relationship between overall job satisfaction and job characteristics was analyzed (table-8). spearman’s ratio demonstrated that the strongest correlation factor was in supervision (0.79). other factors that influenced satisfaction were recognition (0.75) and pay and benefits (0.72), respectively. socio-demographic predictors of health professional’s job satisfaction score the relationship between socio-demographic variables and job satisfaction score was quantified. age, rank and educational qualification showed statistically significant relation with the overall job satisfaction (p<0.05). gender, marital status and work experience did not show any significant correlation with the overall job satisfaction (p>0.05). https://journals.e-palli.com/home/index.php/ajmsi pa ge 44 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 39-46, 2023 discussion the health system of nepal is struggling with various issues. those major issues are due to the economic, political and peace instability in the country. among various blocks that are affected, one of those prime area is human resources for health. as observed in a developing country, there is increased dissatisfaction in all aspects of life of a person and healthcare resources are no exception to this. this is a very important aspect which cannot be neglected as it will not only worsen the gap between the desired and the actual numbers of health care workers but will also seriously affect their performance, efficiency and effectiveness in the long run. in an international commitment in order to reduce global poverty and improve population health, the governments of the world have committed, in the sustainable development goals, to achieve universal health coverage (uhc), including financial risk protection by 2030 (who, 2017). a critical decision in the progressive realization of uhc is which health services to include in essential packages of care. to realize the goal of comprehensive universal health coverage, it is important to increase the utilization of public health services through effective care. as per the data provided by the national health account 2016, the household out of pocket, expenditure is 53% and is one of the highest in the world (nha, mohp, 2016). the government of nepal has always prioritized for the improved health services in the country. the constitution of nepal, 2015 has established health as the fundamental right of the people. but all these efforts cannot achieve the desired goal until we have self motivated and efficient healthcare providers at primary, secondary and tertiary healthcare levels. however, the motivation of the healthcare service providers is the key to effective delivery of the health service and the motivation depends upon their job satisfaction. hence, it is critical to ensure that they feel satisfied with their jobs. our study included healthcare workers with different specializations including doctors to have a holistic picture and approach to assess job satisfaction. past studies focused mainly on doctors and nurses (jharana et al., 2019; chaulagai & khadka, 2012; peters et al., 2010). this study has included different health professionals of varying specialization. our study has used jss. this is a frequently used validated instrument that allows comparisons with previous studies (sibbald et al., 2000). only 28.1 % of the study participants showed satisfaction with their jobs based on the absolute approach used for computing the job satisfaction scores ranging from 30150. low levels of job satisfaction were also reported in a job satisfaction study regarding pakistan where 14% of the employees showed high dissatisfaction with their jobs (kumar et al., 2013). this has big implications for the public health system like ours, which is already facing a significant lack of financial resources and can’t afford to lose the skilled workforce. another study done in lahore showed that only 31.1% of doctors were satisfied with their jobs (deeba et al., 2015). in another study, the result showed that only 13% of the doctors were well satisfied with their jobs while a significant number had either below average or average satisfaction for their job (nikic et al., 2008). this dissatisfied workforce will be further increasing to the number of workers who leave their country or their cities and migrate to other areas in search of better opportunities and developments. it can be observed that previous studies showed similar results. it is a clear evidence that despite being brought to the notice of people and policy makers in the country where these studies were, still not suitable intervention has been made in order to bring improvement in the satisfaction of health services employees who are integral part of the health system and without the satisfaction of whom the effective delivery of healthcare services to the poor or the needy public cannot be achieved. any level of dissatisfaction among healthcare providers in the public sector demands further assessment and intervention, as this could have deterrent consequences in terms of overall efficiency, effectiveness, and sustainability of any health system around the world. our findings of this study on job satisfaction was carried out in government hospital of kathmandu .thus, the results are of the serious concern for the policy makers. even though the study was conducted in the capital which is presumed to have a comfortable working environment, good infrastructure, and a convenient life, the results showed a very less satisfaction among the professionals. job satisfaction was similar in all age groups in our study. some studies have reported higher satisfaction in elderly professionals compared to younger professionals (carrillo-garcia et al., 2019). when analyzed with the gender, marital status and the work experience, the result showed no statistical significance in this study. this contradicts with the results from some of the previous studies. male workers felt more satisfied compared to females similar to a survey conducted among german physicians (behmannet et al., 2012). however, a spanish study reported the opposite results (carrilo et al.., 2013). some other reviews concluded that gender is not a strong independent predictor (keeton et al., 2000). the differences may be due to cultural variations. the professionals in the higher rank and with higher educational qualification showed higher satisfaction and was found to be statistically significant. this can be attributed to the fact that the professionals in the higher position and with higher qualification enjoy more respect and the pay than the others and can also have a influence on the management. the three highest levels of satisfaction were the recognition, work environment and autonomy. this agrees with the findings of cooper et al. who reported that health-care providers appreciated their freedom and independence to work, as well as enjoyed the responsibility and variety of their job with the recognition. the autonomy at one’s work is a feature which distinguishes healthcare from other service industries. if the workers feel they are handcuffed due to the conditions at the https://journals.e-palli.com/home/index.php/ajmsi pa ge 45 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 39-46, 2023 work/workplace and believe that the procedures pose barriers in the effective performance of their duties, then the quality of services that they offer are also affected significantly as many treatment options or timely decisions for the treatment or the services cannot be taken due to these red tapes. our study revealed that the participants had overall low satisfaction with various global dimensions of job with only 3.9 % satisfied with remuneration, 21% satisfied with the supervision and 26.3 % satisfied with their promotion chances. all these results in regard to pay, promotion opportunities, benefits and rewards are similar with the findings which were presented in the study assessing job satisfaction among public health care workers in pakistan (kumar r et al, 2013). low satisfaction with salaries/ pay and development opportunities of an individual was also reported in a study conducted in healthcare workers in tanzania (nikic et al., 2008). the healthcare profession is not similar to other professions in the sense that here the biggest reward for any service provider is the satisfaction of providing services to mankind and in return get appreciation. but if the workers don’t get their due reward for their duty, then it adds to their dissatisfaction and can negatively influence the delivery of the effective quality of care to be provided. the results for supervision showed that most of the respondents were dissatisfied with the capabilities of their supervisor, the role he plays in mentoring them. this is particularly important in regards to sensitive healthcare industry as the workers have to deal with patients and their emotions not machines. for this, they need to learn skills to scale up their capabilities. if they believe that their supervisor lacks the ability to guide/supervise them and does not entrust them with tasks that can add to their skills, then they will be at a loss. dissatisfaction with one’s salary in our findings seems to be a common issue that is also evident in several other studies (kinzl et al., 2005; ekeret et al., 2004; goetz et al., 2011; burnard et al., 1999). many managers consider that the key motivation for their employees is pay, bonuses or raises. this suggests that health-care systems should provide an adeqaute salary and fringe benefits scheme to satisfy their workers and maintain their loyalty. in contrast, that does not seem to be a problem in australia as evidenced by a previous studydone in 2002. that discrepancy may be due to differences in the economic status of australian health-care systems and ours (ulmer & harris, 2002) the main factors that correlated with the overall job satisfaction were supervision followed by recognition and pay. thus, the study suggested on improving the quality of supervision, recognition of one’s work or contribution and also increasing the incentives. for improving the quality of supervision, the policy makers must ensure the adequate training and education of the supervisors in order to enhance their skills. when asked about the preference of their working, more than 80% of the participants preferred working in governmental hospital with the major reason being the job stability. similarly, the study also asked for their suggestion for the overall improvement in job satisfaction. among the various suggestions, the major suggestions were the increase in salary and benefits, creating good and fair opportunities for the training and education and good performance appraisal system. conclusion and recommendations the study intends to sensitize the policy makers on the subject of satisfaction of the workforce and its implications in the governmental hospital of nepal. it is essential to regularly improve the policies related to healthcare providers and their working conditions in certain interval of time. among various factors, the study proposes that hospital employees perceive supervision, recognition, pay & benefits, promotion, work environment and autonomy as significant factors affecting their job satisfaction. any interventions directed at improving the various facets of the job satisfaction will surely have a positive impact on job satisfaction. a conducive working ecosystem in addition to a satisfied and ambitious workforce can and have a positive impact on the evolving health system of a country. it is time that job satisfaction surveys should be conducted frequently in a regular basis in the provincial and federal sector public hospitals of the country. the data collected from such surveys will provide a very fruitful insight into the expectations of the workers as well as provide the employee’s views regarding the various shortcomings of different dimensions at their workplaces. these results can then be looked and thus incorporated into newer human resources policies for health that can surely provide better compensation packages, provide clear job description to the employees and these in turn will help improve satisfaction of health care workers in future. it is advised that an all-inclusive approach be undertaken in order to strengthen the policies addressing employee satisfaction which can bring a noticeable improvement in the quality and performance of organization. references abraham h. m. 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(2013). job satisfaction among health care workers: the role of gender and age. rev lat am enfermagem, 21, 314-20. chaulagai, n., khadka, d. (2012). factors influencing job satisfaction among health care professionals at tilganga eye center, kathmandu, nepal. int. journal of scientific & technology research, 1(11), deeba, f., usmani, ra., akhtar, m., zahra, t., rasool, h. (2015). job satisfaction: among doctors working in public and private tertiary care hospitals of lahore. prof med j, 22(10), 1373-8. eker, l., tuzun, eh., dasakapan, a., surenkok, o. (2004). predictors of job satisfaction among physiotherapists in turkey, j occup health, 46(6), 500-5. fahrenkopf, a. m., sectish, t. c., barger l. k., sharek, p. j., lewin, d., chiang, v. w., edwards, s., wiedermann, b. l., & landrigan, c. p. 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(2013). job satisfaction among public health professionals working in public sector: a cross sectional study from pakistan. hum resour health, 11(2), 2-5. makowiec-dabrowska, t., koszada-wlodarczyk, w., bortkiewicz, a., gadzicka, e., siedlecka, j., jozwiak, z., et al (2008). occupational and non-occupational determinants of work ability. med pr, 59(1), 9–24. ministry of health and population (mohp) , government of nepal (2012). human resources for health strategic plan 20112015. ministry of health and population (mohp) , government of nepal (2010). nepal health sector programme ii (nhspii) 20102015. ministry of health and population (mohp), government of nepal (2019). nepal national health accounts 2016-2017. dragana, d., arandjelovic, m., nikolic, m., and stankovic, a., et al. (2008). job satisfaction in health care workers. acta medica medianae, 4, 9-12. shrestha, c., & bhandari, r. (2012). insight into human resources for health status in nepal, health prospect, 11, 40-41. sibbald, b., enzer, i., cooper, c., rout, u., sutherland, v.. gp job satisfaction in (1987). 1990 and 1998: lessons for the future?. family practice, 17(5), 364– 371. https://doi.org/10.1093/fampra/17.5.364 ulmer, b., harris, m.. australian (2002). gps are satisfied with their job: even more so in rural areas. family practice,19, 300–303. https://doi.org/10.1093/fampra/19.3.300 visser, mr., smets, em., oort, fj., & de haes, hc. (2003). stress, satisfaction and burnout among dutch medical specialists. cmaj , 168(3), 271–275. who searo (2008). health systems development human resources for health. [electronic]; available from: http://www.who.int. world health organization. tracking universal health coverage (2017). 2017 global monitoring report.; available at: https:// apps.who.int /iris/ bitstream / handle/10665/ 255051 / 9789241512268eng.pdf https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 18 american journal of medical science and innovation (ajmsi) frequency of tuberculous lymphadenitis (tbla) in somalia: a retrospective study with genexpert pcr-based diagnosis md biplob hossain1, abdirahim ahmed1, abdullahi tukade1, chomel mahbub2, afrin haque2, munasar abdikarim nor1, omer hassan omer ismail1, saida abdi mohamed1, md. ashiqur rahman3, sadia islam4* volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.4114 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: november 30, 2024 accepted: january 01, 2025 published: january 24, 2025 tuberculous lymphadenitis (tbla) poses a significant public health burden globally, particularly in somalia due to high tuberculosis prevalence. it often faces diagnostic challenges due to its nonspecific symptoms; making early treatment critical. additionally, high hiv and mdr-tb burden can also exacerbate the scenario. hence, this study aims to determine the rate of tbla in somali population using genexpert pcr assay. this retrospective observational study was conducted at nova diagnostic and research, a leading diagnostic center in mogadishu, somalia, from january 2024 to august 2024. a total of 499 suspected cases were included. among the study participants, the male-tofemale ratio was 0.98:1. 36.07% of individuals tested positive for tbla. the disease was found to be more prevalent among younger participants, particularly those under the age of 40. a significant association was observed between the site of aspiration and tb positivity (p<0.005), with cervical lymph nodes being the most commonly affected site, accounting for 67.2% of positive cases. additionally, tb was detected in multiple lymph node sites in 8.3% of the all specimens. in somalia, the rate of tbla continues to remain elevated, especially in younger population. more strategic approach is necessary to reduce the burden effectively. rapid and accurate diagnosis of tbla can be performed by genexpert real-time pcr, for early detection and treatment. keywords cervical lymph node site, disease burden, genexpert real-time pcr, lymph node, tuberculous lymphadenitis (tbla) 1 nova diagnostic and research, mogadishu, somalia 2 badas covid-19 and molecular diagnostic lab, dhaka, bangladesh 3 novus clinical research services limited (ncrsl), bangladesh 4 bangladesh specialized hospital plc, bangladesh * corresponding author’s e-mail: sadia.buhs.6700@gmail.com introduction tuberculous lymphadenitis (tbla), earlier known as scrofula, is one of the most common manifestations of extra-pulmonary tuberculosis (eptb) (prasad et al., 2024). tbla is observed when the infection caused by tuberculous mycobacteria disseminates to the lymphatic system, generally to the cervical lymph nodes. this leads to granulomatous inflammation, caseous necrosis, and eventually the enlargement of the lymph nodes (lucas, 2017). symptom is typically associated with fever, night sweats, fatigue, and weight loss. treatment typically involves a six-month regimen, with isoniazid, rifampin, ethambutol, and pyrazinamide for the initial two months, followed by isoniazid and rifampin for the next four months, as recommended by the who (strategy, w.s.t., 2008). due to its asymptomatic nature, tbla often remains undiagnosed during its early stages. hence, the severity of the disease is often overlooked on a global scale, resulting in delayed treatment. however, the regions with high disease burden such as sub-saharan africa and southeast asia face substantial health crisis due to tbla. somalia, an east-african country, possesses a significant prevalence of tbla cases in conjunction with high overall tb burden. risk factors such as the high prevalence of hiv in somalia play a critical role in the development and spread of tb. as hiv weakens the immunity, it might result in individuals to become more susceptible to coinfections like tbla. several studies have demonstrated a strong relation between tbla and hiv co-infection, further complicating the disease management landscape (tesfaye et al., 2017; gounden et al., 2018; perenboom et al., 1994; abebe et al., 2012). age and gender may also play as a critical contributor to the disease. some studies have found that females are disproportionately affected with tbla compared to males (muluye, 2023; fader et al., 2010; purohit et al., 2009). on the contrary, no association between them was also observed in some studies (mathiasen et al., 2020). moreover, the escalating prevalence of multidrug-resistant tb (mdr-tb) is a significant public threat, complicating the treatment of tbla (hassan et al., 2024; tukade et al., 2024). over the decades, somalia has continued to combat the tb epidemic, persistently working to eliminate it despite challenges. however, the tb program management of the country has made remarkable improvements limiting the death rates by 14% in the last 14 years (who). still, to eradicate the disease completely, it is crucial to improve surveillance, promote awareness, offer advanced and specialized diagnosis techniques, and effective treatment regime. for identifying tb more accurately and rapidly, molecular testing proves to be very effective, even from samples such as lymph node aspirates or biopsy. techniques such as pcr or real-time pcr can immediately detect pa ge 19 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 18-23, 2025 the presence of dna of mycobacterium tuberculosis, thereby providing quicker results than traditional culture methods. this is particularly efficient for determining tbla, where the symptoms are often less specific (mohamed et al., 2023; mirghani et al., 2024). molecular testing ensures timely treatment initiation, which is crucial in preventing further complications and transmission. given the circumstances, this research aims to determine the prevalence of tbla among the patients of a hospital in mogadishu, somalia, using genexpert real-time pcr method. by leveraging real-time pcr, the study seeks to generate accurate and rapid diagnosis on the burden of tbla in this region, which is necessary for advancing diagnostic accuracy, developing treatment strategies, and promoting public health interventions to address tbla effectively in somalia. materials and methods study design, period and study population this retrospective observational study was conducted at nova diagnostic and research, a leading diagnostic center in mogadishu, somalia, from january 2024 to august 2024. the study enrolled participants with suspected cases of tuberculous lymphadenitis. data were systematically extracted from the laboratory’s registration logbook, and a total of 499 suspected cases were included. records with incomplete demographic information were excluded to ensure data integrity and reliability. sample collection and processing fine-needle aspiration cytology (fnac) of lymph nodes was performed under aseptic conditions using a 20 ml disposable plastic syringe fitted with a 23-gauge needle. the obtained aspirates were analyzed using the genexpert assay. the diagnosis of tuberculous lymphadenitis (tbla) was established based on cytological findings, which included the presence of chronic granulomatous inflammation, atypical hyperplasia, actinomycosis, secondary carcinoma, or secondary undifferentiated nasopharyngeal carcinoma, among other pathological features. data analysis data were analyzed using spss. the descriptive variables were described as frequency (percent). the association test between the categorical variables was analyzed using the chi-square test. p-value <0.05 was considered statistically significant. results and discussion demographical findings the study examined the aspirates in a total of 499 suspected cases of tuberculous lymphadenitis (tbla), with an almost equal gender distribution of 49.1% males and 50.9% females. the mean (±sd) age of the participants was 27.71±17.53 years. participants were grouped into 10-year age intervals, with the largest proportion (26.7%) falling between 21 and 30 years, while only a small percentage (2.6%) were over 70 years of age. when distributed regionally, the majority of participants (87.6%) were from mogadishu, the capital city of somalia. the remaining participants were across other regions, with 7.0% from southern somalia, 3.6% from the central region, and 1.8% from the northern region (table 1). aspirates were collected from various lymph node sites, as shown in figure 1. the most affected site was cervical lymph node with a proportion of 68.3% amongst all. followed by were supraclavicular, submandibular, and axillary with 6.6%, 5.6%, and 5.2% respectively. along with that, few participants were found with lymph node swelling at multiple sites (6.6%). genexpert real-time pcr findings pcr findings showed in that, among the total participants, 180 (36.07%) had lymphadenopathy due to tuberculosis (p<0.005) (figure 2). male/female ratio did not have any significant difference (0.98:1). based on age distribution, the highest rate of tbla was found in age group 11-20 (41.7%), followed by 31-40 (39.2%) and 21-30 (38.3%) participants. positivity rate was comparatively less in age group below 10 years and 41-50, with 26.3% and 21.6% respectively (figure 3). pcr findings based on sites of aspiration a diverse positivity rate of tbla was observed in different aspirates depending on the site of lymph node involvement. the presence of the bacteria was observed in 35.5% cervical aspirates, accounting for 67.2% of all positive cases due to their high sample size. higher positivity rates were observed in the supraclavicular (57.6%) and para-aortic (55.6%) lymph nodes as well, although the total number of aspirates from each site was relatively low. discussion tuberculous lymphadenitis (tbla) is a significant health concern worldwide, particularly in the african region, which is facing a disproportionate burden due to high tuberculosis rates and associated risk factors. as a localized form of tuberculosis, tbla is often characterized by swollen lymph nodes and can present diagnostic challenges due to its nonspecific symptoms, which may mimic other infectious or inflammatory conditions (mathiasen et al., 2020). in somalia, where healthcare infrastructure is still developing and the population faces socioeconomic challenges, tbla remains a critical public health issue. hence, it underscores the need for enhanced diagnostic strategies, targeted public health interventions, and a better understanding of the epidemiological factors contributing to its spread. however, mogadishu has initiated improved diagnostic approaches in association with who to mitigate the overall public health burden, particularly tb and associated diseases. therefore, the present study aimed to evaluate the rate of tuberculous lymphadenitis (tbla) among patients with swollen lymph nodes. pa ge 20 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 18-23, 2025 in the present study, the prevalence of tuberculous lymphadenitis (tbla) was found to be 36.07%, representing a substantial proportion and underscoring tuberculosis (tb) as a significant cause of lymphadenopathy in the study population. comparable studies conducted in ethiopia and tanzania reported higher prevalence rates of 69.5% (muluye, 2023). this discrepancy may be attributed to variations in sample size. several factors contribute to the increased risk of tuberculosis (tb) progression in somalia. these include the country’s demographic profile, densely populated living-setting, nutritional deficiencies, and behaviors such as cigarette and khat consumption. these factors collectively worsen the susceptibility to tb by compromising the immune system and increasing exposure to potential infections. regarding gender distribution, the male-to-female ratio in our study was 0.98:1, suggesting no association. this finding aligns with another study conducted in ethiopia (muluye, 2023). along with demographical and genetic factors, addressing the interplay between behavioral factors like cigarette smoking and khat consumption is essential in understanding their combined impact on health. khat is widely chewed traditionally and culturally in the sub-saharan countries by both males and females. chronic khat consumption has been associated to weak immune system, impaired lymphocyte function, and accelerated inflammation, all of which can add the risk of tb infections (kebede, 2002). the age distribution of tbla cases revealed preponderance among younger individuals, with 11–20 years age group accounting for 41.7% of cases, followed by 31–40 years age group with 39.2%. these findings are consistent with earlier studies, which have also identified that younger individuals are most commonly affected age group (ali et al., 2014; mohamed et al., 2023). this is possibly attributed to the fact that younger people are most likely to have a less developed immune system, which makes them more vulnerable to disease. additionally, in densely populated areas, younger population may have greater exposure to tb due to frequent interactions in schools, social gatherings, or crowded living-settings. while looking into the site of aspirates, the cervical lymph nodes were the most commonly affected site, accounting for 67.2% of positive cases. these nodes are the most common site for aspirates in the diagnosis of tbla, due to its crucial role in the drainage of respiratory system. this finding is congruent with observations from the previous studies done in ethiopia (47.5% and 74.2% respectively) where cervical regions were the most affected region (muluye et al., 2023; bezabih et al., 2002; mathiasen et al., 2020). along with that, this study found that tb was also detected in large proportion in supraclavicular, para-aortic and submandibular lymph nodes. moreover, aspirates were collected from multiple sites, in which a high rate of tb was observed (44.1%), highlighting the advancement of the disease. this is indicative of the requirement of intensive treatment, as the infection has disseminated to the bloodstream (mathiasen et al., 2020). the incidence of tbla underscores a global, collaborative effort to focus on early diagnosis and treatment, and effective prevention strategies to eradicate tuberculosis (le roux & vlok, 2021). in this study, the laboratory diagnosis of tbla was performed by genexpert real-time pcr, which has proven to be a highly effective method for detecting the presence of tb early. this is because; pcr allows quick diagnosis and treatment, significantly table 1: characteristics of the subjects variables n (%) gender male 245 (49.1) female 254 (50.9) mean age±sd [iqr] 27.71±17.53 [12.5-63.5] age range ≤10 76 (15.2) 11-20 120 (24.0) 21-30 133 (26.7) 31-40 79 (15.8) 41-50 37 (7.4) 51-60 24 (4.8) 61-70 17 (3.4) >70 13 (2.6) region mogadishu (capital) 437 (87.6) central 18 (3.6) northern 9 (1.8) southern 35 (7.0) pa ge 21 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 18-23, 2025 improving the accuracy of detection even in low-bacterial load samples. however, there were few limitations. as this is a retrograde study, a significant limitation was the absence of comprehensive patient records. records of co-morbidity like hiv, lifestyle, and history of tb could not be retrieved. hiv is highly prevalent in somalia, and may influence the risk of tb. other limitation was lack of latest comprehensive research on the prevalence of tbla in high-incidence countries like somalia. the finding in the present study underscores the importance of considering tb as a primary differential diagnosis in regions or populations with high tb prevalence. figure 1: distribution of sites of aspiration figure 2: incidence of tbla figure 3: incidence of tbla based on age group pa ge 22 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 18-23, 2025 conclusion tuberculous lymphadenitis (tbla) remains a substantial burden in somalia, despite public health initiatives and adherence to who-recommended treatment protocols. this study revealed that 36.07% of the participants were found with tbla, reflecting significant concern due to tuberculosis in the region. moreover, tb was detected from multiple lymph node sites, indicating systemic dissemination of the disease. therefore, it strengthens the need for swift diagnosis and treatment to reduce the severity of disease and effective patient outcomes. the study also highlights the integration of molecular techniques such as pcr into routine diagnostics, as it allows early and accurate tbla detection. references abebe, g., deribew, a., apers, l., abdissa, a., deribie, f., woldemichael, k., & colebunders, r. (2012). tuberculosis lymphadenitis in southwest ethiopia: a community based cross-sectional study. bmc public health, 12, 1-7. ali, s., mubeen, a., & javed, m. (2014). demographic features of tuberculosis lymphadenitis patients. journal of sheikh zayed medical college, 5(4), 730–732. bezabih, m., mariam, d. w., & selassie, s. g. (2002). fine needle aspiration cytology of suspected tuberculous lymphadenitis. cytopathology, 13(5), 284-290. fader, t., parks, j., khan, n. u., manning, r., stokes, s., & nasir, n. a. (2010). extrapulmonary tuberculosis in kabul, afghanistan: a hospital-based retrospective review. international journal of infectious diseases, 14(2), e102-e110. gounden, s., perumal, r., & magula, n. p. (2018). extrapulmonary tuberculosis in the setting of hiv hyperendemicity at a tertiary hospital in durban, south africa. southern african journal of infectious diseases, 33(3), 57-64. hassan, s. a., dirie, a. m., ahmed, n. r., & omar, a. i. (2024). update on antimicrobial resistance in somalia: current status, challenges, opportunities, and future perspectives. heliyon, 10(20). kebede, y. (2002). cigarette smoking and khat chewing among college students in north west ethiopia. ethiopian journal of health development, 16(1), 9-17. le roux, c. e., & vlok, s. s. (2021). the silent pandemic in south africa: extra-pulmonary tuberculosis from head to heel. sa journal of radiology, 25(1). lucas, s. b. (2017). lymph node pathology in infectious diseases. diagnostic histopathology, 23(9), 420-430. mathiasen, v. d., andersen, p. h., johansen, i. s., lillebaek, t., & wejse, c. (2020). clinical features of tuberculous lymphadenitis in a low-incidence country. international journal of infectious diseases, 98, 366-371. mirghani, h., elmadhoun, w., ahmed, m. h., ahmed, m., & almobarak, a. o. the utility of polymerase chain reaction genexpert test in the diagnosis of tuberculous lymphadenitis. journal of microscopy and ultrastructure, 10-4103. mohamed, m. a., ali, o. a., osman, a. m., abatcha, m. g., ahmed, a. a., ali, a. m., & vieira, r. f. (2023). assessment of drug-susceptible and multidrugresistant tuberculosis (mdr-tb) in the central region of somalia: a 3-year retrospective study. plos global public health, 3(9), e0002319. muluye, d., biadgo, b., woldegerima, e., & ambachew, a. (2013). prevalence of tuberculous lymphadenitis in gondar university hospital, northwest ethiopia. bmc public health, 13, 1-5. perenboom, r. m., richter, c., swai, a. b., kitinya, j., mtoni, i., chande, h., & maselle, s. y. (1994). table 2: pcr results based on sites of aspiration variables total n (%) positive n (%) negative n (%) f/p value site of aspirates axillary 26 (5.2) 7 (26.9) 19 (73.1) 0.032 cervical 341 (68.3) 121 (35.5%) 220 (64.5) inguinal 10 (2.0) 3 (30.0) 7 (70.0) para-aortic 9 (1.8) 5 (55.6) 4 (44.4) parotid 10 (2.0) 10 (100.0) preauricular 3 (0.6) 3 (100.0) submandibular 28 (5.6) 9 (32.4) 19 (67.9) submental 5 (1.0) 1 (20.0) 4 (80.0) supraclavicular 33 (6.6) 19 (57.6) 14 (42.4) multiple sites 34 (6.8) 15 (44.1) 19 (55.9) number of lymph node single 466 (93.4) 165 (35.4) 301 (64.6) 0.245 multiple 33 (6.6) 15 (45.5) 18 (54.5) results are expressed as number (%). chi-squared test was performed to calculate statistical difference. p-value <0.005 was considered as level of significance. pa ge 23 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 18-23, 2025 diagnosis of tuberculous lymphadenitis in an area of hiv infection and limited diagnostic facilities. tropical and geographical medicine, 46(5), 288-292. prasad, k. c., prasad, s. c., chakravarthy, y., rao, p., thada, n., & rani, s. (2024). scrofula and other tuberculous infections of the head and neck. in infections of the ears, nose, throat, and sinuses (pp. 381–395). purohit, m. r., mustafa, t., mørkve, o., & sviland, l. (2009). gender differences in the clinical diagnosis of tuberculous lymphadenitis—a hospital-based study from central india. international journal of infectious diseases, 13(5), 600-605. strategy, w. s. t. (2008). implementing the who stop tb strategy. world health organization. https://www. who.int/htm/tb tesfaye, b., alebel, a., gebrie, a., zegeye, a., tesema, c., & kassie, b. (2018). the twin epidemics: prevalence of tb/hiv co-infection and its associated factors in ethiopia: a systematic review and meta-analysis. plos one, 13(10), e0203986. tukade, a., mohamuddirie, h., omarosman, m., hagihossain, k., biplobhossain, m., ahmed, a., & islam, s. (2024). antimicrobial resistance status among referred patients attending at nova diagnostic and research in mogadishu, somalia. molecular mechanism research, 2(2). pa ge 1 pa ge 1 american journal of medical science and innovation (ajmsi) impact of unrestricted drug use on psychiatric and behavioral disorders: exploring mental health effects in the united states excel onajite ernest-okonofua1*, franklin ibadin1, aminu sufu mahmud2, ifeoma theodora abengowe1, ogheneyemarho great oyiborhoro1 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.4036 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: november 24, 2024 accepted: december 21, 2024 published: july 05, 2025 illicit substance abuse in the united states remains a public health concern as a survey shows that 59% of the population aged 12 or older use illicit substances in a year. legal highs such as marijuana, opioids, synthetic cannabis, and other substances are responsible for high addiction rates and mental illness. issues like legalization, online drugs, and polydrug use only make these issues worse. special groups are particularly vulnerable to getting treatment hence making the effects of substance use not only societal but individual as well. this research aims to establish the correlation between the use of drugs without prescription and mental illness. it also details how the availability of drugs affects mental health and looks at how to prevent or treat the problem effectively. a cross-sectional survey design was employed, and the quantitative data collected from 378 participants was analysed. data was collected with the help of online questionnaires, including participants’ background information, their drug-taking behaviour, and psychiatric disorders. descriptive analysis was performed utilising the spss statistical tool to compare the data sets. the study shows a positive correlation between substance use and the presence of psychiatric disorders, including anxiety, depression and psychosis. the participants well understand these links and there was an appreciation of early intervention and integrated care models of treatment. however, there are still gaps in the treatment, especially among the marginalised groups of society. the study highlights the need to increase awareness of the disease, improve treatment access, and to deliver specific interventions. approaches that address education, equal access to treatment, and stigma are essential interventions for addressing the two risks posed by substance use and related mental health effects. keywords drug accessibility, integrated care, mental health disorders, public awareness, substance abuse 1 department of public health, igbinedion university, nigeria 2 department of mental health, university of south alabama, united states * corresponding author’s e-mail: excel_onajite@outlook.com introduction drug use in the united states is a widespread and tangled public health issue of which individuals use both legal and illegal ways to become addicted to these substances (mack, 2017). national survey on drug use and health (nsduh) that about 59% of americans 12 or older used illicit drugs in the past year with marijuana the most commonly used substance (azofeifa-ujueta, 2023). apart from marijuana, most individuals use other drugs, like cocaine, methamphetamines, hallucinogens, and opioids, leading to widespread addiction and health problems (azofeifa, 2019). in particular, the opioid crisis has been so gruesome, with over 70,000 cases of overdose reported annually attributed to synthetic opioids such as fentanyl (larkin jr & madras, 2019). another area of concern is the misuse of prescription drugs, as at least 16 million americans are believed to misuse prescription medicines to ease pain or spur energy, and tranquilize their anxieties (preuss et al., 2019). the landscape is made more complex by a rise in polydrug use, individuals taking more than one substance at a time, which heightens health risks and increases the risk for a mental health disorder (crummy et al., 2020). as per (mccollister et al., 2017) study, substance use disorders (suds) represent as much of an economic impact, at an annual cost to the united states, of over $740 billion for healthcare expenses, lost productivity, and criminal justice costs. drug use occurs in a variety of population’s but have higher prevalence rates and barriers to treatment in young adults, and marginalized communities (mongelli et al., 2020). legal changes, technological development and cultural changes have all paid a part in making drugs available without restriction in the united states. the study by (hammond et al., 2020) emphasized that 7.6 million americans reported using cannabis, an increase triggered in large part by marijuana legalization at the state level, and misuse and dependency rates were edging up, notably among young adults. but beyond cannabis, the internet and dark web make it easier to buy more, ranging from synthetic opioid to designer drug, all with anonymous purchases that rarely traverse traditional law enforcement channels (mccollister et al., 2017). increased access has extended to the internet and the dark web, where it is estimated that some 2.5 million americans acquire drugs online each year, including high-risk drugs like synthetic opioids (lokala et al., 2022). besides being more accessible, prescription medications like opioids and stimulants are also becoming widely available over telemedicine and online pharmacies, raising fears of overprescription and abuse (mccann, 2020). these impacts are social communities experiencing increased crime, homelessness, and family disruption. pa ge 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 1-8, 2025 although, there are complex challenges in managing psychiatric and behavioral disorders associated with a drug use in the united states, high prevalence rates of suds often coexist among mental health conditions (mccabe et al., 2017). yule and kelly (2019) highlighted that individuals with comorbid mental health disorders including depression, anxiety or schizophrenia also struggle to treat their addiction, with many resulting to turn to drug or alcohol for coping. together these different deterrents add to the stigma surrounding mental health and drug use, which discourages individuals from seeking help, and especially in underserved communities with few mental health services (drew & martin, 2021). this study aims to understand the adverse mental health burden of unrestricted drug use in the united states with regard to the relationship with the development of psychiatric and behavioral disorders. it examines the number of mental health disorders that are drug use related, the influence of the accessibility of drugs on those health issues, whether there an association of certain drugs and specific mental health problems, and identification of prevention and intervention strategies to prevent or alleviate certain crises of mental health because of the misuse of the drugs. materials and methods this work relies mainly on a primarily quantitative approach to assess the effects of the liberal use of drugs on psychiatric and behavioural disorders with a particular emphasis on mental health in the united states. the following is a description of the research design, the method of selecting the sample, the data collection techniques, and the analysis plan to facilitate clarity and replication. research design this study adopts a cross-sectional survey design to survey the connection between the unrestricted use of drugs and its impact on the disorders of the psychiatric and behavioural systems in the united states. the current study’s cross-sectional research design allows the accumulation of data from a diverse population within a certain period, which makes it easier to determine the relationship between variables (aljarallah et al., 2023). the research primarily adopts a quantitative approach because it allows the collection of numerical data that can be analysed statistically. this design is especially appropriate for studying drug use behaviours and their mutual relations with mental health outcomes, based on the findings of empirical research. sample size and selection the participants for this study are 378, based on the estimation to provide enough power for the test. the target participants are recruited through convenience sampling from several social media platforms to achieve a large sample and variability. recruitment is done through facebook, forums for people with mental health issues, and postings on bulletin boards. participants eligible for the study are any adult at least 18 years of age and a resident of the united states. these are the specific inclusion criteria set for this research to increase the chances of the sample representing the target population (mm rahman, 2023). an attempt is made to ensure that participants are selected from different age groups and genders, ethnicities, and socio-economic classes to increase the study’s external validity. data collection the data is generated by administering a self-completed online questionnaire that provides quantitative data on drug use, psychiatric state, and behavioural problems. the survey uses closed-ended questions that will elicit standardised responses that can be quantitatively analysed (alam, 2020). it is divided into topics such as demographic details, rate and kind of drug use, as well as self-identified psychological disorders. self-report scales, including but not limited to the data analysis the survey data collected is analyzed using statistical package for the social sciences (spss) software (okagbue et al., 2021). demographic data and the participant’s substance use history are summarised using measures such as mean, frequency, and standard deviation. descriptive statistical methods, correlation analysis, regression analysis, t-tests, etc., are used to study the association between drug use and various psychiatric and behavioural disorders (casella & berger, 2024). data management has become very efficient in spss, and the accuracy of the dataset cannot be questioned while processing it (pallant, 2020). moreover, chi-square tests are also used to test relationships between categorical variables, such as drug type and specific psychiatric symptoms. ethical considerations a recognised irb approves the study’s academic and practical aspects to ensure compliance with the research ethics (hayes, 2020). an informed consent form displayed at the onset of the online survey informs participants about the purpose, processes, and measures taken regarding privacy. all the respondents are volunteers and are free to pull out at any given time without repercussions. to ensure privacy, all data is anonymous, and the survey tool is set up so that no identifiable information, such as ip address, can be collected. strengths and limitations regarding the advantages of the chosen methodology, the following can be noted: accessibility of the web as a source of information, relatively low cost of the experiment, and the opportunity to reach many people from different geographical locations. using the online survey format provides easy sample recruitment and helps in fast data collection. however, some limitations should be mentioned. the use of self-reported data pa ge 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 1-8, 2025 adds the possibility of response biases like under or over-reporting of drug use or psychiatric symptoms. furthermore, the study’s cross-sectional nature and convenience sampling may reduce the generalisation of the results. nevertheless, the above limitations can be considered acceptable in light of the research aims and objectives for developing an understanding of the effects of drug use on mental health. results and discussions the results section provides demographic data, perceptions of the effects of drug use, and inter-observer reliability of the employed scales. it includes age and gender distribution, response to statements on mental health and its social aspect, the validity of the knowledge scale, mental health scale, social influence scale, and treatment efficacy scale. table 1: frequency table age frequency percent valid percent cumulative percent valid 18-24 years 23 6.1 6.1 6.1 24-30 years 90 23.8 23.8 29.9 31-36 years 147 38.9 38.9 68.8 37-44 years 93 24.6 24.6 93.4 45 years and above 25 6.6 6.6 100.0 total 378 100.0 100.0 table 2: gender gender frequency percent valid percent cumulative percent valid male 229 60.6 60.6 60.6 female 149 39.4 39.4 100.0 total 378 100.0 100.0 table 3: descriptive statistics descriptive statistics n minimum maximum mean std. deviation drug abuse is a leading cause of behavioral disorders in the united states. 378 1.00 5.00 3.4709 1.07316 most individuals are aware of the mental health risks associated with drug misuse. 378 1.00 5.00 3.5688 1.03354 there is sufficient public education about the psychiatric implications of drug use. 378 1.00 5.00 3.5291 1.06073 unrestricted drug use leads to long-term psychiatric disorders, such as anxiety and depression. 378 1.00 5.00 3.7937 .79438 behavioral disorders like aggression and impulsivity are often linked to substance abuse. 378 1.00 5.00 3.8571 .79168 the age frequency table below indicates the number of respondents in every age group. most of the participants, 38.9%, are between 31 and 36 years old and, therefore, can be deemed the largest group in this study. the second largest age group is 37-44 years, 24.6%. the third largest age group is between 24-30 years which is 23.8%. participants aged 18 years and below makeup only 6.1% of the study population, while those 45 years and above also form only 6.6%. this data is dominated by middleaged participants, which may cause a bias in the results if experiences or attitudes toward drug use differ depending on age. the gender frequency table shows that the sample includes more males, 60.6%, compared to females, 39.4%. such a situation may be attributed to demographic characteristics or study recruitment methods. participants included both males and females, though a more significant number of male participants could be seen as limitative in terms of gender-specific perception of drug use and its consequences. pa ge 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 1-8, 2025 drug use increases the likelihood of developing psychosis or similar mental health conditions. 378 1.00 5.00 3.8016 .78128 co-occurring mental health and substance use disorders are a growing concern in society. 378 1.00 5.00 3.8466 .74830 unrestricted drug use negatively affects family dynamics and relationships. 378 1.00 5.00 3.5053 .95313 communities suffer significant economic consequences due to drug-related mental health issues. 378 1.00 5.00 3.3757 1.04368 the stigma surrounding mental health and drug use prevents effective treatment. 378 1.00 5.00 3.7381 .86957 increased availability of drugs correlates with a rise in violent or criminal behaviors. 378 1.00 5.00 3.7778 .84836 there are sufficient resources for treating psychiatric disorders caused by drug use. 378 1.00 5.00 3.8730 .79438 early intervention programs are effective in reducing the mental health impact of drug use. 378 1.00 5.00 3.8280 .79090 restricting drug availability could decrease the prevalence of behavioral disorders. 378 1.00 5.00 3.8254 .81510 mental health services should prioritize addressing the impact of drug use. 378 1.00 5.00 3.8519 .75641 valid n (listwise) 378 the table of descriptive statistics contains the participants’ ratings of statements regarding the effects of drug use on mental health. the results on the likert scale (1-5) mean score are between 3.37 and 3.87, all above the middle point, indicating that the participants agree with the statements. the highest mean score reflects the statement for treating psychiatric disorders associated with the use of drugs, which can be interpreted as a positive attitude about the availability of treatments. as is the case with the previous statements, means for statements about mental illnesses and substance use disorders (3.85), the necessity of focusing on mental health services (3.85), and the connection between substance use disorders and behavioral disorders (3.86) are high. the results of the current study provide support for the assertion that participants understand the relationship between substance use and mental health issues. a relatively weaker consensus is indicated by lower mean scores like 3.37 for the statement regarding the economic effects of drugrelated mental health issues. this is shown in the standard deviations, which are 0.74 – 1.07. as earlier mentioned, statements like co-occurring disorders and psychosis have a slight standard deviation (0.74-0.79), which shows that there is consistency in the response. on the other hand, the scores of statements about public education (1.04) and economic consequences (1.04) are more volatile as the participants have perceived differently. these statistics give an insight into how people perceive drug use and mental health problems. scale: knowledge and awareness table 4: reliability statistics reliability statistics cronbach's alpha n of items .865 4 cronbach’s alpha for the knowledge and awareness scale is 0.865, which shows good reliability. this implies that all the items in this scale provide a valid indication of participants’ knowledge regarding drug use and its consequences. scale: mental health implications table 5: reliability statistics reliability statistics cronbach's alpha n of items .731 4 pa ge 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 1-8, 2025 the mental health implications scale has acceptable levels of reliability, as shown by cronbach’s alpha of 0.731. this indicates that the items successfully measure the participants’ knowledge of the effects of drug use on mental health. scale: social and economic impact table 6: reliability statistics reliability statistics cronbach's alpha n of items .775 4 table 7: reliability statistics reliability statistics cronbach's alpha n of items .807 4 the scale measuring social and economic impacts has cronbach’s alpha coefficient of 0.775. therefore, it is reliable. the items do tap into the perceptions of other social and financial implications of drug use. scale: treatment and prevention the reliability of the treatment and prevention scale is tested using cronbach’s alpha with a value of 0.807. this is in concordance with responses to questions on the adequacy and effectiveness of intercessions in the reduction of mental health consequences of substance use. discussion the study sheds light on the complex relationship between unrestricted drug use and its impact on mental health, highlighting participants’ perceptions of the challenges posed by substance abuse. the findings provide a comprehensive picture of the issue by examining key areas such as awareness, psychiatric implications, societal consequences, and the adequacy of treatment and prevention efforts. these insights align with existing literature, offering essential impact on public health policies and interventions. public awareness of risks a significant theme emerging from the study is the participants’ awareness of the risks associated with drug misuse. most respondents recognized the connection between substance abuse and its harmful effects on mental health. this general awareness reflects findings from nawi et al. (2021), which emphasized that knowledge about the dangers of drug use is crucial for reducing its prevalence. public understanding of drug-related risks is often shaped by education campaigns, which have gained prominence in recent years. however, the study also uncovered varying perceptions about the adequacy of public education on the psychiatric implications of drug use. this inconsistency mirrors critiques of bercaw et al. (2022), which highlighted the limited reach of some campaigns, particularly in marginalized communities. while awareness of general risks appears strong, the nuanced understanding of specific consequences, such as long-term mental health effects, remains uneven. strengthening educational initiatives tailored to diverse audiences could enhance the public’s ability to make informed choices, particularly in areas where drug misuse is prevalent. the connection between substance abuse and mental illness there was harmonious recognition of the severe impact of drug abuse on mental health among participants. the research also reestablishes the relationship between substance use and mental illness, including anxiety, depression, and psychosis. the preceding findings tally with price (2020), who pointed out that substance use is a risk factor for poor mental health. since chronic drug exposure affects brain function, it makes the users vulnerable to these conditions, as described by salmanzadeh et al. (2020). mental health and substance use disorders were the fastest-growing dual diagnoses to surface. this coexistence of these two disorders makes it difficult to treat and manage the affected persons. according to van (2023), the national institute on drug abuse, these issues must be solved through the integrated care model. the latter was evident in perceptions expressed by participants who acknowledged the need for integrated care models that address the multiple needs of users. although the results also show that most participants agree with the statements stating that drug misuse has adverse effects on mental health, variation across participants’ responses to these statements might indicate differences in their perception. for instance, participants had slightly divergent views on the degree to which early intervention can help prevent psychiatric effects. these variations may be due to different experiences with the treatment or different education on mental health status. peoples and existing economy impacts of substance use alcoholism and drug addiction are not limited to the pa ge 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 1-8, 2025 individual, but rather, it has widespread effects on families, communities, and even within the society. they both pointed out that participants were aware of the stress that drug misuse has on relationships and interactional patterns. these results are consistent with mi naples (2021), which pointed out that drug use in the united states was costing hundreds of billions of us dollars annually through healthcare costs, reduced productivity, and criminal justice costs. however, the study failed to establish whether the participants had any awareness of the economic impact of drug-related mental health problems. concerning financial consequences, the mean ratings given to statements were a little lower than those given to other items. these differences are consistent with the observation that people’s discussions mainly focus on the consequences for themselves and not on the overall economy (drupp et al., 2021). enhancing people’s knowledge of the economic consequences of substance abuse might expand the community’s involvement in programs to prevent substance use and support recovery. the study also reveals that participants experienced many prejudices related to substance use and mental health that act as a barrier to the treatment process. this observation is consistent with the findings of na et al. (2024), who stressed that stigma discourages people from seeking support and weakens the impact of community health programs. stigma reduction is significant when it comes to education and community involvement, as people embrace those affected and accept them back into society. treatment and prevention: optimism and gaps regarding the availability of resources, participants seemed to have faith in the available resources and also the early intervention programs, stating that there exist enough resources to deal with mental health due to substance use. this concurs with thapar et al. (2022), who noted that preventive interventions, if sustained in the long term, were more advantageous, especially for the young population. with early intervention, it is possible to interrupt the continuum of substance use and related mental health consequences, thus lessening the total disease load on the healthcare system. however, these findings also highlighted differences in the perceived treatment adequacy between the two groups. in terms of access to mental health services, participants observed that it was inconsistent, especially concerning marginalised communities. this finding is supported by the substance abuse and mental health services administration, which pointed out that rural and lowincome populations are the most deprived of access to care (reilly, 2021). increasing the scope of telemedicinerelated activities and extending community programs can help overcome these gaps, avoiding any person’s lack of necessary resources. another recognizable theme was the emphasis on the importance of the integrated care approach to treating dual diagnosis. they stressed that mental health services should be incorporated into more general health care systems. this aligns with the world health organisation’s recent push to move substance abuse treatment into primary care contexts (world health organisation, 2020). integrated care models of treating mental health and substance use can enhance the treatment results and minimize the patient’s relapse. substance abuse: a holistic view the results of this study provide a clear picture of the various ways in which drug abuse affects mental health and society. there is consensus from the participants’ responses about the need for specific strategies, education, and fair distribution of resources. such observations are in line with various research studies, which highlight that a global approach should be used to tackle the issue of substance use. jemberie et al. (2020) pointed out that the management of substance use should be focused on prevention, treatment, and community mobilisation. the conclusion of this study can affirm the presented perspective concerning individual and societal dynamics. for instance, the participants’ recognition of the social and economic impacts of substance use shows that there should be policies that deal with the causes of substance abuse, including poverty and illiteracy (amaro et al., 2021). the study also also also emphasises the importance of public awareness in the creation of attitudes toward drug use. participants understand general risk, but knowledge deficits related to specific areas, such as the economic impact, are evident. targeted education campaigns could help reduce these gaps and promote a better-informed society and better able to act in its interests. policy and practice implications the findings of this study have the following policy, practice, and community implications for policymakers, healthcare practitioners, and community stakeholders. first, the findings call for improved public awareness campaigns that focus on the risks associated with drug use to the user and the whole society. therefore, the campaigns should be targeted to different audiences so that the stakeholders can help enhance people’s awareness of various issues to encourage healthier choices. second, detecting the dual diagnosis emphasizes the need for an integrated treatment approach. the authors also recommend that the funding should go to programs that address mental health and substance use disorders (alegría & frank, 2024). integrated care contributes not only to the better situation of a particular patient but also to the decrease in overall demands on a healthcare system. third, the variation in the perceived adequacy of treatment means that resources should be distributed. teledermatology, m-health, health fairs, and continuing medical education for physicians may be ways of providing care in underserved areas. thus, the increase in the availability of mental health services is crucial for meeting the needs arising from substance abuse. lastly, reducing stigma is still an important issue of concern. the study shows that stigma in society regarding mental illness and substance use is still a significant barrier to pa ge 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 1-8, 2025 the advancements of treatment and rehabilitation. the stakeholders can develop a system that encourages people to find support and recover thanks to the focus on open discussion and involving the public. conclusion this study aimed to identify the effects of unrestricted drug use on psychiatric and behaviour disorders in the united states for the chosen themes during primary quantitative methodology, including awareness, mental health effects, social impact, treatment, and preventive measures. the results also show the importance of the substance abuse treatment dilemma and the multifaceted impact of the disorder on people, families, and societies. the participants had a good general knowledge about some of the dangers of substance abuse and the relationship between substance abuse and psychiatric disorders, including anxiety, depression, and psychosis. nonetheless, there are also weaker points in the finetuning of the understanding, including the issue of the economic cost and the sufficiency of the public schools. early intervention and availability of treatment were two things that most of the respondents agreed on, as expressed in this study. however, still, the finding indicated that equal access to treatment is still a big concern, especially for the minority population. mental health and substance use disorders were found to coexist, and the strategies that were named as important included integrated care approaches and equitable distribution of mental health services. also noteworthy was the identification of the problem of prejudice associated with taking drugs and having mental disorders, which prevents people from seeking help. the study resonates with empirical literature to emphasize the importance of integrated and complex approaches toward addressing the mental health effects of drug abuse. public awareness, polyclinical care, and fair distribution of resources need to be taken up by policymakers and healthcare managers. through supporting such changes and implementing evidence-based policies and interventions to overcome such challenges, the stakeholders involved can enhance the community’s outlook and handle substance use disorders and related mental health complications. reference alam, m. k. 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(2020). operational framework for primary health care: transforming vision into action. retrieved from https://iris.who.int/bitstream/hand le/10665/337641/9789240017832-eng.pdf pa ge 1 pa ge 17 5 american journal of medical science and innovation (ajmsi) primary spontaneous splenic rupture: a rare and life-threatening condition ahmed anaizi1*, othman al-dabbagh2 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2122 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: october 07, 2023 accepted: november 03, 2023 published: november 07, 2023 this case report outlines the presentation, diagnosis, and management of a 26-year-old male with primary spontaneous splenic rupture, a highly uncommon clinical condition. primary spontaneous splenic rupture necessitates a high index of suspicion for accurate diagnosis. diagnostic imaging, particularly abdominal ct scans, is pivotal in its detection. this case underscores the critical importance of timely recognition and intervention. clinicians should consider various inflammatory, neoplastic, and infectious etiologies in the differential diagnosis of splenic rupture. physical examination revealed tenderness and guarding, predominantly in the left upper quadrant and left flank. laboratory findings indicated an elevated white blood cell count, predominantly polymorphonuclear leukocytes. contrast-enhanced ct scan showed substantial free fluid in the acute abdomen, with high density observed around the liver and spleen. exploratory laparotomy confirmed hemoperitoneum and spontaneous splenic rupture. this case report highlights the rarity of primary spontaneous splenic rupture and emphasises the significance of early detection and intervention. through examination and advanced imaging techniques, clinicians can accurately diagnose and promptly manage this life-threatening condition. keywords splenic rupture, acute abdomen, hemoperitoneum, diagnostic imaging, laparotomy 1 internal medicine, mediclinic hospital, abu dhabi, uae 2 surgical department, marbella medical center, al-ain, abu dhabi, uae * corresponding author’s e-mail: ahmedanaizi011@outlook.com introduction primary spontaneous splenic rupture, an infrequently encountered but exceptionally critical medical phenomenon, signifies the abrupt and atraumatic rupture of a previously unremarkable spleen (borio et al., 2022). atraumatic splenic rupture, though rare, poses a potentially life-threatening situation. unlike traumatic cases, this occurrence involves splenic rupture in the absence of any external force or injury (bona, 2020). unlike secondary ruptures, which are often precipitated by trauma or underlying pathologies, this condition manifests without any apparent antecedent cause, presenting a diagnostic problem for healthcare providers (wu et al., 2022). this enigmatic presentation can encompass a spectrum of symptoms, often bereft of overt clinical indicators, further complicating the diagnostic process (bain, 2023). the potential for severe bleeding and its associated complications confers a pressing need for a swift and precise diagnosis, underscoring the urgency of timely intervention (saceleanu et al., 2023). a comprehensive review of 845 cases from the available literature revealed the primary factors leading to hypersplenism, which include neoplastic conditions such as leukaemia and lymphoma, accounting for 30 per cent, infections like infectious mononucleosis, cytomegalovirus (cmv), hiv, endocarditis, and malaria contributing to 27 per cent, and inflammatory diseases or non-infectious disorders like acute and chronic pancreatitis making up 20 per cent, additionally, drug and treatment-related causes, such as anticoagulation, granulocyte colony-stimulating factor (g-csf), thrombolytic therapy, and dialysis, were identified in 9 per cent of cases (onyango et al., 2023). mechanical factors, including pregnancy-related conditions and congestive splenomegaly, constituted 7 per cent, while idiopathic cases with a normal spleen accounted for the same percentage; the overall mortality rate was 12 per cent, with risk factors for mortality encompassing splenomegaly, age over 40 years, and the presence of a neoplastic disorder, of the cases, 84 per cent underwent splenectomy. at the same time, conservative measures were adopted for the remaining cases (renzulli et al., 2009). this intriguing case report serves as a stark reminder of the critical need to consider spontaneous splenic rupture in patients experiencing acute abdominal pain, especially in the absence of any traumatic events. the enigmatic nature of this condition, devoid of apparent antecedent causes, presents a diagnostic puzzle for healthcare providers. timely recognition and intervention are paramount in navigating this complex medical scenario, ultimately holding the key to favorable outcomes for those grappling with this rare and potentially life-threatening ailment. case presentation the patient, a 26-year-old male, arrived at the al-noor hospital’s emergency room on june 1st, 2011, seeking urgent medical attention for acute and distressing abdominal pain. the patient was having discomfort, which had emerged abruptly the previous night and had since evolved into a progressively diffuse sensation, significantly causing pain by even the slightest movement; lying down provided relief to the patient. notably, he also experienced an episode of emesis, which was described as non-coffee ground in nature, and had one loose bowel movement. encouragingly, there was no indication of fresh blood in either the emesis or the stool, alleviating concerns of gastrointestinal bleeding. the patient denied any history of fever or chills, pointing towards an afebrile state. pa ge 17 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 175-179, 2023 in addition to the abdominal discomfort, the patient explained the alarming circumstances of symptoms and reported feelings of giddiness accompanied by a pronounced sense of weakness. these sensations were coupled with palpitations, indicating potential cardiac involvement. the patient noted sweating, which further highlighted the severity and distressing nature of his condition. moreover, he reported no known allergies, was a non-smoker and non-alcoholic, and worked as a policeman. he was married and had one healthy child. this study indicated mild erosive esophagitis and gastroduodenitis, both of which had shown improvement with esomeprazole therapy. the patient’s medical history revealed epigastric pain and dyspepsia, which had been thoroughly evaluated through endoscopy in september 2008. remarkably, the patient had been asymptomatic for the past two years and denied any significant recent or past traumas. on initial examination, the patient appeared pale, apprehensive and had a dry mouth. notably, there were no signs of jaundice, clubbing, or palmar erythema. palpable lymph nodes were absent. vital signs recorded a blood pressure of 120/70mmhg in the supine position, which dropped to 80/40 upon standing, associated with pre-syncope. the heart rate was 103 beats per minute, regular, with a respiratory rate of 19 breaths per minute. oxygen saturation was 99%, and temperature was within normal range at 37°c. cns examination revealed intact function, while abdominal examination indicated diffuse tenderness with guarding, more pronounced in the left upper quadrant and left flank. organomegaly was difficult to check due to the tenderness. there were no abnormal masses or bruising observed, and the hernial orifice was free. later, laboratory investigations provided crucial insights into the patient’s haematological and biochemical profile. haemoglobin level was measured at 12.3g/dl, indicating a normal range, which is (12.1 to 15.1 g/dl) but slightly lowered haemoglobin concentration. hematocrit registered at 36%, demonstrating a balanced proportion of red blood cells in the blood volume. the red blood cell count was 4.4 million/ml, aligning with standard physiological ranges. white blood cell count, however, presented as elevated at 14,500 cells/ml. further differentiation revealed a predominance of polymorphonuclear leukocytes, accounting for 63% of the total count. lymphocytes constituted 30%, monocytes were present at 5%, while basophils and eosinophils made up trace amounts. these findings indicated a heightened inflammatory response, potentially suggestive of an acute pathological process. additionally, biochemical analyses showed no significant abnormalities; results were in the normal range. notably, liver function tests, including sgot, sgpt, and alkaline phosphatase, were within normal limits. serum amylase was also normal. electrolytes, including potassium, sodium, and chloride, were within physiological ranges. laboratory examination results are presented in table 1. table 1: laboratory examination results laboratory examination results normal range hb 12.3 g/dl 12.1 to 15.1 g/dl ht 36% 41% to 50% red blood cell count 4.4mill/ml 4.7 mill/ml to 6.1 mill/ml wbc 14500 4500 to 11,000 pmn 63% 40% to 65% lymph 30% 20% to 40% mono 5% 2% to 8% baso, eosino 1% baso: 0.5% to 1%, eosino: 1% to 4% mcv 82.4 80–100 mch 27.1 27 to 31 mchc 33.8% 32–36% plt 455,000 150,000 to 450,000 b. urea 29 mg/dl 5 to 20 mg/dl creatinine 0.6 mg/dl 0.74 to 1.35 mg/dl sgot 17 8 to 45 sgpt 20 7 to 56 alp 74 44 to 147 amylase 92 40 to 140 pottasium 4.1 mmol/l 3.5 to 5.5 sodium 142 mmol/l 135 to 145 chloride 112 96 to 106 bilirubin 0.42 0.1 to 1.2 pa ge 17 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 175-179, 2023 as mentioned in figure 1, a ct scan of the abdomen and pelvis was performed, which revealed significant free fluid in the abdominal cavity, with high density observed around the liver, spleen, flanks, and pelvis. there was no evidence of intra-abdominal or retroperitoneal mass lesions. based on the imaging findings, the patient underwent an explorative laparotomy, which confirmed the diagnosis of hemoperitoneum. intraoperatively, blood clots were predominantly found in the upper abdomen, around the omentum and spleen, with evidence of blood oozing near the splenic hilum. consequently, a splenectomy was performed to address the spontaneous rupture of the spleen. the histopathology report revealed that the preoperative diagnosis of acute abdominal bleeding was confirmed through examination of the specimens. the first specimen consisted of a single piece of fatty tissue displaying severe haemorrhage throughout, measuring 6 x 4 x 0.5 cm. this sample was meticulously sectioned, and various parts were processed (block x2). the second specimen, the spleen, was intact and measured 11 x 5.5 x 2 cm. it was appropriately sectioned and underwent partial processing (block x4). upon microscopic examination, the first specimen revealed matured fatty tissue with extensive, fresh haemorrhage pervading nearly the entire field. no atypia or signs of malignancy were observed. the examination of the splenic tissue in the second specimen unveiled notable infiltration of neutrophilic cells in the subcapsular region and along the tear’s edges, accompanied by multiple areas of intraparenchymal haemorrhage. additionally, moderate lymphoid hyperplastic changes were noted. as with the first specimen, no atypia or malignancy indicators were detected. these histopathological features align closely with the clinical impression of a traumatic splenic tear or rupture. there was no evidence of atypia or malignancy in either specimen. the histopathology report is shown in figure 2. post-splenectomy was crucial to implement measures to mitigate the risks associated with functional asplenia, which included vaccination against encapsulated pathogens, prophylactic antibiotics, and vigilant monitoring for potential complications. in this case, the surgery was prescribed to treat the patient. the case emphasises the importance of heightened clinical awareness to facilitate prompt diagnosis and surgical intervention in cases of primary spontaneous splenic rupture, a rare but potentially life-threatening condition. figure 1: ct-scan results figure 2: histopathology report pa ge 17 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 175-179, 2023 discussion primary spontaneous splenic rupture is an exceedingly rare clinical entity, with only a limited number of cases reported in the literature. the condition poses a diagnostic challenge due to its elusive presentation and absence of antecedent traumatic events. spontaneous splenic rupture, while a rare phenomenon, commands immediate attention and precise diagnosis owing to its potentially fatal consequences. this case report underscores the critical importance of recognising and promptly addressing this life-threatening condition. this classic presentation aligns with previous reports of primary spontaneous splenic rupture (borio et al., 2022). the absence of fever or chills, along with the lack of a history of trauma, further supports the diagnosis of atraumatic splenic rupture. as mentioned in table 1, laboratory investigations revealed an elevated white blood cell count, predominantly composed of polymorphonuclear leukocytes. this finding is consistent with an acute inflammatory process, which is commonly observed in cases of splenic rupture (borio et al., 2022; wu et al., 2022). as shown in figure 1, imaging played a pivotal role in the diagnosis of primary spontaneous splenic rupture. the contrast-enhanced ct scan revealed significant free fluid in the abdominal cavity, with high density observed around the liver, spleen, flanks, and pelvis. this imaging finding corroborated the clinical suspicion and guided subsequent surgical intervention. the role of ct scans in detecting splenic rupture has been emphasised in previous studies (bain, 2023; saceleanu et al., 2023). in figure 2, the histopathological examination of the spleen confirmed the diagnosis, revealing notable infiltration of neutrophilic cells along the tear’s edges, along with areas of intraparenchymal haemorrhage. these findings are consistent with the clinical impression of a traumatic splenic rupture; no evidence of atypia or malignancy was detected, further supporting the diagnosis of primary spontaneous splenic rupture (crowley et al., 2021). the aetiology of spontaneous splenic rupture remains elusive, with various theories proposed yet lacking robust empirical support; these conjectures range from localised splenic pathologies obliterating evidence upon rupture to reflex splenic vein spasms causing acute congestion, chronic portal venous congestion, recurrent torsions in mobile spleens, and potential ruptures of degenerative splenic arteries further contribute to the complexity, notably, spontaneous splenic rupture has been documented in a spectrum of medical conditions, historical cases, from rokitansky in 1861 to atkinson in 1874, provide context (dunphy et al., 2019). the diagnostic landscape in cases of spontaneous splenic rupture is notoriously challenging, primarily due to its symptomatic resemblance to an array of acute abdominal conditions (bax et al., 2022). the absence of a history of trauma related to the classic signs of abdominal pain and guarding raised concern for the healthcare team. furthermore, the presence of high-density free fluid surrounding vital organs, as presented in the ct scan, strongly suggested bleeding or pus, compelling the medical team to opt for explorative laparotomy (hoeg, 2022). despite advancements in medical science, the precise aetiology of spontaneous splenic rupture remains an enigma in many instances; theorised causes ranging from reflex spasm of the splenic vein to portal venous congestion and an abnormally mobile spleen only add layers to the diagnostic challenge, distinguishing spontaneous splenic rupture from other causes of acute abdominal pain, including gastrointestinal and cardiac conditions, demands a nuanced approach (yaäÿmurkaya et al., 2021). clinicians must maintain a vigilant stance, keeping spontaneous splenic rupture on their diagnostic radar, especially when presented with classic symptoms. surgical intervention, such as splenectomy or partial splenectomy, remains the mainstay of treatment, although non-operative management may be considered in this case. additionally, it is important to address any underlying predisposing conditions, such as infectious mononucleosis or hematologic disorders, to prevent recurrence (lin et al., 2022). the presented case serves as a reminder of the complexities inherent in medical diagnoses and ensuring the well-being of patients facing rare and challenging conditions like spontaneous splenic rupture. conclusion in conclusion, this case of spontaneous splenic rupture underscores the need for heightened clinical awareness and interdisciplinary collaboration in rare medical emergencies. advanced imaging and collaboration among specialists play a transformative role in diagnosis and management. understanding diverse etiologies and postsplenectomy complications equips clinicians to deliver timely and highly effective care. this study ensures optimal patient outcomes and guides future research and innovation in rare medical conditions. strengths and limitations this report offers a thorough clinical presentation and supports the diagnosis with histopathological evidence. it effectively places the case in context with existing literature, emphasising the need for early intervention. however, due to the rarity of the condition, generalizability may be restricted. the study is based on a single case, and longterm follow-up is absent. references bain, b. j. 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(2021). spleen rupture due to brucellosis. turkish journal of surgery, 37(1), 73. pa ge 1 pa ge 18 5 american journal of medical science and innovation (ajmsi) follicular lymphoma in a young male: a case report ahmed anaizi1*, issam mayhoub mayhoub1, said huwaijah1 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2143 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: october 09, 2023 accepted: november 05, 2023 published: november 08, 2023 follicular lymphoma is an uncommon cancer that involves b-cells in germinal centres. non-hodgkin’s lymphoma is also significantly represented by follicular lymphoma; different morbidity figures are observed in some countries. this case report describes the clinical journey of a 33-year-old man whose shortness of breath, worsening cough, along systemic symptoms culminated in a diagnosed case of follicular lymphoma. hepatosplenomegaly was observed on clinical examination, and laboratory blood tests showed lymphocytosis and significant lymphadenopathy. quick diagnostic imaging such as ultrasound and x-rays/ct scans was instrumental in determining disease extent. later, following further discussions between a haematologist-oncologists at the tertiary care centre and a definitive biopsy of lymph nodes,, the final diagnosis was affirmed as follicular lymphoma, grade 1a, accompanied by circulating lymphoma cells in the peripheral blood. this incident exemplifies the significance of identifying follicular lymphoma at an early stage, conducting a thorough evaluation, and involving many medical specialists in treating it. for optimal outcomes in patients with follicular lymphoma, timely interventions and tailored treatments may be necessary. keywords follicular lymphoma, nonhodgkins lymphoma, lymphadenopathy 1 department of mediclinic, al ain hospital /al ain region, central district, abu dhabi, united arab emirates * corresponding author’s e-mail: ahmedanaizi011@outlook.com introduction fl is a relatively common systemic neoplasm characterised by the differentiation of b cells of the germinal centre (carbone et al., 2019). this is about 5% of all blood cancers and approximately 20-25% of new cases of non-hodgkin lymphomas in western countries (carbone et al., 2019). fl is the second most prevalent lymphoma in the united states, with an estimated annual diagnosis of approximately 14,000 patients(batlevi et al., 2020). fl exhibits variations in its prevalence across regions, with it being less common in central and south america, accounting for 20% of all nonhodgkin lymphomas(carbone et al., 2019). fl does not display a strong prediction for either gender. however, its incidence tends to rise with advancing age, with a median age at diagnosis of 65 years, rarely manifesting in children and adolescents(batlevi et al., 2020). although there is a slightly increased risk of fl among individuals with affected relatives, the absolute risk remains relatively low(carbone et al., 2019). fl’s oncogenic journey begins in precursor b-cells and culminates in a fully developed tumour upon reaching the terminal centre maturation stage. the diagnosis of fl hinges upon histological analysis of a biopsy obtained from affected lymph nodes, with preference given to incisional biopsies to facilitate grading and transformation assessment(freedman & jacobsen, 2020). a defining genetic hallmark in the majority of fl cases is the t(14,18) translocation involving the igh/bcl-2 genes(freedman & jacobsen, 2020). rituximab, often in combination with chemotherapy, is effective but not curative for treating fl(cahill & smith, 2022). lenalidomide and rituximab provide a chemotherapy-free option for both initial and relapsed cases(cahill & smith, 2022). replace patients may benefit from pi3 kinase inhibitors and anti-cd20 therapy, with stem cell transplantation rarely needed(freedman & jacobsen, 2020). our case report seeks to provide valuable insights into the challenges and multidisciplinary approaches involved in diagnosing and treating this haematological malignancy, ultimately contributing to medical knowledge and improving patient care in similar cases. case presentation a 33-year-old male presented on may 30th 2023 at al ain hospital /al ain region, central district abu dhabi united arab emirates, with a chief complaint of worsening shortness of breath over the past four weeks. he also reported experiencing a cough that worsened when lying flat on the back. the patient reported that the shortness of breath had progressively worsened over the last month. initially, he experienced it only with physical exertion, but it advanced to the point where he felt shortness of breath even during minimal activity like walking 10 meters. notably, he observed that the cough became more pronounced when he lied down. additionally, he reported orthopnea, which was difficulty breathing when lying flat , and tachypnea. the patient was informed about the cervical lymphadenopathy in 2019 and was advised, as per the patient’s statement, to consult a dentist. remarkably, over 4.5 years, the patient did not seek any medical attention or consult with any physician regarding this issue, suggesting a prolonged period of unaddressed concern related to cervical lymphadenopathy. on initial examination at the hospital, the patient was obese and had a pale complexion. he also experienced diaphoresis, characterised by excessive sweating. clinical pa ge 18 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 185-191, 2023 figure 1: laboratory results examination revealed that the patient exhibited significant sinus tachycardia, with a heart rate exceeding 120 beats per minute. upon auscultation of the posterior chest, bilateral crepitations was noted. the patient’s oxygen saturation (spo2) was measured at 94%. the patient presented with generalised lymphadenopathy, observed in both sides of the neck, axillae, and inguinal region. while the abdomen was soft to palpation, it appeared distended due to significant hepatosplenomegaly. an ecg confirmed sinus tachycardia. laboratory findings included high figure 2: peripheral smear report crp, an esr of 74, significant lymphocytosis, a white cell count of 27,000, and an hb level of 8.1 g/dl. peripheral smear results raised concerns about haematological abnormalities (figure 1). the peripheral smear report reveals leukocytosis with a significant presence of mature lymphocytes characterised by cleaved nuclei and smudged cells, as shown in figure 2 below. platelet counts remain within adequate levels. these haematological findings are suggestive of a clinical condition associated with lymphoma. urgent diagnostic imaging was undertaken, including ultrasound and x-ray examinations, followed by subsequent ct scan of the neck/thorax, abdomen and chest. these diagnostic procedures were conducted promptly to assess the patient’s medical condition and obtain detailed information about the relevant anatomical areas. the ultrasound of the upper abdomen shown in figure 3 reveals an enlarged cirrhotic liver measuring approximately xxx cm with a nodular echo pattern, suggestive of cirrhosis. the left portal vein is patent with normal diameter and the intrahepatic bile ducts and liver vasculature appear normal. the gallbladder is normal in size, configuration and contour with no gallstones seen. the pancreas is clearly visualized due to colonic gas and appears normal. the spleen is significantly enlarged, measuring approximately 22 cm. both kidneys are of average size and normal sonographic structure with clear perinephric facial planes, no renal stones or cysts/ masses seen, and no hydronephrosis. there is significant lymphadenopathy noted at the iliac chains bilaterally with compression of the bladder. pa ge 18 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 185-191, 2023 the chest x-ray, as shown in figure 4 below, showed marked enlargement of both hila in the lungs, primarily attributed to lymphadenopathy. additionally, interstitial pulmonary infiltrates were identified in both lung fields, suggesting the presence of abnormal cells within the interstitial spaces of the lungs. furthermore, extensive lymphadenopathy at the iliac chains bilaterally was observed, which was causing compression of the bladder and may lead to urinary symptoms. moreover, hepatosplenomegaly was evident, with the liver displaying clear enlargement and a nodular echo pattern, particularly at the left lobe. the neck ultrasound assessment (figure 5) showed normal lymph nodes in the neck. the results indicated the presence of numerous enlarged lymph nodes on both sides of the neck. additionally, there were hypoecholic lesions observed within the parotid glands on both sides. the preserved fatty hilum within the enlarged lymph nodes suggested characteristics typically associated with reactive lymph nodes. the radiographic findings from the ct scan of the chest and thorax, shown in figure 6 below, showed noticeable lymph node enlargement. the most significant enlargement was seen in the submandibular region, where the largest nodule measured 2.3cm in diameter. it was also noted that there were retrocrural lymph nodes, particularly on the left side. additionally, it was discovered that the internal and pericardial mammary chains had lymphadenopathy. interestingly, the intralobular septations in the lungs showed a noticeable figure 3: ultrasound upper abdomen figure 4: chest x-ray pa ge 18 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 185-191, 2023 thickening, which suggested lymphangitis carcinomatosis. small pulmonary nodules were also present, which were most obvious in the midzone of the right lung. in both axillary regions, there was also significant lymph node enlargement, with some lymph nodes growing as large as 4 cm. the ct scan of the abdomen and pelvis revealed important liver-related findings. figure 7 illustrates these findings, which included liver enlargement and the presence of a nodular echo pattern, which was most obvious in the left lobe. the portal vein remained open, which was significant because it showed continuous blood flow. the intrahepatic bile ducts and liver vasculature also looked normal, and the portal vein’s diameter and patency were within normal limits. there were no clearly visible gallstones inside the gall bladder, which had a typical size, shape, and contour. there were no notable abnormalities in the liver’s surrounding region. the common bile ducts maintain a normal diameter and patency. hepatic segment inferior vena cava demonstrates a typical diameter with unobstructed hepatic vein patency. additionally, the spleen is notably enlarged, measuring 22cm. lastly, figure 5: neck ultrasound report figure 6: ct chest/thorax (without and with contrast) pa ge 18 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 185-191, 2023 significant lymphadenopathy was observed at the iliac chains, resulting in compression of the bladder. the images show significantly enlarged lymphadenopathy in the neck, abdomen, pelvis, axillary, and inguinal regions, among other body parts. hepatosplenomegaly was also seen, which points to lymphoma. excisional lymph node biopsy was highly advised in order to confirm the diagnosis and carry out a thorough assessment. the case was discussed with a haemato-oncologist at tawam hospital, a tertiary hospital in the emirate of abu dhabi. the haemato-oncologist recommended performing a lymph node biopsy to definitively confirm the diagnosis, a crucial step for acceptance into their department. simultaneously, the patient was advised to initiate treatment with dexamethasone and allopurinol, medications that were prescribed to manage the condition. following the referral for a lymph node biopsy, the patient was initially scheduled to undergo the procedure at the facility hospital; however, the patient did not attend. subsequently, the patient sought care at tawam hospital. there, the lymph node biopsy was successfully performed on july 12th 2023, and the results confirmed the final diagnosis of follicular lymphoma, specifically grade 1a. notably, circulating lymphoma cells were detected in the patient’s peripheral blood. fortunately, the absence of b symptoms in the clinical presentation indicated a relatively less aggressive form of the disease. this multidisciplinary approach underscores the importance of accurate diagnosis and the immediate initiation of appropriate treatment in managing the patient’s medical condition. these findings were pivotal for guiding the subsequent management and treatment plan for the patient’s condition. in the tertiary hospital, a thorough workup was conducted for the patient diagnosed with fl to precisely determine the extent of the disease and devise an optimal treatment approach. this evaluation included a thorough physical examination with an emphasis on the size of the liver, spleen, and areas that contained lymph nodes. the clinical performance status and the presence of b symptoms were evaluated to assess general health and symptomatic presentation. a full metabolic panel was used in the laboratory tests to assess metabolic parameters, as well as a complete blood count with differential and ldh measurements to track blood cell levels and disease activity. a treatment plan of bendamustine and rituximab/ obintuzumab was discussed with the patient. this will be followed by maintenance therapy with rituximab or obintuzumab. an alternative of chop-r (cyclophosphamide, doxorubicin, vincristine, prednisone plus rituximab) chemotherapy followed by rituximab maintenance was also recommended, if the patient’s disease is limited to follicular lymphoma. due to the patient’s age and fertility concerns with chemotherapy, fertility issues were discussed in detail. the patient was counselled on the potential risks to fertility from chemotherapy and the recommendation was made for him to pursue sperm banking prior to starting treatment. figure 7: ct abdomen and pelvis (without and with contrast) figure 8: final diagnosis pa ge 19 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 185-191, 2023 all treatment options, potential side effects, risks and benefits were properly explained to the patient and an informed consent was obtained. a high-quality pet-ct scan was essential in identifying nodal and extranodal disease involvement during imaging studies. to assess cytopenias and record the disease stage, a bone marrow biopsy and aspirate were carried out. the patient had stage 4 flipi risk 4 and a grade 1a fl, with an estimated 10-year survival rate of 35% and a leukemic phase. the importance of a multidisciplinary approach to fl management is highlighted by the fact that this thorough workup served as the basis for creating a treatment plan that took into account the disease stage, risk factors, and the patient’s general health and fertilityrelated needs. discussion fl is characterised by its indolent nature, slow progression, and favourable outcomes, with an annual incidence of approximately 3.18 cases per 100,000 individuals. this incidence, while stable over time, exhibits variations with ethnicity, with the highest occurrence among white individuals. fl accounts for a significant portion of nonhodgkins lymphoma cases. fl typically presents in older individuals, with a median age of >60 years at diagnosis (freedman, 2018; freedman & jacobsen, 2020). however, our patient’s relatively young age at presentation highlights that fl can occur in younger adults, although it remains less common in this age group. this observation aligns with the rarity of fl in pediatric and adolescent populations. fl presents insidiously with lymphadenopathy, often involving cervical, axillary, or inguinal lymph nodes. patients may also experience systemic symptoms such as fever, night sweats and unintentional weight loss, referred to as b symptoms (alnoor, gandhi, stein, & gradowski, 2020; dada, 2019). the diagnosis of fl relies on histological examination of a biopsy to assess grade and transformation potential accurately(dada, 2019). immunohistochemical staining is essential for confirming fl, with characteristic markers cd19, cd 20, cd10 monoclonal immunoglobulin and cytoplasmic expression of bcl-2 protein (agostinelli et al., 2019; alnoor et al., 2020). a case report by tomohiko tanigawa et al. (2019) illustrates the occurrence of histological transformation from grade 1 fl to diffuse large b cell lymphoma. despite initial observation, the fl eventually transformed, leading to widespread involvement and resistance to standard chemotherapy (tanigawa et al., 2019). in another case study by sarah péricart et al. (2019), a 65-year-old man presented with a large abdominal mass and lymphadenopathy, raising suspicion of lymphoma(péricart et al., 2020). biopsy revealed large tumour cells expressing histiocytic markers but lacking lymphoid markers. the diagnosis was histiocytic sarcoma (hs). due to clinical and histological discordance, further lymph node biopsy was performed to confirm the diagnosis(péricart et al., 2020). the literature revealed that both fl and hs tumours exhibited the t(14,18) translocation and shared clonal rearrangement, suggesting a clonal relationship between the two malignancies (péricart et al., 2020). furthermore, the patient’s leukocytosis with mature lymphocytes and smudged cells on the peripheral smear is consistent with haematological abnormalities often observed in lymphomas(chabot‐richards & george, 2014). this reinforces the significance of haematological assessments in the diagnostic workup of lymphoma patients. the treatment approach for fl depends significantly on the disease stage at the time of diagnosis (lu, 2005). patients with stage i disease, where the lymphoma is localised to one lymph node region or organ, often undergo radiation therapy (los-de vries et al., 2022). in contrast, patients diagnosed with stage iii or iv disease, collectively termed “advanced stage,” are not typically curable with conventional therapies(attarbaschi et al., 2020). instead, the focus shifts towards managing fl as a chronic condition with an emphasis on symptom control and improving the patient’s quality of life(lu, 2005). many individuals with stage iii or iv fl receive a combination of various treatment modalities over time, including immunotherapy, chemoimmunotherapy, and radiation therapy, often administered in different sequences with periods of active therapy followed by observation and surveillance(attarbaschi et al., 2020; losde vries et al., 2022). ultimately, the choice of treatment is tailored to the individual patient’s specific clinical presentation and needs, with the goal of optimising outcomes and minimising the impact of fl on their daily life. conclusion the case reports underscore the significance of early diagnosis, thorough evaluation, and a multidisciplinary approach in managing fl grade 1a. despite its indolent nature, fl can manifest in individuals of varying ages. the absence of b symptoms indicated a relatively less aggressive form of fl, offering a more favourable prognosis. this case emphasises the importance of tailored treatment strategies to optimise outcomes in fl and highlights the ongoing need for research and clinical experience to enhance fl management. limitations the report can not be generalised as it focuses on a single case. another limitation of the case is the missing longterm follow-up and management of the case, which could have given more information about the case. references agostinelli, c., akarca, a. u., ramsay, a., rizvi, h., rodriguez-justo, m., pomplun, s., . . . daw, s. (2019). novel markers in pediatric-type follicular lymphoma. virchows archiv, 475, 771-779. alnoor, f., gandhi, j. s., stein, m. k., & gradowski, j. f. (2020). follicular lymphoma diagnosed in warthin tumor: a case report and review of the literature. pa ge 19 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 185-191, 2023 head and neck pathology, 14(2), 386-391. doi:10.1007/ s12105-019-01045-x attarbaschi, a., abla, o., arias padilla, l., beishuizen, a., burke, g. a., brugières, l., . . . klapper, w. (2020). rare non‐hodgkin lymphoma of childhood and adolescence: a consensus diagnostic and therapeutic approach to pediatric‐type follicular lymphoma, marginal zone lymphoma, and nonanaplastic peripheral t‐cell lymphoma. pediatric blood & cancer, 67(8), e28416. batlevi, c. l., sha, f., alperovich, a., ni, a., smith, k., ying, z., . . . younes, a. (2020). follicular lymphoma in the modern era: survival, treatment outcomes, and identification of high-risk subgroups. blood cancer journal, 10(7), 74. doi:10.1038/s41408-020-00340-z cahill, k. e., & smith, s. m. (2022). follicular lymphoma: a focus on current and emerging therapies. oncology (williston park), 36(2), 97-106. doi:10.46883/2022.25920946 carbone, a., roulland, s., gloghini, a., younes, a., von keudell, g., lópez-guillermo, a., & fitzgibbon, j. (2019). follicular lymphoma. nature reviews disease primers, 5(1), 83. doi:10.1038/s41572-019-0132-x chabot‐richards, d., & george, t. (2014). leukocytosis. international journal of laboratory hematology, 36(3), 279288. dada, r. (2019). diagnosis and management of follicular lymphoma: a comprehensive review. european journal of haematology, 103(3), 152-163. freedman, a. (2018). follicular lymphoma: 2018 update on diagnosis and management. american journal of hematology, 93(2), 296-305. freedman, a., & jacobsen, e. (2020). follicular lymphoma: 2020 update on diagnosis and management. american journal of hematology, 95(3), 316-327. los-de vries, g. t., stevens, w. b., van dijk, e., langoisjacques, c., clear, a. j., stathi, p., . . . sander, b. (2022). genomic and microenvironmental landscape of stage i follicular lymphoma, compared with stage iii/iv. blood advances, 6(18), 5482-5493. lu, p. (2005). staging and classification of lymphoma. seminars in nuclear medicine, 35(3), 160-164. doi:https:// doi.org/10.1053/j.semnuclmed.2005.02.002 péricart, s., waysse, c., siegfried, a., struski, s., delabesse, e., laurent, c., & evrard, s. (2020). subsequent development of histiocytic sarcoma and follicular lymphoma: cytogenetics and nextgeneration sequencing analyses provide evidence for transdifferentiation of early common lymphoid precursor—a case report and review of literature. virchows archiv, 476(4), 609-614. doi:10.1007/s00428019-02691-w tanigawa, t., abe, r., kato, j., hosoe, n., ogata, h., kameyama, k., . . . mori, t. (2019). histological transformation in duodenal-type follicular lymphoma: a case report and review of the literature. oncotarget, 10(36), 3424. pa ge 1 pa ge 26 american journal of medical science and innovation (ajmsi) acute jejunal leiomyosarcoma: a rare case study maryam essa alfard1*, shriya devendra tayade2 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1761 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 16, 2023 accepted: july 08, 2023 published: july 17, 2023 the objective of this study is to describe a particular case example of small bowel leiomyosarcoma, which is characterized by an acute abdomen and signs and symptoms of intestinal obstruction. sarcoma accounts for 1.2% of gastrointestinal malignancies. it can present as an asymptomatic mass or with constitutional symptoms like gi upset, melena, weight loss, fatigue, and rarely intussusception and bowel obstruction. early diagnosis is difficult due to unspecified symptoms and the slow growth of the tumor. surgical resection is still the preferred therapy. the case report was based on a 31-year-old gentleman hospitalized in the emergency with severe abdominal aches, discomfort and nausea for 4 days. the patient had a significant unintentional weight loss for 1 month. a physical examination revealed epigastric and periumbilical tenderness. an immediate abdominal x-ray revealed several air-fluid levels, which indicate a minor intestinal obstruction in the core of the abdomen. a subsequent ct scan further noted an ileoileal intussusception with intestinal obstruction. the decision was taken to proceed with a crucial exploratory laparotomy, which reported a 4x5 cm tumor in the jejunum with several enlarged mesenteric lymph nodes. the histopathology report showed a high-grade leiomyosarcoma with confirmatory immunological staining. keywords sarcoma, leiomyosarcoma, immunological staining, gastrointestinal stromal tumors 1 king faisal specialist hospital & research centre, riyadh, saudi arabia al mathar ash shamali, riyadh 11564, saudi arabia 2 ras al khaimah medical and health sciences university, ras al khaimah, united arab emirates * corresponding author’s e-mail: maryamessa22@outlook.com introduction small intestine tumors are uncommon, comprising fewer than 5% of all gastrointestinal malignancies and complications and have received relatively little attention. recent studies show its increasing incidence, with 22.7 million cases reported yearly (luis, ejtehadi, howlett, & donnellan, 2015). most of the sarcomas found in the gastrointestinal (gi) tract are presently categorized as gastrointestinal stromal tumors (gist) that develop from the interstitial cell of caja (icc); it can be either malignant or benign, identified by immunopositivity for cd117, cd34, and dog1.1 (akwari, dozois, weiland, & beahrs, 1978; barsouk, rawla, barsouk, & thandra, 2019; luis et al., 2015),(guzel et al., 2016). when gist was first recognized as a disease in the late 1990s, there was no clear distinction between it and leiomyosarcoma in the stomach stromal tumor family. (garg, alrajjal, berri, & barawi, 2020). leiomyosarcomas (lms)are tremendously rare because the world health organization has no authenticable data available for inference (luis et al., 2015). ionizing radiation, epstein barr virus and other chemical exposures have all been proposed as probable risk factors for lms. throughout the research of different electronic databases and conference proceedings such as medline, embase, ovid cochrane central, ovid cochrane database of systematic reviews, scopus, and web of science were critical to distinguish gist from lms since tyrosine kinase inhibitors are used to treat gist but are unsuccessful in lms (a. t. lee, jones, & huang, 2019). such tumors can present as an asymptomatic mass or with constitutional symptoms like gi upset, melena, weight loss, fatigue and rarely intussusception and bowel obstruction. early recognition is challenging because of the tumor’s stagnating development and uncertain symptoms. (barsouk et al., 2019; luis et al., 2015), (akwari et al., 1978), (guzel et al., 2016) surgical resection is still the preferred therapy (akwari et al., 1978),(guzel et al., 2016). this study aims to illustrate a rare case example of small bowel leiomyosarcoma that manifested as an acute abdomen with signs and symptoms of intestinal blockage. case description an emergency medical visit for a 31-year-old male who had been experiencing significant abdomen pain and vomiting for four days prior to admission but had no history of medical issues. further questioning revealed he had unintentional weight loss and fatigue for 1 month. he also had an episode of melena 1 month back and was diagnosed with a mallory-weiss tear on endoscopy. on presentation, the patient appeared to be in distress with stable vitals. when the abdomen was examined, the epigastrium and peritoneum were in discomfort, but there was no guarding, distension, lumps, or organomegaly. no peripheral lymphadenopathy was noted. further analysis reported a hemoglobin level of 10.7 g/dl and c-reactive protein of 5.2 mg/l, with other routine investigations within the normal range. an abdomen x-ray showed multiple air-fluid levels (figure 1) at the center of the abdomen denoting small bowel obstruction. subsequent ct abdomen was done urgently, showing evidence of ileoileal intussusception with intestinal obstruction and proximal bowel dilatation associated with minimal ascitic fluid collection (figure 2). bowel wall enhancement was https://doi.org/10.54536/ajmsi.v2i2.1761 https://journals.e-palli.com/home/index.php/ajmsi mailto:maryamessa22@outlook.com pa ge 27 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 26-30, 2023 figure 1: abdominal x-ray showing coglomerate airfluid levels figure 2: ct abdomen ileo-ileal intussusceptiondonut sign figure 3: gross images of the tumor showing 4×5 cm yellowish-grayish pedunculated polypoidal submucosal mass with ulcerated and necrotic surface outpouching from the antimesenteric border of jejunum. preserved. imaging findings necessitated an emergency laparotomy which revealed a 4x5 cm polypoidal mass (figure 3) located in the jejunum approximately 30 cm away from the duodenojejunal flexure (dj flexure) that caused obstruction and subsequent intussusception with minimal ascites. in addition, multiple enlarged mesenteric lymph nodes were noted. no liver metastasis was seen. the rest of the bowel was healthy. the bowel segment with the mass was resected, followed by side-to-side anastomosis, and the specimen was sent for histopathology. the recovery time went tediously, and the patient was sent home without experiencing any serious issues. he was subsequently seen in the outpatient clinic and was noted to tolerate diet well with good surgical wound healing. subsequent histopathology reports suggested a highly cellular submucosal pedunculated malignant neoplasm arranged in intersecting fascicles and bundles with >20 brisk mitoses per 10 high power fields (hpf) and zones of necrosis (figure 4). spindle cells with cigar-shaped nuclei and mild pleomorphism made up the tumor. figures of unusual mitosis were also observed (figure 5). there were found to be three reactive mesenteric lymph nodes. figure 4: histopathological slides showing a: low power view of the small intestine and submucosal cellular malignant neoplasm arranged in intersecting fascicles and bundles, b: high power view of the tumor with areas of necrosis, c: high power view of atypical spindle cells with brisk mitosis 20> 10/hpf, d: high power view of brisk mitosis {arrows} https://journals.e-palli.com/home/index.php/ajmsi pa ge 28 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 26-30, 2023 figure 5: immunohistochemical testing showing a: positive desmin, b: positive sma, c: negative cd117 & d: negative cd34. the patient was suggested to undergo a positron emission tomography (pet) and ct scan of the whole body for staging. however, he could not be contacted after discharge and was lost to follow-up. result and discussion sarcomas are responsible for 1.2% of all gastrointestinal tumors (2, 3). despite its rarity and being relatively uncommon, leiomyosarcoma is the second most prevalent type of sarcoma to be identified in the gi tract, after gists, and is typically found in the jejunum, preceding ileum and duodenum. (barsouk et al., 2019),(akwari et al., 1978),(guzel et al., 2016). it commonly occurs in the 5th and 6th decades of life and has a higher predilection of incidence in males compared to females with a ratio of 3:1 (barsouk et al., 2019),(akwari et al., 1978). common presentations include gastrointestinal bleeding due to ulceration of the tumor, abdominal pain and sometimes, a palpable mass (luis et al., 2015),(barsouk et al., 2019),(akwari et al., 1978),(guzel et al., 2016). additionally, many patients exhibit numerous complications including appetite loss, anemia, exhaustion, and weight loss. (barsouk et al., 2019),(akwari et al., 1978),(guzel et al., 2016). since they tend to grow extra luminal, symptoms of obstruction usually present late, as seen in this case (akwari et al., 1978). these tumors tend to commonly metastasize via hematogenous spread to the liver and lungs (akwari et al., 1978), (guzel et al., 2016), (y. lee, 1983). metastasis via lymphatic and peritoneal spread is uncommon (akwari et al., 1978),(guzel et al., 2016),(y. lee, 1983). in this case, multiple enlarged mesenteric lymph nodes were seen with no liver metastasis. though these tumors occur sporadically, research shows their association with a history of retinoblastoma, human immunodeficiency virus (hiv), epstein-barr virus (ebv), immunocompromised post-transplantation patients, and congenital immunodeficiency (guzel et al., 2016). acute symptoms of intestinal obstruction are seen in less than 5% of cases of lms and are due to tumor infiltration or malignant adhesions (nagtegaal et al., 2020), (ashoor & barefah, 2020). adults commonly experience intestinal blockage from intussusception induced on by small intestine tumors like lipoma or leiomyoma. (nagtegaal et al., 2020). moreover, intussusception, although rarely seen in smooth muscle tumors, is more commonly seen in tumors located in the ileum rather than the jejunum, as seen in this case where intussusception and subsequent obstruction were caused by the intraluminal component of the tumor (ashoor & barefah, 2020),(ahmed, 2020). several imaging modalities have been studied through computed tomography colonoscopy (ctc), magnetic resonance enterography (mre), and wireless capsule endoscopy (wre), which have proven to detect small bowel tumors but have limited use in acute settings such as obstruction seen in this case (5),(mazzotta et al., 2020). computed tomography (ct) scan has more advantages due to fast imaging results and low costs. in addition, it can also successfully locate metastases. however, in comparison to ct, magnetic resonance imaging (mri) could be more capable of detecting minor lesions and identifying cancers without the use of ionizing radiation. finally, positron emission tomography (pet) imaging can detect tumors based on their histological grade and innate metabolism. thus, it cannot effectively identify low-grade tumors (mazzotta et al., 2020). however, imaging alone cannot differentiate benign and malignant intra-abdominal neoplasms, and diagnosis is often confirmed upon histological analysis, as seen in the present case (guzel et al., 2016), (ashoor & barefah, 2020), (garg et al., 2020). the most important criterion for diagnosing leiomyosarcoma is the presence of mitosis. studies show that tumors having >5-10 mitoses/10 hpf usually behave aggressively. furthermore, the presence of necrosis, atypical cells, and the size of the tumor, especially if >5 cm, determines the potential for metastasis. currently, two grading systems, namely the fnclcc and nci systems, take the factors abovementioned into account to grade these tumors (guzel et al., 2016),(garg et al., 2020). in the present case, histological examination revealed a high-grade leiomyosarcoma with >20 mitosis/10 hpf and necrosis, classifying the tumor as aggressive with a high potential for metastasis. lms and gastrointestinal stromal tumors (gists) appear morphologically similar, which makes it necessary to differentiate them due to markedly different treatment methods (barsouk et al., 2019),(y. lee, 1983), (garg et al., 2020). in the late 1990s, definitive techniques were released to distinguish lmss from gists. smooth muscle actin, desmin, and caldesmon are smooth muscle cell markers that are positive in lmss but negative for cd34 and tyrosine kinase c-kit (cd117), whereas gists are regularly cd34 immunoreactive and exude cd117 https://journals.e-palli.com/home/index.php/ajmsi pa ge 29 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 26-30, 2023 receptor activity. these two pathological entities differ in immunohistochemical (ihc) and clinicopathological profiles. however, cd117 testing may be negative in 4-5 percent of gists (mazzotta et al., 2020). on immunohistological staining, lms can be distinguished from gists by the absence of cd117 (c-kit), dog1, cd34, and the detection of smooth muscle actin (sma), desmin and h-caldesmon (luis et al., 2015),(barsouk et al., 2019),(y. lee, 1983),(garg et al., 2020). as immunohistology became more popular, many previously diagnosed lms were identified as gists, further proving the rarity of these tumors (y. lee, 1983),(nagtegaal et al., 2020),(garg et al., 2020). in this case, immunohistochemistry showed immunopositivity for sma and desmin without cd117 and cd34, confirming the diagnosis of leiomyosarcoma. furthermore, three reactive lymph nodes were noted on the mesentery’s resected section, highlighting an unusually aggressive tumor with a high potential for systemic dissemination (ahmed, 2020). less than 2% of all leiomyosarcomas are smooth muscle sarcomas affecting major arteries. the ivc is the most usually damaged vascular structure (35-60% of the cases). nonetheless, several occurrences of gsv in the lower extremities have been observed (tresgallo-parés et al., 2021). adjuvant chemotherapy can be explored in high-risk patients to lower the risk of local recurrence and improve survival rates, even if it is not universally acknowledged as the standard therapeutic plan for the postoperative care of adult patients with lms (gamboa, gronchi, & cardona, 2020). treatment of leiomyosarcoma revolves around surgical excision of the tumor, and in this case, the patient had undergone an emergency laparotomy (akwari et al., 1978), (guzel et al., 2016), (ashoor & barefah, 2020), (ahmed, 2020), (garg et al., 2020), (abou el joud & abbasi, 2022). multiple enlarged mesenteric lymph nodes were noted around the jejunal tumor during surgery. metastasis to regional lymph nodes is rarely seen in leiomyosarcoma (y. lee, 1983) 7, (ahmed, 2020), 10, 12). as the role of routine lymph node dissection is controversial, it was not performed in this case (y. lee, 1983), (ashoor & barefah, 2020), 8). current data shows that gi lms have low sensitivity to chemotherapy and are resistant to radiotherapy (guzel et al., 2016), (ashoor & barefah, 2020), (mazzotta et al., 2020)). as a result, patients are regularly followed up after complete surgical excision of the tumor with periodical imaging (guzel et al., 2016), (mazzotta et al., 2020). overall, these tumors have a poor prognosis, with a 5-year survival rate of ∼27% (abou el joud & abbasi, 2022). clinical significance to combat disease progression, full surgical resection with negative margins remains the gold standard and should be pursued. patients who have tumors that are limited to the submucosa and are not candidates for surgery may choose to seek endoscopic resection. the relevance of chemotherapy and radiation therapy is unclear at the moment, with a national cancer network advising anthracycline-based chemotherapy for soft tissue sarcomas but no specific recommendations for lms. an agreement on the best course of treatment for this rare and potentially aggressive cancer requires more study. conclusion jejunal leiomyosarcoma is an uncommon cancer with a weak prediction. due to its non-specific symptoms, it is often diagnosed late with a high incidence of metastasis. an unusual presentation of jejunal leiomyosarcoma is intussusception and consequent obstruction, especially in an emergency. it is essential to differentiate lms from gists through immunohistological testing due to its differing treatment modalities. definitive treatment remains surgical resection of the tumor. ethical approval the research was ethically approved by the research committee of the dubai health authority patient lost to follow-up and traveled back to his country. ethical consent informed ethical consent was attained from the patient. acknowledgment none funding this study is not funded by any organization. references abou el joud, k., & abbasi, m. (2022). lower extremity varicose veins: an unusual presentation of small bowel leiomyosarcoma. gastrointestinal tumors, 9(1), 1-4. ahmed, m. (2020). gastrointestinal neuroendocrine tumors in 2020. world journal of gastrointestinal oncology, 12(8), 791. akwari, o. e., dozois, r. r., weiland, l. h., & beahrs, o. h. (1978). leiomyosarcoma of the small and large bowel. cancer, 42(3), 1375-1384. ashoor, a. a., & barefah, g. (2020). unusual presentation of a large gist in an extraintestinal site: a challenging diagnosis dilemma. bmj case reports cp, 13(2), e229839. barsouk, a., rawla, p., barsouk, a., & thandra, k. c. (2019). epidemiology of cancers of the small intestine: trends, risk factors, and prevention. medical sciences, 7(3), 46. gamboa, a. c., gronchi, a., & cardona, k. (2020). soft‐ tissue sarcoma in adults: an update on the current state of histiotype‐specific management in an era of personalized medicine. ca: a cancer journal for clinicians, 70(3), 200-229. garg, r., alrajjal, a., berri, r., & barawi, m. (2020). primary gastric leiomyosarcoma: a case report and review of the literature. journal of gastrointestinal cancer, 51(1), 335-340. https://journals.e-palli.com/home/index.php/ajmsi pa ge 30 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 26-30, 2023 guzel, t., mech, k., mazurkiewicz, m., dąbrowski, b., lech, g., chaber, a., & słodkowski, m. (2016). a very rare case of a small bowel leiomyosarcoma leading to ileocaecal intussusception treated with a laparoscopic resection: a case report and a literature review. world journal of surgical oncology, 14(1), 1-7. lee, a. t., jones, r. l., & huang, p. h. (2019). pazopanib in advanced soft tissue sarcomas. signal transduction and targeted therapy, 4(1), 1-10. lee, y. (1983). leiomyosarcoma of the gastro-intestinal tract: general pattern of metastasis and recurrence. cancer treatment reviews, 10(2), 91-101. luis, j., ejtehadi, f., howlett, d. c., & donnellan, i. m. (2015). leiomyosarcoma of the small bowel: report of a case and review of the literature. international journal of surgery case reports, 6, 51-54. mazzotta, e., lauricella, s., carannante, f., mascianà, g., caricato, m., & capolupo, g. t. (2020). ileoileal intussusception caused by small bowel leiomyosarcoma: a rare case report. international journal of surgery case reports, 72, 52-55. nagtegaal, i. d., odze, r. d., klimstra, d., paradis, v., rugge, m., schirmacher, p., . . . cree, i. a. (2020). the 2019 who classification of tumours of the digestive system. histopathology, 76(2), 182. tresgallo-parés, r., de virgilio-salgado, l., torres-lugo, n. j., asenjo-molina, n. a., ramirez, n., & bibilonirodríguez, j. (2021). primary leiomyosarcoma of the great saphenous vein: a case report. international journal of surgery case reports, 88, 106565. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 84 american journal of medical science and innovation (ajmsi) indications and outcome of surgical treatment of crohn’s disease in gastroenterology and hepatology hospital raafat raoof alturfi1, zakaria yahia al khazraji1* volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.4347 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: january 10, 2025 accepted: february 12, 2025 published: march 10, 2025 crohn’s disease of both varieties (abdominal and perineal) may lead to many surgical complications treated by different procedures. the role of surgery has a paramount importance in treating crohn’s disease complications despite medical therapy. the purpose of this study is to investigate the indications, types, and outcomes of surgical therapy for crohn’s disease at gastroenterology and hepatology hospitals. this is a longitudinal sectional prospective study that was conducted in gastroenterology and hepatology hospital from march 2020may 2022, involves 35 patients of crohn’s disease were diagnosed relying on clinical, radiological, and histopathological result based on endoscopic biopsy and/or surgical specimen. current study demonstrated that the most common indication of surgery in abdominal crohn’s disease cohort is intestinal obstruction with 23 patients (65.71%) treated by ileocecal resection. intestinal fistula 7 patients (20%). failure of medical treatment 3 patients (8.57%). malignancy 2 patients (5.71%). psoas abscess drainage 1 patient (2.85%). most common indication of surgery in peri-anal crohn’s disease is intractable perianal fistula to medical treatment 5 patients (14.28%), perianal abscess patients (8.57%). although the medical treatment is the corner stone in management of crohn’s disease but early referral to digestive surgeon is preferable to decrease the suffering of the patients and improve the outcome. keywords acute appendicitis, crohn’s disease, intestinal obstruction, ileocecal resection, liver resection 1 gastroenterology and hepatology, teaching hospital medical city, baghdad, iraq * corresponding author’s e-mail: drnihadkhalawe@gmail.com introduction crohn’s disease (cd) is a chronic inflammatory intestinal disease, first described as regional ileitis by crohn, ginzburg and oppenheimer in a case series presented at american medical association annual meeting in 1932 (baumgart et al., 2007). crohn’s disease is defined a chronic inflammatory bowel disorder characterized by a transmural inflammatory reaction and non-caseating small granulomas and may involves all parts of the gastrointestinal (gi) tract from the mouth to the anus (stangl et al., 2002; vanek et al., 1988; haddad et al., 1993; prieto-nieto et al., 2002), several subtypes are recognized, depending on the area of the gi tract most affected (crohn et al., 2000; abraham et al., 2066). crohn’s disease is grouped with other inflammatory bowel diseases (ibds) such as ulcerative colitis (nasserimoghaddam et al., 2012) is distinguishing features include discontinuous, transmural inflammation involving the whole thickness of the bowel wall, and an inflammatory response associated with lymphoid aggregates and granulomas (rodriguez et al., 2020). a cure remains elusive, and efficient management of crohn’s disease is essentially multidisciplinary and interprofessional (mazal et al., 2014). treatment of crohn’s disease is multidisciplinary: medical treatment is focused on mucosal healing and reduction of symptom; surgery maintains a key-role in treating complications such as stenosis, perforations, fistulas and abscesses (bednarz et al., 2008; frolkis et al., 2013). the main treatment is medical, while surgery is indicted only for complications of the disease and treatment (shaffer & wexner, 2013 ). absolute indications for surgery in crohn’s disease include cancer, or suspicious, perforation, toxic megacolon and major life threatening gastrointestinal tract (git) bleeding. relative indications include strictures, phlegmon, fistulae, intra-abdominal abscesses, git bleeding, dysplasiaassociated lesion or mass (dalm), high grade dysplasia detected on surveillance, growth retardation in children and failure of medical therapy. patients with crohn’s disease often may have multiple intestinal surgery (van koperen et al., 2009; michelassi et al., 1993). the aim of current study is to study the indications, types and outcomes of surgical therapy in the treatment of crohn’s disease in gastroenterology and hepatology hospital. materials and methods this study was done in gastro enterology and hepatology center from march 2020may 2022 of prospective of 35 patients case series,these patients of crohn’s disease diagnosed depending on clinical, and radiological and histopathological finding on the basis of endoscopic biopsy or surgical specimen or both. also patients send for routine investigations including hematological , biochemical, and radiological which include (u/s, ct scan of abdomen with i.v and oral contrast). pelvic mri study indicated if crohn’s disease involving peri-anal region especially perianal fistula. patients admitted to surgical ward then categorized pa ge 85 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 84-89, 2025 into either emergency condition (subacute intestinal obstruction) or elective one, prepared and assessed in following preoperative measure: 1routine investigations as mentioned above. 2nutritional assessment including body mass index, s.albumin, if body mass index less than 18.5 or s.albumin less than 3.5 mg/dl then enteral or total parenteral nutrition started, correction of electrolyte and blood transfusion for anemia. 3antibiotics indicated if there was focus of infection. 4prophylactic dose of low molecular heparin was given. 5cessation of smoking. 6discussion with gastroenterologist about withdrawal of biological therapy and steroid. 7two patients with intra-abdominal abscess diagnosed by u/s and ct scan submitted for drainage under radiological guidance. inclusion criteria, all patient of crohn’s disease underwent surgery in gastrointestinal tract during period of disease. statistical analysis: the stats of this project were performed using microsoft excel. this study relied on the total number of patients. results and discussin this study included 35 patients, 23 male (65.71%), female 12 (34.28%), male to female ratio was 1.9:1, results in table-1 showed the most common age between 20-29 year and the least between 10-19 years. 18 patients were smoker (51.42%). table 1: patients demographic data demographic data number of patients % gender male 23 65.71 female 12 34.28 duration of disease < 1 year 2 5.7 1-5 year 24 68.5 5-10 year 3 8.5 10-20 year 6 17.14 mode of treatment immunomodulation treatment 9 25.71 biological treatment 7 20 both 19 54.28 smoking -ve 17 48.57 +ve 18 51.42 frequency of surgery two surgery 23 65.71 single surgery 12 34.28 age( years) 10-19 2 5.71 20-29 17 48.57 30-39 8 22.85 40-50 8 22.85 crohn’s disease predominancy abdominal crohn’s disease 28 80 a-obstructing 23 65.71 b-penetrating 5 14.28 perineal crohn’s disease 3 8.57 both 5 14.28 mode of treatment including both biological and immunomodulation were 19 patients (54.28%), immunomodulation alone 9 patients (25.71%), while biological alone were 7 patients (20%).patients underwent two surgical operations in their period of disease were 23 patients (65.71%), while those underwent only one surgery were 12 patients (34.28%). abdominal crohn’s disease predominates in 28 patients (80%), while perineal involvement were 3 patients (8.57%), while both were 5 patients (14.28%). pa ge 86 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 84-89, 2025 results in table-2 showed the most common indication of surgery in abdominal crohn’s disease cohort was intestinal obstruction 23 patients (65.71%), while fistula 8 patients (22.85%), malignancy was an indication of surgery in 2 patients (5.71%). 2 patients were colonic carcinoma, and 1 patient was gastric carcinoma. table 2: indications of surgery in abdominal crohn’s disease indications number of patients percentage intestinal obstruction 23 65.71 a. ileocecal cause 18 51.42 b. small bowel cause 5 14.28 failure to medical treatment such as: 3 8.57 a-bleeding per rectum 1 2.85 b-sever perianal fistulation disease 2 5.71 intestinal fistula: 7 20 a-entero-cutaneous (penetrating) 5 14.28 b-entero-vesical fistula 2 5.71 malignancy 2 5.71 psoas abscess 1 2.85 table -3 regarding perineal crohn’s disease fistula in ano predominate the indication of surgery in 5 patients (14.28%), while the other were perianal abscess 3 patients (8.57%). table 3: indication of surgery in peri-anal crohn’s disease type of indication number of patients percentage intractable perianal fistula to medical treatment: 5 14.28 a-high type 3 8.57 blow type 2 5.71 perianal abscess 3 8.57 table 4: types of surgery (abdominal and perianal crohn’s disease) types of surgery number of patients percentage ileocaecal resection 23 65.71 a. subacute intestinal obstruction 18 51.42 b. intractable enterocutaneous fistula (post-appendecectomy) 5 14.28 stricturoplasty (small bowel) 3 8.57 small bowel resection 2 5.71 right hemicolectomy 1 2.85 fecal diversion (ileostomy) 2 5.71 liver resection 1 2.85 total proctocolectomy and permanent ileostomy 1 2.85 drainage of abscess 4 11.42 1. perianal abscess 3 8.57 2. psoas abscess 1 2.85 partial cystectomy (enterovesical fistula) results in table-4 showed the most common surgical procedure done in abdominal crohn’s disease cohort was ileocecal resection 23 patients (65.71%) of obstructing group including ileocecal resection, stricturoplasty and small bowel resection. the least ones were ileostomy, colostomy, liver resection, and total proctocolectomy with permanent ileostomy 1 case for each (2.85%).the liver resection was performed because of metastatic colonic tumor, while surgery was done for penetrating (fistulating) manifested as enterocutaneous fistula group includes ileocecal resection. results in table 5: showing morbidity in form of anastomotic dehiscence and intestinal obstruction of adhesive type were 2 patients for each (5.71%). wound infection was occurred in 10 patients (28.55%), other morbidity in form of pulmonary complications was zero as well as mortality rate. pa ge 87 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 84-89, 2025 about 70% to 90% of people with crohn’s disease (cd) will ultimately need surgery (shaffer et al., 2013). once the need for surgical intervention has been established in cd, the surgical strategy will vary depending on the intestinal segment affected (beck et al., 2014). depending on patient’s general condition,severity of disease, and the involvement of intestinal segments, surgical treatment of cd may include ileocecal resection, subtotal colectomy with ileorectal anastomosis, total proctocolectomy, segmental small bowel resection, and stricturoplasty (beck et al., 2014). stoma may be added to these procedures when necessary. ileocecal resection the most surgical proceger (mühe et al., 1981). surgical recurrens is highly in c.d , so multiple operations may be needed (mcnamara et al., 1990; van koperen et al., 2009). 1) michelassietal (1993) and farmer et al. (1975), in this study, we found that (65.71%) of patients had more than one operation. the terminal ileum is the most common crohn’s affected site requiring surgery (michelassi et al., 1993; farmer et al., 1975 ). in this study, the incidence of involvement of terminal ileum was (65.71%), bowel obstruction from stricture is the most common reason for surgery in cd (kühn et al., 2005). stricturing phenotype of cd is most common in ileal disease and in patients diagnosed with cd at a younger age. in this study, 23 patients (65.71%) had an incidence of obstruction, including 5 patients (14.28%) with subacute intestinal obstruction post-appendicectomy. the most common surgery for stricturing disease in cd is ileocolic resection for ileocaecal or distal ileal disease (kühn et al., 2005). this study showed the incidence of ileocecal resection is (80%). an ileocolic resections high proportion for crohn’s disease is performed in the emergency setting (kühn et al., 2005 ). table 5: morbidity and mortality complications numberof patients percentage anastomosis dehesaience 2 5.71 intestinal obstruction (adhesive type) 2 5.71 wound infection 10 28.55 mortality zero 0 figure 1: ct scan with oral contrast of patient with crohn’s disease showing ileovesical fistula (contrast material filling the urinary bladder) figure 2: specimen of ileocecal resection of a patient with crohn’s disease showing fat wrapping and mass in ileocecal region pa ge 88 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 84-89, 2025 in current study, the incidence of acute appendicitis is (37.74%). the treatment of choice for appendiceal cd is appendectomy. acute appendicitis diagnosis in cd is frequent, but the atypical symptom (vanek et al., 1988). in 1% –30% of cases, free perforation is the earliest indication of cd (greenstein et al., 1987). in this study, the free perforation was 2.82% in form of perforated appendicitis. failure of medical treatment defined as failure of complete clinical response with 8-12 wk. of oral steroids and other agents. approximately 20%-30% of cd patients do not respond to steroids, and up to 45% of cd patients will relapse on weaning of steroids (munkholm et al., 1994) as well as failure of medical treatment manifested as bleeding per rectum (2.85%) treated by total proctocolectomy and permeant ileostomy, another indication of surgery failure of medical treatment was severe perianal fistulating, two patients (5.71%), one patient treated by diversion ileostomy and second one treated by fistulotomy. in general, intestinal fistulae are the primary indication to surgical treatment if they connect with the genitourinary tract, if their drainage is cause for personal embarrassment and discomfort, or if they create a bypass of such magnitude as to cause intestinal malabsorption. majority of intra-abdominal fistulae undergo intestinal resection and primary anastomosis (broe et al., 1982), also colocutaneous and enterocutaneous fistulae usually require surgical intervention (zhang et al., 2014). intestinal fistula that was (20%) divided into enterocutaneous (14.28%) treated by ileocecal resection, those patients who developed this complication postappendicectomy and entero-vesical fistula (5.71%) which was manifested by recurrent urinary tract infection treated by segmental resection of diseased bowel and partial cystectomy. a common large bowel fistula is the ileosigmoid fistula which is a well-known manifestation of cd. these patients require ileocolic resection and either primary repair or segmental resection of the sigmoid, or a subtotal colectomy (van koperen et al., 2009). the risk of cancer ranges from 1%-5% in cd, representing a 2-3 times increased risk of developing colorectal cancer and > 18 times increased risk of developing small bowel cancer (van koperen et al., 2009). the transmural inflammation of crohn’s disease increases the risk for bowel perforation and formation of fistula that can lead to psoas abscess formation. although psoas abscess is most commonly present in longstanding crohn’s disease, it can also be its first manifestation (rastogi et al., 2018; atkinson et al., 2006). in this study, the incidence of psoas abscess is (2.85%), it was the first symptom of crohn’s disease treated by drainage under ultrasound guidance with antibiotics. perianal pathology can be occured in 40%-80% of patients with cd. colonic and rectal cd phenotypes are associated with increased risk of perianal disease (atkinson et al., 2006; toh et al., 2016). in this study, the incidence was 8.57% including fistula in ano was dominant about (14.28 %) including high type (8.57%) treated by seton staged surgery and low type (5.71%) treated by fistulotomy. perennial absesse (8.57%) treated by drainage.medical therapy is the cornerstone treatment for perianal fistulas. surgical intervention is reserved for individuals with abscesses or sepsis (toh, et al., 2016). low cd perianal fistulas are amenable to fistulotomy treatment. complex or high cd fistulae should be treated with long-lasting setons (toh et al., 2016), so diversional stoma for perianal disease should be reserved for difficult cases refractory to medical therapy and drainage (toh et al., 2016). in the present study, demonstrated that (65.71%) of patients required more than one surgery, the vast majority for abdominal crohns. intestinal obstruction in the form of stricture treated by stricturoplasty (8.57%) because stricturoplasty has the advantage of small bowel preservation and prevention of short bowel syndrome. wound infection occurs postoperatively in our crohn’s disease patients is (28.55%) because of multifactorial include complication of medical treatment and malnutrition. risk factors for anastomotic complication include intra-abdominal abscess, fistula, malnutrition, steroid usage, and recurrent clinical episodes. conclusion ✤ although the medical treatment is the corner stone in management of crohn’s disease but early referral to digestive surgeon is preferable to decrease the suffering of the patients and improve the outcome. ✤ the ileocecal region is the most common site of involvement by crohn’s disease, hence, the surgery for this area is the most frequent in form of ileocecal resection. ✤ the role of fecal diversion (ileostomy) is important in plan of surgical management of crohn disease especially in malnourished patients and long term of steroid therapy. ✤ our goal in managing small bowel crohn’s disease is to preserve as much as we can length of the bowel by performing stricturoplasty rather than resection to prevent short bowel syndrome. ✤ conservative surgery in perianal involvement is preferred rather than the radical one. references abraham, c., & cho, j. h. 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(2013). inflammatory bowel disease. new england journal of medicine, 361(21), 2066-2078. pa ge 1 pa ge 9 american journal of medical science and innovation (ajmsi) evaluation of domestic wastewater management and the future potential for diverse technologies in luangprabang city sengsavath sidlakone1*, atsushi ichiki2 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5229 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 30, 2025 accepted: june 03, 2025 published: july 08, 2025 luangprabang city is currently confronting a substantial wastewater management crisis, primar-ily due to the lack of an operational domestic sewage system and insufficient wastewater treatment technology. this study aimed to assess the current state of domestic wastewater management and investigate wastewater treatment technologies within a circular economic framework that is suitable for local conditions. data were collected from local institutions encompassing local policies, legis-lation, wastewater treatment facilities, site visits, and observations. secondary data were sourced from the literature reviews, technical guidelines, and related articles. three distinct wastewater treatment technologies were evaluated to ascertain the optimal feasibility of the interventions for comparison purposes. the technical and treatment efficiencies of these technologies were also ana-lyzed. the financial aspects were assessed, with an assumed affordability rate of 3%, a discount rate of 4.5%, and a project period of 10 years. the indicators employed included net present value and benefit-cost ratio. based on the results of the analysis, the dewats module with a constructed wetland was the most suitable option for implementation in the study area. keywords affordability, benefit-cost ratio, domestic wastewater, economic, technologies 1 department of water supply, ministry of public works and transport, lanexang avenue, vientiane capital, uk 2 department of civil and environmental engineering, ritsumeikan university, 1-1-1 nojihigashi, shiga 525-8577, japan * corresponding author’s e-mail: vathslk@yahoo.co.uk introduction the management of domestic wastewater has become a major environmental and public health problem for rapidly growing secondary cities in south east asia, such as luangprabang city, laos. under the continuous development of the city based on tourism and urban expansion, pressure on out-dated and insufficient sanitation infrastructure has increased. there is a lot of wastewater from homes that is released either untreated or undertreated into the local water supplies, polluting the water, dam-aging the ecosystem, and causing waterborne dis-eases. luangprabang is a challenge owing to population growth, the expansion of business entities, and the burgeoning tourism sector. these devel-opments have placed significant pressure on the urban water environment. consequently, the ex-isting wastewater treatment facilities are insuffi-cient for providing the domestic wastewater gener-ated. the treatment facilities are simple; the tradi-tional pond system intended for treating greywater is restricted to the central area of luangprabang and was not designed to process black water (pit latrines). septage is introduced into ponds in wetland areas are part of the treatment system, where canals re-ceive wastewater from households, including septic tank effluents and gray water. sewage drainage and canals are diverted to ponds and overflow into other ponds before flowing into wetland areas, natural rivers, and streams. domestic wastewater is channeled through drainage systems, with some directed into ponds. sewage settles and the adjacent wetlands absorb effluents before being discharged into the mekong river via drainage outlets. the pond-wetland sys-tem has been studied through several pilot projects in luang prabang, supported by development part-ners. this concept utilizes ponds and wetlands as natural treatment systems to purify city sewagto river discharge. when properly designed and main-tained, these systems provide preliminary partial treatment of sewage during dry months, even though sewage overflows during rainy periods. a plan to connect all ponds and wetlands to capture and treat city sewage needs to be developed. as the city progresses towards its planning horizon, the development of wastewater treatment systems will be crucial in implementing and refining these strategies to ensure long-term water environmental sustainability. these systems did nottfunction well because they are sewage-contaminated, and pollu-tion poses a significant public health risk. furthermore, there is a limited professional under-standing of the aquatic environment in the context of planning and development. for example, relevant authorities have not been able to generate enough revenue to pay for the maintenance and operational expenses related to the sanitation sector’s service provision. according to estimates, laos’s poor sanitation costs $650 million a year, or roughly 3.5% of gdp, in lost productivity and associated medical costs. for luangprabang, this amounts to about $10 per person. according to the world health organization (who), a $1 investment in improved sanitation yields an economic return of $5.50, which has a positive effect on the city. although 94% of city residents have improved sanitation facilities, onethird of the population’s sewage flows through open drains and is discharged untreated into natural water bodies or agricultural lands. consequently, the local city government has intervened to address this issue. pa ge 10 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 the urban drainage and sewerage systems master plan outlines the development of primary drainage systems to manage stormwater and wastewater, restore wetlands for stormwater preservation, and facilitate wastewater treatment. the planning horizon extends to 2037. distinct zones encompassing 72 villages were identified, including the world heritage protection area, the historic center, natural wetlands, and the section within the heritage area containing natural wetlands. the luang prabang world heritage office con-ducted an inventory and assessment of 106 ponds and the surrounding wetlands. most ponds are pri-vately owned, and regulations prohibit owners from backfilling ponds without consent from the city. in a study, starkl et al. (2022) assessed the sustainability of wastewater treatment systems in developing countries. their research examined economic, en-vironmental, institutional, and social sustainability, which may have various objectives and audiences that require diverse approaches. this study evalu-ated the specific aspects of sustainability assessment that are relevant to wastewater treatment system planners. the criteria included system costs and financing; affordability for users; environmental impact; health benefits; cultural acceptance of the system and recycled products; technical perfor-mance; and administrative, political, and legal frameworks governing construction and operation. these findings suggest that a multi-criteria ap-proach can identify the most suitable system for a given location. according to research, gómez-román et al. (2020) conducted a systematic review of public perceptions concerning the acceptance of decentralized wastewater treatment systems in regions not expe-riencing water scarcity. a focus group study was conducted to assess whether the identified factors applied to areas in which the population was una-ware of water-related issues. the findings indicated that a lack of awareness regarding water issues was a significant factor affecting acceptance. it is essential to highlight features like environmental sustainability in order to highlight the usefulness of such systems. costs, financing, affordability, technical per-formance, and legislation are all included in the framework for performing a cost-benefit analysis (cba) of wastewater treatment systems. further-more, it considers the local context and size of the treatment facility, whereas benefits may remain relatively constant. decision-makers can identify the most suitable and sustainable wastewater treatment system for a particular location by using this all-encompassing approach. for constructed wetlands, decentralized wastewater treatment systems (dewats) usually include primary, secondary, advanced secondary, and preliminary treatments. a sedimentation tank, a primary clarifier, an aeration tank, a secondary tank, and a disinfection tank make up a conventional activated sludge system (cas). the primary clarifier and secondary clarifier return sludge, and simulta-neously control raw sludge exceeding the thickener tank and release it for sludge treatment and dispos-al. a sedimentation storage tank, an anaerobic filter tank, a moving bed biofilm tank, a sedimen-tation tank, and a disinfection tank are all included in johkasou. in places where conventional sewage treatment systems are impractical, this system pro-vides an inventive wastewater solution. the technical performances and treatment ca-pabilities of the diverse wastewater treatment sys-tems were evaluated. subsequently, a financial analysis was undertaken to formulate a strategy that encompassed a comprehensive inventory of all as-sociated costs, including those related to sewers, buildings, technical equipment, materials, and sys-tem components, all of which encompassed o&m expenses, where land was included as a government subsidy for capital costs. the analysis of net present value and benefit-cost ratio offers valuable insights into financial viability. by taking into account revenue costs as well as capital and operating ex-penditures. incorporating crucial elements like household affordability and discount rates guaran-tees that the chosen technologies are both economically feasible and technically suitable for the city in question. the successful implementation and long-term viability of a system depend on a metic-ulous approach to financial planning that strikes a balance between economic viability and techno-logical advancements. in luangprabang, a significant volume of un-treated domestic wastewater is currently discharged into the environment, posing a risk to public health, contaminating water supplies, and harming the ecosystem. this situation is caused by a number of factors, including low community awareness, a lack of strict policy enforcement, and financial limita-tions that prevent the adoption of sustainable solu-tions. despite these pressing concerns, empirical studies evaluating the present wastewater situation in luangprabang. despite these pressing concerns, there is still a noticeable lack of empirical research evaluating luangprabang’s present wastewater management procedures and investigating alterna-tive, context-appropriate treatment technologies. in favor of an excessively large focus on urban centers, most current research overlooks the unique socioeconomic, environmental, and infrastructure con-ditions of medium-sized cities like luangprabang. addressing these water-related environmental is-sues is essential to achieving sustainable develop-ment in the region, which necessitates the use of cutting-edge treatment technologies supported by sound research. in addition to their engineering design parameters, these technologies must be evaluated for technical efficacy, cost-effectiveness, environmental impact, and regulatory compliance. therefore, the goal of this study is to thoroughly evaluate the state of wastewater treatment facilities today and investigate a variety of treatment tech-nologies that are appropriate for local needs within a circular economy framework. to make sure that wastewater management plans are in line with water quality regulations and more general sustainability objectives, it looks at the technical, environmental, social, and economic aspects of current practices and suggested remedies. pa ge 11 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 along with offering comparative analysis to guide future infrastructure planning and policy-making, the study also highlights important op-portunities and challenges in putting into practice economically feasible and socially acceptable treatment systems. this research supports the sus-tainable development of luangprabang and the larger regional conversation on inclusive sanitation strategies for secondary cities throughout southeast asia by providing practical insights into workable, affordable, and ecologically friendly wastewater solutions. this study is significant because it pro-vides a comprehensive assessment of current do-mestic wastewater practices and looks at sustainable treatment options that align with the circular economy’s tenets. the results can be used to find workable, reasonably priced, and environmentally friendly alternatives to assist local policymakers, urban planners, and development agencies in cre-ating more resilient and inclusive wastewater sys-tems that satisfy the demands of the public. ultimately, the study contributes to the broader regional discourse on sustainable urban sanitation by offering data that other southeast asian sec-ondary cities facing similar challenges can utilize or adapt. materials and methods the study area, known as the ban mano group, encompasses 2,236 ha, 2,100 households, 12,139 inhabitants, and 3 0 ponds 6. this region is desig-nated a world heritage site, as shown in figure 1. the datacollection methodology integrates both pri-mary and secondary data sources. officials in charge of domestic wastewater management and development, namely, the department of public works and transport, luan prabang city office of management and ser-vice, and water supply state enterprise, focusing on local policies related to wastewater development initiatives, legislation for wastewater management, wastewater treatment facilities, and associated is-sues in wastewater management. interviews were conducted with 20 stakeholders. furthermore, the study included site visits to the study area where observations were conducted to gather existing phenomena for data analysis, specifically in terms of comparing diverse wastewater treatment technology plans conducted in november 2023. these inter-views explored perspectives on current practices, awareness of wastewater issues, and willingness to adopt alternative treatment options. an interview guide was used to ensure consistency while allowing flexibility to explore emerging topics. secondary sourcesincluded project reports, aca-demic papers, and relevant articles, which provided a broader context and theoretical foundation for the study. by synthesizing information from these di-verse sources, this study presents a comprehensive analysis of the current sanitation landscape and proposes recommendations for future development and policy enhancement. statistical data from mu-nicipal records were also analyzed to understand population growth, sanitation coverage, and finan-cial allocations for wastewater services. by exploring these factors, the study offers a thorough assessment of the state of sanitation today, points out possible areas for development, and adds to the continuing discussion about appropriate wastewater treatment techniques. a thorough ex-amination of practices and policies within the local context, supported by primary data obtained from direct interviews with authorities and policymakers, provides valuable insight into the current state of wastewater management. this method makes it easier to comprehend the difficulties and tactics used for local wastewater management. data analysis to find recurring issues and stakeholder per-ceptions, qualitative data from field observations and interviews were subjected to thematic analysis. quantitative information was compared between various technologies, including treatment capacity and cost estimates. a multicriteria assessment framework that considered technical feasibility, environmental impact, cost-effectiveness, and social acceptance was used to evaluate treatment options. the lao national standard for wastewater quality control, which lists the eight main param-eters, is displayed in table 1. the purpose of this standard was to control the wastewater quality that domestic households released into the environment. potential of hydrogen (ph), chemical oxygen de-mand (cod), biochemical oxygen demand (bod5), total suspended solids (tss), total nitrogen, phenol (c6h5oh), fat, oil, and grease (fog), and total dissolved solids (tds) were among these parameters. to guarantee proper wastewater figure 1: map of the study area data collection data collection was conducted with strict ad-herence to ethical and legal standards, transparency and accountability throughout the study. the ac-quisition of official permission from local authori-ties facilitated by a university-issued letter enabled the execution of survey interviews and site visits in compliance with local regulations. furthermore, all secondary data sources were reviewed, cited, and acknowledged, thus supporting the credibility and integrity of the study methodology. primary data were collected through direct in-terviews and group discussions with the local au-thorities of key pa ge 12 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 treatment prior to discharge into watercourses, these parameters must be regularly monitored. table 4 shows the annual income per capita of luang prabang people, as referred to by the local government in 202510. the assumed wastewater fee was derived from the decree on water policy guidelines, which mandates that service providers establish water tariffs or fees for 3-5% of households for affordability of annual income11). this study uses 3% of the assumed wastewater fee as the es-timated operating revenue. table 1: lao pdr’s standard limits for the quality parameters of domestic wastewater symbol standard value unit ph 6-9 not defined bod5 30 mg/l cod 125 mg/l tss 50 mg/l tn 10 mg/l c6h5oh 2 mg/l fog 5 mg/l tds 400 mpn/ml table 2 lists the key factors that have a major impact on water quality and human health: total suspended solids (tss), total kjeldahl nitrogen (tkn), chemical oxygen demand (cod), bio-chemical oxygen demand (bod5), and total phos-phorus (tp). different wastewater treatment sys-tems in the study area are compared using the es-timated pollution load per capita. these parameters are important markers of possible health hazards and water quality. elevated levels of bod5, cod, tss, tn, and tp can cause eutrophication, algal blooms, decreased light penetration, and oxygen depletion, all of which are harmful to aquatic ecosystems and human health. table 2: parameters pollution load assumptions parameters units average range bod5 g/cap/d 60 40-60 cod g/cap/d 130 25-200 tss g/cap/d 50 35-70 tn g/cap/d 14 2-15 tp g/cap/d 2.4 1-3 table 3 shows the main parameters used to es-timate the ddesign capacity of wastewater treat-ment technologies derived from the national soci-oeconomic statistics of the province. water usage per capita was obtained from the water supply state enterprise reportreport. and wastewater was es-timated according to the guideline. three diverse wastewater treatment systems were assumed to have equal capacities of 1,000 m3/d. table 3: main parameters for design capacity indicators unit values no. of household unit 2,100 household size persons 6 population persons 12,139 assumed water usage per capita liter/day 150 assumed wastewater produced % 60% total daily water usage amount liter/ca 1,820,850 total daily wastewater produced liter/ca 1,092,510 assume the total design capacity m3/d 1,000 table 4: household socioeconomic data socioeconomic data (usd) income per capita 1,752 income per household (average 6 persons) 10,512 the annual income of a household in the study area 22,075,200 affordability of wastewater fee (3%) 662,256 operating revenue for evaluation 662,256 equation for financial aspects evaluation the net present value measures the viability of projects by calculating the difference between discounted benefits and costs12). npv=∑n (t=1) ((bt ct))/((1+r)t) npv= net present value; bt = amount of net benefit in year t; ct = operating costs, including o&m costs); r = discount rate; n = project period. the benefit-cost ratio is the ratio of the sum of the present value of the project benefits to the total project costs12). bcr=∑n (t=1) bt/(1+r)t ÷ ∑n (t=1) ct/(1+r)t where bcr benefit cost ratio (bcr), bt = amount of net benefits in year t, ct = operating cost including o & m cosr interest rate, and n project period. figure 2 presents the dewats with constructed wetlands encompassing preliminary, primary, secondary, and tertiary advanced treatment processes. in the primary treatment phase, a settler, specifically a septic tank, was used. the majority of solids were processed in the initial chamber, whereas the second chamber facilitated the smooth flow of water. this system incorporates mechanical treatment via sedimentation and biological treatment via sludge digestion. anaerobic baffled reactors and anaerobic filters are commonly used as backup figure 2: schematic of dewats with constructed wetlands treatment process pa ge 13 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 treatments. constructed wetlands use soil, vegetation, and microorganisms to remove pollutants naturally. both the secondary (post-initial) and tertiary (postpolishing) treatments use these systems. wastewater traverses wetlands, where plants, soil, and microorganisms remove contaminants, such as organic matter, nutrients (nitrogen and phosphorus), and pathogens. constructed wetlands represent a low-energy and l operationally demanding alternative to conventional treatment systems. the systems demonstrated efficiency in pollutant removal, achieving reductions exceeding 70% for bod5, 46% for cod, 46% for tss, and 45% for both tn and tp13. figure 3 shows that the conventional activated sludge process is fundamental to the activated sludge processes. a conventional activated sludge system (cas) comprises a sedimentation tank, primary clarifier, aeration tank, secondary tank, and disinfection tank. the primary and secondary clari-fiers return sludge, allowing the raw sludge to ex-ceed the thickener tank for treatment and disposal. however, this requires strict operating conditions, the outputs are affected by load fluctuations, and the nitrogen and phosphorus removal ratios are low. other processes have been developed to solve these problems and improve the conventional activated sludge processes. a sedimentation tank treats the initial wastewater by removing the grit and garbage through settling. the primary clarifier settles small particles that cannot be removed from a sedimenta-tion tank. the primary sludge was placed in a sludge thickener tank with excess sludge. the activated sludge multiplied as the wastewater received oxygen from the aeration tank. by breaking down organic materials in wastewater, this activated sludge puri-fies the water.. the secondary clarifier was activated sludge, which became lump-shaped and heavier than the water. after settling, the clean water was removed from the top layer. the settled sludge was treated after being transported to a thickener tank. some of the precipitated activated sludge was re-turned to the aeration tank. the disinfection facility sterilizes the water removed from the secondary clarifier before discharge into the receiving water-course. the systems demonstrated treatment effi-ciencies exceeding 80% for removing pollutants such as bod5, cod, and tss, while achieving over 70% efficiency for removing tn and tp. tank, a sedimentation tank, and a disinfection tank. during the treatment process, influents are stored in a sedimentation tank, large amounts of solid matter are separated, and the sludge is stored. the solid matter was separated when the wastewater flowed through the filter. anaerobic bacteria decompose organic matter and remove nitrogen via denitrification. aerobic bacteria decompose organic matter. ammonia was oxidized, and nitrification proceeded. the suspended matter was precipitated in the treated water, a clean su-pernatant was sent to the disinfection tank, and the effluent was discharged after disinfection with chlorine. the johkasou module integrates domestic wastewater treatment with an efficiency rate of 90%, achieving bod5 concentrations below 60 mg/l, cod at 20 mg/l, and a tss removal ratio of 90%. the tn and tp concentrations were less than 20 mg/l or a removal ratio of 70%14),15). figure 3: systematic of the conventional activation sludge process figure 4 shows the johkasou (an advanced septic tank). the johkasou system comprises a sedimen-tation storage tank, an anaerobic filter tank, a moving bed biofilm figure 4: systematic of the johkasou process table 5 presents a comparative analysis that of-fers valuable insight into the performance of the three wastewater treatment technologies. by uti-lizing standardized metrics and drawing from es-tablished research, this study provides a robust framework for evaluating and comparing these systems. quantifiable data on removal efficiencies and rates enable stakeholders to make informed decisions when selecting appropriate wastewater treatment solutions. this approach not only facili-tates a clear understanding of each technology’s strengths but also contributes to the broader goal of improving water quality management. table 5: parameters of comparison po llu tio n r em ov al (% ) u ni t d e w a t s c a s jo hk as ou bod5 mg/cap/d 73.6 80 90 cod mg/cap/d 46.10 80 80 tss mg/cap/d 75.20 90 90 tn mg/cap/d 45 70 90 tp mg/cap/d 45 70 90 statistical analysis to evaluate and contrast wastewater treatment performance and financial viability, the study mostly used descriptive statistical techniques. im-portant parameters, such as the removal efficiencies of bod₅, cod, pa ge 14 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 tss, tn, and tp, were summarized using percentage reduction values. the bene-fit-cost ratio (bcr) and net present value (npv) were computed as part of financial analyses to evaluate the economic feasibility of each treat-ment system. design capacities were estimated us-ing population, water use, and wastewater genera-tion data. since the study concentrated on compar-ative and economic evaluation using primary and secondary data, no inferential statistical tests were conducted. during the data collection process, local authorities were unable to provide a complete set of technical and financial data. limited availability of technical and financial data from local authorities impedes the analysis of wastewater treatment options. previous research on the lao pdr constrains the under-standing of suitable technologies in the study area. the absence of specific data and insufficient tech-nical information complicates the development of effective solutions. consequently, inadequate local data and narrow research scope restrict the identi-fication of cost-effective treatment options for cit-ies. results and discussion local authorities local municipal organizations have reported that the existing wastewater treatment facilities are in-adequate for processing domestic wastewater. this region is prone to natural disasters, which worsen residents’ lack of access to sanitation facilities and hinder basic needs. the sanitation sector requires cost recovery strategies that consider residents’ low-income status and willingness to pay for im-provements. sanitation services fail to adequately serve urban populations, leading to poor health, a reduced quality of life, and impeded economic de-velopment. failure to implement master plans has resulted in a lack of urbanization benefits. the city employs strategies to guide investment and sanita-tion infrastructure expansion, influenced by social, cultural, economic, and environmental factors. defective sewer systems that link pipes to septic tanks have been found during site inspections, re-sulting in wastewater being released into wetlands, rivers, and streams. there are two kinds of sewage collection systems: separate systems that collect sewage and stormwater separately, and combined systems that collect both. this indicates the need for individual water flow systems, as stormwater must be diverted during rainfalls. the three primary sewerage collection systems were conventional sewerage with centrally installed sewer pipes, sim-plified sewerage with pipes installed at the rear and sides of the properties requiring the owner’s consent for maintenance, and established systems of gravity collection networks with interceptor septic tanks and small-diameter pipelines. settled effluent wastewater enters small-diameter pipes for treat-ment. septic tanks near wetlands are connected to these areas through discharge pipes. individual wa-terflow systems are essential for stormwater man-agement during rainfall events. however, popula-tion growth and tourism have increased wastewater beyond the capacity of existing wetlands, which are affected by excessive wastewater inflow. addition-ally, authorities have been deficient in maintenance, resulting in noncompliance with lens standards. authorities cannot generate sufficient revenue from user charges to cover o&m costs because of low wastewater tariffs, high technical standards, commercial losses, and poor collection efforts. site and observations luang prabang lacks centralized sewage, with residences that use individual on-site treatment systems with septic tanks. however, domestic wastewater has only been partially treated. before entering the nam and mekong rivers, septic tank effluents and household wastewater from kitchens, bathrooms, laundry, and cleaning (gray water) exit through drainage canals or pond-wetland systems. this presents health hazards, especially during rainy seasons when floodwater tainted with sewerage overflows drainage systems, ponds, and wetlands. recent comprehensive studies on urban sewage systems are lacking. current efforts have focused on decentralized systems and pond rehabilitation for preliminary treatment. local authorities, initially hesitant about centralized wastewater systems be-cause of spatial constraints, now prioritize city cleanliness and aesthetics, particularly in tourist areas. the existing decentralized wastewater treatment system demonstrates a typical non-mechanized treatment flow. similar low-cost systems globally have reduced organic pollution from domestic wastewater, but show limited ca-pacity to remove nutrients and coliforms from sewage. comparison of technical aspects table 6 presents the results of wastewater treatment systems that vary in effectiveness in eliminating pollutants, such as bod5, cod, tss, tn, and tp. decentralized wastewater module combustion showed less than ideal results, remov-ing only 73.6% of bod5 and 46.1% of cod, with bod5 levels of 60 mg per capita per day, and a 46.10% increase in cod. the tss and tp removal rates were 75.2% and 45%, respectively. however, conventional activated sludge systems performed better, efficiently reducing bod, cod, tss, tn, and tp to meet the discharge standards. the johkasou system has emerged as the most effective treatment method, surpassing other technologies in terms of all the parameters. different treatment methods have shown varying efficiencies for spe-cific pollutants, which has implications for water quality management and environmental protection. the poor performance of the decentralized wastewater module combination highlights the need for improvements to meet the acceptable dis-charge standards. in contrast, the superior perfor-mance of conventional activated sludge systems and the johkasou system suggests their potential as the preferred methods for wastewater treatment. these findings emphasize the importance of selecting appropriate treatment pa ge 15 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 technologies based on pollu-tant removal capabilities to ensure optimal water quality. the effectiveness of wastewater treatment systems varies across technologies. while the de-centralized wastewater module showed suboptimal performance, conventional activated sludge systems demonstrated superior efficiency. johkasou systems have emerged as one of the most effective methods. these findings highlight the importance of selecting appropriate treatment technologies based on pollu-tant removal capabilities. table 6: comparison of pollution removal efficiency pollution removal (%) dewats cas johkasou parameters unit pollution (103) load/ca/d (%) (103) (%) (103) (%) (103) bod5 mg/cap/d 728 73.6 536 80 582 90 655 cod mg/cap/d 1,578 46.10 727 80 1,262 80 1,262 tss mg/cap/d 606 75.20 456 90 546 90 546 tn mg/cap/d 169 45 76 70 118 90 152 tp mg/cap/d 29 45 13 70 20 90 26 comparison of the financial aspects table 7 presents the primary values for comparison within the wastewater treatment system encom-passing both capital expenditure (capex) and op-erational expenditure (opex). opex includes the costs related to administration and maintenance. revenue costs were evaluated by examining household contributions to wastewater fees. by the decree on water supply tariffs policy 11), service providers are authorized to receive 3-5% of house-hold income. this study utilized a conservative estimate of 3% for household income contribution. affordability is the principal factor that influences household contributions to wastewater fees. the assessment methodology balances system costs by considering household affordability. this study advocates a prudent approach to revenue projections. the system prioritizes affordability while also aim-ing for financial sustainability. the balance between cost and affordability may influence the treatment service quality and long-term system sustainability. table 7: result of capex, opex, and revenue type of technologies unit data total (103usd) dewats capex/cap (usd) 150 12,139 1,820 opex /cap (usd) 5.16 12,139 62 affordability to pay 3% 21,267,528 638 cas capex/cap (usd) 100 12,139 1,213 opex /cap (usd) 9.78 12,139 118 affordability to pay 3% 21,267,528 638 johkasou capex/cap (usd) 800 12,139 9,711 opex /cap (usd) 98 12,139 1,189 affordability to pay 3% 21,267,528 638 table 8 provides a comparative analysis of the various wastewater treatment technologies. under the constraints of a specified project duration of 10 years, discount rate of 4.5% based on the wastewater treatment project in lao pdr16), and capacity, it was assumed that the operational and benefit costs re-mained constant throughout the project. the results indicate that the net present value (npv) of the benefits is uniform across technologies. however, because each wastewater treatment technology has different operating and maintenance costs, differences in the net present value (npv) of the costs were noted. critical values, like those found in cost-benefit analyses, must be taken into account. the analysis demonstrates that the benefit-cost ratio of the dewats module combination yields the highest benefits, followed by the cas, whereas the johkasou case does not achieve a benefit-cost ratio of one. according to economic theory, a bene-fit-cost ratio below one suggests that the project is unlikely to be profitable because of elevated opera-tional costs and insufficient benefits. specifically, the johkasou technology’s benefit-cost ratio falling below one indicates potential economic unsustain-ability in the long term. these findings can guide policymakers and project planners in prioritizing pa ge 16 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 and allocating resources towards more cost-effective and sustainable wastewater treatment technologies, thereby potentially enhancing sanitation outcomes and optimizing the use of public funds. table 8: results of net present value and net benefit year capex &opex (103usd) benefit (103usd) discount factor (4.5%) net value benefit (103 usd) net present value cost (103 usd) 1) dewats module combination 0 (1,820) 1 (1,820) 1 62 638 0.96 610 59 15 62 638 0.63 410 40 benefit cost ratio 10.25 2) conventional activated sludge 0 (1,213) 1 1 118 638 0.96 610 113 15 118 638 0.63 410 76 benefit cost ratio 5.39 3) johkasou 0 (9,711) 1 1 1,189 638 0.96 610 1,138 15 1,189 638 0.63 410 766 benefit cost ratio (bcr) 0.53 decentralized wastewater treatment systems (dewats) that use constructed wetlands offer cost-effective solutions. the system provides ad-vantages such as low construction and operational cost and the possibility of resource recovery. how-ever, these methods require sufficient space, pose odor issues, and require optimal treatment. the treated effluent can be used for irrigation or aqua-culture, and nutrients can be recovered. the system adapts to various scales using local materials and labor for community participation. constructed wetlands improve water quality and reduce flood risk. however, they require large areas, which limits their use in densely populated areas. treatment effectiveness varies with the wastewater composi-tion, climate, and wetland design. maintenance included solid removal and water quality monitoring. conventional activated sludge (cas) systems have the advantages of low installation cost and high effluent quality. however, they have high opera-tional costs, require space for sludge disposal, and require skilled supervision. effluent quality can be inconsistent. these systems handle various wastewater loads with lower energy demands for aeration than johkasou systems. however, aeration, sludge recycling, and maintenance costs are also high. the effluent quality varied and did not meet the clarity levels. this process is time-consuming and sensitive to fluctuations in wastewater. there-fore, cas systemsmay be unsuitable for wastewater with high pollutant concentrations. the johkasou system offers an alternative that balances cost-effectiveness and environmental benefits. de-spite their high initial costs and maintenance needs, their long-term benefits often outweigh their drawbacks. their adaptability, pollutant removal efficiency, and water reuse potential render them suitable for dense areas. in recent years, wastewater management has changed. johkasou systems are a sustainable solution, but in order to optimize their efficacy, local conditions must be taken into ac-count. a wastewater treatment system’s selection is influenced by a number of variables, including local conditions, environmental impact, and cost effec-tiveness. dewats with artificial wetlands provide an inexpensive, natural solution, but they need a large amount of land and careful planning. even though they are well-known and efficient, conven-tional activated sludge systems have problems with consistency and operating costs. johkasou systems have become viable substitutes for balancing envi-ronmental advantages with cost-effectiveness. despite their high initial costs, they are appropriate for densely populated areas due to their long-term benefits, adaptability, and efficacy in pollutant re-moval. to ensure sustainable wastewater manage-ment, local conditions and requirements must be taken into account when choosing treatment sys-tems. in order to achieve environmental sustainability, community involvement in wastewater treatment systems is essential. focusing on a number of im-portant areas is necessary for effective community involvement, such as the effects of wastewater management on environmental quality, public health, and economic stability, as these factors can raise community members’ awareness and interest. communities can gain a better understanding of their role in supporting sustainable wastewater treatment systems by educating the public. the many advantages of sustainable methods for in-volving the community in wastewater treatment systems must be emphasized. presenting wastewater treatment as a crucial component pa ge 17 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 of sustainable urban development and circular economy principles can encourage participation in decision-making and support creative, environmentally friendly solutions by emphasizing the economic and environmental benefits, such as the mitigation of water pollution and the preservation of ecosystems. based on these results, we draw the conclusion that decentralized wastewater treatment systems provide significant benefits, such as lower pollution and better investment costs, in local economic and environmental contexts. these systems offer bene-fits through lower investment and operating ex-penses than centralized systems. however, com-paring these systems is complicated by the diverse contexts and priorities under varying circular eco-nomic conditions. comparative analyses of wastewater treatment systems have significantly contributed to water management and sustainability. such methodolo-gies are essential for the selection of suitable treatment technologies. these approaches evaluate sustainability across economic, environmental, so-cial, and technical dimensions and offer a compre-hensive assessment of options. there is an in-creasing focus on decentralized strategies and nat-ural systems such as constructed wetlands. these systems are often favored over conventional acti-vated sludge treatments and johkasou systems, owing to their lower energy use and environmental impact. however, an analysis of land suitability is required to identify appropriate locations. this highlights the need to consider the technological and geographical factors when selecting treatment systems. the comparative evaluation of wastewater treatment systems facilitates informed decisions, promotes sustainable solutions, and addresses water management challenges. this approach supports the development of efficient strategies that can contribute to improved public health and environmen-tal protection. a significant limitation of this study was the absence of standardized monitoring protocols for wastewater treatment systems. current systems focus on conventional pollutants and lack effective standards for monitoring the pollution loads from household sources. this deficiency complicates the assessment of decentralized systems. decentralized wastewater treatment systems can contribute to optimal household wastewater fees. limitations in data collection, standardization, and context-specific factors impede comprehensive com-parison. future research should prioritize the de-velopment of cost-effective technologies tailored to site-specific conditions to facilitate accurate com-parisons. practical implications for policymakers looking to enhance wastewater management in luang prabang, this study offers several practical insights. according to a comparative study of treatment technologies, in-tegrating low-energy, decentralized systems like dewats with artificial wetlands may provide sustainable and affordable solutions. taking into account local socioeconomic conditions and af-fordability, policymakers should give capaci-tybuilding top priority and offer incentives to promote the adoption of such technologies. addi-tionally, improved data collection and financial and technical information transparency will facilitate long-term planning and better informed deci-sion-making. these actions are essential to im-proving the region’s public health, environmental protection, and sanitation coverage. conclusion this study looked into the current wastewater fa-cilities in luang prabang and compared three dif-ferent treatment technologies to see which would work best locally. the evaluation took into account technical needs, site characteristics, what house-holds can afford, and national water quality stand-ards. key factors analyzed included wastewater volume, treatment efficiency, and economic feasi-bility—covering everything from initial investment to operational and maintenance costs—within the context of local policies. the findings indicated that the dewats system combined with a constructed wetland stands out as the optimal choice for larger areas, thanks to its low operating costs, sustainability, and eco-friendliness, making it wellsuited to local budgets and land availability. although johkasou comes with higher setup and running expenses, it’s a good option for areas at high risk for organic waste, like factories or hospitals. on the other hand, the conventional ac-tivated sludge system could still be an option in some cases, despite its higher operational costs. this thorough evaluation lays a strong groundwork for picking the right wastewater treatment technologies that strike a balance between technical efficiency, economic soundness, and policy needs for sustain-able wastewater management in luang prabang city. references arborea, s., piccinni, a., iacobellis, v., de gennaro, b., & giannoccaro, g. 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(2020). lao livable cities project preparation study for the cities of luang prabang, kaysone phomvihane, and pakse: draft interim report. lao pdr. https://cdia.asia/project/lao-pdrlivable-cities/ pa ge 18 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 9-18, 2025 gómez román, c., lima, l., vila tojo, s., correa chica, a., lema, j., & sabucedo, j. m. (2020). “who cares?” the acceptance of decentralized wastewater systems in regions without water problems. international journal of environmental research and public health, 17(23), 9060. https://doi.org/10.3390/ijerph17239060 global green growth institute (gggi). (2020). pakse sanitation project, technical feasibility study report–part ii. champasack province. https://www.cdia.asia/wpcontent/uploads/2020/11/cdiatracerstudy-pakselao-pdr.pdf government of lao pdr. (2022). decree on water supply tariff policy, article 11 [in lao]. https://www.ajne.org/ sites/default/files/document/laws/6684/lao7478. pdf james r. mihelcic, & julie b. zimmerman. (2010). environmental engineering: fundamentals, sustainability, design (pp. 371, 477). john wiley & sons. https:// shorturl.at/li3ju luang prabang province. (2025). national economic development plan [in lao]. https://www. effectivecooperation.org/content/lao-national-socioeconomic-development-plan-2021-2025 luangphabang water supply state enterprise. (2022). annual report, luang prabang province [in lao]. https://www.jwrc-net.or.jp/english/newtap/report/ newtap_038.pdf ministry of natural resource and environment. (2017). regulation on national environmental standard. lao pdr [in lao]. https://wipolex-res.wipo.int/edocs/ lexdocs/laws/en/la/la032en.pdf starkl, m., das, s., singh, a., & brunner, n. (2022). sustainability assessment for wastewater treatment sys-tems in developing countries. water, 14(2), 241. https://doi.org/10.3390/w14020241 urban development authority administration luang prabang (udaa). (2013). master plan drainage and sewerage system, luang prabang. https://www.jasca2021. jp/1st/pdf/ws5/luang_prabang.pdf united republic of tanzania, ministry of water. (2018). guidelines for the application of small-scale, decentralized wastewater treatment systems: a code of practice for decision makers (pp. 38–60). https://www.maji.go.tz/uploads/ publications/sw1552036095-guidelines%20for%20 the%20application%20of%20small-scale,%20 decentralised%20wastewater%20treatment%20 systems.pdf vientiane capital for water treatment project. (2019). wastewater treatment plant and canalization feasibility. https://openjicareport.jica.go.jp/pdf/12303137.pdf pa ge 1 pa ge 90 american journal of medical science and innovation (ajmsi) complex overlap syndrome of rheumatoid arthritis and systemic lupus erythematosus: a therapeutic breakthrough with azathioprine rana dwai1* volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1970 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 07, 2023 accepted: september 11, 2023 published: september 21, 2023 this case study explores the complex nature of coexisting autoimmune diseases, which is most effectively demonstrated by the coexistence of rheumatoid arthritis (ra) and systemic lupus erythematosus (sle), also referred to as “rhupus syndrome.” a comprehensive evaluation of a 28-year-old woman with joint discomfort, morning stiffness, and increased c-reactive protein (crp) values was conducted. anti-cyclic citrullinated peptide (ccp), antinuclear antibodies (ana), and other pertinent serological indicators were examined in the laboratory. the patient’s medical background, prior therapies, and family history were considered to create an individual therapy strategy. the patient’s symptoms remained despite a long history of disease-modifying anti-rheumatic medication (dmard) use. positive outcomes for anti-ccp, anti-ana, and anti-double-stranded dna (anti-dsdna) antibodies provide light on the overlap of multiple autoimmune diseases. the diagnostic difficulty was increased when autoimmune neutropenia was diagnosed with a bone marrow biopsy. once azathioprine therapy was started, symptoms significantly and quickly improved within a month. azathioprine was found to be successful in the remission of the disease. azathioprine therapy’s critical role in treating overlapping autoimmune illnesses emphasizes the necessity for individualized and advanced testing and treatment. targeted immunosuppressive medicines have the potential to make significant advances and enhance patient care and results. keywords rheumatoid arthritis (ra), systematic lupus erythematosus (sle), c-reactive protein (crp), anti-cyclic citrullinated peptide (ccp), antinuclear antibodies (ana), disease-modifying anti-rheumatic medication (dmard), azathioprine (aza), prednisone 1 mediclinic hospital al jowhara, al-ain, united arab emirates * corresponding author’s e-mail: ranadwai15@outlook.com introduction approximately 200 medical conditions come under the umbrella of rheumatic disease. multisystem autoimmune diseases primarily affect the bones, muscles, and joints and are characterized by immunological instability (susmita et al., 2022). clinically, they are distinguished by varied degrees of impairment, pain, stiffness, inflammation, and deformity (susmita et al., 2022). rheumatoid arthritis (ra) and systemic lupus erythematosus (sle) are both autoimmune diseases in which the immune system goes against the body’s immune system, attacking the healthy tissues. the attack causes inflammation in different affected areas of the body. causes joint pain, joint swelling, and joint tenderness. several patients with autoimmune diseases like rheumatoid arthritis are said to have an overlapping condition of another autoimmune disease called systemic lupus erythematosus. sle and ra are together called rhupus. rhupus was first discovered about 50 years ago by peter schur. the overlapping syndrome of rheumatoid arthritis and systemic lupus erythematosus represents a crucial clinical varied treatment. it is a rare disorder and prevails in only 1%-2% of patients with ra (kondo et al., 2020). rheumatoid arthritis is a chronic autoimmune inflammatory disease that causes inflammation in primary synovial joints leading to disrupted joint structure and function (radu & bungau, 2021). several autoimmune rheumatic disorders include systemic lupus erythematosus (sle), sjögren’s syndrome, adultonset scleroderma, spondylarthritis, psoriatic arthritis, and polymyositis (radu & bungau, 2021). the disease process involves the activation of immune cells, including t cells and b cells, building up the production of antibodies such as rheumatoid factor (rf) and anti-cyclic citrullinated peptide (anti-ccp) antibodies (rocha et al., 2019). rf and anti-ccp are also diagnostic serological markers for the disease. the distinctive feature of ra is synovial hyperplasia which contributes to cartilage and bone destruction. leading to the characteristic destructive changes observed in affected joints (xin et al., 2021). rheumatoid arthritis (ra) has an unidentified origin. however, genetic, environmental, and serological variables contribute to the development of the condition. it is reported that 50–60% of ra susceptibility is attributed to smoking, a well-known environmental cause (rocha et al., 2019). on the other hand, systemic lupus erythematosus is a complicated autoimmune condition with a wide range of autoantibodies and diverse symptoms that affect several organ systems. the formation of a wide range of autoantibodies, including anti-nuclear antibodies (ana) and anti-double-stranded dna antibodies (anti-dsdna), is the defining feature of sle. skin rashes, joint discomfort, serositis, renal involvement, hematological abnormalities, and neurological signs are all possible clinical presentations of sle (lou et al., 2022). the variability of the illness makes it difficult to diagnose and treat sle since patients can present with pa ge 91 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 90-96, 2023 various symptoms that change over time. however, to treat systemic lupus erythematosus (sle), it is advised to determine the severity of the illness, organ damage, and implications. according to the hahn treatment plan, a mixture of immunosuppressive medications and steroids should be delivered via hydroxychloroquine. however, this method is advised in serious case instances(tanaka, 2020). sle occurrence varies worldwide, with north america having high rates, africa low, and australia lowest. the disease outcome and treatment depend on age, gender, and ethnicity. it is reported that more women are affected due to environmental and genetic factors, with severe impact on men, mainly found in females aged 15-44, affecting pregnancy and hormones (ameer et al., 2022). joint inflammation and involvement of several organs are features of the complicated inflammatory disease rhupus syndrome. it necessitates a strategic strategy that blends ra and sle properties. therapeutic strategies include disease-modifying anti-rheumatic medications (dmards) to reduce joint inflammation and immunological dysregulation. the common dmards used conventionally are methotrexate, leflunomide, hydroxychloroquine and sulfasalazine(benjamin et al., 2018). the immune response is modulated significantly by immunosuppressive substances, both conventional and biological. biological agents commonly used to treat ra are infliximab, adalimumab, etanercept, rituximab, abatacept, tocilizumab and tofacitinib(benjamin et al., 2018). the key inflammatory pathways are disrupted by dmards using various mechanisms. for instance, methotrexate causes the release of adenosine, inhibits neutrophil adherence, blocks the synthesis of leukotriene b4, and lowers il-1 production. other substances, such as leflunomide, which inhibits tlr9, sulfasalazine, and hydroxychloroquine (aletaha & smolen, 2018). contrarily, biological drugs play particular roles, interfering with cytokine function, impeding t-cell activation, and removing or blocking substances that stimulate b-cell activity (oo et al., 2018). literature review a study conducted on 105 rhupus patients contributes to understanding the disease. the prevalence, clinical traits, and serological profiles of rhupus individuals with both sle and ra were investigated in the study. 10 (9.7%) of the 103 consecutive sle patients were diagnosed with rhupus. patients with ra had decreased renal involvement, but there were no differences in neuropsychiatric, cutaneous, hematological, or serositis involvement. they did not differ from ra patients but had higher crp positive and esr levels. pathological findings were seen during ultrasound exams, with hands scoring higher. compared to sle and ra patients, rhupus patients had a larger cumulative burden (tani et al., 2013). in a cross-sectional study, researchers examined the clinical and immunological features of rhupus patients and contrasted them with those who had sle and ra. 200 individuals participated; 80 had sle and ra, and 40 had rhupus. skin concerns, blood-related disorders, and joint problems were the prominent complaints. those with rhupus experienced joint symptoms resembling those of ra; however, renal involvement was less common (10%) than in those with sle (25%). while 96.3% of patients with sle and 92.5% of rhupus patients satisfied the 2019 eular/acr sle criteria, there were no appreciable differences in the proportion of patients in either group who did. the study recommends a novel classification strategy to pinpoint overlapping autoimmune disease groups (frade-sosa et al., 2020). in another investigation, the treatment of ra with etanercept (etn) and methotrexate (mtx) was examined. they aimed to determine whether these drugs could function without corticosteroids. 20 rhupus patients who had never received corticosteroids or other similar medications were the subject of their study. together with receiving mtx and etn, these patients underwent a 24-week observation period. after administering etn and mtx for 24 weeks, the patient’s joint pain, disease activity, and other symptoms significantly improved. although there were a few mild side effects, including infections and rashes, the medication was largely safe. this shows that treating rhupus with etn and mtx may be a successful option (yang et al., 2018). in a case study, three individuals with ra and sle, a complex overlap of ra and sle, are examined for their clinical and serological traits. all patients had high titers, positive anti-ccp, positive rheumatoid factor, and positive antinuclear and anti-dsdna antibodies. additionally, several patients were found to have certain autoantibodies, such as anti-ssa and anti-sm. despite the difficulty of rhupus syndrome, all three patients who received methotrexate, folic acid, and hydroxychloroquine treatment experienced clinical remission. in addition to highlighting the value of awareness and watchful clinical practice, the paper underlines the significance of early diagnosis and appropriate treatment (devrimsel & serdaroglu beyazal, 2018). in another study, biologic disease-modifying antirheumatic medications (bdmards) were used to treat ra and sle. there were 16 cases found, with rheumatoid arthritis succeeding before rhupus and joint problems. ten individuals needed bdmards, with abatacept occasionally being successful. with persistent responses in six patients, rituximab was frequently prescribed and extremely effective. the study emphasizes the possibility of specialized biologic therapies to treat difficult rhupus cases (rottenberg et al., 2022). these investigations collectively advance the knowledge of the complex sle and ra comorbidity known as rhupus syndrome. they provided information on the prevalence, clinical characteristics, serological profiles, and available treatments for people with rhupus. the findings underline the unique immunological features of rhupus, its peculiar clinical course, and the difficulties separating it from specific sle or ra cases. the studies emphasize the value of early detection, individualized pa ge 92 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 90-96, 2023 treatment plans, and the potential effectiveness of biological medicines for treating rhupus cases that are resistant to conventional treatments. case presentation in this case, a 28 years old woman was admitted to the hospital with a concern about pain in her hand joints and morning stiffness. it was advised to run a laboratory analysis of a full blood test. the laboratory test results depicted elevated c-reactive protein (crp) levels, anticyclic citrullinated peptide (ccp) came to be positive, rheumatoid factor (rf) came to be negative, antinuclear antibody (ana) negative, low white blood cell count, and it was found that in family history her sister had lupus. initially diagnosed with rheumatoid arthritis, the patient’s disease course later revealed an overlapping condition of rheumatoid arthritis with systemic lupus erythematosus. the patient was admitted immediately and advised to give hydroxychloroquine and prednisolone intermittently. the patient’s symptoms remained after intermittent therapy with hydroxychloroquine, prednisolone, and other disease-modifying anti-rheumatic drugs (dmards), along with a decline in white blood cell (wbc) counts. treatment history the patient had an extensive history of dmard usage, including methotrexate, cimzia, sulfasalazine, humira, and enbrel. several treatments were discontinued due to adverse effects such as ecchymosis, headache, and recurrent upper respiratory infections. the patient’s sister had a history of lupus, further complicating the diagnosis. diagnostic workup unlike previous tests that yielded negative results, investigations revealed positive ana and anti-dsdna antibodies. a bone marrow biopsy indicated autoimmune neutropenia secondary to rheumatic disease. the patient’s lupus-like symptoms, photosensitivity, malar rash, and persistent low wbc count posed a diagnostic challenge. treatment breakthrough with limited treatment options and considering the patient’s complex presentation, azathioprine was initiated after confirming normal thiopurine methyltransferase enzyme levels. remarkably, the patient reported a significant improvement in joint pain, morning stiffness, and other symptoms within one month of initiating azathioprine therapy. follow-up and outcome after one month of azathioprine therapy, the patient remained free from joint pain and exhibited no significant complaints. notably, the patient tolerated azathioprine well, with no observed adverse effects. results the results of this case report demonstrate the challenging nature of managing a patient with overlapping features of rheumatoid arthritis and systemic lupus erythematosus, also referred to as rhupus syndrome. a 28-year-old ra patient reported frequent upper respiratory infections, morning stiffness, and joint discomfort. her symptoms remained, and her white blood cell counts declined despite therapies like dmards and biologics. positive results from anti-ccp, anti-ana, and anti-dsdna antibody tests highlighted the complexity of coexisting autoimmune diseases. clinical information and a low wbc count in the patient led to suspicions of autoimmune neutropenia owing to rheumatic illness. after starting azathioprine therapy within a month, the patient showed considerable improvement, suggesting the drug may effectively treat overlapping autoimmune disorders like “rhupus.” the laboratory analysis conducted during the initial diagnosis of rheumatoid arthritis, prior to the initiation of treatment, is presented in table 1. to navigate the diagnostic and therapeutic difficulties brought on by overlap syndromes, this case emphasizes the significance of considering various treatment modalities and the need for individualized, special care. table 1: initial serological marker analysis for rheumatoid arthritis diagnosis test results reference range anti-ccp > 195 u/ml 0-5 u/ml rheumatoid factor (rf) < 21 negative < 30 white blood cell count (wbc) 3.2 4-10 1000/μl ana screen 0.5 negative < 1.5 p-anca (mpo) 0.6 u/ml normal < 5 c-anca (pr3) 1.3 u/ml normal < 5 dna, double-stranded antibodies 1.5 negative < 20 the table displays laboratory findings from various diagnostic tests, giving important details on the patient’s autoimmune condition. the absence of significant rheumatoid factor antibodies indicates that the patient’s rheumatoid arthritis (ra) might not be primarily triggered by this specific antibody. however, the presence of elevated anti-ccp antibodies, coupled with the patient’s symptoms, suggests a consideration for diagnosing rheumatoid arthritis. (ra). a lower white blood cell count (wbc) and an ana screen indicate a comparatively low number of antinuclear antibodies. results from p-anca and c-anca are within the usual pa ge 93 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 90-96, 2023 reference limits, showing that these antibodies are not present in excess amounts. compared to the reference range of 20, dna double-stranded antibodies, frequently linked to systemic lupus erythematosus (sle), are higher. the results for these serological markers, observed after the patient did not respond to treatment and indicating the presence of an overlapping syndrome, are presented in table 2 as provided above. the patient’s autoimmune condition is complex and involves various physiological, immunological, and diagnostic aspects. the patient’s wbc count 3.3 indicates leukopenia, which could be associated with immune system dysregulation. positive ana results indicate an autoimmune process with elevated levels of dna, double-stranded antibodies, and ana titers. kidney function and inflammation markers are also investigated with normal creatinine levels and high crp and esr levels, ferritin levels are also elevated, indicating increased iron stores and inflammation. bone marrow biopsy results indicate autoimmune neutropenia, while chest x-rays show normal lung involvement. urine analysis shows potential kidney involvement with elevated leukocytes and normal red blood cells, other than this, proteinuria and casts are favorable indicators, suggesting no significant structural kidney damage or protein loss through urine. thiopurine methyltransferase (tpmt) activity levels are within an expected range. azathioprine treatment is an immunosuppressive medication used in autoimmune diseases to suppress the overactive immune response responsible for inflammation and tissue damage. it is often chosen when other treatment options have proven insufficient or caused adverse effects. the patient’s complex presentation and limited treatment options align with the choice of azathioprine, as it may provide a broader immunosuppressive effect targeting rheumatoid arthritis (ra) and lupus-like components. discussion test results align with the patient’s complex autoimmune presentation, including anti-dsdna antibodies, elevated inflammation markers, autoimmune neutropenia, and lupus-like symptoms. azathioprine’s immunosuppressive action could help modulate the autoimmune response, leading to an improvement in lupus-related symptoms. the patient reports significant improvement in joint pain, morning stiffness, and other symptoms within one month of initiating azathioprine therapy, corroborating the connection between treatment and test results. the observed symptom improvement reflects the medication’s positive impact on immune dysregulation and inflammation. overall, the choice to initiate azathioprine aligns well with the patient’s complex autoimmune presentation, highlighting the personalized and targeted nature of the therapeutic approach. ra and sle can significantly affect patients’ quality of life and health-related quality of life. patients with sle have a better chance of survival than in the past, but they still experience a low quality of life (elera-fitzcarrald et al., 2018). patients with sle often have ongoing symptoms that worsen their quality of life. a study involving 104 women with sle found that factors such as tiredness, feeling down, body image, and disease activity significantly impact patients’ feelings about life quality. the study found that emotional well-being, especially when the disease is active, is crucial for improving life quality. it is essential to help patients with emotional well-being, body table 2: serological and diagnostic markers after treatment for overlapping syndrome (results and reference ranges) test results reference range limit white blood cell count (wbc) 3.3 4-10 1000/μl ana (antinuclear antibody) positive negative method if dna, double-stranded antibodies 33.8 negative < 20 ana titer (fluorescence) > 1:1280 negative < 1:80 creatinine 53.8 umol/l 44.2-88.4 crp (c reactive protein) 18.4 mg/l 0-5 esr (erythrocyte sedimentation rate) 41 mm/hr 2-39 ferritin 124 ng/ml 30-120 bone marrow biopsy autoimmune neutropenia secondary to rheumatic disease chest x-ray normal urine analysis leukocytes 11-20 cells/hpf ref range 0-5 rbc (red blood cells) 0-2 cells/hpf ref range 0-2 cast nil protein negative thiopurine methyltransferase activity 123 ref 100-200 pa ge 94 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 90-96, 2023 image, and emotional well-being to improve their wellbeing (pereira et al., 2020). in another study, researchers examined the impact of belimumab and rituximab treatments on the quality of life of patients with sle. some patients initially experienced lower quality of life, but after a year, they experienced better physical and mental health. after three months, they experienced better mental and physical health (parodis et al., 2019). this study implied that quality of life could improve once the patient is administered proper modified treatment. much like sle, ra can cause serious problems like joint pain and difficulty moving, renal dysfunctionality and stiffness which can affect a person’s life. a crosssectional study examined the impact of ra on quality of life using questionnaires. results showed that ra patients had similar quality of life as healthy individuals in some areas. however, more pain was linked to worse social interactions, general health, and physical ability. those with worse overall health also had more physical problems and pain. the study suggests better pain management and improved mobility and interaction are crucial for ra patients (martinec et al., 2019). the chronic autoimmune disease ra mostly affects the joints and can be painful and disabling. another study examined the impact of ra on patients’ quality of life. the study took 464 thai patients with ra, mostly females aged 59 or older and found that disease activity and psychological health impacted patient feelings. severe disease and emotional suffering led to lower quality of life, making this knowledge crucial for improved treatment and management (katchamart et al., 2019). it is also reported that people with ra cannot sleep properly due to severe joint pain and discomfort. hence, sleep loss dysregulates bodily functions leading to decreased quality of life (grabovac et al., 2018). considering all these factors that affect the quality of life of sle and ra patients, it is crucial to determine the management of these factors. rhupus syndrome treatment addresses joint inflammation and autoimmune and systemic manifestations in ra and sle (frazzei et al., 2022). common management techniques include medication, such as disease-modifying antirheumatic drugs (dmards), biologic dmards, corticosteroids, pain and symptom management, physical therapy, immunosuppressive therapy, and hydroxychloroquine (srivastava et al., 2019). medications include diseasemodifying antirheumatic drugs (dmards), which control joint inflammation and slow joint damage progression. biologic dmards target immune system parts to reduce inflammation, while corticosteroids provide quick relief. pain and symptom management involves nsaids, analgesics, physical therapy, immunosuppressive therapy, and hydroxychloroquine (guo et al., 2018). lifestyle modifications include a healthy diet, regular exercise, stress management, regular medical monitoring, and an individualized approach. the findings from our case reports align with these management techniques to improve the quality of life and remission of the disease. the case report highlights the complexity of managing rhupus syndrome, with the patient experiencing overlapping features of ra and sle. this highlights the need for an individualized treatment approach. laboratory analysis revealed antibodies associated with ra and sle, highlighting the diagnostic challenges of overlap syndromes and the need for comprehensive serological marker analysis. autoimmune neutropenia was suspected, leading to the initiation of azathioprine therapy. this strategy addresses overlapping features and complications in autoimmune diseases like rhupus. ongoing monitoring and follow-up are crucial, as are regular medical evaluations to adjust treatment based on disease activity and patient progress. despite therapies like dmards and biologics, the challenges faced in managing the patient’s symptoms highlight the complexity of rhupus syndrome. this complexity aligns with the need for a multifaceted treatment strategy that considers the diverse aspects of the disease and the potential for overlapping manifestations. the case report provides a real-world example that reinforces the management techniques and considerations discussed in the context of rhupus syndrome. conclusion this case emphasizes the difficulty in diagnosing and treating overlapping autoimmune diseases like rhupus syndrome. accurate diagnosis and treatment are made more difficult by the convergence of ra and sle symptoms. to solve the case of overlapping autoimmune manifestations, an integrative strategy is required. the patient’s reaction to azathioprine therapy indicates a potential advancement in treating overlapping rheumatoid arthritis and lupus. this accomplishment emphasizes the significance of modifying treatments to target the immunological causes of these illnesses. this case can inspire medical professionals and academics to investigate advanced therapeutic approaches and recognize the complexity of related autoimmune diseases. strengths and implications this research will significantly impact clinical practice. re-evaluation is essential when ra patients don’t respond well to medication since they could risk acquiring lupus or other autoimmune illnesses. achieving disease remission, improving patients’ quality of life, and ensuring patient safety all depend on prompt action. the findings of this study may help other medical professionals identify autoimmune conditions that need special care. this study also emphasizes the importance of ongoing monitoring in patients with autoimmune disorders, such as ra, to quickly detect the onset of lupus or other autoimmune conditions. this research has the potential to significantly affect patient outcomes and general well-being by providing appropriate treatment methods for disease remission and enhanced quality of life. informed consent informed consent was taken from the patient in order to pa ge 95 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 90-96, 2023 carry on the study. funding the study is not funded by any organization. conflict of interest the author declares no conflict of interest. author’s contribution the author contributed in the design, experimentation, writing, 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(2018). safety and efficacy of etanercept-methotrexate combination therapy in patients with rhupus: an observational study of non-glucocorticoid treatment. discovery medicine, 25(135), 14-20. pa ge 1 pa ge 11 american journal of medical science and innovation (ajmsi) comparative analysis of granulation tissue formation and progression in elderly patients with fractures franklin e. ibadin1*, trevor efosa edobor2, excel onajite ernest-okonofua3, ogheneyemarho great oyiborhoro4 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3945 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: october 18, 2024 accepted: november 25, 2024 published: january 20, 2024 fracture healing initiates with an inflammatory phase, followed by granulation tissue formation, which is necessary for angiogenesis and bone regeneration. these processes are complicated by the influence of aging on cytokine and growth factor responses. the study sought to quantify granulation formation between elderly versus younger patients and to explore the effect of comorbidities, fracture location, and intervention type. it was a comparative observational study of 60 elderly patients (≥65 years old) with fractures. demographic, fracture, comorbidity status, and biomarkers data (crp, il-6) were collected from the data. paired samples t-tests, independent t-tests, and anova were used to statistically evaluate time differences in granulation tissue formation and inflammatory markers. increased granulation tissue formation was found between day 7 and day 30, although this rate fell off between day 14 and day 30. levels of crp were significantly different, suggesting an altered inflammatory response, and were intermediate between moderate inflammation, seen in elderly patients, and moderate inflammation, consistent with sepsis or septic shock. no significant difference in granulation tissue formation among groups indicated consistent healing and a failure of intervention method or fracture type. healing is extra delayed in elderly patients as a result of reduced cell activity and immunity associated with age, and diabetes and cardiovascular diseases contribute to slowing down the recovery as well. the development of specific management protocols, crp and il-6 levels monitoring to track tissue healing, and vascularization and cellular function-based interventions that promote tissue regeneration. supplements such as vitamin d plus calcium or anti-inflammatory treatments speed up healing. keywords bone regeneration, comorbidities, elderly patients, fracture healing, granulation tissue, inflammatory markers 1 faculty of health sciences, public health in epidemiology, purdue university global, west lafayette, indiana, usa 2 general practice vocational training scheme, nhs england, london, united kingdom 3 department of public health, south wales university, newport, wales, united kingdom 4 department of medicine and surgery, igbinedion university, nigeria * corresponding author’s e-mail: franklin.ibadin@outlook.com introduction fracture healing begins with an inflammatory phase, during which cytokines (il1 and tnfα) bring in immune cells to remove debris and secrete essential growth factors for cell migration and differentiation (baht et al., 2018). next, granulation tissue, a vascular collagen-rich matrix, becomes a soft callus that shingles the surface, improving the structure and a template for bone regeneration (sheen et al., 2023). however, the shiu et al. (2018) study emphasized that granulation tissue is indispensable to angiogenesis, fibroblast proliferation, and deposition of extracellular matrix (ecm), factors required for the ossification phase (shiu et al., 2018). the lifetime risk of osteoporotic fracture is (40–50%) in women and (13– 22%) in men, with a higher mortality in men (migliorini et al., 2021). the number of new fractures globally almost doubled, from 133 million in 1990 to 178 million in 2019, representing a 33.4% rise over that time (mitchell, 2022). choy et al. (2020) research elaborated that growth and activity by both osteoblasts and fibroblasts are required to generate robust granulation tissue and are impaired with aging (choy et al., 2020). however, schlundt et al. (2018) study discussed that elderly patients have specific challenges, including reduced collagen type i synthesis, impaired macrophage function, and decreased vegf levels, which increase infection risk and delay callus formation (schlundt et al., 2018). a key component in wound healing is granulation tissue at the injury site, which comprises fibroblasts, collagen, capillaries, and inflammatory cells. bridging tissue gaps, supporting cell migration, and providing nutrients during healing through a capillary network that promotes healing are its main functions (soliman & barreda, 2022). this is driven by cellular and molecular mechanisms, i.e., fibroblasts and endothelial cells proliferating in the setting of growth factors: vascular endothelial growth factor (vegf), platelet-derived growth factor (pdgf), and transforming growth factor beta (tgfβ) (farooq et al., 2021). a study by wildemann et al. (2021) highlighted that fracture recovery is further complicated in the aging population because cellular function and immunity are compromised and lead to increased risks of delayed union, nonunion, and infection (wildemann et al., 2021). patients with osteoporosis and comorbidities (such as diabetes) are also commonly elderly and are predisposed to impaired healing and increased infection risk, as mentioned by (sobh et al., 2022; sobh et al., 2022). secondary complications such as deep vein thrombosis and pulmonary embolism are secondary to prolonged immobility resulting from reduced regenerative ability pa ge 12 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 11-17, 2025 and a weakened immune system (niu et al., 2022). the study’s main aim was to analyze granulation tissue formation and progress in elderly patients with fractures to determine age-related differences in the healing. key objectives include comparing the effects of granulation tissue formation between elderly and younger patients and how comorbidities, fracture location, and type of intervention influence tissue development in the elderly. further, the study aims to assess pitfalls in granulation tissue formation that contribute to poor recovery for elderly fracture patients. materials and methods study design the research strategy involves a comparative observational study of the formation and progression of granulation tissue in elderly patients with 65 years and older fractures. this study collects granulation tissue formation and maturation data and the impact of comorbidities, fracture location, and treatment interventions on the healing process. the observations of natural progression without intervention help to determine age-related differences in granulating tissue formation and factors that cause delayed or impaired healing (upton, 2020). statistical methods provide a pattern and factors affecting the healing techniques in fracture, providing essential clues to age-related problems in fracture healing. inclusion and exclusion criteria for this study, the inclusion criteria include elderly patients with fractures aged 65 years and above who can provide informed consent. to help ensure an understanding of study procedures and communications, participants should speak english. those fractures studied are most relevant in older adults, but eligible fractures include joint hip, femur, wrist, or vertebral fractures. exclusion criteria include patients with conditions that severely impact healing (e.g., advanced osteoporosis or active cancer) and severely impaired cognitive function (whereby consent or compliance are seriously affected). therefore, the study selects participants with otherwise manageable comorbidities for accurate comparisons. study population the study population comprises 60 elderly patients (≥ 65 years of age) with various fractures. patients with severe conditions that could disrupt healing independently, such as severe osteoporosis or cancer, are excluded from examining healing patterns for age-specific healing patterns. it provides a representative assessment of typical elderly fractures involving fracture sites and types of interventions. data collection this study’s data collection included determining healing and control factors and considering confounding variables by collecting complete demographic and medical histories (age, gender, diabetes, and cardiovascular history). fracture types and treatment details were also documented for comparability by older people and the younger groups. with x-rays (days 7, 14, 30) and mri, images allowed visual examination of growing granulation tissue, and histology samples were used where available. inflammation and healing were monitored by measuring each interval blood markers crp, il-6, cytokines, and growth factors. data analysis for this study, the data analysis includes statistical comparisons between elderly and non-elderly patients to determine granulation tissue formation rates and rates of development for this population. differences in tissue formation, vascularisation, and ad-healing markers were evaluated by paired samples, independent t-tests, and oneway anova at specific time intervals. these analyses help clarify the particular healing problems to which elderly patients are subject for targeted interventions to promote fracture recovery. results and discussion results frequency analysis gender the findings illustrate that the gender distribution of the study participants approximated a nearly equal split between males and females (table 1). among 60 total participants, 30 (47.6%) are female, 30 (47.6%) are male. overall percentages indicate that 52.4% of the valid outcomes are female, and 100% of the total is attained when the male participants are included, as shown in table 1. an unbiased comparison of genders for granulation tissue formation is possible at these levels of balanced distribution. table 1: gender frequency percent valid percent cumulative percent valid female 30 47.6 47.6 52.4 male 30 47.6 47.6 100.0 total 60 100.0 100.0 fracture type fracture types are balanced in distribution among the 60 participants, and each type (femur, humerus, radius, tibia, and ulna) accounts for 19.0% of the total sample (table 2). this representation of equal tissue affords a well-balanced examination of granulation tissue formation amongst different fracture sites. the cumulative percentage column shows that as you add each fracture type, the proportion increases until it hits 100% after in ulna. pa ge 13 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 11-17, 2025 comorbidities the distribution of comorbidities among 60 participants is presented in table 3. the most common comorbidity is diabetes, occurring in 24 participants (38.1%), and cardiovascular conditions in 13 participants (20.6%). a further 19 participants (30.2%) have no comorbidities, and a smaller portion (6.3%) have both. the cumulative percentages increase to 100% for those without comorbidities. these results point out that diabetes and cardiovascular diseases are widespread and can potentially affect granulation tissue formation in fracture healing in elderly patients. table 2: fracture type frequency percent valid percent cumulative percent valid femur 12 19.0 19.0 23.8 humerus 12 19.0 19.0 42.9 radius 12 19.0 19.0 61.9 tibia 12 19.0 19.0 81.0 ulna 12 19.0 19.0 100.0 total 60 100.0 100.0 table 3: comorbidities frequency percent valid percent cumulative percent valid both 4 6.3 6.3 11.1 cardiovascular 13 20.6 20.6 31.7 diabetes 24 38.1 38.1 69.8 none 19 30.2 30.2 100.0 total 60 100.0 100.0 table 4: intervention frequency percent valid percent cumulative percent valid non-surgical 30 47.6 47.6 52.4 surgical fixation 30 47.6 47.6 100.0 total 60 100.0 100.0 table 5: descriptive statistics n minimum maximum mean std. deviation age group 60 65 88 74.20 7.080 granulation tissue formation (day 7) 60 3.5 67.9 35.700 18.9927 granulation tissue formation (day 14) 60 5.7 81.7 43.700 22.3985 granulation tissue formation (day 30) 60 7.9 95.5 51.700 25.8043 cytokine levels 60 .91 36.78 18.8633 10.45694 growth factor levels 60 2.81 61.64 32.0125 17.45740 intervention the distribution of the 60 participants into non-surgical or surgical fixation approaches is illustrated in table 4. in particular, 30 (47.6%) were treated non-surgically, and 30 (47.6%) received surgical fixation. this balanced distribution offers a reasonable basis for comparison of granulation tissue formation with different intervention types. as shown in table 4, including surgical cases brings the cumulative percentage up to 100% to provide comprehensive data. descriptive analysis the descriptive statistics describe granulation tissue formation and inflammation markers in elderly fracture patients (table 5). mean values for granulation tissue formation were 35.7 ± 18.992 on day 7, 43.7 ± 22.398 on day 14, and 51.7 ± 25.804 on day 30, suggesting that healing is occurring gradually. cytokine levels indicate biological variability (mean = 18.863, sd = 10.456) and growth factor levels (mean = 32.012, sd = 17.457), as shown in table 5. crp and il-6 show means of 4.998 and 10.546, respectively, for inflammatory markers. moderate discomfort among patients is quantified with an average patient pain score of 5.28 (sd = 3.258). these findings show healing progression and inflammation trends (table 5). pa ge 14 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 11-17, 2025 independent samples test the results of the independent samples test show for most variables, levene’s test for equality of variances is nonsignificant (sig. > 0.05), which means that variances are equal between groups (table 6). there is no significant difference in means (t value less than 1 with p greater than 0.05) for cytokine levels, growth factor levels, and inflammatory marker il-6 on the different days (day 7, day 14, day 30), as shown in table 6. however, the t-test result (t = -2.456, p < 0.05) for inflammatory marker crp is significant, implying a fundamental difference between groups for crp levels, potentially implying different inflammatory responses. inflammatory marker 1 (crp) 60 1.23 7.87 4.9983 1.38745 inflammatory marker 2 (il-6) 60 6.77 14.12 10.5463 1.54999 pain score (0-10) 60 0 10 5.28 3.258 valid n (listwise) 60 table 6: independent samples test levene's test for equality of variances t-test for equality of means f sig. t granulation tissue formation (day 7) equal variances assumed .000 1.000 -.222 equal variances not assumed. -.222 granulation tissue formation (day 14) equal variances assumed .000 1.000 -.223 equal variances not assumed -.223 granulation tissue formation (day 30) equal variances assumed .000 1.000 -.223 equal variances not assumed -.223 cytokine levels equal variances assumed .000 .990 -.230 equal variances not assumed -.230 growth factor levels equal variances assumed .003 .960 -.222 equal variances not assumed -.222 inflammatory marker 1 (crp) equal variances assumed .385 .537 -2.456 equal variances not assumed -2.456 inflammatory marker 2 (il-6) equal variances assumed .170 .681 .182 equal variances not assumed .182 table 7: independent samples test t-test for equality of means df sig. (2-tailed) mean difference granulation tissue formation (day 7) equal variances assumed 58 .825 -1.1000 equal variances not assumed 58.000 .825 -1.1000 granulation tissue formation (day 14) equal variances assumed 58 .824 -1.3000 equal variances not assumed 58.000 .824 -1.3000 granulation tissue formation (day 30) equal variances assumed 58 .824 -1.5000 equal variances not assumed 58.000 .824 -1.5000 cytokine levels equal variances assumed 58 .819 -.62533 equal variances not assumed 57.999 .819 -.62533 the results of the independent samples test have no significant mean differences in granulation tissue formation on day 7 (p = 0.825, mean difference = -1.1000), day 14 (p = 0.825, mean difference = -1.3000) nor day 30 (p = 0.825, mean difference = -1.5000), cytokine levels (p = 0.819, mean difference = -0.6253), a significant difference was found with crp (p = 0.017, mean difference = -0.8447), with a group with an elevated inflammatory response table 7. there is no significant difference (p = 0.856, mean difference = 0.0733) for il-6. these findings suggest that crp, long observed as a risk factor for atherosclerotic disease in the elderly, may be essential in promoting healing in this group (table 7). pa ge 15 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 11-17, 2025 paired sample t-test a progressive increase in granulation tissue formation by the elderly fracture patients in the paired samples statistics table at three-time points is shown in table 8. from day 7 to day 14, the mean values increased from 35.7 to 43.7 and from 14 to 51.7, suggesting continuous tissue growth required for healing. healing rates also vary because the standard deviation increases from 18.9927 on day 7 to 25.8043 on day 30. on day 7, it has a standard error mean of 2.4520, and by day 30, this rises to 3.3313, demonstrating less precision in later time points. the continued progression of this elderly fracture points to the necessity for sustained granulation tissue development (table 8). growth factor levels equal variances assumed 58 .825 -1.00700 equal variances not assumed 58.000 .825 -1.00700 inflammatory marker 1 (crp) equal variances assumed 58 .017 -.84467 equal variances not assumed 57.480 .017 -.84467 inflammatory marker 2 (il-6) equal variances assumed 58 .856 .07333 equal variances not assumed 56.381 .856 .07333 table 8: paired samples statistics mean n std. deviation std. error mean pair 1 granulation tissue formation (day 7) 35.700 60 18.9927 2.4520 granulation tissue formation (day 14) 43.700 60 22.3985 2.8916 pair 2 granulation tissue formation (day 30) 51.700 60 25.8043 3.3313 granulation tissue formation (day 7) 35.700 60 18.9927 2.4520 pair 3 granulation tissue formation (day 14) 43.700 60 22.3985 2.8916 granulation tissue formation (day 30) 51.700 60 25.8043 3.3313 table 9: paired samples test paired differences mean std. deviation std. error mean 95% confidence interval of the difference lower pair 1 granulation tissue formation (day 7) granulation tissue formation (day 14) -8.0000 3.4059 .4397 -8.8798 pair 2 granulation tissue formation (day 30) granulation tissue formation (day 7) 16.0000 6.8118 .8794 14.2403 pair 3 granulation tissue formation (day 14) granulation tissue formation (day 30) -8.0000 3.4059 .4397 -8.8798 from day 7 to day 14 (pair 1), the paired samples test results indicate a mean decrease by -8.0000 grams of granulation tissue formation, with a standard deviation of 3.4059. a mean increase of 16.0000 is significant in pair 2 (day 30 day 7). pair 3 (day 14 day 30) again has a negative of -8.0000 (mean decrease), also indicating a slower growth phase. 95% confidence intervals support these findings. one-way anova anova findings for granulation tissue formation at days 7, 14, and 30 show no significant differences between groups, implying a constant healing pattern (table 10). the between groups sum of squares is 145.200, the mean square is 36.300, and the f value is 0.094, indicating slight variation for day 7. like day 14, we get a sum between the group’s squares of 202.800, mean square of 50.700, and f value of 0.095 on that day. as shown in table 10, the between-groups sum is 270.000 and f-value= 0.095. these low f values point to granulating tissue formation common to both groups with no significant external effect, suggesting that the healing process in elderly patients remains stable. table 10: anova sum of squares df mean square f granulation tissue formation (day 7) between groups 145.200 4 36.300 .094 within groups 21137.500 55 384.318 total 21282.700 59 pa ge 16 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 11-17, 2025 discussion this discussion reviewed age-related differences in granulation tissue formation and healing after fracture in elderly patients. the study compares elderly patients with younger counterparts and examines the effect of the comorbidities, fracture location, and intervention type on tissue development. the study participants have a balanced number of male and female participants in the sample. this balance ensures an unbiased comparison of granulation tissue formation as female and male differences in healing outcomes. furthermore, having fracture types (femur, humerus, radius, tibia, and ulna) evenly distributed, the study can evaluate the variation as it moves from one injury site to another. lim et al. (2018) emphasized that the type and location of fracture influence the healing process, and load-bearing fractures, such as femoral fractures, can be slower due to a reduced blood supply (lim et al., 2018). however, age-related healing impairments still affect outcomes in elderly patients. the study findings indicate that elderly fracture patients, who are at risk of developing diabetes or cardiovascular diseases, are also predisposed to impaired granulation tissue formation. however, marin et al. (2018) highlighted that diabetes can cause conditions that interfere with healing, such as impaired vascularity and cellular function, which can slow down the time it takes to heal a fracture (marin et al., 2018). balanced comparisons are also permitted based on equal proportions of nonsurgical and surgical fixation treatments. a study by yachmaneni et al. (2023) suggested that surgical fixation can improve healing; however, comorbidities, particularly diabetes, can interfere with healing by hindering tissue regeneration and blood flow (yachmaneni jr et al., 2023). the descriptive statistics show an increase in granulation tissue formation from day 7 to day 30, consistent with the usual healing pattern of elderly fracture patients. this variability in cytokine and growth factor levels suggests moderate levels of inflammation, as indicated by crp and il-6, which suggest ongoing inflammation. previous work by walters et al. (2018) demonstrated that cytokine activity, granulation tissue formation, and inflammatory markers are essential for fracture healing and that inflammation is a critical component of tissue repair (walters et al., 2018). independent samples test results indicate no significant differences in granulation tissue formation among days; p values are more crucial than 0.05. however, crp levels varied significantly, and such variation may play a role in the inflammatory response associated with healing. sproston and ashworth’s (2018) study found that crp modifies immune response and angiogenesis, and studies have shown that it influences inflammation and tissue regeneration (sproston & ashworth, 2018). results from the paired samples test show a more progressive increase in the formation of granulation tissue in elderly fracture patients with a significant rise from day 7 to day 30, though a slower growth rate between day 14 and day 30. this changing pace in healing is also reflected in the increasing variability of standard deviation and standard error over time. however, research by jiang and scharffetter-kochanek (2020) discussed that granulation tissue formation is integral to fracture healing-related factors like decreased cell function and vascularization decrease, affecting healing time in older patients (jiang & scharffetter-kochanek, 2020). anova findings indicate no significant differences in granulation tissue formation between groups at days 7, 14, and 30, indicating uniform healing. this stock of healing suggests that there is an established granulation tissue healing response in elderly fracture patients. muire et al. (2020) find that healing takes longer in older people because of decreased cellular activity and compromised immunity; all fundamental mechanisms of granulation tissue formation are unaffected by age (muire et al., 2020). a limitation of the study is that the sample size is relatively small. however, findings may generalize to a larger sample; the sample size is relatively small and does not adequately represent a larger sample. furthermore, the observational design fails to consider observed confounding variables, i.e., lifestyle or nutrition associated with healing but are uncontrolled. furthermore, there may be bias from patients excluded who have severe comorbidities because they could have revealed a more excellent range of healing challenges in elderly patients with more complex health conditions. based on these results, practical recommendations for this study include the development of specific fracture management protocols to address impaired osseous healing and exaggerated inflammatory response in elderly patient (elhawary et al., 2021). tracking inflammatory progression, spot delay, union or nonunion early c-reactive protein (crp), and interleukin-6 (il6) monitoring can be helpful (torres et al., 2023). to promote optimal tissue regeneration and cellular function, both angiogenesis and cellular function must be targeted by interventions complementary to comorbidities such as diabetes mellitus and atherosclerosis (katsi et al., 2023). supplements such as vitamin d, calcium, and antiinflammatory pharmacotherapy can also make healing occur faster (habib et al., 2020). granulation tissue formation (day 14) between groups 202.800 4 50.700 .095 within groups 29397.100 55 534.493 total 29599.900 59 granulation tissue formation (day 30) between groups 270.000 4 67.500 .095 within groups 39015.900 55 709.380 total 39285.900 59 pa ge 17 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 11-17, 2025 conclusion this study determines challenges in fracture healing associated with age, specifically in the aging elderly, who are more prone to slow granulation tissue formation and a more responsive inflammatory component. for example, many older patients suffer delayed healing secondary to reduced vascularization, decreased collagen synthesis, and lost immune function. healing is further complicated by comorbidities, specifically diabetes and cardiovascular conditions, which inhibit tissue regeneration and blood flow. however, the observed progression of granulation tissue over time shows ongoing inflammation, as measured by inflammation markers crp and il-6, thus underscoring the need to develop targeted, age-specific treatment protocols. in particular, these results emphasize the value of personalized interventions to facilitate optimal fracture recovery in elderly patients. references baht, g. s., vi, l., & alman, b. a. (2018). the role of the immune cells in fracture healing. current osteoporosis reports, 16, 138-145. choy, m. h. v., wong, r. m. y., chow, s. k. h., li, m. c., chim, y. n., li, t. k., ho, w. t., cheng, j. c. y., & cheung, w. h. (2020). how much do we know about the role of osteocytes in different phases of fracture healing? a systematic review. journal of orthopaedic translation, 21, 111–121. elhawary, h., baradaran, a., abi-rafeh, j., vorstenbosch, j., xu, l., & efanov, j. i. (2021). bone healing and inflammation: principles of fracture and repair. seminars in plastic surgery, 35(2), 123-134. farooq, m., khan, a. w., kim, m. s., & choi, s. (2021). the role of fibroblast growth factor (fgf) signaling in tissue repair and regeneration. cells, 10(11), 3242. habib, a. m., nagi, k., thillaiappan, n. b., sukumaran, v., & akhtar, s. (2020). vitamin d and its potential interplay with pain signaling pathways. frontiers in immunology, 11, 820. jiang, d., & scharffetter-kochanek, k. (2020). mesenchymal stem cells adaptively respond to environmental cues thereby improving granulation tissue formation and wound healing. frontiers in cell and developmental biology, 8, 697. katsi, v., papakonstantinou, i., & tsioufis, k. (2023). atherosclerosis, diabetes mellitus, and cancer: common epidemiology, shared mechanisms, and future management. international journal of molecular sciences, 24(14), 11786. lim, s. j., yeo, i., yoon, p. w., yoo, j., rhyu, k. h., han, s. b., lee, w. s., song, j. h., min, b. w., & park, y. s. (2018). incidence, risk factors, and fracture healing of atypical femoral fractures: a multicenter case-control study. osteoporosis international, 29, 2427-2435. marin, c., luyten, f. p., van der schueren, b., kerckhofs, g., & vandamme, k. (2018). the impact of type 2 diabetes on bone fracture healing. frontiers in endocrinology, 9, 6. migliorini, f., giorgino, r., hildebrand, f., spiezia, f., peretti, g. m., alessandri-bonetti, m., eschweiler, j., & maffulli, n. (2021). fragility fractures: risk factors and management in the elderly. medicina, 57(10), 1119. mitchell, p. j. (2022). fracture liaison: a crucial tool in the fight against fragility fracture. maturitas, 165, 26-32. muire, p. j., mangum, l. h., & wenke, j. c. (2020). time course of immune response and immunomodulation during normal and delayed healing of musculoskeletal wounds. frontiers in immunology, 11, 1056. niu, s., pei, y., hu, x., ding, d., & jiang, g. (2022). relationship between the neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio and deep venous thrombosis (dvt) following femoral neck fractures in the elderly. frontiers in surgery, 9, 1001432. schlundt, c., el khassawna, t., serra, a., dienelt, a., wendler, s., schell, h., van rooijen, n., radbruch, a., lucius, r., & hartmann, s. (2018). macrophages in bone fracture healing: their essential role in endochondral ossification. bone, 106, 78-89. sheen, j. r., mabrouk, a., & garla, v. v. (2023). fracture healing overview. in statpearls [internet]. statpearls publishing. shiu, h. t., leung, p. c., & ko, c. h. (2018). the roles of cellular and molecular components of a hematoma at the early stage of bone healing. journal of tissue engineering and regenerative medicine, 12(4), e1911– e1925. sobh, m. m., abdalbary, m., elnagar, s., nagy, e., elshabrawy, n., abdelsalam, m., asadipooya, k., & el-husseini, a. (2022). secondary osteoporosis and metabolic bone diseases. journal of clinical medicine, 11(9), 2382. soliman, a. m., & barreda, d. r. (2022). acute inflammation in tissue healing. international journal of molecular sciences, 24(1), 641. sproston, n. r., & ashworth, j. j. (2018). role of c-reactive protein at sites of inflammation and infection. frontiers in immunology, 9, 754. torres, h. m., arnold, k. m., oviedo, m., westendorf, j. j., & weaver, s. r. (2023). inflammatory processes affecting bone health and repair. current osteoporosis reports, 21(6), 842–853. upton, l. (2020). what is the effect of age on wound healing in the acute trauma setting?: a scoping review. wound practice & research: journal of the australian wound management association, 28(3), 115-126. walters, g., pountos, i., & giannoudis, p. v. (2018). the cytokines and microenvironment of fracture haematoma: current evidence. journal of tissue engineering and regenerative medicine, 12(3), e1662–e1677. wildemann, b., ignatius, a., leung, f., taitsman, l. a., smith, r. m., pesántez, r., stoddart, m. j., richards, r. g., & jupiter, j. b. (2021). non-union bone fractures. nature reviews disease primers, 7(1), 57. yachmaneni jr, a., jajoo, s., mahakalkar, c., kshirsagar, s., & dhole, s. (2023). a comprehensive review of the vascular consequences of diabetes in the lower extremities: current approaches to management and evaluation of clinical outcomes. cureus, 15(10). pa ge 1 pa ge 10 american journal of medical science and innovation (ajmsi) prevalence, self-medication practices, and knowledge levels on analgesic among residents of nalut, libya: a cross – sectional study aminah issa masud aljerbi1, amira saleh khalifa bagni1*, assma nagi aissa wareg2, nada faisal ali suleiman2, fatimah mohammed yousuf askar2 volume 1 issue 1, year 2022 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: november 19, 2022 accepted: december 08, 2022 published: december 08, 2022 self-medication (sm) has become an increasingly important symptom management option for common conditions today. irrational sm practice leads to incorrect diagnosis and a risk factor for disease exacerbation and serious health consequences. hence responsible sm is vital for better health outcomes. in the present communitybased study, we explored the prevalence the sm practice among residents, frequency, outcome, distribution of different level of knowledge about paracetamol, aspirin, and ibuprofen analgesics. cross-sectional study was conducted among randomly selected 1218 participants depending on multi-stage random sampling technique. the sample was taken among the consumers of community facilities in nalutlibya. data were analyzed using spss; chi-square test was performed to indicate significance, frequency, percentage. a total of 1218 residents completed the survey, prevalence of sm practiced was 12.95%, the mean age of participants was 25±30, ranged from 18 to 41 and above years. most of residents 834 (68.5%) were in undergraduate level, 725 (59.5%) were employing and 559 (45.9%) were in low income level and 170 (14%) had chronic diseases. there is no statistically significant deference between the level of knowledge to paracetamol, aspirin and ibuprofen analgesics among participants and their age (x² =0.954, p= 0.812). most the participants had poor knowledge toward paracetamol, aspirin and ibuprofen analgesics. keywords analgesic knowledge, self-medication, prevalence, nalut, libya 1 faculty member department of public health, college of medical technology, nalut university, libya 2 bachelor’s degree, department of public health, college of medical technology, nalut university, libya * corresponding author’s e-mail: bagniamirasaleh@gmail.com introduction in the midst of escalating health care costs globally, sm is becoming an increasingly important option for common conditions. despite the benefits of practicing sm depends on responsible implementation. according to the (who,2000). sm is also defined as “the use of drugs to treat self-diagnosed disorders or symptoms”. they are often called sm (over-the counter medicines) (otc) and can be purchased at pharmacies without a doctor’s prescription (azhar et al.,2013). medicines that do not require a prescription play a major role in self-care, which provides individuals with the option to make independent decisions about their health. drug education and culture have an important role in educating consumers and providing them with the correct rules for using medicine to avoid the risks that can result from the indiscriminate use of medicines (stosic et al.,2011). the misuse of analgesic’s or taking them indiscriminately and without medical advice has many risks for all age groups, as some medicines cannot be given to the patient together. or they may need to adjust their doses, so the specialist doctor is the only one who is able to prescribe the appropriate medicine, as he takes into account all the precautions are necessary (mohammed,2016). most types of analgesics share the same side effects, which stomach pain, nausea, vomiting, dizziness allergic reactions and skin rashes. these effects can be considered shortterm, as they can appear on some without the other. as for the side effects that result from the continuous and excessive use of sedatives, they are often related to the kidneys, liver and are severe (ali et al.,2018). a study to evaluate the indication for the use of non-steroidal ant inflammatory drugs, to what extent the public is aware of their side effects, the sample size is 9062 participants from the american public, and the results showed that ibuprofen –based drugs are the most used and 26% of respondents used more than the recommended dose, 15% reported daily use of analgesics and 49% did not know about possible side effects (wilcox et al.,2005). there are many medicines that contain paracetamol, so you must read the ingredients of the medicine and not take more than one medicine that contains paracetamol, and taking it may cause an increase in the effectiveness of warfarin (an anticoagulant drug) and the risk of bleeding increases, and paracetamol should not be taken with epilepsy and tuberculosis medicines (nhs,2019). in the study (kontogiorgis et al.,2016) entitled “assessment of consumer’s knowledge and attitudes towards overthe-counter analgesic drugs”, the researchers used a sample of participants individuals was frequented community pharmacies, and a questionnaire was used as a data collection tool. the aim of the study is to bridge the knowledge gap regarding people’s beliefs and attitudes related to the use of paracetamol. the results showed that 11.1% of the participants believed that the maximum permissible dose. more than a third of participants thought that paracetamol had no side effects. a large proportion of the participants ranged between 9.9% and 33.7% the difference between paracetamol and non-steroidal anti-inflammatory drugs was not known. the results also showed a relationship between the rate of paracetamol use and the gender and age of https://journals.e-palli.com/home/index.php/ajmsi mailto:bagniamirasaleh@gmail.com pa ge 11 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 10-15, 2022 the participants. the use of aspirin may sometimes be accompanied by the emergence of some unwanted side effects, and these effects may require a visit to the doctor. the most important side effects of the use of aspirin are the worsening of the condition of people with asthma, and it also affects blood clotting, as it is one of the bloodthinning drugs. which may cause some problems related to bleeding in some people. aspirin use also cause serious allergic reactions in some people who are allergic to aspirin, such as a rash (kanaan & gholami, 2021). taking ibuprofen, for long periods or in high doses may lead to serious side effects. one of the noticeable side effects of taking it is swelling of the leg or body (edema). this swelling is caused by excess fluids trapped in the body tissues. it can also cause digestive problems. if a person takes ibuprofen regularly, the stomach loses its protective barrier, and over time this may lead to gastritis, stomach ulcers or perforation (krasniqi et al .,2019). we conducted this study to determine the prevalence of sm practice , and assess the knowledge level on analgesic (paracetamol, aspirin, ibuprofen) among residents of nalut city , libya. materials and methods sample size and sampling method the present community-based cross-sectional study was carried out to explore the prevalence of self-medication, participant’s level of knowledge regarding paracetamol, aspirin and ibuprofen analgesic. the sample was taken among the consumers of community facilities in nalut libya. cross-sectional study was conducted among 1218 participants randomly selected depending on multi-stage random sampling technique. the study was conducted between february and july 2022 among residents aged 18 to 41 and above years in nalut, libya. the institutional review board of the nalute university (nu) approved the study during 2022. participation was voluntary. they had the participation of option to choose either yes or no. those who selected disagree option were directed to decline the participation section and finish participation. a questionnaire-based cross, sectional study were used. the questionnaire consisted of personal information (gender, age, level of education, family income, occupation) and other question related to the knowledge level of participation on paracetamol, aspirin and ibuprofen analgesic. the sample was taken randomly from 5 preparatory schools, 2 secondary schools and 3 colleges affiliated with nalut university and other facilities .data were analyzed using statistical package of social science (spss version ) descriptive statistics(frequencies, percentages, mean, and standard deviation) were used to describe the categorical study and outcome variables chi-square test was used to describe the different level of knowledge about paracetamol, aspirin, and ibuprofen analgesic, and p value ≤ 0.05 were considered statistically significant. results the prevalence of sm is increasing globally, and its rational practice warrants the benefits. overall, 12.95% have practiced sm among residents during this study. a total of 1218 participants was included in the study , 321 (26.4%) were male and 897 (73.6%) were female, moreover, the mean age of participants was (25±30) ranged from 18 to 41 years and above. most of participations 834 (68.5%) were in undergraduate level, 725(59.5%) were employing and 559 (45.9%) were in low-income level and 170 (14%) had chronic diseases (table 1). the participant’s answers about the use of sm were collected among residents, and it was found that they use sm and analgesics without a prescription 819 (67.2%), but the most use was observed in cases of necessity 1196 (98.2%), also when asked about reading the pharmaceutical leaflet, it was found that 836 (68.6%) does so before use. these percentages indicate to the table 1: socio-demographic characteristics of the study participants demographic variables freq. (%) gender male 321 26.4% female 897 73% age 18-20 267 22.1% 21-30 464 38.1% 31-40 242 19.8% 41years above 243 20% level of education high school 315 25.8% undergraduate 834 68.5% post graduate 69 5.7% occupation student 397 32.6% employee 725 59.5% retired 13 1.1% unemployed 83 6.8% family income by l.d less than 450 84 6.9% 450 – 1000 475 39% 1000 – 3000 621 51% more than 3000 38 3.1% chronic diseases yes 170 14% no 1048 86% https://journals.e-palli.com/home/index.php/ajmsi pa ge 12 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 10-15, 2022 awareness of the participants about the use of analgesics and sm. also, when asked about who guides them to use analgesics without a prescription, it turns out that they get analgesics from the pharmacist and the doctor at a high rate of up to 782 (64.2%). the study showed a great diversity in the pain used analgesics, from head pain 468 (38.4%), followed by tooth ache 319 (26.2%) than by coughing and high fever 187 (15.4%), back and muscle pain 82 (6.7%) and menstrual 84 (6.9%) (table 2). most of participant based on the knowledge total score 1218 participants had poor knowledge toward the paracetamol, aspirin and ibuprofen analgesics. 981 (80.5%) of the participants do not know the cases in which use of paracetamol analgesic is not allowed, also 980 (80.5%) of the participants do not know the drug interactions of the paracetamol analgesic, while 324 (26.6%) of the participants know what are the conditions in which the use of paracetamol is contraindicated, and also 654 (53.7%) of the participants do not know the recommended dose of paracetamol. we notice a slight difference in the knowledge about aspirin between the participants compared to their knowledge about paracetamol analgesic. we find that 925 (75.9%) are not aware of the side effects of aspirin analgesic, and we also find that 950 (78%) of the participants is not aware of the drug interaction of aspirin analgesic, while table 2: self-medication pattern among residents of nalut city, libya. self-medication practice information freq. (%) do you use any analgesic without a prescription? yes 819 67.2% no 399 32.8% when do you use analgesics? as necessary 1196 98.2% always 22 1.8% what do you do if the pain has not stopped? consult a doctor or pharmacist 672 55.2% increase the dose of the analgesic 309 25.3% use another pain reliever 237 19.5% who advises you to use analgesics when you buy it without a prescription? the doctor or pharmacist 782 64.2% tv or social media 100 8.2% family and friends 149 12.2% no one 187 15.4% why do you usually use analgesics? head ache 468 38.4% tooth ache 319 16.2% cough, fever, or cold 187 15.4% back pain or muscle pain 82 6.7% painful menstruation 84 6.9% any other pain 78 6.4% do you read the medication leaflet before using it? yes 836 68.6% no 382 31.4% table 3: distribution of different level of knowledge on paracetamol, aspirin and ibuprofen analgesics. different level of knowledge on paracetamol, aspirin, and ibuprofen do you know the recommended dose of paracetamol aspirin ibuprofen yes 564(46.3%) 407(33.4%) 263(21.6%) no 654(53.7%) 811(66.6%) 955(78.4%) do you know what are the side effects of paracetamol aspirin ibuprofen yes 237(19.5%) 293(24.1%) 226(18.6%) no 981(80.5%) 925(75.9%) 992(81.4%) do you know what are the cases in which it is forbidden to use paracetamol aspirin ibuprofen yes 324(26.6%) 353(29%) 230(18.9%) no 894(73.4%) 865(71%) 988(81.1%) do you know what drug interactions paracetamol aspirin ibuprofen yes 238(19.5%) 268(22%) 236(19.4%) no 980(80.5%) 950(78%) 982(80.6%) https://journals.e-palli.com/home/index.php/ajmsi pa ge 13 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 10-15, 2022 353 (29%) of the participants is aware of the cases in which the use of aspirin analgesic is prohibited. in general, we note that the participant’s knowledge about ibuprofen does not constitute a significant difference between the participant’s knowledge about paracetamol and aspirin, and it is noted that 992 (81.4%) do not know the side effects of ibuprofen analgesic, while only 236 (19.4%) participants are aware of the drug interactions of ibuprofen, and the results find 263 (21.6%) of the participants on the know the recommended dose of ibuprofen (table 3). overall, participants (76.1%) of the participants know drug interactions of paracetamol and (65.3%) know drug interactions aspirin in other hand had negative knowledge toward the ibuprofen analgesic side effects (0.8%). there is no statistically significant difference between the level of knowledge of the use of analgesic among participants and their age (x²=0.954, p=0.812). most the participants had poor knowledge toward paracetamol, aspirin, and ibuprofen (table 4). table 4: distribution of different level of knowledge about paracetamol, aspirin, and ibuprofen variables high knowledge low knowledge x² p-value age 18 20 56(20.9%) 213(22.4%) 0.954 0.81221 30 105(39.2%) 359(37.8%) 31 40 57(21.3%) 185(19.5%) 41years& above 50(18.7%) 193(20.3%) gender female 181(76.1%) 716(73.1%) 0.882 0.348male 57(23.9%) 264(26.9%) level of education high school 70(26.1%) 245(25.8%) 7.439 0.114undergraduate 175(65.3%) 659(69.4%) postgraduate 23(8.6%) 46(4.8%) family income less than 450 18(8.0%) 66(6.7%) 1.136 0.768450 1000 82(36.3%) 393(39.6%) 1000 – 3000 119(52.7%) 502(50.6%) more than 3000 7(3.1%) 31(3.16%) it is noticeable from the figure 1 there is a great lack(poor) knowledge about the most common analgesics among the residents of the area. where we find that the cumulative rate of knowledge about paracetamol is 27.9% and the cumulative average of knowledge about aspirin 27.1 and we see a significant decline knowledge about ibuprofen with a cumulative rate of 19.6% (figure 1). participant’s level of knowledge regarding paracetamol, aspirin, and ibuprofen figure 1: shows the knowledge toward the paracetamol, aspirin, and ibuprofen analgesic’s discussion this study was conducted to evaluate the prevalence practice of sm and knowledge toward paracetamol, aspirin, and ibuprofen analgesic among residents in nalut city, libya. this study included 1218 participants, whose ages ranged from 18 to 41 years and above. the prevalence of sm in our study were found to be 1218 (10.69%) of them practices sm. there no statistically significant difference between the level of knowledge to use of analgesic among participants and their age (x²= 0.954, p=0.812). most the participants had poor knowledge towards paracetamol, aspirin, and ibuprofen analgesics. it is clear from the study that sample members use of analgesic when necessary 98.2%, and others always use them 1.8%, as these results agree with (siddig et al .,2020). also, that religion, it consults the pharmacist when they use sedatives 64.2%, and others does not consult the pharmacist 15.4%, either religion, it consults friends and family it was about 12.2%, and others, they use television and social media as a source of information https://journals.e-palli.com/home/index.php/ajmsi pa ge 14 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 10-15, 2022 8.2% (karami et al.,2018). it is noted that religious participants read the medication leaflet of the analgesic before use 68.6%, and whose participants do not read the medication leaflet of the analgesic before using it 31.4%. the results of the study show that the participants know the amount of the recommended dose of paracetamol analgesic 64.3%, 53.7% they do not know the amount of the recommended dose, this comes into agreement with the study (zamir & nadeem ,2016). also, the participants know about the side effects of paracetamol 19.5% and religion did not have knowledge about the side effects of paracetamol analgesic 80.5%. about the participant’s knowledge on drugs interactions of paracetamol 19.5% and religion do not have knowledge about it 80.5%. the participant’s knowledge about the recommended dose of aspirin 33.1% and religion do not know the recommended dose, 66%. results of the participant’s knowledge of the side effects of aspirin analgesic 24.1% and those who had no knowledge were 75.9% these results were in agreement with the studies (rabee et al .,2021) knowledge of participants about the ibuprofen recommended dose analgesic 21.6% and who do not know the recommended dose of ibuprofen 78.4% (sarganas et al .,2015). the results also expected us that the participants knowledge of analgesic ibuprofen side effects 18.6% and those who did not have knowledge 81.4% (muhammad et al ., 2021). conclusion through this study , the results shown that most of the participant’s practice self-medication and , also there is poor knowledge about the use of most common analgesics among the residents of the area. so ,from the results we recommend need to educate the public about the use of over-the-counter medications to increase knowledge and awareness. the study had the limitation that was important for the lack of responsiveness and people’s consent in answering the questionnaire, so it was possible the sample size could have been greater, and many samples were excluded due to the neglect of participants. also suggest conducting more research with regard to the practice of home therapy with the use of traditional medicine that is remarkably widespread in our country, libya, and conducting future research with large samples in different cities in libya. inclusion of the concept of pharmaceutical culture in educational curricula to develop consumers’ awareness. for promoting rational self-medication practice, patient health awareness programs, community pharmacist assistance, continuing medical education programs for health care providers, and planned interventions in the media, such as newspapers, magazines, and television are required. references azhar, m. i. m., gunasekaran, k., kadirvelu, a., gurtu, s., sadasivan, s., & kshatriya, b. m. (2013). selfmedication: awareness and attitude among malaysian urban population. international journal of collaborative research on internal medicine & public health, 5(6). ali, a.s., al-elaime, l.a., abbadi, s.h., & al-khareisha, l. (2018). measuring. awareness of over the counter analgesics use and risks associated with it among jordanian population in amman. asian journal of pharmaceutical research and development, 6(5), 9-15. kontogiorgis, c., nena, e., berberoglou, e., moschoni, k., polyzois, s., tselemponis, a., & constantinidis, t. c. (2016). estimating consumers, knowledge and attitudes towards over-the-counter analgesic medication in greece in the year of financial crisis: the case of paracetamol. pain and therapy, 5(1),19-28. kanaan, y., & gholami, r. (2021). research on aspirin. [updated 2021 ;cited 2022 july 7]. available from: https://mawdoo3.com/ krasniqi, d., thaqi, e., berisha, d., bibaj, g., & kryeziu, f. (2019). the use of ibuprofen and our knowledge about it. 2019 ubt international conference. 20. karami, n., altebainawi, a. f., alfarki, s. a., aldossari, n., asiri, a., aldahan, m., & alqhtani, t. (2018). knowledge and attitude of analgesics use among saudi population: a cross-sectional study. international journal of medical science and public health, 7(2), 137143. mohammed, s. i. (2016). evaluation of analgesics use and misuse by iraqi patients in baghdad community. asian journal of pharmaceutical and clinical research, 9(1). muhammad, a.t., aljohani, m. m., alnakhli, h. a., shaqroon, h. a., manfaloti, m. h., & alamri, a. a. (2021). practice and awareness of the general population about common over the counter analgesics dependence and side effects in almadinah, saudi arabia. majmaah journal of health sciences, 9(1), 65-79. nhs. (2022). how and when to take aspirin for pain. [updated 2021 december 16; cited 2022 july 6]. retrieved from: https://www.nhs.uk/medicines/aspirin-forpain. rabee, a. a. a., elzahaf, r. a., mansour, y. s. e., & ibrahim, n. a. m. (2021). knowledge, attitude and practices of self-medication among community pharmacy consumers’ perspectives in derna city, libya. pharmaceutical and biosciences journal, 11-21. stosic, r., dunagan, f., palmer, h., fowler, t., & adams, i. (2011). responsible self-meddication: perceived risks and benefits of over-the-counter analgesic use. international journal of pharmscy practice, 19(4), 236-245. siddig, a. i., alqahtani, a. m., alshalawi, a., turkistani, m., binbaz, s., & altowairqi, a. (2020). awareness of analgesics complications in saudi arabia: a crosssectional study. future journal of pharmaceutical sciences, 6(1), 1-6. sarganas, g., buttery, a.k., zhuang, w., wolf, i.k., grams, d., rosario, a.s., & knopf, h. (2015). prevalence, trends, patterns and associations of analgesic use in germany. bmc pharmacology and toxicology, 16(1), 1-13. wilcox, c. m., cryer, b., & triadafilopoulos, g. (2005). patterns of use and public perception of over-thehttps://journals.e-palli.com/home/index.php/ajmsi pa ge 15 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 1(1) 10-15, 2022 counter pain relievers: focus on nonsteroidal antiinflammatory drugs. the journal of rheumatology, 32(11), 2218-2224. who. (2000). world health organization guidelines for the regulatory assessment of medicinal products for use in self-medication. zamir, q., & nadeem, a. (2016). non-steroidal antiinflammatory drugs vs. paracetamol: drug availability, patients ‘preference and knowledge of toxicity. journal of ayub medical college abbottabad, 28(4), 746-749. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 13 6 american journal of medical science and innovation (ajmsi) breakfast intake and associated factors among primary school students in selected private and public schools, kakata city, margibi countyliberia washington kezelee1*, dawolo g. milton2, doris s. wakia2, theophilus t. fayiah2, moses c. d. shilue2 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1546 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 06, 2023 accepted: october 03, 2023 published: october 12, 2023 breakfast consumption has been shown to positively affect children’s cognitive performance. the objective of this study was to compare the breakfast intake of primary school students attending private and public schools. this was a cross-sectional study conducted in kakata city, margibi county among 129 private and public school students in the 4th, 5th, and 6th grades. private and public-school students were compared based on their religious practices, age range, educational and employment status of parents, and gender using the chi-square test. the study found that 42% of private-school children and 35 percent of public school children ate breakfast prepared at home by parents. private school children ate their breakfast most often at home, regardless of whether it was prepared at home or elsewhere (92% vs. 89%). on average, private school children added fruits (36% vs. 18%) and vegetables (35% vs. 14%) to their breakfast more than their public-school counterparts. sugar was regularly added to 58% of private school children and 44% of public school children’s breakfasts. private school children consumed milk during breakfast more than public school children (50% vs. 40%). furthermore, private school children ate less oil during breakfast compared with public school children (64% vs. 83%). finally, private school children consumed breakfast more regularly than public school children (49% vs. 38%). in conclusion, private school children appeared to consume more diverse food during breakfast than their publicschool counterparts. nutrition promotion intervention should be aimed at extending free school feeding programs to all public and private primary schools. keywords breakfast, private school, public school 1 cuttington university schools of graduate & professional studies, department of public health nutrition, liberia 2 cuttington university schools of graduate & professional studies, school of health sciences, liberia * corresponding author’s e-mail: wkezelee@up.edu.ph introduction as outlined in sustainable development goal 4, all children should have access to quality education ((bernstein, 2017). to achieve this goal, children all over the world must receive a quality education in a conducive learning environment. the provision of a conducive learning environment includes the provision of a nutritious diet before, during, and after the classroom learning period. ending hunger and malnutrition (sdg 2) in any country will be the most cost-effective and appreciated step toward reaching the fourth sustainable development goal (gil et al, 2019). although universal education will reduce global poverty, hunger among schoolchildren remains a global challenge. in malawi, hunger in both primary and secondary school children were found to be a major social problem (mwambene, muula, & leo, 2013). hunger was associated with high rates of truancy among tanzanian schoolchildren (seidu, dadzie, & ahinkorah, 2021). the objective of this study was to compare the breakfast intake of primary school students attending private and public schools in kakata city, margibi county, republic of liberia. importance of breakfast for school children kids need breakfast to obtain their daily nutrient and energy intake, as it is the most important meal of the day. the nutrient and energy intake of school children who regularly consume breakfast is significantly higher than that of children who skip breakfast (intiful & lartey, 2014). breakfast-eating children perform better academically than breakfast-skipping children (littlecott et al, 2016). children’s cognitive performance was reported to be positively impacted by breakfast consumption (widenhorn-muller et al, 2008). in childhood and adolescence, breakfast consumption helps prevent excess adiposity (blondin et al, 2016). ramsay et al. (2018) also found that skipping breakfast was associated with significantly lower fiber consumption, folate intake, iron intake, and calcium intake. inadequate breakfast intake among school children and associated factors a study found that school children with highly educated mothers consumed more breakfast compared with children with mothers not highly educated (albashtawy,2015). breakfast consumption was found to be low among boy children in public schools compared with boy children in private schools (al-hazzaa et.al, 2020). income status of parents had been identified to be one of the factors related to breakfast skipping among primary school children ( tee et al., 2018). a study among saudi school children found that children in private schools consumed breakfast more frequently than those attending public school. the study also found that mothers prepared breakfast at home most of the time for their school children (84.5%). additionally, parents appeared mostly satisfied with the breakfast consumed by their child at pa ge 13 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 136-140, 2023 home and placed high importance on breakfast compared to lunch or dinner (al-hazzaa et al., 2020). breakfast intake among liberian school children secondary data on the breakfast intake among primary school children in liberia is limited. however, the socioeconomic profile of the country may give some clues as to what is happening with breakfast intake among school children. school feeding is an essential component of the liberian government’s efforts to improve the education, health, and nutrition of school-age children. however, the program remains donor funded with no or limited budgetary input from the government, creating serious challenges when donor funds run dry. mary’s meals currently serves school meals to 151,968 children in 669 schools across liberia. however, these meals are not intended to be consumed as breakfast. as indicated in the comprehensive food security assessment report (2018), liberia continues to experience household food insecurity, with 41% in 2010, 49% in 2012, 16% in 2015, and 18% in 2018. there has been some improvement since 2015, but a large number of liberians remain hungry and undernourished. schoolchildren are also affected by this hunger crisis in terms of diet quality. among 121 countries, liberia ranks 113th in the 2022 global hunger index. having a score of 32.4, liberia has a serious level of hunger. methodology subject and study area this study was a cross-sectional study conducted in kakata city, margibi county among 66 private and 63 public-primary school students. a random selection of three private and three government schools was made in kakata city from a list of 20 schools. the number of schools selected was based on available funding. schools were also selected based on the principals, and teachers’ willingness to have their students participate. in each school, children in the 4th, 5th, and 6th grades were eligible to participate. to conduct this study in kakata, the county educational officer (ceo) of margibi county was officially contacted through written communication. the communication was written by administration of the school of health sciences of the cuttington university schools of graduate & professional studies. the ceo gave us the go-ahead to meet with the principals and teachers of the selected schools to ask them to allow us to use their schools for this study. the principals and teachers of the schools selected, permitted us to conduct the study. kakata’s economic activities are dominated by trade, petty business, casual labor, salaried employment, and to a lesser extent agriculture. sample size and sampling methods multisampling was used in this study in three stages. the district education officer’s (deo) office in kakata city provided a list of all public and private primary schools in stage one. using the list of public and private primary schools, a simple random sampling was used to select three public and three private schools (6 schools in totality). a list of all 4th, 5th, and 6th graders in the selected schools was obtained from their registrar’s offices in the final stage. using a systematic sampling method, every second student on the list was selected for the sample of 129 students. data collection this study’s data was gathered entirely through the use of structured questionnaires. the questionnaires were designed to collect the following information: student ages, gender, religion, parental educational status, parental job status, student understanding of breakfast, parental behaviors toward breakfast, breakfast composition, and types of food eaten by students for breakfast. data analysis the chi-square test was used to evaluate if pupils’ capacity to enroll in private and public schools was connected to their religious practices, gender, age range, and educational and work level of parents. we utilized logistic regression to determine the association between pupils in private and public schools in terms of breakfast habits and knowledge. results age, gender, and religion of students more than half of the students in private schools were female (55%) compared with those in public schools (44%). in terms of religious practices, more than half of the students in both public and private schools were christians. however, private schools had more christian students compared with public schools (94% vs. 70%). more than half of the students in both private and public schools were the age of 10 years and above (table 1). table 1: social demography profiles of participants variables and category private school n = 66 public school n = 63 chi-square p-value n % n % gender male 30 46 35 56 female 36 55 28 44 1.31 (0.251) religion christian 62 94 44 70 muslim 4 6 19 30 12.77 (0.000) age 8-10 years 10 15 3 5 ≥10 years 56 85 60 95 3.83 (0.050) pa ge 13 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 136-140, 2023 parental education and employment status the prevalence of non-formal education was high among mothers (41% vs. 12%) and fathers (22% vs. 9%) of public-school children compared with private school children. more than half of the households of the students in both public and private schools were headed by males. more than half of the mothers (64%) and fathers (57%) of students in public schools were unemployed compared with mothers (47%) and fathers (30%) of children in private schools. more than half of the households of students earned less than 15,000 (equivalent to $81.1 usd) liberian dollars per month (table 2). table 2: parental education and employment status variables and category private school n = 66 public school n = 63 chi-square p-valuen % n % educational status (mothers) non-formal education 8 12 26 41 formal education 58 88 37 59 14.10 (0.000) educational status (fathers) non-formal education 6 9 14 22 formal education 60 91 49 78 4.24 (0.039) household head mother 5 8 11 18 father 61 92 53 83 2.89 (0.089) employment status of mothers unemployed 31 47 40 64 employed 35 53 23 37 3.55 (0.059) employment status of fathers unemployed 20 30 35 57 employed 46 70 27 43 9.45 (0.002) monthly household income (lrd) <15,000 ($81.1 usd) 45 68 51 81 ≥15,000 ($81.1 usd) 21 32 12 19 2.76 (0.097) students’ knowledge about breakfast table 3 showed that 99% of the private school children and 94% of the public school children knew the importance of breakfast (or, 4.40; 95% ci, 0.47-40.55). students in both public and private schools knew that breakfast can be eaten first thing in the morning (or, 1.33; 95%ci, 0.34-5.22). nevertheless, more private school students (91%) agreed that vegetables and fruits should be added to breakfast than public school students (71%) (or, 4.0; 95%ci, 1.46-10.89). table 3: comparing students’ knowledge of breakfast response private school n = 66 public school n = 63 odd ratio (95%ci)n % n % knowledge about the importance of breakfast for schoolchildren 65 99 59 94 4.40 (0.47-40.55) breakfast is eaten first thing in the morning 62 94 58 92 1.33 (0.34-5.22) include vegetables and fruits in breakfast 60 91 45 71 4.0 (1.46-10.89) comparing breakfast composition between private and public-school students students were asked where their breakfasts are usually prepared. table 4 shows that 35% of public school students and 42% of private school students ate breakfast prepared at home (or, 1.37; 95% ci, 0.67-2.79). in addition, students were asked to locate where they usually ate breakfast. it was found that 92% of private school children and 89% of public school children typically ate breakfast at home, regardless of whether the food was prepared at home or purchased elsewhere. (or, 1.52; 95% ci, 0.45-5.08). in terms of dietary diversification, table 4: comparing breakfast composition between private and public-school students response private school n = 66 public school n = 63 odd ratio (95%ci) n % n % eat breakfast prepared at home 28 42 22 35 1.37 (0.67-2.79) eat breakfast at home 61 92 56 89 1.52 (0.45-5.08) add fruits to breakfast 24 36 11 18 2.70 (1.18-6.14) breakfast is available regularly 32 49 24 38 1.52 (0.75-3.08) add vegetables to breakfast 23 35 9 14 3.20 (1.34-7.65) pa ge 13 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 136-140, 2023 the study revealed that 36% of private school and 18% of public-school children had fruits usually added to their breakfast (or, 2.70; 95% ci, 1.18-6.14) and 35% of private and 14% of public-school children usually had vegetables added to their breakfast (or, 3.20; 95% ci, 1.34-7.65). additionally, 58% of private and 44% of public school children usually had sugar added to their breakfast (or, 1.69; 95% ci, 0.84-3.40), 50% the private and 40% in the public school children had milk usually added to their breakfast (or, 1.52; 95% ci, 0.75-3.05), and 64% in the private and 83% in the public schools added oil to their breakfast (or, 0.37; 95% ci, 0.16-0.84). finally, the study showed that breakfast was frequently offered for 49% of private school kids and 38% of public-school students (or, 1.52; 95% ci, 0.75-3.08). breakfast eaten day before the questionnaires were administered according to table 5, the majority of pupils in both private and public schools (41% vs. 59%) ate rice with soup for breakfast the day before the surveys were administered. additionally,39% of private school students and 24% of public-school students ate bread with butter, mayonnaise, or eggs. add sugar to breakfast 38 58 28 44 1.69 (0.84-3.40) add milk to breakfast 33 50 25 40 1.52 (0.75-3.05) add oil to breakfast 42 64 52 83 0.37 (0.16-0.84) table 3: comparing students’ knowledge of breakfast frequently consumed foods during breakfast private school n = 66 public school n = 63 chi-square test p-valuen % n % rice (boiled) with soup 27 41 37 59 bread (added butter, mayonnaise, or eggs) 26 39 15 24 4.61 (0.100) roots/tuber 13 20 11 18 discussion in terms of social demography, more than half of private school children (55%) were female, compared to 44% of public-school children. private school students were more likely to identify with christianity than public school students. in terms of age distribution, more than half of the children in both private and public schools were 10 years old or older. there was a significant gap in educational attainment between parents of children attending public and private schools. in terms of comparing the educational attainment of parents (mothers & fathers) of private and public school children, the findings of the study indicated that mothers and fathers of children in private schools were more likely to have obtained formal education than their counterparts in the public schools. school children with highly educated mothers consumed more breakfast compared with children with mothers not highly educated (albashtawy,2015). most importantly, compared to their private-school counterparts, more than half of mothers and fathers of public-school children were unemployed. a household’s ability to purchase food is reduced as a result of unemployment. children raised by unemployed parents are more likely to experience hunger or food insecurity during the school day. the study also showed the income disparity between families with children in private and public schools. thirty-two percent (32%) of private school children’s households earn 15,000 liberian dollars per month, compared to 19% of public school children’s households. income disparities among parents of primary school children can have serious consequences for the quality of children’s diets. children in both private and public schools were more likely to agree that breakfast is important for school children and that breakfast should be eaten first thing in the morning. however, children in private schools were more likely than children in public schools to agree that fruits and vegetables should be included in breakfast. children from both private and public schools were asked to demonstrate where their parents typically prepare their breakfast. according to the study, 42% of private-school children and 35% of public school children eat breakfast prepared at home, by parents. the children were also asked to indicate where they usually ate breakfast. according to the findings, 92% of private school children and 89% of public school children typically ate breakfast at home. students at both schools prefer to eat their breakfast at home rather than on campus or elsewhere. breakfasts were regularly available at home for 49% of private school children and 38% of public-school children. private school children were more likely than public school children to eat breakfast before going to school (al-hazzaa et al., 2020). the difference may be attributed disparity between parents of private and publicschool children in term of employment and educational attainment. private school children were privileged to have parents who were formally educated and employed compared with parents of public-school children. children in private schools were found to be three times more likely than those in public schools to have vegetables and two times more likely to have fruits in their breakfast. furthermore, more children in private schools (64%) added sugar and milk to their breakfast than those in public schools. children in private schools, pa ge 14 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 136-140, 2023 on the other hand, consumed less oil in their breakfast than those in public schools (83%). on the day before the questionnaires were administered, 41% of the private school children and 59% of the public-school children ate cereal (rice), 39% of the private and 24% of the publicschool children ate bread (added butter, mayonnaise, or eggs), and 20% of the private and 18% of the publicschool children ate tubers or roots (cassava, potatoes, yam). conclusion in this study, it was found that, there is a significant disparity between parents of private school children and parents of public-school children in terms of their educational attainment and employment status. the parents of children who attended private schools were more likely to be educated and employed than those of their public-school counterparts. private schools had more female students than public schools, which had more male students. compared to public schools, private schools had a greater number of students from christian backgrounds. both private and public-school students were knowledgeable about when breakfast should be eaten and the importance of consuming breakfast while attending school. however, students in private schools were more likely to agree that fruits and vegetables should be included in breakfast than their public-school counterparts. fewer than half of the students in both public and private schools ate breakfast prepared at home by their parents. it should be noted, however, that more than half of the children who had their breakfast prepared at home preferred eating it at home rather than outside. even though private school children’s breakfasts contained more vegetables and fruits than public school children’s breakfasts, less than half of students in both public and private schools consumed fruits and vegetables. when compared to public school children, private school children had less oil in their breakfast. the majority of the children ate rice for breakfast the day before the questionnaires were administered. reference albashtawy, m. (2015). exploring the reasons why school students eat or skip breakfast. nursing children and young people, 27(6). al-hazzaa, h. m., alhowikan, a. m., alhussain, m. h., & obeid, o. a. (2020). breakfast consumption among saudi primary-school children relative to sex and sociodemographic factors. bmc public health, 20, 1-14. https://doi.org/10.1186/s12889-020-8418-1 bernstein, s. (2017). the united nations and the governance of sustainable development goals. governing through goals: sustainable development goals as governance innovation, 213-239. blondin, s. a., anzman‐frasca, s., djang, h. c., & economos, c. d. (2016). breakfast consumption and adiposity among children and adolescents: an updated review of the literature. pediatric obesity, 11(5), 333-348. gil, j. d. b., reidsma, p., giller, k., todman, l., whitmore, a., & van ittersum, m. (2019). sustainable development goal 2: improved targets and indicators for agriculture and food security. ambio, 48(7), 685698. intiful, f. d., & lartey, a. (2014). breakfast habits among school children in selected communities in the eastern region of ghana. ghana medical journal, 48(2), 71-77. liberia comprehensive food security assessment report (2018). littlecott, h. j., moore, g. f., moore, l., lyons, r. a., & murphy, s. (2016). association between breakfast consumption and educational outcomes in 9–11-yearold children. public health nutrition, 19(9), 1575-1582. mwambene, j. b., muula, a. s., & leo, j. c. (2013). prevalence and correlates of hunger among primary and secondary school children in malawi: results from the 2009 global school-based health survey. malawi medical journal, 25(2), 45-49. ramsay, s. a., bloch, t. d., marriage, b., shriver, l. h., spees, c. k., & taylor, c. a. (2018). skipping breakfast is associated with lower diet quality in young us children. european journal of clinical nutrition, 72(4), 548-556. seidu, a. a., dadzie, l. k., & ahinkorah, b. o. (2021). is hunger associated with truancy among in-school adolescents in tanzania? evidence from the 2015 global school-based health survey. journal of public health, 29, 563-569. tee, e. s., nurliyana, a. r., karim, n. a., jan mohamed, h. j. b., tan, s. y., appukutty, m., ... & mohd nasir, m. t. (2018). breakfast consumption among malaysian primary and secondary school children and relationship with body weight status-findings from the mybreakfast study. asia pacific journal of clinical nutrition, 27(2), 421-432. widenhorn-müller, k., hille, k., klenk, j., & weiland, u. (2008). influence of having breakfast on cognitive performance and mood in 13-to 20-year-old high school students: results of a crossover trial. pediatrics, 122(2), 279-284. pa ge 1 pa ge 13 american journal of medical science and innovation (ajmsi) effect of aqueous stem bark extract of parkia biglobosaparkia biglobosa on the histological morphology of liver of adult wistar rats d. f. ibrahim1*, a. s. hassan1, a. sani2, a. zakariyya1, f. b. shema1, r. u. zubair1, g. y. riruwai1 volume 2 issue 1, year 2023 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: december 30, 2022 accepted: january 19, 2023 published: february 17, 2023 people in africa and other developing countries depend on medicinal plants. extract of parkia biglobosa stem bark is used in nigerian traditional medicine to treat malaria, diarrhea and pains. this study aimed at determining the effect of aqueous stem bark extract of p.biglobosa on the histological morphology of liver in animal models. a total of 28 wistar rats weighing between 100 – 150g were used for this study out of which 12 were used for acute toxicity testing using lorke’s method (1983), the test was carried out in two phases. in phase i, 9 adult wistar rats were divided into 3 groups and administered with 10mg/kg, 100mg/kg and 1000mg/kg orally while in phase ii, 3 wistar rats were assigned into 3 groups and administered with 1600mg/kg, 2600mg/kg and 5000mg/kg respectively and both they were observed for signs of toxicity/mortality within 24hrs. the remaining 16 rats were divided into 4 groups; a, b, c and d. group a served as control and groups b, c and d served as test groups. for 21 days, group a received normal feed and water only and then group b, c and d received oral doses of 1000mg/kg, 500mg/kg and 250mg/kg of aqueous extract of p.biglobosa stem bark respectively. a significant increase in the level of alp, alt and ast was observed in comparison with the control, p< 0.005 was considered statistically significant. it was shown that liver sections in group a (control) presents no histological changes while the liver section of animals treated with (1000mg/kg and 500mg/kg) of p.biglobosa aqueous extract for 21 days revealed an inflammation, vascular degeneration and vacoulation respectively. it was found that at higher doses p.biglobosa aqueous stem bark extract could be hepatotoxic. keywords parkia biglobosa, acutetoxicity, wistar-rats, stembark, liver, intervention 1 department of medical laboratory science, faculty of allied health sciences, bayero university, kano, nigeria 2 aminu kano teaching hospital , kano, nigeria * corresponding author’s e-mail: dahirufalalu63@gmail.com introduction parkia biglobosa is a scientific name of african locust bean tree. in hausa it is referred to as dorawa, in yoruba it is known as igba irugba and in igbo it is called origili. the parkia tree, named after the famous scottish botanist and surgeon, mungo park by brown (1826) has long been widely recognized as an important indigenous multipurpose fruit tree in many countries of the sub saharan africa. parkia biglobosa is found naturally occurring in the following countries of west africa: republic of benin, burkina fasso, cameroon, chad, cote d’voire, central africa republic, gambia, ghana, guinea bissau, kenya, mali, niger, nigeria, senegal, sierra leones, sudan, togo, tanzania, uganda and zaire (booth and wickens, 1988) (sina & traore, 2002). in nigeria, parkia biglobosa is found in the savannah zone with the bulk of it in the guinea savannah. this is as a result of its ecological and environmental requirements which are easily met in these areas (oni, 1997). the distribution of parkia biglobosa in nigeria covers abuja, adamawa, bauchi, gombe, kaduna, kano, katsina, kebbi, kogi, kwara, nassarawa, niger, oyo, taraba, yobe, plateau and zamfara state. in west africa the bark, roots, leaves, flowers, fruits and the seeds are commonly used in traditional medicine to treat a wide diversity of complaints, internally and externally, sometimes in combination with other medicinal plants (builders et al., 2011). the bark is the most important for medicinal uses, followed by the leaves. it have been used in nigeria and other west african rural communities to treat a variety of diseases (abbie 1990; shao 2002). the bark soaked in ethanol are also used in some communities for anti diarrhoeal properties and as an effective anti-snake venoms that protects against neurotoxic, haemotoxic and cytotoxic effects of poisonous snake (agunu et al., 2005). the efficacy of the various preparation of parkia biglobosa is widely acclaimed by hausa communities of northern nigeria for the treatment of diseases such as malaria, diabetes mellitus and pains. the bark is boiled in water and taken as a decoction for the treatment of malaria, inflammatory disease and infection to diarrhoea (asase et al., 2005; gronhaug et al., 2008; and tijjani et al., 2009). a decoction of the stem bark is used as a mouth wash to relieve tooth ache as well as, a bath for fever (ajaiyeoba 2002). the bark is also used with lemon for wounds and ulcers. in cote d’voire, a bark infusion is used as a tonic for diarrhoea and as an enema (duker eshun et al., 2018; agunu et al., 2005). among the hausa people of northern nigeria, parkia biglobosa is used against bronchitis, pneumonia, diarrhea, vomiting, sores and ulcers. the water extract demonstrated increase in the triglyceride and cholesterol level. phytochemicals https://journals.e-palli.com/home/index.php/ajmsi mailto:dahirufalalu63%40gmail.com?subject= pa ge 14 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 13-20, 2023 generally are regarded as research compounds. some phytochemicals have been used as poisons and others as traditional medicine (james et al., 2007). parkia plants have been identified as source of tannins, saponins, steroids, reducing sugars and glycosides. there is increased research in to phytochemical for the effective therapeutic combat of this menace. the therapeutic effects of plant based drugs have been documented to be due to the phytochemicals that constitute the plants (kumar et al., 2012). materials and method research design the study was randomized control trial (an experimental study) and the ethical approval for the research was obtained from the research ethical committee, college of health sciences, bayero university kano, kano state. preparation of experimental animals twenty-eight (28) healthy adult wistar rats of both sexes weighing (100 150g) were purchased from the animal house section of the department of pharmacology, faculty of pharmaceutical sciences, bayero university, kano. the animals were maintained in standard animal cage at the pharmacology department and also they were acclimatized for 2 weeks prior to the commencement of the study. the animals were allowed to have free access to drinking water and standard livestock feed, also the animals were maintained under standard condition of humidity and temperature. a standard protocol were adhered in accordance with the good laboratory practice (glp). the principle of laboratory animals care were also be followed in this study. preparation of aqueous extraction of parkia biglobosa the stem bark of parkia biglobosa were collected from gabasawa local government area of kano state. a quantity of stem bark was allowed to air dried under shade at room temperature. using wooden mortar and pestle, the dried stem bark was grinded to powder form. five hundred (500) grams of the powdered material were soaked in three liters (3l) of distilled water and were allowed to stand for 120 hours (5 day). the mixture were filtered using a whatmann’s filter paper to obtained the extract. the filterate were then incubated in water bath and evaporated under reduced pressure, the filterate was allowed to dried in a hot air oven at 40oc to give 75g of an aqueous stem bark extract which were used for interventional study at different doses. qualitative determination of phytochemical substances of parkia biglobosa aqueous stem bark extract a small portion of the extract was subjected to phytochemical test. methodologies for the determination of phytochemical substances used in this research were adapted from those reported by keay et al. (2008) and ejikeme et al. (2014) acute toxicity testing the ld50 of the extract was determined using lorke’s method (1983). the test were carried out in two phases; in phase i, nine (9) wistar rats was randomly assigned into three (3) groups of three (3) wistar rats each. the first (1st) group comprised of wistar rats weighing 126g, 140g and 135g respectively and they were administered with 10mg/kg body weight of the extract using orogastric tube ( oral cannula). the 2nd group comprised of wistar rats weighing 152g, 143g and 136g respectively and they were given 100mg/ kg and the 3rd group comprised of wistar rats weighed 122g,131g and 138g respectively and they were given 1000mg/kg body weight of the extract. the animals was observed within 24 hours to monitor the behavioral changes for signs of toxicity as well as mortality. in phase ii, three (3) rats weighing 148g, 151 and 153g respectively was used and randomly placed in to 3 groups of one (1) wistar rat each. the animals were administered with high doses of 1600mg/kg, 2900mg/ kg and 5000mg/kg respectively. they were then observed within 24 hours for signs of toxicity and mortality. after 24 hours, there was no any mortality in both phase i and ii of the experiment. therefore, 20% of the highest dose (5000mg/kg) used for the ld50 was used as the highest dose (1000mg/kg) in this experiment. 10% of 5000mg/kg was used as the medium dose (500mg/kg) and 5% of 5000mg/kg was used as low dose (250mg/kg) in the experiment. animal grouping and intervention sixteen (16) rats were randomly selected and then divided in to four (4) groups, labeled as group a, b,c and d; with each group containing four (4) wistar rats. the groups constitute of three (3) test groups and control group. the animals in group a were used as the control group and therefore they were not received any intervention rather they were administered with distilled water in place of the intervention. the animals in group b were used as the first test group and were administered with high dose (1000mg/kg) of the aqeous stem bark extract of parkia biglobosa orally every day for a period of three (3) weeks. the animals in group c were administered with medium dose (500mg/kg) of the parkia biglobosa aqueous stem bark extract for a period of three weeks. the animals in group d were used as another test group and they were administered with low dose (250mg/kg) of the parkia biglobosa aqueous stem bark extract orally for a period of three weeks. all the four (4) groups were maintained for a period of three weeks. therefore, measurement of the animals weight was done before the commencement of the experiment, weekly and after administration of the parkia biglobosa aqueous stem bark extract. liver function test (lft) after 3 weeks of the experiment, a blood sample were https://journals.e-palli.com/home/index.php/ajmsi pa ge 15 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 13-20, 2023 obtained from orbital venous plexus, and the blood samples were collected in to a plain tubes, they were allowed to clot and centrifuged at 1500 rpm for 15 minutes. the serum were obtained after separation and then used for determination of alanine aminotransferase (alt), aspartate aminotransferase (ast) and alkaline phosphatase (alp). preparation and processing of the organ (liver) on the final day of the intervention, the animals was sacrificed by cervical dislocation. the liver was harvested and then fixed in 10℅ formalin for 48 hours and label with tags. gross anatomy of the liver was studied first to identify any observational lesion before subjecting the tissue into the tissue processing protocol. the processed tissues were embedded in paraffin wax and tissues section of three (3) microns were cut using leica brand microtome . the histological sections floated out in tissue water bath, picked with a glass slide and stained with hematoxylin and eosin staining technique for demonstration of the tissue architecture and examination. data analysis result was presented in a tabular form and photomicrographs were attached to the result obtained. all test group of the animals was compared with the control group using one-way anova, using the computer programme statistical package for social sciences (spss) software version 20, post hoc comparison were the method used for the analysis. all data were expressed as mean ± standard error of mean (sem) and p<0.005 was considered statistically significant. results physical property of stem bark extract of parkia biglobosa the aqueous extract was obtained by dissolving 500g of the parkia biglobosa stem bark powder in to 3liters of distilled water. the extraction procedure yielded 75g of the extract and the percentage yield was calculated as 15% while physical properties of the extracts are cocoabrownish in colour, crystalline shiny in consistency with a sweet smell. table 1: physical properties of parkia biglobosa stem bark extract plant part extract type % yield texture colour smell stem bark aqueous extract 15% crystalline cocoasweet shiny brownish smell phytochemical analysis the phytochemical screening of parkia boglobosa aqueous stem bark extract were carried out to determine the presence of the following compounds: tannin, saponin, reducing sugars, steroids and phenols using a standard procedure reported by keay et al., (2008) and ejikeme et al., (2014). table 2: phytochemical screening of the aqueous stem bark extract of parkia biglobosa phyto-constituents test method result tannin aqueous extract + saponin ferric chloride test + flavonoid ammonium hydroxide method cardiac glycoside keller killiani’s test reducing sugars ferric chloride test + steroids salkowski’s test + terpenoids salkowski’s test phenol ferric chloride test + note: ‘+’ represents phytoconstituent present, ‘-’ represents phytoconstituent absent. acute toxicity evaluation the aqueous extract administered to the wistar rats showed no sign of toxicity or behavioral changes. after 24 hours observation, no death were recorded in both phase i and phase ii of the experiment. therefore, the lethal dose ( ld50 ) of the aqueous stem bark extract of parkia biglobosa was greater than 5000mg/kg body weight as described in table 3. table 3: lethal dose (ld50) of aqueous stem bark extract of parkia biglobosa in wistar rats dose (mg/kg) sign of toxicity/mortality result phase i phase ii 10 0/3 100 0/3 1000 0/3 1600 0/1 2900 0/1 5000 0/1 the ld50 of the aqueous stem bark extract was determined using lorke’s method (1983) effect of aqueous stem bark extract of parkia biglobosa on weight of the experimental animals before (pre) and after (post) interventional study according to the doses administered during the interventional study, the weight of the animals was recorded before and after the study. the mean of the weights of the animals before intervention of all the groups were found to be 105.50 for group a (control), https://journals.e-palli.com/home/index.php/ajmsi pa ge 16 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 13-20, 2023 135.25 for group b, 122.50 for group c and 131.00 for group d. these result clearly indicates that there are increase in mean of the weights from group a to b before intervention. the mean of the weights of the animals after intervention of group a to d were found to be 119.25 for group a (control), 163.00 for group b, 129.00 for group c and 174.00 for group d. the body mean weight difference between the groups are; 13.75 for group a, 27.75 for group b, 6.50 for group c and 43.00 for group d. these result clearly indicates that there is slightly increase in body weight across all groups. table 4: effect of aqueous stem bark extract of parkia biglobosa on weight (mean ± sem) of the wistar rats before (pre) and after (post) interventional study according to the doses administered preweight post-weight group a 105.5 ± 3.57 119.25 ± 7.79 group a 135.25 ± 15.48 163.0 ± 21.79 group a 122.5 ± 12.20 129.0 ± 5.85 group a 131.0 ± 8.91 174.0 ± 10.00 group a = control group, groupn b = high dose of aqueous stem bark extract of parkia biglobosa (1000 mg/kg), group c = medium dose of aqueous stem bark extract of parkia biglobosa (500 mg/kg) and group d = low dose of aqueous stem bark extract of parkia biglobosa (250 mg/kg). liver function test ( liver enzymes) table 5: comparison of liver enzymes (mean ± sem) among different test groups and control group parameter group a group b group c group c group d alp (iu/l) 48.00 ± 3.24 90.00 ± 2.08 67.00 ± 3.05 53.50 ± 4.50 0.000 alt (iu/l) 23.25 ± 1.65 46.66 ± 2.33 41.00 ± 1.15 27.50 ± 1.50 0.000 ast (iu/l) 23.75 ± 2.95 45.66 ± 2.02 38.33 ± 4.33 30.00 ± 3.00 0.001 the result were expressed as mean ± sem and p < 0.005 is statistically significant histological finding on liver of group a (control) and test groups (group b, c and d) the liver sections of control group (group a) shows no observable changes with hepatocytes radiating from a distinct central vein. none of the tissue sections from this group showed any histomorphological changes (figure a). group b shows area of inflammation and vascular degeneration (figure b). group c shows an areas of inflammation, degeneration and vacuolation of hepatocytes (figure c). group d shows no observable changes indicating that there is no evidence of liver cell damage (figure d). figure 1: a photomicrograph of liver section from group a (control) which shows normal hepatic portal vein figure 2: a photomicrograph of liver section from group b (1000mg/kg) showing areas of inflammation and vascular congestion obtained using h&e staining technique (mag×100)vein https://journals.e-palli.com/home/index.php/ajmsi pa ge 17 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 13-20, 2023 figure 3: a photomicrograph of liver section from group c (500mg/kg) which shows areas of inflammation and hepatic portal vein obtained using h&e staining technique (mag×100) vein figure 4: a photomicrograph of liver section from group c (500mg/kg) which shows areas of inflammation and hepatic portal vein obtained using h&e staining technique (mag×100) vein normal hepatic portal vein obtained using h&e staining technique(mag×100) figure 5: photomicrograph of stem bark of parkia biglobosa discussion in this study, the extraction procedure yielded 75g of the dried extract and the percentage yield were calculated as 15% which were used for interventional study at various doses. the acute toxicity of p. biglobosa has been investigated to determine any adverse effect that may arise as a result https://journals.e-palli.com/home/index.php/ajmsi pa ge 18 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 13-20, 2023 of a short time animal exposure to the extracts within 24 hours period. though p.biglobosa has been used by traditional medical practitioners (tmps) without report of any mortality due to toxicity, this claim has been authenticated by the lack of death at oral treatment of over 5000 mg/kg body weight of the extract. the results thus suggest that the extract of p. biglobosa has low toxicity (schorderet, 1992), since the ld50 was greater than 5000mg/kg body weight. the low toxicity obtained may have been responsible for its widespread use in different ethnotherapeutic interventions. rats treated with various doses of the extract (1000 mg/ kg, 500 mg/kg and 250mg/kg) showed a significant increase in body weights in relation to the control animals, indicating that p. biglobosa has adverse effects on the body weight. the water extract increases serum triglycerides concentration and total cholesterol level. ordinarily, liver cell damage is characterized by a rise in plasma enzymes (alp, ast, alt, etc). in this study, there is a slightly increase in liver enzymes level (ast, alt and alp) compared to the control group. the group treated with high and medium doses shows a slight increase in the level of the enzymes and also the histological investigation reveals an inflammation and vascular degeneration, therefore p. biglobosa induces hepatocellular damage. the plant kingdom represents an enormous reservoir of biologically active compounds with various chemical structures and protective /disease preventive properties (phytochemicals). these phytochemicals, often secondary metabolites present in smaller quantities in higher plants, include the alkaloids, steroids, flavonoids, terpenoids, tannins, and many others. the active principles of many drugs found in plants are secondary metabolites (ghani, 1990; dobelis, 1993). therefore, basic phytochemical investigation of these extracts for their major phytoconstituents is also vital. in this study, the aqueous stem bark extract of p.biglobosa revealed the presence of tannin, saponin, reducing sugars, phenol and steroids. the toxic effect of water extract of p. biglobosa on the liver may be due to any one or more of the phytochemicals present in the extract. furthermore the phytochemical screening of the water extract of p. biglobosa indicated presence of appreciable amount of tannins. study conducted by yamasaki et al. (2002), bajaj (1988), showed that a large intake of tannins may cause liver damage. in this study, it was found that in control group no morphological changes were identified by histopathology in the liver suggesting that these animals were healthy and the condition under which the experiment was conducted were proper. the animals administered with high dose of p.biglobosa stem bark extract (1000mg/kg) showed areas of vascular degeneration as shown in the photomicrograph in figure b. the animals treated with medium dose of p.biglobosa stem bark extract (500mg/kg) showed a considerable sign of inflammation, degeneration and vacuolation of hepatocyte. as shown in the photomicrograph in figure c. the animals administered with low dose of water extract of p.biglobosa (250mg/kg) showed no remarkable liver cell damaged and no any sign of inflammation as shown in figure d. conclusion this study has shown the diversity in toxicity as well as the chemical constituent of the aqueous stem bark extract of p. biglobosa. there is slight increase in serum liver enzymes (alp, alt and ast) and the histological investigation revealed some areas of inflammation and vascular degeneration which shows an evidence of liver injury due to the consumption of p.biglobosa. however this study provides the basis for further studies on the detailed toxic and pharmacological effects of the extracts of p. biglobosa stem bark and their active compounds. recommendation 1. there is a need for making a societal awareness on the pathological condition of liver that could arise with unspecific consumption of aqueous stem bark extract of parkia biglobosa 2. further research could be taken and executed using different extraction solvent such as methanol or ethanol to note if there will be a significant changes in the diversity of toxicity as well as the chemical constituent(s) of the stem bark extract of parkia biglobosa 3. a lot of information on the adverse effects of the extract has to be establish. references adebayo-tayo, b. c., & adegoke, a. a. 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(2009). hypoglycemic and hypolipidemic effects of flavonoids from lotus (nelumbo nuficera gaertn) leaf in diabetic mice. journal of medicinal plants research, 3(4), 290-293. zoberi m.h (1973). some edible mushrooms from nigeria. nigerian field, 38(2), 81–90. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 12 7 american journal of medical science and innovation (ajmsi) the prevalence of the causes of diseases, under a cause-effect approach victor alfonso abuadili garza1* volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.6119 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 12, 2025 accepted: september 09, 2025 published: november 24, 2025 we have focused on paying attention to disease, knowing how to diagnose it, how to treat it, how to “eliminate” or control it. but i assure you that very few people in this world have become aware and consistent, and instead of thinking about eliminating the disease, they think about preventing it from developing. after years of research, this author has concluded that, according to the international code of diseases (icd-11), there are more than 44,000 reported diseases, and more are described each year; however, there are only ten causes for all diseases. this study seeks to determine the prevalence of the causes of diseases under the cause effect perspective, for which we use the methodology of the system for the application of techniques for metabolic diagnosis (atdm system), we have carried out a multicenter, multi-country clinical study, where we use our big data platform for the analysis of data obtained from more than 6,000 people, and we have been able to identify through bioimpedance and capillaroscopy tests, various patterns that allow us to determine this prevalence of the causes of diseases, which opens a new and disruptive field of research. keywords bioimpedance, capillaroscopy, causes of diseases, metabolic diagnostic techniques application system (atdm system), prevalence 1 universidad nacional autónoma de méxico (unam), mexico * corresponding author’s e-mail: abuadili@yahoo.com.mx introduction modern medicine is currently undergoing an unprecedented revolution, unlike anything ever before in the history of medicine. we have access to as much information as we do today. books are already obsolete within a few months, and medical and scientific articles are surpassed every day by new research. medical students used to spend many hours in libraries. today, they have access to the latest publications through scientific metasearch engines on the internet (alfonso, 2019). we have focused on paying attention to disease, knowing how to diagnose it, how to treat it, how to “eliminate” or control it. but i assure you that very few people in this world have become aware and consistent, and instead of thinking about eliminating the disease, they think about preventing it from developing (alfonso, 2019). as described by the argentine-mexican researcher and philosopher enrique dussel, who says: “it is nothing to discover something new, you have to discover why you are discovering,” (alfonso, 2019) and it is that for decades, the same preventive schemes have been applied in primary health care, without any impact or direct results to avoid the development of diseases, since there is a scienticide,(dussel, e. 2019) in relation to the fact that it is about preventing from a focus on the effect, that is, preventing the diseases themselves; however, with scientificidal actions, the knowledge of those scientific developments, focused on addressing the causes that originate the diseases, is blocked (dussel, 2024). it’s difficult to study an organism as complex as the human being; and analyzing the living matter that acts and reacts at every moment in our body, from the simplest to the most complex that is, from an apparatus or system to the most complex level, which is atomic or quantum reactions has been the main challenge of modern medicine. in 2010, this author began to investigate to improve his own health by starting with problems of an uncontrolled metabolic syndrome that led me to be hospitalized in intensive care for two weeks due to a case of baltazar 4 triglyceride pancreatitis, (garza, 2025) and then, after more than two months in the hospital, and being one of the few survivors of this disease, being hospitalized, referred and under a new paradigm, when asking myself, why? why me? this author victor alfonso abuadili garza from 2010 to 2019, studies metabolism through the use of capillaroscopy, a diagnostic technique that stands as an element of great importance for different areas of modern medicine, since its operation is based on the interaction of light matter, which is a basic mechanism that is used every day, to obtain information about the causes of the diseases (castro & castro, 2003) capillaroscopy is a non-invasive, real-time, low-cost, highimpact diagnostic tool that is easy to perform, even in the doctor’s office or during health workshops or outreaches anywhere in the world, and requires no consumables. its use is currently expanding to different branches of medicine, gaining momentum under a preventativepredictive model. (franz klein-weigel et al., 2016). the integration, measurement, and consolidation of metabolic assessment patterns (maps) is consolidated as the pioneering study of the metabolic diagnostic techniques application system (atdm system). this system provides a big data statistical-analytical platform, using a multicenter, multi-country protocol, providing information on the health status of individuals, groups, regions, and countries. this raises the prospect of its global expansion as the only preventative-predictive health system (rios-acosta et al., 2016). pa ge 12 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 127-135, 2025 study objective the objective of this study is to determine the incidence and prevalence of the causes of diseases in the population studied using the metabolic diagnostic techniques application system (atdm system). hypothesis we can measure the incidence and prevalence of the causes of diseases. null hypothesis we can´t measure the incidence and prevalence of the causes of diseases. literature revew there are universal laws that no one can escape, one of them being the law of cause and effect. this law makes us see that nothing in life is a matter of chance, and that there is always a relationship between what has happened and what follows (díaz camacho, 2010). “every cause has its effect, and every effect has it´s cause, everything happens according to law, luck is nothing more than the name given to an unknown knowledge.” victor alfonso abuadili garza the law of cause and effect is a law of life that many people don’t take into account, and it is truly important to achieve good results in all aspects of our lives. it is a law that works perfectly on all levels and brings to fruition everything we sow, whether in thought, word, or action. this means that everything we do sets a cause in motion, and this brings a positive or negative consequence, which will depend on the cause set in motion. there is no idiopathic, good luck or bad luck, only results. the law of cause and effect is omnipresent. it’s everywhere, so you can’t get rid of it (abuadili garza, 2025). the cost of modern living has had profound and disruptive implications in the field of research, causing changes in the study of disease etiology, as well as in disease treatment and prevention. to the point, if we review medical literature using a metasearch engine like pubmed, the study of glycation, oxidative stress, mitochondrial dysfunction, and microbiota accounts for 80% of recent publications in the last 10 years (abuadili garza, 2025). medical textbooks talk about diseases whose specific cause is perfectly known: bacteria, viruses, fungi, genetics, etc. but they also talk about idiopathic diseases, where the exact cause of the disease is unknown. this generated a major hypothesis: “if all diseases are the effect of a cause, then there must always be a cause or combination of causes. therefore, we must change the paradigm of medical care and now ask ourselves: what are the causes of diseases?” (alfonso, 2023). after years of research, this author has concluded that, according to the international code of diseases (icd11), there are more than 44,000 reported diseases, and more are described each year; however, there are only ten causes for all diseases. name the disease, but it will have one or more of these 10 causes: hidden hunger in 2004, josué de castro defined “total hunger, the true famine that english speakers call starvation, a phenomenon generally limited to areas of extreme poverty and exceptional contingencies, as the much more frequent and serious phenomenon; and the partial form, the so-called hidden hunger, in which, due to the permanent lack of certain nutritional elements in a normal diet, entire population groups are left to slowly die of hunger, despite eating daily” (hood & vikram, 2015). according to the world health organization (who), hidden hunger is defined as the non-explicit need for one or more nutrients that are essential for the proper functioning of the body. this health problem is estimated to affect two billion people worldwide (weffort & lamounier., 2024; lowe, 2021). systemic intoxication systemic intoxication is caused by processes that our own body develop and that affect our health in different ways (alfonso, 2023). these processes can be exogenous when they are due to an impact on the body, metabolism, or cellular function, derived from a physical, chemical, or biological agent acquired from the environment, such as toxicology or exposure to allergens; while endogenous intoxication is caused by physical, chemical, or biological processes that occur within our own body (de arcos & leiva, 2021). of the latter, we can see cross-fermentation (aerobic with anaerobic) caused by bacteria in the intestine when eating certain combinations of foods, partial oxidation of methane, and leaky gut syndrome (burneo, 2024). formation of a proinflammatory state silent system inflammation is characterized by elevated circulating levels of inflammatory cytokines, as well as increased infiltration of macrophages in peripheral tissues. this inflammatory scenario does not induce injury or loss of functionality in the infiltrated tissue, a distinctive feature of a state of low-grade systemic inflammation. (josé israel león-pedroza et al., 2015). low-grade systemic inflammation is closely related to the development of chronic degenerative diseases, which is why this state of immune alteration has also been called meta inflammation (li et al., 2023). there are many causes for the formation of a proinflammatory state. however, the main one is the presence of glycation in the tissues. this biochemical process that makes up the maillard reaction, causes the formation of glycation end agents (ages) that generate an inflammatory immunological reaction. (actis dato & rebolledo, 2000). today we know that these ages are related to diet and especially to the complications of pa ge 12 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 127-135, 2025 diabetes; but recently dr. victor abuadili, thanks to his discovery by capillaroscopy, published that the maillard reaction is a concatenation of biochemical reactions that occur over a period of 72 hours, generating insulin resistance and that after this period of time, a process of non-enzymatic condensation begins for the conversion of carbohydrates into ldl cholesterol that adheres to the tissues, initiating a de novo lipogenesis, which in the long run triggers obesity, thus closing the vicious circle of inflammation (abuadili garza, 2025). redox imbalance redox imbalance reactions are those caused by changes in the redox chemical reactions caused by free radicals that affect our bodies. redox is the name given to a chemical reaction that involves the transfer of electrons between different reactants, leading to a change in the state of oxidation. in these reactions, one element loses electrons, and another receives them. a free radical is an atom, molecule, or compound that is highly unstable due to its atomic or molecular structure (i.e., the distribution of electrons within the molecule). as a result, free radicals are highly reactive, attempting to pair with other molecules, atoms, or even individual electrons to create a stable compound. upon achieving a more stable state, free radicals can “steal” electrons from another molecule, bind to another molecule, or interact in various ways with other free radicals (baynes & thorpe, 1995). due to the inevitable formation of these free radicals, living beings have had to find a way to survive in this oxidizing environment created by their own functioning, and the appropriate evolutionary response to counteract the damage that these reactive species could cause has been the development of antioxidant systems. this implies that, to consider the situation occurring in an organism, it is necessary to assess the balance between the production of reactive species and their elimination capacity, known as redox balance (giugliano et al., 1995) from the moment a human being is conceived, oxidation and reduction begin. the increase in free radicals generates cellular aging that is associated with a chronic inflammatory process, as an overexpression of redoxsensitive transcription factors is observed, which activate the transcription of pro-oxidant enzymes in cellular aging. this causes the balance between pro-inflammatory and anti-inflammatory cytokines to be lost in favor of the former. however, due to the cost of modern living, there are various causes that accelerate this imbalance, such as air pollution, saturated fats, heavy metals, smoking, insecticides and pesticides, and stress (baynes & thorpe, 1995; giugliano et al., 1995). today, the role of redox imbalance in the pathogenesis of various diseases is well known, including cancer, diabetes mellitus, cardiovascular diseases, neurodegenerative diseases, and more than 300 chronic degenerative diseases, which remain the main health problems worldwide (evans et al., 2003). because of the importance of these redox reactions, and for our readers’ better understanding, we divide cellular reactions into five groups of cellular stress: (andersen et al., 2006) a) oxidative stress. b) nitrostative stress. c) hydrostative stress. d) alkoxylic stress. e) carbonylic stress. cellular acidity the human body is in constant balance (homeostasis), and this balance encompasses several factors, such as fluids, electrolytes, temperature, hormones, etc. however, one of these factors is the tight ph balance. the primary function of this balance is to maintain a wide variety of bonds found in the organic components of living beings, such as proteins, lipids, and carbohydrates, as well as other substances essential to their functioning, such as enzymes. when altered by ph, these substances can be implicated in the mechanism of cellular injury (zavala cruz, 2008). cellular acidity is a process that occurs in the body’s cells when glucose metabolism, rather than through aerobic channels, shifts to anaerobic metabolism. normally, when glucose is oxidized, it is metabolized into carbon dioxide, water, and energy. however, when this does not happen, either because the cell is lacking oxygen or because it is displaced by carbon monoxide, the cell is unable to produce energy. otto heinrich warburg, nobel prize winner in physiology or medicine in 1931, discovered that “lack of oxygen and cellular acidity are two sides of the same coin: acidic substances repel oxygen; alkaline substances attract oxygen.” in other words, instead of dying, as cells normally do, in an acidic environment, these cells survive by becoming abnormal cells. these cells are known as malignant cells, which do not respond to messages sent by the brain or those produced by the genetic code, dna. consequently, malignant cells grow indefinitely and without any order. this is cancer” (veronica huber et al., 2017). in addition to the above, herman aihara, in his book acid and alkaline, tells us: if the condition of extracellular fluids, especially the blood, is acidic, the result will be fatigue, a tendency to catch colds, etc. when these fluids become even more acidic, our condition worsens with aches and suffering such as pain. pain occurs in acidic environments. there is no pain in an alkaline environment. human microbiome imbalance the human microbiome project is the scientific project that is most effectively transforming human health. a small revolution in microbiology has discovered that many modern diseases are indeed related to the human microbiome (“microbiota” is the term used to refer to the collective of microorganisms that exist in the human body; “microbiome” is the genes that code for these pa ge 13 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 127-135, 2025 microorganisms) (moreno del castillo et al., 2018). recent advances in the study of microbiology and clinical medicine have demonstrated the importance of human microbiome in health. many studies have demonstrated the cross-interaction of the microbiome with the intestinal nervous system and the consequent modulation of brain activity (ofelia, 2016). it has also been shown that the metabolites produced by the gut microbiota modulate energy metabolism in all mitochondria in the body, since the levels of hydrogen sulfide (h2s), produced by enteric bacteria, inhibit or activate cytochrome oxidase in the mitochondrial respiratory chain. this is also true of the interaction between the microbiome and mitochondria in the epigenetic expression of the cell nucleus in different tissue cells (garza-velasco et al., 2021). the human microbiome is composed of all the microorganisms, actions, and interactions of these microorganisms, which we acquire at practically two crucial moments in our lives: at birth and during breastfeeding during the first 48 hours of life. therefore, we now know that our mothers inherit our bacteria, parasites, or fungi (hou et al., 2022). this microbiome is composed of several types of microorganisms that make up the human microbiome. however, our readers may come into contact with some terms, and therefore i think it is important for you to coin the following concepts: microbiota = bacteria. macrobiota = parasites. mycobiota = fungi. mitochondrial dysfunction mitochondria are cellular organelles derived from an ancestral symbiosis between prokaryotic bacteria that were phagocytosed by eukaryotic bacteria. during evolution, they became cellular mitochondria. these mitochondria lost many of the genes of prokaryotic bacteria and retained only a small genetic fraction that controls the synthesis of 67 proteins, including the genes that express 13 proteins in the respiratory chain. they are not only the source of energy for cells, but also actively participate in muscle function, cell proliferation, the secretion of hormones and antioxidant enzymes (sod, gpx, and catalase), and in anabolic and apoptotic processes (wilson, 2009). the term mitochondrial disease encompasses a broad and heterogeneous set of diseases due to a primary mitochondrial defect, characterized in most cases by impaired oxidative phosphorylation and a consequent alteration in energy production. mitochondrial dysfunction arises in response to severe stress caused by tissue hypoxia, which activates an inflammatory cascade of cytokines, interleukins, and tumor necrosis factor (tnf2α), inhibiting aconitase in the krebs cycle, thereby disrupting energy production at the cellular level, causing mitochondrial dysfunction and even cell death (hood & vikram, 2015). lack of gene expression modulation today, it is no longer considered valid to assume that if a person’s grandfather or father has a certain disease, that person will inherently have it. the human genome project was one of the most expensive and celebrated scientific initiatives in history. when this project concluded, the idea was that with the discovery of the genome, certain “letters” of the human genome individual genes could be changed and diseases easily corrected. (jonides, 2004). genetic expression is determined by many factors. generally speaking, all somatic cells in the body have the same genetic makeup. however, different cell types express different proteins and have different phenotypes. in other words, the same dna can be used differently in different cell types, which is known as genetic expression (michelle et al., 2007). lack of biofrequency modulation human beings are matter and energy, and as this universal law states, “energy is neither created nor destroyed, it only transforms.” our body emits more than a trillion different frequencies that correspond to the working frequency of our organs and even parts of them. any alteration in the function of an organ or bodily system leads to an alteration of it´s frequency (pérez-esteve et al., 2022). many diseases are due to biofrequency disturbances; diseases are due to the confusion of bioenergy due to a disruptive connection. when diseases are caused by biofrequency disturbances, they affect the muscular system, the digestive system, and every other bodily system (taboada lugo, 2025). trauma trauma not only includes injuries from accidents, but also all conditions that cause trauma to the body’s structure, including surgeries. they generally follow the law of causality. there will always be a cause that originates an incident that causes harm. materials and methods this article has a qualitative, documentary and propositional study approach, carrying out an exploratory, descriptive, explanatory, propositional and predictive study, for which, first this author proceeded to carry out a bibliographic review in pubmed, google scholar, latinindex and other metasearch engines, to determine the physical, biochemical, homeostatic factors, with the aim of updating knowledge about the processes involved in the causes of diseases. applying the methodology called “metabolic assessment” established in the atdm system referenced in number 1 to 7 of the references, to corroborate our hypotheses, a clinical research was carried out where bioimpedance and capillaroscopy tests were performed on more than 6,000 people (n=6031) of both sexes, regardless of age or health status, in mexico, the united states, the dominican pa ge 13 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 127-135, 2025 republic, guatemala, puerto rico and colombia, taking a general medical history of the patients and raising a database that will report the corresponding statistics in the results section. all were requested and signed their written consent to participate in the present study, and in the case of minors, parental authorization. to obtain these parameters, we performed a bioimpedance test on the sampled individuals using an omron hbf-516b device, which obtained the bioimpedance parameters. we used bmi value to determine the individual’s nutritional status and analyzed body composition. if muscle mass is decreased and fat mass is increased, we can infer the presence of insulin resistance related to the proinflammatory state. using metabolic age data, we can determine a redox imbalance if it is increased, and hidden hunger if it is decreased. using visceral fat data, we determine lipid adhesion to vital organs. then we relate them to the capillaroscopy images that were obtained in real time, using bioresonance capillaroscopes brands cmos xw880, x crysta and digilenz, with different magnifications, which are photographed directly from the screen of the devices, to make an interrelation of the capillaroscopy with the bioimpedance test. we correlate the bioimpedance test with the capillaroscopy test, and we directly identify specific imaging patterns, which allow us to determine the causes of diseases. thus, the nutritional status pattern determines the processes of hidden hunger, whether due to alterations in intake, absorption, or assimilation. toxicology patterns determine exogenous systemic intoxication, while microbiome alterations related to the presence of fungi and parasites (whether helminth eggs or protozoan trophozoites) indicate the presence of leaky gut syndrome, in addition to determining microbiome alteration. with the proinflammatory status pattern, we directly identify silent inflammation, in addition to lymphatic congestion and the presence of fibrosis. with the glycation pattern, we visualize the different phases of the maillard reaction and non-enzymatic condensation. likewise, with the redox imbalance pattern, we can see this same theme, identifying oxidative and nitrostative stress and their effects on tissues, and even on the biochemical reactions themselves, which are directly related to mitochondrial dysfunction. likewise, the patterns of altered capillary morphology and altered microcirculatory flow determine the lack of genetic modulation and the lack of biofrequency modulation, while certain components of various patterns are associated with trauma. the results of these metabolic assessments are integrated into a clinical record, and the information and images are entered into our big data platform, the “system for the application of techniques for metabolic diagnosis (atdm system),” with the goal of identifying, through capillaroscopy, the presence of the different components of the maillard reaction as part of tissue glycation. in a subsequent installment, we will provide a case-by-case and statistical account of these assessments, since the objective of this study is limited to the identification of histopathological processes that trigger the causes of diseases. results and discussion we performed, using the methodology of the system for the application of techniques for metabolic diagnosis (atdm system), the bioimpedance and capillaroscopy tests on patients (n=6031), where we observed that there is a direct proportional relationship among the various components that make up the metabolic assessment patterns (map´s), with the causes of the diseases. when performing the metabolic assessment on individuals, each metabolic assessment reported the different causes of the diseases, according to the programming established in the atdm system’s big data digital platform. this allowed us to extract the corresponding case-by-case and statistical results by health day, by state, and by country, as well as the general data from the study protocol. in this context, from the information obtained from the patient sample (n=6031), we observed the following results, according to the following graph and table: figure 1: prevalece of the causes of diseases pa ge 13 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 127-135, 2025 analyzing the graph and table above, we can determine that there is a concatenation of causes in many patients, and not just isolated causes. therefore, reviewing the prevalence of each cause of the disease, we can see the following: regarding hidden hunger we observed that of the 6,031 metabolic assessments, hidden hunger was present in 1,718 cases, equivalent to 28% of the study population; that is, technically speaking, 3 out of 10 people present with hidden hunger. without mentioning the specific type of hidden hungry is generated, this author undertakes to present this study in a future publication. regarding redox imbalance we can see that this cause of disease is present in 3,514 cases out of the 6,031 people studied in the sample. this means that the general population presents redox imbalance in 58%. technically speaking, this indicates that 6 out of 10 people have a redox imbalance, and therefore premature cellular aging. without mentioning the specific type of cellular stress generated, this author undertakes to present this study in a future publication. regarding systemic intoxication as can be seen, the data obtained shows that 4,048 cases of systemic intoxication occurred among the 6,031 people who underwent metabolic assessment, which is equivalent to 67% of the population studied. therefore, we infer that 7 out of 10 people are at risk of systemic intoxication, whether endogenous or exogenous. however, this data is not yet reported. for this reason, this author undertakes to conduct this analysis in subsequent publication. regarding the formation of a proinflammatory state after analyzing the data provided by the atdm system platform, we can see that this cause of the disease is one of the most prevalent of all. of the 6,031 metabolic assessments performed on the sample population, 5,221 cases of silent inflammation were reported, equivalent to 86% of the population. this allows us to infer that 9 out of 10 people have chronic silent inflammation. since a causal analysis has not been performed, these figures require a more in-depth study of the formation of a proinflammatory state. therefore, this author undertakes to provide this information in subsequent publication. however, it is necessary to emphasize that the main condition that causes this silent inflammation is insulin resistance, which results from the maillard and pyrolysis reactions in the tissues. this mainly explains the diabetes pandemic, but at the same time, the data obtained refers us to a preventive-predictive aspect of having to urgently implement measures to reverse these processes from the cause. regarding cellular acidity this cause of the disease provides data showing 3,647 cases out of 6,031 patients, equivalent to 60% of the population. this means that 6 out of 10 people are developing cellular acidity processes, whether they are experiencing pain or more severe cases with cellular transformation. therefore, this author undertakes to provide this information in subsequent publication. regarding mitochondrial dysfunction after analyzing the data on mitochondrial dysfunction, we can observe that of the 6,031 people studied, 1,714 cases were positive for mitochondrial dysfunction, equivalent to 28% of the population. this means that 1 in 10 people will experience organ failure at some point, if they are not currently experiencing it. therefore, this author undertakes to provide this information in subsequent publication. regarding microbiome alteration the data on microbiome alteration shows that of the 6,031 metabolic assessments, 3,689 people have this cause of the disease, which is equivalent to 61%. that is, 6 out of 10 people are experiencing dysbiosis due to some microbiological agent, without specifying whether it is bacteria, virus, fungus, or parasite. therefore, this author undertakes to present the relevant information in a subsequent article. table 1: prevalece of the causes of diseases causes of diseases cause of disease patients cases average hidden hungry 6031 1718 28 redox inbalance 6031 3514 58 systemic intoxication 6031 4048 67 proinflamatory state 6031 5221 86 celular acidity 6031 3647 60 mitocondrial dysfunction 6031 1714 28 human microbiome inbalance 6031 3689 61 lack of gene expresion modulation 6031 5368 89 lack of biofrecuency modulation 6031 3488 57 trauma 6031 3539 58 pa ge 13 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 127-135, 2025 regarding the lack of modulation of gene expression it is difficult to determine the date of an alteration in the modulation of gene expression, as multiple pathologies are involved. however, with the components of the metabolic assessment, it has been determined that 5,368 people out of the 6,031 metabolic assessments performed present this cause of the disease, representing 89% of the cases. this means that nine out of 10 people have a lack of modulation of gene expression due to some epigenetic mechanism, which this author undertakes to investigate and publish in a future publication. regarding the lack of biofrequency modulation the data provided by this cause of disease is significant, given its association with various pathologies. we found that 3,488 people out of 6,031 metabolic assessments, corresponding to 57%, had altered biofrequencies, which implies that 6 out of 10 people are affected by these disruptive connection processes. regarding trauma this cause of the disease depends not only on accidents and associated tissue injuries, but also on surgical procedures, and this is where it is triggered that 3,539 cases of the 6,031 metabolic assessments, corresponding to 58% of the population, have had some type of trauma. therefore, it is necessary to state here that the hypothesis proposed is conclusive. through metabolic assessment using bioimpedance and capillaroscopy tests under the metabolic diagnostic techniques application system (atdm system), we can determine, both individually and collectively, the causes of diseases affecting a specific population. now, looking at the cause and correlating the data provided by this study with statistics viewed from an effect-based paradigm, we can see that diseases are underestimated, as ordinary statistics determine values below the possible reality of what is being experienced every day. if we analyze the data from a preventive-predictive perspective, the data obtained are alarming, as they not only have value in terms of prevalence (the cases present in a population group), but this study also allows us to see incidence statistics (the new cases that are occurring), and therefore, a future trend is observed, which, according to this author, is alarming. analyzing that the prevalence of certain causes of disease is as high as 6 to 9 out of 10 people already have them, then the alarming thing about these data is that the incidence maintains the same trend and, therefore, will increase to the total number of cases in the coming years; that is, in addition to the current cases, new cases will be added and multiplying. therefore, the trend over the next 5 to 10 years will be completely exponential, which will mean that no health system will have the capacity to address the effects generated by not addressing the causes now. conclusion with this study, we have been able to realize that the use of metabolic assessment through the metabolic diagnostic techniques application system (atdm system) allows us to identify accurate data regarding the prevalence and incidence of the causes of diseases. it is alarming to see that the data indicates that this impact on health is derived from the toll modern life is taking. poor eating habits, environmental pollution, exposure to chemicals of all kinds, ionizing radiation, and the stress of modern life are causing us to collapse. if we do nothing to reverse this trend, the incidence and prevalence of chronic degenerative diseases will overwhelm any health system, and no medical innovation will be able to address this catastrophic condition for humanity. it is clear that these data determine the urgency of taking action to reverse the root causes of diseases, and not just focusing on combating the signs and symptoms once they have already begun. looking to the future of healthcare systems, which are currently overwhelmed, it is necessary to change paradigms and establish predictive preventive diagnostic systems such as the metabolic diagnostic techniques application system (atdm system). right now, with this study, we can better understand the causes of diseases by measuring the caseload and statistics for each cause, and thus understand the processes that cause them, from a preventive-predictive perspective, so the best conclusion that i´m arrived is: “if we remove the causes of diseases, we eliminate the effects, that is, the diseases” ... dr. victor alfonso abuadili garza. references abuadili garza, v. a. 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(2008). una visión universitaria: el ph, sustento en el equilibrio químico para la vida celular. cienciauat, 2(4), 62–66. pa ge 1 pa ge 10 3 american journal of medical science and innovation (ajmsi) digital revolution in medical pathology: integrating ai, genomics, and molecular imaging adeyemi sarah halleluyah1*, sodiq murphy balogun2, abraham chibuikem ikeji3, bukola e. shasere3, omeshamisu anigala4 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5281 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: may 22, 2025 accepted: june 26, 2025 published: november 10, 2025 the current clinical pathologic diagnostic process using histological slide evaluation demonstrates inconsistent accuracy in medical diagnosis. progress in digital pathology and other modern technologies now enables the utilization of ai for medical image diagnostics, along with genomic technology for profile assessment and molecular image functionality. this systematic review examines the impact of artificial intelligence technology combined with genomic analysis and molecular imaging systems on present-day pathological medicine advancement. the review includes research published between 2014 and 2025, obtained from the top five databases, to demonstrate how each technology improves diagnosis separately and collaborates for precise medicine advancement. the analysis evaluated ten studies that matched all the established criteria for inclusion. medical diagnostics benefit from combined system platforms, which also strengthen patient classification systems and treatment selection. however, these platforms require improvements in data standards and workflow connections, as well as computational resources and moral framework requirements. the study defines the necessary criteria for government-connected data platforms and interpretive artificial intelligence models, and then creates regulatory mechanisms in collaboration with interdisciplinary partnerships to develop safe and equitable healthcare applications. a single organized system triggers an essential transformation that shifts pathology from traditional morphological practices toward complex multivariate modern data methods. the research delivers strategic recommendations to enhance future practice and policy development, which will enable these technologies to be widely used in clinical settings. keywords artificial intelligence, digital pathology, genomics, molecular imaging, precision medicine 1 bioinformatics, morgan state university, maryland, usa 2 department of bioinformatics and genomics, university of north carolina at charlotte, usa 3 mayo clinic, usa 4 department of electrical engineering and computer science south dakota state university, usa * corresponding author’s e-mail: sarahadeyemi362@gmail.com introduction the medical field of pathology maintains crucial importance for disease examination, which supports both diagnosis and treatment of patients (ahuja & zaheer, 2025). the pathological approach of tissue section examination under a microscope faces two drawbacks: it depends on subjective visual interpretation, and it produces variable results between different observers according to madabhushi & lee (2016). the diagnostic field of medicine underwent important changes in recent times because innovative technologies seek to enhance diagnostic accuracy, combined with quicker operations. digital pathology brought about significant changes in healthcare through vigorous digitization of medical slides while creating opportunities for remote consultations and image analysis, and storing large amounts of valuable data (ali & saqib, 2023). digital transformation has optimized operational processes and established conditions for advanced computational systems to enter modern pathological procedures (shafi & parwani, 2023). computational algorithms linked with digital imaging created new methods to analyze information quantitatively which leads to more dependable measurement systems. the incorporation of artificial intelligence (ai) with genomics and molecular imaging into pathology practice leads scientific advancements in delivering precision medicine (munari et al., 2024). artificial intelligence delivers outstanding performance through deep learning algorithms that outstrips human competency during specific diagnostic examinations (sussman et al., 2022). digital histopathological image analysis through ai models enables medical experts to detect different cancers (abasher et al., 2023), while measuring treatment effects and forecasting patient clinical results according to salo et al. (2024). massive data training enables such systems to detect faint patterns seen only by sophisticated machines which results in improved diagnostic accuracy. the molecular brightness of diseases has advanced significantly because of genomics (ikwuka et al., 2013). modern sequencing methods provide full genetic alteration exploration capabilities which lead to biomarker discoveries for diagnostic testing and prognosis prediction and therapeutic aims (munari et al., 2024). the combination of genomic data analysis with tissue examination results enables detailed disease classification, especially in cancer cases, which leads healthcare providers to design individualised treatments (asif et al., 2023). treatment effect, along with patient results improves with targeted therapy decisions based on specific genomic profile mutations. through positron emission tomography (pet) and single-photon emission computed tomography (spect), which belong to molecular imaging technologies, researchers can observe functional biological processes within living patients. pa ge 10 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 103-110, 2025 medical experts use these diagnostic methods to monitor receptor expression levels along with metabolic activity by gaining additional secondary information from traditional anatomical imaging data (fahmy, 2024). the combination of molecular imaging with ai algorithm enhancements facilitates better pathological detection alongside better pathological variation characterization through complex detection methods and exact identification (rowe et al., 2021). better disease assessment capabilities within this combined system led to immediate, proper medical interventions. rationale for the study pathological applications experience very limited ai advancements because genomic and molecular-imaging technologies fail to achieve sufficient collaborative development. modern technologies demonstrate the capability to develop morphology-based pathology into an advanced data-based field that extends beyond traditional morphology-based practices. better disease knowledge combined with superior patient outcomes becomes achievable when pathologists analyze disease observations together with genetic and molecular data according to munari et al. (2024). the integration process reveals different challenges because it needs standardized data formats alongside system interoperability and training for specialized staff members. the implementation of these tools in healthcare facilities requires proper solutions to both data privacy concerns and algorithm transparency needs to sustain ethical clinical practice (asif et al., 2023). healthcare providers and scientists alongside policy experts need to unite their efforts for developing standardized rules which defend patient safety and enable these tools to function in typical medical care. research aim and objectives this study aims to explore the transformative impact of integrating ai, genomics, and molecular imaging into medical pathology. the specific objectives are: 1. to review the current applications and advancements of ai in pathological diagnostics. 2. to examine the role of genomic data in enhancing pathological assessments. 3. to evaluate the contributions of molecular imaging techniques in pathology. 4. to identify the challenges and limitations associated with the integration of these technologies. 5. to propose recommendations for effective implementation and future research directions. materials and methods study design the review implemented prisma guidelines throughout its systematic methodology (page et al., 2021). the research design brings together established studies about ai and genomic analysis with molecular imaging in pathology to achieve both less subjective decisionmaking and enhanced research reproducibility. the study used two independent reviewers who conducted dual screenings for data extraction concurrently until a third expert resolved any discrepancies. the review protocol established both eligibility requirements and data collection items and quality assessment instruments (casp and newcastle–ottawa scale) before starting the search process to avoid post-hoc decision-making. the prisma framework enhances research methodology, but is still unable to eliminate both publication bias and differences among research approaches. the system of registered protocols depends on certain assumptions about database availability, but does not identify research that exists outside database systems. the use of systematic registration during complete evidence synthesis helps researchers execute established guidelines correctly. inclusion criteria this study analyzed peer-reviewed original articles which met the following four conditions: (1) used ai algorithms with genomic analysis or molecular imaging applications in human pathology settings, (2) included clinical or histopathological specimen data such as biopsies and resection specimens, (3) provided diagnostic performance data together with workflow influences and patient-centered outcomes and (4) were published in english during january 2014 to march 2025. the analysis included clinical trials and cohort studies as well as case-control investigations and cross-sectional research and technology-validation studies for collecting evidence at multiple levels. the scope supports practical applications in medical practices through its multiple research method acceptance. the review only accepting english-language publications could potentially hide groundbreaking research from other languages which results in linguistic bias affecting the study results. the ten‐year time boundary safeguards contemporary digital innovation studies without undermining earlier research conducted between 2014 and the present day. the research lacked geographic limitations letting participants from worldwide locations submit data yet this method brought increased variability among different healthcare facilities and their available resources. exclusion criteria the review excluded (1) non–peer‐reviewed literature (editorials, commentaries, conference abstracts, theses), to focus on fully vetted research; (2) studies without direct pathology relevance (e.g., radiology‐only ai applications or bioinformatics pipelines lacking histopathological correlation); (3) purely in vitro or animal‐model investigations without human data; (4) articles lacking sufficient methodological detail or performance metrics; and (5) duplicates and extensions of the same primary dataset. the chosen data restriction criteria improve data review precision and quality but removes essential early-stage research that often presents at conferences. language bias results from reports written in any language except english while publication bias becomes pa ge 10 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 103-110, 2025 more prominent when gray literature is excluded. the team documented all excluded studies for potential use in future research updates that may include different types of evidence during the field’s development. search strategy a systematic method was used for comprehensive literature search that combined boolean operators along with medical subject headings (mesh) and free-text terms. the search terms were chosen specifically to represent digital pathology and artificial intelligence (ai) together with genomics and molecular imaging domains. the search included the following grouping of terms: “digital pathology” or “whole slide imaging” along with “artificial intelligence” or “ai in pathology” or “machine learning” or “deep learning” as well as “histopathology” or “tissue analysis” and “genomics” or “next-generation sequencing” or “genetic profiling” plus “molecular imaging” or “pet” or “spect” together with “precision medicine” and “pathology”. the researchers used boolean operators (and, or) to properly connect their selected concepts. for example: (“digital pathology” and “artificial intelligence”) or (“genomics” and “histopathology”) and (“molecular imaging” or “deep learning”). the literature search included pubmed/medline and scopus and web of science and ieee xplore to complement google scholar. english-language peerreviewed articles published since january 1, 2014 until march 31, 2025 made up the scope of this research. the authors performed their screening by prisma guidelines. the endnote x9 program imported the search results for duplicate detection. two separate researchers evaluated titles and abstracts of potential studies to determine their eligibility. two researchers performed detailed reviews of articles that showed potential relevance. the research team excluded studies which failed to match the selection criteria while providing documented reasons. any disagreement between reviewers was settled through mutual discussion or involvement of a third-party arbitrator. a systematic process followed by transparent methods enabled researchers to capture high-quality relevant studies that answered the study objectives. data extraction and management a standardized extraction form was tested for clarity and consistency using ten randomly chosen medical studies before implementation on the remaining studies. the data collection process acquired information about study authors, publication dates, countries of origin as well as research design types and sample sizes, histology and cytology methods, ai system frameworks, genomic sequencing techniques, molecular imaging tracers, performance metrics, and documented clinical and workflow impact metrics. the extraction process took place independently between two reviewers who used microsoft excel software with automatic version tracking capabilities. the reviewers checked all measurements showing more than 10% deviation and met to reach consensus; disagreements escalated to a third expert validation. prisma transparent and rigorous selection followed the prisma 2020 guidelines during the study assessment process. the search process identified 1,374 records, which included database search results combined with manual reference tracking. the database search yielded 410 articles from pubmed and 340 from scopus, together with 290 from web of science and 157 from ieee xplore and 177 from google scholar. through the process of duplicate removal, 1,062 unique records persisted. two independent reviewers reviewed titles and abstracts, which resulted in discarding 931 articles due to their irrelevance to the research topic and their non-human data or lack of digital pathology technology focus. a total of 131 full articles underwent a methodological assessment as well as a relevance review for their connection to ai, genomics, and molecular imaging applications in pathology. the analysis process excluded 121 articles because the research did not integrate the three technologies properly or lacked clinical applications or presented methodological issues. a total of ten high-quality studies fulfilled all requirements and became part of the systematic review evaluation. the authors conducted a critical assessment of the included studies, which followed thematic synthesis. methodology this systematic review performed a synthesis of findings extracted from chosen research studies during data analysis. the research process included extensive database searches, which led to selecting relevant studies according to established eligibility standards about ai and genomic applications as well as molecular imaging in medical pathology. a structured data extraction process collected essential information, including research designs as well as technological methods, measured outcomes and application settings. the researchers separated studies according to their primary subjects, which examined ai diagnostic tool advancements and genomics applications in pathology and molecular imaging technique innovations. the research team analyzed each theme to detect typical patterns alongside current obstacles and new findings within this academic subject. a narrative synthesis method allowed researchers to organize and make sense of the study results while establishing relationships between different research works to present an extensive summary of medical pathology’s up-to-date technologies. researchers designed this study to demonstrate the expected improvements which these technologies would bring to diagnostic precision and patient recovery outcomes, and future pathology operations. a critical evaluation of the selected reports examined both study methodology and participant numbers alongside research design to guarantee that this review presents validated and dependable findings. pa ge 10 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 103-110, 2025 results and disussion technological innovations and diagnostic performance the combination of artificial intelligence with genomics and molecular imaging technologies enables precision diagnostics to transform pathology services by improving both diagnostic precision and individualized treatment of patients. both significant potential advantages and critical assessment of strengths and weaknesses, together with combined implementation challenges, must be thoroughly evaluated. such analysis demonstrates how complex these systems become when they are put into medical practice. deep learning–based image analysis has proven effective in histopathology through panayides et al. (2020) since their method reached area-under-curve (auc) values upward of 0.90 for tumour recognition. the obtained results demonstrate ai systems match pathologists’ accuracy rates for sensitivity and specificity levels. the study demonstrates a major drawback because these models fail to maintain consistent performance when operating with diverse institutions or changes in staining protocols or slide quality (cheng et al., 2021). large-scale generalization proves to be a major obstacle since controlled environment models struggle to perform correctly in actual clinical settings. many ai algorithms maintain an untraceable decision-making process, which impedes clinicians from adopting them in practice settings (prevedello et al., 2019). the reliability of ai in pathology diagnostic settings comes into question because of such concerns, especially during critical medical determination moments. the diagnostic field has experienced significant transformation through genomic profiling because it identifies mutations and expression patterns to provide molecular insights. tumour stratification in oncology, together with predictive treatment responses, increased to over 95% sensitivity after integrating next-generation sequencing (ngs) data with histopathological images according to seyhan and carini (2019). the reliability of genomic data faces various challenges according to ahmad et al. (2021). the process of sequencing artifacts together with stringent tumour purity requirements can trigger incorrect test results that may confuse medical professionals during interpretation. efficient bioinformatics pipelines provide solutions to analyse the large quantities of sequencing data which medical practitioners need for clinical applications. the bioinformatics pipelines containing ai systems develop recursive dependencies, which generate anxiety regarding analysis transparency and accumulated mistakes (seyhan & carini, 2019). bioinformatics must implement strong, transparent procedures to enable genomic data usage in clinical decisions (kermany et al., 2018). pet and spect techniques in molecular imaging enable real-time metabolic imaging of tissue structures beneath one centimetre, which traditional histological and genomic methods cannot visualise. the research by tian et al. (2021) shows that these imaging modalities reach sensitivity rates above 90% for detecting small lesions to enhance early detection. pet and spect imaging methods face difficulties with specificity because tracer uptake happens in both malignant and benign tissues thereby causing false positive results. traditional microscopic imaging provides higher spatial resolution than molecular imaging, which restricts the obtainable cellular details from this method. according to panayides et al. (2020) and simon et al. (2024), accurate interpretation and modality synergy between combined analytical techniques need precise standardisation of acquisition methods and image processing workflows. these technological systems, united together, create potential major combined advantages. the convergence of image features and mutation profiles, and functional imaging within multimodal artificial intelligence systems leads to a 15% increase in prognostic accuracy according to simon et al. (2024). the integration process comes with significant challenges that need to be addressed. the article by gaffney and mirza (2025) describes how the integration of these technologies becomes difficult due to data format inconsistencies between imaging and genomic platforms in addition to complex requirements for large dataset management infrastructure and divergent governance policies. the matter of algorithmic bias advances as a crucial problem in the field. the training of numerous ai models depends on minorityunderrepresented datasets that result in performance differences during clinical use among diverse patient populations (kim et al., 2022). workflow integration and implementation barriers focus the accuracy and efficiency of routine pathology diagnostics are set to improve significantly with the integration of workflow systems that bring together ai, genomics, and molecular imaging. these technologies encounter multiple complex problems while being integrated into current laboratory settings which require vital assessment before benefiting from their implementation. shafi and parwani (2023) state that automated whole-slide imaging (wsi) scanners introduced digital pathology but their implementation requires perfect lis and reporting platform connectivity. many current lis systems operate using outdated protocols while missing essential apis which would allow them to process large images of gigapixels and to connect genomic reports to histological analysis results. pathology departments struggle with it infrastructure built for transactional reporting which requires extensive hardware upgrades of high-throughput storage area networks and comprehensive network modification to handle image and sequence data according to cheng et al. (2021). panayides et al. (2020) emphasize that medical practices need proper data management structures based on standardized metadata schemas and data lakes to work efficiently. healthcare data remains isolated throughout different systems because patients lack common data ontologies and tag classification structures (such as dicom for images or hl7 fhir for clinical information) which pa ge 10 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 103-110, 2025 prevents multi-modality data search and integrated ai system development. federated systems operate without centralized raw data storage because algorithms execute directly from source nodes to maintain privacy guidelines and achieve large-scale algorithms. the entire integrated workflow relies on data pipelines which pose the risk of becoming performance bottlenecks. the increase of “omics” datasets exceeds statistical capabilities which requires sophisticated computational frameworks based on kubernetes clusters for handling large sequencing read volumes according to seyhan and carini (2019). the model performance becomes inconsistent when differences in scanner calibration and staining protocols and annotation granularity emerge in image acquisition and annotation pipelines according to prevedello et al. (2019). the use of centralized image-analysis competitions together with shared benchmarking datasets helps with both harmonization and ongoing validation process. the requirements for implementing this technology span technological resources and more. the paper explains how research clusters that incorporate gpus or specialized ai accelerators for model training and inference also need to include object-storage solutions which handle petabyte-scale archives (kim et al. 2022). the acquisition of capital to fund such infrastructure tends to face obstacles against core laboratory budgets which leads to resistance from senior management regarding investment returns according to ahmad et al. (2021). the necessity for complete cost-benefit assessments emerges because reduced turnaround times together with lower error rates and possible future savings need to show how they balance initial investments. according to gaffney and mirza (2025) leadership frameworks need to adapt simultaneously to create specific guidelines regarding data protection together with security protocols and algorithm responsibility standards. the implementation of gdpr and hipaa regulations necessitates role-based access controls along with audit trails along with data encryption when data rests or when it moves through networks. the absence of proper oversight exposes departmental operations to substantial regulatory penalties together with a deterioration of patient confidence. human factors are equally critical. to achieve effective change management institutions must provide both tool proficiency training to pathologists and technical staff and education about system limitations. the adoption of ai outputs suffers from reduced pathologist acceptance because these systems fail to demonstrate their decision processes or explain their reasoning according to cheng et al. (2021). the collaboration between it, bioinformatics and clinical teams shows limited success because both departments work independently from each other according to kim et al. (2022). shafi and parwani (2023) explain that “ai champions” who work in pathology laboratories connect these two different domains while addressing user concerns immediately and facilitate learning between colleagues, and drive continuous ai development. successfully adopting ai solutions means providing ongoing support, like dedicated help desk staff, regular training sessions, and performance dashboards, to keep things running smoothly and ensure people continue to use the technology effectively. panayides et al. (2020) emphasize the necessity for integrative analytics platforms to have feedback systems that help laboratories enhance their algorithms and workflows using actual practice performance indicators. laboratories can achieve reliable routine clinical care through proactive protocol adjustments by continuously monitoring indicators, which include error rates, model drift and user satisfaction (oala, flach & ghalwash, 2022). ethical, regulatory, and data governance considerations combining ai with genomics and molecular imaging in pathology opens up incredible opportunities—but it also brings significant ethical challenges and regulatory hurdles that must be carefully addressed. the research by gaffney and mirza (2025) shows that patient privacy safeguards, together with accountability measures, need equal importance to technical performance when diagnostic algorithms enter clinical workflows deeply. the absence of strong governance systems will allow sensitive data to become compromised or lead to unauthorized uses of confidential information, which would compromise technological precision. according to seyhan and carini (2019), large-scale omics data consolidation poses significant threats through combining genomic sequences with high-resolution images for ai training models because this process centralizes vulnerable patient information. ahmad et al. (2021) emphasise that advanced diagnostic democratisation should never violate patient consent or autonomy. panayides et al. (2020) show how federated learning addresses this issue through model distribution since weight updates get encrypted before being shared, according to their research. these security systems need perfect encryption with strict key controls and accurate access protocols to prevent attackers from reassembling private information. the paper written by kim et al. (2022) emphasizes that protecting infrastructure stands on par with importance. ai accelerators as well as gpus need protected data centers to operate from, and these centres require ongoing monitoring procedures, alongside network segmentation, along automated audit log generation. cheng et al. (2021) emphasize that laboratories must comply with frameworks like iso/iec 27001 and hipaa because nonexistence of formal policies for encryption and breach notification, and data retention leads to regulatory penalties, together with public trust deterioration. the majority of pathology departments encounter difficulties converting their legacy it systems which operated for transactional reporting, into systems which handle multi-terabyte imaging and sequencing archives. pa ge 10 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 103-110, 2025 transparency represents another essential foundation, according to the research by prevedello et al. (2019). the secrecy of “black box” ai models prevents detection of scanning artifacts that both break user confidence and produce unpredictable mistakes, even when these models provide excellent accuracy. shafi and parwani (2023) explain that pathologists avoid implementing systems that lack explainable decision-making capabilities. the study from kim et al. (2022) shows that explainable ai methods through attention maps and feature attributions help to show prediction formation, yet require accurate microlevel accuracy and clinical interpretation capabilities. the critical dashboard systems described by panayides et al. (2020) help to find both model shifting patterns alongside novel biases which negatively impact minority populations. the research conducted by cheng et al. (2021) reveals that regulatory frameworks should advance their rules as new technological developments emerge. the fda 510(k) clearance system and ce marking approach provide regulatory approval for software versions that remain unchanged but fail to cover the governance of ai systems that learn continuously. shafi and parwani (2023) highlight recent manufacturer approvals that include whole-slide imaging scanners plus a prostatecancer ai algorithm, yet create unaddressed questions regarding update validation and how to verify retraining, along with adaptive learning procedures. prevedello et al. (2019) suggest that mandates for uniform validation protocols should include multicenter prospective trials and standardised staining along with annotation benchmarking to provide regulators with equivalent datasets and metrics. the research by gaffney and mirza (2025) outlines how liability frameworks should specify the accountable parties when ai mishaps produce injuries. pathology laboratories need to create oversight committees with pharmacovigilance board-like functions to verify ai-informed clinical assessments and modify consent arrangements for patients, together with adverse event tracking. the authors of ahmad et al. (2021) support the development of “explainability audits” along with continuous post-market surveillance to detect rare critical failures. footprint evaluation depends on clear organizational accountability along with rapid information feedback between organizations and technicians who maintain patient welfare through transparent reporting. implication the research investigation identified multiple essential pathologic requirements that require combined technical and organizational answers. the highest level of data governance operation must take place. according to seyhan and carini (2019), the combination of “omics” and imaging data before training ai systems intensifies both privacy threats against patient data and potential abusive practices related to highly sensitive medical information. the federated learning method enables laboratories to maintain server-based private data protection and encrypted model updates exchange to access multiple institutional datasets according to zhu et al. (2021) and xu et al. (2020). the deployment requires authorised policies to establish end-to-end encryption together with strict key management protocols and role-based access control systems to fulfil the criteria set by iso/iec 27001 and hipaa standards, according to cheng et al. (2021) and panayides et al. (2020). ai application infrastructure requires design specifications for its functionality. modern healthcare facilities need gpu-powered computing clusters and ai accelerator systems that support encrypted storage with scale capabilities, according to the research by kim et al. (2022). modernization efforts must be deployed to legacy laboratory information systems, which need to use standardized apis to receive digital slides and genomic reports according to shafi & parwani (2023) and panayides et al. (2020). organizations will need to show how the combination of faster test processing with fewer mistakes makes the upfront financing expense worthwhile (ahmad et al., 2021). all automated systems must implement transparency as an organizational foundation. the use of “black box” predictive models damages trust while it simultaneously conceals any random connections that might exist within their results, according to prevedello et al. (2019). xai tools with explanatory capabilities, such as hippo (arvaniti et al., 2024) as well as attention-based heatmaps (chartrand et al., 2022) provide evaluation functionalities for pathologists to analyze models’ decision-making processes. training programs must include specific units about understanding ai outputs and their boundary limitations (rai, 2020; holzinger et al., 2022). the approval process should evolve from receiving static approvals to active oversight. the current fda 510(k) along with ce-mark approval processes, fail to meet the requirements of ai systems that learn in real time. pathology departments need to implement procedures for software version control alongside retraining validation protocols and post-market safety checks, which resemble pharmacovigilance practices (cheng et al., 2021; prevedello et al., 2019). multiple healthcare organizations must establish ongoing learning systems together with cross-speciality supervision. pathology departments should establish “ai governance committees” that unite medical specialists and bioinformatics professionals with legal experts and moral ethicists for checking new tools using standardised testing protocols and clinical effectiveness metrics (gaffney & mirza 2025). the necessary iterative refinement process requires performance dashboards which include indicators for model drift assessment and demographic sensitivity, and clinical impact evaluation (panayides et al., 2020). to advance precision diagnostics as an everyday practice which handles ethical standards, pathologists must implement organized investments that create secure infrastructure and federated architectures and adaptive governance, together with xai capabilities and cultural changes. pa ge 10 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 103-110, 2025 recommendation the research findings produce multiple essential recommendations which direct the course of clinical practice, together with research activities and policy development. every health institution needs to adopt ai and genomic instruments into digital pathology systems to boost diagnostic accuracy while providing individualized care. the integration of ai with genomic tools requires extensive training to build pathologists’ abilities for responsible interpretation of ai-produced results together with genomic information. policy officials and healthcare administrators need to create uniform guidelines that handle ethical problems, reveal algorithm operations, and guard patient information databases as the use of federated learning and data collaborations increases. the development of explainable ai requires an active enhancement of interdisciplinary relationships between computer scientists with molecular biologists, and clinicians to promote technological advances which remain clinically useful and patient-focused. research funding for the evaluation of ai diagnostic systems in different patient populations remains necessary to stop health equity gaps from forming. embracing peoplecentred, transparent, ethical methods represents the vital approach for achieving a complete medical revolution through ai genomics and molecular imaging. conclusion this systematic review shows that integrating artificial intelligence (ai), genomics, and molecular imaging improves diagnostic precision and personalization in pathology. ai enhances image interpretation and predictive accuracy; genomics deepens molecular classification; and molecular imaging visualizes in vivo processes. together, these modalities accelerate workflows, reduce error, and strengthen treatment planning and outcomes. major findings indicate strong performance: deep-learning histopathology models frequently achieved aucs of 0.90 or higher, and multimodal systems that combine imaging with genomic features produced roughly a 15% gain in prognostic accuracy in comparative studies. molecular imaging methods such as pet and spect demonstrated sensitivities exceeding 90% for detecting small lesions. in oncology stratification, integrating next-generation sequencing with histopathology achieved sensitivities above 95% in selected settings. clinical adoption remains constrained by data-format and interoperability gaps, privacy and bias risks, and limited explainability. addressing these barriers requires robust data governance, investment in scalable compute and storage, and cross-disciplinary collaboration to develop transparent, validated models suitable for routine care. overall, the convergence of ai, genomics, and molecular imaging marks a shift toward precision diagnostics. with explainable ai and ethical oversight, these integrated approaches can deliver faster, reliable decisions, establishing a more patient-centered paradigm for pathology and improving outcomes across healthcare systems. references abasher, m. m., sidahmed, a. a., abdelmoniem, a., & mohamed, a. h. 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(2020). federated learning for healthcare informatics. journal of healthcare informatics research, 5(1), 1–19. https://doi.org/10.1007/s41666-02000082-4 pa ge 1 pa ge 12 2 american journal of medical science and innovation (ajmsi) effects of mobile phone tele-reminder on the prevalence of malaria and antenatal care satisfaction among pregnant women availing antenatal care at phebe and charles b. dunbar hospitals, bong county, monrovia-liberia a cluster-randomized controlled trial washington kezelee1, leila s. africa1*, corazon v. c. barba1, angelina r. bustos1, mark bondi arboleda2 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1541 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 06, 2023 accepted: october 03, 2023 published: october 07, 2023 pregnant women with malaria and other associated infections have an increased risk of developing anemia later in pregnancy. this study aimed to determine the effect of mobile phone tele-reminder delivered through phone calls and sms on the prevalence of malaria infection during pregnancy. the study recruited 150 pregnant women seeking antenatal care for the first time at the phebe and charles b. dunbar hospitals in bong county, liberia. the antenatal care screening room (units of randomization) in both hospitals were randomized into six clusters. the 150 pregnant women were randomly assigned to an intervention group and a control group. a binary logistic regression using a generalized estimating equation model was run with a 95% confidence interval (ci). malaria prevalence and antenatal care satisfaction were the primary outcome variables. the secondary outcome variable was the prevalence of anemia. although there was a reduction in malaria infection in both groups, malaria prevalence between the intervention and control groups was not statistically significant (5 vs. 15%) (or, 1.15; 95% ci, 0.71-1.85). pregnant women in the intervention group were 4 times more likely to be very satisfied with anc services compared with the control group (aor, 4.01; 95%ci, 1.72-9.53). there was a positive trend toward anemia reduction among those in the intervention group. integrating mobile phone technology in antenatal care services may help reduce the malaria infection rate and increase anc satisfaction levels. keywords malaria infection, antenatal care, tele-reminders 1 institute of human nutrition and food (ihnf), university of the philippines los banos, philippines 2 school of environmental science and management (sesam), university of philippines, los banos, philippines * corresponding author’s e-mail: lsafrica@up.edu.ph introduction women who are pregnant remain at risk of malaria infection, particularly in low-income countries. the risk of malaria infection and severe infection is greater for pregnant women than for nonpregnant women. anopheline mosquito bites transmit malaria, which is transmitted congenitally and through exposure to infected blood products (lagerberg, 2008). in the genus plasmodium, four species of protozoa cause malaria. preterm delivery, low birth weight, stillbirth, congenital infection, and maternal death are some of the effects of malaria during pregnancy. around 19% of infant lbws are caused by malaria in malaria-endemic areas, and 6% of infant deaths are caused by lbws caused by malaria. a lower mean hemoglobin level is associated with malaria among pregnant women (ouédraogo et al., 2013). in 2019, the world health organization found that malaria was endemic in 31 low-income countries. women with malaria and other associated infections later in pregnancy are at an increased risk of low birth weight (accrombessi et al., 2019). statistically significant associations are found between asymptomatic malaria in pregnant women and their hemoglobin levels (feleke et al., 2020). around 100,000 infants die every year in sub-saharan africa due to malaria-related lbw (guyatt & snow,2004). at first antenatal booking, anemia is significantly associated with malaria parasitemia. the adverse birth outcomes in the united republic of tanzania-impacts and prevention of maternal risk factors showed that low birth weight and intrauterine fetal retardation are caused by malaria (watson-jones et al., 2007). who recommends a combination of insecticide-treated nets (itns) and either intermittent preventive treatment in pregnancy (iptp) with sulfadoxine-pyrimethamine for pregnant women. despite relatively high rates of antenatal clinic attendance, coverage of intermittent preventive treatment and use of insecticide-treated nets by expectant women still falls far short of international targets.this is true even though coverage has increased in the majority of countries. to determine whether the implementation of who’s 2012 policy update for intermittent preventive treatment—which seeks to streamline the message and align preventive treatment with the focused antenatal care schedule—leads to improvements in coverage— should be evaluated, van eigk et al. (2013) recommend. parasite resistance threatens the efficacy of iptp with sulfadoxine-pyrimethamine in sub-saharan africa. improved knowledge and education of women of childbearing age have a significant impact on malaria control during pregnancy (iriemenam et al., 2011). the use of insecticide-treated mosquito nets during pregnancy reduced the risk of malaria infection (fana et al., 2015; apinjoh et al., 2015). pa ge 12 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 literature review malaria situation in liberia the liberian health system remains one of the most fragile in the world. ebola outbreaks in 2014-2016 and the recent covid-19 pandemic are key factors driving the disruption of the health system in liberia (tarrattia et al., 2018). despite the adoption of who recommendations on anc for a positive pregnancy experience in 2016, malaria infection during pregnancy has become so alarming in liberia. increasingly, pregnant women in liberia are exposed to malaria, exposing liberia’s health system’s weakness. malaria, which is primarily a major public health problem of pregnant women, is preventable, treatable, and curable, in liberia. children and expectant mothers are especially vulnerable to malaria. to lessen the negative effects of malaria on a pregnant woman’s health, the who advises using a three-pronged strategy: rapid diagnosis and treatment of infections that have been confirmed, use of longlasting insecticidal nets (llins), and iptp (who 2004). pregnant women who are receiving routine prenatal care are given intermittent prevention of malaria in pregnancy (iptp), an antimalarial medication. iptp can help prevent cases of malaria, anemia, placental parasitemia, low birth weight, and neonatal mortality. the percentage of women receiving one or more iptp doses has increased from 58% in 2009 to 90% in 2019–20, and the percentage of women receiving two or more doses has increased from 47% to 70%. in the period between 2011 and 2019, 40% of women received three or more iptp doses (ldhs 2019). plasmodium falciparum infections are anticipated to affect at least one in every eight women receiving their first antenatal care at private clinics in monrovia outside of the wettest months, despite all the efforts the government is making to reduce the prevalence of malaria. young primigravidae have a higher risk of contracting p. falciparum, claim martnez-pérez et al. (2018). use of mobile phones in liberia’s health system the most popular form of communication in liberia now is through mobile phones. even though the country’s gsms have increased their investment, the liberia health system has not yet integrated mobile phones into the delivery of healthcare services. a report from digital liberia 2021 states that there were 3.39 million mobile connections overall, with many people having multiple connections, up 19,000, or 0.6 percent, between january 2020 and january 2021. in the mobile sector, competition led to some of the lowest call prices in the country. internet penetration was 14.9 percent in january 2021, equating to 761,000 internet users in the country. the number of internet users increased by 132,000, or 22 percent, between january 2020 and january 2021. about 84% of urban households and 50% of rural households own mobile phones (ldhs 2019-2020). use of insecticide treated nets (itns) by pregnant women in liberia during the night before the conduct of the national demographic and health survey in liberia (20192020), 47% of pregnant women aged 15-49 slept under a mosquito net, while 78% of pregnant women in households with at least one mosquito net slept under a mosquito net. in 2019, 47% of pregnant women used itns, up from 33% in 2009. the proportion of pregnant women aged 15-49 who slept under an itn the night before the survey is markedly lower in greater monrovia (34%) than in other urban areas (57%) and rural areas (48%) (table 12.8). intermittent preventive treatment of malaria in pregnancy in (iptp) pregnant women who want to prevent malaria are given an entire therapeutic course of antimalarial medication during routine prenatal care visits. this method is known as an intermittent preventive treatment of malaria in pregnancy (iptp). iptp aids in reducing the risk of neonatal mortality, low birth weight, maternal and fetal anemia, placental parasitemia, and episodes of malaria in pregnant women. in liberia, sulfadoxine-pyrimethamine (sp), also known as fansidar is the drug of choice for iptp). women who received one or more iptp doses increased from 58% in 2009 to 90% in 2019–20, while those who received two or more doses rose from 47% to 70%. the proportion of females receiving three or more iptp doses rose from 11% to 40% during the same time frame (ldhs 2019-2020). benefits of mobile phone technology in antenatal care in africa, mobile phones are increasingly crucial for strengthening healthcare systems (howitt 2012). according to jareethum and others (2008), there is a higher satisfaction level of pregnant women who receive sms via mobile phone during their antenatal service compared to the general antenatal care group. a more satisfactory level of patient satisfaction can be achieved when antenatal care consultations are improved to meet the desired needs of pregnant women in developing countries (alhaqbani & bawazir, 2022). mobile phone tele-reminder likely increased counseling about ifas, resulting in a higher level of adherence to ifa supplementation among pregnant women who participated in the intervention (demis, geda, alemayehu, & abebe, 2019. a significant association exists between frequencies of antenatal care (anc) visits to the level of knowledge and the level of practice of mothers about preventing anemia in pregnancy (ghimire & pandey, 2013). in nigeria, mobile phones also contribute to health promotion, prevention, and early identification of diseases, reducing maternal and child mortality (odetola & okanlawon, 2016). using mobile phone applications in clinical settings increases the number of antenatal care visits and improves the quality of anc services (lund et al., 2014). a study carried out in bangladesh to outline the association and the use of mobile phones and essential maternal health care services showed pregnant women who utilized mobile phones utilized antenatal care services and professional delivery pa ge 12 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 services more than those who did not (tang et al., 2019). additionally, with the use of mobile phone technology in healthcare settings, women felt more confident seeking medical care during pregnancy and childbirth and recognizing signs of illness in their newborns (entsieh, emmelin, & pettersson, 2015). using a mobile phone application, odetola & okanlawon (2016) evaluated the effects of a nursing intervention on the uptake of antenatal care, tetanus toxoids, and malaria prevention among pregnant women in nigeria. mobile phone use by nurses during anc was associated with increased attendance at antenatal clinics and ipt uptake. women who received the sms every week were more likely to attend eight anc visits than those who did not (osanyin et al., 2022). women who utilized mobile phones were more likely to use iron tablets and attend anc in a randomized controlled trial conducted by bangal et al. (2017). despite not increasing the proportion of women receiving three doses of iptp-sp, mobile phone intervention did increase the proportion of timely anc visits (ouédraogo et al., 2022). using mobile phones to send short message services on focused antenatal care (fanc) positively affects the uptake of attentive antenatal care among pregnant women in middle and low-income countries (wagnew et al., 2018). compared with the general antenatal care group, there is a higher satisfaction level of pregnant women who receive sms via mobile phone during their antenatal service. higher confidence and lower anxiety levels are seen in pregnant women who get sms via mobile phone during the antenatal period (jareethum et al., 2008). methodology study design in two major referral hospitals, we conducted a threemonth cluster randomized controlled trial with two arms. phebe and charles b. dunbar hospitals, bong county, republic of liberia, were the study sites between may 2022 and august 2022. units of randomization were antenatal care screening rooms with midwives assigned to care for pregnant women. group participants are randomly assigned to each treatment arm in a cluster randomized control trial rather than individuals. there were three anc screening rooms in each hospital dedicated to pregnant women. trained midwives provide all antenatal care in the screening rooms. this study considered each screen room as a cluster. there were two intervention groups in these two arms trials (control and experimental). as there was a possibility that pregnant women receiving antenatal care at phebe hospital might be close relatives of pregnant women receiving antenatal care at charles b. dunbar hospital, we decided to conduct a cluster randomized controlled trial. there was a risk of contamination within and between clusters due to this relatedness. the cluster randomized control trial minimizes the risk of contamination. the administration of the phebe hospital provided ethical clearance for the study. clustering and randomization the randomization units were antenatal care screening rooms with licensed midwives. in cluster randomized controlled trials, the groups are randomized rather than the individual participants. in each of these hospitals, three screening rooms were dedicated solely to providing anc to pregnant women. each screening room was considered a cluster by the researcher in this study. there were three clusters at phebe hospital, referred to as 1, 2, and 3, while there were three clusters at charles b. dunbar hospital, referred to as 4, 5, and 6. a team of midwives administered anc to six clusters of pregnant women receiving anc for the first time. in clinical research, randomization refers to assigning study participants to either a treatment or control group solely by chance (figure 1). the six screening rooms (six clusters) were randomized into an intervention (clusters 1,4, & 6) and a control group (clusters 2,3, & 5). figure 1: operationalization of the study pa ge 12 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 setting phebe and charles b. dunbar hospitals were the research areas. the two hospitals which are situated in bong county are key referral hospitals in liberia. bong county is a centrally located county with diverse ethnic groups. in 1964, bong county was established. dominant among the 12 ethnic groups in the county, is the kpelleh-speaking people. among the 15 counties in liberia, bong county ranks third in terms of area and population. lofa and gbarpolu counties border it on the north, margibi and montserrado counties on the west, grand bassa county on the south, and nimba county on the east. in addition to rice production, the county is one of liberia’s food baskets. cocoa, coffee, rubber, and palms are also grown in the county. approximately 450,000 rural liberians receive quality healthcare at phebe hospital. lutheran church in liberia helped establish the hospital in 1921. the liberian government founds the hospital. participants pregnant women availing antenatal care for the time in their current pregnancy were the participants in this study. pregnant women who have had prior antenatal care at clinics, hospitals, or health centers, were not allowed to take part in this study. for this study, phebe and charles b. dunbar hospitals were selected because of their high attendance at antenatal care, equipped medical and laboratory facilities, access to more than two screening rooms for pregnant women, and patient diversity. sample size calculation the sample population consisted of all consenting pregnant women receiving their first anc visit. malaria is one of the leading causes of anemia among pregnant women in liberia. in the demography and health survey report (2019), anemia is more prevalent among pregnant women (52%) compared to breastfeeding women (48%). as a result of this new intervention, malaria prevalence among pregnant women in liberia is expected to be reduced, thereby eradicating anemia among them. controlling malaria infection can reduce anemia prevalence among pregnant women by 25%. in a cluster randomized control trial, similarity among subjects within preexisting groups or clusters minimizes the variability of responses in a cluster sample, making it challenging to detect actual differences between groups. we used the intracluster correlation coefficients (icc) to measure the degree of dependence within each cluster. we also adjusted for individual and cluster-level characteristics, and the adequate sample size was determined using the median icc in primary healthcare research of 0.005 (adams et al., 2004). the researcher’s first step was to calculate the sample size required for individual randomized controlled trials. next, the derived sample size from the individual randomized controlled trial was then adjusted for the design effect (de). in this study, 150 pregnant women who were getting anc for the first time were recruited. the study included 75 participants in each treatment arm. three clusters were present in each treatment arm. a total of 25 participants were randomly assigned to each cluster. admission of participants each hospital had three screening rooms dedicated exclusively to anc services. a pregnant woman seeking anc for the first time was directed to the registration room to obtain a valid hospital card and identification number. in subsequent hospital visits, the patient used the hospital card and identification number to access health care services. hiv/aids counseling follows the registration process, which aims to prevent mother-tochild transmission of hiv/aids. after counseling, the midwives assigned to those rooms took the patient’s card to any of the screening rooms for further processing. a patient received healthcare from the screening room, where her card was transferred. six clusters (screening rooms) were randomized, so three (3) clusters administered standard/ routine interventions during the study period, while the remaining three administered intervention treatment. as mentioned in the selection criteria, the admission criteria were the same for both arms. the control and intervention groups were blinded. certain information that might influence participants was kept from them. during the intervention, midwives were blinded. recruitment of midwives six (6) licensed and trained midwives were hired to administer the intervention. phebe and charles b. dunbar hospitals employed these midwives full-time. in addition to the three midwives recruited from phebe hospital, three additional midwives were recruited from charles b. dunbar hospital. the head midwives of both hospitals recommended and recruited the midwives. among their responsibilities was administering all treatments to participants in both groups. providers of the intervention treatment were guided by the teleconsultation manual designed for this study. three midwives were randomly selected and charged with administering the intervention treatment throughout the study. the remaining three midwives provided the standard/routine treatment to the control group. the researcher provided a one-day training to the three midwives accountable for administering the intervention. midwives in the intervention group were trained to use the tele-reminder manual to deliver an effective treatment. however, all the midwives were blinded. neither the primary nor secondary outcomes variables were disclosed to them. data collection this study used several validated methods to collect accurate and insightful. all stages of this study were supervised by the researcher. for quality assurance, the researcher scrutinized every data report by the midwives. in both hospitals, midwives were hired to administer the interventions. each participant at baseline, followup, and end line was tested for malaria and anemia pa ge 12 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 by trained laboratory technicians designated by the hospitals. a participant with a positive malaria smear was designated as having malaria. the participant with a hemoglobin level of less than 11g/dl was considered as having anemia. those participants who had malaria and anemia at baseline were treated by doctors assigned at the hospitals before they could fully participate in the study. data collection forms were designed to collect all the data. filling out the form was facilitated by the midwives. the data collection form did not mention participants’ names or personal identities, which might raise concerns about stigmatization. as part of the anc satisfaction assessment, participants were asked how they felt about the hospital’s treatment during the past three months. outcomes the primary outcome was malaria prevalence and antenatal care satisfaction level. the secondary outcome variable measured was the prevalence of anemia. treatment in the control group the control group received all routine and standard anc services (table 1). the participants in this group were followed up every month. a similar pattern of routine anc services was followed in every subsequent follow-up. every follow-up included measurements of primary outcome variables (malaria prevalence and anc satisfaction) and the secondary outcome variable (anemia prevalence). table 1: treatment in the interventions and control clusters treatment types control group (routine care) intervention group (routine + new treatment) reference diet intervention -pregnant women were counseled about healthy eating and physical activity during pregnancy. -using visual aid containing the various food groups, pregnant women were counseled on the need to eat food from the different food groups daily to be kept healthy during pregnancy. -diet counseling focused on iron-rich foods (vegetables, fruits, and meat/fish products). -participants were reminded biweekly to consume daily ironand vitamin-rich foods from local markets and backyard gardens. sunuwar et al, (2019). otoo & adam (2016) who recommendations on anc for a positive pregnancy experience (2016) iron and folic acid supplements both hospitals routinely provided daily oral iron and folic acid supplementation to each participant -biweekly tele-reminders reminded participants to take iron and folate supplements. -ifa supplementation was emphasized in all gomes et al. (2021). who recommendations on anc for a positive pregnancy experience (2016) malaria prevention a mosquito net was given to each participant to prevent malaria. in the second trimester of pregnancy, participants received intermittent preventive treatment with sulfadoxine-pyrimethamine (iptp sp). based on hospital practice, dosing was determined a biweekly tele-reminder emphasized the use of mosquito nets and the importance of adhering to iptp-sp guidelines. a message (sms) reminded them to use mosquito nets regularly and take the iptp-sp. ngabo et al. (2012). who recommendations on anc for a positive pregnancy experience (2016) hygiene education participants were instructed to wash their hands with soap and water after using the latrine and touching contaminated surfaces. participants were encouraged to keep their environment clean at all time during follow-up visits, participants received handwashing soaps in addition to tele-reminders. participants were reminded of the importance of washing their hands with soap and water after using the toilet, before cooking, and before eating participants were also reminded biweekly to keep their environment clean sheth et al. (2010). who recommendations on anc for a positive pregnancy experience (2016) prevention of intestinal parasites/ worm participants were treated with preventive anthelmintics according to hospital practice before undergoing their first anc in the second trimester who recommendations on anc for a positive pregnancy experience (2016) pa ge 12 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 treatment in the intervention group each participant in the intervention group received slightly different interventions than those administered to respondents in the control group. a mobile phone telereminder was delivered biweekly through phone calls and sms to participants in the intervention group. during the mobile phone calls, participants were counseled only on food groups with rich sources of iron (table 1). development of antenatal care tele-reminder messages health messages delivered to the study’s participants are referred to in this study as “core antenatal care tele-reminder messages.” there were three phases to the development of these core healthcare reminder messages (table 2). in phase one, the researcher reviewed world health organization guidelines on antenatal care published in 2016. healthcare messages supported by evidence-based practice were selected from the world health organization’s antenatal care guidelines. during phase two of the development of core healthcare reminder messages. the researcher and the six midwives who administered the treatment (intervention and control) reviewed the components of the world health organization antenatal care guidelines incorporated into the local liberian anc guidelines (figure 2). table 2: core health messages sent via sms types of treatment core health messages via sms iron and folate acid supplementation “increase your blood volume by taking one iron tablet a day.” malaria prevention “before you sleep, please hang the mosquito net over you.” adherence to the anc visit schedule “come to the hospital at the end of the month for treatment.” hygiene practices “to prevent sickness, wash your hands frequently after using the toilet, before eating, and before cooking”. always keep your surrounding clean. phase two was intended to prevent giving health messages to the participants that the ministry of health of liberia did not approve. in phase three, the six midwives pretested the critical health messages among ten mothers (pregnant women) who were not part of the study but received anc services at phebe hospital. data quality control cell-dyn emerald 22, an automated hematology analyzer designed for low-volume clinical settings, was used for hemoglobin testing. a blood smear was conducted for malaria on all participants following all standard procedures followed by trained laboratory technicians at both hospitals. licensed laboratory technicians collected blood samples for hematological (malaria smear) analysis. to ensure data quality control, a regular supervision visit was conducted to ensure that standard operating procedures were followed during blood sample collection. blood specimens were transported in proper containers under the supervision and taken at the recommended time to the analyzer. test materials were observed to avoid negative impacts on test results and to ensure they were properly stored and cleaned. for quality assurance purposes, laboratory technicians were treated blinded. all laboratory results were immediately entered into the laboratory request form of the participants. data analysis method the primary outcome variables were malaria prevalence and anc satisfaction. participants with positive malaria smears were considered as having malaria infection. the chi-square test of independence (for categorical data) was used to assess the treatment effects on the outcome variables. a logistic regression analysis based on longitudinal data was used to determine the treatment effects on malaria infection and the level of antenatal care satisfaction. as facilities rather than individual pregnant women were randomized, a generalized estimating equation was used to account for within-cluster correlation coefficients. results age and pregnancy profile of participants participants range in age from 23 to 24 years old. there was no statistically significant difference between the ages of participants in the intervention group and the control group. most participants were in their first trimester of pregnancy (table 3). table 3: age and pregnancy profile of participants at baseline variables intervention group n = 75 control group n = 75 independent sample t-test p-valuemean ±sd mean ±sd age of participants 24.57 ± 6.280 23.45 ± 6.803 0.297 age in months of pregnancy 3.15 ± 1.245 3.27 ± 1.044 0.513 total pregnancy 2.11 ± 1.640 1.89 ± 1.956 0.470 total living children 1.23 ± 1.341 1.16 ± 1.525 0.777 age in the month of the last child 26.17 ± 28.974 20.75 ± 26.568 0.234 pa ge 12 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 participants have varying educational backgrounds. there were, however, a significant number of them who had at least a primary education. according to statistics (table 4), there is no statistical difference between the groups regarding their educational attainment. the study also showed that more than half of the participants were cohabiting couples. comparing the use of insecticide-treated net and intermittent preventive treatment (iptp) at baseline and end line in both groups, participants were asked if they took intermittent preventive treatment (iptp). in terms of iptp use before the study, there was no significant association between the two groups (p = 0.267). in table 5, the fisher’s exact test after the intervention showed no difference between the intervention group and the control group in terms of iptp adherence (p = 0.221). at baseline, participants were also asked if they had used insecticide-treated nets the night before the study. there was no significant difference between the intervention and control groups regarding insecticide-treated net use the night before the study (p = 0.095). as a result of the intervention, there was a significant difference in iptp usage between the intervention and treatment groups (p = 0.034). table 4: educational level and marital status, baseline variables and category intervention group n = 75 control group n =75 fisher’s exact test p-valuen % n % highest education attainment primary education 54 72 53 70 0.500 secondary education 21 28 22 29 marital status cohabiting 51 68 54 72 0.361 not married 24 32 21 28 table 5: intermittent preventive treatment (iptp) comparison at baseline and end line used mosquito net in the past one night intervention group n = 75 control group n = 75 fisher’s exact test p-value binary logistic regression n (%) n (%) odds ratio (95% ci) baseline 30 (40) 39 (52) 0.095 1.3 (0.46-3.76) endline 68(91) 59 (79) 0.034 intake of ipt baseline 7(9) 4 (5) 0.267 2.6 (0.49-13.88) endline 73 (97) 70 (93) 0.221 comparing malaria prevalence at baseline and after treatment in both intervention and control groups, the prevalence of malaria infection was high at baseline (table 6); however, no significant difference was observed between the intervention and control groups. (43% vs. 45%; p = 0.869). as a result of treatment, the prevalence of malaria among pregnant women in the intervention group was lower than that among those in the control group (5% vs. 15%). however, the intervention group did not differ significantly from the control group (p = 0.050). table 6: comparing malaria prevalence at baseline and after treatment malaria prevalence intervention group n = 75 control group n = 75 fisher’s exact test p-value n (%) n (%) baseline 32 (43) 34 (45) 0.869 endline 4 (5) 11 (15) 0.050 mcnemar test p value 0.000 0.000 unadjusted or* (95%ci) 0.32 (0.09-1.08) binary logistic regression treatment effect on antenatal care satisfaction when adjusted for the age and education level of participants, most of the participants (95%) were very satisfied with anc services in the intervention group and 86% in the control group (table 7). between pregnant women in the intervention group and those in the control group, the odds of being very satisfied with anc services were significantly different (aor, 4.01; 95%ci, 1.72-9.53). the study showed a significant difference between the intervention and control groups in terms of not wanting to quit antenatal care (adjusted odds ratio “aor,” 2.17; 95%ci, 1.09-4.32). pregnant women’s satisfaction is a reflection of the patient’s judgment of different domains of health care, including technical, pa ge 12 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 table 7: treatment effect on antenatal care satisfaction indicators intervention groups n (75) control group n = 75 unadjusted or*(95% ci) adjusted or** (95% ci) logistic regression p-valuen (%) n (%) very satisfied 71(95) 64(86) 5.98 (4.15-8.61) 4.06 (1.72-9.53) 0.001 had no desire to quit anc 69 (92) 58 (78) 3.51 (2.49-4.96) 2.17 (1.09-4.32) 0.027 interpersonal, and organizational aspects. satisfaction with varying elements of received antenatal care improves health outcomes, continuity of care, treatment adherence, and the relationship with the provider. effect of treatment on anemia prevalence the prevalence of anemia was a significant difference between pregnant women in the intervention and control groups (4% vs. 13%; p = <0.039). the result also showed that pregnant women assigned to the intervention group had a significantly greater mean hemoglobin level after the two interventions, t (2.4) = 445, p<0.013; d = 0.23. the effect size of the analysis (d = 0.23) was found to be small (table 8). these results indicate that pregnant women in the intervention group (m = 12.8, sd = 0.71) experienced a small increase in hemoglobin levels than did pregnant women in the control group (m =11.7, sd = 0.63). table 8: impact of treatment on anemia prevalence hemoglobin level in g/dl intervention group control group independent sample t-test p-value(mean ± ds) (mean ± ds) baseline 10.9 ± 0.94 10.8 ± 0.92 0.108 endline 12.8 ± 0.71 11.7 ± 0.65 0.013 paired t-test (p-value) 0.047 0.000 cohen’s d test: 0.23 anemia prevalence intervention group n (%) controlgroup n (%) fisher’s exact test (p-value) baseline 36 (48) 39 (52) 0.37 endline 3 (4) 10 (13) 0.039 mcnemar test p value 0.000 0.000 odds ratio (binary logistic regression): 3.7 (0.9714.00) anemia prevalence among participants with malaria and history of past illnesses based on table 9, 56% of intervention participants and 38% of control participants with malaria at baseline had anemia. participants were asked at baseline whether they had experienced any illness in the past month. as a result, 25% of participants in the intervention group and 19% of participants in the control group who experienced illness in the past month had anemia at baseline. table 9: anemia prevalence among participants with malaria and history of past illnesses at baseline treatment groups participants with malaria & anemia at baseline n = 66 participants with a history of past illnesses with anemia at baseline n = 51 n (%) n (%) intervention group 18 (56) 6 (25) control group 13 (38) 5 (19) fisher’s exact test p-value 0.217 0.412 discussion there is no doubt that malaria during pregnancy can have devastating effects on mothers and their babies, and it is a leading cause of maternal and infant mortality. pregnancy is most affected by malaria in sub-saharan africa, of which liberia is a member. preventive strategies for malaria in pregnancy in liberia include intermittent preventive treatment (iptp) with three or more doses of sulphadoxine-pyrimethamine (sp), using long-lasting insecticide-treated nets, and managing clinical malaria and anemia effectively. pregnant women receive information about malaria causes and prevention during antenatal care visits. however, preventive measures may be overlooked if these educative messages are not consistently reinforced. there was a lower malaria prevalence in the intervention group than in the control group. however, the study found that pregnant women who received the mobile phone tele-reminder did not significantly differ in their odds of not contracting malaria compared to pregnant women who did not receive the intervention. however, despite this, the use of mobile phone tele-reminder as part of antenatal care was of great assistance in educating pa ge 13 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 pregnant women regarding the need for insecticidetreated nets and the causes of malaria infection. by using the mobile phone tele-reminder, midwives may be able to create a balance between myths and realities about malaria infection during pregnancy (entsieh et al., 2015). in developing countries, such as liberia, some of the challenges associated with accessing malaria information among pregnant women may be overcome by midwives by using their mobile phones to reinforce antenatal care counseling (mbunge et al., 2011). these findings agree with odetola and okanlawon (2016) findings, who found that pregnant women were more likely to receive intermittent preventive treatment (ipt) when nurses used mobile phones to deliver anc. in a study by lund et al. (2014), pregnant women who received the intervention had significantly higher levels of satisfaction with their antenatal care than those who did not. to reinforce the counseling messages given to participants at the hospital, midwives used sms reminders and phone calls. as a result of such an integrated intervention approach, pregnant women seem motivated to seek antenatal care to give birth to a healthy baby. there is a possibility that midwives may be able to contribute to adherence to antenatal care in low-income countries if they deliver services using mobile phones. despite still enjoying the comfort of home and family, pregnant women find that receiving healthcare through mobile phone technology is more encouraging and exciting than receiving healthcare in person. according to this study, pregnant women are more likely to seek care timely, suggesting that they are satisfied and anxiety free with the care they receive with the help of the mobile phone application (jareethum et al., 2008). a more satisfactory level of patient satisfaction can be achieved when antenatal care consultations are improved to meet the desired needs of pregnant women in developing countries (alhaqbani & bawazir, 2022). acknowledgement my first and foremost thanks go to the members of my guidance committee, dr. leila s. africa (chair), dr. corazon v.c. barba (co-chair), dr. angelina r. bustos (member), and dr. mark donda arboleda (member) for their support and guidance. last but not least, i would like to express my gratitude to my family for their unconditional love and support. abbreviation anc: antenatal care, g/dl: gram per deciliter hiv: human immune virus ifa: iron & folic acid sms: short message services who: world health organization reference accrombessi, m., yovo, e., fievet, n., cottrell, g., agbota, g., gartner, a., ... & briand, v. (2019). effects of malaria in the first trimester of pregnancy on poor maternal and birth outcomes in benin. clinical infectious diseases, 69(8), 1385-1393. adams, g., gulliford, m. c., ukoumunne, o. c., eldridge, s., chinn, s., & campbell, m. j. (2004). patterns of intra-cluster correlation from primary care research to inform study design and analysis. journal of clinical epidemiology, 57(8), 785-794. alhaqbani, s. m., & bawazir, a. a. (2022, january). assessment of pregnant women’s satisfaction with model of care initiative: antenatal care service at primary health care in cluster one in riyadh, saudi arabia. in healthcare, 10(1), 151. bangal, v. b., borawake, s. k., gavhane, s. p., & aher, k. h. (2017). mobile phone use for improvement in maternal health: a randomized control trial. international journal of reproduction, contraception, obstetrics and gynecology, 6(12), 5458-5464. demis, a., geda, b., alemayehu, t., & abebe, h. (2019). iron and folic acid supplementation adherence among pregnant women attending antenatal care in north wollo zone northern ethiopia: institution based cross-sectional study. bmc research notes, 12(1), 1-7. entsieh, a. a., emmelin, m., & pettersson, k. o. (2015). learning the abcs of pregnancy and newborn care through mobile technology. global health action, 8(1), 29340. fana, s. a., bunza, m. d. a., anka, s. a., imam, a. u., & nataala, s. u. (2015). prevalence and risk factors associated with malaria infection among pregnant women in a semi-urban community of north-western nigeria. infectious diseases of poverty, 4(1), 1-5. feleke, d. g., adamu, a., gebreweld, a., tesfaye, m., demisiss, w., & molla, g. (2020). asymptomatic malaria infection among pregnant women attending antenatal care in malaria-endemic areas of northshoa, ethiopia: a cross-sectional study. malaria journal, 19(1), 1-6. ghimire, n., & pandey, n. (2013). knowledge and practice of mothers regarding preventing anemia during pregnancy in a teaching hospital, kathmandu. journal of chitwan medical college, 3(3), 14-17. guyatt, h. l., & snow, r. w. (2004). impact of malaria during pregnancy on low birth weight in sub-saharan africa. clinical microbiology reviews, 17(4), 760-769. howitt, p., darzi, a., yang, g. z., ashrafian, h., atun, r., barlow, j., ... & wilson, e. (2012). technologies for global health. the lancet, 380(9840), 507-535. lagerberg, r. e. (2008). malaria in pregnancy: a literature review. journal of midwifery & women’s health, 53(3), 209-215. iriemenam, n. c., dosunmu, a. o., oyibo, w. a., & fagbenro-beyioku, a. f. (2011). knowledge, attitude, perception of malaria and evaluation of malaria parasitemia among pregnant women attending antenatal care clinic in metropolitan lagos, nigeria. journal of vector-borne diseases, 48(1), 12. liberia demography and health survey (2019). liberia pa ge 13 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 122-131, 2023 institute of statistic and geo-information services (lisgis). lund, s., nielsen, b. b., hemed, m., boas, i. m., said, a., said, k., ... & rasch, v. (2014). mobile phones improve antenatal care attendance in zanzibar: a cluster randomized controlled trial. bmc pregnancy and childbirth, 14(1), 1-10. martínez-pérez, g., lansana, d. p., omeonga, s., gupta, h., breeze-barry, b., gonzález, r., ... & mayor, a. (2018). prevalence of plasmodium falciparum infection among pregnant women at first antenatal visit in post-ebola monrovia, liberia. malaria journal, 17, 1-10. odetola, t. d., & okinawan, f. a. (2016). effects of a nursing intervention using a mobile phone application on uptake of antenatal care, tetanus toxoids and malaria prevention among pregnant women in nigeria. j int soc telemed ehealth, 4, e13. osanyin, g. e., bankethomas, a., oluwole, e. o., odeseye, a. k., & afolabi, b. b. (2022). effects of a mhealth voice messaging intervention on antenatal care utilization at primary care level in lagos, nigeria: a cluster randomized trial. journal of public health in africa, 13(3). ouédraogo, s., accrombessi, m., ouattara, a., massougbodji, a., dabira, e. d., sarigda, m., ... & sondo, b. (2022). impact of mobile phone intervention on intermittent preventive treatment of malaria during pregnancy in burkina faso: a pragmatic randomized trial. revue d’épidémiologie et de santé publique. tang, s., ghose, b., hoque, m. r., hao, g., & yaya, s. (2019). women using mobile phones for health communication are more likely to use prenatal and postnatal services in bangladesh: a cross-sectional study. jmir mhealth and uhealth, 7(2), e10645. tarr-attia, c. k., bassat, q., breeze-barry, b., lansana, d. p., meyer garcía-sípido, a., sarukhan, a., ... & martínez-pérez, g. (2018). community-informed research on malaria in pregnancy in monrovia, liberia: a grounded theory study. malaria journal, 17(1), 1-13. van eijk, a. m., hill, j., larsen, d. a., webster, j., steketee, r. w., eisele, t. p., & ter kuile, f. o. (2013). coverage of intermittent preventive treatment and insecticide-treated nets for the control of malaria during pregnancy in sub-saharan africa: a synthesis and meta-analysis of national survey data, 2009–11. the lancet infectious diseases, 13(12), 1029-1042. wagnew, f., dessie, g., alebel, a., mulugeta, h., belay, y. a., & abajobir, a. a. (2018). does short message service improve focused antenatal care visits and skilled birth attendance? a systematic review and meta-analysis of randomized clinical trials. reproductive health, 15(1), 1-10. watson-jones, d., weiss, h. a., changalucha, j. m., todd, j., gumodoka, b., bulmer, j., ... & mabey, d. (2007). adverse birth outcomes in the united republic of tanzania: impact and prevention of maternal risk factors. bulletin of the world health organization, 85, 9-18. pa ge 1 pa ge 36 american journal of medical science and innovation (ajmsi) the incidence of head and neck cancer in east sudan mona mahmoud abasher1*, amal abdelhakam sidahmed1, asjad abdelmoniem1, hyffa osman mohamed ahmed1 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1746 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: may 20, 2023 accepted: july 08, 2023 published: july 28, 2023 this review aims to provide an updated and detailed overview of the incidence of head and neck cancer in the eastern region of sudan, focusing on studies conducted between 2018 and 2023. it aims to shed light on changes in incidence rates, emerging risk factors, advancements in diagnostic techniques, treatment modalities, and preventive strategies. accurate knowledge of the latest trends and developments in head and neck cancer incidence is essential for effective public health planning and intervention. one significant aspect that the review highlights is the limited number of head and neck surgeons in east sudan. it emphasizes the need for specialized training in staging malignancies using head and neck anatomy, as this information is vital for determining appropriate treatment approaches. with a shortage of trained professionals, it becomes even more critical to enhance the anatomic understanding and staging capabilities in order to improve patient outcomes and optimize treatment plans. the review underscores the urgency of addressing this gap in healthcare infrastructure. by increasing the number of head and neck surgeons in east sudan and providing them with the necessary training, the region can improve its capacity to accurately stage head and neck cancers, leading to more effective treatment decisions and improved patient care. this review provides a comprehensive resource for understanding the current landscape of head and neck cancer incidence in the eastern region of sudan. it addresses recent trends, emerging risk factors, and the need for improved anatomic understanding and staging capabilities. the findings can guide policymakers, healthcare providers, and researchers in implementing targeted strategies to reduce the burden of head and neck cancer in east sudan and improve patient outcomes. keywords head and neck cancer, east of sudan, incidence, risk factors, diagnosis, treatment, prevention 1 port sudan oncology centre p.o.c, sudan * corresponding author’s e-mail: monaabasherahmed@gmail.com introduction the sixth most prevalent type of cancer worldwide is head and neck squamous cell carcinoma (hnscc) (johnson et al., 2020). hnc was the second most prevalent malignancy recorded in men, after cancer of the prostate, and in women, behind cancers of the breast, cervix uteri, eye, and oesophagus, between 2018 and 2023, according to the nairobi cancer registry (joko‐fru et al., 2020). cancerrelated morbidity and mortality are prevalent in sudan east and are rising quickly. while the number of yearly fatalities in the area from hiv, tb, and malaria is progressively dropping, the number of deaths from cancer is expected to rise by 85% between 2008 and 2030 (ibrahim et al., 2021). these forecasts are primarily based on predicted population increase and aging and assume static age-specific incidence rates. however, population-based cancer registries show rising cancer incidence, perhaps due to hiv and the westernisation of lifestyles (msyamboza et al., 2012). traditional hnscc risk factors include drinking alcohol, smoking, and using tobacco products for chewing; ethnicity, genetic background, regional origin, and dietary condition are other risk factors. human papillomavirus (hpv) infection is a newly identified risk factor for hnscc, defining a new subtype of tumour distinct from hpv-negative tumours (sabatini & chiocca, 2020). the international agency for research on cancer has identified hpv as an hnscc carcinogen (papillomaviruses, 2011). in the upper aerodigestive tract, which includes the mouth (oral cavity), lip, paranasal sinuses, nasal cavity, larynx, and pharynx, a variety of primary cancers arise. these are collectively called head and neck cancers (pai & westra, 2009). hnc is the sixth most prevalent cancer globally, with around 600,000 new cases each year with unacceptable fatality rates, particularly in underdeveloped nations, approaching 300,000 deaths annually (jou & hess, 2017). head and neck squamous cell carcinoma (hnscc), a subtype of hnc that develops from the mucosal lining epithelium of the upper aerodigestive tract, accounts for more than 90% of all cases of hnc (chaturvedi et al., 2013). this means that estimates of the future cancer burden in the area may be greatly exaggerated. in high-income nations, cancer survivorship has increased thanks to earlier cancer detection through screening, more knowledge of the biology and aetiology of tumours, better treatments, and supportive care. the larynx, other pharynx, nasopharynx, oral cavity, and lip sites comprise the sixth most prevalent malignancy (wright, 2023). based on the intricate anatomy and physiology of the head and neck area, upper aerodigestive tract malignancies are staged by site and subsite per the american joint commission on cancer (ajcc) staging manual (allen et al., 2017). the ajcc has identified the aerodigestive anatomic locations of the larynx, hypopharynx, oral cavity, nasopharynx, and sinonasal. squamous cell carcinoma is the most prevalent histology across all head and neck sites (giannis et al., 2021). pa ge 37 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 36-43, 2023 the head and neck are depicted. the mucosal surface of the lips, the front two-thirds of the tongue, the buccal mucosa, the retromolar trigone, and the hard palate are all parts of the oral cavity. the soft palate, palatine tonsils, and tongue base are all located in the oropharynx, directly behind the oral cavity. the nasal cavity, clivus, soft palate, and sphenoid surround the superiorly situated nasopharynx. the supraglottis, glottis, and subglottis are parts of the larynx. the piriform sinus, postcricoid gap, and posterior pharyngeal wall are the subsites of the hypopharynx, located immediately posterior to the larynx. the paranasal sinuses and nasal cavities are additional head and neck locations. literature review particularly in sudan’s east, head and neck cancer is a frequent and alarming problem. an updated and thorough grasp of the incidence, risk factors, diagnostic procedures, treatment modalities, and preventive measures particular to this area is what this literature review tries to deliver. this evaluation addresses significant deficiencies in the healthcare infrastructure while also shedding light on current trends and changes by emphasising investigations carried out between 2018 and 2023. the few head and neck surgeons in east sudan is a key issue that is mentioned in this review. the essential need for specialised training in staging malignancies utilising head and neck anatomy is highlighted by the dearth of qualified experts. accurate treatment strategies can be chosen, ultimately improving patient outcomes, by improving anatomical understanding and staging capabilities. to meet the increasing demands of head and neck cancer management, it is critical to address this gap in the healthcare infrastructure. examining new risk factors is crucial for understanding the state of head and neck cancer in east sudan. infection with the human papillomavirus (hpv) and immunosuppression have both been noted as significant risk factors for the development of head and neck cancer in recent research. these discoveries deepen our comprehension of the local aetiology of the disease and call for specialised preventive measures. modernizations in diagnostic methods and therapeutic approaches are essential for efficient management. this study emphasises the advancements made in fields including laboratory research, imaging modalities (ct, mri), and biopsies. early detection, appropriate staging, and individualised treatment planning have all improved thanks to these developments. east sudan’s healthcare personnel can improve patient care by utilising these diagnostic tools. head and neck cancer prevention and early detection are crucial in reducing the burden. east sudan has implemented public health interventions, tobacco control programs, hpv vaccination, and awareness campaigns to educate the population, promote healthy behaviors, and encourage regular screenings. evaluating these strategies and addressing region-specific challenges is vital for tailored prevention and management approaches. understanding regional challenges, such as limited resources, infrastructure, cultural considerations, and socioeconomic disparities, is essential for designing effective strategies. this review can guide future research, prevention programs, and treatment approaches, ultimately leading to improved outcomes and reduced incidence of head and neck cancer in east sudan. immunosuppression immunosuppressed people are more likely to acquire mouth cancer. patients with human immunodeficiency virus (hiv) are prone to kaposi’s sarcoma and lymphomas but not to oscc. lip tumours have been linked to immunosuppressed organ transplant patients, and the possible cause was suggested to be greater exposure to solar radiation and other risk factors, including smoking (ritchie & singanayagam, 2020). the investigations did not, however, provide evidence linking immunosuppression directly to the emergence of lip cancer (van leeuwen et al., 2009). risk factors identifying risk factors is crucial for understanding the aetiology of head and neck cancer and developing targeted preventive strategies. this section reviews the recent literature on risk factors associated with head and neck cancer in the east of sudan (almarzooqi et al., 2023), including tobacco and alcohol use, betel quid chewing, hpv infection, dietary habits, and genetic predisposition (mosalleum, 2014). the emphasis is on the evolving understanding of these risk factors and their impact on the local population. the most frequent risk factors for people with head and neck squamous cell carcinoma (hnscc) historically have been cigarette and alcohol use (zhou et al., 2020). about 80% of hnscc patients were associated with an elevated risk due to cigarette smoking or alcohol consumption, which is common in those with a lengthy figure 1: shows the flow of head and neck cancer in the human body pa ge 38 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 36-43, 2023 history of both behaviours (cherry et al., 2018). the primary cause of many types of cancer, including hnscc, has been identified as the carcinogenic influence of tobacco use. all tobacco products, including water pipes and electronic cigarettes, have negative, long-term impacts on health, especially in the head and neck region (saunders et al., 2022). histological types and distribution head and neck cancers encompass various histological types with distinct characteristics and treatment implications (chiesa-estomba et al., 2021). this section provides an updated overview of the histological types and their distribution in the east of sudan. the focus is on the prevalence of specific subtypes and any changes observed during the review period (bhattacharjee et al., 2006). histological types head and neck cancers refer to a group of cancers that can occur in various regions of the head and neck, including the oral cavity, pharynx, larynx, and others (doobaree et al., 2009). these cancers are classified based on their histological types, which means the specific cell types and tissue characteristics involved in the cancer formation. histological types help determine the behaviour of the cancer, its response to treatment, and prognosis (da cruz perez et al., 2006). distinct characteristics and treatment implications each histological type of head and neck cancer has distinct characteristics, such as the cell type involved, the pattern of growth, and the molecular features (perri et al., 2020). these characteristics can influence the behaviour of the cancer and its response to different treatment modalities, such as surgery, radiation therapy, or chemotherapy. therefore, understanding the histological types is important for tailoring each patient’s most appropriate treatment approach (de carvalho et al., 2012). overview of histological types it provides an updated overview of the histological types in the east of sudan. this suggests that there may have been figure 2: summary of potential risk factors that cause the generation of hnscc previous studies or data that described the distribution of histological types, and this paragraph aims to present a more recent understanding based on new information or research. distinct characteristics and treatment implications the focus is on the prevalence of specific subtypes within the histological types of head and neck cancers. subtypes refer to different variations or subcategories within a broader histological type (gebril et al., 2022). for example, within the category of squamous cell carcinoma (a common histological type of head and neck cancer), there may be subtypes like basaloid squamous cell carcinoma or papillary squamous cell carcinoma. this paragraph aims to provide information about the prevalence of these specific subtypes in the east of sudan (blumberg et al., 2015). changes observed during the review period any changes observed during the review period will be discussed. this indicates that the researchers or authors of the paragraph have conducted a review or analysis of data from a specific period. they likely compared this data to previous studies or data to identify any shifts or alterations in the prevalence or distribution of histological types or specific subtypes of head and neck cancers in the east of sudan. advances in diagnosis rapid and accurate diagnosis is crucial for optimal head and neck cancer management. this section discusses the recent advancements in diagnostic techniques, including biopsy, imaging modalities (ct, mri), and laboratory investigations (grégoire et al., 2015). the focus is on how these advancements have improved early detection, staging, and treatment planning in the east of sudan. rapid and accurate diagnosis: a prompt and accurate diagnosis is crucial for optimal managing head and neck cancer. early detection and accurate diagnosis allow for the timely initiation of appropriate treatment strategies, which can significantly impact patient outcomes (harris et al., 2010). pa ge 39 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 36-43, 2023 advancements in diagnostic techniques recent advancements have been made in head and neck cancer diagnostic techniques. these advancements refer to improvements or innovations in the methods used to diagnose and evaluate the disease. the following techniques are specifically mentioned: biopsy biopsy is a procedure in which a small tissue sample is taken from the affected area and examined under a microscope to determine if cancer is present. recent advancements in biopsy techniques may include minimally invasive procedures or more precise sampling methods to enhance diagnostic accuracy (kong & birkeland, 2021). imaging modalities the paragraph mentions ct (computed tomography) and mri (magnetic resonance imaging) as imaging modalities to diagnose head and neck cancer. these imaging techniques provide detailed images of the affected areas, allowing healthcare professionals to visualise the tumour’s location, size, and extent of spread (liao et al., 2012). advancements in ct and mri technology may include higher-resolution imaging, improved contrast agents, or specialised protocols for specific head and neck cancer types. laboratory investigations laboratory investigations encompass tests performed on blood, saliva, or other samples to detect specific markers or abnormalities associated with head and neck cancer. recent advancements in laboratory investigations may involve the development of new biomarkers or more sensitive and specific testing methods that aid in diagnosing, staging, or monitoring the disease (peter et al., 2013). improved early detection, staging, and treatment planning these advancements in diagnostic techniques have improved early detection, staging, and treatment planning, specifically in the east of sudan. early detection refers to identifying the cancer early when it is more likely to be treated successfully. accurate staging helps determine the extent of the disease and guides treatment decisions. advanced diagnostic techniques enable healthcare professionals in the east of sudan to identify head and neck cancer earlier, accurately stage the disease, and develop personalised treatment plans tailored to each patient’s condition (scott et al., 2008). methodology to indicate the incidence of head and neck cancer in east sudan in different age groups, several recent studies, review articles, prospective studies, cross-sectional studies, and literature reviews, all published and peer-reviewed, were searched and considered. data was gathered from different search engines and databases such as; google scholar, scopus, pubmed, elsevier, cochrane, sage, medline and web of science. numerous studies were selected from 2018-2023, using the keywords “head and neck carcinomas”, “hnscc”, “east of sudan”, “risk factors”, “incidence”, “advancements”, ‘future challenges”, “diagnosis”, “treatment”.’ the full texts of the retrieved articles were made accessible. this article is a review. thus not all information on the incidence of head and neck cancer has been provided are contained in this. we have included observational studies and all significant, pertinent big trials to highlight the overall conclusions. although we tried to incorporate the largest and most pertinent research, it is important to remember that the tiny, hopeful observational studies were likely chosen due to publication bias. discussion treatment modalities effective management of head and neck cancer requires a multidisciplinary approach. this section reviews the recent advancements in treatment modalities, including surgery, radiation therapy, chemotherapy, targeted therapies, and immunotherapy, in the east of sudan. the focus is on new treatment options, outcomes, and challenges in resourcelimited settings (syrigos et al., 2009). multidisciplinary approach effective management of head and neck cancer requires a multidisciplinary approach. this means that various healthcare professionals from different specialities, such as surgeons, radiation oncologists, medical oncologists, and others, collaborate to develop comprehensive treatment plans and provide optimal patient care. recent advancements in treatment modalities: recent advancements have been made in treatment modalities for head and neck cancer in the east of sudan. these advancements refer to new or improved methods of treatment that have emerged in recent times (galbiatti et al., 2013). the following treatment modalities are specifically mentioned: surgery surgery involves the removal of the tumour and nearby affected tissues. advancements in surgical techniques may include minimally invasive procedures, improved reconstructive options, or more precise surgical navigation systems, which can help maximise tumour removal while minimising damage to healthy tissues (mody, 2021). radiation therapy radiation therapy uses high-energy radiation to kill cancer cells or shrink tumours. recent advancements in radiation therapy may include more precise and targeted radiation delivery techniques, such as intensity-modulated radiation therapy (imrt) or stereotactic radiosurgery (srs), (lalla, r. v., brennan, 2019) which can improve treatment outcomes while minimising side effects. chemotherapy chemotherapy involves using drugs to kill cancer cells or pa ge 40 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 36-43, 2023 prevent their growth. advancements in chemotherapy may include the development of new drugs or more targeted chemotherapy regimens that specifically target cancer cells while minimising damage to normal cells. targeted therapies targeted therapies are drugs that specifically target certain molecular or genetic abnormalities in cancer cells. these therapies aim to disrupt specific pathways or proteins that promote cancer growth (alsahafi, e., begg, k., amelio, i., raulf, n., lucarelli, p., sauter, t., & tavassoli, m. (2019). advancements in targeted therapies may include discovering new targets or developing more effective drugs that can inhibit these targets, leading to improved treatment outcomes. immunotherapy immunotherapy is a treatment that harnesses the body’s immune system to fight cancer (gavrielatou, n., doumas, s., economopoulou, 2021). recent advancements in immunotherapy for head and neck cancer may include immune checkpoint inhibitors, therapeutic vaccines, or adoptive cell therapies, which can enhance the immune response against cancer cells and improve treatment outcomes. new treatment options, outcomes, and challenges the paragraph mentions the focus is on new treatment options, treatment outcomes, and challenges in resourcelimited settings (starzyńska et al., 2022). this indicates that the authors or researchers have examined the introduction of novel treatments, the impact of these treatments on patient outcomes, and the specific challenges faced in implementing these advancements in a resource-limited setting like the east of sudan. resource limitations may include factors such as the availability of specialised equipment, financial constraints, or limited access to certain medications (zaryouh et al., 2022). prevention and screening strategies prevention and early detection play a vital role in reducing the burden of head and neck cancer. this section discusses recent efforts and strategies implemented in the east of sudan for prevention and screening, including public health interventions, tobacco control programs, hpv vaccination, and public awareness campaigns. the focus is on the impact of these strategies and any barriers to implementation (hashim et al., 2019). prevention and early detection prevention and early detection are crucial in combating head and neck cancer. prevention strategies aim to reduce the occurrence of cancer by targeting risk factors, while early detection strategies focus on identifying cancer at an early stage when treatment outcomes are generally more favourable (johnson, d. e., burtness, 2020). recent efforts and strategies in the east of sudan, recent initiatives and tactics have been put into practise to detect and prevent head and neck cancer. this shows that deliberate steps or activities have been done to address the disease’s impact in the area. they mention the following tactics: public health interventions public health interventions refer to targeted actions implemented at the population level to promote health and prevent diseases. in the context of head and neck cancer, public health interventions may include educational campaigns, community outreach programs, or health promotion initiatives to raise awareness about risk factors, promote healthy behaviours, and encourage regular screenings (mady, l. j., kubik, m. w., baddour, k., snyderman, c. h., & rowan, n. r. (2020). tobacco control programs tobacco use is a significant risk factor for head and neck cancer. tobacco control programs aim to reduce tobacco consumption through various measures such as awareness campaigns, tobacco taxation, smoking cessation programs, and the implementation of smoke-free policies in public places (mody, m. d., rocco, 2021). these programs can help decrease the incidence of head and neck cancer by reducing tobacco-related exposures. hpv vaccination the human papillomavirus (hpv) is a known risk factor for certain types of head and neck cancer. hpv vaccination programs target the prevention of hpv infection, primarily through vaccination of adolescents (turbeville, h. r., toni, t. a., & allen, c. (2022). hpv vaccination can significantly reduce the risk of developing hpv-related head and neck cancer. implementing hpv vaccination programs in the east of sudan can contribute to prevention efforts. public awareness campaigns public awareness campaigns aim to educate the general population about the signs and symptoms of head and neck cancer, the importance of early detection, and the availability of screening services. these campaigns raise awareness, improve knowledge, and encourage individuals to seek timely medical evaluation, potentially leading to early diagnosis and treatment. impact of strategies and barriers to implementation the paragraph mentions that the focus is on the impact of these strategies and any barriers to implementation. this indicates that the authors or researchers have evaluated the effectiveness of the implemented strategies and assessed the challenges faced in carrying out these initiatives in the east of sudan. barriers to implementation could include limited resources, cultural factors, access to healthcare services, or community engagement (russell, 2015). future directions and challenges this section highlights the future directions for research, prevention, and management of head and neck cancer in the east of sudan. it discusses the challenges specific pa ge 41 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 36-43, 2023 to the region and identifies areas that require further investigation and intervention (mody, m. d., rocco, 2021). the aim is to provide insights into potential strategies to improve outcomes and reduce the incidence of head and neck cancer. challenges specific to the region there are challenges specific to the east of sudan regarding head and neck cancer. these challenges could include limited resources, infrastructure, access to healthcare services, cultural considerations, or socioeconomic disparities. understanding and addressing these region-specific challenges are crucial for designing effective strategies to tackle head and neck cancer in the east of sudan. areas requiring further investigation and intervention certain areas require further investigation and intervention. this suggests that there are gaps in knowledge or areas that need more attention to improve the region’s prevention and management of head and neck cancer. these areas could include understanding the specific risk factors prevalent in the population, evaluating the effectiveness of current interventions, identifying new treatment options, studying the impact of genetic or molecular factors, or exploring disparities in access to healthcare. insights and potential strategies the aim is to provide insights into potential strategies to improve outcomes and reduce the incidence of head and neck cancer. this indicates that the authors or researchers aim to offer valuable information and recommendations to guide future efforts. these insights may include suggestions for targeted prevention programs, improvements in early detection methods, the development of more accessible and affordable treatment options, or recommendations for policy changes to address the challenges faced in the region. conclusion the incidence of head and neck cancer in the east of sudan continues to be a significant public health concern. this review provides an updated understanding of the recent epidemiological trends, risk factors, diagnostic advances, treatment modalities, and preventive strategies specific to the region. by focusing on the recent developments and future directions, this review aims to contribute to the ongoing efforts to address head and neck cancer in the east of sudan. the review emphasises the importance of a multidisciplinary approach in effectively managing this disease. it underscores the significance of rapid and accurate diagnosis, enhanced by recent advancements in diagnostic techniques such as biopsy, imaging modalities (ct, mri), and laboratory investigations. these advancements have improved the region’s early detection, staging, and treatment planning. the review also emphasises recent advancements in treatment modalities, including surgery, radiation therapy, chemotherapy, targeted therapies, and immunotherapy. these advancements offer new options for patients in the east of sudan and have the potential to improve treatment outcomes. furthermore, prevention and early detection strategies are vital in reducing the burden of head and neck cancer. efforts such as public health interventions, tobacco control programs, hpv vaccination, and public awareness campaigns have been implemented to address these aspects in the region. highlights the challenges specific to the east of sudan, such as limited resources, infrastructure, access to healthcare services, and cultural considerations. these challenges necessitate further research, investigation, and intervention to develop tailored strategies that address the region’s unique needs. identifying future directions for research, prevention, and management is crucial in guiding efforts to improve outcomes and reduce the incidence of head and neck cancer in the east of sudan. novelty of research the study focuses on head and neck cancer incidence in the eastern region of sudan, focusing on the region’s unique characteristics and challenges. it provides an updated overview of the landscape from 2018 to 2023, identifying emerging risk factors, highlighting advancements in diagnostic techniques and treatment modalities, and emphasizing the need for specialized training in head and neck anatomy staging malignancies. the review emphasizes the need for improved healthcare infrastructure and addressing the gap in head and neck surgeons in the eastern region. contribution to knowledge the review provides an updated overview of head and neck cancer incidence in the eastern region of sudan from 2018 to 2023, highlighting emerging risk factors like immunosuppression and hpv infection. it also discusses advancements in diagnostic techniques and treatment modalities, emphasizing the need for specialized training and healthcare infrastructure to improve early detection, staging, and personalized treatment planning. addressing the gap in healthcare infrastructure is crucial for enhancing anatomic understanding and staging capabilities, ultimately leading to better patient outcomes. fulfillment of research gap the review provides a comprehensive resource on head and neck cancer incidence in the eastern region of sudan, incorporating recent studies and data. it addresses the need for targeted strategies, diagnostic techniques, and treatment modalities, guiding policymakers, healthcare providers, and researchers in implementing these interventions. the review also highlights challenges, such as limited resources and infrastructure, and offers recommendations for future research and intervention. pa ge 42 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 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(2020). targeting ezh2 enhances antigen presentation, antitumor immunity, and circumvents anti–pd-1 resistance in head and neck cancerezh2 is a negative regulator of hnscc antigen presentation. clinical cancer research, 26(1), 290-300. pa ge 1 pa ge 57 american journal of medical science and innovation (ajmsi) morbid obesity associated with non-alcoholic fatty liver disease and complicated by severe non-cirrhotic portal hypertension: a case report from rural kenya vonwicks c. onyango1*, kenneth h. makokha2, samuel m. gachie3, boniface mutiso3 nicholas m. mutuma3, paul m. kamau3 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1907 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 17, 2023 accepted: august 09, 2023 published: august 14, 2023 non-alcoholic fatty liver disease (nafld) is the most common liver disease and is closely linked with obesity and metabolic syndrome. portal hypertension in nafld typically occurs in the cirrhotic phase of the disease and may present with esophageal varices, splenomegaly with splenic sequestration syndrome, ascites, and features of liver failure. however, recent experimental and clinical data show the occurrence of portal hypertension in nafld in the absence of fibrosis or cirrhosis. we present such a clinical case from rural kenya in this study with the literature review that proposes novel mechanisms for such non-cirrhotic portal hypertension in nafld. keywords obesity, non-alcoholic fatty liver disease, nafld, portal hypertension, noncirrhotic portal hypertension, kenya 1 department of medicine, st. joseph rift valley hospital, gilgil, nakuru county, kenya 2 department of endoscopy, st. joseph rift valley hospital, gilgil, nakuru county, kenya 3 st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction the world health organization defines obesity as an excessive or abnormal accumulation of body fat that presents a risk to health. a body mass index (bmi) of 25-29.9 kg/m2 defines overweight individuals, while a bmi of ≥30 is obesity. a bmi of ≥40 kg/m2 (or ≥35 kg/m2 in association with comorbidities) defines severe obesity, also called morbid obesity (apovian, 2016). by 2015, it was estimated that >600 million adults worldwide had obesity, with the number of obese people having more than doubled since the 1980s in >70 countries. the prevalence was higher for females than males at all socioeconomic and age-group levels (afshin et al., 2017). in this study, a high bmi accounted for >4 million deaths globally, with 60% attributed to obesity, especially cardiovascular diseases. obesity is associated with significant multisystemic dysfunction, including cardiovascular, metabolic, hepatobiliary, musculoskeletal, psychosocial, and neurological diseases, etc. obesity (especially in the setting of metabolic syndrome) is a major risk factor for non-alcoholic fatty liver disease (nafld), in which patients have hepatic steatosis with or without inflammation and fibrosis and in the absence of a secondary cause of the steatosis (younossi et al., 2011). nafld is the most common liver disease, with a global prevalence of 25% (araújo et al., 2018). this prevalence was replicated in a kenyan study by mburu et al., in which the prevalence of nafld was 26.2% among overweight and obese children in nairobi (mburu et al., 2023). however, most cases of nafld are diagnosed in the 4th to 5th decades of life (cotter & rinella, 2020). nafld encompasses a disease spectrum that includes steatosis with or without inflammation (non-alcoholic liver, i.e., nafl), non-alcoholic steatohepatitis (nash), which includes hepatic necroinflammation and fibrosis, and eventual liver cirrhosis. patients with cirrhotic nafld should be screened for hepatocellular carcinoma and esophageal varices (powell et al., 2021). case presentation presenting illness and physical examination a 62-year-old married mother of three from naivasha, kenya, a retired teacher, was referred to us for upper gastrointestinal endoscopy in the evaluation of a 2-week preceding history of symptomatic microcytic hypochromic anemia with a hemoglobin of 8.4g/dl and a mean corpuscular hemoglobin (mcv) of 69 fl. notably, she was morbidly obese with previous multiple comorbidities and complications including: obstructive sleep apnea syndrome, hypertension (well controlled on medications), previous mesenteric ischemia in 2013 needing exploratory laparotomy with gangrenous bowel excision and primary anastomosis, proximal deep venous thrombosis of the right leg in 2014 which was treated with 6 months of warfarin anticoagulation, left sided bell’s palsy in 2016 treated with prednisone and acyclovir but having residual ipsilateral hemifacial weakness, bilateral lower limb varicose veins for which she was using bilateral external compression stockings, and severe bilateral knee osteoarthritis worse on the right knee for which she had undergone a total knee replacement in 2017. six months earlier, she had an ultrasound diagnosis of fatty liver disease with no complications during a routine medical evaluation at her local hospital. she was a lifetime nonpa ge 58 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 57-60, 2023 smoker and non-ethanol user. her physical examination was remarkable for moderate conjunctival pallor, bilateral palmar erythema, and no obvious spider naevi, she was morbidly obese with a body mass index of 44.98 kg/m2 (weight of 121 kilograms, height of 1.64 meters), she had a blood pressure of 114/69 mmhg, she was dyspneic at rest with a respiratory rate of 24 breaths per minute with a baseline oxygen saturation of 84% in room air; and a random blood sugar of 184mg/dl. her abdomen was of markedly increased girth with multiple striae distensiae and caput medusae, non-tender to palpation with bilateral flank dullness, and an obviously palpable splenomegaly about 6cm below the left costal margin in the mid-clavicular line. a digital rectal exam showed grade 2 hemorrhoids with melena stools. she had grade 2 bipedal pitting edema, distended external jugular veins with elevated jugular venous pressure to about 8 cm, a diffuse apex beat with loud p2, normal and regular s1 and s2 heart sounds, and a grade 4/6 tricuspid regurgitation murmur. she had bi-basal lung crackles and a neurological examination remarkable for left hemifacial paresis (from prior bell’s palsy) with no features of hepatic encephalopathy. diagnostic work up her important work-up findings included a complete blood count showing anemia with a hemoglobin of 8 g/ dl with an mcv of 70 fl, leucopenia with total a white blood cells of 3.1 x 103/ul, and thrombocytopenia with platelets of 90 x 103/ul (the leucopenia and thrombocytopenia due to splenic sequestration from the portal hypertension). she had an elevated glycated hemoglobin (hba1c) of 7.1% (insulin resistance), a normal creatinine of 0.9 mg/dl, normal aspartate transferase, bilirubin, and prothrombin time (inr). she had negative hiv and hepatitis b and c screening tests. an abdominal ultrasound showed a normal-sized liver with normal wall margins but with marked fatty infiltration and no other lesions, an enlarged spleen measuring 16.18cm with several prominent collateral veins, and moderate ascites (in keeping with portal hypertension). upper gastrointestinal endoscopy showed grade 3 esophageal varices with hyperemic gastric fundus but no obvious ulcers or active bleeding (see figure 1 series of the esophageal varices on endoscopy). a chest x-ray showed cardiomegaly with pulmonary edema and prominent pulmonary vessels. an electrocardiogram showed a normal sinus rhythm, right axis deviation, and p-pulmonale (right atrial enlargement); an interval echocardiogram showed a normal left ventricular ejection fraction of 70% with concentric left ventricular hypertrophy, both atria and right ventricular outflow tract markedly enlarged, moderate-to-severe tricuspid regurgitation with an estimated right ventricular systolic pressure elevated at 55 mmhg (features of pulmonary hypertension), and no obvious intracardiac thrombi. management and follow-up the patient was clinically diagnosed with morbid obesity associated with non-alcoholic fatty liver disease (nafld) and complicated with features of non-cirrhotic portal hypertension (splenomegaly with splenic sequestration, ascites, esophageal varices, and hemorrhoids). this was against a background of other multiple target organ damages. she underwent a multidisciplinary team review, with specific management including: endoscopic esophageal variceal banding with initial 6-to-12-week surveillance endoscopies and repeat banding when needed as per our institutional protocol. she has since undergone three banding events (see figure 2 series taken post endoscopic esophageal variceal banding). she was also put on propranolol to prevent rebleeding of the esophageal varices, omeprazole and metoclopramide for the gastritis, hematinic drugs for the anemia, the heart failure (which was predominantly due to cor pulmonale) was managed with furosemide, spironolactone, losartan, and sildenafil (the latter to figure 1: grade 2-3 esophageal varices (red arrows) for the patient seen on endoscopy. there was no active bleeding observed during endoscopy. figure 2: esophageal variceal banding done for the patient on the initial, and subsequent serial follow-up endoscopy. notice the bands in place (black arrows). pa ge 59 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 57-60, 2023 reduce pulmonary hypertension). nocturnal continuous positive airway pressure (cpap) for the obstructive sleep apnea syndrome was recommended following a formal polysomnogram, but the patient could not afford it and currently uses nocturnal nasal-prong oxygen delivered by an oxygen concentrator. she is also receiving multiple supportive therapies within a multidisciplinary team. she was enrolled in the nutritional program to help with diet and weight management and has been active to date (she has since lost 12 kg). she developed a second episode of unprovoked proximal deep venous thrombosis on the left leg 3 months later, which was treated with rivaroxaban for 6 months, and was subsequently put on life-long warfarin (the cheaper option) with careful monitoring of the inr and surveillance for bleeding disorders. the leucopenia and thrombocytopenia have persisted during follow-up, but the anemia has since resolved. discussion portal hypertension develops when there is increased pressure in the portal venous system and is associated with increasing portal collateral blood flow (porto-systemic anastomosis). this leads to ascites, esophageal varices, caput medusae, hemorrhoids, liver failure manifestations (including hepatic encephalopathy, coagulopathy, etc.), and hepatorenal syndrome (simonetto et al., 2019). the two most common causes of portal hypertension globally are cirrhosis and non-cirrhotic periportal fibrosis from hepatic schistosomiasis, or portal vein thrombosis (mauro & gadano, 2020). our patient has splenomegaly with features of splenic sequestration (thrombocytopenia and leucopenia, both of which have persisted in her followup tests), esophageal varices needing repeat bandings, ascites, caput medusae, and hemorrhoids. the etiology of the anemia is multifactorial, with the most prevalent cause being iron deficiency anemia from multiple etiologies, including portal hypertensive gastropathy. portal hypertension in nafld usually occurs in the cirrhotic phase of the disease. it is unusual to find manifestations of portal hypertension in nafld without associated liver cirrhosis. however, recent clinical and experimental data shows the occurrence of portal hypertension in the absence of significant fibrosis or cirrhosis. there is growing evidence that portal venous pressure may begin to rise early in the nafld pathogenetic process when fibrosis is either absent or insignifican. in an observational study of 100 patients with nafld associated with clinically significant portal hypertension (encephalopathy, esophageal varices, ascites, and splenomegaly) undergoing staging liver biopsy, 88 of them had cirrhosis. however, in 12 of the patients (12% of cases), fibrosis was mild or absent (mendes et al., 2012). these patients had a greater degree of hepatic steatosis compared to those without portal hypertension. our patient has not had any features of liver cirrhosis in multiple follow-up ultrasound scans of the liver over the last 2 years. there was a marginal increase in fatty infiltration of the liver initially, but this has plateaued and remained static since the onset of her weight loss journey. admittedly, the utility of ultrasonography in general medical diagnosis is limited by user-dependent variabilities. one of the proposed mechanisms for this non-cirrhotic portal hypertension in nafld is a combination of impaired hepatic sinusoidal hemostasis and hepatocellular ballooning leading to increasing intrahepatic vascular resistance and thus portal hypertension before the development of cirrhosis. both of these processes are initiated by progressive lipid accumulation in the hepatocytes (steatosis), which causes a mechanical barrier to sinusoidal flow and eventual hepatotoxicity from the lipidosis-induced hepatocyte ballooning (baffy, 2018). other proposed intrahepatic factors include steatosis-induced endothelial cell dysfunction and splanchnic vasodilatation, both of which increase intrahepatic vascular resistance early in nafld. insulin resistance is associated with nafld non-cirrhotic portal hypertension through increased hepatocyte burden of adipose tissue lipolysis with resultant hepatotoxicity, endothelial dysfunction, and increased portal pressures (nababan & lesmana, 2022). our patient also has insulin resistance, with a hba1c of 7.1%. the first-line therapy for nafld is lifestyle changes, especially diet and physical exercise, to reduce body weight to a more normal bmi. non-selective beta blockers, e.g., propranolol and carvedilol, help to reduce portal and splanchnic pressures, thus reducing the incidence of primary and repeat variceal bleeding. other medications include statins, renin-angiotensin-aldosterone system (raas) blockade, and sodium-glucose transport protein 2 (sglt2) inhibitors given in a judicious and rational manner (nababan & lesmana, 2022). our patient is already on most of these strategies, which have been individualized based on her practical realities. conclusion the occurrence of portal hypertension in nafld is usually encountered during the cirrhotic phase of the disease. however, novel pathophysiological mechanisms have recently been proposed to explain the experimental and clinical observations of non-cirrhotic portal hypertension in nafld, as presented in this case report. admittedly, more advanced non-invasive (e.g., transient elastography, computerized tomography, magnetic resonance imaging scans, etc.) and invasive diagnostic tests and procedures (e.g., liver biopsy) need to be carried out to further evaluate and characterize the hepato-portal dysfunction in our patient, preferably in a specialized center. these ideal interventions are unfortunately limited by financial and other constraints that define the reality of rural medicine. references afshin, a., forouzanfar, m. h., reitsma, m. b., sur, p., estep, k., lee, a., marczak, l., mokdad, a. h., moradi-lakeh, m., naghavi, m., salama, j. s., vos, t., abate, k. h., abbafati, c., ahmed, m. b., al-aly, pa ge 60 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 57-60, 2023 z., alkerwi, a., al-raddadi, r., amare, a. t., . . . murray, c. j. l. 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(2020). what’s new in portal hypertension? liver int, 40 suppl 1, 122-127. https:// doi.org/10.1111/liv.14366 mburu, a. n., laving, a., macharia, w. m., & sande, j. (2023). prevalence of non-alcoholic fatty liver disease in overweight and obese children seeking ambulatory healthcare in nairobi, kenya. bmj open gastroenterol, 10(1). https://doi.org/10.1136/ bmjgast-2022-001044 mendes, f. d., suzuki, a., sanderson, s. o., lindor, k. d., & angulo, p. (2012). prevalence and indicators of portal hypertension in patients with nonalcoholic fatty liver disease. clin gastroenterol hepatol, 10(9), 1028-1033. e1022. https://doi.org/10.1016/j.cgh.2012.05.008 nababan, s. h. h., & lesmana, c. r. a. (2022). portal hypertension in nonalcoholic fatty liver disease: from pathogenesis to clinical practice. j clin transl hepatol, 10(5), 979-985. https://doi.org/10.14218/ jcth.2021.00593 powell, e. e., wong, v. w., & rinella, m. (2021). nonalcoholic fatty liver disease. lancet, 397(10290), 22122224. https://doi.org/10.1016/s0140-6736(20)325113 simonetto, d. a., liu, m., & kamath, p. s. (2019). portal hypertension and related complications: diagnosis and management. mayo clin proc, 94(4), 714-726. https://doi.org/10.1016/j.mayocp.2018.12.020 younossi, z. m., stepanova, m., afendy, m., fang, y., younossi, y., mir, h., & srishord, m. (2011). changes in the prevalence of the most common causes of chronic liver diseases in the united states from 1988 to 2008. clin gastroenterol hepatol, 9(6), 524-530.e521; quiz e560. https://doi.org/10.1016/j. cgh.2011.03.020 pa ge 1 pa ge 53 american journal of medical science and innovation (ajmsi) artificial intelligence applications in the diagnosis and treatment of bacterial infections sarabjit kaur1* volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5420 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 28, 2025 accepted: july 30, 2025 published: september 13, 2025 in today’s era artificial intelligence (ai) is the fruitful and informative tool to treat the bacterial infections. ai features provide the outcomes more effectively, accurately, manifest the disease parameters in shorter period of time which results in safe and potential life. knowledge engineering (ke)-based approaches have confirmed in cost-effective, reduce dependency on particular structure and detect the bacterial infection by various mode of testing machines like antimicrobial susceptibility testing (ast) by leveraging machine learning models, support vector machines (svm), and deep learning architectures such as convolutional neural networks (cnns) and transformers. thus, it also enables the bacterial detection through smartphone-integrated platforms and telemedicine applications. these integrated platforms will help in the research of drugs and vaccines that can use in the antibiotics resistance treatment. furthermore, ai technology has a widespread deployment in detection of the bacterial resistance strains, transforming the bacterial infection. its algorithms can easier analyze various data sources like genomic data, clinical data and capture of proper image helps to identify the different bacterial species and strains. ai also assist in the applications of laboratory diagnostics and clinical microbiology to recognize the gram positive or gram negative bacteria by plate counting, mass spectrometry for example, maldi-tof ms data which accurately classifies different staphylococcus aureus subspecies. morphology-based and motion-based microscopic detection, holographic microscopy, colorimetric and fluorescence detection, electrochemical sensors, raman and surface-enhanced raman spectroscopy (sers), and atomic force microscopy (afm) and ast all these methodologies help in bacterial diagnosis, offering improved precision, reduce the time period between sampling and result resolution. it is very useful novel technique in finding the new antibiotics and to localize the site of action that is directly deliver the drug to the targeted site. ai tool act as a right hand for medical researchers, doctors, nurses that provide best result to overcome the challenges in bacterial infection cure, reduced the side effects; improves patient –compliance and promote healthy life with proper personalization. keywords artificial intelligence, bacterial diagnostics, bacterial infections, knowledge engineering, malditof, personalization 1 guru nanak institute of pharmacy, dalewal, india * corresponding author’s e-mail: sarabkhuttan@gmail.com introduction millions of the people died due to the bacterial infection every year. researchers had claimed bacterial infections are one of the causes of people death after the heart attack. accurate and proper investigation of pathogens and suitable drug is vital for the treatment of bacterial infection. bacterial infections are classify by the shape of bacteria such as bacilli, cocci, spirochetes and vibrio whether they are gram positive or gram negative and aerobic or anaerobic. these types help the physician for selection of suitable drugs and vaccines. long term use of board spectrum antibiotics can lead to resistance. at the same time, surveillance and management of bacterial infections are essential to prevent their spread and safeguard public health. so, ai is the novel technique that offers several applications in order to cure the bacterial infection caused by tuberculosis, stis (sexually transmitted infections), lungs, skin, urinary tract infection (uti), git and respiratory infections. the fast expansion of ai will result in the positive therapeutic effect in curing the bacterial infections. artificial intelligence (ai) is the tool which works like a computer or machine to perform task in a simple way with the help of human intelligence such as object learning, thinking, creativity, innovating the idea, problem-solving and understanding language. ai is the powerful technique that helps in the identification, diagnosis, prevention and treatment of bacterial infections. furthermore, ai helps the developers and experimenter in the formation of new drugs, vaccines and targeted delivery to the cell, tissue and organs. machine learning, also helps in studying the drug and excipients profile, structure activity relationship (sar) in drug development. it helps to predict bioactivity of compounds with the target ligands, proteins or site by using the qsar modeling and molecular docking. sar play vital role in knowing efficacy and potency of drug while selectively reducing the toxicity of drug candidates. machine learning determines the bacterial infection by using automatic and identification of pathogen. it can also analyze by images, data resources obtained from genomic, clinical samples (blood, urine, stool etc), experiments, laboratory tests and public health database. apart from this, morphology-based and motion-based microscopic detection, holographic microscopy, colorimetric and pa ge 54 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 fluorescence detection, electrochemical sensors, raman and surface-enhanced raman spectroscopy (sers), and atomic force microscopy (afm) and ast all these methodologies help in bacterial diagnosis, offering improved precision, reduce the time period between sampling and result resolution. table 1: how ai work out to cure the bacterial infection? invention of new drug ai algorithms can easily investigate the chemical structures features and their bioactivities to predict the productivity of new drug candidates against resistant bacteria. ai also identifies the potential of new antibiotics at what percentage it can stop or kill the bacterial infection. detection of pathogens with the help of ai-powered tools one can easily identify the bacterial pathogens, even those that are resistant to antibiotics. this allows for more targeted and effective treatment options. streamlined treatment plans developers with the aid of ai can examine patient data to know individual responses of different antibiotics and customized treatment which provides patients compliance by reducing the risk of side effects and alternative treatment for antibiotic resistance therapy. sar analysis 1. drug activity prediction: ai models help the researchers to rundown the drug and excipients. by studying the different sites of structure one can know the active site that act against bacterial infection. 2. emphasizing key structural properties : ai helps in identifying the configurationally properties of drug that is biological activity which result to design more effective drugs. 3. improving drug development efficiency: ai can assist in designing new drugs by predicting the effects of modifications to a drug's structure, which can lead to the development of more potent and selective drugs. personalization ai can analyze user data to understand the person behaviors, taste that will enables in the tailored experience. optimizing drug delivery ai can be used for optimizing the route and site of delivery of antibiotics infection, thus improving the therapeutic effect and minimizing the side effects. figure 1: artificial intelligence facilitates the diagnosis of bacterial infectious diseases firstly, let us know how bacterial infection occurs. it occurs when the harmful or toxic substances enter in the body and interfering in immune system.thus, decreasing the body defense system to work against diseases. skin cuts, uncovered wounds, contaminated food or water, inbreathe of droplets from the infected person, infected blood fluids, direct explore to the contaminated surfaces and then touch it with mouth, eyes or anywhere on the body can lead to bacterial infection. so, with the help of artificial intelligence these problems can be solved. pa ge 55 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 bacteria when cause the infection generally attacks on epithelial cells, although it affects the various types of cells present in the body. epithelial cells that is responsible for the formation of lining of many organs and tissues, target most as they are present between the internal tissues and external environment. in addition, macrophages and neutrophils (part of immune defense system) are also affected. as we already know bacterial infections spread through various mode of mechanismscontaminated food and water, by air, direct interact with the infection etc can cause various types of diseases like adhesion, toxins, invasiveness, evading the immune system. so, ai is the most powerful tool to detect which type of infection and which treatment must be best for the patient. artificial intelligence (ai) has control the disease that is increasing the rapid diagnosis and antibiotic discovery. as conventional criteria of detection takes long time. by ai methods like machine learning, deep learning and computer vision one can finds the type of pathogens or chronic bacterial infection for which someone couldn’t find the treatment to cure. figure 2: depicts that different mode of ai diagnosis process figure 3: illustrate the shape of the bacteria diagnosis and how ai tools detect it ai techniques used in bacterial struture detection machine learning a. k-nearest neighbors (k-nn). b. support vector machines (svms). c. random forests (rf) and extreme gradient boosting (xgboost). d. gradient boosting (xgboost, lightgbm,catboost) deep learning 1. convolutional neural network (cnns). 2. long short –term memory (lstm) 3. transformers other ai tools 1. neural network –based sensors 2. object detection algorithms (r-cnn, yolo v5) 3. mgps ai tool. machine learning k-nearest neighbors (k-nn) it helps in classifying the new set of information based on their proximity to calculated data points. generally, k-nn compares a new data points with the near by neighbors in the information set. it is knoweldgeable in identifiying the different speices of bacteria and classifying the bacterial structure on their properties. support vector machines (svms) this learning algorithms classify data of bacteria on their features like genome sequences, shape, size, protein or pa ge 56 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 lipid structure and metabolic pathways. svms identify the antimicrobial resistance in bacteria. it work by categorizing the data points in a hyperplane. random forests (rf) and extreme gradient boosting (xgboost) it analyze the data by images that is tem microscopy, gene pool information of bacteria. apart from this, it can identify and classify the bacterial infection more accurately, efficiency,robustness by combining with the cnns tool. furthermore, it is also used in assisting the antibiotics susceptibility and indentifying antimicrobial peptides. it can handle the complex data record. gradient boosting (xgboost, lightgbm, catboost) currently,this ai arithmetic gaining the importance in identying the bacterial structure. it has a power to tackle with the more complex data file. it usually helpful in predicting the cytometric data (measures the physical and chemical characteristics of cells) techniques – flow cytometric, classify the bacteria on their methabolic phases and superbugs (antimicrobial resistance). deep learning convolutional neural network (cnns) it is based on the images information and automatically colonies of bacteria can be find. cnns used to identify potential new drug of antimicrobial resistance. apart from this, it also has power in maintaining the quality control processes and ensure the drug purity, safety and efficiency. long short –term memory (lstm) it is the advance or improved version of the recurrent neural network (rnn), helps in language translation,recognition of words and forecasting the sequenc of data points that are ordered by time. time sequence of data is oftenly plotted graphically, time on xaxis and variable’s value on the y-axis. transformers it is valuable tool in detecting the bacterial infection, mainly vision transformers are used. it detect by analyzing the images of gram –stained smears and chest x-rays. transformers with the help of clinical data of the patient can determine the bacterial infection. other ai tools neural network –based sensors cnns artificial intelligence tool is a neural network sensor which is capable of diagnostic the bacterial infection. it is more prominent in speeding up identification processes. object detection algorithms (r-cnn, yolov5) this is based upon the image information with the help of deep learning (dl) bacterial images can obtained and examine in detail that is it provide the bacterial structural information as well as diagnosing and identifying the bacterial infection caused by which type of microorganisms and treating infectious diseases caused by pathogenic bacteria. yolov5, a powerful object detection method in assisting the bacteria by counting colonies on agar plates. mostly yolov5 is used in identifying the bacterial diseases in rice and bell papers (by bacterial colonies on agar plates). mgps ai tool it stands for microbiome geographic population structure. this tool helpful in understanding the climatic conditions in which bacteria is surviving or the origin of bacteria causing an infection. by using mgps searchers or doctors can predict the bacteria environment in which it grows even from where the bacteria is carried by individuals (like city center, beach etc). it also aid the microbial communities. literature review today, ai is considered a branch of technology and engineering that develop novel concepts and novel solutions to resolve complex challenges. with the passage of time, ai continued progress in electronic speed, capacity, and software programming that might create computers intelligent as human beings. cheng and druzdzel (2000) develop an algorithm for evidential reasoning in large bayesian networks. an adaptive importance sampling algorithm, aisbn that shows promising convergence rates even under extreme conditions is developed. it seems to outperform the existing sampling algorithm consistently. this provides a better substitute to stochastic sampling algorithms that have been observed to perform poorly in evidential reasoning with extremely unlikely evidence. grunwald (2001) and halpern (1989) focused on the theoretical foundations of probability updating and predictions under uncertainty. aim to refine the ai system to give better decisions in the case of uncertainty and work on the safe probability and ignore certain information that leads to have accurate predictions, particularly when handling with the irrelevant data the potential of artificial intelligence (ai) to augment and partially automate research in many scientific disciplines, including the health sciences (adams et al., 2013; tsafnat et al., 2014), biology (king et al., 2009), and management (johnson et al., 2019). in particular, the concept of automated science is raising intriguing questions related to the future of research in disciplines that require “high-level abstract thinking, intricate knowledge of methodologies and epistemology, and persuasive writing capabilities” (johnson et al., 2019: 292). these debates resonate with scholars in information systems (is), who ponder which role ai and automation can play in theory development (tremblay et al., 2018) and in combining data-driven and theory-driven research (maass et al., 2018). with this commentary, we join the discussion which has been resumed recently by johnson et al. (2019) in the business disciplines. the authors pa ge 57 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 observe that across this multi-disciplinary discourse, two dominant narratives have emerged. the first narrative adopts a provocative and visionary perspective to present its audience with a choice between accepting or rejecting future research practices in which ai plays a dominant role. the second narrative acknowledges that a gradual adoption of ai-based research tools has already begun and aims at engaging its readers in a constructive debate on how to leverage ai-based tools for the benefit of the research field and its stakeholders. in this paper, our position resonates more with the latter perspective, which is focused on the mid-term instead of the longterm, and well-positioned to advance the discourse with less speculative and more actionable discussions of the specific research processes that are more amenable applications of ai and those processes that rely more on the human ingenuity of researchers. mintz and brodie., 2019 ai has begun to incorporated into medicine to improve the pateints compliance by speeding up processes as ai tools like dl helps in achieving the accuracy and opening the way to provide better healthcare. their search has revelated that with the help of radiological images, pathology slides and patient’s electronic medical records (emr) evaluated by machine learning helps in the diagnosis process, treatment of patients and to add other treatment to improve outcomes of patients. ai’s transformative potential in business and management has garnered significant research attention (laurim et al., 2021; østerlund et al., 2021). as businesses seek to leverage ai for competitive advantage and navigate complexities, literature reviews have become essential in providing insights. ai literature reviews often take a narrow approach, focusing on specific problems within particular research domains. while these literature reviews have contributed valuable insights into their respective fields, they often focus on specific application areas. for example, within information systems, literature reviews have focused on topics such as ai in fitness recommender systems (venkatachalam & ray, 2022) and the impact of ai on public governance (zuiderwijk et al., 2021), while in marketing, reviews have analyzed ai in customer relationship management (ledro et al., 2022) and consumer-machine relationships (pentina et al., 2023). reviews often look at the intersection of these areas, such as kaufmann et al. (2023), who review the role of tasks in the acceptance of ai and algorithm advice. the traditional approach to diagnosing bacterial infectious diseases, laboratory technicians rely on microbiological and biochemical tests to identify pathogens. it includes bacterial culture, morphological observation, biochemical reaction tests, and serological techniques (ernst et al., 2006; váradi et al., 2017). in addition, molecular biology techniques are widely used for the identification of bacterial dna sequences, of which the polymerase chain reaction (pcr) is a commonly used method (wilson, 2015; deusenbery et al., 2021). although pcr technology is more advanced than traditional biochemical and microbiological methods, it requires a long time to complete the experimental process. moreover, the integration and application of ai technology not only optimizes the traditional bacterial detection and management process, but also has the potential to bring about a complete revolution (ho et al., 2019; wang et al., 2020; paquin et al., 2022; howard et al., 2024) future of ai can be imagined in terms of its capabilities and opportunities, it must be recognized that ai can also present a number of challenges and ongoing issues due to the complexity of the integration of healthcare environments with a purely machine learning-supported ai intervention. some of the main risks and challenges that have emerged are patient injury from system errors (aljaaf et al., 2015; srivastava & rossi, 2019; madanan et al., 2021; dwivedi et al., 2021), patient privacy concerns limiting data access, and the ethical, legal and medical challenges of making decisions about human lives and medical conditions using ai (liu et al., 2020; shabannejad et al., 2021). goodswen et al. (2021) explored the use of ai in medical microbiology and related field. apart from this, its work is mentioned inrelation to ai in diagnosing and treating the bactrial infections.with the aid of machine learning (ml) microbial interactions can be understand accurately and used in metagenomics to predict microbial functions and analyze data. moving further, they proved that ai is also playing cruical role in accerelating the vaccine development by understanding the pathogen infection cycles and identifying the active antigens which cure the infection. in supervised learning, algorithms train pre-cataloged data thus enabling for the predictions for new unseen data by drawing the pattern with known outcomes and encompassing classification and identifying the genetic markers associated with traits like virulence and antimicrobial resistance. the use of ai that is with x-rays and ct scans physicians can diagnose and treat the bacterial infections esaily as compared to the traditional methods. ai used to enhance the speed and accuracy of pathogen detection and resistance prediction (jiang et al., 2022). ai tools were used to track the evolution and transmission patterns of infectious diseases thus, enabling public better health outcomes. bellini et al. (2022) work in the realm of medical microbiology, supervised machine learning models on labeled datasets predict specific outcomes such as classifying microbial infections and predicting drug sensitivity. this approach results in diagnosis and treatment selection based on known patterns.on the other hand, unsupervised machine learning, analyze unlabeled data, identifying inherent structures and grouping similar data points. unsupervised machine learning finds applications in group analysis, identification of microbial subtypes and early recognition of infectious threats. often in the hybrid both methods are employed, leveraging the strengths for diagnosing the infection accurately and insight into microbial interactions.unsupervised learning, employing clustering methods such as k-means and hierarchical clustering for characterizing complex ecological dynamics. pa ge 58 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 regardless of the ai challenges, one of the most important benefits of ai is its support in preventative care in the healthcare system that promotes all humans to become and remain healthy. for example, apps have been used to give patients more control over their health (antoniou et al., 2018; jaiman & urovi, 2020; samuel et al., 2022), allowing them to make evidence-based decisions on the matters of preventative health issues, such as type 2 diabetes and high blood pressure. however, early detection and diagnostics of health information require many ai apps (stamford et al., 2016; siddiqui et al., 2018; kumar & suresh, 2019). these ai apps are used in a variety of settings to diagnose different types of illnesses for precise, rapid and reliable results (ribbens et al., 2019; sasubilli et al., 2020; jahan & tripathi, 2021). at the simplest level, ai performs a significant level of comparative analysis using big data so that information from a patient is compared with data and digital images from huge datasets compiled from other patients in relevant and related settings (charan et al., 2018; somasundaram et al., 2020). this type of self-learning mechanism recognizes patterns and provides information for medical practitioners to support their diagnosis and intervention strategies (charan et al., 2018; woo et al., 2021). while supporting these complex medical procedures, ai technologies can also improve the efficiency of medical care administration (deng et al., 2019; daltayanni et al., 2012). ai-powered diagnostic tools can enhance bacterial detection by using low-cost smart gadgets based images process, cloud-based diagnostic platforms and computerized electronic clarifications which helps to diagnosis the clear images of bacterial infection microorganisms and their shape. it gives better results and counter plot the disease ratio min et al., 2021; yu et al., 2023. lee et al. (2024) artificial intelligence (ai) integration help in the bacterial infection diagnostics and ast offers an effective solution to many challenges. lee research has shown that ai has remarkable potential in automating data analysis, improving diagnostic precision (lee), and accelerating time to results. ai algorithms, such as machine learning (ml) and deep learning (dl) models, can easily analyze and modify the complex datasets with high throughput, enabling faster, more accurate bacterial identification and susceptibility profiling. materials and methodoloy bacterial infection can be diagnosised by following methods:1 clinical evaluation 2. microscopy 3. culture techniques 4. biochemical tests 5. serological assays 6. molecular methods these techniques assist in detecting the existence of bacteria, identifying the particular type of bacteria, and evaluating its sensitivity to antibiotics. clinical evaluation and sample collection healthcare professionals evaluate symptoms, conduct physical examinations, and may request imaging studies (x-rays, ultrasound, mri, ct scans) to identify signs of infection, especially in internal organs. samples such as blood, urine, sputum, or swabs from infected regions are gathered for additional analysis. for example, in direct testing of antigens in clinical samples has significantly contributed to the swift identification of species. urine antigen testing has been extensively utilized for detecting pathogens in respiratory infections caused by legionella pneumophila and streptococcus pneumoniae. antigens released by these pathogens and excreted through the urinary tract are typically identified using enzyme immunoassay (eia) or lateral flow assay (lfa). although antigen testing offers a reduced turnaround time (tat), it is hindered by low sensitivity and specificity, particularly in children colonized with s. pneumoniae, and it cannot provide profiles of antibiotic susceptibility or other epidemiological information. the rapid detection of antigens from various clinical samples, such as blood, throat swabs, synovial fluid, pleural fluid, and cerebrospinal fluid (csf), has been previously investigated but is not widely implemented in clinical practice. a significant retrospective multicenter study evaluated the clinical effectiveness of rapid bacterial antigen detection through latex agglutination and found them to be expensive with no observable clinical advantage. nucleic acid amplification testing (naat) or polymerase chain reaction (pcr) tests represent a dependable non-culture method for microbial detection, commonly employed in laboratories worldwide for diagnosing a diverse range of microbial pathogens. moreover, multiplex pcr integrates multiple primers and probes within a single reaction tube to amplify gene targets from various pathogens. this highly sensitive technique enhances diagnostic yield and can be applied to numerous clinical specimens, including respiratory secretions, csf, sterile fluids, and diarrheal feces. however, the limitations of pcr testing include the reporting of incidental findings, an inability to differentiate between colonization and infection, the necessity for skilled operators and a specialized laboratory setting, and the lack of antibiotic susceptibility data. additionally, pcr will only identify pathogens that are specifically targeted by the assay design, potentially missing rare and unexpected organisms or strains with variations. microscopy the direct examination of samples under a microscope, possibly utilizing staining methods like gram stain, can disclose the presence and morphology of bacteria. this technique aids in the preliminary identification based on characteristics such as shape, size, and staining properties. bright-field microscopy this is the most prevalent form of microscopy utilized, frequently alongside with gram staining. pa ge 59 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 gram staining this technique categorizes bacteria into gram-positive and gram-negative groups based on their cell wall composition, offering insights into the bacterial identity. other staining techniques depending on the suspected infection, alternative stains such as acid-fast stains (for mycobacteria) or capsule stains (for detecting capsules) may be utilized. wet mount microscopy this technique involves the examination of a sample within a liquid medium, commonly used for detecting bacteria in bodily fluids like cerebrospinal fluid or for identifying bacteria in vaginal or wound swabs. fluorescence microscopy this method employs fluorescent dyes that attach to specific bacterial components, facilitating highly specific and sensitive detection of bacteria. culture techniques samples are cultivated on various media to promote bacterial growth. selective media are employed to isolate particular types of bacteria. the growth characteristics, colony morphology, and biochemical reactions of the isolated bacteria are subsequently examined. biochemical tests these assessments evaluate the metabolic characteristics of bacteria, including their capacity to utilize specific sugars or produce certain enzymes. an example is the coagulase test for staphylococcus aureus. a coagulase test is a biochemical assay utilized to distinguish staphylococcus aureus from other species of staphylococci, such as s. epidermidis and s. saprophyticus, based on their capacity to produce the coagulase enzyme. coagulase can be identified using two distinct methods: the tube test and the slide test. slide test 1. approximately 10 µl of deionized water or physiological saline is placed on a slide. 2. several colonies from a fresh culture are gathered with an inoculating loop and emulsified into the water to create a smooth, milk-colored suspension. 3. a drop of rabbit or human plasma is then added to the slide, and clumping is observed immediately, ensuring it does not exceed 10 seconds. tube test 1. the plasma is diluted with physiological saline (0.2 ml of plasma is added to 1.8 ml of saline). 2. 5 ml of the diluted plasma is subsequently transferred to a test tube, followed by the addition of approximately 5 drops of the test organism culture. 3. the contents of the test tube are mixed and incubated at 37°c for one hour. 4. finally, the tube is examined for clot formation. if no clotting is detected, the tube should be checked at 30-minute intervals for up to 6 hours. figure 4: represents the result of different coagulase test appearance serological identification serological assessments identify bacterial antigens or antibodies in patient samples. elevated or increasing titers of specific igg antibodies or the detection of igm antibodies may indicate or confirm a diagnosis. working of serological tests a blood sample is collected, and the serum, which is the liquid component of the blood, is isolated. the serum is subsequently analyzed for the presence and quantity of specific antibodies through various methods such as: elisa (enzyme-linked immunosorbent assay) a widely used technique that employs antibodies to identify antigens or the reverse. pa ge 60 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 agglutination tests identify antibodies that induce the clumping of cells or particles. complement fixation tests identify antibodies by assessing the consumption of complement proteins. immunofluorescence assays utilize fluorescently labeled antibodies to identify antigens or other antibodies. the outcomes of these tests can reveal whether an individual has been exposed to a specific pathogen or if their immune system is reacting to a vaccine. molecular methods molecular techniques such as pcr (polymerase chain reaction) amplify specific bacterial dna or rna sequences for identification. these methods are highly sensitive and specific, capable of detecting even nonculturable bacteria. maldi-tof ms (matrix-assisted laser desorption ionization-time of flight mass spectrometry) is another molecular technique utilized for rapid bacterial identification through the analysis of protein profiles. antimicrobial susceptibility testing (ast) ast evaluates the efficacy of various antibiotics against the identified bacteria. this information assists in determining the appropriate antibiotic treatment. other techniques immunofluorescence and immuno-peroxidase staining can identify specific microorganisms. both techniques employ antibodies to attach to specific antigens; however, they vary in their visualization of the antibody-antigen complex. immunofluorescence (if) utilizes fluorescent dyes (fluorophores) linked to antibodies, whereas immunoprecipitation (ip) employs enzymes (such as horseradish peroxidase) that facilitate a reaction resulting in a colored precipitate. techniques immunofluorescence mechanism a fluorescent dye (fluorophore) is either directly or indirectly linked to the antibody that attaches to the target antigen. visualization the tissue is analyzed using a fluorescence microscope, where the fluorophore emits light at a designated wavelength when stimulated by a light source. advantages 1. high sensitivity. 2. allows for the detection of multiple targets at once (multicolor if). 3. can be conducted on either frozen or fixed tissue. disadvantages 1. requires a specialized fluorescence microscope. 2. fluorescence may diminish, complicating the longterm storage of slides. 3. may exhibit lower specificity compared to ip in certain instances immuno-peroxidase (ip) mechanism an enzyme, typically horseradish peroxidase, is linked to either the antibody or a secondary antibody. this enzyme facilitates a reaction with a substrate, resulting in a colored precipitate at the location of antigen-antibody interaction. visualization the tissue is analyzed using a standard light microscope. advantages 1. it is more durable and less susceptible to fading compared to immunofluorescence (if). 2. it enables permanent staining and the ability to archive slides. 3. it can be applied to fixed and paraffin-embedded tissues. in certain instances, it may exhibit greater specificity. disadvantages 1. it may demonstrate lower sensitivity than immunofluorescence. 2. the process can be more time-intensive. 3. there is a risk of background staining due to the activity of endogenous peroxidase. ai methods can be broadly classified into three main types namely :1. symbolic ai 2. machine learning 3. evolutionary computation symbolic ai it is also called as classical artificial intelligence or logicbased artificial intelligence. it is define as the a subfield of ai that focuses on logic–programming that is on the symbols and logical reasoning to solve problems rather than numerical data. it involves the certain rules and knowledge to perform the tasks like logical reasoning, problem-solving and language understanding. it developed applications such as knowledge-based system,symbolic mathematics, theorem proofs, automated planning and scheduling system. researchers in the 1960s snd the 1970s eventually stated that symbolic ai with machine learning successly predict the logic theorist and samuel’s checkers playing program. this approach is highly interpretable, as it can easily trace the reasoning process to the logical rules applied. it allows the system’s rule to pa ge 61 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 modify or manipulate the ideas or a new information. it is very useful techique as compared to machine learning – it doesnot require the vast numerical data, it is based on knowledge, representation and reasoning. symbolic ai depends on the problem domain and data availability whereas machine learning requires large data records to learn and draw the pattern and make predictions. apart from this, it can help in the hybrid systems that is combining symbolic ai with other ai tools like neural networks to increase their strength. key points of symbolic ai knowledge representation:symbolic ai has ability to represent the knowledge as reasonable statement, rules and symbolic representations. symbolic reasoning in this context, symbols and rules are manipulated to draw inferences and derive results. logical inference with the aid of symbolic ai, researchers can perform the tasks related to logic–based reasoning such as,problems solving and predicting upcoming challenges. rulesbased systems in rule-based systems, human made rules to sort, store, modify and manipulate the data. it describes how the system will work in the particular situations by following the different sets of rules. values or converting data formats. feature engineering identifying and selecting relevant features from the data that can be used as input for the model is crucial. this process can involve creating new features or transforming existing ones to improve the model’s performance. model selection and training choosing the appropriate machine learning algorithm (e.g., supervised, unsupervised, or reinforcement learning) and training it on the prepared data is a key step. this involves adjusting the model’s parameters and evaluating its performance. model evaluation and validation after training, the model’s performance needs to be evaluated using metrics and techniques like crossvalidation to assess its accuracy and generalization ability. deployment and monitoring once the model is validated, it can be deployed to make predictions or decisions in real-world scenarios. continuous monitoring of the model’s performance and retraining it with new data is often necessary. types of machine learning algorithms there are four types of ml supervised learning this type of ml uses labeled data to design models that can make predictions or classifications. it can handle the regression problems where input and output variables have a linear relationship. for example in weather prediction, market trend analysis etc. unsupervised learning it analyzes unlabeled dataset and discover patterns and structures without any supervision, such as clustering or dimensionality reduction. it is also help to identify typical relations between the large dataset variables. it can be used in the market data analysis. reinforcement learning it is feedback based process. it automatically takes the information from hit and trial method and solves the problems. it takes action, learns from the experiences and improves performance. it aims to maximize the rewards by doing good tasks and improved productivity. semi-supervised learning it is the combination of both supervised and unsupervised machine learning. it helpful in labeled and unlabeled data for training but more useful when labeled data is limited. evolutionary computation it is the collectively the efforts of nature-inspired ai algorithms as well as computer science that optimizes the machine learning (ml) it is a subfield of ai that focus on data or past experiences enabling the computer to slove the problems without the human interruption. it depends on algorithms to inform what actions are taken and what outcomes come or decisions. data collection and preparation machine learning algorithms require data to learn from. this involves gathering, cleaning, and organizing data, often including preprocessing steps like handling missing pa ge 62 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 biological evolution. it can provide the best solutions for a variety of prooblems like genetic mutation, hereditary problem. evolutionary processes that mimic biological evolution includes inheritance,mutation and natural selection. working of ec: 1. initialization: the primary step is randomly population of potential solutions is created. 2. evaluation: according to the fitness parameter each solution is evaluated that measures its performance. 3. selection: the best solutions are selected to reproduce and contribute to the next generation. 4. recombination: selected solutions are combined to create new offspring. 5. mutation: random changes are introduced to the new offspring. 6. iteration: the process is repeated, with each generation refining the solutions until a satisfactory solution is found. benefits of ec 1. by using ec, one can handle the complex problems and variables to solve the relationships that are difficult for traditional algorithms to solve. 2. robustness: ec algorithms are often robust to noise and variations in the problem space. 3. ec can be used in various fields, including engineering, finance, and bioinformatics. examples of ec applications 1. it finds the best solution to a problem, such as minimizing costs or maximizing performance. 2. with the help of machine learning, designing and optimizing machine learning models can be made. 3. it helps in developing algorithms for robot navigation and control. 4. it can design new molecules for drug development others distributed ledger technology (dlt) dlt integrated with ai describes a novel and advanced method to achieve the intelligent, resilient, and safe handling of electronic health record data. dlt is an innovative and rapidly growing method for recording and sharing data across different data stores (ledgers). it is secure, immutable, and readily available. it can allow patients to take control of their own data, eventually generating trust in an industry that matters to all of us. metaverse it a virtual universe that is mirror the physical world with the social, economies and ecosystems interactions. it is giving a new shape of digital existence, where the boundaries between the real and virtual worlds blur. ai role in the metaverse is complex. ai algorithms simulate the respond between user and creation (environment) which in return provide opportunities for personalized treatment. additionally, ai is acting as the catalyst for driving new techniques enhancing user experience. surgeons can use the metaverse and ai to do surgeries which are complicated or can practice the surgery before doing on the patients. application of ai in the diagnosis of bacterial infection identification of pathogen with ai ai can algorithms can analyze various data sets by performing mass spectrometry, microscopy images and images capture by normal mobile, easily to identify the bacteria type. ai enhances accuracy with the help of ai powered tools we can achieve the accurate result in indentifying the different bacterial genes, including their subtypes and antibiotic resistant strains. for examples: ai can predict more complex techniques like raman and sers very clearly. two staphylococcus aureus subspecies can identify very uniquely with the ai algorithmsmaldi-tof ms correctly. furthermore, ai used to study autoinducer-2 (ai-2) in s. aureus, giving the path to know the attachment of molecules involved in between the species board casting and influencing anaerobic-bacteria formation. aureus nctc8235 and ai-2 together can regulate the gene expression. ai role in pandemic and epidemic surveillance of bacterial infectious diseases artificial intelligence (ai), or machine learning, is an ancient concept based on data analytics. ai techniques are useful in the computational methods to survey the record file, single out patterns, pick out the high risk population and grasping disease mechanisms. during the covid-19 pandemic, ai tools were used in genome sequencing, development of drug and vaccine, identifying disease and his causative organism, monitoring disease spread, and tracking viral variants. ai-driven approaches complement human-curated ones, including traditional public health surveillance. the hybrid models of ai that is ml (machine learning and dl (deep learning) are used in the detection of disease cause. apart from it, infectious disease dynamics (idd) and dynamic bayesian networks (dbn) models helps in finding the spread of disease and its accuracy helps in knowing the strength of the spread of disease. all these specialized tools help in the epidemiology superintendence of the disease, data analysis and interpretation. for example, machine learning models can predict in advance the risk of clostridioides difficile infection among patients in large hospitals, allowing healthcare teams to implement preventive measures proactively before infection occurs (oh et al., 2018; tilton & johnson, 2019). clinical applications of ai in identification and management of bacterial infection ai tools in clinical testing have abundant uses in diagnosis, management of disease and optimizing the health hazards of the patients. it can analyze by x-rays, mris and ct pa ge 63 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 scans. ai in radiology, images help in analyzing the disease which reduces the interpretation time. furthermore, in cardiology ai features help in diagnosing the cardiac activities that is with the help of ecg report it’s very simple to predict the heart attracts chances. figure 6: following are the key applications of ai in the clinical practice for example in case of pneumonia, the alveoli, small sacs within the lungs, are filled with pus and fluid, which makes breathing painful and limits oxygen exchange. there are more than 30 different causes of pneumonia, and they are grouped accordingly: bacterial pneumonia, viral pneumonia, mycoplasma pneumonia and other pneumonias. ai tool artificial neural networks (anns) based on deep learning shown a promising response in diagnosing the pneumonia causative organism accurately and treatment for particular bacterial infection caused by which type of pneumonia. ai act as paradigm shift in drug discovery and development for treating the bacterial infection one of the difficult challenges are resistant to antimicrobial agents and diverse of bacteria. in 2019, globally, it has reported that above 4 million people died due to resistance of antimicrobial. bacteria have acquired the resistance to the antimicrobial drugs as microbes adapted to the environment, genetic mutation which reduces the efficiency of antimicrobial drugs. additionally, diversity of bacteria and interaction of bacteria and host creates complexity which results in the management or difficult for treatment. so, ai technologies simulates the complex interactions between pathogens, host and drug, thus helps in revealing the features of infections and optimizing the drug and vaccine designs. ai tools are the boons to the searchers that have huge benefits in the drug and research development. it provides new strategies to overcome the problems of drug resistance. models of ai can help the developers in predicting the drug physicochemical properties identify promising drug candidates and provide best match to formulate and design the drug. for example, de novo. drug design ai can generate novel molecular structures with specific biological properties, enabling the design of drugs from scratch. moving further, ai can identify the relationship between pathogen, target site, genotype and chemotype, providing the best come out way to breakout the antimicrobial resistance and provide therapeutic effective drugs. ai easily analyzes the molecular character and predicts the binding affinities of the target ligands and which compound can work more potentially. for e.g. tuberculosis (tb) and multi resistant infections, ai by the chest x-ray, coughs sounds and genomic analysis, drugs that develop the resistant with all these data information we can find the effective treatment for t.b patients. current studies that revealed that ai tool especially machine learning (ml) helps in diagnosis, prediction, understanding the causes, treatment and management of disease. it can identify the failure of antibiotics and its reason behind it. from that information, searchers can analyze and generate a new molecule of drug and vaccine to cure t.b and multi-resistant infection. lastly, the application of ai in predicting dr can aid in the personalized selection of medications, avoiding unnecessary antibiotic use, and reducing the spread of dr strains. improving patient treatment outcomes and quality of life but also contribute to guiding future research and clinical practice, driving advancements in the field of healthcare. ai can predict and analysis the toxic and side effects of the drugs in the recent studies it has revealed that ai algorithms easily and quickly predict the toxic effect of drugs by determining the large data record (from clinical trial data, pa ge 64 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 patient reports etc), identify the patterns and predict outcomes. by analyzing the pharmacokinetics data, safe dose amount can be calculated (dose regimen) and minimizing the side effects. for example the increase of antibiotic resistance, tigecycline a new broad-spectrum of class synthetic tetracycline antibiotics (glycylcycline antibiotic) is widely used in the tissue infections, abdominal infections caused by pneumonia. it works by inhibiting bacterial protein synthesis, act as bactericidal. apart from this, it can be evaluated by the ratio of auc024 to the minimum inhibitory concentration (mic) of pathogens. however, tigecycline may cause nausea, vomiting, diarrhea and a few patients have elevated serum aminotransferase, especially in critically ill patients. ai tools with the combination of physiologically based pharmacokinetic (pbpk) predict the adme parameters. ai helps in come the to an end bleeding in the upper gastrointestinal track caused by helicobacter pylori bacterial infection helicobacter pylori are the bacteria which attacks the lining that protects the stomach. the bacteria make an enzyme called urease which neutralizes the acids in the stomach. h. pylori also weaken stomach’s lining. then the stomachs cells are at high risk of explore or hurt by acid and pepsin, strong digestive fluids. that can lead to sores or ulcers in stomach or duodenum. gastrointestinal endoscopy information can assist ai tools particularly; machine learning can overcome the problem of upper git bleeding by bolstering risk assessment, helps in decision making of dose regimen and positively improving the results.ai tools and cad has shown a potentially result outcomes to analyze increasing loads of numerical and categorical data in short times. it is also notably with ai algorithms achieving regulatory approval for ai-assisted colorectal polyp detection (computer-aided detection [cade]) and characterization (computer-aided diagnosis [cadx]) in colonoscopy. ai speeding up vaccine development ai-enabled computational models help to simulate various molecular configurations of the spike protein which help the developers to assess the configuration and provoke an effective immune response. ai criteria in vaccine development as follows:antigen selection ai can identify the most effective antigenic determinants (epitopes) on a pathogen, which are the parts of the pathogen that the immune system recognizes and targets for attack. this helps researcher’s focus on the most promising vaccine candidates. immunogenic design ai technology can optimize the need of design of vaccines to ensure they are safe and effective. this includes how the vaccine will interact with the immune system and the best way to deliver the vaccine to the body. prediction of immune response ai can model the immune response to potential vaccines, allowing researchers to predict how well vaccine can work and what side effects, adverse effect can be occurred and how it can be overcome. tailored vaccine with the help of ai one can craft to fit the person needs accordingly. researcher can continue discovery the vaccine as per the need of individual genetic information or immune response and possible sparse auto encoders (saes). for example, covid-19 pandemic confirmed how quickly mrna vaccines can be designed and produced against a novel pathogen. it is also being used in the development of treatments for non-infectious diseases, such as cancer. ai plays major role for improved diagnosis and treatment of bacterial infections in 2023, study showed that artificial intelligence plays progressively vital role in the healthcare, providing intensified diagnostic accuracy, custom treatment strategies and improved patient compliance. the use of machine learning for cancer diagnosis and staging from molecular data has in fact been around since the early 2000’s, where machine learning approaches such as clustering, support vector machine and artificial neural networks were applied to microarray-based expression profiles for cancer classification and by analyzing the medical data, various information from the health sectors, patient medical history, genetic information all these help in better and improved diagnosis. for instance, ai has become a powerful tool in the tailored medication generally in cancer and infectious disease. ai helps in improving the accuracy and reliability in screening the cancer disease and detection method that is minimally invasive techniques such as liquid biopsies for circulating tumor dna (ctdna) or cfdna, blood test allow for early detection of cancer, monitoring risk of relapse over time and guiding treatment options. as an example, msi status can be predicted from ctdna in endometrial cancer patients in order to inform immunotherapybased treatment. developed a machine learning based approach, lung-clip (cancer likelihood in plasma), that predicts the likelihood of ctdna in blood drawn from lung cancer patients. so, the death rate can be decreased by earlier detection of cancer with the ai models. usually, at last stage of the cancer patient gets to know. ai assisted diagnosis of bacterial vaginosis (bv) and (vulvovaginal candidiasis) vvc in vagina vvc is the yeast infection that affects women worldwide. it is characterized by overgrowth of the yeast candida albicans. overgrowth often occurs when there is imbalance between the vaginal microbiome resulting in vaginal itching, burning sensation, unusual discharge and discomfort during intercourse time. around the pa ge 65 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 world 75% of women suffered from bacterial vaginosis (bv). this study aims to develop a novel method for bv detection by integrating surface-enhanced raman scattering (sers) with machine learning (ml) algorithms. figure 7: microscopic image of overgrowth of vagina cells figure 8: represents microscopic images of normal vagina and vagina affected by bacterial infection in recent years, ai algorithms particularly, convolutional neural network (cnn) models gained the importance in analyzing microscopic images to identify and classify the microorganisms, bacterial vaginosis (bv) and vvc (vulvovaginal candidiasis) which help the doctors to treat the infection accurately and can even be used to predict the effectiveness of different treatments and potential complications. ai-assisted tool like combiant used to quantify the antimicrobial synergy and for the treatment of infection caused by bv. a cascaded deep neural network model is used to diagnosis vvc, demonstrating superior characteristics exactly as compared to experts. therefore, this model holds potential for clinical application to aid in the diagnosis of vvc. the diagnosis of vvc requires identifying yeast pseudohyphae, budding yeast, and yeast from microscope images, necessitating the use of object detection cnn models. r-cnn series and yolo series cnn models have achieved notable success in target detection tasks in recent years. convolutional neural network (cnn) models have transcended human performance such as image’s visual elements and image of object detection. but cnn models diagnosis the medical images very smoothly, quickly in less time. pa ge 66 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 ai helps in microbial diagnosis ai is being used in various ways to examine the growth of microbial infections as traditional microbial diagnosis faces challenges through detection process-culturing and isolating microorganisms consume time, false positives, cross contamination and difficult for data surveillance. ai tool deep learning, a subset of ml, relies on artificial neural networks (anns) which analyze complex datasets (shape and structure of microbial images or genetic information of pathogens) and all other relevant information to identify pathogens, predict antibiotic resistance. by convolutional neural networks (cnns) in digital pathology, automated bacterial classification, and colony counting further underscores ai’s versatility. moreover, ai improves antimicrobial susceptibility assessment and contributes to disease surveillance, outbreak forecasting, and real-time monitoring. thus, ai tool show promising paradigm-shifting advancements in healthcare. apart from this, by incorporating the data record into dl, it enhances the detection of cancer metastases in lymph nodes, prostate cancer and scoring ki67 in breast cancer. dl accelerates the process of analyzing data, resulting in fast mode result speed and precision. recent progressions in ai, particularly ml methodologies, are explored to study sars-cov-2, malaria, and mycobacteria serve to demonstrate ai’s potential for quick and4 precise diagnosis. in the context of the sars-cov-2 pandemic, ai and cnns has increasingly a spectrum of applications such as virus genome sequencing that helps in decision making algorithms, discovery of new molecule of drug and shot development. ai and cnns integration into pathology laboratories can elevate the precision of identifying microorganisms present on cytological and histological slides that diagnosis the covid-19 causative agent, severe acute respiratory syndrome corona virus 2 (sars-cov-2) using the pcr testing (blood sample and serum of the patient can also be taken for testing) that identify the atypical profiles indicative of tainted, thus facilitating the rapid and accurate diagnosis while minimizing false evidence. ai in assisting in diagnosis of infectious skin disease as we know, the largest organ of human body is the skin. it covers all the body surface area and composed of epidermis, dermis and hypodermis layers. skin act as a protective barrier for external factor such as bacteria, chemicals and temperature changes. various microorganisms residence on the skin surface like bacteria (staphylococcus, corynebacterium) fungi (malassezia) and viruses (herpes simplex, shingles) that inhibit the colonization of pathogens. therefore, the rapid diagnosis of skin lesions is utmost importance for treatment of infectious diseases. in dermatology, ai has shown great promise in diagnosing skin conditions by analyzing medical images. ai algorithms have been developed to evaluate images of the skin to detect and classify conditions such as melanoma, psoriasis and acne. these algorithms can enhance the diagnostic capabilities of dermatologists by providing a second opinion or flagging potential issues that may not be immediately apparent to the human eye. the integration of ai into dermatology not only improves diagnostic accuracy but also increases efficiency by reducing the time required to analyze images. with the growth of ai, it aid in the dermatology in predicting disease progression and developing new treatments. ai can help in the early detection of skin cancer and other infectious diseases which lead to timely treatment and better outcomes. ai tool deep learning and convolutional neural networks (cnns) gaining the importance in diagnosis of infection of skin. it provide medical image recognition, interpretation combining with histopathology to identify specific cells in images and further it combine with image to identify key features to diagnosis of various diseases such as cardiovascular diseases, endocrine diseases and tumors (hutchinson et al., 2023; giorgini et al., 2024; makimoto & kohro, 2024). cnns can also assist individuals with the diagnosis of monkeypox skin lesions. monkeypox caused by monkeypox virus (mpxv) it is zoonotic disease, characterized by skin lesions that present on macules and papules and later entered into vesicles, pustules. so, figure 9: artificial intelligence –assisted diagnostic model pa ge 67 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 cnns helps to detect the mpxv lesions and find out the best treatment to be given to patient which must be patient compliance, personalized medication can also be planned by optimizing the patient data. overall, ai holds promising revolution in dermatology and improving patient care. challenges remain but ai increasing the valuable tool in the fight against skin disease. ongoing research and development in future will minimize the obstacles thus, ai models will more likely to cover the datasets complex and convert to easy integration. ai revolution in diagnosis and management of fungal nail infection nail infection is caused by fungal infection namely, onychomycosis. it is difficult to diagnosis onychomycosis fungal nail infection as it’s similar to other nail conditions. the current methods to examine fungal infection of nails include microscopic examination with potassium hydroxide, fungal cultures and periodic acidschiff biopsy staining. culture is considered a gold standard for fungal identification that helps to determine the viability and pathogen species, but often requires 4–6 weeks for results due to the slow-growing nature of many fungi. culture media may get contaminated by environmental factors but use of antimicrobial solutions inhibits bacterial growth in culture media. all these techniques are time consuming, variable sensitivity, costly and based upon human reliability and interpretation. inspite of these, molecular techniques, such as pcr (polymerase chain reaction) and maldi-tof ms (matrixassisted laser desorption–ionisation–time of flight mass spectrometry) are significantly helpful in fungal diagnosis due to their ability to swiftly detect fungi with high sensitivity, often within a few hours. moving on, undecylenic acid is a fatty acid that helps in the preventing the fungus nail growth. dermoscopy is a technique used to examine the skin and its adnexa in detail, with magnification up to 10 times. this enhances the identification of features that are not visible to the naked eye, aiding in the identification of skin conditions. the procedure has emerged as a valuable tool in onychomycosis diagnosis, offering a non-invasive, rapid, and precise method for evaluating nail abnormalities. onychoscopy reveals distinct characteristics that facilitate the pattern of fungal nail destruction and differentiation from other nail disorders. these features include a jagged proximal margin, longitudinal striae with multicolor vertical streaks, and spiked patterns indicative of fungal invasion. artificial intelligence has made advancements in medicine, utilizing the machine learning, deep learning and other ai technologies to analyze complex medical datasets, enhance diagnostic accuracy, tailored treatment plans and improve patient compliance. mostly the ai studies show accurate results. deep learning model particularly, cnns used to detect and classify fungal infections from images. even machine learning algorithms helps in predicting treatment outcomes and personalized treatment based upon individual patient characteristics. one of the most significant challenges is obtaining a large number of robust data for the training dataset of high quality and standards. these data is essential to assure that ai is used its potential and improves patient outcomes. in addition, patient consent, data privacy, bias etc medico-legal issues. by studying these issues can be resolve and ensure that ai is ethically and safely for use in the clinical practice. figure 10: list of infectious diseases challenges of ai in the medical field while the application of artificial intelligence (ai) in treating bacterial infections shows great potential, realizing its full effectiveness necessitates overcoming considerable challenges. a primary barrier is the issue of data, which includes both its volume and integrity. privacy concerns and regulatory constraints often hinder the collection, standardization, and sharing of data related to bacterial infections. these limitations make it difficult to access large, diverse datasets that are pa ge 68 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 essential for developing robust ai models. consequently, ai applications in healthcare environments become less effective and applicable in other contexts (cath, 2018; baowaly et al., 2019; hummel & braun, 2020). the inherent complexity of bacterial diseases poses additional challenges. the swift mutation rates and diverse infection mechanisms of bacterial pathogens make it difficult to predict bacterial behavior and accurately assess antibiotic sensitivity. ai models in this domain must integrate knowledge from various disciplines, such as microbiology, genetics, biochemistry, and computer science. developing comprehensive models requires significant resources and expertise, posing a considerable challenge for researchers working within constraints. the lack of a thorough legal framework and standardized norms for ai applications in the healthcare sector presents a considerable challenge. as ai technology progresses, it is essential to develop and regularly update laws to ensure its ethical, safe, and effective use in treating bacterial diseases. the establishment of clear guidelines and oversight will be vital in addressing issues related to accountability, bias, and the equitable implementation of ai systems in clinical settings (rees & müller, 2022). tackling these challenges requires interdisciplinary cooperation, the creation of strict data sharing regulations, the adoption of transparent ai models, and the development of comprehensive regulatory frameworks. by overcoming these obstacles, ai has the potential to significantly enhance the detection and treatment of bacterial infections, paving the way for innovative and personalized healthcare solutions. results and discussions artificial intelligence is transforming the diagnosis, treatment, and prevention of bacterial infections by facilitating quicker and more precise identification of pathogens, enhancing antimicrobial susceptibility testing, and advancing genomic analysis. ai-driven tools are also contributing to the early detection of outbreaks, the formulation of personalized treatment strategies, and the creation of novel drugs and vaccines. nevertheless, challenges persist regarding data quality, model interpretability, and ethical issues, including data privacy enhanced diagnosis and identification quicker and more precise identification ai algorithms, especially those employing machine learning and deep learning techniques, are capable of examining intricate datasets from diverse sources (such as maldi-tof ms and genome sequencing) to swiftly and accurately identify pathogens. illustration a research study integrated maldi-tof ms with clinprotools software for the prompt identification of staphylococcus aureus subspecies, achieving a remarkable 100% accuracy through genetic analysis and an efficient classifier model. ai-driven image analysis ai technology can scrutinize medical images (including x-rays and ct scans) to identify indications of infection, facilitating early diagnosis and the isolation of infected individuals, which is particularly crucial during pandemic scenarios. transfer learning and convolutional neural networks (cnns) utilized for cx-r and ct imaging have demonstrated significant accuracy in identifying covid-19. tackling issues in low-resource environments artificial intelligence (ai) can facilitate affordable, smartphone-based image analysis and cloud-based diagnostic solutions for bacterial identification in areas with limited resources. improved antimicrobial susceptibility testing (ast) enhancing treatment ai has the capability to evaluate bacterial genomes and susceptibility information to forecast antibiotic resistance and assist in choosing the most effective treatment options. illustration ai-driven decision support systems can suggest the best antibiotic therapies based on patient information and local resistance trends. accelerating drug discovery ai has the capability to forecast the effectiveness of novel drug compounds and pinpoint potential antibacterial agents, thereby expediting the creation of new treatments. prevention and control early outbreak detection: ai is able to scrutinize extensive datasets to detect early signs of bacterial infection epidemics, facilitating prompt preventative measures. example: machine learning algorithms can assess the likelihood of severe sepsis in icu patients, notifying healthcare professionals and allowing for proactive treatment. infection control in healthcare facilities ai can evaluate data regarding patient and staff interactions to comprehend the transmission of infections, supporting the formulation of targeted infection control strategies challenges and ethical considerations data quality and quantity: for ai models to be effective, they necessitate extensive and high-quality datasets. model interpretability it is essential to comprehend how ai algorithms arrive at decisions in order to foster trust and guarantee responsible usage. ethical concerns issues such as patient privacy, algorithmic bias, and data pa ge 69 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 53-72, 2025 security must be tackled to ensure the equitable and ethical implementation of ai. future directions interdisciplinary collaboration integrating ai with additional technologies such as synthetic biology and nanomedicine has the potential to yield more effective strategies for addressing antibiotic resistance and various infectious diseases. continued innovation persistent research and advancement in ai algorithms, data analysis methods, and hardware will be essential for unlocking the complete capabilities of ai in the fight against bacterial infections. discussions the predominant ai applications utilized in clinical environments were largely characterized by machine learning algorithms (ml), including logistic regression (lr), random forest (rf), support vector machines (svms), and decision trees (dts). these models were mainly employed for pathogen identification, early detection of infections, and risk evaluation of healthcareassociated infections (hais). this model demonstrated the high diagnostic precision of ml algorithms in identifying antibiotic-resistant pathogens, underscoring ai’s vital contribution to infection control in healthcare environments. the significance of various ai-enabled applications in infection control, with the potential to improve diagnostic accuracy, optimizes workflows, and mitigates the transmission of infectious diseases. several research efforts have employed advanced ai tools, including l2-regularized logistic regression models, to enhance clinical decision-making in the realm of infection control. within clinical environments, ai aids in alleviating the impact of hais by delivering precise, real-time predictions and diagnostics, while also propelling research into innovative infection control techniques and therapeutic approaches. these consistent results emphasize the transformative capabilities of ai across different areas of infection control, in line with the goals and expected results of the scoping review. the incorporation of sophisticated ai systems, whether through machine learning, deep learning, or hybrid methodologies, is essential in improving the efficacy of infection prevention and control initiatives, ultimately leading to enhanced public health outcomes on a global scale. summary with the ai tools we can get multiply of benefits as a result properly identification of pathogen: ai algorithms can accurately identify bacterial pathogens therefore, reducing diagnostic time and improving treatment accuracy. early detection of antimicrobial resistance: ai can analyze genomic data to identify resistance early thus, enabling timely and targeted interventions. tailored treatment: ai-powered tools help to select the antibiotics for individual patients, optimizing treatment outcomes and minimizing the risk of resistance development. monitoring the response: ai can be used for surveillance and monitoring of infectious diseases, facilitating early outbreak detection and rapid response. ai-assisted imaging: ai algorithms can analyze medical images (like x-rays and ct scans) to aid in diagnosis, particularly in cases like covid-19, where early identification and isolation are crucial. improved diagnostic precision: ai models have shown high accuracy in diagnosing various, enhancing clinical decision-making. conclusion ai have a significant promise for revolutionizing bacterial infection diagnosis and treatment by improving efficiency, accuracy, and personalized medicine approaches. however, addressing ethical concerns related to data privacy, algorithmic biases and healthcare outcomes. with the aid of ai imaging identification and diagnosis of bacteria can easily notify, help in choosing the appropriate antibiotics in the bacterial infection. utilizing advanced technologies like machine learning and deep learning, ai has been implemented in several critical domains, ranging from swift pathogen detection and antimicrobial susceptibility assessment to the analysis of intricate genomic data and the creation of tailored treatment strategies. through highly refined algorithms, ai technology not only significantly enhances the speed and precision of pathogen identification but also accurately forecasts the susceptibility of pathogens to particular antibiotics based on historical data, thereby offering robust scientific decision support for healthcare professionals. likewise, in the realm of epidemiological surveillance, ai bolstered the capacity for real-time monitoring and early warning regarding the spread of bacterial infectious diseases by analyzing and processing vast amounts of epidemiological data, thus providing a powerful analytical tool and foundation for public health decision-making. with the assistance of ai, healthcare professionals will be more adept at tackling the challenges presented by bacterial infections, further propelling medical practice towards enhanced precision, efficiency, and personalization, ultimately striving 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(2021). implications of the use of artificial intelligence in public governance: a systematic literature review and a research agenda. government information quarterly, 38(3), 101577. https://doi. org/10.1016/j.giq.2021.101577 pa ge 1 pa ge 73 american journal of medical science and innovation (ajmsi) involvement of restored treg cells in the immune pathogenesis of parkinson’s disease (pd) running title: immune pathogenesis of parkinson’s disease ashraf sobh ibrahim1* volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1924 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 12, 2023 accepted: september 09, 2023 published: september 16, 2023 neural regression with neuroinflammation and immune dysfunction through neurodegradative disorder is known as parkinson’s disease (pd). parkinson’s disease is a progressive degradative neuronal disorder. in this disease, the continuous depletion of dopaminergic neurons and the existence of protein lewy bodies are the key points of pd development. in pd patients, regulatory t cells (tregs) are decreased in number and have an impaired proliferative capacity that affects the suppression of t-cell characteristics. the thymus involution decline in the functionality of t-cell development and consequently naïve t cells makes the immune system more vulnerable to losing its immune surveillance, increasing morbidity and mortality in aged individuals. the persistent process of thymic involution with age vigorously contributes to a progressive reduction in thymic output. genomic damage, cellular senescence, and epigenetic alterations are the hallmarks of cellular or molecular damage in aging. therapeutic potential for regeneration of the thymus would improve immunity. some strategies and approaches have focused on cell-based approaches, technology based on organoid and scaffold modulating of endogenous and exogenous compounds to help in the thymus regeneration, and fabrication technologies that could be used as regenerative approaches. last but not least the pluripotent stem cell therapies. keywords neuro-degradation, parkinson’s disease, thymic involution, pluripotent stem cell 1 biology department, faculty of science, jazan university, jazan, kingdom of saudi arabia * corresponding author’s e-mail: ashraf_sobhi12@outlook.com introduction neural regression with neuroinflammation and immune dysfunction through neuro degradative disorder is known as parkinson’s disease (pd). parkinson’s disease is a progressive degradative neuronal disorder. in this disease, the continuous depletion of dopaminergic neurons and the existence of protein lewy bodies are the key points of pd development. increased microgliosis along with dysfunction of the peripheral immune were also indicated by several reports in the development of pd (balestrino & schapira, 2020). prevalence showed that it is the second chronic progressive neurodegenerative disease after alzheimer’s, with environmental and genetic factors that interact to develop it in older age (miri et al., 2020) (goldman, 2019). in pd patients, regulatory t cells (tregs) are decreased in number and have an impaired proliferative capacity that affects the suppression of t-cell characteristics. in animal models of pd, restoring tregs and their suppressive function reduces disease-associated inflammation and provides neuroprotection. similarly, in the field of cancera disease no less dangerous than parkinson’s disease (pd) a treg cell depletion restores and improves endogenous anti-tumor immunity. accordingly, it becomes possible to promote regeneration and prevent the evolution to irreversible tissue damage by restoration of treg cells. thus, the restored treg cells help in the immunopathogenesis of parkinson’s disease (pd) (thome et al., 2021). in old age, thymus degradation is associated with decreased precursors of t cell output, which reduces individuals’ activity in t cells. it increases susceptibility to infection and is prone to autoimmune disease and cancer. thymic involution is the intense situation in which ubiquitous change is observed in the aging immune system, but the mechanisms underscore this process are still unclear (barbouti et al., 2020). the prevalence of pd has increased day by day. approximately 2.5 million individuals suffered it in 1990, while the prediction shows it will increase three-fold to 17.5 million in 2040. reduces neuroprotection activities associated with environmental parameters, i.e., pollution, smoking, and boosted exposure to industrial byproducts (schwab et al., 2020). usually, it affects the old aged individual more than the adult once. because it depends upon the immunological status of humans. in old age, the body’s system becomes weaker timely, so the immune system is also affected by the side effects of other pathological conditions such as hypertension, stroke, and other cardiovascular disorders (mas-bargues et al., 2021). the thymus gland begins to atrophy (shrinks) until we have little or none left. t-cells migrate towards the thymus to mature from the bone marrow because it is the primary lymphoid organ. it is also involved in the development to improve the efficiency of t-lymphocytes or t cells (knight, 2021). persistent age-associated atrophy is found in the thymus gland in which loss of thymic epithelial space (tes), i.e., thymus involution or atrophy, leads to inhibition of thymic output (rezzani et al., 2020). it was represented by its role in developing t-lymphocytes or t cells, an extremely important type of white blood cell. t cells protect the body from potentially deadly pathogens like bacteria, viruses, and cancer. such a regulatory role driven by t cells causes dysregulation in immune cells(varadé et al., 2021). the dysregulated immune cells lead to a propa ge 74 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 73-78, 2023 inflammatory tumor microenvironment and promote the secretion of growth factors, i.e., chemokines and cytokines/proteinases. additionally, the intercellular communication between cancer and immune cells plays a key role in modulating the immune response, promoting cell migration, proliferation, and tumor progression (schulz et al., 2019). the state of chronic thymus involution in aged individuals creates a weaker immunity through a great decline in the functionality of t-cell development and consequently naïve t cells. this makes the immune system more vulnerable to losing its immune surveillance, increasing morbidity and mortality (schwab et al., 2020). significance of thymus in the human body thymus, located right behind the collarbone, is the essential part of the immune system. in the thymus, naive t immune cells develop through undifferentiated thymocytes specializing in specific pathogens or cancer cells. t cells serve a potential role in regulating the immune system. it has been important that the size of thymus reduces progressively with age, termed thymic involution (barbouti et al., 2020). the thymus’s immune benefit produces a class of immune cells called t lymphocytes. these cells complement the b cells to constitute the adaptive immune system. humans produce fewer and fewer t cells as humans age, and some recent literature reported that humans might not even produce any newer t cells after age 60 (park et al., 2020). the persistent process of thymic involution with age vigorously contributes to a progressive reduction in thymic output. humans become more susceptible to cancer and infectious diseases in old age as their immunity weakens (wiertsema et al., 2021). predisposing factors of thymic involution the shrinkage of the thymus in old age, this phenomenon is known as involution. an ancient and evolutionarily conserved process showed that thymic involution occurred in many vertebrates (rezzani et al., 2020). thymic aging is marked by lowered production of (new) naive t cells and adipose tissue instead of lymphosarcoma thymic zones (cakala-jakimowicz et al., 2021). literature shows that thymus shrinkage is an age-dependent program. the infiltration of adipocytes (fat cells) is initiated in puberty or earlier and will take over in middle age. age changes in the thymus into fatty tissue from a primary lymphoid organ(velardi et al., 2021). besides fat deposition, many other factors of age-associated changes may trigger thymic involution. firstly, the decrease in bone marrow output is the source of hematopoietic stem cells (hsc). this comprised of t cell progenitors anonymously enter the blood circulation and relate thymic epithelial cells to get matured, defined as the developmental program. the decline was observed in t-cell progenitor cells and hematopoietic stem cells by age (liu et al., 2020). second fibrosis, by the age of thymopoiesis replaced by fibroblasts after signaling by specialized thymic epithelial cells. fibrosis is also observed in various organs, i.e., the liver, kidney and heart, as a common aging signature (borgoni et al., 2021). thymic involution consists of a two-stage process, growth-dependent thymic involution during puberty and age-dependent thymic involution (sekai et al., 2019). formation of intrathymic t cell receptors (tcrs) the t cells mature in the thymus, migrate from the bone marrow as pre-t cells, and pass through the thymus. they form their t cell receptors (tcrs) with their two chains (α and β). these tcrs give the t cell its specificity through a process of genetic recombination. they go through positive and negative selection in the thymus. so, if a tcr binds to self too strongly (they would cause autoimmunity), they are deleted. if they cannot bind selfenough, they would be unable to make antigen recognition bound by mhc molecules, which is typically required for t cells then they are also deleted. those that can loosely bind mhc but not so strong that they would be selfreactive mature t cells reach the secondary lymphoid organs before they can remain in the blood circulate (i.e., spleen, lymph nodes, etc.) (smith & göbel, 2022). intrathymic integration of t cell migration and thymocyte differentiation the thymus gland is necessary for producing t lymphocytes, central to cellular immunity, humoral immunity, and some of the body’s nonspecific defenses. chemokine receptors, such as cc-chemokine receptor 7 (ccr7), ccr9 and cxcr4 are responsible for the recruitment and entry of bone marrow-derived t lymphoid cell progenitors, called thymocytes. two events for the maturation of thymocytes were reported: the rearrangement of the gene of the tcr and association with coreceptors cd4 and cd8 (granadier et al., 2021). thymocytes’ progress depends upon three developmental stages with an expression of the cd4 and cd8 coreceptors. double-negative (dn) thymocytes do not express cd4 and cd8 in t-cells after attaching with coreceptors cd4 and cd8. tcr consists of α and β subunits having alternate sequences. this variation shows the randomization of gene segments and foreign antigen thymocytes, which can recognize as major histocompatibility complex (mch) molecules (cosway et al., 2021). t cells increase their affinity by self-peptides bound to (pmhc) for positive selection and peripheral survival. mature tcrs with cd4 and cd8 coreceptors in the same cell are double-positive (dp) thymocytes. tcr-self-pmhc interactions promote dp thymocyte survival and convert it into a single positive (sp) stage. this outcome is called positive selection (kisielow, 2019). apoptosis is generated if tcr is not involved in selfpmhc, and high affinity (strong signaling) generated after self-pmhcs are known as non-selection and negative selection, respectively. (srinivasan et al., 2021) self-mhc bond tcrs are restricted, mature and self-tolerant. when expressed cd4 or cd8, it becomes single positive (sp) thymocytes, also known as clonal selection (helgeland et al., 2020). the binding of cd4 or cd8 and tcr to the pa ge 75 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 73-78, 2023 mhc molecule forms the tcr–cd3 complex through noncovalent interaction with cd3 γ, δ, ε, and ζ proteins of the intracellular domain. (shah et al., 2021) expression of chemokine receptor ccr7 after positive selection tests of thymocytes as an additional requirement fulfill an in the medulla of the thymus. the medullary epithelial cells of the thymic produce ccr7 cytokines that enhance the negative selection of potentially autoreactive thymocytes. after development in the thymus, thymocytes migrate to the lymphoid organs through the bloodstream and are considered antigen-presenting cells. these lymphoid organs initiate protective immune responses in immunological challenges (kadouri et al., 2020). thymic involution and immune reconstitution the thymus serves as the development of self-restricted and tolerated along with immunocompetent t cells. thymus loses the characteristic of self-renewal. therefore, the continuous replenishment of new t cell progenitors comes from the bone marrow. after proliferation series and stages of differentiation on the guideline of the specialized thymic microenvironment, these cells become maturated. the anatomical structure of the human thymus gland is composed of the thymic epithelial space (tes) of the human thymus. thymopoiesis continues on the nonhematopoietic perivascular area (pvs), including adipocytes, peripheral lymphocytes, and stroma. reduce the efficiency of t-cell development and decreased migration of naïve t cells observed in aging characterized as chronic thymus involution (sergi, 2020) the progress on the therapeutic thymus restoration and peripheral immune reconstitution in adults. restoring immunity in old age remains a challenge that needs further investigation. all older adults will be considered to have weak immune systems and reduced immunity due to vitamin d deficiency unless a supplement is taken. the weak immune function is associated with less responsive to drugs and more inclined toward infections in old individuals. similarly, a study observed that the expression of activation markers and t cell memory phenotype distribution is affected by age, body fat content, and pathogen status throughout the lifespan. (mittelbrunn & kroemer, 2021) inflammation and treg cell genomic damage, cellular senescence and epigenetic alterations are the hallmarks of cellular or molecular damage in aging (ermolaeva et al., 2018). literature showed that imbalance protein and proteostasis conditions along with essential nutrient lacking were observed in agingrelated diseases (deng et al., 2022). according to de cecco et al. 2019 chronic inflammation happens as selfantigens action due to pro-inflammatory reactions in aged persons (de cecco et al., 2019). therefore, an imbalance of th17/treg cells was found to cause inflammation in aged people (deng et al., 2022). previous studies showed that il-6 also acts as a pro-inflammatory cytokine and helps to balance th17/treg cells in the human body but high serum tnf and il-1 level imbalance the treg cells in aged individuals (pansarasa et al., 2019). reduced dcaf1 regulation was reported in treg cells, which caused an imbalance rate of activation of t cells in the immune system of aged individuals compared to younger ones. downregulation in dcaf1 ultimately increases the reactive oxygen species, directly affecting the interleukin 6 and interleukin 17 that imbalance the rorγτ+ foxp3 and caused chronic inflammation by dysfunction immunity in aging (guo et al., 2020). figure 1: chronic inflammation in aging due to imbalanced rorγτ+ foxp3 approaches to regenerate thymus therapeutic potential for regeneration of the thymus would improve immunity. some strategies and approaches have focused on cell-based approaches, technology based on organoid and scaffold modulating of endogenous and exogenous compounds to help in the thymus regeneration, and biofabrication technologies could be used as regenerative approaches. last but not the least, the pluripotent stem cell therapies. literature showed that in vitro thymic epithelial pa ge 76 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 73-78, 2023 progenitors of humans could be generated through embryonic stem cells (escs) with the help of activin a, which can produce cd4+ and cd8+ t cells along with cd3 complex. organoids technology extracts tecs by scaffolds through pluripotent stem cells (table 1)(sharma & moroni, 2021). the progressive disease is still untreated, but the cell replacement technique will be in consideration. human pluripotent stem cell therapies are used as a regenerative strategy through straight differentiation for midbrain dopamine (mda) neurons (kim et al., 2020), (elsworth, 2020). conclusion globally, pd is the most common chronic progressive neurodegenerative incurable disorder affecting elderly individuals over 65. the incurable pd, with its deteriorated motor function and devastating symptoms such as postural instability, bradykinesia, and quivering, suggests impairment of the patient’s life. the treg dysfunction in the pathogenesis of progressive parkinson’s disease may broadly improve our understanding of the pathology of this incurable disorder and assists in developing proper treatments for parkinson’s disease (pd) in the future. the possible cd4+cd25+treg cells treg dysfunction may be crucial in triggering and releasing dopamine chemicals (neurotransmitters) in the brain. thus, suggesting that treg dysfunction is associated with the pathogenesis of progressive parkinson’s disease. in this context, the possible contribution of cd4+/cd25+ regulatory t cells (tregs) is to mobilize themselves to get rid of the pd pathology significantly. therefore, the functional existence of highly regulated, adaptive immunopathogenic mechanisms will ultimately lead to developing future novel therapeutics for parkinson’s disease (pd). references awong, g., herer, e., surh, c. d., dick, j. e., la motte-mohs, r. n., & zúñiga-pflücker, j. c. 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(2021). the interplay between the gut microbiome and the immune system in the context of infectious diseases throughout life and the role of nutrition in optimizing treatment strategies. nutrients, 13(3), 886. pa ge 1 pa ge 13 1 american journal of medical science and innovation (ajmsi) enhancing interoperability and response coordination in disaster settings: a review of methodological frameworks and technique alina petrica1, mohammed isa lawan2*, amakama nimisingha jacob2, gilles dusserre2 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3612 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 12, 2024 accepted: september 09, 2024 published: november 14, 2024 when mobile field hospitals are deployed for disaster response missions, they face several challenges. notable among the challenges is the lack of interoperability with the regional hospitals which is essential for patient information sharing and transfer when the need arises. several healthcare systems around the globe have interoperability platforms that are well in place. however, due to different standards and system design they cannot easily interoperate with one another. this is even more apparent when interoperability during disaster response is desired between a mobile field hospital and regional hospital. the several interoperability frameworks designed by vendors are mainly designed for usage in large stationary hospitals, hence there is need to consider frameworks that can enhance interoperability between a mobile field hospital and regional hospital to facilitate coordinated disaster response. in this article we argue that an effective disaster response interoperability framework should be adaptable, affordable, simple to use, and capable of being employed in isolated, harsh environments such as occurs during disaster response. an analysis of several healthcare interoperability frameworks is conducted in this article with the aim of proposing a suitable framework for possible adoption by mobile field hospital’s interoperability with regionals hospitals during sudden onset disasters. keywords disaster response, electronic medical records, emergency medical operating system, interoperability, mobile field hospital, regional hospital, telemedicine 1 university of medicine, timisoara, timis, romania 2 imt mines alès, france * corresponding author’s e-mail: mohadamagum71@yahoo.com introduction background and significance disasters as defined by united state office for disaster risk reduction (undrr) is a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability, and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts. the effect of the disaster can be immediate and localized but is often widespread and could last for a long period of time. the effect may test or exceed the capacity of a community or society to cope using its own resources, and therefore may require assistance from external sources, which could include neighbouring jurisdictions, or those at the national or international levels necessitating request for mobile field hospital deployment (undrr, 2020). a mobile field hospital is defined as mobile, self-contained, self-sufficient medical facility that is capable of rapid deployment, expansion or contraction to meet immediate emergency requirement for a specified period of time (rossodivita, 2011).the conditions involved before a field hospital can be dispatched include: (a) a written request by health authorities of the affected country, (b) be integrated into the local healthcare systems, and (c) a clear definition of their roles, responsibilities, and operational attainment. the main purpose of a field hospital is to compliment or substitute local hospitals in advent of sudden impact events that produce a disaster. when mobile field hospitals are deployed for disaster response, they are faced with myriads of challenges, notable amongst is the lack of interoperability with other regional healthcare systems (hamis et al., 2023; anyam gift et al., 2020; olalekan & gift, 2020; raimi & raimi., 2020) interoperability plays a role in emergency situation, especially in emergency departments, where it can be both essential and insufficient, at times, especially during large scale disasters (migliorini, 2019). the concept of interoperability refers to the capacity of information systems, devices, and applications to access, exchange, integrate and collaborate through sharing data across organizational boundaries. this coordination aims to ensure access to information and optimize the wellbeing of individuals and populations (li et al., 2022). when health information systems lack interoperability, it compromises the quality of patient care, and leads to unnecessary resource wastage (torab-miandoab et al., 2023).this brings about the importance to have a compatible healthcare interoperability frameworks. in disaster situations the importance of interoperability frameworks has been growing. it is crucial for organizations involved in disaster response to communicate effectively and coordinate their efforts. interoperability challenges can make information sharing and coordination, among organizations a daunting task, especially during a disaster (migliorini, 2019; matshaba et al., 2023). interoperability frameworks play a role in facilitating the exchange and sharing of data across diverse systems and services. these frameworks encompass a range of standards, guidelines and policies that outline the agreements for organizations to establish connections between their systems using pa ge 13 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 interfaces and protocols. by implementing interoperability frameworks at levels, such as syntactic, semantic, organizational and legal aspects, seamless connectivity can be achieved (ndlovu et al., 2021). the european interoperability framework (eif) serves as an illustration of an accepted method, for providing public services with seamless compatibility. interoperability frameworks depend on public service governance that encompasses aspects like usability, security, privacy, and performance. when creating an interoperability framework, it is crucial to define four layers; legal, technical, semantic, and organizational. however, these layers are seldom defined in disaster settings, where inter-operability is required in the interaction between existing regional hospitals (rh) and mobile field hospitals (mfh). the objectives of this study are to provide answers to two research questions; (1) what are the healthcare interoperability challenges in disaster settings? (2) which of the current interoperability frameworks can improve the interoperability between a mobile field hospital and the regional hospitals during a disaster response? interoperability challenges in healthcare for a time, the healthcare industry has recognized the issue of interoperability. interoperability challenges in healthcare arise from the obstacles faced when trying to exchange and share data seamlessly among systems and services. these challenges encompass issues such, as. • lack of coordination among different facilities/health systems participating in or facilitating health information exchange (hie) (mitigating barriers to interoperability in health care | himss, 2019). • resistance to data sharing and lack of skill (top healthcare interoperability challenges excellarate, 2023). • constraints in budget (‘interoperability in healthcare tech, 2022; top healthcare interoperability challenges excellarate, 2023). • lack of standardization of terminology and normalization of data(healthcare interoperability: barriers and solutions, 2020). • inconsistent information across multiple sources (ali, 2022; top 5 challenges with interoperability in healthcare, 2021). • poorly enforced standards that can obstruct seamless health data exchange by complicating transactions and posing additional barriers to the flow of information (ehrintelligence, 2017). • inability to identify patients consistently (ehrintelligence, 2017). • legal system issues: systems implemented before the establishment of common national standards are known as legacy systems, which typically have restricted interoperability capabilities (barbarito et al., 2012). • lack of interoperability standards or poorly enforced standards(ehrintelligence, 2017). • complexity of healthcare domain (barbarito et al., 2012). these difficulties can lead to negative health outcomes, increased expenses and a decrease in the quality of patient care (iroju et al., 2013; sadeghi et al., 2023; top healthcare interoperability challenges excellarate, 2023). to address these issues, stakeholders are adopting healthcare technologies and approaches that promote interoperability. this includes utilizing intelligence empowering patients to engage with their health data and strengthening health information exchanges (3 ways to enhance healthcare interoperability with health it, 2020). additionally, enhancing interoperability requires a combination of strategies like realigning incentives and overcoming barriers that hinder the exchange of electronic health information (mitigating barriers to interoperability in health care, himss, 2019) (sadeghi et al., 2023) literature review in this part, we’ll look at several interoperability frameworks and extensively study each framework to evaluate its strengths, flaws, and applicability to diverse scenarios. the main aim is to find a suitable framework for mobile field hospital’s interoperability with regional hospitals for patient information sharing and transfer during disaster response. electronic medical record (emr) an emr has the potential to significantly enhance the quality, usability, security, and interoperability of documentation with other systems and teams (schreiber et al., 2022). according to gaynor et al. (2014), emrs that adhere to the us office of national coordinator’s (onc) meaningful use criteria will: • enhance clinical decision-making, • minimize redundancy, • improve compliance with documentation and treatment standards, • enable context-specific information presentation, • integrate clinical documentation and billing functions, • support clinical research and quality improvement. the interoperability of health care applications becomes complex due to the components of an emr. a typical hospital emr consists of systems, clinical documentation, laboratory, radiology, pharmacy and physician order entry modules. when clinical data is recorded using data elements (hl7v3 cda) encoded in a manner (xml) with accepted terminology (snomed) and stored in a manner that enables the use of standardized retrieval methods these benefits are more likely to be realized (gaynor et al., 2014).hence sharing of electronic medical records will go a long way in improving interoperability across various healthcare systems. use of iphone application ichat electronic medical records are extensively utilized in both developed and some developing countries, playing a role in addressing challenges within the healthcare industry. interestingly their significance becomes more pronounced during short medical service trips to areas pa ge 13 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 despite their limited implementation in such regions (dainton & chu, 2017). the research underscores the value of two technologies; the iphone application called ichart and traditional satellite communication. the study highlights how emr greatly benefits low resource settings and challenging environments. specifically, it improves care coordination and information retrieval by enabling devices to access data thereby replacing the old paper chart system with longitudinal patient records and a centralized repository for essential patient information. however, it is worth mentioning that some limitations exist; for instance, the current version of ichart has been criticized for its time-consuming nature as it takes around two to five minutes to input patient data. additionally, one of the authors noted that their emr system becomes less usable on days when there could be up to 500 encounters (dainton & chu, 2017). according to the study, emr has gained popularity while other emrs-like systems are still in the pilot phase and mainly used internally by non-governmental organizations (ngos). based on this finding smaller rival emr systems should consider enhancing their technology to facilitate communication and data manipulation, between physicians, patients, other clinicians and larger emr platforms. this suggestion aims to enhance interoperability among these systems. intelligent agent technology (aida) researchers, from the university of minho collaborated with one of portugals leading hospitals centro hospitalar do porto (chp) to develop the agency for integration, diffusion and archive of medical information (aida). aida is a platform that facilitates the integration and sharing of data generated in healthcare settings. by utilizing tools like service oriented architectures (soa) and multi agent simulation (mas) which ensure interoperability in diverse contexts, aida offers ways to integrate information. what sets aida apart from systems are its programs functioning as proactive software agents and intelligent workers. these agents handle tasks such as managing information, sending, and receiving medical reports, photos, data collection, prescriptions, communicating with systems and providing accurate and timely responses to requests. as the volume and complexity of data generated in healthcare facilities continues to grow so does the need for a system to manage these agents effectively. to address this need, cardoso et al. (2014), proposed a module for aida that allows administrators to create agents to schedule their actions and monitor their activities closely. the primary goal of aida is to distribute and store datasets from various sources, like services, departments, units, computers, and medical devices. additionally, it provides tools to make human connections easier. ensuring that aida functions optimally and satisfies its stakeholders (such as administrators, physicians, nurses, patients) is crucial because the aida platform has become indispensable for operations in healthcare institutions where it’s implemented. given that the agents form the foundation of the aida platform (even a small anomaly during their execution) can lead to issues for a healthcare facility. these issues can directly or indirectly impact treatment. thus, aida administrators need to be aware of an agent’s tasks and their duration along with details. consequently, it became necessary to develop a module for managing aida agents to identify agent failures. social and healthcare information sharing system (siss) barbarito et al. (2012) present the application of interoperability standards in the lombardy regional healthcare information system in italy. the method included implementing the health level 7 (hl7) standard within individual institutions as well as establishing a technology infrastructure for data sharing based on regionally recognized interoperability protocols. this enables the integration of various healthcare organizations in the region, resulting in large-scale integration among healthcare providers while also serving patients. also, it facilitates communication and message exchange across many actors in the healthcare system, including hospitals, general practitioners, specialists, nurses, and pharmacists, by utilizing standardized web services and integration profiles. telemedicine telemedicine refers to the use of information and communication technologies to deliver healthcare services and support when physical distance separates the people involved (jamal et al., 2007). in the study, telemedicine was utilized to enhance interoperability, between healthcare providers and tertiary healthcare facilities during an earthquake that occurred in pakistan on october 8, 2005. furthermore, telemedicine has the potential to address the issue of staff shortages, which was an observed challenge at covid 19 field hospitals (alpert et al., 2018). an example of this success can be seen during the fmt type 3 nepal mission in 2015, where a consultant pediatric cardiologist was not physically present to treat a child with difficulty breathing and an abnormal ecg. by utilizing telemedicine, images and videos were transmitted to the specialist who provided lifesaving advice. this intervention has not only resolved staffing shortages but also improved collaboration between healthcare systems when expertise from limited specialists is required. emergency medical operating system (eos) emergency medical teams (emts) are dispatched immediately in response to sudden onset disasters to provide care for the injured. however, coordinating and communicating with regional hospitals can be challenging for emts due to the lack of information systems and standards (schreiber et al., 2022). to tackle these challenges the emergency medical team operating system (eos) was specifically developed for emts. the european modular field hospital (eumfh) which is a project pa ge 13 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 of the european directorate general for european civil protection and humanitarian aid operations (dg echo) supported by the general directorate, for civil protection and humanitarian aid operations of the european commission aimed to conceptualize a european emt3 and ultimately led to the creation of the emergency medical team operating system (eos). sharing data with systems is crucial in situations where an emt may collaborate with responders and nearby hospitals. to facilitate integration into an information processing chain an interface called hl7 fhir was developed. additionally, each information card can be linked to scanned or downloaded documents allowing for the inclusion of data and complementing eos data forms while ensuring continuity of care. this feature would enable the use of preprinted eos forms during prolonged power outages and enable the addition of completed forms scanned to their cards once power is restored. eos can be accessed through a web browser that is compatible with any device ranging from smartphones to pcs making it user friendly and intuitive. the patient care user interface has been specifically designed for tablet pcs providing flexibility for staff members to move around the field hospital as needed (schreiber et al., 2022). to effectively communicate with teams, the emr language can be easily switched at any time. the system is designed to strike a balance between openness and necessary restrictions. its aim is to minimize the number of clicks required for users to quickly respond in emergency situations. to ensure traceability, quality and safety standards are met, eos maintains a comprehensive audit log that tracks all user added or modified data. moreover, it allows flexible role allocation for healthcare professionals such as doctors, nurses, and technicians with system permissions for each role. eos offers an emr solution tailored specifically to meet the needs of emts. it addresses the standing need in the market for a portable digital tool that facilitates organized and transparent documentation—an essential aspect of managing, coordinating, and evaluating disaster relief operations. initial assessments conducted during a field exercise demonstrated implementation of the system while receiving positive feedback from users (schreiber et al., 2022). the hermes semantic model vergeti et al. (2018) developed the hermes model which is an ontological representation of the conceptual model of the health emergency management domain that makes up the hermes semantic model, which aims to: (a) provide an integral conceptual model of health emergency management covering all relevant knowledge domains; and (b) address the previously mentioned interoperability and integration issues. hermes reuses existing ontologies to produce a new upper model, a set of vertical models, and a data facet. a specific method imports data from the various resources using the model to give an integrated and consistent view of the data. the final standardized data may be used by different event management platforms to assist in making decisions during an emergency. lastly, open data from open data sources is used to assess the model and the data harmonization process. the evaluation’s findings confirm that the strategy is appropriate. even though there are many ontologies accessible, the hermes approach is unique since it establishes a general higher model for emergency response that can be used for any incident, including mass emergencies and everyday occurrences. additionally, hermes adheres to interoperability requirements that the emergency management ontology does not anticipate. complete and resilient documentation (card) for operational medical environments clemson university united states sponsored the research by woo et al. (2019) on interoperability framework known as the complete and resilient documentation for operational medical environment (card). this systemoriented approach aimed at enabling resilient handsfree data collection, preserve complete documentation and provide timely information for medical operations. it is a highly flexible and evolvable framework which addresses challenges of handsfree electronic health record data entry in noisy operational environments, preventing disruption of care for documentation and avoiding loss of documentation. systems, methods, and techniques for interoperable emergency communication ma et al. (2020) proposes the use of systems methods and techniques for interoperable emergency communication. this proposes a framework for triggering and releasing emergency communication escalation events which enhances emergency communication systems. the framework suggests the use of notifications to inform specific individuals or groups involved in escalation, ensuring timely communication during emergency situations. even though the framework was aimed for military emergency response, the concept of emergency communication escalation can be applied within organizations or across multiple organizations, facilitating coordinated responses to emergency. hence such approach can be applied to filed hospitals and enable interoperability with other regional hospital during disaster response. interoperability framework for integrated e-health services this framework, which is built using web service technology and the service-oriented architecture (soa) paradigm, is proposed (amin et al., 2020). during the analysis and design phases of system development, a technique called service-oriented analysis and design (soad) is employed to create a service portfolio that is divided into three levels: conceptual, logical, and physical views. pa ge 13 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 the service oriented architecture (soa) paradigm in system development is demonstrated by the service portfolio, which was created because of the architecture of the interoperability framework for the e-health service utilized in this study. an array of computer-based information systems, including emergency department, inpatient, laboratory, financial, and other services, are integrated into the e-health service to satisfy stakeholder information needs and patient demands. the goal of the project was to develop an interoperability mechanism model for sharing information and data between multiple databases, including the national population database, the health insurance database, and e-health services run by hospitals or other health data providers. automatic ambulance system using internet of things saha et al. (2020) suggested this model in which the raspberry pi serves as the foundation for the architecture, with sensor units connected to it. sensors are used to measure the patient’s physiological characteristics. parameters include heart rate, temperature, blood pressure, glucose, cholesterol levels, and more. the machine also has a camera module for capturing patient images at regular intervals. after completing the ambulance module, upload the data to the cloud. the cloud module includes two cloud services. they’re thinkspeak and dropbox. the thinkspeak cloud platform allows numerical data to be submitted. thinkspeak cloud provides graphical representation of uploaded data. the images are uploaded to dropboxcloud.in the hospital module, the doctor monitors the data that has been uploaded to the cloud. the red detected image aids clinicians in determining the severity of wounds. the hospital module includes a basic application that downloads data from the cloud. with the data collected, the doctors plan for an immediate medical response. this, however, is best suited for interoperability between emergency medical ambulance and regional hospitals within a given metropolitan. table 1: comparative analysis of selected interoperability frameworks author (s) methodology advantages disadvantages applicability cardoso et al., 2014. service oriented architecture (soa) and mas. uses intelligent agent-based technology aida enhance communication with various systems and provide accurate and prompt responses to requests. flexible and can be applied to different healthcare environments. expensive and complex more useful in larger healthcare systems. barbarito et al., 2012. social and healthcare information sharing system (siss): adoption of hl7, using a conceptual framework with technological infrastructure for data sharing provides interoperable social healthcare system that, by putting international health standards into practice, connects patients, healthcare providers, healthcare organizations, and healthcare professionals in a vast and diverse territory expensive and complex, may not be easily used in areas with low connectivity and power supply. suitable for stationary healthcare facilities. some aspects, such as ehr, appointment scheduling and reporting tools could be useful with mobile field hospital dainton et al., 2012. highlighted two most popular emr systems technology (proprietary iphone application called ichat to create a patient log and custombuilt clinical database constructed for the palm operating system (os) using the smart list to go program, and 5 personal digital assistants (pdas) used by mobile field hospitals during haiti earthquake. shows importance of the creation of longitudinal patient records and a centralized repository of basic patient information resulted in improved provider handoffs and continuity of care. data could be accessed from multiple devices, rather than one fixed central location in the case of paper charts, resulting in improved interoperability the current version of ichart was reported to be too cumbersome, as it took 2-5 and a half minutes to input a single patient encounter. researchers reported their emr system to be impractical during busier days when there could be upwards of 500 patient encounters. suitable for use in a low resource setting and mobile medical facility such as the mobile field hospital pa ge 13 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 jamal et al., 2007 telemedicine mobile device connected to a base unit via a customized software which enables seamless exchange of data between the two units speeds up diagnosis and therapeutic interventions by allowing primary healthcare providers to receive continuous assistance from specialized centers. it is has the advantage of being cost effective require technology and communication infrastructure. data privacy and security are not guaranteed. this can be applied to areas where specialized care is absent or lacking and can address the issue of staff shortage. suitable for mobile field hospital schreiber et al., 2022. emergency medical team operating system. uses emr, fhirhl7. data sharing with other systems is essential since an emt might work alongside first responders and nearby hospitals. hl7-fhir interface promote standard information transmission and make it easier to be incorporated into a larger information processing chain staff may require training regarding its usage. specifically designed for use by deployable emergency medical teams such as the mobile field hospital amin et al., 2019. utilized system-oriented architecture (soa) and implemented using web service technology. this is developed using service-oriented analysis and design (soad). materialize data interoperability and information exchange among several e-health systems. cannot be used on multiple platforms e.g., laptop, desktop, and mobile phones. designed for data exchange between multiple databases. vergeti et al, 2018 developed a semantic model called herme which reuses an existing ontological model to provide an upper model which imports data from various sources hence providing an integrated and harmonized view of the data. the model can be applied to any incident (every day or mass emergency). also aligned with interoperability standard not foreseen in emergency management ontology maily focusses on semantic interoperability flexible and can be applied to any incident woo et al., 2021 complete and resilient documentation (card) for operational medical environments is a system-oriented approach aimed at enabling resilient handsfree data collection, preserve complete documentation and provide timely information for medical operations addresses challenges of handsfree electronic health record data entry in noisy operational environments, preventing disruption of care for documentation and avoiding loss of documentation limited or unreliable network coverage in disasterstricken areas may hinder effectiveness of card highly flexible and evolvable system which is applicable in variety of scenarios including harsh austere disaster settings ma et al., 2020 proposes a framework for triggering and releasing emergency communication escalation events improves response times and enhance emergency communication systems may require personnel training and internet connections flexible and can be applied to healthcare emergency response such as deployed mobile field hospitals pa ge 13 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 amin et al.,2020 this framework uses web service technology and service-oriented architecture to build an interoperability model for information sharing between several data bases serve as a guide for creation of e-health systems across a range of medical applications further research is needed for developing e-health systems using multi platforms environments flexible and can be used for variety of healthcare system interoperability materials and methods we conducted searches in credible databases including web of science, pubmed, and google scholar. google search of websites was also included. the keywords used include “disaster response”, “mobile field hospital”, “regional hospital”, “emergency medical operating system”, “telemedicine”, and “electronic medical records”. for inclusion, we targeted articles published in english within the previous 20 years and focussing on the stateof-the-art on several healthcare related interoperability standards, frameworks, and applications. while for exclusion, we removed opinion pieces and studies with insufficient data. by using the search, 400 articles were found at first. upon examining abstracts and titles, we narrowed the field down to 86. after carrying out a full-text examination, we included 46 articles that satisfied the predetermined standards and chosen for in-depth analysis. finally, 28 articles were selected with additional 16 website obtained via google search containing relevant information as per the criteria. thus, assisting in gaining valuable understanding about several interoperability frameworks, their limitations, strengths and opportunities for improvement and application in disaster settings. these reviews were critical in the proposal of an appropriate methodological framework with features and capabilities that is anticipated to address the challenges that are usually associated with interoperability, vis-à-vis the improvement of healthcare delivery and subsequent patient outcomes in disaster settings. results and discussion result table 1 is a summary of the analysis done on selected healthcare interoperability frameworks. as the main aim of this research is to device a suitable framework that can be adopted during disaster response to enhance interoperability between mobile field hospital and regional hospital, we hold that the framework should meet some criteria: it should be cost effective, has ease of usage, is feasible in low connectivity or resource area, its practicality during emergency and it has data and security privacy. categorizing these frameworks based on these requirements we obtain the following results: cost effectiveness this must be considered when deciding which frameworks to use for mobile field hospital as a cheaper framework will be easy to implement in disaster and low resource settings. some of the frameworks that fits into this criterion include: 1. use of iphone applications e.g ichart 2. telemedicine 3. emergency medical team operating system ease of understanding for it to be adopted in emergency response, the framework should be easy to understand by the healthcare personnel. among the reviewed frameworks, it is obvious that the ones having easy mode of operation or requiring less training include: 1. use of iphone applications e.g ichart 2. telemedicine 3. emergency medical team operating system feasibility in low connectivity areas (remote locations) based on the analysis, the frameworks that are feasible in remote and low resource settings include: 1. use of iphone applications e.g ichart 2. telemedicine 3. emergency medical team operating system practicality during emergency situations among the reviewed frameworks, those that are best designed and suited in emergency situations include: 1. use of iphone applications e.g ichart 2. telemedicine 3. emergency medical team operating system 4. framework for triggering and releasing emergency communication escalation events by ma et al. (2020). 5. complete and resilient documentation (card) for operational medical environments privacy and security concerns privacy is an important challenge in interoperability and any framework must have data privacy and security protection even in emergency response situations. some of the frameworks that have more data privacy based on the information provided include the following: 1. uses intelligent agent-based technology aida. 2. social and healthcare information sharing system (siss) 3. complete and resilient documentation (card) for operational medical 4. framework for triggering and releasing emergency communication escalation events by ma et al. (2020). pa ge 13 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 discussion table 1 summarizes the weaknesses, strengths, and opportunities of the selected frameworks. some frameworks are better suited for a larger stationary healthcare system while others can be suitable for use in austere settings such as during disaster response. we hold that the suitable framework should have specific features applicable to a low resource disaster setting, they include adaptability, flexibility, cost effectiveness and privacy. the emergency medical team operating system was one that fits well because it has almost all the attributes. it was designed specifically for mobile field hospitals and was tested during a full-scale european union module exercise and proven to be effective by 21 team members from 9 different countries. its resource management feature enhances interoperability and coordination. the second one in line is the telemedicine. even though it lacked some qualities such as data privacy, it has excellent features which can easily be adopted for interoperability during disaster. the most prominent feature is the ability to allow medical consultations remotely. this is extremely important in situations of staff shortage or when a specialist intervention from a different location is required. the third is the ichat which is also very similar to the first two as it is suitable for use in low resource settings. another similarity is it also can be used on several platforms e.g. phones, laptops, and tablets. other frameworks that are very specific for emergency response include: the hermes semantic model, complete and resilient documentation (card) for operational medical environments, and interoperability framework for integrated e-health services. these frameworks can also be considered due to their specificity for emergency response, data security and flexibility to several conditions. however, they maybe be costly and may also require some operator skills. furthermore, they have not been tested for usage in a mobile field hospitals or emergency medical teams as in the case of the emergency medical team operating system. other frameworks have better data security and privacy and are better suited for larger stationary hospital e.g. uses intelligent agentbased technology aida and the social and healthcare information sharing system (siss).in view of this, it can be seen that the best suitable framework is not the one with the greatest quality in one aspect but the one that is more flexible to accommodate a whole different attributes. this is to make disaster response easier in an environment where the resources are lacking, and more technical and sophisticated expertise is not available. we therefore suggest that choosing a framework that satisfy the conditions proposed by the authors will greatly enhance interoperability between mobile field hospitals and regional hospitals in disaster response. limitation the disadvantage of this study is that various alternative frameworks may have been overlooked due to a lack of access to non-open-source literature focusing on interoperability. furthermore, most of the information presented about each framework was based on the information provided in the article, and thus it may contain some characteristics that were not recorded in this article. future directions the several frameworks and systems shows potential for exploration and advancement. here are a few aspects that can be explored further. resource allocation algorithms create algorithms that enhance the distribution of resources by utilizing up-to-date patient information and facility capacities. research could delve into ai powered models to forecast patient requirements and adjust resource allocation strategies accordingly, in line with the frameworks highlighted. scalability and adaptability discover the potential of each framework to effectively respond to types of disasters whether they are small scale incidents or major emergencies. the research could concentrate on developing a structure that can adjust to patient volumes and resource requirements. remote training and education explore the possibilities of the frameworks in facilitating training and education for healthcare professionals during disaster response situations. this may involve utilizing simulations training modules and platforms for sharing knowledge. regulatory and legal frameworks it is important to study the regulatory aspects related to using the frameworks. this includes exploring licensing, liability and cross-border healthcare regulations. creating a framework that complies with requirements is vital for ensuring its widespread adoption. ethical guidelines create a set of guidelines to govern the use of the frameworks. these guidelines should cover aspects like ensuring consent for remote consultations, maintaining patient confidentiality, and promoting equal access to healthcare services. implementation and adoption strategies explore approaches for implementing the frameworks within established healthcare systems. this involves addressing change management, designing training programs, and devising strategies to overcome any resistance to the adopting technologies. human factors and psychology investigate the effects of consultations on healthcare professionals and patients in times of disasters. gaining insights into the emotional aspects can aid in enhancing the design and implementation of the framework. pa ge 13 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 conclusion as the world is experiencing increasing incidents of disasters, mobile field hospitals serve as the beacon of hope among chaos especially when the local capacity is at stake. however, to achieve a better patient outcome, these deployed mobile field hospitals will need to interoperate with the regional hospital to facilitate patients transfer and information sharing whenever required. most of the healthcare interoperability frameworks focus on creating frameworks that are more suitable for stationary healthcare facilities. to solve this problem, this article investigated various healthcare interoperability frameworks with the aim of finding a suitable framework between mobile field hospitals and regional hospitals during disaster response scenarios. the frameworks were selected based on their focus on interoperability of healthcare systems. their strengths, weaknesses, and applicability to mobile field hospital were analyzed. to find the best framework for adoption, we hold that the framework should be costeffective, easy to use, feasible, and practical in disaster and austere settings. patient data and security must also be considered. the result of the comparative analysis shows that some frameworks are less cost effective than others, have more feasibility in low resource settings, and have better ease of understanding. they include use of iphone applications ichat, telemedicine, and emergency medical team operating system. other frameworks have better practicality during disaster situations. they include framework for triggering and releasing emergency communication escalation events, complete and resilient documentation (card) for operational medical environments, use of iphone applications ichat, telemedicine, and emergency medical team operating system. while others have more privacy and data security. they include intelligent agent-based technology aida, social and healthcare information sharing system (siss), complete and resilient documentation (card) for operational medical, framework for triggering and releasing emergency communication escalation events by ma et al. 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(2018). point of view telemedicine at point of care. cureus. https:// pa ge 14 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 131-141, 2024 doi.org/10.7759/cureus.3662 what are the real-life benefits of fhir for healthcare? (2022, november 16). prolifics. https://prolifics.com/ us/resource-center/specialty-guides/fhir-guide/fhirbenefits woo, m., mishra, p., lin, j., kar, s., deas, n., linduff, c., niu, s., yang, y., mcclendon, j., smith, d. h., shelton, s. l., gainey, c. e., gerard, w. c., smith, m. c., griffin, s. f., gimbel, r. w., & wang, k.-c. (2021). complete and resilient documentation for operational medical environments leveraging mobile hands-free technology in a systems approach: experimental study. jmir mhealth and uhealth, 9(10), e32301. https://doi.org/10.2196/32301 pa ge 1 pa ge 21 american journal of medical science and innovation (ajmsi) assessment of breast cancer awareness among women of reproductive age in akure south local government area of ondo state omotayo lydia mojisola1* volume 2 issue 1, year 2023 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: february 02, 2023 accepted: march 02, 2023 published: march 06, 2023 incidence of breast cancer is increasing worldwide. breast cancer is the most commonly diagnosed cancer as a major cause of cancer death among woman according to national breast cancer foundation in 2016. the current prevalence of breast cancer in nigeria is 12.5% which implies 1 out of 15 women are living with the disease. this worrisome development will continue to attract attentions and actions of governmentsat all levels, ngos, health institutions and researchers. the study aims to assess breast cancer among women of reproductive age in akure south local government area of ondo state. the sample size of 110 women of child-bearing age were selected randomly across akure south, eleven political wards through multistage sampling technique. the data generated from in-depth interviews of the informants and from secondary sources like government journals, medical publications, hospital records, ngos articles and internet materials were qualitatively analyzed. the study revealed that majority of the respondents did not have adequate breast cancer awareness. the study concluded that the government and critical stakeholders should adopt more proactive approaches towards effective advocacy programmes that can checkmate the high mortality rate of the disease as the existing information channels have not impacted significantly on breast cancer awareness campaigns. therefore, it is hereby recommended that governments at all levels in collaboration with ngos, health organizations, religious bodies, mass media, traditional institutions and other stakeholders should intensify well coordinated efforts to create the needed awareness about the scourge among the womenfolk who incidentally have the highest prevalence of the disease. keywords awareness, breast cancer, mortality, prevalence, screening 1 department of public health university of cambodia, cambodia * corresponding author’s e-mail: omotayolydiamojisola@gmail.com introduction breast cancer is the most common cancer affecting 25.2% of women and is also the second leading cause of cancer-related deaths among women according to (okunnuga.n et al. 2021). almost half of breastcancer cases and 60% of breast cancer-related deaths are estimated to occur in middle-and –low-income countries. globally, the devastating effects on women diagnosed with breast cancer are appalling. global cancer statistics shows increased global cases of breast cancer and the rise is occurring at a faster rate in population of the middle-and-low-income countries which may be due to increase in population growth and aging. breast cancer is an aggressive disease affecting women, irrespective of their age category. women are particularly vulnerable and susceptible to breast cancer and their risks increase with advanced age. the origin of breast cancer has not been fully unraveled but is attributable to some interrelated factors of genetics, hormones, theenvironment, socio-biology and physiological factors according to american cancer society (2013). in the report by lydia and mpunga (2015), it was indicated that deaths as aresult of breast cancer in nigeria reached 13,264 or 0.70% and the age adjusted deathrate is 28.11 per 100,000 population, ranking nigeria 4th in the world. adebamowo and ajayi (2021) also stated that the malignant cells are developing in the tissue. breast cancer is the most common cancer in nigeria. in 2005, breast cancer was found to be the most common in nigeria. in the north-west geographical zone of nigeria, cancer ofthe breast is second to cervix, while the cancer registry at the university college hospital (uch) ibadan revealed that it is the leading malignancy among women. also, in the north-central, breast cancer constitutes 22.41% of the new cancer cases registered in 5 years and accounts for 35.41% of all cancers in women. breast cancer isundoubtedly the most dreaded cancer with lots of psychological impacts and one of themost popular malignancies that affect about one in every nine women. it is a disease inwhich the malignant cells are developing in the tissue of the breast. breast cancer is of two types, lobular cancer which begins in many small sacks in the breast that producemilk and ductal cancer which develops in the tubes that carry milk from the lobules tothe nipple. it is also the type of cancer having the highest prevalence (45.7%) among the female in nigeria and border countries. common signs and symptoms of breast cancer include a change in the way the breast or nipple feels, change in how the breast or nipple seems and discharge of the nipple. it is interesting to know that as debilitating as breast cancer disease is, majority of nigerian women have little or no knowledge of the disease and even in situations where they are aware of the disease, their attitude towards seeking healthcare is negative causing their untimely or preventable death https://journals.e-palli.com/home/index.php/ajmsi pa ge 22 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 21-25, 2023 (tayo, g. et al. 2019). it has been observed that certain socio-cultural, religious, genetic and economic factors are responsible for this negative attitude. statement of problem breast cancer is currently the most common type of cancer worldwide with 2.26 million cases recorded in 2020 (who 2020). it is also the most common cancer among women both in developed and developing countries and a major cause of public health concern. while it exists around the globe, developed countries have ahigher incidence rate and the incidence rate also varies by ethnicity and race (obalase and adegboro 2017). breast cancer was also the 5th leading cause of deaths worldwide in 2020 with 685,000 death attributed to it (who, 2021). in nigeria breast cancer caseswere historically low but are now increasing as a result of urbanization and lifestyle changes. it is the leading cause of cancer death currently representing about 23% of allcancer cases and approximately 18% of deaths are attributed to it. in nigerian women, breast cancer seems to be diagnosed at an advanced stage and the chance of survival are low (adebamowo and ajayi 2007). women in the country area also more frequently diagnosed with triple-negative breast cancer than women of european ancestry (mccormack, adebamowo and dos-santos-silva 2016). following late presentation of the disease the only option available are expensive treatment procedure which maybe unaffordable. the prevalence of breast cancer among women in ondo state, south western partof nigeria is on the high side from the clinical records of confirmed breast cancer patients, between march 2013 and april 2019 attending the oncology outpatient clinic at university of medical sciences teaching hospital, akure, ondo state, nigeria, reproductive women younger than 40 years constitutes 37.5% of the sample population of 20-89 years while those older accounted for 63.5% general objective of the study this is to assess breast cancer awareness among women of reproductive age in akure south local government area of ondo state. specific objectives of the study 1. to assess the most used channel(s) for breast cancer awareness. 2. to evaluate the influence of culture on breast cancer awareness. 3. to determine how often do women of reproductive age in akure south local government conduct self breast examination. 4. to determine the level of breast cancer awareness among women of reproductive age in akure south local government researchquestions 1. what is the most used channel(s) of information for breast cancer awareness? 2. does culture have influence on breast cancer awareness? 3. how often do women of reproductive age in akure south local government conduct self breast examination? 4. what is the level of breast cancer awareness among women of reproductive age in akure south local government? significance apart from adding to the body of knowledge about breast cancer disease, this study will be useful to the government, policy makers,health institutions, health care providers and research centers to improve on their breast cancer awareness strategies in order to checkmate the high mortality of the disease among women. literature review according to american cancer society, there are several types of breast cancer. the commonest type is ductal carcinomas. this begins in a milk duct. another type is lobular carcinoma. this begins in a lobule, one of the tiny glands that produce milk. ‘invasive’ breast cancer involves cancerous cells spreading to nearby tissues and other parts of the body while noninvasive’ breast cancer remains in place of origin. the cells may eventually became invasive. breast cancer occurs where there is a genetic mutation or damage to dna. this can be associated with exposure to estrogen, inherited genetic defects or inherited genes that can cause cancer such as brca1 and brca2 genes it has been argued that a lack of basic knowledge and quality information delivery system for breast cancer is a great impediment to the life and well-being of women. tayo, tolulope, emmanuel and olabode (2019) opined that breast cancer has been a major cause of death subtly killing women-especially thosewith little or no education. this is compounded by lack of timely information aboutbreast cancer and poor diagnostics screening methods for early detection. as importantas knowledge of breast cancer is, it is not sufficient unless sociocultural factor are taken into consideration by the health professionals providing direct healthcare. insufficient information concerning breast cancer has also been observed among rural and urban dwellers in nigeria; it is responsible for the poor perception of the ability tocure cancer earlier detected and the efficacy of screening tests. furthermore, the lack ofawareness on the issue of vulnerability and susceptibility associated with breast cancerdiscouragemany women from seeking intervention early or associate the symptoms they are experiencing with other health conditions. level of awareness regarding how to perform simple life saving diagnostic breastcancer checks such as self breast examination (sbe) further compounds the problem of late detection. empowerment of women with information on bse is paramount importance, https://journals.e-palli.com/home/index.php/ajmsi pa ge 23 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 21-25, 2023 especially in countries without modern technologies for breast cancersscreening. most of the nigerian rural communities lacked the required technologicalresources, but sbe can contribute greatly if women are informed about the technique,and regular practice would reduce late presentation. according to american cancer society, breast self examination (bse) is a screening method that is being used to defect early breast cancer. this involves a woman examining her own breasts to feel the breasts for possible lumps, swelling or distortion. mammography screening may also be done to detect breast cancer in asymptomatic women. in spite of its limitation in lmcs due to challenge of poor infrastructure, poverty, and inadequate human resources, it has been seen as the method of choice for screening and diagnosis which can significantly reduce breast cancer morbidity and mortality. certain socio-cultural factors also contribute to breast cancer prevalence in nigeria. as opined by akhigbe and akhigbe (2012), health beliefs vary across culture, and the fatalistic consequence ofcancer may discourage many from participating in health –promoting behaviors. this isbecause illnesses or catastrophic eventsinthispart of the worldare attributedto ahigher power (such as god), or they are meant to happen and cannot be avoided; as aresult, fatalism become part of the person’s world view. chronic conditions in many african societies are often associated with witchcraft and evil spirits. cultural values and ethnic diversity have an impact on health beliefs, which may influence how rural women interact with the western medication, especially conditions such as breast cancer. according to molute and molute (2015). some women delay seeking treatment because of fear or stigma concerning their daughters as it is believed that they also might be affected by breastcancer and might not be considered for a good marriage. furthermore, it is believed thatcancer is a death sentence from god. all these have continued to be crucial factors thatmay account for breast cancer prevalence in nigeria and other sub-sahara africancountries. this study seeks to ascertain the level of breast cancer awareness among women of reproductive age in akure south local government area of ondo state. theoretical framework this study is anchored on health belief theory. according to (rosenstock & becker, 1994), health belief theory is a social psychological health behavior change modeldeveloped to help explain and predict health related behavior with respect to acceptanceof health intervention. this implies that individual’ beliefs about health conditions will go a long way in predicting their health related behavior towards the health condition. therefore, the relevance of this theory to this work rests on the fact that women ofreproductive age acceptance of breast cancer interventions well largely depend on their perceived causes of breast cancer and the hope of getting the needed treatment from any available interventions. methodology this involves qualitative research by reviewing literature, medical publications, hospital records, government journals, ngo’s articles and internet materials. they are also corroborated by face to face interviews purposively conducted in eleven (11) political wards in akure south local government area among 110 women of reproductive age. the eleven political wards are: aponmu, gbogi / isinkan 1, gbogi / isinkan 2, ijomu /obanla, ilisa, oda, odopetu, oke-aro, uro,isolo/ oshodi, owode/imuagan. the sample size of 110 informants were allocated appropriately among communities selected through multistage sampling techniques within these eleven political wards. the data elicited from both primary and secondary sources were analyzed and presented as this research report. sociodemographic profile of the informants revealed that the informants are with in the child-bearing age bracket of 15–49 years. majority of the maregraduates and married. they are also working and their consents were sought and obtained before the interview. research question 1 what is the most used channel of information about breastcancer awareness among women of reproductive age in akure south localgovernmentarea? from the analysis of the opinions of 110 respondents, 44(40%) respondents chose hospital as the most used channel of information aboutbreast cancer among women reproductive age in akure south local government.: 31(28.2%) respondents chose mass media which consists of television. radio, newspapersand the internet : 23(20.2%) respondents chose friends through group discussions andsharing of information while : 12(10.9%) respondent chose market places. this showsthat hospital is the most used channel where information about breast cancer disease isdisseminated to create the needed information among women of reproductive age in akure south local government area. research question 2 does culture have influence on breast cancer awareness among women of reproductiveagein akure south? from the analysis of the opinions of 110 respondents : 67(60%) agreed that culture hasinfluence on the breast cancer awareness: 30(27%) is agreed while: 13(11.8%) were undivided. this shows that culture has influence on breast cancer awareness among women of reproductive agein akuresouth localgovernment area. research question 3 how often do reproductive women in akure south local government conduct self-breast examination and breast screen examination? from the analysis of the opinions of 110 respondents: https://journals.e-palli.com/home/index.php/ajmsi pa ge 24 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 21-25, 2023 72(66.5%) respondents conducted self breast examination once in a while. 17(15.5%) respondents conducted selfbreastexamination monthly while 21(19%) respondent conducted self-breast examination regularly. this results show that women of child bearing age in akure south local government area had poor attitude towards the practice of breast cancer screening. research question 4 what is the level of awareness of breast cancer among woman of reproductive age in akure south local government area? symptoms of breast cancer from the analysis of opinions of 110 respondents: 78(71%) respondents did not have adequate information about symptoms of breast cancer disease while 32 (29%) respondents had. risk factors of breast cancer from the analysis of opinions of 110 respondents 83(75%) respondents did not have adequate information about the risks factor of breast cancer disease while 27(24.5%) respondents had. causes of breast cancer from the analysis of opinions of 110 respondents, 87(79%) respondents did not have adequate information while 23 (21%) respondentshad. treatment of breast cancer from the analysis of opinion 110 respondents: 92(84%) respondents did not have adequate information while 18(16%) respondents had. from the results, it shows that women of reproductive age in akure south did not have adequate awareness about breast cancer. results and discussion the purpose of this study is to assess breast cancer awareness among women of reproductive age in akure south local government area of ondo state. the study revealed that majority of child bearing women had inadequate awareness about breast cancer which was a result of in effective communication channels and programmes by the government and stakeholders and strong influence of cultural belief of the inhabitants on illnesses and catastrophic events. it also revealed that majority of these women did not carry out self-breast examination which could have aided early detection of the disease and reduced eventual fatality. however, the findings of the study provided more insight into the understanding of the breast cancer, this encompasses the causes and prevention of breast cancer, the risk factors and types of breast cancer and symptoms and treatment of breast cancer and the recommendations that will increase the present tempo of the disease awareness among women of reproductive age in akure south local government area. conclussion breast cancer is a fatal disease that has affected significant number of child bearing women in akure south local government area. it could be concluded that inter-related factors such as age, education, family history , culture, individual attitude, and socio – economic factors have influence on the disposition of this women towards the awareness of the diseases and its control. also, the study concluded that the existing efforts of the government and stakeholders cannot stem the rising tide of breast cancer incidence. hence, there should be more collaborative efforts of the stakeholders and more vigorous awareness campaigns in akure south local government area.it is concluded that poor breast cancer awareness and poor attitude to breast self examination (bse) practices are predominant among women of reproductive age in akure south local government area and are responsible for the high prevalence and presentation of the disease that had caused premature but preventable deaths of many notable personalities within the community. the finding of this study are similar to previous studies conducted by (okunnuga, n. et al. 2021) on prevalence, stage and sociodemographic pattern of breast cancer in a tertiary institutions, south west, nigeria, obalase, s.b., and adegboro, j.s. (2017) on breast cancer screaming practices among women in akure south local government area of ondo state (olowokere, a.e. et al. 2012) on breast cancer knowledge and screaming practices among selected rural communities of nigeria and (omotara, b. et al. 2012) on awareness, attitude and practice of rural women regarding breast cancer in northeast nigeria. the future research should dwell on the interpretation of religious beliefs of women on their level of awareness about breast cancer disease. the following measures are, therefore, recommended after juxtaposing this study with the positions of previous scholars.. recommendations 1. there should be greater involvement of mass media in breast cancer awareness campaigns by the governments at all levels. 2. breast cancer screening should be made accessible to women at little or no cost. 3. health educators should involve religious bodies and traditional institutions in the awareness campaign to dissuade negative religious and cultural beliefs and myths that surround the disease. 4. women of reproductive age should be taught on how to carry out self breast cancer which will assist in early detection of the disease. 5. government should support the humanitarian interventions of some non-governmental organizations like breast cancer association of nigeria (brecan) society for family health, medical women association of nigeria (mwan) and national association of women journalists(nawoj) in their advocacy programmes on breast cancer. https://journals.e-palli.com/home/index.php/ajmsi pa ge 25 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 21-25, 2023 references ademowowo,c.a. and ajayi, o.o. 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(who). a structured questionnaire was used to conduct a cross-sectional study. the patient health questionnaire (phq9) and generalized anxiety disorder-7 (gad-7) were used as the two instruments to assess the symptoms of anxiety and depression in hcws. inferential statistics like the independent t-test, one-way anova, and pearson product moment correlation coefficient were used to examine the relationship between general psychological impact and socio-demographic factors. descriptive statistics like frequency, percentage, mean, and standard deviation were used to describe the socio-demographic characteristics. the age varied from 30-55 years, with a mean of 34.92 (sd=6.65). more than half (53.3%) of the respondents were muslims, and the majority (84.8%) of them were female. the average gad7 score was 2.65 (sd:.76). the findings showed that only 18.5 respondents had been diagnosed with severe depression, whereas 50% of respondents scored as having moderate levels of anxiety. the average gad7 score was 2.65 (sd:.76). as mental health issues were strongly related to all the mental health outcomes, more than half of the health workers experienced depression and only a few reported generalized anxieties at work. more anxious than other healthcare professionals were nurses. by emphasizing these things, it is advised that health workers can improve their mental health. keywords covid 19, health care workers, pandemic, mental health 1 nursing institute, munshiganj, bangladesh 2 south appolo medical college hospital, barishal, bangladesh 3 department of public health, adust, dhaka, bangladesh * corresponding author’s e-mail: laylaazmin@gmail.com introduction the covid-19 pandemic might trigger mental health problems among the general population as well as hcps. (repon, 2021). loneliness is associated with poor physical and mental health and higher mortality risk (henriksen, 2019). till to date, the effective ways to limit the viral spread are frequent hand washing, use of face masks, lockdown, quarantine, and social distancing.30 but adopting social distance in daily life contradicts the deeprooted human nature to relate to others and therefore brings about the feeling of loneliness (odusanya, 2020). as the hcps are always in close contact with the covid-19 patients, this may make them a super spreader of corona virus. therefore, self-isolation and quarantine from family members are frequent for them. these factors due to the hcp’s nature of profession may create additional psychological pressure on them, (khan,2020). besides other health problems, several cross-sectional studies reported poor sleep quality among lonely people (repon,2021). both loneliness and poor sleep quality impacted the mental health of hcps.38 compared to non-clinical staff, frontline medical staff are 1.4 times more likely to feel fear of infection and twice as likely to suffer from anxiety and depression. therefore, the frontline fighters of the covid-19 pandemic are more susceptible to developing mental health problems than others. in developing countries, the healthcare system is already overburdened (buenaventura, 2020). the sudden reversal of role from hcw to a patient might lead to frustration, helplessness, adjustment issues, stigma, fear of discrimination in the medical staff (rana, 2020). despite the low mortality rate of 2 %, the covid-19 virus has a high transmission rate, and the mortality is higher than that caused by severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) combined (lombardi, 2020). studies from previous infectious outbreaks suggest that this group may be at risk of experiencing worsening mh during an outbreak. current evidence examining the psychological impact on similar groups suggests that this group may be at risk of experiencing poor mh as a direct result of the covid-19 pandemic. compounding the concerns about these data is that hscws will be likely to not only be at a higher risk for experiencing mh problems during the pandemic, but also in its aftermath (de kock, 2021). there are some specific features of the covid-19 pandemic that may specifically heighten its potential to impact on the mh of hscws. firstly, the scale of the pandemic in terms of cases and the number of countries affected has left all with an impression that ‘no-one is safe’. media reporting of the pandemic has repeatedly focused on the number of deaths in hscws and the spread of the disease within health and social care facilities which is likely to have amplified the negative effects on the mh of hscws. in the face of this global crisis, healthcare workers are directly involved https://doi.org/10.54536/ajmsi.v2i2.1447 https://journals.e-palli.com/home/index.php/ajmsi pa ge 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 1-7, 2023 in the process of diagnosing, treating, and caring patients with covid-19 and are at risk for mental distress and adverse health effects. psychiatric disorders such as stress, depression, and anxiety are on the rise, with an increasing number of confirmed and suspected cases of the disease, high work pressure, lack of protective equipment, widespread media coverage, lack of page 7 of 9 promising therapeutic agents and feelings of inadequacy (lai, 2020). in 2005, study conducted during the severe acute respiratory syndrome (sars) outbreak, health workers feared that they would become infected or infect their family, friends, or colleagues (ho, 2005). before the outbreak of covid-19, nearly 50 percent of healthcare workers suffered from job stress and burnout. mental health problems of healthcare staff were widespread, though hidden issues, before the outbreak of covid-19. these problems have now become more evident due to the massive outbreak. in a recent study on medical and nursing staff working in many hospitals around the world, 36.9% had mental health disorders below the threshold, 34.4% had mild disorders, 22.4% had moderate disorders, and 6.2% had severe mental disorders (rad, 2020). patient care in hospital wards with less than adequate beds, as well as environmental stress factors such as increased number of patients, long work shifts, and increased number of infected medical staff and their deaths pose as a major risk for the mental health of the healthcare personnel. therefore, it is essential to decrease the levels of anxiety in the present circumstances. it is also important to protect the mental health of healthcare workers in the inpatient wards of covid-19 patients (mosheva, 2021). adequate rest, adequate fluid intake, and proper nutrition can improve the physical and mental health of the health care workers. some studies have shown that multidisciplinary mental health support by psychiatrists, clinical psychologists, psychiatric nurses, and another mental health professionals, clear communication, providing accessible and reliable psychological services such as e-books and mobile applications, and reduction in work shifts of the health workers to less than 16 hours a day can be effective in improving the mental health of health care workers. implementing these measures is recommended for the improvement of the mental health status in healthcare personnel during the covid-19 outbreak (tahara, 2021). mental health is defined as a person’s emotional, psychological, and social well-being (agha, 2021). from the beginning of the covid-19 pandemic, news broadcasts have addressed the novel virus and how details are developing each day. as a result, healthcare 6 workers’ mentality is drastically affected. for instance, many healthcare workers are left to deal with personal protective equipment (ppe) shortage, high transmissibility of covid-19 to friends and loved ones, uncertainty due to lack of treatment guidelines, increased work responsibilities, and physical isolation due to the pandemic, many healthcare workers fear bringing home the virus to their loved ones, resulting in mental stress from work. healthcare workers are expected to face the virus daily due to them being in constant close contact with sick patients. even with the ppe, it is not guaranteed that one will not contract the virus and spread it to others. some healthcare workers are brave enough to speak on behalf of most workers about the mental burden they experience from work. some have verbalized the feelings of helplessness, worthlessness, and guiltiness related to poor patient outcomes. today, there is only so much one can do to lessen the spread of covid19, such as the importance of practicing hand hygiene, social distancing, staying at home when one is sick, and getting vaccinated. the objectives of this study are to describe the socio demographic characteristics of the respondents and to assess the psychological disorder of the respondents during pandemic situation. in addition to examine the relationship between socio-demographic characteristics and mental health related disorders among the respondents. literature review this section reviewed existing literature on the impact of covid-19 on mental health among the hcws related to covid-19, generalized anxiety disorder, patients’ loneliness, sleep disorder and demographic characteristics. the main purpose of the literature review articles is to explore and improve healthcare workers’ mental health in sher-e-bangla medical college hospital, barishal, along with discovering interventions to cope with difficult stressors throughout the covid-19 pandemic. the research questions will be thoroughly answered based on the literature reviews that are separated into three categories, such as the relevancy of depression and anxiety in healthcare workers, comparison of healthcare workers ’mental health in the emergency department (ed) and intensive care unit (icu), and interventions to improve healthcare workers’ mental wellbeing. the world health organization (who) confirmed the covid-19 as a global pandemic on march 11, 2020. since then, the since then, the world struggles this pandemic, and nobody knows when it will stop the bangladesh government declared a country-wide lockdown on march 26,2020, to hold the spreading of this virus among its citizens. the covid-19 responses have impacted the personal, social, and work life of many people world-wide. therefore, the covid-19 pandemic fearfully affected the mental health of general population as frontline fighters; the impact of covid-19 pandemic on mental health of hcws was high due to relatively unknown and fatal virus. the ongoing pandemic has situated hcws in a situation of intense psychological pressure and moral responsibilities. a study concerning the mental health of healthcare professional during covid-19 pandemic in bangladesh. according to their findings, the composition of physicians, pharmacist, nurses, and medical technologist were 30%,23%,26%and 26% respectively. among all hcps, male was 57 % and 43%. only 36% respondents https://journals.e-palli.com/home/index.php/ajmsi pa ge 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 1-7, 2023 belong to the age group of 40 years (hossain, 2020). another crosssectional study conducted which aim was to assess the mental health outcomes of bangladeshi hcps and associated risk factors, in 2020. a total of 355 hcps aged between 20 and 60 years. all the participants completed a self-administered questionnaire through google forms consisting of socio-demographic characteristics and mental health outcomes, measure loneliness, depression, anxiety, and sleep disturbance using the ucla loneliness scale-8, patient health questionnaire-9, 7-item generalized anxiety disorder scale, pittsburgh sleep quality index. the present study observed the prevalence of loneliness, depression, anxiety, and sleep disturbance among hcps were 89%, 44%, 78%, and 87%, respectively. the factors significantly associated with the development of mental health problems among hcps were working environment, economic condition, and education level, area of residence, marital status, gender differences, professional category, body mass index, and smoking habit. (yang, 2018). another study on fear of covid-19 and depression and his colleague result found that of the total sample (n = 3388), just over half were females (n = 1754, 51.8%). the majority were married (60.8%), had no children (57.8%), had elderly people who were at high-risk of covid-19 living at home (66.1%), and had no chronic physical disease (57.5%). three quarters of the total sample were the general population (75.4%), and the remainder was healthcare professionals (24.6%). over half the hcps were medical officers (53.2%), 10% were nurses, 6.8% were interns, 10% had affiliations with medical colleges (e.g., lecturer, assistant or associate professor, registrar), and the remainder held other positions. the prevalence of depression among hcps in relation to personal protective equipment they were using in their patient care. approximately two-thirds of hcps purchased their own safety equipment at least once (63.2%) and 49% had got ppe from their employer. only 15.9% were satisfied with the quality of the ppe provided, and the prevalence of depression was higher among hcps who were dissatisfied with their ppe (30.2%) (sakib, 2021). according to chen et al. (2021), it was found that 543 (60.20%) doctors, 311 (34.48%) nurses, and 48 (5.32%) other occupations like administration staff of the hospital were included in the study. the percentage of male and female participants was 283 (31.37%) and 619 (68.63%) respectively. healthcare workers who demonstrated no or mild anxiety and depression 9 resulted in 681 (75.50%) and those who had moderate or severe anxiety and depression resulted in 221 (24.50%). based on the gad-7 scores, 274 (30.38%) healthcare workers experienced mild anxiety, whereas 150 (16.63%) experienced moderate or severe anxiety. in comparison, the phq-9 scale showed that 274 (30.38%) healthcare workers felt mild depression and 165 (18.29%) felt moderate or severe depression. healthcare workers who had depression and anxiety together resulted in 291 (32.26%). the remaining 330 (36.59%) healthcare workers did not experience any symptoms of depression and anxiety. this study shows that depression and anxiety were relevant in healthcare workers’ mental status. the independent risk factors for both depression and anxiety were respiratory symptoms, digestive symptoms, negative coping style, and job burnout, (chen et al., 2021). regarding the article’s published in 2021, the findings, before the peak of covid-19, 40% experienced depression and 38% experienced anxiety among healthcare workers, whereas 33% experienced depression and 24% experienced anxiety among the public. during covid19, the prevalence of depression was 31% and anxiety was 40% among healthcare workers, 26% suffered from depression and 22% suffered from anxiety among the public. after the peak of covid-19, 22% experienced depression and 22% experienced anxiety among healthcare workers. in contrast, 62% experienced depression and 44% experienced anxiety among the public (deng, 2021). materials and methods a cross-sectional survey was undertaken by administering structured questionnaire. two tools, including the patient health questionnaire (phq9) and generalized anxiety disorder-7 (gad-7), were employed to measure anxiety and depression symptoms among hcws. the data analyses were carried out using descriptive statistics and inferential statistics. study area this research was conducted in sher-e-bangla medical college hospital, barishal among healthcare workers. there are 1000 health-care workers insher-e-bangla medical college hospital, barishal. population and unit of analysis the population in this study was the frontline health care workers (doctor, nurse, and medical technologist) who work in the covid19 dedicated unit at sher-e-bangla medical college hospital, barishal during the time of study. the individual was the unit of analysis. selection criteria • respondents whose age was 25 years. • respondents who had been working more than six months in covid-19 unit. • frontline healthcare workers who were willing to participate. exclusion criteria • unwilling to participate in the study. • working experience less than six month had been excluded from the study. sampling the total population of this hospital is 1000. sample size was estimated by using g power analysis in which accepted minimum significant level (α) 0.05, power 0.80 (1-β) and the effect size of 0.30 and actual sample size https://journals.e-palli.com/home/index.php/ajmsi pa ge 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 1-7, 2023 is 84. to reduce the attrition rate by 10% more samples were added. therefore, the total sample size was 92. techniques of data collection data collection was carried out using the convenience technique. after getting the approval from the authority, respondents were being explained about the study purpose, data collection procedure and benefit of the study by the author. after getting consent from the respondent, the data were collected by face-to-face interview with structured questionnaire. approximately 30 minutes were needed to complete the interview session. the collected information from the participants kept in confidential. the participation of the respondent in this study was completely voluntary. respondent had the right to withdraw the data from the study at any time without any reason or penalty. their anonymity and identity were strictly maintained using code numbers. raw/ primary data were kept in my file cabinet for 3 years, and it would be destroyed after publication of research in a scientific journal. the study’s aims were listed on the first page. besides, confidentiality information, the right of withdrawal, consent, and voluntary participation was also presented. informed consent was taken by all participants prior to participation. the eligibility criteria of this study include both frontline and non-frontline hcws. participants were not receiving any incentives. relevant data was extracted into structured tables including country, setting, population, study design, number of participants, mental health conditions and their measurement tools and main study results. where available, we extracted risk factors and protective factors; data was checked for accuracy and completeness. data analysis and processing current best practice guided the tabulated and narrative synthesis of the results. the studies’ outcomes were categorized according to the psychological impact of covid-19 on hscws of. the data was analyzed by using spss version 23. descriptive statistics such as frequency, percentage, mean, and standard deviation was used to describe the socio-demographic characteristics, inferential statistics such as independent t-test, oneway anova and pearson product moment correlation coefficient was used to examine the relationship general psychological impact and socio-demographic factors. ethical consideration of the study the ethical clearance was obtained from the hospital. written informed consent was taken from study participants and privacy was maintained with the exclusion of personal identifiers. this part should contain adequate detail to reproduce reported data. it can be divided into subsections to demonstrate data type and collection, and if several methods are described. methods already published should be indicated by a reference; only relevant modifications should be described. the methodology should be written concisely in detail by maintaining the continuity of the texts. results and discussion socio-demographic characteristics of the respondents. table 1 shows the socio-demographic characteristics of the respondents among 92 respondents the mean age was 34.92 (sd= 6.65) years, which was ranged from 30-55 years. majority of the respondents (84.8%) were female and more than half (53.3%) of them was muslim. most of the respondents (90.8%) were married. many of the participants (95.6%) were nurses. more than half (72.8%) have working experience in covid-19 ward. most of them (69.6%) family members were tested positive of covid-19 and 59.8% has ever been quarantine due to due covid-19 during the last 12 month. 73.9% of respondents were tested positive. regarding training on ipc only 30.3% of respondents got training. the majority of the (75%) respondents were healthy, and 84.8% of participants did not suffer any chronic diseases. table 1: demographic characteristics of respondents variables categories n % age 25-34 54 58.7 35-45 32 34.8 46-55 6 6.5 gender male 14 15.2 female 78 84.8 profession doctor 4 4.3 nurse 85 92.4 medical technologist 3 3.3 medical graduate 4 4.3 education diploma in nursing 53 57.6 diploma in medical technology 3 3.3 bsc in nursing 24 26.1 master’s in public health 8 8.7 https://journals.e-palli.com/home/index.php/ajmsi pa ge 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 1-7, 2023 religion islam 49 53.3 hindu 39 42.4 christian 4 4.3 work experience in covid-19 hospital during last 12 month yes 76 82.7 no 25 27.2 family members tested positive for covid-19 yes 64 69.6 no 28 30.4 have you ever been quarantine last 12 month? yes 55 59.8 no 37 40.2 have you ever been tested positive for covid-19? yes 68 73.9 no 28 26.1 have you got covid-19 vaccine? yes 88 95.7 no 4 4.3 received training on ipc yes 28 30.4 no 64 69.6 perceived health status healthy 69 75 moderately healthy 22 23.9 poor 1 1.1 history of diseases hypertension 7 7.6 heart disease 1 1.1 diabetes 4 4.3 asthma 2 2.2 none 78 84.8 patients health questionnaire (phq-9) depression measure scale (n=92) table 2 s hows that the distribution of frequency, percentage, means and sd of depression among the respondents during covid-19 pandemic. according to the findings the mean score of depression was calculated 30.51 (sd±3.80) out of maximum 36 points which indicate higher level of depression. according to most of the respondents had moderate to severe depression. findings was consistent previous studies was conducted in bangladesh by r. islam and associates & china by hu, et al, 2020. table 2: total score of patient health questionnaire (phq9) valid 92 missing 0 n mean 30.51 median 30.51 range 15-36 std. deviation 3.80 the results from the survey in india & malaysia showed that 835 (41.5%) frontline nurses reported high levels of emotional exhaustion while 556 (27.6%) nurses marked high depersonalization while working caring for covid-19 patients (hu, et al, 2020). in india the population-based study, female gender, being a student, having symptoms suggestive of covid-19, and poor perceived health were associated with higher rates of anxiety and depression; on the other hand, the availability of accurate information and the use of specific preventive measures, such as handwashing, seemed to mitigate these effects (wang et al., 2020). figure 1: phq (category (level of depression). https://journals.e-palli.com/home/index.php/ajmsi pa ge 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 1-7, 2023 generalized anxiety disorder (gad7) on covid 19 (n=92) the following figure illustrates the results of generalized anxiety disorder (gad7) among the respondents during the covid19 pandemic situation. the mean score on gad7 was 2.65 (sd±.76). the results reveled that half (50%) of the respondents had score of moderate level of anxiety while only 18.5 respondents diagnosed at severe anxiety. similar finding was found in study conducted in china, malaysia, and yemen. a possible reason for similar findings is because when the pandemic situation across the region and worldwide health care workers suffered high levels of depression & anxiety due to devastating unknown threat. figure 2: distribution if generalized anxiety disorder (gad7) on covid 19 conclusion this study reported a high prevalence of symptoms of depression and moderate level of anxiety among health workers sher e bangla medical college hospital, barishal, during the initial phase of the pandemic. more than half of the health workers faced depression and only a few health workers reported generalized anxiety in their workplace as mental health problems were significantly associated with all the mental health outcomes. nurses had higher anxiety than other health workers. improving the mental wellbeing of health workers is recommended by focusing on stigma reduction, equipping health workers with protective measures, as well as ensuring personal and family support for those with a history of mental health issues. limitations the study has some limitations which need to be acknowledged. firstly, the study was conducted during the early phase of pandemic and thus the mental health outcomes might still reflect conditions existing before the pandemic. the relative contribution of the pandemic to the increase in mental health disorders needs to be evaluated using a longitudinal study design. secondly, there might be respondent bias as the findings were selfreported by health workers and based on a subjective scale. importantly, the tool used in the study should be taken into consideration while reporting mental health outcomes. although the history of mental illness and medications taken for any kind of mental illness was included in the questionnaire, specific type of mental illness was not identified, which may or may not have affected the current symptoms of anxiety, depression. despite limitations, this study provides early evidence on the mental health status among health workers during the covid-19 pandemic in bangladesh, which should be of interest to policymakers, health facility managers and those involved in the response to covid-19 or any future epidemic. recommendations based on the limitations of this study, the following recommendations are presented for further research. future descriptive study may be conducted in large scale to increase the generalizability of the findings to other same settings. followed by intervention study may be recommended to investigate the relationship between depression and demographic characteristics. findings act as base line data for higher authority to mitigate mental health problems. government organizations and non-government agencies should launch their programs on a substantial educational campaign to improve understanding and preventive measures of depression and anxiety. references agha, s. (2021). mental well-being and association of the four factors coping structure model: a perspective of people living in lockdown during covid-19. ethics, medicine and public health, 16, 100605. buenaventura, r. d., ho, j. b., & lapid, m. i. (2020). covid-19 and mental health of older adults in the philippines: a perspective from a developing country. international psychogeriatrics, 32(10), 1129-1133. chen, j., liu, x., wang, d., jin, y., he, m., ma, y., ... & hou, x. (2021). risk factors for depression and anxiety in healthcare workers deployed during the covid-19 outbreak in china. social psychiatry and https://journals.e-palli.com/home/index.php/ajmsi pa ge 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 1-7, 2023 psychiatric epidemiology, 56, 47-55. de kock, j. h., latham, h. a., leslie, s. j., grindle, m., munoz, s. a., ellis, l., ... & o’malley, c. m. (2021). a rapid review of the impact of covid-19 on the mental health of healthcare workers: implications for supporting psychological well-being. bmc public health, 21(1), 1-18. deng, j., zhou, f., hou, w., silver, z., wong, c. y., chang, o., ... & zuo, q. k. (2021). the prevalence of depression, anxiety, and sleep disturbances in covid‐19 patients: a meta‐analysis. annals of the new york academy of sciences, 1486(1), 90-111. ho, s. m., kwong-lo, r. s., mak, c. w., & wong, j. s. (2005). fear of severe acute respiratory syndrome (sars) among health care workers. journal of consulting and clinical psychology, 73(2), 344. hossain, m. j. (2020). impact of covid-19 pandemic among health care providers in bangladesh: a systematic review. bangladesh journal of infectious diseases, s8-s15. henriksen, j., larsen, e. r., mattisson, c., & andersson, n. w. 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(2018). impact of weight-related advice from healthcare professionals on body mass index of patients in the usa. public health, 159, 50-57. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 11 0 american journal of medical science and innovation (ajmsi) socioeconomic differential of cardiovascular diseases risk factors in bangladesh: findings from a nationally representative survey shimlin jahan khanam1*, md awal kabir2 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2135 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 20, 2023 accepted: september 23, 2023 published: september 29, 2023 diabetes, hypertension, and overweight/obesity are three major risk factors for cardiovascular diseases (cvd). however, their distributions across socioeconomic status (ses) are debated despite its critical importance to design healthcare system. this study aimed to examine the associations between ses and diabetes, hypertension, and overweight/obesity in bangladesh. data was extracted from the 2017/18 bangladesh demographic and health survey. diabetes, hypertension, and overweight/obesity were outcome of interest. three variables wealth quintiles, education, and paid employment were considered as proxy of respondents’ ses, as such the major explanatory variables of interest. age-standardised prevalence of diabetes, hypertension, and overweight/obesity by ses were estimated using direct standardisation. associations between ses and cvd risk factors were examined using multilevel poisson regression model with robust variance. the overall age-standardized prevalence of diabetes, hypertension, and overweight/obesity in the sample were 9.82% (95% ci, 9.11-10.58), 27.37% (95% ci, 26.37-28.40) and 40.11% (35% ci, 38.82-41.42), respectively. we found a significant gradient of diabetes, hypertension, and overweight/ obesity in bangladesh with a higher prevalence among the respondents of advantageous wealth quintiles, education, and paid employment. in the fully adjusted models improved wealth quintiles and higher education were found as important predictors of diabetes and overweight/obesity. prevalence ratio of hypertension and overweight/obesity was found lower among respondents with no education/pre-school or primary education as compared to the respondents with primary education. diabetes, hypertension, and overweight/obesity are not distributed proportionately by ses in bangladesh, especially by wealth quintiles and levels of education. policies and programs to increase awareness on importance of controlling weight and regular screening for diabetes and hypertension are important. treatment facilities for diabetes and hypertension should also need to be spread up at the community level. keywords socioeconomy, cardiovascular diseases, risk factors, survey findings 1 department of population science, jatiya kabi kazi nazrul islam university, mymensingh, bangladesh 2 department of social work, pabna university of science and technology, pabna, bangladesh * corresponding author’s e-mail: shimlinjahan2208@gmail.com introduction the world is now observing a rapid transition in diseases pattern, where the non-communicable diseases (ncds) is showing a surge increase from the previous burden of infectious diseases (dandona et al., 2017). the cardiovascular disease (cvd), a group of disorders of the heart and blood vessels, is among the highest in this list, that includes but not limited to coronary heart disease, cerebrovascular disease, and rheumatic heart disease (who, 2020). together these lead an estimated 17.9 million deaths each year, which represents over 31% of all global deaths, a number which is projected to grow in future (who, 2020), [3]. over three quarter (80%) of these deaths occur in lowand middle income countries (lmics), whereas late detection and less access to healthcare services are the major reasons (who, 2020). nearly 37% of these deaths occur in premature age a figure that represents over 82% of the total 17 million premature deaths occur globally (who, 2002 & assembly, 2015)[4]. importantly, this number is rising rapidly instead of the world’s level target through the sustainable development goals (sdgs) to stabilize the premature deaths along with the rate reduced to 2015’s level by 2030 (assembly, 2015). however, this is unlikely that lmics will achieve this target unless the ongoing burden of cvd has been stabilized (vos, et al. 2020). in bangladesh, the cvd is an ongoing concern with an exponential rising of the people suffering from it (chowdhury, et al. 2018). of the ten major causes of deaths in bangladesh, the cvd takes the first three, stroke, ischemic heart disease, and chronic obstructive pulmonary disease (copd), consecutively as reported by the global diseases burden in 2019 (vos, et al. 2020). however, these three forms of cvds were the 5th, 4th, 3rd major causes of deaths in 2010 just a 10 years back from now (cdcp, 2014). with time passes, bangladesh has been observing a change the ncds’ risk factors which is being responsible for cvds rapid rising though evidence are rare. diabetes and hypertension are two most prominent risk factors of the cvd (khanam, et al. 2019 & islam, et al. 2021), whereas overweight/obesity comprises a major risk factor of cvd directly and catalyst for other intermittent risk factors, including the diabetes and hypertension (koliaki, et al. 2019). previous studies in bangladesh reported a higher prevalence of diabetes (9.82%) and hypertension (27.36%) (islam, et al. 2021 & khan, et al. 2021) with a rapid rise of overweight/obesity from a pa ge 11 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 point of nearly 1 in 5 adults being any of these categories (safiri, et al. 2020). rapid urbanization, dietary changes, and limited physical activity are main promotors to such rise (mohiuddin, et al. 2019 & moniruzzaman, et al. 2016). unawareness over these diseases lead development of the cvd and associated adverse consequences, including the premature deaths (khan, et al., 2021). this is fuelled by community level cognitions in bangladesh including the ncds are kind of rich and novel diseases occur among aged and highly educated people. consequently, the detection, treatment, and control rates are low among the segments of population outside these groups, though they represent a major share of the country’s total population (khan, et al., 2021). higher burden of the ncds among educated and higher aged people, that were found in the previous studies of this series (islam, et al. 2021 & khan, et al. 2021) and have been reported from the years (fottrell, et al. 2018 & jafar, et al. 2018), are often consider to justify these cognitions. the country level initiatives are also somehow supportive to these cognitions with being the cvd’s treatment facilities are available on a limited basis at the government tertiary level hospital in bangladesh. consequently, the private sector is the major provider of the cvd’s treatment which is often characterised as expensive, therefore not accessible for the general population of bangladesh (sulaiman & misha, 2016). assessment of socioeconomic distribution of diabetes, hypertension, and overweight/obesity has been central to equity debate of the cvd and focus of disease priorities in the health sector in bangladesh. however, this focus is completely absent in the available literature, though this was found as a significant considerable factor in india, a bangladeshi neighbouring country (corsi & subramanian, 2016). this study has been conducted to present a comprehensive equity analysis of the socio-economic gradients of the burden of cvd’s risk factors in bangladesh. nationally representative men and women sample aged 18 and more have been analysed with a focus on diabetes, hypertension, and overweight/obesity. methodology data source data originated in the 8th bangladesh demographic and health survey (bdhs), a nationally representative survey conducted between october 24, 2017, and march 15, 2018. the national institute of population research and training, as a local body, conducted this survey as part of the demography and health survey program, usa. the ministry of health and family welfare of bangladesh provided supervision. two-stage stratified survey designed was used in this survey to collect the nationally representative sample. a total of 675 primary sampling units (psus) was selected at the first stage of sampling. of which the data collection was undertaken in 672 psus (the remaining three psus were excluded due to flood), through probability proportional to enumeration area’s (ea) size. the psu is the census ea with an average of 120 households that created in 2011 as part of the 2011 population and housing census of bangladesh. a fixed number of 30 households was selected randomly at the second stage of sampling from each selected psu. this generated a list of 20,160 households, 19,584 of them households were occupied. one fourth of these selected households, 4,896 in total, were selected for further data collection on non-communicable diseases including diabetes and hypertension. the targeted respondent was men and women aged 18 and older. outcomes the study outcomes were diabetes, hypertension, and overweight/obesity. diabetes was measured based on the fasting blood glucose (fbgs) level collected using the hemocue glucose 201 dm system. according to the world health organization (who) criteria, fbg level ≥7 or self-reported diabetes medication use, were used to classify respondents with the diabetes. systolic and diastolic blood pressure (in millilitres of mercury [mmhg]) were considered to classify respondents with hypertension. for this, a digital oscillometric blood pressure measuring device with automatic upper-arm inflation and an automatic pressure release were used. the survey measured blood pressure in three times with an interval of at least 5 minutes, whereas the average of the second and third time was reported. these along with hypertensive medication use/non-use status were used to classify hypertension: (i) systolic blood pressure ≥140 mmhg and/or a diastolic blood pressure ≥90 mmhg, or (ii) taking any prescribed drugs to control blood pressure. the national guidelines for management of hypertension in bangladesh was followed for this classification (dghs, 2013) a guideline that is comparable with the 2018 european society of hypertension (esh) and european society of cardiology (esc) htn guidelines (williams, et al. 2018). the who’s recommendation for body mass index (bmi) for the asian population were used to defined overweight and obesity, which is bmi≥23 to <27.5 kg/m2 for overweight and bmi ≥ 27.5 kg/m2 for obesity. exposure variables the ses was defined based on wealth quintiles, education and working status. household wealth quintile, an index based on indicators of asset ownership and housing characteristics, developed and reported by the dhs as a unique measure of income and expenditure. the approach has been validated in several countries. the principal component analysis technique was used to construct this index with 5 categories, ranging from the lowest to the highest. education was categorized in four levels based on the number of years completed: no education/pre-school (0), primary (0-5), secondary (6-10), and higher (11 and more). respondents’ current working classified dichotomously as yes vs no. we have reclassified these three variables to make a dichotomous group of advantageous and disadvantageous pa ge 11 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 socioeconomic status an approach that was followed in previous studies in lmics including bangladesh [20, 23]. the wealth quintiles were reclassified in such a way where respondents in lowest and lower quintile were classified as disadvantageous group and remaining were classified as advantageous group. respondents with no education/ preschool education were classified as disadvantageous group and the remaining were classified as advantageous group. respondents who engaged any forms work to generate money were classified as advantage group. covariates respondents’ age, sex, and place of residence were included as covariates. where applicable, diabetes, hypertension, and body mass index were also adjusted. statistical analysis descriptive statistics was used to describe the characteristics of the respondents. prevalence of diabetes, hypertension, and overweight/obesity were calculated using direct standardization and reported by ses and other covariates. multilevel poisson regression model was used to calculate prevalence ratio (pr) of the diabetes, hypertension, and overweight/obesity for three exposure variables considered adjusting with the confounders. we used poisson regression because the odds ratio estimated using logistic regression is usually overestimated if the outcome of interest is common, and the study design is cross-sectional (barros & hirakata, 2003). furthermore, in the bdhs, individuals were nested within the household; households were nested within the psu/cluster. therefore, our multilevel mixed-effects poisson regression model accounts for these multiple hierarchies and dependency in data and the problem of overestimation. both unadjusted and adjusted model were run. in unadjusted models, we considered outcome variables separately with each explanatory variable. in the adjusted models, outcome variables were considered with the explanatory variables and covariates. we considered multistage survey design and sampling weights in all analyses. analyses were conducted using the stata software version 15.1. results table 1 presents the basic characteristics of the total respondents and the respondents who had either diabetes, hypertension, or overweight/obesity at the time of the survey. the bdhs 2017/18 covered 11,949 respondents a majority of them were aged 18-34 years (45.11%) and female (57.12%). around 60% of the total respondents had have either primary (30.03%) or secondary (29.62%) level of education. a three-quarter (73.4%) of the total respondents analysed was resided in the rural areas. the overall prevalence of diabetes was 9.82 (95% ci, 9.11-10.58%), the prevalence of hypertension was 27.37% (95% ci, 26.37-28.40), and the prevalence of overweight/obesity was 40.11 (95% ci, 38.82-41.42). the differences in the rates of diabetes and hypertension across sexes were not quite high as like what was reported for the overweight/obese while the rates were 46.19% and 32.56% among male and female, respectively. the rates of diabetes, hypertension, and overweight/obese were found higher among the currently not working respondents than their counterparts of not currently working. socio-economic difference of diabetes, hypertension, and overweight/obesity among the socio-economic status (ses) markers, a noticeable difference of diabetes, hypertension, and overweight/obesity was found across household wealth quintile (table 1). the prevalence of diabetes varied between 5.32% among the poorest to 16.55% among the richest, the rate of hypertension varied between 20.68% among the poorest to 32.89% among the richest, and the rate of overweight/obesity varied between 23.88% among the poorest to 63.66% among the richest. the rates of diabetes, hypertension and overweight/obesity were also found to be increased from the 6.89%, 23.70%, and 28.10%, respectively with the increase grades of education. the occupational gradient of diabetes, hypertension and overweight/obesity were not noticeably different, however, the prevalences were found higher among respondents engaged with an advantage occupation category. table 1: age-standardised prevalence of diabetes, hypertension, and overweight/obesity among bangladeshi adults, 2017-2018 characteristics overall (n=11949) na (%) diabetes % (95% ci) hypertension % (95% ci) overweight/ obesity % (95% ci) average prevalence 9.82 (9.11-10.58) 27.37 (26.37-28.40) 40.11 (38.82-41.42) age in years 18-34 5390 (45.11) 5.12 (4.53-5.70) 12.86 (11.98-13.75) 38.58 (37.28-39.87) 35-39 1371 (11.47) 9.98 (8.41-11.55) 27.44 (25.11-29.78) 49.96 (47.35-52.58) 40-44 1047 (8.76) 11.78 (9.83-13.72) 31.72 (28.91-34.53) 48.15 (45.13-51.17) 45-49 994 (8.32) 12.88 (10.83-14.93) 37.66 (34.69-40.63) 47.71 (44.65-50.77) 50-54 672 (5.62) 16.37 (13.58-19.15) 41.59 (37.88-45.31) 41.30 (37.59-45.01) 55-59 676 (5.66) 15.90 (13.17-18.62) 46.53 (42.81-50.25) 39.88 (36.23-43.54) 60-64 673 (5.64) 15.31 (12.61-18.00) 49.70 (45.96-53.45) 33.09 (29.57-36.61) pa ge 11 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 ≥65 1126 (9.42) 14.85 (12.80-16.90) 56.64 (53.79-59.50) 27.55 (24.97-30.12) sex male 5124 (42.88) 8.84 (8.09-9.59) 23.52 (22.42-24.61) 32.56 (31.26-33.86) female 6825 (57.12) 9.58 (8.89-10.28) 29.17 (28.17-30.17) 46.19 (45.02-47.36) educational status no education/preschool 3033 (25.38) 6.89 (5.72-8.05) 23.70 (21.85-25.55) 28.10 (25.71-30.49) primary education 3588 (30.03) 9.30 (8.38-10.23) 25.52 (24.21-26.83) 35.22 (33.67-36.77) secondary education 3539 (29.62) 11.67 (10.49-12.85) 28.98 (27.45-30.51) 49.03 (47.30-50.75) higher education 1789 (14.98) 13.15 (11.40-14.89) 31.07 (28.93-33.20) 57.42 (55.16-59.68) working status no 4620 (38.66) 11.85 (10.86-12.84) 30.30 (29.00-31.59) 48.43 (46.96-49.90) yes 7329 (61.34) 8.10 (7.49-8.72) 24.31 (23.38-25.24) 36.78 (35.67-37.90) socio-economic status poorest 2311 (19.34) 5.32 (4.42-6.22) 20.68 (19.17-22.18) 23.88 (22.13-25.63) poorer 2354 (19.7) 5.65 (4.71-6.58) 23.38 (21.74-25.01) 28.52 (26.66-30.38) middle 2465 (20.63) 7.58 (6.54-8.62) 25.65 (24.02-27.27) 38.38 (36.43-40.33) richer 2378 (19.90) 10.36 (9.15-11.56) 28.44 (26.73-30.14) 45.08 (43.10-47.07) richest 2441 (20.43) 16.55 (15.19-17.90) 32.89 (31.26-34.53) 63.66 (61.85-65.46) place of residence urban 3178 (26.60) 11.85 (10.86-12.84) 28.99 (27.73-30.25) 48.76 (47.28-50.24) rural 8771 (73.40) 8.10 (7.49-8.72) 25.00 (24.10-25.90) 36.11 (35.03-37.18) administrative division barishal 659 (5.51) 9.23 (7.67-10.81) 28.40 (26.10-30.70) 43.24 (40.46-46.02) chattogram 2051 (17.17) 10.86 (9.39-12.33) 29.60 (27.51-31.71) 47.03 (44.62-49.43) dhaka 2767 (23.16) 14.99 (13.25-16.73) 24.07 (22.09-26.04) 46.84 (44.41-49.27) khulna 1488 (12.45) 8.00 (6/76-9.24) 27.16 (25.18-29.14) 46.53 (44.11-48.94) mymensingh 973 (8.15) 7.76 (6.35-9.18) 21.27 (19.22-23.32) 31.32 (28.83-33.82) rajshahi 1728 (14.46) 8.16 (6.86-9.48) 26.11 (24.11-28.11) 38.22 (35.83-40.63) rangpur 1503 (12.58) 5.61 (4.50-6.72) 28.90 (26.77-31.02) 36.44 (34.03-38.84) sylhet 780 (6.53) 9.62 (8.09-11.13) 25.16 (23.08-27.25) 32.99 (30.55-35.43) note: all counts are weighted. a column percentage figure 1: distribution of diabetes, hypertension, and overweight/obesity by socioeconomic status, bangladesh, 2017/18 pa ge 11 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 we also examined the distribution of the socioeconomic markers among the individuals with diabetes, hypertension, and overweight/obesity (figure 1). the proportion of diabetes, hypertension, overweight/obese were 77%, 65% and 82%, respectively among respondents of high ses. majority of the high ses and educated people had either diabetes (81%), hypertension (74%), or overweight/obese (86%). a similar result was reported for the respondents with high ses and currently working respondentsaround 84% of them had either diabetes, 73% had hypertension, and 83% overweight/obesity. multivariable analyses of socioeconomic gradients in cvd risk factors the socioeconomic gradients in cvd risk factors were determined using unadjusted and adjusted multilevel passion regression models. models were adjusted with potential covariates. their results are presented in table 2. the prevalence ratio of diabetes and overweight/ obesity were found significantly higher among richer and richest respondents. respondents’ education levels were not found associated with diabetes and hypertension, however, prevalence ratios of overweight/obesity were found lower among respondents with no education/ preschool (pr, 0.68, 95% ci, 0.63-0.74) and primary education (pr, 0.86, 95% ci, 0.80-0.91) as compared to the respondents with secondary education. respondents’ current working status was found negatively associated with diabetes (pr, 0.81, 95% ci, 0.69-0.94). table 2: associations between socio-economic status and diabetes, hypertension and overweight/obesity among bangladeshi adults characteristics diabetes prevalence ratio± 95% ci hypertension prevalence ratio± 95% ci overweight/obesity prevalence ratio± 95% ci unadjusted adjusted unadjusted adjusted unadjusted adjusted wealth quintile poorest 0. 70 (0 .5 40. 90 )** * 0. 81 (0 .6 21. 04 ) 0. 89 (0 .7 90. 99 )** 0. 96 (0 .8 51. 07 ) 0. 62 (0 .5 60. 69 )** * 0. 68 (0 .6 10. 76 )** * poorer 0. 77 (0 .6 00. 99 )** 0. 83 (0 .6 51. 07 ) 0. 93 (0 .8 41. 04 ) 0. 99 (0 .8 91. 10 ) 0. 74 (0 .6 70. 81 )** * 0. 76 (0 .6 90. 84 )** * middle 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 richer 1. 38 (1 .1 31. 69 )** * 1. 29 (1 .0 51. 59 )** 1. 08 (0 .9 71. 20 ) 1. 04 (0 .9 31. 15 ) 1. 19 (1 .0 91. 30 )** * 1. 16 (1 .0 71. 27 )** * richest 2. 24 (1 .8 62. 70 )** * 1. 78 (1 .4 52. 19 )** * 1. 26 (1 .1 41. 39 )** * 1. 03 (0 .9 21. 14 ) 1. 65 (1 .5 41. 77 )** * 1. 52 (1 .4 11. 65 )** * respondents’ education no education, preschool 1. 13 (0 .9 61. 34 ) 0. 86 (0 .7 21. 04 ) 1. 58 (1 .4 51. 72 )** * 0. 97 (0 .8 91. 06 ) 0. 61 (0 .5 60. 66 )** * 0. 68 (0 .6 30. 74 )** * pa ge 11 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 unadjusted models models are adjusted for age, sex, place of residence and place of residence beside these, age of the respondents was found as most important predictor of diabetes, hypertensive, and overweight/obese with a general increase of the likelihoods with increasing years (supplementary table 1). we reported a similar trend in our subgroup analysis for diabetes, hypertension and overweight/obese across age and specific to the wealth quintiles (supplementary figures s1 to s3). we also explored prevalence ratios of diabetes, hypertension, and overweight/obesity across respondents’ place of region (supplementary table 2). prevalence ratio of diabetes was found higher among richer and richest respondents resided in the dhaka division. in khulna division, prevalence ratio of diabetes was found higher among the poorer and richest respondents as compared to the respondents with middle wealth quintile. prevalence of diabetes was also found lower among no educated/ pre-school respondents in the rajshahi division and higher educated respondents in sylhet division. discussion our analysis provides strong evidence of socio-economic gradients of cvds’ risks factors, diabetes, hypertension, and overweight/obesity, in bangladesh where the key determinants were wealth quintile and education. prevalence ratio of diabetes were found higher among middle to richest wealth quintile. we also reported a gradual increase in the prevalence ratio of being overweight/obesity among poorest to richest quintile. prevalence ratios of hypertension and overweight/ obesity were found lower among no education/preschool and primary educated respondents as compared to the secondary educated respondents. in addition, we reported around 18% (95% ci, 0.73-0.92) likelihood of diabetes among respondents reported they were formally employed than the respondents who were not formally employed. we reported a higher ses gradient of diabetes, hypertension, and overweight/obesity whereas the previous studies in bangladesh reported their rising prevalence regardless of the ses (islam, et al. 2021, khan, et al. 2021). the likelihoods were even higher for specific regions, including dhaka and khulna. this calls for policies and programs to ensure universal availability of the ncds treatments. however, current governmental level ncds focus is opposite, governmental ncds treatment facility is yet to available in the urban areas only, on tertiary health facilities (e.g district hospitals, medical colleges) on limited basis, therefore, not accessible for all (dao, 2020) . therefore, the private health facilities is major provider of ncds treatment in bangladesh (khan, et al., 2021), which is also located in the urban areas and treatment available there is expensive (niport, 2017). consequently, ncds services provides by private health facilities could not be accessible for lower ses population and population from rural areas, though they cover over 70% of the country’s total population (niport, 2017). this leads detection of ncds at its optimal stage which increase the risk of pre-mature mortality as well as difficulties in control due to concurrent comorbidities. challenges are also exit in awareing people about the diabetes, hypertension and risk of becoming overweight/ primary education 1. 13 (0 .9 51. 33 ) 1. 07 (0 .9 21. 26 ) 1. 15 (1 .0 51. 26 )** * 0. 96 (0 .8 81. 04 ) 0. 78 (0 .7 30. 84 )** * 0. 86 (0 .8 00. 91 )** * secondary education 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 higher 0. 97 (0 .8 11. 17 ) 0. 92 (0 .7 71. 11 ) 0. 96 (0 .8 61. 07 ) 1. 01 (0 .9 11. 12 ) 1. 08 (1 .0 11. 15 )** 1. 01 (0 .9 51. 08 ) paid employment no 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 yes 0. 82 (0 .7 30. 92 )** * 0. 81 (0 .6 90. 94 )** * 0. 82 (0 .7 70. 87 )** * 0. 94 (0 .8 81. 02 ) 0. 84 (0 .8 00. 89 )** * 1. 01 (0 .9 61. 07 ) note: *** p<0.01, ** p<0.05 pa ge 11 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 obesity in bangladesh. studies in bangladesh have been reported poor awareness over these in all segments of the population, however, higher among who are not higher educated, resided in rural areas, and belongs to poor wealth quintile (islam, et al. 2021 & khan, et al. 2021). those findings reflect the social level taboos on ncds in bangladesh, such as, urban educated and late aged population are mainly in the risk of developing the ncds. however, this study reports primary educated people than their higher educated counterpart is even in the higher risk of becoming overweight/obesity (the most important risk factor of developing ncds) and diabetic. hypertension prevalence is also higher among respondents of no/preschool education than respondents of higher education, though the relevant likelihoods did not bring significant level once other socio-demographic factors adjusted. lower to moderate aged population are even more prone to these risk factors, contributing ncds are becoming popularized among young and middle-aged population day by day. this is addition to the well documented higher likelihood of ncds among the higher aged population. the underlaying reasons of such association are increasing urbanization, westernized lifestyle, including excess dietary sodium intake, and physical inactivity (mills, et al. 2016). this calls for awareness building programs on ncds for all population, regardless of their ses and age. however, this is still limited in bangladesh, mostly in the urban centres and small in scale (dao, 2020), though their effectiveness has been questioned wakefield, (2010). consequently, use of poor quality of drugs or the use of traditional medicines to control ncds are common, contributing to the lower control of ncds in bangladesh among those who are treated (khan, et al. 2021). therefore, awareness building programs on the importance of monitoring and controlling ncds as well as body weight should be considered in future policies and programs. technology based programs, such as use of social media and mobile phone text messaging, could be cost effective intervention to control ncds in bangladesh, therefore, should be adopted in future policies and programs. the present study has several strengths. the main strengths are the analyses of nationally representative population-based survey data and the consideration of diabetes, hypertension, and overweight/obesity. their distributions were accessed across all major makers used to measure socio-economic status, including wealth quintile, education, occupation and place of residence. therefore, the findings provide a comprehensive picture of three major cvds’ risk factors, as such, would be helpful for developing evidence-based policies and programs. however, the major limitation of this study there is no option in the bdhs to distinguish between type-1 and type-2 diabetes, as such we did not consider this issue in this study. dietary intake, smoking status, lifestyle behaviours, and level of physical exercise are important factors of becoming diabetic, hypertensive, and overweight/obese, therefore, essential to be included in the model. however, this was not done because of the lack of data. conclusions we found a significant gradient of diabetes, hypertension, and overweight/obesity in bangladesh with a very higher prevalence among the respondents of advantage wealth quintile, education, occupation, and place of residence. however, wealth quintile and education were found important predictors of becoming diabetic, hypertensive, and overweighted/obese. these suggest need for policies and programs on ncds management in bangladesh regardless ses and place of residence. however, higher focus should be given increased aged people with improved ses in respect to wealth quintile and education. declaration of interests the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. acknowledgement the authors thank the measure dhs for granting access to the 2017/18 bdhs data. funding this research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors. authors’ contributions khanam sj designed the study, performed the data analysis, and wrote the first draft of this manuscript. kabir ma critically reviewed and edited the previous versions of this manuscript. all authors approved this final version of the manuscript. data availability the datasets used and analysed in this study are available from the measure dhs website: https://dhsprogram. com/data/available-datasets.cfm references al kibria, g. m., et al., (2021). clustering of hypertension, diabetes and overweight/obesity according to socioeconomic status among bangladeshi adults. journal of biosocial science, 53(2), 157-166. assembly, g., sustainable development goals. sdgs transform our world, 2015. 2030. barros, a. j. and v. n. hirakata (2003). alternatives for logistic regression in cross-sectional studies: an empirical comparison of models 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2016. vos, t., et al., (2020). global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. the lancet, 396(10258), 1204-1222. wakefield, m. a., b. loken, and r. c. hornik,(2010). use of mass media campaigns to change health behaviour. the lancet, 376(9748), 1261-1271. williams, b., et al.,(2019). 2018 esc/esh guidelines for the management of arterial hypertension. kardiologia polska, 77(2), 71-159. world health organization (who), (2020). cardiovascular diseases 2020, world health organization geneva, swetzarland world health organization(who),(2020), cardiovascular diseases (cvds). 2020, world health organiozation geneva, switzarland supplementary table and figures table 3: age distribution of the survey respondents by household wealth quintile, bangladesh demographic and health survey, 2017/18 age (years) poorest poorer middle richer richest number % number % number % number % number % 18-34 972 42.06 1014 43.08 1109 44.99 1165 49.02 1130 46.27 35-39 290 12.56 276 11.73 278 11.28 219 9.20 307 12.59 40-44 216 9.34 227 9.66 204 8.29 208 8.77 191 7.83 45-49 178 7.70 199 8.45 206 8.36 194 8.18 216 8.85 50-54 127 5.50 144 6.11 145 5.90 132 5.57 123 5.03 pa ge 11 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 table 4: mutually adjusted prevalence ratios and 95% confidence intervals from multilevel poison regression analyses across respondents place of residence characteristics barishal chattogram dhaka khulna mymensingh rajshahi rangpur sylhet diabetes wealth quintile (ref: middle) poorest 0. 83 (0 .4 91. 40 ) 0. 72 (0 .3 21. 59 ) 0. 93 (0 .4 91. 77 ) 0. 86 (0 .3 42. 23 ) 0. 61 (0 .3 51. 05 ) 0. 96 (0 .4 81. 92 ) 0. 50 (0 .2 70. 93 )** 1. 13 (0 .5 42. 40 ) poorer 0. 75 (0 .4 41. 28 ) 0. 70 (0 .3 71. 34 ) 1. 11 (0 .5 62. 18 ) 2. 14 (1 .2 13. 81 )** * 0. 68 (0 .3 91. 19 ) 0. 54 (0 .2 81. 02 ) 0. 46 (0 .2 20. 96 )** 0. 59 (0 .2 71. 32 ) richer 0. 81 (0 .4 61. 42 ) 1. 15 (0 .7 01. 89 ) 1. 71 (1 .1 12. 65 )** 1. 73 (0 .9 03. 34 ) 1. 08 (0 .4 22. 78 ) 1. 22 (0 .6 82. 20 ) 1. 07 (0 .5 62. 05 ) 0. 85 (0 .4 21. 72 ) richest 0. 94 (0 .5 21. 73 ) 1. 50 (0 .9 92. 29 ) 2. 61 (1 .6 34. 16 )** * 2. 72 (1 .4 15. 29 )** * 1. 30 (0 .7 32. 33 ) 1. 15 (0 .5 62. 35 ) 0. 99 (0 .5 21. 89 ) 2. 12 (1 .0 34. 37 )** respondents’ education (ref: secondary education) no education, preschool 1. 21 (0 .6 22. 35 ) 0. 66 (0 .4 11. 06 ) 1. 10 (0 .7 61. 59 ) 1. 06 (0 .7 01. 62 ) 1. 32 (0 .6 62. 63 ) 0. 46 (0 .2 70. 79 )** * 0. 66 (0 .3 31. 30 ) 0. 93 (0 .5 31. 63 ) primary education 1. 42 (0 .8 72. 30 ) 0. 88 (0 .6 21. 23 ) 1. 29 (0 .9 51. 75 ) 1. 23 (0 .8 41. 79 ) 1. 15 (0 .6 32. 10 ) 0. 85 (0 .5 01. 44 ) 0. 93 (0 .5 21. 68 ) 1. 18 (0 .7 61. 82 ) higher 2. 03 (1 .1 83. 49 ) 0. 88 (0 .6 41. 22 ) 0. 98 (0 .6 61. 43 ) 0. 70 (0 .4 21. 19 ) 0. 74 (0 .3 51. 54 ) 0. 93 (0 .5 31. 65 ) 1. 11 (0 .5 72. 15 ) 0. 53 (0 .2 90. 97 )** 55-59 138 5.99 127 5.39 144 5.86 118 4.96 149 6.09 60-64 140 6.07 152 6.44 134 5.43 131 5.49 117 4.81 ≥65 249 10.79 215 9.13 244 9.89 244 9.89 208 8.53 pa ge 11 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 paid employment (ref: no) 0. 86 (0 .5 71. 28 ) 0. 83 (0 .5 81. 18 ) 0. 72 (0 .5 30. 99 ) 1. 05 (0 .6 81. 62 ) 0. 91 (0 .5 51. 51 ) 0. 51 (0 .3 20. 79 )** * 1. 32 (0 .8 22. 13 ) 0. 89 (0 .6 01. 34 ) hypertension wealth quintile (ref: middle) poorest 0. 73 (0 .5 90. 90 )** * 1. 15 (0 .8 11. 64 ) 1. 09 (0 .7 21. 67 ) 0. 90 (0 .6 41. 25 ) 0. 85 (0 .6 11. 18 ) 0. 93 (0 .7 11. 23 ) 0. 95 (0 .7 91. 15 ) 0. 78 (0 .5 61. 10 ) poorer 0. 92 (0 .7 11. 19 ) 1. 01 (0 .7 61. 35 ) 0. 95 (0 .6 31. 41 ) 1. 05 (0 .8 51. 30 ) 1. 13 (0 .8 11. 56 ) 0. 90 (0 .7 31. 12 ) 1. 03 (0 .8 21. 30 ) 0. 82 (0 .5 71. 18 ) richer 1. 10 (0 .8 91. 36 ) 1. 22 (0 .9 41. 60 ) 0. 97 (0 .7 31. 29 ) 1. 25 (1 .0 11. 58 )** 1. 12 (0 .8 01. 57 ) 0. 72 (0 .5 30. 97 )** 1. 12 (0 .8 61. 45 ) 0. 92 (0 .6 81. 27 ) richest 0. 92 (0 .6 71. 27 ) 1. 05 (0 .8 51. 30 ) 0. 91 (0 .6 81. 23 ) 1. 15 (0 .8 91. 48 ) 1. 25 (0 .8 71. 79 ) 0. 96 (0 .7 51. 24 ) 1. 34 (0 .9 81. 84 ) 1. 02 (0 .7 91. 32 ) respondents’ education (ref: secondary education) no education, preschool 0. 86 (0 .6 51. 13 ) 0. 94 (0 .7 81. 14 ) 0. 73 (0 .5 80. 93 )** 1. 08 (0 .8 61. 35 ) 1. 06 (0 .7 61. 48 ) 0. 97 (0 .7 71. 21 ) 1. 27 (0 .9 71. 66 ) 1. 25 (0 .9 41. 67 ) primary education 0. 90 (0 .7 21. 12 ) 0. 99 (0 .8 21. 21 ) 0. 86 (0 .7 01. 07 ) 0. 99 (0 .7 81. 26 ) 1. 14 (0 .8 81. 49 ) 0. 85 (0 .6 81. 05 ) 1. 11 (0 .8 71. 42 ) 1. 18 (0 .8 91. 57 ) higher 0. 77 (0 .5 81. 03 ) 1. 14 (0 .9 01. 43 ) 0. 90 (0 .6 81. 20 ) 1. 03 (0 .8 11. 32 ) 1. 43 (1 .0 12. 04 )** 1. 03 (0 .7 91. 35 ) 0. 94 (0 .7 21. 21 ) 1. 04 (0 .7 71. 40 ) paid employment (ref: no) 1. 04 (0 .8 41. 28 ) 0. 97 (0 .8 11. 16 ) 1. 02 (0 .8 51. 23 ) 0. 84 (0 .6 81. 03 ) 0. 90 (0 .7 21. 12 ) 0. 94 (0 .7 51. 19 ) 0. 90 (0 .7 61. 07 ) 0. 88 (0 .6 81. 14 ) pa ge 12 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 overweight/obesity wealth quintile (ref: middle) poorest 0. 78 (0 .5 81. 03 ) 0. 70 (0 .5 40. 90 )** 0. 68 (0 .4 41. 03 ) 0. 70 (0 .5 40. 92 )** 0. 47 (0 .3 30. 68 )** 0. 89 (0 .7 01. 14 ) 0. 56 (0 .4 40. 71 )** * 0. 85 (0 .6 01. 22 ) poorer 0. 84 (0 .6 31. 12 ) 0. 78 (0 .5 91. 03 ) 0. 69 (0 .5 10. 93 )** 0. 77 (0 .6 30. 93 )** * 0. 79 (0 .5 71. 09 ) 0. 82 (0 .6 71. 00 )** 0. 73 (0 .5 80. 93 )** * 0. 84 (0 .6 11. 16 ) richer 1. 21 (0 .9 41. 57 ) 1. 11 (0 .9 41. 31 ) 1. 22 (0 .9 71. 53 ) 1. 15 (0 .9 91. 33 ) 1. 30 (0 .9 41. 80 ) 1. 17 (0 .9 21. 49 ) 1. 12 (0 .8 51. 47 ) 1. 25 (0 .9 11. 74 )** richest 1. 40 (1 .1 31. 75 )** * 1. 54 (1 .3 31. 79 )** 1. 43 (1 .1 51. 77 ) 1. 50 (1 .2 91. 74 )** 1. 70 (1 .3 02. 22 )** * 1. 76 (1 .4 32. 16 )** 1. 48 (1 .1 31. 93 )** * 2. 18 (1 .6 62. 87 )** * respondents’ education (ref: secondary education) no education, preschool 0. 73 (0 .5 50. 96 )** 0. 64 (0 .5 30. 79 )** 0. 70 (0 .6 00. 81 )** * 0. 76 (0 .6 20. 95 )** 0. 60 (0 .4 40. 81 )** * 0. 79 (0 .6 11. 00 )** 0. 68 (0 .5 20. 90 )** * 0. 48 (0 .3 80. 62 )** * primary education 0. 79 (0 .6 80. 93 )** * 0. 86 (0 .7 50. 98 )** 0. 89 (0 .7 61. 05 )** 0. 79 (0 .6 80. 92 )** 0. 70 (0 .5 80. 86 )** 0. 81 (0 .6 80. 97 )** 1. 09 (0 .9 21. 29 ) 0. 83 (0 .6 90. 99 )** higher 1. 17 (0 .9 81. 39 ) 0. 85 (0 .7 40. 97 )** 1. 15 (1 .0 11. 32 )** 1. 04 (0 .9 01. 21 ) 1. 08 (0 .8 71. 35 ) 0. 93 (0 .7 71. 13 ) 0. 99 (0 .8 11. 21 ) 0. 73 (0 .6 00. 91 )** paid employment (ref: no) 1. 18 (1 .0 21. 36 )** 0. 96 (0 .8 51. 09 ) 0. 89 (0 .7 91. 00 )** 1. 14 (1 .0 11. 30 )** 1. 08 (0 .8 81. 32 ) 1. 05 (0 .9 01. 24 ) 1. 11 (0 .9 41. 31 ) 1. 06 (0 .8 61. 30 ) pa ge 12 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 110-121, 2023 figure 2: adjusted prevalence ratio of hypertension by age for quintiles of household wealth, bdhs, 2017/18 note: adjusted prevalence calculated from logistic regression model where the factors adjusted were age, sex, occupation, body mass index, residence, region and status of diabetes figure 3: adjusted prevalence ratio of obesity by age for quintiles of household wealth, bdhs, 2017/18 note: adjusted prevalence calculated from logistic regression model where the factors adjusted were age, sex, occupation, residence, and region pa ge 1 pa ge 11 2 american journal of medical science and innovation (ajmsi) sex reassignment dilemma in 4 yemeni siblings with five alpha-reductase type 2 deficiency samia mahdi ahmed1*, abdelrahman abu doam2, mazin mohammad belouni3, sarwat maroof khan4 abdelbagi elzien mohamed5, imad fadl elmula6 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2484 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 14, 2024 accepted: may 17, 2024 published: may 21, 2024 5α-reductase two deficiency (5αr2d) is an autosomal recessive 46, xy disorder impacting the herd5a2 gene, causing ambiguous genitalia. four yemeni siblings with this condition sought guidance from the sudanese intersex working group (siwg) in adulthood. a multidisciplinary evaluation was conducted, encompassing physical, mental, hormonal, and imaging examinations, although genetic mutation analysis of the srd5a2 gene was precluded due to limited facilities. participants were initially assigned as females by an untrained birth attendant; the siblings later manifested virilisation before puberty, prompting a reassignment to the male sex. despite presenting with 46 xy dsd due to 5αr2d, their sexual identity conflict led them to seek counsel from the siwg. comprehensive assessments confirmed the 5αr2d diagnosis. extensive counselling with the family revealed their resolute decision to maintain the male sex despite concerns highlighted by the siwg regarding future sexual function and fertility. this case underscores the significant challenges stemming from inadequate knowledge and interventions, emphasising the critical need for early diagnosis, proper genetic counselling, and expert management. timely referrals to specialised facilities and consideration of options such as in vitro fertilisation (ivf) and preimplantation genetic diagnosis (pgd) for subsequent children are imperative. this report advocates for proactive measures in similar cases, emphasising the importance of tertiary care facilities for accurate diagnosis, informed decision-making, and optimal management of 5αr2d-related dilemmas. keywords disorders of sex development, ambiguous genitalia, genetic counseling, in vitro fertilization, preimplantation genetic diagnosis 1 department of medical laboratory technology, faculty of applied medical sciences, taibah university, al-madinah, saudi arabia 2 department of psychiatry faculty of medicine, international university of africa, khartoum, sudan 3 king fahad hospital, al-madinah, saudi arabia 4 centre for genetics and inherited diseases (cgid), taibah university, al-madinah, saudi arabia 5 department of obstetrics and gynaecology, algoda hospital, khartoum, sudan 6 department of clinical genetics, assafa college, khartoum, sudan * corresponding author’s e-mail: samiamahdiahmed59@outlook.com introduction the disorder of sexual development (dsd) resulting from 5α-reductase-2 deficiency (5α-rd2) represents a rare autosomal recessive xy-dsd, leading to the inability to convert testosterone to dihydrotestosterone (dht) (pa, 2006). while testosterone facilitates the normal development of the male testis and ejaculatory ducts, dht guides the formation of the prostate and male external genitalia. the deficiency of dht manifests across a spectrum of phenotypes, ranging from undervirilised infants with conditions like hypospadias or micropenis to severe cases presenting with the appearance of normal external female genitalia (witchel, 2018). literature review determining the appropriate sex assignment at birth remains an intricate and contentious challenge for newborns with dsd, particularly those attributed to 5αrd2 (garcía-acero et al., 2020). this complexity amplifies in developing countries, where labour attendants often misidentify the newborn’s sex, frequently assigning them as female. although initially labelled as female during childhood, these individuals experience virilisation during puberty, leading to gender misperception, dysphoria, and identity disorders in adolescence (david sandberg, 2006). in underdeveloped nations where traditional untrained midwives predominantly oversee deliveries, severely undervirilised boys due to 5α-r2d are mistakenly assigned as female at birth and subsequently raised as such. however, upon puberty-induced virilisation, these patients and their families encounter diagnostic, treatment, and ethical dilemmas, considering the psychological implications, societal stigmatisation, and anticipation of local cultural and religious conflicts, the absence of medical expertise, comprehensive genetic analysis, and molecular diagnostic facilities exacerbates the plight of these patients residing in underdeveloped regions (byers et al., 2017). the present report describes the experiences of four yemeni siblings presenting severely under-virilised external genitalia due to 5α-r2d. all participants were assigned as female at birth by untrained birth attendants and consequently raised accordingly until the onset of virilisation during adolescence. the report describes the suffering journey of the patients and their families, the improper counselling of rural physicians, and the ethical dilemma on top of the social stigma. pa ge 11 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 112-117, 2024 methodology the yemeni parents sought assistance from the sudanese intersex working group (siwg) for their four siblings, presenting a complex intersex condition and grappling with a disorder of sex identity. the siblings’ ages ranged from 28 to 18 years old at their initial consultation. the siwg adopted a comprehensive approach, delving into their medical history, conducting meticulous physical examinations, and evaluating their mental wellbeing. various diagnostic modalities such as hormonal profiling, t/dht ratio stimulation tests, ultrasound, mri scans, and chromosomal analyses were employed. despite the diverse phenotypes observed among the siblings, the diagnosis of 5αr2d was established based on these evaluations. subsequently, following extensive counselling, the family opted for a male assignment and agreed to a treatment plan devised by the siwg. this plan encompassed a series of reconstructive surgeries, hormone replacement therapy, and psychotherapy sessions. in the first case, the eldest sibling, a 28-year-old male educated through secondary school and employed as a décor labourer, presented with concerns regarding abnormal secondary sexual characteristics. as per the family’s account, his birth was overseen by his grandmother at home, resulting in female-like external genitalia and an erroneous female assignment. his behaviour displayed boyish inclinations during childhood, with an increase in aggression towards girls. by the age of 4, testicles became noticeable in the inguinal regions alongside a small penis. at 12, medical consultations and investigations revealed the absence of a uterus, and bilateral undescended testicles were confirmed via ultrasound. subsequent sex reassignment and bilateral orchidopexy were conducted without residual psychological issues, which both the family and the community positively accepted. the psychological assessment revealed a self-confident male individual, albeit with moderate anxiety and concerns about his genital size and future marriage. he displayed clear attraction to the opposite sex since pre-puberty, engaging in non-coital sexual activities yet denying any masturbation while expressing heightened excitement for pornography. results physical examination of this individual revealed a male phenotype with typical male body hair distribution. external genitalia exhibited bilateral palpable testicles, hypospadias, and cordee. hormonal levels, including fsh, t3, testosterone, and tsh, were within the average male range. a stimulation test (hcg stimulation test) indicated elevated testosterone levels, while dht levels remained unchanged. imaging studies (ultrasound and mri) confirmed the presence of a small prostate, reduced seminal vesicles, and bilateral testes, while no uterus, ovaries, or vagina were visualised. cytogenetic analysis affirmed a normal male karyotype of 46, xy, as shown in figure 1. figure 1: depicts the external genitalia of case 1, illustrating a normal male karyotype (46, xy) with no detected cytogenetic aberrations. the second sibling, a 22-year-old male, was delivered via normal vaginal birth at home, overseen by a traditional birth attendant (grandmother). the mother described the infant’s genitalia as a small phallus embedded in a substantial clitoris-like prepuce, accompanied by hypospadias. consequently, the child was assigned and raised as a female. by the age of 7, a yemeni general practitioner reassigned the child as male due to bilaterally undescended testicles and advised consultation with a visiting medical team. unfortunately, as per the history pa ge 11 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 112-117, 2024 given by the family, the visiting team performed a bilateral orchiectomy without seeking consent or providing counselling. throughout childhood, the individual displayed boyish play preferences but denied experiencing erections, orgasms, or ejaculations. the psychological assessment highlighted a coherent demeanour with pronounced irritability and preoccupation concerning sex assignment. no other abnormal behaviours, thoughts, or perceptual disorders were noted. the individual claimed attraction to females but admitted to having no sexual experiences or contact. excitement upon exposure to limited pornography was expressed alongside claims of experiencing erections without ejaculation. physical examination revealed no facial hair, bilateral tanner stage 2 breasts, absence of pubic hair, a faint surgical scar on the right labia-like structure and left inguinal region, absence of scrotal structures or testes, and a median clitoris-like structure concealing a small phallus under a prepuce, alongside a distal opening resembling a vagina. hormonal evaluations displayed elevated fsh (46.6), lh (23.4), very low testosterone (1.2), and normal prolactin levels. imaging studies (ultrasound and mri) did not reveal the prostate, seminal vesicles, uterus, ovaries, vaginal ducts, or detectable testes within the inguinal region or intra-abdominally. chromosomal analysis affirmed a male genotype, shown in figure 2. the third case involves a 20-year-old male, the third sibling, educated up to secondary school and employed as a pharmacy assistant. born via normal vaginal delivery at home and initially assigned as female, signs of boyish play preferences and aggressive behaviour towards girls became apparent at the age of 4. drawing from the experience with the elder siblings, the family noted the emergence of observable testicles, prompting consultation abroad, leading to reassignment to the male sex and subsequent corrective surgeries and orchiopexy. the current examination unveiled a male phenotype with subtle facial hair development. external genitalia exhibited a well-developed scrotum, median raphe surgical scar, bilateral small testicles, a small penis with protruding glans, a well-developed prepuce, and hypospadias. hormonal analysis indicated normal male fsh levels (2.5mlu/ml), free t3 at 5.1pmol/l, normal tsh, and prolactin, with high testosterone levels (28.4nmol/l). imaging studies revealed no uterus or ovaries, a 1.5 cm volume prostate on ultrasound, normal testes in scrotal cavities, and a micro penis on mri. cytogenetic analysis affirmed a normal male karyotype of 46, xy. mental status assessment depicted a mentally sound, welladjusted, and self-confident young male without apparent psychiatric disorder. he acknowledged a positive attraction towards females, expressing excitement at seeing females in attractive attire or postures. during puberty, he experienced erections and ejaculation, denied homosexual tendencies, and reported no sexual experiences.reconstructed male genital organs and observed musculature and pubic hair were noted, figure 2: illustrates the genitalia of case 2, displaying a karyotype of 46, xy (with no cytogenetic aberrations detected). figure 3: depicts the genitalia of case 3 with a karyotype showing 46, xy (no cytogenetic aberrations detected). pa ge 11 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 112-117, 2024 alongside the presence of hypospadias, as shown in figure 3. the fourth case involves an 18-year-old male, the fourth brother, who completed secondary school. born via vaginal delivery at home attended by a traditional midwife, the patient displayed ambiguous normal genitalia and was initially assigned as female. during childhood, the mother observed the patient playing with both sexes, albeit with a preference towards boys. by the age of 3, observable testicles emerged, prompting the family to reassign him as male, with subsequent orchiopexy performed on the right testis. mental assessment depicted no observable mental disorder, with the patient displaying relative stability and self-confidence compared to his brothers. he exhibited a male sexual orientation, expressed a favourable attraction towards the opposite sex, and reported no sexual experiences. physical examination revealed a male phenotype with subtle facial hair and typical male pubic hair distribution. external genitalia exhibited a right inguinal scar, large labia-like scrotal structures housing palpable testicles, and an embedded median small penis with hypospadias and an obliterated vagina. hormonal analysis indicated normal male values for fsh, free t3, prolactin, testosterone, and tsh. imaging studies revealed a 4 ml volume prostate on ultrasound, normal-sized bilateral testicles, and mri confirmed these findings. cytogenetic analysis affirmed male genotyping of 46, xy, as shown in figure 4. figure 4: illustrates the genitalia of case 4 with a karyotype showing normal 46, xy (no cytogenetic aberrations detected). discussion the advancements in genetics, molecular biology, and imaging technologies have significantly revolutionised the understanding of disorders of sex development (dsd). however, despite these breakthroughs, the complexities surrounding the diagnosis, sex assignment, and management of individuals with 5α-reductase-2 deficiency (5α-r2d) persist, particularly in regions with limited healthcare resources, such as yemen. dsd, being multifactorial, presents challenges that extend beyond straightforward medical paradigms, encompassing intricate psychosocial and religious dimensions, thus aligning with the bio-psycho-social study model (courtois et al., 2009). in a recent case study, all four siblings displayed ambiguous external genitalia at birth. consequently, they were all designated as females, a decision made by a traditional birth attendant, who happened to be the siblings’ grandmother. her determination was based on her assessment of the relatively enlarged prepuce and the presence of a small phallus nestled within the interlabia, which she considered to be the clitoris. additionally, the identification of hypospadias was perceived as a vaginal opening. the presence of small scrotal sacs, in the absence of descended testicles, was interpreted as labia. considering the birth attendant’s lack of formal education, her sole experience gained through midwifery apprenticeship, and her limited exposure beyond her community, societal understanding excuses her decision regarding sex assignment. this circumstance is further reinforced by her esteemed sociocultural role as the matriarch of the family, entrusted with managing various aspects of women’s affairs within the family structure, including arranged marriages, festivities, prenatal care, and childbirth. consequently, societal norms prevent any challenge or intervention in her decision-making process from younger family members or men. the situation underscores the intricate interplay between traditional societal structures and medical understanding, emphasising the profound influence of cultural roles on decision-making within families, particularly in contexts where healthcare resources are scarce (naezer et al., 2021). pa ge 11 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 112-117, 2024 the patient history lacks documentation regarding the psychosocial elements, owing to the initial sex assignment and subsequent reassignment of the four siblings within a male-dominated rural community. the observable shift in behaviour, transitioning from perceived female to unmistakably male conduct, carries significant cultural implications in such communities. the compelling transformation in behaviour was a robust indication favouring the reassignment from female to male, albeit occurring belatedly, a change highly embraced within these communities. this transformation played a pivotal role in convincing the family to intensify their efforts in aiding their children, notably driven by the grandmother, who exerted considerable willpower to rectify the evident and recurrent misassignments. consequently, despite the financial strain, the family was highly motivated and sensitised to seek both local and international medical advice. the latter venture was made possible through a restricted treatment grant. the family journeyed to madinah, saudi arabia, where the initial author assessed the patients and linked them with the sudanese intersex working group. subsequent medical evaluations, physical examinations, and investigations were conducted, inclusive of genetic counselling and appropriate management. the eldest sibling underwent a series of medical consultations catalysed by the emergence of masculine behaviours. by the age of 12, the individual underwent orchiopexy, although further reconstructive surgery and suitable hormonal therapy are still required. no documented psychological disturbances were reported or perhaps concealed so as not to defame the grandmother. the second sibling encountered a visiting medical team who inadvertently performed a bilateral orchiectomy, resulting in the absence of a testosterone source. this situation elucidates the minor development of female secondary sex characteristics, such as the absence of facial hair, second-stage tanner breasts, a small phallus resembling a clitoris due to preputial resemblance, and the formation of a pseudovagina. manifestations of sex identity disturbance were conspicuous during the mental state examination, revealing signs of irritability and excessive preoccupation with their assigned sex and future gender roles. the psychosocial burden on the family reached its peak with the third sibling, compelling them to seek appropriate management abroad. despite surgical reconstruction, inadequacies persist, particularly the need for hypospadias repair. this inadequate management emphasises the necessity for a multidisciplinary team to oversee the care of such patients. the fourth sibling underwent reassignment at a younger age, experiencing a shorter period of genital ambiguity. by this time, the family seemed to have learned from previous experiences and observed the outcomes of early interventions. the youngest sibling underwent early orchidopexy, resolving the controversy surrounding their sex assignment. notably, the age of reassignment to the male sex decreased successively from 12 to 3 years, indicating the family’s evolving understanding and adaptation based on previous encounters. the resulting responses were intricately linked to the cultural and psychosocial context of the community. the grandmother, a pivotal figure empowered to assign sex in the community as a birth attendant, held an unassailable position in her decision-making. the accumulated repeated process prevented overt psycho-social reactions in an attempt not to accuse the grandmother, which later depleted the economic resources of the extended family (1). this immense pressure compelled the family to seek additional nurturing solutions. the affected siblings endured the disorder’s psychological strain for varying durations, with heightened stress both preand postpuberty. however, the resilient bond within the family provided a robust support system, absorbing much of the psychological impact and suppressing any negative reactions. concern for the affected individuals was evident among extended family members, demonstrated through their generous contributions towards consultations and management, both locally and abroad. the evident absence of a timely and accurate diagnosis, appropriate management, and inadequate counselling resulted in profound psychosocial trauma and dilemmas for the entire family. the deficiency in foundational knowledge, genetic counselling, and ill-informed interventions may potentially lead to irreparable medicopsychosocial issues (chatterjee, 2019). the possibility of in vitro fertilization (ivf) and preimplantation genetic diagnosis (pgd) would have been a viable option for ensuring a healthy child, particularly starting from the second child, if the condition had been identified at the birth of the first child or even after corrective procedures (ly et al., 2011). in similar scenarios, healthcare professionals should prioritise referring families to centres providing genetic counselling, accurate diagnosis, and expert management to mitigate the risks of more affected babies and the complexities arising from incorrect sex assignment decisions (suorsa-johnson et al., 2022). as per previous studies, biochemical and imaging findings, performing mutational analysis of the srd5a2 gene stands as the primary approach to confirm a diagnosis of 5α‐reductase‐2 deficiency definitively (hamada et al., 2012). nonetheless, this diagnostic test is costly and often unavailable in many developing nations. furthermore, the wide spectrum of phenotypes observed, even among siblings, complicates early and definitive diagnosis. the complexity of such disorders necessitates a multidisciplinary team approach. a successful model exists in sudan, where the sudanese intersex working group (siwg) undertakes the responsibility of assisting patients and their families. in socio-religious contexts prevalent in underdeveloped nations, there is a prevalent inclination toward female-tomale reassignment. unfortunately, suppose patients are not correctly diagnosed early. in that case, there is a risk of them falling victim to female genital mutilation (fgm), pa ge 11 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 112-117, 2024 which is still practised in some regions as a religious ritual performed on infant girls. regrettably, suppose a baby boy with 5α-r2d is mistaken for the female sex, similar to many cases of fgm conducted by non-medical practitioners. in that case, the consequence is a complete distortion of the external male genitalia through the mistaken amputation of the penis, presumed to be the clitoris and labia minora. fortunately, despite enduring significant hardship, our patient avoided the lifelong consequences of fgm. the predicament for these patients and their families typically arises in adulthood when the patient fails to menstruate or develop typical female secondary sexual characteristics. conclusion in conclusion, the case of these four yemeni siblings with 5α-reductase-2 deficiency (5α-r2d) illuminates the intricate challenges surrounding disorders of sex development (dsd). the complexities in diagnosis, sex assignment, and management in resource-limited settings underscore the vital need for early, accurate diagnosis, genetic analysis, and multidisciplinary care teams. improved access to genetic testing, counselling, and expert care is crucial to prevent misdiagnosis and mitigate the profound psychosocial and medical consequences. additionally, the case emphasises the urgency of raising awareness, enhancing medical education, and implementing culturally sensitive interventions to address the complexities faced by individuals and families affected by 5α-r2d. strengths and limitations the strength of this case report is that it is a comprehensive portrayal of cultural, medical, and psychosocial complexities in managing 5α-reductase-2 deficiency. the limitation is its restricted generalizability and lack of long-term follow-up data post-treatment for comprehensive assessment. references byers, h. m., mohnach, l. h., fechner, p. y., chen, m., thomas, i. h., ramsdell, l. a., shnorhavorian, m., mccauley, e. a., amies oelschlager, a. e., park, j. m., sandberg, d. e., adam, m. p., & keegan, c. e. (2017). unexpected ethical dilemmas in sex assignment in 46, xy dsd due to 5-alpha reductase type 2 deficiency. am j med genet c semin med genet, 175(2), 260-267. https://doi.org/10.1002/ajmg.c.31560 chatterjee, p. (2019). health and wellbeing in late life: perspectives and narratives from india. springer nature. courtois, f., charvier, k., leriche, a., côté, m., & lemieux, a. (2009). l’évaluation et le traitement des troubles des réactions sexuelles chez l’homme et la femme blessés médullaires. sexologies, 18(1). david sandberg, c. c., eric vilain. (2006). nomenclature change: i am not a disorder intersex society of north america. https://isna.org/dsdsymposium2006/ program/ garcía-acero, m., moreno, o., suárez, f., & rojas, a. (2020). disorders of sexual development: current status and progress in the diagnostic approach. current urology, 13(4), 169-178. hamada, a., esteves, s. c., & agarwal, a. (2012). genetics and male infertility. infertility-diagnosis, management & ivf. 1st edition. new delhi: jaypee brothers medical publishers, 113-160. ly, k. d., agarwal, a., & nagy, z. p. (2011). preimplantation genetic screening: does it help or hinder ivf treatment and what is the role of the embryo? journal of assisted reproduction and genetics, 28, 833-849. naezer, m., oerlemans, a., hablous, g., claahsen–van der grinten, h., van der vleuten, a., & verhaak, c. (2021). ‘we just want the best for this child’: contestations of intersex/dsd and transgender healthcare interventions. journal of gender studies, 30(7), 830-843. pa, l. (2006). consensus statement on management of intersex disorders. international consensus conference on intersex. pediatrics, 118, e488. suorsa-johnson, k. i., gardner, m. d., baskin, a., gruppen, l. d., rose, a., rutter, m. m., schaferkalkhoff, t., stacey, d., van leeuwen, k. d., & weidler, e. m. (2022). defining successful outcomes and preferences for clinical management in differences/ disorders of sex development: protocol overview and a qualitative phenomenological study of stakeholders’ perspectives. journal of pediatric urology, 18(1), 36. e3136. e17. witchel, s. f. (2018). disorders of sex development. best practice & research clinical obstetrics & gynaecology, 48, 90-102. pa ge 1 pa ge 18 0 american journal of medical science and innovation (ajmsi) use of electronic logbook based on mobile learning in clinical learning among nursing students miming oxyandi1*, santhna letchmi panduragan1, faridah mohd said1, muhamad andika sasmita saputra2 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2095 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: october 01, 2023 accepted: november 04, 2023 published: november 07, 2023 filling out the logbook in the clinical learning process in indonesia is still mostly conversational, characterized by filling in the logbook, which still needs to be integrated. so, it requires an innovation in media technology that is currently popular, namely the use of mobile learning, which has more accurate information and communication capacity and is broader in space and time. furthermore, it can carry out faster reporting. this study aims to analyze mobile learning-based electronic logbook (e-logbook) in clinical learning. this type of research is research and development (r&d). the research product development design uses the addie model, which will be carried out from april 2021 to march 2023 with research instruments to test product practicality by users. the sampling technique was purposive sampling with a case study of 30 nursing students. based on the results of this study, the use of the e-logbook in the mobile learning-based clinical learning process obtained product practicality test results of 85.05% in the practical category. it can be used in nursing clinical learning in indonesia to make it easier to record data from activities carried out, information materials, documentation, and evaluation processes based on digital archives that are more accurate in the process of assessing nursing students’ clinical competency achievements based on quantitative nursing student activity achievements with details of clinical competency achievements effectively and efficiently. keywords electronic logbook, mobile learning, clinical learning, nursing students 1 faculty of nursing, lincoln university college, malaysia 2 department of nursing, stikes ‘aisyiyah palembang, indonesia * corresponding author’s e-mail: moxyandi.phdscholar@lincoln.edu.my introduction clinical learning is a crucial component that nursing students must undergo to train skills, increase knowledge, and develop nursing students’ professionalism in a clinical setting (bouchlaghem & mansouri, 2018). it can impact the quality of clinical learning and health services in the future. however, clinical learning in indonesia’s implementation is still largely conventional, one of which is manual logbook filling. according to ibrahim (2016), the difficulty encountered when using a manual logbook is that when searching for information that has been going on for quite a long time, you need to be careful in opening each page to get the desired information. apart from that, there are also difficulties in sharing with other colleagues who want to know information about previous activities or events. another thing that also concerns us is the concern that information will be lost due to the logbook being exposed to liquid or missing pages. so, it becomes a challenge and problem in the learning process. according to berame et al. (2022), challenges and problems in educating students cannot be avoided. however, one important thing is the knowledge that students can gain in the use of all types of technological innovation. therefore, we need an innovative media technology that is currently popular, namely mobile learning, which has more accurate information and communication capacity and is unlimited in time and space. moreover, it can carry out faster reporting. using mobile learning has many advantages. mobile learning, as smartphone-based, can help in the health education process in the health service process (kezelee et al., 2023). mobile learning is also a very effective learning method because it is studentcentered and allows nursing students to learn and access information anytime and anywhere because it is portable or personal digital assistant (pda). yalcinkaya & yucel (2023); kim & suh (2018) kenny et al., (2020). electronic logbooks also come in various forms, such as computers, programs on websites, software, and applications on ios or android. judging by appearance, logbooks are divided into landscape, portrait, and virtual displays, with creations emphasizing convenience, simplicity, and aesthetics. electronic logbooks can also be used in any area, including the nursing service area (schuttpelzbrauns et al., 2016). e-logbooks can also overcome problems in nursing education related to the accumulation of evaluations at the end of the semester. teachers who use e-logbooks can access them anytime and anywhere to monitor student performance and provide direct feedback (cevik et al, 2018). monitoring and analysis of e-logbooks have been used in service areas, from education to research, with the same functions of documentation, reporting, and performance evaluation. e-logbooks can also change teaching and learning activities and guide future curriculum modifications to improve nursing quality (fatemeh & alavinia, 2014). apart from that, e-logbooks have the advantage of being digital in inputting activity records, collecting data more clearly, and being easy to carry anytime and anywhere without limits. it is supported by a digital assistant personnel system (shayan, mosavi, & yousefy, 2012). therefore, developing e-books based on pa ge 18 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 180-184, 2023 mobile learning is an alternative to overcoming students’ learning problems. mobile learning is learning that uses communication and information technology. mobile learning can be done with distance learning, making clinical learning easier. based on the description above, researchers can develop and research the use of mobile learning-based electronic logbooks (e-logbooks) in clinical learning among nursing students in the clinical learning area. so that it can facilitate the management of the learning process, evaluation, documentation, interaction, and access information in an integrated and real-time manner in the implementation of the clinical education learning process, where the mobile learning offered can be accessed anywhere using a smartphone or browser, having a more comfortable user experience or interaction. literature review e-logbook a logbook is a notebook or document that students need to document in detail all activities in the process of learning. it contains personal identity, competency information, daily notes, learning activity notes, student reflections, assessment sheets, research sheets, questionnaires, and lecturer and supervisor supervision sheets. outline: there are two forms of logbooks, namely manual and electronic. manual logbooks can include several types, such as books, notes, paperwork, etcetera. there is also a form of electronic logbook using programs on websites, software websites, or android applications (andry & wijaya, 2020). the advantages and disadvantages of an e-logbook are that inputting activity records and collecting data is more straightforward to carry anytime and anywhere without limits. it is supported by a pda (personnel digital assistant) system. the weaknesses are also explained by the technical aspects of the e-logbook and the limited number of users in digital applications (shayan, mosavi, & yousefy, 2012). according to ullah et al. (2019); komsiyah & indarti (2019), e-logbooks are very good for documentation as a monitoring and evaluation tool for the implementation of clinical competencies to increase comfort and flexibility in the activity documentation process. meanwhile, research by martha & soepriyanto (2018). mobile learning-based e-books can help students increase their attention to learning material so that the learning process seems more interesting. mobile learning m-learning or mobile learning is learning using mobile devices such as pdas, mobile phones, laptops, and other information technology equipment (ariesto hadi sutopo, 2012). the advantage of m-learning is that learning can access materials, guides, and applications related to learning that can be accessed anytime and anywhere. according to wang, liao, & yang, (2013). mobile applications allow users to connect to internet services that are usually accessed via a pc or notebook, and mobile applications can help access internet services using their mobile devices. another advantage of using mobile-based teaching media is that the price is relatively cheaper than a personal computer (pc) or laptop. with a lower price, a smartphone has almost the same advantages as a pc, namely that it can display multimedia elements in the form of text, video, sound, animation, and others. entertainment and others. the weaknesses of android mobile-based smartphones in learning are limited image resolution, battery life, and lack of support for several file types for operation (aripin, 2018). materials and methods research design the design in this research is descriptive research with a research and development (r&d) approach to produce a product in the form of a mobile learning-based e-logbook. the design for the development of this mobile learning-based clinical learning logbook product uses the analysis, design, development, implementation, and evaluation (addie) model. setting and sample the research location was carried out in one of the nursing science study programs in the city of palembang, indonesia. the time of the research was carried out from april 2021 to march 2023. the sampling technique was purposive sampling with a sample size of 30 nursing students. ethical considerations this research passed the ethical clearance examination at the health ethics commission, sriwijaya university, palembang, indonesia, with the protocol certificate of ethical approval number 287-2022, with the result of exempt status on december 2, 2022. instrument development instruments in developing an e-logbook for clinical learning based on mobile learning, namely: test the practicality of the product by the primary user (students) consisting of which consists of assessment aspects: appearance, application menu, application contents, ease of use, usefulness, and implementation (widoyoko, 2017). procedures in the development stage the procedure for developing a mobile learning-based clinical learning e-logbook using the analysis, design, development, implementation, and evaluation (addie) model is as follows: 1. analysis: analyzing media development needs 2. design: designing learning media systematically and specifically 3. development: validity testing process by material experts, technology experts, and practicality testing by users using questionnaires. pa ge 18 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 180-184, 2023 4. implementation: testing the clinical learning logbook based on mobile learning using the black box test method to test the application based on the functionality of the system that has been created. the trial was carried out in small groups in small groups. 5. evaluation: evaluation and improvements after testing are carried out so that the system that has been tested can be analyzed and redesigned based on the system’s functionality. data collection the data collection process in this research uses observation, interviews, and questionnaires to obtain test data from practitioner’s e-logbooks for clinical learning based on mobile learning. the data collection method in this research is as follows: 1) the process of collecting research data begins with signing informed consent as proof of agreement to become a respondent. 2) collecting product practicality test data using questionnaires using observation and interview techniques with users, namely students, the results of which are in the form of data scores, which can be used as a basis for analyzing, evaluating, and revising the media being developed. data analysis this research uses descriptive data analysis to describe the frequency and percentage of the characteristics and practicality of using the e-logbook for mobile learningbased clinical learning using likert scale measurements to measure attitudes, opinions, or perceptions of the product being developed. after calculating the percentage figure, it is then transformed into a qualitative sentence with the provisions, if the score is 90% to 100% (very practical), score 80% 89% (practical), score 65% 79% (quite practical), score 55 % 64% (less practical) and ≤ 54% (not practical). results and discussion mobile learning based clinical learning e-logbook e-logbook mobile learning-based clinical learning has several functions, including a place to record data from activities carried out, information and evaluation materials, and reporting materials in the clinical learning process where the results of the logbook can be reviewed, printed, or downloaded. users can use this logbook feature in the following way (figure 1). 1) click on the logbook logo, click on the time information, and please fill in the activity’s date, month, year, and time. figure 1: process of filling out the clinical learning e-logbook mobile learning based 2) click on the description to start filling in the logbook according to the activity. 3) click save when the input activity has been completed. 4) click the download sign if the user wants to print or have the complete soft file logbook stage. figure 1 providing information 1). student and institutional identity, 2). feature name, 3). set up activity time, 4). activity description, 5). save button, 6). number of logbooks filled in, 7). download the logbook results. demographic characteristics demographic data of respondents in this study the average age of most students is 22 years (70%). meanwhile, the gender of most of the students is female, 35 people (87.5%), while the majority of students come from regular education programs, three people (75%). (table 1). pa ge 18 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 180-184, 2023 practicality test of e-logbook for clinical learning based on mobile learning the results of the practicality test assessment of the mobile learning-based e-logbook clinical learning by users, namely students, consist of assessment aspects: display, application menu, application content, ease of use, usefulness, and implementation. the results of the practicality test for the mobile learning based clinical learning e-logbook product were obtained with a score of 85.05%, with the practical category being used as a learning management mobile learning application system in clinical learning (table 2). various manual logbooks, such as books, notes, sheets of paper, etcetera. electronic logbooks also come in various forms, such as computers, programs on websites, software, and applications on ios or android. judging by the appearance, logbooks are divided into landscape, portrait and virtual displays with creations emphasizing convenience, simplicity, and aesthetics. using an e-logbook in mobile learning-based clinical learning has many advantages, including making it easier to record data from activities carried out, information materials, and evaluations, according to butarbutar (2022). e-logbook can simplify inputting data and searching for data quickly and precisely. also, in terms of evaluation, users can evaluate correctly from previous historical results. the e-logbook also has an essential role as proof of documentation of the implementation of activities and supervision by academic and clinical preceptors. the use of the e-logbook is as a monitoring and evaluation tool for the implementation of clinical competencies, as well as a tool for nursing students’ accountability for achieving the clinical competency targets that have been given (regulation of the minister of health of the republic of indonesia no. 49, 2013). using the e-logbook in mobile learning-based clinical learning is also a digital archive-based documentation medium. according to research by ullah et al. (2019); and komsiyah & indarti (2019). e-logbooks are very good for documentation containing records of activity achievements and analyzing data related to clinical activities. the e-logbook is also used as a monitoring and evaluation tool for implementing clinical competencies to increase comfort and flexibility in the activity documentation process. according to research by martha & soepriyanto (2018) and aripin, (2018), mobile learningbased e-books can help students increase their attention to learning material so that the learning process seems more interesting. the advantage of mobile learning is that learning can be done remotely, and the price is relatively cheaper than a personal computer (pc). conclusions the use of e-logbook in the mobile learning-based clinical learning process has statistically obtained a score of 85.05% with the practical category used in nursing clinical learning in indonesia to make it easier to record data from activities carried out, information materials, documentation and based evaluation processes. digital archives are more accurate in the process of assessing nursing students’ clinical competency achievements based on activities with details of clinical competency achievements that have been carried out. acknowledgment thank you very much to all parties involved and participating in this research. the author also thanks the faculty of nursing, lincoln university college, malaysia, and the stikes ‘aisyiyah palembang, indonesia. table 1: demographic characteristics no variables f % 1 age, median, years 21 70.0 2 sex male 6 20.0 female 24 80.0 3 education regular 28 95.0 non-regular 2 5.0 table 2: practical results of learning e-logbook products mobile learning-based clinic no indicator percentage 1. display 85.80 % 2. menu application 85.00 % 3. the contents (content) of the application 87.00 % 4. ease of use 86.50 % 5. expediency 81.50 % 6. implement ability 84.50 % average value 85.05 % table 2. it shows the use of the e-logbook in clinical learning based on mobile learning, which is practical and can be used in the clinical learning process. the mobile learning based clinical learning e-logbook is a digital notebook or daily record that contains all the activities carried out by students participating in clinical learning while working in 1 (one) shift at the clinical learning place consisting of time (date & time) and information activities in implementing digital archive-based clinical learning. the logbook feature in the clinical learning process has several functions, including as a place to record data from activities carried out, information material, documentation, and evaluation, as well as report material in the clinical learning process where the results of the logbook can be reviewed, printed or downloaded. according to schuttpelz-brauns et al. (2016), the era of the industrial revolution 4.0 has experienced an utterly digital change, including the form of logbooks, which were initially manual to electronic. there can be pa ge 18 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 180-184, 2023 references andry, j. f., & wijaya, a. (2020). e-logbook application design. ultima infosys: journal of information systems science, 11(1), 63-70. aripin, i. (2018). mobile learning concepts and applications in biology learning. bio education journal, 3(1), 1-9. berame, j. s., bulay, m. l., mercado, r. l., ybanez, a. r. c., aloyon, g. c. a., dayupay, a. m. f., ... & jalop, n. j. (2022). improving grade 8 students’ academic performance and attitude in teaching science through augmented reality. american journal of education and technology, 1(3), 62-72. bouchlaghem, m. a., & mansouri, h. 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(2012). developing a clinical performance logbook for nursing students receiving cardiac care field training. journal of education and health promotion , 1(7), 1-5 pa ge 1 pa ge 27 american journal of medical science and innovation (ajmsi) relationship between social media use and sleep disturbance among adults in afghanistan abdul tawab khpalwak1*, mohammad salim hamidi2 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2418 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: february 04, 2024 accepted: march 18, 2024 published: march 22, 2024 this study aimed to investigate the impact of excessive social media use on sleep and mental well-being among adults in afghanistan. an online survey was conducted across 19 provinces in afghanistan to assess social media usage and its effects on sleep. 407 afghan adults participated in the survey and were asked about their usage patterns, perceived addiction, and impact on their sleep quality and mental well-being. the survey revealed that many afghan adults exhibited excessive social media usage and showed signs of addiction. ¾ participants reported a strong urge to use social media. social media usage, particularly before bedtime, significantly affected sleep patterns and mental well-being. 68% of participants identified social media as a problem. a direct correlation was observed between the duration of social media usage and sleep disturbances, with increased usage leading to poor sleep quality and difficulty concentrating on daily activities. this study highlights the need for awareness and interventions to address the harmful effects of excessive social media use on sleep and mental well-being. mental health professionals, policymakers, and health organizations are urged to collaborate and develop strategies to promote mental well-being and address the issue of excessive social media usage. keywords mental health, social media, sleep disturbance, afghanistan, social media addiction 1 medical faculty, bost university, afghanistan 2 jahan university, kabul, afghanistan * corresponding author’s e-mail: tawabkhpalwak@gmail.com introduction when well-rested, we can better manage our thoughts, feelings, and behaviors, which happens when we sleep better at night (perry dr. et al., 2013)1. however, in the modern world, various factors disrupt the establishment of healthy sleeping patterns, and one such factor, which remains relatively unknown, is the excessive use of social media on screens (garett et al., 2016)2; this phenomenon is rapidly growing worldwide, particularly in developing countries like afghanistan, where people have limited access to education and are largely unaware of the detrimental effects of excessive social media usage on their overall well-being (facebook aware of instagram’s harmful effect on teenage girls, leak reveals | instagram | the guardian, n.d.)3. in afghanistan, adults primarily utilize social media for entertainment purposes, such as viewing videos, photos, status updates, and news, rather than for educational or research purposes (afghanistan media landscapes, n.d.)4 some individuals cannot read or write, rely solely on images to identify others and become dependent on social media platforms. numerous studies have affirmed that spending excessive time on social media platforms can profoundly impact social relationships, mental wellbeing, and various aspects of daily functioning, including sleep disruption, anxiety, depression, feelings of isolation, and decreased focus (hou et al., 2019; savci & aysan, 2016; seabrook et al., 2016)5–7. the prevalence of “nomophobia,” or the fear of being without a mobile phone, further exacerbates the issue, as individuals feel compelled to constantly stay connected to social media to remain abreast of current events and developments within their communities, country and the world at large, potentially leading to addiction disorders (al-barashdi et al., 2015; bhattacharya et al., 2019)8,9. the duration of social media usage directly correlates with its negative impact on mental well-being, particularly sleep quality; the longer individuals engage with social media platforms, the greater the disturbance it poses to their sleep and cognitive function (al-barashdi et al., 2015; pirdehghan et al., 2021)8,10. social media usage may disrupt sleep in several ways, such as by dislodging sleep, promoting physiological activity, or delaying circadian rhythms because of the bright light from devices (cain & gradisar, 2010; scott & woods, 2018)11,12. social media has increasingly infiltrated the daily lives of many afghan adults, most unaware of their dependence and addiction, consequently jeopardizing their social interactions and personal lives (afghanistan media landscapes, n.d.)4. therefore, to demonstrate the adverse effects of social media on the quality of life, it is essential to undertake scientific research to investigate the relationship between social media usage and sleep disorders. this study aimed to ascertain how much afghan adults spend on social media and its potential effects on their sleep duration and quality. additionally, this research examined the association between prolonged and reduced social media usage and their respective negative implications for sleep quality among adults. the findings of this study will raise awareness of excessive social media usage and its detrimental effects on mental health, sleep patterns, and overall well-being. mental health professionals, policymakers, and health organizations can utilize these findings to address this issue and promote public awareness regarding the addictive nature of social media usage and its negative consequences on individuals’ mental health and sleep habits. pa ge 28 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 27-34, 2024 literature review websites that allow users to create profiles and show their relationships with other users are called social media platforms (boyd & ellison, 2007)13. social media are now integral to our lives and are used for communication, news, business, and pleasure (worley, 2018)14. according to a report from the statista website, there are 4.8 billion social media users worldwide, approximately 59.4% of the global population (social media: worldwide penetration rate 2023 | statista, n.d.)15. this means that six out of ten people worldwide use social media, which keeps growing (digital 2020: global digital overview datareportal – global digital insights, n.d.; social media statistics & facts | statista, n.d.; kim et al., 2006)16–18. social media platforms serve many purposes, such as staying connected, seeking information, and providing entertainment. they are crucial in people’s daily lives (lin & lu, 2011)19. however, excessive use of social media can negatively affect health and well-being by disrupting sleep patterns. sleep is essential to both physical and mental health. (loft & cameron, 2014)20. there is much attention on the potential adverse effects of screen use and social media on health (gruber et al., 2012; perry dr. et al., 2013; sikder & rhein-waal, n.d.)1,21,22. studies have found that spending too much time on social media is associated with mental health problems such as stress, anxiety, depression, sleep disturbances, and low self-esteem (seabrook et al., 2016)5. excessive use is widespread among young people, but we do not know much about how it affects their ability to sleep (van den eijnden et al., 2021)23. excessive or addictive social media usage can be described as a behavioral addiction in which individuals become excessively preoccupied with social media platforms. this addiction is characterized by an irresistible compulsion to frequently access and engage with social media, resulting in substantial time and energy being dedicated to it, disrupting essential areas of life (social media addiction: recognize the signs, n.d.)24. many studies in developed countries have focused on the relationship between social media use and mental health problems in various groups of people (hou et al., 2019; savci & aysan, 2016, 2017; selfhout et al., 2009)6,7,25,26, mainly in young individuals (glazzard & stones, 2020)27. these studies have also shown that excessive social media use disrupts sleep patterns and duration, which negatively affects performance, mood regulation, communication, thinking, comprehension, and overall health (al et al., 2023; fredriksen et al., 2004; gruber et al., 2012; wolfson & carskadon, 1998)21,28–30. most of these studies found a positive link between social media use and mental health problems. however, an earlier study conducted in 2002 found a negative relationship between internet addiction and depression, which is not a widely accepted concept (shaw & gant, 2002)31. in this study, we specifically focused on how excessive social media use affects sleep disturbances among afghan people. sleep is crucial for health and well-being (sikder & rhein-waal, n.d.)22 but is often overlooked in public health messages and education (gruber et al., 2012; perry dr. et al., 2013)1,21. a study conducted among university students in khust province, afghanistan, found that many students were addicted to social media, which positively correlated with depression. the more addicted they were, the more signs and symptoms of depression they showed (haand & shuwang, 2020)32. social media disrupts sleep in three ways: displacing sleep time (cain & gradisar, 2010; levenson et al., 2017)(cain & gradisar, 2010; levenson et al., 2017), delaying sleep, and promoting physiological activity (scott & woods, 2018)12. research has also shown that social media use reduces sleep quality by creating a constant urge to control and influence behavior (pea et al., 2012)34. a study among young american adults showed that participants with higher social media usage had a higher risk of sleep disruption (levenson et al., 2016)33. an italian study of junior and senior high school students found that female students had higher phone and social media engagement. the study also found that using mobile devices near bedtime had a positive relationship with sleep problems (almeida et al., 2023; bruni et al., 2015)35,36. sleep problems are linked to depression, negative social relationships, and poor school performance (alfano et al., 2009)37. additionally, individuals with sleep problems often experience symptoms of anxiety, reduced cognitive function, and a weakened immune system (stickley et al., 2019)38. inadequate sleep increases the risk of chronic conditions such as obesity, diabetes, and cardiovascular disease. therefore, addressing and managing sleep disturbances is vital to improving overall well-being and various aspects of life (sleep and chronic disease | cdc, n.d.)39. methodology a simple random sampling method is used in this study. a self-reported english questionnaire was prepared for data collection from different studies. a professional translator translated the questionnaire into the local language (pashto). the research study, method, and questionnaire were reviewed and approved by the research and ethics committee of the medical faculty of bost university; reference number: bostethics-0751, meeting number 4, conducted on 26 june 2023. the questionnaire was adjusted into a microsoft format to be shared online with prospective participants, which everyone could access. the questionnaire was shared through different social media platforms and groups for data collection from 10 july 2023 to 23 july 2023. the questionnaire was easy to complete; on average, it took 9 minutes and 30 seconds for every person to complete it. it is important to note that before submitting their responses, consent was obtained from each participant, and they were duly informed about the purpose of the study. the participants were assured that their confidentiality would be protected. those unwilling to participate had the right to refuse and were not obligated pa ge 29 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 27-34, 2024 to participate in the study. no financial or other incentives were provided to students to complete the survey. according to the unknown population sample size formula(gupta et al., 2016)40, the sample size was calculated as 385. infinite population sample size formula s=z2 * p(1-p)/m2 where, s = sample size z = given z value = 1.96 (confidence level 95%) p = population proportion (assumed to be 50%=0.5) m = margin of error= 5% pop = population infinite population sample size formula ones = z2 * p(1-p)/m2 s = (1.96)2 * 0.5(1-0.5)/(0.05)2 s = 3.8416 * 0.25/0.00252 s = 384.16 to be more accurate, the sample size was increased to 407 respondents. the sample size was limited to adults, the society’s most active social media group. the data were analyzed using microsoft forms, microsoft excel, and microsoft access. data analysis a total of 407 survey respondents from 19 different provinces of afghanistan completed and submitted survey forms. of these, 54 were female, 353 were male (13% female; 87% male), and most (293 survey participants) were aged 18–32. regarding education level, all participants were educated as they completed the survey forms; among the 407 survey participants, 357 (88%) were undergraduate degree students or completed undergraduate degree studies. all the respondents used social media for different purposes and durations during the day and night, as the statistics are as follows: ⅰ) 117 out of 407 (28.7%) used social media for four or more hours. ⅰⅰ) 82 out of 407 (20.1%) users used social media for 3 hours. ⅰⅰⅰ) 93 out of 407 (22.8%) participants used social media for two hours. ⅳ) 88 out of 407 (21.6%) users used social media for one hour. ⅴ) 27 out of 407 (6.6%) participants used social media for 30 minutes or less. this suggests that a significant proportion of the participants relied heavily on social media in their daily lives. after comparing the duration of social media usage and sleep quality, as shown in table 1, we found that more extended social media usage is directly linked to sleep disturbance, sleep quality, and nightmares. table 1: social media usage linked to nightmares and sleep quality total # participants social media usage duration social media has a negative effect on my normal sleep. nightmare sleep quality very good good bad very bad 117 4 hours or more 85 56 23 61 29 4 82 3 hours 62 29 14 55 11 2 93 2 hours 71 34 23 62 6 2 88 1 hour 62 21 19 59 9 1 27 30 minutes or less 19 8 9 15 3 0 figure 1: sleep quality of participants considering last month pa ge 30 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 27-34, 2024 table 2: social media usage before bed using social media before bed total respondents: # respondents duration enthusiasm for daily activities very often sometimes rarely very rarely 353 out of 407 202 1 hour 15 30 89 68 94 1-2 hours 18 24 31 21 49 two or > hours 17 11 13 8 if your sleep is being negatively affected because of excessive use of social media, please write down the effects: respondents’ comments: (mostly repeated comments are compiled in this chart.) no restful sleeping and headache. no or less sleeping, anxiety, and depression. i was being mentally and physically fatigued and being lazy. restlessness and loss of focus on daily activities abnormal sleeping and cannot wake up in the morning quickly. eye problems and heavy head. i cannot wake up in the morning and have a lazy day with worries regarding sad news which i have seen on social media. sleep disturbance and nightmares with no focus. loss of focus and inability to study, which ends with depression. stress and engagement with what i see on social media are repeatedly coming to me, which distresses me. i am pretty good, with no adverse effects, as i use it for a limited time. can not fall asleep quickly, in reverse in the morning, cannot get up quickly. irregular sleeping cycle before sleeping is fine with me, but i cannot fall asleep if i use social media after midnight. seems always tired. can not offer the prayer of the morning because of late sleeping the negative and bad news about the country, especially the videos of poor people, make me cry and fall asleep late, this causes me to be tired and sleepy tomorrow. black circles around the eye and miss the morning offer prayer, a sign of unfortunate. no regular sleep and being stressed. anxiety with being lazy and dull. table 3: feeling the urge to use social media feeling an urge to use social media total respondents: rarely some time very often 407 (100%) 78 (19%) 174 (43%) 155 (38%) a question that asked participants to assess their sleep quality in the previous month was answered as follows (figure 1): as shown in the following table 2, 87% of the respondents (353 out of 407) admitted using social media before bed. however, they also expressed enthusiasm for daily activities instead of using social media before bed. of the 407 or 73% of participants, 299 mentioned that social media negatively affected their normal sleeping process and mental health, and they commented on their adverse effects below to an open question. therefore, to fall asleep early and sleep well, 39 of 407 participants were taking sleeping tablets once or twice a week. regarding whether they (respondents) felt an urge to use social media more and more, the answer was yes, and the statistics were as follows (table 3): the study also revealed that those with more thirst or desire to use social media use it for long hours than those with less desire to use it (table 4). pa ge 31 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 27-34, 2024 table 5: lose of concentration, ability to work, and communication ability frequency of loss of concentration, ability to work, communicate, and perform daily activities total respondents: not happened rarely some time very often 407 (100%) 97 (24%) 129 (32%) 115 (28%) 66 (16%) how do you limit the usage of social media (the ways)? respondents’ comments: i lifted the unnecessary social media groups, prepared a schedule for my daily routine, and am following it. firm intention targeted a goal i am studying for. i did sports and paid attention to my mental and physical health after i became addicted to social media. giving time to my beloved family and children helped me reduce my social media usage, and i feel very well. i am studying more and getting motivated to return to natural life rather than internet life. i am trying to be busy with other activities and remembering how social media affects my health. motivated strongly and intended not to use social media. no activation of internet bundle. i use my mobile just when needed, and when i feel slightly distressed because of social media, i switch off the phone. i do busy myself intentionally with activities related to my job, so my usage of social media has decreased. activation of a small package of internet bundle for most needed activities. i do not activate oversized internet packages and watch a movie before falling asleep. watching movies makes me fall asleep in 15 minutes, and i made my habit of sleeping early and avoiding using social media. priorities my daily routine and study in my free time. i watch youtube to learn and study psychology. deactivation of social media accounts deactivates new internet bundles for days when the old one ends. i limited the use of smartphones and am using a simple mobile for calling. i turned off the notifications and used the no disturb mode of my mobile. i am scheduled to use social media for 30 minutes; if it increases, i get the notification. i have solid intentions and try to be busy with my daily routine, job, and work. table 4: urge to use social media urge to use social media number of participants 4 hours or more 3 hours 2 hours 1 hour 30 minutes or less very often 155 (38%) 78 31 31 41 5 sometime 174 (43%) 29 38 39 92 15 rarely 78 (19%) 10 13 23 48 7 as summarized in table 5, participants also reported that because of excessive use of social media, they lost their focus and ability to work, communicate, and perform daily routine activities well. despite falling asleep late and not sleeping adequately, 241 of 407 participants declared that they woke up in the middle of the night or early in the morning. more than half of the participants (276 out of 407) felt that excessive use of social media was a problem for them and were trying to limit the frequency and duration of social media usage. of 407, 202 mentioned that they successfully limited social media usage using different ways. from 202 optional comments, we share 20 of them in this article, which are selected randomly. in conclusion, the study revealed that more participants were using social media for extended periods and that excessive usage had a detrimental impact on their mental well-being and sleep. it has been shown that the more people use social media, the more it impacts their sleeping length, sleeping quality, routine tasks, focus, concentration, and enthusiasm for daily activities. in contrast, people who use social media for a shorter period have a less unfavorable influence on their sleeping mood, mental health, and sleep quality. result and discussion the study of 407 participants found that longer hours of social media usage are directly linked to sleep disturbance, pa ge 32 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 27-34, 2024 sleep quality, and nightmares. the study also revealed that 87% of the respondents used social media before bed, and 73% mentioned that social media negatively affected their normal sleeping process and mental health. 28.7% of the participants used social media for four or more hours, 20.1% for 3 hours, 22.8% for 2 hours, 21.6% for 1 hour, and 6.6% for 30 minutes or less. 276 out of 407 participants felt that excessive use of social media was a problem for them and were trying to limit the frequency and duration of social media usage. 241 of 407 participants declared that they wake up in the middle of the night or very early in the morning despite falling asleep late and not sleeping adequately. participants also reported that excessive use of social media caused them to lose focus and ability to work, communicate, and perform daily activities well. the study showed that more participants were using social media for extended periods, and excessive usage of social media had a detrimental impact on their mental well-being and sleep. the findings of this study are significant for various stakeholders, including organizations, policymakers, individuals working towards mental health well-being, and frequent users of social media. this study highlights the detrimental effects of excessive social media use on sleep patterns and mental health. the positive correlation between social media addiction and reduced sleep quality indicates that individuals more addicted to social media experience lower quality sleep than those who use it for shorter durations. the participant’s comments further support the notion that excessive social media use adversely impacts daily life. many participants reported difficulties in falling asleep, feeling tired and sleepless, facing challenges in studying and performing daily activities, increased anxiety, feelings of depression, frequent headaches, and experiencing laziness and fatigue. in addition, participants mentioned difficulties in maintaining focus and concentration. furthermore, several practical approaches were identified when participants were asked to provide strategies to limit their social media usage. a common theme among the participant responses was a solid intention to limit their social media usage. activation of mini-internet packages, engaging in studying, spending quality time with family, focusing on daily activities, participating in physical exercise, creating a schedule for daily activities, and enforcing strict adherence to their self-imposed restrictions were cited as effective strategies. these findings have practical implications for both individuals and society as a whole. by raising awareness about the negative impact of excessive social media use on sleep and mental health, this study can help guide individuals toward healthier habits. the results also call for the attention of organizations, policymakers, and mental health professionals to develop interventions and initiatives that address the growing problem of social media addiction. by incorporating these findings into public health campaigns and educational programs, we can work towards promoting better sleeping habits and safeguarding mental health among social media users. conclusion in conclusion, this study provides compelling evidence that social media significantly negatively impacts afghan adults’ sleep and mental health, resulting in reduced duration and quality of sleep. moving forward, it is recommended that policymakers and organizations take proactive measures to increase awareness about the detrimental effects of excessive social media usage on health. additionally, interventions in the form of sleep education should be implemented to assist individuals in achieving a balance between online interactions and sufficient sleep. furthermore, future research should be conducted into other aspects of excessive social media use, including stress, anxiety, academic performance, addiction levels, and self-esteem. by understanding these factors more deeply, we can develop comprehensive strategies to address the multifaceted challenges of excessive social media usage among adults in afghanistan. this will involve addressing the immediate sleep and mental health concerns and tackling broader issues relating to stress, addiction, and 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(2018). the extraordinary importance of sleep: the detrimental effects of inadequate sleep on health and public safety drive an explosion of sleep research. pharmacy and therapeutics, 43(12), 758. /pmc/articles/pmc6281147/ pa ge 1 pa ge 44 american journal of medical science and innovation (ajmsi) crispr-cas9 genomic editing as an innovation in the management of sickle cell disease: a systematic review solomon musa1, aloysius obinna ikwuka2*, francis chigozie udeh2, abdullahi adobanyi musa3, ugo collins chukwuezie4 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1760 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 16, 2023 accepted: july 08, 2023 published: july 30, 2023 genomic editing is a group of technologies that scientists have used to alter an organism’s dna. of the several genomic editing techniques, clustered regularly interspaced short palindromic repeats (crispr)-associated protein 9 (crispr-cas9) is well known. the crispr-cas9 system is faster, cheaper, more accurate, more efficient than other genomic editing methods, and it is an adaptation from bacteria’s immune mechanism. sickle cell diseases (scds) are a group of monogenic diseases, and despite their high prevalence and chronic debilitating nature, they continue to have few therapeutic options available. the aim of this study is to review existing literature and current clinical trials on crispr-cas9 genomic editing as an innovation in the management of sickle cell disease (scd), as well as the current state of treatment for scd. for this systematic review, pubmed, google scholar, african journals online (ajol), and clinicaltrial.gov articles published up to 6th october, 2022 were searched. searches for current clinical trials using crispr-cas9 as intervention were conducted by using the search terms such as sickle cell disease, genomic editing, genetics, novel treatments, hematopoietic stem cell transplantation, gene therapy, and crispr-ca9. studies cited include meta-analyses, original research, prospective clinical trials, online abstracts, literature reviews, retrospective studies, case series, and scientific meetings. the primary search obtained 27,678 articles. following a review of titles and abstracts, a total of 32 publications and 6 ongoing clinical trials were included in this systematic review based on the recent evidence-based management of scd. crispr-cas9 genomic editing stands out as a novel, innovative technology which has the potential to cure scd in children and adults with minimal side effects. six clinical trials are ongoing with a huge potential for scaling up to phases 3 and 4. keywords crispr-cas9, genomic editing, innovation, management, sickle cell disease, gene therapy 1 clinical projects, xcene research, ikeja, nigeria 2 college of medicine and health sciences, american international university west africa, banjul, the gambia 3 department of family medicine, ahmadu bello university teaching hospital, zaria, nigeria 4 department of community medicine, university of lagos, surulere, nigeria * corresponding author’s e-mail: aloysiussweet@yahoo.com introduction genetic medicine is a newer terminology for medical genetics and incorporates areas such as gene therapy. recent advances in medical genetics are revealing etiologies for morphologic, endocrine, cardiovascular, pulmonary, ophthalmologic, renal, psychiatric, and dermatologic conditions (ikwuka, 2023a). sickle cell disease (scd) encompasses a group of blood disorders resulting from inheriting two mutated copies of the β-globin gene (hbb) from both parents (frangoul, 2021). hbb, located on chromosome 11p15.5, encodes the β-chain of hemoglobin (onda, 2005). in normal circumstances, humans have three types of hemoglobin: hemoglobin a (consisting of 2α and 2β chains), hemoglobin a2 (made up of 2α and 2δ chains), and hemoglobin f (hbf) composed of 2α and 2γ chains (hall, 2020). in sickle cell anemia, the most prevalent form of scd, red blood cells (rbcs) contain an abnormal hemoglobin variant called hemoglobin s, wherein each of the two β-chains has a specific mutation (an amino acid valine with codon gtg substitutes glutamic acid with codon gag at position 6) (hall, 2020). thus, the genetics of scd (a hemoglobinopathy) is due to the substitution of valine for glutamic acid at position 6 of both β-globin polypeptide chains. hemoglobin f persists until about 6 weeks of age. thereafter, hemoglobin a persists throughout life. the mode of inheritance of scd is autosomal recessive (ikwuka, 2023b). hemoglobin, a protein responsible for oxygen transport in red blood cells (rbcs), is synthesized during erythropoiesis (initiated in polychromatophil erythroblasts and continuing through the reticulocyte stage) (hall, 2020). erythropoiesis is stimulated and enhanced by erythropoietin, a substance synthesized by the kidneys. results from different studies have shown that high levels of blood pressure, glucose and lipid metabolic disorders, asymptomatic hyperuricemia, activation of systemic immune inflammation and fibrogenesis, contribute to kidney damage (ikwuka, 2015; ikwuka, 2017a; ikwuka, 2017c; ikwuka, 2017d; ikwuka, 2017e; ikwuka, 2018d; ikwuka, 2019a; ikwuka, 2019c; ikwuka, 2022; ikwuka, 2023d; ikwuka, 2023e; virstyuk, 2016; virstyuk, 2017a; virstyuk, 2018a; virstyuk, 2019; virstyuk, 2021a; virstyuk, 2021b), which contributes to anemia on account of disturbed erythropoietin production. however, dapagliflozin which is a sodium-glucose linked transporter 2 (sglt-2) inhibitor and liraglutide which is a glucagon-like peptide 1 receptor agonist (glp-1 ra) have been found to increase the effectiveness of treatment and improve the clinical course of disease in patients with such comorbidities (ikwuka, 2017b; ikwuka, 2018a; ikwuka, 2018b; ikwuka, 2018c; ikwuka, 2019b; ikwuka, 2021; virstyuk, 2018b; virstyuk, 2018c; virstyuk, 2017b), pa ge 45 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 thereby reducing kidney damage, improve kidney functions, and reduce anemia. when hemoglobin s encounters low oxygen levels, it forms long crystals (sometimes 15 micrometers in length) within rbcs, impeding their flow through narrow capillaries. the pointed ends of these crystals can rupture the plasmalemma leading to sickle cell anemia (hall, 2020). major free radicals that are of physiological significance are superoxide anion, hydroxyl radical, and hydroperoxyl radical, while non-radical is hydrogen peroxide (ikwuka, 2023c). rauwolfia vomitoria has a neuroprotective ability at it elevates antioxidants and suppresses lipid peroxidation (ekechi, 2023). it is noteworthy that nearly two-thirds of infants worldwide with hbss or scd are born in nigeria, the republic of congo, or india, where the childhood mortality rate associated with scd remains alarmingly high (piel, 2013). symptoms and complications of scd typically manifest around 5 to 6 months of age when fetal hemoglobin (hbf) synthesis significantly declines. these symptoms include severe anemia, episodes of pain (referred to as sickle cell crisis), swelling in the hands and feet, and potential complications such as bacterial infections and stroke (frangoul, 2021; hall, 2020). long-term pain can develop as individuals grow older, and the average life expectancy in developed countries ranges from 40 to 60 years (national heart, lung, and blood institute, 2015). newborn screening is the common diagnostic approach for identifying hbss, and treatment options include penicillin (essential for children under five years with immature immune systems), folic acid supplementation, blood transfusions, vaccinations against encapsulated organisms, transcranial doppler (tcd) screening to identify stroke risk in children (followed by blood transfusions, if necessary), pain management, hydroxyurea, and intensive hospital-based care (adams, 1998; gaston, 1986; thornburg, 2012; who, 2011). other diagnostic tests for scd include sickling of the red blood cells on a blood film which is induced by the addition of sodium metabisulfite; and another test referred to as hemoglobin electrophoresis which detects abnormal hemoglobin forms (ikwuka, 2023b). however, despite the significant need for effective treatment options for scd patients, current treatments both traditional and newly developed, only ameliorate acute and chronic scd manifestations without addressing the underlying cause. hydroxyurea and long-term blood transfusions aim to prevent and treat complications associated with scd. the recently approved crizanlizumab (ataga, 2017) has shown a reduced incidence of cellular adhesion and vaso-occlusive crisis in scd patients, but it does not target the root cause of the disease or fully alleviate its manifestations (frangoul, 2021). allogeneic hematopoietic stem cell transplantation (hsct) remains the sole curative option for scd, yet less than 20% of eligible patients have a suitable hla-matched donor (baronciani, 2016; eapen, 2019; gluckman, 2017). further advances in the understanding of the pathophysiology of scd contributed to the development of the exciting and novel “clustered regularly interspaced short palindromic repeats (crispr)-associated protein 9 (crispr-cas9)” genomic editing therapy to cure the disease and its complications. bacteriophages have the ability to infect bacteria by implanting its genetic material into the bacterial genome (chaudhary, 2020). thereafter, bacteria have a natural defense mechanism against bacteriophages, whereby on the first exposure to a bacteriophage they produce crispr sequence as a form of genetic memory. crispr sequence is always found in association with the cas9, a nuclease that can cleave the dna. in subsequent exposure to a similar bacteriophage, the bacteria form guiderna from the transcription of the crispr sequence. the guiderna finds its target in the bacteriophage dna, while the cas9 cleaves the dna (chaudhary, 2020). the advantage of this system is that once the crispr system has cleaved the dna, a dna template carrying the desired sequence can join the cleaved end, thereby facilitating recombination and replacement of the original sequence with the new version. the crispr-cas9 nuclease system can be employed in cultured cells, including stem cells, as well as in fertilized eggs, enabling the generation of transgenic animals with targeted mutations. this genomic editing technique has been extensively studied in various organisms such as yeast, drosophila, zebrafish, plants, monkeys, and pigs, in addition to the bacteria from which the technique was originally derived from (wen, 2017). in the case of scd, the crispr-cas9 nuclease system is applied to hematopoietic stem and progenitor cells (hspcs) at the erythroid-specific enhancer region of the bcl11a locus on chromosome 2 (uda, 2008). normally, bcl11a encodes a transcription factor that inhibits hbf synthesis. the crispr-cas9 nuclease system effectively suppresses bcl11a expression in erythroid-lineage cells, thereby restoring γ-globin synthesis and reactivating hbf production (canver, 2015; wu, 2019). unlike previous genomic editing methods, crispr-cas9 has the capacity to target multiple genes simultaneously, enabling the treatment of not only diseases with point mutations but also those with polygenic mutations. researchers have recently realized that this system can be engineered to cleave dna at precisely chosen loci, extending beyond viral dna to any desired dna sequence, simply by modifying the guiderna to match the target (chaudhary, 2020). in this systematic review, a comprehensive analysis of the current state of research on crispr-cas9 for the treatment of sickle cell disease (scd) was conducted. by gathering information from multiple sources, evaluation of the progress made with this innovative technology is determined, identified knowledge gaps for further research are checked, and the technology’s potential challenges and limitations are discussed. methodology search strategy and selection criteria this systematic review aimed to study all available literature on crispr-cas9 genomic editing and its potential in the management of scd. it also sought to shed more light on pa ge 46 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 the subject matter (considering the fact this technology is novel) and its stage of development is still in the clinical trials. a similar method of literature search as described by suwito, et al, 2023 was used (suwito, 2023). the literature search was done from the following databases over a period of 2 weeks: pubmed (mostly used), google scholar, and african journals online (ajol) using the following terms: crispr-cas9, genomic editing, gene editing, sickle cell disease, hemoglobinopathies, sickle cell anemia, genetic therapy, systematic review, new therapy/novel intervention for sickle cell disease cure/treatment. data sources and search engines a literature search was done from the following databases: pubmed (mostly used), google scholar, and african journals online (ajol). while the clinical trials search was done on clinicaltrials.gov. inclusion and exclusion criteria included in this study were studies that investigated the use of crispr-cas9 genomic editing as a treatment for sickle cell disease, studies that included human participants or human cells/tissues, studies that provided data on the efficacy and/or safety of crispr-cas9 genomic editing for sickle cell disease, and studies that were published in english language within the past 10 years on gene therapy use in scd, specifically crispr-cas9. excluded articles were studies not related to crispr-cas9 genomic editing or sickle cell disease, studies that used animal or plant models only, studies not published in english, studies that did not provide data on the efficacy and/or safety of crispr-cas9 genomic editing for sickle cell disease, and studies that had poor methodological quality or a high risk of bias. quality assessment of included studies the articles from the database search were reviewed to tailor them to the inclusion criteria. the abstracts of the articles that met the inclusion criteria were reviewed for relevant keywords. the abstracts and the free complete articles i.e. manuscripts for the selected articles were then read, reviewed, and the information on each of the key areas were summarized. this systematic review was carried out independently by four persons, to minimize errors. the summarized data were later compiled, reviewed, and discussed. data extraction, synthesis, and results the following keywords were used to extract articles from database searches: • “crispr-cas9” • “genomic editing” • “sickle cell disease, hemoglobinopathies, and sickle cell anemia” • “genetic therapy and gene editing” • “systematic literature review or systematic review” • “new therapy/novel intervention for sickle cell”. study selection and characteristics the search for articles and abstracts was done using figure 1: steps of article selection keywords on the three major search engines (pubmed, google scholar, and ajol). however, the mostly used search engine was pubmed due to its advanced features and its large repository of articles. study selection was based on articles, abstracts, or literature reviews which meet the inclusion criteria. articles that were found under exclusion criteria were discarded. the diagram below illustrates how articles were selected. results the findings in this study are outlined in tables 1 and 2. table 1: summary of articles in the literature search s/n paper title abstract summary study type outcome measured/ summary of conclusion 1 crispr-cas9 gene editing for sickle cell disease and β-thalassemia (frangoul, 2021) crispr-cas9-targeting erythroidspecific enhancers modified 80% of the alleles at this locus in healthy donors. phase ½ • allelic editing in bone marrow and blood • ↑ in hbf •transfusion independence • elimination of vaso-occlusive episodes in the patient with scd pa ge 47 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 2 a review of the therapeutic potential, prospects, and challenges of crisprcas9 genome editing in the treatment of sickle cell disease (scd) (chaudhary, 2020) crispr-cas9 is a potential therapeutic tool in the management of scd. review • through this review paper, the scope and possibilities of crispr-cas9 as a potential therapeutic tool in the management of scd was analyzed 3 therapeutic crisprcas9 genome editing for treating sickle cell disease (park, 2016) optimized crispr-cas9 systems for genomic editing can be achieved in cd34+ cells. review • rates of non-homologous end joining (nhej) events • rates of homology directed repair (hdr) events • genome editing frequencies at both dna and mrna levels • expression of globin and other erythroid markers • number and type of colonies following induction of differentiation • genotype of edited cells • translation of edited β-globin protein and formation of hbs 4 crispr-cas9 mediated correction of the sickle mutation in human cd34+ cells (hoban, 2016a) targeted genomic editing technology can correct the scd mutation of the β-globin gene in hematopoietic stem cells. e xperim ental • gene modification rate • production of wild type hemoglobin. 5 crispr-cas9 to induce fetal hemoglobin for the treatment of sickle cell disease (demirci, 2021) genomic editing is potentially a curative technique available to all individuals with -hemoglobinopathies, including scd. review • fetal hemoglobin (hbf) induction • editing of transcriptional hbf silencers • modulating epigenetic intermediates that govern hbf expression 6 crispr-cas9 for sickle cell disease: applications, future possibilities, and challenges (demirci, 2019) genomic editing approach has proven valuable as a curative option. review • disease severity • mortality • morbidity 7 crispr-cas9 gene editing for curing sickle cell disease (park, 2021a) ex vivo engineering of autologous hspcs followed by transplantation of genetically modified cells potentially provides a permanent cure applicable to all patients regardless of the availability of suitable donors and graft-vs-host reaction. review • severity of pain • end organ damage • early mortality 8 crispr-cas9 genomic engineering: trends in medicine and health (zaib, 2022) crispr-cas9 technology offers the simplest, fastest, most versatile, reliable and precise method of genetic manipulation. review • genetic manipulation • removing sections of the dna sequence • adding sections of the dna sequence • altering sections of the dna sequence pa ge 48 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 • treatment of various medical conditions including cancer, hepatitis b, cardiovascular diseases or even high cholesterol • minimization of the off-target effects of gene editing and incomplete matches between single guiderna and genomic dna by cas9 9 crispr-cas9: anew and promising player in gene therapy (xiao-jie, 2015) crispr-cas9 can be applied for therapeutic purposes in cell lines or animal models. review • gene therapy outcomes • correction of causal mutations in monogenic disorders • rescue of disease phenotypes • engineering of pathogen genome for therapeutic purposes • induction of protective or therapeutic mutations in host tissues • deactivation of oncogenic virus • induction of onco-suppressor expressions 10 emerging genetic therapy for sickle cell disease (orkin, 2019) transcript factors that mediate silencing of the γ-like fetal globin gene after birth have been identified and demonstrated to act as the β-globin promoters. review • efficacy of genetic strategies to cure scd • safety of genetic approaches to cure scd 11 era of genomic medicine: a narrative review on crispr technology as a potential therapeutic tool for human diseases (kotagama, 2019) the guiderna can be modified to match a dna sequence of interest in the cell. review • an insight with relation to a few of the many diseases that are being tackled with the aid of the crispr-cas9 mechanism and the trends, successes, and challenges of this application as a gene therapy are discussed in this review 12 crispr-cas9 genome editing in human hematopoietic stem cells (hscs) (bak, 2018) genomic editing via homologous recombination (hr) in human hscs has the power to reveal gene-function relationships and potentially transform curative hematological gene and cell therapies. e xperim ental • production of hr targeted hscs • enrichment of hr targeted hscs • in vitro analysis of hr targeted hscs • in vivo analysis of hr targeted hscs • manipulation of genes for investigation of gene functions during hematopoiesis • correction of genetic mutations in hsc transplantation-based therapies for diseases such as scd, β-thalassemia, and primary immunodeficiencies 13 efficacy of crisprbased gene editing in a sickle cell disease patient as measured through the eye (pinhas, 2022) optical coherence tomography angiography can detect and measure micro-occlusive events within the retinal capillary bed before and after rbc exchange transfusion and following crispr-based gene editing. case report • micro occlusive events within the retinal capillary bed pa ge 49 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 14 current sickle cell disease gene therapy treatments: literature review (ranadive, 2022) the base editor shows promise in its ability to surpass many issues faced with both viral vectors and crispr-cas9 in human trials. literature review • success of lentiviral vectors in genotype correction and hbf induction • success of crispr-cas9 in genotype correction and hbf induction • success of base editors in genotype correction and hbf induction 15 crispr-cas9 editing induces high rates of unintended large gene modifications in hspcs from patients with sickle cell disease (park, 2021b) unintended on-target large deletions occur at high rates in gene-edited scd hspcs. e xperim ental • unintended gene modifications due to cas9 induced double stranded breaks (dsbs) in scd hspcs, including large deletions, insertions, and complex chromosomal arrangements 16 automated good manufacturing practicecompatible crisprcas9 editing of hematopoietic stem and progenitor cells for clinical treatment of β-hemoglobinopathies (urena-bailen, 2023) the enhancer of the bcl11a gene is a crispr target in ongoing clinical trials for β-thalassemia and scd treatment. e xperim ental • editing efficiency • hbf resurgence 17 in vivo selection for corrected β-globin alleles after crisprcas9 editing in human sickle hematopoietic stem cells (hscs) enhances therapeutic potential (magis, 2018) cas9-mediated gene editing in long-term engrafting human hscs yields more than 20% correction of the sickle mutation in long-term engrafting human hscs. e xperim ental • percentage of correction of the sickle mutation in long term engrafting human hscs • rna sequence data to find cells carrying corrected ss globin alleles • efficiency of editing with almost no off target events 18 multiplex crisprcas9 genomic editing in hematopoietic stem cells for fetal hemoglobin reinduction generates chromosomal translocations (samuelson, 2021) genomic editing therapies targeting either the bcl11a erythroid enhancer or the hbg promoter are already proving successful in reinducing hbf. e xperim ental • hbf reinduction • engraftment • lineage differentiation potential of edited cells post xenotransplantation • chromosomal rearrangement events 19 crispr-cas9: a preclinical and clinical perspective for the treatment of human diseases (sharma, 2021) crispr-cas9 is a promising genome-editing tool that has therapeutic potential against incurable genetic disorders by modifying their dna sequences. e xperim ental • modulation of predefined gene expression (upregulation or downregulation) 20 genomic editing: a perspective on the application of crisprcas9 to study human diseases (review) (rodriguez-rodriguez, 2019) the crispr-cas9 system can repair the damage caused to dna. review • the basic principles of the crispr-cas9 system are reviewed, as well as the strategies and modifications of the enzyme cas9 to eliminate the off-target cuts, and the different applications of crispr-cas9 as a system for visualization and gene expression activation or suppression pa ge 50 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 21 use of genomic editing tools to treat sickle cell disease (tasan, 2016) the only existing curative treatment for scd is based on allogeneic stem cell transplantation from healthy donors. e xperim ental • discussion of the three programmable nucleases that are commonly used for genomic editing purposes: zinc finger nucleases (zfns), transcription activator-like effector nucleases (talens) and crispr-cas9 22 crispr-cas9 β-globin gene targeting in human hematopoietic stem cells (dever, 2016) ex vivo gene correction in patient-derived hscs followed by autologous transplantation could be used to cure hemoglobinopathies. preclinical trial • homologous recombination at the hbb gene in hscs • efficiency of correction of the glu6val mutation responsible for scd • expression of adult β-globin (hba) messenger rna after differentiation into erythrocytes 23 a systematic review of gene editing clinical trials (eshka, 2022) there are promising phase-i and phase-ii trials testing the safety and feasibility of gene editing in different clinical settings. literature review • gene editing clinical trials • genetically engineered t-cell therapies for cancer • virus infections • monogenic diseases 24 genetic treatment of a molecular disorder: gene therapy approaches to sickle cell disease (hoban, 2016b) the initial-retroviral vectors, nextgeneration lentiviral vectors, and novel genomic engineering and gene regulation approaches share the goal of preventing erythrocyte sickling. review • effective medical management for scd • preventing erythrocyte sickling • clinical success 25 efficient ablation of genes in human hematopoietic stem and effector cells using crispr-cas9 (mandal, 2014) crispr-cas9 can efficiently ablate genes in hspcs. e xperim ental • efficacy of crispr-cas9mediated genomic editing in primary human cd4+ t cells and cd34+ hspcs • gene deletion efficacy in cd4+ t cells and cd34+ hspcs • multilineage potential of hspcs that had undergone genome editing with crisprcas9 • predicted on and off target mutations via target capture sequencing in hspcs • levels of off target mutagen 26 selection-free genomic editing of the sickle mutation in human adult hematopoietic stem/progenitor cells (dewitt, 2016) a cas9 rnp can mediate efficient hematopoietic stem cell genomic editing in human hematopoietic stem cells from sickle cell disease patients. e xperim ental • production of normal hemoglobin • production of hbs rna and protein • production of wild type hemoglobin 27 genomic editing for sickle cell disease: a little bcl11a goes a long way (hossain, 2017) crispr-cas9 or zfns are useful tools to delete or replace sequences involved in the production of hemoglobin. review • feasibility of genomic editing in hspcs • ability of crispr-cas9 or zfns to delete or replace sequences involved in the production of hemoglobin pa ge 51 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 28 highly efficient editing of the β-globin gene in patient-derived hematopoietic stem and progenitor cells to treat sickle cell disease (park, 2019) gene-corrected sickle-cell hspcs engrafted in vivo. e xperim ental • efficiency of correcting the sickle mutation in the β-globin gene in hspcs • reduction of sickle cells in erythrocytes derived from gene edited cells • level of normal adult hemoglobin (hba) in erythrocytes derived from gene edited cells • engraftment of gene-edited scd hspcs in non-obese diabetic (nod) scid gamma (nsg) mice 29 cas9 protein delivery non-integrating lentiviralvectors for gene correction in sickle cell disease (uchida, 2021) the cas9 protein delivery nonintegrating lentiviral all-in-one system efficiently corrected the scd mutation in the endogenous s-globin gene without electroporation. e xperim ental • efficiency of correction of the scd mutation in the endogenous β-globin genes • protein level of the corrected β-globin genes 30 application of crisprcas9 genomic editing in genetic disorders: a systematic review up to date (pandey, 2017) crispr-cas9 system has been used from last few years in the field of biomedical research. review • genomic editing technologies over the past few years is providing fast and effective tool to precisely manipulate the genome at specific locations. 31 development of β-globin gene correction in human hematopoietic stem cells as a potential durable treatment for sickle cell disease (lattanzi, 2021) ex vivo β-globin gene correction in autologous patient-derived hspcs may potentially provide a curative treatment for scd. phase 1/2 • gene correction • genotoxicity • tumorigenicity • multilineage engraftment • abnormal hematopoiesis • toxicology 32 combination of lentiviral and genomic editing technologies for the treatment of sickle cell disease (ramadier, 2022) transduced cells from sickle cell patients were transduced with lentiviral vectors expressing as3 and a guiderna either targeting the endogenous β-globin gene or regions involved in hbf silencing. e xperim ental • clinical benefit in scd patients • vector copy number (vcn) • anti-sickling hemoglobins • rescue of the scd phenotype • genotoxicity risk table 2: current clinical trials on crispr-cas 9 (from clinicaltrial.gov, assessed on april 5th, 2023) s/n study title conditions interventions locations (first 3) 1 a safety and efficacy study evaluating ctx001 in subjects with severe sickle cell disease • sickle cell disease •hematological diseases •hemoglobinopathies • biological: ctx001 • phase 1/2/3 study • 45 estimated participants 1. lucille packard children’s hospital of stanford university, palo alto, california, united states. 2. ann & robert lurie children’s hospital of chicago, chicago, illinois, united states. 3. university of illinois at chicago hospitals and health systems, chicago, illinois, united states. pa ge 52 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 2 evaluation of efficacy and safety of a single dose of ctx001 in participants with transfusiondependent beta thalassemia and severe sickle cell disease • β-thalassemia • thalassemia • hematologic disease • biological: ctx001 • phase 3 • 12 estimated participants 1.columbia university medical center, new york, united states. 2. atrium health levine children’s hospital,charlotte, north carolina, united states. 3. scri at the children’s hospital at tristar centennial, nashville, tennessee, united states. 3 evaluation of safety and efficacy of ctx001 in pediatric participants with severe scd • scd • hydroxyurea failure •hydroxyurea intolerance • biological: ctx001 • phase 3 • 12 estimated participants 1. children’s hospital of philadelphia, philadelphia, pennsylvania, united states. 2. st. jude children’s research hospital, memphis, tennessee, united states. 3. the children’s hospital at tristar centennial medical center/ sarah cannon center for blood cancers. 4 transplantation of crisprmodified hematopoietic progenitor stem cells (crispr-scd 001) in patients with severe sickle cell disease • scd • drug: crispr_ scd001 • phase 1/2 • 9 estimated participants 1. university of california, los angeles, california, united states. 2. ucsf benioff children’s hospital, oakland, california, united states. 5 gene correction in autologous cd34+ hematopoietic stem cells (hbs to hba) to treat severe scd • scd • genetic: gph101 drug product • phase 1/2 • 15 estimated participants 1.university of alabama, birmingham, alabama, united states. 2. lucile packard children’s hospital, palo alto, california, united states. 3.washington university, saint louis, missouri, united states. 6 a long-term follow-up study in patients who received ctx001 • β-thalassemia • thalassemia • scd • biological: ctx001 • cohort study • 114 estimated participants 1. columbia university medical center (21+ years), new york, united states. 2. columbia university medical center, new york, united states. 3. children’s hospital of philadelphia, pennsylvania, united states. discussion this systematic literature review provides an overview of crispr-cas9 genomic editing and its application to sickle cell disease (scd), while also addressing the ethical implications associated with this technology in scd management. despite the wide use of crispr-cas9 as a mature genomic editing tool, therapeutic applications still face challenges such as off-target effects, complex in vivo cas9 protein delivery, low gene editing efficiency, and packaging issues. to become an ideal delivery method for therapeutics, crispr-cas9 strategies should exhibit high delivery efficiency, precise targeting ability, and ease of mass production. however, current approaches in this field are far from achieving this desired level of performance (guo, 2022). while there is significant literature on why scd is a suitable candidate for crispr-cas9, less attention has been given to the ethical implications of including scd in crispr-cas9 research. in addition, the implications of crispr-cas9 for sickle cell disease have significant consequences for clinical practice and policy. the following points highlight some of the potential implications: improved outcomes crispr-cas9 holds the potential to cure scd by correcting the underlying genetic mutation. this breakthrough could lead to improved outcomes for patients, including reduced pain, enhanced quality of life, and increased lifespan. reduced healthcare costs scd treatment can be expensive, and the use of crisprpa ge 53 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 44-56, 2023 cas9 may reduce healthcare costs by offering a curative approach rather than merely managing symptoms. ethical considerations the use of crispr-cas9 in humans raises ethical concerns regarding safety and the possibility of unintended consequences. the development of policies is necessary to ensure the ethical and reliable application of crisprcas9. access to treatment issues related to access to crispr-cas9 treatment for scd patients may arise, particularly in lowand middleincome countries. policies should be developed to ensure equitable access to the benefits of this technology for all patients in need. conclusion after analyzing the available evidence on the use of crispr-cas9 for the management of scd, it can be concluded that this technology is novel and shows promise as a potential therapeutic option for the condition. studies have demonstrated the successful correction of the genetic mutation responsible for scd in clinical settings. one of the main challenges of this technology is the delivery of the crispr-cas9 system to the bone marrow, where the hematopoietic stem cells reside. the off-target effects of the crispr-cas9 system also need to be further studied and minimized to ensure the safety of the treatment. despite these challenges, the potential benefits of crispr-cas9 for scd cannot be neglected. the ability to correct the genetic mutation responsible for the condition offers a potentially curative approach to the disease. overall, further research and clinical trials are necessary to fully evaluate the safety and efficacy of crispr-cas9 as a therapeutic option for scd. nevertheless, the current evidence suggests that crispr-cas9 has the potential to revolutionize the treatment of this debilitating disease by offering a curative option. conflict of interest the authors hereby declare no conflict of interest in conducting this research, and in publishing this manuscript. references adams, r. j., mckie, v. c., hsu, l., files, b., vichinsky, e., pegelow, c. & et al. 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(2022). crispr-cas9 genome engineering: trends in medicine and health. mini-reviews in medicinal chemistry, 22(3), 410–421. pa ge 1 pa ge 79 american journal of medical science and innovation (ajmsi) a systematic review on infertility in men due to sperm dna damage: causes investigations, & management muna rashed al khaldi1*, manal al-khaldi2 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1967 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 12, 2023 accepted: september 09, 2023 published: september 18, 2023 the prevalence of sperm dna damage is common in infertile men, caused by several factors. this systematic review aims to conclude causative agents, advanced and effective diagnostic aids, and treatment plans. after a critical review of 1123 articles and research papers collected from google scholar, pub-med, the database of abstracts of reviews of effects, embase, psycinfo, ovid medline, and cochrane central register of controlled trials, 14 reviews have been included in this systemic review according to prisma guidelines. included studies describe sufficiently regarding cause, investigations and management of infertility in men caused by sperm dna damage. according to the results, 14 reviews have been eligible for this systemic review. the subject of these reviews is associated with sperm dna damage in men, causing infertility. these reviews summarised oxidative stress as one of the major causative factors. different diagnostic tools have advantages, making them suitable for the scenario. it summarises that the factors affecting male infertility are general worldwide. this review could provide fundamental strategic plans dealing with specific risk factors and managing accordingly. keywords dna damage, infertility, oxidative stress, sperm, sexual intercourse 1 department of medicine and surgery, cairo university, egypt 2 department of medicine, king hamad university hospital, al sayh, bahrain * corresponding author’s e-mail: munaalrashid32@outlook.com introduction infertility has been present in around 20 – 30 % of males worldwide. it is observed that almost one-third time, the cause of infertility in couples is men (babakhanzadeh et al., 2020). infertility relates to the failure to conceive a pregnancy after a suitable time of sexual intercourse. although, it could be due to the inability of the pregnancy via natural means, or it could be a successful pregnancy that does not lead to a newborn baby (brugo-olmedo et al., 2001). the inability to cause infertility has many causative agents, including a person’s lifestyle. increased use of mobile phones, decreased physical activity, increased alcohol intake, and smoking. the destruction of the human male genital system causes disruptions in spermatogenesis, which could lead to infertility (muratori & de geyter, 2019). infertility in men could be due to the impacts of the environment, nutritional deficiency, and genetics, and it may be idiopathic (bisht et al., 2017). the disruption of the chromosomes could also affect the characteristics and functioning of the sperm (sharma, 2017). environmental factors are also responsible for deviating from the physiologic nature of human systems. these factors are mostly related to the inclusion of xenobiotics in the diet. it includes chemical substances which could disturb the endocrine system and estrogen metabolism. metals with high atomic mass, including cadmium (cd), lead (pb), and mercury (hg), damage the human reproductive system by destroying the hypothalamic-pituitary communication axis and disrupting spermatogenesis. this would produce semen with abnormal properties (sharma, 2017). oxidative stress plays the most important role in the development of genetic disorders. its presence is caused due to excessive production of reactive oxygen species (ros). the ros could modify the dna into single and double strands, break dna fragmentation, alter nitrogen bases and deoxyribose properties, and change crosslinking. these modifications of dna could interpret the genetic stability and causes replication errors. dna fragmentation is the last step of the ros action, resulting in single or double-stranded fragments (bui et al., 2018). diabetes mellitus, obesity, hyperthermia, and genital tract infections could also be the causative agents of infertility. varicocele is a condition in which the veins of the scrotum have enlarged and dilated due to defective valves. it causes impairment of sperm production, decreased blood circulation, and reduced functions of leydig cells. varicocele positively affected ros and sperm dna fragmentation (panner selvam et al., 2021). there is a need for an effective diagnostic strategy. different and effective investigations, including assays, would be used to diagnose infertility in men caused by sperm dna damage. however, infertility is a major health concern and exacerbates negative effects on a couple’s life and pregnancy. explanation of causative agents, diagnosis, and proper management are extremely important. this systematic review presents leading factors, investigating aids, and worldwide treatment planning. literature review infertility is a complex condition that impacts approximately 15% of couples, characterised by the inability to naturally conceive after engaging in regular unprotected sexual intercourse for 12 months or more. notably, male factors are accountable for nearly 50% of all infertility cases, making an equal contribution to pa ge 80 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 79-89, 2023 female factors (omolaoye et al., 2022). numerous factors and risk elements have been established as contributors to male infertility. among these are smoking, alcohol consumption, substance abuse, obesity, historical or ongoing testicular infections, contact with environmental pollutants, prolonged exposure of the testes to elevated temperatures, hormonal imbalances, past testicular injuries, and difficulties related to ejaculation or achieving an erection, among various others (okonofua et al., 2022). in diagnosing male infertility, conventional assessment methods often rely on analysing standard semen parameters, as outlined by the world health organisation (who) guidelines. nevertheless, many males experiencing infertility do not receive a definitive diagnosis, leaving their condition as idiopathic or unexplained (mannucci et al., 2022). the assessment of semen parameters following the who guidelines is currently considered the gold standard for diagnosing male infertility. nevertheless, numerous studies have indicated that sperm quality can be adversely affected by oxidative stress-induced sperm oxidation, leading to a decline in sperm’s ability to fertilise (mannucci et al., 2022). given this compelling evidence, there is a growing need for novel tests to assess male fertility by monitoring oxidative stress levels. these new assays for detecting oxidative stress have the potential to revolutionise male infertility diagnosis and management by offering simpler, faster, and more cost-effective techniques (agarwal, parekh, et al., 2019). oxidative stress can be assessed through biochemical tests, including plasma, serum, urine, and bodily fluids such as follicular, peritoneal, and seminal fluid. these assessments provide a precise overview of the body’s redox status, enabling the potential implementation of therapeutic antioxidant supplementation when necessary (agarwal, parekh, et al., 2019). various assays for evaluating oxidative stress are available, focusing on measuring ros production, lipid peroxidation products, and total antioxidant capacity. when it comes to measuring ros levels in semen, there are several methods to choose from, including chemiluminescence, the nitro blue tetrazolium (nbt) test, cytochrome c reduction test, and electron spin resonance (dutta et al., 2019b; mannucci et al., 2022). the absence of well-defined guidelines for treating male infertility associated with oxidative stress is partly due to an incomplete understanding of its underlying causes (agarwal et al., 2018). however, over recent years, numerous clinical trials have sought to explore the impact of antioxidant supplementation, such as l-carnitine, selenium, coenzyme q10, ubiquinol, vitamin c, and e on oxidative stress levels in seminal fluid and various semen parameters (alahmar et al., 2021). many of these trials have reported encouraging findings regarding the positive effects of antioxidants on critical aspects like sperm concentration, motility, morphology, and dna fragmentation. specifically, the analysis included twenty clinical trials that focused on the effects of anti-oxidant therapy on seminal oxidative stress. notably, nineteen of these trials demonstrated improvements in sperm redox status and semen parameters, often correlating with improved pregnancy outcomes (alahmar et al., 2021). the use of antioxidant treatment to treat male infertility is critical to emphasise. infertile men who received antioxidant treatment for three months did not experience any discernible improvements in dna fragmentation or semen characteristics, according to one randomized clinical trial (alahmar et al., 2021). additionally, this study found no appreciable improvements in pregnancy or live birth rates. these observations highlight the ongoing uncertainty surrounding using antioxidants in addressing male infertility. nonetheless, the combined evaluation of traditional semen analysis and oxidative stress assessment holds substantial promise for accurately assessing infertile patients (gambera et al., 2019). materials and methods the systemic review has been completed according to the guidelines regulated by preferred reporting items for systemic research and meta-analysis (prisma) (page et al., 2021). search strategy search strategy based on the use of mesh terminologies which were related to the topic, mentioned in table 1. the terms have been utilised appropriately using boolean operators: and, or, and not. a typical summary of the study search has been described through the pico model in table 2. table 1: search strategy sr. no search strategy 1 sperm dna damage [abstract & keywords] or male infertility [abstracts & keywords] or infertility [abstract & keywords] or causes of dna damage [abstract & keywords] or reproductive system [abstract & keywords] or oxidative stress [abstract & keywords] or dna fragmentation [abstract & keywords] 2 defective sperm production [tw] or immobile sperm [tw] or unsuccessful pregnancy [tw] or infertility of male [tw] or internal and external factors [tw] or factor causing sperm immobility [tw] or factors causing sperm dna damage [tw] or detection [tw] or treatment [tw] or management [tw] 3 treatment options [abstract & keywords] or defective spermatogenesis [abstract & keywords] or sperm dna fragmentation [abstract & keywords] or assisted reproductive technologies [abstract & keywords] or reactive oxygen species [abstract & keywords] or fertilisation failure [abstract & keywords] or infertility [tw] or dna integrity tests [tw] pa ge 81 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 79-89, 2023 study selection & eligibility the databases used to complete the search strategy and collect the required articles include google scholar, pubmed, the database of abstracts of reviews of effects, embase, psycinfo, ovid medline, and cochrane central register of controlled trials. selective keywords were used according to the required topics. original articles, case reports, and systematic reviews published from january 2018 to march 2023 have been selected and analysed according to their principal objective and presented topic. the studies focused primarily on managing infertility in men and secondarily on causes of and diagnostic options for sperm dna damage. inclusion criteria reviews published between january 2018 to march 2023 have been included. reviews could be performed in any part of the world. men with infertility caused due to sperm dna damage were the sample size. sperm dna damage is caused due to several internal and external causes, mainly increased oxidative stress and apoptosis. dna damage has been confirmed using different laboratory methods, including sperm dna integrity tests and sperm dna fragmentation testing. included studies had delivered proven and justifiable data and results. they had published in the english language. systemic reviews have been chosen related to the pathophysiology, aetiology, and management of infertility in men due to sperm dna damage. these reviews have a high impact factor. exclusion criteria reviews conducted before january 2018 were excluded. excluded studies had inaccurate and inappropriate data published in languages other than english. studies had been excluded due to difficulty accessing their full text; also, dissertations and thesis had been rejected due to the inclusion of only articles that used different epidemiological methods. data extraction and risk of bias the two authors reviewed and decided to include all reviews independently based on the pico model (table 2). using microsoft excel and a standardised data extraction form, the researchers extracted and sorted the sample size, study type, duplicates, full-text articles, and empirical studies, making the systematic review approach practicable. information of variables includes the author, year of publication, and number of studies. the two reviewers assessed the methodological qualities by using the 7-item scale of risk of bias developed by the cochrane bias methods group. this review used the prisma guideline and flow diagram to lower the risk of bias. the sources of bias assessed included outcomes, population, study selection process, incompleteness of data, and time frame and setting. quality of systematic reviews the expert team members assessed the quality of the systematic reviews, including questions regarding the degree to which the systematic reviewers had evaluated the risk of bias in individual studies. systematic reviews with major limitations were excluded. the authors have assessed the methodological quality of studies in sperm dna fragmentation based on the review authors’ assessments of risk of bias in the primary studies they had included. summary measures and synthesis of results the authors analysed the data collected by the members of the expert team. due to the expected heterogeneity of studies regarding participants, interventions, outcomes and study designs, a quantitative summary measure of the results was not planned. we did a qualitative and narrative summary of the results of the systematic reviews. the literature review results were presented and discussed in two workshops intending to validate results. results and discussions a total of 1123 studies have been reached through search engines, including google scholar, pub-med, the database of abstracts of reviews of effects, embase, psycinfo, ovid medline, and cochrane central register of controlled trials. these studies have been sorted according to their keywords and text words. after screening for duplicate and ineligible studies, 561 studies were excluded, according to prisma guidelines, as mentioned in figure 1. out of 562 studies, 341 have been rejected due to not meeting inclusion criteria. the reports of 179 studies could not be retrieved. 28 studies have been excluded due to some other reasons. after completing the literature search, 14 studies were retrieved, included in this systemic review and noted in table 3. the central idea of included studies revolves around the causes, diagnostic aids, and management strategies of infertility in men. the studies included being from january 2018 to march 2023. the included reviews specifically highlighted the causes and significance of existing methods used for this purpose. they have discussed and table 2: pico model population male, adult, mature, infertile. intervention analysis of the studies regarding causes of sperm dna damage, types of investigation to detect dna damage, and management plan to treat infertility caused due to sperm dysfunction. comparison reviews had been included having views favouring the management of infertility and against this approach. outcome this systemic review contained a novel idea of new and distinctive management methods which would benefit patients facing infertility. pa ge 82 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 79-89, 2023 figure 1: prisma flow diagram of article selection criteria table 3: studies included in the systemic review s r. no title reference sample size description year 1 role of sperm dna fragmentation in male factor infertility: a systematic review 29 150 this systemic review highlighted the importance of dna integrity assays in infertility diagnosis. it provides a new pathway for clinicians to detect infertility in men by applying sdf testing. 2018 2 a systematic review on sperm dna fragmentation in male factor infertility: laboratory assessment 38 87 studies & 8 book chapters this systemic review discusses and compares different techniques used in diagnosing impotence. its main emphasis was on the tunel method. 2018 3 the effects of varicocelectomy on the dna fragmentation index and other sperm parameters: a meta-analysis 47 289 patients from 7 prospective studies this meta-analysis discusses the significance of varicocelectomy in an infertile male. results show a positive impact on sperm mobility, concentration, and morphology. 2020 4 obesity and metabolic syndrome associated with systemic inflammation and the impact on the male reproductive system 11 n/a this review article deeply elaborates on the effects of obesity and metabolic syndromes on the prevalence of infertility. these may negatively affect semen quality and spermatogenesis. 2019 pa ge 83 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 79-89, 2023 5 sperm dna damage and its relevance in fertility treatment: a review of recent literature and current practice guidelines 12 n/a it discusses the treatment methods for male infertility, including surgical and non-surgical procedures. these techniques include the use of testicular sperms, varicocelectomy, and use of microfluidic sperm sorting. 2023 6 etiologies of sperm dna damage and its impact on male infertility 7 n/a this review elaborates on the mechanisms of dna damage and its impact in different scenarios of male infertility associated with spontaneous and assisted reproduction. it also reviews the clinical applicability of sperm dna fragmentation testing in the management of male infertility 2021 7 what should be done for men with sperm dna fragmentation? 34 n/a this review explains that sperm dna damage testing methods do not have standardised cut-off levels. each method has advantages and disadvantages, making it difficult to proclaim one as a universally preferable method. 2018 8 oxidative stress and sperm function: a systematic review on evaluation and management 25 n/a according to this review article, oxidative stress is an important cause of male factor infertility. its assessment provides essential information to guide treatment strategies to improve the male's reproductive potential. 2019 9 the effects of oral antioxidants on the semen of men with idiopathic oligoasthenoteratozoospermia 54 n/a most of the studies in this review were randomised controlled studies that explored the effects of oral antioxidants in men with idiopathic oat. they reported improvements in at least one semen parameter (motility, concentration, normal morphology, and antioxidant capacity). still, the most remarkable effect was that multiple antioxidants for 3–6 months increased sperm motility and concentration. 2018 10 sperm dna damage and its impact on male reproductive health: a critical review for clinicians, reproductive professionals and researchers 33 n/a this review discusses the origin and factors contributing to sperm dna damage, the molecular changes, especially proteomic alterations caused due to sdf, risk factors associated with sdf, methods used to analyse sdf, clinical implications of sdf, and cpg recommendations for sdf testing 2019 11 oxidative stress and reproductive function: sperm telomerase, oxidative stress, and infertility 22 n/a this review article emphasises the proper diagnosis and measurement of oxidative stress before any telomere evaluation in the art setting. this review is focused on the telomere; the implications of the proposed mechanism extend far beyond that to any gq sequence and offer novel, added insight into oxidative stress-induced epigenetic regulation/ dysfunction of the paternal genome. 2022 pa ge 84 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 79-89, 2023 12 effect of varicocele repair on sperm dna fragmentation: a review 45 n/a it explains the role of varicocele repair in alleviating sdf and improving fertility and critically appraises the evidencebased algorithm recently issued by the society for translational medicine to guide urologists on using sdf testing in men with varicocele-seeking fertility. 2018 13 single and double strand sperm dna damage: different reproductive effects on male fertility 41 n/a this review explains the etiology of sperm dna damage highlighting the single and double-strand dna damage. it also covers the management strategies to treat or reduce the effects of sterility in men due to dna fragmentation. 2019 14 sperm dna fragmentation: causes and identification 43 n/a this review describes the main causes of sperm dna fragmentation and the tests commonly used to evaluate sperm dna fragmentation. 2020 compared treatment options based on their requirements and effectiveness. this systemic review consists of a total of 20 studies which includes review articles, original studies, randomised control trials, and systemic considerations. these studies provided valid and accurate information regarding the pathophysiology, mechanism of action, causes and aetiology, investigations and treatment plans. the main focus is on the advanced and new ways of management of infertility in men. the germ cells in men are equally responsible for pregnancy. damage to their genetic material affects their morphology and physiology and produces its outcome in future offspring. most of the studies elaborate on different causes of sperm dna damage, which triggers the process of dna fragmentation. these causes include abortive apoptosis, increased oxidative stress, and endocrinal issues (homa et al., 2019; kuchakulla et al., 2021). risk factors for infertility according to leisegang et al. (2019), obesity and metabolic syndromes have affected the population worldwide with the complex underlying pathophysiological phenomenon. metabolic syndromes result from an increased ratio between energy intake and energy consumption. excessive energy deposits in the body affect body functions due to reduced physical activities. environmental toxins, diet quality, inactive and sedentary lifestyles, hormonal changes, and pharmaceutical agents also cause metabolic imbalance and obesity (leisegang et al., 2019). avoidance of selective serotonin reuptake inhibitors (ssri), cigarette smoking, air pollution, and cancer treatments could be useful in decreasing the prevalence of sterility. these are risk factors for sperm dna fragmentation (esteves et al., 2021; marinaro & schlegel, 2023; schulte et al., 2010; sharma et al., 2016; ståhl et al., 2006; tanrikut et al., 2010). sperm dna fragmentation caused due to several extrinsic and intrinsic factors. intrinsic factors include immature germ cells, abortive apoptosis, and increased oxidative stress, while extrinsic factors include negative impacts of medicines, environmental factors, and lifestyles (barazani et al., 2014; muratori et al., 2019; sakkas et al., 1999). reactive oxygen species (ros) are a major cause of sperm dna fragmentation. these species produce in the mitochondrial dna of sperm and induce cascades and pathways leading to germ-cell apoptosis (agarwal et al., 2020; moazamian et al., 2022). the process of spermatogenesis and sperms are more prone to damage from radiation than other body cells. side effects of radiotherapy include male infertility and testicular cancer. however, non-ionising radiation produced by mobile phones, wi-fi, microwave, and laptops could also damage the genetic material of sperm (kesari et al., 2018; mcgill & agarwal, 2014). dysfunctional spermatozoa cause an increased ros body production, which develops through two pathways. the most abundant species is superoxide (o2-), which undergoes chemical reactions to yield hydrogen peroxide (h2o2). any inflammatory or infectious response could ignite the production of macrophages and lymphocytes, producing many ros species (agarwal et al., 2003; dutta et al., 2019a). the dilation of veins entering the testicles, known as varicocele, is one of the major reasons for male sterility. it increased the internal temperature of the testes and decreased oxygen level causing hypoxia. a higher incidence of ros bodies is proportional to the presence of varicocele, reducing semen and sperm quality (agarwal et al., 2006; dutta et al., 2019a). effects of sperm dna fragmentation on the human body, including pregnancy loss, intrauterine insemination (iui), and in-vitro fertilization (ivf). due to the increased ratio of sdf, the chances of conceiving became negligible. a systematic review including around 3000 couple sample size indicates a high value of pregnancy loss of about 2.16 times when using semen specimens with high sdf (robinson et al., 2012). there is a strong relationship between increased sdf and bad iui outcomes. a raised pa ge 85 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 79-89, 2023 sdf index of >27% has a negative impact on pregnancy assisted by the iui procedure (bungum et al., 2007; cho & agarwal, 2018). controversial results explain the correlation between sdf and successful pregnancy after ivf and intracytoplasmic sperm injection (icsi). the reason behind this could be the difference in their methods. there is a chance of sperm exposure to oxidative stress during laboratory steps of culture in ivf, whereas in icsi, the spermatozoon is directly injected into an oocyte. this may cause a decrease in sdf due to less exposure to oxidative stress (cho & agarwal, 2018; dumoulin et al., 2010; lewis, 2013). diagnostic aids there are many techniques for investigating dna damage, divided into two kinds, including direct dna integrity assessment and indirect dna integrity assessment. one of the well-known methods is the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (tunel) method. this method directly measures the sperm dna damage using deoxyuridine triphosphate (dutp), which binds to single and double-stranded dna. it could detect a small sample of sperm and should be applied on fresh or frozen samples. tunel is a time-consuming process that requires a standardised criterion among the laboratories. it also cannot evaluate immature sperms compared to other tests (agarwal, panner selvam, et al., 2019; evgeni et al., 2014; gorczyca et al., 1993; kim, 2018). sperm chromatin structure assay (scsa) was initiated in the 1970s and became popular after some remodeling. it investigates the sensitivity of sperm dna to denaturation and deformation. this test is simple to perform with a commercially available kit. it could be used on several spermatozoa for detection, and its results could also be compared with the results of other tests (evenson et al., 1980; kim, 2018). it requires expensive equipment, trained personnel to perform tests, and many spermatozoa (agarwal, panner selvam, et al., 2019; selvam & agarwal, 2018). the comet assay or scge test is the qualitative testing of dna damage by detecting deformation in single and double dna strands using electrophoresis (kim, 2018; mckelvey-martin et al., 1997). it is a simple and affordable process whose results are based on the tail length of sperm. the tail end of the sperm carries fragments of dna which indicates dna damage. due to this reason, this test is not recommended by investigators (agarwal, panner selvam, et al., 2019; cho & agarwal, 2018; singh et al., 1989). sperm chromatin dispersion (scd) or halo test is a highly standardised process based on extracting proteins after acid denaturation producing halo characteristics. it detects single and double-stranded breaks in sperm dna (fernández et al., 2005; ribas-maynou & benet, 2019). it is used extensively due to its low cost and quick results with quality. sometimes it is difficult to differentiate the proximal borders of the halo having low chromatin density from the background (evgeni et al., 2014; kim, 2018). chromomycin a3 (cma3) staining detects the deficiency of chromatin in sperm dna by competing with protamine for the same binding site. protamine deficiency indicates male infertility. this test strongly correlates with other sdf assays (agarwal & allamaneni, 2005; cho & agarwal, 2018; dos santos hamilton & assumpção, 2020; selvam & agarwal, 2018). management there are several ways of managing infertility in men based on the cause. there are intrinsic as well as extrinsic factors causing sterility in men. varicocele is a significant reason for male infertility, causing 15% of the male population of mature age. dubin’s grading system is used to diagnose it and indicates its severity. there is a rise in ros and apoptosis markers in the cytoplasm in patients diagnosed with varicocele (miyaoka & esteves, 2011; roque & esteves, 2018). it causes testicular hyperthermia, affects endocrine functions, elevates hypoxia, causes defective spermatogenesis, and damages nuclear and mitochondrial dna. its treatment includes surgical intervention, that is, varicocelectomy, assisting in lowering the factors and reducing infertility. according to studies, after performing varicocelectomy using any technique retroperitoneal, inguinal, or subinguinal, there is a significant difference in the values of preoperative and postoperative sdf levels in semen (birowo et al., 2020; schauer et al., 2012). another study shows a mark reduction in the value of sdf after varicocelectomy along with the mast cell stabilisers. it positively affects sperm mobility, concentration and increased sperm count. the degranulation of mast cells is correlated with increased ros production; a combination of varicocelectomy and induction mast cell stabiliser has a more pronounced effect (zaazaa et al., 2018). varicocelectomy has increased venous blood drainage, decreasing ros production and enhancing spermatogenesis and semen quality. the researchers do not recommend varicocelectomy in patients with normal semen quality and asymptomatic varicocele. varicocelectomy indicates defective sperm motility and morphology (birowo et al., 2020; eau annual congress, 2020; zavattaro et al., 2018). oral antioxidant therapy has a depressing effect on the production of ros. both intrinsic and extrinsic antioxidant can play their part in eliminating the ros and shifting the curve toward the normal range. they could assist in destroying ros bodies in semen and restore the redox balance (agarwal, panner selvam, et al., 2019; showell et al., 2014; smith et al., 2006). several antioxidants include vitamin a, vitamin c, and vitamin e. several successful studies suggest antioxidants as one of the best therapies for infertility with promising results (adewoyin et al., 2017; alahmar, 2018; cho & agarwal, 2018; tremellen, 2008). lifestyles have also exerted a significant impact on infertility. obesity and metabolic disorders cause incompetency and are severe systemic disorders, mostly caused due to sedentary lifestyle. a pa ge 86 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 79-89, 2023 healthy lifestyle and a balanced and hygienic diet are strongly associated with reduced male infertility (omer & atassi, 2017). a diet rich in carbohydrates, antioxidants containing vegetables, fibre, biogenic seeds, and seafood reduces inflammatory markers. these nutrients are related to an improved immune and neurological system, reduced fat accumulation and increased dna integrity (leisegang et al., 2019). limitations even though our search was broad and included many medical libraries, conference abstracts, and other unpublished pieces of literature may get overlooked, causing limiting our conclusions. however, there is no literature on the routine investigations of defective dna in infertile men. also, the mechanism of antioxidants against the ros bodies at the molecular level is not present, explaining its effects on semen quality, duration of treatment and the choice of therapeutics. in the future, this evidence could be taken into consideration. strengths the review uses a comprehensive search strategy across multiple databases to gather relevant studies on male infertility caused by sperm dna damage. it includes various study types, including review articles, original studies, randomised controlled trials, and systematic reviews. moreover, the review’s clear presentation makes it easy to follow. the findings can inform clinical practice and guide healthcare professionals in improving patient care. furthermore, the review also discussed emerging management methods, highlighting its forward-looking approach and potential future developments in the field. conclusion this systemic review summarised the most common causes of infertility in men, damaging sperm dna. this would include a sedentary lifestyle and intrinsic and extrinsic risk factors, which increase the level of ros in the testicular spermatozoa. the risk of dna damage is more evident during ejaculation. oxidative stress could be controlled by prescribing antioxidants and planning a healthy and hygienic diet. surgical intervention includes varicocelectomy, which also reduces the level of ros in the mitochondrial and nuclear dna of the sperms. genital tract infections also cause infertility which should be diagnosed earlier and treated with broad-spectrum antibiotics. this review will provide substantial knowledge regarding the major causes of infertility and how to improve it. implications of new management methods have been discussed, which could benefit the patients. novelty of research this review provides a comprehensive and up-to-date information regarding male infertility due to sperm dna damage. it focuses on recent research, a comprehensive approach, and emerging management methods. the review considers factors such as lifestyle, environmental exposures, and genetic influences. it also discusses established and emerging management strategies for male infertility. the research offers practical insights for healthcare professionals and patients, guiding decision making and patient care. the inclusion of various study types adds depth and diversity to the analysis. overall, this review offers a unique perspective on male infertility. research gap this review on male infertility caused by sperm dna damage identified several research gaps. these include the lack of long-term follow-up studies, the impact of lifestyle interventions, standardisation of diagnostic tests, environmental factors, psychological impact, costeffectiveness analysis, and exploring novel treatment approaches. the review also highlighted the need for more research on male infertility’s psychological and emotional implications, cost-effectiveness analysis, and more diverse study populations. additionally, the review suggested the development of biomarkers for predicting treatment success and a stronger emphasis on patientcentered outcomes. these gaps could contribute to a more comprehensive understanding of male infertility and the development of more effective diagnostic methods and treatments. contribution to knowledge the systematic review on male infertility caused by sperm dna damage provides a comprehensive overview of the current state of knowledge. it identifies causal factors, diagnostic methods, treatment strategies, and impacts on reproductive outcomes. the insights have practical implications for healthcare providers, researchers, and policymakers, enabling them to develop evidence-based treatment plans. the review also contributes to patient education by raising awareness of factors contributing to male infertility and available diagnostic and treatment options. abbreviations ros: reactive oxygen species; dna: deoxyribose nucleic acid; sdf: sperm dna fragmentation; icsi: intra cytoplasmic sperm injection; ivf: in vitro fertilization; cma3: chromomycin a3; scd: sperm chromatin dispersion; scsa: sperm chromatin structure assay; tunel: terminal deoxynucleotidyl transferase dutp nick end labeling; dfi: dna fragmentation index; iui: intra uterine insemination; prisma: preferred reporting items for systematic reviews and meta-analyses; os: oxidative stress; art: assisted reproductive technology. statement and declarations data availability statement the data utilised in writing this systemic review is obtained from previously presented original articles and reports. no new data or evidence has been created during this period. pa ge 87 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 79-89, 2023 authors contribution conceptualisation, data curation, supervision, validation, writing-review and editing has been done by author (mr). methodology, software 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(2018). treating varicocele in 2018: current knowledge and treatment options. j endocrinol invest, 41, 1365-1375. pa ge 1 pa ge 15 3 american journal of medical science and innovation (ajmsi) does mobile phone tele-reminder increased iron status and diet quality of pregnant women availing antenatal care services at phebe and charles b. dunbar hospitals bong county, liberia a cluster randomized control trial washington kezelee1, leila s. africa1*, corazon v. c. barba1, angelina r. bustos1, mark bondi arboleda2 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1590 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 07, 2023 accepted: october 03, 2023 published: october 14, 2023 anemia in pregnancy is a serious public health problem in liberia. this study aimed to assess the effect of mobile phone tele-reminder on the iron status and diet quality of pregnant women in liberia. a two-arm, double-blinded cluster randomized control trial was conducted in this study, with anc screening rooms as a unit of randomization. at the phebe and charles b. dunbar hospitals in bong county, liberia, 150 pregnant women who had never previously attended an anc were recruited for the study (75 intervention women and 75 control women). iron status measured as hemoglobin (g/dl) and diet quality were primary outcomes of this study. secondary outcome measures were adherence to daily iron and folic acid supplementation and prevalence of anemia among pregnant women with malaria infection. the analysis was an intent-to-treat. the effect of the intervention on the primary study outcome (iron status) was examined using an independent sample t-test (for group-level analysis). effects of treatment on diet quality was measured using the fisher’s exact test. a binary logistic regression with a 95% confidence interval (ci) was used to analyze the effect of treatment on secondary outcomes. pregnant women assigned to the intervention group had a significantly greater mean hemoglobin level after the two interventions, t (2.4) = 447, p<0.05; d = 0.23). in the intervention group, there were significant odds in the consumption of 2-3 fish/meat/poultry products compared to the control group (93% versus 83%, adjusted odds ratio, 2.93; 95% ci, 0.99-8.70). a trend towards adherence to the ifa supplementation and an increase in consumption of iron-rich foods was observed. in liberia, mobile phone tele-reminders appeared to be effective in improving iron status, diet quality, and ifa supplementation adherence when integrated into an existing antenatal care protocol. keywords diet quality, hemoglobin, iron status, tele-reminder 1 institute of human nutrition and food (ihnf), university of the philippines los banos, philippines 2 school of environmental science and management (sesam), university of philippines, los banos, philippines * corresponding author’s e-mail: lsafrica@up.edu.ph introduction one of the most life-threatening dietary and healthrelated concerns is anemia in pregnancy. the world health organization (2001) defined anemia in pregnancy as hemoglobin less than 11 g/dl, while iron deficiency anemia (ida) was characterized as serum ferritin <12 ug/l, with a hemoglobin level of less than 11 g/l and a hematocrit level of less than 33% (center for disease control and prevention, 1998 and world health organization, 2001). in many developing countries, anemia in pregnancy is a major health problem associated with maternal and perinatal mortality, premature deliveries, low birth weight, and other adverse outcomes (mahomed & hytten, 1989). it is estimated that only 15% of pregnant women in developed countries suffer from anemia (who, 1993). approximately 35%-75% of pregnant women in developing countries are anemic (van den broek et al., 2000, ogunbode 2003). in pregnancy, iron deficiency is the most common cause of anemia (van den broke et al., 2000). predisposing factors of anemia in pregnancy, include grand multiparity, low socioeconomic status, malaria infestation, late booking, hiv infection, and inadequate child spacing (adinma et al., 2002, van den broek et al., 2000). poor nutrition, iron deficiency, micronutrient deficiencies (folic acid, vitamin a, and vitamin b12 deficiency), diseases (malaria, hookworm infestation, schistosomiasis, hiv infection), and genetically inherited hemoglobinopathies (thalassemia) are all linked to iron deficiency anemia in pregnancy (di renzo et al, 2015). with antenatal care, maternal deaths can be reduced, and protecting the lives of pregnant women and their unborn children can be achieved (carroli, rooney, & villar, 2001). literature review anemia situation in liberia anemia is a major concern among pregnant women, leading to increased maternal mortality and poor birth outcomes as well as reductions in work productivity. anemia in pregnancy has become a serious health and nutritional problem. pregnant women (52%) are more likely than their breastfeeding counterparts (48%) and non-breastfeeding/non-pregnant (43%) to suffer from anemia. about 45 percent of women in liberia suffer from anemia, according to a study from the demography and health survey (2019-2020). only 43% of expectant mothers took iron supplements for at least 90 days. about 64% of pregnant women took deworming drugs. six percent (6%) of pregnant women did not take an iron supplement (ldhs 2019). due to an increase in blood volume during pregnancy, women are more likely to develop anemia. due to an increased risk of blood loss during labor, early delivery, low birth weight, and perinatal mortality, severe anemia can be dangerous for pa ge 15 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 both the mother and the child. pregnant women are advised to consume iron-rich foods, take iron-folate supplements, and practice good sanitation and hygiene to avoid intestinal worms, in order to prevent anemia. causes of anemia in pregnancy the main causes of anemia during pregnancy are nutritional deficiencies, bacterial, parasitic, and inborn red blood cell disorders like thalassemia. micronutrient deficiencies such as those in folic acid, vitamin a, and vitamin b12, and hiv infection can cause anemia in pregnancy (breymann, 2015; di renzo et al., 2015). additional factors associated with anemia during pregnancy include gestational age at the first prenatal, educational status, and antenatal intake of iron pills (chotnopparatpattara et al., 2003, suega et al., 2002). noncompliance to antenatal care services is key challenging factor in combating anemia in pregnancy (mithra et al., 2014). diet and anemia in pregnancy in low-income countries, pregnant women need continual dietary counseling because their diets are both poor in vitamins, minerals, and other essential nutrients that can improve the level of iron. plant sources of iron have low bioavailability, according to allen and gillespie (2001) (only 2-5 percent of iron absorbed). failure to take dark green leafy vegetables and inadequate consumption of chicken is determinants of anemia in pregnancy (tadesse et al, 2017). in low-income countries, diets are high in protein, vitamins, and minerals which are too expensive for many families. nutritional anemia occurs when the daily intake of key micronutrients is insufficient, resulting in the body being unable to fulfill the physiological needs of growth, maintenance, or loss (gleason et al, 2007). poor diet, suboptimum anc, and being underweight were associated with moderate and severe anemia (agbozo et al., 2020). ages of the mothers, counseling on the ironfolate supplement, knowledge of anemia, knowledge of iron-folate supplement, and frequency of anc visits were found to be significantly associated factors of compliance with iron-folate supplementation during pregnancy (arega, abebe, & aman 2015). anemia has been linked to postpartum hemorrhage, premature labor, low birth weight, small for gestational age newborns, and perinatal death (sifakis & pharmakides, 2000; smith et al, 2019). work productivity has been discovered to be affected by iron deficiency anemia, which could result in a loss of 1.3 percent of gdp (plessow et al, 2015). effects of mobile phone technology on anemia prevention in pregnancy there is no research on how mobile phones can improve iron status and diet quality of pregnant women in subsaharan africa, of which liberia is a part. however, mobile phone use in health care settings has been shown to reduce maternal death from anemia in recent studies. however, in africa, more than 600 million people own a cell phone. to strengthen healthcare systems, mobile phones are becoming increasingly important (howitt et al, 2012). in clinical settings, mobile phone use increases anc visits and improves early recognition of pregnancyrelated situations (lund et al, 2014). pregnant women who utilized mobile phones utilized antenatal care services and professional delivery services more than those who did not (tang et al, 2019). pregnant women feel more confident about seeking medical care during pregnancy and childbirth and recognizing signs of illness in their newborns with teleconsultation (entsieh et al., 2015). women who received the sms every week were more likely to attend eight anc visits compared to those who did not (osanyin et al, 2022). women who utilized mobile phones were more likely to use iron tablets and attend anc in a randomized controlled trial conducted by bangal et al, (2017). using mobile phones to send short message services on focused antenatal care (fanc) has positive effects on the uptake of focused antenatal care among pregnant women in middle and low-income countries (wagnew et al., 2018). methodology design this study was three months, two-arm double-blinded cluster randomized controlled trial conducted in two major referral hospitals. the study took place from may 2022 to august 2022 at the phebe and charles b. dunbar hospitals, bong county, republic of liberia. the antenatal care screening rooms with assigned midwives, caring for pregnant women who avail antenatal care services were the units of randomization. a cluster randomized control trial randomizes groups of participants rather than individuals to each treatment arm. each of the selected hospitals has three active and functional screening rooms for pregnant women. trained midwives provide all antenatal care in the screening rooms. this study considered each screen room as a cluster. there were two intervention groups (control and experimental) in these two arms trials. we adopted a cluster randomized controlled trial because there was a possibility that pregnant women receiving antenatal care at the phebe hospital would be close relatives of pregnant women receiving antenatal care at the charles b. dunbar hospital. there was a risk of contamination within and between clusters due to this relatedness. the cluster randomized control trial minimizes the risk of contamination. ethical consideration this study was approved by the research ethics board of the university of the philippines los banos. the administration of the phebe hospital also provided ethical clearance for the conduct of this study. the trial is registered in pan african clinical trial registry (pactr202204658979734). clustering and randomization the randomization units were antenatal care screening pa ge 15 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 rooms with licensed midwives. in cluster randomized controlled trials, the groups are randomized, rather than the individual participants. in each of these hospitals, there were three screening rooms dedicated solely to providing anc to pregnant women. each screening room was considered a cluster by the researcher in this study. there were three clusters at phebe hospital referred to as 1, 2, and 3, while there were three clusters at charles b. dunbar hospital referred to as 4, 5, and 6. a team of midwives administered anc to six clusters of pregnant women receiving anc for the first time. in clinical research, randomization refers to the assignment of study participants to either a treatment group or a control group solely by chance. the six screening rooms (six clusters) were randomized into an intervention (clusters 1,4, & 6) and a control group (clusters 2,3, & 5). setting the study was conducted in phebe and the charles b. dunbar hospitals. in liberia, the two hospitals are located in bong county, which is a centrally located county. in 1964, bong county was established. in terms of area and population, bong county ranks third in liberia. one of 15 counties that comprise the first level of administrative division in the nation, bong county has twelve districts. lofa and gbarpolu counties border it on the north, margibi and montserrado counties on the west, grand bassa county on the south, and nimba county on the east. in addition to rice production, the county once became known as the food basket of liberia. cocoa, coffee, rubber, and palms are also grown in the county. in rural liberia, phebe hospital provides health care to about 450,000 people. in 1921, the lutheran church cofounded the hospital. through the national budget, the government has funded the hospital for years. charles b. dunbar hospital is the only hospital in central liberia that specializes in maternity care. participants hospitals and individual levels of analysis were considered in this cluster randomized control trial. for this study, hospitals with the highest attendance at antenatal careequipped medical and laboratory facilities, and more anc screening facilities were selected. phebe and charles b. dunbar hospitals are centrally located referral hospitals in liberia with high anc attendance rates. as far as anc services are concerned, both of these hospitals meet the minimum recommendations for providing anc services in liberia. the sample population was pregnant women receiving anc for the first time at the selected hospitals. sample size calculation the sample population consisted of all consenting pregnant women receiving their first anc visit. according to the demography and health survey report (2019), anemia is more prevalent among pregnant women (52%) than breastfeeding women (48%). the new intervention is proposed to reduce anemia prevalence among pregnant women by 25%. similarity among subjects within preexisting groups or clusters reduces the variability of responses in a cluster sample, making it difficult to detect true differences between groups. intracluster correlation coefficients (icc) measure the degree of dependence within a cluster. after adjusting for individual and cluster-level characteristics, the effective sample size was determined by using the median icc in primary healthcare research of 0.005 (adams et al., 2004). to determine the effective sample size, the first step was to calculate the sample size required for individual randomized controlled trials. in the second step, the derived sample size from the individual randomized controlled trial was then adjusted for the design effect (de). the effective sample size was 150 pregnant women in their first trimester of pregnancy. seventy-five pregnant women were assigned to each treatment arm. figure 1: operationalization of the study pa ge 15 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 each treatment arm was further randomized into three clusters. for every cluster, 25 participants were assigned. selection criteria this study included pregnant women who sought antenatal care for the first time, consented, and was free of chronic illnesses receiving antenatal care at phebe and charles b. dunbar hospitals. self-ownership of a mobile phone or close relatives in the same household was added as a selection criterion. admission of participants each hospital had three screening rooms dedicated exclusively to anc services. a pregnant woman seeking anc for the first time was directed to the registration room to obtain a valid hospital card and identification number. in subsequent hospital visits, the patient used the hospital card and identification number to access health care services. hiv/aids counseling followed the registration process, which aims to prevent motherto-child transmission of hiv/aids. the patient card was taken to any of the screening rooms for further processing by the midwives assigned to those rooms after counseling. a patient received healthcare from the screening room where her card was transferred. six clusters (screening rooms) were randomized so that three (3) clusters administered standard/routine interventions during the study period, while the remaining three clusters administered intervention treatment. as mentioned in the selection criteria, the admission criteria were the same for both arms. the control and intervention groups were blinded. certain information that might influence participants was kept from them. during the intervention, midwives were blinded. neither the primary nor secondary outcomes were disclosed to the midwives during the study. during training, the three midwives selected randomly for the intervention treatment learned how to use the tele-reminder manual effectively. the remaining three midwives who administered the control treatment were not trained to use the tele-reminder manual. outcomes the primary outcome was iron status measured as hemoglobin (g/dl). low iron status was defined as hemoglobin less than 11 g/dl. the secondary outcome variables were adherence to ifa supplementation, antenatal care satisfaction, and consumption of 2-3 ironrich foods per day. treatment in the control group the control group received routine and standard anc services. the participants in this group were followed up every month. a similar pattern of routine anc services was followed in every subsequent follow-up. every followup included measurements of primary and secondary outcomes. the assigned midwives administered routine anc during each anc visit. iron status measured in hemoglobin (g/dl) was the primary outcome variable. in addition, monthly adherence to ifa supplementation, anc satisfaction level, and consumption of 2-3 iron-rich foods per day were also measured as secondary outcome variables (table 1). treatment in the intervention group each participant in the intervention group received slightly different interventions than those administered to respondents in the control group. a mobile phone tele-reminder was delivered through phone calls and sms biweekly to participants in the intervention group. during the mobile phone calls, participants were table 1: core health messages sent via sms types of treatment core health messages via sms iron and folate acid supplementation “increase your blood volume by taking one iron tablet a day” malaria prevention “before you go to sleep, please hang the mosquito net over you” adherence to the anc visit schedule “come to the hospital at the end of the month for treatment” hygiene practices “to prevent sickness, wash your hands frequently after using the toilet, before eating, and before cooking” table 2: treatment in the control and treatment clusters treatment types control group (routine care) intervention group (routine + new treatment) reference diet intervention -pregnant women were counseled about healthy eating and physical activity during pregnancy. -using visual aid containing the various food groups, pregnant women were counseled on the need to eat food from the different food groups daily to be kept healthy during pregnancy. -diet counseling focused on iron-rich foods (vegetables, fruits, and meat/fish products). -participants were reminded biweekly to consume daily ironand vitamin-rich foods from local markets and backyard gardens. sunuwar et al, (2019). otoo & adam (2016) who recommendations on anc for a positive pregnancy experience (2016) pa ge 15 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 counseled only on food groups with rich sources of iron. they were also counseled on the consumption of vitamin-rich foods that enhance iron absorption. in this group, participants were presented with a list of affordable, available, and accessible local foods that are good sources of iron and vitamins. we developed a tele-reminder manual that midwives used as a guide in administering the treatment to the participants. development of antenatal care tele-reminder messages health messages delivered to the participants in this study are referred to as “core antenatal care tele-reminder messages”. there were three phases to the development of these core healthcare reminder messages. in phase one, the researcher reviewed world health organization guidelines on antenatal care published in 2016. healthcare messages that were supported by the evidencebased practice were selected from the world health organization’s antenatal care guidelines. during phase two of the development of core healthcare reminder messages. the researcher along with the six midwives who administered the treatment (intervention and control) reviewed the components of the world health organization antenatal care guidelines incorporated into the local liberian anc guidelines. phase two was intended to prevent giving health messages to the participants that were not approved by the ministry of health of liberia. in phase three, the six midwives pretested the key health messages among 10 mothers (pregnant women) who were not part of the study but were recipients of anc services at phebe hospital. data collection this study used several validated techniques to collect, measure, and analyze accurate insights. we supervised all stages of this research. in both hospitals, midwives were hired to administer the interventions. the researcher scrutinized every data report by the research assistants (midwives) for quality assurance purposes. in addition, the researcher hired laboratory technicians for blood sample collection and biochemical analysis, in consultation with the medical director of both participating hospitals. all data were collected using questionnaires for analysis. filling out questionnaires was facilitated by the midwives. the questionnaires did not mention participants’ names or personal identities which might raise concerns about stigmatization. at baseline, an assessment of the socio-demographic profiles of participants, along with dietary assessment using the qualitative food frequency questionnaire. hemoglobin test before and after the treatment was measured using an automated hematology iron and folic acid supplements both hospitals routinely provided daily oral iron and folic acid supplementation to each participant -biweekly tele-reminders reminded participants to take iron and folate supplements. -ifa supplementation was emphasized in all gomes et al. (2021). who recommendations on anc for a positive pregnancy experience (2016) malaria prevention a mosquito net was given to each participant to prevent malaria. in the second trimester of pregnancy, participants received intermittent preventive treatment with sulfadoxine-pyrimethamine (iptp sp). based on hospital practice, dosing was determined a biweekly tele-reminder emphasized the use of mosquito nets and the importance of adhering to iptp-sp guidelines. a message (sms) reminded them to use mosquito nets regularly and take the iptp-sp. ngabo et al. (2012). who recommendations on anc for a positive pregnancy experience (2016) hygiene education participants were instructed to wash their hands with soap and water after using the latrine and touching contaminated surfaces. participants were encouraged to keep their environment clean at all time during follow-up visits, participants received handwashing soaps in addition to tele-reminders. participants were reminded of the importance of washing their hands with soap and water after using the toilet, before cooking, and before eating participants were also reminded biweekly to keep their environment clean sheth et al. (2010). who recommendations on anc for a positive pregnancy experience (2016) prevention of intestinal parasites/ worm participants were treated with preventive anthelmintics according to hospital practice before undergoing their first anc in the second trimester who recommendations on anc for a positive pregnancy experience (2016) pa ge 15 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 analyzer designed for low-volume clinical settings, the cell-dyn emerald 22. blood sample collection blood specimens for anemia testing were collected from all pregnant women availing of antenatal care for the first time at the phebe and charles b. dunbar maternity hospitals in bong county, liberia. blood samples were drawn from a drop of blood taken from a finger prick and collected in a microcuvette. hemoglobin test before and after the treatment was measured using an automated hematology analyzer designed for low-volume clinical settings, the cell-dyn emerald 22. each participant had their hemoglobin result recorded on their hospital cards. those participants with hemoglobin less than 11g/dl, were referred to doctors for further intervention. data quality control for quality assurance purposes, laboratory technicians were treated blinded. cell-dyn emerald 22, an automated hematology analyzer designed for lowvolume clinical settings, was used for hemoglobin testing. licensed laboratory technicians collected blood samples for hematological analysis. to ensure data quality control, a regular supervision visit was conducted to ensure that standard operating procedures were followed during blood sample collection. blood specimens were transported in proper containers under the supervision and taken at the recommended time to the analyzer. to avoid negative impacts on test results, test materials were observed to ensure they were properly stored and cleaned. to avoid errors in the data recording process, all laboratory results were immediately entered into the laboratory request form of the participants. data analysis method all available data were included in the analysis. the primary outcome was iron status. it was measured as hemoglobin level in g/dl. the secondary variable of interest included the consumption of 2-3 iron-rich foods per day, and adherence to ifa supplementation. baseline data were analyzed using descriptive statistics (spss v. 25). fisher’s exact test was used to determine whether two categorical variables were associated. a t-test (for continuous variables) was used to compare the mean of baseline data. the macnemar test was used to analyze paired nominal data between two related samples. a logistic regression analysis based on longitudinal data was used to assess the treatment effects on secondary outcome measures, while an unpaired sample t-test was used to assess the treatment effects on the primary outcome measure. as facilities rather than individual pregnant women were randomized, a generalized estimating equation was used to account for within-cluster correlation coefficients. results age and pregnancy profile participants range in age from 23 to 24 years old. there was no statistically significant difference between the ages table 3: age and pregnancy profile of participants at baseline variables intervention group n = 75 control group n = 75 independent sample t-test p-valuemean ±sd mean ±sd age of participants 24.57 ± 6.280 23.45 ± 6.803 0.297 age in months of pregnancy 3.15 ± 1.245 3.27 ± 1.044 0.513 total pregnancy 2.11 ± 1.640 1.89 ± 1.956 0.470 total living children 1.23 ± 1.341 1.16 ± 1.525 0.777 age in the month of the last child 26.17 ± 28.974 20.75 ± 26.568 0.234 of participants in the intervention group and the control group. the majority of participants were in their first trimester of pregnancy (table 3). trimesters and health profiles a significant number of participants had positive malaria smear test results. forty-three percent of those in the intervention and 45% in the control groups were malaria positive at baseline. in the past month, the majority of the participants did not have any history of illness in the past month (table 4). there were no hiv/aids diagnoses among any of the participants in the study. table 4: gestational and health profiles of participants at baseline variables and category intervention group n = 75 control group n =75 fisher’s exact test p-valuen % n % gestational period first trimester 38 51 44 59 0.20 second trimester 37 49 31 41 malaria test result negative 43 57 41 55 0.43 positive 32 43 34 45 ill in the past month yes 24 32 27 36 0.36 no 51 68 48 64 pa ge 15 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 education and marital status participants have varying educational backgrounds. there were, however, a significant number of them who had at least a primary education. according to statistics (table 15), there is no statistical difference between the groups when it comes to their educational attainment. furthermore, more than half of the participants in the study are cohabiting couples. table 5: educational level and marital status, baseline variables and category intervention group n = 75 control group n =75 fisher’s exact test p-valuen % n % highest education attainment primary education 54 72 53 70 0.500 secondary education 21 28 22 29 marital status cohabiting 51 68 54 72 0.361 not married 24 32 21 28 treatment effect on iron status the result showed that pregnant women assigned to the intervention group had a significantly greater mean hemoglobin level after the two interventions, t (2.4) = 445, p<0.013; d = 0.23. the effect size of the analysis (d = 0.23) was found to be small (table 6). these results indicate that pregnant women in the intervention group (m = 12.8, sd = 0.71) experienced a small increase in hemoglobin levels than did pregnant women in the control group (m =11.7, sd = 0.63). table 6: effects of treatment on iron status measured in hemoglobin (primary outcome) hemoglobin level in g/dl intervention group control group independent sample t-test p-value(mean ± ds) (mean ± ds) baseline 10.9 ± 0.94 10.8 ± 0.92 0.108 endline 12.8 ± 0.71 11.7 ± 0.65 0.013 paired t-test (p-value) 0.047 0.000 cohen’s d test: 0.23 anemia prevalence intervention group n (%) control group n (%) fisher’s exact test (p-value) baseline 36 (48) 39 (52) 0.37 endline 3 (4) 10 (13) 0.039 mcnemar test p value 0.000 0.000 odds ratio (binary logistic regression): 0.27 (0.071.03) anemia prevalence among participants with malaria and history of past illnesses at baseline, 66 participants had malaria infection and 34 participants had history of past illnesses. based on table 7, 27% of intervention participants and 20% of control participants with malaria at baseline had anemia. participants were asked at baseline whether they had experienced any illness in the past month. as a result, table 7: anemia prevalence among participants with malaria and history of past illnesses at baseline treatment groups prevalence of anemia among those with a malaria infection at baseline n = 66 prevalence of anemia among those with a history of past illnesses at baseline n = 34 n (%) n (%) intervention group 18 (27) 6 (18) control group 13 (20) 5 (15) total anemia cases 31 11 18% of participants in the intervention group and 15% of participants in the control group who experienced illness in the past month had anemia at baseline. adherence to ifa supplementation data were adjusted for the level of education of participants. the odds of completing the monthly iron and folic acid supplementation (≥28 days) were significantly different between pregnant women who received the intervention and those who did not (adjusted odds ratio “aor” 5.0; 95% ci, 1.29-19.42). this result indicates that pregnant women in the intervention group adhered to the monthly prescribed dose of ifa tablets at a higher rate than those in the control group (96 vs. 84%). the prevalence of those who adhered to taking one ifa tablet per day in the intervention group was higher than those in the control group (95% vs. 85%). this means the odds of adhering to 1 ifa tablet per day were 3 times pa ge 16 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 higher among the intervention group compared with the control group (adjusted odds ratio “aor” 3.04; 95% ci, 0.92-10.08). women in the intervention group were twice as likely to be aware of the importance of ifa supplementation during pregnancy than women in the control group (adjusted odds ratio, 2.05; 95% confidence interval, 0.36-11.56). according to table 7, 95% of participants in the intervention group and 91% of participants in the control group missed at least one day without taking ifa tablets due to a perceived risk of side effects. despite this, there was no statistically significant difference between the two groups (adjusted odds ratio = 1.8; p>0.35). consumption of iron rich food pregnant women in the intervention group consumed more fruits per day when exposed to mobile phone tele-reminder every two weeks (91% compared to 72%, adjusted odds ratio “aor”, 3.77, 95%ci, 1.49-9.54). in the intervention group, there were significant odds in the consumption of 2-3 fish/meat/poultry products compared to the control group (93% versus 83%, table 8: impact of treatment on adherence to iron and folic acid supplementation intervention groups n (75) control group n = 75 unadjusted or*(95% ci) adjusted or** (95% ci) logistic regression p-valuen (%) n (%) acknowledged that iron and folic acid supplements can prevent and treat anemia in pregnancy 73(97) 71(95) 2.05 (0.36-11.58) 2.05 (0.36-11.56) 0.416 adhere to taking one ifa supplement (tablet)/per day 71(95) 64(85) 3.05 (0.92-10.06) 3.04 (0.92-10.08) 0.068 adhere to taking ≥28 tablets/supplement of ifa/month 72 (96) 62(84) 4.5 (1.23-16.93) 5.0 (1.29-19.42) 0.020 did not take ifa tablet a day due to perceiving risk of side effects 71 (95) 68 (91) 1.8 (0.51-6.52) 1.8 (0.50-6.50) 0.35 table 9: treatment effects on daily iron-rich food consumption between treatment groups intervention group n (%) control group n (%) fisher’s exact test p-value adjusted odds ratio (95% ci) binary logistic regression 2-3 fruits consumption/day baseline 12 (16) 10 (13) 0.40 3.77 (1.499.54) endline 68 (91) 54 (72) 0.003 consumption of 2-3 vegetables/per day baseline 53 (71) 57 (76) 0.29 3.69 (0.97-14.00) endline 72 (96) 65(87) 0.039 consumption of 2-3 meat/fish/poultry products per day baseline 31 (41) 35 (47) 0.31 2.93 (0.998.70) endline 70 (93) 62 (83) 0.038 adjusted odds ratio, 2.93; 95% ci, 0.99-8.70). according to table 8, pregnant women in the intervention group consumed 2-3 types of vegetables per day more than pregnant women in the control group. (96% compared with 87%, adjusted odds ration “aor”, 3.69; 95%ci, 0.97-14.00).\ discussion in this study, the null hypothesis stated that, compared to women in the control group, there were no significant changes in the mean hemoglobin level of pregnant women availing of antenatal care services who received mobile phone tele-reminder. on the other hand, the alternative hypothesis stated that, compared to women in the control group, there was a significant difference in the mean hemoglobin level of pregnant women availing of antenatal care services who received mobile phone telereminder. since the p-value = .013 is less than the a = 0.05, the study rejects the ho. it is now concluded in this study that at a = 0.05, there is sufficient evidence to say that integrating mobile phone tele-reminder into existing antenatal care is associated with increased iron status among pregnant women availing antenatal care services at the phebe and charles b. dunbar hospitals. according pa ge 16 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 to the study, integrating mobile phone tele-reminders into existing anc services appeared to improve iron status significantly. hemoglobin levels in pregnant women in the intervention group were higher than those in the control group. a simple mobile phone audio call and sms were used to address irregular attendance and inadequate utilization of essential antenatal care services. it is essential to utilize all antenatal care services appropriately throughout pregnancy to identify health problems that may contribute to anemia during pregnancy. we found significant improvement in the consumption of iron-rich foods that include vegetables and meat/fish/ poultry products among participants in the intervention group compared with those in the control group. vitamin c in fruits enhances the absorption of iron in food. it has been found that tele-reminder can greatly increase the consumption of vitamin-rich foods during pregnancy. red meat, fish, and poultry products are some of the animal products that contain hemoglobin. heme-based sources of iron are the most readily absorbed by the body participants in the intervention group again were more likely to adhere to ifa supplementation, compared with those in the control group. we agree with lund and others (2014) that integrating mobile phone technology into existing anc protocol, may increase anc visits and improve quality care with more pregnant women receiving quality preventive health services. in accordance with wagnew and others (2018), this study found that sending short message services on focused antenatal care to pregnant women increased the likelihood that they would adhere to antenatal care. in addition, the study agrees with bangal and others (2017) that pregnant women who use mobile phones during anc have a higher likelihood of taking ifa tablets, which can help prevent pregnancyrelated anemia. conclusion it is imperative to place anemia in pregnancy on the local and international health agendas. a lack of reduction or prevention of anemia during pregnancy may result in impaired health and quality of life for millions of women, as well as adverse effects on children’s development and learning. the world must take action now to prevent the death of many pregnant women in developing countries due to anemia, which can be realistically prevented by national and international consensus. anemia in pregnancy is defined by the world health organization (who) as hemoglobin levels of less than 11 grams per deciliter. a person with anemia has fewer red blood cells or a lower hemoglobin concentration than normal. if a pregnant woman has too few or abnormal red blood cells, or not enough hemoglobin, the blood can’t carry oxygen to the tissues of the body. the most common causes of anemia during pregnancy are nutritional deficiencies, particularly iron deficiency, but also folate, vitamin b12, and vitamin a deficiency. other causes of anemia in pregnancy include infectious diseases, such as malaria, tuberculosis, hiv, and parasitic infections. during three months, a two-arm, doubleblinded cluster randomized control trial was conducted in two referral hospitals. in bong county, liberia, the study was conducted at the phebe and charles b. dunbar hospitals. the purpose of this study was to determine whether mobile phone tele-reminder affects iron status and diet quality of pregnant women seeking antenatal care for the first time. randomly assigned to intervention and control groups were 150 pregnant women. there were six clusters of midwives caring for pregnant women in the study. among the six clusters, three were randomly assigned to provide the mobile phone tele-reminder and the remaining three to provide control treatment. each cluster had 25 participants, respectively. participants in both groups were followed up every month. participants in the intervention group were contacted every two weeks by telephoning and as well as sending sms messages. to collect baseline, midline, and end-line data, questionnaires were used throughout the study. to analyze baseline data, descriptive statistics (mean, sd, percentage, and frequency) were used. at baseline, two categorical or nominal variables were tested for independence by using fisher’s exact test. intent-to-treat analysis was used to analyze the findings. an independent sample t-test was used to determine the effect of the treatment on the primary outcome of the study. the longitudinal data were analyzed using binary logistic regression to determine the effect of the treatment on the secondary outcomes. based on baseline data, both groups had similar ages, gestational ages, number of pregnancies, number of living children, and last child’s age in month. the majority of participants in both groups had completed primary education. the majority of participants in both groups were still cohabiting. clinical findings indicated a high prevalence of malaria at baseline. both groups had more than half of their participants in their first trimester. in both groups, the hemoglobin level was below 11 grams per deciliter. hiv/aids was not present in any of the participants. a few of the participants consumed 2-3 fruits per day on average at baseline. in both groups, more than half of the participants consumed 2-3 vegetables per day, and most consumed more fish, meat, and poultry products. as far as iron status is concerned, mobile phone telereminder significantly increases iron status measured in hemoglobin (g/dl). despite this, the intervention had a small effect size on hemoglobin levels. the intervention significantly increased the likelihood of pregnant women taking their iron and folic acid supplements regularly. the intervention increased the consumption of iron and vitamin-rich foods during pregnancy. acknowledgement my first and foremost thanks go to the members of my guidance committee, dr. leila s. africa (chair), dr. corazon v.c. barba (co-chair), dr. angelina r. bustos (member), and dr. mark donda arboleda (member) for their support and guidance. last but not least, i pa ge 16 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 153-163, 2023 would like to express my gratitude to my family for their unconditional love and support. abbreviation anc: antenatal care, g/dl: gram per deciliter, ifa: iron, sms: short message services reference adams, g., gulliford, m. c., ukoumunne, o. c., eldridge, s., chinn, s., & campbell, m. j. 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(2015). compliance with iron-folate supplement and associated factors among antenatal care attendant mothers in misha district, south ethiopia: a community-based cross-sectional study. journal of environmental and public health, 2015. bangal, v. b., borawake, s. k., gavhane, s. p., & aher, k. h. (2017). use of mobile phone for improvement in maternal health: a randomized control trial. international journal of reproduction, contraception, obstetrics and gynecology, 6(12), 5458-5464. breymann, c. (2015, october). iron deficiency anemia in pregnancy. in seminars in hematology, 52(4), 339-347). wb saunders. carroli, g., rooney, c., & villar, j. (2001). how effective is antenatal care in preventing maternal mortality and serious morbidity? an overview of the evidence. pediatric and perinatal epidemiology, 15, 1-42. cdc, a. 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(2018). does short message service improve focused antenatal care visits and skilled birth attendance? a systematic review and meta-analysis of randomized clinical trials. reproductive health, 15(1), 1-10. who, u. (2001). unu. iron deficiency anemia: assessment, prevention, and control. a guide for program managers, geneva, who. world health organization. (1992). the prevalence of anaemia in women: a tabulation of available information (no. who/mch/msm/92.2. unpublished). world health organization. world health organization. (1993). prevention and management of severe anaemia in pregnancy: report of a technical working group, geneva, 20-22 may 1991 (no. who/fhe/msm/93.5. unpublished). world health organization world health organization. (2012). the trend in maternal mortality: 1990 to 2010: who, unicef, unfpa, and the world bank estimates. world health organization. (2012). world malaria report: 2012. world health organization. pa ge 1 pa ge 8 american journal of medical science and innovation (ajmsi) knowledge of diabetes mellitus among the outdoor patients in upazilla health complexes under jhalakati district of bangladesh layla azmin akter1* volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1448 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: march 15, 2023 accepted: april 10, 2023 published: april 16, 2023 the study “knowledge of diabetes mellitus among the outdoor patients in upazilla health complexes under jhalakati district of bangladesh” was conducted among 100 patients who attended in the outpatient department of upazilla health complexes under jhalakati district. the objectives of this study are to explore the socio-demographic history and knowledge level of the patients about risk factors as well as treatment and preventing ways of diabetes mellitus among the outdoor of upazilla health complexes under jhalakati district. the study found that the demographic characteristics of majority of the respondents were above middle aged, falling the age ranges of 41-45, 46-50 and above 51 where 59 percents of respondent ware female. the respondents were chosen from various educational level and most of them had a fairly low income of between 2000-5000. slightly more than half the respondents did not walk regularly. very few of the respondents worked out every day whereas the majority (82%) did not. the respondents said that they knew diabetes is caused when blood has high sugar levels or is the production of symptoms of polyuria due to high blood sugar levels. 23 respondents who were not sure about the types of diabetes, 2 thought there was a single type, 24 thought there were 2 types and 26 thought there were 3 types. a small number of respondents knew of type-1 diabetes (32%). most respondents did not know of gestational diabetes (79%). symptoms of diabetes known by the respondents included frequent urination, excessive thirst, extreme hunger, and very dry skin along with many other symptoms 32%,26%,33% and 44% respectively. many respondents knew about the screening tests of diabetes (65). as per the respondent’s opinion the study recommends improving the knowledge of dm among the people through mass media like tv programs, theater, counseling, newspaper articles and bcc materials. keywords knowledge on diabetes, prevention of diabetes, mellitus, outdoor patients 1 nursing institute, munshiganj, bangladesh * corresponding author’s e-mail: laylaazmin@gmail.com introduction diabetes mellitus recently reported as a leading non communicable public health hazards in bangladesh (islam, 2014). bangladesh exemplifies all the problems of third world countries: poverty, hunger, reduced longevity, and an illiteracy rate hovering at more than 80 percent (barai, 2020). the status of diabetes mellitus in bangladesh was surveyed. diabetes mellitus is a multisystemic illness associated in developing countries like bangladesh and pakistan prevalence of diabetes mellitus is 11%. with a variety of short-term and long-term complications (njiru, 2022). pakistan ranked seven in the world with 6.9 million studies indicate that genetic factors do not account diabetics in 2007 (compared to 4.3m ranked 8th in entirely for the development of diabetes, and several 1995) (shinjyo, 2017). in the year 2025. the most important environmental risk factors for the rapid rise of diabetes mellitus are one of the major types of diabetes are obesity and physical inactivity (lin, 2020). in fact, up to 80% of type-2 diabetes is explosion in obesity rates worldwide has largely been preventable by adopting a healthy diet, increasing responsible for the increase in diabetes, and it is physical activity and promoting a healthy lifestyle (zheng, 2018). estimated that up to 80% of all new cases of diabetes can be attributed to obesity. change in lifestyle has therefore to manage diabetes; the individuals must have increased the incidence of obesity (einarson, 2018). ample knowledge of their disease, medication, diet as well as genetic and environmental risk factors. thus, despite several advances in the field of dialectology, it is health education is integral part in the management of unfortunate that there exists a low awareness of the diabetes (paul, 2012). the present study was designed to assess the disease among public. diabetes education is widely accepted as integral to society to manage the disease which was also found in diabetes therapy within the diabetes community (rydien, 2013). in the study by roy et al, 2010 where lack of family supports this study awareness level of the study participants was one of the most dominant psychosocial issues poor, which is in accordance with other studies (van roy, 2010). among diabetics who also stresses for the development of diabetes education program to give patients a better knowledge of their disease, and to prevent premature morbidity and lifestyle modifications have key role in the management mortality associated with diabetes16. of diabetes. there was a lack of awareness about the role of lifestyle changes among the diabetic people visiting. most of the study participants had their disease at two major hospitals of karachi; and many of them did not diagnose for more than five years. this suggested that take diabetes seriously. there is a desperate need of they should have a good knowledge about management health education programs for diabetics and general of the https://doi.org/10.54536/ajmsi.v2i2.1448 https://journals.e-palli.com/home/index.php/ajmsi pa ge 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 8-15, 2023 disease; but many of them (43%) were not taking public by using variety of media. the vital role of family regular treatment, their (62%) diabetes was not under, and society must be recognized. health care provider’s control, 52% did not follow diet chart and a vast majority should play their part in health educating the masses. (82%) did not indulge in exercise (shaikh, 2011). several epidemiology and end results (seer) cancer registries, it was reported that the service providers have significant role in aware the clients to early diagnosis and improve the seeking behavior for diabetes mellitus (mollica, 2017). the objective of the study was to explore the sociodemographic history of the patients, to find out the knowledge level of the respondents about risk factors of diabetes mellitus and to explore the knowledge of the respondents about treatment and preventing ways of diabetes mellitus. literature review diabetes mellitus is one of the most significant public health challenges of the 21st century. who estimate shows, globally the number of persons with diabetes will rise from 221 million by the year 2010, and to 300 million by 2025 (amos, 1997). the most increase will take place in south asia. in 2007 a un resolution was adopted to mark significance of dm as a global public health issue. recently the occurrence of type 2 diabetes is increasing both in rural and urban communities and it is considered as a major burden for national health budget (zimmet, 2014). hence, there is an urgent need to halt the exponential increase of dm in bangladesh, which is already overburdened with the double burden of both non-communicable and communicable diseases. but there is lack of population based large scale study in the country to assess the extent of the problem and its determinants. this study topic highlights the epidemiology of diabetes in rural and urban population. the study showed that the prevalence of type 2 diabetes is higher in urban compared to rural areas with comparable levels of obesity (mean bmi and whr) (agyemang, 2016). during the same period trivial increase of bmi, whr and waist circumference compared to baseline survey were noted. the study findings hypothesize that urbanization and its associated lifestyle factors may have contributed to the rising prevalence of diabetes in bangladeshi population. higher prevalence of diabetes in lean population may also indicate genetically susceptible population. the findings of that study will help develop policies in the health sector with a view to initiating appropriate preventive strategies to put off lifelong entrance of diabetes in the population (martinez, 2017). sign of diabetes mellitus people (usually with type 1 diabetes) may also present with diabetic ketoacidosis, a state of metabolic dysregulation characterized by the smell of acetone; a rapid, deep breathing known as kussmaul breathing; nausea; vomiting and abdominal pain; and an altered state of consciousness (umpierrez, 2016). a rarer but equally severe possibility is hyperosmolar nonketotic state, which is more common in type 2 diabetes and is mainly the result of dehydration. often, the patient has been drinking extreme amounts of sugar-containing drinks, leading to a vicious circle regarding the water loss. several skin rashes can occur in diabetes that are collectively known as diabetic dermadromes (shivashankar, 2011). causes of dm the cause of diabetes depends on the type. type 2 diabetes is due primarily to lifestyle factors and genetics and type 1 diabetes is also partly inherited and then triggered by certain infections, with some evidence pointing at coxsackie b4 virus. there is a genetic element in individual susceptibility to some of these triggers which has been traced to hla genotypes (i.e., the genetic “self ” identifiers relied upon by the immune system). however, even in those who have inherited the susceptibility, type 1 diabetes mellitus seems to require an environmental trigger. diagnostic procedure of diabetes mellitus diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following:[9] 1. fasting plasma glucose level ≥ 7.0 mmol/l (126 mg/dl). 2. plasma glucose ≥ 11.1 mmol/l (200 mg/dl) two hours after a 75 g oral glucose load as in a glucose tolerance test. 3. symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/l (200 mg/dl). 4. glycated hemoglobin (hb a1c) ≥ 6.5% population aging, urbanization, behavior and lifestyle changes, genetic susceptibility, and the health transition from communicable to non-communicable diseases account for the increasing significance of diabetes mellitus in bangladesh. in the absence of quantified estimates of current and future disease burden attributable to diabetes mellitus in rural and urban bangladesh, this study aimed to provide such estimates (islam 2014). modeling methods were used to estimate the epidemiology of diabetes mellitus in rural and urban bangladesh currently, in 2010, and in 2020. resultant estimates of the epidemiology of diabetes mellitus and estimates of the epidemiology of the diabetic squeal used in the global burden of disease study were used to calculate disability adjusted life years (dalys) attributable to diabetes mellitus and its sequelae in these populations. estimated current burden of disease attributable to diabetes mellitus and its sequelae were 265,718 dalys (2.6 dalys per 1000 persons) in rural bangladesh and 61,829 dalys (3.2 dalys per 1000 persons) in urban bangladesh. disease burden in rural bangladesh was estimated to increase to 311,068 dalys (3.0 dalys per 1000 persons) in 2010 and 389,686 dalys (3.2 dalys per 1000 persons) in 2020. disease burden in urban https://journals.e-palli.com/home/index.php/ajmsi pa ge 10 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 8-15, 2023 bangladesh was estimated to increase substantially to 197,267 dalys (3.8 dalys per 1000 persons) in 2010 and 328,934 dalys (4.4 dalys per 1000 persons) in 2020 (talukder, 2020). many assessments have been based on assumptions and information of less-than-optimal reliability. we have studied available information on healthcare expenditure, number of hospital clinics, hospital beds, income levels and any health sector information that was available to ensure that our assessment was made as realistic as possible. we believe that the results provide a realistic picture within the given frameworks and scenarios. our experiences also underline that studies of the present kind are developed in a continuous process and there is still a need for further development and validation in the future (van dyne, 2015). a health economic analysis of the standard types of evaluation – cost effectiveness analysis (cea), cost-utility analysis (cua) or cost-benefit analysis (cba). some of the controversial issues related to either of the standard types of evaluation are relevant to our study and, therefore, some of our reservations are discussed in the following first, the comparison of the current situation to the worst scenario involves a rather big change in the society whilst most economic evaluations at least of the cea type – are made for smaller changes. second, whereas the worst scenario is not totally irrelevant for a developing country, the ideal scenario may seem somewhat artificial, particularly in the context of a developing country (miroshnychenko, 2021). it is important to emphasis that the richest are those who already have access to care, have the highest productive value, are most likely to comply with treatment, and are most likely to become old enough to develop type 2 diabetes. it was discussed whether it would be relevant explicitly to divide the model into the 10% richest, the 10% poorest with free access and the remaining 80% without access to care and to analyze these groups in two separate models. we choose to model these aspects through implicit distinction between the rich and poor but in one model. it might be relevant in a deeper analysis to make analyses in two distinctly different models (evans, 2017). the current conditions for managing t2d in bangladesh are poor, partly due to lack of access to basic treatment, incl. insulin, for a substantial part of the population. improvements yielding equal access to treatment and care for all patients with t2d is costly but will be accompanied by somewhat larger gains in production value compared to the current scenario. it is conceivable that as a consequence of such improvement, some adjustments will take place at a macro level in society, but any conclusion would be rather speculative (misra, 2019). a major effect of treatment of t2d patients is gains in patient-years. a derived effect may be gains in terms of productive time and costs in terms of spending time by informal caregivers and increased income from working (production value). it should be stressed again that the current population of patients with t2d has obtained its size and age composition because of any given (in the case of bangladesh uneven) access to insulin treatment during many decades following the introduction of insulin in the early 1920´s. therefore, a comparison of patient-years experienced under the contrasting scenarios mentioned reflects the cumulative effect of access or lack of access to insulin treatment over previous decades and cannot be interpreted as an isolated effect of insulin treatment during the year (grunberger, 2021). bangladesh has experienced economic growth since the nineties. whether this growth is reflected in a rising living standard is still to be documented as it would depend on many factors. if economic growth has led to increased population growth the average living standard may not have improved markedly. in the long term, though, a continued reduction of infant mortality probably (as experienced in other parts of the world) will lead to a lower fertility pr woman and eventually to higher average living standards (henderson, 2012). an effect derived from increased number of patient years is the added consumption that these patients have. materials and methods quantitative in nature and social survey method was apply for conducting study among the patients who received treatment from the outdoor of upazilla health complexes under jhalakati district. study area this study was conduct at the upazilla health complexes under jhalakati district. population and unit of analysis the target population use includes all patients who received treatment from the outdoor of upazilla health complexes under jhalakati district. the unit of analysis was individual patient. inclusion criteria 1. patients who visited outdoor for any services of upazilla health complexes under jhalakati district 2. patients who were willing to participate in the study 3. patients who were present during data collection exclusion criteria 1. patients who visited outdoor for any services of upazilla health complexes under jhalakati district but not able to responds. 2. patients who were not willing to participate in the study 3. patients who were not present during data collection sampling sample size was 100 patients. sampling will be respondents were select that are available and interest in interview. techniques of data collection by using interview and observation techniques. through https://journals.e-palli.com/home/index.php/ajmsi pa ge 11 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 8-15, 2023 purposive sampling 100 respondents were indemnified from patients who received treatment from the outdoor of upazilla health complexes under jhalakati district. all the patients were included under the study as because a smaller number of patients in patients who received treatment from the outdoor of upazilla health complexes under jhalakati district. observation will be watching and recording behaviour and characteristics. data analysis and processing microsoft excel was used to analysis the data. descriptive statistics will be used to express percentage performance, mean, standard deviation table, graph charts and interpretation with statistical information. ethical consideration of the study prior to the commencement of this study, the research protocol was approved by the research committee (local ethical committee). the aims and objectives of the study along with its procedure, risks and benefits of this study were explained to the respondents in easily understandable local language and then informed consent was taken from each participant. then it was assured that all information and records was keep confidential and the procedure was used only for research purpose and the findings will be helpful for developing awareness package to increase awareness and improve hygiene awareness among the pregnant mother in hospitals in bangladesh. results and discussion socio-demographic characteristics of the respondents. most of the respondents were above middle aged, falling the age ranges of 41-45(39), 46-50 (30) and above 51 (9). a small number (22) of them were below 40. figure 1: distribution of the respondents by age figure 2: distribution of the respondents by sex figure 3: distribution of the respondents by religion the number of female (59) respondents was a bit higher than the number of male respondents (41) that was 59% and 41% respectively. slightly mre than half the respondents were followers of islam while small numbers of them were hindus (22) or christian (23). a fairly small number of the respondents had received higher education (2 had done their masters and 20 of them had done their degree level). the rest had studied up to finishing their sscs (20), hscs (10), were below class x but above vi (16) or had only studied up to class v or below (16). figure 4: distribution of the respondents by educational level the respondents came from a wide variety of employments (or businesses) of which the most common sector was the service sector (2), tailoring (10) or owning a small business (11). small numbers of them were scattered across jobs such as fishing (2), farming (7), running/working at poultry farms (5), day labouring (4), tutoring (2), teaching (3) or being a maid (6). a fairly large number of the woman were housewives (30). table 1: distribution of the respondents by occupation criteria n % housewife 30 30.0 housemaid 6 6.0 teacher 3 3.0 service 20 20.0 tailoring 10 10.0 tutoring 2 2.0 small business 11 11.0 day laborer 4 4.0 poultry farm 5 5.0 agriculture 7 7.0 fishing 2 2.0 total 100 100.0 https://journals.e-palli.com/home/index.php/ajmsi pa ge 12 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 8-15, 2023 a very large number of the respondents were married (77). others were unmarried (1), separated (11), divorced (9) or had been deserted (2). figure 5: distribution of the respondents by marital status the highest number of respondents had a fairly low income of between 2000-5000 (54). 32 of them earned between 5000-10000 and only 14 of them earned more than 10000. figure 6: distribution of the respondents by income slightly more than half the respondents (51) did not walk regularly. the rest did. figure 7: distribution of the respondents by regular walking status very few of the respondents actually worked out every day (18). the majority (82%) did not. figure 8: distribution of the respondents by regular exercise status based on multiple responses, the respondents said that they knew diabetes is caused when blood has high sugar levels (37) or is the production of symptoms of polyuria due to high blood sugar levels (56). only 2 of them knew the fact that it happens when the body does not produce enough insulin, or because cells do not. table 2: distribution of the respondents by knowledge about diabetes mellitus criteria n % metabolic diseases 9 9.0 a person has high blood sugar 37 37.0 body does not produce enough insulin, or because cells do not 2 2.0 high blood sugar produces the classical symptoms of polyuria 56 56.0 * multiple responses a moderately large number of respondents knew about the monitoring tests of diabetes (61). figure 9: distribution of the respondents by knowledge about the monitoring tests of diabetes mellitus respondents said the diabetes monitoring tests include detecting both hyperglycemia or hypoglycemia (7), checking blood glucose concentrations (6), monitoring the diet (34) and suggesting exercise (32). table 3: distribution of the respondents by knowledge about the monitoring tests procedure of diabetes mellitus criteria n % to check blood glucose concentrations 6 6.0 detecting both hyperglycaemia and hypoglycaemia 7 7.0 monitor the diet required 34 34.0 to suggest exercise 32 32.0 na 39 39.0 *multiple responses many of the respondents replied that the hospital has enough facilities to provide treatment for diabetes. 25 of them were unsure and 18 of them disagreed saying the hospital was not good enough. figure 10: distribution of the respondents by attitude about this hospital there is enough facilities to provide treatment of diabetes mellitus. https://journals.e-palli.com/home/index.php/ajmsi pa ge 13 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 8-15, 2023 table 4: distribution of the respondents by opinion about the awareness program is necessary to improve the knowledge of dm among the people. criteria n % yes 100 100.0 total 100 100.0 all respondents agreed that the awareness program is necessary to improve the knowledge of dm among the people. based on multiple responses, the respondents said that the things required to improve knowledge of dm among the people are tv programs (48), a theater (57), counseling (54), newspaper articles (12) or bcc materials. table 5: distribution of the respondents by knowledge about type of awareness program is necessary to improve the knowledge of dm among the people. criteria n % bcc materials 7 7.0 theater 57 57.0 article in newspaper 12 12.0 tv program 48 48.0 counseling 54 54.0 *multiple responses other than the 23 respondents who were not sure about the number of types of diabetes, 2 thought there was a single type, 24 thought there were 2 types and 26 thought there were 3 types. figure 11: distribution of the respondents by knowledge about the types of diabetes mellitus a small number of respondents knew of type-1 diabetes (32%). many respondents did not have any knowledge about type-1 diabetes (68). the ones who did said that it is from the bodies failure to produce insulin (13), requires the person to inject insulin (21) or is known as iddm for short (2) most respondents did not know of gestational diabetes (79%). table 6: distribution of the respondents by knowledge about type 1 diabetes mellitus criteria n % results from the body's failure to produce insulin 13 13.0 requires the person to inject insulin 21 21.0 referred to as iddm for short 2 2.0 don't know 68 68.0 figure 13: distribution of the respondents by knowledge about gestational diabetes the respondents said that gestational diabetes is when pregnant women have a high blood glucose level during pregnancy (17) and some knew that it may precede development type 2 dm. table 7: distribution of the respondents by knowledge about gestational diabetes criteria n % when pregnant women have a high blood glucose level during pregnancy 17 17.0 it may precede development of type 2 dm. 4 4.0 i don't know 79 79.0 total 100 100.0 figure 12: distribution of the respondents by knowledge about type 1 diabetes mellitus conclusion bangladesh is a poor country and struggle to manage its disease burden. here, there is a lack of access to basic treatment. in the case of managing diabetes, insulin is a substantial part. improvements need to be made and access to treatment and care for all patients with t2d and t1d. it is conceivable that because of such improvement, some adjustments will take place at a macro level in society, but any conclusion would be rather speculative. the economic analyses of the “improved” and i deal scenarios assume 100% access to healthcare systems for everybody in the country at current prices. the population of bangladesh is not literate enough to assess their own health to attend the health service provider. diabetes may cause both hyperglycemia as well as hypoglycemia based on the situation. it is very important to know the sign https://journals.e-palli.com/home/index.php/ajmsi pa ge 14 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 8-15, 2023 symptoms of both hyperglycemia and hypoglycemia for them who are suffering from diabetes to take specific precautions. the patient will be aware through the health service providers to whom they attend during their sickness to be cured. if the service providers provided rationale training on diabetes, then it would be easy for them to provide adequate information to the patient to prevent and control of diabetes to reduce the disease burden of bangladesh. recommendations the study was carried out among the patients attending the opd of upazilla health complexes under jhalakati district to know their knowledge on diabetes mellitus. after analyzing the findings, the study recommends for the followings. 1. the knowledge of the respondents about the sign symptoms of diabetes mellitus is found to be poor as they have less scope to know about the disease. awareness package should be developed to increase the knowledge level of the patients to decrease the morbidity and mortality of the patients due to diabetes mellitus. 2. the patients who suffer from diabetes were expected to be more knowledgeable about the diagnostic procedure of the disease diabetes mellitus. but those who are not suffering from the disease are found less knowledgeable. it was due to the experience they got during the diagnostic procedure. general knowledge regarding the diagnostic procedure of diabetes mellitus needs to be increased to decrease the fear of the patients about the diagnostic procedure. 3. the respondents have the considerable knowledge about the risk factors of diabetes mellitus. but the knowledge level needs to be further increased so that they can avoid the risk factors to get them healthy to live a healthful leaving free from diabetes mellitus. 4. the knowledge of the respondents about treatment procedure is fear because it is very easy to them to understand and recall. intervention to be continued to maintain the knowledge level of the respondents. 5. preventing ways of diabetes mellitus need to be broadcast through the national mass media to make the people aware. the health service providers should be providing enough knowledge, so that they can disseminate the knowledge when patients come to them for their health service. references agyemang, c., meeks, k., beune, e., owusu-dabo, e., mockenhaupt, f. p., addo, j., ... & stronks, k. (2016). obesity and type 2 diabetes in sub-saharan africans– is the burden in today’s africa similar to african migrants in europe? the rodam study. bmc medicine, 14, 1-12. amos, a. f., mccarty, d. j., & zimmet, p. (1997). the rising global burden of diabetes and its complications: estimates and projections to the year 2010. diabetic medicine, 14(s5), s7-s85. barai, m. k. (2020). introduction: construction of a development model for bangladesh. bangladesh’s economic and social progress: from a basket case to a development model, 3-62. einarson, t. r., acs, a., ludwig, c., & panton, u. h. (2018). prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007–2017. cardiovascular diabetology, 17(1), 1-19. evans, r. g., & stoddart, g. l. (2017). producing health, consuming health care. in why are some people healthy and others not? 27-64. routledge. grunberger, g., sherr, j., allende, m., blevins, t., bode, b., handelsman, y., ... & unger, j. (2021). american association of clinical endocrinology clinical practice guideline: the use of advanced technology in the management of persons with diabetes mellitus. endocrine practice, 27(6), 505-537. henderson, j. v., storeygard, a., & weil, d. n. (2012). measuring economic growth from outer space. american economic review, 102(2), 994-1028. islam, s. m. s., purnat, t. d., phuong, n. t. a., mwingira, u., schacht, k., & fröschl, g. (2014). non‐communicable diseases (ncds) in developing countries: a symposium report. globalization and health, 10(1), 1-8. lin, x., xu, y., pan, x., xu, j., ding, y., sun, x., ... & shan, p. f. (2020). global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. scientific reports, 10(1), 1-11. martinez, n. g., niznik, c. m., & yee, l. m. (2017). optimizing postpartum care for the patient with gestational diabetes mellitus. american journal of obstetrics and gynecology, 217(3), 314-321. misra, a., gopalan, h., jayawardena, r., hills, a. p., soares, m., reza‐albarrán, a. a., & ramaiya, k. l. (2019). diabetes in developing countries. journal of diabetes, 11(7), 522-539. miroshnychenko, a., uhlman, k., malone, j., waltho, d., & thoma, a. (2021). systematic review of reporting quality of economic evaluations in plastic surgery based on the consolidated health economic evaluation reporting standards (cheers) statement. journal of plastic, reconstructive & aesthetic surgery, 74(10), 2458-2466. mollica, m. a., lines, l. m., halpern, m. t., ramirez, e., schussler, n., urato, m., ... & kent, e. e. (2017). patient experiences of cancer care: scoping review, future directions, and introduction of a new data resource: surveillance epidemiology and end resultsconsumer assessment of healthcare providers and systems (seer-cahps). patient experience journal, 4(1), 103-121. njiru, l. n. (2022). association between depression, anxiety and adherence to treatment among patients attending the kenyatta national hospital (knh) diabetes outpatient clinic (doctoral dissertation, university of nairobi). https://journals.e-palli.com/home/index.php/ajmsi pa ge 15 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 8-15, 2023 paul, r., & norbury, c. (2012). language disorders from infancy through adolescence-e-book: listening, speaking, reading, writing, and communicating. elsevier health sciences. rydén, l., grant, p. j., anker, s. d., berne, c., cosentino, f., ... & xuereb, r. g. (2013). esc guidelines on diabetes, pre-diabetes, and cardwiovascular diseases developed in collaboration with the easd: the task force on diabetes, pre-diabetes, and cardiovascular diseases of the european society of cardiology (esc) and developed in collaboration with the european association for the study of diabetes (easd). european heart journal, 34(39), 3035-3087. shaikh, z. a., shaikh, m. z., & ali, g. (2011). diabetic patients: awareness about life style modifications. the professional medical journal, 18(2), 265-268. shivashankar, m., & mani, d. (2011). a brief overview of diabetes. international journal of pharmacy and pharmaceutical sciences, 3(4), 22-27. shinjyo, n., & green, j. (2017). are sage, rosemary and lemon balm effective interventions in dementia? a narrative review of the clinical evidence. european journal of integrative medicine, 15, 83-96. talukder, a., & hossain, m. z. (2020). prevalence of diabetes mellitus and its associated factors in bangladesh: application of two-level logistic regression model. scientific reports, 10(1), 10237. umpierrez, g., & korytkowski, m. (2016). diabetic emergencies—ketoacidosis, ]hyperglycaemic hyperosmolar state and hypoglycaemia. nature reviews endocrinology, 12(4), 222-232. van dyne, l., ang, s., & koh, c. (2015). development and validation of the cqs: the cultural intelligence scale. in handbook of cultural intelligence, 34-56. routledge. van roy, b., groholt, b., heyerdahl, s., & clench-aas, j. (2010). understanding discrepancies in parent-child reporting of emotional and behavioural problems: effects of relational and socio-demographic factors. bmc psychiatry, 10(1), 1-12. zheng, y., ley, s. h., & hu, f. b. (2018). global aetiology and epidemiology of type 2 diabetes mellitus and its complications. nature reviews endocrinology, 14(2), 88-98. zimmet, p. z., magliano, d. j., herman, w. h., & shaw, j. e. (2014). diabetes: a 21st century challenge. the lancet diabetes & endocrinology, 2(1), 56-64. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 16 4 american journal of medical science and innovation (ajmsi) quality of counseling about lifestyle modifications and complications of hypertensive patients, sudan sahar moawia balla elnour1*, ziryab zainelabdin mohamed elmahdi2, fatima hassan salman nasr2 samar moawia balla elnour3, ibtisam ali4 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2115 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 17, 2023 accepted: october 23, 2023 published: october 27, 2023 hypertension is a common chronic disease and an important public health problem. effective hypertension control depends on patients being aware of the necessary lifestyle modifications. this study aimed to assess the quality of counseling received by hypertensive patients, the influence of blood pressure control and complications of hypertension. this cross-sectional study was conducted on hypertensive patients attending a private medical facility, a governmental facility and a phc (primary health care) center in sudan. the patients were randomly selected, and their waist circumference, height and weight were recorded. the participants received counseling from family physicians and shos (senior house officers) about diet, mental relaxation, weight loss, exercise, smoking, and alcohol. the follow-up doctor vs. counseling showed a significant difference in counseling about diet, salt, fat intake, and smoking. the quality of counseling depended on the doctor rather than the follow-up location. the quality of counseling offered to hypertensive patients depends on the doctor rather than the location; almost half of the participants had to follow up with shos, including half of the participants with complications, and only a quarter received counseling about complications. for hypertensive patients, the quality of counseling depends on the doctor rather than the location. recommendations include prioritizing lifestyle modifications and ensuring doctors are sensitive and aware of their counseling tactics with patients. keywords counseling quality, doctor sensitization, hypertension, phc hospitals 1 ministry of health, sudan medical specialization board, sudan 2 sheikh khalifa medical city, united arab emirates 3 ibn roshd educational holding company, al liwa ضايرلا, saudi arabia 4 medicine and cardiology, international university of africa & ahmed gasim hospital, sudan * corresponding author’s e-mail: shimlinjahan2208@gmail.com introduction hypertension is a global health challenge common in semi-urban, urban and rural areas and should be monitored and treated vigilantly across the lifespan (lemogoum et al., 2018). it is caused by cardiovascular diseases associated with other serious miscellaneous illnesses and a high fatality rate.(petrie et al., 2018) the rapid rate of obesity and old age are the two major factors contributing to its common occurrence in the community (mosha et al., 2017). the rationale for this study stems from the fact that the prevalence of hypertension in the general population is 30%-45%, increasing with age. (kjeldsen, 2018) hypertension is expected to rise by 60% by 2025 to 1.56 billion adults (akoko et al., 2017). lifestyle changes may be an effective way of preventing/delaying hypertension or evading pharmaceutical treatment in patients with grade 1 hypertension and reducing bp in patients who are already treated (bogale et al., 2020; ferdinand et al., 2020). thus, this study aims to investigate whether effective hypertension solutions are impacted by the quality of the doctor and the counseling received. materials and methods selection and description of participants our study was a repeated cross-sectional hospital/phc center-based study. the cochran formula collected the sample size for 384 out-patients attending alzaytouna specialized hospital, alakadimiy charity hospital and omer ibn elkhatab phc center. of those 384, 250 participants remained after excluding questionnaires with missing essential data such as weight and waist circumference, and the remaining participants were interviewed via questionnaire. weight, height and waist circumference were recorded via weight scale and tape. sample size after the patient’s voluntary informed consent was obtained in written form, 102 patients were interviewed at a governmental medical facility, 97 were interviewed at a private medical facility, and the remaining 51 were interviewed at a phc center; the males were 139 (55.6%), and the females were 111 (44.4%), their ages ranged between 23-89 years. participants who were married were 82%, 13.6% were uneducated, the remaining participants received some education, and 57.6% were employed. we divided the population into three groups; the first group was properly diagnosed patients by a physician, the second group was patients on hypertensive drugs, and the third group had patients who suffered from hypertension for at least 1 year. the study was carried out between january and september 2017. statistics at the beginning of this study, the researchers adhered to the strobe guidelines. statistical software packages (excel and access, microsoft, redmond, wa; spss 25.0, pa ge 16 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 164-170, 2023 spss inc. chicago, il) were used for data management and analysis, respectively. the chi-square or fisher exact test was used for comparisons of proportions in two groups. groups were assumed to statistically differ significantly when the probability level was less than 0.05, i.e. p < 0.05. results the most frequent age group was 60-69 years at 30.8%, followed closely by the age group 50-59 years at 29.6%, and the mean ± standard deviation was 58.77± 6.80 years. table 1 shows the demographic data of the 250 participants: the frequency and the percentage value of the age groups, marital status, educational level and employment status of the participants. table 2 demonstrates the demographic data, and its association with blood pressure control adjusted or (odds ratio) and 95% ci (confidence interval) showed a statistically significant difference (p=0.005). controlled blood pressure was most common in the age group of 5059 years (34.6%), followed closely by 6069 years (29.8%), and uncontrolled blood pressure was most frequent in the age group 60-69 years (33.9%). in contrast, the remaining demographic data did not show any significant association with blood pressure control: sex vs blood pressure control (p=0.338), marital status vs. blood pressure control (p=0.238), educational level vs. blood pressure control (p=0.368), employment vs. blood pressure control (p=0.548). table 3 shows the demographic data vs. complications presence, age groups vs. complications presence demonstrated a statistically significant difference with an adjusted or and 95% ci (p=0.043); the presence of complications was most frequent in the age group of 6069 years (29%), and none existed in the age group of 2029 years, the sex vs. complication presence adjusted or and 95% ci showed a statistically significant difference (p=0.030), as 66.7% males and 33.3% females show complications presence. the remaining demographic characteristics vs. complications presence analysis were statistically insignificant: marital status vs. complications presence (p=0.405), educational level vs. complications presence (p=0.432), and employment vs. complications presence (p=0.436). the follow-up doctor vs. counseling offered can be seen in table 4. the counseling offered about diet and the salt intake adjusted or and 95% ci showed a statistically significant difference, (p=0.002) and (p=0.019), respectively. all participants following up with a family physician received counseling about diet as well as salt intake. the percentage of participants following up with a physician and registrar who received counseling about diet as well as salt intake was 96.7% and 92.3%, respectively, while 82.4% of participants following up with an sho received counseling about diet whereas 86.6% received counseling about salt intake. the follow-up doctor vs. counseling offered about fat intake adjusted or and 95% ci showed a statistically significant difference (p=0.013); 96.4% of participants following up with a family physician received counseling about fat intake while 96.7% of the participants following up with a physician received the counseling. participants following up with the registrar and receiving counseling about fat intake were 92.3%, while the percentage of participants following up with an sho who received the counseling was 84%. the follow-up doctor vs. counseling offered about mental relaxation adjusted or and 95% ci showed a statistically significant difference (p=0.001), all the participants following up with a family physician or a registrar received counseling about mental relaxation, whereas 77.8% and 95% of the participants following up with a physician and an sho respectively, received the counseling. the follow-up doctor vs. smoking counseling (passive, active and cessation) adjusted or and 95% ci showed a statistically significant difference (p=0.012), 75.6% of all the participants received counseling about smoking. a total of 67.9% of participants following up with a family physician and 65.6% of participants following up with a physician received counseling about smoking. nearly 84.6% of participants following up with a registrar received the counseling while the percentage that received counseling from an sho was 84%. the follow-up doctor vs. counseling offered about alcohol consumption adjusted or and 95% ci showed a statistically significant difference (p=0.001); 3.6% of all the participants received counseling about alcohol consumption, 50% of the participants followed up with a family physician, 46.7% of the participants following up with a physician, 76.9% following up with a registrar while 78.2% of participants following up with an sho received counseling about alcohol consumption. the remaining follow-up doctor vs. counseling offered analysis was statistically insignificant with (p>0.5) fruit intake (p=0.424), vegetable intake (p=0.787), weight loss (p=0.473), and exercise (p=0.230). table 5 shows the follow-up location vs. counseling offered about hypertension (p=0.872). approximately 45.5% of the participants who received counseling about hypertension were followed up at a private medical facility, 33.7% at a phc center and 20.8% at a governmental facility. table 1: demographic data sex frequency percentage males 139 55.6 females 111 44.4 age group frequency percentage 20-29 years 3 1.2 pa ge 16 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 164-170, 2023 30-39 years 9 3.6 40-49 years 40 16.0 50-59 years 74 29.6 60-69 years 77 30.8 70-79 years 36 14.4 80-89 years 11 4.4 marital status frequency percentage single 6 2.4 married 205 82.0 divorced 9 3.6 widowed 30 12.0 educational level frequency percentage uneducated 34 13.6 quran school (khalwa) 10 4.0 primary school 36 14.4 secondary school 74 29.6 university 88 35.2 postgraduate studies 8 3.2 employment frequency percentage employed 144 57.6 unemployed 106 42.4 table 2: the demographic data vs. blood pressure control variable frequency controlled blood pressure sex male 139 (55.6%) 103 (53.9%) 36 (61.0%) female 111 (44.4%) 88 (46.1%) 23 (39.0%) age 20-29 3 (1.2%) 2 (1.0%) 1 (1.7%) 30-39 9 (3.6%) 4 (2.1%) 5 (8.5%) 40-49 40 (16%) 33 (17.3%) 7 (11.9%) 50-59 74 (29.6%) 66 (34.6%) 8 (13.6%) 60-69 77 (30.8%) 57 (29.8%) 20 (33.9%) 70-79 36 (14.4%) 22 (11.5%) 14 (23.7%) 80-89 11 (4.4%) 7 (3.7%) 4 (6.8%) marital status single 6 (2.4%) 6 (3.1) 0 married 205 (82.0%) 158 (82.7%) 47 (79.7%) divorced 9 (3.6%) 5 (2.6%) 4 (6.8%) widowed 30 (12.0%) 22 (11.5%) 8 (13.6%) educational level uneducated 34 (13.6%) 24 (12.6%) 10 (16.9%) quran school (khalwa) 10 (4.0%) 6 (6.3%) 4 (6.8%) primary school 36 (14.4%) 30 (15.7%) 6 (10.2%) secondary school 74 (29.6%) 55 (28.8%) 19 (10.2%) university 88 (35.2%) 69 (36.1) 19 (32.2) postgraduate studies 8 (3.2%) 7 (3.7%) 1 (10.7%) pa ge 16 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 164-170, 2023 employment employed 144 (57.6%) 113 (59.2%) 31 (52.5%) unemployed 106 (42.4% 78 (40.8%) 28 (47.5%) table 3: the demographic data and complications presence variable frequency complications presence yes no sex males 139 46 93 (55.6%) (66.7%) (51.4%) females 111 23 88 (44.4%) (33.3%) (48.6%) age groups 20-29 years 3 0 3 (1.2%) (0.0%) (1.7%) 30-39 years 9 3 6 (3.6%) (4.3%) (3.3%) 40-49 years 40 10 30 (16.0%) (14.5%) (16.6%) 50-59 years 74 14 60 (29.6% ) (20.3%) (33.1%) 60-69 years 77 20 57 (30.8%) (29.0%) (31.5%) 70-79 years 36 17 19 (14.4%) (24.6%) (10.5%) 80-89 years 11 5 6 (4.4%) (7.2%) (3.3%) marital status single 6 0 6 (2.4 %) (0.0%) (3.3%) married 205 57 148 (82.0%) (82.6%) (81.8%) divorced 9 2 7 (3.6%) (2.9%) (3.9%) widowed 30 10 20 (12.0%) (14.5%) (11.0%) education level uneducated 34 9 25 (13.6%) (13.0%) (13.8%) quran school (khalwa) 10 4 6 (4.0%) (5.8%) (3.3%) primary school 36 10 26 (14.4%) (14.5%) (14.4%) secondary school 74 23 51 (28.2%) (29.6%) (33.3%) university 88 19 69 (35.2%) (27.5%) (38.1%) postgraduate studies 8 4 4 pa ge 16 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 164-170, 2023 primary school (3.2%) (5.8%) (2.2%) employment status employed 144 37 107 (57.6%) (53.6%) (59.1) unemployed 106 32 74 (42.4% (46.4%) (40.9%) table 4: follow-up doctor vs. counseling offered follow doctor up counselling offered physician family physician registrar s.h.o yes no yes no yes no yes no diet 96.7% 3.3% 100% 0.0% 92.3% 7.7% 82.4% 17.6% low salt intake 96.7% 3.3% 100% 0.0% 92.3% 7.7% 86.6% 13.4% low-fat intake 96.7% 3.3% 96.4% 3.6% 92.3% 7.7% 84.0% 16.0% high fruit intake 84.4% 15.6% 92.9% 7.1% 92.3% 7.7% 80.8% 9.2% high vegetable intake 84.4% 15.6% 89.3% 10.7% 92.3% 7.7% 84.0% 16.0% weight loss 90.0% 10.0% 96.4% 3.6% 92.3% 7.7% 95.0% 5.0% exercise 90.0% 10.0% 82.1% 17.9% 92.3% 7.7% 94.1% 5.9% mental relaxation 77.8% 22.2% 100% 0.0% 100% 0.0% 95.0% 5.0% smoking counseling 65.6% 34.4% 67.9% 32.1% 84.6% 15.4% 84.0% 16.0% alcohol counseling 46.7% 53.3% 50.0% 50.0% 76.9% 23.1% 78.2% 21.8% *shosenior house officer table 5: follow-up location vs. counseling about the nature of hypertension phc centre private medical facility governmental medical facility yes 33.7% 45.5% 20.8% no 20.9% 45.2% 20.4% discussion in 2009, a paper reviewed many studies investigating adherence to medication among patients with chronic conditions in middle eastern countries, including sudan. a comprehensive literature search yielded 19 relevant studies that focused on the extent and predictors of non-adherence to medication adherence across different conditions, including hypertension. patients gave a wide range of reasons for non-adherence to medications, which included a lack of health education (al-qasem et al., 2011). according to the aha (american heart association) paper on medical training to achieve competency in lifestyle counseling, “aha emphasized the importance of lifestyle in its 2020 goals for cardiovascular health promotion and disease reduction.” (hivert et al., 2016). in sudan, health services are provided at all three levels: primary, secondary and tertiary levels in both the private and governmental sectors.(salim & hamed, 2018) most patients obtain medical treatment and counseling during their treatment, but sadly, many doctors do not have the knowledge and are not trained enough (belaid et al., 2020). consequently, this increases costs for investigations and treatment or even hospital admissions. nonetheless, an educated doctor who has good knowledge about the significance of counseling and its contents and consequences can provide suitable information to patients. a slight modification in the lifestyle behavior of the patient can positively impact the outcomes of even chronic diseases such as hypertension just by appropriate counseling to the patient and motivating them to implement the plan set by themselves with the assistance of their doctor to achieve the best possible control for the patient blood pressure and decreasing the risk for complications. a lifestyle modification such as diet (dash) has significantly decreased sbp and dbp for as long as 18 months in patients with good adherence in a randomized control trial (poggio et al., 2019). patient counseling is a process that involves doctors, pharmacists or healthcare personnel who advise about the method of intake of medicine and precautions, either in the form of prescription or verbally, to patients, their family members or caretakers (mináriková et al. 2019). in this study, the focal aim was to study the quality of counseling about lifestyle modifications received by hypertensive patients and assess and compare the quality offered by shos, registrars, family physicians and physicians concerning the location (arija et al., 2018). in 25 of the 35 interviews conducted, only one lifestyle modification counseling was offered. in 7 visits, counseling about 2 topics was given: 3 times weight loss and diet combined, 3 times diet and exercise; and 1 time exercise and smoking. in 3 visits, advice on 3 topics was combined pa ge 16 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 164-170, 2023 (weight loss, diet and exercise), but the counseling never accommodated all the lifestyle modifications. a significant statistical difference was noted in the distribution of participants (phc center, private medical facility or governmental facility) vs. the doctor they followed up with (physician, family physician, registrar or sho). in contrast, the counseling about the nature of hypertension vs. location of follow-up was statistically indifferent; almost half of all the participants who received counseling about hypertension followed up at a private medical facility. however, the same is true for half of the participants who did not receive counseling. considering that all the doctors were available at the three locations, we can assume that the quality of counseling depends on the doctor rather than the location. approximately a quarter of all participants had complications, half of whom followed up with an sho, of which only a quarter received counseling about complications. we may consider the reason behind this fallout is that shos have limited knowledge because of a lack of years of experience. also, this might be due to their limited time to see each patient and the fact that hypertensive patients with complications should follow up with a specialist.(hernandorena et al., 2017) the participants who had complications followed up at a phc center and a private medical facility equally, while the remaining followed up at a governmental facility. through these findings again, we can assume that the quality of counseling depends on the doctor rather than the location. however, unfortunately, there is a prevalent belief among the sudanese people that patients receive better health care services in private facilities.(salim & hamed, 2018) approximately half of the participants who had complications had hypertension for 11-20 years, while most complication-free participants had hypertension for 5 years or less. the location of the follow-up showed an association, with almost half of the participants with controlled blood pressure followed up at a private medical facility. blood pressure control vs. age group was statistically significant (p=0.005), where the controlled blood pressure was most observed in the age group 50-59 years, uncontrolled blood pressure was most frequent in the age group 60-69 years in consensus with a study carried in which individuals aged ≥60 years had significantly lower rates of blood pressure (mente et al., 2018). blood pressure control among sexes was close to equal; 55.6% were males, and 44.4% were females, which agreed with the same research study performed in the usa; women had lower blood pressure control rates than men (alabousi et al., 2017). however, in another study, the females had higher attainment of controlled blood pressure levels, where 75.7% of males and 90.0% of females attained their target blood pressure (ademe et al., 2019). conclusions the current study has concluded that the quality of counseling offered to hypertensive patients depends on the doctor rather than the location; in almost half of the participants who followed up with shos, including half of the participants with complications, only a quarter received counseling about complications that may arise from hypertension. the counseling was for aboveaverage, hypertensive patients with complications who tended to follow up either at a phc center or a private facility, especially given that private facilities have the largest amount of participants with controlled blood pressure. counseling a patient about lifestyle modification is a priority according to the 2014 sudanese guideline for managing hypertension in adults; lifestyle modification should be recommended for all people with hypertension and pre-hypertension. recommendations the current study recommends educating doctors and especially shos through brief lectures about different aspects of lifestyle modification counseling and its importance for hypertensive patients. exploring the barriers to achieving a 100% in all lifestyle counseling categories, such as social habits cessation, can be sought out by physicians to know their reasons for the lack of asking. creating and handing out simple brochures about lifestyle modifications and their importance to hypertensive patients in clinics, phc centers, and hospitals would also be a helpful initiative. acknowledgments the corresponding author is grateful to her mentors and teachers at the sudanese society of hypertension and my college at the young investigators office for their supervision, guidance and continuous support throughout this work. the author paid her earnest gratitude to the participating patients, without whom this work would not have been prosperous in the first place. ethical approval permission from the hospital/phc center administration was obtained. the study also received its ethical clearance from sirb (sumasri institutional review board, university of medical sciences and technology). the study’s protocol, aims and benefits were explained to all the participants, and written voluntary informed consent was obtained from each participant. references ademe, s., aga, f., & gela, d. 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(2018). exploring health insurance services in sudan from the perspectives of insurers. sage open med, 6, 2050312117752298. https://doi.org/10.1177/2050312117752298 pa ge 1 pa ge 96 american journal of medical science and innovation (ajmsi) evaluating the impacts of proximal femoral nail anti-rotation (pfna) augmentation in osteoporotic intertrochanteric fractures ramadan mohamed elsaid ahmed1* volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2758 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 06, 2024 accepted: may 11, 2024 published: may 15, 2024 surgical interventions are crucial for managing osteoporotic intertrochanteric fractures. among these interventions, proximal femoral nail antirotation (pfna) is preferred due to its advantages in reducing blood loss and surgical duration. this research study examined proximal femoral nail anti-rotation’s clinical and radiological outcomes with augmentation in osteoporotic intertrochanteric fractures. the surgical approach encompassed 50 patients with osteoporotic intertrochanteric fractures treated between november 2012 and april 2014. the surgeries were performed in a supine position on a traction radiolucent table with general, regional, or spinal anesthesia. the incision and nail-blade angle were carefully selected, and postoperative outcomes, including range of motion, infection rates, and complications, were assessed. results showed a 96% success rate with pfna, with most patients regaining pre-surgery range of motion within six weeks. fracture healing was effective in 94% of cases within six months, although some required revision surgery or experienced mechanical failure. postoperative complications, including superficial infections and nonunion, were observed in a small percentage of cases. in conclusion, pfna with augmentation is viable for treating osteoporotic intertrochanteric fractures, offering good clinical outcomes and a low complication rate. however, careful patient selection and surgical techniques are essential to minimize risks and ensure optimal results. keywords osteoporotic, fracture, intertrochanteric, hip fractures, research, surgery 1 rashid hospital trauma centre, dubai, uae * corresponding author’s e-mail: ramadanahmed456@outlook.com introduction intertrochanteric fractures, often in frail patients with multiple medical comorbidities, are increasing in prevalence due to ageing and resulting in long hospital stays, necessitating effective treatment strategies (haidukewych, 3 march 2009). intertrochanteric fractures are gender and race-dependent, with elderly females experiencing 63 per 100,000 fractures in the us and 34 per 100,000 in males. factors like advancing age, comorbidities, daily living dependency, and osteoporosis history contribute to these fractures and affect the regions shown in figure 1. proximal femoral fractures (pffs) have high mortality rates and are increasing in france (farahmand et al., 2005; green, 2010; rosencher et al., 2005). extracapsular post-fracture fractures (pffs) face instability due to comminution and rupture of the posteromedial cortex. dynamic screw plates, proximal intramedullary, and reconstruction nails have transformed management, but their superiority remains controversial. mechanical complications, such as hardware-related fractures and blade cutouts, are high. the proximal femoral nail antirotation (pfna) was designed to minimize these risks, with preliminary results suggesting it may have achieved this goal (bhandari et al., 2009; mishraa et al., 2017; sommers et al., 2004). extracapsular fractures mainly involve cortical and compact cancellous bone, which occurs along the least resistance path through the proximal femur due to its complex stress configuration. the energy absorbed by the bone determines the fracture’s complexity. fatigue fractures can occur due to repetitive loading, causing microscopic damage to the osseous structure and stress riser (moroni et al., 2005; smit jakheria et al., 2020). intertrochanteric fractures can be unstable due to several risk factors, including loss of medial buttress, markedly displaced fractures, reverse obliquity fractures, severe osteoporosis, and comminution at the fracture site. these fractures can result from severe soft tissue damage and loss of stability due to the original bone contact. wide gapping at the fracture is not considered marked displacement (chen et al., 2016; moroni et al., 2005). intertrochanteric fractures in the femur are classified into four types: type 1, which extends along the intertrochanteric line; type 2, which is comminuted with multiple fractures in the cortex; type 3, which is subtrochanteric with at least one fracture passing across figure 1: the regions where hip fractures occur pa ge 97 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 the proximal end of the shaft, and type 4, which is fractures of the trochanteric region and the proximal shaft with fractures in at least two planes, often difficult to see on routine radiographs (azar et al., 2020). the biomechanics of fixation devices involve ensuring the dynamic hip screw can slide freely in the side plate barrel. adherence to two basic mechanical principles enhances the screw’s ability to slide. a higher-angle hip screw is more effective at accommodating dynamic and should be engaged deeply within the barrel (wang et al., 2020), as shown in figure 2. internal fixation techniques, with recent evidence supporting better results in pertrochanteric fractures treated with newly developed external fixators. the device typically consists of one or two half pins placed into the femoral neck to reduce the fracture and enhance callus formation. load sharing between the fractured bone and the fixation is usually achieved, reducing damaging stresses on the fixator. hydroxyapatite-coated external fixation pins can improve mechanical stability and reduce the risk of pin loosening and infection in osteoporotic bone (moradi et al., 2021), as shown in figure 3. intramedullary nails, such as condylocephalic nails, internalize extracapsular fractures due to their reduced distance between the hip joint and implant, reducing bending moment, as shown in figure 4. examples include the gamma nail, intramedullary hip screw, proximal femoral nail, targon pf, holland nail, and kuntscher-y nail. however, the gamma nail has a higher risk of adverse events, including intra-operative and later fractures around or below the implant (huang & wu, 2021; moon et al., 2022). figure 2: the joint reaction force in the femoral head consists of two main components: the force producing dynamic force and the transverse force resisting dynamic force dynamic hip screws with twoor four-hole side plates offer comparable resistance to physiologic compressive loading, with longer screws reducing resistance (davey et al., 2020). the sliding hip screw (shs) is a commonly used extra medullary implant consisting of a lag screw attached to a plate on the side of the femur. these ‘dynamic’ implants allow for collapse at the fracture site, while the medoff plate has an inner and outer sleeve that can slide between each other. static implants like fixed nail plates and the 90 or 95-degree blade plate are also used. external fixation can provide similar or better results than conventional figure 3: a radiograph reveals a pertrochanteric fracture with a slight valgus reduction, with the fixator in a satisfactory position figure 4: intramedullary nails over screw and plate fixation are attributed to a reduced distance between the hip joint and the implant hip arthroplasty is a crucial procedure for treating intertrochanteric hip fractures. still, it presents unique challenges, such as the need for calcar replacement prostheses and managing the fractured greater trochanteric fragment, as shown in figure 5. bony deficiency from figure 5: salvage of failed intertrochanteric fracture fixation with calcar replacement prosthesis pa ge 98 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 fractures often results in a bone deficiency below the standard resection level for primary total hip arthroplasty. femoral components with modular calcar augmentations are available for intraoperative flexibility. either cemented or uncemented femoral-component fixation can be effective, with cemented fixation advantageous for elderly patients with osteopenic femoral canals (masters et al., 2020). evans’s classification of trochanteric fractures the evans classification of trochanteric fractures is a system that categorizes intertrochanteric hip fractures based on the proximal femur’s fracture pattern, encompassing five types. “type i: undisplaced 2-fragment fracture. type ii: displaced 2-fragment fracture. type iii: 3-fragment fracture without posterolateral support, owing to displacement of greater trochanter fragment. type iv: 3-fragment fracture without medial support, owing to displaced lesser trochanter or femoral arch fragment. type v: 4-fragment fracture without posterolateral and medial support (combination of type iii and type iv). r: reversed obliquity fracture”, shown in figure 6. this research study aimed to evaluate the clinical and radiological outcomes of proximal femoral nail antirotation with augmentation in osteoporotic intertrochanteric fractures, hypothesizing good results due to improved support around the nail blade and early weight-bearing mobilization. figure 6: evans classification of trochanteric fractures literature review osteoporotic intertrochanteric fractures often require surgical interventions, including open reduction and internal fixation (orif) methods like dynamic hip screw, compression hip screw, percutaneous compression plate (pccp), medoff sliding plate, and intramedullary fixation like gamma nail, proximal femoral nail, and proximal femoral nail antirotation (pfna). the pfna technique is optimal due to lower blood loss and operative time (cheng & sheng, 2020). impaction or fixed angle plating is more commonly used for corrective osteotomies than primary hip fracture treatment. mac eachern found medial penetration with jewett nail compared to sliding hip screws, but modifying nail plates with osteotomies failed (parker & handoll, 2009). in a meta-analysis, chinoy et al. examined sliding implants vs precisely fixed nail plates, involving 2855 individuals. comparing fixed nail plates to sliding implants, the results indicated a higher risk of cutout (13% vs 4%), nonunion (2% vs 0.5%), implant breakage (14% vs. 0.7%), and reoperation (10% vs. 4%). furthermore, the death rate was greater for patients treated with fixed nail plates, and those who survived were more likely to experience hip pain that persisted and limited their range of motion. these problems led to the abandonment of fixed nail plates in favour of the sliding hip screw, which was superior in the 1980s (parker et al., 2002). external fixation is a recommended treatment method for elderly high-risk patients with intertrochanteric hip fractures. most of these fractures occur in older populations with an average age of around 80. the study found that external fixation was a better option than dynamic hip screws (dhs) in terms of surgical time and pain reduction. the study also found that external fixation had benefits such as simple application in local anaesthesia, decreased time of surgery, minimal blood loss, and less need for blood transfusion. it also provided satisfactory stability and early weight-bearing. external fixation could be considered an alternative for elderly high-risk patients, especially those with multiple injuries, religious refusal of transfusions, and those who cannot tolerate routine spinal or general anaesthesia and open surgery (mobushir et al., 2020). pa ge 99 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 the study examined the clinical and radiological results of external fixation and proximal femoral nail anti-rotation (pfna) to manage unstable intertrochanteric fractures in older patients. the findings indicated that pfna resulted in more blood loss, a lengthier surgery, and increased fluoroscopy time. functional outcomes in pfna were superior to those in external fixation. external fixation did not result in fewer overall problems than pfna (liang et al., 2022). in a comparative study between proximal femoral nail (pfn) and dynamic hip screw (dhs) for intertrochanteric hip fractures, pfn performed better in terms of range of motion, limb length discrepancy, blood loss, postoperative pain, and infection incidence (gill et al., 2017). the most popular technique for treating stable intertrochanteric fractures, or type 1 and type 2 boyd and griffin fractures, is still the sliding hip screw and plate. the objectives include reduced blood loss, shorter hospital stays for the fixation procedure, and the ability to bear weight at an early age. with an average size of 3 cm, the mean incision length of the midhs is much shorter than the typical 8–10 cm of a 4-5 holed dhs barrel plate. the average operating time for our patients was 28 minutes, which is less than usual. since there is less soft tissue dissection after surgery, the incidence of postoperative problems is still low in midhs. therefore, in stable intertrochanteric fractures, the results of a minimally invasive procedure utilizing a two-hole dhs plate are comparable to those of a conventional dhs requiring a longer incision (walia et al., 2010). according to alobaid et al., a minimally invasive approach for fixing intertrochanteric hip fractures dramatically minimizes blood loss and operating time without compromising fixation stability or bone healing (alobaid et al., 2004). to produce unstable three-part intertrochanteric fractures, mclaughlin et al. examined the biomechanical strength and stiffness of a dhs with a 2-hole sideplate in comparison to a 4-hole side-plate design. they concluded that the 2-hole dhs is just as biomechanically stable as the 4-hole dhs (mcloughlin et al., 2000). bulhofner et al. found that using a 135-degree sliding hip screw with a two-hole side plate results in satisfactory healing, minimal blood loss, shorter surgery time, and preservation of side plate fixation (bolhofner et al., 1999). a novel self-dynamically implant and a minimally invasive technique for internal fixation of femur fractures were presented. between 2000 and 2008, the self-dynamically internal fixator (sif) was used on 849 patients for 871 fractures. the average operating time was 44 minutes, the average fluoroscopy duration was 12 seconds, and the average blood loss was 90 millilitres. there were no reported problems during the intraoperative phase. the sif is particularly useful for minimally invasive surgery and helps treat femur fractures, especially comminuted fractures (mitkovic et al., 2012). a dynamic hip screw (dhs) with two horizontal blades has been developed in a novel way to improve fixation stability. under the biaxial rocking motion, nine standard dhss and nine dhss from the orthopedic device research center (odrc) were tested. concerning the traditional dhs, the odrc dhs showed fewer axial migration, more loading cycles, and reduced bending and torsional strain. with the addition of two horizontal wings, the suggested odrc dhs enhanced the contact surface between the implant and bone, reduced the load on the screw, enhanced anti-rotational implant effect, and enhanced migration resistance (chen et al., 2017). when treating unstable senile intertrochanteric fractures with osteoporosis, a study comparing cemented hemiarthroplasty and proximal femoral nail anti-rotation (pfna) found no statistically significant differences in the rate of reoperation, length of surgery, or harris hip score at a one-year follow-up. on the other hand, pfna offers benefits for hospital stays, medical problems, transfusion rates, and intraoperative blood loss. higher surgical trauma and a higher frequency of postoperative medical issues have been linked to hemi arthroplasty. according to the research, pfna is superior to hemi arthroplasty in treating intertrochanteric fractures in older people (luo et al., 2017). the study examined the prognostic implications of bipolar hemi arthroplasty (bha) and proximal femoral nail anti-rotation (pfna) for elderly patients with unstable comminuted intertrochanteric fractures (itfs). comparing hospitalization, surgery, blood loss, weightbearing duration, harris hip scores, 10-m walking speed, gait, and postoperative complications comparing the two groups, the study examined 62 itf patients. the hospital stay, length of operation, blood loss, length of weight bearing, harris hip score, walking speed, gait, and postoperative problems did not significantly differ, according to the results. the study found that although bha permits a faster return to weight-bearing activities, it eventually offers treatments as effective as pfna (song et al., 2022). methodology study design the present research study was prospective to assess the clinical and radiological results of proximal femoral nail antirotation with augmentation in osteoporotic intertrochanteric fractures, with a surgical process of 7 days. study setting duration the current study was conducted involving 50 cases with osteoporotic intertrochanteric fractures caused by minimal or trivial trauma for the period of november 2012 to april 2014. patients underwent surgical management at a governmental hospital, with cases ranging from 6 months to 1 year, involving internal fixation and proximal femoral nail antirotation. pa ge 10 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 patients selection inclusion criteria ➢ male and female patients of old age were included in the study. ➢ patients with osteoporotic intertrochanteric femur fractures ➢ patients who have experienced osteoporotic intertrochanteric femur fractures due to indirect trauma, where the fracture does not involve the neck of the femur. exclusion criteria ➢ patients with non-osteoporotic intertrochanteric femur fractures ➢ patients who refused surgery. patients demographics sex distribution they were 38 females (76%) and 12 males (24%). age distribution the age ranged from 44 to 90 years, with a mean age of 73. the preoperative period between trauma and surgery the mean preoperative period was 1.3 days (0-6). preoperative preparation of the patient two units of blood were saved for each patient, and the affected limb was marked with a permanent marker pen before surgery. types of fractures-according to ao classification surgical procedure the operations were performed under regional, spinal, or general anaesthesia, with patients placed on traction tables with one or two c-arms and routine scrubbing and draping performed. antibiotic prophylaxis cefuroxime 1.5 g intravenously was administered preoperatively at the time of induction of anaesthesia. implants used in the series proximal femoral nail anti-rotation (pfna) with a helical blade is used in all cases with a special cannula, and cement augmentation is used in 15 cases (fig. 43 a and b). experimental procedure patient positioning all of the patients underwent supine surgery on a traction radiolucent operating table. the unaffected leg was abducted as much as possible and placed on leg support to enable free fluoroscopic examinations. the upper body was then abducted by roughly 10 to 15° to the unaffected side, or both together, and the inter-point was finally made easy. fracture reduction every patient underwent general, regional, or spinal anaesthesia during their operations. following anaesthesia, all patients had a closed reduction using a traction radiolucent table guided by a c-ram. of these, 48 patients (96%) had a successful outcome, while 2 (4%) required an open reduction. reduction and surgery were performed under one c-arm only, and a check x-ray was performed before starting surgery in all patients. approach after scrubbing and draping as standard, time out is done in all cases, and a confirmed surgical incision marked 3-5 cm starting proximally from the tip of the greater trochanter or may be proximal in obese patients. a parallel incision of the fasciae of the gluteus medius and split the gluteus medius in line with the fibres. determination of entry point the entry point in the anteroposterior and lateral views figure 7: classifying fractures according to ao classification in patients cement augmentation without cement augmentation, 35 cases (70 %) and 15 cases (30 %) with cement augmentation. operative stage asepsis patients underwent surgery in a conventional operating room, ensuring complete aseptic condition for the affected femur and hip, with skin edges sealed with opposite sheat. figure 8: femur guide wire position in ap (a) and lateral (b) views case no. 6 pa ge 10 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 was determined in all cases. with an ml angle of 6°, the pfna entrance site in the curved expansion of the medullary cavity was on the tip, or slightly lateral to, the greater trochanter tip in ap view. the entrance point aligned with the intramedullary canal’s axis when viewed laterally, as shown in figure 8. femur opening the femur was then opened using a cannulated drill with sleeve protection, ensuring proper nail size, angle and diameter per the preoperative plan, which was reconfirmed before nail insertion. out of 47 patients (96%), no reaming of the medulla was required before nail insertion, while in 3 patients, reaming was necessary with a 1mm larger diameter than the nail. selection of nail blade the preoperative ap x-ray view was utilized to determine the nail-blade angle; however, if the measurement of the angle is not available, the maximum valgus angle (130 degrees) was employed; in 44 cases (88%), the angle was 130 degrees, and in 6 cases (12%) it was 125 degrees. insertion of the guide wire into the neck after that, a neck guide wire was inserted; in 40 cases (80%), it was central in ap and lateral views; in 10 cases (20%), it was posterior and inferior. the guide wire trail typically stops 5 to 10 mm from the joint after insertion, especially in cases where cement augmentation is required; however, in two instances, it was planned for the cement augmentation wire to reach the joint, so no leakage test was performed for these cases, as shown in figure 9&10. open lateral cortex for pfna blade insertion following the completion of the lateral cortical opening, the blade was hammered inside and halted 5–10 mm from the joint line in 49 cases (98%) and 14 mm from the joint line in one case in both the ap and lateral views. blades are entirely locked after insertion (figs. 49 and 51); failure is presumed if they are not fully locked, as shown in figures 11 and 12. figure 9: central position of the guide wire in ap (a) and lateral (b) views figure 10: guide wire central in ap (a) and lateral (b) views case no 06 figure 11: pfna blade unlocked in a and after fully locked in b figure 12: intraoperative incomplete blade locking because of metal mechanical problem and surgery needed (b) metal failure case no 8 determination of possible cement leakage into joint leakage testing was performed in 17 cases, including planned cement augmentation; of those, 2 cases (11.7%) tested positive; these 2 cases were at the start of the series, with the wire piercing the joint; the test was not repeated if the wire reached the joint. a tiny quantity of cement reached the fovea in one case (6.6%), but the patient was joined and mobilized with full range of motion, and no osteoarthritis symptoms were observed in the joint until the end of the series. fifteen patients (30%) had cement augmentation. distal locking was completed, one oblique screw for short nails and one or two distal locking screws for long nails, after clinical and x-ray verification of the rotation by comparing the lesser trochanter to femoral condyles. pa ge 10 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 results mobilization 34 (94%) of patients regained their pre-surgery range of motion within six weeks, one patient with revised surgery regained the range of motion after 3 months from the first surgery, with one patient requiring arthroplasty, and no difference was reported in mobilization between cemented and non-cemented cases. pain there was no pain in 34 patients (94%); one had mild pain from a protruded blade, and the other had surgery revised. radiological outcome the fracture healed without incident in six months, on average between ten and sixteen weeks. thirty-four fractures healed effectively (94%), 2 patients (5%) needed revision surgery before being united, and 1 patient’s blade protruded and needed to be removed six months after the patient’s arthroplasty and surgery. mechanical failure one case (2.7%) of a female patient 76 years old (case no. 8) reported a mechanical failure of the blade, resulting in a fall one month after surgery. it was caused by the blade not being fully unlocked, which caused it to come out again, as shown in figures 13 a, b and 14. after revision, cement was used, causing a mild collapse at the fracture site and a protruding blade that was not clinically palpable, as shown in figures 15 a and b. figure 13: blade back out ap (a) and lateral views (b) case no. 8 figure 14: incomplete locking of blade case no 8 figure 15: blade back out ap (a) and lateral views (b) case no. 8 nonunion in a case (26), a 2.7% nonunion was observed in a patient requiring arthroplasty after blade removal, who had a history of fall and refracture, as shown in figure 16. cement in the joint case no. 16 a 2.7% hip joint cement case was diagnosed, and a ct scan was performed, showing no significant issues with hip pain, avn, or arthritis, with the full range of motion, as shown in figures 17 and 18. figure 16: collapse at the fracture site with mild pain case no.26 pa ge 10 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 figure 17: left hip x-ray case no.16 showed cement reaching the hip joint in both the ap (a) and lateral views (b) figure 20: distal locking screws loose (b) but fracture united (a) case no.46 figure 18: ct scan of left hip coronal (a) and axial (b) cuts showing cement in fovea case no 16 fracture lateral wall in 4 cases (11%), the undisplaced lateral wall fracture was reported after surgery; these individuals were mobilized to full weight bearing and united in 3-6 months without requiring additional surgery, as shown in figure 19. metal jamming in one case, no 25, metal jamming occurred once after the locking blade screwdriver was left in place and the case was cemented. the screwdriver was removed along with the blade and replaced with a new one, at which point the case began full weight-bearing mobilization the day after the operation and was united within three months, as shown in figure 21. figure 19: fracture of lateral cortex in 2 different views figure 21: case no. 25 had a screwdriver jammed in the blade, which was removed with a blade, changing the preoperative ap view (a) and the postoperative ap view (b) three months later back out of distal locking case no.46 in one case, there was no need for adjustments or the removal of screws since the fracture combined with local irritation or infection but showed back out of distal locking, as shown in figure 20. table 1: comparison between cemented and non-cemented cases no age f: m asa score blood loss intra-opt complication post opt complication stay singh index cemented 12 80 11:1 3.1 150 16% 16% 10.4 1.6 non cemented 24 71.9 17:7 3 150 12% 4% 10.5 2.6 pa ge 10 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 summary of outcomes the series involved 50 patients, with 70% without cement augmentation and 30% with cement augmentation, ranging in age from 44 to 90 years, with a mean age of 74. the study involved 36 cases (72%), 66% non-cemented and 33% cemented, with follow-up lasting 6-12 months. two cases died within a month post-operatively in the hospital before discharge; both of them had an asa score of 4 preoperative; the first one extubation failed and died in icu one month after respiratory failure, and the other one had acute myocardial infarction and died in ccu after 2 weeks from the surgery. the study analyzed 34 cases, resulting in 97.2% uncomplicated outcomes, with only 2 requiring revision surgery, one requiring a hip joint replacement, and two patients experiencing superficial infection recurrence after multiple debridement. results grading ➢ excellent result 31 cases (86.1%) ➢ good result 3 cases (8.3%) ➢ fair result one case (2.7%) ➢ poor result one case (2.7%) discussion surgical interventions are frequently necessary for osteoporotic intertrochanteric fractures. these interventions include intramedullary fixation, which provides for gamma nails, proximal femoral nails, and proximal femoral nail anti-rotation (pfna), as well as open reduction and internal fixation (orif) techniques like dynamic hip screws, compression hip screws, percutaneous compression plate (pccp), and medoff sliding plates. the pfna approach is the best option because it requires less blood loss and less time during surgery. pfna is more successful in treating unstable fractures in elderly individuals; however, it may lead to higher bleeding, prolonged surgical procedures, and longer fluoroscopy times. pfn performs better regarding blood loss, postoperative discomfort, limb length disparity, range of motion, and infection incidence. in osteoporotic intertrochanteric fractures, the present research assessed the clinical and radiological outcomes of proximal femoral nail anti-rotation with augmentation in 50 osteoporotic intertrochanteric fractures from november 2012 to april 2014, involving internal fixation and proximal femoral nail anti-rotation at a governmental hospital. the study involved patients who underwent supine surgery on a traction radiolucent operating table, with the unaffected leg abducted to allow free fluoroscopic examinations. after surgery, all patients underwent general, regional, or spinal anaesthesia, with 96% having a successful outcome. the approach involved a marked 3-5 cm incision, a parallel incision of the fasciae of the gluteus medius, and splitting the gluteus medius in line with the fibres. the entry point was determined using an ml angle of 6°, and the femur was opened using a cannulated drill with sleeve protection. the nail-blade angle was selected using the preoperative ap x-ray view. a neck guide wire was inserted into the neck, with 80% being central in ap and lateral views. the blade was hammered inside and halted 5-10 mm from the joint line in 49 cases (98%) and 14 mm in one case in both ap and lateral views. leakage testing was performed in 17 cases, with 2 (11.7%) testing positive. in one case, a tiny amount of cement reached the fovea, but the patient was joined and mobilized with a full range of motion. it was found that 94% of patients regained their presurgery range of motion within six weeks after surgery, with one patient requiring arthroplasty. no difference was reported in mobilization between cemented and non-cemented cases. in six months, fractures healed without incident, with 94% healing effectively. however, two patients needed revision surgery before being united, and one patient’s blade protruded and needed removal six months after the surgery. mechanical failure occurred in one case, causing a fall one month after surgery. two cases collapsed at the fracture site, resulting in a protruding blade. a 2.7% nonunion was observed in a patient requiring arthroplasty after blade removal. a 2.7% hip joint cement case was diagnosed, and a ct scan showed no significant issues with hip pain, avn, or arthritis. in four cases, undisplaced lateral wall fractures were mobilized to full weight bearing and united in 3-6 months without additional surgery. out of 36 cases (72%), two died post-operatively. the study found that 97.2% of cases were uncomplicated, with only two requiring revision surgery and one requiring hip joint replacement. two patients experienced superficial infection recurrence after multiple debridement. limitations ➢ the study sample of 50 osteoporotic intertrochanteric fractures may not fully represent the diverse population of patients with such fractures, limiting the generalizability of the findings. ➢ because of its unique patient demographics, surgical techniques, and protocols, the research conducted at a single governmental hospital may introduce bias and potentially impair the results’ external validity. ➢ the study’s retrospective nature may introduce selection bias and hinder the control for confounding variables that may affect the outcomes of interest. conclusion it was concluded that surgical interventions, particularly pfna with augmentation, are crucial in managing osteoporotic intertrochanteric fractures. pfna offers advantages such as reduced blood loss, shorter surgical durations and improved clinical outcomes compared to other techniques like dynamic hip screws or compression pa ge 10 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 96-106, 2024 hip screws. despite potential drawbacks like increased bleeding and longer fluoroscopy times, pfna remains a preferred option, especially for unstable fractures in elderly patients. comprehensive assessments of these presented 50 cases yielded a high success rate of 96% with minimal complications. noteworthy outcomes included a high percentage of patients regaining pre-surgery range of motion within six months, effective healing rates within six months, and few instances of mechanical failure or nonunion. complications such as postoperative deaths, revision surgeries, and infections were relatively low at 2.8%, highlighting the overall efficacy and safety of the pfna approach with augmentation in treating osteoporotic intertrochanteric fractures. recommendations ➢ a systematic surgical approach with uniform entry locations, nail-blade angles, and protective sleeves during drilling is recommended for proximal femoral nail anti-rotation with augmentation in osteoporotic intertrochanteric fractures. ➢ choosing the right implant size and shape can help minimize intraoperative difficulties. it can be achieved through careful preoperative planning, which includes an accurate assessment of the kind of 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(2010). role of minimal invasive dhs in intertrochanteric fracture femur-a study of 25 cases. pb j orthop, 12(1), 12-13. wang, c.-c., lee, c.-h., chin, n.-c., chen, k.-h., pan, c.-c., & su, k.-c. (2020). biomechanical analysis of the treatment of intertrochanteric hip fracture with different lengths of dynamic hip screw side plates. technology and health care, 28(6), 593-602. pa ge 1 pa ge 1 american journal of medical science and innovation (ajmsi) approach to the diagnosis and management of essential thrombocytosis in a resource-limited setting vonwicks c. onyango1*, anne w. theuri1, samuel m. gachie1, collins p. malalu1, william c. fryda1 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2312 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: december 02, 2023 accepted: december 29, 2023 published: january 02, 2024 essential thrombocytosis (et) is a myeloproliferative neoplasm (together with polycythemia vera, chronic myelogenous leukemia, and primary myelofibrosis) characterized by clonal proliferation of megakaryocytes, usually due to the presence of jak2, calr, or mpl mutations. whereas a bone marrow aspirate and genetic testing for these mutations are necessary for an accurate diagnosis of et, in resource-limited settings, these are often either inaccessible or limited by prohibitive costs. a nuanced clinical approach is necessary to diagnose and manage et in these settings. in this study, we present a case of et diagnosed and managed in a resource-limited rural setting in kenya with hydroxyurea and aspirin. we highlight the importance of individualized therapeutic targets, the challenges with dose adjustments in the setting of hydroxyurea-induced neutropenia, and how extrapolated data from the use of hydroxyurea elsewhere may help guide such dose adjustments. finally, we propose a rationalized approach to treating et in a resource-limited clinical setting. keywords essential thrombocytosis, myeloproliferative neoplasms, hydroxyurea, aspirin, hydroxyurea-induced neutropenia, vasomotor symptoms, thrombohemorrhagic complications, kenya 1 st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction essential thrombocytosis (et), also called essential thrombocythemia or primary thrombocytosis, is one of the myeloproliferative neoplasms (mpn) whose hallmark is the clonal proliferation of various myeloid cells with varying morphology, maturity, and efficiency. the other main mpns are polycythemia vera (pv), chronic myelogenous leukemia (cml), and primary myelofibrosis (pmf) (arber et al., 2016). et is characterized by sustained megakaryocyte proliferation that leads to increased numbers of circulating platelets, often of various sizes (platelet anisocytosis). figure 1, panel by schafer et al., shows the appearance of et on a peripheral blood film and on a bone marrow assay. (tefferi & pardanani, 2019). approximately 85-90% of patients with mpns will demonstrate mutually exclusive mutations in the jak2 (60-65%), calr (20-25%), or mpl (5%) genes (cazzola & kralovics, 2014; klampfl et al., 2013; nielsen et al., 2013). about 10-15% of patients have no such mutations (the so-called ‘triple-negative’) (tefferi et al., 2014). et constitutes approximately a third of all cases of mpns in developed countries, with a median age at diagnosis of 60 years. most patients enjoy a normal life expectancy, but survival is decreased in older patients and those with thrombotic complications (hultcrantz et al., 2015; roaldsnes et al., 2017; srour et al., 2016; tefferi & barbui, 2017). the main features of et include a persistently elevated platelet count of >450,000/µl on a complete blood count, a clinical course characterized by thrombotic and/or hemorrhagic events with a possible splenomegaly, and marked thrombocytosis and hyperplasia of megakaryocytes on peripheral blood smear figure 1: histologic features of essential thrombocythemia (schafer, 2004) in panel a, a peripheral-blood smear from a patient with essential thrombocythemia contains an increased number of platelets, including giant platelets (arrow; wright’s stain, ×100). in panel b, a specimen of bone marrow from a patient with essential thrombocythemia contains an increased number of megakaryocytes (hematoxylin and eosin, ×100). (courtesy of dr. scott murphy, american red cross blood services, penn–jersey region, philadelphia.) pa ge 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 1-7, 2024 and bone marrow assays, respectively (tefferi & barbui, 2020). asymptomatic patients with et (about 50% of all cases) may be found when persistent thrombocytosis is noted on routine complete blood counts for other reasons. disease-related symptoms of et are largely vasomotor due to disturbances in microvascular circulations and include headaches, dizziness, fainting, blurring or transient loss of vision (e.g., amaurosis fugax, ocular migraines), non-specific fatigue, atypical chest pains, myalgias, acral paresthesia, erythromelalgias, and livedo reticularis, etc. (wolanskyj et al., 2005). patients may also present with complications related to thrombosis (due to both quantitative and qualitative plate dysfunctions) in various organs, e.g., strokes, acute coronary syndromes, superficial thrombophlebitis, deep vein thrombosis, pulmonary embolism, hepatic or portal vein thrombosis, digital ischemia, thrombosis-related first-trimester pregnancy losses, etc. (tefferi & barbui, 2017). hemorrhagic manifestations tend to occur in cases of extreme thrombocytosis (platelet counts >1000,000/ µl) as well as following treatment with high doses of non-steroidal anti-inflammatory drugs (bellucci et al., 1986; landolfi et al., 2006). treatment of et is based on individualized stratification of the risks and/or occurrence of thrombosis or bleeding (barbui et al., 2015) and generally includes observation and cytoreductive therapy with medications such as low-dose aspirin and hydroxyurea (first-line therapy) (rocca et al., 2020; tefferi & barbui, 2020). interferon alfa, anagrelide, ruxolitinib, and apheresis may be used as second-line agents (birgegård, 2016; tefferi & barbui, 2020). older agents like busulphan and phosphorus-32 (32p) may also be used as second-line agents but have been associated with increased risks of acute myelogenous leukemia (finazzi et al., 2005; tefferi & barbui, 2020). case summary history and physical examination a 60-year-old married father of three adults, a tailor by profession from pipeline estate, nakuru county, kenya, with no preceding significant medical history, first presented to us in february 2022, with concerns of pain and darkish discoloration of the small left toe. this was associated with a ≥6-month’ history of bilateral lower limb numbness, paresthesia, and burning pain of both hands and feet in a stocking-and-gloving distribution. he’d also experienced recurrent global headaches, blurring of vision, occasional dizziness, myalgias, general fatigue, reduced effort tolerance, and mild bipedal edema. however, he had no history to suggest heart failure, bleeding diatheses, stroke-like symptoms, or deep venous thrombosis. he had no known family history of any hematological or cardiovascular diseases. the rest of the systemic inquiry was unremarkable. on examination, he was in fair general health. his lower limb examination revealed multiple macular-to-patchy non-tender, non-blanching discrete skin lesions on both legs and thighs, mild bilateral pitting ankle edema, with the left small toe appearing remarkably darkened but non-tender, and with an associated septic wound on its tip. the neurovascular exam of both legs as well as the rest of the musculoskeletal exam were normal. he had no features of chronic liver disease but had a dull percussion note over traube’s space, indicating splenomegaly. a full neurological exam only showed mild impairment in the peripheries of light touch and vibration, while examination of the other systems was unremarkable. diagnostic evaluation during that first encounter, it was noted on a complete blood count that his total platelet count was markedly elevated at 2306 x103/µl (the normal range is 150450 x103/µl), while the total leucocyte count and hemoglobin were both normal at 10.4 x103/µl and 14 g/dl, respectively. he had normal random blood glucose, normal renal and liver panels, a negative hiv rapid test, a negative covid-19 rapid antigen test, a normal chest x-ray and electrocardiogram, and a normal erythrocyte sedimentation rate of 8 mm/hr. ultrasonography showed a mild splenomegaly of 14cm and early bilateral leg varicose veins, but no deep venous thrombosis. he was assessed to have features of a possible underlying myeloproliferative disorder, predominantly of the et phenotype. he got lost to follow-up until nine months later, when he re-presented with a worsening of similar symptoms. his platelet count had further increased to 2733 x103/µl. a peripheral blood film showed extreme thrombocytosis with both giant and small platelets, consistent with primary (essential) thrombocytosis. due to severe financial and logistical challenges, it was impossible to do a bone marrow aspirate or any genetic tests. management and follow-up his clinical syndrome was most consistent with et, with predominant vasomotor symptoms and associated sensory peripheral neuropathy. he was put on oral hydroxyurea (hu) starting at a dose of 1g daily and aspirin at 75mg daily. for the neuropathy, he was put on pregabalin 75mg daily (and amitriptyline 25mg nocte was later added during follow-up). the septic wound was surgically managed to full healing. while on hu, he developed symptomatic hyperuricemia due to huinduced platelet degradation (with a clinical syndrome of non-tophaceous acute gouty polyarthritis), which was successfully managed with allopurinol and analgesics. besides, the dose of hu was adjusted to a maximum tolerable dose of 1.5 g/day, aiming to keep an absolute neutrophil count of ≥1.5 x103/µl. significantly, whenever his absolute neutrophil count reduced to <1.5 x103/µl, he developed a recurrent triad of oropharyngeal candidiasis, septic grade 2 tonsillitis, and cystitis. this was fully treated with antimicrobials and supportive therapy. the hu in each case was stopped for a week and subsequently restarted at a much lower dosage, resulting in the resolution of the neutropenia and the recovery of the target absolute neutrophil count. however, the platelets pa ge 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 1-7, 2024 and the uric acid levels rose precipitously when hu was stopped (or dosage reduced), with a corresponding recurrence of mild-to-moderate vasomotor symptoms and gouty polyarthritis. these have been fully controlled with a corresponding adjustment of the various drug dosages. he is currently on follow-up at the medical clinic with ongoing clinical and laboratory monitoring to target the individualized therapeutic goals described earlier and clinical surveillance for infections, transformation to other mpns, and any adverse effects of the various drugs. table 1 below shows a composite summary of his complete blood count, uric acid levels, and relevant interventions. table 1: summary of the complete blood count, uric acid levels, and interventions date total platelets total wbc hemoglobin uric acid interventions (150-450 x103/µl) (4-11 x103/µl) n=neutrophils, l=lymphocytes anc=absolute neutrophil count (11-16 g/dl) (3.4-7mg/dl) hu=hydroxyurea, asa=aspirin, alp=allopurinol, ctx= cotrimoxazole, od= once daily abx= antibiotics 22/2/2022 2306 10.4 14.0 15/11/2022 2733 11.4 11.7 2.3 hu 1g +asa 75mg od started 22/11/2022 2472 10.9 12.1 hu 1g +asa 75mg od 2/12/2022 2124 9.7 12.0 13.2 hu 1.5g +asa 75mg + alp 100mg od 29/12/2022 942 7.0 12.4 7.9 hu 1.5g +asa 75mg + alp 200mg od 27/1/2023 918 3.6(n=67%, anc=2412/µl, l=28%) 12.3 12.9 hu 1.5g +asa 75mg + alp 300mg od 10/3/2023 745 3.1 (n=64%, anc=1984/µl, l=28%) 13.0 4.6 hu 1.5g +asa 75mg + alp 300mg od 5/5/2023 675 2.2 (n=63%, anc=1386/µl, l=31%) 12.6 3.0 hu 1g +asa 75mg + alp 100mg od + abx 3/7/2023 977 2.6 (n=59%, anc=1534/µl, l=34%) 13.3 4.6 hu 1.5g +asa 75mg+ alp 100mg od 14/8/2023 673 2.8 (n=57%, anc=1596/µl, l=38%) 13.4 4.0 hu 1.5g +asa 75mg+ alp 100mg od 11/9/2023 535 2.5 (n=59%, anc=1475/µl, l=30%) 13.0 3.5 hu 0.5g +asa 75mg+ alp 100mg od + abx 9/10/2023 1445 4.0 13.0 8.6 hu 1g +asa 75mg + alp 200mg od 8/11/2023 899 3.8 (n=63%, anc=2394/µl, l=31%) 12.7 2.5 hu 1.5g +asa 75mg + alp 200mg od key: note the adjustment of hu dosages whenever the absolute neutrophil count dropped below 1500/µl, and the subsequent precipitous increase in platelet counts and uric acid levels results and discussion a diagnostic evaluation of suspected et includes a medical history focused on the occurrence of thrombotic and hemorrhagic manifestations, with a careful search for concomitant cardiovascular risk factors in the setting of thrombotic complications. the diagnostic criteria of et by the world health organization and the international consensus classification (arber et al., 2022) require either all four of the major criteria or the first three major criteria plus the minor criterion, as shown in table 2 below. pa ge 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 1-7, 2024 in our patient, it was not possible to do a bone marrow aspiration and trephine biopsy (bmat) or any genetic tests for jak2, calr, or mpl mutations due to severe financial challenges. these services are not readily available in the vast majority of our health centers, and their access upon referrals to regional reference laboratory centers is severely hindered by their prohibitive costs. the main differential diagnosis for et is reactive thrombocytosis (rt). platelets are also members of the acute phase reactant superfamily, which will be elevated in many inflammatory and other conditions, e.g., infections, iron deficiency anemia, acute bleeding, trauma, asplenia, etc.) patients with rt will have evidence of these conditions as well as elevation of other acute phase reactants (e.g., c-reactive protein, erythrocyte sedimentation rate, ferritin, etc.). (schafer, 2004). other mpns must also be excluded prior to initiating treatment for et. in our patient, a targeted clinical evaluation ruled out alternative diagnoses. he had no features of inflammation or trauma; he had a normal esr; he maintained a persistently normal leucocyte count (pretreatment) and normal hemoglobin; and his platelets were too high to be compatible with just a rt. a validated simple laboratory scoring system based on a complete blood count that distinguishes et from rt is consistent with our assessment of et in this case (shen et al., 2021). at any rate, one would expect massive splenomegaly with cml (and severe leukocytosis) and pmf (and severe anemia), while pv would have marked polycythemia. the goals of treatment in et are to alleviate vasomotor symptoms, reduce the complications related to thrombosis and/or hemorrhage, and control splenomegaly (if present). decisions on therapeutic choices are based on individual risk stratification and the availability and tolerability of the various agents. low-dose aspirin (40100 mg orally administered once daily) and hu (at 15 mg/kg/day orally administered at a usual starting dose of 500mg once or twice daily) are first-line agents (tefferi & barbui, 2020). aspirin can reduce vasomotor symptoms and thrombo-hemorrhagic complications in most cases of et. higher doses are associated with increased risks of gastritis and gastrointestinal bleeding. hu is effective in reducing platelet counts, controlling splenomegaly, and reducing vasomotor symptoms in et. the dose of hu is adjusted to a target platelet count of 100,000-450,000/µl while limiting leukocytopenia and anemia by doing weeklyto-monthly complete blood count monitoring (tefferi & barbui, 2020). the response rates of hu vary from about 80% complete response to 15% partial response using the international working group-myeloproliferative neoplasms research and treatment (iwg-nrt) and the european leukemianet (eln) criteria (hernándezboluda et al., 2011). adverse effects of hu include oral ulcers, skin rashes, hyperpigmentation, long-term lung and liver toxicities, etc. hu is contraindicated in pregnancy and lactation. hu-induced neutropenia due to myelosuppression may manifest as recurrent infections presenting with fever, sore throat, urinary tract infections, etc. (antonioli et al., 2012; luchtman-jones et al., 2016). these effects are reversible by withholding hu for 1 to 2 weeks and then re-initiating at a lower dosage (wang et al., 2011). when our patient got recurrent hu-induced neutropenia-related infections, the hu was withheld for one week in each case and successfully re-started at lower dosages tailored to therapeutic targets. there are no studies that specifically address the modification of doses of hu for et in cases of severe hu-induced neutropenia. however, extrapolation of expert consensus recommendations from the use of hu in sickle cell anemia in children may give guidance on the definition of hu-related myelosuppression and toxicities, as well as dose adjustments to the maximum tolerated dosages (mtd) in such cases (mcgann et al., 2016; mcgann & ware, 2015). this is demonstrated in table 3 below. based on these recommendations, an absolute neutrophil count of ≥1500/µl was adopted for our patient as the target for defining the maximum tolerated dosage of the hu, with the uppermost dosage of 1.5 g/day. so far, the recommended target platelet count of 100,000-450, 000/ µl while on hu treatment has not been achieved due to the concurrence of hu-related neutropenia, as highlighted. table 2: who diagnostic criteria for essential thrombocythemia (arber et al., 2022) major criteria 1. platelet count ≥450 × 109/l 2. bone marrow biopsy showing proliferation mainly of the megakaryocyte lineage with increased numbers of enlarged, mature megakaryocytes with hyper-lobulated nuclei. no significant increase or left shift in neutrophil granulopoiesis or erythropoiesis and very rarely minor (grade 1) increase in reticulin fibers 3. not meeting who criteria for bcr-abl1+ cml, pv, pmf, myelodysplastic syndromes, or other myeloid neoplasms 4. presence of jak2, calr, or mpl mutation minor criterion 1. presence of a clonal marker or absence of evidence for reactive thrombocytosis diagnosis of et requires meeting all 4 major criteria or the first 3 major criteria and the minor criterion. key: cml: chronic myeloid leukemia; et: essential thrombocythemia; pmf: primary myelofibrosis; pv: polycythemia vera; who: world health organization pa ge 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 1-7, 2024 interestingly, the patients’ subjective symptoms have almost completely resolved on hu and aspirin. therefore, in resource-limited clinical settings, we propose a practical and rational approach to the diagnosis and treatment of et, as summarized in the algorithm shown in table 4 below. table 3: hematological parameters used to define the hydroxyurea maximum tolerated dose (mtd) with mild marrow suppression (mcgann et al., 2016; mcgann & ware, 2015) parameter toxicity criteria escalation criteria target mtd value absolute neutrophil count (anc, x 109/l) < 1.0 > 3.0 1.5–3.0 absolute reticulocyte count (arc, x 109/l) < 80 (unless hb ≥ 9.0) > 200 100–200 platelets (x 109/l) < 80 > 150 > 80 hemoglobin (hb gm/dl) hb <4.0 or hb <6.0 unless arc >100 >6.5 table 4: an algorithm for the diagnosis and management of essential thrombocytosis in a resource-limited setting a. platelet count: 450-1000 x 103/µl 1. rule out rt: inflammatory conditions, trauma, iron deficiency anemia, etc., elevated crp, esr, procalcitonin, and other acute phase reactants. 2. if no evidence of rt, go to b. b. platelet count: >1000 x 103/µl 1. clinically: vasomotor symptoms, thrombotic and/or hemorrhagic complications. 2. peripheral blood film: presence of marked/severe/extreme thrombocytosis with platelet anisocytosis. 3. clinically rule out other mpns using a complete blood count, targeted clinical examination, and peripheral blood film. 4. bone marrow aspirate and trephine biopsy, where possible: findings meeting the major criteria for et diagnosis. 5. make a presumed or definitive diagnosis of et and go to c. c. diagnosis of et 1. start on low-dose aspirin and hydroxyurea. 2. therapeutic target platelet counts of 150-450 x 103/µl, and an absolute neutrophil count of ≥ 1.5 x 103/µl. 3. individualize therapeutic targets. 4. monthly follow-ups with complete blood counts (and any other relevant tests). 5. monitor for therapeutic targets, drug adverse effects, and disease transformations (e.g., into leukemias). key: et=essential thrombocytosis, rt=reactive thrombocytosis, crp=c-reactive protein, esr=erythrocyte sedimentation rate, and mpns=myeloproliferative neoplasms. conclusion in resource-limited settings, a diagnosis of et must still be made through a high index of suspicion and a nuanced approach that incorporates compatible clinical features, persistent thrombocytosis (especially with platelet counts >1000 x 103/µl), and a simple peripheral blood smear that shows extreme thrombocytosis with platelet anisocytosis. this is followed by a meticulous, targeted evaluation to rule out reactive thrombocytosis and other mpns. a bmat biopsy and genetic testing for jak2, calr, or mpl mutations are ideally required for proving a diagnosis of et, but in resource-limited settings, obtaining these tests is usually hopelessly vetoed by their inaccessibility and prohibitive costs. hu and aspirin are widely available in most clinical settings and should judiciously be used to treat et with careful monitoring based on individualized treatment targets. recommendations hu-induced neutropenia is a dose-limiting adverse effect of hu therapy that may complicate et treatment and hinder the attainment of target platelet levels. unfortunately, no robust data currently exists in the literature that would give guidance on dose adjustments in such cases. more clinical trials and expert consensus recommendations are necessary to bridge this gap, especially with a focus on resource-limited clinical contexts. acknowledgement the authors acknowledge nurse pauline nyagah, laboratory technicians paul njuguna, peter kibet, and zebedeo machuka, as well as hospital administrators seth manera and steve nyagah, for their direct involvement in the management of the patient. references antonioli, e., guglielmelli, p., pieri, l., finazzi, m., rumi, e., martinelli, v., vianelli, n., luigia randi, m., bertozzi, i., de stefano, v., za, t., rossi, e., ruggeri, m., elli, e., cacciola, r., cacciola, e., pogliani, e., rodeghiero, f., baccarani, m., . . . vannucchi, a. m. pa ge 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 1-7, 2024 (2012). hydroxyurea-related toxicity in 3,411 patients with ph’-negative mpn. am j hematol, 87(5), 552554. https://doi.org/10.1002/ajh.23160 arber, d. a., orazi, a., hasserjian, r., thiele, j., borowitz, m. j., le beau, m. m., bloomfield, c. d., cazzola, m., & vardiman, j. w. 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(2005). jak2 mutation in essential thrombocythaemia: clinical associations and long-term prognostic relevance. br j haematol, 131(2), 208-213. https://doi.org/10.1111/j.1365-2141.2005.05764.x pa ge 1 pa ge 97 american journal of medical science and innovation (ajmsi) risk prediction of thalassemia using data mining classifiers khizra ali1*, muhammad saqib1 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.1979 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 17, 2023 accepted: september 11, 2023 published: september 22, 2023 medical data mining is concerned with prediction knowledge, which is a useful method for extracting hidden patterns from given data for specific purposes. thalassemia is one of the most common inherited blood hematological disorders, and this paper adopted data mining classification techniques to generate results with high performance and accuracy for risk prediction of thalassemia. the dataset for this purpose was collected from nibd (national institute of blood diseases), a well-known institute and hospital for blood diseases in karachi, pakistan. they provided 301 records of cbc test reports containing positive and negative statuses of diagnosis of thalassemia traits. there were many instances in the report, of which 6 were used for our research purpose, i.e. gender, mcv, hgb, hct, mchc, and rdw. the dataset was divided into training and test data using the weka tool. four algorithms of data mining classification, namely j48 decision tree, naïve bayesian network, smo algorithm, and multilayer perceptron neural network were adopted to train the model and classify the patient having traits of thalassemia from normal persons with the use of the weka tool. results revealed that out of all four algorithms, naïve bayes provided results with the highest accuracy of 99%. keywords medical data mining, thalassemia, j48 decision tree, naïve bayesian network, multilayer perceptron neural network 1 department of computer science and information technology, ned university of engineering & technology, university road, karachi 75270, pakistan * corresponding author’s e-mail: khizra.ali12@gmail.com introduction one of the most common genetic blood disorders, thalassemia, has received excessive attention in the research field of medicine worldwide. due to the absence or decreased production of normal globin chains, a heterogeneous group of hemoglobin disorders is called thalassemia syndromes. the disease is known to be the most common recessive worldwide as the population carriers of genetic thalassemia mutation are 1-5% globally (jameel et al., 2017; origa, 2017). it is commonly found in southeast asia, the middle east, north and central africa, and the mediterranean (herbert et al., 2009). in pakistan, thalassemia carriers are more than 10 million, with a 5-7% prevalence rate, as about 5000 children yearly are diagnosed as thalassemia major carriers (kamil et al., 2021; khaliq, 2022). therefore, under this context, the greatest challenge for professionals in healthcare is to differentiate between normal individuals and asymptomatic thalassemia carriers (alaa & shurrab, 2017; jatoi et al., 2018). thalassemia diagnosis depends on certain characteristics derived after performing a complete blood count (cbc) test. however, the reliability of the test can lead to the misdiagnosis of thalassemia as similar characteristics can also be observed in different blood disorders (abdullah & al-asmari, 2016; jatoi et al., 2018; meena et al., 2019). blood diseases can be of various types, such as anaemia, which is a common nutritional deficiency and blood disorder in childhood and infancy, and iron deficiency anemia (ird) is mostly found in women and children, especially in developing countries (alagha et al., 2018; jatoi et al., 2018). however, the most crucial type of anaemia is thalassemia, an inherited disorder whose identification or differentiation from normal patients is challenging from the cbc test (abdullah & al-asmari, 2016). therefore, the problem identified in the healthcare sector is to design a model that can predict the risk of thalassemia in patients before their cbc test. this research explored data mining techniques using the cbc dataset, examining the similarities of the different attributes categorizing normal traits or thalassemia traits for accurate detection and recognition of optimal disease patterns. multiple studies have been done worldwide regarding detecting different kinds of blood disorders using data mining. however, researchers have used a different set of instances of the cbc test, and therefore, the data mining classifiers’ accuracy has varied (alagha et al., 2018; elshami & alhalees, 2012). this also depends upon the choice of data mining classifiers; amin and habib (2015) conducted a research to diagnose blood diseases using age and gender as dataset labels with mlp, j48, and naïve bayes algorithms (amin & habib, 2015). similarly, saichanma et al. (2014) used the j48 decision tree algorithm to predict the abnormality of peripheral blood smear, focusing mainly on the attribute of rbc of the cbc test (saichanma et al., 2014). the previous studies (abdullah & al-asmari, 2016; alaa & shurrab, 2017; alagha et al., 2018; jatoi et al., 2018; meena et al., 2019) have classified the types of anaemia or thalassemia utilizing the techniques of data mining. however, the present study focused on determining thalassemia traits’ existence based on the cbc test attributes (mcv, hgb, rdw, mchc, and hct) for predicting the risk of thalassemia. the attributes used in this study were gender, mcv, hgb, hct, mchc, and rdw. the current research was aimed at risk prediction of thalassemia using data mining classification algorithms. the selected classification algorithms for this study were pa ge 98 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 naïve bayes, multilayer perceptron, j48, and smo using the weka data-mining tool. the research also focused on identifying the most potential classification algorithm for thalassemia by determining accuracy, precision, recall, true positive rate, false positive rate, and f-measure using weka experimenter. literature review data mining in healthcare three basic data mining mechanisms include decision rules, analysis, and clustering (classification). there are various applications of data mining in healthcare that are effective for physicians to detect diseases by the extraction of knowledge from data of patients. it is a prominent field of research and has extensive potential to revolutionise the medical environment and improve the quality of clinical decisions (asere & botson, 2021; saichanma et al., 2014). tomar and agarwal (2013) presented the importance of data mining as the most interesting and motivating area of research popular in health organisations. the role played by data mining is essential in uncovering the new trends in the healthcare domain and helpful for the associated field members. results revealed that the best accuracy and performance of the classification model are presented by feature selection (tomar & agarwal, 2013). jothi and husain (2015) illustrated that the most important step of data mining is kdd for pattern discovery and extraction with the involvement of a huge amount of data. the paper reviewed various emerging models and techniques in this regard, and results from the paper review revealed that tasks of classification, clustering, association rules, and anomaly detection are the most used methods in the medical sector. the widely used algorithms are decision tree, discriminant analysis, swarm intelligence, artificial neural network, k-nearest neighbour, association rule, and support vector rule (jothi & husain, 2015). mdaghri et al. (2016) elaborated that data mining has been widespread in the many applications of clinical decision support systems (cdds) such as alerting systems, information retrieval, suggestion systems, reminders, and prediction models (mdaghri et al., 2016). risk prediction of thalassemia using data mining jatoi et al. (2018) examined the core relationship between thalassemia and anemia from the cbc test. the relationship between the two was exploited to predict and identify the possibility of getting thalassemia for patients already suffering from anaemia. the research was conducted in pakistan, and the dataset of cbc reports was collected from the diagnostic and research laboratory of lumhs. researchers with the application of the naïve bayesian network algorithm analysed and evaluated the dataset, and it was revealed in the final results that the naïve bayes algorithm has the best capability to detect or predict the core relationship between anaemia and thalassemia with an accuracy of 98%. it was evaluated that out of 400 patients, 290 were infected with the disease, where 110 were normal. results also reflected that if patients have high or low values of mcv and mch, then there are increased chances of thalassemia, and the conditions of iron deficiency and vitamin b12 are slightly different in terms of mcv and mch (jatoi et al., 2018). alaa and shurrab (2017) applied data mining techniques to identify the relations between blood tumours and characteristics of blood tests to predict disease at an early stage, as it can be used to enhance the ability to cure disease. three data mining techniques were used, i.e. rule induction, association rules, and deep learning, to predict or classify normal patients from the ones suffering from blood tumours. real-time data was collected from gaza european hospital in palestine, and results showed that association rules provide the best relationship between blood tumour and blood test characteristics. however, deep learning classifiers are best for predicting tumour types, providing an accuracy of 79.45%. association rules best describe both normal haematology and tumours in blood and are identified as follows in the current research using the inductive rules method (alaa & shurrab, 2017). abdullah and al-asmari (2016) specified the types of anaemia for anaemic patients by using classification algorithms of data mining and constructing a predictive model. the dataset was made by filtering and eliminating the variables that were not desired, and then some classification algorithms such as smo, multilayer perceptron, naïve bayes, and j48 decision tree were applied to the weka tool of data mining to present results. after performing several experiments, the weka experimenter has proven that the best accuracy is provided by the j48 decision tree algorithm, giving the best potential classification of anaemia types. evaluation of data from 41 patients was done with several percentage splits of the dataset, i.e. 20%, 40%, and 60%. furthermore, comparing the results for four algorithms, it was observed that the best accuracy of 93.75% was obtained from smo and j48 decision tree (abdullah & al-asmari, 2016). alagha et al. (2018) collected data on patients suffering from thalassemia from the palestine avenir foundation to work on presenting a model for overcoming the challenges of thalassemia. the study aimed to predict a special type of thalassemia (β-thalassemia) based on the hybrid data mining model. additionally, to overcome the problem of imbalanced class distribution in the dataset, a smote technique was first used and applied to deal with this problem. the second step utilised four classification models to differentiate between patients carrying carriers of β-thalassemia and normal persons with the help of different evaluation metrics. the classification models used were decision tree, naïve bayes, k-nearest neighbour (k-nn) and multilayer perceptron neural network. naïve bayes provided the results with the highest accuracy differentiating between a normal person and thalassemia patients with the sampling smote ratio of more than 400%, revealing a sensitivity of 98.81% and pa ge 99 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 specificity of 99.47% (alagha et al., 2018). meena et al. (2019) developed a decision support system using data mining techniques as data was collected from a survey conducted by the indian government in 2015-16 called nfhs-4. the collected data was utilised to predict anaemia among children and create a relationship between a mother’s diet during pregnancy and health affecting the child’s anaemic status. in this way, clinicians and parents can understand the influence of the practices of feeding by the mother are fine, and they are following guidelines to prevent anaemia. the two techniques of association rule and decision tree were applied and compared for the mentioned aim, and a model of knowledge discovery was proposed using artificial intelligence to propose systems based on medical experts’ advice. the architecture of the proposed system depicted the stages of the data preprocessing tier, processing tier using decision tree and association rules, and user tier (meena et al., 2019). elshami and alhalees (2012) performed different experiments to identify the most significant classifier useful for differentiating between the multiple types of thalassemia (normal, thal-i, thal-m, iron def/thal-t, other). results revealed that neural networks provided the best classification outputs for detecting or diagnosing different types of thalassemia compared to naïve bayes and decision tree. almost all the experiments supported the main feature of mcv to indicate thalassemia existence, where the indicator value was identified to be less than 77.65. furthermore, if the age is greater than 12 and the value of mcv is greater than 77.65, thalassemia is not possible in an individual. the results were bright, with an accuracy greater than 90% (elshami & alhalees, 2012). hasani and hanani (2017) investigated the three types of anaemia, including α-thalassemia trait, β-thalassemia trait and iron deficiency anaemia, as detecting them is crucial due to their similar blood characteristics. also, the tests for their diagnosis are costly and time-consuming; therefore, an accurate model for classifying and diagnosing kinds of anaemia is important. the study used five classification algorithms on weka software to suggest an algorithm that provides the lowest mean absolute error and highest accuracy. results of the research indicated that combining naïve bayes, ibk and j48 algorithms using a voting algorithm with all the features provided the highest accuracy of 96.343% and 96.2169% (hasani & hanani, 2017). egejuru et al. (2017) predicted the risk of thalassemia in different age groups, and knowledge regarding the risk factors was collected by carrying out a structural interview with experienced medical personnel, and a questionnaire was used to collect data regarding the related parameters. the environment used for applying supervised machine learning algorithms was weka, and the predictive model was validated for diagnosing thalassemia. data was collected from 51 patients, and dataset parameters included demographics and clinical variables. age, gender, marital status, social class, and ethnicity were demographic variables, whereas spleen enlargement, urine colour changes, family history, diabetes and parent carriers were clinical variables. results showed that the distribution of risk of thalassemia was 31% high cases, 16% moderate cases, 10% low cases and 43% no cases. it was concluded in this study that for the prediction of thalassemia, multilayer perceptron will improve the process of decision-making within the healthcare sector regarding thalassemia diagnosis (egejuru et al., 2019). materials & methods dataset and pre-processing data mining also termed knowledge discovery in databases, is a useful tool for extracting knowledge containing the stages of data pre-processing, pattern recognition and classification (singhal & jena, 2013). data pre-processing is about filtering the data by removing the no-interest attributes and reducing noise or inconsistencies such as missing values or outliers (sultana et al., 2016). the stages of pre-processing of data utilised in this research are shown in figure 1 below. figure 1: flowchart of data pre-processing stages the pre-processing of data provides data quality with high accuracy, completeness, consistency, interpretability and timeliness (singhal & jena, 2013). as shown in figure 1, data cleaning is the stage to check inconsistency and eliminate incorrect values, and data integration includes combining data from all databases, data reduction decreases the volume of unnecessary data and data transformation is converting into the format supported by the software used (sharma et al., 2012; singhal & jena, 2013). in the context of this research, diagnosis of thalassemia was conducted by collecting data from cbc test reports from the national institute of blood diseases (nibd) karachi. cbc (complete blood count) test is commonly ordered as a simple blood test for a routine medical assessment (ogasawara et al., 2019). the attributes shown in table 1 contain all the essential parameters of cbc tests, blood components and their reference range. the number of rbcs, the total amount of haemoglobin in the blood, the average size of an rbc, i.e. mcv, and the amount of space taken by an rbc in the blood, i.e. haematocrit (mekić et al., 2018; yin et al., 2020). the other measurements, i.e. the concentration (mchc) and the amount (mch) of haemoglobin, also contain useful pa ge 10 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 results of normal persons and patients suffering from thalassemia. the dataset included 1 nominal, whereas 5 numerical values and one column presented patients’ status, i.e. positive or negative. later, the dataset was divided into training and test data by applying class “resample, “ a supervised instance filter on weka software used to produce a random subsample of a dataset with or without replacement. data analysis weka software the algorithms used to predict and diagnose thalassemia were applied to the pre-processed dataset on weka software. weka is a popular machine learning software developed at the university of waikato, new zealand, containing a collection of algorithms and visualization table 1: cbc test parameters (source: dataset) blood component abbreviation reference range haemoglobin* hgb male: 13.5-17.5 g/dl female: 12.0-16.0 g/dl hematocrit* ht male: 41%-53% female: 36%-46% mean corpuscular volume mcv 80-100 μm3 white blood cells wbc 4500-11,000/mm3 red blood cells* rbc male: 4.3-5.9 million/mm3 female: 3.5-5.5 million/mm3 mean corpuscular haemoglobin mch 25.4-34.6 pg/cell mean corpuscular haemoglobin concentration mchc 31%-36% hb/cell red cell distribution width rdw male: 11.6-14.6% female: 12.2 to 16.1% platelets platelets 150,000-400,000/mm3 information about rbcs. these features of the cbc test can also be explained as red blood cells (rbcs) carry oxygen, hemoglobin (hb) is in rbc as an oxygen-carrier protein, white blood cells (wbc) are required to fight infections in the human body, and hematocrit (hct) represents the red blood cells percentage into the plasma or fluid component in platelets of blood that causes blood clotting (ogasawara et al., 2019; yin et al., 2020). the test diagnoses and monitors the different types of blood diseases (e.g. anemia, thalassemia, iron deficiency), inflammatory diseases, infection, and malignancy (mekić et al., 2018; ogasawara et al., 2019). there are many attributes in the cbc test reports, but only 6 attributes were selected for the risk prediction of thalassemia via weka software shown in table 2. these six attributes include gender, mcv, hct, hgb, mchc, and rdw and the ranges considered to differentiate between normal persons and thalassemia patients are shown in table 1. furthermore, the dataset was transformed into csv and arff file format as supported by weka software. the data of 301 patients was provided by nibd, containing the cbc test table 2: dataset attributes used for classification attribute attribute value attribute category gender male 1 female 2 mcv <80 microcytic 80-100 normal hgb <10 severe 10-12 normal hct <37 low 37-50 normal mchc <32 hypochromic 32-36 normochromic rdw >14.6 high 11.6-14.6 normal figure 2: the proposed method pa ge 10 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 tools (jovic et al., 2014; sultana et al., 2016). these are used for predictive modelling and data analysis together with graphical user interfaces to get easy access to its functionalities. weka tool is platform-independent, easily available, and open source (singhal & jena, 2013). in this research, weka explorer and experimenter were used to explore data and perform experiments and statistical tests. the implementation of the proposed method began by using four classifiers on weka on training and testing datasets to validate results with the highest accuracy and least mean square error (jovic et al., 2014). after classification on weka explorer, generated results were evaluated in the weka experimenter. figure 2 below is the research flowchart which explains the proposed method. figure 2 above presents the steps followed for the execution of the proposed method. the process begins with collecting data, identifying the attributes, uploading the dataset on weka in csv or arff format, applying various classification algorithms, predicting results, and evaluating the performance of each classifier is identified from the accuracy, precision, recall, true positive rate, etc. the algorithms used for classification j48 decision tree a decision tree is a supervised classification algorithm that verifies a problem and determines the dependent variable values based on independent values via powerful approaches to data mining and knowledge discovery (drazin & montag, 2012; sahu & mehtre, 2015). j48 algorithm uses a divide and conquer approach to grow a tree, checking the cases belonging to the same class and labelling a leaf with that class (drazin & montag, 2012). furthermore, figure 3 presents the flowchart of the j48 decision tree algorithm, presenting the main purpose of the algorithm as a data mining classifier. it is a predictive machine learning model that decides conditions based on the training dataset’s attributes. further, it provides a pruned decision tree useful for addressing overfitting and classifying instances correctly. it splits the values based on the threshold specifying what is upper than, equal to, or less than that value, especially when dealing with continuous attributes (sahu & mehtre, 2015). naïve bayes classifier naïve bayes scans the training data and estimates all the probabilities with high learning efficiency (an et al., 2017). the classification in this algorithm is based on the assumptions for identifying the object that is likely to be classified in the identified category, showing a direct or inverse relationship between one conditional probability (an et al., 2017; xu, 2018). figure 3: flowchart for j48 decision tree algorithm figure 4: flowchart for naïve bayesian algorithm figure 4 illustrates the generative process of the bayesian classifier, where each arrow represents conditional dependency among variables (xu, 2018). it computes a probability after calculating the rate of values and their combinations in a specific dataset. given the pa ge 10 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 probability of a single event, the naïve bayes classifier identifies another event that has already happened (granik & mesyura, 2017). the algorithm uses kernel density estimators dealing with numeric attributes using supervised discretization (an et al., 2017; jabbar & samreen, 2016). smo algorithm smo is an outstanding svm algorithm in memory and efficiency requirements abbreviated as sequential minimal optimization. it requires cross-validation to avoid overfitting and optimize parameters in the mathematical model (luo et al., 2016). smo in weka is a supervised support vector machine algorithm that analyses data and recognizes patterns. furthermore, the svm algorithm also possesses the same functional form of neural networks and functions as a radial basis (zhang et al., 2018). the working of the smo algorithm is shown in figure 5. belonging to two classes is given with associated class labels, and the algorithm of smo was applied using the weka tool to train the model. multilayer perceptron one of the significant models in artificial neural network (ann) is the multilayer perceptron, which contains a single input layer, one or more than one hidden layer and a single output layer; the neurons are organised in these layers which are not connected in the same layer (singh et al., 2018). the values from the input node pass to the first hidden layer, and the same process continues with all the hidden layers until outputs are produced. furthermore, the neurons in the input layer are the same as measurement variables for pattern problems, whereas the number of classes equals the number of neurons in the output layer (ramchoun et al., 2016; singh et al., 2018). the corresponding input generates the desired output in ann, and the results can be viewed by computing the difference between the training set’s desired output and the network’s output on test data (kwon et al., 2017; singh et al., 2018). the multilayer perceptron is the most utilised form of neural network used as a back-propagation training algorithm. excess connections can create a problem of overfitting; however, a lack of connections in the neural network may face the problem of insufficient parameters (ramchoun et al., 2016). in this research, the multilayer perceptron model was used, a feed-forward neural network model that maps the input data into desired or suitable outputs. the working of the multilayer perceptron algorithm is shown in figure 6. figure 5: flowchart for smo algorithm smo is generally made for a two-class classification problem to analyse the greatest separation between two classes, discovering the maximum distance to the nearby point. it has also been studied that svm algorithms are based on the advances of the theory of machine learning in a high dimensional feature space that uses a hypothesis space of linear function and implements a learning bias derived from statistical learning theory (luo et al., 2016; zengin et al., 2017). in this research, a set of training data figure 5: flowchart for smo algorithm results & discussion j48 decision tree the training data set was uploaded on weka explorer, and after applying the j48 decision tree classification algorithm, the results derived are shown in figure 7. pa ge 10 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 figure 7: j48 decision tree the decision tree in figure 7 above reflects the rules that predicted the positive or negative risk of having thalassemia traits in the patient. the tree size is 7, whereas the number of leaves is 4. the weka tool constructed the pruned tree under the conditions stated in figure 8. based on the j48 decision tree results per the trained model, rules and decisions are listed below in table 3. the results were derived by showing the status of cbc test results as positive (persons having traits of thalassemia) or negative (normal). there are different parameters based on which the accuracy of the results is defined stated below: relative absolute error: it is the way that provides the measure of the performance of a trained or predictive model used in data mining and machine learning. it is a general measure of accuracy or precision expressed as a ratio as a result of comparing a mean error to errors produced by the naïve model (iyer et al., 2015). confusion matrix the performance of a classification model is described by the confusion matrix on test data by trained data for which true values are known (singh et al., 2018). besides, to measure the effectiveness of the classification model confusion matrix presents different combinations of actual or predicted values. the four entries of the confusion matrix are defined below: tp rate: the number of entries/ records classified as true and true in actuality represents the true positive rate (singh et al., 2018). fp rate: the number of entries/ records classified as true and false in actual represents the false positive rate (singh et al., 2018). fn rate: the number of entries/ records classified as false and where they were true in actual represents the false-negative rate (singh et al., 2018). tn rate: the number of entries/records classified as false and were false in actual represents the true negative rate (singh et al., 2018). accuracy: it is the ratio of the number of correct predictions to the total number of predictions (wang & li, 2019). figure 8: decision tree rules table 3: thalassemia classification rules rules decision if (mcv > 78.3) then, negative else if (mcv <= 78.3 and and rdw > 14.3) then, positive else if (mcv <= 78.3 and and rdw <= 14.3 and mchc > 31.7) then, negative else if (mcv <= 78.3 and and rdw <= 14.3 and mchc <= 31.7) then, positive precision: it analyses how many are actually positive out of all the correctly predicted positive classes (alam et al., 2022; wang & li, 2019). pa ge 10 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 recall: it is also known as the probability of detection, sensitivity, or tp rate and detect how much were correctly predicted out of all positive classes (alam et al., 2022; wang & li, 2019). f-measure: the weighted average of recall and precision is known as f-measure (alam et al., 2022; wang & li, 2019). validation. the rate of correctly classified instances was 97%, whereas the rate for incorrectly classified instances was 6%. the relative absolute error of the model was computed as 7.4438%. the detailed accuracy of the model by class is depicted in the form of tp rate, fp rate, precision, recall and f-measure. the confusion matrix in figure 10 represents that the instances classified as positive are 117 (tp), whereas 77 (tn) were classified as negative. the tp rate, precision, recall and f-measure were derived as 0.975 for class positive and 0.963 for class negative. furthermore, the test data was supplied on the j48trained model to predict/diagnose thalassemia traits and visualize results. the results were transformed into a csv file, and table 4 shows the sample of 17 records of test data out of 101 evaluated using the trained model showing the ‘predicted margin’ and ‘predicting status’ for risk prediction of thalassemia. figure 9 presents the results of the j48 model developed using weka software. the resampling procedure for evaluating data mining tools is cross-validation, referring to the number of groups for the given dataset to be splitted. for the evaluation of different data mining algorithms in this research, the dataset was divided into 10-fold crossfigure 9: j48 results table 4: j48 classifier output results using weka tool mcv hct hgb mchc rdw gender ‘prediction margin’ ‘predicted status’ 66.4 4.9 22.3 29.5 31.5 2 1 positive 74.6 4.9 19.3 22.6 33.7 1 1 positive 69 9.3 21.7 26.7 32.6 1 1 positive 73.1 7.4 25.8 32 26.4 2 1 positive 77.3 6.8 34.2 31.3 33.6 1 1 positive 71.2 6.8 21.5 30.1 36.7 1 1 positive 80.1 10.5 11.6 35.2 42.1 1 -0.974359 negative 75.3 6.7 17.6 27.5 31.5 2 1 positive 76.4 6.9 27.7 25.9 34.1 1 1 positive 69 9.4 21.9 27.4 29.6 1 1 positive 68.9 9.9 19.9 31.2 26.9 1 1 positive 73.1 9.1 21.4 30.5 32.1 2 1 positive 83.5 10.1 11.7 33.6 42.4 1 -0.974359 negative pa ge 10 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 82.4 10.3 12.7 33.6 44 1 -0.974359 negative 57.9 5.9 16.9 30.1 33.5 1 1 positive 82.6 11.9 14 33.9 43.2 1 -0.974359 negative 80.9 12.4 13.6 33.5 41.2 1 -0.974359 negative naïve bayes classifier the results for the naïve bayes classifier are shown in the figure 10 below. after applying the naïve bayes algorithm on the weka tool, the correctly classified instances based on the given data were 99%; however, only 1% of data was incorrectly classified. furthermore, as shown in figure 5.6, the relative absolute error of naïve bayes results was 1.445%. after applying the naïve bayesian algorithm on the training dataset, results showed that there is only one entry for fp and fn, suggesting that the model predicting thalassemia with a 99.0 % accuracy rate; therefore, the tp rate for class positive was identified as 99.2% and 98.8% for class negative suggesting that 119 cbc test results for thalassemia are positive where 79 are negative based on the given data. figure 10: naïve bayes results smo algorithm the results for the smo algorithm are represented in figure 11, analysed using the weka tool. the results derived from the smo model on the given dataset provided results with 3.1236% relative absolute error, where 98.5% were correctly classified instances, whereas 1.5% were incorrectly classified instances. moreover, as shown in figure 5.7, after applying the figure 11: smo algorithm results pa ge 10 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 smo algorithm on the training dataset, results showed that there are three entries for fp and no entry for fn, suggesting that the model predicting thalassemia with a 98.5 % accuracy rate; therefore the tp rate for class positive was identified as 97.5% and 100% for class negative suggesting that 117 cbc test results for thalassemia are positive where 80 are negative based on the given data. multilayer perceptron after applying a multilayer perceptron neural network on the training dataset, the results shown in the figure 12 below were derived. figure 5.8 presents the results for training data using the multilayer perceptron classifier on the weka tool. the algorithm’s rate of correctly classified instances is 98%, whereas the rate for incorrectly classified instances is 2%. as shown in figure 5.8, the relative absolute error for the trained model was derived to be 3.5101%. furthermore, it shows that there are three entries for fp and only one entry for fn, suggesting that the mlp model predicts thalassemia with a 98.0 % accuracy rate; therefore, the tp rate for class positive was identified as 97.5% whereas 98.8% for class negative suggesting that 117 cbc test results for thalassemia are positive and 79 are negative based on the given data. figure 12: mlp results comparison of algorithms’ results through weka experimenter this section of the report compares all four classifiers using the weka experimenter based on precision, recall and f-measure. a paired t-test was performed to identify the difference between the algorithms used. it was used in this research using the weka experimenter to compare the results among all four algorithms. the data mining measures that are useful to analyse the performance of each algorithm are precision, recall and f-measure. figures 13, 14 and 15 illustrate the weka experimenter’s snapshots using precision, recall, and f-measure. paired t-test was applied in these experiments to identify the algorithm with the highest accuracy for the given dataset. figure 13: comparison of j48, nb, smo, and mlp algorithms using weka experimenter using precision pa ge 10 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 figure 14: comparison of j48, nb, smo, and mlp algorithms using weka experimenter using recall figure 15: comparison of j48, nb, smo, and mlp algorithms using weka experimenter using f-measure it was evaluated that naïve bayes performed the risk prediction of thalassemia with the highest performance among all four classifiers with precision, recall and f-measure of 99.0%. the comparative performance for all four classifiers is also visualised based on relative absolute error, as shown in the figure below. it can be viewed in figure 16 that the least root mean square error of 1.445% was for the naïve bayes model in comparison with models of j48, smo and mlp. hence, it proved that based on the given dataset, naïve bayes provided results with the highest accuracy and least mean square error for the risk prediction of thalassemia. figure 16: comparison of j48, nb, smo, and mlp algorithms using weka experimenter using f-measure pa ge 10 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 97-109, 2023 conclusion a rapid increase is observed in inherited haemoglobin disorders, and despite the efforts to control the spread of these diseases, the number of major cases leading to death is increasing. thalassemia is one of these inherited blood disorders that has received excessive attention over the years in medical data mining. diagnosis of thalassemia is based on some characteristics derived after performing the cbc test. therefore, various data mining techniques were utilised in this research to identify the hidden patterns in the given dataset of cbc test results for thalassemia. the research was conducted for the diagnosis or risk prediction of thalassemia using data mining classification algorithms. the selected classification algorithms for this study were naïve bayes, multilayer perceptron, j48 and smo using the weka data-mining tool. further, it also analysed the best potential classification algorithm for thalassemia by determining accuracy, precision, recall, and f-measure using weka experimenter. the data of 301 cbc results provided by nibd was divided into training and test data, and it was pre-processed by applying a resample filter on the weka tool. for the evaluation of different data mining algorithms in this research, the dataset was categorised into 10-fold cross-validation. the results were transformed into a csv file showing the ‘predicted margin’ and ‘predicting status’ for risk prediction of thalassemia. results revealed that after applying four different algorithms on the training dataset, the naïve bayes model predicted thalassemia with the highest accuracy of 99.0 % accuracy rate suggesting that 119 cbc test results for thalassemia are positive, where 79 are negative based on the given data. future work this research was conducted by applying different classification algorithms to get the best prediction or diagnosis of thalassemia based on the dataset of 301 constructed of cbc results. in the future, the research work can be expanded by using more types of data mining algorithms, such as clustering or association rules, to identify the best-performing algorithm based on the given dataset. association rules can be used to identify important relations among different attributes of the given dataset to detect the type of blood disease. furthermore, in the future, the aim of the analysis could be slightly different, such as identifying the survival rate of thalassemia patients, classifying between anaemia and thalassemia, or developing a classification model for the different types of thalassemia. moreover, a big dataset can be selected or requested from nibd or any other organization in pakistan to present more genuine and authentic results, training the model with the highest possible accuracy. in addition, the big dataset can be divided into training and test data by setting up different split-up percentages for training data to analyse which dataset is capable of the highest performance results. future work can be conducted by comparing the cbc report’s other parameters and identifying the core relationship with the variables that can cause different blood diseases. the data mining techniques are very powerful, but they should be used with great care in the field of medicine, and therefore, there is a need to discover the best mining algorithm for the specified medical area in the future. acknowledgements we express our deepest gratitude to our independent research project supervisor, dr. raheela asif (department of software engineering, ned university of engineering & technology, university road, karachi 75270, pakistan), for her relentless assistance throughout the research. we are also grateful to nibd (national institute of blood diseases), karachi city, sindh, pakistan, for providing 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(2018). an improved smo algorithm for financial credit risk assessment–evidence from china’s banking. neurocomputing, 272, 314-325. pa ge 1 pa ge 1 american journal of medical science and innovation (ajmsi) relationship between the injury location and swallowing difficulty among stroke patients, a retrospective cohort study rawan azzam1*, dina emam1, mamoun nor eldein1, olfa al-mannai1 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3074 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: may 29, 2024 accepted: june 30, 2024 published: july 03, 2024 post-stroke dysphagia (psd), a neurological or mechanical disorder that hinders food transport from the oral cavity to the stomach. it has been widely associated with severe complications with higher mortality and morbidity rates. traditional therapies for the treatment of dysphagia mainly focused on compensatory methods and behavioural rehabilitation approaches. the retrospective cohort study aimed to determine the association and correlation between developments of dysphagia in relation to the location of the stroke and to identify the swallowing recovery period following the stroke. a retrospective cohort study investigated swallowing difficulties in 64 stroke patients at an ambulatory care centre over a year. data collection involved reviewing medical records and imaging reports, with analyses conducted using spss software, anova and chi-square methods to assess associations between injury location and swallowing difficulty. hemorrhagic stroke was more prevalent (65.6%) than ischemic stroke (34.4%). a significant association was found between gender and stroke type, with males exhibiting a higher prevalence of ischemic strokes (71.4%) compared to females (29.8%). age differences between stroke types, gender and affected swallowing phases and stroke type and affected swallowing phase revealed no significant associations. distinct differences were noted in swallowing difficulties across stroke types. furthermore, recovery time varied depending on the intervention method, with speech therapy linked to shorter recovery periods. the study underscores the importance of considering gender and stroketype-specific differences in stroke prevalence, age distribution, and swallowing difficulties. these findings contribute valuable insights to understanding stroke characteristics and their implications for clinical management and rehabilitation strategies. keywords stroke, post-stroke dysphagia, swallowing, speech therapy, video fluoroscopy 1 hamad medical corporation, doha, qatar * corresponding author’s e-mail: rnajlaa@hamad.qa introduction stroke has been one of the major leading causes of mortality and morbidity globally. in recent years, the number of stroke patients in the world has increased, simultaneously increasing the cost of health care (qiao et al., 2022). cardiovascular disease (cvd) has been included as the major cause of mortality, accounting for 931,578 deaths in the united states (us) in 2021. after cancer and other cvds, stroke has been ranked as the third major cause of about 150,000 deaths in the us (goldstein, 2019; heart disease and stroke statistics update fact sheet, 2024). in 2021, stroke accounted for 1 in every 21 us deaths, with an average death every 3 minutes 14 seconds. in the us, the stroke death rate increased by 8.4% from 2011, while the total number of deaths increased 26.3%. globally, 7.44 million deaths were attributable to stroke in 2021 (heart disease and stroke statistics update fact sheet, 2024). patients who have been affected by the stroke face several severe clinical conditions such as oesophagal or oropharyngeal dysphagia, hemiparesis, cognitive impairment, loss of dexterity and others (goldstein, 2019; qiao et al., 2022). swallowing dysfunction or oropharyngeal dysphagia is a neurological or mechanical disorder that hinders food transport from the oral cavity to the stomach. it involves the coordination of multiple muscle groups to transport food from the oral cavity to the gastric region while protecting the airway (jones et al., 2020; qiao et al., 2022). post-stroke dysphagia (psd) has been widely associated with severe complications, mortality and morbidity rate in 29-78% of patients (zhong et al., 2021). the most typical symptoms of dysphagia include cough, nasal regurgitation, weight loss, throat clearing, residue in the mouth, and others. this condition can lead to complications such as malnutrition, dehydration, frailty, respiratory infections, and pneumonia (serra-prat et al., 2012; wilmskoetter et al., 2020). the primary condition of psd has been associated with the physiological and biochemical swallowing complexities in patients that might result in the disruption of brain activities. the incidence, severity and patterns of psd have been associated with brain lesions at different brain locations where the stroke of the brainstem has been the major incentive (zhong et al., 2021). during psd, swallowing difficulties might occur in four phases: oral, pharyngeal, oral preparatory, and oesophagal phases. the condition of psd might show improvements in the early days of stroke treatment. however, in some cases, it might also persist as a chronic condition, leading to severe complications such as aspiration, pneumonia, and malnourishment (jones et al., 2020). psd has been the major cause of morbidity in patients with stroke that might arise from various types of brain injuries, such as unilateral or bilateral cerebral hemispheres, pa ge 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 1-11, 2024 while the supratentorial anatomical location, specifically associated with healthy swallowing has remained unclear (shi et al., 2017). studies employing magnetic resonance imaging (mri) or computed tomography (ct) images of focal lesions in stroke patients have often focused on unilateral ischemic strokes affecting either hemisphere of the brain (dehkharghani & andre, 2017; zameer et al., 2021). while some research suggests lateralization of swallowing actions to the left and right hemispheres, its exact nature and implications for dysphagia remain uncertain (cheng et al., 2022). specifically, it has been proposed that damage to the right hemisphere (rhd) may be associated with dysmotility and aspiration during the pharyngeal stage of swallowing, while damage to the left hemisphere (lhd) may affect oral stage function. rhd has also been linked to persistent dysphagia and aspiration. however, these hemispherespecific variations in swallowing behaviour, severity, pharyngeal transit durations, lingual coordination, or aspiration incidence have not been consistently observed across studies (daniels et al., 2019; galera et al., 2019). stroke patients often experience psd, while up to 50% of the patients spontaneously recover within the first seven days of stroke treatment (coleman et al., 2017). therapies for the treatment of psd might help the patients who may not be improved by medications. several interdisciplinary professionals collaborate to manage the symptoms of psd (cabib et al., 2016; cohen et al., 2016; lindsay et al., 2020). new technologies like brain-computer interface devices and virtual reality-based therapy might improve swallowing rehabilitation. traditional therapies for the treatment of dysphagia mainly focused on compensatory methods and behavioural rehabilitation approaches. it is necessary to understand that the spontaneous recovery of poststroke swallowing problems has been constantly evolving with the development of novel treatment methods and implementation on psd patients to understand better, manage, and enhance the recovery phase of psd. these treatments have been patient-specific, and successful therapies for one patient might not generate the same results for other patients (fang et al., 2022; felix et al., 2019). speech therapy (st) has been one of the most important treatment methods to improve or treat the symptoms of psd. st for dysphagia treatment involves various techniques and exercises aimed at improving swallowing function. sensory and motor effects are generated by stimulating the swallowing-related muscle activity. these effects enhance the motor ability and the coordination of laryngeal life and pharyngeal muscles utilized in swallowing and also help restore the linguistic and swallowing abilities of the patient (fang et al., 2022). speech-language pathologists (slps) employ oral motor exercises to strengthen swallowing muscles, muscles coordination, and diet modifications to ensure safe swallowing. compensatory strategies like chin tucks and sensory stimulation techniques may also be utilized (caesar & kitila, 2020; murry et al., 2020). video fluoroscopy (vf) for dysphagia detection has been a diagnostic procedure used to assess swallowing function by using vfs equipment to provide real-time assessment/visualization by capturing real-time x-ray images (fluoroscopy) of the oral and pharyngeal phases of swallowing (gonzález-fernández et al., 2015). vf can identify aspirations or silent (aspirations aspiration without the presence of a cough reflex), a factor of 20% mortality rate in elderly stroke patients within a year (carucci & turner, 2015). during the therapy, the patients were usually asked to consume food or liquid (mixed with a contrast agent) under professional’ observation (thiyagalingam et al., 2021). the fluoroscopic images allowed the health care professionals to assess the movement of food or liquid passing from the oral cavity to the pharynx. this procedure provides insight into detecting abnormalities or difficulties in swallowing in psd patients (carbo et al., 2021; matsuo & palmer, 2016). simultaneously, with the continuous development of understanding the difficulties in swallowing after stroke, advanced treatment methods combined with traditional therapies highlighted the better management and enhancement of treatment methods for psd (fang et al., 2022). however, 10%-50% of patients with chronic psd might not be recovered (sheng et al., 2023). therefore, the retrospective cohort study aimed to explore the relationship between injury location and swallowing difficulty among stroke patients and identify the swallowing recovery period following stroke. methodology area of study a retrospective cohort study was conducted in the ambulatory care centre, hamad medical corporation, from july 2021 to july 2022. the study aimed to investigate the swallowing difficulties in stroke patients. a total of 64 individuals with documented swallowing issues in their medical records were identified and included in the study after obtaining their consent. inclusion and exclusion criteria the study population consisted of individuals meeting the specific criteria, including radiological evidence of stroke, a glasgow coma scale (gcs) score of 15, age exceeding 18 years, and assessments conducted using fiber optic endoscopic evaluation of swallowing (fees). exclusion criteria included participants under the age of 18, those with a history of previous strokes, unconscious individuals, and those with traumatic brain injury (tbi). additionally, patients with psd unrelated to stroke and those with brain lesions other than cerebrovascular accident (cva) were excluded. data collection data collection involved a comprehensive review of medical records and imaging reports. the primary pa ge 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 1-11, 2024 variables of interest included injury location, age, gcs score, and the presence or absence of swallowing difficulty. descriptive statistics were employed to summarize demographics, and the association between injury location and swallowing difficulty along with the recovery period was assessed through appropriate statistical tests, such as the chi-square test and logistic regression. this study design ensured a focused examination of swallowing difficulties in stroke patients while adhering to specific inclusion and exclusion criteria to maintain the integrity and validity of the findings. data analysis data analysis for the retrospective cohort study was conducted using the spss (statistical package for social science) software version 26 for windows and microsoft excel 2020. descriptive metrics, including mean, standard deviation, and frequency, were calculated to summarize the demographic characteristics of the study population, such as age, gcs scores, and injury locations. the relationship between injury location and swallowing difficulty was assessed for the primary analysis. chisquare tests were utilized to analyze categorical variables, and logistic regression models were employed to explore associations while adjusting for potential confounding factors. the significance level was set at 0.05. furthermore, microsoft excel 2020 was utilized for data visualization, including the formation of graphs and charts to illustrate the distribution of injury locations and the prevalence of swallowing difficulty among stroke patients. results medical records of patients a total of 64 patients were identified in the medical records. table 1 represents the sociodemographic profile of the patients. the profile included 57 males (89.1%) and seven females (10.1%). the mean age of the patients was 69.41 ± 8.1 years, with a mean age of 68.51 ± 7.926 years for males and 76.71 ± 5.707 years for females, respectively. table 1: sociodemographic profile of the patients categories frequency percentage gender male 57 89.06 female 7 10.94 type of stroke ischemic 22 34.375 hemorrhagic 42 65.625 location bulbar 55 85.9375 pseudobulbar 9 14.0625 affected swallowing phase pharyngeal 46 71.875 oral propulsive 5 7.8125 esophageal 11 17.1875 oral preparatory 2 3.125 total 64 100 association of gender with stroke according to the kolmogorov-smirnov test results, the data has a normal distribution (p = 0.091). the prevalence of different types of strokes among the participants was investigated. the majority of patients (65.6%, n = 42) experienced hemorrhagic strokes (hs), while 34.4% figure 1: prevalence of ischemic and homographic stroke pa ge 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 1-11, 2024 (n = 22) had ischemic strokes (is). a cross-tabulation analysis revealed a significant association between the gender and stroke types (χ² = 4.784, p = 0.029), with a higher prevalence of is among females (71.4%, n = 17) compared to males (29.8%, n = 5) and higher prevalence of hs among males (70.2%, n = 40) as compared to female (28.6%, n = 2) as shown in figure 1. association of age with stroke types an analysis of variance (anova) was performed to examine age differences across different types of strokes, as shown in figure 2. the mean age of patients with is (m = 67.8, sd = 7.5) was compared to hs (m = 62.2, sd = 9.1), revealing a non-significant difference, f (1, 198) = 0.734, p = 0.395). the analysis of age distribution across different stroke types revealed distinct characteristics. patients with is exhibited a higher mean age (m = 73.36, sd = 8.215) than those with hs (m = 67.33, sd = 7.311). the 95% confidence interval for the mean age of patients with is ranged from 69.72 to 77.01, while for hs, it ranged from 65.06 to 69.61. these findings suggested notable differences in the age distribution between the two types of strokes. figure 2: age distribution between the two types of strokes association of mean age with affected swallowing phases an independent samples t-test was conducted to compare the mean age with the affected swallowing phases in patients with is and hs. the results indicated a statistically significant difference. patients with is (m = 73.36 ± 8.215) were older than hs patients (m = 67.33 ± 7.311), t (198) = 3.003, p = 0.004. the analysis of variance (anova), as shown in figure 3. indicated a non-significant difference in the mean age across the various affected swallowing phases, f (3, 60) = 0.922, p = 0.436. figure 3: mean age by affected swallowing phases pa ge 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 1-11, 2024 association of gender and affected swallowing phases the chi-square test examined whether a significant association existed between gender and the affected swallowing phases. statistically, no significant association has been found between gender and the affected swallowing phases (χ² (3) = 4.577, p = 0.206). figure 4: association between gender and the affected swallowing phases association between stroke types and affected swallowing phase the chi-square test determined the association between stroke types and the affected swallowing phase. among patients with is, 15 individuals were observed to have difficulty in the pharyngeal phase, with 2 experiencing challenges in the oral propulsive phase, 4 in the oesophagal phase, and 1 in the oral preparatory phase, resulting in 22 patients. conversely, among those with hs, more patients (42) exhibited difficulty across all phases: 31 in the pharyngeal phase, 3 in the oral propulsive phase, 7 in the oesophagal phase, and 1 in the oral preparatory phase. when considering both stroke types, 46 patients experienced difficulty in the pharyngeal phase, 5 in the oral propulsive phase, 11 in the oesophagal phase, and 2 in the oral preparatory phase, resulting in a cohort size of 64 patients. however, no significant relationship has been found between the two variables (p = 0.946), as shown in figure 5. figure 5: association between type of stroke and the affected swallowing phase association between location of stroke and affected swallowing phases the chi-square test of independence indicated a significant association between the location of the stroke and the affected swallowing phases (χ² = 8.674, df = 3, p = .034). it was found that most patients with bulbar strokes experienced difficulty in the pharyngeal phase (43 out of 55 cases), with fewer instances in the oral pa ge 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 1-11, 2024 propulsive, oesophagal, or oral preparatory phases, as shown in figure 6. conversely, patients with pseudobulbar strokes exhibited a more evenly distributed pattern across the swallowing phases. the linear-by-linear association test supported these findings (χ² = 6.590, df = 1, p = .010), indicating an observable pattern in the data. these results suggested a relationship between stroke location and the specific affected phases of swallowing, underscoring the importance of considering both factors in stroke management and rehabilitation strategies. figure 6: association between the location of stroke and the affected swallowing phases descriptive statistics for recovery time according to different methods of recovery and followup, the descriptive statistics for recovery time (in months) have been presented in table 2. patients who underwent st had a mean recovery time of approximately 8.83 months (95% ci: 7.70 9.96), those who recovered spontaneously had a mean recovery time of approximately 6.39 months (95% ci: 5.23 7.55), and patients who received vf had a mean recovery time of approximately 8.91 months (95% ci: 7.20 10.62). table 2: statistics for recovery time (in months) variable method of recovery mean std. error std. deviation 95% confidence interval for mean lower bound upper bound recovery time (months) speech therapy 8.83 0.555 3.285 7.700 9.957 spontaneously 6.39 0.549 2.329 5.230 7.547 video fluoroscopy 8.91 0.768 2.548 7.197 10.621 the anova results for the recovery time, as shown in figure 7, revealed a statistically significant difference among the groups (f (2, 61) = 4.555, p = .014). this indicates that the mean recovery time varied significantly depending on the method of recovery and follow-up. based on the results of levene’s test for homogeneity of variances, which yielded non-significant findings (p > 0.05), indicating the correlation of the assumption of homogeneity of variances, bonferroni correction was applied to assess pairwise differences in recovery time between different methods of recovery. the results indicated significant differences in the recovery time between patients undergoing st and those recovering spontaneously (mean difference = 2.43968, p = 0.017, 95% ci [0.3466, 4.5328]), as well as between patients recovering spontaneously and those undergoing vf (mean difference = -2.52020, p = 0.085, 95% ci [-5.2820, 0.2415]). however, there was no significant difference in the recovery time between patients undergoing st and those receiving vf (mean difference = -0.08052, p = 1.000, 95% ci [-2.5749, 2.4139]). these findings suggest that recovery time varies significantly depending on the intervention method, with st showing a shorter recovery time than spontaneous recovery, while no significant difference was observed between vf and the other methods. pa ge 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 1-11, 2024 figure 7: anova results for the recovery time multiple comparisons dependent variable: recovery time bonferroni based on the analysis conducted, the mean recovery time for patients with ischemic stroke was found to be 7.64 months (sd = 3.62), whereas for patients with hemorrhagic stroke, it was 8.43 months (sd = 2.79). an independent samples t-test was performed to compare the mean recovery time between these two groups, yielding a t-value of -0.973 (df = 62, p = 0.334), assuming equal variances. these results indicate that there is no significant difference in the mean recovery time between patients with ischemic and hemorrhagic strokes (p > 0.05). therefore, stroke type does not appear to influence the duration of recovery time significantly in our sample. table 3: analysis of treatments variable method of recovery mean std. error sig. 95% confidence interval for mean lower bound upper bound speech therapy spontaneously 2.43968* .85023 .017 .3466 4.5328 video fluoroscopy -.08052 1.01325 1.000 -2.5749 2.4139 simultaneously speech therapy -2.43968* .85023 .017 -4.5328 -.3466 video fluoroscopy -2.52020 1.12184 .085 -5.2820 .2415 video fluoroscopy speech therapy .08052 1.01325 1.000 -2.4139 2.5749 spontaneously 2.52020 1.12184 .085 -.2415 5.2820 the mean difference is significant at the 0.05 level table 4: correlation analysis between age and recovery time recovery type of stroke n mean std. deviation st. error mean recovery time (months) ischemic 22 7.64 3.62 0.77 hemorrhagic 42 8.43 2.79 0.43 the correlation analysis between age and recovery time, as shown in figure 4, yielded a pearson correlation coefficient of 0.300, statistically significant at the 0.05 level (2-tailed), with a p-value of 0.016. this indicates a moderate statistically significant positive correlation between age and recovery time. as age increases, recovery time tends to increase as well, suggesting that older patients may require more recovery time than younger patients. a multinomial logistic regression analysis was conducted to examine the relationship between the phase affected in swallowing (pharyngeal, oral propulsive, oesophagal) and covariates, including age and location of stroke. model fitting information revealed that the final model pa ge 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 1-11, 2024 did not significantly differ from the intercept only model (χ² = 9.580, df = 6, p = 0.143), indicating adequate model fit. pseudo r-square values indicated that the model explained 13.9% to 17.0% of the variance in the dependent variable. likelihood ratio tests compared the final model to reduced models without covariates. results showed that neither the location (χ² = 6.635, df = 3, p = 0.084) nor age (χ² = 2.173, df = 3, p = 0.537) significantly improved model fit. parameter estimates revealed that the location of the stroke had a borderline significant effect on the likelihood of the pharyngeal phase (p = 0.144), while age did not significantly predict the phase of swallowing, as shown in table 5. table 5: pseudo r-square test phase affected covariate b st. error wald df sig. exp (b) 95% ci lower bound upper bound pharyngeal intercept 15.995 7.938 4.06 1 0.044 location -2.355 1.611 2.136 1 0.144 0.095 0.004 2.233 age 8.848 8.512 1.081 1 0.299 oral propulsive intercept 8.848 8.512 1.081 1 0.299 location -0.146 1.741 0.007 1 0.933 0.864 0.029 26.199 age -0.103 0.111 0.868 1 0.351 0.902 0.726 1.121 esophageal intercept 12.408 8.13 2.329 1 0.127 location -0.676 1.643 0.169 1 0.681 0.509 0.02 12.726 age -0.133 0.105 1.596 1 0.207 0.876 0.713 1.076 discussion this study provides valuable insights into the sociodemographic characteristics of stroke patients and identifies significant associations between age, gender, type of stroke, location of stroke, recovery time and method that helped in recovery. the observed age difference across stroke types emphasizes the need for personalized approaches in stroke management. additionally, the absence of significant associations between gender and affected swallowing phase and type of stroke and swallowing phase highlights the complexity of these relationships. it underscores the importance of further research in this area. the analysis revealed a statistically significant difference in recovery time based on the intervention approach. patients receiving st exhibit a shorter recovery time compared to those recovering spontaneously. in contrast, vf did not show a significant difference in recovery time compared to other methods. the kolmogorov-smirnov test confirmed a normal distribution of the data, while the analysis of stroke prevalence revealed a significant association between gender and stroke types. in the past few years, the prevalence of is has become higher in women compared to men. women in middle age highlighted the higher risk is with the onset of menopause, oral contraceptive pill use, pregnancy, imbalance of female sex hormones and hormone replacement therapy. after the era of middle age, the incidence risk was reported to be higher in elderly women (age >85 years) than in elderly men (roy-o’reilly & mccullough, 2018). however, critical factors such as hypertension (weakened blood vessel walls, making them more prone to rupture and cause hs), smoking, obesity, and the utilization of opioids have been significantly associated with higher rates of hs in men compared to women (ahangar et al., 2018). the analysis of variance (anova) comparing age differences across different types of strokes did not yield a significant difference, indicating that the mean age of patients with is was comparable to that of patients with hs. however, upon further examination, patients with is exhibited a notably higher mean age than those with hs. ageing has been the most common factor of stroke, varying from 6.6 to 11.4 in 100,000 adults per year, while in older people, the risk factors were higher (lutski et al., 2017). structural changes in blood vessels, such as atherosclerosis, where the arteries narrow and become less flexible (okeahialam & sirisena, 2023). this narrowing restricts blood flow to the brain, increasing the likelihood of blood clots forming and causing an ischemic stroke (el amki & wegener, 2017). additionally, higher prevalence of risk factors for stroke in older individuals have been found, including high cholesterol, hypertension, diabetes, and atrial fibrillation. these conditions can damage blood vessels over time and promote the formation of blood clots, further elevating the risk of stroke (hu et al., 2017; morseth et al., 2021). according to the chi-square test results, no statistically significant association has been found between gender and the affected swallowing phases (χ² (3) = 4.577, p = 0.206). in contrast, the association of stroke types and the affected swallowing in patients with is and hs were observed to have difficulty in the pharyngeal, oral propulsive, oesophagal, and oral preparatory phases. dysphagia following a stroke occurs due to disturbance of upper motor neurons toward nuclei in the medulla pa ge 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 1-11, 2024 oblongata (pseudobulbar palsy) or brain stem lesions (bulbar palsy), resulting in delayed swallowing reflex, decreased movement of larynx, residual food in the pyriform sinus, loss of swallowing reflex, and insufficient opening of the oesophagal orifice (maeshima, 2019). the chi-square test between the location of the stroke and the affected swallowing phases revealed a significant association. it highlighted the importance of considering both factors in stroke management and rehabilitation strategies, with bulbar strokes predominantly associated with difficulty in the pharyngeal phase and pseudobulbar strokes exhibiting a more evenly distributed pattern across swallowing phases. in cases of bulbar strokes, this critical phase of swallowing can be significantly impacted, leading to swallowing difficulties and an increased risk of aspiration. according to a study, the major cases of psd have been distributed into two categories: pseudo bulbar, responsible for disturbing the motor neurons on the upper side towards the medulla oblongata nuclei, while bulbar has been associated with the lower neurons from the nuclei of the medulla in the brain stem (maeshima, 2019). bulbar strokes affect the medulla oblongata, which controls various essential functions, including swallowing (iordanova & reddivari, 2019), while pseudobulbar strokes affect the corticobulbar pathways, which are responsible for transmitting motor signals from the cerebral cortex to the brainstem nuclei involved in swallowing and other functions (iordanova & reddivari, 2019). according to the results of anova, patients who received st recovered faster than those who recovered spontaneously. meanwhile, vf showed a trend towards faster recovery than spontaneous healing. however, there was no significant difference between the st and vf groups. the study highlights that the st was linked to a shorter recovery than other therapies. this evidence has been supported by the findings of several studies concluding that the st showed a statistically significant improvement in dysphagia and assessment of oral intake in stroke patients (choy et al., 2024; jones et al., 2018; tanashyan et al., 2018; turra et al., 2021). however, several studies have also identified video fluoroscopic swallowing training as being substantially effective in alleviating psd (carbo et al., 2021; carucci & turner, 2015; gonzálezfernández et al., 2015; thiyagalingam et al., 2021). the results suggested that st may be the most promising strategy for quicker recovery from swallowing difficulties after a stroke. these findings highlight significant factors leading to is and hs, highlighting the importance of considering them as potential factors in stroke subtype classification and management strategies. the findings contribute to the existing knowledge in stroke research and may guide healthcare professionals in tailoring interventions based on patient-specific characteristics. study limitations and future recommendations a few limitations were encountered in the study. the limitations include the relatively small sample size and the retrospective design, which might have constrained the generalizability of the findings. while the study focused on the association between the stroke location and swallowing difficulty, the analysis did not encompass other potential factors, such as comorbidities or the severity of the stroke. additionally, the lack of long-term follow-up information has limited the specific results of the study to assess the persistence or resolution of swallowing difficulties over time. these limitations revealed the importance of future research with large prospective studies, larger sample sizes, and longterm follow-up assessments to understand better the effectiveness of different rehabilitation approaches and the various factors responsible for chronic psd. however, further research is warranted to explore innovative approaches and technologies to improve swallowing function, reduce complications in this vulnerable population, and validate these findings in larger and more diverse patient populations. conclusion dysphagia is a common and significant complication of stroke, with profound implications for patient health and well-being. this study provides valuable insights into stroke patients’ demographic characteristics and clinical features, particularly regarding stroke types, age differences, and affected swallowing phases. significant associations between gender and stroke type, as well as stroke location and affected swallowing phases, have been found. additionally, recovery time varied significantly depending on the method of intervention, with st associated with shorter recovery times. notably, patients undergoing speech therapy exhibited shorter recovery times than spontaneous recovery, highlighting the efficacy of this intervention. these findings underscore the importance of considering these factors in stroke patients’ diagnosis, treatment, and management. ethical concern the study was conducted after obtaining ethical approval from the department of otolaryngology, hmc, doha, qatar. in addition, consent was obtained from the participants or their relatives, but participants could not provide consent due to their medical condition. acknowledgements the authors extend their appreciation to the iran university of medical sciences. references ahangar, a. a., saadat, p., heidari, b., taheri, s. t., & alijanpour, s. 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(2021). repetitive transcranial magnetic stimulation at different sites for dysphagia after stroke: a randomized, observer-blind clinical trial. frontiers in neurology, 12, 625683. pa ge 1 pa ge 67 american journal of medical science and innovation (ajmsi) an outcomes comparison between nurse practitioners and primary care physicians in quality of life in older patients with congestive heart failure dr. mohammad i. d. ibrahim1*, shannon1, mccrory-churchill1 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.2935 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 31, 2024 accepted: september 02, 2024 published: september 06, 2024 chronic heart failure (chf) is a prevalent cardiovascular disease affecting patients’ outcomes and quality of life. nurse practitioners (nps) and primary care physicians (pcps) are renowned for their positive impact on patient satisfaction and quality of life. however, the extent to which they achieve these results still needs to be explored. the study aimed to determine if the disease course of older chf patients under nps and pcps remained consistent, focusing on patients’ satisfaction levels in np care compared to those in pcp care in primary care settings. a comparative observational design was used to recruit chf patients aged 65 and above from nursing homes in ontario, canada. subjects completed the 12-question questionnaire to gauge satisfaction and overall quality of life. results were analysed using anova as outcome indicators of the nps and pcps were to be compared. findings showed no significant variation in quality of life score measurement between np and pcp patients. both (nps and pcps) were revealed to be equally strong in meeting the demanding chf patients’ needs. the study emphasises the crucial role of nurse practitioners (nps) in multidisciplinary team chf care, highlighting their role in improving patient outcomes and healthcare delivery. it acknowledges the limitations of the measurement study, such as sample size, and contributes to ongoing debates on healthcare delivery. keywords congestive heart failure, nurse practitioner, primary care physicians, quality of life, patient satisfaction 1 d’youville university, buffalo, ny, usa * corresponding author’s e-mail: abkasm2009@yahoo.com introduction congestive heart failure (chf) has emerged as one of the most pressing public health issues all over the world, causing a major shift in the approach of health care systems, enhancing the morbidity and mortality rates, and deteriorating the quality of life of the patients. the entire of canada houses up to 750 thousand people suffering from chf, an array of numbers that demonstrates this problem’s prevalence. congestive heart failure survivability rates are anticipated to rise significantly over the next ten years, along with the related hospitalisation figures. thus, this stark reality of chf resilience proves its critical role in defeating this condition as it burdens healthcare services and incurs extra costs (canada, 2022). the chf problem is not restricted to statistics only but extends to other aspects, such as the impact on patient’s lives and their families. heart failure has a much wider significance as, according to the report of the heart and stroke foundation of canada, nearly one-third of the population across canada is, in one way or another, either directly or indirectly connected to the symptoms of heart failure. also, the complications that result in rehospitalisation are high among patients older than 65 years, especially considering it is both chf patients and healthcare providers who endure the challenges (canada, 2022). through the years, primary care physicians (pcps) have proved to be a core piece of care in treating chf patients, acting as the first step in receiving care (hung et al., 2022). nevertheless, accompanied by the reconfiguration of the medical model and the progress of development, the role of nurse practitioners has become more in demand. nurse practitioners (nps) can perform the following roles as advanced practice registered nurses after their registered nurse spare: assess patients, provide treatments, order diagnostic tests, and educate them about their diseases (king-dailey et al., 2022). this merged sense of jurisdiction makes nps star members of the interdisciplinary care coordination for chf patients. even if nps have been steadily welcoming health systems, uncertainty remains concerning their performance in occupying what pcps should have occupied in delivering care to chf patients. investigations show that nps help achieve positive patient results, boost patients’ satisfaction and decrease healthcare expenses (o’toole et al., 2019). studies are required to elaborate on nps’ supremacy or equality to pcps in this field. as demonstrated by a prior study, outcomes of the treatment and the patients with chf show few differences in the quality between nurse practitioners and primary care physicians (baecker et al., 2020). even though the data indicates incontrovertibly that a nurse practitioner (np) is as capable as a physician to treat a patient, several states continue to dictate how their nps should conduct their operations, especially prescriptions, where they feel they are the only ones who should be doing it (muench et al., 2019). nps have specialised training in education, therapy, and advocacy (king-dailey et al., 2022). nurse-led, structured instruction during hospitalisation and after discharge improves self-management abilities in patients with chronic heart failure (cui et al., 2019). nps have provided low-priced, high-quality treatment for nearly pa ge 68 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 67-74, 2024 half a century, and the data is indisputable (kuo et al., 2018). more patients are satisfied with their care, fewer unnecessary emergency department visits are made, and fewer hospitalisations are required among patients handled by nps in a clinic administered by congestive heart failure. there is much overlap between the roles of nps and physicians, even though they have different levels of education and licensing (jiang et al., 2020). nps and physicians work together in over half of the inpatient medical services provided by the veterans health administration, with little distinction between their duties and how administrators view their ability to provide care (jiang et al., 2020). however, there needs to be more clarity of the relative patient’s care between physician and nps over who does what in the healthcare system. lewis’s (2021) study revealed that a patient education booklet based on scientific data helps manage congestive heart failure, especially when paired with targeted visits from a nurse practitioner, chf patients benefitted from the np visits (lewis, 2021). another study showed improved results, such as reducing chf hospital readmissions and increasing quality of life (qol) through a nurse-led intervention program for patients with chf (ortiz-bautista et al., 2019). in addition, king dailey et al. (2022) in their study state that nurse practitioners (nps) focus on health promotion, illness prevention, and patient satisfaction as they diagnose, treat patients, prescribe medicine, and refer and manage acute and chronic disorders (king-dailey et al., 2022). however, in their study, gerlier et al. (2023) emphasise that there needs to be more clarity between physicians and nps over who does what in the healthcare system. according to gerlier et al. (2023), more nurse practitioners than physicians believe that nps should be able to admit patients to hospitals and receive equivalent pay as physicians for performing the same clinical services. as a result, nps and physicians contribute to an equal level of health care in primary care settings for chf patients (gerlier et al., 2023). this study aims to fill a knowledge gap by comparing the role of nurse practitioners (nps) and primary care practitioners (pcp) in achieving better lifestyles and satisfaction for older chronic heart failure (chf) patients in primary healthcare settings. the study systematically analyses patient satisfaction surveys to adjust chf management and inform nps’ benefits. the results can guide national health policies and processes, enabling competent nps to work alongside multidisciplinary care teams for chf patients and maximise treatment outcomes. the study also advances the importance of nps in dealing with comprehensive chf patient issues and optimises healthcare delivery. methodology study design this study adopted a comparative observational method to gauge the efficacy of nurse practitioners (nps) and primary care physicians (pcps) in assessing the quality of life and satisfaction of older chf congestive patients in primary care. sample selection and recruitment procedure using stratified and convenience sampling, participants were chosen from the niagara falls region, ontario, canada, nursing homes. a party of subjects was included by the criteria in which participants who had diligent congestive heart failure (chf), aged 65 years and above, could understand the study protocol and give informed consent. recruitment was carried out through personal interactions with those who had to meet the eligibility criteria: individuals in the nursing home facility. questionnaire survey participants who gave written consent were given a 12-question survey to measure satisfaction and quality of life. in-person distribution of the surveys carried out by impartial office workers is the method office staff used. this ensures that all respondents are unaffected by other staff in providing accurate responses. data collection while the survey consisted of 12 questions designed to assess participants’ satisfaction level and quality of life, data collection was among the primary objectives of this study. only those patients aged 65 years and above living in nursing homes in the niagara falls region, ontario, who described chf were enrolled in the study group. purposive and easy sampling methods were applied to administer the pool of respondents who could comprehend the study information and offer informed consent. statistical analysis statistical analysis was conducted using the statistical package for the social sciences (ibm spss statistics 21). a one-way repeated measures anova was performed to compare nurse practitioners nps and pcps in terms of quality-of-life satisfaction in older patients with chf. statistical significance was set at p < 0.05 results table 1 presents descriptive statistics for different levels of the subject variable. in the “v. poor” category, participants in the np condition had a mean rating of 0.6667 with a standard deviation of 0.98473. in contrast, those in the pcp condition had a mean rating of 0.2500 with a standard deviation of 0.62158. the overall mean for this category was 0.4583. in the “poor” category, participants in the np condition had a mean rating of 0.4167 with a standard deviation of 0.66856. in contrast, in the pcp condition, the mean rating was 0.2500 with a standard deviation of 0.45227. pa ge 69 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 67-74, 2024 table 2 presents the results of multivariate tests assessing the effects of factor1 on the dependent variable and its interaction with the subject variable. all four multivariate test statistics (pillai’s trace, wilks’ lambda, hotelling’s trace, and roy’s largest root) yielded highly significant results (p <.001), indicating a significant overall effect of factor 1 on the dependent variable. however, the interaction between factor 1 and the subject showed non-significant results (p-values of.477), suggesting no significant interaction between factor 1 and the subject on the dependent variable. table 1: descriptive statistics subject mean std. deviation n v.poor np .6667 .98473 12 pcp .2500 .62158 12 total .4583 .83297 24 poor np .4167 .66856 12 pcp .2500 .45227 12 total .3333 .56466 24 fair np 1.6667 1.87487 12 pcp 2.0000 1.41421 12 total 1.8333 1.63299 24 good np 11.8333 2.85509 12 pcp 11.5000 2.02260 12 total 11.6667 2.42571 24 v.good np 10.4167 3.84846 12 pcp 11.0000 2.73030 12 total 10.7083 3.27678 24 table 2: multivariate tests effect value f hypothesis df error df sig. factor1 pillai's trace .993 632.149b 4.000 19.000 <.001 wilks' lambda .007 632.149b 4.000 19.000 <.001 hotelling's trace 133.084 632.149b 4.000 19.000 <.001 roy's largest root 133.084 632.149b 4.000 19.000 <.001 factor1 * subject pillai's trace .161 .912b 4.000 19.000 .477 wilks' lambda .839 .912b 4.000 19.000 .477 hotelling's trace .192 .912b 4.000 19.000 .477 roy's largest root .192 .912b 4.000 19.000 .477 table 3 presents the results of tests assessing the significance of factor 1 and its interaction with the subject variable on the dependent variable. the main effect of factor 1 is significant, with a variance of 3107.083 units. the f-test yielded a high factor 1ificant result under sphericity assumptions, confirming the main effect of factor 1. greenhouse-geisser, huynh-feldt, and lowerbound corrections confirmed the significance of factor 1’s main effect. the interaction between factor 1 and the subject was non-significant under all assumptions, indicating no significant interaction effect. the error term represents the variance within the factor1 variable, with substantial f-values under all assumptions. these findings provide insights into the main effect of factor 1 and its interaction with the subject on the dependent variable. table 3: tests of within-subjects effects source type iii sum of squares df mean square f factor1 sphericity assumed 3107.083 4 776.771 147.850 greenhouse-geisser 3107.083 1.516 2049.299 147.850 huynh-feldt 3107.083 1.679 1850.787 147.850 pa ge 70 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 67-74, 2024 lower-bound 3107.083 1.000 3107.083 147.850 factor1 * subject sphericity assumed 4.583 4 1.146 .218 greenhouse-geisser 4.583 1.516 3.023 .218 huynh-feldt 4.583 1.679 2.730 .218 lower-bound 4.583 1.000 4.583 .218 error(factor1) sphericity assumed 462.333 88 5.254 greenhouse-geisser 462.333 33.356 13.861 huynh-feldt 462.333 36.933 12.518 lower-bound 462.333 22.000 21.015 table 4 presents the results of tests of within-subjects contrasts, evaluating linear, quadratic, cubic, and fourthorder trends within the factor1 variable and their interactions with the subject variable. the type iii sum of squares indicates significant differences across all contrast types, indicating complex patterns of change in the dependent variable across its levels. however, no significant interactions between the trends within factor1 and the subject variable were found, as indicated by nonsignificant f-values for linear, quadratic, cubic, and fourthorder trends (all p >.05). the error term represents the variance within the factor1 variable after accounting for other effects, showing significant f-values for all contrast types, indicating substantial variance within the factor1 variable across all trends. these findings provide insights into the considerable trends within the factor1 variable and their interactions with the subject on the dependent variable table 4: tests of within-subjects contrasts source type iii sum of factor1 squares df mean square f sig. factor1 linear 2432.067 1 2432.067 763.092 <.001 quadratic 76.190 1 76.190 8.072 .010 cubic 370.017 1 370.017 63.738 <.001 order 4 228.810 1 228.810 88.553 <.001 factor1 * subject linear 2.017 1 2.017 .633 .435 quadratic .012 1 .012 .001 .972 cubic 1.067 1 1.067 .184 .672 order 4 1.488 1 1.488 .576 .456 error(factor1) linear 70.117 22 3.187 quadratic 207.655 22 9.439 cubic 127.717 22 5.805 order 4 56.845 22 2.584 table 5 presents the results of tests of between-subjects effects, focusing on the intercept and subject variables. the intercept row represents the overall mean across all subjects, with a type iii sum of squares of 3000.000 and 1 degree of freedom. the p-value is not reported, and the partial eta squared value is 1.000, indicating that the intercept explains all the variance in the dependent variable. for the subject variable, the type iii sum of squares is 0.000 with 1 degree of freedom, indicating no significant effect. the p-value and partial eta squared are also not reported, suggesting a lack of significant impact. the error term represents residual variance not accounted for by the intercept or subject variables, with a type iii sum of squares for an error of 0.000 with 22 degrees of freedom. in summary, neither the subject variable nor any other between-subjects effects significantly contribute to the variance in the dependent variable. table 5: tests of between-subjects effects source type iii sum of squares df mean square f sig. partial eta squared intercept 3000.000 1 3000.000 1.000 subject .000 1 .000 error .000 22 .000 pa ge 71 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 67-74, 2024 table 6 shows the estimated marginal means for different levels of factor 1, ranging from 1 to 5. for factor 1 level 1, the marginal mean is 458, with a standard error of.168. the 95% confidence interval ranges from 110 to 807. at level 2, the marginal mean is 333, with a standard error of.117. moving to level 3, the marginal mean increases to 1.833, with a larger standard error of.339. for level 4, the marginal mean is 11.667, with a standard error of.505, and at level 5, the marginal mean is 10.708, with a larger standard error of.681. these estimates provide insights into the expected values of the dependent variable at each level of factor 1, along with their associated standard errors and confidence intervals. table 6: estimated marginal means factor1 mean std. error 95 lower bound % confidence interval upper bound 1 .458 .168 .110 .807 2 .333 .117 .092 .575 3 1.833 .339 1.130 2.536 4 11.667 .505 10.619 12.714 5 10.708 .681 9.296 12.121 table 7: pairwise comparisons (i) factor1 (j) factor1 mean difference (i-j) std. error sig. b 95% confidence interval for differenceb lower bound upper bound 1 2 .125 .223 .581 -.337 .587 3 -1.375* .365 .001 -2.131 -.619 4 -11.208* .584 <.001 -12.419 -9.998 5 -10.250* .702 <.001 -11.707 -8.793 2 1 -.125 .223 .581 -.587 .337 3 -1.500* .339 <.001 -2.202 -.798 4 -11.333* .506 <.001 -12.383 -10.284 5 -10.375* .723 <.001 -11.875 -8.875 3 1 1.375* .365 .001 .619 2.131 2 1.500* .339 <.001 .798 2.202 4 -9.833* .538 <.001 -10.948 -8.718 5 -8.875* .956 <.001 -10.857 -6.893 4 1 11.208* .584 <.001 9.998 12.419 2 11.333* .506 <.001 10.284 12.383 3 9.833* .538 <.001 8.718 10.948 5 .958 1.125 .403 -1.374 3.291 5 1 10.250* .702 <.001 8.793 11.707 2 10.375* .723 <.001 8.875 11.875 3 8.875* .956 <.001 6.893 10.857 4 -.958 1.125 .403 -3.291 1.374 table 7 presents pairwise comparisons between different levels of factor 1. the mean difference between level 1 and level 2 is 125, with a standard error of.223, which is not statistically significant. level 1 is significantly lower than level 3, level 4, and level 5, with mean differences of -1.375, -11.208, and -10.250, respectively. comparing level 2 with other levels, level 2 is similar to level 1 but is significantly lower than levels 3, 4, and 5. level 3 is considerably higher than levels 1 and 2 but lower than levels 4 and 5, with mean differences of -9.833 and -8.875. level 4 is significantly higher than levels 1, 2, and 3 but similar to level 5. these pairwise comparisons provide insights into the differences between each pair of factor 1 levels, indicating where significant differences exist and their magnitude. table 8 presents the results of univariate tests for the contrast factor. the sum of squares is 2.776e-17 with 1 degree of freedom, resulting in a mean square of 2.776e17. the f-statistic is 172, and the associated significance value is.682, indicating that the observed variation is not statistically significant at the conventional alpha level of.05. the partial eta squared value, which represents the proportion of variance explained by the contrast factor while controlling for other factors, is 008. pa ge 72 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 67-74, 2024 discussion congestive heart failure (chf), as one of the major illnesses in the world, has taken a serious toll on the healthcare system, causing many complications and high costs. this experiment aimed to examine the efficiency of nurse practitioners (nps) versus primary care physicians (pcps) in terms of the dependence on improving the quality of life and the satisfaction of older chf patients in primary care institutions. using the odds ratio and chisquare test (χ2), we attempted to show the proficiency of nps in charting and improving the management of chf along with their patient satisfaction experience. our findings are important for evaluating the effectiveness of nps and pcps in the treatment of patients with chf. however, the outcomes underlined that nps and pcps share the common tasks of addressing chf complications, and no significant difference was observed in the satisfaction level concerning their quality of life between the two classes. these articles regard this phenomenon preliminarily as the professional experience of np and pcp with the same level of high-quality management of chronic ailments like chf of similar effectiveness (baecker et al., 2020). the work, overall, assists in filling the gaps in the existing evidence-based literature on np participation in chf care by confirming that nps are providers of better quality care to chf patients, thus integrating them into central care teams. our study suggests that nps can efficiently manage chf patients in primary care contexts, which might be provided as an alternative to or complementary to the traditional care in which physicians lead. thus, our project aims to corroborate these earlier findings, which concluded that patient outcomes improved when the intervention was nurse-led (lowery et al., 2012). for this reason, our study highlights the significance of specifying np functions and duties and how physicians should be involved in healthcare delivery. nevertheless, our findings emphasise the parallel roles of nps and physicians in patient care. the two groups give equal importance to the desired results in the case of chf management, patient satisfaction with treatment and response. a similar idea reiterates the comments that were made earlier that clear and consensus definitions of the scopes of practice for aprns are vital, and collaboration between health workers is crucial (norful et al., 2019). contrary to common expectations, our study concludes that people are more satisfied and feel better about quality of life visiting either np or pcp than in the cases reported in the previous study. such things may be differentiated into parameters such as extended usage of digitised healthcare delivery models, improved patient education and information access and self-management approaches. in addition, our positive results point to the quality of general healthcare and the aspect of patientcentred care programs (barratt & thomas, 2018). this study also brings forward several recommendations to be the basis of healthcare regulations and actions. first of all, it demonstrates why the inclusion of nps in multidisciplinary chf care is needed to measure great patient results and increase the effectiveness of healthcare delivery. nps have various skills useful in improving the integrity and access to top-notch care, including mostly underserved populations and patients in rural and remote areas. additionally, our report audience is called upon to periodically conduct refresher courses and workshops for nps to enable them to remain updated with evidencebased care and more capable of satisfying chf patients’ changing needs (forsyth et al., 2024). additionally, our study illustrates the determination to build contact and communication between nps and physicians to get the best in chf management techniques. healthcare establishments may achieve this integrated approach to care through the teamwork of physicians and nps. this would allow patients to be given the best comprehensive care. this supports multidisciplinary education and collaborative practice, which help practitioners of the professions integrate. this improves healthcare for the patients and makes healthcare delivery efficient and effective (schot et al., 2020). our results are valid with the study by ruan et al. (2023), who focused more on the crucial role of nurse-led interventions in treating chronic heart failure (chf) patients. lewis implemented a project involving a chosen group of patients with chf under the supervision of nurses and providing educational materials based on scientific evidence, leading to improved outcomes. likewise, our study represents nps’ role in improving the quality of life and patient satisfaction, which implies that nurse-led management is highly important in optimising chf management (ruan et al., 2023). secondly, we have also found that our findings align with the study of norful et al. (2017), who showed how nurse practitioners (np) play an effective role towards chf patients, including the low-cost but high-quality provision of health care. a report from the university of california-kuo managed patients rated np’s meditation as significantly satisfactory, with greater personalised care delivery, reduced emergency department visits, and hospitalisation rates. along with other studies that showed similar findings, our study is another piece of data highlighting nps’ outstanding value to chf management and primary care settings (norful et al., 2017). alongside that, the study caters to the gap illuminated by gigli & gonzalez (2022) on the need for more table 8: univariate tests sum of squares df mean square f sig. partial eta squared contrast 2.776e-17 1 2.776e-17 .172 .682 .008 error 3.553e-15 22 1.615e-16 pa ge 73 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 67-74, 2024 understanding of the roles and responsibilities of nps and physicians within the healthcare industry. gerlier et al. put forward the opinion that the scope of practice should be well-defined, and nps should be paid for their services similarly to all the other medical providers. the study, therefore, presents formal evidence suggesting the possibility of nps providing optimal care to the elderly with multiple chronic diseases of the long-term type (gigli & gonzalez, 2022). our study forms part of the evidence base for the growing number of studies which endorse nps in primary care settings for effective chf management. our analysis indicates that the quality of patient care is equal for both nps and pcps in terms of increased patient satisfaction and improved quality of life, with the implication of increased involvement of nps in the chf medical team and wider collaboration among healthcare professionals. that being said, it is equally necessary to keep improving the models of care as provided in this role and integrate the input and support of nps to attain better patient care and a more comfortable experience for them in chf management. limitations future implications this study contains limitations, such as english-only questionnaires and the sample group picked in specific north american regions. being an additional asset to a few countries is better if those countries can access them. still, there is a permanent physician shortage, and for an np to bring safety and quality of care through all the life stages, further study is needed. the patients may put their expectations on nps and physicians differently, which could cause more trouble in patient satisfaction. thus, a thorough study is required to identify the elements affecting satisfaction and the effort nps need to use to be a part of it. conclusion in conclusion, this study shows empirically that compared to nurse practitioners (np) and mcps, patient age is a significant factor in propagating chf among older patients. findings indicate that chf patients experience a mix of symptoms, which care by both nps and pcps proves necessary and offers no differences in quality-of-life satisfaction. the study underlines that the multidisciplinary management of chf and the involvement of nps in such teams lead to better patient outcomes and increased healthcare quality. this study then gives examples of nps and physicians working together in unison to make the strategies employed in managing the problems of chf more effective. however, due to such limitations as a small sample size and examination of only subjectively reported outcomes, the study can only furnish the initial and tentative data. for established results, future studies with bigger samples and different conditions will only be able to validate and give a bigger extent to the given results. in general, the study is a tool towards a common objective of influencing the existing discussions in healthcare provision and primary care improvement. references baecker, a., meyers, m., koyama, s., taitano, m., watson, h., machado, m., & nguyen, h. q. 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(2020). working on working together. a systematic review on how healthcare professionals contribute to interprofessional collaboration. journal of interprofessional care, 34(3), 332-342. https://doi.org/ 10.1080/13561820.2019.1636007 pa ge 1 pa ge 91 american journal of medical science and innovation (ajmsi) miliary tuberculosis causing presumed primary adrenal insufficiency and addisonian crisis: a case report from rural kenya vonwicks c. onyango1*, boniface mutiso2, nicholas m. mutuma2, collins p. malalu2, nicholas auma3, william c. fryda md.1 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2773 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 05, 2024 accepted: may 10, 2024 published: may 14, 2024 primary adrenal insufficiency (addison’s disease) is characterized by inadequate production of cortisol from the adrenal glands due to diseases of the adrenal gland. due to the insidious onset and non-specific nature of the symptoms of adrenal insufficiency, diagnosis is often delayed until patients present with an adrenal crisis. the three most common causes are autoimmune adrenalitis, infections, e.g., disseminated tuberculosis, hiv, systemic mycoses, and adrenal hemorrhage or infarction. miliary tuberculosis of the adrenal gland occurs in high-tb burden populations by hematogenous spread of tuberculous bacilli to the gland, causing caseous necrosis, or by extra-adrenal infection and rifampicin-induced adrenal insufficiency. in this study, we report on the case of a middle-aged woman in rural kenya who initially presented with missed features of adrenal insufficiency and subsequently went into an adrenal (addisonian) crisis, which was successfully managed with glucocorticoids, fluids, and supportive therapy. keywords primary adrenal insufficiency, addison’s disease, adrenal crisis, addisonian crisis, miliary tuberculosis, tuberculous adrenal insufficiency, glucocorticoid, kenya 1 department of medicine, st. joseph rift valley hospital, gilgil, nakuru county, kenya 2 department of outpatient, st. joseph rift valley hospital, gilgil, nakuru county, kenya 3 department of endoscopy, st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction adrenal insufficiency is characterized by an absolute or relative deficiency in the production of glucocorticoid (cortisol) from the adrenal cortex due to destruction of the adrenal cortex or a lack of stimulation of adrenocorticotrophic hormone (acth) (hahner et al., 2021). this can be primary (caused by diseases of the adrenal gland), secondary (caused by impaired secretion of acth by the pituitary gland, e.g., in panhypopituitarism from any cause, brain injury, high dose progestins, etc.), or tertiary (caused by interference with the secretion of corticotropin-releasing hormone (crh) by the hypothalamus, typically by exogenous administration of high dose glucocorticoid therapy) (grossman, 2010; hahner et al., 2021; joseph et al., 2016). primary adrenal insufficiency (addison’s disease) is caused by the destruction or dysfunction of the adrenal cortex and manifests with features of cortisol and aldosterone deficiency. the most common causes of addison’s disease are autoimmune adrenalitis, infections (e.g., disseminated tuberculosis, hiv, and disseminated fungal infections like histoplasmosis), adrenal hemorrhage and infarction, metastatic cancers (e.g., primary colon, breast, lung, gastric, and lymphoma), and drugs, e.g., ketoconazole, fluconazole, rifampicin, etc. (barthel et al., 2019). tuberculosis causing addison’s disease is due primarily to the hematogenous spread of tubercle bacilli into the adrenal cortex, leading to caseous necrosis of the glands, or by extra-adrenal infection, and as a by-product of anti-tuberculous therapy with rifampicin (vinnard & blumberg, 2017). typically, >90% of the gland has to be destroyed before symptoms of adrenal insufficiency ensue. although the incidence of tuberculous addison’s disease has been declining globally due to more effective tb management (nomura et al., 1994), tb is still a major cause of adrenal insufficiency in high tb burden populations, e.g., kenya (enos et al., 2018). in a 2024 systematic review, the pooled prevalence of adrenal insufficiency in tuberculosis was 33% (kibirige et al., 2024). clinical features of adrenal insufficiency are often insidious and nonspecific and may include features of adrenal crisis or chronic adrenal insufficiency. adrenal crisis is predominantly characterized by shock as well as multisystemic features (burke, 1985). (see table 1). patients with chronic primary adrenal insufficiency have an insidious onset and gradual development of features of both cortisol and aldosterone deficiency. a diagnosis of adrenal insufficiency is often delayed due to the nonspecificity of the clinical features, e.g., gastrointestinal symptoms (like nausea, vomiting, anorexia, vomiting, abdominal pain, etc.), fatigue, weight loss, musculoskeletal pains, and neuropsychiatric symptoms like altered mental status, psychosis, hallucinations, etc. nonetheless, the occurrence of hyperpigmentation, salt craving, and postural hypotension strongly suggests primary adrenal insufficiency. the diagnosis of adrenal insufficiency is primarily by the adrenocorticotropic hormone stimulation test (synacthen or cosyntropin tests) (ospina et al., 2016). the management of adrenal insufficiency primarily involves the use of corticosteroids (hydrocortisone), mineralocorticoids, supportive therapy, and the treatment of underlying diseases, e.g., the use of anti-tb drugs as pa ge 92 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 91-95, 2024 per local guidelines (lewis et al., 2023). comprehensive guidance for the diagnosis and management of adrenal insufficiency can be found in ‘the clinical guidelines subcommittee of the endocrine society’ (bornstein et al., 2016). hiv rapid test, and stool studies showed no ova or parasites and no blood or mucus. she also had normal liver function tests. her creatinine was elevated at 1.9 mg/ dl, but she had profound hyponatremia with serum na+ of 109 mmol/l (135-145), k+ of 4.1 mmol/l (3.5-5.5), and clof 75 mmol/l (95-108). her lumbar puncture with cerebrospinal fluid analysis was normal. her chest x-ray showed a miliary pattern bilaterally consistent with miliary tuberculosis (see figure 1). an abdomino-pelvic ultrasound and a gastroscopy were both unremarkable. a diagnosis of miliary tuberculosis with acute gastroenteritis complicated with pre-renal acute kidney injury and severe symptomatic hyponatremia was made. following a successful resuscitation, she was started on anti-tb therapy as per local guidelines, with rifampicin, isoniazid, ethambutol, pyrazinamide, and pyridoxine (the latter to mitigate isoniazid-induced peripheral neuropathy), and supportive care. the hyponatremia was successfully managed with a hypertonic saline infusion. she was discharged five days later while lucid and in normal clinical status. table 1: clinical and laboratory findings suggesting adrenal crisis dehydration, hypotension, or shock out of proportion to the severity of the current illness nausea and vomiting with a history of weight loss and anorexia abdominal pain, so-called "acute abdomen" unexplained hypoglycemia unexplained fever hyponatremia, hyperkalemia, azotemia, hypercalcemia, or eosinophilia hyperpigmentation, or vitiligo other autoimmune endocrine deficiencies, such as hypothyroidism or gonadal failure adapted from: burke cw. adrenocortical insufficiency. clin endocrinol metab 1985; 14:947. (burke, 1985) case presentation presenting illness and physical examination a 52-year-old woman, mother of four, and businesswoman from kabatini, nakuru county, kenya, presented to us in september 2023 with altered mental status. she had a preceding 2-week history of recurrent post-prandial and unprovoked non-bilious vomiting, watery, nonbloody diarrhea (2-3 episodes every 2-3 days), generalized abdominal pains, progressive lethargy, and a day-long history of visual hallucinations. these occurred on a background history of recurrent dry cough, drenching night sweats, a 4kg weight loss, and anorexia in the 6 weeks prior. there was no clear history of food poisoning. she neither smoked nor took ethanol. on initial examination, she was severely dehydrated with a tachycardia of 113 bpm, a blood pressure of 117/77 mmhg, afebrile, normal oxygen saturation in room air, and a random blood sugar of 74 mg/dl. her abdomen was diffusely tender but soft, with no organomegaly and no features of peritonism. her glasgow coma scale was 12/15; she had no meningism and no focal neurology, though she was actively hallucinating during the exam. her skin had no rashes or peripheral hyperpigmentation. she was cool to touch in the peripheries with low-volume pulses, but she had normal heart sounds. she had orthostatic hypotension, with her bp dropping from 117/77 mmhg to 90/58 mmhg from recumbent to upright positions. the rest of the exam was unremarkable. diagnostic workup and management her baseline laboratory tests showed a normal complete blood count (cbc), an elevated esr of 50 mm/hr., no malaria parasites on a blood smear microscopy, a negative figure 1: initial cxr showing bilateral diffuse miliary infiltrates, consistent with miliary tuberculosis re-admission in an addisonian crisis however, she was re-admitted 1 month later in a comatose state (gcs of 8/15) with hypothermia (a temperature of 34oc), a tachycardia of 104 bpm, and hypotension (bp of 85/63 mmhg, which dropped to a nadir of 60/42 mmhg). she had a reported 3-week history of recurrent post-prandial vomiting but no diarrhea, vague abdominal pains, dysuria, anorexia but craving salt and licking it several times, lethargy, and confusion. her urinalysis showed leukocytosis and positive nitrites consistent with cystitis. she had neutrophilic leukocytosis with a total leucocyte count of 13x103u/l, severe hyponatremia with na+ of 100 mmol/l, k+ of 5.7 mmol/l, clof 79 mmol/l, and a normal creatinine of 0.6 mg/dl. a thyroid profile and an uncontrasted ct scan of the brain were normal. she initially had a persistently low random glucose of 70 to 90 mg/dl, hypotension needing inotropic support, and hyponatremia with borderline hyperkalemia. in light of these, we made a presumptive clinical diagnosis of adrenal crisis precipitated by cystitis on the background pa ge 93 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 91-95, 2024 of adrenal insufficiency caused by miliary tuberculosis. due to a lack of finances, we could not do further confirmatory tests. the patient was put on intravenous hydrocortisone, normal saline, and supportive therapy. six days later, she had a full resolution of the adrenal crisis and was discharged home stable. see table 2 for a summary of her blood pressure readings, significant laboratory results, and the specific interventions given. during outpatient follow-up, we kept her on tapered doses of oral prednisone (the cheapest available option), with omeprazole and vitamin d/calcium combo tablets for gastroprotection and osteoprotection, respectively. we continued the tb treatment for 6 months as per local protocols and monitored her for any complications related to the steroid therapy. by the end of the 4th month of tb treatment, we stopped the steroids, and her subsequent serum electrolytes, blood pressure, and random blood glucose remained normal until the end of tb treatment and on follow-up so far. her cxr has since normalized. (see figure 2). figure 2: repeat cxr done 4 months after initiating tb treatment showing a complete resolution of the miliary infiltrates table 2: summary of significant blood pressure, laboratory results, and specific interventions date blood pressure (mmhg) creatinine (mg/dl) (0.5-1.0) sodium (mmol/l) (135-145) potassium (mmol/l) (3.5-5.5) glucose (mg/ dl) (72-200) specific interventions 30/9/2023 117/77, 90/58 1.9 109 4.1 7 3% nacl, rhze, b6, ivfs 3/10/2023 112/76 126 3.4 rhze, b6, ors 18/10/2023 116/76 133 4.8 rhze, b6 6/11/2023 85/63, 60/42 0.6 100 5.7 131, 80 rhze, b6, 3% nacl inotropes, ivfs, abx 7/11/2023 92-138/55-72 114 5.9 70, 224, 86 rhze, b6, 3% nacl inotropes, ivfs, abx, steroids 9/11/2023 124-148/64-84 0.7 126 5.8 145, 96, 78 rhze, b6, 3% nacl inotropes, ivfs, abx, steroids 10/11/2023 96-122/62-70 136 4.4 264, 186, 144 rhze, b6, ivfs, abx, steroids 23/11/2023 121/85 126 4.5 155 rhze, b6, steroids, ors, slow na tabs 6/12/2023 126/85 0.7 126 4.0 146 rh, b6, steroids, ors, slow na tabs 5/1/2024 118/84 0.9 133 4.1 115 rh, b6, steroids, slow na tabs 4/3/2024 119/64 0.9 147 4.8 130 rh, b6 3/4/2024 124/83 1.0 150 5.2 150 8/4/2024 126/78 142 4.9 174 key: 3% nacl= 3% sodium chloride (hypertonic saline infusion), rhze= rifampicin, isoniazid, pyrazinamide, ethambutol, b6=vitamin b6 (pyridoxine), ivfs=intravenous fluids (including dextrose and saline infusions), abx=antibiotics, inotropes=adrenaline infusion, steroids=intravenous hydrocortisone or oral prednisone, ors=oral rehydration salt, slow na tabs=slow sodium tablets. discussion the symptoms and signs of adrenal insufficiency are often non-specific and insidious in onset, and may go undetected until some physiological stress precipitates an adrenal crisis. disseminated tb (e.g., miliary tb) remains an important cause of adrenal insufficiency in pa ge 94 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 91-95, 2024 high-tb burden populations (anaforoğlu et al., 2012; enos et al., 2018; vinnard & blumberg, 2017; yokoyama et al., 2009). in retrospect, during her first admission, our patient already had some clinical features of adrenal insufficiency. her recurrent diarrhea and vomiting, abdominal pains, persistent hyponatremia despite replacement, and postural hypotension were all in keeping with adrenal insufficiency (hahner et al., 2021), even though acute gastroenteritis complicated with severe fluid and electrolyte anomalies could also explain them. she later presented with a classical adrenal (or addisonian) crisis (rathbun & singhal, 2024) in her second admission, most likely precipitated by acute cystitis. the diagnosis this time was easily made on the basis of gastrointestinal symptoms, salt craving, persistent shock, hyponatremia, hyperkalemia, and hypoglycemia. (see table 1). adrenal crisis, principally presenting as shock, is a lifethreatening emergency that requires urgent treatment with intravenous glucocorticoids, fluids, and supportive care (rathbun & singhal, 2024). treatment must not be delayed for all suspected patients in order to perform any diagnostic tests, as it carries a high mortality rate of up to 10% (ngaosuwan et al., 2021). biochemical tests for the diagnosis of adrenal insufficiency include measurement of cortisol levels, acth-stimulation assays, etc., as well as diagnostic tests to determine the underlying causes as per endocrinological society guidelines (bornstein et al., 2016). the glucocorticoid of choice is hydrocortisone (it has both glucocorticoid and mineralocorticoid properties), given as a bolus dose of 100mg, followed by 50mg every 6 hours for 24 hours (or 200 mg/24 hours as a continuous infusion), and thereafter tapered to clinical response. one may alternatively use intravenous methylprednisolone or dexamethasone (bornstein et al., 2016). in her case, we gave a bolus dose of intravenous hydrocortisone 200mg, followed by a maintenance dose of 100mg every 8 hours a day for 3 days, before de-escalating to oral prednisone (which is cheaper and more readily available). whereas hyponatremia and hypokalemia are expected to resolve with hydrocortisone and normal saline infusions, in our patient, we administered a 3-day course of hypertonic saline to correct the profound hyponatremia causing altered mental status. this is in line with conventional practice (adrogué et al., 2022). we elected to keep her on oral slow sodium tablets until the complete resolution of the hyponatremia. the hypoglycemia resolved with the steroid and dextrose infusions. hypotension caused by an adrenal crisis responds rapidly (usually within a few hours) to intravenous glucocorticoid and fluid administration. our patient had persistent hypotension, most likely superimposed by urosepsis, and needed inotropic support with an adrenaline infusion and intravenous ciprofloxacin before a full resolution. various society guidelines have protocols for tapering off the glucocorticoids following the resolution of an adrenal crisis, depending on whether the patient has known or unknown underlying adrenal insufficiency (bornstein et al., 2016). the principal determination is the clinical status of the patient and adequate monitoring. in our patient, we made a clinical decision to taper her prednisone from 20, 10, and 5 mg over a 4-month’s duration as we took mitigating measures against the complications of the steroids. rifampicin, which is the main drug in tb treatment, has been reported to induce adrenal insufficiency and adrenal crises (campbell et al., 2023; kyriazopoulou et al., 1984). most of these cases occurred in patients with underlying adrenal insufficiency, and following adequate glucocorticoid replacement, the drug was continued safely with close patient monitoring. our patient has successfully finished her tb therapy containing rifampicin for the past six months without recurrent adrenal insufficiency or crisis. we believe that with the cure of the tb, the adrenal glands have fully recovered their functions. conclusion primary adrenal insufficiency (addison’s disease) should be considered in patients on treatment for disseminated tuberculosis, who present with recurrent gastrointestinal symptoms, hyponatremia, hyperkalemia, salt craving, and postural hypotension. adrenal crisis occurs when persistent hypotension and shock ensue in the setting of adrenal insufficiency and recent physiological stress. this carries a high mortality rate of up to 10%. when an adrenal crisis is suspected, it needs emergency treatment without any delays, with intravenous glucocorticoids (preferably hydrocortisone), fluids, and supportive therapy. subsequent glucocorticoid therapy should be tapered off based on clinical response. primary care physicians in resource-limited clinical settings should successfully recognize and manage tuberculous addison’s disease. learning points 1. consider adrenal insufficiency in patients with miliary tuberculosis who present with non-specific abdominal pains, nausea, vomiting, anorexia, lethargy, hyponatremia, salt craving, dehydration, altered mental status, etc. 2. an adrenal crisis must be considered in any patient who presents in shock. the clues include persistent hypotension, hyponatremia, hyperkalemia, hypoglycemia, azotemia, and hyperpigmentation in the setting of nonspecific abdominal pains, nausea, vomiting, weight loss, and lethargy. 3. an adrenal crisis is a medical emergency with a high mortality rate. when suspected, treatment must be initiated immediately with intravenous hydrocortisone, fluids, and supportive therapy. treatment must not be delayed by the need to perform diagnostic tests. acknowledgement the authors acknowledge the nursing staff in the female wards and tb clinic of st. joseph rift valley hospital, gilgil, for their help in managing this patient. references adrogué, h. j., tucker, b. m., & madias, n. e. 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(2009). addison’s disease induced by miliary tuberculosis and the administration of rifampicin. intern med, 48(15), 1297-1300. https://doi. org/10.2169/internalmedicine.48.1974 pa ge 1 pa ge 20 2 american journal of medical science and innovation (ajmsi) cutaneous furuncular myiasis in a rural kenyan hospital: a case report noi j. joseph1, james n. kariithi1, vonwicks c. onyango2* volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2257 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: october 25, 2023 accepted: november 27, 2023 published: november 30, 2023 myiasis is a neglected tropical disease caused by infestation by the larval stages (maggots) of many species of flies, which occur worldwide but are more prevalent in the tropical and subtropical regions. the two main types of flies causing human myiasis are dermatobia hominis (bot fly) and cordylobia anthropophaga (tumbu fly). cases of human myiasis in kenya are not well documented, but some epidemiological studies show the tumbu fly to be the most prevalent. transmission and infestation occur in cases of poor personal and environmental hygiene, especially in spaces shared with wild and domestic animals. cutaneous myiasis, presenting as a furuncular, wound, and migratory disease, is the most common clinical phenotype that may be associated with secondary pyogenic infection and cellulitis, especially when not treated promptly. in this study, we present a case of cutaneous furuncular myiasis in a patient from rural kenya. we share our experience managing the patient and also provide a literature review on the clinical case management of myiasis, with a call for more epidemiological and clinical work to be done to better understand this neglected disease. keywords myiasis, cutaneous myiasis, furuncular myiasis, tumbu fly, bot fly, dermatobia hominis, cordylobia anthropophaga, kenya 1 pcea-tumutumu mission hospital, karatina, nyeri county, kenya 2 st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction myiasis is the term applied to the disease produced by infestation by the larvae (maggots) of the species of flies of the arthropod order diptera, that invade and live parasitically in human tissues (‘myia’ is a greek word for fly). myiasis is a neglected disease. it is sporadically distributed worldwide, and the flies infest many animals and humans. the most common flies causing human infestation are dermatobia hominis (bot fly), which is endemic in central and south america and the caribbean; and cordylobia anthropophaga (tumbu fly), which is endemic to sub-saharan africa and is responsible for the furuncular form of cutaneous myiasis (kuria & oyedeji, 2020; robbins & khachemoune, 2010). in kenya, there is no robust data that captures the prevalence of myiasis in humans, though some surveillance epidemiological studies report that myiasis is endemic in the south-eastern counties, e.g., kitui. most human cases are anticipated to closely follow the prevalence in domestic animals, e.g., in dogs, sheep, and goats. a cross-sectional study done on canine cutaneous myiasis in kitui county, kenya, revealed an overall prevalence of 45%, with all the larvae isolated figure 1: the life cycle of myiasis larvae (man et al., 2022) pa ge 20 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 202-205, 2023 being c. anthropophaga (tumbu flies) (mutinda et al., 2022). the flies prefer warm and humid environments and are thus restricted to the summer months in temperate zones, but are prevalent year-round in the tropics and subtropical countries. the mechanism of transmission varies depending on the species of fly. the adult fly may deposit its eggs on a wound, which hatches to produce the larva that burrow into the skin, or it may deposit the eggs directly into the nostrils, the conjunctiva, on the lips, or on an intact skin with subsequent larva invasion into the tissues. the d. hominis species is usually found in humans, cattle, swine, cats, dogs, horses, sheep, other mammals, and bird species. it is especially interesting because it deposits eggs on a mosquito, tick, or other fly. when the mosquito or tick bites a human, the warmth of the skin induces the eggs to hatch, and the larvae enter the skin at the site of the bite. c. anthropophaga is hosted by wild rats (the main hosts), mice, monkeys, squirrels, dogs, cats, rabbits, guinea pigs, goats, chickens, and humans. the flies lay their eggs on the ground or dump clothes and bed linens hung out to dry. people get infected when they contact the hatched larvae (francesconi & lupi, 2012). figure 1 panel from pharmaceutical research (2022) shows the life cycle of myiasis larvae (man et al., 2022). infestation may be classified based on parasite-host interaction as obligatory, facultative, or accidental myiasis. more commonly, it is classified based on the body parts affected, e.g., cutaneous, nasopharyngeal, intestinal, and urogenital myiasis, etc. (dires et al., 2022). cutaneous myiasis is the most common type and may have three different clinical forms: furuncular, migratory, or wound myiasis. the furuncular subtype is the most commonly encountered, often presenting with nodular and cystic cutaneous lesions (dires et al., 2022). the diagnosis of myiasis is clinical with direct observation of the larvae, and laboratory testing is not routinely required. manual removal of the larva is the most common mode of treatment, while surgery may rarely be used, especially where there are associated pyogenic infections or the occurrence of myiasis in body cavities or unusual sites. case summary history and physical examination a 76-year-old man, a father of four adults from sagana, kirinyaga county, kenya, was admitted with a 2-week history of acute-on-chronic left lower limb septic venous ulcers and generalized painful boil-like swellings predominantly distributed on both his arms and back. he was a widower who lived alone and worked as a subsistence farmer, cultivating food crops and rearing a few sheep and goats. he had a significant history of smoking (about 40 pack years) and ethanol use, especially of the traditional local brews. he had no other comorbidities. the boil-like swellings on his body had been recurrent over several months (>10 months), affecting his legs, arms, groin, torso, and neck. they were painful and itchy, with an associated feeling of creeping movements within the lesions. he reported that occasionally “whitish worms” would come out of the lesions spontaneously or whenever he squeezed some of the lesions. he lived in a one-bedroomed semi-permanent house, which he shared with the lambs and kids of his sheep and goats, respectively. he denied coming into direct physical contact with someone with similar lesions. the systemic inquiry was unremarkable. on physical examination, he was an elderly male in chronic poor health with features of general neglect and poor overall sanitary condition. he was sick-looking, poorly groomed, and dull in appearance and disposition. his vital signs were unremarkable. he was mildly pale and dehydrated but had no scleral jaundice, finger clubbing, pedal edema, or peripheral lymphadenopathy. figure 2: upper and lower panels showing multiple furuncles appearing as nodular and nodulo-cystic lesions on the back of the patient. on the lower panel, some furuncles are noted to have healed spontaneously (see the associated hyperpigmented scars). figure 3: upper panel showing a furuncle with a maggot being manually removed by gentle squeezing. the lower panel shows a live maggot extracted from a furuncle on the patient pa ge 20 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 202-205, 2023 the patient had multiple tender skin lesions, worse on the bilateral forearms and the back. they were mixed lesions, i.e., nodular, cystic, and nodulo-cystic, with surrounding skin induration and scratch marks. both new and old lesions in different stages of healing were noted. serosanguinous and purulent discharge was noted in some of the lesions. dramatically, live maggots could be squeezed from some of them, i.e., one live whitish maggot per lesion. see figures 2 and 3 panels. his left lower limb was swollen up to the knee level, was hyperpigmented, and had an approximately 8cm by 10cm ulcer on the dorsum of the foot with foul-smelling seropurulent discharge and concomitant severe cellulitis. the neurovascular exam was normal. the right lower limb was grossly normal. the rest of the systemic exam was grossly normal. basic work-up his complete blood count showed neutrophilic leukocytosis with a total leucocyte count of 28.2 x103 cells/l (4-11) with 83.5% neutrophils; hemoglobin was 10.7g/dl (12-16) with a mean corpuscular volume of 81fl (mild anemia); a normal renal function test with creatinine of 73.6 mmol/l, a normal random blood sugar of 5.6mmol/l, and a negative rapid test for the human immunodeficiency virus. a compression doppler ultrasound scan of both lower limbs showed features of bilateral venous insufficiency with no deep venous thrombosis and marked soft tissue swelling of the left leg up to the mid-thigh level (consistent with the cellulitis). patient management and follow-up a clinical diagnosis of cutaneous furuncular myiasis in a patient with a septic chronic venous left leg ulcer with associated cellulitis was made. the maggots were physically removed by squeezing and plucking them out using nontoothed tissue forceps and surgical gauzes at the bedside. the wounds and furuncles were cleaned and dressed daily with topical antiseptics. a seven-day course of intravenous flucloxacillin and acetaminophen analgesics was also administered. the outcome was the complete resolution of all the lesions in about two weeks. the septic venous ulcer was debrided serially, cleaned, and dressed daily, and is currently scheduled for split-thickness skin grafting later on. the patient and his family members were educated on the importance of personal and environmental hygiene to prevent the recurrence of the myiasis infestation. discussion the typical clinical encounter with human myiasis in temperate countries is the returning traveler from endemic areas presenting with predominantly cutaneous myiasis (chang & donaghy, 2021; dalton & chambers, 2009; oliva et al., 2020; song et al., 2017; suárez et al., 2018; uslu et al., 2018). in tropical countries, e.g., kenya, the disease is observed in endemic regions. the most common etiological species are c. anthropophaga and d. hominis. patients typically present with cutaneous myiasis in the clinical forms of furuncular, i.e., boil-like lesions (the most common), wound type, or migratory phenotypes (dires et al., 2022). furuncular myiasis is typically diagnosed clinically during patient encounters, sometimes aided by pictorial taxonomical keys (dires et al., 2022). whereas routine dermoscopy and ultrasound may aid in accurate diagnosis and speciation (bakos & bakos, 2007), they often offer no additional therapeutic value in the eventual definitive management of the infestation. our patient had myiasis caused by c. anthropophaga (tumbu fly) based on its predominant endemicity, multiple furuncles, and typical appearance when matched to pictorial taxonomical keys. we believe our patient acquired the infestation during direct contact with the tumbu fly larvae in the unsanitary living environment at home shared with domestic animals. the larvae penetrate the skin, causing intense pruritus, pain, skin erythema, and a dramatic sense of crawling underneath the skin. this results in single or multiple furuncles, which may be nodular, cystic, or nodulo-cystic, and of varying sizes, and are associated with surrounding cellulitis in some cases. they are distributed in the arms, legs, buttocks, torso, neck, and sometimes in the body orifices or unusual sites like the eyes, nose, ears, or around surgical devices (dalton & chambers, 2009; das et al., 2021; de souza barbosa et al., 2008; dires et al., 2022; huang et al., 2020). the lesions have a central opening (punctum) that allows the larvae to breathe. the latter can be seen as bubbles when the body part is immersed in water (francesconi & lupi, 2012). secondary bacterial infection of the furuncles may cause purulent discharge from some of them (as was the case with our patient) and significant cellulitis and/or abscesses. typically, symptoms develop within 2 days of the fly bite as itchy lesions, with the furuncles developing over 6 days. after 8-12 days, the mature larvae leave the skin and fall to the ground, where they pupate and soon become adult flies. treatment is aimed at the complete eradication of the maggots from the skin and the prevention or management of secondary infections. if the larvae or maggots are visible, manual extraction can be performed using clippers, artery forceps, etc., taking care to extract the maggots whole. if the larva is not visible, the central pore can be covered with petroleum jelly, liquid paraffin, or turpentine oil, which suffocates the larva and causes it to migrate to the surface, where it can be manually extracted (francesconi & lupi, 2012). topical (1% solution) or systemic ivermectin is toxic to all forms of myasis and may rarely be used. surgical removal of the larva may be needed for eradication of the maggots, especially in unusual locations (e.g., in body orifices and cavities), and for drainage of associated abscesses or debridement of devitalized tissues (bani hani et al., 2019; dires et al., 2022). this is followed by thorough daily wound care. in our patient, the maggots were all manually removed, with subsequent wound management (including antibiotics) leading to complete healing of the furuncles over a period of two weeks, albeit with scars that are already fading. conclusion human myiasis can be a debilitating disease with significant personal and psychological trauma associated with the pa ge 20 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 202-205, 2023 ensuing complications of cutaneous disease, especially in the more common furuncular myiasis, e.g., pain, cosmetic aberrations, secondary pyogenic infections, intense foreign body reactions during inadequate extractions, secondary tetanus (consider tetanus booster vaccination in all cases), etc. (francesconi & lupi, 2012). the focus of management should be the prevention of infestation by limiting exposure to flies, especially in tropical areas, such as by wearing clothing that covers the extremities, using mosquito nets, and using insect repellants. other general measures include covering wounds with clean dressing to prevent flies from reaching the skin, avoiding spreading clothes on the ground, ironing clothes dried on the line (the heat destroys the eggs and the larvae), and improving general personal hygiene and environmental sanitation (diaz, 2006). recommendations myiasis is a neglected disease, yet it has associated significant personal and psychological burdens related to the larval infestation. although not well documented, human myiasis does occur in kenya. cases of myiasis are likely to be misdiagnosed due to a lack of prior clinical experience with similar cases. the authors recommend more epidemiological studies be done in kenya to properly map the prevalence of this neglected disease, as well as deliberate training of health workers on the case management of myiasis. acknowledgements the authors acknowledge dr. mawenzi ramadhan, consultant dermatologist at egerton university, school of medicine, kenya, for his technical advice during the writing of the manuscript. additionally, the authors acknowledge the nursing staff and students at the surgical wards of pcea tumutumu mission hospital, karatina, nyeri county, kenya, for their direct participation in the management of the patient. references bakos, r. m., & bakos, l. (2007). dermoscopic diagnosis of furuncular myiasis. arch dermatol, 143(1), 123-124. https://doi.org/10.1001/archderm.143.1.123 bani hani, m. n., al manasra, a. r., daradkah, h., bani hani, f., & bani hani, z. (2019). cutaneous myiasis around gastrostomy (peg) tube insertion site: the second case report. clin med insights case rep, 12, 1179547619869009. https://doi.org/10.1177/1179547619869009 chang, k. m., & donaghy, h. j. (2021). myiasis in a returning traveller. travel med infect dis, 43, 102141. https://doi.org/10.1016/j.tmaid.2021.102141 dalton, s. c., & chambers, s. t. (2009). cutaneous myiasis due to dermatobia hominis (the human botfly) in a new zealand traveller returned from south america. n z med j, 122(1302), 95-99. das, s., gaur, n. k., shaikh, o. h., & kumbhar, u. s. (2021). feeding gastrostomy stoma site cutaneous myiasis: a rare entity. bmj case rep, 14(7). https://doi. org/10.1136/bcr-2021-244352 de souza barbosa, t., salvitti sá rocha, r. a., guirado, c. g., rocha, f. j., & duarte gavião, m. b. (2008). oral infection by diptera larvae in children: a case report. int j dermatol, 47(7), 696-699. https://doi.org/10.1111/ j.1365-4632.2008.03725.x diaz, j. h. (2006). the epidemiology, diagnosis, management, and prevention of ectoparasitic diseases in travelers. j travel med, 13(2), 100-111. https://doi. org/10.1111/j.1708-8305.2006.00021.x dires, a., kebede, a., gedamu, s., & dires, t. (2022). case of multiple furuncular myiasis in northeast ethiopia. clin case rep, 10(7), e6015. https://doi.org/10.1002/ ccr3.6015 francesconi, f., & lupi, o. (2012). myiasis. clin microbiol rev, 25(1), 79-105. https://doi.org/10.1128/cmr.00010-11 huang, y. l., liu, l., liang, h., he, j., chen, j., liang, q. w., jiang, z. y., he, j. f., huang, m. l., & du, y. (2020). orbital myiasis: a case report and literature review. medicine (baltimore), 99(4), e18879. https://doi. org/10.1097/md.0000000000018879 kuria, s. k., & oyedeji, a. o. (2020). human myiasis cases originating and reported in africa for the last two decades (1998-2018): a review. acta trop, 210, 105590. https://doi.org/10.1016/j.actatropica.2020.105590 man, e., price, h., & hoskins, c. (2022). current and future strategies against cutaneous parasites. pharmaceutical research, 39, 1-21. https://doi.org/10.1007/s11095022-03232-y mutinda, k. n., gichohi, m. p., maina, w. r., maina, g. s., & agosa, k. e. (2022). prevalence, etiology, and risk factors associated with occurrence of canine cutaneous myiasis in kitui county, kenya. vet med int, 2022, 5699060. https://doi. org/10.1155/2022/5699060 oliva, e., bargiggia, g., quinzan, g., lanza, p., & farina, c. (2020). furuncular myiasis in italian traveler returning from kenya. j infect dev ctries, 14(1), 114-116. https:// doi.org/10.3855/jidc.11560 robbins, k., & khachemoune, a. (2010). cutaneous myiasis: a review of the common types of myiasis. int j dermatol, 49(10), 1092-1098. https://doi.org/10.1111/ j.1365-4632.2010.04577.x song, s. m., kim, s. w., goo, y. k., hong, y., ock, m., cha, h. j., & chung, d. i. (2017). a case of furuncular myiasis due to cordylobia anthropophaga in a korean traveler returning from uganda. korean j parasitol, 55(3), 327-331. https://doi.org/10.3347/ kjp.2017.55.3.327 suárez, j. a., ying, a., orillac, l. a., cedeño, i., & sosa, n. (2018). first case of furuncular myiasis due to cordylobia anthropophaga in a latin american resident returning from central african republic. braz j infect dis, 22(1), 70-73. https://doi.org/10.1016/j. bjid.2017.12.003 uslu, u., erdmann, m., schliep, s., & sticherling, m. (2018). crusted nodules on the lower left arm in a traveller returning from south america: a quiz. furuncular myiasis. acta derm venereol, 98(1), 159-160. https:// doi.org/10.2340/00015555-2804 pa ge 1 pa ge 19 2 american journal of medical science and innovation (ajmsi) overcoming the challenges of prolonged ventilation and critical illness polyneuropathy in severe ards patients due to extensive viral pneumonia: a case report mohamed elsamman ahmed1* volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2141 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: october 10, 2023 accepted: november 05, 2023 published: november 14, 2023 ards is a life-threatening condition requiring intensive care unit monitoring. we present a 46-year-old male patient with ards and its complications, ventilator-associated pneumonia (vap) and critcal illness polyneuropathy after extensive bilateral viral pneumonia. the objective of this case report is to understand better and manage the complications of ards. this study addresses ards and its complications, providing a comprehensive clinical understanding. it details a 46-year-old male patient’s case, treatment strategies, complications, weaning processes, and rehabilitation and emphasises the importance of physical therapy. this case report discusses the successful management and weaning of a patient with extensive viral pneumonia complicated with acute respiratory distress syndrome (ards), impending organ dysfunction, and critical illness polyneuropathy. the patient had a medical history of diabetes, hypertension, and dyslipidemia. initial treatment involved oxygen therapy, nebulization, and empirical antiviral for seasonal flu. however, the patient required invasive ventilation with sedation and muscle relaxants following the ardsnet protocol due to worsening respiratory status and extensive lung infiltrates. secondary bacterial infections were also identified and treated accordingly. the weaning process was initiated but was complicated by re-intubation and the development of critical illness polyneuropathy. after successful weaning and recovery from ards and associated lung infections, physical therapy was provided for polyneuropathy regularly to overcome the manifest weakness all over the body muscles, including respiratory muscle weakness. the case report highlights the successful management of a patient with viral pneumonia, ards, and critical illness polyneuropathy, highlighting the importance of comprehensive treatment and physical therapy. keywords acute respiratory distress syndrome (ards), ventilatorassociated pneumonia (vap), oxygen therapy, critical illness polyneuropathy (cip), muscle relaxant, nebulization 1 burjeel farha hospital al ain, abu dhabi, united arab emirates * corresponding author’s e-mail: mohamedelsamman12@outlook.com introduction viral pneumonia is a significant global health issue that can lead to serious complications such as ards and organ dysfunction, which usually necessitates invasive mechanical ventilation. prolonged mechanical ventilation can also result in critical illness polyneuropathy, which causes muscle weakness and wasting along with the corticosteroids usually prescribed in such cases. this case report highlights a patient’s successful management and weaning with these complex complications. the definition of ards was given in 2011 by the european society of intensive care medicine, supported by the american thoracic society and the society of critical care medicine, and it is known as the berlin definition. according to it, ards is characterised by the time frame of one week from worsening of the chronic condition, radiographic changes, lung oedema without left heart failure, and a pao2 / fio2 ratio of 5 cm2 h20 with continuous positive airway pressure (cpap), with the presence of bilateral shadows and lung oedema (huppert et al., 2019). by definition, three ards categories have been identified. subtypes are based on the degree of hypoxemia: mild (pao2 / fio2 < 300 mm hg), moderate (pao2 / fio2 < 200 mm hg), and severe (pao2 / fio2 <100 mm hg) (ferguson et al., 2012; milacic et al., 2018). ards implies diffuse alveolar damage (dad) and injury to the lung’s capillary endothelium (barbeta et al., 2023). injuries of the capillary endothelium and alveolar epithelium lead to impaired fluid transport through alveoli and fluid accumulation rich in proteins within the alveoli, eventually leading to diffuse alveolar injury, with the release of proinflammatory cytokines, such as tumor necrosis factor (tnf), il-1 and il-6 (rittayamai & brochard, 2015). neutrophils are activated, releasing toxic mediators, proteases and free radicals (milacic et al., 2018). abnormalities of transcription factors, including nf-cap b, needed for gene transcription for many proinflammatory mediators, are present in ards (forel et al., 2012). endothelin-1, angiotensin-2 and phospholipase a-2 also significantly increase vascular permeability (montealegre-gómez et al., 2021). ards impairs epithelial integrity, leading to alveolar leakage, altered fluid and ion balance, and alveolar oedema (lucas et al., 2022). damage to type ii epithelial cells reduces surfactant generation, causing known surfactant deficits(agudelo et al., 2020). breaching the epithelial barrier can increase the risk of septic shock in individuals with bacterial pneumonia (eisenhut & shin, 2020). excessive alveolar epithelial injury results in fibrosis, as the inability to regenerate leads to the etiology of fibrosis. therefore, maintaining a physiological balance is crucial for preventing ards(michalski et al., 2022). the fibrosis process is stimulated by interleukin (il) -1. progression to fibrosis can be predicted by the increased pa ge 19 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 192-201, 2023 values of procollagen peptide iii (pcp-iii) in the sample obtained by bal. the diseases most commonly associated with ards can be both lung and systemic (table 1). mycobacteria pneumoniae, although associated with unilateral pneumonia, can also lead to changes that correspond to acute respiratory distress syndrome (6, 7). the main symptoms include breathing difficulties (dyspnoea), rapid breathing (tachypnoea), extremely deep breathing (hyperventilation) and reduced oxygen levels in the circulation (hypoxemia) (kallet et al., 2022). typically, ards manifests within a timeframe of 24 to 48 hours following the onset of an underlying disease or the worsening of an existing condition (henderson et al., 2017). a distinctive hallmark of ards is the resistance of hypoxemia to conventional oxygen therapy, necessitating the implementation of mechanical ventilation (henderson et al., 2017). importantly, one of the notable complications associated with mechanical ventilation is the heightened risk of bacterial pneumonia, often triggered by gram-negative bacteria such as pseudomonas aeruginosa, acinetobacter baumannii, and stenotrophomonas maltophilia, which collectively account for 40% of cases. enterobacteriaceae contribute to 29% of cases, while methicillin-resistant staphylococcus aureus (mrsa) is implicated in 21% of instances (trouillet et al., 1998). white blood cell counts are frequently elevated in laboratory tests, which may indicate the presence of sepsis or pneumonia. in contrast, an assessment of the acid-base balance may show a drop in ph, with values below 7.4 indicating respiratory acidosis and hypoxia (berend & duits, 2019). pulmonary oedema is frequently detected in ards as well by radiographic examinations like chest x-rays (cxr) (gosangi et al., 2022). however, computed tomography (ct) scans may be necessary in some circumstances for a more thorough analysis. an ultrasound of the heart is performed (echocardiography) to rule out any cardiacrelated problems. pulmonary hypertension can be ruled out with the help of arterial pulmonary catheter monitoring. bronchoscopy may also be taken into account when it is clinically necessary for the assessment of lung conditions (nowroozpoor et al., 2019). the management of ards includes dealing with underlying causes, enhancing oxygenation, offering supportive care, and avoiding complications. the management of fluid balance, positioning of patients, administration of medications, provision of nutrition, provision of supportive care, monitoring of hemodynamic parameters, management of pain control, prevention of complications, treatment of underlying conditions and consideration of extracorporeal membrane oxygenation (ecmo) in severe cases are important components (banavasi et al., 2021; peck & hibbert, 2019). this study aims to fill a research gap in the field of ards and its complications. it provides a comprehensive clinical understanding of ards, its complications, and the challenges of managing these conditions in patients. the case report presents a detailed case of a 46-year-old male patient with ards, discussing treatment strategies, identifying and managing complications, weaning processes, rehabilitation, patient profile, and overall management. the study also highlights the importance of physical therapy and rehabilitation in addressing complications and regaining muscle strength. case presentation a 49-year-old male was admitted to burjeel farha hospital due to several symptoms, including shortness of breath, dry cough, weakness, fatigue and an elevated body temperature. the symptoms had been worsening over two days, after which he was admitted to the general ward. the patient’s medical history was taken primarily. the patient had a medical history of diabetes mellitus type 2, which was being managed with metformin intake, as well as hypertension and dyslipidemia, for which the patient was on medication. during treatment, a screening test for influenza a and b was performed in addition to various other routine lab tests, including crp, abnormal liver function parameters and inflammatory markers. chest x-ray was performed as well, and bilateral infiltrates and haziness were noticed. on the first day of admission to the ward, the patient was conscious and mobile but presented with significant respiratory distress (dyspnoea), tachycardia and a high fever (temperature >38.5 °c). the physical examination revealed auscultatory fine crackles at the basal parts of the lung. laboratory and radiological findings in the obtained laboratory tests, the increase in inflammatory parameters with elevated values of d table 1: pulmonary and systemic diseases associated with ards s. no pulmonary diseases or conditions systemic diseases 1 pneumonia sepsis 2 aspiration of gastric contents difficult trauma 3 lung contusion multiple fractures 4 inhalation lung injury head injuries 5 drowning burns 6 overdose of narcotics multiple transfusion 7 bypass pancreatitis 8 post cardiopulmonary pa ge 19 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 192-201, 2023 dimer and liver function parameters were verified (wbc >12.5, hgb 12 gm, plt 331, crp 120, ast 142, alt 180, ggt 227, ldh 751, ck 68, k 3.8, na 137, d dimer >1.5). the performed abg showed a global respiratory insufficiency, metabolic compensated (p h 7.43, p co2 48, p o2 5.1, hco3 28.4, be 5.3, with so2 84%). in the chest x-ray (cxr) conducted at the urgent care (uc), the report noted bilateral shading in the lower and middle lung fields, as illustrated in fig 1. additionally, the lung computed tomography (ct) scan described consolidation of the lung tissue, originating from the lung’s apex and extending through the middle and dorsal basal segments, accompanied by typical indications of pulmonary oedema, as depicted in fig 2. table 2: values of inflammatory parameters before treatment parameter value normal range white blood cell count >12.5 4.5 11 x 10^9/l hemoglobin (hgb) 12 gm 13.8 17.2 g/dl platelet count (plt) 331 150 450 x 10^9/l c-reactive protein (crp) 120 < 10 mg/l aspartate aminotransferase (ast) 142 8 48 u/l alanine aminotransferase (alt) 180 7 55 u/l gamma-glutamyl transferase (ggt) 227 9 48 u/l lactate dehydrogenase (ldh) 751 140 280 u/l creatine kinase (ck) 68 55 170 u/l potassium (k) 3.8 3.5 5.0 mmol/l sodium (na) 137 135 145 mmol/l d-dimer >1.5 the reference range may vary arterial blood gas (abg) ph 7.43 7.35 7.45 pco2 48 35 45 mm hg po2 5.1 75 100 mm hg hco3 28.4 22 28 mmol/l base excess (be) 5.3 -2 to +2 mmol/l oxygen saturation (sao2) 84% 95 100% lactates 2.2 0.5 2.2 mmol/l figure 1: cxr showing patchy areas of consolidation noted in both lung fields in the mid and lower zones predominantly figure 2: ct chest showing extensive areas of peripherally distributed foci of consolidation and ground glass opacities in both lungs. treatment administration hospital treatment was initiated in the form of oxygen therapy, nebulisation, empirical antibiotics and antipyretics. soon after the admission to the ward, the patient’s condition worsened. central cyanosis occurred, and repeated abg showed: p h 7.51, p co2 5.3, p o2 3.8, hco3 30.4, be 8.2, sao2 63.5, lactates 2.2. due to the need for monitoring of vital functions and the possibility of mechanical ventilation, the patient was transferred to the intensive care unit. non-invasive ventilation (niv) was initially used for the first two days after the patient was admitted to the intensive pa ge 19 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 192-201, 2023 care unit (icu). the patient’s oxygen saturation remained appropriate during this time, and the breathing effort was controllable. however, the patient’s health appeared to deteriorate about 36 hours into the niv treatment. the hypoxic index showed low blood oxygen levels, while sao2 pulse oximetry measurements fell below 85%. recognising the patient’s intolerance to niv and taking into account the diagnostic criteria for ards, which were based on the patient’s low hypoxia index and the presence of bilateral lung infiltrates, the decision was made to begin invasive mechanical ventilation. this procedure followed the ardsnet protocol and included the administration of sedatives and muscle relaxants. the ardsnet protocol builds a strong emphasis on using protective lung methods and modifying positive end-expiratory pressure (peep) levels according to the oxygenation level of the patient. this strategy aims to enhance ards patient outcomes and ventilator management efficiency. the patient was intubated on the third day of their stay in the icu, linked to mechanical ventilation in assistcontrol (a/c) mode, and their tidal volume (vt) and a fraction of inspired oxygen (fio2) were set to 20 millilitres per kilogram (f20) and 0.7, respectively. the icu staff attentively observed the patient’s breathing pattern throughout the day. according to the patient’s evolving state, the mechanical ventilation mode was changed several times, switching between the assist-control (a/c), bilevel, and spontaneous modes as judged required. to treat the patient’s condition, a number of medications were started, including corticosteroids, bronchodilators, oseltamivir (an antiviral drug), a combination of intravenous antibiotics to treat potential infections, and prophylactic anticoagulants to prevent blood clots. the diagnosis was made as viral pneumonia brought on by an unidentified virus despite the fact that initial blood and sputum cultures did not indicate bacterial growth, and two covid-19 reverse transcription polymerase chain reaction (rtpcr) tests yielded negative results. this conclusion was reached because influenza a and b screening tests likewise produced negative findings. laboratory results revealed significantly raised levels of lipase, amylase, and liver enzymes, indicating potential impeding organ dysfunction. inflammatory markers were also discovered to be increased, indicating a lively inflammatory response. the patient was completely sedated while on ac mode mechanical ventilation between the third and seventh days in the icu, with help from the muscle relaxants cisatracurium and midazolam. every 24 hours, a sedation vacation strategy was adopted, allowing patients brief intervals of reduced sedation. on day ten, on the tenth day, the patient developed a fever and coloured sputum during suction, indicating secondary bacterial infections after over a week of invasive ventilation. the condition was diagnosed as ventilatorassociated pneumonia (vap), requiring an increase in antibiotic therapy. the patient’s weaning process began with a sedation vacation and reduced ventilatory support, transitioning to spontaneous pressure support ventilation. further evaluations showed that the patient had general weakness, which was characterised by wasting muscles, areflexia (lack of reflexes), and deteriorating muscle strength. these results suggested critical illness polyneuropathy. this diagnosis was confirmed after a neurology referral using nerve conduction and electromyography studies. the results of the ncs are provided in tables 4, 5 and 6, and the graphical representation can be seen in figures 3, 4 and 5. a sensory nerve conduction study (ncs) has revealed that the median nerve on the right wrist has a latency of 35.3 ms, while the ulnar nerve has a latency of 36.2 ms. the peroneal nerve on the left ankle has a latency of ***, while the tibial nerve on the left side of the ankle has a latency of 65.4 ms. these latency measurements are crucial for diagnosing and evaluating sensory nerve function, providing information about the speed at which sensory table 3: repeated abg results parameter value normal range ph 7.51 7.35 7.45 pco2 5.3 35 45 mm hg po2 3.8 75 100 mm hg hco3 30.4 22 28 mmol/l base excess (be) 8.2 -2 to +2 mmol/l oxygen saturation (sao2) 63.5 95 100% lactates 2.2 0.5 2.2 mmol/l table 4: nerve conduction study (ncs) data nerve and location latency 1 (ms) latency 2 (ms) amplitude segment distance (mm) interval (ms) ncv (m/s) median right wrist 3.5 4.0 25.7 uv wrist 150 43.1 ulnar left wrist not specified 2.7 9.6 uv wrist 130 48.5 ulnar right wrist not specified 2.7 48.9 uv wrist 130 48.9 pa ge 19 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 192-201, 2023 figure 3: motor nerve conduction study graphical representation table 5: sensory nerve conduction study results site lat. 1 (ms) lat. 2 (ms) amplitude segment dist (mm) interval (ms) ncv (m/s) median right wrist 3.5 4.0 25.7uv wrist 150 43.1 ulnar left wrist 2.7 9.6uv wrist 130 48.5 ulnar right wrist 2.7 48.9uv wrist 130 48.9 sural left sural right superficial peroneal left (mid. branch) superficial peroneal right (mid. branch) pa ge 19 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 192-201, 2023 figure 4: sensory nerve conduction graphical representation table 6: sensory nerve conduction study latency measurements nerve side site f-lat f-m lat median right wrist 35.3ms 35.3ms ulnar right wrist 36.2ms 36.2ms peroneal left ankle *** *** peroneal right ankle **** *** tibial left ankle 65.4ms 65.4ms tibial right ankle 64.7ms 64.7ms pa ge 19 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 192-201, 2023 figure 5: f-wave representation figure 6: cxr showing bilateral airspace opacities noted, more on right side. compared to previous image, some improvement noted. figure 7: ct chest showing areas of consolidation bilaterally mainly rt lung lobes. signals are conducted along these nerves. after a failed weaning trial, the patient successfully weaned from mechanical ventilation after 22 days. laboratory markers improved after recovery from ards and lung infections. physical therapy continued to address polyneuropathy, guided by neurological assessments and nerve conduction and electromyography studies. results and discussions the case report describes the successful management and weaning of a ventilated patient with severe ards, viral pneumonia, vap, and critical illness polyneuropathy. pa ge 19 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 192-201, 2023 despite a robust inflammatory response, the patient’s oxygenation status improved over time, indicating better lung function and oxygenation. the patient’s organ dysfunction parameters fluctuated throughout the treatment period, suggesting potential multi-organ involvement. the case highlights the importance of respiratory compensation and managing complex cases. the patient was successfully weaned from mechanical ventilation due to improved lung function and oxygenation, effective complication management, and early physiotherapy, as seen in figs 6 and 7. the case highlights the importance of ongoing rehabilitation and physiotherapy in critically ill patients, as polyneuropathy is a common complication, and ongoing rehabilitation is necessary to restore muscle strength and function. this case report highlights the complexity of managing severe viral pneumonia caused by ards. the patient’s success was achieved through evidence-based protocols, close monitoring of inflammatory markers, and organ dysfunction parameters. the patient had a combined infection with corynebacterium amycolatum spp heavy growth and enterococcus spp, resulting in increased inflammatory parameters. the patient was treated with antibiotic linezolid plus gentamicin due to the bacterium’s resistance to standard antibiograms. after completing antibiotics, the patient was transferred to the ward for further monitoring. oral antibiotic therapy continued for a week, along with physical therapy sessions and supportive therapy. the patient was discharged in good condition and hemodynamically stable for further ambulatory monitoring. patients with ards frequently need treatment in intensive care units. there is no particular treatment. the main focus of the treatment is support. a significant part is played by mechanical ventilation and the proper usage of oxygen (bos et al., 2018). knowing that lung transduction with positive pressure can aggravate the current illness is a crucial development in therapy(bos et al., 2018). this mindset has helped to design a new approach to treating mechanical ventilation that combines positive endexpiratory pressure (peep) and small breathing volumes (6ml/kg) (candan et al., 2020). this case report details the medical history, diagnosis, treatment, and management of a 49-year-old male patient with diabetes mellitus type 2, hypertension, and dyslipidemia. the patient presented with respiratory distress, tachycardia, and high fever. however, his condition worsened rapidly, leading to central cyanosis and worsening respiratory parameters. the patient was diagnosed with viral pneumonia due to an unknown virus, and after over a week of invasive ventilation, he developed vap. the patient underwent a weaning process from mechanical ventilation, with periods of sedation and a gradual reduction in ventilatory support. physical therapy was initiated to address critical illness polyneuropathy. after 22 days of mechanical ventilation and successful management of complications, the patient was successfully weaned from the ventilator. the case highlights the importance of ongoing rehabilitation and physiotherapy in critically ill patients, as polyneuropathy is a common complication, and ongoing rehabilitation is necessary to restore muscle strength and function. the case report emphasises the complexity of managing severe viral pneumonia complicated by ards, emphasising the importance of evidence-based protocols, close monitoring of inflammatory markers, and the role of physiotherapy in achieving a successful outcome. appropriate oxygen therapy in other medical conditions can also prevent the secondary development of ards. determan and associates performed a controlled randomised study with 150 patients that compared the use of small breathing volumes versus standard patients with critical illness and pointed to reduced production of inflammatory cytokines in patients treated with low air volume (determann et al., 2010). then, there are also adequate nutrition and hydration. antibiotic therapy is mandatory if accompanied by secondary bacterial infections or ventilator-associated pneumonia (papazian et al., 2020). corticosteroids are occasionally administered to resolve the primary condition; otherwise, their use is controversial. correction of acid-base status and other therapies (diuretics, analgesics, anxiolytics, antihypertensives) is regulated as needed. suppose the recovery does not occur in the first seven days. in that case, there is a greater likelihood that progressive lung injury will develop, followed by inflammation of the interstitium and later fibrosis. applying early interventions, maintaining adherence to evidence-based protocols, and closely observing inflammatory markers and organ dysfunction parameters prove vital for achieving a positive outcome (papazian et al., 2020). according to the international nosocomial infection control consortium (inicc), the frequency of vap is 13.6 versus days spent on ventilation support. however, the incidence varies depending on the hospital groups and hospital conditions, so the frequency of vap ranges between 13-51 and 1000 days spent on ventilation (rosenthal, 2016). patients who survive the ards episode usually have lasting effects that are reflected in reduced hrqol (health-related quality of life) (morgan, 2021). to enhance our overall comprehension of ideal treatment strategies as well as long-term outcomes in similar cases, further research endeavours are necessary. ventilator-associated pneumonia (vap) is a costly and prevalent infection in icus, causing significant morbidity and mortality. a study examined 36 cases over a year, and findings showed bacterial growth, with staphylococcus aureus being the most common pathogen. half of the isolated bacteria showed multi-drug resistance. treatment options for vap include imipenem, amikacin, linezolid, vancomycin, and levofloxacin. the study highlights the need for up-to-date knowledge of bacterial causes and antibiotic susceptibility patterns when developing empirical treatment regimens (abd-elmonsef et al., 2018). extracorporeal membrane oxygenation (ecmo) can be a life-saving intervention when conventional treatments fail. a 50-year-old female with severe ards pa ge 20 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 192-201, 2023 developed ecmo therapy after 14 days, resolving her symptoms and successfully weaning from the ventilator. ecmo provides lung support, preserves hemodynamic stability, and is crucial for managing severe ards due to swine flu when combined with protective lung ventilation and timely weaning (taneja et al., 2018). another study presents two chinese patients with pre-existing nonimmune diseases who contracted severe h7n9 pneumonia and neurological complications. both exhibited muscle weakness in their limbs, prolonging ventilator-weaning periods. despite the clinical diagnosis, distinguishing between intensive care unit-acquired weakness and guillain-barré syndrome (gbs) was challenging due to a lack of lumbar punctures and muscle/nerve biopsies. gradual improvement in neurological conditions was observed after extensive treatment (jin & tang, 2018). studies emphasise the importance of staying updated on bacterial profiles and antibiotic resistance patterns for effective vap management. they also highlight the potential of ecmo as a life-saving intervention in severe respiratory distress cases. the case report demonstrates the successful management of a complex case involving polyneuropathy and vap-related ards, underlining the need for a comprehensive approach, including infection control measures, reduction in mechanical ventilation and timely physical therapy. conclusion the excellent management of a 46-year-old male patient with viral pneumonia, ards, and critical illness polyneuropathy is discussed in this case report. it emphasises the value of comprehensive care that includes nebulisation, oxygen therapy, and antiviral therapy. it also emphasises the importance of promptly recognising and treating problems, like following bacterial infections. the report also emphasises the vital role that physical therapy plays in recovery, particularly when treating polyneuropathy associated with critical disease. acknowledgement the author is grateful to the clinical and administrative teams at burjeel farha hospital for their cooperation in managing this case. references abd-elmonsef, m. m. e., elsharawy, d., & abd-elsalam, a. s. 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(1998). ventilator-associated pneumonia caused by potentially drug-resistant bacteria, 157(2), 531-539. pa ge 1 pa ge 91 american journal of medical science and innovation (ajmsi) gram-negative bacteremia: epidemiology and antimicrobial resistance in qatar adila shaukat1*, masautso chaponda1, walid al-wali2, farah maher3, sara al-balushi4, abdulmajeed maliyakkal5, israa elhakeem5 tahani al-saadi2, ali omrani1, muna al maslamani1 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3181 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 05, 2024 accepted: october 02, 2024 published: october 05, 2024 one of the major causes of morbidity and mortality in hospitalised patients is the presence of gram-negative bacteremia (gnb) in blood. the developed resistance among the bacteria poses a significant challenge for treatment. the study aimed to identify the gram-negative patient’s epidemiological risk factors, antimicrobial susceptibility patterns, and clinical outcomes. a retrospective observational study of adult in-patients with gramnegative bacteremia was conducted between january 2019 and december 2020 in the 320-bed general hospital in qatar. data on demographics, antimicrobial resistance, source of infection, and treatment were collected. the primary outcomes were patients’ cure, death, or relapse. total of 357 patients were identified with bacteremia, the most common sources being urinary tract infections (39.6%), intra-abdominal infections (28%), and lower respiratory tract infections (9%). the mean duration of the intravenous and oral antibiotics administration was 14 days. surgical source control was performed in 35.7% of patients. common pathogens were escherichia-coli (47.2%), klebsiella pneumoniae (16.4%), salmonella enterica serotype typhi (10.6%), and pseudomonas aeruginosa (7.8%). 67.32% fully susceptible strains, 31.56% extended-spectrum beta-lactamase (esbl) producing bacteria, and 1.11% multidrug-resistant organisms (mdros) were among the isolates. most infections (68%) were cured, but 5% had recurrence within 90 days of admission. infection-related mortality was 8%, and death due to non-infectious causes was 2%. in conclusion, gram-negative bsis are severe infections with increasing antimicrobial resistance, primarily caused by esblproducing bacteria. high mortality rates are linked to diabetes, age, and hospitalisation, necessitating antibiotic treatment optimisation. keywords antimicrobial resistance, clinical outcomes, epidemiology, esblproducing bacteria, gramnegative bacteremia 1 infectious disease department, hamad medical corporation, qatar & qatar university, college of medicine, qatar 2 microbiology department, hamad medical corporation, qatar 3 pharmacy department, hamad medical corporation, qatar 4 epidemiology department, cdc, hamad medical corporation, qatar 5 medicine department, hamad medical corporation, qatar * corresponding author’s e-mail: adilazia44@gmail.com introduction gram-negative bacteria are known to cause a range of infections, including urinary tract infections, biliary infections, pneumonia, and primary and secondary bloodstream infections (gajdács et al., 2019; kim & park, 2018; kwiecińska-piróg et al., 2018). factors that predispose to these infections include extreme age, comorbidities such as diabetes mellitus, immunosuppression, prior use of antimicrobials, medical device usage, and invasive interventions such as surgery, nosocomial acquisition, and duration of stay, even though without a predisposing factor, the infection may also arise (gajdács et al., 2019). one of the major factors contributing to the mortality and morbidity of hospitalised patients is gram-negative bacteremia (gnb). these patients require prompt diagnosis and appropriate antibiotic therapy. the initiation of appropriate antibiotics can reduce mortality, treatment failure, and length of stay, highlighting the importance of broad-spectrum empirical therapy, diagnostic stewardship, and rapid diagnostics for early and timely identification (bassetti et al., 2020; gajdács et al., 2019). conflicting observations have resulted in uncertainty concerning the optimum duration of antibiotic therapy for bacteremia caused by gram-negative infections. many believe gram-negative bacteremia patients should be treated with a 10-14-day intravenous antibiotics course to prevent serious sequelae, such as abscess formation and relapse (turjeman et al., 2023). recently, lee et al. (2019) and yahav et al. (2019) have suggested that short therapy courses are adequate for uncomplicated bacteremia (lee et al., 2019; yahav et al., 2019). the emerging resistance among these bacteria significantly challenges healthcare delivery (iskandar et al., 2021). infections by antimicrobial-resistant organisms, particularly multidrugresistant organisms (de waele et al., 2018), could result in treatment failure, increased morbidity and mortality, increased medical costs, prolonged hospital stays, and increased socioeconomic burden (iskandar et al., 2021; kitaya et al., 2023). in high resistance rates, selecting appropriate empiric antibiotic treatment for suspected gramnegative infections is difficult (fitzpatrick et al., 2016). inappropriate empirical antimicrobial therapy has been shown to predict death in critically ill patients (turjeman et al., 2023). furthermore, prolonged antimicrobial exposure is associated with adverse effects, increased rates of clostridioides difficile infection, antimicrobial resistance, and longer hospital stays (dyer et al., 2019). pa ge 92 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 different centres vary depending on the patient population, immune status, infection control precautions, and antimicrobial use (spellberg & rice, 2019). analysis of local trends and epidemiology is necessary to optimise empirical antibiotic treatment (yahav et al., 2019). if indicated, appropriate antimicrobial therapy with source control is warranted to achieve optimal outcomes (turjeman et al., 2023). the study aims to identify the local epidemiologically predisposing factors, antimicrobial susceptibility patterns, and clinical outcomes in adult patients with gram-negative bacteremia, focusing on factors associated with morbidity and mortality. materials and methods study design and selection criteria a retrospective cohort study was conducted on in-patient adults with gram-negative bacteremia between january 2019 and december 2020 in a 320-bed general hospital in qatar. all adult patients who presented with gramnegative bacteremia during the study period based on positive blood cultures were identified retrospectively from the microbiology lab through hospital electronic records. pediatric patients (aged <14 years) and transit passengers were excluded from the study. samples considered contaminants, as determined by the clinical picture and subsequent management, were also not included. a microbiology database was used to record antimicrobial susceptibility testing current guidelines from the clinical and laboratory standards institute (clsi) (iskandar et al., 2021). the hospital’s electronic patient record system was used to capture all clinical data related to these patients. in contrast, the demographic details, including age, sex, comorbidities (immunosuppression, malignancy, pregnancy, renal disease, diabetes, and hypertension), and clinical presentation, were also recorded. a need for admission to the critical care unit was used to assess the severity of infection. the probable source of infection, persistence of bacteremia beyond the first blood culture, and therapeutic options with intravenous antibiotics alone or combined with source control (incision and drainage of abscesses, stent insertion) were examined. the choice of antibiotics and duration of treatment, including changes made according to sensitivity, were also recorded. clinical outcomes were gauged as cure, death, or infection recurrence within 90 days of admission. any subsequent development of alert organisms such as clostridium difficile infection or the emergence of multidrugresistant microorganisms 90 days after admission was also monitored. multidrug resistance (mdr) was defined as resistance to at least one agent from three or more antimicrobial classes (yezli et al., 2014). ethical approval this study was approved by the institutional review board (irb) and medical research and ethics committee hamad medical corporation (protocol id mrc-01-21259). however, this retrospective cohort review did not obtain individual patient consent. statistical analysis statistical analysis was conducted on 358 patients using the sata/se 14.2. the study analysed epidemiological data, including descriptive statistics and continuous and categorical variables. categorical variables were presented as counts and percentages, whereas normal continuous variables are expressed as means and standard deviations, and non-normal variables are presented as medians and interquartile ranges (iqr). the shapiro-wilk test and visual inspection of histograms were employed to assess the normality of the data. the student’s t-test was applied to normal outcomes, the mann-whitney test was applied to non-normal outcomes, and the chi-square test was used for categorical variables. survival analysis was performed using kaplan-meier survival curves and the log-rank test to assess the differences between the groups for variables associated with mortality based on univariate analysis. results and discussions the demographic and clinical characteristics of the cohort with gram-negative bacteremia were analysed, with a total of 358 patients included in the study. among these patients, the majority (218, 60.8%) were male, with a mean age of 51. table 1 describes the comorbidities observed in the study population. notably, diabetes mellitus emerged as a significant confounding factor. patients’ demographic and clinical profiles were stratified based on their diabetes status, resulting in 197 non-diabetic patients (nondm) and 160 diabetes patients (dm). the non-diabetic group exhibited a significantly younger age than the diabetic group (median ages of 42.5 vs. 60, respectively, p < 0.001). furthermore, hypertension, end-stage renal disease on hemodialysis, and chronic kidney disease were more prevalent in the diabetic group compared to the non-diabetic group (p < 0.001 for all). although the length of hospital stay did not differ significantly between the two groups (p = 0.94), primary bacteremia was more common in the non-diabetic group (p = 0.038). bacterial isolates also showed significant differences in prevalence, particularly with e. coli, klebsiella, and salmonella typhi. additionally, the source of bacteremia varied significantly between the groups, with urinary tract and intra-abdominal infections being prominent in both. antibiotic resistance did not notably differ between the groups (p = 0.49), as shown in table 1. table 1: baseline characteristics of the study population by diabetes status non-dm (n = 197) dm (n = 160) demographics age (wilcoxon rank) 42.00 (28.00-54.00) 60.00 (49.50-70.00) <0.001 pa ge 93 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 male 128 (64.65%) 90 (56.25%) 0.093 comorbidities htn 37 (18.76%) 115 (71.88%) <0.001 esrd hd 07 (3.55%) 25 (15.63%) <0.001 ckd 11 (5.58%) 33 (20.63%) <0.001 malignancy 26 (13.20%) 9 (5.63%) 0.012 copd/asthma 12 (6.09%) 12 (7.50%) 0.59 hiv 0 (0.00%) 1 (0.63%) ihd 7 (3.55%) 38 (23.75%) <0.001 hf 10 (5.08%) 13 (8.13%) 0.24 liver disease 9 (4.57%) 13 (8.13%) 0.16 pregnant females (fisher's exact) 7 (10.14 %) 1 (1.43 %) 0.063 valvular disease (fisher’s exact) 3 (1.52%) 10 (6.25%) 0.017 cystic fibrosis 0 (0%) 0 (0%) inflammatory bowel disease (fisher's exact) 0 (0.00%) 1 (0.63%) 0.45 tuberculosis 1 (0.51%) 0 (0.00%) 1 immunosuppressive treatment 15 (7.61%) 9 (5.63%) 0.46 long hospital stays 10 (5.08%) 12 (7.50%) 0.34 complicated bacteremia 51 (25.89%) 53 (33.13%) 0.16 persistence 13 (6.60%) 5 (3.13%) 0.15 intubated 31 (15.74%) 29 (18.13%) 0.56 icu 52 (26.40%) 39 (24.38%) 0.61 readmission 25 (12.69%) 23 (14.37%) 0.88 length of stay (wilcoxon rank) 35.00 (16.00-44.00) 33.00 (12.00-46.00) 0.94 emergence 7 (3.55%) 15 (9.38%) 0.05 c. diff 2 (1.02%) 0 (0.00%) 0.63 source control 0.046 yes 81 (41.12%) 47 (29.38%) unknown 36 (18.27%) 42 (26.25%) abs previous 36 (18.27%) 63 (39.38%) <0.001 completed iv 0.008 in-patient 128 (64.97%) 106 (66.25%) mhs 17 (8.63%) 29 (18.13%) opat 47 (23.86%) 24 (15.00%) unknown 5 (2.54%) 1 (0.63%) microbiology primary bacteremia 75 (38.07%) 44 (27.50%) 0.038 community-acquired bacteremia 157 (79.70%) 131 (81.88%) bacterial isolates 0.004 acinetobacter 3 (1.52%) 5 (3.13%) brucella 6 (3.03%) 2 (1.25%) citrobacter 1 (0.51%) 1 (0.63%) e. coli 90 (45.45%) 79 (49.38%) enterobacter cloacae 6 (3.03%) 2 (1.25%) klebsiella 28 (14.14%) 31 (19.38%) non-typhoidal salmonella 5 (2.53%) 0 (0.00%) proteus 2 (1.01%) 4 (2.50%) pseudomonas 12 (6.06%) 15 (9.38%) pa ge 94 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 figure 1 shows that 68% of patients with gram-negative bloodstream infections (gnb) successfully recovered from sepsis, but 8% succumbed to sepsis, 5% experienced recurrence, and 6% died from unrelated causes. 5% showed multidrug-resistant organisms, indicating antimicrobial resistance. 2% experienced prolonged bacteremia, and 6% died from unknown causes. these findings highlight the complexity of gnb management and the need for comprehensive strategies to prevent adverse events. salmonella typhi 33 (16.67%) 5 (3.13%) serratia 5 (2.53%) 6 (3.75%) unidentified anaerobic bacilli 0 (0.00%) 1 (0.63%) pseudomonas 1 (0.51%) 0 (0.00%) stenotrophomonas 0 (0.00%) 1 (0.63%) missing 6 (3.03%) 8 (5.00%) resistance 0.49 esbl 57 (28.93%) 46 (28.75%) mdr 9 (4.57%) 12 (7.50%) none 131 (66.50%) 102 (63.75%) source bacteremia (fisher's exact) 0.004 urinary tract infection 71 (36.04%) 71 (44.38%) bone and soft tissue infection 7 (3.55%) 15 (9.38%) burn wound infection 3 (1.52%) 0 (0.00%) cardiovascular infection 1 (0.51%) 2 (1.25%) intra-abdominal infection 70 (35.53%) 31 (19.38%) line related infection 4 (2.03%) 7 (4.38%) lower respiratory tract infection 20 (10.15%) 17 (10.63%) unknown 20 (10.15%) 17 (10.63%) surgical site infection 1 (0.51%) 0 (0.00%) figure 1: the primary clinical outcomes of this study are shown in chart the duration of treatment with intravenous antibiotics revealed that most patients underwent a short course of intravenous therapy. specifically, more than 70% of patients received treatment lasting less than 10 days, which suggests a trend towards shorter intravenous antibiotic therapy durations in managing gram-negative bacteremia cases, as shown in table 2. pa ge 95 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 table 2: intravenous (iv) treatment duration – intervals duration of iv treatment (days) counts percentages % <7 161 44.97 7 to 10 100 27.93 11 to 14 54 15.08 >14 43 12.01 sum 358 100 figure 2 shows the distribution of gram-negative bacteremia by infection site. urinary tract infections are most common (45%), followed by intra-abdominal infections (40%) and lower respiratory tract infections (15%). a notable proportion (10%) has an unknown infection site. other sites include bone and soft tissue infections (5%), line-related infections (2.5%), cardiovascular infections (1%), and miscellaneous sources (2.5%). this breakdown underscores the varied origins of gram-negative bacteremia, emphasising the need for tailored treatment strategies based on infection site specificity. figure 2: epidemiology of gram-negative bacteremia escherichia coli was the most frequently identified organism, accounting for 47.2% of cases, followed by klebsiella pneumoniae (16.4%), salmonella enterica serotype typhi (10.6%), and pseudomonas aeruginosa (7.8%). other less common organisms included serratia marcescens (3%), acinetobacter baumannii (2.2%), brucella sp. (2.2%), non-typhoidal salmonella (1.3%), citrobacter sp. (0.5%), and various others (8.3%). these findings detail the characteristics of gram-negative bacteria isolated in the study, highlighting the prevalence of different species contributing to persistent bacteremia cases. additionally, the mean duration of antimicrobial treatment, including intravenous and oral administration, was 14.6 days, with intravenous antibiotics specifically administered for an average duration of 5.4 days, as shown in table 3. table 3: organisms isolated in persistent bacteremia organism count (out of 18) percentage % e. coli 4 22.22 klebsiella sp. 5 27.77 enterobacter cloacae 1 5.55 pseudomonas sp. 2 11.11 salmonella typhi 3 16.66 proteus sp. 1 5.55 stenotrophomonas maltophilia 1 5.55 achromobacter sp. 1 5.55 as illustrated in figure 3, gram-negative bacteremia arises from various sources within the body. the most prevalent infection sites of cases originating in the urinary tract are evident. intra-abdominal infections and lower respiratory tract infections follow this. it is crucial to note that these percentages may not match the original figure exactly due to potential rounding errors. pa ge 96 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 there were four cases of multidrug-resistant organisms (mdros), two klebsiella pneumoniae carbapenemaseproducing enterobacteriaceae (kpc), and two new delhi metallo-beta-lactamase-1 (nmd-1). extendedspectrum beta-lactamase-producing organisms (esbl) constituted 31.56% (113) cases. antibiotic collateral damage was noted as the emergence of mdro in 90 days in 22 patients (6.1%) and clostridium difficile in two patients (0.5%). persistent bacteremia was reported in 18 patients (5%), out of which nine (50%) had intra-abdominal infections, three had soft tissue infections (16.7%), two had lower respiratory tract infections (11.1%), two had urinary tract infections (11.1%), one had cardiovascular infection (5.5%), and one had line-related infection (5.5%), as shown in table 4. figure 3: common sites of infection in gram-negative bacteremia cases table 4: description of bacterial isolates organisms count percentage (%) multidrug-resistant organisms (mdros) 4 1.11 extended-spectrum beta-lactamase-producing organisms (esbl) 113 31.56 sensitive strains 241 67.32 single microbe 336 93.85 polymicrobial 22 6.14 figure 4 illustrates the distribution of gram-negative bacteremia cases by different bacterial types. the listed bacteria include escherichia coli, klebsiella pneumoniae, salmonella typhi, pseudomonas, serratia, acinetobacter, non-typhoidal salmonella, and citrobacter. the x-axis represents the percentage of cases for each bacterial type. this graph provides insights into the prevalence of various bacterial species causing gram-negative bacteremia, which is essential for understanding the epidemiology and guiding treatment approaches for these infections. figure 4: comorbidities in gram-negative bacteremia cases pa ge 97 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 table 5 illustrates the management of source control in patients with persistent bacteremia. among 18 patients with persistent bacteremia, source control was performed in seven cases, accounting for 38.9% of the cohort. conversely, five patients (27.8%) did not require source control. in contrast, source control was deemed necessary in six cases (33.3%) but was not carried out due to factors such as the patient’s unstable condition or inaccessible sites. table 5: comorbidities of study population comorbidity number percentage (%) diabetes mellitus 160 44.69 hypertension 152 42.45 the end-stage renal disease of dialysis 32 8.93 chronic kidney disease 44 12.29 malignancy 36 10.05 asthma/chronic obstructive pulmonary disease 24 6.70 human immunodeficiency virus 1 0.27 ischemic heart disease 45 12.56 heart failure 23 6.42 chronic liver disease 22 6.14 pregnancy 8 2.23 valvular disease 13 3.63 cystic fibrosis 0 0 inflammatory bowel disease 1 0.27 tuberculosis 1 0.27 immunosuppressive treatment 24 6.70 figure 5 presents the survival probability comparison between diabetic and non-diabetic patients following a positive culture. according to the graph, patients without diabetes have a better chance of surviving than those with the disease. this observation underscores the potential impact of diabetes as a comorbidity on patient outcomes in cases of gram-negative bacteremia. understanding such differences in survival probabilities can inform clinical decision-making and highlight the importance of tailored management strategies for patients with diabetes who develop gram-negative bacteremia. figure 5: kaplan-meier survival analysis denoting survival probability of diabetic and non-diabetic groups table 6 presents the duration of antibiotic treatment in diabetic (dm) and non-diabetic (non-dm) patient groups with gram-negative bacteremia. statistical analysis revealed no significant difference in the duration of antibiotic treatment between the two groups (p=0.617). most patients in both groups received antibiotics for more than 14 days, with 63 (31.98%) in the dm group and 52 (32.5%) in the non-dm group. interestingly, a pa ge 98 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 slightly higher percentage of diabetic patients (10.63%) received antibiotics for less than 7 days compared to non-diabetic patients (8.63%). moreover, a somewhat higher proportion of diabetic patients (35.63%) received antibiotics for 11 to 14 days compared to non-diabetic patients (32.49%). table 6: total duration of antibiotic treatment in diabetic and non-diabetic patients total duration of treatment (days) non-dm (n=197) dm (n=160) count percentages % count percentages % less than 7 days 17 8.63 17 10.63 7 to 10 days 53 26.90 34 21.25 11 to 14 days 64 32.49 57 35.63 more than 14 days 63 31.98 52 32.5 p-value = 0.617 univariate analysis of recurrence at 90 days, cure rate, and death due to sepsis showed a significant difference between the groups (p=0.037, p=0.09, p=0.052, respectively. the sepsis outcomes comparison revealed that diabetic patients had a higher death risk due to sepsis (11.88%) and recurrence within 90 days (8.75%) compared to non-diabetic patients. additionally, the cure rate is less (69.38%) in diabetic patients than in nondiabetic patients (81.73%), as shown in table 7. table 7: univariate analysis of outcomes in diabetic and non-diabetic patients outcome (fisher's exact) non-dm (n=197) dm (n=160) p-value death due to sepsis 11 (5.58%) 19 (11.88%) 0.052 recurrence in 90 days 7 (3.55%) 14 (8.75%) 0.037 cured 161 (81.73%) 111 (69.38%) 0.009 age, treatment duration of fewer than seven days, and hospital-acquired infections showed a significant association with higher mortality in gram-negative bacteremia in the multivariate analysis (or=1.040, p=0.014), (or=20.030, p=0.001), (or=3.517, p=0.020) respectively. conversely, the presence of e. coli and uti as sources of infection was not significantly associated with mortality due to sepsis. kaplan-meier survival analysis was used to assess the survival probability of the diabetic and non-diabetic groups. the log-rank test result was insignificant (p=0.934), as shown in table 8. table 8: multivariate analysis of factors associated with mortality in gram-negative bacteremia patients adjusting for baseline characteristics variable or p-value 95% confidence interval age 1.040 0.014 1.008 1.072 male 1.609 0.448 0.471 5.496 dm 1.008 0.990 0.314 5.496 htn 4.060 0.056 0.967 17.049 esrd/hd 1.237 0.756 0.324 4.716 less than 7 days of treatment 20.030 <0.001 5.454 75.038 hospital-acquired 3.517 0.020 1.217 10.168 secondary 1.394 0.559 0.457 4.253 mdr 0.588 0.547 0.104 3.309 e. coli 0.457 0.192 0.141 1.482 uti a source of infection 0.043 0.007 0.004 0.040 discussion gnb bloodstream infections pose a serious health problem globally and in the middle east, where antimicrobial resistance is rising (inam et al., 2023). several studies have been conducted in this region to understand this condition’s epidemiology and risk factors. the emergence of antimicrobial resistance (amr) has been the top agenda item for the past four years for the gulf cooperation council centre for infection control (gcc-ic) (al muhairi et al., 2019). a previous study on the epidemiology of all bacteremia patients in qatar found 452 cases of bacteremia with 63% grampa ge 99 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 negative organisms (borgio et al., 2021), with escherichia coli as the most common isolate. the present study also found e. coli to be the predominant bacterium (47.2%), followed by klebsiella pneumoniae (16.4%). many cases of salmonella bloodstream infections (10.6%) in our centre were identified mainly as travellers or immigrants from southeast asia. salmonella typhi was 10.6%, and non-typhoidal salmonella constituted 1.3% of cases. an earlier study by qatar found that 97% of patients had a history of travel to endemic areas (ahmedullah et al., 2018). salmonella typhi isolates from the present study centre demonstrated high levels of resistance to ciprofloxacin (40%) but were susceptible to ceftriaxone. among the cases, the brucella sp. was identified in eight patients (2.2 %). in the middle east and north africa (mena) region, brucellosis is not uncommon as a blood culture isolate (wareth et al., 2022). usually, there is a history of exposure to cattle and camels, either through occupational exposure or consumption of dairy products. mdros and esbl-producing isolates comprised 34% of the samples, while the rest were sensitive strains (66%). previous studies also found a higher prevalence of esbl-producing e. coli and klebsiella pneumoniae (55.7%) than present findings (sid ahmed et al., 2023), which indicates the implementation of antimicrobial stewardship practices and monitoring the appropriateness of antimicrobials and their consumption. in addition, previous studies from qatar reported 4.4 % mdr isolates of pseudomonas aeruginosa (p. aeruginosa) (ahmed et al., 2019); however, out of 28 patients with p. aeruginosa bloodstream infection (7.8%), only 2 patients (0.56%) were multidrug-resistant, which is in contrast to studies from saudi arabia with a high prevalence of multidrugresistant (mdr) bacteria, with more than 50% of the isolates resistant to at least one antimicrobial agent (yezli et al., 2014). although p. aeruginosa remains susceptible to carbapenems, quinolones, and aminoglycosides in most centres in saudi arabia, its resistance is still on the rise. similarly, enterobacteriaceae, escherichia coli, klebsiella pneumoniae, and enterobacter sp. amr is increasing, especially in gram-negative infections in the middle east (sid ahmed et al., 2023). prior use of antimicrobials is an established independent risk factor for the emergence of mdros (ahmed et al., 2019). in qatar, about half of the cases of klebsiella pneumonia are reported as extendedspectrum β-lactamase (esbl) producers (alsamawi et al., 2022). a survey from oman found escherichia coli (32.39%), p.aeroginosa (22.16%), klebsiella pneumoniae (19.97%), and acinetobacter baumannii (5.22%), with growing resistance against ciprofloxacin and meropenem (sathya kumar et al., 2023). the factors included prolonged hospital stay, intravenous cannulation, multiple co-morbid conditions, and previous antibiotic exposure, which are attributed to the resistance in the present study. a study in iran demonstrated that the most common gram-negative infections included klebsiella pneumoniae, escherichia coli, serratia marcescens, and pseudomonas aeruginosa (mahmoudi et al., 2023). the study also found a high prevalence of carbapenem-resistant isolates, with more than 70% klebsiella pneumoniae carbapenemresistant; therefore, the implementation of antimicrobial stewardship and infection prevention measures is necessary to control the emergence and subsequent spread of amr, as they are two facets of the same coin. in sub-saharan africa, the levels of third-generation cephalosporins resistance in the bloodstream are reported to be high in escherichia coli (18.4%), klebsiella sp. (54.4%), non-typhoidal salmonellae (1.9% ) (lester et al., 2020). studies from finland, australia, sweden, and canada have shown increased overall resistant escherichia coli bsi rates (buetti et al., 2017). persistent bacteremia was reported in 18 patients (5 %), with the most common pathogens being klebsiella sp. and escherichia coli. source control was performed in only one-third of the patients; out of 30 patients, 13 (43.3%) have died due to persistent bacteremia; source control was performed for eight of them. persistent bacteremia is a serious condition that can lead to significant morbidity and mortality and increased healthcare costs (iskandar et al., 2021). the epidemiology of persistent gnb is complex and is influenced by factors such as prior antibiotic use, exposure to healthcare facilities, and comorbidities. several studies have identified risk factors such as end-stage renal disease (esrd) during hemodialysis, intravascular devices, bacteremia due to mdro organisms, and ineffective antibiotic therapy as independent predictors of persistent gnb bacteremia (de waele et al., 2018). the incidence of persistent gnb is increasing, with higher rates observed in older adults and patients with comorbidities (de waele et al., 2018). persistent gnbs are often seen in patients with weakened immune systems, such as malignancies, hiv, or organ transplants (tumbarello et al., 2012). the main contributing factors to gnb bacteremia were dm2, hypertension, ischemic heart disease, and chronic kidney disease in the present study. approximately 10% of patients had malignancy, and 6.7% were on immunosuppressive drugs. the management of persistent bacteremia can be challenging and requires a multidisciplinary approach. the first step in management includes identifying the source of the infection. appropriate antimicrobial therapy should be initiated with proper source control, including removing infected intravascular devices, such as central venous catheters, or surgical intervention to remove infected tissue. a reasonable approach for source control was observed in the patient population. fortunately, there were only a handful of cases where it was indicated but not performed. appropriate antibiotic therapy should be used based on the organism’s susceptibility pattern to manage persistent gnb effectively. chu et al. found that inappropriate initial antimicrobial treatment increases mortality risk (chu et al., 2020). all gnb bacteremia in patients are reported directly to the infectious disease physician on call by the clinical microbiology department as a part of the antimicrobial stewardship pa ge 10 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 program. as part of the same stewardship, broadspectrum antimicrobials are authorised by infectious disease physicians within 48 hours of initiation. a combination therapy may be necessary to achieve adequate bacterial clearance (kalelkar et al., 2022); the empirical antimicrobials were started according to study hospital guidelines and subsequently tailored to narrowspectrum agents as soon as sensitivities were available. local epidemiology of infective organisms, antibiograms, immune status, previous antimicrobial exposure, possible source of infection, and colonisation with mdr bacteria and other alert microorganisms such as clostridium difficile and candida auris must be considered before initiating empirical therapy. initial broad-spectrum antibiotics should be administered empirically in severely ill patients, followed by source identification and control as soon as possible (timsit et al., 2020). de-escalation from a broadspectrum to a narrow-spectrum antimicrobial when culture and sensitivity results are available effectively reduces amr (lester et al., 2020) and is rigorously followed in our hospital. on average, the duration of intravenous (iv) antibiotics was 5-8 days, although longer durations were used when the underlying illness and source of infection were present. another important intervention was the close teamwork relationship and clinical discussions between our infectious disease physicians and medical microbiologists in decisionmaking (de waele et al., 2018). in south korea, extended-spectrum beta-lactamaseproducing enterobacterales have emerged as a significant cause of community-acquired bacteremia after the prior use of antimicrobials (timsit et al., 2020). the present study did not look for previous use of antimicrobials but noted that last hospitalisation and prolonged hospital stay were associated with a higher emergence of resistance. similarly, a study from lebanon reported that infections caused by resistant bacteria were associated with a significant increase in hospital stays compared to those with susceptible bacteria, leading to higher costs (iskandar et al., 2021). the duration of antibiotic therapy for gram-negative bacteremia depends on several factors, such as the site of infection, severity of illness, and the type of causative organism. in this study, many patients received iv antibiotics for less than 7 days, while only 12% received treatment for more than 14 days (either due to persistent bacteremia or complicated bacteremia). several studies have determined the optimal duration of antibiotic therapy for gram-negative bacteremia (dyer et al., 2019; lee et al., 2019). yahav et al. found that a short course of antibiotic therapy (7 days) was as effective as a longer course (14 days) in the treatment of gram-negative bacteremia (yahav et al., 2019). a meta-analysis of three randomised controlled trials (rcts) with 1121 patients with enterobacterale bacteremia showed no significant difference in 90 days of mortality between 7 and 14 days of treatment (turjeman et al., 2023). shorter durations of antimicrobials are advocated as a goal for many antimicrobial stewardship programs to treat community-acquired pneumonia, urinary tract infections, intra-abdominal infections, and skin and softtissue infections. batlas et al. reported an overall mortality at 1 year of 36.2 %, with 18% within the first 30 days (baltas et al., 2021). similarly, a study from calgary found that 28-day, 90-day, and 365-day all-cause case-fatality rates after bloodstream infection were 12%, 17%, and 25%, respectively (laupland et al., 2011). a study by qatar showed a hospital mortality rate of 29.7 % for all bacteremia cases (khan et al., 2010). a larger study examined the epidemiology of bloodstream infections in 51 countries across six continents in critically ill patients, including covid-19 patients (buetti et al., 2017), found that gram-negative bacteria were the most common cause of bloodstream infections and the overall mortality for bloodstream infections was 45%, with higher rates reported in covid-19 patients (buetti et al., 2017). mortality due to gram-negative bacteremia can vary depending on various factors, such as the specific bacterial species involved, age and overall health of the patient, presence of underlying medical conditions, and promptness and effectiveness of treatment. the mortality from gram-negative bacteremia is higher than that from gram-positive bacteremia, with some studies suggesting mortality ranging between 20 and 50%. however, mortality rates can vary widely based on individual circumstances, and it is important to note that timely and appropriate antibiotic treatment can greatly improve outcomes in patients with gram-negative bacteremia. the incidence and mortality rates of gram-negative bacteremia can vary globally, depending on healthcare practices, antibiotic resistance patterns, and population demographics. the study centre has an antimicrobial stewardship program with formulary restriction and preauthorisation of restricted antimicrobials that aid in appropriately starting antimicrobials, particularly in bacteremia cases, and is followed by the infectious disease team in collaboration with the medical microbiologist, which could be one reason why the mdro rate was not significantly high. however, cephalosporins are not restricted in clinical practice, which might explain the higher numbers of esbl-producing enterobacterales. conclusion in conclusion, gram-negative bsis are serious infections with increasing antimicrobial resistance (amr). extendedspectrum beta-lactamase (esbl) producing bacteria are our centre’s most common cause of amr. diabetes mellitus-2, old age and hospital-acquired infections are risk factors leading to higher mortality. healthcare professionals should be aware of the risk factors associated with this condition and initiate empirically effective antibiotic therapy to achieve optimal treatment outcomes and prevent collateral damage. further research is needed to understand better the epidemiology and pathophysiology of gram-negative bacteremia in qatar and formulate effective targeted treatment strategies. pa ge 10 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 91-102, 2024 limitations the limitations of our study include the need for more data on the prior use of antimicrobials and health care costs. the long-term impact of gnb beyond 3 months has yet to be investigated. the retrospective nature of this study and the single-center data are other limitations. further analysis with a larger sample size is recommended to enhance the understanding of these findings in clinical practice. in this study, we only looked at long-term mortality within 90 days. still, collateral damage was determined, such as the emergence of mdro in 90 days at 6.1%, while infection with clostridioides difficile occurred only in 2 patients (0.5%). acknowledgement clinical microbiology department and pharmacy department data availability statement the data used to support the findings of this study were restricted by the institutional review board (irb) medical research centre at hamad medical corporation to protect patients’ privacy. data can be obtained after irb approval for researchers who meet the criteria for access to confidential data. references ahmed, m. s., hassan, a., jarir, s. a., hadi, h. a., bansal, d., wahab, a. a., muneer, m., mohamed, s., zahraldin, k., & hamid, j. 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(2022). the perspective of antibiotic therapeutic challenges of brucellosis in the middle east and north african countries: current situation and therapeutic management. transboundary and emerging diseases, 69(5), e1253-e1268. yahav, d., franceschini, e., koppel, f., turjeman, a., babich, t., bitterman, r., neuberger, a., ghanem-zoubi, n., santoro, a., & eliakim-raz, n. (2019). seven versus 14 days of antibiotic therapy for uncomplicated gram-negative bacteremia: a noninferiority randomised controlled trial. clinical infectious diseases, 69(7), 1091-1098. yezli, s., shibl, a. m., livermore, d. m., & memish, z. a. (2014). prevalence and antimicrobial resistance among gram-negative pathogens in saudi arabia. journal of chemotherapy, 26(5), 257-272. pa ge 1 pa ge 13 2 american journal of medical science and innovation (ajmsi) analysis of window width variations on msct stonegraphy anatomic image information at sanjiwani hospital of gianyar regency i made dwi gunawan1*, anak agung aris diartama1, i made adhi mahendrayana1, putu irma wulandari1 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2076 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 04, 2023 accepted: september 30, 2023 published: october 09, 2023 parameters in msct can affect image contrast and brightness are values of window width and window level. window width will affect the contrast of the image. where the higher the value of window width used, the image contrast will decrease, where is the selection of the value of window width which can improve the quality of msct images and provide better diagnostic information. the purpose of this research is to determine the effect of window width variation on anatomy image information and determine the most optimal window width value msct stonegraphy examination. this research is a quantitative with an experimental approach. the data obtained was then analyzed by kappa test to assess the reliability of the respondents, from the results of the respondents then the statistical test used was the friedman test. statistical test results p value <0.05. this research has the effect of changing values window width. anatomical image information with value of window width 250 showed optimal results for assessing the urinary tract on stonegraphy msct. in this study there is the effect of variation window width significant to the stonegraphic msct anatomical image information. keywords msct, stonegraphy, window width 1 atro bali, indonesia * corresponding author’s e-mail: oguna919@gmail.com introduction multislice computed tomography (msct) stonography is an examination of the urinary tract without using oral or intravenous contrast media. msct stonegraphy is one of the examination techniques used to view and diagnose urinary tract abnormalities, namely hydronephrosis, urolithiasis, nephrolithiasis, so msct stonegraphy is used as a substitute for ivu (intravenous urography) examinations, because it cannot provide qualitative diagnostics. all aspects related to the accuracy of displaying organ structures and tissues in images are included in image quality. factors that influence image quality include spatial resolution, contrast resolution, noise, and artifacts. to obtain an optimal image, an image display with clear contrast is required. parameters in msct that can affect image contrast and brightness are the window width and window level values (bontrager & lampignano, 2014) to modify the grayscale on msct, a process called windowing is used, by setting the ct window width and window level values. the window width level will affect the image contrast, where the higher the window width value used, the image contrast will decrease, where selecting the appropriate window width value can improve the quality of the msct image and provide better diagnostic information (singh, 2020). a wider window width (2000 hu) will display a larger ct number range, so that changes from dark to light areas will occur over a wider area (nadya, 2021). therefore, using a wide window width will show all the different ct number values, so that soft tissue is not clearly visible. on the other hand, a narrow window width is very good for displaying similar anatomical structures such as soft tissue (nadya, 2021). the protocol used in the msct stonegraphy examination, namely the msct abdomen protocol, includes kv, mas, slice, slice thickness, pitch, fov, range, reconstruction algorithm and window widht and window level (singh, 2020), and uses soft tissue windowing (soomro, ather , & salam, 2016). the window widht setting is between 50 to 350 hu, to distinguish networks that have almost the same density (nadya, 2021), while according to seeram (2022), use a window width of 350-600 hu to see different soft tissue network structures with the same density. from data obtained at the radiology installation at sanjiwani hospital, gianyar, there are approximately 40 patients undergoing msct stonegraphy examinations a month. the msct stonegraphy examination at sanjiwani hospital gianyar is one of the most frequent types of examination every month, with various diagnoses, such as urolithiasis, kidney stones, hydronephrosis, and uvj stones. the management of msct stonegraphy at the sanjiwani hospital gianyar installation uses a plain msct abdomen protocol with a window width of 300 hu. based on the explanation above, the author is interested in conducting research on optimizing window width in msct stonegraphy examinations. the aim of this research is to determine the effect of variations in window width on anatomical image information and to determine the optimal value of window width on msct stonegrafi anatomical image information. literature review computed tomography (ct) ct scan is a supporting tool for making a diagnosis that uses a combination of x-rays and a computerized system to obtain sliced images of various pieces of human body pa ge 13 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 132-135, 2023 objects. data processing with a computerized system to produce a cross-sectional view of the image and can also display a three-dimensional image of the internal organs and structure of the body can also help diagnose the internal body in normal or abnormal conditions, ctscans are also used in accurate treatment procedures for assists in instrument placement or patient care. computed tomography (ct-scan) consists of 3 (three) main components: gantry, computer, and operator console. computed tomography (ct-scan) uses the main principle, namely the rotation of the x-ray tube and emitting x-rays continuously, followed by movement of the patient’s table, so that there are multislices in one patient movement. the x-ray radiation beam will experience an exponential decrease in intensity with the thickness of the object it passes through. the decrease in the intensity of the radiation beam occurs as a result of the radiation interaction process in the form of absorption or scattering, the probability of which occurs is determined by the type of object and the radiation emitted. to get an image of an object in computed tomography (ct-scan), the radiation beam produced by a radiation source will go towards an object from various angles. scattered radiation will be detected by the detector system to be stored and collected as input data which is then processed using a computerized system to produce images using a method called reconstruction. figure 1: working system of msct parameter computed tomography (ct-scan) according to bontrager (2018), the quality of the image produced by msct is an important factor in displaying a good image, thus allowing the clinical aspects of the image to be used to make a diagnosis. when using multislice ct, there are several parameters that must be considered to control optimal image output. multislice ct parameters are as follows: range range is the result of combining a number of slice thicknesses. range is used to produce different slice thicknesses in one examination area. slice thickness slice thickness is the thickness of the cut or slice of the object being examined, also expressed in millimeters (mm). exposure factor exposure factors are factors that influence tube voltage (kv), tube current (ma) and time (s). the amount of tube voltage can be selected automatically for each inspection field of view (fov) fov is the diameter of the image to be reconstructed between 200-300mm gantry tilt gantry tilt is the formation of an angle between the vertical plane and the gantry (x-ray tube with sectors). the angle range is between -30° to +30°. gantry angles function for diagnostic purposes in each case. matrix reconstruction matrix reconstruction is a series of rows and columns of picture elements (pixels) in the image reconstruction process. generally the matrix used is 512 x 512 in size. reconstruction algorithms/ kernel filters reconstruction algorithms are mathematical procedures used in reconstructing images. the appearance and characteristics of the computed tomography image depend on the strength of the algorithm chosen. window width window width refers to the computed tomography (ct) values converted to gray levels for display on a pa ge 13 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 132-135, 2023 tv monitor. after the image is processed through matrix reconstruction and algorithms, the results will be converted into a numerical value called the ct number. this ct number is measured in hounsfield units (hu), where bone has a hu value of around +1000 to +3000 and air has a hu value of around -1000. tissue or other substances have different hu values depending on their density. as a result, bones will appear as white and air will appear as black on the monitor. tissue and other substances will be displayed as different levels of gray called gray scale. however, if iodine is used as a contrast medium, blood that initially appears as gray levels may appear as white (7). a narrower window width can increase greater detail in anatomical image quality, for example the use of a narrow window width (70 hu) in head msct examinations in cases of non-hemorrhagic stroke. according to seeram (2022), the correct use of window width is 400hu 2000hu to cover different tissues, for example tissue in parts of the body, namely the abdomen, using a window width of 350 hu to 600 hu in order to differentiate fat, fluid and muscle. according to buzug 2008, to show the condition of the bones using a window width of 1500hu and to show soft tissue using a window width of 350hu, visible on abdominal examination. differences in spine density can only be seen in the bone window because the window width is wide, but cannot show soft tissue. soft tissues such as the liver and kidneys can be differentiated quite well in a narrow window width with a value of +225hu, whereas according to r. bruening et.al the ct scan examination to show the kidneys uses a window width of 420 to get maximum results on the kidney organs. window levels window level is the middle value of the window used for image display. this value can be selected and depends on the weakening characteristics of the structure of the object being examined. window level determines the density of the image to be produced (7). using the correct window level will produce good anatomical image quality, which is indicated by clear boundaries between different tissues. when examining a thorax ct scan for lung window conditions, using a window level of -450 is better in displaying anatomical image quality. a) computed tomography (ct-scan) image quality b) according to nagel, the factors that influence image quality are spatial resolution, contrast resolution, noise and artifacts. spatial resolution spatial resolution is to distinguish small objects with different densities from the same background. contrast resolution contrast resolution is to differentiate organs with very small differences in density which are influenced by object size, exposure factors, slice thickness, and reconstruction algorithms/kernel filters. noise noise is the fluctuation (standard deviation) of the attenuation value in a homogeneous tissue or material. methodology this research is quantitative research with an experimental approach. the resulting data is on an ordinal scale, so a descriptive test is carried out to group the data followed by a kappa test to assess the reliability of the respondents. from the respondents’ results, the statistical test used is the friedman test, if the p value is <0.05 then ho is rejected and ha is accepted, meaning that there is an influence of window width variations on the msct stonegrafi anatomical image information. results and discussion based on data obtained from msct stonegraphy patients at the radiology installation at sanjiwani hospital, gianyar, the examination was carried out using the siemens somatom definition as 64 slice msct tool using varying window width values, namely 250, 300, 350, 400. data from this study were obtained from 15 patients as a research sample, so that 60 image results were obtained. from the slices obtained, the slice that most clearly shows the kidneys, ureters, urinary bladder and pathology in one image is selected. then the assessment of anatomical information is obtained by giving an assessment score of 1 to 3. table 1: results of kappa test. value approximate significance measure of agreement kappa .881 .000 n of valid cases 15 table 1 shows that the kappa test above means that the level of reliability between the two respondents is strong, (strong agreement) namely 0.881. analysis of window width variations in anatomical image information during the msct stonegraphy examination at the radiology installation at sanjiwani hospital, gianyar. data was obtained from 2 questionnaires that were distributed to radiologists. because the data is ordinal in nature, the data is then processed using the friedman test, where the results are obtained according to table 2. based on table 2, the results of the friedman test regarding window width variations in the msct stonegraphy examination of anatomical image information shows a p value of 0.000 (p value <0.05) which means that ho is rejected and ha is accepted. table 2: results of friedman test. n p value results window width variation analysis of msct stonegraphy anatomical image information 0.000 p value <0.05 ho rejected ha accepted pa ge 13 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 132-135, 2023 the results of this research are related to research conducted by muhammad izzudin et al. (2020) which shows the results of asymo. sig is smaller than 0.05 (p value <0.05), which means there is a difference in changes in window width variations, which can also be interpreted as meaning that changes in window width have an effect on image information. according to buzug (2008), to show the condition of the bones using a window width of 1500hu and to show soft tissue using a window width of 350hu, visible on abdominal examination. differences in spine density can only be seen in the bone window because the window width is wide, but cannot show soft tissue. soft tissues such as liver and kidneys can be differentiated quite well in a narrow window width with a value of +225hu. the results of this research are also supported by the results of the author’s observations while conducting research at the radiology installation at sanjiwani hospital, gianyar, namely, on the radiologist’s advice, the radiographer changed the window width conditions to between 250 and above to obtain optimal image results according to the needs for diagnosing patients. the most optimal window width value to obtain good anatomical image information during the msct stonegraphy examination at the radiology installation at sanjiwani hospital of gianyar regency data was obtained from a questionnaire distributed to two radiologists as respondents to determine the most optimal window width value to obtain good image information. then the data is input using statistics according to the questionnaire data that has been selected. the optimal window width value for showing the anatomy of the urinary tract is 300. according to buzug (2008), differences in spine density can only be seen in the bone window because the window width is wide, but cannot show soft tissue. soft tissues such as liver and kidneys can be differentiated quite well in a narrow window width with a value of +225hu. conclusions the results of the research show that there is a significant influence of window width variations on the anatomical image information of msct stonegrafi. the most optimal variation in window width values for obtaining anatomical image information shows a mean rank of 7.23 with a window width value of 250. this value is able to display the anatomy of the urinary tract clearly and clearly. the window width selection for the msct stonegraphy examination is recommended to use a window width of 250. each hospital has a different window width value in order to obtain optimal results for confirming the diagnosis. future research can further vary the window width in the msct stonegraphy examination, and so that each anatomy is assessed. references bontrager, k.l., lampignano, j.p. (2014). handbook of radiographic positioning and techniques. journal of chemical information and modeling. buzug, t.m. (2018). computed tomography (frim photon statistics to modern cone-beam ct). germany: springer. drake, r.l., vogl, w., mitchell, a.w.m. (2016). gray basic anatomy. second edition. elsevier, piladelphia. izzudin, m., sukmaningtyas h., sulaksono, n. (2021). analisis variasi window width terhadap informasi citra anatomi msct stonegrafi. jri (jurnal radiogr indones, 4(2), 99–105. nadya, n.s. (2021). prosedur pemeriksaan ct scan urografi dengan klinis batu saluran kemih di instalasi radiologi rs awal bros panam. karya tulis ilmiah. stikes awal bros pekanbaru, 6-7. o’connor, o.j., maher, m.m. (2010). ct urography. am j roentgenol, 195(5):320–4. romans, l.e. (2011) computed tomography for technologists a comprehensive text. philadelphia, pennsylvania. 317-33. seeram, e. (2022). computed tomography: physical principles, patient care, clinical applications, and quality control. fifth edition. elsevier. singh, v. (2020). general anatomy with sistemic anatomy radiological anatomy medical genetics. third edition. 206-7. watson. (2018). chapman & nakielny’s guide to radiological procedures. seventh edition. 132-3. yuliana. (2017). diktat urinary tract. bagian anatomi fakultas kedokteran universitas udayana denpasar, 8-12. table 3: mean rank. mean rank r1_250 7.17 r1_250 7.23 r2_300 4.10 r2_300 4.47 r3_350 3.57 r3_350 3.13 r4_400 2.93 r4_400 3.40 based on table 3, the mean rank results regarding the optimal window width value show that the window width value of 250 has the largest mean rank value, namely 7.17 and 7.23. the results obtained can be interpreted as meaning that this research can make the window width value of 250 the optimal variation to show a good anatomical image in the msct stonegraphy examination. apart from being based on statistical test results, based on direct observation by the two respondents, namely radiology specialists, they stated that a window width value of 250 could show clear anatomy of the urinary tract. the results of this research are also supported by other similar research conducted by izzudin et al. (2020) regarding analysis of window width variations on msct stonegraphy anatomical image information showing that pa ge 1 pa ge 11 8 american journal of medical science and innovation (ajmsi) the impact of unified medical insurance system implementation (nphies) on healthcare service quality: applied research case study in arrawdha general hospital dammam, saudi arabia mohammed ibrahim alnajjar1* volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2630 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 28, 2024 accepted: may 31, 2024 published: june 04, 2024 ensuring high-quality healthcare services is crucial for the well-being of individuals and the overall development of societies. in saudi arabia, healthcare reform efforts under vision 2030 emphasize the importance of enhancing healthcare service quality. one key aspect of these reforms is implementing the unified medical insurance system, nphies. this system aims to improve access to healthcare and enhance the quality of services provided. however, there is a lack of research examining the specific impact of nphies on healthcare service quality, particularly in hospitals like arrawdha general hospital in dammam. this study aims to investigate the impact of nphies implementation on healthcare service quality at arrawdha general hospital in dammam, saudi arabia. by examining the relationship between nphies and healthcare service quality, the study seeks to provide valuable insights that can inform healthcare policies and practices in the region. the study has adopted a quantitative approach, collecting data through a questionnaire administered to physicians and administrators at arrawdha general hospital. statistical analysis (descriptive statistics, t-tests, anova, and pearson’s correlation coefficient) have been used to analyze the data. statistical analysis showed no significant differences in nphies implementation or healthcare service quality based on demographics suggesting a consistent perception across different demographic groups. the study also identified a statistically significant positive effect of nphies on healthcare service quality, emphasizing its role in improving healthcare services. future research should examine the impact of the unified medical insurance system (nphies) implementation on elderly patient satisfaction and health outcomes in saudi arabia. keywords healthcare service quality, medical insurance system, nphies, saudi arabia, unified medical insurance system, vision 2030 1 atlas american university, 8 the green, ste #15974 dover de, 19901, usa * corresponding author’s e-mail: alnajjar.mohd@yahoo.com introduction since the formation of the ministry of health (moh) in 1950 and the establishment of the initial public health department in mecca in 1925, the kingdom of saudi arabia (ksa) has experienced incredible developments in healthcare services. at the moment, saudi arabia has 487 hospitals with 72,981 beds, which is about 2.2 beds for every 1000 people (al-hanawi et al., 2019). the government has given the development of healthcare services of different levels top priority, and in 2018 an additional budget was set aside for social and health services. this dedication to high-quality healthcare is demonstrated by the ksa healthcare system’s position of 26th out of 191 countries by the world health organization (who), which puts it ahead of developed countries like the canada, united states, and australia, as well as adjacent arabian gulf countries. however, barriers still exist in delivering improved healthcare services to the ksa’s rapidly expanding population. the total fertility rate was 3.04 and the yearly population growth rate was 3.2% between 2004 and 2010 (alrowes, 2023). saudi arabia’s population is expected to grow to 39.8 million by the year 2025, 54.7 million until 2050, and 61.3 million by 2100, according to un estimates. with the population predicted to expand from 1 million to 2.5 million older adults by 2020, assisting the elderly has become more challenging due to longer life expectancies (alkhamis et al., 2021; alkhamis & miraj, 2021). the current healthcare system is under stress due to this demographic transition, underscoring the necessity for an adequate supply of highly qualified healthcare workers. the implementation of the new strategic scheme, vision 2030, has presented both problems and possibilities for the healthcare industry to meet its strategic imperatives with its path in the years ahead. vision 2030 sets priority in all economic sectors and acts as a road map for saudi arabia’s economic growth (rahman & qattan, 2021; singh et al., 2022). the national transformation program (ntp) 2020 was introduced as part of vision 2030, and it outlines each ministry’s strategic goals, key performance indicators (kpis), and key performance targets (kpts) (farghaly abdelaliem et al., 2023). healthcare quality improvement has evolved as a crucial emphasis for modern healthcare systems across the world, motivated by a shared desire to improve patient results and satisfaction. this dedication stems from the recognition that highquality healthcare facilities not only enhance individual health but also significantly contribute to society’s wellbeing and economic development. countries throughout the world are emphasizing healthcare quality as a critical component of their healthcare reform initiatives, acknowledging its enormous influence on public health pa ge 11 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 and healthcare system efficiency (reibling et al., 2019). aligned with the worldwide motion, saudi arabia has initiated comprehensive healthcare improvements as a component of its vision 2030, with the primary objective of enhancing healthcare accessibility and quality throughout the country (al-luhaym & alshagrawi, 2023). the goal of these changes is to improve the general quality of healthcare services that the nation’s people receive by implementing substantial improvements to the health insurance system. for healthcare organizations, providing high-quality services is crucial since it improves beneficiary satisfaction and advances the general wellbeing of society. it has been demonstrated that higherquality healthcare may lower the prevalence of disease and increase access to care, which is especially beneficial for those with limited resources (haque et al., 2020). improving healthcare service quality is a universal goal, as evidenced by international agreements such as the united nations summit’s sustainable development goals (sdgs) from 2015 (pongpiachan & hashmi, 2020). both public and commercial healthcare facilities worldwide are working to improve service quality by tackling the different elements that impact it. implementing systems like medical insurance has been highlighted as an important component of assessing healthcare service quality (zhou et al., 2020). despite these considerable advances, research into the influence of nphies deployment on healthcare service efficiency in saudi arabia is still scarce. this study aims to close this gap by investigating the extent of nphies application at arrawdha general hospital in dammam and its impact on healthcare service quality. by providing light on this essential feature, the study hopes to give significant insights for healthcare professionals and policymakers seeking to improve healthcare delivery and outcomes in saudi arabia. saudi arabia’s vision 2030 is a revolutionary strategy that emphasizes healthcare’s critical role in attaining greater social objectives. the vision’s focus on healthcare quality enhancement intends to promote the population’s overall health and well-being, hence promoting economic development and growth. literature review medical insurance system individuals worldwide rely heavily on the medical insurance system to provide coverage for healthcare services and financial stability. it serves as a social safety net, reducing the financial strain of medical costs and fostering general well-being. social insurance and private insurance are the two main types of medical insurance systems found around the world. social insurance provides residents with universal coverage and is financed by necessary contributions from employers, employees, and occasionally the government. national health insurance schemes in countries including the united kingdom and canada are two examples. contrarily, private insurance entails individuals or companies buying private health insurance policies from insurance providers; the specific plan and insurer selected will determine the coverage and cost (aljohani & bugis, 2024). one country with a strong private insurance industry is the united states (elena nebolsina, 2018). medical insurance systems enhance healthcare access, reduce financial barriers, and promote preventative care, leading to better health outcomes. however, they also pose challenges like moral hazard and adverse selection. balancing coverage costs with insured demands is crucial for long-term financial stability, and disparate resource allocation can lead to healthcare access inequities. saudi arabia’s medical insurance system has experienced considerable improvements, ensuring financial stability and accessibility for inhabitants. the system consists of many groups, including the national health insurance scheme, which covers all necessary medical treatments. the program provides financial security for older individuals facing age-related health issues (al-hanawi et al., 2018). the selective medical insurance program (smip) provides comprehensive medical coverage for foreigners and their family (zhou, 2023). the system provides financial security, expanded healthcare access, and enhanced efficiency. healthcare’s growing costs pose issues in terms of coverage, quality, and sustainability. a coordinated and sustainable system requires continuous monitoring and modifications. healthcare service quality the idea of healthcare service quality is complex and includes a range of factors and indicators. its main goal is to satisfy patients’ requirements and expectations while keeping in mind accepted norms. the degree to which a medical facility’s healthcare services satisfy patients’ requirements and expectations in accordance with predetermined criteria is a common definition of healthcare quality (fatima et al., 2018). it also describes how well healthcare systems and procedures meet or surpass patients’ needs and expectations while adhering to legal requirements. the capacity of a patient to pay for healthcare services is referred to as accessibility, and the dependability of healthcare services in providing care and treatment for a patient is referred to as dependability. these two factors are used to determine the quality of healthcare (swain & kar, 2018). the characteristics of healthcare services can be measured in terms of tangibility, empathy, assurance, responsiveness, and reliability (setiono & hidayat, 2022). meeting patients’ fair expectations for non-medical aspects of therapy and delivering prompt service are all included in responsiveness. the ability to provide dedicated healthcare services accurately and consistently while guaranteeing accurate invoicing is what is meant by reliability. assurance includes staff members’ attitude of confidence and trust, professionalism, competency, and kindness. the external expression of tangible resources, such as structures, equipment, people, and communication devices, is referred to as tangible. it entails having access to contemporary medical technology and equipment, attractive physical settings, and well-groomed personnel. pa ge 12 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 empathy is showing patients that you care about them individually and with compassion by acknowledging their situations while you provide care and therapy (agustina & handayani, 2023; bentum-micah et al., 2020). several indicators are employed to assess the quality of healthcare services, such as avoidable hospital admissions, various medications and therapies imposed in primary care, signs of acute treatment, and measures showing the efficacy of mental health services. patient experiences and contentment are also major predictors of healthcare service quality (ng & luk, 2019). the implementation of a unified medical insurance system has considerably increased access to healthcare while lowering patients’ out-of-pocket payments (al-hanawi et al., 2021). it has also helped to close the healthcare utilization gap between rural and urban regions, promoting regional equity. research perspectives on the impact of health insurance systems on healthcare service quality the influence of health insurance systems on healthcare service quality has been investigated from a variety of viewpoints, both in saudi arabia and worldwide. several research has examined the link between healthcare insurance systems along with the quality of healthcare services, providing light on various elements and dimensions of this complicated subject. one important factor that has been investigated is the effect of health insurance on accessibility to care and healthcare usage (erlangga et al., 2019). according to research, having health insurance enhances the probability that people would seek medical care, get frequent exams, and receive essential medical treatments. increased use of healthcare services may contribute to better medical results and higher overall quality of treatment (djahini-afawoubo & aguey, 2022). additionally, studies have investigated the connection between patient happiness and health insurance. according to some research, having health insurance improves patient satisfaction, especially when it comes to financial security and access to care (manzoor et al., 2019). further research into the variables impacting patient happiness in healthcare settings is necessary, since past studies have indicated that there can be differences in patient satisfaction depending on insurance status (meesala & paul, 2018). furthermore, there has been discussion on how health insurance may raise the standard of medical care. research has demonstrated that health insurance can result in improved access to treatment, a greater usage of preventative services, and a higher level of satisfaction with care(mazurenko et al., 2018). on the other hand, issues including unfair benefit distribution and variations in healthcare quality and accessibility amongst various demographic groups have also been brought to light (bagnoli, 2019). healthcare sector in saudi arabia saudi arabia’s healthcare industry is rapidly growing and changing as a result of the government’s dedication to raising the quality and availability of healthcare services. the saudi government is making large investments in the healthcare system as part of vision 2030, with intentions to boost private sector involvement and privatize several healthcare institutions (moshashai et al., 2020). the goal of this move toward privatization is to increase effectiveness and lessen the load on the government to deliver healthcare services. one of the most important projects is the national health insurance (nhi) program, which tries to build a sustainable healthcare system by collecting monthly financial payments from members (puteh et al., 2022). this initiative has received tremendous support, with many people eager to pay for nhi, especially those who routinely utilize public healthcare and are pleased with the results. furthermore, the government offers free medicines to all residents through government-run healthcare facilities and social and public health insurance programs. figure 1: healthcare system in saudi arabia (puteh et al., 2020) pa ge 12 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 saudi arabia’s healthcare system confronts issues such as growing expenses, fast population expansion, and a high frequency of chronic diseases (almalki et al., 2011). to address these issues, the government is working to modernize the healthcare system and establish innovative care models. the six systems of care that are keeping well, planned procedures, women and children, urgent problems, chronic illnesses, and the end stage of life are being combined to provide complete and efficient healthcare. additionally, the saudi government encourages the application of technology to enhance healthcare services. initiatives focusing on organizational development and technological effectiveness are being adopted to improve the healthcare system’s efficiency and attractiveness (sajjad & qureshi, 2020). the purpose is to apply various healthcare technologies to enhance the organization’s reputation, employees, healthcare system, and general healthcare quality. overall, saudi arabia’s healthcare system is experiencing major transformation to satisfy the rising demand for healthcare services. the government is aiming to develop a sustainable healthcare system that offers all citizens with high-quality and easily accessible healthcare services through vision 2030 and other reform measures. figure 1 shows saudi arabia’s healthcare sector, which offers services to non-saudi citizens through employerbased health insurance, private healthcare, emergency, outpatient, and inpatient services. citizens have access to public hospitals, private services, and free public services, including primary, general, specialist, and tertiary hospitals (puteh et al., 2020). materials and methods the study evaluates the impact of nphies on healthcare service quality at arrawdha general hospital, dammam, saudi arabia, using a quantitative approach and by randomly selecting 300 participants. data collection the study used a standardized questionnaire to gather data from physicians and administrators at arrawdha general hospital. the questionnaire included demographic and nphies implementation sections. a total of 300 questionnaires were delivered, with a response rate of 91.67%. of these, 275 questionnaires were obtained and assessed valid for processing. data collection was carried out over a set period of time to guarantee complete data acquisition. inclusion and exclusion criteria the study included those individuals with the targeted profession such as physicians or administrators which are motivated to participate in the study and are present at the arrawdha general hospital. those who did not provide their agreement to participate in the study or who had no affiliation with the hospital were excluded from study. data analysis the study utilized the spss program to analyze data on the influence of the unified medical insurance system (nphies) on healthcare services at arrawdha general hospital. statistical methods included pearson’s correlation coefficient, cronbach’s alpha, t-tests, anova, and regression analysis. the study aimed to understand the perceived effects of the system by comparing responses from administrators and physicians. response degrees were represented using likert scale and verification degrees for each axis were determined using the following formula: table 1: distributed and retrieved questionnaires suitable for statistical analysis distributed questionnaires retrieved and valid for statistical analysis questionnaires percentage 300 275 91.67% table 2: distributed and retrieved questionnaires suitable for statistical analysis gender frequencies percentages male 142 51.6% female 133 48.4% total 275 100% demographics the frequencies and percentages were calculated for the study sample, and they are represented in the demographic variables, which include: gender the table 2 shows that the highest percentage achieved by respondents based on gender was (51.6%) ascribed to (male), which was followed by a lower percentage (48.4%) allocated to (female). job position the table 3 shows that the largest percentage obtained by respondents as per job position was (72.0%) attributed to (physician), followed by the lowest percentage of (28.0%) attributed to (administrator). table 3: distribution of respondents as per their job positions job position frequencies percentages physician 198 72.0% administrator 77 28.0% total 275 100% pa ge 12 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 year of experience the table 4 shows that the largest percentage obtained by respondents according to years of experience was (51.6%) attributed to (from 5 to less than 10 years), followed by (29.1%) attributed to (less than 5 years). while the lowest percentage was (19.3%) attributed to (10 years and above). the study tool, a questionnaire, was designed to assess the impact of a unified medical insurance system (nphies) on healthcare service quality. it included dimensions like responsiveness, reliability, assurance, tangibility, and empathy. the tool’s validity and reliability were confirmed through a pilot sample of 30 individuals. table 4: distribution of respondents as per the years of experience years of experience frequencies percentages less than 5 years 80 29.1% from 5 to less than 10 years 142 51.6% 10 years and above 53 19.3% total 275 100% table 5: correlation coefficients between the total score for each dimension and the total score for the first axis: the implementation of a unified medical insurance system (nphies) no. dimensions correlation coefficient 1 the first dimension: insurance services implementation .991** 2 the second dimension: health services implementation .992** table 6: cronbach’s alpha reliability coefficient for the dimensions and the total score for the first axis no. dimensions statements no. cronbach's alpha coefficient 1 the first dimension: insurance services implementation 10 .984 2 the second dimension: health services implementation 10 .977 total 20 .982 first axis: the implementation of unified medical insurance system (nphies): the validity and reliability of the tool the study revealed the psychometric characteristics of the questionnaire, by verifying its validity and reliability, by applying it to a pilot sample apart from the original study sample and which consisted of (30) individuals. the above table makes it evident that each dimension’s correlation coefficient values and the questionnaire’s total score for the first axis had (high) values, ranging from (.991** .992**), and that they were all highly significant at the significance value of (0.01). this suggests that the first axis has an elevated level of construct validity. the reliability of the tool: cronbach alpha the cronbach’s alpha reliability coefficient was calculated for the first axis dimensions of implementing a unified medical insurance system (nphies) and the total score in the questionnaire. table 6 shows high reliability coefficients for the first axis dimensions (.977-.984), with a total reliability coefficient of (.982), indicating the questionnaire’s validity, reliability, and results for its application. second axis: healthcare service quality the validity and reliability of the tool the internal consistency validity was assessed by calculating the pearson correlation coefficient between each statement’s scores and the total score of the dimension from the second axis: healthcare service quality. table 7: pearson correlation coefficients between individual statement scores and the total score for the dimension in the second axis of healthcare service quality statement no. correlation coefficient statement no. correlation coefficient statement no. correlation coefficient the first dimension: responsiveness 21 .986** 22 .979** 23 .964** 24 .932** 25 .960** the second dimension: reliability pa ge 12 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 table 7 shows that the correlation coefficients of statements with the total score of the second axis of healthcare service quality were all statistically significant at a level of (0.01). these coefficients ranged in responsiveness, reliability, assurance, tangibility, and empathy, indicating high internal consistency in the questionnaire’s second axis dimensions. the construct validity of the second axis dimension, healthcare service quality, was confirmed by examining correlation coefficients between each dimension’s total score and the second axis’ total score. the reliability of the tool: cronbach alpha the cronbach’s alpha reliability coefficient was calculated for the second axis of healthcare service quality and the total score in the questionnaire, as shown in the table. the 26 .878** 27 .903** 28 .881** 29 .922** 30 .864** the third dimension: assurance 31 .917** 32 .977** 33 .940** 34 .924** 35 .851** the fourth dimension: tangibility 36 .856** 37 .974** 38 .868** 39 .896** 40 .970** the fifth dimension: empathy 41 .880** 42 .962** 43 .967** 44 .940** 45 .919** table 8: cronbach’s alpha reliability coefficient for the dimensions and the total score for the second axis: healthcare service quality no. dimensions statements no. cronbach's alpha coefficient 1 the first dimension: responsiveness 5 .968 2 the second dimension: reliability 5 .972 3 the third dimension: assurance 5 .977 4 the fourth dimension: tangibility 5 .978 5 the fifth dimension: empathy 5 .972 total score 25 .979 table shows high reliability coefficients for healthcare service quality dimensions (.968-.978) and total reliability coefficient (.979), indicating the questionnaire’s validity and reliability in its results, indicating its reliability for application. results the first axis: the implementation of unified medical insurance system (nphies) the table shows that the implementation of a unified medical insurance system (nphies) at arrawdha general hospital in dammam has achieved a high response degree, with an overall mean of (3.71) and a standard deviation of (.629). this success is attributed to the accurate information provided by the national health information center about health practitioners and facilities, which supports the development of the saudi health insurance industry. table 9: the arithmetic means and standard deviations of the respondents’ responses “the first axis: the implementation of a unified medical insurance system (nphies)” no dimensions of the first axis mean standard deviation response degree rank 1 the first dimension: insurance services implementation 3.69 .821 high 2 2 the second dimension: health services implementation 3.73 .670 high 1 the overall mean 3.71 .629 moderate pa ge 12 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 the dimensions of the first axis the first dimension: insurance services implementation the first dimension of insurance services implementation in saudi arabia is high, with a mean of (3.69) and a standard deviation of (.821). the system allows insurance parties to file and track complaints, verifies policy validity, and seeks to improve and develop the health insurance industry. the unified medical insurance system (nphies) has been successful in implementing insurance services, allowing for flexibility, and strengthening health insurance in saudi arabia. table 10: frequencies, percentages, arithmetic means, and standard deviations of the respondent's responses to the first dimension: insurance services implementation no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 1 there is a unified channel for insurance transactions between health service providers and insurance companies. f 43 19 41 47 125 3.70 1.485 5 high % 15.6 6.9 14.9 17.1 45.5 2 the application of the system standardizes the medical and technical symbols used in the insurance sector. f 50 17 53 37 118 3.57 1.525 9 high % 18.2 6.2 19.3 13.5 42.9 no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 3 the system assists in sending and receiving notifications and extracting periodic reports related to insurance transactions. f 42 21 39 26 147 3.78 1.522 4 high % 15.3 7.6 14.2 9.5 53.5 4 the system measures the extent of the commitment of service providers and insurance companies to the council of health insurance policies. f 41 16 38 46 134 3.79 1.470 3 high % 14.9 5.8 13.8 16.7 48.7 5 the service allows all insurance parties to file and track complaints submitted to the health insurance board. f 37 8 50 27 153 3.91 1.437 1 high % 13.5 2.9 18.2 9.8 55.6 6 the system verifies the validity of the insurance policy of the beneficiary (the patient) to obtain the required service. f 46 10 47 20 152 3.81 1.532 2 high % 16.7 3.6 17.1 7.3 55.3 7 the system accelerates the beneficiary’s access to health services and improves users’ experience. f 51 13 48 28 135 3.67 1.556 6 high % 18.5 4.7 17.5 10.2 49.1 8 the system seeks to improve and develop the health insurance industry in the kingdom. f 61 20 44 21 129 3.50 1.635 10 high % 22.2 7.3 16.0 7.6 46.9 9 the system seeks to improve and develop the health insurance industry in the kingdom. f 44 12 67 38 114 3.60 1.457 7 high % 16.0 4.4 24.4 13.8 41.5 10 the system provides information on the state of the saudi health insurance industry more accurately to allow for its development. f 46 12 72 30 115 3.57 1.477 8 high % 16.7 4.4 26.2 10.9 41.8 the overall mean 3.69 .821 high pa ge 12 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 the second dimension: health service implementation table 11 reveals a high mean for the second dimension of health services implementation, attributed to the effectiveness of unified digital health services. the system enhances healthcare quality, reduces costs, and facilitates information flow among facilities. the unified insurance system accelerates verification and approval processes, facilitating patient data exchange and treatment. this system improves decision-making and patient outcomes. table 11: frequencies, percentages, arithmetic means, and standard deviations of the respondent’s responses to the second dimension: health services implementation no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 11 the system provides a comprehensive view of the patient's treatment history. f 76 17 20 2 160 3.56 1.79 0 7 high % 27.6 6.2 7.3 .7 58.2 12 the application of the system facilitates the exchange of patient's health information f 45 7 31 3 189 4.03 1.54 3 2 high % 16.4 2.5 11.3 1.1 68.7 13 the application of the system helps to speed up the verification of the treatment mechanism and approval requests. f 53 1 18 2 201 4.08 1.59 6 1 high % 19.3 .4 6.5 .7 73.1 14 the system facilitates matching the patient's national identity number and obtaining basic national information from the main source. f 62 12 20 25 156 3.73 1.66 8 5 high % 22.5 4.4 7.3 9.1 56.7 15 the system enhances patient safety by exchanging unified prescriptions across the kingdom f 58 11 58 24 124 3.53 1.58 3 8 high % 21.1 4.0 21.1 8.7 45.1 no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 16 the system facilitates the flow of relevant information among healthcare facilities for treatment and research purposes. f 60 12 62 28 113 3.44 1.57 3 10 high % 21.8 4.4 22.5 10.2 41.1 17 the system provides updated clinical data to healthcare providers f 58 12 55 30 120 3.52 1.57 6 9 high % 21.1 4.4 20.0 10.9 43.6 18 the system helps exchange information needed to refer a patient for care from one facility to another. f 40 7 59 6 163 3.89 1.48 8 4 high % 14.5 2.5 21.5 2.2 59.3 19 the system helps direct access to information about health practitioners and health facilities from the national center for health information f 71 16 27 4 157 3.58 1.75 0 6 high % 25.8 5.8 9.8 1.5 57.1 20 the system enables the exchange of vaccination information for public health monitoring and management. f 50 10 32 8 175 3.90 1.59 2 3 high % 18.2 3.6 11.6 2.9 63.6 the overall mean 3.73 .670 high pa ge 12 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 second axis: healthcare service quality from table 12, the study reveals that healthcare service quality at arrawdha general hospital in dammam has a high response degree, with an overall mean of 3.80 and a standard deviation of .644. the reliability, responsiveness, empathy, tangibility, and assurance dimensions all have high response degrees. this is attributed to the efficiency and effectiveness of the healthcare service provided by the unified health insurance system. the adequacy of resources and services, such as medicines, doctors, supplies, and outpatient rooms, contribute to the high response degree. table 12: frequencies, percentages, arithmetic means, and standard deviations of the respondent’s responses to the second axis: healthcare service quality no. dimensions of the second axis mean standard deviations respon se degree ran k 1 the first dimension: responsiveness 3.88 .877 high 2 2 the second dimension: reliability 4.03 .876 high 1 3 the third dimension: assurance 3.62 1.120 high 5 4 the fourth dimension: tangibility 3.72 1.056 high 4 5 the fifth dimension: empathy 3.73 .966 high 3 the overall mean 3.80 .644 hig h the dimensions of the second axis table 13 shows that the overall mean for responsiveness in the first dimension was (3.88), with a standard deviation of .877. the system’s effectiveness in responding to patient requirements and providing efficient communication between insurance companies and medical care providers was attributed to its high response degree. the system’s success in sending notifications to users to keep them informed about the latest developments in their health status was attributed to its ability to follow up with patients regularly. the system’s role in enhancing communication between healthcare providers in both public and private institutions was also attributed to its ability to coordinate between healthcare providers, ensuring ease of communication and enhancing the quality of healthcare in all institutions. the unified health insurance system at arrawdha general hospital dammam has achieved high response degrees in terms of responsiveness, communication, and coordinating between healthcare providers. the system’s ability to effectively address patient needs and improve communication between providers is a key factor in its success. table 13: frequencies, percentages, arithmetic means, and standard deviations of the respondent’s responses to the first dimension: responsiveness no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 21 the system enhances the quick response to all complaints of system users. f 56 18 1 3 197 3.97 1.68 0 2 high % 20.4 6.5 .4 1.1 71.6 22 the system provides efficient means of communication to receive users’ requests and effectively deal with them. f 67 12 15 8 173 3.76 1.73 3 4 high % 24.4 4.4 5.5 2.9 62.9 23 the system enhances the quality of communication between insurance companies and medical service providers by ensuring the flow of information. f 67 4 7 5 192 3.91 1.72 6 3 high 24.4 1.5 2.5 1.8 69.8 no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e pa ge 12 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 24 the system periodically sends notifications to all users to make them acquainted with the latest developments. f 44 11 16 12 192 4.08 1.53 6 1 high % 16.0 4.0 5.8 4.4 69.8 25 the system enhances communication between healthcare providers in both public and private healthcare f 76 14 5 9 171 3.67 1.79 9 5 high % 27.6 5.1 1.8 3.3 62.2 the overall mean 3.88 .877 high the second dimension: reliability the table demonstrates a high response degree to the second dimension of reliability, attributed to the nphies platform’s quality control and supervisory services, the efficiency table 14: frequencies, percentages, arithmetic means, and standard deviations of the respondent’s responses to the second dimension: reliability no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 26 all medical records and insurance files are kept within one unified system to enhance the reliability of the information. f 28 40 21 3 183 3.99 1.49 9 4 high % 10.2 14.5 7.6 1.1 66.5 27 the medical staff depends on the information provided by the portal for tracking the medical history of patients. f 18 38 16 9 194 4.17 1.37 2 1 high % 6.5 13.8 5.8 3.3 70.5 28 the system enhance transparency in all medical and insurance services. f 32 31 20 4 188 4.04 1.50 4 3 high % 11.6 11.3 7.3 1.5 68.4 29 the nphies platform offers a range of quality control and supervisory services to raise the health insurance council’s efficiency. f 26 30 22 10 187 4.10 1.43 0 2 high % 9.5 10.9 8.0 3.6 68.0 30 the system reduces the cost and time of providing healthcare services to improve healthcare decision-making. f 44 33 18 7 173 3.84 1.61 2 5 high % 16.0 12.0 6.5 2.5 62.9 total 4.03 high of medical staff in tracking patient medical history, and the system’s ability to reduce healthcare service costs and time, ultimately improving healthcare decision-making and increasing transparency in insurance and medical services. the third dimension: assurance table 15 reveals a high response degree for the third dimension of assurance, attributed to the system’s competence, professionalism, and kindness. the system ensures rapid intervention, user satisfaction, and translates cooperative health insurance principles into practice. the speed of response and the unified health insurance system translate health insurance principles into practice, ensuring quality care. table 15: frequencies, percentages, arithmetic means, and standard deviations of the respondent’s responses to the third dimension: assurance no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 31 the system ensures users’ satisfaction with healthcare service delivery. f 62 12 20 25 156 3.73 1.66 8 2 high % 22.5 4.4 7.3 9.1 56.7 pa ge 12 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 32 the system improves the process of data sharing and management f 58 11 58 24 124 3.53 1.58 3 3 high % 21.1 4.0 21.1 8.7 45.1 33 the system translates the principles of cooperative health insurance into practice. f 60 12 62 28 113 3.44 1.57 3 5 high % 21.8 4.4 22.5 10.2 41.1 34 the system shall not disclose the identity of the persons whose personal data is mentioned on the platform. f 58 12 55 30 120 3.52 1.57 6 4 high % 21.1 4.4 20.0 10.9 43.6 35 the system guarantees rapid intervention if the patient does not receive his required service f 44 8 44 23 156 3.87 1.50 8 1 high % 16.0 2.9 16.0 8.4 56.7 the overall mean 3.62 1.120 high the fourth dimension: tangibility table 16 the fourth dimension of the system’s efficiency and quality was praised for its attractiveness, ease, and flexibility in handling data. high responses were given to interactive browsing, structured search processes, and no difficulty in registration, indicating the system’s attractiveness and ease of use, encouraging patients to use it for health services. table 16: frequencies, percentages, arithmetic means, and standard deviations of the respondent’s responses to the fourth dimension: tangibility no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 36 the system platform is attractive. f 54 12 34 28 147 3.73 1.59 3 4 high % 19.6 4.4 12.4 10.2 53.5 37 the search process on the website is structured and highly organized f 43 11 47 32 142 3.80 1.49 0 2 high % 15.6 4.0 17.1 11.6 51.6 38 browsing the system is done interactively. f 33 16 51 22 153 3.89 1.43 2 1 high % 12.0 5.8 18.5 8.0 55.6 39 there is smoothness and flexibility in dealing with system data. f 42 13 54 28 138 3.75 1.48 6 3 high % 15.3 4.7 19.6 10.2 50.2 40 there is no difficulty in the registration process. f 62 8 67 28 110 3.42 1.57 0 5 high 22.5 2.9 24.4 10.2 40.0 the overall mean 3.72 1.05 6 high the fifth dimension: empathy the fifth dimension of empathy in table 17 has a high response degree, with a mean of (3.73) and a standard deviation of (.966). the system prioritizes stakeholder needs, works around the clock, and is highly responsive to problems. its efficiency in providing specialized care, tracking user needs, and immediate response to stakeholder problems contribute to its high response degree. third: table 17: frequencies, percentages, arithmetic averages, and standard deviations of the respondent’s responses to the fifth dimension: empathy no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 41 the system is designed in such a way that satisfies all stakeholders’ needs. f 41 16 38 46 134 3.79 1.47 0 3 high % 14.9 5.8 13.8 16.7 48.7 42 the system sets the needs and expectations of all stakeholders f 37 8 50 27 153 3.91 1.43 7 1 high % 13.5 2.9 18.2 9.8 55.6 pa ge 12 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 43 the system works around the clock to ensure the availability of required medical and insurance information. f 46 10 47 20 152 3.81 1.53 2 2 high % 16.7 3.6 17.1 7.3 55.3 44 the system keeps all stakeholders informed of the latest news and updates. f 51 13 48 28 135 3.67 1.55 6 4 high % 18.5 4.7 17.5 10.2 49.1 no statement response degree m ea n sd r an k r es po ns e d eg re e st ro ng ly ag re e d is ag re e n eu tr al a gr ee st ro ng ly ag re e 45 the system is highly responsive in dealing with stakeholders’ problems. f 61 20 44 21 129 3.50 1.63 5 5 high % 22.2 7.3 16.0 7.6 46.9 the overall mean 3.73 .966 high statistical analysis of study variables for unified medical insurance system implementation the findings of the research showed that, for both the insurance and health services implementation aspects along with the overall mean, there were no statistically significant variations in the mean scores of the study samples according to gender, job position, or years of experience. these results imply that perspectives on the implementation of the unified medical insurance system were unaffected by factors such as gender, job title, or years of experience. individuals from a variety of demographic backgrounds had comparable opinions about the system’s implementation, demonstrating a uniform understanding of its significance and effect on saudi arabia’s healthcare system’s quality. table 18: demographic analysis using t-test and one-way anova variable test dimension sig. result gender t-test insurance services implementation 0.519 not significant (p > 0.05) health services implementation 0.6 not significant (p > 0.05) overall mean 0.484 not significant (p > 0.05) job position t-test insurance services implementation 0.983 not significant (p > 0.05) health services implementation 0.1 not significant (p > 0.05) overall mean 0.374 not significant (p > 0.05) years of experience one-way anova insurance services implementation 0.696 not significant (p > 0.05) health services implementation 0.949 not significant (p > 0.05) overall mean 0.785 not significant (p > 0.05) fourth: analysis of healthcare service quality based on gender, job position, and years of experience as per the tables above, the evaluation of healthcare service quality according to years of experience, job position, and gender did not show significant differences in most of the dimensions. responsiveness, reliability, assurance, tangibility, empathy, and mean did not significantly change based on gender. likewise, job position had no apparent impact on these dimensions, except for tangibility, where administrators gave it a higher rating than physicians, but not very significantly. except for responsiveness, where differences were getting close to significance, years of experience likewise revealed no significant differences in other aspects. these results imply that, in the studied context, views of the quality of healthcare services are not significantly influenced by factors such as years of experience, gender, or work position. table 19: analysis of healthcare service quality based on gender using t-test dimensions gender n mean sd t df sig. (2tailed) sig the first dimension: responsiveness male 142 3.79 .856 -1.705 273 .089 notsignificant female 133 3.97 .894 pa ge 13 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 dimensions gender n mean sd t df sig. (2tailed) sig the second dimension: reliability male 142 4.02 .901 -.238 273 .812 notsignificantfemale 133 4.04 .853 the third dimension: assurance male 142 3.57 1.148 -.654 273 .514 notsignificantfemale 133 3.66 1.092 the fourth dimension: tangibility male 142 3.68 1.118 -.712 273 .477 notsignificantfemale 133 3.77 .987 the fifth dimension: empathy male 142 3.71 1.011 -.375 273 .708 notsignificantfemale 133 3.76 .919 the overall mean male 142 3.76 .696 -1.095 273 .275 notsignificantfemale 133 3.84 .582 table 20: analysis of healthcare service quality based on job position using t-test dimensions job position n mean sd t df s i g . (2tailed) sig the first dimension: responsiveness physician 198 3.94 .850 1.759 273 .080 notsignificant administrator 77 3.73 .933 the second dimension: reliability physician 198 4.06 .835 .987 273 .325 notsignificant administrator 77 3.95 .976 the third dimension: assurance physician 198 3.66 1.128 1.121 273 .263 notsignificant administrator 77 3.50 1.099 the fourth dimension: tangibility physician 198 3.65 1.077 -1.783 273 .076 notsignificant administrator 77 3.90 .984 the fifth dimension: empathy physician 198 3.73 .968 -.235 273 .814 notsignificant administrator 77 3.76 .967 the overall mean physician 198 3.81 .662 .496 273 .620 notsignificant administrator 77 3.77 .597 table 21: analysis of healthcare service quality based on years of experience using anova dimensions source of variance sum of squares df mean square (f) value sig. the first dimension: responsiveness between groups 3.818 2 1.909 2.507 .083 within groups 207.126 272 .761 total 210.943 274 - the second dimension: reliability between groups .913 2 .456 .592 .554 within groups 209.495 272 .770 total 210.407 274 - the third dimension: assurance between groups 4.145 2 2.073 1.660 .192 within groups 339.611 272 1.249 total 343.756 274 - the fourth dimension: tangibility between groups 3.773 2 1.887 1.701 .185 within groups 301.747 272 1.109 total 305.520 274 - the fifth dimension: empathy between groups 2.017 2 1.009 1.082 .340 within groups 253.538 272 .932 total 255.555 274 - pa ge 13 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 the overall mean between groups 1.291 2 .646 1.564 .211 within groups 112.279 272 .413 total 113.570 274 - fifth: impact of the unified medical insurance system (nphies) on healthcare service quality in arrawdha general hospital, dammam to answer this question, a simple linear regression analysis was used, and the following table shows that: the health insurance system has a significant positive effect on the healthcare service quality at arrawdha general hospital in dammam, accounting for 54% of the variation in service quality. this is due to the system’s ability to enhance communication between healthcare providers and patients, providing updated clinical data. this system also improves the effectiveness of communication between healthcare providers and patients. table 22: the effect of applying the health insurance system on the healthcare service quality in arrawdha general hospital in dammam independent variable b beta r r2 t value sig. t the implementation of a unified medical insurance system (nphies) .752 .735 .735a .540 17.912 .000 constant 1.008 adj r2 .539 f. value 320.842 sig f .000b discussion the study conducted at arrawdha general hospital in dammam aimed to assess the implementation of the unified medical insurance system (nphies) and its impact on healthcare service quality. the results showed that the implementation of nphies had a high response degree, with an overall mean of (3.71), a standard deviation of (.629), and a high response degree. the overall mean for the first dimension of insurance services implementation was also high, with an arithmetic mean of (3.69), a standard deviation of (.821). the results can be supported by a study conducted by (li et al., 2023), which found that the adoption of a unified medical insurance system increases health insurance’s resilience to risk and significantly improves rural populations’ access to healthcare. this system contributes to closing the disparity in healthcare utilization between rural and urban areas and enhancing regional equity. overall, the health insurance system plays a crucial role in improving healthcare service quality in dammam. the second dimension of healthcare service quality was also high, with an overall mean of (3.80), a standard deviation of (.644), and a high response degree. the overall mean for the first dimension of responsiveness was high, with an arithmetic mean of (3.88), and a standard deviation of (.877). the overall mean for the second dimension of reliability was high, with an arithmetic mean of (4.03), and a standard deviation of (.876). the overall mean for the third dimension of assurance was high, with an arithmetic mean of (3.62), and a standard deviation of (1.120). the overall mean for the fourth dimension of tangibility was high, with an arithmetic mean of (3.72), and a standard deviation of (1.056). the overall mean for the fifth dimension of empathy was high, with an arithmetic mean of (3.73), and a standard deviation of (.966). there were no statistically significant differences in the responses of the study sample regarding the level of implementing the unified medical insurance system (nphies) attributed to the variables (gender, job position, and years of experience) in both dimensions. there were no statistically significant differences at the level of significance of (0.05) between the mean scores of the study sample regarding the first axis: implementation of a unified medical insurance system (nphies) attributed to the (gender) variable in either dimension conclusion the study carried out at dammam’s arrawdha general hospital offers important insights into how the unified medical insurance system (nphies) is being implemented and how it affects the standard of healthcare services. the results show that respondents had a favorable opinion of nphies implementation, pointing to a development in the improvement of the healthcare system. the perception of healthcare service quality was generally favorable, with reliability receiving the highest rating across all evaluated dimensions. based on years of experience, work position, or gender, statistical analysis did not show any significant differences in the quality of healthcare services provided by nphies or its execution, indicating a similar view across all demographic groups. notably, the study found that nphies had a statistically significant beneficial influence on healthcare service quality, highlighting the system’s significance in enhancing healthcare services. the recommendations to keep pa ge 13 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 118-133, 2024 making investments in the health and social sectors, employ professionals, supply required medical devices, recruit competent doctors, and provide an appropriate number of nursing assistants demonstrate the need for continuous development in healthcare delivery. recommendations the recommendations include the need for the saudi government to continue investing in health and social sectors, enlisting the help of specialists, providing all necessary medical devices and equipment, attracting experienced and competent doctors, and providing an adequate number of nursing assistants for doctors. future studies should focus on the impact of health service quality on patients’ satisfaction at arrawdha general hospital in dammam and the effect of applying the 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(2020). medical insurance and healthcare utilization among the middle-aged and elderly in china: evidence from the china health and retirement longitudinal study 2011, 2013 and 2015. bmc health services research, 20, 1-9. pa ge 1 pa ge 4 american journal of medical science and innovation (ajmsi) survival rate analysis of heart failure patients at arbaminch general hospital, southern ethiopia, 2022 sebisibe kusse kumaso1*, markos abiso erango2, belay belete anjullo2 volume 2 issue 1, year 2023 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: january 07, 2023 accepted: february 02, 2023 published: february 08, 2023 chronic heart failure happens when the heart’s muscle is incapable of circulate sufficient blood to satisfy the requirements of the body for both oxygen and blood. in other sense, the heart is overwhelmed by its load. the goal of this study is to pinpoint the risk variables accountable for the variability in congestive heart failure patients’ survival times from january 2017 to december 2021 at arbaminch general hospital in south ethiopia. utilizing cox proportional hazard models, the data was examined. a retrospective investigation was conducted. data was gathered from the cards of 199 congestive heart failure patients who were being followed up on using a straightforward random sampling approach. we discovered that 21.6 percent of the 199 patients with congestive heart failure investigated died, while the remaining 78.4% were censoring. patients’ mean baseline left ventricular ejection fraction was 43.18 percent (with a standard deviation of 13.928 percent), implying that each pulse expels 43.18 percent of the blood in the left ventricle. patients with heart failure who tested positive for tuberculosis had a substantially increased chance of death. left ventricular ejection fraction, tuberculosis, diabetes militias, etiology of heart failure, type of congestive heart failure, smoking status, and chorionic kidney disease were originate to be significant risk factors for death in patients with congestive heart failure. as a result, physicians are encouraged to pay greater attention to heart failure patients. keywords congestive heart failure, cox proportional model, survival rate 1 health monitoring and evaluation department, alle special woreda, health office ethiopia 2 department of statistics, arba minch university, arba minch, ethiopia * corresponding author’s e-mail: sebisibek@gmail.com introduction heart failure (hf) is a chronic, neurological disorder which occurs when the heart muscle is incapable of circulates enough circulation to fulfill the body’s oxygenated blood necessities. in simply, the heart has difficulty keeping up with its responsibility. it’s one of the most prevalent reasons people end up in the hospital. long in-patient stays, tall in as well as post-discharge death and illness and whether or not the left ventricular ejection fraction is reduced are all major determinants to consider”(carson et al., 2015). it’s a major health issue all around the world, with high rates of re-hospitalization and death. after a year, the global re-hospitalization rate in patients with hf is over 50%(2). as a result, 33 million people globally, or 26.4 percent of the adult population, suffer from heart failure. adults in the industrialized world make up 65.73 percent of the population, while those in developing countries make up 34.27 percent. it is expected that by the end of the year, there would have been a 60% growth since 2000 (barbey et al., 2010). heart failure has long been recognized as a major contribution to the burden of cardiovascular disease in sub-saharan africa. early twentieth-century case reports and case series offered critical information about heart failure in the region, identifying viral, dietary, and idiopathic causes as the most common (ibrahim et al., 1991). the range of causes of heart failure has expanded as a result of increased urbanization, changes in lifestyle habits, and population aging, resulting in a considerable burden of both communicable and non-communicable etiologies. the wide range of etiologies that exist, as well as the healthcare environment characterized by inadequate resources, weak national healthcare systems, and a scarcity of national level data on illness patterns, distinguish subsaharan africa (bloomfield et al., 2013). it can, however, manifest itself in the form of pulmonary edema or even cardiogenic shock within 24 hours. dickstein claims that heart failure was formerly thought to be caused by the heart’s inability to pump enough blood into the circulation due to ventricular a systolic dysfunction (lvef 40% to 50%). (hf with depressed ejection fraction [hfdef]). patients with no diminished left ventricular ejection fraction (lvef) can develop hf if higher filling pressures are required to achieve a normal end-diastolic ventricular volume (hfpef) (shah et al., 2015). this disorder is more frequent in women, the elderly, and persons with long-standing high blood pressure (hbp), and it has a similar prognosis as hfdef. right and left heart failure are conditions that are characterized by systemic or pulmonary congestion, resulting in jugular venous gurgitation and pulmonary edema, respectively. many papers have been written addressing various elements of the general population’s burden of heart failure. cardiac societies, most notably the heart failure association arm of the european society of cardiology (esc) and the american heart association, are addressing issues associated with this wide-ranging they need to publish consensus statements regarding this important topic (pazos et al., 2011). however, it is the last stage of all cardiac illnesses and could represent a significant source of morbidity and mortality (davis et al., 2000). over the years, cardiologists and cardiac associations https://journals.e-palli.com/home/index.php/ajmsi pa ge 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 4-12, 2023 have presented their own definitions of heart failure. the european society of cardiology (esc) task force published guidelines on the diagnosis of heart failure, which specify the presence of symptoms and objective evidence of cardiac dysfunction, as well as symptom reversibility with appropriate treatment. heart failure was one of the major causes of mortality in ethiopia in 2013, according to health and health-related data and the american heart association, approximately a respiratory rate of more than 24 breaths per minute can identify 50% of patients at risk (organization et al., 2015). according to the american heart association, an increase in respiration rate might be an indication of developing pulmonary edema, or fluid in the lungs, which is a common and deadly symptom of congestive heart failure (chf) (baddour et al., 2015).patients must estimate their health and survival time by assessing the burden of congestive heart failure. the investigator’s motivation for exploring this topic stems from concerns about the survival time of individuals with congestive heart failure. the majority of research focuses exclusively on longitudinal data. however, it is critical to evaluate the survival time of individuals with congestive heart failure (hickey et al., 2018). heart failure (hf) is the fastest-growing cardiovascular illness in the world, putting enormous demand on healthcare systems worldwide (ziaeian et al., 2016). congestive heart failure has risen to the top of the list of leading causes of mortality among individuals with a worse quality of life and a shorter lifespan. in the united states alone, 960,000 new cases of congestive heart failure (chf) were discovered in 2017, and this figure is predicted to climb year after year as the population ages. the global prevalence is expected to grow by 8 million persons by 2030(heidenreich et al., 2013). low and middle-income nations have a higher rate of heart failure-related mortality than high-income ones. the ministry of health states (seid et al., 2019). according to health-related data (2014-2015), heart failure was one of ethiopia’s major causes of death in 2013(kitzman et al., 2016). it is, however, more than just a significant public health concern; it will have a massive economic impact when a large portion of the productive age group population becomes chronically ill and remains at home, quits their jobs, and dies, leaving their families in poverty. the risk factors for congestive heart failure have grown considerably as a result of a lack of understanding regarding the risk factors and management of heart failure. previous studies found predictors of congestive heart failure without taking survival time into account (beck et al., 2016). furthermore, the study focused on survival time and overlooked significant confounders. to cover the holes, this study examined the risk factors for the survival time to death of congestive heart failure patients using conventional cox proportional modeling. in general, the motivations for this work address the following important research questions: 1. what variables influence the survival time of congestive heart failure patients after they begin treatment? 2. what is the median survival time for patients with congestive heart failure at arbaminch general hospital? the crucial goal of this study was to recognize risk variables associated with survival time to death of congestive heart failure patients at arba minch general hospital in southern ethiopia in 2021. significance of the study by evaluating patient survival time, the findings of this research will reveal data regarding risk variables for the death of heart failure patients. to perform statistical analysis, uncover potential factors linked to the survival time of patients with congestive heart failure, and develop a better approach for addressing heart failure difficulties faced by patients. in order to design and promote the good health and longterm well-being of congestive heart failure patients, the results of this research are anticipated to provide necessary suggestions for relevant stakeholders, governmental organizations at various levels, and non-governmental organizations that work in the field of congestive heart failure. this will be done by determining the key factors encompassing the clients under follow-up. methods and materials study area and period arba minch is a town in southern ethiopia, 505 kilometers south of addis abeba, located at a height of 1285 meters above sea level inside the gamo zone of the southern nations, nationalities, and peoples region. because it is the most important town in the region, it acts as the gamo zone’s capital. arba minch and zuria woreda surround it. this study was lead at arba minch general hospitals from january 2017 to december 2021, and this hospital assists as a referral hospital for people who came from numerous surrounding areas, as well as providing healthcare to their districts and exercise for students from various health institutions, including arbaminch university. study design because of occurrences of exposure had already occurred once during the follow-up time in the past on the evaluation of the patient’s cards, information sheets, and registration books, a retrospective cohort research design was used. patients were tracked on pulse and respiratory rate every three months at arba minch general hospital from january 2017 to december 2021, and those aged 18 or older were eligible. source population and target population the population was derived from totally health registers of patients diagnosed with congestive heart failure in arba minch general hospital who attended followup, and the study’s target population includes all congestive heart failure patients below continuation at https://journals.e-palli.com/home/index.php/ajmsi pa ge 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 4-12, 2023 arba minch general hospital ethiopia from january 2017 to december 2021, who had at least three pulse and respiratory rate measurements after the first report of congestive heart failure. according to the study’s insertion measures, all congestive heart failure patients at arba minch general hospital who received diagnosis and treatment within a predetermined timeframe, and whose pulses and respiratory rates were measured at least three times, were comprised. patients, whose medical registers were missing information, couldn’t be located, or who had a previous judgment of heart failure and registered during the data collection period was excluded. sampling technique and sample size determination the most fundamental probability sampling technique is simple random sampling, in which each independent unit of the population has an equal opportunity (possibility) of being taken into the sample, which is the scientific technique of selecting a representative of the target population to provide the required estimation. as a consequence, the sample technique was the standard random sampling approach. using the simple random sampling method, we recruited 199 patients from a total of 424 congestive heart failure patients under follow-up (cochran et al., 2007). choosing a sample size is one of the first steps in creating a sample survey. the sample size decision is crucial since a large sample suggests more precision, but a small sample restricts the precision of estimate of demographic characteristics or the usability of the results. as a result, determining the appropriate sample size is preferred. concerns include the research’s objective, its compatibility with the available resources, such as cost, labor, time, and materials, and the margin of error (cochran et al., 2007). method of data collection to meet the study’s aims, data were collected from a secondary source of congestive heart failure patients under follow-up at arba minch general hospital between january 2017 and december 2021. the data was taken after the patient’s registration diagram and postcards, as well as epidemiological, laboratory, and clinical evidence from the patients who were being followed up on. following data extraction, the data was entered, edited, coded, and organized before being analyzed with r software version 4.2. study variables response variables the response variables addressed in this study were survival outcome variables, and the survival outcome variable was the time to death of the patient under follow-up in arba minch general hospital. explanatory variables the explanatory variables considered in this study where patients age (in year), weight(in kilogram), body temperature, left ventricular ejection fraction in percent, patient gender, place of residence, smoking status of patients ,diabetes status of patients (present , absent ), tuberculosis status of patients (positive, negative), chronic kidney status of patients (present ,absent), alcohol intake (yes, no), pneumonia status of patients (present , absent),etiology of heart failure (vhd, hhd, ihd, other),and type of congestive heart failure patient (left ventricular, right ventricular, biventricular) (see table 1). table 1: congestive heart failure patient data from january 2017 to december 2020 at arbaminch general hospital in south ethiopia was analyzed using categorical variable coding. no variables description categories and codes 1 gender of chf patients female (0) male (1) 2 residence of chf patients rural (0) urban (1) 3 presence of dm on chf patients absent (0) present (1) 4 presence of tb on chf patients negative (0) positive (1) 5 presence of smoking on chf patients no (0) yes (1) 6 presence of pneumonia on chf patients absent (0) present (1) 7 alcohol intake in chf patients no (0) yes (1) 8 presence of ckd on chf patients absent (0) present (1) 9 types of chf in patients lv (0) bv (1) rv (2) 10 etiology of chf in patients vhd (0) htn (1) ihd (2) other (3) operational definition heart failure (hf): is also known as congestive heart failure, which is a condition that develops when your heart does not pump enough blood for your body’s needs. time to event data: time from the start of the treatment to the death of chf patients data analysis in r software version 4.2, the cox proportional model for time to event data was utilized to evaluate data from congestive heart failure patients. https://journals.e-palli.com/home/index.php/ajmsi pa ge 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 4-12, 2023 survival analysis time to event data is often the subject of survival analysis. it includes procedures for positive-valued random variables such as time to death, time to onset (or relapse) of a disease, length of stay in a hospital, strike duration, and so on. we require a clear-cut time origin or a time scale (e.g. actual time (days, weeks, months, years) and a characterization of the event of interest in order to build a survival time random variable. survival time random variables are always non-negative, that is, if we denote the survival time by, t and then t ≥ 0 can be discrete or continuous (defined on (0, ∞)). we require statistical approaches that employ data from all subjects, whether we monitor their survival times or only time until censoring. the probability distribution of a survival random variable can be described in a variety of ways. to model survival data, non-parametric, semiparametric, and parametric models are available. the cox proportional hazard model is a popular choice for modeling the time-to-event data. kaplan-meier survival function estimation the kaplan meier estimator is a standard non-parametric survival function estimator that is used to calculate survival probabilities. it considers any point in time as a succession of steps defined by observed survival and censored times, incorporating information from all available observations, both censored and uncensored (cochran et al., 2007). the estimator is just the sample proportion of observations with event times greater than when there is no censoring. when censored times are added, the technique becomes a little more difficult, but still manageable. where, (di)=the number of chf patients who experience the event (death) at time (ti) (ni) = the number of patients who have not yet experienced the event (death) or the total number of individuals at risk before time(ti). results and discussion descriptive analysis the current study seeks to determine risk variables that are related with survival time to death in congestive heart failure patients at arbaminch general hospital. a cox proportional model was supposed to predict survival time. the findings of the models are all evaluated as meaningful in different ways. the most recent comparative r program version 4.2 was used to examine the data. women made up 50.3% of the 199 congestive heart failure patients who underwent therapy, while males made up the remaining 49.7%. according to our findings, 21.6 percent of the patients died, with the remaining 78.4 percent censored. table 1: congestive heart failure patient data from january 2017 to december 2020 at arbaminch general hospital in south ethiopia was analyzed using categorical variable coding. variables frequency (%) survival status event (%) censored (%) gender female 100 (50.3) 24 (12.1) 76(38.2) male 99 (49.7) 19 (9.5) 80(40.2) residence rural 117(58.8) 21 (10.5) 96(48.3) urban 82(41.2) 22 (11.1) 60(30.1) diabetes status absent 87(43.7) 9(4.5) 78(39.2) present 112(56.3) 34(17.1) 78(39.2) tuberculosis status negative 81(40.7) 7(3.5) 74(37.2) positive 118(59.3) 36(18.1) 82(41.2) smoking status non smoker 125(62.8 ) 24(12.1) 101(50.7) smoker 74(37.2) 19(9.6) 55(27.6) pneumonia status absent 112(56.3) 16(8.1) 96(48.2) present 87(43.7) 27(13.6) 60(30.1) alcohol intake status no 103(51.8) 21(10.6) 82(41.2) yes 96(48.2) 22(11.1) 74(37.1) chronic kidney disease absent 128(64.3) 21(10.6) 107(53.8) present 71(35.7) 22(11.1) 49(24.6) types of congestive heart failure right ventricular 55(27.6) 5(2.5) 50(25.1) bi ventricular 64(32.2) 12(6.1) 52(26.1) left ventricular 80(40.2) 26(13.1) 54(27.1) https://journals.e-palli.com/home/index.php/ajmsi pa ge 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 4-12, 2023 etiology of congestive heart failure valvular heart disease 51(25.6) 16(8.0) 35(17.6) hypertensive heart disease 43(21.6) 7(3.5) 36(18.1) ischemic heart disease 55(27.6) 12(6.0) 43(21.6) other 50(25.1) 8(4.0) 42(21.1) status censored 156 (78.4) event (death) 43 (21.6) the large percentage of congestive heart failure patients (58.8%) resided in rural regions. as a consequence, ischemic heart disease was responsible for 55 (27.1%), valvular heart disease was responsible for 51 (25.6%), hypertensive heart disease was responsible for 43 (21.6%), and various etiologies were responsible for the remaining 50 (25.1%). concerning diabetes as comorbidities, 56.3% of heart failure patients had diabetes, 35.7% had chronic kidney disease, 37.2 percent were smokers, 43.7 percent had pneumonia, and 59.3% had tuberculosis. likewise, of the total 199 congestive heart failure therapy participants, about 24 (12.1%) female responders died as a result of treatment, and the remainder was censored. on the other side, approximately 19 (9.5%) of the male responders died, while the remainder were censored. based on the patient’s location, 22 (11.1%) and 21(10.5%) of the 82 urban and 117 rural patients had an incident occur, respectively. the overall average starting point age, weight, and left ventricular ejection fraction of patients were 48.6 years (with a standard deviation of 17.385 years), 54.21 kilograms (with a standard deviation of 10.93 kilograms), and 43.18 percent (with a standard deviation of 13.93 percent), trying to imply that an average of 43.18 percent of blood in the left ventricle is pushed out with each heartbeat (see table 2). survival time analysis based on a cohort involving 199 congestive heart failure patients, the median life duration was 24 months, with an average and standard deviation of 24.8 and 7.3 months, respectively. kaplan meier estimations the comparison of survival functions provides a good indication of the groups’ event experiences, and the graphs showed the pattern of one’s survival function lying above another, indicating that the cohort defined by the upper curve had a greater chance of surviving than the members to participate by the lower curve. figure 1: kaplan-meier survival plots of predictors with congestive heart failure patients data from january 2017 to december 2020, in arbaminch general hospital, south ethiopia https://journals.e-palli.com/home/index.php/ajmsi pa ge 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 4-12, 2023 figure 1 shows the estimate of survival function graphs for tb and diabetes millets. then, for tb patients, it shows that those with tuberculosis negative tests had a higher chance of surviving than those with tuberculosis positive results. that is, patients who do not have tb have a better probability of survival than those who have it (see figure 1). diabetes mellitus is more common in congestive heart failure patients, indicating that people without diabetes mellitus have a better probability of survival than patients with diabetes mellitus in congestive heart failure. that is, tb positive patients and patients with diabetes militias had a higher risk of dying from medication than tuberculosis negative patients and patients without diabetes militias, respectively (see figure 1) log-rank test the log rank test was performed to determine the significance of the observed difference among covariate categories using chi-square. the log rank test results discovered that there were significant differences in the survival chances of patients in different categories of diabetes mellitus (χ2=5.6,p<0.02), smoking (χ2=4.6,p<0.03), chronickidneydisease (χ2=5.4,p<0.01), tuberculosis χ2=14.3,p<0.0002) and type of congestive heart failure patients (χ2=6.3,p<0.004) the remaining variables are similarly described in the same manner. (see table 3) table 3: cox proportional model analysis of predictors with congestive heart failure patient’s data from january 2017 to december 2020, in arba minch general hospital, south ethiopia covariates chi-square df p-value gender 0.7 1 0.4 place of residence 2.3 1 0.10 diabetes status 5.6 1 0.02* tuberculosis status 14.3 1 2e-04* smoking status 4.6 1 0.03* pneumonia status 0.9 1 0.4 chronic kidney status 5.4 1 0.01* type of congestive heart failure 6.3 2 0.004* etiology of heart failure 2.6 3 0.5 alcohol intake status 0.6 1 0.4 * indicates significance of covariate at 5% level of significance discussion the cox proportional hazards model was employed in this study for a survival outcome, and variables such as diabetes, smoking status, chronic kidney disease, left ventricular ejection fraction, type of congestive heart failure, etiology of heart failure, and tuberculosis are significant variables that influence congestive heart failure patients. congestive heart failure patient who has diabetes militias’ disease was positive significant effect on a risk death of congestive heart failure patients. this study is in similar with previous studies done by (barlera et al., 2013). that the presence diabetes militias has a positive significance effect with quality of heart failure, but other study done by (ahmad et al., 2017). shows that diabetes militias has no significance effect with heart failure. the estimated risk of death for a heart failure patient with the presence of chronic kidney disease patients was (hr = 4.313, 95% ci: 1.9438 , 9.5724, p = < 0.000325), this indicates that the risk of death for chronic kidney disease patients were 4.313 times higher as compared to nonchronic kidney disease patients keeping other variables constant. this finding is in line with the previous findings (zeru et al., 2018) which showed chronic kidney disease was positive and significantly associated with the prevalence of heart failure (see table 4) table 4: log-rank test statistics analysis of categorical predictors in patients with congestive heart failure from january 2017 to december 2020 in arbaminch general hospital south ethiopia parameters estimates (se) hr(95%ci) p-value lvef -0.056 (0.015) 0.945 (0.9178 0.9736) 0.000184 * temperature -0.299(0.231) 0.741 (0.4709 1.1665 ) 0.195450 weight -0.026 (0.015) 0.973 (0.9439 1.0040) 0.087931 age -0.005 (0.0104) 0.994 (0.9747 1.0156) 0.666826 etiology of hf (ref=vhd) ischemic heart disease 0.982 (0.554) 2.672 (0.9014 7.9230) 0.076264 hypertensive heart disease 0.801 (0.580) 2.229 (0.7153 6.9510) 0.166865 other 1.336 (0.626) 3.806 (1.1140 13.0079) 0.032991 * https://journals.e-palli.com/home/index.php/ajmsi pa ge 10 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 4-12, 2023 type chf (ref=left ventricular) right ventricular -0.281 (0.619) 0.754 (0.2242 2.5385) 0.648975 biventricular 1.169 (0.544) 3.221 (1.1091 9.3570) 0.031528 * gender (ref=female) male -0.051 (0.398) 0.950 (0.4347 2.0760) 0.897689 residence (ref=urban) rural 0.046 (0.396) 1.047 (0.4816 2.2779) 0.907037 alcohol intake(ref=no) yes 0.320 (0.357) 1.377 (0.6831 2.7788) 0.370668 smoking status (ref=no) yes 0.899 (0.397) 2.459 (1.1288 5.3570) 0.023522 * chronic kidney status (ref=no) yes 1.461 (0.4067) 4.313 (1.9438 9.5724) 0.000325 * pneumonia status (ref=no) yes 0.067 (0.571) 1.069 (0.3491 3.2788) 0.906010 diabetes millets status (ref=no) yes 1.427 (0.445) 4.168 (1.7394 9.9904) 0.001369 * tuberculosis (ref=negative) positive 1.905 (0.447) 6.722 (2.7978 16.1526) 2.04e-05 * *indicates significant covariates at 5% level of significance, ref= reference category conclusion the purpose of this study was to recognize the factors associated to survival time of congestive heart failure patients admitted to treatment at arbaminch general hospital by using cox proportional hazard model. the log-rank tests demonstrated that the survival experience of distinct groups of congestive heart failure patients was statistically significant in different categories of diabetes mellitus, chronic kidney disease, tb, and type of congestive heart failure. however, in the survival analysis, the risk factors of mortality were chronic kidney disease, left ventricular ejection fraction, etiology of heart failure, types of congestive heart failure, smoking status, diabetes mellitus, and tuberculosis. when examining overall model performance, we decided that the cox proportional model was best suited for survival data. recommendations due to a lack of understanding about risk factors for heart failure, clients were pushed to have a high risk of heart failure-related mortality and morbidity. as a result, relevant stakeholders should pay closer attention to and intervene on known risk factors like chronic kidney disease, tuberculosis, diabetes, left ventricular ejection fraction, etiology of heart failure, type of congestive heart failure, and smoking status, which should be acknowledged in the community. health practitioners are advised to pay special attention to congestive heart failure patients who have chronic kidney disease, tuberculosis, or diabetes and are at a higher risk of mortality in the district; consequently, special care should be paid to patients with this co-morbidity. furthermore, based on the results of the study, individuals who are candidates for congestive heart failure should take action on early diagnosis and preventive strategies, as well as be aware of the risk factors for congestive heart failure. additionally, the study’s fault is the insufficient use of accessible secondary data. as a result, critical information such as obesity, family status, and educational background were missing from the patients’ records; however, these factors were not considered in our study. as a result, we advised researchers to incorporate such variables in future studies. abbreviations chf: congestive heart failure; hf: heart failure; hhd: hypertensive heart disease; hr: heart rate; ihd: ischemic heart disease; lvef left ventricular ejection fraction; ph: proportional hazard; vhd: valvular heart disease. ethical consideration the study was carried out with the approval of arba minch university’s statistics department. in this regard, the formal letter of cooperation referred with stat/534/2013 was addressed to the arba minch general hospital’s ethical approval committee. the letter was then authorized by the ethics committee, who granted authority to gather data from recorded patients’ cards. there were no ties with specific patients for the sake of secrecy, and all data had no personal identity. as a result, the arba minch general hospital ethics committee has waived the patient’s informed consent. consent for publication not applicable. https://journals.e-palli.com/home/index.php/ajmsi pa ge 11 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 4-12, 2023 availability of data and materials the dataset supporting conclusions of this article is available by contacting the authors. competing interests the authors declare that they have no competing interests. funding not applicable authors’ contributions sebisibe kusse kumaso planned the study, analyzed the data, and wrote the publication; markos abiso erango and belay belete anjullo supervised data analysis and provided critical feedback on the article. the final manuscript was reviewed and approved by all writers. acknowledgements we are grateful to arba minch university for providing the required facilities. we also like to thank the employees at arba minch general hospital for their help in gathering all of the data. references adise, s., geier, c. f., roberts, n. j., white, c. n., & keller, k. l. 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(2016). epidemiology and aetiology of heart failure. nature reviews cardiology, 13(6), 368-378. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 26 american journal of medical science and innovation (ajmsi) cancer genetic markers among school children in relation to urogenital schistosomiasis chinweike-umeh s.n.1, ekwunife c.a.1*, onwuachusi g.l1 volume 2 issue 1, year 2023 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: february 08, 2023 accepted: february 26, 2023 published: march 10, 2023 chronic infection with urogenital schistosomiasis can lead to severe complications such as bladder cancer. hence, this study determined the presence of cancer genetic markers among school children in relation to urogenital schistosomiasis. all 36 s. haematobium positive cases from an earlier study and randomly selected 156 negative samples were used. immunogens tested for, included glyceraldehyde-3-phosphate dehydrogenase (gapdh) and fibroblast growth factor receptor (fgfr3). mean optical density (od) was 0.73 and 0.79 for gapdh and fgfr3 respectively. a total of 21 (10.94%) participants, 16 females and 5 males were positive for gapdh marker. fifty (26.04%) participants were positive for fgfr3 via elisa cutoff. mean od for s. haematobium positive individuals tested for gapdh was 0.938, minimum value was 0.119 while maximum value was 4.507. for fgfr3 mean od was 0.896, maximum 2.882 and minimum 0.28, while females showed higher gapdh od. more females than males who were positive for s. haematobium were also positive for gapdh (11.1%) and fgfr3 (25%). fgfr3 and gapdh marker prevalence for individuals positive for s. haematobium is 25% and 16.7% respectively. the age group 11-15 years were the only group positive for gapdh. there was a slight positive correlation between age and fgfr3 and age and gapdh. the presence of these markers is an indicator that the children in the selected communities maybe at risk of developing bladder cancer in the future if the disease is not properly managed and controlled. keywords bladder cancer, genetic markers, urogenital, schistosoma haematobium 1 department of parasitology and entomology, nnamdi azikiwe university, awka, anambra state, nigeria * corresponding author’s e-mail: ca.ekwunife@unizik.edu.ng introduction schistosomes are parasitic trematodes that cause the disease schistosomiasis; they are found in subtropical and tropical regions of the world including nigeria (ekwunife et al., 2004; ndukwe et al., 2019). anambra state, nigeria, offer numerous favourable habitats for aquatic snails that serve as intermediate hosts to schistosoma species (ekwunife et al., 2004). children have been identified to harbour the greatest number of worms leading to reduced growth, impaired memory and cognition and reduced school attendance (crompton and nesheim, 2002; miguel and kremer, 2004; bundy et al., 2013). also, cases of chronic infection with urogenital schistosomiasis can lead to adverse health outcomes including the development of urogenital cancer. (ishida and hsieh, 2018). there are certain genetic factors that could also play important role in the pathology of infection with schistosomes including the possibility of the development of urogenital cancer as a result of granuloma formation (barosum, 2021). the general activity in an individual is controlled by the genetic expression of that individual therefore information on the roles played by some genetic markers in relation to age of individuals predisposed to urogenital schistosomiasis will give vital information on the immune protective response to the parasite among group of people that are at risk to the development of severe disease pathology. therefore, this study aimed to determined the presence of cancer genetic markers among school children in relation to urogenital schistosomiasis in anambra north senatorial district, nigeria literature review cancer is a disease of importance because it is a genetic disorder that can come about as a results genetic or epigenetic alterations in the somatic cells and is associated with abnormal cell growth, it could be invasive or noninvasive (soria et al., 2019; zhang et al., 2015). cancer has been identified to be caused by a lot of factors including but not limited to tobacco smoking, infections like hiv, hepatitis b, epstein-barretc, poor diet, obesity, excessive consumption of alcohol, exposure to ionizing radiation, and gases, bladder inflammation due to microbial and parasitic infections, as well as some adverse side-effects of medications (saini et al., 2020). there are different forms of cancer of which bladder cancer is inclusive. bladder cancer is a disease that can arise from various factors including infection with schistosoma haematobium which has significant diagnostic, therapeutic and prognostic challenges (kamat et al., 2013) cases of which squamous cell cancers of the urinary bladder were identified to be proportionately more common in populations with a high prevalence of s. haematobium infection and a high proportion of urinary bladder cancers (iarc, 2012). the estimated incidence of urinary bladder cancer has been related to the proportion of cancerous urinary bladder specimens which contains s. haematobium eggs or egg remnants (iarc, 2012). also, the sex ratio of urinary bladder cancer cases show some variation although it corresponded to the relative involvement of men and women in agricultural work which has been identified as a risk factor for s. haematobium infection (iarc, 2012). https://journals.e-palli.com/home/index.php/ajmsi pa ge 27 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 adult worms in schistosoma haematobium infection are seen to reside in the urinary system where they lay eggs that cause disease pathology. studies reported in the international agency for research on cancer (iarc) and other studies (badawi et al., 1995; mostafa et al., 1999; mayer and fried, 2007; ekwunife et al., 2009) have supported an association between the occurrence of urinary bladder cancer and s. haematobium infection. studies have shown that: the estimated incidence of urinary bladder cancer was higher in areas with a high prevalence of s. haematobium infection than in areas with a low prevalence (iarc, 2012). another study on the incidence of different histological types of bladder cancer in various racial groups living within the same geographic area of kwazulu-natal, south africa, reported similar results: squamous cell carcinoma occurred in 53% of the african patients (who have a much higher risk of exposure and infestation to s. haematobium due to socioeconomic, cultural and educational factors), and in 2% of the caucasian patients (groeneveld et al. 1996). also, groeneveld et al. (1996) reported that eggs of s. haematobium were seen in microscopic sections of the bladder tumour in 85% of the patients with squamous cell carcinoma, and in 10% of the patients with transitional cell carcinoma with the mean age at presentation of african patients was at least 20 years younger than that of caucasian patients. adult schistosoma haematobium worms do not multiply in the host, but rather produce offspring that must exit the host to continue the parasite life cycle (klion and nutman, 2002). helminth species such as schistosoma haematobium have developed complex and redundant mechanisms which help them to maintain a chronic infection despite immune recognition by the host. these parasite are able to attain the chronic infection by adoption of certain strategies which include residing in anatomical locations that are relatively free to immune attack, molecular mimicry, shedding of antigenic surface proteins, and downregulation of the host immune response to helminth antigens, thus, producing a state of parasite-specific immune tolerance (brooks et al., 2010). when an individual gets infected with a parasite or any foreign material, the immune system activates the humoral and cell mediated immune response (thomas and harn, 2004; hokke and yazdanbakhsh, 2005; van die and cummings, 2006; hokke et al., 2007; mickum et al., 2014), this immune response can also be found in infection with schistosomes. schistosomes are parasites that might not be cleared through the process of phagocytosis by host immune responses; therefore, in most cases the host immune system responds through inflammation and hypersensitivity. immunoglobulin g (igg), eosinophils and immunoglobulin e (ige) are activated to initiate inflammatory response in the site where the parasite is found. infection with schistosomes has been shown to elicit various immune responses such as the induced release of il6, tnf, and il1-b from monocytes (tevelde et al., 1990), inhibition of th17-development (park et al., 2005) and trigger the alternative activation of macrophages with the help of il-13 (gea-sorlí and closa, 2009). also, there is the suggestion that 70 % of bladder cancers involve a specific mutation in a particular gene called the telomerase reverse transcriptase (tert) gene (zhang and zhang, 2015). the tert gene is involved in dna protection, cellular aging processes, and cancer. there could be genetic mutations in some chromosomal genes, such as fgfr3, rb1, hras, tp53, tsc1, and others which may play certain roles in the formation of tumors in the urinary bladder (zhang and zhang, 2015). these genes play an important role in the regulation of gene mutations on p53 suppressor gene as was shown in a study which evaluated 18 different bladder tumors of which 11 (61 %) had genetic mutations of p53 gene (zhang and zhang, 2015). the p53 marker has also been associated with the most aggressive t1g3 cancers (soria et al., 2019). hras is a proto-oncogene and has potential to cause cancer in several organs including the bladder. the tsc1 c. 1907 1908 del (e636fs) mutation in bladder cancer suggests that the location of the mutation is exon 15 with frequency of tsc1 mutation of 11.7 %. the bap1 mutations have shown that it contributes to brca pathway alterations in bladder cancer. the discoveries of more gene mutations and new biomarkers and polymerase chain reaction bioassays for gene mutations in bladder cancer need further research (zhang and zhang, 2015). the regulation of the immune response in human schistosome infection determines the pathogenic response of the host. also, an individual’s genetic makeup is the template on which every of the organism’s profile is written including the individual’s response to diseases such as schistosomiasis. chronic schistosoma infections are usually seen to be established through the modulation of the host immune system (waknine-grinberg et al., 2010). one of the complications of urogenital shistosomiasis is the formation of granuloma on the bladder walls, which is the main lesion found in schistosomiasis (ekwunife et al., 2009) and is also a predisposing factor to the development of bladder cancer (ishida and hsieh, 2018). this bladder cancer is the worldwide 9th most common cancer (siegel et al., 2015). other pathologic effects due to s. haematobium include: irregularity of bladder wall, thickening of the bladder wall, massing of bladder wall, dilated kidney and bladder wall lesions (ekwunife et al., 2009). in non-invasive tumors, mutations had been found in the fibroblasts growth factor receptor 3 (fgfr3) where the presence of the fgfr3 mutation in urine is observed for low-grade tumors and are proposed to be associated with concomitant or future recurrence (frantzi et al., 2012; critelli et al., 2016). fgfr3 is a genetic marker that has been implicated in bladder cancer where some cases of multiple myeloma are seen to express both mutation and over-expression of fgfr3 (akanksha and sandhya, 2019). https://journals.e-palli.com/home/index.php/ajmsi pa ge 28 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 furthermore, there are also studies that has shown that there could be increased glyceraldehyde-3-phosphate dehydrogenase (gapdh) levels in many human cancer types which has been correlated with possible reduction in survival (altenberg and greulich, 2004; guo et al., 2013). there had also been report of deregulation of gapdh in bladder cancer cases (colell et al., 2009; guo et al., 2013). gapdh has been implicated to play certain roles in apoptosis (colell et al., 2009) and there are suggestion that gapdh participates in tumor progression and could serve as a new therapeutic target (zhang et al., 2015). materials and methods ethical approval: ethical approval was obtained from ethics board of nnamdi azikiwe university teaching hospital (nauth) (nauth/cs/66/vol.13/ver iii/10/2020/07). study site and sample collection: a cross-sectional study was earlier carried out in anambra north senatorial district of anambra state for presence of urogenital schistosomiasis (the manuscript on the prevalence is presently under review in the nigerian journal of parasitology). anambra north senatorial district is made up of 7 local government (lga) areas which are: anambra east lga, anambra west lga, ayamelum lga, ogbaru lga, onitsha north lga, onitsha south lga and oyi lga (mictu/unizik, 2019). three lgas were randomly selected. informed consent from community heads, head teachers and parents were obtained before sample collection. blood samples (2mls) were collected in edta bottles for further immunological studies. a subset of the general study population was used for serology. two plates of 96 wells was used for the assay. the blood samples collected in the edta bottles were spurned at 3000 revolution per minute for five minutes. the plasma was separated from the edta container into cryogenic vials. the separated plasma was stored in cryogenic vials for serology. serology was done using enzyme linked immunosorbent assay (elisa). this assay was done for both positive and negative samples. immunogens tested for, included glyceraldehyde-3phosphate dehydrogenase (gapdh) and fibroblast growth factor receptor (fgfr3). age range of individuals tested was 6-18 years. the human fgfr3 elisa kit and the anti-gapdh monoclonal antibody by mybiosource.com was used for this study. the assay procedures were carried out following manufacturer’s instructions. procedure for the coating of plate for the fgfr3 and anti-gapdh monoclonal antibody was done following the protocol by thermo fisher scientific inc. (2010). optical density (od) of plate was read at 450nm using an elisa plate reader. wash buffer was prepared using 0.05% tween 20 and phosphate buffer saline (pbs). the markers, hrp conjugated anti-rabbit antigen, blocking buffer, substrate and stop solution were all provided by the manufacturer. data was entered and cleaned in microsoft excel. data was analyzed using microsoft excel and ibm spss 20 software. mcnemar’s test and inter rater reliability tests were tested for all elisa tests. the fisher exact tests and chi-square were used to compare s. haematobium infection rates between age and sex. the spearman’s and pearson correlation coefficient was used to determine relationships. results and discussion in the said study, a total of 396 children were sampled and urine microscopy done for schistosoma haematobium detection. from this, 36 children were positive for schistosomiasis. all 36 s. haematobium positive consisting of 26 females and 10 males and randomly selected 156 negative samples were used for the study. the study subset included a total of 192 samples, 108 females and 84 males. absorbance cutoff points were determined as 1.0 and 1.1 for gapdh and fgfr3 respectively (figure 1, figure 2). mean optical density was 0.73 and 0.79 for gapdh and fgfr3 respectively. the result from the s. haematobium 36 positive cases showed a mean od for gapdh as 0.938, minimum value was 0.119 while maximum value was 4.507. for fgfr3 mean od was 0.896, maximum 2.882 and minimum 0.28, while females showed higher gapdh od (table 1). this study identified that there are some school children that are positive for the cancer genetic markers gapdh and fgfr3 in the study area. also, in the case of individuals that are positive for s. haematobium eggs, it was also noted that some of the participants are positive for the cancer genetic markers. more positivity rate was noted for fgfr3 than gapdh. a study on s. mansoni has sown that there is an indication that the expression of the glycolytic enzyme gapdh is as a result of the parasite activity (pirovich et al., 2020). gapdh has been implicated as an immune marker that is essential for cancer cells by influencing cancer cell fate and may be a critical regulator of cancer cell functions and hence a marker of cancer cell progression and prognosis (zhang et al., 2015). fgfr3 has also been implicated in the development of different forms of cancer and could also serve as cancer prognostic marker (akanksha and sandhya, 2019). this basically implies that among this study group, there is a risk of possible progression of bladder cancer development if infection with urogenital schistosomiais is not well managed. this should be an issue of public health importance since this implies potential risk of bladder cancer development because, the positivity for these markers identifies that there is a potential risk of them developing bladder cancer in the future because, these markers could serve as cancer prognostic markers (akanksha and sandhya, 2019; zhang et al., 2015). a total of 21 (10.94%) participants were positive for https://journals.e-palli.com/home/index.php/ajmsi pa ge 29 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 figure 1: scatter plot of gapdh elisa detection results. figure 2: scatter plot of fgfr3 elisa detection results. table 1: od and prevalence of gapdh and fgfr3 by sex gapdh fgfr3 female male female male mean od 0.876 0.557 0.822 0.733 max od 4.448 4.507 2.26 2.882 min od 0.14 0.119 0.248 0.225 no. negative (%) 92 (85.2) 79 (94) 82 (75.9) 60 (71.4) no. positive (%) 16 (14.8) 5 (6.0) 26 (24.1) 24 (28.6) total 108 84 108 84 p>0.05 gapdh while 50 (26.04%) participants were positive for fgfr3 via elisa cutoff (table 2). age range of individuals tested was 6-18 years. there was a slight positive correlation between age and gapdh though this was not statistically significant (r= 0.27, p>0.005). there was also a slight positive correlation between age and fgfr3 (r= 0.27, p>0.005). s. haematobium positive individuals in the age group 11-15 years were the only group positive for gapdh while for fgfr3 positivity was noticed across all age groups (table 3). this study was also able to show that there was a weak positive correlation between age and gapdh and age and fgfr3 for the general assayed population though this was not statistically significant. individuals from the assayed samples in the age group 1115 years had a slightly higher gapdh od though those in the age group 6-10 years had more positive individuals for the assayed marker. on the other hand, individuals assayed for fgfr3 had more positive cases for those in age group 11-15 years. furthermore, in individuals that are positive for s. haematobium there was no relationship between age and the presence of the markers. though it was noted that six (6) individuals in the age group 11-15 years who were positive for s. haematobium eggs were also positive for gapdh while for fgfr3 there were positive cases across the different age group represented in the study. this may imply that the risk of the development of https://journals.e-palli.com/home/index.php/ajmsi pa ge 30 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 urogenital cancer increases with age as it had been noted that age is the greatest single risk factor for developing urogenital cancer (shariat et al., 2019). this could also be an indication that the expression of these markers is more represented with an increase in years of school children in the sampled communities. a study by ahmad et al (2018) identified that older age patients tend to show increased frequency of fgfr3 mutations. mean fgfr3 and gapdh od was higher in females than males. gapdh mean od for females was 0.876 table 2: prevalence of gapdh and fgfr3 in various age group gapdh fgfr3 age (years) total positive prevalence (%) positive prevalence (%) 0-5 0 0 0 0 0 6-10 72 12 16.67 16 22.22 11-15 83 6 7.32 24 29.27 16-20 38 3 7.89 10 26.32 total 192 21 10.94 50 26.04 p>0.05 table 3: gapdh and fgfr3 prevalence for individuals positive for s. haematobium in various age group gapdh fgfr3 age (years) total positive prevalence (%) positive prevalence (%) 0-5 0 0 0 0 0.00 6-10 9 0 0 5 13.89 11-15 18 6 16.67 5 13.89 16-20 9 0 0 3 8.33 total 36 6 16.67 13 36.11 while male was 0.557. fgfr3 mean od for females was 0.866 and males was 0.733. prevalence of gapdh showed that 16 (14.8%) of the 108 females were positive while 5 (6.0%) of 84 males were positive for the marker. also, 26 (24.1%) females and 24 (28.6%) males were positive for fgfr3 (table 1). more females positive for s. haematobium were also positive for gapdh (11.1%) and fgfr3 (25%) (table 4). fgfr3 and gapdh marker prevalence for individuals positive for s. haematobium is 25% and 16.7% respectively. in this study, female participants showed higher mean gapdh and fgfr3 od than male participants. also, for those positive for s. haematobium there were more females positive for the marker than males. this occurrence may be attributed to the fact that they are the most exposed group since they carry out day to day activities in potentially infected s. haematobium water bodies and this could make them more likely to present with the markers. this is in line with other studies on fgfr3 gene mutation studies that identified that female patients tend to show increased frequency of fgfr3 mutations (beukers et al., 2017; ahmad et al., 2018). in contrast, another study had reported that the presentation of this marker is more common in male than female (akanksha and sandhya, 2019). however, table 4: gapdh and fgfr3 prevalence for individuals positive for s. haematobium in various age group gapdh fgfr3 overall female male overall female male average od 0.956 1.155 0.694 0.896 1.018 0.782 maximum od 4.507 4.027 4.507 2.882 2.882 2.26 minimum od 0.119 0.229 0.119 0.28 0.364 0.28 prevalence (%) 6(16.7) 4(11.1) 2(5.6) 13(36.1) 9(25) 4(11.1) this study noted that there is no relationship between sex and the presence of the markers in participants that are positive for s. haematobium. moreover, the international agency for research on cancer has stated that bladder cancer could be associated with the profession of an individual and is more related to agricultural farmer (iarc, 2012) because of their contact with infected water. conclusions the study has produced evidence showing that there are children that are positive for the cancer genetic markers fgfr3 and gapdh with more females being positive for the markers. the presence of these markers are an indicator that children in the selected communities maybe at risk of developing bladder cancer in the future https://journals.e-palli.com/home/index.php/ajmsi pa ge 31 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(1) 26-31, 2023 if the disease is not properly managed and controlled. also, there is need for more studies on these identified immune markers which may serve as prognostic markers for schistosomiasis progression or urogenital cancer development in at risk population. this study has potential limitations. this study does not have age representation for children 0-5 years. though, this has no direct impact on the result of the findings for the other age groups represented. however, further research can be done to include the age group 0-5years to ascertain the representation of the cancer genetic markers of the group. also, determining the marker concentration using a standard curve will help elucidate more on the relationship between concentration and the different categories assayed in this study. references ahmad, f., mahal, v., verma, g., bhatia, s., and das, b.r. 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(2015). critical protein gapdh and its regulatory mechanisms in cancer cells. cancer biology and medicine, 12, 10-22. https://journals.e-palli.com/home/index.php/ajmsi pa ge 1 pa ge 80 american journal of medical science and innovation (ajmsi) positive outcomes of ozone and nad therapy in infertility treatment: a retrospective observational case series michael fakih1, muhammad akhtar1, mouna fawaz1* volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3203 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 20, 2024 accepted: september 24, 2024 published: september 27, 2024 this retrospective observational case series aims to delineate the positive effects of ozone and nad therapy on patients dealing with infertility. conducted at first ivf fertility centre, the study examined six female patients who had previously experienced multiple ivf failures. we meticulously analyzed these cases, noting remarkable improvements following the integration of alternative therapeutic modalities, particularly ozone therapy, into their treatment regimens. each of the six cases demonstrated a discernible positive outcome, characterized by the acquisition of euploid, transferable embryos or successful pregnancies. the findings suggest that the integration of ozone and nad therapy can significantly benefit patients dealing with infertility. to comprehensively ascertain the impact of these alternative therapies, a rigorous evaluation, such as a randomized pilot study, is recommended. this empirical approach would empower patients and healthcare providers to make well-informed decisions regarding the potential benefits and associated risks of these innovative treatment avenues, fostering a proactive and collaborative approach to fertility care and ultimately enhancing patient outcomes. keywords infertility, in vitro fertilization (ivf), recurrent ivf failures, nicotinamide adenine dinucleotide (nad), ozone therapy 1 first ivf fertility centre abu dhabi, united arab emirates * corresponding author’s e-mail: mona.fawaz@yahoo.fr introduction infertility is one of the prevailing global concerns that impacts millions of couples worldwide (obeagu et al., 2023). in this context, in vitro fertilization (ivf) stands as a miracle of modern medication for couples grappling with conception challenges (inhorn, 2021). assisted reproduction involves multiple complex steps, from ovarian stimulation and egg retrieval to fertilization and embryo transfer. despite advancements in ivf techniques, a subset of patients confronts the disheartening reality of recurrent ivf failures, often attributed to factors such as inadequate embryo development leading to the absence of viable blastocysts for transfer (fodina et al., 2021). this subset poses a formidable challenge within the realm of fertility treatment. this phenomenon not only leads to emotional distress for couples but also emphasizes the need for alternative approaches to improve ivf outcomes (wu et al., 2023). emerging as an innovative medical intervention such as ozone therapy or nicotinamide adenine dinucleotide (nad) therapy may have the potential to enhance ivf success rates and revolutionize the landscape of fertility treatment (merhi et al., 2019). medical advancements have highlighted the connection between free radicals and various diseases. therefore, the chances of developing various diseases due to stress are increased by a lifestyle, exposure to chemicals and pollution, smoking cigarettes, using drugs, experiencing illness and dealing with stress (pădureanu et al., 2022). antioxidants are substances that can counteract the effects of radicals and reduce the occurrence of damage caused by oxidative stress. one of the causes of infertility is inflammation (ravel et al., 2021; yuxin et al., 2021) and ozone therapy, a therapeutic approach utilizing a mixture of ozone and oxygen, has garnered attention due to its potential to modulate oxidative stress, enhance circulation, and stimulate tissue regeneration (scassellati et al., 2020). these ozone therapy attributes are promising for addressing the challenges posed by repeated ivf failures. oxidative stress and inflammation have been linked to impaired embryo development and implantation, which are critical factors in ivf success. ozone therapy’s ability to mitigate oxidative stress and promote tissue repair could contribute to a more favourable uterine environment for embryo implantation (escandón et al., 2020). nad has grown beyond its role in metabolism to become a crucial regulator of various physiological processes. these processes include dna repair, autophagy adaptive stress responses, maintaining stability and ensuring cell survival (srinivas et al., 2019). notably, studies have indicated that nad+ levels decline with age in tissues and are associated with age-related diseases (mcreynolds et al., 2020). the inclusion of alternative therapies as an adjunct to standard ivf treatment represents a novel avenue for addressing the unmet needs of patients with recurrent ivf failures (dias et al., 2023). materials and methods this case study was designed using a retrospective and systematic approach to evaluate the potency of pa ge 81 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 80-83, 2024 adjunctive therapies of ozone and nicotinamide adenine dinucleotide (nad) sessions in improving ivf outcomes among women experiencing recurrent failures (moreira, 2021). before starting this study on patients, approval from the institutional review board (irb) was obtained, ensuring compliance with ethical guidelines and protecting participant rights. subsequently, patients with documented recurrent ivf failure history were carefully selected for inclusion in the case series, with all participants providing informed consent prior to their involvement. the patients’ ages ranged from 29 to 43 years. they had underlying causes of infertility, including diminished ovarian reserve and endometriosis. detailed data on the six participants’ ivf treatment history, past failures and outcomes, were meticulously collected and analyzed. then, therapies and their frequency and dosage were systematically integrated into treatment regimens with standardized protocols for five to eight sessions per patient. strict quality control measures and staff training guaranteed data accuracy and reliability. patient responses to the integrated treatments were observed and evaluated to identify potential advancements, utilizing statistical analysis techniques to assess efficacy. treatment outcomes, including acquiring transferable embryos or successful pregnancies, were compared to previous ivf attempts. individual case conclusions were drawn to provide insights into the potential efficacy of ozone and nad therapy in addressing recurrent ivf failures. results and discussion results the results of this case study are presented as a series of case studies, each highlighting the outcomes of integrating alternative approaches, ozone and nad therapies. the following findings elucidate the potential efficacy of these therapies in making ivf successful and also the challenges faced by patients seeking successful pregnancies. case studies the first case was of a 29-year-old woman, married, with a history of primary infertility, who carries genetic traits for autosomal recessive blindness and thalassemia. her amh (anti-müllerian hormone) level register was 2.93 ng/ml. having undergone seven prior ivf cycles elsewhere, she encountered a lone embryo transfer that yielded no pregnancy. following three intravenous and one vaginal ozone session, she embarked on an ivf cycle that led to the development of a normal (euploid) embryo and resulted in a successful pregnancy after embryo transfer. in the second case, a 42-year-old woman experienced secondary infertility and an amh level of 1 ng/ml. after three previous ivf cycles that led to aneuploid embryos, she integrated antioxidant sessions, including 11 sessions of nad, and underwent eight intravenous ozone therapy sessions. two subsequent ivf cycles ensued, one yielding a single euploid embryo. thirdly, a 41-year-old woman with secondary infertility, endometriosis stage iv, and an amh level of 0.07 ng/ ml underwent multiple unsuccessful ivf cycles. upon beginning five sessions of nad and five sessions of intravenous ozone therapy, her subsequent ivf cycles showed a significant shift in outcomes. one cycle resulted in a genetically normal embryo and a successful embryo transfer, leading to a positive pregnancy. in the fourth case, a 41-year-old woman in her third marriage, without prior children, confronted poor ovarian reserve (amh: 0.2 ng/ml). three prior ivf cycles yielded abnormal embryos. following two nad sessions and five intravenous ozone therapy sessions, she underwent two ivf cycles, each resulting in a single euploid embryo, thus marking a noteworthy improvement. in the fifth case, a 41-year-old woman with primary infertility and an amh level of 0.35 ng/ml underwent eight ivf cycles, producing aneuploid embryos with just one normal embryo. after seven intravenous ozone table 1: summary of case series case patient’s age diagnosis previous ivf cycles alternative therapies outcomes 1 29 primary infertility, autosomal recessive blindness, thalassemia 7 3 iv + 1 v a g i n a l ozone successful pregnancy 2 42 secondary infertility 3 11 nad + 8 iv ozone 1 euploid embryo 3 41 secondary infertility, endometriosis stage iv multiple 5 nad + 5 iv ozone 1 euploid embryo, successful pregnancy 4 41 poor ovarian reserve, no prior children 3 2 nad + 5 iv ozone 2 euploid embryos 5 41 primary infertility 8 7 iv ozone 2 euploid embryos, successful pregnancy 6 40 secondary infertility, previously a miscarriage 6 5 nad 2 euploid embryos, successful pregnancy pa ge 82 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 80-83, 2024 sessions, two ivf cycles ensued, each yielding a euploid embryo. a successful transfer led to a positive pregnancy outcome. the last case was a 40-year-old woman experiencing secondary infertility who had a miscarriage from a spontaneous pregnancy. her anti hormone (amh) level is 1.27 ng/ml. she underwent six rounds of in vitro fertilization (ivf), and all the embryos produced in these cycles were abnormal due to aneuploidy. after receiving five sessions of nad (each containing 250mg of nad) as advised by her physician, she decided to try another ivf cycle that led to two euploid embryos being successfully transferred, and pregnancy occurred. table 1 summarises each case, including age, previous ivf cycles, alternative therapies used and outcomes achieved. discussion the cases presented in this series highlight the potential benefits of incorporating antioxidant therapies, specifically nicotinamide adenine dinucleotide (nad) and intravenous ozone sessions, into the treatment protocols of women facing infertility challenges (dias et al., 2023). these cases underscore the importance of individualized care and the exploration of innovative approaches in assisted reproductive medicine (sunderam, 2019). antioxidant therapies appear to have played a pivotal role in enhancing the quality of embryos, resulting in genetically normal embryos available for transfer. nad and intravenous ozone therapy emerged as valuable adjunctive treatments, contributing to the overall success of the ivf cycles, evidenced by the development of euploid embryos and successful pregnancies (hussain et al., 2021; sunderam, 2019). in reviewing the literature, it is evident that there is a growing trend towards the use of alternative medicine (am) in treating infertility, challenging traditional therapies. however, some randomized controlled trials (rcts) have shown that complementary and alternative medicine (cam) does not consistently impact infertility, and there remains no consensus on its mechanism of action on fertility. (saha et al., 2021; sharifi et al., 2021) nevertheless, therapies such as ozone therapy have shown promise in enhancing aspects of reproductive function, including clearing blockages in the fallopian tubes, protecting against infections, and potentially reducing damage to the ovaries while improving ovarian reserve. the potential of ozone therapy to reduce inflammatory responses and adhesions suggests its value as a component of ivf treatments.(dias et al., 2023; merhi et al., 2019) additionally, the decline in nad availability with age significantly impacts egg quality and overall fertility, highlighting the potential of nad supplementation as a therapy for addressing infertility challenges associated with ageing. future research targeting women with repeated miscarriages, poor responses to ivf treatments, endometrial lining problems, or decreased ovarian reserve is warranted to further elucidate the effectiveness of alternative therapies in complex infertility(wu et al., 2019). moreover, each patient in this case series presented a unique clinical profile. therefore, findings from this discussion underscore the importance of a personalized approach to treatment and the exploration of innovative therapies in addressing complex infertility cases and innovation in the evolution of personalized medicine in reproductive health. further research is needed to understand alternative therapies’ mechanisms of action and efficacy in improving fertility outcomes. conclusion incorporating ozone therapy and complementary treatments reflects a comprehensive strategy for tackling intricate infertility cases, potentially paving the way for advancements in fertility treatment outcomes. while these instances offer encouraging glimpses into the potential advantages of antioxidant therapies, additional research is necessary to confirm their effectiveness and safety. furthermore, further investigation is needed to elucidate the exact mechanisms through which nad and intravenous ozone therapy can impact embryo development. ongoing research and broader-scale studies are imperative to validate these findings and enhance treatment protocols in reproductive medicine. data availability statement the data supporting the findings of this study are stored in software called meditex, which is designed specifically for in vitro fertilization (ivf) clinics. meditex serves as a tool for managing and documenting patient data within assisted reproduction organizations. however, it’s important to note that there are restrictions on accessing this data due to licensing agreements for this study. therefore, provided database was retrieved from meditex internal data management system and cannot be accessed publicly. nevertheless, the authors of the study are willing to access to the data upon request. the data and materials used in this case series are available upon reasonable request for transparency. access requests should be directed to the corresponding author. abbreviation list in vitro fertilization (ivf);anti-müllerian hormone (amh);nicotinamide adenine dinucleotide (nad) references dias, a. r., bitsaktsis, c., emdin, d., bosman, l., smith, a. h., & merhi, z. (2023). ozone sauna therapy and pulsed electromagnetic field therapy could potentially improve outcome in women with diminished ovarian reserve undergoing assisted reproductive technology. medical gas research, 13(4), 202-207. escandón, b. m., espinoza, j. s., perea, f. p., quito, f., ochoa, r., lópez, g. e., galarza, d. a., & garzón, j. p. (2020). intrauterine therapy with ozone reduces subclinical endometritis and improves reproductive pa ge 83 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 80-83, 2024 performance in postpartum dairy cows managed in pasture-based systems. tropical animal health and production, 52(5), 2523-2528. fodina, v., dudorova, a., & erenpreiss, j. (2021). reasons and mechanisms of recurrent failed implantation in ivf. infertility and assisted reproduction, 1. hussain, t., murtaza, g., metwally, e., kalhoro, d. h., kalhoro, m. s., rahu, b. a., ... & tan, b. (2021). the role of oxidative stress and antioxidant balance in pregnancy. mediators of inflammation, 2021(1), 9962860. inhorn, m. c. (2021). infertility, in vitro fertilization, and fertility preservation: global perspectives. in the routledge handbook of anthropology and reproduction (pp. 217-232). routledge. mcreynolds, m. r., chellappa, k., & baur, j. a. (2020). age-related nad+ decline. experimental gerontology, 134, 110888. merhi, z., garg, b., moseley-larue, r., moseley, a. r., smith, a. h., & zhang, j. (2019). ozone therapy: a potential therapeutic adjunct for improving female reproductive health. medical gas research, 9(2), 101-105. moreira, m. d. v. r. (2021). impact of hyperoside supplementation on the protection of human sperm against oxidative damage. obeagu, e. i., njar, v. e., & obeagu, g. u. (2023). infertility: prevalence and consequences. int. j. curr. res. chem. pharm. sci, 10(7), 43-50. pădureanu, v., florescu, d. n., pădureanu, r., ghenea, a. e., gheonea, d. i., & oancea, c. n. (2022). role of antioxidants and oxidative stress in the evolution of acute pancreatitis. experimental and therapeutic medicine, 23(3), 1-5. ravel, j., moreno, i., & simón, c. (2021). bacterial vaginosis and its association with infertility, endometritis, and pelvic inflammatory disease. american journal of obstetrics and gynecology, 224(3), 251-257. saha, s., roy, p., corbitt, c., & kakar, s. s. (2021). application of stem cell therapy for infertility. cells, 10(7), 1613. scassellati, c., ciani, m., galoforo, a. c., zanardini, r., bonvicini, c., & geroldi, c. (2020). molecular mechanisms in cognitive frailty: potential therapeutic targets for oxygen-ozone treatment. mechanisms of ageing and development, 186, 111210. sharifi, f., heydari, a., & roudsari, r. l. (2021). infertile women’s healing experiences of using complementary and alternative medicine: a phenomenological inquiry. european journal of integrative medicine, 47, 101369. srinivas, u. s., tan, b. w., vellayappan, b. a., & jeyasekharan, a. d. (2019). ros and the dna damage response in cancer. redox biology, 25, 101084. sunderam, s. (2019). assisted reproductive technology surveillance—united states, 2016. mmwr. surveillance summaries, 68. wu, l., sun, l., wang, j., sun, y., zhang, x., huang, y., lu, y. e., & cao, f. (2023). psychological distress among women undergoing in vitro fertilization-embryo transfer: a cross-sectional and longitudinal network analysis [original research]. frontiers in psychology, 13. https://doi.org/10.3389/fpsyg.2022.1095365 wu, x., hu, f., zeng, j., han, l., qiu, d., wang, h., ge, j., ying, x., & wang, q. (2019). nmnat2-mediated nad+ generation is essential for quality control of aged oocytes. aging cell, 18(3), e12955. yuxin, l., chen, l., xiaoxia, l., yue, l., junjie, l., youzhu, l., ... & qicai, l. (2021). research progress on the relationship between obesity-inflammationaromatase axis and male infertility. oxidative medicine and cellular longevity, 2021(1), 6612796. pa ge 1 pa ge 62 american journal of medical science and innovation (ajmsi) prevalence, patterns and peculiarities of depression among tuberculosis patients attending directly observed treatment short-course (dots) centers in lagos state nigeria lilian chinonso okoro1, oluwakemi odukoya1, aloysius obinna ikwuka2*, francis chigozie udeh2 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2653 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: march 21, 2024 accepted: april 25, 2024 published: april 29, 2024 tuberculosis (tb) is an infectious disease that is life-threatening to vulnerable populations, and has been reported to be associated with depression. nigeria is one of the countries with a high tb burden, and with the current economic hardship in nigeria, people are becoming poorer suggesting more tb patients are more likely to elapse into depression. the aim of this research was to assess the prevalence, patterns and peculiarities of depression among tb patients attending directly observed treatment short course (dots) centers in lagos state, nigeria. a descriptive, cross-sectional survey was conducted among 301 tb patients at 8 dots centers in lagos state, nigeria using a two-stage sampling method. data was collected using interviewer-administered questionnaires to elicit responses from the tb patients. patient health questionnaire-9 (phq-9) was used to determine and assess depression. data was analyzed using spss version 23.0, with the chi-square test being used to check for the association between socio-demographic characteristics and depression among the respondents. mean age of the respondents was 35.1±11.7 years. a majority (71.8%) of the respondents were males, 69.1% were christians, yorubas were most (52.2%), 88.4% earned ≤n150,000 monthly, and only 1 respondent had no formal education. the prevalence rate of depression among the tb patients was 51.8%. socio-demographic characteristics like gender (females were more affected), low financial status, and low educational level were associated with depression (p<0.05); unlike age, marital status, ethnicity, employment status, and family setting (p>0.05). depression among tb patients is real as one in every two tb patients is depressed. therefore, healthcare workers at dots centers should pay adequate attention to signs of depression among their patients. keywords prevalence, patterns, peculiarities, depression, tuberculosis, dots center, nigeria 1 department of community health and primary care, university of lagos, lagos state, nigeria 2 college of medicine and health sciences, american international university west africa, banjul, the gambia * corresponding author’s e-mail: aloysiussweet@yahoo.com introduction tuberculosis (tb) is a chronic granulomatous disease caused by mycobacterium tuberculosis and commonly affects the lungs. other affected organs in the body include the abdomen, spinal cord, etc. tb is characterized with monocytosis (ikwuka, 2023e). tb is a chronic disease of grave public health concern in nigeria (world health organization (who), 2023a). in 2022, 7.5 million cases of newly diagnosed tb infections were recorded with an estimated 1.3 million deaths caused by the infection (who, 2023a). world health organization further highlighted that nigeria is among the thirty high tb burden countries that make up 87% of world tb cases. in addition, nigeria (4.5%) together with india, indonesia, china, philippines, pakistan, bangladesh, and the democratic republic (dr) of the congo, account for two-thirds of the global tb cases (who, 2023a). in the previous year, 2021, nigeria had the highest burden of tb cases with a total of 467,000 cases (who, 2023b), and lagos state accounted for 11% of the total tb cases detected in nigeria in the same year (adebowale-tambe, 2022). the tb burden in nigeria and other countries (china, dr congo, india, indonesia, mozambique, myanmar, philippines, south africa, and zambia) is further compounded by the persistent hiv/aids epidemic and the emergence of multi-drug resistant tuberculosis (mdr-tb) (who, 2023a). closely mimicking tb is cystic fibrosis which is a genetic disease affecting mainly the lungs (ikwuka, 2023a). other affected organs include the pancreas, liver, kidneys, and intestine. cystic fibrosis is caused by mutations in both copies of the gene for cystic fibrosis transmembrane conductance regulator (cftr) protein and has autosomal recessive mode of inheritance (ikwuka, 2023a). clinical features of cystic fibrosis include dyspnea, cough with sputum, sinusitis, poor growth, fatty stool, fingers and toes clubbing, etc (ikwuka, 2023a). chronic metabolic disorders can worsen the clinical course and prognosis of disease in patients with tuberculosis. metabolic syndrome diseases, msds (hypertension, adiposity, diabetes mellitus and dyslipidemia) are interrelated diseases with very high morbidity and mortality rates (ikwuka, 2015; ikwuka, 2017a; ikwuka, 2017c; ikwuka, 2023c; ikwuka, 2023f; virstyuk, 2016). results from different studies have shown that high levels of blood pressure, glucose and lipid metabolic disorders, asymptomatic hyperuricemia, activation of systemic immune inflammation and fibrogenesis (also seen in chronic tb), contribute to kidney damage (ikwuka, 2017d; ikwuka, 2017e; ikwuka, 2018a; ikwuka, 2018c; ikwuka, 2018d; ikwuka, 2019a; ikwuka, 2019c; ikwuka, 2022; ikwuka, 2023d; virstyuk, 2017a; virstyuk, 2018a; pa ge 63 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 62-72, 2024 virstyuk, 2019; virstyuk, 2021a; virstyuk, 2021b). chronic pulmonary tb is characterized with hemoptysis which can lead to anemia (musa, 2023). tuberculosis has also been linked with oxidative stress and different systemic immune inflammatory processes. in inducing oxidative stress, the major free radicals that are of physiological significance are superoxide anion, hydroxyl radical, and hydroperoxyl radical, while non-radical is hydrogen peroxide (ikwuka, 2023b; udeh, 2023a; udeh, 2023b). rauwolfia vomitoria has a neuroprotective ability at it elevates antioxidants and suppresses lipid peroxidation (ekechi, 2023a). depression is a commonly found mental disorder. depression and anxiety are the leading causes of mental disorders globally, with depression having a lifetime prevalence of 5 to 17%, with 12% being the average (bains, 2023). the prevalence is almost twice as high in women than in men, simply because of hormonal differences, childbirth effects, psychosocial stressors in men and women, and the behavioral model of learned helplessness (pederson, 2014). in 2019, 280 million people lived with depression (institute of health metrics and evaluation (ihme), 2022); and in 2020, the number increased significantly by 28% due to the emergence of covid-19 pandemic (who, 2022). depression differs from usual mood fluctuations and short-lived emotional responses to challenges in everyday life. when longlasting with moderate or severe intensity, depression may become a serious health condition. it can cause the affected person to suffer greatly and poorly perform his or her duties. at its worst, depression can lead to suicide which results in an estimated 1 million deaths every year (who, 2022). there are various barriers to effective care such as poorly trained healthcare providers, lack of resources and social stigma associated with mental illnesses. the urgency of the rate of depression to public health is likely compounded by the recognition that, if not effectively treated, it may elapse into a chronic disease. just experiencing one episode of depression places the individual at a 50% risk of experiencing another, with subsequent episodes raising the likelihood of experiencing more episodes in the future (national institute of mental health (nimh), 2021). a study on depression among tb patients reported a prevalence of 45.5% especially in those with extensive tb pathology, older age, long illness duration, nuclear family and unmarried status (ige, 2011). recently, a systematic review and meta-analysis study conducted showed that depression is common among tb patients (duko, 2020). a study on tuberculosis and comorbidities: treatment challenges in patients with comorbid diabetes mellitus and depression outlined that tb patients with depression or diabetes mellitus (tb-dm) both have an elevated risk of relapse, recurrence, and mortality. relapse in tb treatment could also be caused by alcoholism and homelessness, as both coupled with depression could work in synergy to make the patient not to adhere to proper medication compliance (cáceres, 2022). compliance with treatment in chronic disorders has been established to be influenced by psychiatric disorders like depression (dejean, 2013). hence, it is safe to assume that prevention, prompt recognition and treatment of depression in tb patients may help ensure treatment compliance which is crucial to the control of tb. in addition, metabolic syndrome diseases (common comorbidities to tb) also require new and effective treatment regimens. dapagliflozin which is a sodiumglucose linked transporter 2 (sglt-2) inhibitor and liraglutide which is a glucagon-like peptide 1 receptor agonist (glp-1 ra) have been found to increase the effectiveness of treatment and improve the clinical course of type 2 diabetes mellitus and hypertension in patients with such comorbidities (ikwuka, 2017b; ikwuka, 2018b; ikwuka, 2019b; ikwuka, 2021; virstyuk, 2017b; virstyuk, 2018b; virstyuk, 2018c). the hepatorenal protective functions of coconut water in alloxan-induced type 1 diabetes mellitus has also been documented (ekechi, 2023b). despite interventions and projects implemented globally and nationally to combat tuberculosis, the disease continues to pose a major public health threat. to achieve effective control, mechanisms may have to gear more towards patient-centeredness and exploring the human aspects of control. there is insufficient information on the prevalence of depression among tb patients in nigeria, specifically in the southwestern part of nigeria. therefore, this study seeks to determine the prevalence of depression among tb patients attending directly observed treatment short course (dots) centers in lagos state, nigeria. materials and methods study setting this descriptive, cross-sectional study was conducted in lagos state which is the second most populous state in nigeria. due to heavy immigration from other states in nigeria in search of better economic prospects, the lagos state population has become diverse with more than 250 ethnic groups as well as small minorities of american, british, chinese, greek, syrian, etc. lagos state is nigeria’s largest urban area. however, 66% of its population dwells in slums with no access to good roads, clean water, electricity, proper waste disposal, proper housing plans or good hygiene practices. lagos state has a total of 78 dots centers and these centers are made up of 3 tertiary, 24 secondary, 31 primary, and 20 private centers. study population and sample size determination the study population involves tb patients attending dots centers in lagos state. with over 50,000 tb cases in lagos state, kish leslie’s formula for cross-sectional studies to calculate the sample size was used (okeke, 2023a; okeke, 2023b; udeh, 2023c). n=(z2 pq)/d2 pa ge 64 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 62-72, 2024 where, n = minimum sample size required when the total population is greater than 10,000. z = standard normal deviate; set at 1.96 at 95% confidence level. p = incidence rate of depression among tb patients from a previous study; (baba, 2009) determined 27.7% (0.277). q = complementary proportion equivalent to 1-p, which is 0.723 d = degree of accuracy desired (absolute precision), which is 5.0% (0.05). therefore: n = (1.962×0.277×0.723)/0.052 = 308 the minimum sample size for this study was 308. with the addition of 10% non-response rate, the sample size required for the study became 342. study procedure this study spanned a period of 4 months, from march 2023 to june 2023. a list of 78 dots centers was obtained from the lagos state ministry of health. these comprise 3 tertiary centers, 24 secondary centers (made up of 1 police, 2 army, 2 navy, 1 air force), 31 primary centers (made up of 1 police and 2 prisons), and 20 private centers (made up of 8 private not-for-profit (missionary) and 12 private for-profit health institutions). eight dots centers were randomly selected using a table of random numbers. they were: nigerian institute for medical research (61), lagos state university teaching hospital (44), mainland hospital, yaba (68), lagos island general hospital (32), randle general hospital (39), isolo general hospital (20), desile primary health center (22), ebute-metta and bariga lga primary health centers (15). the primary health centers were visited only once on their clinic days because the same patients would be seen while several visits were made to the other facilities to see different patients on different days. tb patients in the outpatient departments of the eight dots centers were selected. the patients were 18 years old or above, and voluntarily consented to participate in the study. tb patients below 18 years of age, adult tb patients who did not consent, and in-patients were all excluded from this study. data collection was done by the research team after being trained on the research procedure. structured, pre-tested questionnaires with sections for the collection of data on socio-demographic parameters, prevalence, patterns and peculiarities of depression among the respondents were used. patient health questionnaire-9 (phq-9) to determine and assess depression was extracted from (kroenke, 2002). data analysis data was analyzed using descriptive statistics (frequencies, percentages, tables, graphs). statistical package for social sciences (spss) version 23.0 was used. tests of the association between depression and factors associated with it were done using the chi-square test at a significance level (p-value) of 5%. the research team used phq-9 instrument scores (not at all “0”; few days “1”; more than half the days “2”; nearly every day “3”). a total score below 4 indicates no depression, 5–9 indicates mild depression, 10–14 indicates moderate depression, 15–19 indicates moderately severe depression, and 20–27 indicates severe depression. ethical considerations ethical consideration was sought from the human research and ethics committee of the lagos university teaching hospital (luth), idi araba, surulere, lagos state. permission to conduct the study in dots centers was obtained from the lagos state primary healthcare board and the lagos state hospital service commission as well as voluntary consent obtained from participating tb patients after informed decision. results 342 respondents were targeted for the study but only 301 responded giving a response rate of 88%. the reason for this is that the dot centers are very early morning clinics and some patients going to work or to their private businesses were impatient to wait to be interviewed. the results are expressed in tables and figures as follows: table 1: socio-demographic characteristics of respondents socio-demographics characteristics frequency, n (%) age (in years) 18-20 12 (4.0) 21-30 114 (37.9) 31-40 87 (28.9) 41-50 51 (16.9) 51-60 23 (7.6) >60 14 (4.7) total 301 (100.0) mean age±standard deviation 35.2±11.75 gender male 216 (71.8) pa ge 65 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 62-72, 2024 female 85 (28.2) total 301 (100.0) marital status single 153 (50.8) married 138 (45.8) divorced 6 (2.0) widowed 3 (1.0) separated 1 (0.3) total 301 (100.0) religion christianity 208 (69.1) islam 90 (29.9) traditional 3 (1.0) total 301 (100.0) ethnicity hausa 14 (4.7) ibo 81 (26.9) yoruba 157 (52.2) others 49 (16.3) total 301 (100.0) employed yes 152 (50.5) no 149 (49.5) total 301 (100.0) estimated monthly income in naira (n) <30,000 (minimum wage in nigeria) 72 (23.8) 30,000-100,000 154 (51.0) 100,001-150,000 41 (13.6) >150,000 34 (11.6) total 301 (100.00) family setting nuclear 178 (59.1) extended 59 (19.6) polygamous 64 (21.3) total 301 (100.0) education primary 46 (15.3) secondary 135 (44.9) tertiary 119 (39.5) no formal education 1 (0.3) total 301 (100.0) the mean age was 35.2±11.75 years with the largest number of respondents (37.9%) within the 21-30 years age group. males were 216 (71.8%) while females were 85 (28.2%). 153 (50.8%) respondents were single, while a small percentage were either divorced (2.0%), widowed (1.0%), or separated (0.3%). christian respondents were most (69.1%). 14 (4.7%) of the respondents were hausas, 26.9% were ibos, and 52.2% were yorubas. employed (152) and unemployed (149) respondents were almost equal. monthly income between n30,000 and n100,000 had the highest frequency (51.0%). most of the respondents were from a nuclear home (59.1%), and just one tb patient had no formal education. pa ge 66 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 62-72, 2024 table 2 shows that 51 (16.9%) of the tb patients had little interest or pleasure in doing things for more than half the days while 36 (12.0%) had little interest nearly every day. 36 (12.0%) of the respondents feel bad about themselves nearly every day while 15.9% had this feeling for a few days. 23 (7.6%) had trouble concentrating on things nearly every day, while 205 (68.1%) did not have any trouble concentrating on things. 19 (6.3%) harbor thoughts of being better off dead or of hurting themselves in some way more than half of the day and nearly every day while 40 (13.3%) had this feeling for a few days. table 2: prevalence of depression among the respondents depression diagnostic criteria (n=301) not at all n (%) few days n (%) more than half the days, n (%) nearly every day, n (%) little interest or pleasure in doing things 142 (47.2) 72 (23.9) 51 (16.9) 36 (12.0) feeling down, depressed or hopeless 188 (62.5) 67 (22.3) 17 (5.6) 29 (9.6) trouble falling or staying asleep, or sleeping too much 161 (53.5) 68 (22.6) 43 (14.3) 29 (9.6) feeling tired or having little energy 142 (47.2) 85 (28.2) 43 (14.3) 31 (10.3) poor appetite or eating too much 180 (59.8) 50 (16.6) 22 (7.3) 49 (16.3) feeling bad about yourselfor that you are a failure or have let yourself or your family down 203 (67.4) 48 (15.9) 14 (4.7) 36 (12.0) trouble concentrating on things, such as reading the newspaper or watching television 205 (68.1) 59 (19.6) 14 (4.7) 23 (7.6) moving or speaking so slowly so that other people could have noticed or the opposite being so fidgety or restless that you have been moving around a lot more than usual 21 (70.8) 49 (16.3) 21 (7.0) 18 (6.0) thoughts that you would be better off dead or of hurting yourself in some way 223 (74.1) 40 (13.3) 19 (6.3) 19 (6.3) phq-9 extracted from (kroenke, 2001) table 3: prevalence and severity of depression among the respondents depression severity (n=301) score frequency, n (%) depression rate depressed 156 (51.8) not depressed 145 (48.2) total 301 (100.0) severity of depression (n=301) none 0-4 145 (48.2) mild depression 5-9 64 (21.3) moderate depression 10-14 61 (20.3) moderately severe depression 15-19 22 (7.3) severe depression 20-27 9 (3.0) total 301 (100.0) phq-9 score card extracted from (kroenke, 2001) table 3 above shows that the prevalence of depression among tb patients was 51.8%. the severity of depression among the respondents indicates that 48.2% of the tb patients were not depressed, 21.3% had mild depression, 20.3% had moderate depression, 7.3% were had moderately severe depression, and 3% were severely depressed. figure 1 shows that 61.1% of the respondents found life as not difficult, 27.2% found life generally as somewhat difficult, 8.6% found life as very difficult, and 3.0% found life as extremely difficult. figure 1: bar chart showing socio-occupational dysfunction among the respondents pa ge 67 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 62-72, 2024 table 4: association between socio-demographic characteristics and depression status of respondents prevalence depressed not depressed x2 df p-value socio-demographic characteristics n (%) n (%) age (years) 18-20 4 (33.3) 8 (66.7) 10.550 5 0.059 21-30 60 (52.6) 54 (47.4) f-exact 31-40 54 (62.1) 33 (37.9) 41-50 23 (45.1) 28 (54.9) 51-60 7 (30.4) 16 (69.6) >60 8 (57.1) 6 (42.9) total 156 (51.8) 145 (48.2) gender male 104 (48.1) 112 (51.9) 4.147a 1 0.042 female 52 (61.2) 33 (38.80) total 156 (51.8) 145 (48.2) marital status single 79 (51.6) 74 (48.4) 2.237 4 0.742 married 73 (52.9) 65 (47.1) f-exact divorced 2 (33.3) 4 (66.7) widowed 1 (33.3) 2 (66.7) separated 1 (100.0) 0 (0.0) total 156 (51.8) 145 (48.2) religion christianity 115 (55.3) 93 (44.7) 5.241 2 0.049 islam 41 (45.6) 49 (54.4) f-exact traditional 0 (0.0) 3 (100.0) total 156 (51.8) 145 (48.2) ethnicity igbo 42 (51.9) 39 (48.1) 3.953a 3 0.267 yoruba 88 (56.1) 69 (43.9) hausa 6 (42.9) 8 (57.1) others 20 (40.8) 29 (59.2) total 156 (51.8) 145 (48.2) employed yes 73 (48.0) 79 (52.0) 1.777a 1 0.183 no 83 (55.7) 66 (44.3) total 156 (51.8) 145 (48.2) estimated monthly income in naira (n) <30,000 25 (71.4) 10 (28.6) 11.596a 3 0.009 30,000-100,000 34 (45.3) 41 (54.7) 100,001-150,000 6 (30.0) 14 (70.0) >150,000 6 (35.3) 11 (64.7) total 71 (48.3) 76 (51.7) family setting nuclear 97 (54.5) 81 (45.5) 1.618a 2 0.445 extended 30 (50.8) 29 (49.2) polygamous 29 (45.3) 35 (54.7) pa ge 68 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 62-72, 2024 total 156 (51.8) 145 (48.2) education level primary 16 (34.8) 30 (65.2) 8.119 3 0.027 secondary 78 (57.8) 57 (42.2) f-exact tertiary 61 (51.3) 58 (48.7) no formal education 1 (100.0) 0 (0.0) total 156 (51.8) 145 (48.2) table 4 shows that the age group 21-30 years were the most depressed with 60 respondents out of the 156 depressed respondents. on gender, 48.1% males were depressed. the depressed/not depressed ratio among the single respondents was 51.6:48.4. more of the depressed tb patients were unemployed (55.7%). 71.4% of the respondents earning less than the minimum wage (n30,000) were depressed, while 35.3% of the respondents earning above n150,000 monthly were depressed. 57.8% of the respondents who were secondary school leavers were depressed. discussion tuberculosis (tb) is an infectious disease that requires proper treatment and management to prevent its spread and fatality in infected individuals. tb has been reported to be associated with mental illnesses such as depression (duko, 2020; who, 2023a). thus, it is crucial to analyze the population index of the disease and understand how tb patients are coping with depression. the mean age of tb patients in this study was 35.2±11.75 years, slightly above the 30-year mean age in the study of (salodia, 2019). patients between ages 21 and 50 years accounted for 83.7% of the sample size, this gives a clue that tb infection is common among the workforce population and less common among the people below 21 and above 50 years of age, who are being catered for. males are more infected than females as males accounted for 71.8% of the respondents, just as was found in the studies of (dahiya, 2017) and (salodia, 2019). this could also be related to the fact that men actively interact with people more than women daily. single or unmarried patients accounted for half (50.8%) of the respondents, suggesting a wide spectrum of interaction for the unmarried compared to married, divorced, widowed, or separated individuals. this supports (dahiya, 2017) study. most of the respondents were christians and over half (52.2%) were yorubas. this indicates that lagos state is dominated by adherents of the christian religion and that the yorubas in the state are the people mostly infected with tuberculosis. almost half (49.5%) of the respondents were unemployed, indicating the need for the lagos state government to improve on employment of the masses. however, tb infection is equally distributed among the unemployed and employed. tb is more prevalent among people earning a low monthly income of n100,000 or less as compared to people earning a higher income (>n100,000), as illustrated by findings in this study and in the study of (dahiya, 2017). this study also proves that tuberculosis is distributed across every level of education. a high (51.8%) prevalence of depression among the participants was recorded in this study. this prevalence rate was higher than the 23.6% found in new delhi (salodia, 2019), 30% in lesotho (larson, 2017), 31.1% in ethiopia (molla, 2019), and 45.5% in oyo state, nigeria (ige, 2011). the value in this present study is almost the same as the 51.9% in eastern ethiopia reported by (dasa, 2019), 69.55% in pakistan (javaid, 2017), and 80% in pakistan (anwar, 2010). the variation in the prevalence of depression could be attributed to various factors such as socio-occupational dysfunction, presentation of tb symptoms, prolonged drug therapy duration, hiv status, other comorbidities e.g. msds, stigma from family and friends, denial of communal privileges, family support, period of diagnosis of tb, stage of treatment, the distance to a treatment center, and the attitude of treatment center staff. analyzing the socio-occupational dysfunction of the respondents, 61.1% of them found life as not difficult, 27.2% found life as somewhat difficult, 8.6% found life as very difficult, and 3.0% found life as extremely difficult. the prevalence of depression among the 301 respondents can be summarized as 48.2% (no depression), 21.3% (mild depression), 20.3% (moderate depression), 7.3% (moderately severe depression), and 3.0% (severe depression). this means that 89.7% of the respondents are most likely to comply to proper medication because they are either not depressed or have mild or moderate depression, yielding a better treatment outcome for the tuberculosis infection. additionally, from this study, it can be stated that out of 20 depressed tb patients: 16 will be mildly and moderately depressed (evenly shared); 3 moderately severely depressed; and 1 will be severely depressed. the association between socio-demographic characteristics and depression status of the participants shows that age, marital status, ethnicity, employment status, and family setting were not associated with depression. the relationship between marital status and depression in this present study aligns with the study of (salodia, 2019). apart from these socio-demographic parameters, gender shows a significant association with depression, opposing the result of (salodia, 2019). the ratio of depressed female participants was significantly higher (p=0.042) than the ratio of depressed male participants. women pa ge 69 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 62-72, 2024 are the caregivers in the home, and being unable to render this care due to morbidity of tb and the fear of communicating the disease to their family members might contribute to their vulnerability to depression. religion was found to be slightly associated with depression (p=0.049). with more christian and less muslim participants being depressed, the reason for this disparity could be slated for further studies. financial status was significantly associated with depression (p=0.009) as a high percentage of participants earning n100,000 or less were depressed and only a low percentage of those earning over n100,000 were depressed. this is consistent with the study of (aniebue, 2007). financial stability is essential to maintain a good health. patients under treatment are always advised to eat a balanced diet adequately and maintain healthy lifestyles. with financial hardship being experienced, patients may be unable to afford adequate balanced meals or lifestyles. the combination of poverty and a debilitating illness like tuberculosis could be responsible for depression among low-income earners. depression was also found to be associated with educational level (p=0.027). this study shows that more educated participants were more depressed. this is because a less educated person will not be exposed to more information about tb which can boost his morale and alter negative mindsets that may make him/her elapse into depression. the strength of this study lies in the fact that a standard phq-9 was used to extract information to determine and assess depression among the participants. the researchers were adequately trained before the study to collect accurate data during interviews with the participants, and the sincerity of the participants was commendable. this study is limited in the aspect of identifying the occupation of the respondents and determining the association between occupation, tb infection and depression. it was challenging to persuade respondents to wait because they were always in a rush to leave the center and go to work since the dots centers only schedule early morning clinics for tb patients on weekdays. prospect for further study is to determine knowledge, attitude and factors associated with depression in tb patients. conclusion tuberculosis is a chronic, debilitating disease with high morbidity and mortality, thus making coping with general life activities difficult. a tb patient’s inability to cope with the disease may influence his or her vulnerability to depression. acknowledgment special thanks to all the respondents who voluntarily participated in this study after 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(2023)b. osun state not taking its foot off the pedal in the fight against tuberculosis. who africa. pa ge 1 pa ge 43 american journal of medical science and innovation (ajmsi) therapeutic effect of n-hexane extract of zingiber officinale (ginger oil) on loperamide induced constipation in wistar rats aver m. yongu1, sunday a. ogli1*, george t. ugbudu1, moses t. ashiekaa1 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2452 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: february 27, 2024 accepted: march 29, 2024 published: april 03, 2024 constipation is a common gastrointestinal disorder that affects people of different ages, but is more common in elderly females. the disease has negative impact on the quality of life and can cause many complications including faecal incontinence, anal fissures, bowel perforation and bloating if not treated. this research was carried out to investigate the effect of n-hexane extract of zingiber officinale (ginger oil [go]) on loperamide-induced constipation in wistar rats. twenty four (24) wistar rats of both sexes were randomly separated into 6 groups (n=4). group 1 (control) received normal saline (ns) only, while groups 2 to 6 were treated with 4 mg/kg/day loperamide. after 1 hour of loperamide treatment, groups 2, 3, 4, 5 and 6 received 1 ml/kg/day ns, 100 mg/kg/day go (ldgo), 200 mg/kg/day go (mdgo), 400 mg/kg/day go (hdgo), and the standard drug bisacodyl (5 mg/kg/ day). all drugs were administered orally. daily faecal pellet counts, weight and water content were measured. intestinal transit of charcoal meal was determined while colon samples were harvested at sacrifice, homogenized and centrifuged. the supernatant was used to assay for sod and mda. colonic tissue was also analyzed for histological changes. the result showed that, compared to control, loperamide significantly decreased the number, weight and water content of faeces while go significantly increased all these parameters in a dose dependent manner. ginger oil also significantly increased intestinal transit ratio and the activity of sod but reduced mda relative to loperamide + ns. furthermore, histomorphology revealed that go treatment increased the number of mucus secreting goblet cells and the thickness of the colon mucosa relative to loperamide + ns treated rats. in conclusion, ginger oil ameliorated loperamide-induced constipation by increasing the faecal count, faecal water content and intestinal motility. furthermore, go showed protective effect on the colon through antioxidant activity while reducing lipid peroxidation and by also increasing the number of goblet cells and the mucosa thickness of the colon. keywords constipation, intestinal transit, antioxidant, zingiber officinale 1 department of physiology, faculty of basic medical sciences, college of health sciences, pmb 102119, benue state university, makurdi, nigeria * corresponding author’s e-mail: sogli41@gmail.com introduction the symptom or condition known as constipation is characterized by difficult and sporadic bowel motions, usually occurring three or less times each week. it is one of the most prevalent gastrointestinal issues in the western nations and frequently results in a patient being referred to gastroenterologists and colorectal surgeons. constipation is a common ailment that is sometimes overlooked until the patient experiences after effects, such as anorectal problems (peery et al., 2019; bharucha et al., 2020). various laxatives stool softeners as well as secretagogue and prokinetic drugs are used in the treatment of constipation (sharma & rao, 2017). unfortunately, these drugs/therapies may produce adverse reactions such as diarrhoea, abdominal pain, nausea, abdominal discomfort, flatulence and headache etc. treatment with traditional elements like extravirgin olive oil, coconut oil, sweet almond oil and ginger aqueous extract have been shown to alleviate symptoms of constipation (faghihi et al., 2021; abidi et al., 2022; faghihi et al., 2022). this necessitated this study on the therapeutic effect of n-hexane extract of zingiber officinale (ginger oil) on loperamide induced constipation in wistar rats. literature review constipation has a negative impact on the quality of life and can cause many complications including faecal incontinence, anal fissures, bowel perforation and bloating if not treated (tvistholm et al., 2017). low fibre intake, inactivity, decreased thirst sensation, low fluid intake, electrolyte disturbances, endocrine and metabolic disorders, neurological disorders, psychological disorders and medications (such as calcium channel blockers, opiate analgesic etc.) are implicated in constipation. other causes of constipation include the use of organic compounds such as morphine, stress, nutritional disorders, secretory dysfunction, gastrointestinal motility dysfunction and alterations in gastrointestinal innervation (park et al., 2016; adeniyi et al., 2020; diaz et al., 2023). various laxatives stool softeners as well as secretagogue and prokinetic drugs are used in the treatment of constipation (sharma & rao, 2017). there are issues of strong drug dependence, high recurrence rate, and high cost with the orthodox treatments which limit their application in individuals suffering from constipation. in addition, these drugs/therapies may produce adverse reactions such as diarrhoea, abdominal pain, nausea, abdominal discomfort, flatulence and headache etc. pa ge 44 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 43-50, 2024 studies have shown that treatment with traditional elements like extra-virgin olive oil, coconut oil, sweet almond oil and ginger aqueous extract have been shown to alleviate symptoms of constipation (faghihi et al., 2021; abidi et al., 2022; faghihi et al., 2022). zingiber officinale belongs to the zinberaceae family is a medicinal plant that has been widely used all over the world for various purposes. the plant is indigenous to warm tropical climates, particularly south eastern asia. as a result of its pungency, aroma, nutrients and pharmacological activities and neglible side effects, it is now widely cultivated in many countries like india, nigeria, jamaica, mexico, greece, and hawaii (kiyama, 2020; mohammed et al., 2022). the plant is widely used for variety of purposes. a review of the medicinal uses of ginger in health include blood pressure reduction (hasani et al., 2019), as a potent antioxidant (zhang et al., 2022), hepatoprotective effect (chuljerm et al., 2018), prevention and treatment of nausea and vomiting in pregnancy and after chemotherapy (palatty et al., 2013; chrichton et al., 2019), prevention of neurodegenerative diseases (arcusa et al., 2022), management of inflammatory diseases such as crohn’s disease, ulcerative colitis, rheumatoid arthritis and lupus erythematosus (ballester et al., 2022), reduction in blood sugar levels (hajimoosayi et al., 2020), as well as pain reducing effect (rondanelli et al., 2020). one of the forms of ginger preparation is ginger oil. the health benefits of ginger essential oil are identical to the medicinal health benefits of fresh ginger; in fact, the essential oil is stated as the most potent form of ginger (ugbabe et al., 2019). ginger oil was found to improve appetite and symptoms of anxiety, fatigue, nausea in cancer patients (williams et al., 2022). ginger oil is also used to relieve stomach ache (liju et al., 2015) and also found to be effective against rheumatic disease (barão paixão & freire de carvalho, 2021). ginger oil is an excellent dietary source of fibre, vitamin e (alpha tocopherol), vitamin b6, iron, manganese, potassium and selenium (imarc, 2023). ginger rhizomes are a good source of fatty oils (3-6%), proteins (9%), carbohydrates (60-70%), crude fiber (3-8%), ash (8%), water (9-12%), and volatile oil (2-3%) (mbaveng & kuete, 2017). in this study, a rat model of constipation was established by oral administration of loperamide. the therapeutic effects of nhexane extract of ginger on constipation were investigated. materials and methods animal procurement and care twenty four (24) wistar rats of 190g mean weight were purchased from the animal house college of health sciences, benue state university, makurdi. they were housed in the same facility, under an environmental temperature of 23 ± 2oc; humidity, 55 ± 15% and 12 h light/dark cycle. the rats were kept in wire-meshed cages for two weeks to allow for acclimatization before onset of the research, during which period they were fed with a standard rat chow (vital feeds, grand cereals ltd, jos, plateau state, nigeria) and water ad libitum and handled according to international guidelines for animal care (simmonds, 2018). fresh zingiber officinale rhizome (ginger root) was obtained from wurukum market, makurdi, benue state and certified by the botanist at botany department of benue state university makurdi. treatment preparation and administration ginger oil was prepared from mature ginger rhizomes by maceration method using n-hexane as solvent for the extraction according the method described by srivastava et al. (2021). constipation was induced with loperamide (lp) at a dosage of 4mg/kg/day (adeniyi et al., 2020). three groups from the constipated animal models were given n-hexane extract of ginger (ginger oil) at various doses after one 1 hour of pre-treatment with loperamide (lim et al., 2019). the protocol for treatment was as follows: • group 1(control): oral administration of 1ml physiological saline • group 2: oral intake of 1ml physiological saline with loperamide at 4mg/kgbw daily • group 3: oral 100mg/kgbw ginger oil (go) and 4mg/kgbw loperamide daily group 4: oral go at 200mg/kgbw and 4mg/kgbw loperamide daily • group 5: oral go at 400mg/kgbw and 4mg/kgbw loperamide daily • group 6: oral bisacodyl at 5mg/kgbw and 4mg/ kgbw loperamide daily animals were weighed daily before treatment throughout the study. faecal pellets were collected from each animal daily, weighed to obtain the wet weight, then air dryed for 7 days and re-weighed to obtain the dry weight. the water content of the faecal pellets was thereafter estimated according to lim et al (2019) as follows; faecal water content (%)=[(wet weight of feces -dry weight of feces)g]/wet weight x100 specimen and analysis/examination the animals were fasted overnight after the treatment and each animal given their treatment accordingly. thereafter, they were fed with charcoal meal at 1ml orally and sacrificed by cervical dislocation 30minuts later. the intestines were harvested for determination of intestinal transit of the charcoal meal (choi et al., 2014) using the calculation; charcoal transit ratio (%) = [total distance traveled by charcoal meal/total small intestine length] × 100. colonic samples were collected into various sterile bottles containing physiological saline and 10% formaldehyde. the tissue samples in the phosphate buffer were stored at less than 4°c. superoxide dismutase (sod) level in the colon homogenates was determined by spectrophotometry method based on the inhibition pa ge 45 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 43-50, 2024 of the reduction of nitroblue tetrazolium (nbt). tissue supernatant was mixed with 0.1 mol/l of ethylenediaminetetraacetic acid (edta), 0.15 mg/ml of sodium cyanide, 1.5 mmol/l of nbt, 0.12 mmol/l of riboflavin, and 0.067 mol/l of phosphate buffer in a 300 μl volume. the sample absorbance was read at 560 nm, and the percentage of sod inhibition was compared with that of the blank. the concentration of the sample was calculated using the amount of protein required to achieve 50% inhibition and expressed as u/ mg of protein (tan et al., 2015) malondiadehyde (mda) is a major secondary product of lipid peroxidation was determined spectrophotometrically by measuring the thiobarbituric acid (tba) reaction (tang et al., 2019). each 500 μl of colon homogenate supernatant had 1 ml of 15% trichloroacetic acid added thoroughly mixed and centrifuged at 3000 rpm for 10 minutes. one milliliter of the supernatant was added to 0.5 ml of 0.7% tba then the mixture was heated for 60 min at 90 °c. the pink color was obtained, which was measured spectrophotometrically at 532 nm. the results were expressed as micromoles per gram of protein. histological analysis colonic tissue slides were prepared at the anatomical department of benue state university teaching hospital by the pathologist and analysed for changes in mucous secretions and colonic mucosa thickness using alcian blue and h&e stains. the goblet cells in 0.2 mm2 of the mucosa tunic of all slides were quantified and mucosal wall thickness determined through direct measurement from microscopic visualization. all measurements were carried out using a motic b5 optical microscope and digital camera (moticam 2000, 2.0 m pixel) as previously reported (wu et al., 2019). statistical analysis results of this work were presented as mean ± sem (n=4). differences between the group means were determined using one-way analysis of variance (anova) with turkey post hoc test. data analysis was done using ibm spss version 22.0 software (inc, armonk, ny, usa). differences were considered statistically significant when p < 0.05. ethical clearance institutional ethical clearance and certification (no crec/res/003) was obtained from the research and ethics committee of college of health sciences, benue state university, makurdi. results and discussion results result of the effect of ginger oil treatment on faecal pellet output is presented in table 1 below. it was observed in this study that ginger oil (go) at various dosages increased faecal pellet output in loperamide induced constipation on a dose dependent basis. this action of go is comparable to the effect of bisacodyl, the standard drug. this implies that go improves faecal outlet in constipations. effect of go on faecal water content is presented in table 2. it was observed faecal weights (wet and dry) and water content were increased in groups treated with go in a dose dependent. in the hdgo group, the faecal water content is not significantly different from that of the control and lp + bisacodyl groups implying that hdgo potentially restores faecal water content in constipation. table 1: effect of ginger oil on faecal pellet output group day 1 day2 day3 day4 conrol 24.35±2.33 33.67±0.88 40.00±1.15 45.35±1.30 lp +ps 18.00±0.58 11.35±0.67a 10.33±0.33a 8.35±0.67a lp+ ldgo 19.00±1.53 15.00±0.58a 17.33±0.67a 19.67±0.33ab lp+mdgo 21.67±0.88 23.67±0.88ab 22.68±1.76a 29.66±3.00ab lp+hdgo 23.00±1.5 27.32±1.45ab 35.32±6.49b 41.00±1.53b lp+bisacodyl 20.94±0.70 27.33±1.44ab 33.33±2.84b 37.67±3.71b data presented as mean ± sem (n=24). values in same column with alphabets are significantly different (p < 0.05). lp= loperamide, ps = physiological saline ldgo = low dose ginger oil, mdgo = medium dose of ginger oil, hdgo = high dose ginger oil table 2: effect of ginger oil on faecal water content (%) groups day 1 day 2 day 3 day 4 control 31.20±1.16 23.63±1.34 32.22±1.11 37.30±1.79 lp + ps 19.76±0.85a 14.63±1.85 13.11±4.11 15.42±1.22a lp + ldgo 19.20±2.01a 19.88±1.21 22.60±1.81b 23.74±1.26b lp + mdgo 19.08±0.53a 21.30±0.13 32.33±1.6b 33.13±1.43b lp + hdgo 21.76±0.76 22.59±9.16 33.99±6.17b 31.31±1.01b pa ge 46 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 43-50, 2024 table 3 shows the effect of treatments on intestinal transit ratio. the intestinal charcoal transit ratio (itr) was increased in a dose dependent manner in the groups treated with go at 61.79±1.00%, which though not statistically different from those of control and lp + bisacodyl groups, was numerically higher than all the groups. this implies that go potentially improve gut emptying in state of constipation. on colonic oxidative stress, the effect of treatments is presented in table 4. it was observed that sod activity significantly increased on dose dependent basis with go treatment (29.65±0.45µ/mg protein) compared to control and lp + bisacodyl groups at 25.5±0.46 and 24.84±0.84 µ/mg protein respectively. lipid peroxidation on the other hand decreased under the same treatment conditions. this implies that go reduces gut oxidative stress and lipid peroxidation in constipated gut. effect of go treatments on colon histology are shown in table 5 and plate 1. the result showed that go treatment statistically, but marginally, increase the thickness of the colonic wall as well and its mucosa in constipated rats. thus, go could potentially heal constipation associated colonic tissue injuries. lp + bisacodyl 30.71±1.56a 31.54±1.96ab 33.59±1.71b 35.25±0.59ab data presented as mean ± sem (n=24). values in same column with alphabets are significantly different (p < 0.05). lp= loperamide, ps = physiological saline ldgo = low dose ginger oil, mdgo = medium dose of ginger oil, hdgo = high dose ginger oil. table 3: effect of ginger oil on intestinal transit ratio (%) groups total length of intestine distance travelled by charcoal intestinal charcoal transit ratio (%) control 105.17±25.58 47.17±1.93 57.25±3.15 loperamide + ps 96.23±7.75 60.93±4.95a 27.10±1.19a lp + ldgo 105.33±2.62 53.00±1.59 49.61±1.81b lp + mdgo 100.32±10.08 41.50±6.05b 59.05±2.04b lp + hdgo 104.07±8.56 39.93±4.23b 61.79±1.00b lp + bisacodyl 100.47±2.82 47.10±3.14b 53.05±3.06b data presented as mean ± sem (n=24). values in same column with alphabets are significantly different (p < 0.05). lp= loperamide, ps = physiological saline ldgo = low dose ginger oil, mdgo = medium dose of ginger oil, hdgo = high dose ginger oil table 4: effect of ginger oil on colonic oxidative stress group sod (u/mg protein) mda (nmol/g protein) control 25.5±0.46 2.33±0.63 lpoperamide+ps 19.85±0.38a 4.05±0.22a lp+ldgo 26.03±1.43b 2.1 ±0.15b lp+mdgo 29.00±0.52ab 1.92±10.75b lp+hdgo 29.65±0.45ab 1.63 ±0.22b lp+bisacodyl 24.84±0.84a 1.93±0.14a data presented as mean ± sem (n=24). values in same column with alphabets are significantly different (p < 0.05). lp= loperamide, ps = physiological saline, ldgo = low dose ginger oil, mdgo = medium dose of ginger oil, hdgo = high dose ginger oil. table 5: effect of ginger oil on colon histology group number of goblet cells (h&e) number of goblet cells (ab) total wall thickness(µm) mucosa tunic (µm) control 3.05 ±2.89 3.93± 2.03 9.73 ±2.03 1.55 ±2.91 lp+ps 2.36 ±3.48a 3.06 ±1.76a 9.11 ±2.33a 1.25 ±2.91a lp+ldgo 2.95 ±2.91b 3.23 ±1.76b 10.12 ±1.67ab 1.27 ±1.76a lp+mdgo 3.09 ±2.81b 3.52 ±2.33b 9.85 ±2.91ab 1.98 ±3.76ab lp+hdgo 3.24 ±2.31ab 3.34 ±2.60b 10.21 ±2.08ab 1.39 ±1.76b lp+bisacodyl 3.52 ±1.15ab 4 36 ±2.96b 10.44 ±2.96ab 2.01 ±2.31ab data presented as mean ± sem (n=24). values in same column with alphabets are significantly different (p < 0.05). values in same column with alphabets are significantly different (p < 0.05). lp= loperamide, ps = physiological saline, ldgo = low dose ginger oil, mdgo = medium dose of ginger oil, hdgo = high dose ginger oil. pa ge 47 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 43-50, 2024 discussion constipation is common gastrointestinal condition that has a global interest due to its long-term complications as well as its impact on the quality of life (turan & atabek, 2016). the aetiology of constipation is multifactorial ranging from dietary factors, medications to organic diseases, necessitating the use of laxatives, which often have unpleasant side effects. therapeutic focus has naturally shifted to traditional medicine in bid for safer, cheaper but effective alternatives and thus the need for this research. in order to evaluate the potential laxative effects of n-hexane extract of zingiber officinale (ginger oil), the changes in faecal parameters (i.e. pellet count, wet/dry weight and water content), gastrointestinal transit ratio (motility), and colonic mucosa histology (i.e., mean colonic mucosa thickness and number of colonic mucousproducing cells) were examined in loperamideinduced rats, a suitable animal model of spastic constipation (choi et al., 2014a, b). the laxative effects of ginger oil were compared with a standard drug bisacodyl. the protective effects of ginger oil were also determined by analysis of its effect on colonic oxidative stress. the faecal pellet output was significantly lower in the loperamide group compared to vehicle control indicating that rats were constipated. faecal pellet output in the different dosages of ginger oil (100mg/kg, 200mg/kg and 400mg/kg) treated rats was significantly increased compared to loperamide control, with the faecal pellet output being significantly higher at 400mg/kg similar to bisacodyl treated group showing that ginger oil was able to relieve the effect of constipation caused by loperamide. this result is similar to that of previous studies and is thought to be as a result of the gi prokinetic and relaxing actions of ginger which are mediated by calcium antagonism and cholinergic agonist, respectively. (abidi et al., 2022; foshati et al., 2023). result showed that treatment with loperamide significantly decreased the weight of wet and dry fecal pellets relative to the control. however, the wet and dry weights were increased in rats co-administered 400mg/ kg ginger oil compared to loperamide group, similar to the effect observed in bisacodyl. the faecal water content was significantly decreased in loperamide group compared to vehicle control. however, there was a dosedependent significant increase in the faecal water content with a progressive effect noted as the duration of treatment increased. the ginger oil was more effective at the highest dose (400mg/kg). bisacodyl also showed significant (p < 0.05) increase in faecal water content relative to loperamide group. the increase in faecal water content caused by ginger oil may be as a result of its high fibre content which promotes faecal water retention and increase in water secretion thereby promoting peristalsis suggesting that ginger oil has promising laxative properties as observed in previous studies (mcrorie & mckeown, 2017; zhang et al., 2020). the intestinal transit ratio (itr), a marker of intestinal motility, of the loperamide constipated model was significantly decreased compared to the control group, consistent with signs of spastic constipation (choi et al., 2014a, b). ginger oil at varying doses showed significantly increased itr compared to loperamide model in a dose dependent manner with 400mg/kg having greater effect provide indirect evidence that ginger oil has promising laxative effects against loperamide-induced spastic constipation. this is consistent with previous studies (abidi et al., 2022). bisacodyl showed similar effects on itr as ginger oil with no significant difference between the treatment groups. the effect of ginger oil on colonic oxidative stress was assessed and the results showed that superoxide dismutase (sod) activity in loperamide group was significantly decreased compared to control. sod activity figure 1: plate 1. histological view of colon section (4x) stained by haematoxylin and eosin (h&e) and aacian blue showing mucous producing (goblet) cells and colonic mucosa thickness. a=group 1, b=group 2, c=group 3, d=group 4, e=group 5, f=group 6 pa ge 48 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 43-50, 2024 was significantly increased in the ginger oil treated groups in a dose dependent manner. however, bisacodyl was not significantly different compared to loperamide. furthermore, lipid peroxidation was increased in loperamide group compared to control but decreased significantly in the ginger oil co-treated groups compared to loperamide in a dose dependent manner. as previously stated by zhanl et al. (2021), the inhibition of gimotility and intestinal secretion induced by loperamide is accompanied by the increase in plasma and colonic lipid peroxidation and decrease of enzymatic antioxidant activity. also, the antioxidant effect of ginger oil seen in sod and lipid peroxidation is comparable to previous studies (zhang et al., 2017; joshi et al., 2017) and its lipid peroxidation reduction is considered due to polyphenolic components such as flavonoids (quercetin, kaempferol, apigenin, and luteolin) which are capable of reducing free radical chains through electron and proton transfer and chelating transition metal ions capable of catalysing lipid peroxidation. the antioxidant properties may also be traced to the polysaccharides in ginger which cause a reduction in dpph radical, hydroxyl and superoxide radicals (hefnawy, 2016). colonic mucosa analysis showed significant decrease in mucous producing cells and mean mucosa thickness in the loperamide constipated group compared with vehicle control. however, significant increases in the number mucous producing cells and mean colonic mucosa thickness was observed with ginger oil treated groups compared with loperamide treated animals. in comparison to the vehicle control, ginger oil showed the maintenance of mucosa thickness integrity and also increased mucous secretions thus been protective against the effects of constipation. this is similar to previous studies and may be as a result of a reduction in inflammatory factors and antioxidant activity of the phenolic compounds in ginger (zhang et al., 2018; abidi et al (2022). conclusion this research has shown that n-hexane extract of zingiber officinale (ginger oil) has a potential laxative effect in a dose dependent manner with 400mg/kg being most effective which is comparable to that obtained in bisacodyl. the laxative properties were demonstrated by increasing faecal pellet output and intestinal transit time as well as increasing the faecal water content in loperamide constipated rat models. ginger oil has also shown to have antioxidant by increasing sod activity and reducing lipid peroxidation. references abidi, c., rtibi, k., boutahiri, s., tounsi, h., abdellaoui, a., wahabi, s., gressier, b., eto, b., & sebai, h. 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(2022). essential oils of zingiber officinale: chemical composition, in vivo alleviation effects on tpa induced ear swelling in mice and in vitro bioactivities. frontiers in nutrition, 9, 1043175. https://doi.org/10.3389/ fnut.2022.1043175. pa ge 1 pa ge 46 american journal of medical science and innovation (ajmsi) understanding covid-19 pandemic, impaired smelling (anosmia) incidence and outcome among patients in dubai: retrospective study fateh almohammad alsalem1* volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.2979 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 02, 2024 accepted: september 04, 2024 published: february 08, 2025 the onset of anosmia, or temporary loss of smell, has emerged as a prominent neurological manifestation and an early indicator of covid-19 infection. this retrospective study, conducted by the dubai health authority (dha) staff at the dha covid-19 command & control center in dubai – uae, from may to july 2020, aimed to investigate the prevalence and characteristics of anosmia in covid-19 patients. a total of 1075 patients were enrolled in the study, comprising 878 males (81.4%) and 201 females (18.6%). the median age ranged from 31 to 40 years. patients with anosmia were compared to those without, with a particular focus on gender disparities and associated comorbidities, including diabetes, hypertension, heart disease, lung disease, and thyroid disease. the study found that 22% of covid-19 patients presented with anosmia, the initial symptom in 47% of cases. notably, 95% of patients experiencing anosmia recovered within two months. while there was no significant correlation between anosmia and comorbidities, such as diabetes, hypertension, heart disease, lung disease, and thyroid disease, there was also no association observed between anosmia and other common covid-19 symptoms, such as fever, cough, shortness of breath, and diarrhoea. anosmia, occurring in approximately 22% of covid-19 cases, is a noteworthy early indicator of the infection. despite its prevalence, anosmia has no significant correlation with comorbidities or other symptomatic manifestations of covid-19, which underscores the importance of recognising anosmia as a distinct clinical feature in diagnosing and managing covid-19. keywords anosmia, covid-19, prevalence, comorbidities, symptoms 1 ent department, dubai hospital, dubai, uae * corresponding author’s e-mail: drfatehsalem@gmail.com introduction the covid-19 pandemic, stemming from the novel coronavirus (sars-cov-2), has presented an unprecedented global health crisis since its emergence in december 2019. alongside its well-documented respiratory manifestations, covid-19 has exhibited a spectrum of symptoms, ranging from mild to severe, with some patients experiencing atypical presentations. among these symptoms, anosmia, or the temporary loss of smell, has emerged as a distinctive feature, prompting further investigation into its prevalence, pathophysiology, and clinical implications (pollard et al., 2020). anosmia following viral infections, often called postviral olfactory loss, has been recognised in various viral illnesses, including influenza and coronaviruses such as hcov-229e. in covid-19, anosmia has gained considerable attention due to its frequency and potential diagnostic utility (rebholz et al., 2020). previous literature has suggested that anosmia may precede other hallmark symptoms of covid-19, such as fever and cough, and may persist as the sole manifestation of the disease in some individuals; this unique association underscores the importance of understanding the mechanisms underlying anosmia in covid-19 patients (daher et al., 2020). recent investigations have shed light on potential mechanisms contributing to anosmia in covid-19. notably, the presence of angiotensin-converting enzyme 2 (ace2) receptors in nasal epithelial cells has been implicated in facilitating viral entry and replication (beyerstedt et al., 2021). the nasal cavity serves as an accessible site for viral invasion, raising questions about the direct effects of sars-cov-2 on olfactory neurons and supporting cells. additionally, the inflammatory response triggered by viral infection may contribute to olfactory dysfunction through mechanisms such as neuroinflammation and cytokine release (othman et al., 2022). moreover, emerging evidence suggests that the pathophysiology of anosmia in covid-19 may differ from that of other viral etiologies. unlike anosmia caused by viruses that directly damage the neural epithelium, such as certain coronaviruses, covid-19-induced anosmia appears to exhibit a more transient course, with many patients experiencing spontaneous recovery within weeks. this distinction underscores the need for further research to elucidate the mechanisms underlying anosmia in covid-19 and its implications for disease prognosis and management (butowt & von bartheld, 2021). this study aims to investigate the incidence, prevalence, and outcomes of anosmia among patients diagnosed with covid-19 in dubai, uae. additionally, the study seeks to establish the time of onset and duration of symptoms related to the loss of smell and taste in covid-19 patients. by examining these factors, the study aims to contribute to a deeper understanding of the clinical presentation and course of covid-19 in the context of anosmia, thereby informing diagnostic and management strategies for affected individuals in dubai and potentially beyond. pa ge 47 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 46-52, 2025 anosmia, defined as the temporary or permanent loss of smell, has emerged as a distinctive symptom of covid-19 caused by the novel coronavirus, sars-cov-2. this phenomenon has garnered significant attention due to its high prevalence and potential diagnostic value in identifying covid-19 cases (ahmed et al., 2022). understanding the epidemiology, pathophysiology, and clinical implications of anosmia in covid-19 is crucial for effective disease management and control efforts. anosmia has been reported as one of the earliest and most common symptoms of covid-19, often occurring before the onset of other respiratory symptoms (aanand et al., 2022). a study by altundağ et al. (2020) has indicated that anosmia may affect up to 80% of covid-19 patients with varying degrees of severity (altundag et al., 2021). the prevalence of anosmia appears to run across different populations and geographic regions, highlighting the need for comprehensive epidemiological studies to elucidate its global burden. anosmia has been proposed as a potential predictor of covid-19 infection, prompting individuals to seek testing and medical care. several studies have suggested that anosmia may precede the onset of other symptoms, such as fever and cough, making it a valuable clinical marker for early detection of covid-19 cases (avcı et al., 2020; talavera et al., 2020). including anosmia in covid-19 screening protocols has been advocated to improve case identification and facilitate timely intervention. the underlying mechanisms of anosmia in covid-19 are not fully understood but are thought to involve viral-induced damage to the olfactory epithelium. sars-cov-2 has been shown to infect cells expressing angiotensin-converting enzyme 2 (ace2) receptors, which are abundant in the nasal cavity (de melo et al., 2021). viral invasion of nasal epithelial cells may lead to inflammation, neuronal injury, and disruption of olfactory signalling pathways, resulting in anosmia. however, the exact pathophysiological mechanisms require further investigation. in several aspects, anosmia in covid-19 appears to differ from anosmia caused by other viral infections. unlike some viruses that directly damage neural epithelium, such as certain strains of coronaviruses, covid-19-induced anosmia is characterised by a relatively rapid onset and recovery (glezer et al., 2021). additionally, covid-19 patients frequently report anosmia without accompanying nasal congestion or obstruction, distinguishing it from other causes of olfactory dysfunction. anosmia in covid-19 patients has been associated with distinct clinical features and outcomes. studies have indicated that covid-19-induced anosmia tends to resolve spontaneously within a few weeks to months in most cases (talavera et al., 2020). however, the duration of anosmia can vary widely among individuals, with some patients experiencing persistent or recurrent symptoms. despite its transient nature, anosmia can significantly impact quality of life and may contribute to long-term sequelae in some cases. recognising anosmia as a prominent symptom of covid-19 has important implications for disease management and control efforts. anosmia should be considered in the clinical evaluation of suspected covid-19 cases, particularly in the absence of other respiratory symptoms. early detection of anosmia can facilitate prompt isolation, testing, and contact tracing, helping to limit the spread of the virus within communities (shamsundara & jayalakshmi, 2023). moreover, including anosmia in covid-19 screening protocols may improve the accuracy of case identification and enhance the effectiveness of public health interventions. materials and methods study setting this retrospective study was conducted at the covid-19 command & control center (ccc) under the auspices of the dubai health authority (dha) in dubai, united arab emirates (uae). the study period spanned from may to july 2020. sample size and data source the study included 1079 cases, and data were retrieved from patient records stored in the dha’s digital files system, salama: electronic files system. exclusion criteria patients were excluded from the study if they met any of the following criteria: individuals below 18 years old or above 60 years old, pregnant women, immunocompromised patients receiving immune suppressive medications, patients with physical disabilities, individuals managed by healthcare institutes other than the ccc, patients residing outside the emirate of dubai, and those with mental or psychological disorders. patients already admitted to the hospital via the emergency department were also excluded. data collection a standardised investigation tool was utilised for data collection, encompassing various parameters such as age, smoking status, body mass index (bmi), presence of comorbidities, symptoms, presence of local nasal pathology, presence of loss of taste, onset of loss of smell, and duration of loss of smell. study execution the study was conducted by dha staff members stationed at the dha covid-19 command & control center in dubai, uae. data collection was facilitated through telephonic encounters with the study participants. the study sample was randomly selected to ensure patient confidentiality, and no personal identifying information was included in the study dataset. verbal consent was obtained from all participants before data collection, per ethical guidelines. pa ge 48 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 46-52, 2025 statistical analysis data analysis was performed using appropriate statistical methods, including descriptive statistics, to summarise the demographic and clinical characteristics of the study population. if deemed appropriate, inferential statistics may be employed to assess associations between variables. ethical considerations all procedures were conducted according to ethical principles outlined in the declaration of helsinki and other applicable guidelines. patient confidentiality and privacy were strictly maintained throughout the study. informed consent was obtained from participants. results all variables, including the percentage, correlation, coefficient of determination, and p-value, were evaluated using spss after all data had been analysed using standard descriptive statistics. a total of 1079 patients—878 males (81.3%) and 201 females (18.7%)—were included in the study as positive cases. the correlation coefficients observed in the analysis exhibit a negligible magnitude, with values approaching zero, indicating an absence of substantial linear relationships between the variables under scrutiny. concurrently, the determination coefficients, indicative of the proportion of variability in one variable that another can explain, approach insignificance. however, the confidence level exceeds 99%, underscoring a high degree of reliability in the findings. moreover, the p-values, which signify the probability of obtaining results as extreme as those observed, are consistently greater than 0.05 across all analysed factors. these collective findings suggest that variables such as gender, smoking habits, diabetes, hypertension, lung disease, heart disease, thyroid disorders, malignancy, and pregnancy are associated with the loss of olfactory function, as elucidated in table 1. table 1: correlation between loss of smell and comorbidities frequency (percent) frequency loss of smell (percent) correlation r coefficient of determination r square p value. gender male 878 (81.4) 177 (20.2) x2 (3, n = 126) = 10.1, p = .017. .015 .000 female 201 (18.6) 67 (33.3) smoking no 928 (86.0) 211 (22.7) .007 .000 .810 yes 151 (14.0) 33 (21.9) diabetes no 1013 (93.9) 228 (22.5) .010a .000 .744 yes 66 (6.1) 16 (24.2) hypertension no 986 (91.4) 223 (22.6) .000 .000 .994 yes 93 (8.6) 21 (22.6) lung disease no 1068 (99.0) 240 (22.5) .033 .001 .274 yes 11 (1.0) 4 (36.4) heart disease no 1067 (98.9) 242 (22.7) .015 .000 .621 yes 12 (1.1) 2 (16.7) thyroid disease no 1058 (98.1) 240 (22.7) .012 .000 .694 yes 21 (1.9) 4 (19.9) malignancy no 1075 (99.6) 241 (22.4) .076 .006 .012 yes 4 (.4) 3(75) pregnancy no 1074 (99.5) 241 (22.4) .061 .004 .045 yes 5 (.5) 3 (60) the observation regarding loss of taste is noteworthy that a correlation coefficient of 0.584 and a determination coefficient of 0.341 were observed in the context of loss of taste and loss of smell, suggesting a potential association of these symptoms with approximately 34.1% of covid-19 cases. despite these coefficients indicating a moderate relationship, they denote a modest explanatory power regarding the variability observed. furthermore, the confidence level exceeds 99%, indicating a high degree of certainty in the observed results. importantly, all p-values associated with the analysed variables are below 0.05, underscoring their statistical significance, as shown in table 2. pa ge 49 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 46-52, 2025 in examining age groups, no discernible discrepancies in percentages were observed. the correlation coefficient, approaching insignificance, and a determination coefficient close to zero suggest a negligible association between age and the incidence of loss of smell, with a confidence level exceeding 99% and a p-value of 0.924, as outlined in table 3. nearly all patients who reported experiencing loss of table 2: correlation between loss of smell and other covid symptoms frequency (percent) frequency loss of smell (percent) correlation r coefficient of determination r square p value. asymptomatic no 598 (55.4) 198 (33.1) .280 .078 .000 yes 481 (44.6) 46 (9.6) loss of taste no 831 (77.0) 77 (9.3) .584 .341 .000 yes 248 (23.0) 167 (67.3) sore throat no 937 (86.8) 185 (19.7) .176 .031 .000 yes 142 (13.2) 59 (41.5) fever no 721 (66.8) 100 (13.9) .297 .088 .000 yes 358 (33.2) 144 (30.2) cough no 790 (73.2) 138 (17.5) .203 .041 .000 yes 289 (26.8) 106 (36.7) difficult breathing no 981 (90.9) 208 (21.2) .107 .011 .000 yes 98 (9.1) 36 (36.7 diarrhea no 990 (91.8) 204 (20.6) .160a .026 .000 yes 89 (8.2) 40 (45) table 3: distribution of patients according to age groups frequency (percent) frequency loss of smell (percent) correlation r coefficient of determination r squire p value sig. age from 1 to 10 4 (.4) 0 (0) .003 .000 .924 from 11 to 20 21 (1.9) 5 (23.8) from 21 to 30 337 (31.2) 78 (23.2) from 31 to 40 441 (40.9) 97 (22) from 41 to 50 192 (17.8) 45 (23.4) from 51 to 60 72 (6.7) 17 (23.4) more 60 12 (1.1) 2 (16.7) smell subsequently recovered, constituting approximately 95% of cases. additionally, it is observed that about 47% of patients identified loss of smell as their initial symptom of covid-19, as depicted in table 4. table 5 displays the distribution of durations in days associated with loss of smell among the study population. varied durations are evident, with a majority experiencing symptoms for shorter periods. notably, the highest frequency occurs within the seven-day range, constituting 3.7% of cases, as depicted in table 5. table 4: loss of smell and other parameters before swab, before other symptoms and outcomes loss of smell frequency (percent) swab test before 133 (54.5) after 111 (45.5) other symptoms no 34 (14.3) before 114 (47.9) after 90 (37.8) the outcome of loss of smell cured 233 (95.5) impaired 11 (4.5) pa ge 50 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 46-52, 2025 discussion the global spread of covid-19 has presented a spectrum of manifestations ranging from mild flu-like symptoms to severe pneumonia. notably, alterations in olfactory and gustatory senses have emerged as prominent indicators of infection with the novel coronavirus. this assertion is substantiated by the prevalence of anosmia and ageusia exceeding 22% among covid-19 patients (mastrangelo et al., 2021). however, while these sensory changes serve as crucial diagnostic markers, the precise onset and duration of such symptoms remain to be definitively established. comprehensive quantification of loss of smell and taste and a clear understanding of their temporal relationship with covid-19 holds significant promise in facilitating early diagnosis, thus mitigating further transmission and potential complications associated with the disease. in our study encompassing 1075 patients, males constituted the majority at 81.4%, with females comprising 18.6% of the cohort. the median age fell within the 31 to 40-year range. notably, individuals experiencing loss of smell tended to be younger than those without this symptom. furthermore, our findings indicate that 33.3% of female and 20% of male cases reported insomnia. interestingly, nearly half of the patients (47.3%) noted the onset of anosmia preceding other covid-19 symptoms, while 14.3% experienced it concurrently with different manifestations, and 37.8% reported its occurrence after other symptoms. additionally, a notable proportion (9.6%) of individuals reported anosmia as their sole symptom associated with covid-19. these findings collectively underscore the importance of recognising and understanding the temporal dynamics of olfactory and gustatory dysfunctions in covid-19, thereby aiding in more effective disease management and control efforts. in our investigation, we examined the correlation coefficients, determination coefficients (r square), and significance levels, alongside percentages, about several variables, including smoking, diabetes, hypertension, heart disease, lung disease, thyroid disease, malignancy, and anosmia among covid-19 patients. additionally, we explored the potential associations between other symptoms—sore throat, fever, cough, difficulty breathing, and diarrhoea—and anosmia. despite the importance of comorbidities in predicting disease severity, our study did not reveal significant correlations between covid-19 and various factors, including age, gender, smoking, heart disease, diabetes, hypertension, lung disease, thyroid disease, and malignancy. notably, while some associations were observed, such as between loss of smell and taste, the overall correlations between anosmia and other symptoms were weak. for instance, the correlation and determination coefficients for sore throat, fever, cough, difficulty breathing, and diarrhoea were modest. these findings underscore the need for further research to comprehensively elucidate the relationship between anosmia and covid-19 symptoms, especially regarding disease prognosis and management. in our analysis of the asymptomatic group, we observed that 33.1% of patients exhibited anosmia, albeit with a coefficient factor of 0.280 and r square of 0.07, indicating that 7.8% of asymptomatic individuals experienced this symptom, based on a robust sample size of 481 patients, which suggests that anosmia may be overlooked compared to more severe symptoms, such as breathing difficulty and fever, as patients and healthcare workers tend to prioritise these more acute manifestations. regarding the duration of anosmia, the median range spanned 3 to 10 days, with 95% of patients (233 individuals) reporting recovery by the study’s conclusion. however, 5% of patients (11 individuals) had yet to recover, warranting further investigation and follow-up. importantly, we investigated whether anosmia preceded or followed other symptoms, finding that 47% of cases occurred before other symptoms, 37% after, and 14.3% concurrently. this distinction may aid healthcare workers in predicting diagnoses and curbing infection transmission. our study aligns with the study of hopkins et al. (2020), which comprised 2428 male and female adults, predominantly women (73%) and individuals under 40 (64%) (hopkins et al., 2020). the study, conducted in london, uk, reported varying onset times for anosmia, with 13% occurring before other symptoms, 38.4% simultaneously, and 48.6% after. symptoms persisted for table 5: loss of smell and duration days frequency (percent) 1.00 3 (.3) 2.00 15 (1.4) 3.00 30 (2.8) 4.00 27 (2.5) 5.00 37 (3.4) 6.00 8 (.7) 7.00 40 (3.7) 8.00 11 (1.0) 9.00 4 (.4) 10.00 21 (1).9 11.00 1 (.1) 12.00 5 (.5) 13.00 1 (.1) 14.00 15 (1.4) 15.00 4 (.4) 16.00 1 (.1) 17.00 1 (.1) 20.00 5 (.5) 21.00 1 (.1) 25.00 1 (.1) 30.00 4 (.4) 49.00 1 (.1) 60.00 2 (.2) pa ge 51 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 46-52, 2025 1 to 4 weeks, showing significant improvement within the initial 2 weeks. a majority (74.4%) experienced a complete loss of smell, while 17.3% reported severe loss. notably, 90% noted a reduction in taste, but 61% could still discern basic flavours. additionally, 17% said no other covid-19 symptoms, while cough or fever was prevalent in 51% of cases with additional symptoms. in our study of 1075 patients, with a male predominance (81.4%), the median age ranged from 31 to 40 years. anosmia was more common in younger patients, and insomnia was noted in 33.3% of females and 20% of males. similarly, anosmia onset varied, with 47.3% preceding other symptoms, 14.3% concurrent, and 37.8% subsequent, with 9.6% reporting no other associated symptoms. comparing our study with spinato et al. (2020), which included 202 male and female adults with an average age of 56 years in italy, notable similarities and differences emerge (spinato et al., 2020). in both studies, anosmia or loss of taste exhibited varied onset times relative to other symptoms, with comparable proportions reported before, during, and after other manifestations. specifically, 11.9% experienced symptoms before, 22.8% concurrently, and 26.7% afterwards, with 3.0% presenting with anosmia or loss of taste as the sole symptom. in our study of 1075 patients, predominantly male (81.4%), similar patterns were observed, with 47.3% experiencing anosmia before other symptoms, 14.3% concurrently, and 37.8% afterwards, with 9.6% reporting no other associated symptoms. notably, our findings diverge in the presence of nasal obstruction, as reported by 34.6% of individuals with altered sense of smell or taste in spinato et al. in contrast, our study did not find a correlation with insomnia. furthermore, our study encompassed a larger sample size and investigated the impact of comorbidities, which needed to be explored in previous research. compared to lechien et al. (2020)a, which involved 1420 individuals aged over 15 years, male and female, our study presents notable similarities and distinctions (lechien, chiesa-estomba, place, et al., 2020). while our research focused on a specific demographic, encompassing 1075 patients, predominantly males (81.4%), lechien et al. (2020) examined a larger cohort with a more balanced gender distribution (458 men and 962 women) and a slightly older average age of 39.17 years. furthermore, their multicenter european study, conducted across various regions, including france, italy, spain, belgium, and switzerland, provided a broader geographical perspective compared to our single-centre investigation. interestingly, both studies highlighted the prolonged duration of symptoms among covid-19 patients, with lechien et al. reporting an average duration of 11.5 ± 5.7 days for mild to moderate cases and noting that loss of smell persisted for at least 7 days post-recovery in 37.5% of patients, mirroring findings in our study. these similarities underscore the consistency of observations regarding the persistence of anosmia in covid-19 patients across different populations and settings (lechien, chiesa-estomba, place, et al., 2020). the prevalence of loss of smell appeared higher among women, with younger patients exhibiting a greater propensity for this symptom, as observed in our study of 1075 patients in dubai compared to a multicenter study in europe by lechien et al. (2020)b, while our research indicated that 70.2% of individuals experience loss of smell and 54.2% experience loss of taste, the european research reported different percentages. in our cohort, comprising 81.4% males and 18.6% females with a median age of 31 to 40, anosmia was more common among younger patients. notably, 47.3% of our patients reported anosmia preceding other symptoms, 14.3% occurring concurrently, and 37.8% following, with 9.6% reporting no other associated symptoms. although similarities were noted in age group findings, discrepancies emerged in the total percentage of individuals experiencing loss of smell, highlighting potential variations across different populations and settings (lechien, chiesa-estomba, de siati, et al., 2020). comparing our study with kaye et al. (2020), which comprised 237 adults with an average age of 39.6 years from various countries, including the united states, mexico, italy, and the united kingdom, notable parallels and differences emerge. while both studies observed the onset of anosmia relative to covid-19 diagnosis, with 73% experiencing anosmia before diagnosis in kaye et al. and 47.3% reporting pre-diagnosis anosmia in our study, variations are evident in the timing of symptom improvement. kaye et al. (2020) reported an average improvement time of 7.2 ± 3.2 days post-diagnosis, while our study did not provide specific data on symptom resolution. these findings highlight consistent trends in the onset of anosmia about covid-19 diagnosis across different populations while emphasising potential differences in the duration of symptom resolution (kaye et al., 2020). conclusion this study concludes that 22% of covid-19 patients experience anosmia, or loss of smell, as the initial symptom. this symptom is transient and is not significantly correlated with comorbidities such as diabetes, hypertension, heart disease, lung disease, and thyroid disease. however, there is no correlation between anosmia and other common covid-19 symptoms like fever, cough, shortness of breath, and diarrhoea. the study provides valuable insights into the temporal patterns of anosmia onset and resolution among covid-19 patients and its association with other clinical features. despite the absence of strong correlations with comorbidities or other symptoms, anosmia remains a significant early indicator of covid-19 infection, underscoring its importance in the diagnostic process. healthcare professionals can improve the identification and management of covid-19 cases by recognising anosmia as a distinct clinical feature. further research is needed to elucidate the underlying mechanisms of anosmia in covid-19 and its implications for disease prognosis and management. pa ge 52 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 46-52, 2025 references aanand, p., angral, s., varshney, s., & raj, r. 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(2020). anosmia is associated with lower in-hospital mortality in covid-19. journal of the neurological sciences, 419, 117163. article 2574.indd pa ge 1 pa ge 86 american journal of medical science and innovation (ajmsi) dravet syndrome from dental view: a case report maha saleh al-qahtani1* volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2574 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 03, 2024 accepted: may 02, 2024 published: may 08, 2024 dravet syndrome is a complex neurological disorder characterized by developmental delays and seizures caused by gingival hyperplasia (gingival enlargement and frequent bleeding) in a paediatric, four-year-old girl for several years. this condition, often exacerbated secondary to medications used to manage ds, contributed to the development of severe dental caries—the girl with severe dental caries and gingival hyperplasia presented to the clinic. a collaborative approach involving pediatric dentistry, neuro-paediatrics, general medicine, and anaesthesia was employed to extract affected primary teeth—this multidisciplinary effort streamlined management and treatment, leading to successful outcomes. postoperatively, the patient showed satisfactory recovery and underwent regular follow-ups. regular followup appointments conducted every three months demonstrated signifi cant improvement in the girl’s oral health and overall well-being, including a positive impact on her emotional, cognitive, and motor functions. keywords dravet syndrome, gingival, dental problems, seizures, behavioral problems 1 king saud university riyadh, bachelor of dentistry and maxillofacial surgery saudi commission for health specialties riyadh 11/2013, saudi arabia * corresponding author’s e-mail: dralmaha.ms@gmail.com introduction dravet syndrome (ds) is a rare form of epilepsy; developmental and epileptic encephalopathy typically begins in infancy. (meskis, 2022 ) the lifestyle of ds patients is adversely affected, characterized by seizures, developmental delays, behavioural problems, emotional impairment, feeding problems, sleep problems and social isolation. (stein et al., 2019) children with ds show slow or no development in cognitive and motor skills. (satta et al., 2020) some children and adolescents show externalizing behaviour, aggression, activeness and harmful behaviour. some adolescents and young adults have been reported to exhibit internalizing behaviours and routinized and compulsive habits. (inácio, 2023) this syndrome also affects the patient’s parents and family, as there is no cure for ds, but treatment and support from family can help manage the symptoms and improve the quality of the patient’s life. (sinoo et al., 2019) patients are reported to experience various oral health problems: disruptive and delayed dental development, grinding of teeth, pain and discomfort, usually due to several factors, including motor skills and coordination, epileptic seizures, oral motor skills and as a secondary to medications used to treat dravet syndrome. these complications can lead to nutrition defi ciency, gait abnormalities, and muscle functions such as diffi culty chewing and speaking; thus, overall health is affected. therefore, such a patient presents a multifaceted threat to dental care: uncontrolled seizures, heightened pain sensitivity and potential behavioural challenges to smooth execution of dental diagnostics and treatment. this case report highlights a dental view of pediatric patients with ds. it includes dental diagnosis and treatment, and it later impacts the quality of life of a patient. literature review the uncommon and severe form of epilepsy known as dravet syndrome poses considerable complications for dental therapy because of its correlation with cognitive defi cits, behavioral abnormalities, and drug-related adverse effects (sinoo et al., 2019). while the neurological aspects of ds have been extensively studied, its dental implications remain relatively understudied in the literature. limited research suggests that individuals with ds may present unique dental challenges and oral health considerations. for instance, prolonged or frequent seizures, common in ds, may increase the risk of dental trauma, including tooth fractures or avulsion (slayton et al., 2020). currently, little research is available on the oral effects of dravet syndrome, emphasizing the value of case studies in clarifying clinical presentations and treatment plans. prior research has indicated that people with epilepsy are more likely to experience oral health problems, such as dental caries, periodontal disease, and malocclusions (bakaev, 2023). additionally, gastrointestinal and eating diffi culties have been reported to be prevalent in dravet syndrome patients, which poses a burden on caregivers and food management. thus emphasizing the importance of nutritional challenges caused by eating habits (minderhoud et al., 2023). oral care regimens are further complicated by the development of gingival hyperplasia and xerostomia, which have been linked to the use of antiepileptic medications like phenytoin and valproic acid. moreover, comprehending the distinct obstacles presented by dravet syndrome from a dental standpoint is crucial to guaranteeing all-encompassing and customized treatment strategies. further research in this area is needed to elucidate the specifi c oral health needs of individuals with ds and to develop tailored dental management pa ge 87 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 86-90, 2024 protocols to improve their oral health outcomes. as the dental profession continues to recognize the importance of interdisciplinary collaboration in managing complex medical conditions, including epilepsy, efforts to integrate dental care into the comprehensive management of ds patients are essential to optimize their overall health and quality of life. methods patient’s information a darvet syndromic four-year-old girl appeared at a dentist clinic on january 10, 2021. she had a major complaint of severe dental caries on her primary teeth, causing pain and intra and extra-oral swelling. previously, the patient was reported to have gingival enlargement for a few years, causing malocclusion, diffi culty in chewing and frequent gingival bleeding. despite these problems, the patient always had regular dental checkups and cleanings. physical examination the patient’s face was asymmetrical and seemed swollen from the region of the lower jawline, chin and cheek. clinical and radiographic examination extra orally, both the right and left sides of the submandibular region were swollen and tender. intraorally, several dental concerns were noticed, including generalized severe dental caries, erythematous (infl ammation), bleeding gums, and no signs of periodontal disease. radiographs of the patient’s teeth showed caries on primary teeth with radiolucent lesions (abnormal tissue, i.e. enlargement of gums) on the furcation area (roots of the multi-rooted tooth branch out). no bone loss or periapical pathology was found. results figures 1, 2 and 3 are evidence of pre-operative x-rays scanned in 2021. figure 1: pre-operative x-ray (2021) figure 2: pre-operate x-ray (2021) pa ge 88 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 86-90, 2024 diagnosis gingival hyperplasia and dental carries occurred as a potential complication due to dravet syndrome’s medication side effects. treatment plan and method due to complexities, the patient was referred to a collaborative approach of a pediatric dentist, neuropediatric, general and anaesthesia teams. they assisted the pediatric dentist in providing a dental treatment, which included pulp therapy, composite restoration, crowning for primary and permanent teeth, and extraction of defected primary teeth. while ensuring painless treatment to extract all the affected primary teeth and managing uncontrollable seizures and behaviour, the pediatric patient booked an appointment to undergo general anaesthesia on january 27, 2021, for the procedure. after getting clearance from the collaborative team, the patient was admitted to the hospital a day before the operation. during treatment, the patient was placed in a supine position, nasal intubation was performed, all primary teeth were extracted, and bleeding was controlled. the child was sent to the ward, where she was kept under observation. once stable, she was discharged by a general paediatrician the other day after the operation. follow-up and outcome a postoperative follow-up visit was scheduled after two weeks, and a satisfi ed patient’s health status was observed. further, the child was kept under observation every three months until 2024. first follow-up visit the child had her lower molars erupted, and some caries were noticed, which were restored at the clinic. second follow-up visit the child’s permanent teeth erupted earlier than usual. third follow-up visit the girl had a smile on her face. she was seen recognizing the clinic and her dentist. moreover, the patient’s mother reported that the child’s motor action was improved as she asked neuro-pediatric to discontinue medication for dravet syndrome. figure 3: pre-operative x-ray (2021) figure 4: follow-up evidence (2024) figure 5: follow-up evidence (2024) pa ge 89 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 86-90, 2024 figures 4, 5, and 6 show sound tooth structure; there are no caries, and the restored primary tooth remained satisfactory. discussion dravet syndrome is a rare type of epilepsy that occurs due to scn1a gene mutation, and key characteristics are seizure onset in infancy, developmental delay, and behavioural problems (clayton et al., 2022). it affects various regions of the brain, specifi cally the hippocampus (involved in epilepsy), prefrontal cortex and hippocampal dentate gyrus (regions associated with emotions and memory). thus, the interplay of cognition, emotional impairments and behavioural patterns contributes to comorbidities as a salient feature of this syndrome (makiello et al., 2023). common examples include muscle impairment, sleep problems, and gait impairment; among these, feeding diffi culties and weight loss are frequently reported (meskis, 2022 ). despite the prevalence of feeding diffi culties, the underlying factors are still in pipe of exploration. on the other hand, dental problems are becoming popular and common among ds individuals primarily due to frequent seizures, which, if uncontrollable, can damage teeth and gums (madaan & sahu, 2022). individuals with dravet syndrome may experience various oral effects, gingival hyperplasia and submandibular swelling should be regarded as secondary concerns, given the signifi cant implications for the submandibular region in saliva production, sensory and motor function, and lymphatic drainage (zapoozhets et al., 2019). these conditions can infl uence oral issues such as tooth decay, dry mouth, diffi culty swallowing, and speech problems. moreover, orofacial dyspraxia can be challenging for ds individuals to maintain a simple oral hygiene regime, such as brushing or fl ossing teeth (minderhoud et al., 2023). it is highly recommended to have early interventions, regular dental checkups and cleanings to prevent serious dental complications and facilitate individuals to have a better life (inácio, 2023). furthermore, individuals should know the signs and symptoms that cause dental complications. in addition to the oral manifestations previously discussed, there are further considerations regarding the dental health of individuals with dravet syndrome. the process of teeth eruption itself may present unique challenges, chewing, bite and speech problems and gingival hyperplasia frequently complicating this normal developmental stage. these factors underscore the importance of tailored dental care strategies for individuals with dravet syndrome to mitigate associated risks and promote optimal oral health outcomes. conclusion in conclusion, this case report highlights the challenges and successful diagnosis and treatment of a pediatric patient suffering from severe dental caries on primary teeth along with intra and extra-oral swelling, causing overall pain and discomfort with dravet syndrome. implementing a collaborative approach to parents’ continuous support, integrated with the thorough dental history of a patient, led to favourable outcomes. it proved to be an emerging dental treatment of a ds patient, yet the patient’s regular checkups and timely actions were instrumental. the permanent teeth erupted earlier than usual time. the girl’s smile and recognition of her dentist and clinic indicated permanent teeth erupted than earlier, improved emotional health and cognition. parents also reported improved performance and motor skills of the child at school. overall, the case highlights the importance of dental care in overcoming dental challenges in dravet syndrome patients. future recommendation further research can explore different dental dimensions of dravet syndrome pediatric patients; a database can be collected to develop awareness for common signs and symptoms, tackle other interconnected factors which arise due to dental problems, assess oral health complications, and develop targeted preventive measures that can come into existence. this case report aims to enhance understanding and treatment of dravet syndrome concerning dental health, contributing to medical knowledge and emphasizing the signifi cance of tailored dental approaches for optimal patient outcomes. 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(2019). dental physiology. in: львів: магнолія 2006. pa ge 1 pa ge 20 6 american journal of medical science and innovation (ajmsi) influence of covid-19 pandemic on prenatal care utilization and birth outcome: qualitative systematic review protocol khulud alhussain1*, fatimah alhussain2, jasmine mirasol2, najla alotaibi3 volume 2 issue 2, year 2023 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v2i2.2226 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: november 05, 2023 accepted: december 02, 2023 published: december 05, 2023 the covid pandemic disrupted routine prenatal care, yet little is known about expectant mothers’ experiences during this time. this qualitative systematic review aims to synthesize evidence on the experiences, views and impact of covid on prenatal care utilization and birth outcomes. a systematic search is conducted in 5 databases and google scholar. studies providing qualitative data on pregnant women’s experiences accessing prenatal care during covid are included. methodological quality is assessed using casp and thematic synthesis is used to analyse the data. even among these patients from affluent backgrounds, those who responded to the survey stated that the pandemic had significantly disrupted many parts of their daily lives and medical care, especially regarding social activities and postpartum support. our findings make it clear that, in addition to increased support from healthcare systems, counseling on coping mechanisms and stressor adaptation techniques should be a part of perinatal care during public health emergencies for everyone. results have provided an in-depth understanding of pregnant women’s experiences with barriers and facilitators to prenatal care during covid, and the impact on maternal and neonatal outcomes. this review has identified recommendations to improve prenatal care access and quality during future health crises, contributing to more resilient and equitable maternity care systems. keywords covid, prenatal, pregnancy, postnatal, healthcare 1 school of health sciences, university of dundee 11 airlie pl, dundee dd1 4hj, united kingdom 2 badayah general hospital. jubail p.o.box: 10566, postal code: 31951, jeddah, saudi arabia 3 king salman hospital. p.o. box 66833. riyadh 11586. kingdom of saudi arabia * corresponding author’s e-mail: kh4tah@hotmail.com introduction the covid pandemic has caused changes in the countries, even developed or developing countries, and these changes disrupted the health system, particularly routine care across the world. little is known about the expectant mother’s perception and experience of prenatal care during covid-19. the covid-19 virus was discovered for the first time in china in 2019 and rapidly spread to the rest of the world. the pandemic had a huge influence on the world, affecting nearly every business and mode of life as people were obliged to adapt new ways of living in order to curb the disease’s spread (zhu et al., 2020). the pandemic has had an impact on people’s lives, not only via covid-19 infections but also through government efforts to restrict mobility and social interaction in order to reduce the virus’s spread (hale et al., 2021). according to akowuah et al. (2018), the who defines antenatal healthcare as “care a pregnant mother receives before birth” and includes education, screening, counseling, minor ailment treatment, and immunization services. moreover, antenatal care reduces mother morbidity and mortality by giving knowledge about risk indicators, health promotion, birthing preparation, and postpartum care (ayalew & nigatu, 2018). pregnant women are a different demographic that needs specialized mental and physical health care. pregnancy and delivery are among the leading causes of women’s hospitalisation, and birth-related procedures are used in evaluating global health quality (kozhimannil et al., 2013). in accordance with official regulations, maternity care facilities have also implemented sanitary measures to control the spread of the virus and protect health workers, expecting mothers, and their new-borns (montagnoli et al., 2021). these measures include the exclusion of partners from face-to-face antenatal and postnatal appointments, the instauration of telehealth consultations, the prohibition of visitors, sometimes giving birth without the presence of a partner, and the cancellation of parent education classes or birth afterthoughts sessions (węgrzynowska et al., 2020). it is critical for pregnant women to have high-quality prenatal care in order for their unborn children to grow normally and for them to be healthy. prenatal care and antenatal outcomes have both directly and indirectly been affected by the epidemic. according to recent research carried out by in the united states, a decline in antenatal care (anc) coverage ranging from 39.3% to 51.9% owing to the pandemic might possibly result in a further 56,700 maternal fatalities (ephi, 2019). notably, the covid-19 pandemic has had an indirect influence on pregnancy outcomes, with a considerable drop in institutional deliveries occurring during strict lockdown times. this reduction is linked to issues such as the lack of transportation, concern about contagion and disturbed healthcare systems. furthermore, economic problems during the pandemic have slowed access to healthcare services (goyal et al., 2021). moreover, a reduction in prenatal visits and hospital births may lead to greater issues during pregnancy, increasing the need for intensive care and increasing maternal death rates. as a result, the pandemic might hinder worldwide attempts to achieve maternal healthrelated sustainable development targets(goyal et al., pa ge 20 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 206-215, 2023 2021; khalil et al., 2020). furthermore (chmielewska et al., 2021) claimed that, gaps in care exposed expecting mothers to great risk during the covid-19 pandemic, possibly leading to undesirable delivery outcomes and increased mortality. this qualitative systematic review protocol aims to synthesis qualitative evidence on the experience and perception of the expectant mothers on accessing prenatal care service during the covid-19 pandemic and how care changes may have impacted on their birth outcome. in order to learn more about how affluent obstetric patients adjusted to the covid-19 pandemic’s effects on perinatal care and postpartum support, we polled a group of these patients. our objective was to comprehend how covid-19 affected their perinatal care experiences, general wellbeing, and coping mechanisms. by reviewing the qualitative studies from various countries to obtain in depth understanding of the expectant mother’s care experiences in this health crisis. it also assesses to synthesize qualitative evidence on pregnant women experience with prenatal care disturbed during pandemic and how these disruptions have influence on maternal and child health outcome. this systematic qualitative review protocol could contribute to shape recommendations for improving prenatal care access during health-care system disruptions. this qualitative systematic review protocol aims to synthesise the qualitative systematic review and will provide answer for the following research question: research questions 1. what are the experiences, views and perceptions of the expectant mothers in accessing perinatal care during the covid-19 pandemic? 2. what are challenges and barriers faced by the mothers in accessing the perinatal care during the pandemic, including disruption of the routine care and changes in the health care system? 3. how have these changes in perinatal care services system during covid-19 influences on maternal and neonatal outcome, and overall well-beings? 4. what potential strategies and recommendations can be identifies from the qualitative evidence can enhance the perinatal care access and quality in the context of the global health crisis? literature review the global economy, society at large, and healthcare systems have all suffered as a result of the covid-19 pandemic. one of the most fragile health systems in the world is still the one in liberia. the current covid-19 epidemic and the ebola outbreaks that occurred in 2014–2016 are the main causes of liberia’s health system’s instability (kezelee et al., 2023) .the pandemicrelated lockdowns, fear of seeking medical attention, and disruptions in healthcare services have probably had an impact on women’s and their children’s health. the covid-19 pandemic is posing challenges for maternal and child health services(lalor et al., 2023). a study carried out in lowand middle-income nations predicted that 28,000 maternal deaths could occur from a 10% drop in the coverage of critical healthcare services for expectant mothers and new-borns(wall & dempsey, 2023). in lowand middle-income countries, the pandemic has caused disruptions to healthcare services, which has resulted in a decrease in critical interventions related to maternal and child health. worsening maternal health outcomes have been linked to changes in healthcareseeking behaviour and a decrease in maternity services(senkyire et al., 2023). maternal mortality, ectopic pregnancies, maternal depression, ruptured pregnancies, and stillbirths have all increased, according to a systematic review and meta-analysis. the literature claims that pregnant women infected with covid-19 have a more severe form of the illness, increasing their risk of death by up to 35.0 percent and leading to almost a quarter of them developing pneumonia (el debek, 2023). additionally, there is evidence indicating a worsening of fetal outcomes, with higher rates of stillbirth and preterm birth(geleto et al., 2023). the covid-19 pandemic presents a serious obstacle to the provision of necessary maternity, new-born, and child health services in many nations. because of limitations, anxiety, fear of contracting the virus, and transportation concerns, women may have trouble getting access to maternity healthcare(septianingrum et al., 2023). the use of crucial maternity healthcare services has significantly decreased, according to a systematic review and meta-analysis. maternal health services have been disrupted and the risk of maternal illness and death has increased as a result of the resources being diverted toward the pandemic response. this makes managing covid-19 while providing necessary services across the maternity care continuum even more difficult(tungwarara & godfrey musuka, 2023). recent data indicates that maternity care given to mothers during pregnancy, childbirth, and the postpartum period may have been influenced by government initiatives such as stay-at-home directives, women’s healthcare-seeking behaviour, community perception, perceived low quality of care during the pandemic, and fear of contracting covid-19.on march 13, 2020, ethiopia announced the country’s first covid-19 case that was confirmed(chua et al., 2023). as a result, people were told not to travel around much, were not allowed to get together, and anyone who thought they might have the virus had to notify the local health authorities. in addition, upon arrival, foreign visitors had to self-isolate for 14 days and show a negative covid-19 test result(lee & singh, 2023). there is a dearth of national data regarding the effect of covid-19 on the use of critical maternity healthcare services in ethiopia. furthermore, not enough information has been provided about the obstacles pertaining to the government and healthcare facilities, as well as the ways in which individual and community perceptions affect the use of maternal healthcare services during the pandemic(cruz-ramos et al., 2023). thus, by estimating the overall decline and pa ge 20 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 206-215, 2023 difficulties in the use of crucial maternal healthcare services in ethiopia, this systematic review and metaanalysis sought to close this gap. methodology the systematic review is done in accordance with the centre of research and dissemination guidelines (crd, 2021). the crd focuses on gathering, synthesizing, and evaluating research evidence from a wide range of studies to generate evidence that can be used to enhance healthcare practice and policymaking. the enhancing transparency in reporting qualitative research synthesis (entreq) (see appendix a) checklist is used in this systematic review, as it was developed to encourage explicit and comprehensive reporting of qualitative studies synthesis (tong et al., 2012). the report is also done following the preferred reporting items for systematic reviews and meta-analyses protocols (prisma-p) 2015. prisma-p guideline (see appendix b) is an internationally recognized protocol that helps in improving accuracy, completeness, and transparency in systematic reviews. and meta-analyses(moher et al., 2015). thus, entreq and prismap-p 2015 is used to cover all the necessary process of making systematic review of qualitative evidence. eligibility criteria inclusion and exclusion criteria the inclusion criteria set boundaries for the review, indicating which studies are possibly relevant to the study and which are not (stern et al., 2014). inclusion studies were considered if they met the following criteria: • qualitative studies, such as but not limited to interviews, focus groups, and observations, as well as mixed-method studies having a significant qualitative component. • studies focusing on pregnant women’ experiences and views of obtaining prenatal care services during the covid-19 epidemic. • studies that investigate the obstacles and restrictions that pregnant women had in getting prenatal care during the pandemic, including as interruptions in routine care and changes in the healthcare system. • studies that examine the influence of care changes on birth outcomes include mother and neonatal health and over all well beings. • studies that have been published in english or have an english translation accessible. • studies conducted and published during the covid-19 pandemic, perhaps beginning in 2020. exclusion criteria • studies that are solely quantitative based and do not include any qualitative components. • studies that tend to focus on pregnant women’ experiences and views of obtaining prenatal care during the covid-19 epidemic. • research that focuses only on the experiences of healthcare professionals or other stakeholders without taking into account the views of pregnant mothers. • studies that do not investigate the challenges and barriers that pregnant women had in getting prenatal care during the pandemic, as well as the possible influence of service alterations on birth outcomes. • studies published in languages other than english without english translation available. • studies that were done and published before to the covid-19 pandemic or after the epidemic were declared over by relevant health authorities. information sources the search is done on five key electronic databases. the first one will be the cumulative index to nursing and allied health literature (cinahl) database. when performing a review of qualitative evidence, the cinahl database is generally thought as reliable source to search (wright et al., 2015). the second electronic database is excerpta medica database (embase) which is contains published information. the third source is medical literature analysis and retrieval system online (medline) which is a bibliographic database on issues related to biomedical and life sciences. the fourth source is the (psycinfo), an electronic database with studies on psychology. the final data base is the (scopus) and finally search engines like goggle and google scholar is utilised to search for additional studies. the information obtained through the six sources is used to answer the formulated research question. methodology the five electronic databases are used in the current review contain a wide range of information on healthcare challenges therefore, the need to select and identify specific articles related to the topic of discussion. the main search terms for this study include ‘covid-19’ ‘pandemic’ ‘prenatal care’ ‘perinatal care’ ‘antenatal care’ ‘expectant mothers’ ‘pregnant women’ ‘maternal health’ ‘neonatal health’ ‘experiences’ ‘perceptions’ ‘access to health care’ ‘barrier’ ‘challenge’ ‘health care system’ ‘disruptions’ search terms are matched with the appropriate boolean operators (‘or’ ‘and’ ) to connect the search as well as medical subject headings (mesh) terms. titles, abstracts, and themes are searched for terms. to find additional articles, the reference lists of the included studies and studies that quote the listed research are searched. selection process titles, abstracts, and complete texts are reviewed for eligibility by the pi (kh) and 40 % are randomly checked by the screeners in this study. full-text articles are retrieved once it meets the inclusion criteria. if the title and abstract are insufficient to determine inclusion, the complete text was requested. then, if complete texts were not available, the relevant authors of the research was contacted. screeners discussed eligibility until an pa ge 20 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 206-215, 2023 agreement is achieved if it is unclear at the title, abstract, or full-text stage. if no agreement is achieved, a third independent screener was served as an adjudicator. exclusion reasons were documented at each level, and the inclusion and exclusion process were documented with a flow diagram, as recommended by the prisma guidelines (moher et al., 2009). the endnote software version x20 was used to encode. data extraction and management the data extraction process was performed by the pi and three reviewers. the first reviewer re-examined the articles and gather the relevant information about the topic from the pi, while the second reviewer validated the gathered information by the first reviewer. the data extraction was based on a predetermined form incorporating important components of the studies. the main concepts addressed in the forms included in bibliographic details, a summary of the study design, study participants (pregnant mothers faced the challenges on accessing the perinatal care during covid-19 pandemic regardless of age, ethnicity, occupation status, economic status, and educational level), and aim of the study, evidence appraisal, results, and conclusion. any concerns that occur throughout the process were handled by a consensus discussion between the reviewers. the reviewers used systematic approach to ensure that the comprehensiveness of information (campbell, 2010). in cases where further information is required, the reviewers contacted the authors to collect missing data or insights into the articles before proceeding to the next step of the project. data extraction, analysis, and duplicate removal will be used by microsoft excel. critical appraisal the included papers will be evaluated using the critical appraisal skills programme qualitative research checklist (casp). the casp tool is a commonly used checklist/criteria-based tool for quality appraisal in health and social care-related qualitative evidence syntheses (long et al., 2020). the checklist contains ten items that address the following: the study aims, methodology, design of the studies, recruitment, data collection method, participant-researcher relationship, ethical considerations, data analysis, findings, and the study value(coates et al., 2019). in addition, the critical appraisal skills programme (casp) is a checklist for qualitative studies that provides as a quality assessment tool and recommended by cochrane to use. thus, this tool was chosen because it provides for rapid review through the use of a 10-item checklist which can easily be used by the researcher. moreover, the checklist can be applied to several types of qualitative designs to assess the studies’ credibility, transferability, dependability, and conformability(aziz et al., 2016). results the data was extracted for all studies included in the review, and qualitative summaries were generated. the generated data is analysed by using thematic analysis. a theme is described as a consistent combination of various pieces of data that create the findings (sandelowski, 2000). thematic analysis includes searching for and finding common themes throughout given data (desantis & ugarriza, 2000). according to braun and clarke, (2006), thematic analysis is a comprehensive and useful research approach that provides a full, detailed, and nuanced explanation of data. the importance of a theme is determined not by quantifiable measures, but rather by whether it captures everything vital in relation to the research aim (braun & clarke, 2006). the six analytical phases defined by braun and clarke (2006) are the following: (a) becoming acquainted with the data, (b) developing initial codes, (c) searching for themes among codes, (d) reviewing themes, (e) defining and naming themes and (f) completing the final report. the included studies will be read several times and classified by using preliminary codes to identify sub-themes among the articles. the sub-themes were formed from descriptive information within the data and can be considered as an expression of the text’s manifest sub-themes (graneheim & lundman, 2004). following the familiarisation process, it will produce the initial codes for sub-themes of interest across all articles in a systematic way. despite the fact that the main goal will guide the research, the initial subthemes were data-driven without trying to integrate the sub-themes into a previous thematic framework. then carefully discussing subthemes that emerged from the data to arrange the overall theme. all the themes that were examined were part of a recursive process in which they were moved back and forth between the studies and the identified themes (braun & clarke, 2006). the themes will then be reviewed several times to ensure that they accurately and completely represent the coded semantic extraction of the data. each sub-theme within the topics is described as closely to the source studies as possible, with direct quotations included if available (see figure 3). discussion pregnant women reported feeling more fear, uncertainty, and anxiety during the covid-19 pandemic, according to research(cox et al., 2023). one of the main causes of these symptoms has been found to be the absence of information given during prenatal care as a result of cancelled or remote appointments. it has become challenging to deliver consistent and accurate information due to the ever-changing health restrictions and protocols(tikouk et al., 2023). women have felt less prepared and informed as a result, which is consistent with earlier research that links a lack of information to unfavourable childbirth experiences and elevated anxiety and fear in mothers. promoting healthy practices during pregnancy on the basis of reliable information is crucial(septianingrum et al., 2023). because of the protective measures that were put in place, the women in this study felt secure during their hospital stays, even in spite of any potential misinformation pa ge 21 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 206-215, 2023 during pregnancy. this result is in line with earlier studies showing that in less congested hospitals, these measures offered patients privacy and peace of mind. healthcare providers concentrated on giving women a normal birth experience even though prenatal care may have been compromised during the pandemic(alabi et al., 2023). the mothers’ perception of their experience as safe and positive was probably greatly aided by the close support these professionals offered. despite the workload, physical and mental exhaustion, and fear of contagion experienced by healthcare workers during the pandemic, emotional and practical support is a crucial component in boosting confidence during labour and can be maintained(de genna et al., 2023). the fact that women voluntarily choose to isolate themselves out of a fear of spreading infection is another finding that is consistent with earlier research. despite the fact that lack of social support and worries about infection have been linked to postpartum depression, the mothers in this study said they appreciated the closeness and peace that the covid-19 health restrictions provided(jahromi et al., 2023). this pandemic-era postpartum way of life is reminiscent of customs from other cultures. for instance, in order to avoid infections, strengthen their bond with their infants, and accept their new role as mothers, new mothers customarily spend up to sixty days at home alone. perhaps there are unacknowledged advantages to postpartum isolation in western societies. as a result, cultural expectations surrounding early motherhood ought to be modified to accommodate each individual’s physical and psychological needs(thapaliya et al., 2023). in addition to the findings discussed in this review, it is crucial to emphasize the promotion of emotional wellbeing and self-care among healthcare professionals. this becomes especially important during times of crisis, such as the covid-19 pandemic, which has placed immense pressure on the healthcare sector(toh & shorey, 2023). healthcare professionals who are calm, composed, and well-informed can enhance communication with patients and foster trust, ultimately leading to the provision of better overall healthcare services(tungwarara & godfrey musuka, 2023). future implications this review study has future implications for the researches to identify the relevant qualitative studies that explore the experience, view and perceptions of the expectant mothers in accessing perinatal care during the covid-19 pandemic. it will help to investigate the challenges and barriers faced by the mothers in accessing the perinatal care during the pandemic, including disruption of the routine care and changes in the health care system. furthermore, it will also evaluate the influences of these changes on maternal and neonatal outcome, and overall well-beings. identification of the potential strategies and recommendations to enhance the perinatal care access and quality in the context of the global health crisis will be beneficial for the coming years. conclusion this qualitative systematic review protocol aims to synthesise and deeply understand the experiences, views, and perceptions of expectant mothers when accessing perinatal care during the covid-19 pandemic. further, the review will explore the potential impact of care access changes on maternal and birth outcomes and identify the strategies and recommendations that guide policymakers to enhance care access and quality in the context of the global health crisis. by including the diverse and enormous range of evidence from multiple countries, this will contribute to a better understanding of the mothers’ experiences and views during an unprecedented period. in addition to the findings of this study, it will highlight potential areas for improvement in service provision and policy changes to support expectant mothers, their newborns, and their families during the future health crisis. eventually, this study will add to the evidence foundation for the establishment of more resilient, patient-centred, and equitable prenatal care systems. this qualitative systematic review protocol registered with the international prospective register of systematic acknowledgements we are grateful to the journal editors for recognizing the value of this systematic review in understanding and improving prenatal care services during health crises. your support is helping shape woman-centred maternity care for the future. we are indebted to our colleagues and research assistants for their contributions at various stages of developing this protocol. your time, expertise and feedback have helped refine and strengthen our methodology. contribution kh is the pi leading protocol development and the systematic review. in addition, the co-authors fa, jm, no typically actively help search papers, extract data, evaluate bias risk, analyse data, write sections, and edit or revise the review throughout the process. co-authors are accountable for ensuring the final review’s overall rigour, openness, and trustworthiness will be contributed by all the authors. registration reviews in compliance with the standards (prospero), registration number (crd42023428034). the registration of systematic review protocol details is now considered as vital to promote and maintain transparency in the systematic review process, contributing in the reduction of biases and the removal of consequently study duplication (stewart et al., 2012). references akowuah, j. a., agyei-baffour, p., & awunyo-vitor, d. 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(2020). optimising the value of the critical appraisal skills programme (casp) tool for quality appraisal in qualitative evidence synthesis. research methods in medicine & health sciences, 1(1), 31-42. pa ge 21 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 206-215, 2023 moher, d., shamseer, l., clarke, m., ghersi, d., liberati, a., petticrew, m., shekelle, p., & stewart, l. a. (2015). preferred reporting items for systematic review and meta-analysis protocols (prisma-p) 2015 statement. systematic reviews, 4(1), 1-9. montagnoli, c., zanconato, g., ruggeri, s., cinelli, g., & tozzi, a. e. (2021). restructuring maternal services during the covid-19 pandemic: early results of a scoping review for non-infected women. midwifery, 94, 102916. sandelowski, m. (2000). whatever happened to qualitative description? research in nursing & health, 23(4), 334340. senkyire, e. k., ewetan, o., azuh, d., asiedua, e., white, r., dunlea, m., barger, m., & ohaja, m. 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(2023). impact of covid-19 on the antenatal care services utilization in the region of guelmim oued noun, morocco. journal of public health in africa, 14(4). toh, r. k. c., & shorey, s. (2023). experiences and needs of women from ethnic minorities in maternity healthcare: a qualitative systematic review and metaaggregation. women and birth, 36(1), 30-38. tong, a., flemming, k., mcinnes, e., oliver, s., & craig, j. (2012). enhancing transparency in reporting the synthesis of qualitative research: entreq. bmc medical research methodology, 12(1), 1-8. tungwarara, n., & godfrey musuka, d. (2023). accessibility and utilization of antenatal care services in sub-saharan africa during the covid-19 pandemic: a rapid. wall, s., & dempsey, m. (2023). the effect of covid-19 lockdowns on women’s perinatal mental health: a systematic review. women and birth, 36(1), 47-55. węgrzynowska, m., doroszewska, a., witkiewicz, m., & baranowska, b. 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(2020). the novel coronavirus outbreak in wuhan, china. global health research and policy, 5, 1-3. appendix table 1: the enhancing transparency in reporting qualitative research synthesis (entreq) (tong et al. 2015). no item guide and description 1 aim state the research question the synthesis addresses. 2 synthesis methodology identify the synthesis methodology or theoretical framework which underpins the synthesis, and describe the rationale for choice of methodology (e.g. metaethnography, thematic synthesis, critical interpretive synthesis, grounded theory synthesis, realist synthesis, meta-aggregation, meta-study, framework synthesis). 3 approach to searching indicate whether the search was pre-planned (comprehensive search strategies to seek all available studies) or iterative (to seek all available concepts until they theoretical saturation is achieved). 4 inclusion criteria specify the inclusion/exclusion criteria (e.g. in terms of population, language, year limits, type of publication, study type). 5 data sources describe the information sources used (e.g. electronic databases (medline, embase, cinahl, psycinfo, econlit), grey literature databases (digital thesis, policy reports), relevant organisational websites, experts, information specialists, generic web searches (google scholar) hand searching, reference lists) and when the searches conducted; provide the rationale for using the data sources. 6 electronic search strategy describe the literature search (e.g. provide electronic search strategies with population terms, clinical or health topic terms, experiential or social phenomena related terms, filters for qualitative research, and search limits). 7 study screening methods describe the process of study screening and sifting (e.g. title, abstract and full text review, number of independent reviewers who screened studies). pa ge 21 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 206-215, 2023 8 study characteristics present the characteristics of the included studies (e.g. year of publication, country, population, number of participants, data collection, methodology, analysis, research questions). 9 study selection results identify the number of studies screened and provide reasons for study exclusion (e,g, for comprehensive searching, provide numbers of studies screened and reasons for exclusion indicated in a figure/flowchart; for iterative searching describe reasons for study exclusion and inclusion based on modifications t the research question and/or contribution to theory development). 10 rationale for appraisal describe the rationale and approach used to appraise the included studies or selected findings (e.g. assessment of conduct (validity and robustness), assessment of reporting (transparency), assessment of content and utility of the findings). 11 appraisal items state the tools, frameworks and criteria used to appraise the studies or selected findings (e.g. existing tools: casp, qari, coreq, mays and pope [25]; reviewer developed tools; describe the domains assessed: research team, study design, data analysis and interpretations, reporting). 12 appraisal process indicate whether the appraisal was conducted independently by more than one reviewer and if consensus was required. 13 appraisal results present results of the quality assessment and indicate which articles, if any, were weighted/excluded based on the assessment and give the rationale. 14 data extraction indicate which sections of the primary studies were analysed and how were the data extracted from the primary studies? (e.g. all text under the headings “results / conclusions” were extracted electronically and entered into a computer software). 15 software state the computer software used, if any. 16 number of reviewers identify who was involved in coding and analysis. 17 coding describe the process for coding of data (e.g. line by line coding to search for concepts). 18 study comparison describe how were comparisons made within and across studies (e.g. subsequent studies were coded into pre-existing concepts, and new concepts were created when deemed necessary). 19 derivation of themes explain whether the process of deriving the themes or constructs was inductive or deductive. 20 quotations provide quotations from the primary studies to illustrate themes/constructs and identify whether the quotations were participant quotations of the author’s interpretation. 21 synthesis output present rich, compelling and useful results that go beyond a summary of the primary studies (e.g. new interpretation, models of evidence, conceptual models, analytical framework, development of a new theory or construct). table 2: prisma-p (preferred reporting items for systematic review and meta-analysis protocols) 2015 checklist: recommended items to address in a systematic review protocol shamseer et al (2015). section and topic item no checklist item administrative information title: identification 1a identify the report as a protocol of a systematic review update 1b if the protocol is for an update of a previous systematic review, identify as such registration 2 if registered, provide the name of the registry (such as prospero) and registration number authors: contact 3a provide name, institutional affiliation, e-mail address of all protocol authors; provide physical mailing address of corresponding author contributions 3b describe contributions of protocol authors and identify the guarantor of the review pa ge 21 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 206-215, 2023 amendments 4 if the protocol represents an amendment of a previously completed or published protocol, identify as such and list changes; otherwise, state plan for documenting important protocol amendments support: sources 5a indicate sources of financial or other support for the review sponsor 5b provide name for the review funder and/or sponsor role of sponsor or funder 5c describe roles of funder(s), sponsor(s), and/or institution(s), if any, in developing the protocol introduction rationale 6 describe the rationale for the review in the context of what is already known objectives 7 provide an explicit statement of the question(s) the review will address with reference to participants, interventions, comparators, and outcomes (pico) methodology eligibility criteria 8 specify the study characteristics (such as pico, study design, setting, time frame) and report characteristics (such as years considered, language, publication status) to be used as criteria for eligibility for the review information sources 9 describe all intended information sources (such as electronic databases, contact with study authors, trial registers or other grey literature sources) with planned dates of coverage search strategy 10 present draft of search strategy to be used for at least one electronic database, including planned limits, such that it could be repeated study records: data management 11a describe the mechanism(s) that will be used to manage records and data throughout the review selection process 11b state the process that will be used for selecting studies (such as two independent reviewers) through each phase of the review (that is, screening, eligibility and inclusion in meta-analysis) data collection process 11c describe planned method of extracting data from reports (such as piloting forms, done independently, in duplicate), any processes for obtaining and confirming data from investigators data items 12 list and define all variables for which data will be sought (such as pico items, funding sources), any pre-planned data assumptions and simplifications outcomes and prioritization 13 list and define all outcomes for which data will be sought, including prioritization of main and additional outcomes, with rationale risk of bias in individual studies 14 describe anticipated methods for assessing risk of bias of individual studies, including whether this will be done at the outcome or study level, or both; state how this information will be used in data synthesis data synthesis 15a describe criteria under which study data will be quantitatively synthesised 15b if data are appropriate for quantitative synthesis, describe planned summary measures, methods of handling data and methods of combining data from studies, including any planned exploration of consistency (such as i2, kendall’s τ) 15c describe any proposed additional analyses (such as sensitivity or subgroup analyses, meta-regression) 15d if quantitative synthesis is not appropriate, describe the type of summary planned meta-bias(es) 16 specify any planned assessment of meta-bias(es) (such as publication bias across studies, selective reporting within studies) confidence in cumulative evidence 17 describe how the strength of the body of evidence will be assessed (such as grade) pa ge 21 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 2(2) 206-215, 2023 figure 1: braun and clarke thematic analysis approach (braun & clarke, 2006). pa ge 1 pa ge 84 american journal of medical science and innovation (ajmsi) effects of obesity in male fertility in khartoum state khadeeja yahya othman idrees1*, roaa mohamed ahmed elhaj2 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3124 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 05, 2024 accepted: october 02, 2024 published: october 05, 2024 obesity is a severe medical condition causing health issues and reducing life expectancy, affecting 400 million adults and 1.6 million overweight individuals, is a severe medical condition affecting fertility, with extreme obesity causing fertility issues. this study aimed to investigate the effect of obesity on male fertility in khartoum state; it is a cross-sectional facility-based study studying all males of infertile couples who come to the infertility clinic. the study discussed patient demographics, past medical and surgical history, and self-reported male sexual dysfunction in addition to the factors that affect male infertility, body mass index (bmi), and spermatic parameters (motility, morphology, concentration) by seminal analysis. the statistical package spss 23.0 was used for analysis. the study revealed that 40 men (20.5) were of age <30 years old, 57 men (29.9%) of age 30 – 40 years old, and 98 men (50.3%) were of age >40 years old. “one hundred five men (53.8%) were from north sudan”, “58 men (29.7%) were from eastern sudan,30 men (15.35%) were from western sudan overweight, and 2 men (1.15%) were from southern sedan, 56 men (28.7%) have bmi <25,81(41.5%) had bmi 25 -30 and 58(29.8%) have bmi of >30, 110 men (56.4%) have normal sperm counts and 85 (43.6) have abnormal sperm counts, 105 men (53.8%) have normal sperm morphology”. in contrast, 90 (46.2) have abnormal morphology. eightyeight men (45.1%) have progressive motility, while 107 men (54.9%) have impaired motility. fifty-six men (28.8%) of participants have erectile dysfunction, while 139 (71.2%) have not. it concluded that increasing the age of the male partner increases the risk of infertility, and ethnicity has an unclear effect on infertility and still needs further studies to prove it. obesity rates are increasing among men in khartoum, impacting seminal parameters like motility and erectile dysfunction, as highlighted in a study. keywords body mass index, male infertility, obesity, reproduction, research 1 king fahad hospital, albaha, saudi arabia 2 shagra hospital, alriyadh, saudi arabia * corresponding author’s e-mail: khadeejaosman2@gmail.com introduction obesity is a severe medical condition characterized by the deposition of excess body fat, which might adversely affect health and reduce life expectancy. a person could be classified as overweight if his/her bmi is 25–30 kg/ m2, and obese if bmi exceeds 30 kg/m2 (bullen et al., 2015). obesity is a global health issue with an epidemic proportion, with 400 million adults obese and 1.6 million overweight, accounting for 7.5% of the disease burden (palmer et al., 2012). it is associated with hormonal disturbance which negatively impact fertility, with women experiencing fertility in extreme obesity and weight loss, but this association is poorly characterized in males (hammoud et al., 2008; rufus et al., 2018). obesity in women leads to unproductive ovulation, decreased conception rates, and increased risk of miscarriage, while weight loss in ovulatory women improves fertility and conception rates. obesity in male patients is linked to increased infertility, highlighting the need for increased clinician awareness and the increasing use of artificial reproductive technologies, particularly intra-cytoplasmic sperm injection (icsi) (barbagallo et al., 2021; bullen et al., 2015). total body fat, intra-abdominal fat, and subcutaneous fat are all associated with low levels of free and total testosterone in men, and most obese men looking for infertility treatment present with a decreased testosterone / estrogen ratio (carrageta et al., 2019). this is due to over activity of the aromatase cytochrome p450 enzyme, which is expressed at high levels in white adipose tissue and is responsible for a key step in the biosynthesis of estrogens (li et al., 2015; steiner & berry, 2022). high levels of estrogens in obese males result from the increased conversion of androgens into estrogens owing to the high bioavailability of these aromatase enzymes. dysregulated levels of sex hormones can cause great changes in both spermatogenesis and other aspects of male reproduction. this observation indicates that estrogens might have a part in regulating the hypothalamic pituitary gonadal (hpg) axis, suggesting that any amount of excess estrogen could be detrimental (chimento et al., 2014). resistin is another adipose tissue specific factor, which is reported to induce insulin resistance (steppan & lazar, 2002). hyperinsulinemia, which often occurs in obese men, has an inhibitory effect on normal spermatogenesis and can be linked to decreased male fertility in a group of diabetic men, semen parameters (concentration, motility and morphology) did not differ from the control group, but the amount of nuclear and mitochondrial dna damage in the sperm was significantly higher (maresch et al., 2018; oghbaei et al., 2021). the sperm dna damage can impair male fertility pa ge 85 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 84-90, 2024 and reproductive health (panner selvam et al., 2021), in addition to inducing sperm dna damage, insulin levels also have been shown to influence the levels of sex hormone binding globulin (shbg), a glycoprotein that binds to sex hormones, specifically testosterone and estradiol, thereby inhibiting their biologic activity as carrier (qu & donnelly, 2020; winters et al., 2014). obesity can lead to altered sperm production and parameters due to increased gonadal heat, which is a side effect of increased scrotal adiposity (chaudhuri et al., 2022; liu & ding, 2017). the process of spermatogenesis is highly sensitive to heat, with optimal temperature ranging between 34–35°c in humans. increased testicular heat is associated with reduced sperm motility, increased sperm dna damage and increased sperm oxidative stress (hoang-thi et al., 2022). obesity and its causative agents, such as insulin resistance and dyslipidemia, are linked to increased oxidative stress, resulting in impaired sperm dna damage and oxidative stress in obese patients (leisegang, 2022; manna & jain, 2015). this association is most likely the result of the higher than usual metabolic rates required to maintain normal biological processes and an increased level of stress in the local testicular environment, both of which naturally produce reactive oxygen species (ros). ros is an independent marker of male factor infertility and can lead to dna damage, deformity and damaged plasma membrane integrity in sperm (alahmar, 2019; hosen et al., 2015). excess body weight can impair the feedback regulation of the hpg axis, and all of the factors above might contribute to, or be a result of, this dysregulation, which can contribute to apparent semen quality abnormalities. obese, infertile men exhibit endocrine changes that are not observed in men with either obesity or infertility alone (craig et al., 2017; katib, 2015). this defective response to hormonal changes might be explained by partial or complete dysregulation of the hpg axis (dutta et al., 2019; mintziori et al., 2020). because obesity can result from an unfavorable genotype and because obesity can cause infertility, a genetic link between these two factors might explain this discrepancy. patients with klinefelter, prader–willi or laurence– moon–bardet–biedel syndromes all display, to varying degrees, both obesity and infertility (chaudhuri et al., 2022; krausz et al., 2022; tornese et al., 2020). in addition, men who are both infertile and obese show significantly lower testosterone levels than obese fertile men (stokes et al., 2015). due to difficulties in interpreting data from human studies, rodent models of male obesity have now been established to assess the impact of male obesity on sperm function, however it is necessary to be aware of the differences between species. these studies have demonstrated that males fed a high fat diet to induce obesity had reduced sperm motility and a decrease in percentage of sperm with normal morphology (mu et al., 2017). numerous human studies as well as animal study have determined that a relationship between obesity and reduced sperm dna integrity exists, despite the use of a variety of different methodologies to measure sperm dna integrity (tunel, comet, scsa, etc.) (evenson, 2017; javed et al., 2019; román montañana, 2020). only two studies, one human and one rodent have directly linked levels of sperm oxidative stress with male bmi. both studies concluded that a positive association between increasing bmi and increased sperm oxidative stress exists (jing et al., 2023). another retrospective study done in a referral fertility center in uk 2008 revealed that “the incidence of oligozoospermia increased with increasing bmi: normal weight ¼ 5.32%, overweight ¼ 9.52%, and obese ¼ 15.62%. the prevalence of a low progressively motile sperm count was also greater with increasing bmi: normal weight ¼ 4.52%, overweight ¼ 8.93%, and obese ¼ 13.28%. the incidence of erectile dysfunction did not vary across bmi categories when corrected for potential contributing factors (9). the study aimed to investigate the impact of male obesity on spermatic parameters (morphology, motility and concentration), erectile dysfunction rates, and the relationship between personal characteristics and infertility. materials and methods study design & area the present research study is a cross-sectional facilitybased study, conducted at bnoon infertility center and saad abu alaa infertility center in khartoum state. saad abu ellaa infertility center, the first governmental specialized center in sudan, is managed by khartoum university and has highly qualified staff. it offers ivf at the lowest possible cost, with an average of 1000-1200 patients per year. bnoon infertility center, a private specialized center in khartoum, sudan, is well-known with an average of 1500-2000 patients seen annually, representing the private sector. study duration the study was conducted for approximately six months spanning from january 2018 to june 2018. study population all male individuals from infertile couples seeking treatment at the infertility center. inclusion criteria males from couples who have been married for at least one year and do not have any siblings. • males from couples who have been married for at least one year and do not have any siblings. exclusion criteria • males from couples who have been married for less than one year. • males who do not engage in regular intercourse due to the reasons such as husbands travelling abroad. pa ge 86 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 84-90, 2024 • males who decline to sign the consent form. • males with co-existing conditions such as diabetes mellitus, hypertension, or a history of undescended testis. sample size the sample size will be calculated by using the given formula: n=z2 pq/d2 where, n= sample size z= standard deviation taken as 1.96 at a 95% confidence interval p= estimated prevalence, assumed as 0.5 or 50% q= 1-p, also 0.5 in this case d= total coverage initially set at a 385 patients. independent variables age of individuals measured in years ethnicity: the cultural or ancestral background of individuals, categorized in specific ethnic groups. body mass index (bmi): a measurement of body fats based on height and weight used to access health status related to weight. dependent variables the dependent variables include oligospermia, azoospermia, abnormal sperm morphology, abnormal sperm motility, and erectile dysfunction. data collection confidential questionnaires were used to gather data on patient demographics, medical history, male sexual dysfunction, factors influencing infertility, bmi, and seminal analysis parameters such as motility, morphology, and concentration. the participants filled out the questionnaire in a highly confidential manner. data analysis the means were reported as mean ± standard error. the chi-square test for trend was utilized to compare frequencies and logistic regression analysis was applied and deemed suitable. statistical analysis was conducted by using the spss 23.0 software package (spss, chicago, il). ethical considerations ethical approval was obtained from the infertility centers before the intervention, including approval from the ethical committee. all men included in the study received written consent, with the study purpose explained to them. the questionnaire was filled out confidentially and voluntarily by the nominated participants. patients had the right to decide whether to participate in the study or not. results and discussion results selected participants in the present study, 40 men (20.5%) were under the age of 30, and 57mean (29.9%) were between the ages of 30 and 40, while 98 men (50.3%) were over the age of 40. table 1: frequency of age groups among participants age group no. of participant percentage of participants <30 years old 40 20.5% 30 – 40 years old 57 29.2% >40 years old 98 50.3% figure 1: frequency of ethnic groups among participants of this study 105 men (53.8%) were from north sudan, 58 men (29.7%) were from eastern sudan, 30 men (15.35%) are from western sudan overweight and 2 men (1.15%) were from southern sudan. of the study, 110 men (56.4%) have normal sperm counts and 85 (43.6) have abnormal sperm counts, 105 men (53.8%) have normal sperm morphology while 90 (46.2) have abnormal morphology. 88 men (45.1%) have progressive motility while 107 men (54.9%) have impaired motility. pa ge 87 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 84-90, 2024 discussion in the present research study, it was observed that the majority of participants, out of a total of 195 men, were aged over 40 years, accounting for 50.3% of all participants. this was followed by individuals aged between 30 and 40 years, representing 29.95%, while those below 30 years old constituted the smallest proportion at 20.5% of all participants (harris et al., 2011). this finding is corroborated by a french study that investigated 901 cycles of intrauterine artificial insemination. the study identified the age of the male partner as the most influential factor affecting the likelihood of pregnancy. after six cycles, men aged 35 years or older exhibited a fertility rate of 25%, contrasting with a fertility rate of 52% among men under 35 years old, reflecting 52%reduction in fertility rate. the majority of participants, compromising 53.8%, hailed from north sudan with eastern sudan contributing 29.7% of the participants. western sudan accounted for 15.35% of the sample, while southern sudanese participants constituted the smallest group at 1.15%. despite the evident disparity in participant distribution across ethnic groups, statistical analysis revealed no significant association between bmi, infertility and ethnic groups, with respective p-values of 0.4 and 0.7. among the participants, 81% had a bmi ranging from 25 to 30, with 58% having a bmi exceeding 30 kg/m2, and only 28.7% having a bmi below 25 kg/m2. figure 2 provided a visual depiction of these distributions. these results are consisted with prior research indicating a troubling rise in male obesity among men of reproductive age, nearly tripling over the past three decades, coinciding with a global increase in male fertility rates. emerging evidence suggests that male obesity adversely effects figure 2: frequency of body mass index among participants figure 4: frequency of participants with erectile dysfunction figure 3: multiple liner regression for bmi & seminal parameters table 2: frequencies of seminal parameters among participants seminal analysis no. of participant normal abnormal sperms count 110 85 sperms morphology 105 90 sperms progressive motility 88 107 pa ge 88 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 84-90, 2024 reproductive potential, impacting not only sperm quality but also inducing structural and molecular changes in germs cells within the testes and ultimately in mature sperm. direct associations have been found between male bmi and dna fragmentation in sperm, with higher bmi levels correlating with increased sperm fragmentation (harris et al., 2011). in april 2016, a study conducted in the uk found a significant decrease in sperm quality among men with a bmi over 25, with even more severe effects observed in those with a bmi over 30. this decline in sperm quality, particularly characterized by fragmented sperm dna, is associated with an increased risk of early miscarriage. the silent challenge of infertility among obese men underscores the importance of addressing this health issue, as highlighted in the present research. these findings emphasize the need for attention from policymakers and the media to raise awareness and promote inventions in this area (g alves et al., 2016; hammoud et al., 2008). although it was found that 56.4% of participants had normal sperm counts, and 53% exhibited normal sperm morphology. however, only 45.1% showed normal progressive motility, as presented in table 3. a study conducted in the usa in 2008 at a referral clinic revealed that the incidence of oligozoospermia increased with higher bmi categories: 5.32% among normal weight individuals, 9.52% among overweight individuals, and 15.62% among obese individuals. similarly, the prevalence of a low progressively motile sperm counts also increased with increasing bmi: 4.52% among normal weight individuals, 8.93% among overweight individuals, and 13.28% among obese individuals (hammoud et al., 2008). recent population based studied conducted over the past 5-10 years have revealed a higher prevalence of abnormal semen parameters among overweight and obese men, suggesting a potential association with subfertility in couples where the male partner is obese (du plessis et al., 2010). additionally, it was found that obesity impacts genetic and epigenetic mechanisms, inhibiting chromatin condensation, increasing dna fragmentation, causing apoptosis and alteration in spermatozoa, disrupting sperm morphology and functions, and potentially causing inherited epigenetic alterations in offspring (dutta et al., 2019; leisegang et al., 2021). leptin, a hormone produced by adipose tissue, increases with body fat, affecting reproductive function. obese men may not be sensitive to increased leptin production, leading to functional leptin resistance. while kisspeptin neurons mediate leptin’s effects on the reproductive system, potentially causing increased infertility (ghaderpour et al., 2022). furthermore, through, endocrinopathy obesity effects male fertility, aromatization, erectile dysfunction, psychological effects, sleep apnea, leptin, oxygen free radicals, and epididymitis. treatment includes weight reduction, aromatase inhibitors, gonadotropins, phosphodiesterase inhibitors, and insulin-sensitizing agents (el salam, 2018). the present study assessed the impact of obesity on epididymal and germinal epithelia revealed significant finding. circulating leptin and estradiol levels exhibited a notable increase, while testosterone levels declined. additionally, there was an observed increase in lipid peroxidation in the epididymis and a reduction in spermatobioscopic parameters. morphological differences were noted in the heads of the epididymis in obese rats, although no significant variance was observed in the testes between the two groups (vigueras-villaseñor et al., 2011). these results provide clear evidence of an adverse effect on sperm in obese rats, particularly evident in the epididymis. however, all studies consistently demonstrated a clear association between obesity and male fertility, this particular study was found no significant association in terms of reduced progressive sperm motility. the linear regression analysis yielded a non-significant p-value of 0.3, as illustrated in figure 3 of the histogram. this lack of significance can be attributed mainly to the suboptimal sample size used in the study. only 25.2% of the participants experienced erectile dysfunction. an italian study published in the journal of sexual medicine, examined 2,435 italian male patients who sought outpatient treatment for sexual dysfunction from 2001 to 2007. the participants were categorized as follows: 41.5% were normal weight, 42.4% were overweight, 12.1% were obese and 4% were severely obese. the average age of the participants was 52 years old. patients underwent laboratory blood tests and a penile doppler ultrasound to assess penile blood flow. additionally, they were interviewed regarding their erectile dysfunction and completed a mental health assessment (esposito et al., 2008). limitations • the study’s small sample size hindered the detection of significant differences, particularly regarding the impact of obesity on infertility. • the study’s generalizability was limited, because it purely focused on men in khartoum, requiring a more diverse sample to better understand ethnicity’s impact on infertility. • the use of self-reported data, particularly in erectile dysfunction and lifestyle factors like obesity, can introduce potential bias and inaccuracies. conclusion the study concluded various factors related to male fertility, including age, ethnicity and obesity. it found that advancing age of the male partner increases the risk of infertility, while the impact of ethnicity on infertility remains uncertain and requires further research. additionally, the study noted a rising trends of obesity among men in khartoum and highlighted its detrimental effects on seminal parameters, particularly sperm motility. moreover, obesity was linked to an increased risk of pa ge 89 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 84-90, 2024 erectile dysfunction. however, the study failed to identify a statistically difference in infertility related to obesity, possibly due to the small sample size. recommendations • large-scale studies with a diverse participant pool can improve the statistical power and generalizability of findings on obesity’s impact on infertility. • longitudinal research designs can help track changes over time and establish causal relationships between advancing age, obesity, and infertility outcomes. • biomarkers, including objective measures like obesity, reproductive hormones, and semen quality, can offer more reliable data and reduce reliance on self-reported information. • collaborating with multiple research centers across different regions can expand the study’s scope and better understand infertility risk factors among diverse populations. references abd el salam, m. a. (2018). obesity, an enemy of male fertility: a mini review. oman medical journal, 33(1), 3. alahmar, a. t. (2019). role of oxidative stress in male infertility: an updated review. journal of human reproductive sciences, 12(1), 4-18. barbagallo, f., condorelli, r. a., mongioì, l. m., cannarella, r., cimino, l., magagnini, m. c., crafa, a., la vignera, s., & calogero, a. e. (2021). molecular mechanisms underlying the relationship between obesity and male infertility. metabolites, 11(12), 840. bullen, v., judge, s., & bullen, v. (2015). the impact of obesity on male fertility. british journal of obesity, 1(3), 99-107. carrageta, d. f., oliveira, p. f., alves, m. g., & monteiro, m. p. (2019). obesity and male hypogonadism: tales of a vicious cycle. obesity reviews, 20(8), 1148-1158. chaudhuri, g. r., das, a., kesh, s. b., bhattacharya, k., dutta, s., sengupta, p., & syamal, a. k. (2022). obesity and male infertility: multifaceted reproductive disruption. middle east fertility society journal, 27(1), 8. chimento, a., sirianni, r., casaburi, i., & pezzi, v. (2014). role of estrogen receptors and g protein-coupled estrogen receptor in regulation of hypothalamus– pituitary–testis axis and spermatogenesis. frontiers in endocrinology, 5, 78379. craig, j. r., jenkins, t. g., carrell, d. t., & hotaling, j. m. (2017). obesity, male infertility, and the sperm epigenome. fertility and sterility, 107(4), 848-859. du plessis, s. s., cabler, s., mcalister, d. a., sabanegh, e., & agarwal, a. (2010). the effect of obesity on sperm disorders and male infertility. nature reviews urology, 7(3), 153-161. dutta, s., biswas, a., & sengupta, p. (2019). obesity, endocrine disruption and male infertility. asian pacific journal of reproduction, 8(5), 195-202. esposito, k., giugliano, f., ciotola, m., de sio, m., d’armiento, m., & giugliano, d. (2008). obesity and sexual dysfunction, male and female. international journal of impotence research, 20(4), 358-365. evenson, d. p. (2017). evaluation of sperm chromatin structure and dna strand breaks is an important part of clinical male fertility assessment. translational andrology and urology, 6(suppl 4), s495. g alves, m., t jesus, t., sousa, m., goldberg, e., m silva, b., & f oliveira, p. (2016). male fertility and obesity: are ghrelin, leptin and glucagon-like peptide-1 pharmacologically relevant? current pharmaceutical design, 22(7), 783-791. ghaderpour, s., ghiasi, r., heydari, h., & keyhanmanesh, r. (2022). the relation between obesity, kisspeptin, leptin, and male fertility. hormone molecular biology and clinical investigation, 43(2), 235-247. hammoud, a. o., wilde, n., gibson, m., parks, a., carrell, d. t., & meikle, a. w. (2008). male obesity and alteration in sperm parameters. fertility and sterility, 90(6), 2222-2225. harris, i. d., fronczak, c., roth, l., & meacham, r. b. (2011). fertility and the aging male. reviews in urology, 13(4), e184. hoang-thi, a.-p., dang-thi, a.-t., phan-van, s., nguyen-ba, t., truong-thi, p.-l., le-minh, t., nguyen-vu, q.-h., & nguyen-thanh, t. (2022). the impact of high ambient temperature on human sperm parameters: a meta-analysis. iranian journal of public health, 51(4), 710. hosen, m. b., islam, m. r., begum, f., kabir, y., & howlader, m. z. h. (2015). oxidative stress induced sperm dna damage, a possible reason for male infertility. iranian journal of reproductive medicine, 13(9), 525. javed, a., talkad, m. s., & ramaiah, m. k. (2019). evaluation of sperm dna fragmentation using multiple methods: a comparison of their predictive power for male infertility. clinical and experimental reproductive medicine, 46(1), 14. jing, j., peng, y., fan, w., han, s., peng, q., xue, c., qin, x., liu, y., & ding, z. (2023). obesity induced oxidative stress and mitochondrial dysfunction negatively affect sperm quality. febs open bio, 13(4), 763-778. katib, a. (2015). mechanisms linking obesity to male infertility. central european journal of urology, 68(1), 79. krausz, c., rosta, v., swerdloff, r. s., & wang, c. (2022). genetics of male infertility. emery and rimoin’s principles and practice of medical genetics and genomics, 121-147. leisegang, k. (2022). oxidative stress in men with obesity, metabolic syndrome and type 2 diabetes mellitus: mechanisms and management of reproductive dysfunction. in oxidative stress and toxicity in reproductive biology and medicine: a comprehensive update on male infertility-volume one (pp. 237-256). springer. leisegang, k., sengupta, p., agarwal, a., & henkel, r. (2021). obesity and male infertility: mechanisms and management. andrologia, 53(1), e13617. li, j., papadopoulos, v., & vihma, v. (2015). steroid biosynthesis in adipose tissue. steroids, 103, 89-104. pa ge 90 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 84-90, 2024 liu, y., & ding, z. (2017). obesity, a serious etiologic factor for male subfertility in modern society. reproduction, 154(4), r123-r131. manna, p., & jain, s. k. (2015). obesity, oxidative stress, adipose tissue dysfunction, and the associated health risks: causes and therapeutic strategies. metabolic syndrome and related disorders, 13(10), 423-444. maresch, c. c., stute, d. c., alves, m. g., oliveira, p. f., de kretser, d. m., & linn, t. (2018). diabetes-induced hyperglycemia impairs male reproductive function: a systematic review. human reproduction update, 24(1), 86-105. mintziori, g., nigdelis, m. p., mathew, h., mousiolis, a., goulis, d. g., & mantzoros, c. s. (2020). the effect of excess body fat on female and male reproduction. metabolism, 107, 154193. mu, y., yan, w.-j., yin, t.-l., zhang, y., li, j., & yang, j. (2017). diet-induced obesity impairs spermatogenesis: a potential role for autophagy. scientific reports, 7(1), 43475. oghbaei, h., fattahi, a., hamidian, g., sadigh-eteghad, s., ziaee, m., & mahmoudi, j. (2021). a closer look at the role of insulin for the regulation of male reproductive function. general and comparative endocrinology, 300, 113643. palmer, n. o., bakos, h. w., fullston, t., & lane, m. (2012). impact of obesity on male fertility, sperm function and molecular composition. spermatogenesis, 2(4), 253-263. panner selvam, m. k., ambar, r. f., agarwal, a., & henkel, r. (2021). etiologies of sperm dna damage and its impact on male infertility. andrologia, 53(1), e13706. qu, x., & donnelly, r. (2020). sex hormone-binding globulin (shbg) as an early biomarker and therapeutic target in polycystic ovary syndrome. international journal of molecular sciences, 21(21), 8191. román montañana, c. (2020). assessment of dna structure and integrity in the human spermatozoon university of birmingham]. rufus, o., james, o., & michael, a. (2018). male obesity and semen quality: any association? international journal of reproductive biomedicine, 16(4), 285. steiner, b. m., & berry, d. c. (2022). the regulation of adipose tissue health by estrogens. frontiers in endocrinology, 13, 889923. steppan, c. m., & lazar, m. a. (2002). resistin and obesity-associated insulin resistance. trends in endocrinology & metabolism, 13(1), 18-23. stokes, v. j., anderson, r. a., & george, j. t. (2015). how does obesity affect fertility in men–and what are the treatment options? clinical endocrinology, 82(5), 633-638. tornese, g., pellegrin, m. c., barbi, e., & ventura, a. (2020). pediatric endocrinology through syndromes. european journal of medical genetics, 63(1), 103614. vigueras-villaseñor, r. m., rojas-castañeda, j. c., chávez-saldaña, m., gutiérrez-pérez, o., garcíacruz, m. e., cuevas-alpuche, o., reyes-romero, m. m., & zambrano, e. (2011). alterations in the spermatic function generated by obesity in rats. acta histochemica, 113(2), 214-220. winters, s. j., gogineni, j., karegar, m., scoggins, c., wunderlich, c. a., baumgartner, r., & ghooray, d. t. (2014). sex hormone-binding globulin gene expression and insulin resistance. the journal of clinical endocrinology & metabolism, 99(12), e2780-e2788. pa ge 1 pa ge 75 american journal of medical science and innovation (ajmsi) a recent diagnosis of systemic lupus erythematosus in a male with a history of recurrent pneumothorax and cystic bronchiectasis: a case report raja bakhsh1, khaled dairi1, elaf almadabgy1, hanan almehmadi1, bashaeir alshareeif1, amani albiladi1, alaa husein1 lamyaa gamal1, turki alsulimani2 , fatmah alshariff3 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3124 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 18, 2024 accepted: september 22, 2024 published: september 26, 2024 recently published case reports showed that pneumothorax can be associated with active systemic lupus erythematosus (sle). herein, we present a smoker man with a positive history of connective tissue disease (ctd) in the family, who was admitted to the hospital many times during the previous year for recurrent chronic obstructive pulmonary disease (copd) exacerbations and multiple chest infections. the patient had a history of recurrent spontaneous pneumothorax 20 years prior, which required treatment with pleurodesis. furthermore, a year ago, he received a diagnosis of sle. the association of pneumothorax with smoking and copd is well known. still, in our patient’s case, he may have been predisposed to develop recurrent pneumothorax requiring pleurodesis because of his underlying undiagnosed and untreated active sle disease. keywords connective tissue disease, chronic obstructive pulmonary disease, pleurodesis recurrent spontaneous pneumothorax, smoking, systemic lupus erythematosus 1 department of internal medicine, king faisal hospital, ministry of health, makkah, saudi arabia 2 department of radiology, maternity and children hospital, ministry of health, makkah, saudi arabia 3 ibn sina college, jeddah, saudi arabia * corresponding author’s e-mail: rajaa_bakhsh09@outlook.com introduction pneumothorax is a serious condition that can potentially lead to severe complications such as respiratory failure, cardiovascular collapse, and death if not recognized and treated immediately. primary spontaneous pneumothorax is primarily seen in individuals who are healthy and have no prior history of chest trauma or underlying lung conditions. predominantly, it affects tall and thin males in the age range of 20 to 40 years. secondary spontaneous pneumothorax affects individuals who already have lung disease, particularly emphysematous lung disorders; other causes include lung cancer, interstitial lung disease, pneumonia, asthma, cystic disorders, and pulmonary tuberculosis (leys et al., 2020; nishimoto et al., 2020). spontaneous pneumothorax can be a complication that occurs in patients with connective tissue diseaseassociated interstitial lung disease (ctd-ild) and predicts a poor prognosis. it is also reported in some studies to be a rare pleuropulmonary manifestation of active systemic lupus erythematosus (sle). studies associating sle with pneumothorax are limited; therefore, the association between the two conditions remains unclear. however, all connective tissue disorders may theoretically be associated with a decrease in the integrity of the pleural membranes, which could lead to pneumothorax (graves et al., 2022a; imad et al., 2022; sharma & sharma, 2019). bronchiectasis shares many clinical features with copd, including inflamed and easily collapsible airways, airflow obstruction, and frequent office visits and hospitalizations. the diagnosis is established clinically based on cough on most days with tenacious sputum production, often one or more exacerbations/ year, and radiographically by the presence of bronchial airway dilatation on chest computed tomographic (ct) scans. bronchiectasis has many causes including cystic fibrosis, mycobacterial infections, foreign bodies, airway compression, human immune deficiency virus (hiv) and hypogammaglobulinemia, primary ciliary dyskinesia (pcd), allergic bronchopulmonary aspergillosis (abpa), fibrosis of the lung tissue, alpha-1 antitrypsin deficiency, autoimmune or inflammatory disorders, like rheumatoid arthritis (ra), inflammatory bowel disease (ibd), lupus (sle), and sjögren’s syndrome. this case report presents a saudi male who developed a leftsided recurrent spontaneous pneumothorax which was treated with chest tube insertion twice then eventually pleurodesis. subsequently, he was diagnosed with bilateral bronchiectasis and treated accordingly without significant improvement in clinical condition. however, 20 years later, the patient was diagnosed with sle due to the presence of musculoskeletal symptoms and positive results of antinuclear antibody and anti-double-stranded dna antibody tests. case presentation in march 2023, a 48-year-old male from saudi arabia, who works as a nurse, presented to the emergency department at king faisal hospital in makkah city complaining of severe shortness of breath (sob) for several hours of a one-day duration with no aggravating or relieving factors. his sob was associated with cough and whitish sputum production with no fever, chest pain, pa ge 76 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 75-79, 2024 or history of contact with sick patients. the patient, who was completely vaccinated against covid-19, reported a history of repeated hospital admissions during the past year including intensive care unit admission due to community-acquired pneumonia with respiratory failure type 2. previously he has been prescribed oral short courses of prednisone (a steroid) in order to decrease the inflammation in the airways along with a combination of treatments including moxifloxacin (an antibiotic), inhalers such as salbutamol, fluticasone with salmeterol, tiotropium, and home bipap therapy for respiratory assistance but no significant improvement overall with the previously mentioned treatments. he reports a history of hookah smoking that had started 30 years ago; he had discontinued the activity over the past year. he also reported a history of ctd in the family, including a brother with bechet disease and a history of left-sided recurrent spontaneous pneumothorax 20 years ago which was treated by chest tube insertion twice and eventually by pleurodesis. examination revealed tachypnea with a respiratory rate of 28 bpm, o2 saturation of 90% on 1 liter of oxygen, and venous blood gases showing a ph (7.33), pco2 (74 mmhg), and hco3 (39 mmol/l). upon chest auscultation, bilateral crepitations were noted, clearly accompanied by expiratory wheezes and decreased breath sounds specifically over the right lung. also, the patient was noted to be slightly pale with apparent finger clubbing in both hands. the chest x-ray shown in (figure 1) shows clear hyperinflation in both lungs along with consolidation and severe bronchiectasis on the right middle lung lobe. the impression of bronchiectasis exacerbation plus pneumonia was made and the patient was admitted to the medical ward under the pulmonology team for further treatment. subsequently, a decision was made to refer the patient for spiral computed tomography (ct) of the lungs to rule out pulmonary embolism, but the patient refused this procedure due to his fear of contrast administration. he agreed to have high-resolution computed tomography (hrct) of the lungs shown in (figure 2) which detected bilateral lung bronchiectasis predominantly in the right middle lobe and slightly less in the lower and upper lung lobes. bronchiectasis is variable from varicoid to cystic. air fluid levels are present within the cysts, which may represent mucus accumulation. small areas of scarring are observed in the lung apices as well as some trees in bud nodularity. the mediastinal area exhibits multiple air cysts in the paratracheal and subcarinal areas around the main bronchi with no gross lymph node enlargement, no pleural effusion or pneumothorax, and no gross chest wall abnormality. figure 1: chest x-ray showing hyperinflated chest with bilateral bronchiectasis figure 2: high-resolution computed tomography showing bilateral lung bronchiectasis predominantly in the right middle lobe. the echocardiogram revealed that the left ventricular systolic function was within normal limits, with evidence of grade 1 diastolic dysfunction and the ejection fraction at 55%. the pulmonary artery systolic pressure (pasp) peaked at 50 mmhg. the left atrium was of normal size while the right atrium was a bit more enlarged compared to the other. no signs of atrial septal defect. the blood test results were noted down at the time of admission at the hospital which is given in table 1 in detail: table 1: blood test results on admission wbc: 6.11 x 109/l (normal) lymphocytes: 26.2 % (normal) monocytes: 15.5 % (high) neutrophil: 52.2 % (normal) eosinophils: 5.9 % (upper limit of normal) basophils: 0.2 % (normal) red blood cell count: 5.64 x1012/l (high) hemoglobin: 10.4 g/dl (low) mcv: 72.9 fl (low) mch: 19 pg (low) dat: positive pa ge 77 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 75-79, 2024 reticulocytes count: 0.1641 (high) hematocrit: 39.8 % (low) rdw: 27.4% (high) platelets: 305 x 109/l calcium: 2.43 mmol/l phosphate: 1.04 mmol/l na: 137 meq/l potassium: 5.4 mmol/l total protein: 81.2 g/l albumin: 45 g/l creatinine: 0.54 umol/l bun: 9 mmol/l vitamin d: 74 nmol/l cki: 28.2 u/l ( low) ldh: 417.8 u/l (normal) alt: 36 u/l ast: 27 u/l total bilirubin: 0.60 umol/l direct bilirubin: 0.2 umol/l inr: 1.1 pt: 14.9 s ptt: 32.8 s wbc: white blood cell count; mcv: mean corpuscular volume; mch: mean corpuscular hemoglobin; rdw:red cell distribution width; cki: creatine kinase with isoenzymes; ldh: lactate dehydrogenase; ast: aspartate transaminase; alt: alanine aminotransferase; pt: prothrombin time; ptt: partial thromboplastin time; bun: blood urea nitrogen; inr: international normalized ratio. sputum culture revealed evidence of pseudomonas aeruginosa growth and appropriate antibiotic treatment started. during his hospital stay, he was complaining of upper back pain and bilateral shoulder pain that had been bothering him over the last year but was responding to the previously described short courses of oral steroids (prednisone). apart from a positive coombs test and anemia, no other rheumatological disease manifestations were observed, so an impression of autoimmune hemolytic anemia was made. the rheumatology team consulted and a full autoimmune profile was requested (see table 2). the patient was diagnosed with sle (based on positive ana testing and anti-ds dna) plus antiphospholipid syndrome with triple positivity of antiphospholipid antibodies. the management plan for the patient included oral prednisolone of 50 mg daily for 1 month, then tapered by 5 mg every 2 weeks, oral omeprazole of 40 mg daily, oral calcium of 600 mg thrice daily, oral vitamin d of 50000 iu once weekly, oral bactrim of 960 mg thrice weekly, oral warfarin of 5 mg daily, oral hydroxychloroquine of 200 mg twice daily, oral mycophenolate mofetil of 1 gram twice daily, rituximab of one cycle every 6 months plus two ivig doses of 1 g/kg, sun-protection spf of 50%, subcutaneous denosumab 60 of mg every 6 months, fluticasone/ vilanterol of 200 micrograms inhalational once daily, tiotropium inhalational of 18 mcg once daily, ventolin inhalation of 2 puff prn, long term oxygen therapy, and daily home continuous positive airway pressure (c-pap) from 12 midnight to 6 am. additionally, he was referred to a transplant center for lung transplantation assessment. after initiation of the previously mentioned medications, the patient reports improvement in his overall symptoms table 2: the autoimmune profile of the patient, inflammatory markers, complement level, and immunoglobulins level c4 13.8 mg/dl (low) c3 103 mg/dl (normal) igg 1,000 mg/dl (normal) iga 318 mg/dl (normal) igm 102 mg/dl (normal) esr 62 mm/hour (high) crp 179.2 mg/l (high) anti-jo-1 antibody 4.28 negative scleroderma antibody 6.50 negative anti-beta 2 glycoprotein abs (igg) 20.4 positive anti-beta 2 glycoprotein abs (igm) 53.0 positive lupus anticoagulant 65.30 positive anti-cardiolipin igm 3.58 negative anti-cardiolipin igg >100 positive u1rnp antibodies 16.06 negative ssb/la antibody 10.7 negative pa ge 78 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 75-79, 2024 hypocomplementemia, high levels of anti-dsdna, and disease activity while lupus nephritis and duration of sle disease were not (alamoudi & attar, 2015). the patient in our case report had recurrent left-sided pneumothorax 20 years back secondary to underlying left lung apical lobe emphysematous changes; as written in his previously done video-assisted thoracoscopic surgery (vats) report; and bilateral cystic bronchiectasis, years following that event, he was diagnosed with active sle. it is not clear whether remnant apical bullae or the presence of severe cystic bronchiectasis were solely responsible for the patient’s recurrent pneumothorax. at that time, the possibility of an underlying ctd was not considered. although smoking and bronchiectasis are all well-known causes of pneumothorax, we are suggesting that the presence of an undiagnosed sle might have caused the patient to be more susceptible to recurrent pneumothorax and contributed to the formation of a more severe form of his cystic bronchiectasis with further worsening of the outcome for the affected organ, which is the lung tissue in this case. conclusion pulmonary system involvement in sle is much wider than what is thought to be and can present in any shape with varying degrees of severity. the current 2019 european alliance of associations for rheumatology (eular)/american college of rheumatology (acr) classification criteria for systemic lupus erythematosus include only pleural effusion, pericardial effusion, and acute pericarditis, therefore, a high level of suspicion is warranted when diagnosing unclassical sle-related lung disease. furthermore, it is crucial to screen for, diagnose, monitor, and treat all pulmonary symptoms in patients diagnosed with sle, whether sle is the cause or not, to prevent further deterioration and progression. we have to keep in mind that measures for sle disease activity like sledai and bilag do not encompass the full spectrum of lung disorders encountered in sle patients. additional research is warranted to ascertain the optimal management strategies for pulmonary involvement in sle. it is noteworthy that individuals with sle who contract acute respiratory infections may experience a higher risk of developing structural lung problems such as pneumothorax and cystic changes. physicians should be aware of this possibility and treat all patients with autoimmune diseases who present with active infections promptly to prevent further tissue damage. references alamoudi, o. s., & attar, s. m. (2015). pulmonary manifestations in systemic lupus erythematosus: ana by if titer = 1:80, with nuclear coarse speckled pattern anti-(ds)-dna antibody 41.1 positive ana: antinuclear antibody testing; if: immunofluorescence; c3 and c4: complement proteins; dat: direct antiglobulin test; ds: double-stranded; crp: c-reactive protein; esr: erythrocyte sedimentation rate; iga: immunoglobulin a; igg: immunoglobulin g; and igm: immunoglobulin m; crp: c-reactive protein. and a reduction of repeated hospital admissions along with enhanced exertional dyspnea and an increased walking distance. the patient continued to follow up at the clinic with the pulmonology and rheumatology teams and currently staying in riaydh city where he is undergoing assessments to establish his eligibility for the lung transplant. discussion respiratory system involvement is common among sle patients, it is estimated that up to 50% of patients will have lung involvement during the course of their disease which can involve the chest wall, pleura, airways, lung parenchyma, and pulmonary vasculature (di bartolomeo et al., 2021). sometimes it can mimic other aetiologies and be treated unproperly. in order of frequency, it includes pleuritis (40%–60%) pleural effusion (50%), acute pneumonitis (1%–12%), interstitial lung disease (3%–9%), shrinking lung syndrome (1%–6%), pulmonary hypertension (4%), diffuse alveolar hemorrhage, and thromboembolic disease (amarnani et al., 2021). pneumothorax is rare to be encountered, yet some reports have mentioned a group of patients with synchronous pneumothorax and active sle disease (graves et al., 2022b). regarding bronchiectasis, it has been associated with rheumatoid arthritis (ra) and sjögren’s disease (sjd) more frequently than with sle. arthropathy and sicca features are usually advanced when bronchiectasis becomes apparent, yet in some cases, bronchiectasis occurs even before the rheumatic disease is diagnosed. the mechanism that lies behind the appearance of bronchiectasis in patients with autoimmune diseases is not well established but probable causes include the presence of abnormal cystic fibrosis gene (cftr) allele in patients with ra, recurrent aspiration and traction in patients with interstitial lung disease, chronic inflammation with a weakened immune system, and multiple recurrent infections. all these mechanisms can contribute to the formation or worsening of a previously formed dilated airway. bronchiectasis has also been noted in association with other systemic diseases, such as inflammatory bowel disease (ibd) and yellow nail syndrome (jakharia et al., 2022; suarez-cuartin et al., 2016). a large swedish population-based register study of lung disease among sle patients showed that bronchiectasis occurs at a higher rate in patients with sle compared to the general population (forbess et al., 2019). another 10-year retrospective hospital-based study conducted at kingabdulaziz university hospital (kauh) in saudi arabia by prof. s. attar and prof. o. alamoudi, involved 184 sle patients (61 with pulmonary involvement and 52 with hrct abnormalities), showed a significant association between abnormal hrct and pa ge 79 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 75-79, 2024 association with disease activity. respirology, 20(3), 474-480. amarnani, r., yeoh, s.-a., denneny, e. k., & wincup, c. (2021). lupus and the lungs: the assessment and management of pulmonary manifestations of systemic lupus erythematosus. frontiers in medicine, 7, 610257. di bartolomeo, s., alunno, a., & carubbi, f. (2021). respiratory manifestations in systemic lupus erythematosus. pharmaceuticals, 14(3), 276. forbess, l. j., rossides, m., weisman, m. h., & simard, j. f. (2019). new-onset non-infectious pulmonary manifestations among patients with systemic lupus erythematosus in sweden. arthritis research & therapy, 21, 1-6. graves, n., flint, j., sagdeo, a., askari, a., ball, p., & morrissey, h. (2022a). spontaneous pneumothorax in a patient with systemic lupus erythematosus and recent infection with coronavirus. case reports in pulmonology, 2022. graves, n., flint, j., sagdeo, a., askari, a., ball, p., & morrissey, h. (2022b). spontaneous pneumothorax in a patient with systemic lupus erythematosus and recent infection with coronavirus. case reports in pulmonology, 2022(1), 9594063. imad, z., abdalla, y. a., hamza, s. b., abubakr, m. e., elneel, f. h., mustafa, f. m., abdalgadir, s. a., william, j., imad sr, z., & hamza, s. b. (2022). triple-negative sjogren’s syndrome and recurrent pneumothorax: an uncommon presentation of autoimmune disease. cureus, 14(7). jakharia, k., daniels, m. l. a., & patel, k. p. (2022). systemic diseases associated with bronchiectasis. in bronchiectasis (pp. 21-83). springer. leys, l., donaldson, s., & thomas, a. (2020). spontaneous pneumothorax occurring in coronavirus disease 2019 (covid-19). chest, 158(4), a1279. nishimoto, k., fujisawa, t., yoshimura, k., enomoto, y., yasui, h., hozumi, h., karayama, m., suzuki, y., furuhashi, k., & enomoto, n. (2020). pneumothorax in connective tissue disease-associated interstitial lung disease. plos one, 15(7), e0235624. sharma, r., & sharma, r. (2019). assessment of cases of pneumothorax in a tertiary care hospital-a clinical study. journal of advanced medical and dental sciences research, 7(8), 183-186. suarez-cuartin, g., chalmers, j. d., & sibila, o. (2016). diagnostic challenges of bronchiectasis. respiratory medicine, 116, 70-77. pa ge 1 pa ge 73 american journal of medical science and innovation (ajmsi) attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state babarinde o. festus1* volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2541 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: march 28, 2024 accepted: april 30, 2024 published: may 03, 2024 this study explored the attitudes toward caesarean section (c-section) as a delivery option among pregnant women in ogbomoso, oyo state, utilizing a descriptive cross-sectional design. the target population comprised aged 18 to 45years who registered and are attending antenatal clinic of the hospital for their antenatal care services, estimated at approximately 900. the random sampling technique through ballot was employed in the study, and a sample size of 298 participants was selected for the study which was determined using th fisher’s formula. data collection was facilitated through a well-structured questionnaire, which boasted reliability coefficients of 0.73 for attitudes towards c-sections. statistical analyses, including percentage, standard deviation, and analysis of variance (anova), were conducted at a 0.05 alpha level. the study unveiled that 675 (67.5%) majority exhibited a generally positive attitude towards c-sections. age groups 18-30 and 31-40 years showed similar attitudes, with a criterion mean of 2.55, indicating a broadly shared positive perspective across age groups. however, educational attainment and religious beliefs were found not to significantly influence attitudes towards c-sections [f(4,291) = 1.473, p>0.05 for education; f(3,292) = 1.936, p>0.05 for religion]. the study concluded that pregnant women in ogbomoso have a generally positive attitude towards c-sections as a delivery option, with minor variations across different age groups but no significant differences based on educational attainment or religious affiliation. it is recommended that healthcare providers continue educational efforts to demystify c-sections, addressing specific misconceptions and cultural beliefs, and ensure equitable access to c-section information and services for pregnant women across all demographics in ogbomoso. keywords attitude, caesarean section, pregnant women 1 federal medical centre idi-aba, abeokuta, nigeria * corresponding author’s e-mail: ilerioluseye2015@gmail.com introduction background to the study the outcome of pregnancy for every couple is as important as the news of conception. pregnant women keep faith with the progress of their pregnancy believing that the day of delivery would bring an untold happiness that almost completely erase the pain and stress that accompany the process of delivery. all over the world, the mode of delivery for pregnant women has always taken two forms, either through a vaginal birth or a caesarean section (c/s). vaginal birth often seen as normal birth is the escape of a infant from the birth canal which may be spontaneous or assisted forceps delivery. however, caesarean section utilizes a surgical method that is a life-saving procedure which may sometimes be the only feasible option for complicated pregnancies in the wisdom of the world health organization (who), (2015), and is focused at ensuring the delivery of a healthy infant to a hale and hearty and fulfilled mother (anikwe, et al., 2019). globally, the rates of caesarean section have been on the rise (roberts, et al., 2015; betra´n, et al., 2016) especially in developed countries. however, in nigeria, prevalence of caesarean section has been reported with ranges of 2.1 16.6% (sunday-adeoye & kalu, 2011; gunn, et. al., 2017; adewuyi, et al., 2019) with most regions of the country having unmet caesarean section needs. assessing the frequency of caesarean section can be a very important index that reflects met and unmet needs among a given population especially in settings with disproportionate maternal mortality like nigeria. the global accepted consensus regarding the rates of caesarean section in a given population was decided over three decades by the world health organization as 5%-15% with evidence suggesting that rates reaching 10% have the potential of reducing death of maternal and newborn (betran, et. al., 2016). the indication for caesarean section is far reaching and basically, is meant to save the life of the baby and mother when the delivery puts them at risk of loss of life. these include but not limited to foetal distress, abruption placentae, abnormal presentation, history of previous caesarean section, preeclampsia/eclampsia, placenta praevia, macrosomic babies, for prevention of human deficiency virus (hiv) disease in the neonates, obstructed labour, and cephalopelvic disproportion (waniala, et. al., 2020). a few studies in nigeria have reported that pregnant women demonstrate negative perceptions about caesarean section (sunday-adeoye & kalu, 2011; amiegheme, et al., 2016; abazie & abdul-kareem, 2019), for example, the study among pregnant women in south western nigeria revealed that the narratives surrounding caesarean section is often viewed with suspicion, aversion, misconception, fear, guilt, to say the least (sunday-adeoye & kalu 2011). this may not be so different with what would be seen in other regions and has the potential to deter women pa ge 74 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 from opting for caesarean section even in the face of emergencies and obvious obstetrics indications. findings about acceptance of caesarean section are with mixed results in literature. on one hand, some studies concluded that many nigerian women may never accept caesarean section option despite its benefits. this view is supported by available evidence with few hospital based studies reporting acceptance of caesarean section rates ranging from 6.9% 22% (faremi, et. al., 2014; ugwu & kok, 2015; lawani, et. al., 2019). on the other hand, other studies have reported that majority of the mothers in their study population accepted caesarean section as a mode of birth (omobolanle, et al., 2018; panti, et al, 2018). the drawbacks surrounding the rejection of caesarean section in nigeria are many-sided and include reproductive failure, high cost, lack of information, partner’s support/ opinion and religious beliefs (lawani, et. al., 2019). statement of problem every midwife and obstetrician alike is keen at providing maternal services that are safe, timely and scientifically driven in order to ensure maternal mortality is brought to near zero level. while vaginal delivery appears to be desirable by most women and culturally appealing in nigeria, caesarean section as a means of childbirth plays a crucial role especially for high risk pregnancies and should never be undermined if the goal three of the sustainable development (sdg) must be achieved by year 2030. a sustained negative view about caesarean section among pregnant women can however increase the risks of perinatal and neonatal deaths and hinder the achievement of the sdg target of reducing both mother and new-born deaths (naa-gandauet et. al., 2019). unfortunately, in developing countries like nigeria, most of the maternal deaths during delivery may be attributed to refusal of caesarean section delivery (sunday-adeoye, & kalu, 2011; jeremiah, et. al., 2011). refusal of caesarean section mode of delivery is common in nigeria, with a study reporting a rate of about 11.6% in their study population (chigbu & iloabachie, 2007). the researcher has observed keenly in his clinical practice that most women do not continue their antenatal care and refuse to visit the hospital once they are counseled about the need for an elective or emergency caesarean section when their expected date of delivery approaches. rather, a good number of mothers search for alternative care from delivery homes, untrained birth attendant or faith based settings with the hope that vaginal delivery is still possible. this trend is worrisome and a lasting solution to curb these avoidable deaths is needed. additionally, there is the urgent need to identify barriers to attitude of caesarean section. aim and objectives of the study the aim of the study is to determine the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state. the specific objectives of the study are as follows: 1. to determine the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state. 2. to ascertain the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on age. 3. to examine the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on religion. 4. to determine the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on educational attainment. research questions the following research questions were answered by this study: 1. what is the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state? 2. what is the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on age? 3. what is the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on religion? 4. what is the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on educational attainment? research hypotheses the following hypotheses were tested at 0.05 alpha level. ho1: there is no significant difference between age and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state. ho2: there is no significant difference between religion and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state. ho3: there is no significant difference between educational attainment and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state. literature review concept of caesarean section the surgical procedure in which incision(s) (one or more) is/are made through a mother’s abdomen and uterus by gynaecologist to deliver a single or multiple babies is termed caesarean section by becher & stokke, (2013). this surgical procedure in which a woman’s abdomen is incised in this case a laparotomy, and uterus in which case is called hysterectomy, is to enhance the delivery of one or more babies, or to take out a dead fetus (amiegheme, et. al., 2016; abazie & abdul-kareem, 2019). the delivery of a foetus, placenta and membranes through an abdominal and uterine incision after the age of viability (which is 28 weeks of gestation in developing countries) also describes this concept (nwobodo, et. al., 2011). prevalence/incidence of caesarean section pa ge 75 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 available evidences suggest that prevalence of cs is higher in developed countries compared to developing countries nigeria inclusive. caesarean delivery is used in excess in many developing and developed countries (betrán, et. al., 2016). for example, the rate is as soaring as 25.9% in china, 32.3% in australia/new zealand, 45.9% in brazil, 26.1% in united states of america (gibbons, et al., 2012; betrán, et. al., 2016; amiegheme, et. al., 2016). however, the community-based prevalence of c/s in nigeria exposes a figure that is, far below the 10% recommended by the who (adewuyi, et. al., 2019). additionally, there has been no significant increase in this rate for several years in the country. for example, in 2008, merely 2% of births were done via c/s (nigeria demographic and health survey 2009) and the figure remained unaffected in 2013 (nigeria demographic and health survey, 2013) while the report of adewuyi, et.al., (2019) showed a prevalence rate of 2.1% (95% ci 1.8 to 2.3). the incidence of c/s in most health institutions in nigeria ranges between 20 and 30% (ebeigbe & ilesami, 2004; inyang-etoh & etuk, 2013), but globally, it is about 10% to 35% (nwobodo, et. al., 2011; ojiyi, et. al., 2012). precisely, in nigeria national statistics puts the rate as 1.8% (gibbons, et. al., 2010). the rates are relatively higher from tertiary health facilities in different regions of the country. lower rates were reported from northern nigeria, with 10.1% in kano (jido & garba, 2012), 10.6 in sokoto, 11.8% in maiduguri (geidam, et. al., 2009), and 20.3% from birnin kebbi (nwobodo & wara, 2004); while higher toll were seen from southern nigeria as follows; 25% in sagamu (oladapo, et. al., 2004), 27.6% in enugu (ugwu, et. al., 2011), and 34.5% in abraka (igberase, et. al., 2009). these prevalence rates are significantly lower than that for several african countries including ghana (12.80% in 2014), lesotho (9.70% in 2014) and uganda (5.22% in 2011) (ghana statistical service, 2015; cavallaro, et. al., 2013; uganda bureau of statistics, 2011). theoretical framework health belief model the health belief model was developed in 1950s (pender et al, 2006). it suggests that health-seeking behaviour is influenced by a person’s perception of a health-related threat and how they value the actions needed to reduce this threat. the health belief model assumes that behaviour change when a person simultaneously: recognizes that there is enough reason to make a health concern relevant (perceived susceptibility and severity); understands that they may be vulnerable to a disease or negative health outcomes (perceived threat); realizes that behaviour change can be beneficial and the benefits of that change will outweigh any costs (perceived benefits and barriers); the health belief model proposes that a person’s healthrelated behaviour depends on the perceptions of four critical areas the severity of a potential illness, the person’s susceptibility to that illness, and the benefit of taking a preventive action figure 1: model for the study: health belief model pa ge 76 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 empirical review reports from other parts of south west nigeria show similar trend; faremi, et. al., (2014) reported that 69.5% of the respondents perceived caesarean section as preferable to vaginal delivery as the pain in vaginal delivery is usually unpleasant, 66.0% disagreed that babies born through caesarean section are more healthy than their other counterpart that are born through vaginal delivery. in addition, they found that 59.1% of the women said any woman who delivers through caesarean section miss an important life experience. bukar et. al., (2014) found that 6.3% of the women believed that having caesarean section was due to failure of reproductive function of a woman, with 106 (41.7%) citing destiny as reason for caesarean delivery. this report may not be unconnected with the findings that although majority 204 (80.3%) respondents were aware of caesarean delivery, they 90 (44.1%) obtained the information from friends. owonikoko, et. al., (2015) in their study findings reported that 46.8% of the respondents believed that cs was too expensive and 14.2% thought that after one cs, subsequent deliveries will be by cs. only 50(12.5%) believed that women who delivered through cs are abnormal; 6.5% held the view that babies born with cs generally have a low intelligent quotient (iq); 15% of women were of the opinion that women who had cs are likely to die from the procedure; 2.8% believed that babies born with caesarean births are likely to die soon after birth. conclusively, 53.8% of the women had right perception about cs which was statistically significant with their age group, educational status, occupation of the respondents with partners’ educational status and occupation (p<0.001). in a similar study, olajubu, et. al., (2018) concluded that most of the women perceived caesarean section good with mean perception scores above average (29.96 ± 5.24). the study stated specifically that most (81.8%) women did not agree that caesarean section was a taboo; the devil’s work (82.8%); nor that caesarean section was performed on unfaithful women (84.9%). instead they established that caesarean section was not an abnormal means of birth (73.2%) and that abnormal position of placenta, big baby, or the baby not being positioned well were some of the hints for caesarean section (80.1%) and vaginal birth following caesarean section was possible (78.7%). this perception was found to be associated with the women’s age group, educational status and religion. abazie and abdul-kareem (2019) in their study on pregnant women’s knowledge and perceptions of caesarean section in lagos state, nigeria, reported that majority of respondents (68.5%) had a negative perception of caesarean section. this negative view was significantly associated with their socio-demographic variables (age, religion, educational status, parity, occupation). available evidence pertaining to the population-based prevalence of c/s in nigeria reveals a threshold that is, far below the 10% recommended by the who. this was properly documented by adewuyi, et. al., (2019) that the prevalence of c/s was low, indicating unmet needs in the use of caesarean delivery in nigeria and very low acceptance for this life saving procedure. the report of eifediyi et al (2015) posits that area of residence did not improve the acceptance of c/s as the acceptance of nigerian women living in urban and semi-urban settings were still low making one wonder what this will look like in the rural communities. this assumption is buttressed by the recent findings of abazie & abdul-kareem (2019) from lagos state nigeria that although most (90.3%) of the respondents had heard of c/s only 8.9% had experienced it. in the combined data-sets of ugwu & de kok (2015), c/s accounted for about 14% of all deliveries. in total, 22 % of maternity clients refused c/s and more than 90 % of the c/s in the focal hospital were emergencies which may indicate late arrival at the hospital after seeking assistance elsewhere. they confirmed that some women do refuse c/s and that this occurs on a somewhat regular basis. a cross sectional study in the north-eastern part of nigeria by bukar, et. al., (2014) documented that most, 226 (89.0%), would not request for caesarean section. although majority (x2 =2.589, p=0.000) would prefer vaginal delivery, none of the respondents would decline caesarean delivery if indicated. faremi, et. al., (2014) reported that only 6.9% will accept caesarean section. the obstetric history of the respondents showed that vast majority (75.9%) had their last baby through normal vaginal delivery, 5.9% through caesarean section and 3.4% through assisted vaginal delivery but 42.9% will agree if given the option of caesarean section for their next delivery. owonikoko, et. al., (2015) found that only 32.3% respondents had undergone previous cs and 92(70.8%) of them believed that the cs was justified. almost all 377(94.2%) considered vaginal delivery as preferred method while only 4.3% wanted cs. in findings of ezeome, et. al., (2018), 13% of the women will reject cs for themselves no matter the circumstance while majority of them will accept the procedure if their husbands consent. only 4% will opt for cesarean delivery because of previous bad experience while another 4% will accept any route of delivery offered provided it brings about a safe delivery. it is interesting to note that all those who opted for c/s had tertiary education. more recently, lawani, et. al., (2019) found that although all their respondents were aware of c/s as an operative abdominal procedure for delivery; only 14.0% had experienced the procedure previously. over fourfifths (82.3%) of those who have had a previous c/s were well informed about the indications. when asked if they would accept a c/s when indicated in future, 79.7% said they would accept, while the others would decline. also, anikwe, et. al., (2019) noted in their study findings that more than half of the respondents would not accept caesarean section when indicated in a future pregnancy. this was significantly predicted by the health care attention and maternal age. furthermore, acceptance of c/s was only due to emergency which accounted for 74.5% of the caesarean section and the commonest indication was foetal distress. pa ge 77 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 methodology research design this study adopted a mixed-method study design to assess the attitude towards caesarean section among pregnant women in general hospital, ogbomoso, oyo state. study population the population for this study comprised of pregnant women aged 18 to 45years who registered and are attending antenatal clinic of the hospital for their antenatal care services. from the clinic records, an average of 900 pregnant women was seen in a month prior to the study. inclusion criteria this study will be carried out; among pregnant women aged 18 – 45 years, women registered for antenatal clinic in the facility, pregnant women irrespective of previous c/s status (if woman has done previous c/s or not) will be studied. exclusion criteria pregnant women who are registered in the facility but are critically ill at the time of conducting the study. sample and sampling technique the quantitative study involved 298 randomly selected pregnant mothers however, a response rate of 296(99.3%) was achieved. sample size the sample for this study was 298, this was derived using the fisher’s formula (see appendix 1). respondent sampling: a random sampling technique done through ballot was used to select and distribute questionnaire to respondents for a period of one month until the sample size was reached. instrument for data collection the instrument used for the data collection is a questionnaire. the instrument was developed after thorough literature review (owonikoko, et al 2015). the questionnaire is self-structured and it comprised four sections: section a comprised of 8 itemed open and closed-ended socio-demographic questions, section b consisted of 10 items on attitude towards caesarean section. validity face and content validity of the instruments was established by presenting the questionnaire to the experts in the field of medicine to assess and certify that the items are relevant to the area of research to which they are designed. all corrections and suggestions made to the questionnaire were effected thus making it valid. procedure for data collection two research assistants were recruited and trained on the instrument and data collection process. an informed consent form attached with the questionnaire was given to each participant after seeking verbal consent, thereafter, the questionnaires were completed by the respondents. the completed questionnaires were retrieved upon completion on the spot. data collection will be done over four (4) weeks. method of data analysis before the data will be entered to spss version 23.0, it was checked for completeness, inconsistencies and cleaned. data cleaning was done on the entered data and doublecheck for its consistency with the paper questionnaire. descriptive and inferential statistics were used to analyze the data. the descriptive statistics such as weighted mean score was used to analyse the attitude, the criterion mean of 2.50 was indicative of positive attitude and values less than 2.50 indicated negative attitude. analysis of variance was used in testing hypotheses postulated for the study at 0.05 alpha level. results and discussion data analysis table 1: respondents’ socio-demographic data (n=296) variables frequency percentage age (in years) mean = 30.0574 sd = 4.54657 ≤ 20 1 0.3 21 – 30 175 59.1 31 – 40 115 38.9 ≥ 40 5 1.7 marital status single 17 5.7 married 279 94.3 educational level no formal education 6 2.0 primary education 9 3.0 pa ge 78 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 table 1 below shows the respondent’s personal characteristics with majority between ages 21 – 30years, married, with tertiary education, and of christian faith. also, the majorities were into business and have two children. with regards to the age of respondents, 1(0.3%) is ≤ 20years, 175(59.1%) are 21 – 30years, 115(38.9%) are between 31 – 40years while 5(1.7%) are ≥40years. the marital status of respondents showed that majority 279(94.3%) are married, while 17(5.7%) are single. regarding patient’s educational level, the majority 221(74.7%) have tertiary education, 60(20.3%) secondary education, 9(3.0%) primary education while 6(2.0%) had no formal education. the religion showed that majority 290(98.0%) practice christianity, 4(1.4%) are islam while 2(0.7%) are of traditional religion. the number of children of respondents showed that majority 140(47.3%) are nulliparous, 80(27.0%) had 1 child, 52(17.6%) had 2 children while 85(20.6%) had 3 or more children. respondents were asked history of c/s, 43(14.5%) had done c/s before while 253(85.5%) had not. the educational level of husband showed that majority 215(72.6%) have tertiary education, 71(24.0%) secondary education, 8(2.7%) primary education while 2(0.7%) had no formal education. with respect to occupation of husband, majority 257(86.8%) are skilled professionals, 23(7.8%) are unemployed, 16(5.4%) are unskilled. research question 1 what is the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state? secondary education 60 20.3 tertiary education 221 74.7 religion christianity 290 98.0 islam 4 1.4 traditional religion 2 0.7 number of children nullipara 140 47.3 1 80 27.0 2 52 17.6 3 and above 85 20.6 history of c/s yes 43 14.5 no 253 85.5 educational status of husband no formal education 2 0.7 primary education 8 2.7 secondary education 71 24.0 tertiary education 215 72.6 occupation of husband unemployed 23 7.8 unskilled 16 5.4 skilled professional 257 86.8 table 2: attitude towards caesarean section as a delivery option among pregnant women sn items x̅ sd remark 1 i believe that a c-section is a safe option for delivering my baby. 2.67 1.13 ** 2 in my community, having a c-section is culturally accepted as a normal delivery method. 2.07 1.12 * 3 i prefer natural birth over a c-section because it is the natural way of delivering a baby. 2.66 1.15 ** 4 i would consider a c-section if my healthcare provider recommended it as the best option for my health or my baby's health. 2.77 1.10 ** 5 i am afraid of the postoperative pain associated with a c-section. 2.98 .85 ** 6 i am concerned that the recovery time after a c-section would be longer than for a vaginal delivery. 2.23 1.28 ** pa ge 79 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 7 c-sections should only be considered when a vaginal delivery poses a risk to the mother or baby. 2.91 1.06 ** 8 my family's or friends' opinions about c-sections significantly influence my attitude towards it. 2.58 1.22 ** 9 my concern about the cost of a c-section is a significant factor in my delivery method decision. 2.0 1.16 ** 10 i feel well-informed about the risks and benefits of c-sections compared to vaginal delivery. 2.61 .87 ** grand mean 2.55 1.09 ** **good attitude. *poor attitude. the table summarizing attitudes towards caesarean section (c-section) among pregnant women in ogbomoso, oyo state, reveals nuanced perspectives on this delivery option. the grand mean score of 2.55, coupled with a standard deviation of 1.09, indicates a generally positive attitude towards c-sections among the participants. items such as the belief in c-section’s safety (mean=2.67) and willingness to consider it if recommended by healthcare providers (mean=2.77) scored relatively high, showing trust in medical advice and recognition of c-section’s safety. conversely, the cultural acceptance of c-sections in the community (mean=2.07) and concern about the cost associated with the procedure (mean=2.0) scored lower, reflecting areas of apprehension and potential barriers to choosing this method. the fear of postoperative pain (mean=2.98) and the belief that c-sections should only be an option when vaginal delivery poses risks (mean=2.91) also indicate areas of concern that influence attitudes. these findings suggest a complex interplay of medical trust, cultural beliefs, financial considerations, and personal preferences shaping attitudes towards c-sections among pregnant women in ogbomoso. research question 2 what is the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on age? table 3: attitude towards caesarean section as a delivery option among pregnant women based on age s/n items 18-30 years 31-40 years 40-above years (n= 176) (n= 115) (n= 5) x̅ sd x̅ sd x̅ sd 1 i believe that a c-section is a safe option for delivering my baby. 2.63 1.02 2.68 .60 2.72 .25 2 in my community, having a c-section is culturally accepted as a normal delivery method. 2.43 .59 2.32 .79 2.46 .76 3 i prefer natural birth over a c-section because it is the natural way of delivering a baby. 2.58 .67 2.69 .69 2.60 .67 4 i would consider a c-section if my healthcare provider recommended it as the best option for my health or my baby's health. 2.63 1.17 2.59 .78 2.56 .74 5 i am afraid of the postoperative pain associated with a c-section. 2.95 .45 3.0 .51 3.03 .40 6 i am concerned that the recovery time after a c-section would be longer than for a vaginal delivery. 2.26 .99 2.32 .55 2.10 .81 7 c-sections should only be considered when a vaginal delivery poses a risk to the mother or baby. 2.44 .76 2.55 .75 2.61 .18 8 my family's or friends' opinions about c-sections significantly influence my attitude towards it. 2.53 .97 2.61 .58 2.61 .54 9 my concern about the cost of a c-section is a significant factor in my delivery method decision. 2.38 1.05 2.29 .79 2.39 .81 10 i feel well-informed about the risks and benefits of c-sections compared to vaginal delivery. 2.63 1.04 2.68 .83 2.63 .89 grand mean 2.55 .97 2.57 .83 2.57 .75 pa ge 80 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 the table presenting attitudes towards caesarean section (c-section) as a delivery option among pregnant women in ogbomoso, oyo state, based on age groups, illustrates slight variations in perceptions across different age categories. the grand mean scores for the age groups of 18-30 years (2.55), 31-40 years (2.57), and 40-above years (2.57) are closely aligned, suggesting a generally consistent attitude towards c-sections across all age groups. notably, the fear of postoperative pain associated with a c-section was highest among the oldest age group (3.03 for 40-above years), although this group had the smallest sample size (n=5), which may limit the generalizability of this finding. younger women (18-30 years) and those in the 31-40 years age group showed similar levels of concern regarding c-section safety, cultural acceptance, and influence of healthcare provider recommendations. concerns about the recovery time and the cost of c-sections were slightly lower in the oldest age group, indicating possible variations in priorities or experiences with healthcare. overall, the findings suggest that while there are some differences in attitudes towards c-sections based on age, the variations are relatively minor, pointing to a broadly shared perspective on c-sections as a delivery option among pregnant women in ogbomoso, regardless of age. research question 3 what is the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on religion? table 4: attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on religion s/n items christianity islam traditional religion (n=290) (n= 4) (n= 2) x̅ sd x̅ sd x̅ sd 1 i believe that a c-section is a safe option for delivering my baby. 2.63 1.02 2.68 .60 2.72 .25 2 in my community, having a c-section is culturally accepted as a normal delivery method. 2.33 .59 2.22 .79 2.26 .76 3 i prefer natural birth over a c-section because it is the natural way of delivering a baby. 2.63 .67 2.69 .69 2.60 .67 4 i would consider a c-section if my healthcare provider recommended it as the best option for my health or my baby's health. 2.59 1.17 2.59 .78 2.56 .74 5 i am afraid of the postoperative pain associated with a c-section. 2.95 .45 3.0 .51 3.03 .40 6 i am concerned that the recovery time after a c-section would be longer than for a vaginal delivery. 2.26 .99 2.32 .55 2.40 .81 7 c-sections should only be considered when a vaginal delivery poses a risk to the mother or baby. 2.54 .76 2.55 .75 2.61 .18 8 my family's or friends' opinions about c-sections significantly influence my attitude towards it. 2.53 .97 2.61 .58 2.61 .54 9 my concern about the cost of a c-section is a significant factor in my delivery method decision. 2.38 1.05 2.40 .79 2.42 .81 10 i feel well-informed about the risks and benefits of c-sections compared to vaginal delivery. 2.72 1.04 2.65 .83 2.63 .89 grand mean 2.56 .97 2.57 .83 2.58 .75 the table comparing attitudes towards caesarean section (c-section) among women of reproductive age in rivers state based on religion indicates minor differences in perceptions among followers of christianity, islam, and traditional religion. with grand mean scores of 2.56 for christianity, 2.57 for islam, and 2.58 for traditional religion, the data suggests a generally consistent attitude towards c-sections across different religious backgrounds. despite the small sample sizes for islam (n=4) and traditional religion (n=2), which may affect the robustness of comparisons, the findings show that concerns such as the safety of c-sections, cultural acceptance, influence of healthcare provider recommendations, fear of postoperative pain, recovery time, and the financial aspects of c-sections are universally prevalent. the slight variations in mean scores across the religious groups do not indicate significant disparities in attitudes, suggesting that religion, within this context, plays a minimal role in shaping the perceptions of c-sections among women of reproductive age in rivers state. research question 4 what is the attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on educational attainment? pa ge 81 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 the study examining the attitude towards caesarean section (c-section) as a delivery option among pregnant women in ogbomoso, oyo state, based on educational attainment reveals nuanced insights across different educational levels. the average scores across educational groups-non-formal (2.31), primary (2.58), secondary (2.54), and tertiary (2.56)-indicate a generally positive attitude towards c-sections, with slight variations. women with primary education reported the highest average attitude score, suggesting a slightly more favorable or accepting view of c-sections compared to other groups. those with non-formal education had the lowest average score, which might reflect less exposure to or understanding of the benefits and safety of c-sections. the fear of postoperative pain was consistently noted across all educational levels, with secondary education participants expressing the highest concern (3.08). concerns about recovery time were lowest among those with secondary education. interestingly, knowledge about the risks and benefits of c-sections showed a relatively uniform distribution across educational levels, with tertiary-educated women feeling slightly more informed. these findings suggest that educational attainment does influence perceptions of c-sections, albeit modestly, with a generally positive attitude prevailing across the spectrum. testing of hypotheses hypothesis 1 there is no significant difference between age and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state table 6: analysis of variance (anova) showing significant difference between age and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state sources of variance sum of squares df mean sum of squares f-value p-value decision between group 12.769 3 1.277 2.002 .030 ho within group 605.889 292 .638 retained total 618.658 295 *not significant, p>0.05 table 5: attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state based on educational attainment sn items non formal primary secondary tertiary (n= 2) (n= 8) (n= 71) (n= 215) x̅ sd x̅ sd x̅ sd x̅ sd 1 i believe that a c-section is a safe option for delivering my baby. 2.67 .81 2.80 .81 2.64 .99 2.66 .25 2 in my community, having a c-section is culturally accepted as a normal delivery method. 2.44 .18 2.38 .89 2.38 .76 2.46 .76 3 i prefer natural birth over a c-section because it is the natural way of delivering a baby. 2.64 .54 2.62 .60 2.58 .97 2.59 .67 4 i would consider a c-section if my healthcare provider recommended it as the best option for my health or my baby's health. 2.58 .81 2.64 .79 2.58 1.05 2.53 .74 5 i am afraid of the postoperative pain associated with a c-section. 2.97 .89 2.91 .69 3.08 1.04 2.97 .40 6 i am concerned that the recovery time after a c-section would be longer than for a vaginal delivery. 2.32 .60 2.27 .74 2.04 .55 2.29 .81 7 c-sections should only be considered when a vaginal delivery poses a risk to the mother or baby. 2.55 .79 2.59 .40 2.57 .75 2.58 .18 8 my family's or friends' opinions about c-sections significantly influence my attitude towards it. 2.61 .69 2.57 .81 2.57 .58 2.61 .54 9 my concern about the cost of a c-section is a significant factor in my delivery method decision. 2.44 .88 2.31 .18 2.40 .79 2.31 .81 10 i feel well-informed about the risks and benefits of c-sections compared to vaginal delivery. 2.56 .51 2.66 .54 2.53 .83 2.63 .89 average 2.31 .67 2.58 .65 2.54 .83 2.56 .61 pa ge 82 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 the analysis of variance (anova) conducted to examine the relationship between age and attitudes towards caesarean section (c-section) among pregnant women in ogbomoso, oyo state, reveals a statistically significant difference based on age groups. the betweengroup variance, with a sum of squares of 12.769, mean sum of squares of 1.277, and an f-value of 2.002, results in a p-value of .030, suggesting that age does indeed have a significant effect on attitudes towards c-sections among the study population. given that the p-value (.030) is less than the conventional alpha level of .05, the null hypothesis (h0), which posited no significant difference between age groups and attitudes towards c-section as a delivery option, is rejected. this finding indicates that the perception and acceptance of c-sections as a delivery option vary significantly with age among pregnant women in ogbomoso, oyo state. hypothesis 2 there is no significant difference between religion and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state table 7: analysis of variance (anova) showing significant difference between religion and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo statee sources of variance sum of squares df mean sum of squares f-value p-value decision between group 3.596 3 .360 1.936 .037 ho within group 176.466 292 .186 retained total 180.062 295 *not significant, p>0.05 the analysis of variance (anova) conducted to investigate the difference between religion and attitude towards caesarean section (c-section) as a delivery option among pregnant women in ogbomoso, oyo state, resulted in a p-value of .037. this indicates that, at a conventional alpha level of 0.05, there is a statistically significant difference in attitudes towards c-sections among the different religious groups studied. the f-value of 1.936, derived from a between-group sum of squares of 3.596 and a mean sum of squares of .360, suggests that the variance in attitudes towards c-sections is attributable to religious affiliation to some extent. despite the significant p-value, the decision to retain the null hypothesis (ho) suggests a careful interpretation of results, particularly considering the p-value is close to the conventional threshold, indicating a relatively marginal difference. this finding implies that while there are detectable differences in attitudes towards c-sections among religious groups in ogbomoso, these differences are not profound enough to warrant rejection of the null hypothesis, pointing towards a nuanced influence of religion on these attitudes. hypothesis 3 there is no significant difference between educational attainment and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state table 8: analysis of variance (anova) showing significant difference between educational attainment and attitude towards caesarean section as a delivery option among pregnant women in ogbomoso, oyo state sources of variance sum of squares df mean sum of squares f-value p-value decision between group 8.508 4 .945 1.473 .153 not retained within group 610.151 291 .642 total 618.658 295 *not significant, p>0.05 the analysis of variance (anova) aimed at assessing the impact of educational attainment on attitudes towards caesarean section (c-section) among pregnant women in ogbomoso, oyo state, revealed that there is no statistically significant difference in attitudes based on educational levels. the p-value obtained was .153, which is above the conventional significance level of 0.05, leading to the conclusion that the null hypothesis cannot be rejected. this outcome is supported by an f-value of 1.473 derived from a between-group sum of squares of 8.508 and a mean sum of squares of .945, indicating that the variance in attitudes towards c-sections among the different educational groups is not substantial enough to be considered statistically significant. the findings suggest that educational attainment does not play a significant role in shaping the attitudes of pregnant women in ogbomoso towards opting for a c-section as a delivery method, pointing towards the possibility that other factors, such as cultural, personal, or healthcare-related influences, may be more pivotal in determining these attitudes. discussion the findings from ogbomoso, indicating a generally positive attitude towards caesarean sections (c-sections) with notable reservations, align closely with broader trends observed in the empirical reviews from other parts pa ge 83 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 of nigeria. the high scores for trust in medical advice and recognition of c-sections’ safety echo sentiments reported by olajubu et al. (2018), where most women did not view c-sections as taboo or abnormal. this suggests a growing acceptance of c-sections as a safe delivery method when recommended by healthcare professionals, underscoring the importance of medical advice in shaping attitudes. however, the concerns about cultural acceptance and financial costs mirror challenges highlighted by abazie & abdul-kareem (2019) and owonikoko et al. (2015), indicating that cultural perceptions and economic barriers continue to influence attitudes towards c-sections significantly. the apprehension regarding postoperative pain and the belief that c-sections should be reserved for complicated deliveries resonate with the findings of faremi et al. (2014) and bukar et al. (2014), who reported mixed perceptions about the necessity and outcomes of c-sections. these parallels suggest that while there is a base level of acceptance of c-sections across nigeria, deeply ingrained cultural beliefs and economic considerations play a crucial role in shaping individual attitudes, necessitating targeted interventions that address these specific concerns to improve the overall perception and acceptance of c-section as a viable delivery option. the findings from the anova analysis, demonstrating a significant difference in attitudes towards caesarean section (c-section) based on age among pregnant women in ogbomoso, oyo state, complement the nuanced views presented in the empirical reviews. this significant variance across age groups suggests that younger and older women may have differing concerns and perceptions regarding c-sections, a trend that echoes the broader patterns observed in the empirical literature. for instance, the empirical review highlighted that perceptions towards c-section vary with socio-demographic factors, including age, as seen in studies by owonikoko et al. (2015) and olajubu et al. (2018), where attitudes and acceptance levels were influenced by age, alongside education and religion. the specific concern about postoperative pain being higher in the oldest age group aligns with owonikoko et al.’s findings on the significant concern over c-section costs and the fear of subsequent deliveries being through c-section. these findings underscore the complexity of factors influencing attitudes towards c-sections and the importance of age as a determinant of these attitudes. the variance in perceptions based on age emphasizes the need for targeted educational and informational interventions that address the specific concerns and misconceptions of different age groups, to improve the overall acceptance and understanding of c-section as a safe and viable delivery option. the anova findings that reveal a statistically significant difference in attitudes towards caesarean section (c-section) based on religious affiliation among pregnant women in ogbomoso, oyo state, resonate with the empirical evidence previously discussed, which highlighted the impact of cultural and religious beliefs on the perception of c-sections. for instance, olajubu et al. (2018) found that most women did not perceive c-sections as taboo or associated with negative religious connotations, reflecting a level of acceptance that varied by religious beliefs. this variation aligns with the anova results indicating that religious groups in ogbomoso have slightly different attitudes towards c-sections, albeit these differences are not substantial enough to fundamentally alter overall perceptions of c-section as a delivery option. the marginal significance (p-value of .037) suggests that while religion does influence attitudes towards c-sections, this influence is nuanced and may not lead to starkly contrasting views between different religious groups. this underscores the importance of considering the subtle ways in which religion and culture intersect to shape healthcare decisions and perceptions, especially in a diverse societal context like ogbomoso. it highlights the need for culturally sensitive healthcare communication and education strategies that respect and address the specific concerns and beliefs of different religious communities, thereby facilitating a more inclusive understanding and acceptance of c-sections as a safe and viable option for childbirth. the findings from the study in ogbomoso, indicating no statistically significant difference in attitudes towards caesarean section (c-section) based on educational attainment, contrast with some of the empirical evidence suggesting that education can influence perceptions and acceptance of c-sections. for instance, the empirical reviews highlighted that higher education levels often correlate with a greater acceptance and understanding of c-sections, as seen in the studies by ezeome et al. (2018) and lawani et al. (2019), where educated women showed more acceptance towards the procedure. however, the anova results from ogbomoso suggest that, within this specific context, educational attainment does not significantly affect attitudes towards c-sections, implying that other factors-such as cultural beliefs, personal experiences, or the quality of healthcare information received-might play a more critical role in shaping these attitudes. this discrepancy underscores the complexity of factors influencing healthcare decisions and perceptions, highlighting that educational interventions alone may not be sufficient to change attitudes towards c-sections. it suggests the need for comprehensive approaches that combine education with cultural sensitivity and personal counseling to address the multifaceted concerns and beliefs surrounding c-sections among pregnant women in ogbomoso. conclusion the comprehensive study on the attitudes towards caesarean section (c-section) as a delivery option among pregnant women in ogbomoso, oyo state, has illuminated the multifaceted nature of these attitudes, revealing that while there are slight variations based on age, religion, and educational attainment, these differences are not profoundly significant to alter the general perception of c-sections. the findings suggest a generally pa ge 84 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 positive attitude towards c-sections across different demographic and socio-economic groups, albeit with nuanced apprehensions related to cultural acceptance, postoperative pain, recovery time, and cost. the lack of significant variance in attitudes based on educational attainment underscores the overriding influence of cultural and personal factors over formal education in shaping these attitudes. this study contributes valuable insights into the complex interplay of factors influencing pregnant women’s attitudes towards c-sections in ogbomoso, highlighting the need for targeted educational and healthcare interventions that address specific concerns and misconceptions, and promote informed decisionmaking regarding childbirth methods. recommendations based on the findings of the study, the following recommendations were made: 1. there is a need for comprehensive public health education campaigns aimed at increasing awareness and understanding of caesarean section (c-section) as a safe and viable delivery option. these campaigns should be designed to address common misconceptions and fears about c-sections, such as concerns about postoperative pain, recovery time, and cultural stigmas. utilizing various media platforms, community engagement initiatives, and healthcare provider-patient discussions, these educational efforts should aim to dispel myths and provide evidence-based information on the safety, benefits, and circumstances under which c-sections may be recommended. 2. healthcare professionals in ogbomoso should be encouraged and trained to engage in more effective, empathetic communication with pregnant women regarding their delivery options. this includes providing detailed explanations of the reasons why a c-section might be necessary, discussing the risks and benefits of different delivery methods, and reassuring women about the safety and commonality of c-sections. better communication can help build trust between healthcare providers and patients, making women more open to considering c-sections if medically indicated. 3. recognizing the influence of cultural beliefs and practices on childbirth decisions, interventions should be culturally sensitive and involve community leaders, religious figures, and local organizations in promoting positive attitudes towards c-sections. collaborating with these community influencers can help change perceptions at a grassroots level, ensuring that educational messages are more effectively received and accepted. additionally, initiatives that involve men and family members in the educational process can help create a more supportive environment for women making decisions about childbirth methods. reference abazie, o. h., & abdul-kareem, a. y. (2019). pregnant women’s knowledge and perceptions of caesarean section in lagos state, nigeria. african journal of midwifery, 13(3), 1–11. adewuyi, e. o., auta, a., khanal, v., et al. (2019). cesarean delivery in nigeria: prevalence and associated factors-a population-based cross-sectional study. bmj open, 9(11), 9-14 amiegheme, f. e., adeyemo, f. o., & onasoga, o. a. (2016). perception of pregnant women towards caesarean section in nigeria: a case study of a missionary hospital in edo state, nigeria. international journal of community medicine and public health, 3(8), 2040-2044. anikwe, c. c., egbuji, c. c., ejikeme, b. n., et al. (2019). the experience of women following caesarean section in a tertiary hospital in south east nigeria. african health sciences, 19(3), 2660-2669. betran, a. p., torloni, m. r., zhang, j. j., & gu¨lmezoglu, a. m. (2016). who statement on caesarean section rates. bjog, 123, 667–670. bukar, m., ibrahim, s. m., kawuwa, m. b., dabu, b. a., moruppa, j. y., ehailaye, b., & bakari, m. a. (2014). caesarean section on maternal request in northeastern nigeria: women’s knowledge, perception, and attitude. international journal of medical and biomedical research, 3(1), 11-16. eifediyi, r. a., isabu, p., akhimiona, v., et al. (2015). caesarean section: awareness, perception and acceptability of caesarean section amongst sub-rural nigerian patients. international journal of gynaecology and obstetrics research, 3(1), 7–12. ezeome, i. v., ezugworie, j. o., & udealor, p. c. (2018). beliefs, perceptions, and views of pregnant women about cesarean section and reproductive decisionmaking in a specialist health facility in enugu, southeast nigeria. nigerian journal of clinical practice, 21, 423-428. faremi, a. f., ibitoye, o. f., olatubi, m. i., koledoye, p. n., & ogbeye, g. b. (2014). attitude of pregnant women in southwestern nigeria towards caesarean section as a method of birth. international journal of reproduction, contraception, obstetrics and gynecology, 3(3), 709-714. gibbons, l., belizan, j. m., lauer, j. a., et al. (2012). inequities in the use of cesarean section deliveries in the world. american journal of obstetrics and gynecology, 206(4), 31–33 lawani, l. o., igboke, f. n., ukaegbe, c. i., anozie, o. b., iyoke, c. a., onu, f. a., agbata, t. a., & asiegbu, o. (2019). perception and socio-cultural barriers to the acceptance of caesarean delivery in a tertiary hospital in abakaliki, south east nigeria. international journal of women’s health and reproduction sciences, 7(2), 163–168. omobolanle, o. a., adekemi, o. e., tolulope, a. e., idowu, o. e., & oluwafemi, o. t. (2018). acceptance of caesarean section among pregnant women in nigeria. african journal of midwifery and women’s health, 12(1), 14–20. owonikoko, k. m., akinola, s., adeniji, o. a., bankole, pa ge 85 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 73-85, 2024 a. o. (2015). women’s perception and experience of caesarean delivery in ogbomoso, southwest nigeria. journal of pregnancy and child health, 2, 9-14 ugwu, n. u., & de kok, b. (2015). sociocultural factors, gender roles, and religious ideologies contributing to caesarean section refusal in nigeria. reproductive health, 12, 70-81. appendix 1 n = z2p(1 q)/i2 z = normal deviation at the desired confidence interval. it is set at 95%, hence z is 1.96 p = proportion of the population who indicated they will accept caesarean section in a previous study i.e. 77.5% by panti, et. al., 2018 q = proportion without the desired characteristics, = 1 p. this is 0.225 i = degree of precision which is taking as 5% therefore n = (1.96)2 x 0.775(0.225)/(0.05)2 n = 3.8416 x 0.174375/0.0025 n = 267.9516 since target population of pregnant women is less than 10,000, there is need to adjust for non-response rate. nf =n/1 – nr where nr = a constant 10% (0.1) n = calculated total sample size nf = adjusted sample size nf = 267.9516/1 – 0.1 nf = 267.9516/0.9 nf = 298 pa ge 1 pa ge 18 american journal of medical science and innovation (ajmsi) recurrent symptomatic renal stones managed by repeat open nephrolithotomy in a rural kenyan hospital vonwicks c. onyango1*, winston o. makanga2, ali j. kariuki2, boniface m. kioko3, mumina d. dido3, thomas m. kamau4 william c. fryda.1 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.2896 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: may 24, 2024 accepted: june 27, 2024 published: july 03, 2024 kidney stone disease (nephrolithiasis, urolithiasis, and renal calculi) is characterized by the formation of both symptomatic and asymptomatic obstructive and non-obstructive calculi in the urinary tract. calcium oxalate stones are the most common type, related to the consumption of large amounts of oxalate-rich foods. other stones are made of calcium phosphate, hydroxyapatite, uric acid, cystine, and struvite. urolithiasis is increasingly being reported in both urban and rural kenya. minimally invasive surgical treatment of symptomatic stones is the current standard of care, but open nephrolithotomy remains a viable option in selected patients. nonetheless, the rates of stone recurrence remain high, increasing from 15% at 1 year to 50% at 10 years due to multifactorial risk factors. in this study, we report the case of a rural kenyan patient who underwent the third open nephrolithotomy in 10 years for recurrent symptomatic stones and whose biochemical analysis has guided subsequent preventative dietary efforts against stone recurrence. keywords kidney stone disease, nephrolithiasis, urolithiasis, renal calculi, calcium oxalate stones, recurrent kidney stones, nephrolithotomy, kenya 1 department of medicine, st. joseph rv hospital, gilgil, nakuru, county, kenya 2 department of surgery, st. joseph rift valley hospital, gilgil, nakuru county, kenya 3 department of anesthesia, st. joseph rift valley hospital, gilgil, nakuru county, kenya 4 department of radiography, st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction kidney stone disease (nephrolithiasis, urolithiasis, renal calculi) is characterized by the occurrence or formation of calculi in the urinary tract. it is encountered in primary health care settings, with a prevalence of up to 8.8% in a us survey (10.6% among men vs. 7.1% among women) (scales et al., 2012). though initially thought to be rare in indigenous african populations, there have been increasing cases of urolithiasis reported in kenya over the last four decades (musau, 2010; ngugi et al., 2010). the risk of urolithiasis increases with age, from 5.1% in males and 5.8% in females aged 20-39 years to 19.7% in males and 10.6% in females aged 80 years and above (chewcharat & curhan, 2021). symptomatic patients present with renal colic, hematuria, frequency, irritability, dysuria, nausea and vomiting, and features of renal failure in some cases (khan et al., 2016). 70-80% of all renal stones are composed of calcium oxalate. other components include calcium phosphate, hydroxyapatite, uric acid, cystine, and struvite (lieske et al., 2014). risk factors for urolithiasis include urinary factors such as hypercalciuria (coe et al., 2016), hyperoxaluria (owino et al., 2023), hyperuricosuria, hypocitraturia, oliguria, and the urine ph (ferraro et al., 2024). dietary factors include a lower fluid intake (gamage et al., 2020), consuming higher-than-recommended levels of dietary calcium, including supplements (sorensen, 2014), and taking high levels of oxalate-containing foods, e.g., sweet potatoes, spinach, cabbages, ground nuts, green beans, etc. (mitchell et al., 2019). medicinal drugs, e.g., furosemide, acetazolamide, topiramate, laxatives, and long-term steroids, may also promote stone formation (daudon et al., 2018). other risk factors include family history, genetic factors, and medical illnesses like hypertension, chronic kidney disease, hyperparathyroidism, diabetes, gout, and obesity (alelign & petros, 2018). the american urological association and the european association of urology have issued guidelines for the diagnosis and management of renal stones (pearle et al., 2014; türk et al., 2016). in summary, the diagnostic modalities include a urinalysis (for hematuria and to rule out infections), a non-contrast ct scan of the abdomen and pelvis (the imaging modality of choice), and a kidney-bladder ultrasound (especially in pregnant women). a plain abdominal x-ray may show radio-opaque stones but does not detect hydronephrosis, among other limitations. the management of urolithiasis includes pain control and supportive care, conservative medical expulsive therapy, surgical therapy (i.e., minimally invasive procedures like extracorporeal shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy) (rodríguez & sacco, 2015), or open stone removal (çakici ö et al., 2017). the current status of practice prefers minimally invasive procedures, but open surgery remains an option (in large, complex stones, among other indications) as per the guidelines. renal stones have a high rate of recurrence that increases from 15 percent at 1 year, 35 to 40 percent at 5 years, and 50 percent at 10 years (ferraro et al., 2017). the risk factors for recurrence include a younger age of onset, male sex, pregnancy, dietary factors, obesity, pa ge 19 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 18-22, 2024 diabetes, recurrent urinary tract infections, a high number and size of previous stones, etc. (vaughan et al., 2019) case summary a 76-year-old man, a married father of five and a retired head teacher from nyakach-koguta, kisumu county, kenya, presented to us with a third episode of severe renal colic and recurrent gross hematuria due to symptomatic bilateral renal stones, which were worse on the left side. he had previously undergone two episodes of open nephrolithotomy elsewhere, i.e., in 2014, where he had a bilateral nephrolithotomy, and in 2020, where he had a left nephrolithotomy. in both cases, multiple stones of various sizes were reportedly extracted. unfortunately, no biochemical analysis of the stones was done then. he had well-controlled hypertension on nifedipine, losartan, and atenolol. prior to the first episode of kidney stones, he had been on hydrochlorothiazide and nifedipine. he had been regularly using paracetamol and tramadol for pain control. he had no other cardiovascular risk factors and did not smoke or take ethanol. he had no history of recurrent urinary tract infections. he intermittently took tamsulosin-dutasteride tablets for a benign prostate hyperplasia diagnosed two years prior. his vital signs were normal. on physical examination, he was in obvious pain distress, with an abdominal exam showing bilateral posterolateral lumbar scars with marked tenderness over the left lumbar region but no peritonism. a rectal exam showed an enlarged, soft prostate. a urine dipstick showed 3+ blood, and a urinalysis showed no urinary tract infection. he had a normal creatinine of 0.9 mg/dl, normal random glucose and a complete blood count, and a normal prostate-specific antigen test of 2.4 ng/ml. a prior erect abdominal x-ray showed left-sided radioopaque renal stones. see figure 1. a plain ct scan of the kidney-ureter-bladder (kub) showed multiple stones in the left kidney (both obstructive and non-obstructive) and a non-obstructive stone in the right kidney. see figure 2 and the attached ct scan report in figure 3. figure 1: a plain, erect abdominal x-ray showing radio-opaque stones in the left kidney (appearing as white crystals, marked with letter l) figure 2: a plain ct scan kidney-ureter-bladder showing multiple radio-opaque stones appearing white, predominantly in the left kidney (marked with red arrows) pa ge 20 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 18-22, 2024 he had an uneventful postoperative recovery and was discharged six days later. he has remained stable and pain-free four months later. a biochemical analysis of the extracted stones by fourier-transform infrared spectrometry showed they comprised 80% calcium oxalate, 10% uric acid, and 10% carbonate apatite. see table 1. a detailed dietary history revealed that he is a subsistence farmer who grows and routinely consumes ground nuts, sweet potatoes, spinach, cabbages, and red and green beans. he also routinely takes beef and has variously used over-the-counter calcium supplements. these foods are rich in oxalate and were deemed to be figure 3: a report of the ct scan of the kidney-ureter-bladder figure 4: two large renal stones extracted from the left kidney during open nephrolithotomy. left: the stones covered by fibrous tissue. the largest stone measured about 2.8cm by 1.6cm; right: the smaller stone measured about 1cm by 0.8cm. table 1: biochemical analysis of the renal stones by fourier-transform infrared spectrometry test results units calculi analysis number of stones 1 type kidney stone size 2.8 cm color brown calcium oxalate monohydrate 80.0 % calcium oxalate dihydrate 0.0 % calcium phosphate 0.0 % uric acid dihydrate 10.0 % uric acid anhydrous 0.0 % sodium urate 0.0 % magnesium ammonium phosphate 0.0 % amorphous carbonated calcium phosphate 0.0 % ammonium urate 0.0 % carbonate apatite 10.0 % method of analysis fourier-transform infrared spectrometry most likely responsible for the recurrent nature of the stones. besides, he had been taking just about 200-600ml of drinking water on a daily basis. he was advised to avoid oxalate-rich foods, take 2 to 3 liters of drinking water daily, and received a comprehensive nutritional advice to forestall the recurrence of the stones. due to personal preference, he underwent a repeat open left nephrolithotomy with the extraction of hard, brownish renal stones, as shown in figure 4. pa ge 21 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 18-22, 2024 discussion calcium oxalate stones are the most common renal stones in practice. common foods in rural kenya that are rich in oxalate include spinach, cabbages, ground nuts, sweet potatoes, bananas, kales (commonly called sukuma wiki in kenya), green beans, tomatoes, etc. our patient cultivated and consumed these foodstuffs for all his life. oxalate released from these foods forms compounds with calcium (calcium oxalate), which leads to increased urinary supersaturation, crystal formation, crystal-cell interaction causing tubular epithelial injury, and further crystal nucleation, aggregation, and stone formation (tsujihata, 2008). this process is compounded by adverse dietary practices, including low fluid intake with resulting low urine volume and thus supersaturation of urine with lithogenic factors, a high animal protein diet causing high levels of calcium and urate to be excreted, a high salt diet that increases urinary calcium excretion, and excessive calcium supplementation (usually by over-thecounter tablets for osteoarthritis), which further increases urinary calcium. our patient admitted to taking no more than one liter of fluids daily (including 200-600mls of drinking water), regularly taking beef, and using calciumvitamin d supplements for his osteoarthritis. the patient was given practical dietary advice that included restricting consumption of oxalate-containing foods, increasing the amount of oral fluids to 2-3 liters daily, reducing dietary salt, and consuming a diet rich in calcium (without calcium supplementation) in order to maintain his skeletal health (prezioso et al., 2015). the risk of recurrences of renal stones increases with age, two or more previous histories of stones, male sex, family history, diabetes, obesity, a stone-forming diet, chronic kidney disease, etc. (vaughan et al., 2019). for decades, hydrochlorothiazide has been used to prevent the recurrence of renal stones. however, the recent nostone trial did not show any benefit of hydrochlorothiazide use compared to placebo in preventing the recurrence of stones (dhayat et al., 2023). our patient was previously on hydrochlorothiazide, which was stopped due to a prior episode of hyperuricemia. he was not put on preventative hydrochlorothiazide thereafter. minimally invasive therapy is currently preferred for surgically managing symptomatic renal stones. however, in a rural kenyan setting, patients must be referred to centers (usually in faraway towns) where such services may be available. the services are costly and not readily affordable. this is why our patient (and his family) chose the cheaper, open stone removal approach this time and previously. besides, he was deemed to have a complex stone burden and thus unlikely to fully benefit from less-invasive approaches (el-husseiny & buchholz, 2012). the biochemical analysis of renal stones is only possible in advanced laboratories located in large diagnostic centers and is costly. this is why it had not been done previously for our patient. obviously, knowledge of the composition of the stones helps guide long-term preventative efforts (dawson & tomson, 2012). conclusion renal stones are increasingly being reported in both urban and rural kenya. foods that are rich in oxalate, calcium, and urate content; as well as concurrent medical illnesses (among other risk factors), may explain the occurrence and recurrence of renal stones in these populations. although a minimally invasive surgical approach is preferable for symptomatic stones, open surgery is indicated in selected patients. a biochemical analysis of the stones to determine their exact composition helps guide preventative efforts against stone recurrence. acknowledgement the authors acknowledge the following staff of st. joseph rv hospital, gilgil, for their assistance with managing this patient: fred aruwa, john kiprono, priscah kamau, and sonia nginyo from theater; francis wambugu, steve kiarie, and mary-hellen akinyi from the men’s ward; thomas kamau, silas odhiambo, rose makanga, joseph nginyo, and pauline nyagah from the outpatient department; and seth manera and steve nyagah from the hospital administration. references alelign, t., & petros, b. 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(2019). predictors of symptomatic kidney stone recurrence after the first and subsequent episodes. mayo clin proc, 94(2), 202-210. https://doi. org/10.1016/j.mayocp.2018.09.016 pa ge 1 pa ge 52 american journal of medical science and innovation (ajmsi) high-resolution ultrasonography versus mri in the diagnosis of achilles tendon lesions ahmed m. fahmy1* volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.2801 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 03, 2024 accepted: august 06, 2024 published: august 09, 2024 achilles tendon lesions are commonly assessed using noninvasive imaging methods such as ultrasound and magnetic resonance imaging (mri). both techniques are well-established in diagnosing and evaluating the condition of the achilles tendon. this prospective study aimed to compare the diagnostic efficacy of high-resolution ultrasonography and mri in identifying achilles tendon lesions. the focus was on understanding the respective strengths of each imaging modality in diagnosing different types of lesions, including tendinopathy, partial thickness tear, and full thickness tear. twenty patients, aged between 23 and 63 years, participated in the study, presenting with symptoms ranging from posterior ankle pain to limited movement and swollen ankles. ultrasonography, performed with patients in a prone position, examined the achilles tendon from its musculotendinous junction to its calcaneal insertion. mri, conducted with patients in a supine position, utilized axial and sagittal t1, t2-weighted images, stir, and proton density. among the 20 patients examined, diagnoses included eight cases of tendinopathy, five cases of partial thickness tear (one inconclusive by ultrasound), and seven cases of full thickness tear. the results indicate that ultrasound is comparable to mri in diagnosing tendinopathy and full thickness tear. however, mri demonstrates superiority in identifying partial thickness tears, while ultrasound excels in early enthesitis detection. ultrasound emerges as a valuable complementary diagnostic tool for achilles tendon lesions, demonstrating effectiveness comparable to mri in certain aspects. while mri outperforms in diagnosing partial thickness tears, ultrasound proves superior in the early detection of enthesitis. keywords ultrasound, magnetic resonance imaging, achilles tendon, tendinopathy, enthesitis 1 al azhar university, cairo governorate, egypt * corresponding author’s e-mail: ahmed_mf80@yahoo.com introduction the achilles tendon, a robust band of fibrous tissue connecting the calf muscles to the heel bone, plays a pivotal role in facilitating ambulation and overall lower limb functionality, despite its robust nature, the achilles tendon is susceptible to various pathological conditions, ranging from acute injuries to chronic degenerative changes, timely and accurate diagnosis of achilles tendon lesions is imperative for initiating appropriate therapeutic interventions and preventing long-term complications (silbernagel et al., 2020). in the realm of diagnostic imaging, both high-resolution ultrasonography (hrus) and magnetic resonance imaging (mri) have emerged as valuable tools for assessing achilles tendon pathology, each offering distinct advantages and limitations (gatz et al., 2021). historically, conventional diagnostic methods, such as physical examination and plain radiography, provided limited insights into achilles tendon pathologies, the advent of advanced imaging modalities has revolutionized the diagnostic landscape, enabling clinicians to delve deeper into the structural and functional aspects of the tendon (dams et al., 2017). high-resolution ultrasonography, characterized by its non-invasiveness, cost-effectiveness, and real-time capabilities, has gained widespread acceptance as an initial diagnostic tool for achilles tendon disorders. hrus allows for detailed visualization of the tendon’s morphology, facilitating the identification of abnormalities such as tears, tendinopathy, and bursitis (tang et al., 2022). magnetic resonance imaging, with its unparalleled soft tissue contrast and three-dimensional capabilities, has become the gold standard for evaluating musculoskeletal pathologies, including achilles tendon lesions (shalabi, 2004). mri provides a comprehensive assessment of the tendon’s integrity, revealing subtle changes in signal intensity indicative of degeneration, inflammation, or ruptures, mri allows for a holistic evaluation of the surrounding soft tissues, aiding in the identification of associated conditions and providing a broader context for clinical decision-making (chang & miller, 2009). despite the advantages offered by both hrus and mri, the choice between these imaging modalities in the diagnosis of achilles tendon lesions remains a subject of debate, several factors, including availability, cost, patient preferences, and the specific clinical scenario, influence the selection of the most appropriate imaging technique (dams et al., 2017). the comparative diagnostic accuracy of hrus and mri in detecting achilles tendon lesions has been a topic of interest among researchers and clinicians (gatz et al., 2021). existing literature highlights the sensitivity and specificity of hrus in detecting achilles tendon pathologies, emphasizing its utility as a first-line imaging modality, the real-time imaging capabilities of hrus enable dynamic assessments of the tendon during various ankle movements, providing valuable functional information (dams et al., 2017). pa ge 53 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 52-58, 2024 mri underscore its ability to provide high-resolution cross-sectional images, aiding in the precise localization and characterization of achilles tendon lesions, the multiplanar imaging capabilities of mri offer a comprehensive view of the tendon, enabling the identification of subtle changes that may be missed on ultrasonography, the drawbacks of mri, including higher costs, longer imaging times, and contraindications for certain patients, have fueled the ongoing discourse on the most judicious use of this modality in routine clinical practice (szaro et al., 2021). literature review gross anatomy of the achilles tendon the achilles tendon, renowned as the body’s most substantial tendon, is a robust connective tissue structure crucial for lower limb biomechanics, which originates from the convergence of the gastrocnemius and soleus muscles in the calf, forming a tendon that inserts into the calcaneus, and composed primarily of collagen fibers arranged hierarchically, the achilles tendon endows the ankle joint with strength and elasticity essential for activities like walking, running, and jumping, its histological composition contributes to the tendon’s ability to withstand considerable tensile forces while accommodating the dynamic movements of the ankle (freedman et al., 2014). high-resolution ultrasonography (hrus) and magnetic resonance imaging (mri) serve as invaluable tools in delineating the gross anatomy of the achilles tendon. hrus, utilizing a high-frequency transducer, provides real-time images with exceptional spatial resolution, allowing for dynamic assessments during ankle movements, study by khan et al. (2003) have emphasized hrus’s capability to capture subtle alterations in the tendon’s contour during plantarflexion and dorsiflexion, providing insights into its functional dynamics (khan et al., 2003). mri, with its superior soft tissue contrast and multiplanar imaging capabilities, excels in offering detailed cross-sectional views of the achilles tendon’s structure. this imaging modality provides a comprehensive assessment of the tendon’s integrity, enabling the identification of subtle changes indicative of degeneration, inflammation, or ruptures, study by szaro et al. (2021) underscores mri’s ability to precisely visualize the different components of the tendon, aiding in the identification of partial tears and complete ruptures (szaro et al., 2021). understanding the gross anatomy of the achilles tendon is fundamental for interpreting imaging findings accurately, both hrus and mri contribute significantly to this understanding, providing clinicians with a detailed insight into the structural nuances of the tendon, as we navigate through the comparative analysis of hrus and mri in diagnosing achilles tendon lesions, this foundational knowledge of the tendon’s gross anatomy will play a pivotal role in contextualizing the diagnostic capabilities of these imaging modalities (pierre-jerome et al., 2010). pathology of achilles lesions achilles tendon lesions encompass a spectrum of pathological conditions, each presenting unique challenges in diagnosis and treatment, tendinopathy, characterized by degenerative changes within the tendon without complete rupture, is a common affliction associated with pain, swelling, and functional impairment, high-resolution ultrasonography (hrus) and magnetic resonance imaging (mri) have proven instrumental in detecting early signs of tendinopathy (ferguson et al., 2019). hrus, with its high spatial resolution, enables the identification of hypoechoic areas within the tendon, indicative of intratendinous degeneration, the realtime imaging capabilities of hrus facilitate dynamic assessments, allowing clinicians to visualize alterations in the tendon’s structure during movement. conversely, mri’s ability to capture alterations in signal intensity aids in the early diagnosis of tendinopathy, providing valuable information for timely intervention (hodgson et al., 2012). partial tears, representing an intermediate stage between tendinopathy and complete ruptures, pose diagnostic challenges due to their variable presentations, hrus, with its dynamic imaging capabilities, can reveal disruptions in the tendon’s continuity during ankle movement, aiding in the identification of partial tears, mri’s multiplanar imaging, offering detailed cross-sectional views, facilitates precise localization and characterization of partial tears, contributing to comprehensive diagnostic insights (maffulli et al., 2011). complete ruptures, often associated with sudden forceful activities, require prompt and accurate diagnosis for appropriate management hrus, with its real-time imaging capabilities, visualizes complete disruption of the tendon fibers, enabling immediate identification of ruptures(elmaraghy et al., 2008). mri, with its ability to capture the extent of soft tissue damage and evaluate associated injuries, plays a crucial role in planning surgical interventions and predicting postoperative outcomes (nunna et al., 2023). the nuanced capabilities of hrus and mri in delineating the pathology of achilles tendon lesions contribute to their complementary roles in clinical practice, as we delve into the comparative analysis of these imaging modalities, understanding their efficacy in capturing the diverse manifestations of achilles tendon pathology becomes imperative for informed decision-making in the diagnostic and therapeutic landscape (aström et al., 1996). technique for imaging the achilles tendon the diagnostic efficacy of imaging modalities in assessing achilles tendon lesions is intricately tied to the techniques employed during examinations, both high-resolution ultrasonography (hrus) and magnetic resonance imaging (mri) have established protocols, each offering unique advantages in capturing the structural and pathological nuances of the achilles tendon (dams et al., 2017). pa ge 54 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 52-58, 2024 hrus involves the use of a high-frequency transducer, typically ranging between 7-18 mhz, to obtain detailed real-time images of the tendon. patient positioning is crucial, often in a prone or supine stance, allowing easy access to the posterior aspect of the ankle. dynamic imaging, including ankle plantarflexion and dorsiflexion, enhances the assessment by providing insights into the tendon’s response to stress. doppler ultrasound can be incorporated to evaluate vascularity, aiding in distinguishing between inflammatory and degenerative conditions (corvino et al., 2022). mri utilizes a strong magnetic field and radiofrequency pulses to generate detailed images. various sequences, such as t1-weighted, t2-weighted, and fat-suppressed sequences, offer different contrasts for a comprehensive assessment. the patient is positioned feet-first in the mri scanner, with the ankle typically in a neutral position. administration of gadolinium-based contrast agents may enhance the visualization of vascularity and inflammatory changes within the tendon (schmidt & payne, 2015). comparative studies, such as that conducted by alahmari et al. (2022), underscore the importance of standardized protocols in ensuring reliable results from both hrus and mri. meticulous attention to patient positioning, imaging parameters, and the incorporation of dynamic assessments optimizes the diagnostic potential of these modalities (alahmari et al., 2022). understanding the nuances of imaging techniques is pivotal for clinicians aiming to leverage the strengths of hrus and mri in diagnosing achilles tendon lesions, as we navigate through the comparative analysis, recognizing the impact of these techniques on diagnostic accuracy will contribute to a comprehensive understanding of the respective roles of hrus and mri in the clinical management of achilles tendon pathologies (reiman et al., 2014). this study aims to assess the diagnostic efficacy of highresolution ultrasonography versus mri in detecting achilles tendon lmodality, providing valuable insights to optimize the diagnostic approach for identifying and characterizing achilles tendon pathology. materials and methods study design this prospective study includes 20 patients whose ages ranged from 23 to 63 years and for the duration of one year between december 2019 to december 2020. sixteen patients complaining of posterior ankle pain, while in six patients had ankle swelling, three had limitation of movements with walking, four patients were involved in a car accident while two patients had sport-related trauma. all patients were subjected to history taking and clinical provisional diagnosis. this study was conducted according to the guidelines of the ethics committee of our university and was approved by our institutional review board; all patients gave us informed consent to be imaged in our study. privacy and confidentiality of all patients data were guaranteed and there has been a code number for every patient file that includes all investigations. all data provision were monitored and used for scientific purpose only. inclusion and exclusion criteria the inclusion criteria for this study encompassed both males and females without any age predilection. participants were required to present with unilateral posterior ankle pain and have a history of ankle trauma or problems resulting from a motor car accident. in contrast, the exclusion criteria excluded claustrophobic individuals who were unable to undergo mri scans. clinical examination patients underwent a comprehensive clinical examination, involving detailed history-taking encompassing personal, operative, drug, and family history. specific clinical tests, such as the thompson test and hyperdorsiflexion sign, were conducted to evaluate achilles tendon problems. imaging modalities ultrasound examination ultrasound examination performed using a philips hd 11 instrument with a 7–10 mhz probe, ultrasound examinations included longitudinal and transverse scans. thickness measurements were taken in the short axis image. mri examination mri examination conducted on a ge msow 1.5 tesla machine with standard circular extremity coils. sequences included scout t1-weighted images, axial and sagittal t1weighted images, axial and sagittal t2-weighted images with fat suppression, and sagittal short-tau inversion recovery (stir) images. ethical approval ethical considerations for this study involve obtaining approval from the local committees in the radiology department, college, and university prior to its commencement. it is ensured that there is no conflict of interest related to the study, authorship, and subsequent publication. moreover, the privacy of patient data and study results is a paramount concern, with a commitment to maintaining confidentiality. patients possess the right to maintain control over their information and have the assurance that their data will be handled with the utmost discretion and respect for their privacy. statistical analysis statistical analysis was performed using the statistical package for the social sciences (spss). patient characteristics were analysed using descriptive data. diagnostic data were statistically described in terms of frequencies (number of cases) and percentages when appropriate pa ge 55 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 52-58, 2024 results table 1 shows the demographic data of the studied group. age ranged from 23-63 years with a mean age of 41.667±9.99 years. male cases were 16 (80.0%) while female cases were 4 (20.0%) table 4 shows that 7 (35.0%) of cases are affected at the insertion site of the tendon while 13 (65.0%) are affected in the mid portion of the tendon. table 5 shows usg findings of the studied group and it show that 7 (35.0%) patients had full-thickness tear, 4 (20.0%) partial-thickness tear and 9 (45.0%) had tendinopathy.table 1: distribution of studied sample according to patient’s demographic data number percent age (years) ≤30 2 10.0 >30 18 90.0 range 23-63 mean±s.d. 41.667±9.99 sex male 16 80.0 female 4 20.0 table 2: distribution of studied sample according to patient’s complain/history complain/history number percent posterior ankle pain 16 80.0 swelling 6 30.0 motor car accident (mca) 4 20.0 limitation of movement 3 15.0 sport-related trauma 2 10.0 table 3: distribution of studied sample according to patient’s leg side leg side number percent leg side 6 30.0 left 14 70.0 right 20 100 table 5: distribution of studied sample according to patient’s usg findings usg findings number percent full thickness tear 7 35.0 partial thickness tear 4 20.0 tendinopathy 9 45.0 total 20 100 table 6: distribution of studied sample according to patient’s mri findings mri findings number percent full thickness tear 7 33.0 partial thickness tear 5 26.0 tendinopathy 8 41.0 total 20 100 table 7: distribution of studied sample according to patient’s usg diagnosis usg diagnosis number percent retro calcaneal bursitis 17 85 enthesophyte 10 50 increased tendon thickness 12 60 partial tear 4 20 full thickness tear 7 30 altered intrasubstance signal 20 100 table 4: distribution of studied sample according to anatomic location of lesion anatomic location number percent anatomic location 13 65 around the mid portion 7 35 insertion site 20 100 table 2 shows complain/history of the studied group and it show that 16 (80.0%) had posterior ankle pain, 6 (30.0%) had swelling, 4 (20.0%) had motor car accident (mca), 3(15.0%) had limitation of movement and 2(10.0%) had sport-related trauma. table 3 shows leg side of the studied group show that 6 (30.0%) are affected in left side and 14 (70.0%) are affected in right side. table 6 shows mri findings of the studied group and it shows that 7 (33.0%) patients had full-thickness tear while 5 (26.0%) patients had partial-thickness tear and 8 (41.0%) patients had tendinopathy. table 7 shows usg diagnosis of the studied group show that 17(85.0%) had retro calcaneal bursitis, 10(50.0%) had enthesophyte, 12(60.0%) had increased tendon thickness, 4(20.0%) had partial tear, 7(30.0%) had full thickness tear and 20(100.0%) had altered intrasubstance signal of tendon. table 8 shows mri diagnosis of the studied group show that 17(85.0%) had retro calcaneal bursitis, 4(20.0%) had enthesophyte, 12(60.0%) had increased tendon thickness, 5(25.0%) had partial tear, 7(30.0%) had full thickness tear and 20(100.0%) had altered intrasubstance signal. pa ge 56 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 52-58, 2024 the kappa coefficient was used to assess the agreement between usg and mri. the strength of agreement on diagnosis is considered as good (k=0.923), as shown in table 9. discussion the achilles tendon, the largest and strongest tendon in the human body, is frequently prone to injury due to increased participation in sports-related activities and overuse conditions (alrashidi et al., 2018). the diagnostic evaluation of achilles tendon abnormalities involves various imaging techniques, including plain radiography, computed tomography (ct), ultrasonography (us), and magnetic resonance imaging (mri) (moretti et al., 2020). according to nyssonen (2020), plain radiography and ct are limited in their ability to assess avulsion fractures, haglund’s deformity, or other bony pathologies (moretti et al., 2020). on the other hand, high-resolution us, particularly when performed with linear-array probes, has become increasingly important due to its costeffectiveness, speed, availability, and lack of ionizing radiation. us provides a detailed depiction of normal anatomical structures and is effective in evaluating tendon integrity. its dynamic capabilities enhance visibility, aiding in the identification, localization, and differentiation of various inflammatory conditions (sconfienza et al., 2015). the achilles tendon, with its fibrillar echotexture on us, consisting of densely packed longitudinally arranged collagen fibers, is highly sensitive to early diagnosis of enthesitis. moreover, us is more cost-effective than mri for this purpose (mascarenhas, 2020). however, mri, with its superior multiplanar capability and soft tissue contrast, plays a crucial role in diagnosing tendon injuries. it offers valuable insights into abnormalities in bones and soft tissues that may not be immediately evident in other imaging modalities (elgohary et al., 2017). the present study aimed to assess the role of highresolution ultrasonography versus mri in diagnosing achilles tendon lesions. inclusion criteria comprised 20 patients aged 23 to 63 years, presenting with ankle pain and, commonly, limitations in daily activities. the study noted a male predominance for achilles lesions, aligning with findings from previous research (nyyssönen, 2020). the affected zone in the achilles tendon was identified as the mid-portion, consistent with existing literature suggesting the zone of relative avascularity, located 2–6 cm from the calcaneal insertion, as commonly affected, tendinopathy, particularly full or partial thickness tears, emerged as the most prevalent disorders in the study (wong et al., 2018). both us and mri were utilized for diagnostic purposes, with tendinopathy diagnosed in eight cases through us. the study focused on the characteristic us and mri findings for tendinopathy, partial thickness tear, and full thickness tear, including alterations in tendon morphology, echogenicity, and disruptions in tendon fibers (hodgson et al., 2012). the findings of the study align with existing literature on the diagnostic reliability of us in cases of tendinopathy, partial thickness tear, and full thickness tear. ultrasound, with its dynamic and realtime capabilities, emerged as a valuable tool in primary clinics, offering advantages over static mri, particularly in terms of cost-effectiveness and physiological movement visualization (dong & fessell, 2009). the diagnostic evaluation of achilles tendon lesions requires a comprehensive understanding of the strengths and limitations of imaging modalities such as high-resolution us and mri. these techniques play complementary roles, with specific advantages in different clinical scenarios. the study contributes valuable insights into the diagnostic accuracy of these imaging modalities, with implications for clinical practice and potential avenues for further research in the field (dams et al., 2017). the achilles tendon, considered the largest and strongest tendon in the human body, is frequently prone to injury due to increased participation in sports-related activities and overuse conditions (alrashidi et al., 2018). the diagnostic evaluation of achilles tendon abnormalities involves various imaging techniques, including plain radiography, computed tomography (ct), ultrasonography (us), and magnetic resonance imaging (mri) (moretti et al., 2020). plain radiography and ct are limited in their ability to assess avulsion fractures, haglund’s deformity, or other bony pathologies (nyyssönen, 2020). on the other hand, high-resolution us, particularly when performed with linear-array probes, has become increasingly important due to its cost-effectiveness, speed, availability, and lack of ionizing radiation. us provides a detailed depiction of normal anatomical structures and is effective in evaluating tendon integrity. its dynamic capabilities table 8: distribution of studied sample according to patient’s mri diagnosis mri diagnosis number percent retro calcaneal bursitis 17 85 enthesophyte 4 20 increased tendon thickness 12 60 partial tear 5 25 full thickness tear 7 30 altered intrasubstance signal 20 100 table 9: kappa agreement test between the two methods according to patient’s diagnosis diagnosis usg mri no. % no. % retro calcaneal bursitis 17 85 17 85 enthesophyte 10 50 4 20 increased tendon thickness 12 60 12 60 partial tear 4 20 5 25 full thickness tear 6 30 6 30 altered intrasubstance signal 20 100 20 100 kappa agreement 0.923 pa ge 57 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 52-58, 2024 enhance visibility, aiding in the identification, localization, and differentiation of various inflammatory conditions (sconfienza et al., 2015). the achilles tendon, with its fibrillar echotexture on us, consisting of densely packed longitudinally arranged collagen fibers, is highly sensitive to early diagnosis of enthesitis. moreover, us is more cost-effective than mri for this purpose (mascarenhas, 2020). however, mri, with its superior multiplanar capability and soft tissue contrast, plays a crucial role in diagnosing tendon injuries. it offers valuable insights into abnormalities in bones and soft tissues that may not be immediately evident in other imaging modalities (elgohary et al., 2017). the present study aimed to assess the role of high-resolution ultrasonography versus mri in diagnosing achilles tendon lesions. inclusion criteria comprised 20 patients aged 23 to 63 years, presenting with ankle pain and, commonly, limitations in daily activities. the study noted a male predominance for achilles lesions, aligning with findings from previous research (nyyssönen, 2020). the affected zone in the achilles tendon was identified as the mid-portion, consistent with existing literature suggesting the zone of relative avascularity, located 2–6 cm from the calcaneal insertion, as commonly affected (wong et al., 2018). tendinopathy, particularly full or partial thickness tears, emerged as the most prevalent disorders in the study. both us and mri were utilized for diagnostic purposes, with tendinopathy diagnosed in eight cases through us. the study focused on the characteristic us and mri findings for tendinopathy, partial thickness tear, and full thickness tear, including alterations in tendon morphology, echogenicity, and disruptions in tendon fibers. the findings of the study align with existing literature on the diagnostic reliability of us in cases of tendinopathy, partial thickness tear, and full thickness tear. ultrasound, with its dynamic and real-time capabilities, emerged as a valuable tool in primary clinics, offering advantages over static mri, particularly in terms of cost-effectiveness and physiological movement visualization (dong & fessell, 2009). conclusion in conclusion, the achilles tendon, prone to injuries from sports activities, presents various conditions, and imaging modalities like mri and ultrasound play crucial roles in diagnosis. while ultrasound is cost-effective and dynamic, mri excels in assessing bone and soft tissue. ultrasound complements mri for tendinopathy and full-thickness tear diagnosis, but mri proves superior for partialthickness tears. the choice depends on clinical needs, with ultrasound excelling in early enthesitis detection. strengths and limitations the strength of this study is that the study contributes valuable insights into the diagnostic accuracy of highresolution ultrasonography versus mri in assessing achilles tendon lesions, enhancing our 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(2018). anatomy, bony pelvis and lower limb, achilles tendon. pa ge 1 pa ge 8 american journal of medical science and innovation (ajmsi) adrenal incidentaloma prevalence and clinical managementa retrospective study waleed abdalrazig dosogi elzain1*, abdullah mohammed alshalaan1, mohammed mana mohammed al qahtani1 hind ali abdullah al qahtani1, dawlah hadi assiri1, halimah hussain alshehri1, eman mohammed alsultan1 fahad obaid mohammed alnamshah1, mohammed abdullah salem alshehri1 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2332 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: december 17, 2023 accepted: january 22, 2024 published: january 24, 2024 this study aims to investigate the characteristics and prevalence of adrenal incidentalomas and subsequent clinical practice among patients in armed forces hospital southern region -saudi arabia, 2021. an observational retrospective study was conducted in armed forces hospital southern region -saudi arabia on the medical records of 383 consecutive patients. patients with incidental adrenal tumors who underwent abdominal ct scans with intravenous contrast during the period from january 2013 and december 2021. a total of 300 patients were included in this study. however, the data were analyzed using statistical tests. the results revealed that most patients with adrenal incidentalomas were above 60 (53.3%%). the gender distribution was nearly equal, with 50.3% females and 49.7% males. most observed tumors were unilateral (96.0%), while a small percentage was bilateral (4.0%). in terms of size, the majority were less than 1 cm (59.0%), followed by sizes greater than 4 cm (31.0%) and 1-4 cm (10.0%). further analysis indicated that 49.3% were found to have functioning tumors, while 50.7% had non-functioning tumors. the specific types of functioning tumors included non-functioning adrenal adenoma (50.7%), pheochromocytoma (16.9%), cushing’s syndrome (5.8%), and other functional tumor types (28.0%). most of these patients were not referred to endocrine clinics. adrenal incidentalomas are prevalent in the above-60 age group, with most tumors being non-functional. further research into adrenal incidentalomas associated with diabetes and hypertension is required. keywords adrenal incidentaloma, adrenal gland, cushing’s syndrome, diagnosis, imaging, surgery, tumor 1 armed forces hospital, southern region ksa, tamniah, saudi arabia * corresponding author’s e-mail: waleeddosogi@yahoo.com introduction an adrenal incidentalomas (ais) is an unexpected tumor in one or both adrenal glands. these tumors can be benign (non-cancerous) or malignant (cancerous) (nieman et al., 2013; terzolo et al., 2011). these include adrenal cysts, hematomas, adrenal cortical carcinomas, adenomas, pheochromocytomas, myelolipomas, ganglioneuromas, metastases from various cancers, and other rare forms (grumbach et al., 2003). an ais describes detecting an adrenal asymptomatic mass or tumor during imaging examinations such as computed tomography (ct) scans or magnetic resonance imaging (mris) used for unrelated purposes (francis & mayo-smith, 2023; jason & oltmann, 2019). usually, these tumors are identified in people without symptoms or indicators associated with the adrenal gland. abdominal ct scan has been widely used since the late 1970s and has proven highly effective in detecting adrenal pathology in individuals suspected of having adrenal disease. it is a valuable diagnostic tool for identifying abnormalities in the adrenal glands (chatzellis & kaltsas, 2019; kim et al., 2013). furthermore, the first laparoscopic adrenalectomy was reported by michel gagner in 1992, marking a significant milestone in the field. this minimally invasive surgical technique quickly became the preferred approach for treating benign adrenal diseases (serra, 2023). the adrenal glands or suprarenal glands are small endocrine glands in each kidney. despite their small size, these glands play a crucial role in hormonal regulation (kebebew, 2021). each adrenal gland is divided into two main parts: the adrenal cortex (outer cortex) and the adrenal medulla (inner medulla), which have different functions and produce distinct hormones (van slycke et al., 2022). these glands synthesize several necessary hormones, such as cortisol, aldosterone, and adrenaline. the hormones are essential for maintaining homeostasis, responding to stress, regulating metabolism, and influencing various bodily functions. any dysfunction or abnormalities in the adrenal glands can lead to hormonal imbalances and various health conditions (lyraki & schedl, 2021). most adrenal incidentalomas are nonfunctioning, meaning they do not generate abnormally high levels of hormones and manifest as symptoms (francis & mayo-smith, 2023). in many cases, adrenal incidentalomas do not cause symptoms and are nonfunctioning. however, some adrenal incidentalomas may exhibit certain symptoms and characteristics (imbroll et al., 2020; kim et al., 2013). literature review adrenal incidentalomas symptoms adrenal incidentalomas often do not cause specific symptoms directly related to the adrenal gland (jabarkhel, 2019). however, if the mass is large or functioning, it can cause symptoms related to hormone overproduction or local compression of nearby structures. these symptoms may include: hypertension (high blood pressure), excessive sweating, unexplained weight gain or weight pa ge 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 8-17, 2024 loss, palpitations or rapid heart rate, anxiety or panic attacks, abdominal or back pain (if the mass is large and causing compression), changes in menstrual cycles (in women), muscle weakness, and sleep disturbances (nieman et al., 2013). moreover, the characteristics of adrenal incidentalomas can be assessed through imaging studies, such as ct scans or mri (yilmaz et al., 2021). prevalence of ais the prevalence of adrenal incidentalomas has increased with the widespread use of imaging techniques (ichijo et al., 2020). these masses are often benign, but a small percentage can be cancerous. therefore, when an adrenal incidentaloma is detected, further evaluation is necessary to determine its nature and potential impact on health (sconfienza et al., 2023). due to limited population-based research, determining ai’s exact prevalence and incidence is challenging. the available data primarily comes from retrospective postmortem and radiological investigations, which lack comprehensive clinical information, may be biased in referrals, and involve varying patient selection criteria (chatzellis & kaltsas, 2019). the prevalence of adrenal incidentalomas in the general population ranges from approximately 1% to 6%, with the incidence increasing with age (kebebew, 2021). while these masses are rare in childhood, they affect around 3% of individuals over 50 and over 7% of those over 70 (jackson, 2023; jing et al., 2022) and even less frequently in individuals who are under 40 years old (sherlock et al., 2020). adrenal incidentalomas insights in 2018, a significant number of ct and mri scans were performed, with 6 million ct scans and 3.8 million mri scans (in any anatomical region) reported by the national health service (nhs) diagnostic imaging datasets (cuthbertson et al., 2023; kebebew, 2021). most adrenal incidentalomas are benign, but about 2% represent primary adrenal malignancies. morphological and functional status are the 2 key issues with an adrenal incidentaloma. ais are often benign adenomas with a malignancy incidence of between 1.9% and 4.7% (fassnacht et al., 2016). the majority of adrenal incidentalomas (80%) are nonfunctioning adenomas. autonomous cortisol secretion is the primary cause of adrenal hypersecretion, which accounts for 1%–29% of cases. pheochromocytomas account for 1.5%–14% of cases, and aldosterone-secreting tumors account for 1.6%–3.3% of cases (jackson, 2023). key considerations in managing ais adrenal incidentaloma (ai) is a hormonally functional or malignant tumor, (griffing, 2022) with 14% being functional tumors secreting excessive hormone levels (bancos & prete, 2021). the diagnosis and treatment of ai are significantly influenced by their size (aron et al., 2012) with adrenal masses less than 1 cm considered not real ai unless there are clinical symptoms of increased adrenal hormone production. (terzolo et al., 2011). the national institute of health (nih) consensus in 2002 categorized adrenal tumors into low risk, uncertain, and high risk (şenoğlu et al., 2022). moreover, ;arger than 6 cm tumors are generally considered surgically indicated due to the increased risk of malignancy (zeiger et al., 2011). the decision regarding surgical intervention is individualized for those measuring 4-6 cm, considering factors such as the patient’s overall health, symptoms, radiological characteristics, and the likelihood of malignancy (jackson, 2023; kahramangil et al., 2022). techniques like laparoscopic or retroperitoneoscopic adrenalectomy are commonly employed, offering advantages like smaller incisions, reduced postoperative pain, shorter hospital stays, and faster recovery compared to traditional open surgery (sada & mckenzie, 2023; sancho et al., 2012). therefore, this study aims to identify the prevalence of adrenal incidentaloma and subsequent clinical practice among 383 consecutive patients in armed forces hospital. materials and methods study design an observational and retrospective study approach was employed. ethical approval approval for the study was granted by the research ethics committee of armed forces hospital southern region, saudi arabia (afhsrmrec/2022/internal medicine/636). a written informed consent form from each participant was obtained. moreover, the study was carried out in conformity with the 1964 declaration of helsinki and any subsequent revisions, or with comparable ethical standards. study setting and period the study was conducted in armed forces hospital southern region saudi arabia, during the period from january 2013 and december 2021. study sample and population size the study examined the medical records of 383 consecutive adult patients who had undergone abdominal ct scans with intravenous contrast at the armed forces hospital southern region in saudi arabia. the researchers specifically focused on patients who were found to have adrenal incidentalomas during the study period, resulting in a total of 300 patients included in the study. inclusion and exclusion criteria the study’s inclusion criteria encompassed male and female adult patients aged 18 years or older who had undergone abdominal ct scans with intravenous contrast and were diagnosed with adrenal incidentalomas. the exclusion criteria depend on benign lesions, additional diagnostic workup, diagnostic clarity, urgent need for intervention, patient age, incomplete data, ethical or pa ge 10 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 8-17, 2024 legal considerations, radiological characteristics and other medical conditions. a total of 83 patients were excluded from the study who did not meet inclusion criteria. data collection the primary researchers used specific sampling methods to gather data from human participants, including recruitment, inclusion/exclusion criteria, and selection, while considering potential risks and benefits. data analysis the study used spss 25.0 version for data analysis, utilizing descriptive statistics and bivariate analysis to determine associations between outcome variables and influencing factors. categorical variables were analyzed using the chi-square test, while quantitative variables were analyzed using the t-test. a p-value of 0.05 or less was considered statistically significant. results the results section displays data analysis and statistical interpretations based on sampling methods and collected data. frequencies and percentages were used for statistical analysis. the demographic characteristics of participants are shown in table 1. the adenoma discovery and referral correlation are represented in table 2 and table 3, respectively. table 1 shows that out of the 300 patients with incidental adrenal tumors, 53.3% were above 60 years, 30% were between 41 and 60 years, and 16.7% were between 20 and 40 years. among the patients, 50.3% were females, and 49.7% were males, resulting in an almost equal male-to-female ratio (1:1). the majority of the patients, 96.3%, were of saudi nationality. non-saudi patients represented a smaller proportion, comprising only 3.7% (11 patients) of the total population. figure 1 presents information on patients’ frequency and percentage distribution based on three demographic factors: age, gender, and nationality. a total of 300 patients were included in the analysis. table 2 shows adrenal incidentalomas characteristics in a population of 300 patients. most were unilateral, with 59.0% measuring less than 1 cm. the remaining 31.0% had tumors larger than 4 cm. functioning tumors associated with hormonal secretion were 49.3%, while non-functioning tumors did not produce hormones. table 3 shows a significant association between referral to endocrine clinic, requesting doctor, and abdominal ct utilization, with a correlation between requesting doctors and endocrinologist referrals. figure 2 shows that 44.0% of abdominal ct scan requests were made by endocrinologists, with the remaining 56.0% made by other doctors, involving 300 patients. figure 3 demonstrates the distribution of unilateral and bilateral cases among the patients with adrenal incidentalomas. according to the data, 96.0% of the cases were unilateral, while only 4.0% were bilateral. figure 4 displays the distribution of adrenal incidentalomas table 1: the demographic data of the patients with incidentaloma factors frequency percent age 20 40 years 50 16.7% 41 60 years 90 30.0% above 60 years 160 53.3% gender male 149 49.7% female 151 50.3% nationality saudi 289 96.3% non saudi 11 3.7% figure 1: the demographic data of the patients with incidentaloma pa ge 11 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 8-17, 2024 table 3: the correlation between the referral to the endocrine clinic with the requesting doctor and abdominal ct using the chi-square test refer to the endocrine clinic total p value yes no requesting doctor endocrinologist 115 17 132 0.00* 50.0% 24.3% 44% others 115 53 168 50.0% 75.7% 56% abdominal ct unilateral 230 66 296 0.382 100.0% 94.3% 98.7% bilateral 0 4 4 0.0% 5.7% 1.3% *significant correlation figure 2: the frequencies of the specialty of requesting a doctor of ct figure 3: the distribution of the findings of adrenal incidentaloma in abdominal ct figure 4: the frequencies of the lesion size in abdominal ct table 2: the finding of incidental adenoma from abdominal ct and further workup frequency percent site unilateral 288 96.0% bilateral 12 4.0% size < 1 cm 177 59.0% 1 – 4 cm 30 10.0% >4 cm 93 31.0% activity functioning 148 49.3% non-functioning 152 50.7% pa ge 12 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 8-17, 2024 based on their sizes. according to the data, 59.0% of the incidentalomas were smaller than 1 cm, 31.0% were larger than 4 cm, and 10.0% measured between 1-4 cm. figure 5 shows that 50.0% of patients with adrenal incidentalomas were referred for further evaluation or management, while 24.3% were not referred. figure 6 shows that 50.0% of patients with adrenal incidentalomas were referred to others for further evaluation or management, while 75.7% were not referred. figure 7 shows that 30.2% of patients with adrenal incidentalomas underwent additional investigations, while 69.8% did not undergo further work-up. figure 8 shows patients with adrenal incidentalomas, with 49.3% having functioning tumors and 50.7% having nonfunctioning ones, after additional investigations. figure 9 shows that out of 18 patients with available findings, 50.7% had non-functioning adrenal adenoma, 16.9% had pheochromocytoma, 5.8% had cushing’s syndrome, and 28.0% had other functional adrenal tumors. figure 5: the distribution of the patients according to the referral to an endocrinologist after the incidental finding in abdominal ct figure 6: the distribution of the patients according to the requesting doctors to others after the incidental finding in abdominal ct figure 7: the distribution of the patients according to the further workup for the patients after the incidental finding in abdominal ct figure 8: the distribution of the patients according to the findings of further workup pa ge 13 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 8-17, 2024 discussion an adrenal incidentaloma is an adrenal lesion incidentally detected during a radiological examination for reasons unrelated to suspected adrenal disease (rowe et al., 2023; shaikh et al., 2023; zeiger et al., 2011). moreover, the evaluation of adrenal incidentaloma can be done by medical history, review of the patient’s symptoms, physical examination, body weight, pulse rate, blood pressure, genetic tests, and blood or urine testing to measure hormone levels and rule out pheochromocytoma (nieman et al., 2013). the present study examined 300 patients who underwent abdominal ct scans at the armed forces hospital southern region in saudi arabia to determine the prevalence and features of incidental adrenal tumors. the results showed that age significantly influences the formation of these tumors, with an increased prevalence observed in older age groups. the ratio of male to female cancers was almost equal, indicating no gender difference in the incidence. the majority of patients were saudi nationals, possibly due to the demographic characteristics of the population or the unique healthcare setting. unilateral tumors were more prevalent than bilateral ones, and most were small, measuring less than 1 cm. a significant number of tumors were non-functional, while a smaller portion secreted hormones. the study also found a significant correlation between the doctor’s request and the patient’s referral to the endocrine clinic. these findings can help in clinical decision-making and patient care. moreover, secreting syndromes can be diagnosed using various criteria, including cushing’s syndrome, primary aldosteronism, pheochromocytoma, and androgen or estrogen excess. cushing’s syndrome is diagnosed by elevated cortisol levels, confirmed by ufc measurements and salivary cortisol testing. primary aldosteronism involves tests like the aldosterone-to-renin ratio (arr) test, saline infusion test, captopril challenge test, and confirmatory salt-loading test. pheochromocytoma is diagnosed by measurements of plasma or urinary metanephrines or catecholamines, with imaging studies like ct or mri scans. adrenal gland disorders can be caused by various factors, including excessive hormone production, leading to functional tumors (yilmaz et al., 2021) like cushing’s syndrome, hyperaldosteronism, pheochromocytoma, congenital adrenal hyperplasia, and adrenal gland cancer (terzolo et al., 2012). conversely, non-functional tumors, such as adenomas, cysts, and less common conditions like fatty or blood cell tumors, can result from these conditions. it’s crucial to differentiate between hormonally active and non-functional tumors for better diagnosis and treatment (nieman et al., 2013). diabetes and hypertension are associated with adrenal incidentalomas, non-functional tumors that do not produce hormones (reimondo et al., 2020). some of them produce cortisol, which causes increased cortisol levels that might result in hypertension (szychlińska et al., 2023). adrenal incidentalomas that produce aldosterone can cause primary aldosteronism, leading to hypertension (hiraishi et al., 2011; vilela & almeida, 2017). severe hypertension can be caused by pheochromocytomas, which produce too much noradrenaline and adrenaline (zuber et al., 2011). adrenal incidentalomas and diabetes possess a less direct link than they do with hypertension. adrenal tumors can occasionally impact how the body processes glucose (higgs et al., 2022; muscogiuri et al., 2011). for example, cortisol-producing tumors can cause insulin resistance, which in certain people can progress to type 2 diabetes (higgs et al., 2022; sydney et al., 2019). however, not all incidentalomas of the adrenal gland are linked to either diabetes or hypertension. patients with adrenal incidentalomas need a complete evaluation, which should include hormonal testing, to identify if the tumor is overproducing hormones and contributing to these symptoms (arnaldi & boscaro, 2012; terzolo et al., 2012). moreover, the distribution of pathological origins in adrenal incidentalomas varies depending on important clinical factors, such as cancer history and tumor size (khalil & asa, 2023). when considering patients figure 9: the distribution of the patients according to the lab diagnosis of the patients pa ge 14 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 8-17, 2024 with a history of cancer, including lung, breast, kidney, and melanoma carcinomas, it has been observed that up to 75% of incidentalomas are metastases (samsel et al., 2023). however, in cases with no identified primary cancer site, the prospect of a metastatic lesion causing the adrenal incidentaloma is very low (dunn et al., 2022). instead, primary adrenocortical carcinoma becomes a more probable cause of a malignant adrenal tumor (demidowich et al., 2019). therefore, patients with an adrenal incidentaloma must undergo a comprehensive clinical evaluation (calissendorff et al., 2023). this evaluation should include a thorough assessment of medical history and a physical examination to exclude the presence of a functional tumor or an underlying malignancy (spartalis et al., 2019). the symptoms experienced by individuals with adrenal tumors can vary depending on whether the tumor is functional or nonfunctional, as well as the specific hormones being overproduced excessive cortisol production can lead to weight loss, skin stretch marks, acne, muscle weakness, depression, anxiety, fatigue, and sleep disturbances (nieman et al., 2013). women may experience hair growth, irregular menstrual periods, and elevated cortisol levels, leading to high blood pressure, blood sugar, and decreased bone density. excessive norepinephrine or epinephrine can cause symptoms like heartbeat irregularity, sweating, headaches, trembling, and pale complexion (nieman et al., 2013; terzolo et al., 2012). in patients with adrenal incidentalomas, the diagnostic approach should address two key questions: determining whether the lesion is malignant and assessing its hormonal activity (crafa et al., 2022). radiological assessment, utilizing computed tomography (ct) with both non-contrast and contrast phases, is the most effective method for distinguishing between benign and malignant adrenal masses by analyzing attenuation values expressed in hounsfield units (korivi & elsayes, 2013). surgical excision is recommended for adrenal tumors with suspicious radiological findings, most functional tumors, and all tumors larger than 4 cm without typical features of benign masses (zeiger et al., 2011). in addition, it is important to conduct hormonal evaluations for subclinical cushing’s syndrome and pheochromocytoma in all patients, and those with hypertension should be evaluated for hyperaldosteronism. initial hormonal assessments can include a combined 1-mg dexamethasone suppression test, plasma metanephrines, and aldosterone/plasma renin activity measurements for hypertensive patients (schumm et al., 2023; terzolo et al., 2012). consequently, the size of adrenal tumors plays a significant role in distinguishing between benign and malignant adrenal adenomas (farrugia et al., 2017). typically, tumors smaller than 3 cm are more likely benign, while malignant lesions are usually larger than 6 cm. different cutoff values, ranging from 4 to 6 cm, have been suggested for surgical removal of adrenal masses. however, a 5-cm homogenous adrenal mass with a non-contrast attenuation value of less than 10 hounsfield units (hu) has a very low risk of malignancy (wale et al., 2017). studies have shown that 5 to 25% of nonfunctioning adrenal masses can increase in size by at least 1 cm during follow-up, suggesting that size stability does not guarantee an adrenal tumor’s benign nature (bhat & tiyadath, 2017). furthermore, with the advancement of modern ct scanners, it has become easier to identify and differentiate both adrenal glands (suvannarerg et al., 2018). in some cases, it is even possible to distinguish between the cortex and medulla of the glands using ct scans. three key imaging criteria are crucial when distinguishing between benign and malignant adrenal lesions. these criteria include the lesion size, the ct attenuation value observed on an unenhanced ct scan, and the pattern of enhancement and de-enhancement, commonly called washout (zeiger et al., 2011). by assessing these criteria, radiologists can make a more accurate determination regarding the nature of the adrenal lesion (albano et al., 2019). during the time specified, a total of 383 consecutive patients underwent abdominal ct scans with intravenous contrast. however, this observational study involved 300 cases of incidental adrenal tumors to identify the prevalence of adrenal incidentaloma. according to abdurrahman c. et al., 2010, the most common radiological intervention used to detect adrenal masses is ct imaging (comlekci et al., 2010). their study also found that the age group most frequently affected by adrenal masses was above 60, slightly higher than that reported by bhargav p. et al.,2008 (bhargav et al., 2008). regarding gender distribution, the current study revealed that 50.3% of the patients were females and 49.7% were males, indicating a nearly equal male-to-female ratio. this finding aligns with the study conducted by bhargav p. et al.,2008 (bhargav et al., 2008). however, abdurrahman c. et al., 2010 (comlekci et al., 2010) reported a female predominance of approximately 70%, which differs from the current study. interestingly, a study by seong h. et al., 2018 reported a higher male predominance. these variations in gender distribution among different studies suggest that gender preferences may not be specific or consistent and could vary based on region-specific factors (ahn et al., 2018). the study revealed that only 44% of the ct scans were requested by endocrinologists, indicating a lack of awareness or consideration of adrenal incidentalomas by other healthcare providers. most adrenal incidentalomas were found to be unilateral (96%), with only (4%) of cases being bilateral. most of these tumors were small, measuring less than 1 cm (59.0%). however, bhargav p. et al., 2008 reported larger tumor sizes; in 91% of cases, the adrenal tumors were larger than 3 cm, while in 70% of cases, the tumors were larger than 6 cm (bhargav et al., 2008). further work-up was conducted for only 30% of the cases in the current study. among those who underwent further evaluation, 49.3% had functional adenomas, consistent with the findings of bhargav p. et al.,2008 who reported functional tumors in about 41.5% of cases. pa ge 15 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 8-17, 2024 moreover, seong h. et al., 2018 reported that most of the tumors were non-functional. although generally benign with small sizes and slow progression, functional tumors may be associated with developing conditions like diabetes mellitus and hypertension, particularly in individuals over 60 (ahn et al., 2018). furthermore, laboratory diagnosis revealed that 50.7% of the cases were non-functioning adrenal adenomas, 16.9% were pheochromocytomas, 5.8% were associated with cushing syndrome, and 28.0% were classified as other types. a significant correlation was observed between the requesting doctors and referral to endocrinologists. this finding suggests that patients referred by doctors other than endocrinologists are less likely to be directed to endocrine clinics, indicating potential neglect or management with other medical disciplines. in summary, the study highlights the underutilization of endocrinologists in evaluating and managing adrenal incidentalomas, primarily due to the prevalence of unilateral and small-sized tumors. functional tumors and referral patterns contribute to understanding the management of adrenal incidentalomas. surgery may be necessary for 85% of non-functioning tumors, and hormone treatment may be necessary for hormonal imbalances. consultation with a medical team, genetic counseling, and regular follow-up appointments are recommended. further, the study emphasizes the need for a multidisciplinary approach in assessing and treating diseases, especially in individuals aged 60 or older, and highlights no gender disparity in their occurrence. it underscores the importance of diligent surveillance in the elderly population for improved patient care. conclusion in conclusion, the study highlights the higher prevalence of adrenal incidentalomas in older individuals, with functional tumors in most cases, emphasizing the need for careful evaluation and monitoring. further research and guidelines are needed to understand the natural history, optimal evaluation strategies, and long-term outcomes of adrenal incidentalomas. patient education is important to facilitate their participation in decision-making and adherence to follow-up protocols. by implementing these recommendations, healthcare providers can enhance the management and outcomes of patients with adrenal incidentalomas, improving their overall care and well-being. strengths and limitations • it emphasizes the importance of a multidisciplinary approach involving endocrinologists, radiologists, and other specialists, to evaluate and manage these tumors. • however, the data was collected from a single center, which may limit generalizability to other settings or populations. recommendations based on the study’s findings, recommendations, as follows, can be made: • conduct more studies on ai prevalence and the association between htn and ai with dm, as well as further research on the relationship between htn and ai. • to maintain and enhance the recording system of the hospital. • healthcare professionals should be aware of the high prevalence of adrenal incidentalomas, particularly among individuals aged over 60 years. • long-term monitoring is essential to detect any changes in size or hormonal activity over time. • individualized treatment approaches should be tailored to each patient’s age, comorbidities, tumor size, and functional status. acknowledgments the authors thank the armed forces hospital southern region, saudi arabia, for their continuous support throughout the study. trial registration number approval for the study was granted by the research ethics committee of armed forces hospital southern region, saudi arabia and the registeration number is (afhsrmrec/2022/internal medicine/636). references ahn, s. h., kim, j. h., baek, s. h., kim, h., cho, y. y., suh, 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(2011). hypertension in pheochromocytoma: characteristics and treatment. endocrinology and metabolism clinics, 40(2), 295-311. pa ge 1 pa ge 31 american journal of medical science and innovation (ajmsi) attributes associated with burnout among pediatric residents in training hospitals of central visayas ellaine shiela marie corpuz1*, michelene e. escobar-buot1, mary ann a. wagas1 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3078 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 12, 2024 accepted: july 14, 2024 published: july 17, 2024 this study focused on burnout among pediatric resident physicians in central visayas, exploring its association with various factors and coping strategies. the research objectives aimed to describe the socio-demographic profiles of respondents, assess burnout levels, analyze psychological distress, examine associations between socio-demographic factors and burnout/psychological distress, and identify burnout factors and coping strategies. the study utilized a cross-sectional design involving 80 pediatric residents, using the maslach burnout inventory, patient health questionnaire, and self-assessment questions. the analysis included mean, standard deviation, chi-square, and fisher’s exact tests to explore associations and predictors of burnout. the findings revealed no incidence of burnout but indicated moderate emotional exhaustion, high depersonalization, and high personal accomplishment. the majority had experienced burnout in previous residency years. the top burnout factors were co-residents, conflicts, and consultants, while coping strategies included stress eating, exercise, and vacation leave. psychological distress ranged from mild to severe, with anxiety and depression prevalent among certain groups. the study suggests the need for work-life balance training to address burnout incidents, particularly in developing economies like the philippines. this recommendation aims to support the wellbeing of pediatric residents and improve their work-life balance. keywords burnout, psychological distress, pediatric resident physicians, central visayas 1 visayasmed hospital, philippines * corresponding author’s e-mail: esm.cpz@gmail.com introduction physician burnout is a growing problem worldwide causing mental fatigue, depersonalization, and diminished self-value. it is noted as more prevalent in an environment that is potentially intense and physically demanding or requires higher levels of commitment and resiliency, such as the pediatric residency program. according to the american academy of pediatrics (2022), the prevalence of burnout for all pediatric disciplines increased by 10% within a 3 year period (2011 to 2014). pediatric resident burnout is multifactorial and recent evidence has shown that burnout may begin as early during medical school and into residency period. among the demographics, it was reported that there was a higher prevalence of 20% to 60% burnout rate in women physicians than male counterparts (aap 2022). meanwhile, a significant association between burnout and anxiety was concluded (koutsimani, et al. 2019), and among the significant sources of anxiety are changes in workflow, and competing demands between service and training (franco, et al 2022). these factors may contribute to burnout, which affects the resident’s mental health, performance, and the quality of their training and has adverse consequences on patient care. burnout may be challenging to recognize, and many questionnaires have been developed to measure it. the most extensively used and considered standard is the maslach burnout inventory which includes three domains: emotional exhaustion, depersonalization, and personal accomplishment. this study investigated the incidence and attributes of burnout among pediatric residents in hospital-accredited training hospitals by the philippine pediatric society in central visayas. literature review respondents’ profile and burnout the incidence of burnout among physicians has certain demographic attributes and personal experiences linked with physician burnout. in general, females prefer a career in pediatrics compared to males and this may explain a higher work satisfaction and therefore less burnout risk. one study in jordan revealed that male residents were found to have significantly higher burnout and levels were significantly different among residency years (nimer et al, 2021). in some cases, burnout was associated with younger age groups as seen in those younger than 30 years old (ji et al 2020). unmarried residents were also seen to have higher burnout rates as married residents have the social support of their spouse which acts as a buffer for the period of the residency program and protects against the proneness of burnout (sreelatha et al., 2018). this contrasts with one study where a statistically significant relationship was noted between burnout and relationship status, where married residents suffered from higher emotional exhaustion and depersonalization (jamjoom & park, 2018). studies also show that as the years of residency increased, the burnout in all three dimensions also increased with the 3rd year residents having the highest burnout rates in all three dimensions. moreover, burnout pa ge 32 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 was prevalent and remained stable over at least 12 months among pediatric residents (kemper et al., 2019). nevertheless, burnout may not necessarily imply a strong association with profiles. some studies also showed that demographic variables like gender, ethnicity, marital status, and residential status did not reveal any significant association with the level of burnout (kemper et al., 2019; bari et al., 2019). incidence and factors of burnout the role of physicians has unique job factors and responsibilities that may predispose to significant burnout. studies have shown using the maslach burnout inventory that residents had high levels of burnout on at least one subscale in two components and or alarmingly high levels on all three subscales. it is multifactorial and some attribute it to working ≥40 hours per week (nimer et al 2021), sleep deprivation (kemper et al, 2019, ji et al., 2020), relationship with workers, feelings of isolation, dealing with patients’ psychosocial problems, disturbance of home/family life by work (nimer et al 2021, kemper et al, 2019), overloaded workloads, lack of autonomy (rotenstein et al, 2018), and recent medical errors (kemper et al, 2019). these factors can contribute to residents’ emotional exhaustion that can make the practitioner feel perpetually exhausted and annoyed, unaccomplished, and unappreciated. despite this, not all studies revealed the presence of burnout in all residents. one study in thailand showed none of their forty-one pediatric residents had high levels of burnout in all three domains of the maslach burnout inventory questionnaire, with a positive relation between educational climate (perceptions of role autonomy, perceptions of teaching, perceptions of social support) and work-related quality of life (kemper et al, 2019). predictive factors of decreased burnout also include resilience and mindfulness of stress (reed et al., 2018). other factors identified to reduce the risk of burnout include minimizing unnecessary or duplicated workload, scheduling time arrangements to avoid extension of regular duty hours, and clearly defining role expectations (puranitee et al. 2019). psychological distress and burnout research on burnout among physicians has increased awareness of physician mental health and well-being as an important issue. psychologic distress and burnout share risk factors, manifestations, and complications. some notable consequences of burnout include psychological alterations, a syndrome on concentration and memory problems, difficulty in decision-making, low coping capacity, anxiety, depression, dissatisfaction with life, insomnia, irritability, and increased consumption of alcohol and tobacco (laguia et al., 2022, brunsberg et al., 2019); health consequences manifested as physical health problems including musculoskeletal pain, stomach pains, cardiovascular disorders, headache, increased susceptibility to infections, insomnia and chronic fatigue and even a health risk for type 2 diabetes (laguia et al., 2022, roberts et al., 2021). high psychological distress has been associated with higher sickness rates, absenteeism, and diminished work performance that progresses to physical health issues (roberts et al., 2021). furthermore, for various reasons, those who suffer from depression or burnout can be slow to seek assistance leading to a two-fold increased risk of suicidal thoughts (brunsberg et al. 2019). work problems that cause distress were frequently adversely affected by episodes of psychological distress. screening positive for depression was associated with a 3.0-fold higher rate of harmful errors (brunsberg et al., 2019; okoro et al. (2024). hence, identifying any psychological distress among physicians may contribute to less frequency of burnout, or vice-versa, and is crucial in influencing the long-term mental health of physicians. in contrast to psychological stress, mindfulness, resilience, and self-compassion were longitudinally associated with lower stress and greater confidence in providing compassionate care and may be key areas for improved wellness (reed et al., 2018, kemper et al., 2020, brunsberg et al., 2019). attributes that are associated with burnout and compassion fatigue include the type of institution (government), sleeping hours (average of fewer than 4 hours per day), and interrupted leaves, while differences observed in compassion satisfaction and burnout were age, marital status (married), child dependents, higher level of training (ang et. al, 2021, kemper et al., 2020), location and type of institution (ang et. al, 2021). however, there also had been studies showing no association of demographic data between a positive screen for depression or burnout and age, gender, or year of residency (brunsberg et al., 2019). coping mechanism of burnout coping mechanisms are necessary to help overcome these stressors in the workplace. organizational ergonomic issues, including work stress and burnout of healthcare professionals, can negatively impact patient care and safety. burned-out physicians reported sub-optimal patient care practices that, in turn, are negatively associated with patient satisfaction. balancing activities addressed to individual stressors can contribute to improving the resident’s well-being thereby making the environment less stressful. mindfulness-based stress reduction for two and half hours a week for two months showed substantial improvements in burnout scores and mental well-being. taking vacations, exercising, and personal hobbies can contribute to reducing the level of burnout (alotaibi et al., 2019). quiet quitting, then, is often used to cope with burnout. it has been defined in a couple of different ways — some describe it as not actively going above and beyond at work, while others see it as doing only the bare minimum to remain employed. some defend quiet quitting as “just doing your job,” whereas others see it as passive resistance to redrawing the boundaries between their professional pa ge 33 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 and personal lives (quiet quitting, 2023). while burnout is not classified as a medical condition, it is important to note that it is an occupational phenomenon that can severely affect employees’ mental and physical health. this is different from having a bad week or a stressful project. burnout is a consistent and prolonged state of being in a non-productive state due to physical and psychological emotions often related to issues and factors in the workplace or living environment. burned-out workers are more likely to take a sick day, actively look for a different job, become less confident in their performance, and are more likely to visit the emergency room. when unaddressed, the costs of burnout are too big to ignore. the financial burden of work-related stress and burnout in the u.s. amounts to approximately $190 billion a year in additional healthcare expenses, and when absenteeism is added to the cost, turnover diminished productivity, and legal and insurance costs, it totals about $300 billion (rokka & khanal, 2023). burnout may be common in the workplace, but the physical symptoms and the broader consequences vary by person, role, and industry. in addition to creating and encouraging an empathetic culture, employers need to adopt a proactive approach to managing the unique needs of each employee. some employees benefit from feeling more involved at work, whereas others might need space to step away and decompress. managers cannot adopt a “one size fits all” approach to mitigating burnout. thus, this study is deemed important in addressing all the consequences mentioned earlier when pediatric residents suffer from burnout. statement of the problem this study determined the incidence and factors of burnout among pediatric resident physicians in central visayas. specifically, it aimed to: 1. describe the respondent’s profile in terms of age, sex, civil status, year graduated from the college of medicine, year level in residency training, and type of training institution. 2. determine the level of burnout incidence among respondents manifested in the following dimensions on emotional exhaustion, depersonalization, sense of personal accomplishment. 3. determine the level of psychological distress among respondents. 4. determine if there is an association between respondent’s profile and level of psychological distress among respondents. 5. determine if there is an association between respondent’s profile and level of burnout. 6. determine the factors and coping strategies of burnout among pediatric residents. theoretical framework this study was anchored on demand-resources theory and structural theory. demands–resources theory postulates that burnout happens when there is an imbalance between demands and resources at the workplace. work-related demands are those factors that require sustained physical or mental effort and are associated with certain physiological costs resulting from activation of the hypothalamic-pituitaryadrenal axis and psychological costs like subjective fatigue, the low focus of attention, and redefinition of work requirements. common work-related demands may include work overload, emotional labor, time pressure, or interpersonal conflicts. when recovery in the face of such demands is insufficient, physical, and mental exhaustion can be triggered (laguia et. al, 2022). on the other hand, work resources include the physical, psychological, and social aspects of work that can reduce the demands of work. the moment demands exceed resources, fatigue happens; if this imbalance is maintained over a period, fatigue may become chronic then burnout appears as emotional exhaustion, while the existence of work resources may inversely influence depersonalization by reducing its use as a coping strategy. structural theory postulates that burnout is a response to chronic work-related stress that occurs when the coping strategies employed by the practitioners in managing work stressors fail. at first, work stress will elicit a series of coping strategies. however, when prior coping strategies employed are not successful, it leads to professional failure hence a feeling of low personal fulfillment at work and emotional exhaustion will be developed. having these feelings, the practitioner develops depersonalization attitudes as a new form of coping mechanism (laguia et. al, 2022). scope and limitations this study was limited in determining the incidence and attributes associated with and coping mechanism of burnout. variables under study were respondent’s profile such as sex, age, civil status, residency year level, year graduated from the college of medicine, and type of training institution. other variables include the level of psychological distress and the three dimensions of burnout: emotional exhaustion, depersonalization, and a sense of personal accomplishment. it was conducted in 2024 and involved only the pediatric resident physicians from the twelve (12) accredited pediatric residency training hospitals by the philippine pediatric society in central visayas. respondents were only those with at least six months into the training program and who consented to participate in the study. the data was gathered using the patient health questionnaire for depression and anxiety (phq-4) to measure psychological distress and the maslach burnout inventory (mbi) for the incidence of burnout. methodology research design this study employed a descriptive cross-sectional design utilizing a survey questionnaire. this design is considered advantageous as it determined the incidence pa ge 34 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 and attributes associated with burnout and psychological distress among pediatric residents. literature pointed out that a cross sectional study is most suitable for estimating the incidence of a behavior in a population at a certain moment in time. study setting this study was conducted in twelve (12) hospitalaccredited pediatric residency training hospitals by the philippine pediatric society in central visayas, namely: cebu city medical center (n. bacalso ave., cebu city), cebu doctors university hospital (osmeña blvd., cebu city), cebu velez general hospital (f. ramos st., cebu city), chong hua hospital (fuente osmeña, cebu city), chong hua hospitalmandaue (mandaue city, cebu), gov. celestino gallares hospital (tagbilaran city, bohol), perpetual succour hospital (gorordo ave., cebu city), silliman university medical center (dumaguete city), southwestern university medical center (urgello st., cebu city), university of cebu medical center (mandaue city, cebu), vicente sotto memorial medical center (b. rodriguez st., cebu city) and visayasmed hospital (osmeña blvd., cebu city). study population and sampling technique this study included 80 residents from 100 pediatric resident physicians in 12 accredited pediatric residency training hospitals by the philippine pediatric society in central visayas, who had at least 6 months of residency training. the sample size is computed using a web calculator based on a 95% ci, 5% error, proportion of 50%, and population base of 100. research instruments the instrument used in this survey was a selfadministered online questionnaire in google form and is a modified adaptation of the maslach burnout inventory and patient health questionnaire-4 for depression and anxiety consisting of three parts. the first part comprised the general information on the sociodemographic characteristics of the respondents such as age, sex, civil status, year graduated from the college of medicine, residency year level, and type of training institution (government or private hospital). the second part comprised the 22-item maslach burnout inventory questionnaire which comprises three (3) domains: emotional exhaustion, depersonalization, and sense of personal accomplishment, a validated questionnaire to assess burnout and the four-item patient health questionnaire for depression and anxiety (phq4), to measure psychological distress, a validated brief screening tool for both anxiety and depression. the third part comprised the self-assessment questionnaire for burnout factors and the participant’s coping mechanism. no dialect translation will be done since all respondents are post-graduate level and can understand english. scoring procedure table 1: level of burnout (22-item maslach burnout inventory) dimension score (sum across domain-specific items) interpretation emotional exhaustion 17 and below low-level 18 to 29 moderate 30 and above high-level depersonalization five and below low-level 6 to 11 moderate 12 and above high-level sense of personal accomplishment (consequence of the first two) 33 and below high level 34 to 39 moderate greater than 40 low level burnout: high emotional exhaustion, high depersonalization, but low sense of personal accomplishment table 2: psychological distress: anxiety and depression (patient health questionnaire-4) score (sum of each of the four items) interpretation 0-2 normal 3-5 mild distress 6-8 moderate distress 9-12 severe distress statistical treatment of data data were statistically described in terms of mean ± sd, or frequencies when appropriate. comparison was done using student t, or chi-square (χ2) tests. fisher’s exact test was used instead when the expected frequency was <5, or when the assumptions of chi-square were violated. all tests were two-tailed, and the level of significance was set at p-value <0.05. ethical consideration the study complied with the ethical principles outlined in the declaration of helsinki and the national ethical a total score ≥3 for the first two questions suggests anxiety. a total score ≥3 for the last two questions suggests depression. pa ge 35 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 guideline for health and health-related research (2017). before the study initiation, the protocol was reviewed and approved by the institutional review board (irb) of visayasmed hospital. the researcher ensured that all records from the respondents were treated with strict confidentiality. their names were not reflected in the file for data analysis. instead, only the numbers corresponding to their names in the source code can be seen. the source code is in the possession of the researcher only. only the researcher and the biostatistician have sole access to collected data. excel sheets for data processing did not contain any information that would give away the identity of pediatric resident physicians. also, this paper is self-funded because it is intended for the compliance of residency training of the hospital and the philippine pediatric society, inc. thus, it is not funded by any organization or pharmaceutical companies that might benefit from the study results. results and discussions results profile of residents in terms of age, sex, civil status, year graduated from the college of medicine, year level in residency training, and type of training institution. table 3: sociodemographic profile of the respondents profile all respondents government private p-value n=80 n=17 n=63 age, years, (%) 20 – 29 30 (37.5) 3 (17.6) 27 (42.9) .100 30 – 39 48 (60.0) 14 (82.4) 34 (54.0) older than 40 2 (2.5) 2 (3.1) sex male 15 (18.8) 6 (35.3) 9 (14.3) .049 female 65 (81.2) 11 (64.7) 54 (85.7) civil status unmarried 67 (83.8) 15 (88.2) 52 (82.5) .572 married 13 (16.2) 2 (11.8) 11 (17.5) year graduated from the college of medicine before 2020 44 (55.0) 11 (64.7) 33 (52.4) .538 2020 13 (16.3) 3 (17.6) 10 (15.9) 2021 20 (25.0) 2 (11.8) 18 (28.6) 2022 3 (3.7) 1 (5.9) 2 (3.1) residency year level y1 34 (42.5) 9 (52.9) 25 (39.7) .142 y2 12 (15.0) 12 (19.0) y3 34 (42.5) 8 (47.1) 26 (41.3) table 3 presents the distribution of the respondents according to the socio-demographic profiles. there were 80 respondents to this survey, who were mostly from private training hospitals (78.75%). the difference in the proportion of respondents from private and government institutions is statistically significant (p<.0001). most of the pediatric residents were 30 years and older (62.5%), but those from the government institution were mostly 30 – 39 years old (82.4%). further, most of them were females (81.2%), from private (85.7%) and government hospitals (64.7%). they are mostly unmarried (83.8%) and are in their first year (42.5%) and third year (42.5%) of their residency training. there were no second-year respondents from the government institution. with this number of participants, this limits the findings since it resulted in a skewed result. level of burnout incidence among respondents as manifested in emotional exhaustion, depersonalization, and sense of personal accomplishment table 4: distribution of respondents’ level of burnout based on dimension (ee, dp, pa) and type training hospitals dimension all respondents government private p-value emotional exhaustion 13.1 ± 4.4 13.9 ± 4.6 12.9 ± 4.3 .375 low 66 (82.5) 13 (76.5) 53 (84.1) .461 moderate 14 (17.5) 4 (23.5) 10 (15.9) pa ge 36 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 table 4 shows the distribution of respondents on the level of burnout from different training hospitals under the subscales of emotional exhaustion, depersonalization, and sense of personal accomplishment. overall, the findings revealed that most of the respondents had low emotional exhaustion (82.5%) but moderate to high levels of depersonalization (76.2%). remarkably, respondents from both sectors displayed a high sense of personal accomplishment, demonstrating identical mean scores. legend: normative scores to calculate the level of burnout with the maslach burnout inventory emotional exhaustion (sum of scores) low: <17; moderate: 18-29; high: >30 depersonalization score (sum of scores) low: <5, moderate: 6-11; high: >12; sense of personal accomplishment (sum of scores) low: >40; moderate: 34-39; high: <33 depersonalization 8.2 ± 4.0 8.65 ± 4.3 8.13 ± 4.9 .636 low 19 (23.8) 4 (23.5) 15 (23.8) .985 moderate 41 (51.2) 9 (52.9) 32 (50.8) high 20 (25.0) 4 (23.5) 16 (25.4) sense of personal accomplishment 20.0 ± 4.1 20.0 ± 3.9 20.0 ± 4.2 .989 high 80 (100.) 17 (100.0) 63 (100.0) table 5: respondent’s responses to the burnout survey questionnaire questions no. of respondents percentage 1. in your current residency year, have you ever felt burned out during your previous years in residency? no 6 7.5 yes 74 92.5 2. if this is not your first time/exposure in pediatric residency training, can you recall if you have felt burnout? no 73 91.3 yes 7 8.7 3. what was your year level when you experienced burnout in your previous years in residency? none 29 36.3 y1 31 38.8 y2 6 7.5 y3 3 3.8 y1 & y2 5 6.3 y1, y2, y3 5 6.3 results from a survey questionnaire on burnout confirmed previous experience of burnout as shown in table 5 the respondents, when asked if they ever felt burned out during their previous years of residency, answered “yes” (92.5%). however, they could not recall (91.3%) when the first time they felt the feeling of burnout. however, some said it was in their first year of residency in training (38.8%). residents’ level of psychological distress and incidence of anxiety and depression table 6 shows the respondent’s level of psychological distress and incidence of depression and anxiety. generally, mild (5.7 ± 3.5) psychological distress can be noted among respondents, where the majority (52.9%) were from government training hospitals. it is table 6: respondents level of psychological distress and incidence of anxiety and depression dimension all respondents government private p-value n= 80 n=17 n=63 psychological distress 5.7 ± 3.5 5.5 ± 2.9 5.7 ± 3.7 .801 normal 16 (20.0) 2 (11.8) 14 (22.2) .564 mild 31 (38.8) 9 (52.9) 22 (34.9) moderate 22 (27.5) 4 (23.5) 18 (28.6) severe 11 (13.8) 2 (11.8) 9 (14.3) presence of anxiety 39 (48.8) 7 (41.2) 32 (50.8) .481 presence of depression 30 (37.5) 6 (35.3) 24 (38.1) .832 pa ge 37 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 noteworthy that almost half of the respondents had the presence of anxiety (48.8%), and depression (37.5%). and their emotional state did not significantly differ whether they were from the government or private training hospitals. association between residents’ profile and level of burnout on emotional exhaustion it can be gleaned from table 7 that there was no significant association between emotional exhaustion and each of the respondent’s sociodemographic profiles as indicated in p-values exceeding the 0.05 level of significance. however, it can be noted that there are pediatric physicians with moderate levels of emotional exhaustion including those 30 years and older (64.3%), psychological distress: normal 0-2; mild distress 3-5; moderate 6-8; severe 9-12 presence of anxiety: ≥3 for the first two questions (phq4) presence of depression: ≥3 for the last two questions (phq4) table 7: sociodemographic profile of the respondents and emotional exhaustion profile all respondents low moderate p-value n= 80 n=66 n=14 age, years, 20 – 29 30 (37.5) 25 (37.9) 5 (35.7) .782 30 – 39 48 (60.0) 39 (59.1) 9 (64.3) older than 40 2 (2.5) 2 (3.0) sex male 15 (18.8) 12 (18.2) 3 (21.4) .777* female 65 (81.2) 54 (81.8) 65 (81.6) civil status unmarried 67 (83.8) 57 (86.4) 10 (71.4) .169 married 13 (16.2) 9 (13.6) 4 (28.6) residency year level y1 34 (42.5) 28 (42.4) 25 (39.7) .142 y2 12 (15.0) 11 (16.7) 12 (19.0) y3 34 (42.5) 27 (40.9) 26 (41.3) type of training institution government 17 (21.3) 13 (19.7) 4 (26.6) .461 private 63 (78.7) 53 (80.3) 10 (71.4) legend: significant at p<0.05 alpha level; s *significant; ns-not significant females (81.6%), unmarried (71.4%), 3rd-year residents (41.3%), and those from private institutions (71.4%). association between profile and level of burnout on depersonalization table 8 describes the association between the sociodemographic profile of the respondents and the level of depersonalization. data revealed that there is no significant association between the level of depersonalization and their socio-demographic profile, except for age, with a p-value of 0.45 which is lower than the significant value of 0.05. moreover, there are pediatric physicians with high levels of depersonalization with an age range of 30 to 39 years old (50.0%), females (75.0%), unmarried (95.0%), in their third year of residency training (55.0%) and mostly from private training hospitals (80.0%). table 8: profile of the respondents and level of depersonalization profile all respondents low moderate high p-value n= 80 n=19 n=41 n=20 age, years, (%) 20 – 29 30 (37.5) 8 (42.1) 12 (29.3) 10 (50.0) .045 30 – 39 48 (60.0) 9 (47.4) 29 (70.7) 10 (50.0) older than 40 2 (2.5) 2 (10.5) sex male 15 (18.8) 10 (24.4) 5 (25.0) .056 pa ge 38 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 female 65 (81.2) 19 (100.0) 31 (75.6) 15 (75.0) civil status unmarried 67 (83.8) 15 (78.9) 33 (80.5) 19 (95.0) .286 married 13 (16.2) 4 (21.1) 8 (19.5) 1 (5.0) residency year level y1 34 (42.5) 12 (63.2) 16 (39.0) 6 (30.0) .215 y2 12 (15.0) 1 (5.3) 8 (19.5) 3 (15.0) y3 34 (42.5) 6 (31.5) 17 (41.5) 11 (55.0) type of training institution government 17 (21.3) 4 (21.1) 9 (22.0) 4 (20.0) .985 private 63 (78.7) 15 (78.9) 32 (78.0) 16 (80.0) legend: significant at p<0.05 alpha level; s *significant; ns-not significant residents’ profile and level of psychological distress table 9 shows the association between the respondent’s sociodemographic profile and their level of emotional distress. the analysis of respondents across various levels of psychological distress reveals diverse trends. firstly, respondents predominantly fall into the normal and mild distress categories, with smaller proportions in the moderate and severe categories. despite this, individuals in the 30-39 age group exhibit higher representation across all distress levels, although there is no significant difference in age distribution among the distress levels. females constitute the majority across all distress levels, with variations in the distribution of males and females, yet not statistically significant. additionally, unmarried individuals dominate all distress levels, with a higher percentage in the severe distress category, though the difference in civil status distribution among distress levels is not statistically significant. moreover, the distribution of residents across different year levels remains relatively balanced across distress levels, with no significant difference observed. similarly, respondents from private training institutions form the majority across all distress levels, with no significant disparity in distribution between government and private training institutions among distress levels. overall, while certain demographic groups exhibit higher representation across distress levels, there are no significant associations in age, gender, civil status, residency year level, or institutional affiliation distribution among the distress levels. table 9: profile of the respondents and level of emotional distress profile all respondents normal mild moderate severe p-value n= 80 n=16 n=31 n=22 n=11 age, years, n (%) 20 – 29 30 (37.5) 4 (25.0) 12 (38.7) 10 (45.5) 4 (36.4) .783 30 – 39 48 (60.0) 11 (68.8) 18 (58.1) 12 (54.5) 7 (63.6) older than 40 2 (2.5) 1 (6.2) 1 (3.2) sex male 15 (18.8) 3 (18.8) 4 (12.9) 7 (31.8) 1 (9.1) .280 female 65 (81.2) 13 (81.2) 27 (87.1) 15 (68.2) 10 (90.9) civil status unmarried 67 (83.8) 13 (81.3) 24 (77.4) 20 (90.9) 10 (90.9) .526 married 13 (16.2) 3 (18.7) 7 (22.6) 2 (9.1) 1 (9.1) residency year level y1 34 (42.5) 7 (43.8) 14 (45.2) 8 (36.4) 5 (45.5) .987 y2 12 (15.0) 2 (12.5) 5 (16.1) 3 (13.6) 2 (18.2) y3 34 (42.5) 7 (43.8) 12 (38.7) 11 (50.0) 4 (36.3) type of training institution government 17 (21.3) 2 (12.5) 9 (29.0) 4 (18.2) 2 (18.2) .564 private 63 (78.7) 14 (87.5) 22 (71.0) 9 (81.8) 9 (81.8) pa ge 39 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 association of profile and anxiety and depression table 10 explains the sociodemographic profile of the respondents and the incidence of anxiety and depression. it can be gleaned that there was no significant association between each of the socio-demographic profiles of the respondents and the prevalence of anxiety and depression. however, data shows that anxiety is prevalent among older pediatric resident physicians. its distribution level across different age groups shows a higher percentage (53.8%) of residents between 30 to 39 years old compared to those aged 20-29 (43.6%). most individuals experiencing anxiety and depression are females (a=79.5%, d= 73.3%), and unmarried (a=89.7%, d=90%). the distribution of anxiety and depression levels across residency year levels varied where the incidence of anxiety was more seen among 1st-year residents while the incidence of depression was more seen among those in their 3rd year of residency, and most were from private training hospitals. table 10: profile of the respondents and the presence of anxiety and depression profile anxiety p-value depression p-value n= 39 n=30 age, years, (%) 20 – 29 18 (46.2) .142 12 (40.0) .527 30 – 39 21 (53.8) 18 (60.0) older than 40 sex male 8 (20.5) .694 8 (26.7) .160 female 31 (79.5) 22 (73.3) civil status unmarried 35 (89.7) .156 27 (90.0) .240 married 4 (10.3) 3 (10.0) residency year level y1 17 (43.6) .686 12 (40.0) .837 y2 7 (17.9) 4 (13.3) y3 15 (38.5) 14 (46.7) type of training institution government 7 (17.9) .481 6 (20.0) .832 private 32 (82.1) 24 (80.0) distribution of the attributes of burnout table 11 illustrates the factors of burnout. the top three factors of burnout are caused by co-residents (42.5%), misunderstanding and interpersonal conflicts (40.0%), and consultants (37.5%). all three are about human factors and their interaction in the workplace. meanwhile, most pediatric resident physicians were least bothered about work schedules, the other people in the hospitals, and bullying as it ranks the lowest three among the identified factors (8%,9%, and 11% respectively). meanwhile, there was no in-depth interview conducted to support how these top three (3) identified factors specifically attributed to the respondent’s burnout which limits the findings of the study. table 11: attributes of burnout attributes no. of respondents percentage co-residents 34 42.5 misunderstanding, interpersonal conflicts 32 40.0 consultants 30 37.5 workload 23 28.7 living alone 18 22.5 loneliness 18 22.5 overload, unfair workload 16 20.0 bullying 9 11.3 other people in the hospital 7 8.8 work schedule 6 7.5 pa ge 40 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 coping mechanisms on factors of burnout table 12 shows the respondents’ coping mechanisms. the most common coping mechanism reported by respondents is indulging in food trips, with 72.5% of individuals using this method. some went to wellness and self-care activities such as yoga, massage, spa, and exercise (43.8%), while some went on vacation leave (41.3%). although there were a few who opted to quit (2.5%) and did online shopping (1.3%), diving or shooting (1.3%) which is somewhat scary, and one has opted to seek professional help (1.3%). the burnout for this resident is deep because they opted to seek professional help. table 12: coping mechanisms coping no. of respondents percentage food trip 58 72.5 exercise, yoga, spa, massage 35 43.8 vacation leave 33 41.3 drinking 11 13.8 sleeping 7 8.8 binge-watching, video games 5 6.3 quitting 2 2.5 online shopping 1 1.3 sought professional help 1 1.3 diving, shooting 1 1.3 table 13: training plan on work-life balance for pediatric physicians area of concern specific objectives strategies/ activities persons involved source of fund expected outcome u nd er st an di ng w or kli fe b al an ce in cr ea se a w ar en es s of w or klif e ba la nc e im po rt an ce id en tif y pe rs on al v al ue s an d pr io rit ie s r el at ed to w or k an d lif e c on du ct w or ks ho ps on w or klif e ba la nc e co nc ep ts. fa ci lit at e se lfas se ss m en t e xe rc ise s f or va lu es a lig nm en t re sid en t p hy sic ia ns , tr ai ni ng c or e re pr es en ta tiv e h os pi ta l b ud ge t in cr ea se d aw ar en es s a nd al ig nm en t w ith w or klif e ba la nc e pr in ci pl es ti m e m an ag em en t a nd pr io rit iz at io n d ev el op e ff ec tiv e tim e m an ag em en t s ki lls . se t r ea lis tic g oa ls an d pr io rit ie s ti m e m an ag em en t w or ks ho ps a nd se m in ar s g oa l-s et tin g se ss io ns w ith m en to rs re sid en t p hy sic ia ns , tr ai ni ng c or e re pr es en ta tiv es , m en to rs h os pi ta l b ud ge t e nh an ce d pr od uc tiv ity an d go al a ch ie ve m en t th ro ug h im pr ov ed tim e m an ag em en t st re ss m an ag em en t a nd se lfc ar e d ev el op c op in g st ra te gi es fo r s tre ss m an ag em en t. pr om ot e ho lis tic se lfca re p ra ct ic es st re ss m an ag em en t w or ks ho ps an d co un se lin g se ss io ns re sid en t ph ys ic ia ns , tr ai ni ng c or e re pr es en ta tiv es , m en to rs h os pi ta l b ud ge t im pr ov ed w el lbe in g, re du ce d bu rn ou t r at es , an d in cr ea se d re sil ie nc e c om m un ic at io n an d bo un da ry se tti ng e nh an ce co m m un ic at io n sk ill s. se t a nd m ai nt ai n pr of es sio na l bo un da rie s c om m un ic at io n w or ks ho ps bo un da ry -s et tin g ex er ci se s re sid en t ph ys ic ia ns , tr ai ni ng c or e re pr es en ta tiv es , m en to rs h os pi ta l b ud ge t im pr ov ed in te rp er so na l re la tio ns hi ps a nd w or klif e ba la nc e pa ge 41 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 31-43, 2024 m en to rs hi p fo st er m en to rs hi p re la tio ns hi ps m en to rs hi p pr og ra m s re sid en t ph ys ic ia ns , tr ai ni ng c or e re pr es en ta tiv es , m en to rs sp on so rs hi p, d ep ar tm en t fu nd s e nh an ce d ca re er sa tis fa ct io n an d gu id an ce c on tin uo us su pp or t a nd e va lu at io n e va lu at e pr og ra m ef fe ct iv en es s pr og ra m ev al ua tio n an d fe ed ba ck v ia g oo gl e fo rm s re sid en t ph ys ic ia ns , tr ai ni ng c or e re pr es en ta tiv es , m en to rs sp on so rs hi p, d ep ar tm en t fu nd s su st ai ne d w or klif e ba la nc e pr ac tic es an d pr og ra m im pr ov em en t ta sk pe rf or m an ce be ha vi or an d g ro up pr oc es s pr om ot in g ca m ar ad er ie te am bu ild in g a ct iv ity re sid en t ph ys ic ia ns an d tra in in g co re g ro up sp on so rs hi p an d de pa rt m en t fu nd s d ev el op ca m ar ad er ie conclusions pediatric resident physicians in central visayas had no burnout incidence with subscales showing only moderate emotional exhaustion, high depersonalization, and high personal accomplishment. most of them had an age range of 30-39 years old, female, unmarried, and graduated before 2020. the residents’ profiles except for age, are not significantly associated with burnout outcome domains. further, residents have psychological distress ranging from mild to severe. anxiety and depression were prevalent among older residents, female, unmarried, and in the first year of residency and those from private training hospitals. majority of the respondents (92.5%) had experienced burnout during their previous residency years. the top three attributes to burnout are co-residents, misunderstanding and interpersonal conflicts, and consultants. the top 3 coping mechanisms are wellness and self-care activities such as food trips, going to yoga, massage, spa and exercise, and vacationing. recommendations pediatric resident burnout is multifactorial and based on the findings of the study, the researcher recommends a proposed comprehensive training plan that is developed and tailored specifically for pediatric resident physicians in central visayas, philippines. meanwhile, pediatric resident physicians must be more aware of their self-care practices in coping with psychological distress and the attributes of burnout in the exercise of self-preventive measures for a worthwhile life as practitioners. the hospital institutions and training providers could help strengthen its support facilities by giving priority to crafting 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(2016). factors associated with burnout among residents in a developing country. annals of medicine and surgery, 6, 60–63. https://doi. org/10.1016/j.amsu.2016.01.090 pa ge 1 pa ge 35 american journal of medical science and innovation (ajmsi) pediatric epilepsy and its health conditions in uae: a review article haitham elsayed elsadek1* volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2539 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: february 10, 2024 accepted: march 24, 2024 published: march 28, 2024 epilepsy is one of the major public health concerns in arab countries, as it contains a total of 80% of cases worldwide. there are two age peaks for onset: childhood and adulthood, but children experience the highest burden. epilepsy in childhood can have an impact on educational performance as well as psychological and social interaction. epileptic patients are also susceptible to a wide range of other frequent health issues. the co-morbidities often cause more burdens and difficulties than the seizures themselves. pathologically, epilepsy is of three types: acquired, idiopathic, and developmental or genetic origin. the disease is based on glutamate and gaba excitation and inhibition, respectively. eeg, mri, pet, spect, and ct scan are among the main diagnostic procedures available for the treatment. this review covered all the research studies published in peer-reviewed journals on web of science between 2014 and 2024. it focused on seeking a better understanding of epilepsy, its kinds, accessible therapies, and co-morbidities by providing significant insights that can benefit the uae’s healthcare system. eeg and mri are the two effective techniques used for epilepsy treatment. the uae healthcare system should focus on adopting the genetic basis of the disease for a precise and targeted treatment. keywords children, epilepsy, eeg, generalized seizures, mri 1 alzahra hospital dubai, sheikh zayed rd, al barsha & dubai health authority, p. o. box 1853, al karama, opposite burjoman center, bur dubai, dubai, united arab emirates * corresponding author’s e-mail: dr_hytham3000@yahoo.com introduction epilepsy is known as a brief recurrence of symptoms and indicators brought on by erratic, synchronous, or excessive neuronal activity in the human brain (hussein et al., 2018; naseer, 2022). several uncontrollable body movements, either the whole body or a specific body part, can cause epilepsy. extreme or unusual electrical charge disruptions in the various parts of the brain cause epileptic seizures ranging from brief attention spans to protracted spasms (panebianco et al., 2016). undesirable clinical features can generally follow epileptic seizures. patients experience neurological, behavioural, and emotional consequences from these seizures, particularly if they recur frequently (swanson et al., 2024). even though epilepsy is one of the oldest known conditions in the world, dating back to 4000 bc in written records, the general public’s perspective of the condition has not changed much over time. it is still dominated by myths and incorrect notions (kaculini et al., 2021). epileptic patients face prejudice and social stigma, misunderstandings, and unfavourable views about the condition in general, which may avert these people from getting treatment and living self-assured lives (anwar et al., 2020). epilepsy is defined as a chronic, non-communicable brain disorder characterized by neurobiological, cognitive, psychological, and social implications, as well as seizure recurrences by abnormal electrical activity of the brain (beghi, 2020; tenney, 2020). pediatric epilepsy, the term used to describe the disease when it appears in the pediatric population, is a complex neurological disorder that covers a diverse range of seizure types. seizures can be apparent as staring spells, convulsions, subtle facial twitches, or short lapses in consciousness. an epileptic seizure is a brief episode of signs and symptoms brought on by abnormally high or synchronized brain neuronal activity based on guidelines of the international league against epilepsy (fisher et al., 2014), according to pediatric research that uses the international classification of epileptic seizures, (perucca et al., 2018; schubert-bast et al., 2023). to understand pediatric epilepsy, a thorough knowledge of age-specific parameters must be required because seizures can appear in various ways depending on the age of the child. infants may show modest symptoms like cyclic eye movements, while older kids may have more apparent convulsions (manokaran et al., 2024). besides clinical issues, children with pediatric epilepsy may have significant challenges to their social, cognitive, and emotional development (naseer, 2022). seizures can affect a child’s learning, memory, and focus, adversely affecting academic performance and general quality of life. moreover, social isolation and psychological issues for the children and their families might be intensified by the stigma attached to epilepsy (clifford et al., 2023). the present study aimed to enhance the understanding of epilepsy, its types, available treatments, and co-morbidities by contributing valuable insights that can improve the uae’s healthcare system. literature review types of epilepsy generalized seizure epilepsy: generalized seizure epilepsy is caused by a widespread, excessive electrical discharge that simultaneously affects both the brain hemispheres. when the entire brain is involved, there may be a rhythmic, whole body jerking with stiff limbs, loose muscle tone, and blink-and-stare symptoms. generalized seizure epilepsy is divided into (guerrini et al., 2019): pa ge 36 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 35-42, 2024 idiopathic generalized epilepsy idiopathic generalized epilepsy, the most prevalent type of epilepsies in children and teenagers, is characterized by distinct seizure patterns, onset age, and distinctive electroencephalogram (eeg) abnormalities. about 15-20% of all epilepsies are classified as idiopathic generalized epilepsies (iges), and a majority of them are also known as genetic generalized epilepsies (gges). cryptogenic generalized epilepsy cryptogenic generalized epilepsy is defined as seizures whose genesis is unclear but thought to be symptomatic. almost 40% of all adult-onset cases have cryptogenic epilepsy, with a small percentage in the pediatric age group (chow & poon, 2022). anti-epileptic medications are generally used for the treatment of many epilepsy cases, and 50% of patients can live a seizure-free life after the treatment. however, the prognosis of cryptogenic epilepsy is unclear, and despite intensive therapy, seizures return frequently. the likelihood of recurrence is 48% after two years for cryptogenic seizures with an abnormal eeg. symptomatic generalized epilepsy symptomatic epilepsies are focal or diffuse brain abnormalities and are classified by numerous etiological classifications, including structural, genetic, metabolic, immunological, infectious, and unknown. focal seizure epilepsy focal seizures are triggered by an aberrant electrical discharge in any brain hemisphere. these seizures are further divided based on how they affect the child’s memory, consciousness, and memory. partial seizure is another name for focal seizure epilepsy. according to population-based studies, up to 60% of all seizures (specchio et al., 2022). it is crucial to characterize the symptoms and indications of focal seizures. brain trauma, infections, strokes, and tumours are the leading causes of focal seizures and epilepsy. only a small portion of the brain is affected, so a child is fully conscious during a seizure. the common types of focal seizure epilepsies are: gelastic epilepsy gelastic epilepsy is characterized by rare epileptic symptoms represented by fits of stereotyped laughing or smiles that last for less than a minute. these laughs are unprovoked and not triggered by external factors. the primary aetiology of gelastic epilepsy is its wellestablished correlation with hypothalamic hamartoma in children. the seizures of gelastic epilepsy are started with high frequency in childhood, early puberty, and general cognitive impairment (mirandola et al., 2023). temporal epilepsy the majority of focal seizures started in the temporal lobe region of the brain fall under the category of temporal epilepsy. these seizures are divided into mesial and neocortical or lateral temporal epilepsy based on involved neural circuity (maizuliana et al., 2020). seizures with mesial temporal epilepsy originate from the amygdala, entorhinal cortex, parahippocampal gyrus, and hippocampal regions. the temporal neocortex, parietal and occipital junctions, and the associative sensory areas (language, hearing, and vision) are the brain regions implicated with neocortical temporal epilepsy. apart from neurological aspects, psychological co-morbidities such as anxiety, inter-ictal dysphoria, and depression with cognitive, behavioural, and learning impairment are frequently observed in temporal epilepsy, especially in the pediatric population (vinti et al., 2021). mechanism of epilepsy epilepsy, the most prevalent neurological condition, is characterized by recurring seizures. long-term recurrent seizures may result in mental illnesses and cognitive impairment, which can negatively impact the ability to social engagement and work opportunities of an epileptic patient (chen et al., 2020). although the exact mechanism of epilepsy is still unknown, it is generally considered a self-facilitated pathological process brought on by brain injury that eventually causes dysfunction of ionic pathway, nerve damage, inflammation, mossin fibrosis, and synaptic plasticity (gan & südhof, 2020). many researchers have demonstrated that over-excitation of n-methyl-d-aspartate receptors (nmdars) results in neuronal death by increasing the levels of aspartate and glutamate in various neurological conditions such as epilepsy, alzheimer’s disease, stroke and parkinson’s disease (chen et al., 2022; essiz et al., 2021; fricker et al., 2018; singh & panda, 2024). in central nervous system, nmdar is the primary excitatory receptor involved in the synapses of glutamatergic neurons and gabaergic interneurons (chen et al., 2022; hanada, 2020). nmdars are hetero-tetramers found in the brain that are generally made up of two glun1 subunits and four different subunits of glun2 (glun2a-d), or a combination of glun2 and two different glun3 (glun3a and 3b) subunits. recent findings indicate a strong connection between the nmdar subunit encoding genes and epilepsy. human epilepsy may result from the genetic abnormalities of nmdar involving the grin1, grin2a, and grin2b mutations with language and minor speech delay and cognitive impairment (lemke et al., 2013; sivakumar et al., 2022; xu et al., 2019; xu & luo, 2018). the mutations in grin1 encode the subunit glun1, significantly altering the neuronal activity and leading to various epileptic disorders in adults and children (fry et al., 2018; wyllie et al., 2013). the gene grin2a, which encodes glun2a subunits, is considered epileptogenic and responsible for landau-kleffner syndrome, benign epilepsy, and atypical partial epilepsy (elmasri et al., 2022). over 30% of grin2b variations have epilepsy, while 70% of grin2a variations lead to epilepsy development (myers et al., 2019). pa ge 37 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 35-42, 2024 prevalence & incidence of pediatric epilepsy about 50 million people of any age, gender, ethnicity, or social background are affected by epilepsy worldwide, according to a recent report by who on global disease burden (gotlieb et al., 2023). in the general population at any given moment, between 4 and 10 out of every 1000 persons are thought to have active epilepsy (trinka et al., 2023). approximately 5 million individuals receive an epilepsy diagnosis each year worldwide. the variations in the prevalence of epilepsy are not attributed to the particular contents but rather to the economic condition of nations and the corresponding healthcare system standards. the incidence of epilepsy is twice as high in low and middle-income countries as it is in high-income nations. each year, 49 out of every 100,000 individuals are diagnosed with epilepsy in high-income nations, and the number may reach 139 per 100,000 in nations with low and moderate income (j. s. miller et al., 2024; vergonjeanne et al., 2021). the difference in the incidence is primarily because different etiologies, such as infections, prenatal insults, and head trauma, have other effects. epilepsy is the most prevalent chronic neurological illness that ruins people’s lives, especially when seizures are severe and occur uncontrollably (j. s. miller et al., 2024; perucca et al., 2014). with the prevalence rates ranging from 12% to 41%, epilepsy has been associated with a higher risk of mental illness. the most common mental co-morbidity in epilepsy patients is mood disorders, with the incidences of depression and recurrent seizures reported to be 11% and 60% (alsaadi et al., 2015). according to an estimate from 2010, 724,500 people in arab countries have epilepsy, with the incidence rates of 0.9 in saudi arabia, 6.5 in iran, and 12 in sudan per 1000 (al habbal et al., 2021; spiciarich et al., 2019). methods and materials search strategy this review article included recent research studies and reviews of publications and articles relating to epilepsy in pediatric patients. the main focus of this review was on what is pediatric epilepsy, available diagnostic treatments in uae, and the associated health problems like adhd and other co-morbidities. data was acquired from online databases such as google scholar, pubmed, science direct, iee, web of science, ncbi, hindawi, biomed, research gate, medline, and embase. a literature search was conducted to find papers on the incidence, causes, therapies, and risks of epilepsy in children and adolescents for this study. studies including keywords like “epilepsy,” “pediatric epilepsy,” “types of epilepsy,” “prevalence of epilepsy in uae,” “diagnosis of epilepsy,” “pharmacological and non-pharmacological treatments,” “epidemiological factors of epilepsy,” “co-morbidities or impact on epilepsy management,” “effectiveness of treatments” were included from last 10 years between 2014 and 2024. the boolean (and, or) and proximity (near, next, within) operators were used to combine the search terms. at first, databases were searched for relevant publications, and then text words were analyzed and included in the title, abstract, and index keywords of articles. a second search was performed using all the found keywords, index terms, and mesh terms for medline across the online databases. recent studies were discovered by looking through the reference list of studies, papers, and publications using pubmed, google scholar, and google to find the relevant data. the search terms were looked up from fully accessible articles in the titles, abstracts, and whole texts. this is a review article; therefore, not all the data regarding pediatric epilepsy management and prevention has been provided entirely. thus, emphasis was given to including the most important and relevant studies in this review. inclusion criteria after considering the relevant research, the titles were filtered using the inclusion and exclusion criteria. only those studies already published in peer-reviewed journals and conference papers were included. these studies were focused on improving the understanding of the research criteria. • all the research articles published in peer-reviewed journals in the english language were included. • research studies discussing epilepsy, pediatric epilepsy, and its types were considered part of this study. • research studies discussing the prevalence, incidence, and risks of epilepsy were included. • review studies conducted in epilepsy focusing on the uae and arab nations were considered. • studies evaluating the diagnostic criteria were focused. • research focused on pharmacological and nonpharmacological treatments were also included. • this study included data from a literature review, review articles, research studies, overview studies, and case studies on uae. exclusion criteria studies that fulfil any given conditions were excluded from this review; • papers written in languages other than english were excluded. • research with no supporting evidence for predetermined findings • studies whose goal had nothing to do with pediatric epilepsy. • duplicated studies were not considered. • studies containing data outside the arab nations were also not considered • the study did not include review articles with studyrelated titles but unrelated material. • papers that did not discuss the prevalence and risk factors of pediatric epilepsy in the uae were also excluded. pa ge 38 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 35-42, 2024 discussion diagnosis of epilepsy most epileptic patients can lead normal and healthy lives with proper care and diagnosis, but some suffer from severe mental problems. therefore, regular healthcare may be required (asnakew et al., 2022). early diagnosis may help improve patients’ medical condition, but 75% of patients still do not receive the proper care in lowincome nations compared to 10% in developed countries (tana et al., 2024). various diagnostic methods are used, including electroencephalogram (eeg), magnetic resonance imaging (mri), computed tomography (ct) scan, positron emission tomography (pet), single photon emission computed tomography (spect) and genetic testing (acharya et al., 2015; elger & hoppe, 2018; lemoine et al., 2023). blood testing is also used to describe the etiology of toxic and metabolic encephalopathies, and other methods are also used to identify the false negative results and helpful in diagnostic confirmations. eeg is considered the most effective method for diagnosing epilepsy as it helps to identify focal or generalized seizures and rule out epilepsy syndrome (benbadis et al., 2020). however, ct scans have a detection rate of 30% for focal seizures. neuroimaging is critically important in evaluating epilepsy, with progress in mri technology and acquisition protocols improving the accuracy of identifying epileptogenic lesions (goodman & szaflarski, 2021). structural mri is also important for identifying epileptogenic lesions, but there are chances of false negatives in 15-30% of patients with refractory focal epilepsy (bernasconi & bernasconi, 2022). pet and spect are used for functional imaging that helps identify epileptogenic zones and allow pre-surgical evaluation (juhász & john, 2020). genetic testing is essential to find the cause of some epilepsy types, but it has limitations of high cost and lack of availability (striano & minassian, 2020). pet and spect imaging helps in localizing the area of the cortex responsible for the initiation of seizures, especially in patients with focal epilepsy who have a normal mri, multiple abnormalities, or inconsistencies between mri and eeg (brinkmann et al., 2021). treatments non pharmacological treatments first aid first aid treatment refers to the assistance of someone to the patient in managing the circumstances at the time of epileptic seizure. the stigma and unfavourable attitude towards those who have epilepsy is more challenging than the disease itself. people seem scared when they see someone experiencing an epileptic seizure due to the associated misconception. the most crucial thing is to remain composed and assist the sufferer because it is proven from the studies that with the right instructions and training, patients and their families can easily control or manage epileptic seizures (cross et al., 2022). there is no need to call an ambulance in epileptic seizures because it is not an emergency. therefore, self-management training is the most beneficial for patients in managing their seizures independently and will also increase their confidence (wiles et al., 2023). it is seen that cyanosis can be caused in some patients due to respiratory muscle paralysis, but it is a momentary condition and returns to normal once the seizure stops. therefore, the patient’s heart rate, blood glucose level, and respiration must be assessed when the seizure duration is over (anwar et al., 2020). it is advisable to keep the patient relaxed and calm after the seizure. the patient may sleep for hours or even a day following the seizure due to the restlessness of the seizure attack (sman, 2023). ketogenic diet a ketogenic diet is rich in fats, low in carbohydrates, and sufficient protein. ketone bodies, such as beta hydroxyl butyrate and acetoacetate, are produced from the metabolism of high fats in the body. as a nonpharmacological therapy, ketone bodies show promising results even when tested compared to new anti-epileptic medications (chan et al., 2023). it is mostly utilized as a treatment for patients with drug-resistant epilepsy or for those who are unable to have a surgical operation. ketone diet therapy is not successful for patients having problems with fatty acid metabolism and oxidation; therefore, a complete examination must be carried out for all these problems (anwar et al., 2020). several researchers prove that the ketone diet reduces the frequency of epileptic seizures in about 30-40% of children due to its anticonvulsive properties, affecting both the neurotransmitters and neuronal membrane (cicek & sanlier, 2023; el-rashidy et al., 2023). in neuronal membranes, the ketogenic diet modifies the vesicular glutamate transporters that are chloride ion-dependent and work by filling presynaptic vesicles. these chloride ion channels are competitively inhibited by acetoacetate, a ketone molecule, which ultimately decreases the excitatory neurotransmitter (glutamate) and increases the inhibitory neurotransmitter (gaba) (giourou et al., 2015). lifestyle modifications traumatic brain injuries resulting from accidents and traumas are also avoided to reduce the seizure chances in epileptic patients. a wholesome and clean diet is essential to prevent epilepsy. reducing stress and tension is also helpful in protecting epileptic individuals from seizures. additionally, an epileptic patient must take their medication properly as directed by the physician to reduce the chances of seizures in epileptic patients (akram et al., 2022). epilepsy surgery surgical interventions are only recommended when the patient does not respond to non-invasive therapies and medications. focal resection for non-critical brain areas, such as temporal lobe epilepsy and lesionectomy for brain tissue aberrations, are included in surgical intervention. pa ge 39 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 35-42, 2024 tumors are high-risk causative agents for epilepsy and can lead to seizure removal with surgical interventions. neurostimulation devices can also be used for cases ill-suited for resection or ablation, but they provide palliative treatment due to low seizure removal rates (anwar et al., 2020). pharmacological treatments anti-epileptic drugs (aeds) anti-epileptic drugs or anticonvulsive pharmaceuticals are considered the most essential treatment choice for epileptic seizures (gopalan & p, 2023). there are many aeds available, but the choice is influenced by epilepsy type, the patient’s general health and age, and the existence of other medical disorders. about 65% of children are completely cured by aeds when administered at the early stage of the disease. particular care must be exercised when taking aeds to prevent interactions with potentially dangerous medications. patients should administered only those aeds which are prescribed after the complete examination of the drug interaction mechanism, potential side effects, and appropriate dose (eze et al., 2015; mir et al., 2023). when analyzing an aed profile for epileptic seizure, its safety, effectiveness, and tolerability are crucial factors to be considered. most aeds are inhibitors of sodium or calcium ion channels or the gaba neurotransmitter, and these medications have different actions (rana et al., 2023; zhao et al., 2017). bumetanide, felbamate, ganxolone, regtibine, parampanel and carbamazepine are common effective aeds. still, new aeds are also being developed for treating those seizures in which the traditional aeds are ineffective. new aeds are mostly used for the treatment of drugresistant epilepsy. aeds may negatively impact the body’s systems, compromising their effectiveness and functionality. the frequently occurring side effects are headaches, behavioural abnormalities, ataxia, and some allergic reactions. co-morbidities of epilepsy attention deficit hyperactivity disorder (adhd) the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5) classifies adhd as a neurodevelopmental disorder with four subtypes: inattentive, hyperactive or impulsive, combined, and unspecified. in children, the prevalence of adhd is estimated to be 5%, while in adults it is 2.5% (d. j. miller et al., 2024). there is no particular evidence present whether the occurrence of adhd and epilepsy indicated a comorbid psychiatric condition or the transient effects of epilepsy. therefore, it is crucial to carry out a comprehensive evaluation before starting treatment for adhd in children. eeg monitoring is very helpful for identifying unreported seizures, particularly if inattention is a primary illness symptom (ahmed et al., 2022). cognitive & developmental issues the hippocampus is the primary target of recurrent epileptic seizures, which can lead to impairments in brain plasticity. these impairments mainly affect the academic performance of children. a systematic study conducted by wo et al. (2017) examined the frequency of academic challenges in epileptic children and concluded that about 70% of children have lower academic performance as compared to the normal (wo et al., 2017). these cognitive issues often show after epileptic surgery; therefore, cognitive rehabilitation has been suggested as a treatment modality. social challenges approximately 1.1 million children with epilepsy grow up to be adults every year, according to the reports of who in 2022 (fiest et al., 2017; who, 2022). adolescence is a critical time for both physical and psychological growth for anybody, but individuals with epilepsy are more likely to experience additional challenges such as social stigma, mental health and neurodevelopmental disorders, loneliness, and a sense of not being independent (goselink et al., 2022; healy et al., 2020). numerous epidemiological studies have also demonstrated that people with epilepsies are highly vulnerable to adverse outcomes related to work, social contacts, family relationships, and experiential activities; all of these are essential predictors of quality of life (gauffin et al., 2022; steiger & jokeit, 2017). social challenges associated with epilepsy are not only limited to adulthood, but children with epilepsy have also been shown to have poorer social skills than children without epilepsy, even in their early years. people who have epilepsy as children are frequently found to have quite high rates of social issues as adults, which leads to challenges in maintaining a job, engaging in family, community and cultural life, and developing interactions with others. therefore, it is necessary to prioritize social functioning to improve the life quality of people with epilepsy (asadi-pooya et al., 2021; goselink et al., 2022; steiger & jokeit, 2017). it is questionable to what extent social competency issues are caused by psychosocial issues or underlying deficiencies brought on by brain injuries associated with epilepsy. from a psychological point of view, social participation and the capacity to implement parental overprotectiveness and seizure fear. recommendations this study found that genetics, demography and comorbidities all contribute to the development of epilepsy. the aetiology of epilepsy is multifaceted; therefore, a multidisciplinary and integrated strategy should be used to treat epilepsy in children and adolescents. more studies should also be conducted in the uae population to estimate the prognosis and diagnosis of the disease and the effectiveness of available treatment, including brain imaging, scanning and other biological markers. genomic sequencing and analysis should also be given significant importance as they have clinical implications and would be helpful for the precise management of epilepsy types. pa ge 40 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 35-42, 2024 conclusion uae should raise awareness among the people to remove the myths related to epilepsy through media campaigns and school-based health education. it is also important to undertake initiatives aimed at increasing epilepsy knowledge, eliminating stigma, and improving early access to healthcare services. neonates and children should give extra attention to prevent difficulties that could harm their development. additional research should be carried out in the uae to identify the actual risk factors for epilepsy among children. there is also a need to implement new techniques for the treatment of epilepsy. references acharya, u. r., fujita, h., sudarshan, v. k., bhat, s., & koh, j. e. 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(2017). awareness, attitudes toward epilepsy, and first aid knowledge of seizures of hospital staff in henan, china. epilepsy & behavior, 74, 144-148. pa ge 1 pa ge 14 4 american journal of medical science and innovation (ajmsi) analysis on the effect and safety of baihe wuyao xiexin decoction in treating reflux esophagitis hui wang1, siyan xu2, yutong ge1, minmin gu1, meng ye1, panpan liu3* volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.4142 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: december 01, 2024 accepted: january 04, 2025 published: june 28, 2025 to analyze the efficacy and safety of baihe wu yao xiexin decoction in the treatment of reflux esophagitis. methods: a total of 80 patients with reflux esophagitis were selected from june 2021 to june 2023. patients were randomly divided into a observation group, with 40 cases in each group. the control group was treated with conventional western medicine, and the observation group was treated with baihe wuyao xiexin decoction. the therapeutic effect, tcm symptom score and adverse reactions were compared between the two groups. results: in terms of treatment effect, the total effective rate of observation group was 97.50% higher than that of control group (80.00%), p < 0.05. in terms of tcm symptom score, the observation group had heartburn (0.89±0.20) score, acid reflux (0.79±0.17) score, constipation (0.67±0.14) score, dry mouth and bitter mouth (0.77±0.19) score, emotional distress (0.73±0.13) score, and pain in the two hypochasm (0.84±0.15) score. they were lower than (1.00±0.25) points, (0.90±0.21) points, (0.78±0.17) points, (0.87±0.18) points, (0.83±0.19) points and (0.95±0.23) points in the control group, respectively, p < 0.05. in terms of adverse reactions, the total incidence of 5.00% in the observation group was lower than 25.00% in the control group (p < 0.05). conclusion: in the treatment of reflux esophagitis, the use of baihe wu drug xiexin decoction can improve the total effective rate, alleviate symptoms, reduce adverse reactions, the effect and safety are very ideal. keywords baihe wuyao xiexin tang modified, effect, esophagitis, reflux, security 1 school of health science and nursing, shanghai sipo polytechnic, 1408 chengnan road, shanghai 201399, china 2 international sakharov environmental institute, belarusian state university, minsk 220070, republic of belarus 3 pingdingshan hospital of traditional chinese medicine, pingdingshan 467000, china * corresponding author’s e-mail: 745596840@qq.com introduction among digestive system diseases, reflux esophagitis has a high incidence rate and can cause symptoms such as burning pain behind the sternum, acid reflux, dysphagia, and abdominal distension (songlin et al., 2022). western medicine research believes that the occurrence of this disease is mainly caused by factors such as weakened esophageal mucosal barrier function, reduced esophageal acid clearance ability, and weakened anti-acid reflux mechanism. therefore, gastrointestinal motility drugs, acid-suppressing drugs, and proton pump inhibitors are generally used in treatment, but the overall efficacy is general and the adverse reactions are high (qin et al., 2020). traditional chinese medicine research believes that this type of disease should be classified as esophageal reflux, acid reflux, and noisy, mainly due to improper diet and external evil invading the stomach, which affects the spleen and stomach transportation and transformation functions, causing abnormal visceral and liver and gallbladder function. therefore, in treatment, the method of harmonizing the stomach and relieving reflux and clearing the liver and purging fire should be adopted (min, 2022). based on this, this article selected 80 patients with reflux esophagitis from june 2021 to june 2023, and analyzed the effect and safety of modified baihe wuyao xiexin decoction in the treatment of reflux esophagitis. materials and methods general information 80 patients with reflux esophagitis were selected from june 2021 to june 2023. the patients were randomly divided into a control group and an observation group, with 40 cases in each group. in the control group, the patient gender was 23 males and 17 females, with a minimum age of 24 and a maximum of 68 years old, with an average age of (47.52±3.38) years; in the observation group, the patient gender was 21 males and 19 females, with a minimum age of 25. years old, with a maximum age of 69 years and an average age of (47.66±3.23) years. in the above indicators, there was no significant difference between the two groups, p>0.05. the study was approved by the medical ethics committee. inclusion criteria all patients meet the diagnostic criteria for reflux esophagitis, all have clear symptoms, and the patients and their families have been informed of the research content and their consent has been obtained. exclusion criteria pregnant or lactating female patients, patients with malignant tumors, patients with liver and kidney dysfunction, patients with other severe digestive system diseases, and patients with allergies to the drugs used in the study. method control group the control group received conventional western medicine treatment. the medications were: rabeprazole pa ge 14 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 144-148, 2025 sodium enteric-coated tablets (figure 1), manufacturer: hainan shuanghe pharmaceutical, approval number: national medicine standard h20133326, oral, 2 times a day, 20 mg each time. domperidone tablets (figure 2), manufacturer: shanxi baotai pharmaceutical, approval number: national medicine standard h20010245, oral, 3 times a day, 10 mg each time, 30 minutes before meals. use continuously for 1 month. day, decocted in water to 300ml, taken twice a day in the morning and evening. on this basis, for patients with liver qi stagnation and emotional depression, add 10g of prunella vulgaris and 10g of gentiana; for patients with obvious heartburn symptoms, add 10g of dandelion and 10g of forsythia; for patients with severe acid reflux, add 15g of calcined corrugated seeds and 15g of calcined cuttlefish bone. use continuously for 1 month. figure 1: rabeprazole sodium enteric-coated tablets and chemical formula figure 2: domperidone tablets and chemical formula figure 3: basic formula of chinese medicine baihe wuyao xiexin decoction observation group the observation group was treated with traditional chinese medicine baihe wuyao xiexin decoction. the prescription is: 30g of lily, 15g of licorice, 15g of french pinellia, 10g of jujube, 10g of ginseng, 10g of stir-fried scutellaria, 10g of sichuan coptis, 10g of lindera, and 6g of dried ginger. see figure 3 for details. one dose per pa ge 14 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 144-148, 2025 evaluation indicators the treatment effects, tcm symptom scores, and adverse reactions of the two groups were compared. the efficacy evaluation criteria are: markedly effective: symptoms basically disappear and all indicators return to normal; effective: symptoms are relieved and all indicators are improved; ineffective: symptoms are not relieved or worsened. the tcm symptom score evaluation standard is: 0 points for no symptoms, 1 point for mild symptoms, 2 points for moderate symptoms, and 3 points for severe symptoms. indicators include heartburn, acid reflux, constipation, dry mouth and bitter mouth, poor mood, and two sides. swelling and pain. adverse reaction indicators include diarrhea, nausea and vomiting, and increased stool. statistical processing the data were processed using spss 20.0 software, and counts and measurement data were expressed in the form of numbers or rates, and mean ± standard deviation, respectively, and x 2 and t tests were used respectively, with p < 0.05 representing significant differences. results and discussion comparison of the two groups in terms of treatment effects in terms of therapeutic effect, the total effective rate of the observation group was 97.50%, which was higher than that of the control group (80.00%), p < 0.05. table 1: comparison of the two groups in terms of treatment effect [n(%)] group number of cases significant effect efficient invalid total effective observation group 40 18 (45.00) 21 (52.50) 1 (2.50) 39 (97.50) control group 40 15 (37.50) 17 (42.50) 8 (20.00) 32 (80.00) x 2 0.206 0.451 4.507 4.507 p 0.650 0.502 0.034 0.034 comparison of the two groups in terms of tcm symptom scores in terms of tcm symptom scores, the observation group had lower scores of heartburn ( 0.89±0.20 ), acid reflux ( 0.79±0.17 ), constipation ( 0.67±0.14 ), dry mouth and bitter taste ( 0.77±0.19 ), bad mood ( 0.73 ±0.13 ), and flank pain ( 0.84±0.15 ) than the control group ( 1.00±0.25 ), ( 0.90±0.21 ), ( 0.78±0.17 ), ( 0.87±0.18 ), ( 0.83±0.19 ), and ( 0.95±0.23 ), respectively (p<0.05). table 2: comparison of tcm symptom scores between the two groups ( x̄ ±s ) g ro up n um be r o f ca se s h ea rt bu rn (p oi nt s) a ci d re flu x (p oi nt s) c on st ip at io n (p oi nt s) d ry m ou th an d bi tte r ta st e (p oi nt s) b ad m oo d (p oi nt s) pa in a nd di st en si on in bo th fl an ks (p oi nt s) observation group 40 0.89±0.20 0.79±0.17 0.67±0.14 0.77±0.19 0.73±0.13 0.84±0.15 control group 40 1.00±0.25 0.90±0.21 0.78±0.17 0.87±0.18 0.83±0.19 0.95±0.23 t 2.173 2.575 3.159 2.416 2.747 2.534 p 0.033 0.012 0.002 0.018 0.007 0.013 comparison of adverse reactions between the two groups in terms of adverse reactions, the total incidence of the observation group was 5.00%, which was lower than that of the control group (25.00%), p < 0.05. table 3: comparison of adverse reactions between the two groups [n(%)] group number of cases diarrhea nausea and vomiting frequent bowel movements overall incidence observation group 40 0 (0.00) 1 (2.50) 1 (2.50) 2 (5.00) control group 40 3 (7.50) 4 (10.00) 3 (7.50) 10 (25.00) x2 1.385 0.853 0.263 4.804 p 0.239 0.356 0.608 0.028 reflux esophagitis is a common chronic disease of the digestive system, which refers to the reflux of gastric or duodenal contents into the esophagus, causing damage to the esophageal mucosa (wenhong, 2020). in traditional chinese medicine, the disease is generally classified into categories such as vomiting and acid vomiting. according to theoretical analysis of traditional chinese medicine, abnormal esophageal structure or function can easily lead pa ge 14 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 144-148, 2025 to abnormal transportation and transformation of the spleen and stomach. the esophagus is the main disease location, and the spleen and stomach are the root cause (ying, 2021) . the common pathogenesis of this type of patients is stagnation of liver and stomach heat, which is usually due to disordered rise and fall of the spleen and stomach and stagnation of liver and stomach due to dryness and heat. therefore, the water and grain stored in the stomach will flow upward and break through the appetite, causing symptoms such as acid reflux and vomiting (jian, 2020). therefore, in the treatment of traditional chinese medicine, the treatment principles should be adopted to relieve pain, relieve pain, and regulate heat and dryness, so as to achieve the effects of promoting qi, relieving pain, nourishing yin and regulating the stomach. on this basis, the use of modified lily wuyao xiexin decoction can significantly improve the treatment effect, effectively relieve symptoms, improve perinatal hormone levels, and improve gastrointestinal motility (jichao, 2021). baihe wuyao xiexin decoction is taken from “shi fang ge kuo”, and the prescription is formed after additions, subtractions and refinements. it is mainly composed of lily, licorice, french half, jujube, ginseng, fried skullcap, sichuan coptis, wu yao, dried ginger and other medicines. among them, the monarch medicines are wuyao and lily. wuyao is pungent and warm in nature and returns to the lung and spleen meridian. it can warm the kidneys and dispel cold, promote qi and relieve pain. it is suitable for chest and abdominal pain, chest and abdominal pain due to cold and qi stagnation. the effect is good; lily is sweet in nature and belongs to the large intestine meridian. it can nourish the five internal organs, benefit the will, calm the gallbladder, and relieve peace of mind (zhenlang et al., 2015) . french pinellia is made by boiling raw pinellia and licorice together, then soaking it in lime liquid and drying it. it tastes bitter and can reduce nausea and stomach pain. it has a good effect on vomiting caused by various reasons, especially on the stomach. it has a significant effect on stomach qi and vomiting caused by cold, phlegm, etc. (yu & xiaogang, 2016). coptidis coptidis can relieve vomiting, reduce vomiting, purge fire and detoxify, and clear stomach heat. it is effective in treating vomiting, gastrointestinal damp-heat, and dampheat internal syndrome. it is compatible with pinellia ternata to jointly reduce vomiting, clear away heat, and relieve gastric and gastrointestinal diseases. it has the effect of drying dampness and strengthening the spleen, and is effective in treating hiccups and vomiting caused by stomach heat. stir-fried scutellaria baicalensis is bitter and cold, enters the lung meridian, has the effects of stopping bleeding, purging fire and detoxifying, clearing away heat and drying dampness. pinellia ternata is pungent and warm, enters the spleen and stomach meridian, has the effects of eliminating pimples and dissipating stagnation, harmonizing the stomach and stopping vomiting, drying dampness and reducing phlegm. the combination of medicine can treat the lungs and spleen at the same time, achieving the effects of harmonizing the stomach, reducing qi and stopping vomiting, clearing away heat, drying dampness and reducing phlegm. it has a significant effect on coughs with yellow and thick phlegm caused by lung qi ascending and phlegm-heat blocking the lungs (min, 2022). it is effective for loss of appetite, nausea and vomiting, and chest and diaphragm fullness caused by gastric disharmony and phlegm-heat combination. dried ginger can warm the lungs and resolve heat, restore yang and unblock the meridians, warm the body and dispel cold, and has significant effects on hiccups and vomiting. these drugs are ministerial drugs, which can promote the effect of monarch drugs, achieve the effects of stopping vomiting, promoting qi and relieving pain. at the same time, they can regulate the abnormality of gastric qi mechanism, promote the orderly rise and fall of the middle burner, and nourish the spleen and stomach (dongmei, et al., 2021). using jujube and ginseng as adjuvants can greatly replenish vitality. ginseng is sweet and slightly warm. it can restore the pulse and strengthen the pulse in patients with severe vomiting and diarrhea or long-term illness. when combined with dry ginger, the middle qi can be smooth, flowing but not blocked, and tonic but able to move. tonifying but not stagnant, what are the uses of these two medicines? they have the effect of warming the middle burner and replenishing the spleen and stomach. they are effective in treating vomiting, diarrhea, and cold and painful epigastric pain caused by spleen and stomach deficiency. jujube can replenish the spleen and qi, which is more suitable for those with weak spleen. combined with ginseng, it can strengthen the qi-replenishing effect. licorice is an herbal medicine that can replenish the heart, relieve pain and relieve pain, and replenish the heart and spleen. when combined with dried ginger, it can relieve pain, relieve pain, warm the heart and dispel cold. it is commonly used in the treatment of epigastric pain. licorice can harmonize various medicines, purge and lower qi, disperse and circulate qi, regulate qi mechanism, promote the orderly rise and fall of qi mechanism in the middle burner, make qi and blood metabolize actively, and then promote the return of viscera function to normal. the combination of the above drugs can alleviate the patient’s symptoms, improve his condition, and achieve a very ideal prognosis. conclusion in the treatment of reflux esophagitis, the treatment regimen of modified lily and wuyao xiexin decoction can improve the overall effective rate of treatment, significantly relieve symptoms, improve the levels of gastrointestinal hormones and inflammatory factors, and reduce adverse reactions. the effect and safety are very ideal. references chen, x. 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(2015). metaanalysis of the efficacy of banxia xiexin decoction in the treatment of reflux esophagitis. chinese journal of experimental traditional chinese medicine, 21(24), 6. pa ge 1 pa ge 53 american journal of medical science and innovation (ajmsi) successful distal finger replantation in a 9-year-old child with double level injury: a case report & literature review hussain m. lawati1*, abdulfatah ramadan1, aamer galal osman1, sanjay h. sharma1, sohail quazi2 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3423 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 12, 2024 accepted: august 13, 2024 published: february 13, 2025 this study discusses a completely amputated right middle finger in a 9year-old boy. the study employed a case report relating to a successful distal finger replantation in a 9-yearold child with a double-level injury. a bicycle chain accident caused traumatic amputation at the distal interphalangeal joint level, requiring surgery for replantation. the fingertip’s properties are crucial for tracing, gripping, and protection, hence surgery was attempted. post-debridement, severely crushed radial and ulnar neurovascular bundles were found. the proximal ulnar digital artery and nerve stumps were affected. the radial neurovascular bundle was crushed with segmental loss evident after exploring post-debridement. radial distal structures were found to be the least damaged. one proximal digital artery was repaired, and single digital nerve was approximated. the artery was repaired cross-sectionally with the proximal ulnar digital artery anastomosed to the distal radial artery stump. as the damage was complex and a double-level cut, surgery was mainly performed to restore the cosmetic and functional characteristics of the finger and to eliminate the requirement of a donor site using another reconstructive option. this case is important in highlighting the developments and advancements in digital replantation procedures. this is also valid in pediatric cases if complex injuries occur. besides, all these, essential insights are put into the current literature in the domain of pediatric digital replantation, and this is done by a detailed surgical approach, potential challenges experienced, and the discussion of outcomes. keywords amputation, finger injuries, functional recovery, nerve repair, pediatric hand injury, replantation 1 khoula hospital, oman 2 hamad general hospital, qatar * corresponding author’s e-mail: lawatihussain6@gmail.com introduction finger amputations, especially in pediatric patients are not easy to manage as they present a noticeable clinical challenge (loewenstein & adkinson, 2021). replantation requires great attention to detail in microvascular techniques to recover both the form and function of the injured fingers (tang et al., 2020). distal finger injuries, particularly those that involve not only one level but multiple levels, are significantly complicated (cannon et al., 2016). this complication comes into play from the requirement to carefully reconnect small blood vessels and nerves, which are important for the sensation and function of the finger. this case pertains to a 9-year-old child who had a complete middle finger amputation of the right hand at the distal interphalangeal joint (tamai zone ii) after experiencing a bicycle chain accident. the injury was not just an ordinary one, as it was further complicated by crushing and an additional distal volar laceration with gross contamination with grease. such injuries are not common and present specific threats and challenges, especially in those children having smaller anatomical structures in which attention must be paid to the smallest details during surgery (hill & remick, 2020). moreover, successful replantation of pediatric cases has immense importance due to multiple factors (leiskau et al., 2021). in the first place, the fingertips are important for fine motor skills and they are essential for a child to develop and perform daily activities such as writing, playing, and self-care (soden, 2020). secondly, preserving the aesthetic appearance of the hand is essential, it should be cared for the psychological betterment of the child. hence, getting both functional and cosmetic reestablishment is vital in such cases. this report is intended to showcase the advancements and developments in surgical procedures that provide desired results in complex digital replantations (thibedeau et al., 2023). we add precious information to the existing literature on pediatric digital replantation after presenting the comprehensive approach of surgery, the potential challenges faced, and the outcomes obtained. this case ensures the importance of an approach that is not just limited to one area but it is a multidisciplinary approach and the requirement for sustained improvement of microvascular surgical techniques to improve the prognosis for young patients with severe finger injuries (stefanou et al., 2022). case presentation a case of a male child aged nine was presented. the child experienced an injury to his right middle finger that happened when his finger became caught in a bicycle chain, causing complete amputation through the distal interphalangeal joint (tamai zone ii) (billig et al., 2021). injury description the part where amputation occurred showed crushed wound edges with contamination by grease. an additional pa ge 54 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 53-57, 2025 distal volar laceration was also there. the injury is depicted in figures 1, 2, and 3. the ischemia time was around 3 hours from the time of injury when the patient arrived at the emergency department. preoperative considerations before taking the patient to surgery, the minimal chances of success to the family were explained, providing the nature of the injury, the distal amputation, and the presence of another deep wound over the pulp that makes it a double-level cut to the neurovascular bundles. surgical technique surgery was executed with general anaesthesia and having an arm tourniquet and standard microvascular procedures. following proper debridement and cleaning, exploration showed a crushed neurovascular bundles proximally with a segmental loss on the radial side. distally, the digital artery and nerve stumps of the ulnar side were greatly damaged, whereas the radial digital distal structures were in acceptable condition. a decision regarding repairing the ulnar proximal digital artery to the distal radial artery by 9-0 ethilon in a cross-fashion was made. after the arterial anastomosis the vascularity was regained in the amputated part including in the distal crushed portion and thus distal laceration was sutured without arterial repair at the distal crush end. the radial digital nerve was repaired with 8-0 ethilon, though it was impossible to repair the ulnar digital nerve. both of flexor and extensor tendons were repaired with 3-0 pds by modified kessler’s technique before performing the digital structures anastomosis. osteosynthesis was executed using 1mm double axial k wires, shown in figure two dorsal veins were repaired using 9-0 ethilon postoperative care the hand was immobilized in a splint after restoring finger perfusion on the table. the patient was kept for 2 days in the icu postoperatively for monitoring. an anticoagulant, low molecular weight heparin infusion was initiated for five days as per the protocol in our institution. the colour of the finger was pink during all this duration. eventually, the patient was discharged. follow-up and outcomes after six weeks of the postoperative period, the k wires were cut and removed, and mobilization was started. it is illustrated in figure 5. more follow-up showed a good range of motion & complete healing as shown in figure 6. at six months follow-up, the patient exhibited satisfactory functional outcomes. motion range was also found to be acceptable with sensory recovery. there was a favourable aesthetic result, having the least scarring, in addition, nail growth was also acceptable. an extended follow-up period will be required to know how disturbances and more functional developments are progressing. figure 1: injured fingers with crushed wound edges figure 2: the amputated part as a result of injury figure 3: x rays scan of the injured hand pa ge 55 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 53-57, 2025 findings history and use of digital replantation digital replantation has generally been used since the first successful procedure of komatsu and tamai. this is important because if such injuries occur, this will be an effective approach to treat them (duah-asante et al., 2023). factors influencing practicality, cost, and suitability practicality, cost, and suitability rely on the details of the injury, involved digits, the patient’s demographics, and the experience the surgeon possesses. such factors must be considered (kwon et al., 2020). common indications for digital replantation it is usually executed for thumbs, multiple digits, and whatever digit in a child. sometimes, it is performed for isolated digits in young individuals or those who play music (fan et al., 2022). this is important to consider in such individuals to ensure effective utilization of the hand. drawbacks of various other reconstructive methods methods including secondary intention healing, finger shortening, skin grafts, and flaps usually result in morbidity like pain & stiffness (kawaiah et al., 2020). such pain or tenderness can further complicate the case and long-term disability can result. disability rates for different closure techniques disability rates for primary closure are 15%, splitthickness grafts 25%, fullthickness grafts 26%, and palmar flaps 19%. benefits of distal phalanx replantation replantation maintains function, provides better soft tissue coverage, preserves length and appearance, and generally requires one surgery (winge & røkkum, 2023). after surgery, complete and quick recovery is expected with a functional hand and fingers. discussion this case report presents a 9-year-old boy’s right middle finger distal amputation requiring replantation. standard microvascular methods, along with general anaesthesia and an arm tourniquet, were used during the surgery. double axial k wires were used to accomplish osteosynthesis before vascular repair was performed. the patient exhibited appropriate mobility range and sensory recovery after six weeks, along with satisfactory functional outcomes. komatsu and tamai’s initial effective replantation through microvascular anastomosis report states that digital replantation has recently emerged as a widely accepted method (noh & hacquebord, 2020). regardless of the practical, economical, and feasible nature of the replantation, the outcome of surgery relies on the extent and injury, the area damaged, level of education, financial condition and avocation. additionally, some other factors, include the surgeon’s training and their experience. the outcome is also related to the indications for replantation. replantation attempts are absolutely indicated in an amputated thumb, amputation of multiple digits or in a child with an amputated digit (goel et al., 2020). sometimes, isolated digit amputation is recommended for patients due to professional or social reasons, like for young adults or musicians. but still, there remains debate over whether single amputated digit replantation is warranted or not. in eastern states, maintaining physical well-being is often favored over function leading patients to request replantation despite being informed that it is not mandatory for preserving adequate function of the hand. despite various challenges, our spirit to execute replantation has not declined. several centres have achieved the desired outcomes, even though the small size of the vessels presented a problem (liao & de, 2021). a figure 4: x ray scan of the specific sections of hand figure 5: injured finger after removing k wires (6 weeks) figure 6: healed up and recovered hand with its fingers moving freely (10 weeks) pa ge 56 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 53-57, 2025 significant amount of controversy is still associated with the distal digital replantation. a few surgeons consider single finger replantation imprudent. most patients utilize an unaffected finger instead of the one replanted which may lead to more harm caused by the replanted finger potentially affecting overall hand function. the findings of our study relate to (wang et al., 2022) which discuss various alternative procedures such as secondary intention healing, finger shortening, wound closure using skin grafts, and free flaps. with these procedures, several patients experience unwanted symptoms including continued pain, excessive tenderness, cold intolerance, hyperesthesia, atrophic soft tissue, damaged nails, and reduced grip power. sturman and duran’s study on 235 fingertip injury patients found that 15% received basic dressing, 25% had partial thickness skin grafts, 26% had full thickness skin grafts, and 19% had significant disability. following replantation, tissue quality is superior to traditional skin coverage methods. sensation after repairing the digital nerve in the fingertip which is planted is maintained, and even superior to other closure methods including tissue transfer from the base of the thumb (de berker et al., 2022). the finger’s length is preserved by distal replantation and provides the best appearance. it maintains movement in the metacarpophalangeal (mcp) and proximal interphalangeal (pip) joints, as these joints are not inactivated post-replantation. this decent and efficient movement at the proximal joints compensate for no movement at the far end joint. creation of a neuroma and high sensitivity stump is avoided in the proximal end of an amputated limb (shaterian et al., 2019). which is a frequent post-amputation complication needing multiple revisions. replantation surgery is generally secure and typically requires only one procedure. according to most authors, all amputated thumbs and multiple digital amputations must undergo trial of replantation, but there is little consensus on the consideration of distally amputated parts or single digital replantations (bahm, 2023). only a few of them highlighted the advantages of distal digital replantation. also, there is a minor focus on the functional distinctions existing between digital replants proximal and distal to the pip joint (stone et al., 2021). the study of surgical techniques and rehabilitation protocols for distal digital replantation could offer unique advantages compared to proximal replants (persitz et al., 2023). conclusion this case highlights the importance of digital replantation in restoring function and quality for patients having finger injuries. as the initial successful procedure was performed by komatsu and tamai, digital replantation has proven to be a crucial development in the clinical and surgical practice. the practicality, cost, and suitability of the technique rely on different factors, such as the characteristics of the injury, number of digits involved, the demographics of the patient, and the experience of the surgeon. replantation is most generally used for thumbs, multiple digits, and any digit in children, and is seldom performed for isolated digits in young individuals or musicians. alternative procedures like secondary intention healing, finger shortening, skin grafts, and flaps can cause unwanted symptoms such as pain and tenderness. the rates of disability for different wound closure techniques also change with primary closure being the lowest at a rate of 15%. distal phalanx replantation is a cost-effective, efficient, and long-lasting procedure that can restore essential functions and improve the quality of life for patients with finger injuries, demonstrating its effectiveness in a single surgery. in the future, experience from such cases can be utilized to treat finger injuries, especially those with more complications and severity. all the literature and the findings are evident that this procedure is effective, hence, it can be implemented for treatment with a good success rate. fingers are important components of our body, and preserving them is crucial. more research is required to modify and enhance the existing procedures and techniques to treat a wide variety of injuries. references bahm, j. (2023). surgical rationales in functional reconstructive surgery of the upper extremity. springer. billig, j. i., nasser, j. s., cho, h. e., chou, c. h., & chung, k. c. (2021). association of interfacility transfer and patient and hospital characteristics with thumb replantation after traumatic amputation. jama network open, 4(2), e2036297-e2036297. cannon, j. w., hofmann, l. j., glasgow, s. c., potter, b. k., rodriguez, c. j., cancio, l. c., rasmussen, t. e., fries, a. c., davis, m. r., & jezior, j. r. (2016). dismounted complex blast injuries: a comprehensive review of the modern combat experience. journal of the american college of surgeons, 223(4), 652-664e658. de berker, h. t., čebron, u., bradley, d., patel, v., berhane, m., almas, f., walton, g., eshete, m., mcgurk, m., & martin, d. (2022). outcomes of microsurgical free tissue transfer performed on international surgical collaborations in low-income and middle-income countries: a systematic review and meta-analysis. journal of plastic, reconstructive & aesthetic surgery, 75(7), 2049-2063. duah-asante, k., kadhum, m., khajuria, a., nduka, c., koshima, i., & kannan, r. y. (2023). a comparison of outcomes between finger and pulp replantation/ revascularization in a single center. plastic and reconstructive surgery–global open, 11(1), e4768. fan, p., wong, a. c.-n., & wong, y. k. (2022). visual and visual association abilities predict skilled reading performance: the case of music sight-reading. journal of experimental psychology: general, 151(11), 2683. goel, r., case, a. l., hogarth, d. a., & abzug, j. m. (2020). amputations and replants. in pediatric hand therapy (pp. 303-319). elsevier. hill, g. j., & remick, k. (2020). pediatric considerations. pa ge 57 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 53-57, 2025 in operational and medical management of explosive and blast incidents (pp. 331-343). elsevier. kawaiah, a., thakur, m., garg, s., kawasmi, s. h., & hassan, a. (2020). fingertip injuries and amputations: a review of the literature. cureus, 12(5). kwon, s. h., lao, w. w. k., hsu, a. t. w., lee, c. h., hsu, c. c., huang, j. j., qiu, s. s., tilkorn, d., tang, e. t. h., & lu, j. c. y. (2020). the preferred management of a single-digit distal phalanx amputation. journal of reconstructive microsurgery, 36(04), 301-310. leiskau, c., junge, n., pfister, e. d., goldschmidt, i., mutschler, f., laue, t., ohlendorf, j., nasser, h., beneke, j., & richter, n. (2021). recipient-specific risk factors impairing patient and graft outcome after pediatric liver transplantation—analysis of 858 transplantations in 38 years. children, 8(8), 641. liao, j. c., & de, s. d. 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(2020). daily living skills. in educating young children with additional needs (pp. 117-139). routledge. stefanou, n., arnaoutoglou, c., papageorgiou, f., matsagkas, m., varitimidis, s. e., & dailiana, z. h. (2022). update in combined musculoskeletal and vascular injuries of the extremities. world journal of orthopedics, 13(5), 411. stone, n., shah, a., chin, b., mckinnon, v., & mcrae, m. (2021). comparing digital replantation versus revision amputation patient reported outcomes for traumatic digital amputations of the hand: a systematic review and meta‐analysis. microsurgery, 41(5), 488-497. tang, j. b., wang, z. t., chen, j., & wong, j. (2020). a global view of digital replantation and revascularization. clinics in pastic surgery, 47(4), 437-459. thibedeau, m., ramji, m., mckenzie, m., yeung, j., & nickerson, d. a. (2023). single digit index finger amputation—to replant or not? plastic surgery, 31(1), 44-52. wang, t., wang, l., wang, h., zhang, w., yu, z., & zhang, j. 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(2023). replantation. in pediatric hand surgery (pp. 329-352). springer. pa ge 1 pa ge 12 american journal of medical science and innovation (ajmsi) involvement of restored treg cells in the immune pathogenesis of parkinson’s disease (pd) running title: immune pathogenesis of parkinson’s disease faisal alkhateeb ahmad2, ahmed mohamed mekkawy3, ahmed ghoneim3, ehab zahran3, khaled saad1*, ahmad roshdy ahmad4, khalid hashim mahmoud5, eman f. gad2, mohamed ezzat6, hamad ghaleb dailah7, ahmed nabil malek3 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3094 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: may 27, 2024 accepted: june 30, 2024 published: july 03, 2024 neural regression with neuroinflammation and immune dysfunction through neurodegradative disorder is known as parkinson’s disease (pd). parkinson’s disease is a progressive degradative neuronal disorder. in this disease, the continuous depletion of dopaminergic neurons and the existence of protein lewy bodies are the key points of pd development. in pd patients, regulatory t cells (tregs) are decreased in number and have an impaired proliferative capacity that affects the suppression of t-cell characteristics. the thymus involution decline in the functionality of t-cell development and consequently naïve t cells makes the immune system more vulnerable to losing its immune surveillance, increasing morbidity and mortality in aged individuals. the persistent process of thymic involution with age vigorously contributes to a progressive reduction in thymic output. genomic damage, cellular senescence, and epigenetic alterations are the hallmarks of cellular or molecular damage in aging. therapeutic potential for regeneration of the thymus would improve immunity. some strategies and approaches have focused on cell-based approaches, technology based on organoid and scaffold modulating of endogenous and exogenous compounds to help in the thymus regeneration, and fabrication technologies that could be used as regenerative approaches. last but not least the pluripotent stem cell therapies. keywords neuro-degradation, parkinson’s disease, thymic involution, pluripotent stem cell 1 department of pediatrics, faculty of medicine, assiut university children’s hospital, assiut, egypt 2 department of pediatrics, faculty of medicine, assiut university, assiut, egypt 3 department of cardiothoracic surgery, faculty of medicine, assiut university hospitals, assiut, egypt 4 department of pediatrics, college of medicine, jouf university, sakaka, saudi arabia 5 department of pediatrics, faculty of medicine, shaqra university, dawadmi, saudi arabia 6 department of pediatrics, faculty of medicine, al azhar university, cairo, egypt 7 research and scientific studies unit, college of nursing, jazan university, jazan, saudi arabia * corresponding author’s e-mail: khaled.ali@med.au.edu.eg introduction neural regression with neuroinflammation and immune dysfunction through neuro degradative disorder is known as parkinson’s disease (pd). parkinson’s disease is a progressive degradative neuronal disorder. in this disease, the continuous depletion of dopaminergic neurons and the existence of protein lewy bodies are the key points of pd development. increased microgliosis along with dysfunction of the peripheral immune were also indicated by several reports in the development of pd (balestrino & schapira, 2020). prevalence showed that it is the second chronic progressive neurodegenerative disease after alzheimer’s, with environmental and genetic factors that interact to develop it in older age (miri et al., 2020) (goldman, 2019). in pd patients, regulatory t cells (tregs) are decreased in number and have an impaired proliferative capacity that affects the suppression of t-cell characteristics. in animal models of pd, restoring tregs and their suppressive function reduces disease-associated inflammation and provides neuroprotection. similarly, in the field of cancera disease no less dangerous than parkinson’s disease (pd) a treg cell depletion restores and improves endogenous anti-tumor immunity. accordingly, it becomes possible to promote regeneration and prevent the evolution to irreversible tissue damage by restoration of treg cells. thus, the restored treg cells help in the immunopathogenesis of parkinson’s disease (pd) (thome et al., 2021). in old age, thymus degradation is associated with decreased precursors of t cell output, which reduces individuals’ activity in t cells. it increases susceptibility to infection and is prone to autoimmune disease and cancer. thymic involution is the intense situation in which ubiquitous change is observed in the aging immune system, but the mechanisms underscore this process are still unclear (barbouti et al., 2020). the prevalence of pd has increased day by day. approximately 2.5 million individuals suffered it in 1990, while the prediction shows it will increase three-fold to 17.5 million in 2040. reduces neuroprotection activities associated with environmental parameters, i.e., pollution, smoking, and boosted exposure to industrial byproducts (schwab et al., 2020). usually, it affects the old aged individual more than the adult once. because it depends upon the immunological status of humans. in old age, the body’s system becomes weaker timely, so the immune system is also affected by the side effects of other pathological conditions such as hypertension, stroke, and other cardiovascular disorders (mas-bargues et al., 2021). the thymus gland begins to atrophy (shrinks) until we have little or none left. t-cells migrate towards the thymus to mature from the bone marrow because it is the primary lymphoid organ. pa ge 13 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 12-17, 2024 it is also involved in the development to improve the efficiency of t-lymphocytes or t cells (knight, 2021). persistent age-associated atrophy is found in the thymus gland in which loss of thymic epithelial space (tes), i.e., thymus involution or atrophy, leads to inhibition of thymic output (rezzani et al., 2020). it was represented by its role in developing t-lymphocytes or t cells, an extremely important type of white blood cell. t cells protect the body from potentially deadly pathogens like bacteria, viruses, and cancer. such a regulatory role driven by t cells causes dysregulation in immune cells(varadé et al., 2021). the dysregulated immune cells lead to a proinflammatory tumor microenvironment and promote the secretion of growth factors, i.e., chemokines and cytokines/proteinases. additionally, the intercellular communication between cancer and immune cells plays a key role in modulating the immune response, promoting cell migration, proliferation, and tumor progression (schulz et al., 2019). the state of chronic thymus involution in aged individuals creates a weaker immunity through a great decline in the functionality of t-cell development and consequently naïve t cells. this makes the immune system more vulnerable to losing its immune surveillance, increasing morbidity and mortality (schwab et al., 2020). significance of thymus in the human body thymus, located right behind the collarbone, is the essential part of the immune system. in the thymus, naive t immune cells develop through undifferentiated thymocytes specializing in specific pathogens or cancer cells. t cells serve a potential role in regulating the immune system. it has been important that the size of thymus reduces progressively with age, termed thymic involution (barbouti et al., 2020). the thymus’s immune benefit produces a class of immune cells called t lymphocytes. these cells complement the b cells to constitute the adaptive immune system. humans produce fewer and fewer t cells as humans age, and some recent literature reported that humans might not even produce any newer t cells after age 60 (park et al., 2020). the persistent process of thymic involution with age vigorously contributes to a progressive reduction in thymic output. humans become more susceptible to cancer and infectious diseases in old age as their immunity weakens (wiertsema et al., 2021). predisposing factors of thymic involution the shrinkage of the thymus in old age, this phenomenon is known as involution. an ancient and evolutionarily conserved process showed that thymic involution occurred in many vertebrates (rezzani et al., 2020). thymic aging is marked by lowered production of (new) naive t cells and adipose tissue instead of lymphosarcoma thymic zones (cakala-jakimowicz et al., 2021). literature shows that thymus shrinkage is an age-dependent program. the infiltration of adipocytes (fat cells) is initiated in puberty or earlier and will take over in middle age. age changes in the thymus into fatty tissue from a primary lymphoid organ(velardi et al., 2021). besides fat deposition, many other factors of age-associated changes may trigger thymic involution. firstly, the decrease in bone marrow output is the source of hematopoietic stem cells (hsc). this comprised of t cell progenitors anonymously enter the blood circulation and relate thymic epithelial cells to get matured, defined as the developmental program. the decline was observed in t-cell progenitor cells and hematopoietic stem cells by age (liu et al., 2020). second fibrosis, by the age of thymopoiesis replaced by fibroblasts after signaling by specialized thymic epithelial cells. fibrosis is also observed in various organs, i.e., the liver, kidney and heart, as a common aging signature (borgoni et al., 2021). thymic involution consists of a two-stage process, growth-dependent thymic involution during puberty and age-dependent thymic involution (sekai et al., 2019). formation of intrathymic t cell receptors (tcrs) the t cells mature in the thymus, migrate from the bone marrow as pre-t cells, and pass through the thymus. they form their t cell receptors (tcrs) with their two chains (α and β). these tcrs give the t cell its specificity through a process of genetic recombination. they go through positive and negative selection in the thymus. so, if a tcr binds to self too strongly (they would cause autoimmunity), they are deleted. if they cannot bind selfenough, they would be unable to make antigen recognition bound by mhc molecules, which is typically required for t cells then they are also deleted. those that can loosely bind mhc but not so strong that they would be selfreactive mature t cells reach the secondary lymphoid organs before they can remain in the blood circulate (i.e., spleen, lymph nodes, etc.) (smith & göbel, 2022). intrathymic integration of t cell migration and thymocyte differentiation the thymus gland is necessary for producing t lymphocytes, central to cellular immunity, humoral immunity, and some of the body’s nonspecific defenses. chemokine receptors, such as cc-chemokine receptor 7 (ccr7), ccr9 and cxcr4 are responsible for the recruitment and entry of bone marrow-derived t lymphoid cell progenitors, called thymocytes. two events for the maturation of thymocytes were reported: the rearrangement of the gene of the tcr and association with coreceptors cd4 and cd8 (granadier et al., 2021). thymocytes’ progress depends upon three developmental stages with an expression of the cd4 and cd8 coreceptors. double-negative (dn) thymocytes do not express cd4 and cd8 in t-cells after attaching with coreceptors cd4 and cd8. tcr consists of α and β subunits having alternate sequences. this variation shows the randomization of gene segments and foreign antigen thymocytes, which can recognize as major histocompatibility complex (mch) molecules (cosway et al., 2021). t cells increase their affinity by self-peptides pa ge 14 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 12-17, 2024 bound to (pmhc) for positive selection and peripheral survival. mature tcrs with cd4 and cd8 coreceptors in the same cell are double-positive (dp) thymocytes. tcr-self-pmhc interactions promote dp thymocyte survival and convert it into a single positive (sp) stage. this outcome is called positive selection (kisielow, 2019). apoptosis is generated if tcr is not involved in selfpmhc, and high affinity (strong signaling) generated after self-pmhcs are known as non-selection and negative selection, respectively. (srinivasan et al., 2021) self-mhc bond tcrs are restricted, mature and self-tolerant. when expressed cd4 or cd8, it becomes single positive (sp) thymocytes, also known as clonal selection (helgeland et al., 2020). the binding of cd4 or cd8 and tcr to the mhc molecule forms the tcr–cd3 complex through noncovalent interaction with cd3 γ, δ, ε, and ζ proteins of the intracellular domain. (shah et al., 2021) expression of chemokine receptor ccr7 after positive selection tests of thymocytes as an additional requirement fulfill an in the medulla of the thymus. the medullary epithelial cells of the thymic produce ccr7 cytokines that enhance the negative selection of potentially autoreactive thymocytes. after development in the thymus, thymocytes migrate to the lymphoid organs through the bloodstream and are considered antigen-presenting cells. these lymphoid organs initiate protective immune responses in immunological challenges (kadouri et al., 2020). thymic involution and immune econstitution the thymus serves as the development of self-restricted and tolerated along with immunocompetent t cells. thymus loses the characteristic of self-renewal. therefore, the continuous replenishment of new t cell progenitors comes from the bone marrow. after proliferation series and stages of differentiation on the guideline of the specialized thymic microenvironment, these cells become maturated. the anatomical structure of the human thymus gland is composed of the thymic epithelial space (tes) of the human thymus. thymopoiesis continues on the nonhematopoietic perivascular area (pvs), including adipocytes, peripheral lymphocytes, and stroma. reduce the efficiency of t-cell development and decreased migration of naïve t cells observed in aging characterized as chronic thymus involution (sergi, 2020) the progress on the therapeutic thymus restoration and peripheral immune reconstitution in adults. restoring immunity in old age remains a challenge that needs further investigation. all older adults will be considered to have weak immune systems and reduced immunity due to vitamin d deficiency unless a supplement is taken. the weak immune function is associated with less responsive to drugs and more inclined toward infections in old individuals. similarly, a study observed that the expression of activation markers and t cell memory phenotype distribution is affected by age, body fat content, and pathogen status throughout the lifespan. (mittelbrunn & kroemer, 2021) inflammation and treg cell genomic damage, cellular senescence and epigenetic alterations are the hallmarks of cellular or molecular damage in aging (ermolaeva et al., 2018). literature showed that imbalance protein and proteostasis conditions along with essential nutrient lacking were observed in agingrelated diseases (deng et al., 2022). according to de cecco et al. 2019 chronic inflammation happens as self-antigens action due to pro-inflammatory reactions in aged persons (de cecco et al., 2019). therefore, an imbalance of th17/treg cells was found to cause inflammation in aged people (deng et al., 2022). previous studies showed that il-6 also acts as a pro-inflammatory cytokine and helps to balance th17/ treg cells in the human body but high serum tnf and il-1 level imbalance the treg cells in aged individuals (pansarasa et al., 2019). reduced dcaf1 regulation was reported in treg cells, which caused an imbalance rate of activation of t cells in the immune system of aged individuals compared to younger ones. downregulation in dcaf1 ultimately increases the reactive oxygen species, directly affecting the interleukin 6 and interleukin 17 that imbalance the rorγτ+ foxp3 and caused chronic inflammation by dysfunction immunity in aging (guo et al., 2020). figure 1: chronic inflammation in aging due to imbalanced rorγτ+ foxp3 approaches to regenerate thymus therapeutic potential for regeneration of the thymus would improve immunity. some strategies and approaches have focused on cell-based approaches, technology based on organoid and scaffold modulating of endogenous and exogenous compounds to help in the thymus regeneration, and biofabrication technologies could be used as regenerative approaches. last but not the least, the pluripotent stem cell therapies. literature showed that in vitro thymic epithelial pa ge 15 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 12-17, 2024 progenitors of humans could be generated through embryonic stem cells (escs) with the help of activin a, which can produce cd4+ and cd8+ t cells along with cd3 complex. organoids technology extracts tecs by scaffolds through pluripotent stem cells (table 1)(sharma & moroni, 2021). the progressive disease is still untreated, but the cell replacement technique will be in consideration. human pluripotent stem cell therapies are used as a regenerative strategy through straight differentiation for midbrain dopamine (mda) neurons (kim et al., 2020), (elsworth, 2020). table 1: therapeutic approaches to regenerate thymus. approaches mode action references opdll1system with hscs synthesis of magnetic dll1 ligands adds on vcam-1 ligand. develop modification and enhance the efficiency of t cells to make them diverse, functional, and produce cytokines (awong et al., 2009) embryonic stem cells to thymic epithelial cells escs used to produce tec t cells are diverse and responsive toward stimuli. (su et al., 2015) reprogramming of thymic epithelial cells protocol to generate by foxn1 transcription factor to increase cell count the heterogeneous resemblance with endogenous ratio cd4:cd8 (otsuka et al., 2020) thymic epithelial cells generated from scaffolding decellularized tissue by synthetic or natural polymers bulk production with desired properties. (bortolomai et al., 2019) (barthlott et al., 2021) thymic organoids (artificial) ms5-dll1 cells cultured differentiation of t cell (seet et al., 2017) (montel-hagen et al., 2019) conclusion globally, pd is the most common chronic progressive neurodegenerative incurable disorder affecting elderly individuals over 65. the incurable pd, with its deteriorated motor function and devastating symptoms such as postural instability, bradykinesia, and quivering, suggests impairment of the patient’s life. the treg dysfunction in the pathogenesis of progressive parkinson’s disease may broadly improve our understanding of the pathology of this incurable disorder and assists in developing proper treatments for parkinson’s disease (pd) in the future. the possible cd4+cd25+treg cells treg dysfunction may be crucial in triggering and releasing dopamine chemicals (neurotransmitters) in the brain. thus, suggesting that treg dysfunction is associated with the pathogenesis of progressive parkinson’s disease. in this context, the possible contribution of cd4+/cd25+ regulatory t cells (tregs) is to mobilize themselves to get rid of the pd pathology significantly. therefore, the functional existence of highly regulated, adaptive immunopathogenic mechanisms will ultimately lead to developing future novel therapeutics for parkinson’s disease (pd). references awong, g., herer, e., surh, c. d., dick, j. e., la motte-mohs, r. n., & zúñiga-pflücker, j. c. 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(2021). the interplay between the gut microbiome and the immune system in the context of infectious diseases throughout life and the role of nutrition in optimizing treatment strategies. nutrients, 13(3), 886. pa ge 1 pa ge 18 american journal of medical science and innovation (ajmsi) assessment of knowledge regarding airplane ear preventive measures among air travelers of najran university’s staff ahmad zaker m almagribi1* volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2419 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: january 25, 2024 accepted: february 22, 2024 published: february 26, 2024 passengers before air travel should be frequently advised on the possible preventive measures to reduce any sort of ear discomfort. a cross-sectional survey-based approach was adopted to assess the prevalence of obt, source of information on preventive measures for obt, and respondents’ level of knowledge of preventive measures for aeroplane ear discomfort. 206 respondents i.e., air travellers of najran university’s staff were sampled using a purposive sampling technique. results highlighted that the prevalent symptoms of ear discomfort during air travel, which are most commonly observed such as ear pain, popping noises, reduced hearing, dizziness, and ringing noises in the ear. also, findings explored that obt is the severe health issue caused during air travel however mild concerns include pain or loss of hearing, vertigo and ear discharge. most respondents were aware of ‘chewing gum or sweets’ and ‘yawning or swallowing’ as prevention measures, and ‘blowing against a pinched nose (valsalva maneuver)’ as preventive measures for ear discomfirt during air travel. ‘internet’ (11.2%), ‘posters/leaflets in aeroplanes’ (7.8%), ‘posters/leaflets in airports’ (6.8%), and ‘social media’ are the most common sources of information for preventive measures to reduce prevalence of obt. adopting passive methods like yawning, moving the jaw, swallowing, etc. are quick techniques to deal with ear discomfort. keywords otic barotrauma (obt), airplane ear preventive measures, public knowledge, eustachian tube function, middle-ear barotrauma 1 department of surgery, college of medicine, najran university, kingdom of saudi arabia * corresponding author’s e-mail: dr.ahmad.zaker@hotmail.com introduction a number of individuals fly both private and commercial flights on a regular basis, as the airlines are reportedly serving more than 100,000 passengers every day. these individuals are exposed to otic barotrauma (obt) and seek help from an otolaryngologist. a practising otolaryngologist possesses knowledge of barometric changes essential for identifying ear infections (mitchellinnes et al., 2014; wu & kozin, 2024). obt is a traumatic injury of the tympanic membrane and the middle ear resulting from an existing high-pressure differential between the external environment and the middle ear. this pressure is commonly experienced when slight changes in pressure are faced during air travel due to different elevations. the mild symptom is slight aural discomfort due to the increased adoption of air travel, with number of passengers increasing from 310 million to 3.7 billion every year for the last 50 years, with 1 million flying each moment (naouri et al., 2016). eustachian tube dysfunction is estimated to be around 30% in children and 10% in adults. it is experienced when cabin air pressure is at cruising altitude at sea level being lower than air pressure. this cabin air pressure at typical cruising altitudes (11 000–12 200 m) is equal to atmospheric air pressure (1800-2400 m) (naouri et al., 2016; who, 2007). obt is also referred to as the pathological change which results from poor eustachian tube function due to factors like increased likelihood of middle-ear barotrauma and degree of mastoid pneumatisation (mitchell-innes et al., 2014). other symptoms include pain or loss of hearing (naouri et al., 2016), vertigo and discharge in severe cases (michael et al., 2021), long-term morbidity such as tympanic membrane perforation in rare cases (ryan et al., 2018), sensorineural and conductive hearing loss 5 and perilymph fistula (bhattacharya et al., 2019). nevertheless, it is fortunate that a number of aeroplane ear preventive measures exist, such as swallowing and yawning for performing the valsalva maneuver. however, it is evident with limited benefits in reducing ear discomfort linked with obt in adults due to a lower level of awareness among the public. past studies have highlighted the symptoms, causes and preventions of obt, but limited research is available on public awareness for obt causes and prevention in saudi arabia. therefore, the current research was conducted to analyse the public perceptions of the knowledge of obt, identifying symptoms’ frequency and awareness levels for prevention measures among academic staff who are frequent air travellers of najran university, saudi arabia. a cross-sectional survey-based approach was adopted to cater for the following objectives: 1. to assess the respondents’ level of knowledge of preventive measures for aeroplane ear discomfort. 2. to investigate respondents’ source of information on preventive measures for obt. 3. to estimate the prevalence of obt among the public in saudi arabia. literature review in a survey-based study, distributing an online questionnaire among commercial aircrew of three airlines in finland, the researchers examined the most common symptoms of middle ear (me) barotraumas, pa ge 19 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 18-26, 2024 which may affect flight safety. among 1789 respondents, 1516 reported experiencing me barotraumas during flight, among which 5% had to undergo a surgical procedure due to an increasing number of upper respiratory tract infections. a common factor reported is poor performance subjected to toynbee and valsalva maneuvers (lindfors et al., 2021). it is reported that obt is one of the most reported medical complications of aviation caused by to middle ear’s traumatic inflammation. the cross-sectional research was conducted to examine the quick response of travellers at the departure or arrival airport departments to identify their knowledge of the positive signs or symptoms of obt. the suggestive preventive measures include chewing gum, the valsalva maneuver, frequent swallowing and yawning to relieve ear tension (almufarrej et al., 2023). the vaccine-preventable emergencies and tropical infectious diseases are the mainstay of pre-travel consultations. however, accidents and injuries, which are known as non-communicable diseases, also occur during travel, and therefore public should be aware of these as well. results showed that 1 in 100,000 travellers die due to trauma (40%) and other diseases (60%), among which <3% are also associated with infectious diseases. these infections can be prevented with awareness of effective measures (potin et al., 2023). a serious threat to flight safety is health incapacitation therefore a study a study was carried out examining the upper respiratory infection (uri) and ear-nose-throat (ent) barotrauma among commercial pilots. results were collected within one year from 463 pilots. these results reported that uri symptoms increased to 50.1% and ent barotraumas to 55.5%. consequently, pilots taking decongestant medicine increased to 59.5% (boel & klokker, 2017). another study highlighted that a common infection observed among air travellers is barotitis media (bm), which is the key cause of severe discomfort and sometimes permanent balance and hearing deficits. a questionnairebased survey was provided to 97 respondents identifying their travel history, advice-seeking behaviours before travelling and bm knowledge for effective air travel experience. results showed that persistent ear pain and duration of the last flight are significantly associated with knowledge of participants of bm (michael et al., 2021). in a systematic review, it is discussed that among flight attendants and physical health risk factors, the most prevalent physical risk factors include abnormal air pressure and ionising radiation. the most prevalent outcomes due to abnormal air pressure include barotrauma and cerebral blood flow. the change is characterised by low oxygen concentrations accompanied by an increase in altitude and a decrease in atmospheric pressure (russo et al., 2023). methodology study design this study is a cross-sectional online survey-based research conducted between march 2023 to may 2023 among academic staff of najran university to explore their knowledge on awareness and symptoms of obt during air travel. a quantitative research design was adopted in the current study since knowledge patterns among targeted respondents were observed from numerical data. quantitative research is essential for seeking data from a broader population, providing findings with higher generalisability and objective answers (taherdoost, 2022). therefore, to draw a statistical pattern on the awareness of respondents regarding obt and the symptoms identified most commonly during air travel, a quantitative research design was used. sample size and population the targeted population of the research included air travellers to observe their obt awareness and symptoms. for this purpose, the academic staff of najran university who have travelled at least once by air were considered eligible for the research. purposive sampling is a sampling technique used to target the respondents who are selected “on purpose” to provide specific outcomes in the research (mweshi & sakyi, 2020).therefore, a total of 206 respondents who agreed to participate in the research were sampled using a purposive sampling technique to assess the knowledge regarding aeroplane ear preventive measures among air travellers of najran university’s staff. data collection and analysis in this research, data was collected through a primary source such that close-ended surveys were conducted to get the first-hand opinion of respondents on knowledge of aeroplane ear preventive measures. google formbased questionnaires containing 10 questions with multiple choices to investigate research objectives were distributed among the sampled respondents with messages containing informed consent to participate or not and details about research aims and data security. spss 26.0 was used for data analysis, applying frequency analysis to the gathered data and highlighting the most frequent symptoms and preventions during air travel among the public in saudi arabia. results demographics the respondents were asked a few questions relevant to their gender and age demographics and their job designation in their organisation to limit any biases in results. table 1 depicts the gender demographics of the respondents. it shows that the majority of respondents, i.e., 54.9%, were male, whereas 45.1% were female out of the 206 academic staff who participated in the study. pa ge 20 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 18-26, 2024 table 2 below shows the age demographics of the respondents. it can be viewed in the table that the majority of the respondents, i.e., 30.1% (62), each belonged to the age group of 36-40 years and greater than 40 years. besides, 19.9% (41) lied in the age group 31-35, 17.0% (35) were aged between 26 and 30 years; however, only 2.9% (6) respondents were aged between 20 and 25 years. the research respondents were also asked about their job roles at the najran university. as shown in table 3, 26.2% (54) respondents were assistant professors, 10.7% (22) respondents were associate professors, and 11.2% (23) respondents were in masters at the time of data collection. however, 51.5% (106) of respondents marked ‘other’ when asked about their job role. table 1: gender demographics frequency percent valid percent cumulative percent female 93 45.1 45.1 45.1 male 113 54.9 54.9 100.0 total 206 100.0 100.0 table 2: age demographics frequency percent valid percent cumulative percent >40 62 30.1 30.1 30.1 20-25 6 2.9 2.9 33.0 26-30 35 17.0 17.0 50.0 31-35 41 19.9 19.9 69.9 36-40 62 30.1 30.1 100.0 total 206 100.0 100.0 table 3: respondents’ job roles frequency percent valid percent cumulative percent assistant professor 54 26.2 26.2 26.2 associate professor 22 10.7 10.7 36.9 master 23 11.2 11.2 48.1 other 106 51.5 51.5 99.5 professor 1 .5 .5 100.0 total 206 100.0 100.0 objective 1: to assess the respondents’ level of knowledge of preventive measures for aeroplane ear discomfort a few questions were asked relevant to research objective 1, investigating the respondents’ level of knowledge on preventive measures for aeroplane ear discomfort. how often do you fly? it was essential to ask respondents about how often they fly to make sure results reflect their true flight experiences in terms of symptoms observed and prevention taken for obt. table 4 shows that the majority of the respondents, i.e., 51.9% (107), mentioned that they at least fly once a year, 23.8% (49) mentioned they travel up to 3 times per year, 14.6% (30) up to 6 times per year, and 8.3% (17) stated they travel up to 12 times per year. however, only 3 respondents claimed they have never air travelled yet. table 4: respondents’ frequency of air travel frequency percent valid percent cumulative percent i have never flown yet 3 1.5 1.5 1.5 up to 12 times per year 17 8.3 8.3 9.7 up to 3 times per year 49 23.8 23.8 33.5 up to 6 times an year 30 14.6 14.6 48.1 at least once a year 107 51.9 51.9 100.0 total 206 100.0 100.0 pa ge 21 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 18-26, 2024 which prevention mention measure are you aware of, mark all that apply? the research respondents were asked to mark all that apply in terms of the prevention measures they have known or used during air travel for obt. as shown in table 5, it was observed that 23.8% (49) respondents marked ‘none of the above’, reflecting that they have not heard of any prevention before. however, 23.8% (49) respondents mentioned that they are aware of ‘chewing gum or sweets’, reflecting that it is the most common measure the general public is aware of for treating obt during air travel. furthermore, 15.5% (32) were aware of both ‘chewing gum or sweets’ and ‘yawning or swallowing’ as prevention measures, 12.1% (25) respondents have heard of ‘chewing gum or sweets’, ‘yawning or swallowing’, and ‘blowing against a pinched nose (valsalva maneuver)’ depicting these 3 as the most common known preventions. however, the results also showed that the least heard prevention measures by the respondents include ‘otrivin’ and ‘decongestant, i.e. lorinase’ reported along with any other reported prevention as well including ‘chewing gum or sweets’, ‘yawning or swallowing’, ‘otrivin’, ‘decongestant, i.e. lorinase’, ‘blowing against a pinched nose (valsalva maneuver)’. table 5: prevention measures respondents have heard frequency percent valid percent cumulative percent blowing against a pinched nose (valsalva maneuver) 9 4.4 4.4 4.4 chewing gum or sweets 49 23.8 23.8 28.2 chewing gum or sweets, blowing against a pinched nose (valsalva maneuver) 11 5.3 5.3 33.5 chewing gum or sweets, otrivin 2 1.0 1.0 34.5 chewing gum or sweets, yawning or swallowing 32 15.5 15.5 50.0 chewing gum or sweets, yawning or swallowing, blowing against a pinched nose (valsalva maneuver) 25 12.1 12.1 62.1 chewing gum or sweets, yawning or swallowing, decongestant i.e. lorinase, blowing against a pinched nose (valsalva maneuver) 1 .5 .5 62.6 chewing gum or sweets, yawning or swallowing, otrivin 2 1.0 1.0 63.6 chewing gum or sweets, yawning or swallowing, otrivin, blowing against a pinched nose (valsalva maneuver) 1 .5 .5 64.1 chewing gum or sweets, yawning or swallowing, otrivin, decongestant i.e. lorinase, blowing against a pinched nose (valsalva maneuver) 4 1.9 1.9 66.0 none of the above 49 23.8 23.8 89.8 otrivin 3 1.5 1.5 91.3 otrivin, blowing against a pinched nose (valsalva maneuver) 1 .5 .5 91.7 yawning or swallowing 13 6.3 6.3 98.1 yawning or swallowing, blowing against a pinched nose (valsalva maneuver) 4 1.9 1.9 100.0 total 206 100.0 100.0 would you consider using these measures now? table 6 depicts that the majority of the respondents, i.e., 32.0% (66), said ‘maybe’ when asked whether they use these measures or not, 30.1% (60) marked ‘definitely yes’, 24.8% (51) marked ‘probably yes’, 8.3% (17) stated ‘probably no’ and only 4.9% (10) marked ‘definitely no’. table 6: measures considered by respondents frequency percent valid percent cumulative percent definitely no 10 4.9 4.9 4.9 definitely yes 62 30.1 30.1 35.0 maybe 66 32.0 32.0 67.0 pa ge 22 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 18-26, 2024 objective 2: to investigate respondents’ source of information on preventive measures for obt the respondents were asked questions relevant to sources of information for them regarding the preventive measures for obt. which of the following sources of information are you aware of for air travel? mark all that apply table 7 depicts that the most common sources of information for air travellers include ‘internet’ (11.2%), ‘posters/leaflets in aeroplanes’ (7.8%), ‘posters/leaflets probably no 17 8.3 8.3 75.2 probably yes 51 24.8 24.8 100.0 total 206 100.0 100.0 table 7: source of information for obt prevention measures frequency percent valid percent cumulative percent internet 23 11.2 11.2 11.2 internet, social media 15 7.3 7.3 18.4 internet, social media, and other 3 1.5 1.5 19.9 posters/leaflets at airports 14 6.8 6.8 26.7 posters/leaflets at airports, internet 3 1.5 1.5 28.2 posters/leaflets at airports, internet, social media 6 2.9 2.9 31.1 posters/leaflets at airports, posters/leaflets in aeroplanes 2 1.0 1.0 32.0 posters/leaflets at airports, posters/leaflets in aeroplanes, internet 3 1.5 1.5 33.5 posters/leaflets at airports, posters/leaflets in aeroplanes, internet, social media 1 .5 .5 34.0 posters/leaflets at airports, posters/leaflets in aeroplanes, posters/leaflets in gp practices/hospital, internet, other 1 .5 .5 34.5 posters/leaflets at airports, posters/leaflets in aeroplanes, posters/leaflets in gp practices/hospitals, internet, social media 2 1.0 1.0 35.4 posters/leaflets at airports, posters/leaflets in aeroplanes, posters/leaflets in gp practices/hospitals, social media 1 .5 .5 35.9 posters/leaflets at airports, posters/leaflets in aeroplanes, social media 1 .5 .5 36.4 posters/leaflets at airports, posters/leaflets in gp practices/ hospitals, social media 1 .5 .5 36.9 posters/leaflets at airports, none of the above 1 .5 .5 37.4 posters/leaflets at airports, social media 1 .5 .5 37.9 posters/leaflets in aeroplanes 16 7.8 7.8 45.6 posters/leaflets in aeroplanes, internet 3 1.5 1.5 47.1 posters/leaflets in aeroplanes, internet, other 1 .5 .5 47.6 posters/leaflets on aeroplanes, internet, social media 2 1.0 1.0 48.5 posters/leaflets in aeroplanes, internet, social media, other 1 .5 .5 49.0 posters/leaflets in aeroplanes, social media 2 1.0 1.0 50.0 posters/leaflets in gp practices/hospital 4 1.9 1.9 51.9 posters/leaflets in gp practices/hospitals, internet 1 .5 .5 52.4 none of the above 53 25.7 25.7 78.2 other 32 15.5 15.5 93.7 other, none of the above 1 .5 .5 94.2 social media 12 5.8 5.8 100.0 total 206 100.0 100.0 pa ge 23 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 18-26, 2024 in airports’ (6.8%), and ‘social media’ (5.8%). however, 1.9% also reported ‘posters/leaflets in gp practices/ hospitals’ as their source of information for prevention measures during air travel. do you agree getting more information will be useful? table 8 below presents that upon asking respondents whether the providing more information will be useful or table 8: usefulness of provision of more information frequency percent valid percent cumulative percent no 6 2.9 2.9 2.9 not sure 27 13.1 13.1 16.0 yes 173 84.0 84.0 100.0 total 206 100.0 100.0 not for them regarding obt prevention. most of them (84.0%) responded ‘yes’ to the asked question, 13.1% (27) were not sure about it and only 2.9% (6) responded ‘no’. objective 3: to estimate the prevalence of obt the prevalence of obt was also determined among the target respondents by inquiring about the most common symptoms of obt suffered during air travel. mark all those apply from the symptoms following you have faced during air travel? table 9 below presents the responses of students identified when they were asked about the symptoms they have ever observed while flying. it is observed that 17.0% (35) respondents mentioned ‘ear pain’ as the most common symptom during air travel, 8.7% (18) mentioned ‘ear pain’ as the most repeated symptom, and 7.3% (15) marked ‘popping noises’ as a common symptom suffered during air travel. however, 3.4% (7) mentioned suffering from ‘ringing noises in the ear’, 2.4% (5) mentioned ‘dizziness’, and 0.5% (1) mentioned ‘ear discharge’ while on an aeroplane. nonetheless, 32.5% (67) of respondents mentioned that they did not suffer from any of the listed symptoms. a few respondents marked more than one symptom to be suffered from during air travel. for example, 3.9% (8) respondents mentioned ‘ear pain, dizziness’ and ‘ear pain, popping noises’ together as the symptoms they suffered while flying. table 9: most common symptoms of obt suffered during air travel frequency percent valid percent cumulative percent dizziness 5 2.4 2.4 2.4 ear discharge 1 .5 .5 2.9 ear discharge, dizziness 1 .5 .5 3.4 ear discharge, ringing noises in the ear, dizziness 1 .5 .5 3.9 ear pain 35 17.0 17.0 20.9 ear pain, dizziness 8 3.9 3.9 24.8 ear pain, ear discharge 1 .5 .5 25.2 ear pain, popping noises 8 3.9 3.9 29.1 ear pain, popping noises, dizziness 1 .5 .5 29.6 ear pain, ear discharge, popping noises 2 1.0 1.0 30.6 ear pain, popping noises, reduced hearing 2 1.0 1.0 31.6 ear pain, popping noises, reduced hearing, dizziness 2 1.0 1.0 32.5 ear pain, popping noises, reduced hearing, ringing noises in the ear, dizziness 2 1.0 1.0 33.5 ear pain, popping noises, ringing noises in the ear 1 .5 .5 34.0 ear pain, reduced hearing 8 3.9 3.9 37.9 ear pain, reduced hearing, dizziness 2 1.0 1.0 38.8 ear pain, ringing noises in the ear 5 2.4 2.4 41.3 none of the above 67 32.5 32.5 73.8 popping noises 15 7.3 7.3 81.1 popping noises, dizziness 3 1.5 1.5 82.5 pa ge 24 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 18-26, 2024 ear discharge, popping noises, dizziness 1 .5 .5 83.0 ear discharge, popping noises, reduced hearing 1 .5 .5 83.5 popping noises, reduced hearing, ringing noises in the ear 1 .5 .5 84.0 popping noises, ringing noises in the ear 3 1.5 1.5 85.4 reduced hearing 18 8.7 8.7 94.2 reduced hearing, dizziness 2 1.0 1.0 95.1 reduced hearing, ringing noises in the ear 3 1.5 1.5 96.6 ringing noises in the ear 7 3.4 3.4 100.0 total 206 100.0 100.0 have you had previous ear surgery? lastly, respondents were also asked to mention if they have had any previous ear surgery due to obt suffered during air travel. table 10 shows that the majority of them responded ‘no’, i.e., 98.5%; however, 1.5% (3) respondents said ‘yes’, depicting that knowledge regarding ear preventive measures is essential since it may limit even the small chance of suffering from obt such that an individual had any recent ear surgery should delay air travel. table 10: respondents with previous ear surgery frequency percent valid percent cumulative percent no 203 98.5 98.5 98.5 yes 3 1.5 1.5 100.0 total 206 100.0 100.0 discussion preventive measures of airplane ear discomfort the current research’s key objective is to identify the knowledge of air travellers on the key interventions which could be undertaken while feeling aeroplane discomfort. the results of the current research showed that respondents were aware of a few preventive measures like chewing gum or sweets, yawning or swallowing, blowing against a pinched nose (valsalva maneuver), otrivin, and decongestant, i.e. lorinase. notably, in past research, it is addressed that rapid free fall causes ambient pressure change, equalising the middle ear pressure. it can be prevented by the valsalva maneuver, which is a process helpful in severe cases; however, it requires an oxygen mask. therefore, adopting passive methods like yawning, moving the jaw, swallowing, etc. are quick techniques to deal with ear discomfort (naouri et al., 2016; sannigrahi et al., 2018). similarly, bhattacharya et al. (2019) highlighted chewing, swallowing and yawning as helpful measures which should be taken during landing and taking-off since they activate eustachian tubes’ muscles bi-laterally. nonetheless, it is recommended not to sleep during the descent and ascent of flights as it is the period which may create sudden pressure change. earplugs also assist in equalising the pressure slowly when ear discomfort is felt against the eardrum (bhattacharya et al., 2019). valsalva maneuver is one such effective prevention which is beneficial for crucial ear discomfort conditions such as the prevalence of aerotitis media (sharma et al., 2020). however, another research highlighted that if yawning, jaw movements, and swallowing do not prevent ear discomfort, then the air should be forced into the cavities of the middle ear by raising nose and mouth pressure to occlude the nostrils (bagshaw & illig, 2019). sources of information on preventive measures for ear discomfort during air travel health information should be delivered by effective means or sources of measures of preventive measures through websites, leaflets, personal communication and advertisements (mitchell-innes et al., 2014). concurrently, the recent research findings suggested that air travellers should be communicated with basic preventive measures as only a few respondents mentioned the sources of information, including posters/leaflets at airports, posters/leaflets in aeroplanes, posters/leaflets in gp practices/hospitals, internet, and social media. in this aspect, mitchell-innes et al. (2014) examined that flight leaflets are the most effective source for obt since they are provided during the onset of facing any symptoms of ear discomfort during travelling. some other sources for air travel health advice include the internet, brochures, books, travel agents, and newspapers (naouri et al., 2016). another study pointed out that for the public, education leaflets should be posted on the official website as a significant source for informing about ear discomfort. however, social media is also a useful resource (ho et al., 2017). prevalence of obt ear discomfort during flight or aeroplane air is common whether the travellers are flying in business class or getting leg space; the problem is often faced. the current research highlighted the prevalent symptoms of ear discomfort during air travel, highlighting symptoms pa ge 25 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 18-26, 2024 which are most commonly observed such as ear pain, popping noises, reduced hearing, dizziness, and ringing noises in the ear. similarly, past research highlighted that air travel symptoms include fullness, pain, discomfort, and moderate to mild loss of hearing. however, severe hearing loss, severe pain, vertigo, tinnitus, and hemotympanum are the symptoms affected individuals face in severe cases (bhattacharya et al., 2019). nevertheless, another painful ear disorder experienced during air travel due to external pressure’s rapid change is called aerotitis media, which leads to pain, vertigo, tinnitus and hearing loss (sharma et al., 2020). besides, some of the risk factors for tinnitus and hearing loss other exposure to high noise and low pressure in aircraft include hypertension, acoustic trauma, flying time, smoking and diabetes mellitus causing hearing loss (muyassaroh et al., 2021). respondents were also asked if they have had any previous ear surgery and few of them responded ‘yes’. consequently, bhattacharya et al. (2019) highlighted in their research that individuals suffering from sinusitis, recent ear surgery, common cold, ear infection or nasal congestion should reschedule travel plans or use decongestants an hour or 30 minutes before travel to limit the change of ear discomfort. conclusion the pressure changes during air travel is one of the most common challenge which causes barotrauma or obt. considerably, equilibration is achieved normally by jaw movements, swallowing, chewing or yawning. also, prior to the flight the use of an oral decongestant limits the incidence of obt which is generally recommended to passengers. the research highlighted that it is important to increase the awareness on the prevention measures during air travel to limit ear discomfort among passengers. the common symptoms are often mild but they can get worse like trouble hearing, feeling that eat is blocked, dizziness, severe ear pain and ear discharge. these can cause severe issues and an ear surgery is required therefore taking early measures is important to secure the eardrum. therefore, education leaflets should be posted on the official website of airlines as a significant source for informing about ear discomfort. limitations and future implications the research sample size was limited to the academic staff of najran university however for generalisability for broader saudi population, the future research can be enhanced by considering diverse demographics to limit any bias. additionally, the recent study was limited to survey-based research however in the future it ca be improved using open-ended interviews to support survey findings with in-depth perceptions. the current research highlights the most common symptoms observed during air travel and the commonly known preventive measures among public. it will be beneficial for the healthcare sector, aeroplane industry and researchers to increase the general awareness on measures which prevent obt and other challenges pertinent to ear discomfort during air travel. references almufarrej, a. a., almutairi, k. a., alzamel, o. m., alsubaie, n. s., alghamdi, m. s., hajr, e. a., & alotaibi, f. z. (2023). assessment of travelers’ knowledge about symptoms and prevention strategies of otic barotrauma in saudi arabia: a cross-sectional study. saudi journal of otorhinolaryngology head and neck surgery. bagshaw, m., & illig, p. (2019). the aircraft cabin environment. in travel medicine (pp. 429-436). elsevier. bhattacharya, s., singh, a., & marzo, r. r. (2019). “airplane ear”—a neglected yet preventable problem. aims public health, 6(3), 320. boel, n. m., & klokker, m. (2017). upper respiratory infections and barotrauma among commercial pilots. aerospace medicine and human performance, 88(1), 17-22. ho, l.-l., tsai, y.-h., lee, w.-p., liao, s.-t., wu, l.-g., & wu, y.-c. (2017). taiwan’s travel and border health measures in response to zika. health security, 15(2), 185-191. lindfors, o. h., ketola, k. s., klockars, t. k., leino, t. k., & sinkkonen, s. t. (2021). middle ear barotraumas in commercial aircrew. aerospace medicine and human performance, 92(3), 182-189. michael, g. c., usman, m. b., aliyu, i., grema, b. a., & ahmed, a. o. (2021). pre-air travel healthseeking behaviour, prevalence of barotitis media, its knowledge and associated factors among recently travelled patients in kano, nigeria. nigerian postgraduate medical journal, 28(2). mitchell-innes, a., young, e., vasiljevic, a., & rashid, m. (2014). air travellers’ awareness of the preventability of otic barotrauma. the journal of laryngology & otology, 128(6), 494-498. muyassaroh, m., sayuti, f. i., ruspita, d. a., kusuma dewi, a. m., budiarti, r., naftali, z., & widodo, p. (2021). factors associated with hearing loss in helicopter aircrew of indonesian army aviation center, semarang. sains medika: jurnal kedokteran dan kesehatan, 12(2). mweshi, g. k., & sakyi, k. (2020). application of sampling methods for the research design. archives of business review–vol, 8(11). naouri, d., lapostolle, f., rondet, c., ganansia, o., pateron, d., & yordanov, y. (2016). prevention of medical events during air travel: a narrative review. the american journal of medicine, 129(9), 1000. e10011000. e1006. potin, m., carron, p.-n., & genton, b. (2023). injuries and medical emergencies among international travellers. journal of travel medicine, taad088. russo, a. c., marqueze, e. c., furst, m. s. g., benevides, e. a. d. s. e., roscani, r. c., salim, c. a., & guimarães, p. c. v. (2023). aircrew health: a systematic review of physical agents as occupational risk factors. international journal of environmental research and public health, 20(10), 5849. pa ge 26 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 18-26, 2024 ryan, p., treble, a., patel, n., & jufas, n. (2018). prevention of otic barotrauma in aviation: a systematic review. otology & neurotology, 39(5), 539-549. sannigrahi, p., sushree, s., & agarwal, a. (2018). aeromedical concerns and lessons learnt during oxygen jump at dolma sampa. indian journal of aerospace medicine, 62(2), 16-20. sharma, s., joshi, h., & anand, p. (2020). otitis in aerospace-aerotitis: a review. indian journal of forensic medicine & toxicology, 14(4). taherdoost, h. (2022). what are different research approaches? comprehensive review of qualitative, quantitative, and mixed method research, their applications, types, and limitations. journal of management science & engineering research, 5(1), 53-63. who. (2007). international travel and health: situation as on 1 january 2007. world health organization. wu, m. j., & kozin, e. d. (2024). medical and surgical management of otic barotrauma. in otologic and lateral skull base trauma (pp. 149-157). elsevier. pa ge 1 pa ge 90 american journal of medical science and innovation (ajmsi) how long can one live without a permanent pacemaker in complete heart block? a case report from rural kenya onyango c. vonwicks1*, auma nicholas2, malalu p. collins1, fryda c. william1 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.4385 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: january 10, 2025 accepted: february 12, 2025 published: march 11, 2025 complete heart block is characterized by a total atrioventricular dissociation resulting in junctional or ventricular escape rhythms. it is associated with high cardiovascular mortality rates without definitive treatment. the current guidelines recommend the placement of a permanent pacemaker to manage all cases of a complete heart block not caused by reversible or physiological causes, irrespective of patient symptoms. the natural history and prognosis of complete heart block not treated with pacemaker placement are unknown. in this study, we present the case of an elderly woman from rural kenya who was diagnosed with a complete heart block 30 years ago and recommended a permanent pacemaker but declined. she has lived a relatively normal and active life without a pacemaker, albeit with compensated heart failure. this case suggests that a subset of patients with complete heart block may have good clinical outcomes without the need for a permanent pacemaker. it would be worthwhile to do further studies to map this subset of patients’ natural history and prognostic factors. keywords case report, complete heart block, kenya, permanent pacemaker, third-degree atrioventricular block 1 department of medicine, st. joseph rift valley hospital, gilgil, nakuru county, kenya 2 department of endoscopy, st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction a complete heart block (chb) (also called thirddegree atrioventricular block) occurs when there is no conduction at all from the atria to the ventricles and may be paroxysmal or permanent (kusumoto et al., 2019). the causes may be reversible or irreversible, including myocardial infarction, myocarditis, infective endocarditis, cardiomyopathy, hyperkalemia, atrioventricular nodal blocking medications (e.g., beta-blockers, calcium channel blockers, digoxin, adenosine, etc.), post-cardiac surgery/ procedures, congenital heart block, idiopathic, etc. (meloy et al., 2022). patients may present with fatigue, chest pain, dyspnea, palpitations, presyncope and syncope, heart failure, cardiogenic shock, or sudden cardiac arrest (meloy et al., 2022). they have bradycardia due to the occurrence of escape rhythms, which may be junctional (rates of 40-60 bpm) or ventricular (rates of 20-40 bpm). patients with chb have very poor outcomes without prompt and appropriate treatment with pacemaker placement (knabben et al., 2025). chb is an independent predictor of in-patient and 6-year mortality (savic et al., 2021). the prevalence of chb varies widely based on various populations, e.g., 0.004% in china to 0.04% in iceland and michigan (kojic et al., 1999; ostrander et al., 1965; shan et al., 2021). the diagnosis is confirmed on an electrocardiogram, which shows severe bradycardia and evidence of atrioventricular dissociation: the atrial (p waves) and ventricular (qrs complexes) activities are independent of each other. the atrial rate is higher than the junctional or ventricular escape rate. see figures 1 and 2 below by yang et al. (2018) and bhasin and roy (2019), respectively. electrophysiology (ep) study may rarely be used to make the diagnosis. figure 1: the ekg shows a complete heart block with a junctional escape rhythm, an atrial rate of around 90 bpm, and a ventricular rate of 45 bpm (yang et al., 2018). figure 2: the ekg shows a complete heart block with a ventricular escape rhythm, an atrial rate of about 88 bpm, and a ventricular rate of about 30 bpm (bhasin & roy, 2019). pa ge 91 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 90-93, 2025 the management guidelines for chb have been proposed by the european society for cardiology, the american college of cardiology, the american heart association, and the heart rhythm society (glikson et al., 2021; kusumoto et al., 2019). in summary, patients with complete heart block not caused by physiologic or reversible causes should undergo a permanent pacemaker placement irrespective of the symptoms (class i recommendation with level c evidence). the long-term outcomes of chb are not well documented, probably because they are usually treated with pacemakers in urgent-care settings (knabben et al., 2025). the prognosis is most likely influenced by the underlying etiology of the chb (reversible vs. irreversible causes), the severity of the clinical presentation, and the occurrence of hemodynamic instability (this can lead to death if not promptly treated by temporary and/or permanent pacemaker placement) (knabben et al., 2025). case summary clinical history and physical examination a 79-year-old widow, a mother of 10 and a farmer from mbaruk, nakuru county, kenya, first presented to us in 2021 with clinically decompensated biventricular congestive heart failure and severe bradycardia (heart rate of 34 bpm) on a background of poorly controlled isolated systolic hypertension, which was diagnosed some 30 years prior (baseline home bps of 163170/71-73 mmhg during this presentation.). she had been non-compliant on the prescribed amlodipinelosartan-hydrochlorothiazide combination tablet. she was overweight (bmi of 28.8 kg/m2) but with no other cardiovascular risk factors. she had been diagnosed with hypertension and a “slow heart” in a peripheral facility in 1995 and was put on unknown medications and referred to a cardiologist for a possible pacemaker placement. she defaulted on the medications and did not go for her referral. she continued to have “occasional” dizziness thereafter with her heart rates ranging from 30 to 40 bpm whenever they were checked. in the year 2008, she had several syncopal episodes and was referred to the national referral hospital, where she was diagnosed with “severe hypertension” and a complete heart block. six months before this, her husband had died, and her home and property had been destroyed in the 2007-2008 kenyan post-election violence. subsequent multiple cardiologist reviews and recommendations for a permanent pacemaker placement were futile as she declined “the placement of any gadgets in me that god did not put in there himself!” she underwent serial counseling for the same, but she declined. she describes herself as a “staunch christian with unshakable faith in god.” reportedly, the etiology of the chb was never found despite “multiple blood tests,” and it was thus labeled idiopathic. no invasive tests or procedures were done during the etiological workup. she subsequently defaulted on her discharge medications (unknown) and was not on any treatment until 2 years before her presentation to us, when she was put on an antihypertensive and referred to a cardiologist, who again failed to talk her into getting a pacemaker upon re-confirming a complete heart block. interestingly, she reported no further presyncopal or syncopal episodes after 2008 except for onoff palpitations with heavy physical exertions. she had no history suggesting heart failure or acute coronary syndrome before her presentation to us. presently, she was in decompensated biventricular heart failure at new york heart association (nyha) dyspnea scale grade 3 precipitated by a community-acquired pneumonia (curb-65 score of 2). her bp was 163/79 mmhg, pulse rate of 32 bpm (which did not change following a trial administration of 1.2 mg of atropine intravenously), with an oxygen saturation of 97% in room air. she was afebrile. she had grade 3 bi-pedal pitting edema, elevated jvp with the classical cannon ‘a’ wave, a hyperactive precordium with variable but normal s1, s2, and an s3 gallop rhythm and no murmurs, bibasal crackles on the lung auscultation with right midlung zone crepitations, and a tipped tender hepatomegaly on abdominal examination. the rest of the physical examination was unremarkable. work-up, management, and follow-up her baseline laboratory tests were all normal, including a complete blood count, renal, thyroid, and liver panels, serum electrolytes including calcium, blood sugar, lipid profile, and a urinalysis. serum troponins were negative. the covid-19 antigen and pcr tests were negative. her ekg showed a complete heart block with a ventricular escape rate of 36 bpm, some premature ventricular contractions, and no evidence of acute ischemic changes. see figure 3 below. her cxr showed cardiomegaly with pulmonary edema and right lung mid-lobe opacification. an interval echocardiogram showed grade 2 diastolic dysfunction, dilated left atrium and ventricle with a left ventricular ejection fraction of 87%, no regional wall motion anomalies, normal valves, no thrombus, and no pericardial effusion. another echocardiogram done 12 months later showed a small apical thrombus. figure 3: the ekg done in 2021 shows a complete heart block with ventricular escape rhythm; the atrial rate is about 90 bpm, while the ventricular rate is about 36 bpm. two premature ventricular contractions are noted. pa ge 92 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 90-93, 2025 figure 4: the ekg done in 2024 shows a complete heart block with ventricular escape rhythm; the atrial rate is about 84 bpm, while the ventricular rate is about 30 bpm. we successfully managed her as an outpatient with furosemide, spironolactone, losartan, an antibiotic (coamoxiclav), and supportive therapy. we added rivaroxaban later on following the finding of an apical thrombus. we counseled her several times on the need for a pacemaker, but she has declined. it is now 4 years since she has been on follow-up at our clinic and 30 years since she was diagnosed with a complete heart block. she remains in complete heart block (see figure 4 below) and in compensated heart failure (nyha 1-2, current baseline), but with no pacemaker. she has had no admissions for heart failure, no chest pains, no syncope, but occasional mild dizziness while working on her farm. she had an episode of orthostatic hypotension in 2023 following an acute diarrheal illness, which resolved with careful hydration and temporary withdrawal of the diuretics. she still does almost all activities of daily living independently. discussion patients with chb who are managed with a permanent pacemaker have an overall good prognosis. alpert and katti demonstrated overall survival rates of 91% at 1 year, 63% at 5 years and 41% at 10 years (alpert & katti, 1982). this is influenced by patient demographics and the underlying cause and/or complications of the chb, e.g., advanced age, congestive heart failure, ischemic heart disease, etc., which were associated with lower survival rates compared to the presence of hypertension, diabetes, or valvular heart disease in this study (alpert & katti, 1982). little information is recorded in the literature about the prognosis of patients with chb who are not treated with a pacemaker. a ten-year retrospective study by edhag and swahn of 101 patients with arrhythmic syncope and chb not treated with pacemakers (68 of them had chb) showed that of those who had chb, survival was 68% at 1 year and 37% at 5 years (edhag & swahn, 1976). there are several case reports of patients who were diagnosed with chb and managed without a permanent pacemaker placement who led relatively active lives. for example, a 23-year-old chinese woman diagnosed with congenital chb at the onset of an episode of adamsstokes attack declined a pacemaker and led an active life during a 28-year follow-up period in which she had an uneventful pregnancy (su et al., 2022). a 26-year-old primigravida with chb remained stable throughout the pregnancy and underwent a cesarean section under spinal anesthesia without a pacemaker (swain et al., 2022). our patient has seemingly followed a clinical course almost similar to the chinese woman (although the latter had an initial temporary pacemaker and later on had a relatively good compensation for her chb from the junctional escape rhythm). our patient was diagnosed with chb during an adams-stokes attack and recommended for a permanent pacemaker placement but declined due to personal and religious reasons. she has lived for about 30 years now with chb without a pacemaker and has been active throughout, including in her old age presently, where she is still doing most of her activities of daily living independently. she has survived several episodes of presyncope and syncopal attacks and has been in compensated heart failure with preserved ejection fraction since we started following her 4 years ago. the reasons for her relatively stable clinical course remain largely speculative for now, including the possible roles of unknown cardiovascular compensatory mechanisms and her religious faith. we are unable to do any further etiological and prognostic studies for her chb (e.g., cardiac mri, biopsy, etc.). undoubtedly, more studies are needed to correctly map out the natural history of chb and elicit more reliable and predictable prognostic markers in this subset of patients who decline permanent pacemaker placement but seemingly remain relatively stable over many years. conclusion the case of our patient adds to a subset of known (and unknown) patients with chb who surprisingly led a relatively stable and active clinical course over many years without any pacemaker placement. this may suggest that some patients with chb may not necessarily require a permanent pacemaker, as is the current evidence-based recommendation by various guidelines. accordingly, more studies are needed to map out the natural history of chb in this subset of patients and to determine more reliable markers of prognosis to influence decisions regarding true indications and timing of pacemaker placement. references alpert, m. a., & katti, s. k. (1982). natural history of high-grade atrioventricular block following permanent pacemaker implantation. journal of chronic diseases, 35(5), 341-349. https://doi.org/https://doi. org/10.1016/0021-9681(82)90005-4 bhasin, d., & roy, a. (2019). complete heart block. circulation, 140(6), 516-519. https://doi.org/10.1161/ circulationaha.119.042001 edhag, o., & swahn, a. (1976). prognosis of patients with complete heart block or arrhythmic syncope pa ge 93 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 90-93, 2025 who were not treated with artificial pacemakers. a long-term follow-up study of 101 patients. acta med scand, 200(6), 457-463. glikson, m., nielsen, j. c., kronborg, m. b., michowitz, y., auricchio, a., barbash, i. m., barrabés, j. a., boriani, g., braunschweig, f., brignole, m., burri, h., coats, a. j. s., deharo, j. c., delgado, v., diller, g. p., israel, c. w., keren, a., knops, r. e., . . . group, e. s. d. (2021). 2021 esc guidelines on cardiac pacing and cardiac resynchronization therapy: developed by the task force on cardiac pacing and cardiac resynchronization therapy of the european society of cardiology (esc) with the special contribution of the european heart rhythm association (ehra). european heart journal, 42(35), 3427-3520. https:// doi.org/10.1093/eurheartj/ehab364 knabben, v., chhabra, l., & slane, m. (2025). thirddegree atrioventricular block. in statpearls. statpearls publishing. kojic, e. m., hardarson, t., sigfusson, n., & sigvaldason, h. (1999). the prevalence and prognosis of thirddegree atrioventricular conduction block: the reykjavik study. j intern med, 246(1), 81-86. https:// doi.org/10.1046/j.1365-2796.1999.00521.x kusumoto, f. m., schoenfeld, m. h., barrett, c., edgerton, j. r., ellenbogen, k. a., gold, m. r., goldschlager, n. f., hamilton, r. m., joglar, j. a., kim, r. j., lee, r., marine, j. e., mcleod, c. j., oken, k. r., patton, k. k., pellegrini, c. n., selzman, k. a., thompson, a., & varosy, p. d. (2019). 2018 acc/aha/hrs guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the american college of cardiology/american heart association task force on clinical practice guidelines and the heart rhythm society. circulation, 140(8), e382-e482. https://doi. org/doi:10.1161/cir.0000000000000628 meloy, p., rutz, d., & bhambri, a. (2022). 3rd-degree atrioventricular block. j educ teach emerg med, 7(2), o1-o28. https://doi.org/10.21980/j8np9s ostrander, l. d., brandt, r. l., kjelsberg, m. o., & epstein, f. h. (1965). electrocardiographic findings among the adult population of a total natural community, tecumseh, michigan. circulation, 31(6), 888-898. https://doi.org/10.1161/01.cir.31.6.888 savic, l., mrdovic, i., asanin, m., & krljanac, g. (2021). the impact of complete atrioventricular block on in-hospital and long-term mortality in patients with st-elevation myocardial infarction. eur heart j acute cardiovasc care, 10(suppl 1). https://doi.org/10.1093/ ehjacc/zuab020.125 shan, r., ning, y., ma, y., liu, s., wu, j., fan, x., lv, j., wang, b., li, s., & li, l. (2021). prevalence and risk factors of atrioventricular block among 15 million chinese health examination participants in 2018: a nation-wide cross-sectional study. bmc cardiovascular disorders, 21(1), 289. https://doi.org/10.1186/ s12872-021-02105-3 su, l. n., wu, m. y., cui, y. x., lee, c. y., song, j. x., & chen, h. (2022). unusual course of congenital complete heart block in an adult: a case report. world j clin cases, 10(19), 6602-6608. https://doi. org/10.12998/wjcc.v10.i19.6602 swain, s., routray, s., behera, s., & mohanty, s. (2022). pregnancy with complete heart block. bmj case reports, 15(1), e244598. https://doi.org/10.1136/bcr2021-244598 yang, y. c., pata, r. k., & aung, t. t. (2018). a case of complete heart block with diagnostic challenge and therapeutic dilemma. journal of investigative medicine high impact case reports, 6, 2324709618788110. https://doi.org/10.1177/2324709618788110 pa ge 1 pa ge 98 american journal of medical science and innovation (ajmsi) hiv testing uptake: when testers are not tested – implications for reaching the first 95 ogundipe olubiyi love1*, ekundayo olajumoke kemi², oludare akinola joseph3, kajero ayokunle1, guilavogui jean paul yassa4 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.6082 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 01, 2025 accepted: october 10, 2025 published: november 04, 2025 achieving the first unaids 95-95-95 target requires optimizing provider-initiated hiv testing and counselling (pitc). limited attention has been given to how hiv testing services (hts) providers’ own testing practices influence their ability to convince clients to test. this study assessed hiv testing habits of hiv testing services (hts) providers in ondo and ekiti states, nigeria, and their association with client uptake. a cross-sectional survey was conducted across 200 hts centres, enrolling 786 active counsellors, testers, or dual-role providers. a structured questionnaire captured socio-demographic data, role, hiv knowledge score, and self-reported recency of hiv testing. provider activities were observed over three months to document client uptake rates. descriptive statistics, chi-square tests, and multivariable logistic regression were applied. only 23% of providers had tested within the last 6 months; 11% had never tested. testers were more likely to have tested recently (53%) compared to counsellors (8%). counsellors who tested recently achieved higher client uptake (87%) than those who tested >12 months ago (42%) or never (12%). independent predictors of client uptake included tertiary education (or=1.91; 95% ci: 1.44–2.54), being a tester/dual-role provider (or=2.41; 95% ci: 1.58–3.69), higher knowledge score (or=3.06; 95% ci: 2.07–4.52), and recent self-testing (or=2.59; 95% ci: 1.70–3.95). age was inversely associated (or = 0.89 per year), and males had slightly higher odds (or = 1.20). provider-side factors, especially personal hiv testing behaviour, knowledge, education, and role, strongly influence client uptake. normalizing regular provider self-testing, enhancing knowledge, and promoting multi-role competency may substantially improve hiv testing coverage, advancing progress toward nigeria’s 95-95-95 targets. keywords hiv testing services, hiv multi-role competences, unaids 95-95-95 1 ondo state primary health care development agency, nigeria ² bamidele olumilua university of education, science and technology, nigeria ³ society for family health, oyo state, nigeria 4 public health for all institute, conakry, guinea * corresponding author’s e-mail: myloveinitiative@gmail.com introduction hiv remains a major public health challenge globally, particularly in sub-saharan africa (moyo et al., 2023). in nigeria, around 1.9 million individuals were living with hiv as of 2020 (bassey & miteu, 2023), yet fewer than one-third know their status (mcclarty et al., 2024). the unaids 9595-95 targets require aggressive strategies to improve testing coverage (frescura et al., 2022). however, for this goal ramping up hiv testing and understating barriers is required (parikh et al., 2025; ogunnusi et al., 2024). healthcare providers, especially hiv testing services (hts) counsellors and testers, are central to these efforts. while a lot of work has been done on various factors influencing service update for reproductive health services (mshweshwe-pakela et al., 2022; mavodza et al., 2021, mannoh et al., 2022). however, limited attention has been given to providers’ own hiv testing practices and how these may affect their ability to encourage client testing. this study evaluates hiv testing uptake among hts providers in ekiti and ondo states and examines its association with client uptake. materials and methods study area the study was conducted in ondo and ekiti states, southwest nigeria. recent studies documented hiv prevalence at 2.3% and 1.4% for ondo and ekiti states, respectively (onazi et al., 2025). the states’ populations engaged in diverse economic activities, including agriculture, trade, and public service (folorunso, 2020). the study sites included both urban and semi-urban facilities, covering a range of primary and secondary healthcare centres as well as private facilities and civil society organizations that provide hiv testing and counselling services. sample size determination the study targeted all active hts providers within the selected 200 facilities. a total of 786 eligible participants (counsellors, testers, or those performing both roles) who had been actively engaged in hiv testing services for at least 12 months were enrolled. this census approach ensured comprehensive representation of the hts workforce across the two states. instrument reliability the reliability of the questionnaire was assessed using the test-retest method. the instrument was administered twice to a group of 786 respondents from the hts for the period of the research. the responses from both rounds pa ge 99 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 98-102, 2025 were compared using the pearson correlation coefficient, yielding a value of 0.85, indicating high consistency over time. this result confirmed the stability and reliability of the instrument for the research study design and population a cross-sectional study design was employed. the study population comprised active hiv counsellors, testers, and dual-role providers working in the selected facilities. the sample included providers from varied settings to ensure diversity in socio-economic background, service delivery context, and client demographics. data collection a structured, pre-coded questionnaire using google form was developed to capture socio-demographic characteristics, professional role in hts, hiv knowledge, and self-reported recency of hiv testing. in addition, provider activities were observed over three months to record client hiv testing uptake rates attributable to each provider. data analysis data were cleaned and analysed using descriptive statistics to summarize socio-demographic characteristics, hiv knowledge, provider roles, and testing habits. chi-square tests were used to assess associations between provider characteristics and hiv testing behaviours. multivariable logistic regression was employed to identify predictors of client hiv testing uptake, with variables such as age, gender, education level, role, hiv knowledge score, and the provider’s own recent hiv testing history included in the model at 95% confidence intervals. results and discussion socio-demographic profile of providers the study included 786 active hiv testing services (hts) providers across 200 centres. the majority of respondents were aged 26-45, indicating that most providers were in the prime working age group. females represented a higher proportion (59.3%) compared to males (40.7%), and a significant majority had at least secondary education (33.1%) or tertiary education (53.4%). most providers (60%) held dual roles (both counselling and testing), which could influence their familiarity and proficiency with testing procedures, and this is represented in table 1. testing recency and practice patterns testing recency and practice patterns are figuratively summarized in figures 1 and 2. providers’ testing habits reveal critical insights: only 23 % of all providers reported testing themselves within the last 6 months, indicating a low rate of recent self-testing among providers. a notable 53% of testers tested within the last 6months, whereas only 8% of counsellors tested within this period -highlighting a substantial disparity based on role. meanwhile, 42% of counsellors last tested between 6-12months ago, and an alarming 12% never tested at all. this suggested that a considerable proportion of providers may not regularly engage in self-testing, potentially affecting their capacity to effectively promote testing among clients (figure 3). impact of providers’ testing habits on clients’ testing success providers who tested recently were significantly more effective at motivating clients to test. providers who tested within 6months achieved an 87% client testing success rate. conversely, those who tested than 12months ago or never tested had considerably lower success rate42% and 12% respectively. this pattern underscores the importance of provider self-testing in building credibility and trust with clients, thereby enhancing their motivation to get tested. factors influencing clients testing outcomes the regression result provide insight into the key determinants of successful client testing uptake: age each additional year in the provider’s age slightly reduced the likelihood of successfully convincing a client to test (or=0.89). this may reflect younger providers employing more current, persuasive communication strategies or being more familiar with recent testing protocols. gender male providers had a marginally higher success rate (or=1.20), possibly due to gender-related differences in communication styles or rapport-building level education providers with tertiary education were almost twice as likely to succeed in persuading clients (or=1.91). higher education may confer better communication skills, enhanced health literacy, and confidence, all of which are critical for effective counselling. role within hiv testing service those who performed both testing and counselling (or dual roles) had over twice the odds of client testing success compared to counsellors alone (or=2.41). their procedural familiarity and direct testing capabilities potentially make them more persuasive. hiv knowledge score a higher hiv knowledge score was a strong predictor of success (or=3.06). technical competence and evidencebased counselling seem to motivate more clients to proceed with testing. providers own recent hiv testing (self-testing) providers who had tested recently were significantly more effective (or=2.59). their personal experience likely reduces stigma models positive health behavior, pa ge 10 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 98-102, 2025 and enhances credibility, all critical factors in encouraging clients to test. the proportion of provider who tested within the last 6months was low, indicating a gap in personal engagement with hiv testing. there is a clear relationship between provider characteristics (education, role, knowledge, testing behavior) and client testing outcomes, emphasizing the need for targeted interventions. figure 1: hiv testing habit of the hts provider figure 2: role based hts recency among respondents table 1: socio-demographic characteristics of respondents (n=786) variable frequency percentage (%) age ≤25 120 15.3 26–35 250 31.8 36–45 220 28.0 46–55 130 16.5 56+ 66 8.4 male 320 40.7 female 466 59.3 no formal education 36 4.6 primary 70 8.9 secondary 260 33.1 tertiary 420 53.4 married 500 63.6 single 210 26.7 divorced/separated 76 9.7 counsellor 181 23.0 tester 134 17.0 both 471 60.0 pa ge 10 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 98-102, 2025 table 2: hiv testing status of personnel by categories and corresponding client success rate. personnel category testing history client testing rate (%) testers test in last 6 months 98 testers test in last 12 months 92 testers never tested 93 counsellors test in last 6 months 87 counsellors test in last 12 months 42 counsellors never tested 12 table 3: logistic regression analysis of predictors of client success rate variable b s.e. wald df sig. exp(b) 95% c.i. lower 95% c.i. upper age -0.120 0.050 5.760 1 0.017 0.890 0.805 0.984 gender (male=1) 0.180 0.080 5.060 1 0.025 1.200 1.023 1.406 education (tertiary) 0.650 0.150 18.780 1 <0.001 1.910 1.436 2.540 role (tester/both vs counsellor) 0.880 0.220 16.000 1 <0.001 2.410 1.576 3.688 knowledge score 1.120 0.200 31.360 1 <0.001 3.060 2.072 4.518 client uptake rate* 0.950 0.020 20.000 1 <0.001 2.590 1.700 3.947 constant 0.658 0.713 0.853 1 0.356 1.931 figure 3: hiv test recency-based client success rate among counsellors discussion 200 hts centers in ekiti and ondo states, involving 786 counsellors and testers active for at least 12 months. only 23% of all respondents tested within the last 6 months, 11% had never tested (figure 1). testers were more likely to have tested recently (53%) compared to counsellors (8%) (figure 2). counsellors who had tested recently achieved higher client uptake rates (87%) than those who had not (42%), and providers who never tested had the lowest client uptake (12%) (figure 3). the multivariable regression analysis (table 3) confirms that a combination of socioeconomic status, provider characteristics, and behavioral practices significantly influences the likelihood of successfully convincing a client to update their hiv test. providers with tertiary education had nearly double the odds of client testing success (or = 1.91; 95% ci: 1.44– 2.54) compared to those with lower education. higher education may confer stronger communication skills, health literacy, and confidence in counselling, enhancing persuasive capacity. this aligns with global evidence that educational attainment in health workers correlates with improved health service delivery outcomes (liu & eggleton, 2022). role within the hiv testing service also emerged as a strong predictor. testers and those combining roles were more than twice as likely to achieve uptake (or = 2.41; 95% ci: 1.58–3.69) compared to counsellors alone. this is consistent with findings from kyilyosudu et al. (2023), which suggested that multi-role providers can leverage procedural familiarity and direct testing capability to improve uptake. knowledge score was a powerful independent predictor (or = 3.06; 95% ci: 2.07–4.52), underscoring the importance of technical competence and evidence-based counselling in motivating clients. pa ge 10 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 98-102, 2025 the association supports prior literature showing that increased provider hiv knowledge enhances offer rates and acceptance of testing. most notably, providers’ own hiv testing behavior was strongly associated with client success (or = 2.59; 95% ci: 1.70–3.95). providers who have tested recently may model positive health behavior, reduce stigma, and speak from experience, thereby increasing credibility and trust. similar patterns were observed by jamil et al (2021), where providers who used hiv self-testing themselves were significantly more likely to offer it to clients. age had a modest but significant negative association (or = 0.89 per year), suggesting younger providers might employ more persuasive communication techniques or be more attuned to current testing protocols. gender also showed a small effect (or = 1.20), potentially reflecting cultural norms in provider-client interactions. from a program perspective, these findings suggest that interventions to improve client hiv testing uptake should include: (i) institutionalizing regular, confidential hiv testing for all providers; (ii) targeted capacity building for counsellors; (iii) fostering multi-role competency; and (iv) embedding provider role-modelling into training. these measures align with the unaids 95-95-95 target for 2030, which emphasizes expanding diagnosis through innovative strategies. this study identifies clear quantifiable predictors and the association between behavioral and structural determinants in successful hiv testing service updates. while self-report bias in provider testing history could be a limitation, further studies should explore the longitudinal effects of provider testing interventions on client uptake. conclusion the identity of the provider and their own actions matter greatly for clients’ hiv testing uptake. normalizing provider self-testing, enhancing knowledge, and broadening role competencies can accelerate progress toward national and global hiv diagnosis targets. these results collectively suggest that improving providers’ own testing habits, enhancing their hiv knowledge, and fostering continuous professional development can significantly influence client testing behavior. encouraging regular self-testing among providers may serve as a behavioral model for clients, reducing stigma and increasing the acceptability of testing services. references bassey, a. e., & miteu, g. d. (2023). a review of current trends in hiv epidemiology, surveillance, and control in nigeria. annals of medicine and surgery, 85(5), 1790–1795. folorunso, f. a. (2020). perceived political economy of strikes on selected communities in ondo and ekiti states, south western nigeria. frescura, l., godfrey-faussett, p., feizzadeh, a., el-sadr, w., syarif, o., ghys, p. d., & 2025 testing treatment target working group. (2022). achieving the 95–95– 95 targets for all: a pathway to ending aids. plos one, 17(8), e0272405. jamil, m. s., eshun-wilson, i., witzel, t. c., siegfried, n., figueroa, c., chitembo, l., & johnson, c. (2021). examining the effects of hiv self-testing compared to standard hiv testing services in the general population: a systematic review and meta-analysis. eclinicalmedicine, 38, 100991. kyilyosudu, h., msuya, s. e., ngocho, j. s., & damian, d. j. (2023). factors associated with offer and uptake of provider-initiated hiv testing and counselling among men attending healthcare facilities in moshi municipality, northern tanzania. plos one, 18(9), e0291792. liu, j., & eggleston, k. (2022). the association between health workforce and health outcomes: a cross-country econometric study. social indicators research, 163(2), 609–632. mannoh, i., amundsen, d., turpin, g., lyons, c. e., viswasam, n., hahn, e., & hansoti, b. (2022). a systematic review of hiv testing implementation strategies in sub-saharan african countries. aids and behavior, 26(5), 1660–1671. mavodza, c. v., mackworth-young, c. r., bandason, t., dauya, e., chikwari, c. d., tembo, m., & bernays, s. (2021). when healthcare providers are supportive, “i’d rather not test alone”: exploring uptake and acceptability of hiv self-testing for youth in zimbabwe – a mixed method study. journal of the international aids society, 24(9), e25815. mcclarty, l. m., green, k., leung, s., ejeckam, c., adesina, a., shaw, s. y., & aliyu, g. (2024). advancing programme science approaches to understand gaps in hiv prevention programme coverage for key populations in 12 nigerian states: findings from the 2020 integrated biological and behavioural surveillance survey. journal of the international aids society, 27, e26269. moyo, e., moyo, p., murewanhema, g., mhango, m., chitungo, i., & dzinamarira, t. (2023). key populations and sub-saharan africa’s hiv response. frontiers in public health, 11, 1079990. mshweshwe-pakela, n., mabuto, t., ntombela, n., hlongwane, m., kubeka, g., kerrigan, d. l., & hoffmann, c. j. (2022). facilitators and barriers to implementing provider-initiated hiv counselling and testing at the clinic level in ekurhuleni district, south africa. implementation science communications, 3(1), 19. ogunnusi, o. n., olofin, d. o., olajumoke, a. m., olanipekun, i. a., & ojeniran, t. p. (2024). modeling and forecasting the prevalence of human immunodeficiency virus (hiv) in birnin gwari local government area of kaduna state. applied research and innovation, 2(2), 47–54. onazi, m., james, a., ejura, d. a., & adams, d. a. (2025). hiv counselling and testing (hct) service uptake and the epidemiology of hiv/aids among women attending antenatal care (anc) in high and low prevalence states. international research journal, 8(7), 325–339. parikh, u. m., jacobs, j. l., njuguna, n., torjesen, k., & mellors, j. w. (2025). hiv-1 testing in the context of expanding prep modalities. journal of the international aids society, 28(suppl 2), e26491. https://doi. org/10.1002/jia2.26491 pa ge 1 pa ge 59 american journal of medical science and innovation (ajmsi) understanding hypertension prevalence among starving young adults in conflict-affected sudan amani a. ali1*, ali y. h.2, intisar k. s.2, abdellatif m. m.2, hind a. rikabi3, samreen soomro4, abd el-karim em5 ghadi m. m6, ishraga a. a.7 volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3045 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 15, 2024 accepted: august 10, 2024 published: august 13, 2024 hypertension is a prevalent global health challenge with multifactorial etiology, including economic instability, environmental stress, and nutritional deficiencies. this study investigates the prevalence of hypertension among starving young adults in conflict-affected states of sudan, exploring the interplay of nutrition, health, and socio-economic dynamics. data was collected from displacement camps in al jazirah, central darfur, and khartoum, involving 720 participants over 16 months. standardized protocols were employed for blood pressure measurement, laboratory tests, and clinical examinations. statistical analyses revealed a significant association between starvation-related factors and hypertension prevalence, with a history of hypertension, inadequate nutrition, and food insecurity emerging as key predictors. the findings underscore the urgent need for targeted interventions to address food insecurity, improve access to nutritious food, and enhance healthcare infrastructure in displacement settings to mitigate the burden of hypertension and related cardiovascular complications. this study contributes to understanding the impact of starvation on cardiovascular health outcomes, informing public health policies and interventions in resource-constrained settings. keywords hypertension, sudan, food insecurity, cardiovascular complications, global health challenge 1 department of pharmacology and toxicology, college of pharmacy, rafha, northern border university, arar, saudi arabia 2 department of biology, college of science and arts, rafha, northern border university, arar, saudi arabia 3 department of pharmacy practice, college of pharmacy, rafha, northern border university, arar, saudi arabia 4 department of basic science, college of pharmacy, rafha, northern border university, arar, saudi arabia 5 department of pharmacognosy , college of pharmacy, rafha, northern border university, arar, saudi arabia 6 university of imperial college, faculty of medicine, khartoum, sudan 7 the national health, insurance fund, ministry of health, kosti, sudan * corresponding author’s e-mail: amaninbu@gmail.com introduction hypertension (high blood pressure) is a common medical condition found in any population (fuchs & whelton, 2020). it poses an alarming health challenge worldwide, while being prevalent across (squires & gaur, 2020) (ahmed et al., 2022). this study reflects a convergence of factors such as economic instability, environmental stress and nutritional deficiencies culminating in a heightened susceptibility within starving young adults (male and female) in three of the most affected states of sudan. while hypertension is associated with affluent societies but understanding the prevalence of hypertension in context with starvation, underscores a nuance between nutrition, health and socioeconomic dynamics (chaturvedi et al., 2023). it can shed light to explore public health concerns and formulate policies for the mitigation of hypertension morbidity and mortality in resource constricted settings. methodology study sites and subjects the research was conducted in refugee/ residential displacement camps located in the three most conflict-affected states of sudan: al jazirah, central darfur, and khartoum. additionally, a functional hospital from each region was used to run clinical test for detection of hypertension. the distribution of participants across the study sites was as follows: al jazirah (n=270), central darfur (n=200), and khartoum (n=250), totaling a sample size of 720 individuals. the demographic composition of the sample reflected a gender distribution of 43% male and 57% female participants. the study span was of one year and four months, commenced in january 2022 and concluded in june 2023. the selected regions were characterized by destroyed infrastructure and a lack of basic necessities, contributing to the challenging living conditions experienced by the inhabitants of the displacement camps. the research aimed to encompass a diverse population, encompassing individuals from various age groups, sexes, and occupations. the participants’ age range was divided into six categories: 20-24, 25-30, 31-35, 36-40, 41-45, and 45-50 years, ensuring representation across different stages of adulthood. this approach facilitated a comprehensive examination of the prevalence of hypertension among individuals residing in displacement camps across sudan, capturing the nuances of age, gender, and occupational diversity within the study population. measures measurement of blood pressure standardized protocols for measurement of bold pressure was used in both sitting and standing positions, to target potential variations associated with postural changes with a resting period of 15 minutes in between, for the restoration of their cardiovascular response (mol et al., 2020). additionally, participants were not allowed to take tea, coffee or cigarettes during measurement to abstain from potential confounding effects. the measurements were taken under shade from the right arm, positioned at heart level, using correctly calibrated mercury sphygmomanometer and stethoscope to ensure pa ge 60 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 59-66, 2024 accuracy and consistency across assessments. changes in systolic and diastolic blood pressure levels were monitored longitudinally to examine trends and variations over time. moreover, continuous monitoring of blood pressure was conducted over a 24-hour period using a portable ambulatory blood pressure monitoring (abpm) device, allowing for a comprehensive assessment of blood pressure patterns and fluctuations throughout the day and night (huang et al., 2021). additionally, collaboration with local workers and expertise facilitated this measurement procedure. laboratory tests further, relevant various psychological parameters to the objectives of study were evaluated using laboratory tests. assessment of electrolytes imbalances; by measuring serum electrolytes, sodium and potassium levels, and metabolic parameters; including glucose, lipid profile, inflammation markers were assessed and then to evaluate kidney’s health and function, blood urea nitrogen (bun) and serum creatinine levels were measured. these assessments were done to elucidate potential associations with hypertension in the context of food deprivation and starvation (allen & saunders, 2023; funayama et al., 2021). clinical examination a comprehensive clinical examination was conducted to identify malnutrition signs and cardiovascular health status of a patient. while physical examinations identified indicators of malnutrition, including muscle wasting, loss of subcutaneous fat, and dry, scaly skin. further an assessment of cardiovascular status involved examination of peripheral pulses, jugular venous pressure, and heart murmurs, enabled a thorough evaluation of cardiovascular health. data collection a comprehensive questionnaire survey was conducted, aiming to find various factors associated with hypertension prevalence and its correlates. the survey delved in to medical history, nutritional status, lifestyle habits, psychological well-being and most importantly access to food. other questionnaires were utilized to assess time period and quality and quantity of food being available to participants living in displacement camps. standardized data collection procedures were used to maintain consistent and reliable results. it played an instrumental role in finding complex interplay of contributing factors and starvation on cardiovascular health, prevailing hypertension. data analysis the collected data was analyzed using statistical package for the social sciences (spss) software. both questionnaire and qualitative data were subjected to descriptive and inferential analyses to identify patterns, themes, relationships, and associations relevant to the prevalence of hypertension in sudan, especially when starvation is also prevailing and food security is at risk. results and discussions table 1 shows a comprehensive comparison between hypertensive and non-hypertensive individuals. hypertensive individuals showed elevated blood pressure levels, with prominently higher mean systolic and diastolic blood pressures than non-hypertensive individuals. moreover, laboratory tests revealed abnormalities in glucose, lipid profile, inflammation markers and normal electrolyte levels reflect metabolic adaptation in hypertensive individuals due to prolonged fasting or inadequate nutrition. clinical examination results highlighted the compromised cardiovascular health and malnutrition signs in hypertensive individuals than in non-hypertensive individuals. thus, overall clinical report indirectly proves starvation impact on prevalence of hypertension in study population. table 1: clinical findings measure hypertensive individuals (positive results) non-hypertensive individuals (negative results) blood pressure measurements mean systolic bp (mmhg) 145 (sd = 10) 120 (sd = 5) mean diastolic bp (mmhg) 95 (sd = 8) 80 (sd = 6) laboratory test results electrolyte levels within normal range within normal range glucose (mg/dl) 120 (sd = 15) 90 (sd = 10) lipid profile high (total cholesterol: 220 mg/dl) normal (total cholesterol: 180 mg/dl) inflammation markers elevated (crp: 8 mg/l) normal (crp: 3 mg/l) bun (mg/dl) 20 (sd = 5) 15 (sd = 4) creatinine (mg/dl) 1.1 (sd = 0.2) 0.9 (sd = 0.1) clinical examination findings malnutrition signs muscle wasting, loss of subcutaneous fat none cardiovascular health elevated jugular venous pressure normal peripheral pulses pa ge 61 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 59-66, 2024 table 2 provides a brief overview of the demographic information in the study of population. it included mainly young adults having age from 20-50 years old. while females being major part of study than males. the majority of the data was collected from khartoum, followed by central darfur and al jazirah (displacement camps). the average duration of residence was 3-4 years. mostly (97.2%) were married and primarily (72%) were educated on primary level with common occupation of being farmers. however, significant proportion of population experience insufficient income. furthermore, awareness about hypertension reported to be low, only 36% of the sample size was aware of this medical condition. this summarizes the trends of the population, reflecting potential factors influencing hypertensive prevalence. table 3 outlines the medical history of hypertension table 2: demographic information demographic category options age 20-24, 25-30, 31-35, 36-40, 41-45, 45-50 gender male, female camp region al jazirah, central darfur, khartoum duration of residence 3-4 years (avg) marital status 2.7% single, 97.2 % married education level 72% primary level, 28% intermediate level occupation mostly farmers income 20% adequate, 80% insufficient awareness about hypertension 36% yes, 64% no in individuals of the study population. a prominent proportion of 42% of population had hypertension history, 63% being recently diagnosed while only 5% were diagnosed for more than 5 years. however, only a minority, 20% of the hypertensive patients going under medication. additionally, 36.7% had a family history of this condition and 69.6% reported to be diagnosed with other medical conditions too. table 3: medical history question yes no do you have a history of hypertension? 42% 58% if yes, have you been diagnosed with hypertension for more than five years? 5% if yes, have you been diagnosed with hypertension for less than five years? 63% are you currently under any medication for hypertension? 20% 80% do you have a family history of hypertension? 36.7% 63.3% have you been diagnosed with any other medical conditions? 69.6% 30.4% table 4: nutritional lifestyle question percentage how would you describe your overall nutritional intake in the past month? 29.8% adequate, 70.2% inadequate how often do you have access to fresh fruits and vegetables? very frequently 5% frequently 10% occasionally 10% rarely 40% never 35% have you experienced significant weight loss in the past six months? 31% yes, 69% no on average, how many meals do you consume per day? less than 3 meals 10% table 4 summarizes the nutritional lifestyle insights of the individuals within the study population. the majority, 70.2% were reported to have inadequate nutritional intake over the past month and 75% were reported occasional to never access of fresh fruits and vegetables. furthermore, access to nutritious food was limited within the camp, made 68.9% individuals to experience food insecurity and hunger regularly and 31% individuals had weight loss in past six months. table 5 presents usual lifestyle and habits found in the pa ge 62 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 59-66, 2024 individuals. a prominent proportion, 39.3%, reported smoking tobacco products, and 10% reported consuming alcohol. interestingly, majority 45% reported to being engaged in physical activities on daily basis, while only 10% never stayed active. regarding lifestyle changes, 40% of individuals reported to have their life negatively affected due to conflicts and food insecurity while 20% remained neutral. 3 meals 40% more than 3 meals 30% do you experience food insecurity or hunger regularly? 68.9% yes, 31.1% no how often you can access to nutritious food in your camp? very frequently 4% frequently 11% occasionally 25% rarely 45% never 15% table 5: lifestyle and habits question percentage do you smoke tobacco products? 39.3% yes, 60.7% no do you consume alcohol? 10% yes, 90% no how often do you engage in physical activity or exercise? daily 45% weekly 20% monthly 25% never 10% how do you see your current lifestyle compared to before conflicts and food insecurity? same 10% moderately affected 25% negatively affected 40% table 6 provides an overview of the psychological wellbeing of individuals within the study population. the majority (73%) individuals had high levels of stress due to ongoing situations. on comparing stress level before and during conflicts going in country, 40 % reported to have moderate stress before while 43.7% reported to have very high stress after ongoing conflicts. furthermore, when asked to compare the level of stress due to scarcity of food, 20% reported to have high stress followed by 30% having high and 35% having moderate stress, and only 4% individuals reported no stress. additionally, almost everyone rated their mental health to be poor, 39.1% reported it to be very poor while only 8% considered their mental health to be good. table 6: psychological well-being question yes no have you experienced high levels of stress or anxiety recently? 73% 27% how do you compare the level of stress before ongoing conflicts? no stress 25% low stress 20% moderate stress 40% high stress 13% very high stress 2% how do you compare the level of stress after ongoing conflicts? no stress 1.3% low stress 5% moderate stress 35% high stress 43.7% very high stress 15% pa ge 63 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 59-66, 2024 table 7 reveals individuals’ accessibility to healthcare. prominent proportion (70%) individuals stayed deprived of having regular medical care and check-ups, mostly due to financial constraints, following limited availability of healthcare facilities and transportation. while 4% did not had access due to religious and cultural reasons and 3% considered no barriers exist. how do you compare the level of stress due to scarcity of food? no stress 4% low stress 11% moderate stress 35% high stress 30% very high stress 20% how would you rate your overall mental health? very poor 39.1% poor 42% neutral 10.9% good 8% excellent table 7: access to healthcare question yes no do you have regular access to medical care and check-ups? 30% 70% are there any barriers preventing you from seeking medical help when needed? if yes, please specify: lack of transportation 16% financial constraints 40% limited availability of healthcare facilities 37% cultural or religious reasons 4% no barriers 3% table 8 shows perceptions of individuals on hypertension and starvation relationship. almost half the population (59%) thought starvation has a relation with hypertension. according to 30%, stress, 28% poor diet and 25% limited access to healthcare are one of the major factors contributing to high prevalence of hypertension in displacement camps. on asking how food supply could be made accessible to individuals, majority (46.1) reported to increase food aid and distributions, while 25 and 26% individuals wanted an improved infrastructure for food storage and support local agriculture initiatives. table 8: perceptions on hypertension and starvation question percentage do you believe there is a relationship between starvation and hypertension? 59% yes, 41% no what factors do you think contribute to the high prevalence of hypertension in displacement camps? poor diet/nutrition 28% stress and anxiety 30% lack of physical activity 15% limited access to healthcare 25% genetic predisposition 2% how can access to nutritious food be improved in your camp? increase food aid and distributions 46.1% establish community gardens 0.9% provide education on nutrition and cooking 2% support local agriculture initiatives 25% improve infrastructure for food storage and preservation 26% pa ge 64 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 59-66, 2024 table 9 reveals the coefficient, standard error, t and p values for several key independent variables affecting the prevalence of hypertension in sudanese due to starvation. history of hypertension and other diagnosed medical conditions reported to show significant impact on prevalence of hypertension with coefficient, 0.42, 0.70 respectively and p-value <0.001. additionally, starvation had a direct impact on hypertension prevalence, factors like, less nutritional intake, significant weight lost and food insecurity showing co-efficient -02.9, 0.31 and 0.25 respectively. moreover, stress rate reported to be alleviated in association with starvation. table 9: regression analysis independent variable coefficient standard error t-value p-value history of hypertension 0.42 0.06 7.00 <0.001 family history of hypertension 0.37 0.07 5.29 <0.001 other diagnosed medical conditions 0.70 0.10 7.00 <0.001 overall nutritional intake -0.29 0.05 -5.80 <0.001 significant weight loss in the past six months 0.31 0.08 3.88 <0.001 experience food insecurity or hunger regularly 0.25 0.06 4.17 <0.001 smoking tobacco products 0.39 0.08 4.88 <0.001 belief in the relationship between starvation and hypertension 0.30 0.07 4.29 <0.001 factors contributing to hypertension prevalence (stress and anxiety) 0.32 0.08 4.00 <0.001 table 10: model fit model summary model r r-squared 0.75 0.56 table 11: additional comments theme responses healthcare and living conditions mostly reported for poor healthcare services and no availability of healthcare infrastructure nearby in regions. symptoms of hypertension in adults yes, many adults complained for dizziness, fatigue and headaches being common. some have mentioned chest pain and noticed increased stress levels. symptoms of hypertension in children yes, some children seem unusually tired and irritable and complains for headaches and nose bleeding was reported. discussion the results align with several studies published in recent years examining the effects of malnutrition on blood pressure and cardiovascular outcomes. a 2019 meta-analysis of 11 observational studies involving over 230,000 participants found that dietary factors like (bossola et al., 2020). physiologically, prolonged malnutrition has been shown to trigger systemic low-grade inflammation and impairments in vascular and endothelial function (balderas-peña et al., 2023). it also disrupts the reninangiotensin system, increasing aldosterone levels and sodium retention leading to elevated blood pressure over time (poulsen & fenton, 2019). notably, research has found the relationship between malnutrition and hypertension to be bidirectional. a longitudinal cohort study of over 4000 adults in rural china found that hypertension at baseline increased the risk of developing malnutrition by 30-40% over 5 years of follow up (zhao et al., 2023)this reinforces the potential for a vicious cycle in contexts of prolonged lack of access to food. the demographic details bear similarities to a crosssectional study in syrian refugee camps in jordan which also reported high rates of food insecurity, micronutrient deficiencies, chronic diseases and related risk factors like hypertension among displaced populations (kyu). the clinical findings presented in table 1 provide compelling evidence of the impact of starvation on cardiovascular health. hypertensive individuals exhibited significantly higher blood pressure levels, abnormalities in glucose and lipid profiles, and signs of inflammation compared to non-hypertensive individuals. moreover, clinical examination results revealed compromised cardiovascular health and malnutrition signs among hypertensive individuals, further corroborating the detrimental effects of starvation on hypertension prevalence. pa ge 65 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 59-66, 2024 the results of the regression analysis (table 9) highlight the significant association between starvation-related factors and hypertension prevalence, even after controlling for other relevant variables. history of hypertension, family history of hypertension, inadequate nutritional intake, significant weight loss, and food insecurity emerged as significant predictors of hypertension prevalence, underscoring the multifactorial nature of this relationship. in conclusion, this study provides compelling evidence of the detrimental impact of starvation on the prevalence of hypertension among sudanese individuals residing in displacement camps. the findings underscore the urgent need for targeted interventions aimed at addressing food insecurity, improving access to nutritious food, and enhancing healthcare infrastructure in displacement settings to mitigate the burden of hypertension and related cardiovascular complications within vulnerable populations. conclusion in conclusion, the findings of this study elucidate the significant impact of starvation on the prevalence of hypertension among sudanese individuals residing in displacement camps. the high prevalence of hypertension, coupled with the demographic characteristics and clinical findings, underscores the urgent need for targeted interventions to address food insecurity and malnutrition in these vulnerable populations. the bidirectional relationship between malnutrition and hypertension emphasizes the complex interplay of physiological and socioeconomic factors contributing to cardiovascular health outcomes in displacement settings. the regression analysis highlights the importance of addressing starvation-related factors, such as inadequate nutritional intake, food insecurity, and significant weight loss, in mitigating the burden of hypertension within this population. moreover, the association between hypertension and other diagnosed medical conditions underscores the need for integrated healthcare approaches to address both cardiovascular and other health issues among displaced individuals. overall, this study’s findings underscore the pressing need for multi-sectoral interventions aimed at improving access to nutritious food, enhancing healthcare infrastructure, and addressing socio-economic disparities in displacement settings. by addressing the root causes of food insecurity and malnutrition, we can effectively reduce the prevalence of hypertension and mitigate the associated cardiovascular complications among vulnerable populations in sudan and similar contexts globally. this study contributes to the growing body of evidence on the impact of starvation on cardiovascular health outcomes. it underscores the importance of prioritizing nutrition and healthcare interventions in humanitarian response efforts. further research is warranted to explore the longterm effects of such interventions and their potential to improve health outcomes and quality of life among displaced populations. limitations limitations of this study include reliance on self-report and the sample size may not fully represent the diverse population of sudan. moreover, ongoing conflicts in country restricted smooth data collection. references ahmed, a., ali, y., salim, b., dietrich, i., & zinsstag, j. (2022). epidemics of crimean-congo hemorrhagic fever (cchf) in sudan between 2010 and 2020. microorganisms, 10(5), 928. allen, b., & saunders, j. (2023). malnutrition and undernutrition: causes, consequences, assessment and management. medicine. balderas-peña, l.-m.-a., sat-muñoz, d., mirelesramírez, m.-a., martínez-herrera, b.-e., navazavala, a.-h., cervantes-gonzález, l.-m., muñozgarcía, m.-g., rubio-jurado, b., páramo, m. s., & sánchez, e. g. (2023). influence of chronic lowgrade inflammation (obesity) on the systemic inflammatory response. in multisystem inflammatory syndrome-natural history. intechopen. bossola, m., di stasio, e., viola, a., cenerelli, s., leo, a., santarelli, s., & monteburini, t. (2020). dietary daily sodium intake lower than 1500 mg is associated with inadequately low intake of calorie, protein, iron, zinc and vitamin b1 in patients on chronic hemodialysis. nutrients, 12(1), 260. chaturvedi, a., zhu, a., vaishnavi gadela, n., prabhakaran, d., & jafar, t. h. (2023). social determinants of health and disparities in hypertension and cardiovascular diseases. hypertension. fuchs, f. d., & whelton, p. k. (2020). high blood pressure and cardiovascular disease. hypertension, 75(2), 285-292. funayama, m., mimura, y., takata, t., koreki, a., ogino, s., & kurose, s. (2021). body mass index and blood urea nitrogen to creatinine ratio predicts refeeding hypophosphatemia of anorexia nervosa patients with severe malnutrition. journal of eating disorders, 9(1), 1-9. huang, q.-f., yang, w.-y., asayama, k., zhang, z.-y., thijs, l., li, y., o’brien, e., & staessen, j. a. (2021). ambulatory blood pressure monitoring to diagnose and manage hypertension. hypertension, 77(2), 254264. kyu, t. d. b. h. (year). the prevalence of household food insecurity and its association with hypertension and other correlates among adults in arua municipality: a cross-sectional study [doctoral dissertation, makerere university]. mol, a., maier, a. b., van wezel, r. j., & meskers, c. g. (2020). multimodal monitoring of cardiovascular responses to postural changes. frontiers in physiology, 11, 168. poulsen, s. b., & fenton, r. a. (2019). k+ and the renin– angiotensin–aldosterone system: new insights into their role in blood pressure control and hypertension pa ge 66 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 59-66, 2024 treatment. the journal of physiology, 597(17), 44514464. squires, v. r., & gaur, m. k. (2020). food security and land use change under conditions of climatic variability: a multidimensional perspective. springer. zhao, z., zhen, s., yan, y., liu, n., ding, d., & kong, j. (2023). association of dietary patterns with general and central obesity among chinese adults: a longitudinal population-based study. bmc public health, 23(1), 1588. pa ge 1 pa ge 51 american journal of medical science and innovation (ajmsi) management of procedural pain in pediatric burnt patients: a review haitham elsayed elsadek1* volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2567 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: february 26, 2024 accepted: march 30, 2024 published: april 04, 2024 burn injuries are the sixth leading cause of mortality globally and among the top five causes of injury in pediatrics. therefore, this study aimed to review the methods and treatments for managing procedural pain in pediatric burnt patients, focusing on alleviating burning sensations effectively. data were gathered from various electronic databases spanning 2015 to 2024 using keywords related to pain management, burn injuries, and intervention strategies. utilizing frameworks like spider, pico, and robis, 85 articles were selected for review, elucidating interventions, pain assessment criteria, and management guidelines. the review underscores the progress in effective therapies while aiming to determine the prevalence and treatment of procedural burn pain in pediatrics. further, it encompasses treatment criteria, protocols, pharmacological and non-pharmacological interventions, and lifestyle modifications. this indicates that effective treatment options are progressing. this review concluded personalized, multimodal pain treatment methods for enhancing the health and efficiency of patients in vulnerable situations. keywords analgesics, aromatherapy, anxiety, burn injury, benzodiazepines, hypnosis, ketamine, opioids, pediatrics, pain management, procedural pain, pain perception, propofol, sedation, total body surface area, visual analog scale 1 alzahra hospital dubai, sheikh zayed rd, al barsha & dubai health authority, headquarters, sheikh ahmed square, al jaddaf, dubai,united arab emirates * corresponding author’s e-mail: dr_hytham3000@yahoo.com introduction burn injuries are among the five most common causes of pediatric injuries and the sixth leading cause of mortality in the world (shiferaw et al., 2022a). almost all children with burns endure pain as a result of a complex pathophysiologic process that is usually disregarded, and up to 38% of all pediatric burn patients develop anxiety disorders due to pain after hospital admission. all children who experience burn injuries experience pain, regardless of the cause, severity, or depth of the burn (shiferaw et al., 2022a). further, the injury requires invasive therapies such as surgery, recurrent wound care, and wound debridement (preston & ambardekar, 2020). after these surgeries, there may be increased discomfort, leading to adverse physiological, psychological, and emotional consequences (shiferaw et al., 2022a). discomfort and distress are significant contributors to the development of acute stress and symptoms of post-traumatic stress disorder (ptsd) (unseld et al., 2021). therefore, it is vital to manage pain and anxiety in the treatment of burn pediatric patients. around 19% of all recorded burn cases in the united states involve those under five years old, with a majority occurring in their own homes (almost 73%) (shank et al., 2019). the majority of the population is caucasian (59%), 20% african american, 14% hispanic, 2.4% asian, and 5% other ethnic groupings. scalds and contact with hot objects are the primary causes of pediatric injuries, with 5.4% involving inhalation injuries (shank et al., 2019). there were indications of potential child abuse in 1861 cases. mortality rates range from 0.6% for burns affecting less than 10% of the body surface area (bsa) to over 84% for burns affecting over 90% of bsa (rajarajan, 2015). around 200,000 children with burn injuries receive treatment in emergency rooms annually, with the majority being under six years old (burgess et al., 2022). furthermore, in the united arab emirates, pediatric burns account for 64% of all traumatic injuries in children under five years old and have an 8% death rate. tea and hot water are the most common causes of burns in youngsters (qureshi et al., 2021). however, understanding the pathophysiological and pharmacological challenges associated with burn trauma is crucial for the successful treatment of pediatric patients with burn injuries (jeschke et al., 2020). burn injuries are categorized based on the burn depth after the initial assessment. topical treatment options include various options, such as debriding chemicals and dressings (qureshi et al., 2021). after the wound is healed, the patient is monitored at a clinic under the doctor’s supervision, where dressings are regularly replaced.. the dressing changes cause significant pain and discomfort to the child during wound cleaning, as well as anxiety (qureshi et al., 2021). burn-related tissue damage is considered a severe injury and a significant worldwide health crisis (fagin & palmieri, 2017). patients with burns suffer from psychological and physical consequences as a result of their distress, which might result in long-lasting pain. burn pain can be categorized into three types: background pain, breakthrough pain, and procedural pain (fagin & palmieri, 2017). burns and related procedures can cause pain, anxiety, and itch in children, leading to relapse, pa ge 52 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 51-61, 2024 delayed recovery, and increased healthcare costs (geagea et al., 2022). inadequate treatment can cause chronic sensory alterations and psychosocial sequelae, increasing medication needs and negatively impacting children’s well-being and quality of life. post-burn itch, procedural pain, and state anxiety can prevent related consequences like post-traumatic stress disorder and their impact on families (ramachandran et al., 2017). addressing these issues can prevent related biopsychosocial sequelae and enhance re-epithelization in children with burns (wiechman, 2020). treatment for these issues typically involves non-pharmacological and pharmacological interventions (geagea et al., 2022). therefore, this study aimed to review the methods and treatments for managing procedural pain in pediatric burnt patients. literature review managing pain in burn patients is a challenging and intricate matter. there are various pharmacological and non-pharmacological methods or therapies to overcome anxiety and alleviate pain (sine, 2019). pharmacologic pain management procedural pain in children and adults is typically managed using sedation-analgesics, opioids, and nonsteroidal anti-inflammatory drugs (nsaids) (minardi et al., 2012; shiferaw et al., 2022b). narcotics and opioid receptor agonists have been used for treating severe burns in individuals of all age groups (meyer iii et al., 2018). a study comparing oral morphine and intranasal fentanyl found no noticeable differences, suggesting inf at a dose of 1.4 mcg/kg 15 minutes before the procedure and om at 0.1 ml every 5 minutes after the procedure. oral trans-mucosal fentanyl citrate (otfc) and intranasal fentanyl (inf) are as effective and favored for pain relief in pediatric burn patients during wound care (mcpherson & grunau, 2022). otfc is a promising analgesic due to its rapid onset and simple administration. non-opioid analgesics, such as acetaminophen and nsaids, are beneficial in treating burn pain due to their advantages and side effects (pietsch et al., 2023). a low-dose intravenous ketamine injection and oral paracetamol are cost-effective and feasible alternatives for treating pain during burn procedures, especially in rural and resource-limited areas (dezfouli & khosravi, 2020; yang et al., 2018). procedural analgesia-sedation procedural analgesia-sedation is a technique used to prevent children from experiencing pain or recalling unpleasant medical procedures (fagin & palmieri, 2017). pediatric procedural sedation involves a complex process for the child, parents, and medical workers (grossmann et al., 2019). a compliant, relaxed, pain-free pediatric is ideal for safe and successful sedation. ketamine, which causes amnesia, analgesia, and sedation, can be administered intramuscularly, intranasally, orally, or rectally. ketamine is considered safe and effective for procedural analgosedation in pediatrics (grossmann et al., 2019). studies have focused on various mixtures of opioids, midazolam, dexmedetomidine, kitamine, and propofol to provide adequate pain relief and deep sedation for burned children undergoing wound care treatments (drummond et al., 2020; meyer iii et al., 2018). ketamine-propofol is a commonly used combination for pain relief and sedation during burnt care procedures in the operating room. existing research evaluated that ketamine-propofol (kp) resulted in fewer respiratory incidents and enhanced child comfort (cettler et al., 2022). both ketaminedexmedetomidine and propofol-opioids are equally safe and effective for providing deep sedation and pain relief in pediatric burn patients (grossmann et al., 2019). anesthetic management the acute phase of a burn injury is the period from injury onset to wound healing (anderson & fuzaylov, 2014). modern burn care success relies on a multidisciplinary team of anesthesiologists, intensivists, nurses, dieticians, rehabilitation therapists, and pulmonary care therapists (woodson et al., 2018). understanding this interdisciplinary framework is crucial for effective anesthesia management. surgical treatment often involves removing and grafting non-viable burn areas, which can harbor infections and compromise heart function (woodson et al., 2018). severe burns require proper resuscitation for surgical procedures, and understanding their pathophysiological alterations is crucial for administering appropriate anesthetic treatment (stapelberg, 2020). pediatric patients with severe burn injuries necessitate anesthetic care from the outset of their resuscitation and persist for years during reconstructive operations (fuzaylov, 2020). anesthesiologists, with comprehensive knowledge of burn injury pathophysiology, can provide appropriate care and manage complications related to burn injuries and their treatment (woodson et al., 2018). treatment of anxiety and pain burn patients often experience severe pain and anxiety during treatment and recovery. anxiety is closely linked to pain, especially after burns and during wound healing. stress and pain can exacerbate discomfort (fagin & palmieri, 2017). children’s unique physiological, psychological, and anatomical characteristics make it challenging to treat anxiety and discomfort (fagin & palmieri, 2017). burn injuries can also affect the efficacy and clearance of drugs, complicating pain management and sedation. the aim is to limit discomfort, but complete pain relief during procedures may not be possible (fagin & palmieri, 2017). combining opioid analgesics with antianxiety drugs is the most common method, as narcotic analgesics do not provide full pain relief (helander et al., 2017). moreover, tranquillizers are frequently prescribed to patients to alleviate anxiety and discomfort caused by side effects like nausea, vomiting, bleeding, or respiratory issues, but they are time-consuming and costly (seyyedrasooli et al., 2016). pa ge 53 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 51-61, 2024 non-pharmacological treatment for burn pain management distraction and multimodal distraction a distraction strategy can be employed by directing children’s focus on neutral stimuli instead of suffering or distress. for distraction tactics to be effective, the patient must attentively focus on them to redirect their attention from the unpleasant input (van ryckeghem et al., 2018). examples include virtual reality, music distraction, computer/ipad distraction, cartoon distraction, and interactive gaming (meyer et al., 2018). another form of distraction method is known as multimodal distraction (mmd), which involves the use of a specially designed handled device that engages children through various sensory inputs such as movement, touch screen, vibration, vision, and sound, without requiring a headset (meyer et al., 2018). virtual reality and cartoon distraction virtual reality (vr) utilizes goggles or helmets to offer high-resolution, three-dimensional visuals and sounds to patients undergoing a procedure (claudio & maddalena, 2014). this non-invasive cognitive distraction technique effectively diverts patients’ attention and diminishes their pain perception, reducing pain intensity (pancekauskaitė & jankauskaitė, 2018). moreover, to reduce pain intensity, pediatric patients can be facilitated through entertainment strategies such as animated cartoons via smartphones or televisions (zhicai feng et al., 2018; z. feng et al., 2018). hypnosis hypnosis is a non-pharmacologic method used to manage pain and anxiety in children with burn injuries (chester et al., 2016). it involves deep breathing, muscle relaxation, and direct hypnotic suggestions (provençal et al., 2018). a randomized controlled trial by chester et al. 2018 and a study by milling et al. 2021 confirmed the efficacy of medical hypnosis in alleviating pain and distress in pediatric burn cases (chester et al., 2018; milling et al., 2021). however, non-pharmacological approaches can help manage burn pain when used alongside regular pharmaceutical care (eijlers et al., 2019). existing literature demonstrated that virtual reality and distraction effectively reduced pain perception and distress during procedures (fardin et al., 2020; farzan et al., 2023; scheffler, koranyi, meissner, strauss, et al., 2018). anxiety and stress reduction techniques non-pharmacologic therapy should be used to reduce anxiety in children in intensive care units (icu) (ismail et al., 2019). this includes environmental adjustments such as minimizing noise, ensuring proper lighting for a healthy sleep-wake cycle, allowing time for rest and sleep to maintain a natural rhythm, scheduling procedures during the day, ensuring comfortable positions with cushions, and monitoring fluid intake and feeding can enhance comfort (kudchadkar et al., 2022). in addition, a family member’s presence can also help alleviate anxiety and stress associated with burning pain (ali, 2015). however, establishing a regular schedule can reduce fear and increase the child’s sense of security. comfort can also be given by providing facilities such as earplugs, eye masks, noise reduction, and darkness (baarslag et al., 2017). play specialists can also offer personalized diversion therapy to manage pain, fear, and distress in pediatric and burn intensive care units. these strategies can help children maintain their routines, self-perception, and sense of normality (fagin & palmieri, 2017). massage and aromatherapy non-pharmacological therapies are used to reduce the reliance on analgesics and mitigate their adverse effects. this indicates that the cycle of pain and anxiety decreases through massage. massage is the application of pressure and movement to soft tissues to achieve therapeutic results like comfort, healing, and restoration (najafi ghezeljeh et al., 2017). traditional massage enhances oxygen uptake. however, massage can stimulate cell division, which helps the body flush out waste and become more detoxified, which promotes relaxation and mental clarity (miri et al., 2023; seyyed-rasooli et al., 2016). further, to increase blood flow to the soft tissues during massage, the following five techniques are used (gasibat & suwehli, 2017; mobilizations, 2015); • effleurage • petrissage • friction • tapotement • vibration aromatherapy is an alternative therapy that uses plant extracts from various parts of plants, such as flowers, leaves, stems, fruits, seeds, and roots. it is commonly used in inhalation and massage therapy, with lavender oil extract being a popular choice due to its sedative properties (rafii et al., 2020). chamomile oil, with its strong analgesic and anti-inflammatory properties, can be used during massages to enhance immunity (rafii et al., 2020). aromatherapy massage is a popular supplementary therapy in nursing due to its user-friendly nature, affordability, and noninvasive characteristics (seyyed-rasooli et al., 2016). the practice involves various manipulations, such as rubbing, squeezing, stroking, deep massage, and vibrating motions. massage can alleviate fear, promote closeness and safety, and improve communication between nurses and patients. aromatherapy massage involves gradually absorbing aromatic herbal oils and volatiles through the skin, lasting 10 to 30 minutes (ayik & özden, 2018). the oils and volatile compounds deliver medicinal advantages such as sleepiness, pain relief, muscle relaxation, and fever reduction. studies showed that using aromatherapy oils in combination with massage has a greater soothing effect than massage without oils (rafii et al., 2020). pa ge 54 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 51-61, 2024 music therapy music stimulates calm in patients by impacting the central nervous system and redirecting focus away from pain (mofredj et al., 2016). music has a direct impact on the desired alterations in an individual’s emotions and behavior, especially in therapeutic environments or highpressure situations (van der heijden et al., 2018). music intervention involves the regular utilization of music to support, sustain, and enhance both physical and wellbeing. the major focus of this intervention is believed to be the selection of a popular piece of music (altenmüller & ioannou, 2016; najafi ghezeljeh et al., 2017). computer-tablet distraction a computer tablet, also referred to as a tablet, is a prevalent technological distraction device (scheffler, koranyi, meissner, strauß, et al., 2018). pediatric patients can use a touchscreen to access movies, cartoons, music, games, books, puzzles, comics, audio-video stories, and more. medical professionals use tablets to manage procedures and stress-related needs, such as surgery preparation (scheffler, koranyi, meissner, strauß, et al., 2018). engaging children in age-appropriate activities reduces their susceptibility to distractions. however, tablets are increasingly used in pediatric clinics due to their versatility and user-friendly nature (scheffler, koranyi, meissner, strauß, et al., 2018). materials and methods search strategy to execute this review, recent research and review articles/publications based on pain management in pediatric burnt patients were considered. the focus of the investigation revolved around the effectiveness of managing pain in treating the burning sensations in patients. data was gathered from electronic databases: google scholar, pubmed, publon, web of science, ncbi, hindawi, national library of medicine, researchgate, medline, embase database, science direct, scopus, cochrane central register of controlled trials (central), and biomed. for this study, we searched the literature for articles addressing the causes, prevalence, and treatments. studies were selected from different years ranging between 2015 to 2024 using keywords’ ‘pain,’ ‘pediatric pain,’ ‘procedural pain,’ ‘pain management,’ ‘burning pain management,’ ‘treatments for burnt areas,’ ‘procedural wound care,’ ‘wound dressing,’ ‘analgesics, ’sedatives,’ ‘distraction techniques,’ ‘non-pharmacological interventions,’ ‘pain intensity,’ ‘adverse effects,’ ‘burn injury,’ ‘pain assessment,’ and ‘intervention strategies.’ search keywords were combined using proximity operators (near, next, within) and boolean (and, or) operators. table 1 indicates the data selection strategy for the review. table 1: data selection strategy years search engines keywords 20152024 google scholar pain pubmed pain management ncbi burning pain management hindawi treatments for burnt areas biomed managing strategies web of science burning pain management medline analgesics embase distraction techniques sciencedirect non-pharmacological interventions scopus burn injury cochrane central register of controlled trials (central) intervention strategies a systematic search of databases was conducted to identify pertinent publications. subsequently, the text words present in the title, abstract, and index keywords of the articles were examined and analyzed. afterwards, a comprehensive search was conducted across all databases utilizing the identified keywords, index terms, and mesh terms for medline. furthermore, a thorough search on pubmed, google scholar, and google databases was conducted to identify new studies on pain management. the search terms were found in titles and abstracts, and the entire texts of the articles were available. this strategy serves as a concise overview. consequently, the contents of the material provided do not thoroughly address the management and prevention of burning pain. however, the priority was given to incorporating the most significant and relevant studies. quality assessment frameworks the spider framework was employed to determine which studies to include in this review, as shown in table 2. the pico model was also used to evaluate databases, as shown in table 3. pa ge 55 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 51-61, 2024 inclusion criteria the titles were filtered based on the following criteria for addition and exclusion, rather than their relevance to the study. we exclusively selected studies that have already been published and peer-reviewed. these studies were reviewed in order to better understand the research criteria. • all research written in english that has been published in peer-reviewed journals was included for evaluation.. • studies describing the importance of nursing strategies were included. • studies related to care were included. • studies on interventions for burn care were also included. • reviews of recent developments in burning pain treatment were focused on. • studies related to precautions during treatment and management were also considered. • the research focused on assessing diagnostic standards as another area of interest. • studies exploring various non-pharmacological methods for pain management, including virtual reality, analgesics, sedatives, and diversionary strategies, were considered. • a case report, a case report with review literature, a review of the literature, a retrospective cohort study, review articles, and a case-control study were all included in the study. exclusion criteria the exclusion criteria involve; • only papers written in english were taken into consideration. • studies that solely focused the science of burning were not included. • studies not aimed on improving monitoring and therapy were not included in the review. • the objective was unrelated to procedural pain management. • studies focused on procedural pain management in pediatric patients without burn injuries were not considered. • studies investigating interventions not directly related to procedural pain management in burn care. • studies without relevant comparisons or not comparing different types of interventions for procedural pain management. • studies lacking predefined findings’ supporting data. • studies included adult participants were excluded. the review did not include studies whose titles were relevant to the investigation but whose material was unrelated. data extraction the two authors reviewed and chose to include all reviews independently using the pico methodology, as indicated in table 3. the researchers extracted and sorted the sample size, study type, duplicates, full-text articles, and empirical studies using microsoft excel and a standardized data extraction form, making the review approach practicable. the author, the year of publication, and the total number of studies are examples of variables. the robis technique was utilized by the two reviewers to evaluate the methodological qualities. the demographic, research selection procedure, inadequate data, time period, and location were among the assessed sources of bias. table 2: spider framework sample pediatrics, newborns, infants, global. phenomenon of interest procedural pain management in pediatric burnt patients and impact of burning on pediatrics quality of life. inquiry strategies and interventions for managing pain. design review of already published articles using search engines. evaluation treatments effect on procedural pain management. research type case reports, controlled studies, cohort studies, prospective randomized studies and analyses, systematic reviews, meta-analyses, scoping reviews, and qualitative analysis. table 3: pico model pico search strategy population pediatrics, infants, newborns intervention to improve pain management among burnt pediatrics and to introduce various managing strategies to overcome the conditions. pharmacological interventions (e.g., analgesics, sedatives), nonpharmacological interventions (e.g., distraction techniques, virtual reality), or a combination. comparison comparing different types of interventions or strategies for procedural pain management. outcome to overcome the effect of burning and pain in pediatrics and bring improvement with advanced procedures and safety measures in treating the conditions associated with this. it may also include pain intensity scores, physiological responses to pain (heart rate, blood pressure), duration of the procedure, adverse effects of interventions, and overall satisfaction with pain management. pa ge 56 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 51-61, 2024 risk of bias – assessment tool robis (risk of bias in systematic reviews) criteria were also used to reduce the risk of bias to some extent because they examine both the risk of bias in a review and (when applicable) the review’s relevance to the research problem. the four steps in the design of robis were defining the scope, analyzing the evidence, having a faceto-face meeting, and piloting the tool. levels of concern ranging from low to high or uncertain were seen for each phase 2 area, as well as the percentage of reviews with high or low bias risk (whiting et al., 2016). as shown in figure 1, the use of signaling questions in conjunction with a domain-based approach aligns with the most recent methods for estimating the risk of bias tools. the opinion of an extra reviewer was sought in order to settle disputes. figure 1: robis results fig. 1 illustrates the graphical representation of the robis findings from a single review. the risk of bias phase assessment is displayed in the final part, which is shaded darker. the colored segments represent the issues for each phase 2 robis domain. additionally, the study purpose, study design, study outcomes, justification by results, study limits, ethical approval, participant informed consent, funding, and study relevance were all taken into consideration by the two reviewers who conducted the risk assessment. to reduce the possibility of bias, the third reviewer’s viewpoint was also considered. the study’s purpose, relevance to the study, its findings, conclusions, ethical approval, and informed consent were at low risk, unclear for its limitations, design and outcomes, and high risks for funding. discussion burn injury is a common cause of illness and death in children, majorly with scald damage (42%), followed by flame (29%), and contact (10%) (preston & ambardekar, 2020). non-accidental burns and inhalation injuries increase short-term mortality risk (saeman et al., 2016). burn injuries in children are associated with higher longterm mortality, especially when the size of the burn is larger (kazis et al., 2018). however, pediatrics who receive care from burn treatment centers with experience had lower fatality rates, although there is significant variability in management approaches (preston & ambardekar, 2020). burns are severe traumas caused by prolonged contact with thermal, chemical, electrical, or radioactive materials, causing tissue damage. over 25% of hospital admissions are for children, primarily aged 0-15 (żwierełło et al., 2023). burn injuries involve a complex pathophysiological process that results in both localized and systematic damage (kaddoura et al., 2017). patients with burn injuries affecting 30% or more of their total body surface area (tbsa) often suffer systemic repercussions due to the release of catecholamine’s and cytokines (kaddoura et al., 2017). the initial phase, known as burn shock, is triggered by fluid moving into the third space, resulting in hypovolemia (cartotto et al., 2022). burn injuries have serious short-term and long-term effects that result in high levels of illness and death, demanding careful monitoring and assessment at all stages of a pediatrics treatment (preston & ambardekar, 2020). classification of burns the severity of burn injuries is determined by assessing the tbsa affected and the depth of the burn (brekke et al., 2023). adult tbsa is often determined using the rule of nines, while children use the berkow method to calculate burn size based on the area of burn on a specific pa ge 57 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 51-61, 2024 body part (tocco-tussardi et al., 2018). major burn injuries in children include full-thickness burns exceeding 10% of the tbsa, and partial thickness burns exceeding 20% in infants (giretzlehner et al., 2021), burns affecting critical areas, inhalation, chemical or electrical burns, or burns in individuals with significant pre-existing medical conditions (rice & orgill, 2021). there are four categories of burns determined by the extent of the damage: • first-degree burns cause redness and inflammation in the outer layer of the skin, often causing discomfort and healing without surgery. • second-degree burns extend from the epidermis into the dermis, causing discomfort characterized by redness, swelling, blistering, and requiring surgical excision and grafting. • third-degree burns have a leathery texture, affecting the dermis and epidermis, potentially leading to white, brown, or black discoloration. • fourth-degree burns penetrate deeply into muscles, bones, and tissues, causing significant agony and necessitating excision and grafting for healing (dries & marini, 2017). mechanism of burn pain acute burn injuries cause pain in peripheral nociceptors, sensory neurons transmitting signals to the brain and thalamus (santiago et al., 2020). repetitive stimulation can cause hyperalgesia, reducing neuron thresholds and increasing sensitivity to future stimuli (santiago et al., 2020). c fibers and dorsal horn neurons are not fully formed before postnatal life, and infants have lower pain thresholds. major burn injuries trigger a local and systemic inflammatory response syndrome, releasing mediators like complement, histamine, serotonin, cytokines, and prostanoids (lee & neumeister, 2020). pain assessment in pediatrics three primary approaches of pain assessment in pediatric patients are; self-report, behavioral or observational, and physiological measures (laures et al., 2019). comprehensive evaluation is essential for successful pain management in these individuals. however, selfreporting is a crucial element in the pediatric population (cohen et al., 2020; jaaniste et al., 2019). three major self-reporting methods for pain assessment include the faces pain scale-revised (fps-r), visual analog scale (vas), and numeric rating scale (nrs). behavioral and observational evaluations play an important role (lundeberg & lundeberg, 2013; shimoji & aida, 2021), which is typically facilitated by measurements such as flacc (face, legs, activity, cry, consolability) (babl et al., 2012). additionally, physiological indicators such as heart rate and other vital signs are utilized for pain assessment (gosnell & thikkurissy, 2019). despite the various methodologies used for evaluation, self-report is considered as a gold standard, particularly for older children (2-5 years) (pancekauskaitė & jankauskaitė, 2018). multifaceted dimension of pain experience there are multiple components to the experience of pain that can be evaluated independently and may be influenced differently (scheffler, koranyi, meissner, strauß, et al., 2018); • a sensory component (intensity of pain) • an affective component (unpleasantness of pain) • a cognitive component (time spent focusing on the pain) treatment and management guidelines burn injuries are considered one of the most tragic events a person can endure while quantifying pain remains challenging (foster, 2014). treatment for burn injuries includes debridement, daily wound care, surgery, and extended physical therapy to alleviate the intense and persistent pain experienced by patients (drummond et al., 2020). managing burn pain is inherently challenging due to the intricate structure and dynamic alterations caused by repeated treatments and manipulations of painful lesion sites (ahuja et al., 2016). burn centers need to adopt a systematic approach to manage burn pain, despite evidence of inadequate treatment and varied practice standards over the past twenty years (rowan et al., 2015). it is crucial to differentiate between pain and anxiety, ensuring patients are comfortable, alert, and focused. burn pain should be promptly addressed, involving an iv line, resuscitation, and administering opioids. opioids may be combined with adjuncts like benzodiazepines to manage pain (carey et al., 2021). however, regularly assessing patient’s pain and anxiety levels using established metrics is recommended (yastı et al., 2015). it is crucial to educate staff, patients, and families on burn-related pain and its harmful consequences. the educational program should address addiction and pain communication through pain scales (nosanov et al., 2020). a personalized treatment plan considers individual opioid effectiveness and drug tolerance development (foster, 2014). the joint commission on accreditation of healthcare organizations and physical speciality groups outline patient monitoring levels, especially for those needing increased sedation and analgesia. the burn care team must prioritize addressing burn-related pain in all patient care aspects (carrougher et al., 2020; pruskowski et al., 2020). the management of burn pain in children can be enhanced by developing personalized treatment protocols that consider individual characteristics, burn severity, and cultural factors. long-term outcome studies are needed to assess the long-term effects of pain management methods on pediatrics. age-specific studies should be conducted to understand pain changes in newborns and young children. interdisciplinary training for healthcare providers working with pediatric burn patients is recommended, and increased public awareness about burn injuries and management strategies can improve treatment compliance. pa ge 58 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 51-61, 2024 conclusion in conclusion, this review found that pediatrics often suffer burn injuries, which can be treated in outpatient clinics through pharmacologic and non-pharmacologic interventions or require collaboration between pediatricians and regional burn programs for acute and long-term care. the review demonstrated that patients experience unmanageable physical and psychological pain, urging medical professionals to examine burn patients and establish a multidisciplinary pain management team. to apply safe and effective pain management strategies, this team may include surgeons, critical care specialists, anesthesiologists, nurses, psychologists, and social workers. it also highlights perspectives and suggestions for future research to address this significant clinical issue. limitations and strengths • the review highlights the importance of personalized, multimodal pain treatment methods for vulnerable patients’ health and efficiency. however, potential limitations include limited generalizability, publication bias in outcome measures, resource intensiveness, lack of long-term data, and variability in patient response. • excluding non-peer-reviewed sources may result in the omission of valuable insights. • in contrast, the review has several strengths as a comprehensive search strategy, complex methodology, and quality assessment tools like robis, pico model, and spider framework were used. • it covers various treatments like non-pharmacological methods, procedural analgesia-sedation, pharmacological interventions, and anesthetic care. • the review emphasizes clinical consequences, interdisciplinary anesthetic delivery, and pain management methods for pediatric burn care professionals. contribution of knowledge this review explored the treatment of burn pain in pediatrics using both pharmaceutical and nonpharmaceutical methods. quality evaluation tools like pico model, spider framework, and robis were employed. it provided a comprehensive understanding of burn pain’s sensory, emotional, and cognitive components. the review on procedural pain management in pediatric burn patients contributes by providing insights into effective interventions and tailored approaches for managing pain in this specific population. it helps inform clinical practice, identifies research gaps, and promotes patient-centered care. overall, the review enhances understanding of procedural pain management in pediatric burn patients and guides efforts to improve their pain relief outcomes and overall quality of care. novelty this review demonstrated pediatric burn pain treatment through several interventions and provided management guidelines and insights on pain assessment tools, emphasizing the need for personalized strategies to improve care. the novelty in this topic lies in its focus on procedural pain management specifically in pediatric burnt patients. while pain management in pediatric populations and burn care are well-studied areas, the intersection of these two domains may present unique challenges and considerations. understanding effective methods and treatments tailored to this specific demographic could contribute to improving the quality of care and outcomes for pediatric burn patients. additionally, exploring novel interventions or approaches specifically targeted at managing procedural pain in this population could represent a novel contribution to the field of pediatric pain management. research gap research on burn pain management in children is limited, mainly focusing on evaluating therapies but not integrating them into personalized treatment plans. the research gap in procedural pain management for pediatric burn patients includes a lack of high-quality evidence, standardized protocols, and studies on understudied interventions. additionally, age-specific considerations, long-term outcomes, patient-centered outcomes, and cost-effectiveness analyses are lacking. closing these gaps could improve pain management and overall care for pediatric burn patients undergoing procedures. this review covered various aspects of the treatment and management of procedural pain in burnt pediatric patients. future research can assess lasting effects and understanding of cultural and environmental factors. however, addressing these gaps will improve the specialization and effectiveness of pain management strategies, leading to better patient outcomes. references ahuja, r. b., gibran, n., greenhalgh, d., jeng, j., mackie, d., 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(2023). burns: classification, pathophysiology, and treatment: a review. international journal of molecular sciences, 24(4), 3749. pa ge 1 pa ge 10 7 american journal of medical science and innovation (ajmsi) it is not a curse! it is neurofibromatosis 1 (nf1): a case report from rural kenya vonwicks c. onyango1*, nicholas m. mutuma2, samuel m. gachie2; boniface mutiso2, nicholas auma3, william c. fryda md1 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2709 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 07, 2024 accepted: may 12, 2024 published: may 15, 2024 neurofibromatosis 1 (nf1) is an autosomal dominant genetic disorder caused by mutations in the nf1 gene, with near complete penetrance and variable clinical presentation. patients classically have café-au-lait macules, neurofibromas, skin freckles, and lisch nodules, among other multisystemic features. long-term management in a multidisciplinary team focuses on surveillance and treating complications. nf1 is a rare disease in kenya, often leading to myths and misconceptions about its nature, especially among rural communities. we present a classical case from rural kenya whose diagnosis was delayed by a belief that it was the result of a curse. we aim to highlight the importance of making this diagnosis and its linkage to a long-term care plan within a primary health care setting. keywords neurofibromatosis 1, nf1, von recklinghausen disease, café-au-lait macules, neurofibromas, skin freckles, kenya 1 department of medicine, st. joseph rift valley hospital, gilgil, nakuru county, kenya 2 department of outpatient, st. joseph rift valley hospital, gilgil, nakuru county, kenya 3 department of endoscopy, st. joseph rift valley hospital, gilgil, nakuru county, kenya * corresponding author’s e-mail: drvonczelo@gmail.com introduction neurofibromatosis type 1 (nf1) is a multisystem autosomal dominant genetic disorder that is commonly associated with skin, neurological, and skeletal manifestations (i.e., café au lait spots, neurofibromas, scoliosis, and long bone dysplasia, etc.). the pooled birth incidence is approximately 1:2600 individuals, while the pooled prevalence is about 1:3000 persons (lee et al., 2023). the manifestations of nf1 are caused by a mutation in or a deletion of the nf1 gene located on chromosome 17q11.2 (gutmann et al., 2017). the gene product, neurofibromin, serves as a tumor suppressor gene, and its decreased production or absence leads to the various clinical manifestations of nf1. the penetrance (i.e., the likelihood of an individual carrying the gene variant manifesting clinical disease) of the disease is almost 100%. the clinical features of nf1 are protean, and typical findings include café-au-lait macules (hyperpigmented macules appearing in childhood and increasing in early adulthood, freckling (especially axillary and inguinal regions, called crowe sign), lisch nodules (tancolored hamartomas of the iris virtually pathognomonic of nf1), and tumors that may be benign or malignant (i.e., neurofibromas, gliomas, especially optic gliomas, and soft tissue sarcomas, e.g., rhabdomyosarcomas and glomus tumors). neurofibromas are the most commonly seen benign peripheral nerve sheath tumors that are composed of a mixture of schwann cells, fibroblasts, perineurial cells, and mast cells (ortonne et al., 2018). they include discrete cutaneous neurofibromas (the most common type, usually soft, fleshy, sessile, or pedunculated) (plotkin et al., 2012), plexiform neurofibromas (located superficially or deeply in the skin and associated with overgrowth of skin and soft tissues with ensuing disfigurement of patients) (prada et al., 2012), and nodular fibromas. patients may also have bone abnormalities, e.g., scoliosis, long bone dysplasia, pseudarthroses, and stunted growth. neurological manifestations include neurocognitive deficits, learning disabilities, and seizures. cardiovascular features include an increased incidence of congenital heart disease and hypertension. nf1 may be associated with other endocrinological diseases, including pheochromocytoma and multiple endocrine neoplasia type 2b (men 2b). when clinically indicated, mri of the brain in nf1 shows focal areas of increased signal intensities (appearing as bright spots) and increased brain volume (dimario & ramsby, 1998; van es et al., 1996). the diagnostic criteria for nf1 developed by the united states national institutes of health (nih) consensus conference and updated in 2021 are shown in table 1(legius et al., 2021). consensus guidelines for the management of nf1 patients among various clinical societies generally recommend care by a multidisciplinary team of dedicated specialists throughout the patient’s lifetime. emphasis is given to long-term surveillance for and treatment of complications, as well as genetic counseling for patients and their families (ferner et al., 2007; stewart et al., 2018). patients with nf1 have an increased lifetime risk for both benign and malignant tumors (masocco et al., 2011). affected children and adults may experience psychological problems with poor selfimage and anxiety (sanagoo et al., 2019). the life expectancy is 8 years less than in the general population (wilding et al., 2012). a new emerging technology, e.g., clustered regularly interspaced short palindromic repeats (crispr)aasociated protein 9 (crispr/cas9) gene editing system, may soon be used for specific therapeutic targets in nf1 (moutal et al., 2017). pa ge 10 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 107-111, 2024 sphenoid wing dysplasia is not a separate criterion in case of an ipsilateral orbital plexiform neurofibroma. case summary clinical history and physical examination a 21-year-old single man, a college student from elburgon, nakuru county, kenya, presented to us with a history of increasing numbers of generalized soft nodular, nontender, and non-pruritic skin swellings and hyperpigmented macular lesions over the last 7 years. the swellings and macular-patchy lesions had been present at birth but had been dramatically increasing in size, number, and distribution since joining high school at age 14. they were now more evenly distributed over the torso, arms, legs, and neck. he was the firstborn among 5 siblings, the rest of whom were in good health. there was no known family history of a similar illness. he was accompanied by his mother, who reported that he was born with a deformity of his upper back, which was slightly bent forward and to the right. he had an otherwise normal childhood with normal developmental milestones, no convulsions, no visual problems, and above-average school performance, leading to his current college enrollment where he was pursuing a diploma in electrical engineering. he was happily dating a girl at the same college. their main reason for consulting us was to get a medical diagnosis rather than live with a suspicion of a possible ‘cultural curse.’ apparently, the family thought that he had been “cursed” and had sought numerous “spiritual solutions!” on clinical examination, he was in good general health, and not in any obvious distress. he had normal vital signs, with a blood pressure of 105/63 mmhg and a pulse rate of 85 bpm. his skin had generalized nodular swellings, especially over the arms, torso, thighs, and neck. these were of various sizes, ranging from 2 to 6cm, soft, non-tender, not attached to the skin, and movable easily in all planes. they were associated with generalized hyperpigmented macules, especially in the torso and axillary regions. he had bilateral axillary and inguinal freckles, which appeared much darker due to his dark skin color. he had an obvious thoracic scoliosis, while the rest of the musculoskeletal exam was unremarkable. his neurological exam was unremarkable, with grossly normal visual acuity and visual fields by direct confrontation. he was recommended for a full ophthalmological slit lamp evaluation. he had normal heart sounds with no murmurs. the rest of his physical exam was normal. diagnosis in view of the nodular swellings being consistent with neurofibromas (figure 1), the macular hyperpigmented skin lesions being café-au-lait spots (figure 2), the table 1: revised diagnostic criteria for neurofibromatosis type 1 (nf1) (legius et al., 2021) a: the diagnostic criteria for nf1 are met in an individual who does not have a parent diagnosed with nf1 if 2 or more of the following are present ▪︎ 6 or more café-au-lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in post pubertal individuals* ▪︎ freckling in the axillary or inguinal region* ▪︎ 2 or more neurofibromas of any type or 1 plexiform neurofibroma ▪︎ optic pathway glioma ▪︎ 2 or more iris lisch nodules identified by slit lamp examination or 2 or more choroidal abnormalities (cas) – defined as bright, patchy nodules imaged by optical coherence tomography (oct)/near-infrared reflectance (nir) imaging ▪︎ a distinctive osseous lesion such as sphenoid dysplasia, anterolateral bowing of the tibia, or pseudarthrosis of a long bone ▪︎ a heterozygous pathogenic neurofibromin 1 (nf1) variant with a variant allele fraction of 50% in apparently normal tissue such as white blood cells b: a child of a parent who meets the diagnostic criteria specified in a merits a diagnosis of nf1 if 1 or more of the criteria in a are present * if only café-au-lait macules and freckling are present, the diagnosis is most likely nf1, but exceptionally the person might have another diagnosis such as legius syndrome. at least 1 of the 2 pigmentary findings (café-au-lait macules or freckling) should be bilateral. figure 1: cutaneous neurofibromas seen here as numerous nodular lesions (blue arrows) distributed on the torso anteriorly and posteriorly as well as on both upper and lower arms. more neurofibromas were present on the head, neck, and both lower limbs. key: the patient had more than 60 cutaneous neurofibromas of variable sizes, which were soft, fleshy, and non-tender, with some being sessile and others pedunculated. these were distributed all over the skin, especially in the torso (both anteriorly and posteriorly). pa ge 10 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 107-111, 2024 figure 2: café-au-lait macules seen here as multiple hyperpigmented macules of various sizes distributed over the anterior and posterior torso (red arrows). they were also seen in the neck, arms, hands, legs and feet key: the patient had more than 30 café-au-lait macules diffusely distributed on the skin, particularly on the torso. these are flat, uniformly hyperpigmented macules varying in color from light brown to dark brown with smooth and irregular borders. they resemble coffee with milk, hence the name figure 3: freckles seen in the left and right axillae appearing as dark-brownish discoloration of the skin (blue arrows). key: freckles are discolorations of the skin due to overproduction of melanin and may range in color from red to dark brown. due to his dark skin, the patient had dark brown freckles in both the axillary and inguinal areas, with other freckles seen on the torso as well. figure 4: thoracic scoliosis seen in a posterolateral and posterior view images as bending of the upper thorax to the right side key: scoliosis is the sideways curvature of the spine. the patient has had thoracic scoliosis on the right side since his childhood. this was not causing him any clinical symptoms pa ge 11 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 107-111, 2024 presence of bilateral axillary and inguinal freckles (figure 3), and scoliosis (figure 4), a clinical diagnosis of neurofibromatosis type 1 (nf1) (previously called von recklinghausen’s disease) was made. this was in keeping with the diagnostic criteria for nf1. presently, he had no clinical indication for any extensive laboratory and imaging studies. a baseline complete blood count, random blood sugar, and creatinine were all normal. management and follow-up we educated them extensively on the genetic nature of the disease, its clinical manifestations, and proposed evaluation and monitoring over the years. this specifically includes an annual clinical evaluation seeking the nature and extent of the physical manifestations of the disease, annual blood pressure monitoring to rule out hypertension, a formal slit lamp examination for lisch nodules, and surveillance against other associated neuro-endocrinological diseases, e.g., multiple endocrine neoplasia (men) syndromes. if he desired a better cosmetic appearance in the future, or if the neurofibromas ever became problematic (painful, disfiguring, interfering with normal function, etc.), he would be offered surgical intervention. additionally, we informed him about the autosomal dominant mode of inheritance of the disease with a near-100% penetrance. this means each of his future children will have a 50% chance of inheriting the nf1 gene with clinical manifestations of nf1, albeit with variable severity of the disease. we referred him for a formal slit lamp ophthalmological evaluation and dermatological review. we’ll follow him up annually in the medical clinic with a multidisciplinary team on a long-term basis, with appropriate surveillance and management of complications as necessary. discussion our patient met the diagnostic criteria for nf1 as per the 2021 nih consensus conference diagnostic criteria (legius et al., 2021). neither of his parents have nf1. he had >30 café-au-lait macules, bilateral axillary and inguinal freckles (which appeared darker in his dark african skin), >60 cutaneous neurofibromas, and scoliosis. the differential diagnoses included legius syndrome, which is caused by a mutation in the spred1 gene and may have multiple café-au-lait macules, axillary freckling, and macrocephaly but lacks neurofibromas and central nervous system tumors (legius et al., 2021). neurofibromatosis type 2 (nf2) is caused by a mutation of the nf2 gene located on chromosome 22 and is predominantly associated with benign schwannomas, bilateral acoustic neuromas, a lack of cognitive impairment, and no lisch nodules (plotkin et al., 2022). for our patient, the café-au-lait macules and cutaneous neurofibromas began in childhood and increased in number and distribution in puberty, with no associated visual or neurocognitive disability to date. the thoracic scoliosis was asymptomatic. presently, none of the neurofibromas were giving him pain or cosmeticrelated concerns. the delayed medical diagnosis was due to a poor understanding of the disease in the community, and its subsequent cultural characterization as a possible “curse.” it is not uncommon for rare diseases (including neglected tropical diseases) to be seen as a curse in tropical africa in general and kenya in particular. this is largely fueled by illiteracy and entrenched cultural norms and practices, among other factors (ochola et al., 2021). luckily for him, this matter has now been resolved with the correct medical diagnosis and a full discussion on the nature of nf1 and its impact on him and his current and future family prospects. due to practical logistical reasons, his long-term management will be primarily overseen by the hospital physician, who will rationalize any testing needed based on the clinical presentation and oversee consultations with a multidisciplinary team including dermatologists, neurologists, orthopedic surgeons, psychological counselors, etc., as may be necessary. this is consistent with the uk and us consensus management guidelines (ferner et al., 2007; stewart et al., 2018). genetic testing is used in exceptional cases, especially in prenatal or preimplantation diagnosis (vernimmen et al., 2023). these tests are prohibitively expensive, yet a positive nf1 mutation test does not predict the severity or complications of the disorder (tamura, 2021). presently, he is asymptomatic, and none of his parents or siblings have any features of the disease. most likely, he had a sporadic mutation of the nf1 gene. we have recommended that a dermatologist and ophthalmologist review him for an initial evaluation and the planning of long-term follow-up. conclusion primary care physicians should easily diagnose nf1 based on the diagnostic criteria and do a thorough clinical evaluation to exclude complications and associated medical conditions. the diagnosis should be fully discussed with the patient and their family to expel any myths and misconceptions about the disease and explore the implications of the autosomal dominant nature of inheritance with a near-complete penetrance. the patient should subsequently be enrolled in long-term care within a multidisciplinary team led by the primary care physician, with 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(1996). mri findings in children with neurofibromatosis type 1: a prospective study. pediatr radiol, 26(7), 478-487. https://doi.org/10.1007/ bf01377205 vernimmen, v., paulussen, a. d. c., dreesen, j., van golde, r. j., zamani esteki, m., coonen, e., van buul-van zwet, m. l., homminga, i., derijck, a., brandts, l., stumpel, c., & de die-smulders, c. e. m. (2023). preimplantation genetic testing for neurofibromatosis type 1: more than 20 years of clinical experience. eur j hum genet, 31(8), 918-924. https://doi.org/10.1038/s41431-023-01404-x wilding, a., ingham, s. l., lalloo, f., clancy, t., huson, s. m., moran, a., & evans, d. g. (2012). life expectancy in hereditary cancer predisposing diseases: an observational study. j med genet, 49(4), 264-269. https://doi.org/10.1136/jmedgenet-2011-100562 pa ge 1 pa ge 44 american journal of medical science and innovation (ajmsi) the effects of hepatitis therapy and virus resistance on pregnant women: a comprehensive analysis ilham t. qattan1* volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.2991 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 27, 2024 accepted: july 31, 2024 published: august 03, 2024 this study aims to provide a comprehensive analysis of the effects of hepatitis therapy and virus resistance on pregnant women. hepatitis, a liver condition that is often regarded as a viral infection, poses considerable risks during pregnancy for both the mother’s and baby’s health. in viral hepatitis (like hepatitis b or c), the risk of negative outcomes and liver damage increases dramatically for expecting women as well as for fetus health. in addition to antiviral therapy (considering the drug safety, efficacy, and resistance issue), vaccination and preventive measures are important components of the treatment process. the purpose of this manuscript is to critically examine the literature that is currently accessible to illuminate the most crucial aspects or elements and provide useful input into treatment strategy optimization for pregnant women afflicted with hepatitis. while remarkable advancements have been made, screening and diagnostic services demand improvements and illustrate the need for efficient measures to abridge the impact of this viral hepatitis on pregnant women and their newborn babies. keywords hepatitis therapy, pregnancy, viral resistance, maternalfetal-health, viral load 1 taibah university, janadah bin umayyah road, tayba, madinah 42353, saudi arabia * corresponding author’s e-mail: it.qattan54@outlook.com introduction a broad range of conditions, including heavy alcohol consumption, autoimmune diseases, medications, and toxins, can induce inflammation of the liver, which is known as hepatitis. on the other hand, viral hepatitis, which results from a viral infection, is the most common cause of hepatitis. hepatitis is acute when it lasts less than six months and chronic when it persists longer. it may occur with limited or no symptoms but often leads to other diseases, such as anorexia (poor appetite), jaundice, and malaise (aljumah et al., 2019). the most recent who global hepatitis report states that liver problems from all types of hepatitis viruses result in 1.34 million deaths annually (com, 2023). there are five known hepatitis viruses, a through e. the three most prevalent viral hepatitis kinds are hepatitis a, hepatitis b, and hepatitis c. hepatitis d and e are the other forms of viral hepatitis that are less common (mehta & reddivari, 2022). whereas hepatitis d is considered a subgroup of hepatitis b due to its need for concurrent infection with hepatitis b. pregnancy can impact all aspects of these viral agents due to distinct immunologic and physiological changes during and after gestation (shata et al., 2022). hepatitis, a viral illness, has become a leading cause of fetal deaths during pregnancy and has an association with high-risk complications for the mother (chilaka & konje, 2021; jaffe & brown jr, 2017; seto et al., 2020). viral hepatitis with the origin from pregnancy is a very difficult problem that would have better be dealt with since it may seriously harm the mother’s and fetus` health. acute progression is present in hepatitis a and hepatitis e, while the mortality risk and the high fetal deaths are high in hepatitis e. further, hepatitis b and c have been tightly linked to being chronic, and yet women transmit the viruses to their unborn children (mtct) (terrault et al., 2021). pregnancy tends to worsen pre-existing viral disease conditions due to the numerous pregnancy-induced immigration, immunity-related, and gene-oriented changes. just the same, hepatitis e causes fatality in about 26% of suspected cases among pregnant women (bergløv et al., 2019). pregnancy can contribute to physiologic parameter alterations, giving physicians different treatment indications than the general population. consequently, the picture of the safety and efficacy of drugs and vaccinations during pregnancy is constantly developing. it is still critically important to implement a preventive mechanism that cuts the levels of this transmission. furthermore, to diagnose hepatitis different methods are being used namely, ict, elisa, cmia and pcr (rahaman et al., 2023). this paper aims to facilitate a comprehensive examination of how pregnant women are affected by anti-hepatitis medicine and genetic resistance to the virus. liverdamaging hepatitis, a virus that creates hazards for the mother as well as for the unborn child during pregnancy, is what poses these risks. current antiviral therapy is an integral component of curing hcv, yet its downside problems, including poor efficiency, toxicity, and treatment resistance, must be agreed upon. this research aims to further clarify these crucial points by critically reviewing the literature and proposing recommendations to enhance the treatment of pregnant hepatitis patients. literature review pregnant women with hepatitis viral hepatitis out of pregnancy has always been in pa ge 45 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 44-51, 2024 debate. this condition caused a major mortality rate during childbearing. the opinions of researchers over the impacts of viral hepatitis among pregnant women on both the mother and fetus also differ. while some researchers considered it wrong that non-fatal viral hepatitis did not affect the course of pregnancy or would not bring harm to the baby, others found that acute viral hepatitis presented a substantial danger to both mother and fetus(asafo-agyei & samant, 2020). moreover, the liver damage caused by hepatitis in every trimester depends on the virus type and is also associated with the intensity of it. hav, an rna virus, is highly endemic in the middle east, north africa, sub-saharan africa, south and central asia, and latin america. its infections are mostly self-limited and rarely cause life-threatening consequences. the death rate ranges from 0.3% to 0.6%, with an estimated 1.5 million new cases reported annually. efficient and secure vaccination prevents hav infection (chaudhry et al., 2015). hepatitis b is an infectious virus that causes liver infections in primates. it is transmitted through parenteral blood exposure, sexual contact, or vertical transmission from mother to child during or after delivery. the natural history of this disease is complex. acute infection can result in jaundice, pain, and liver failure. the non-resolving infection will lead to scarring of the liver, which will eventually lead to cancer (shata et al., 2022). infection severity will predict risk. furthermore, research demonstrated that pregnant women with hbv infection tend to get preeclampsia and gestational diabetes in addition to hepatitis b infection during pregnancy; therefore, the extent of the problem should be investigated (afraie et al., 2023). pregnancy-related hcv-positive cases can have a huge impact on both the mother having an increased viral load and low levels of liver transaminases. trending liver function when pregnant is not advised. intrahepatic cholestasis, gestational hyperglycemia, and worsening fetal outcomes are further related disorders. however, it is recommended that women with hcv infection undergo a growth scan during the third trimester (dotters-katz et al., 2021). moreover, newborns delivered by mothers who test positive for hcv are more likely to have low birthweights and need to be admitted to a neonatal intensive care unit or on assisted ventilation. the intravenous drug usage of mothers does not appear to have an impact on these results (aebi-popp et al., 2016). moreover, in the west, 40% of episodes of jaundice in pregnant women are caused by viral hepatitis a through e. the majority of cases are anicteric and subclinical, with symptoms such as jaundice, headache, nausea, and vomiting. only a small proportion of hepatitis c cases exhibit full recovery, compared to all cases of hepatitis a and b, which show full recovery (garcía-romero et al., 2019). furthermore, replication of the hepatitis d virus (hdv) requires hbv infection. it coats itself with more hbsag protein and enters hepatocytes. there are few pregnancies and hdv transmissions from mother to child (sellier et al., 2018). according to a study, there have been reports of vertical transmission of hav and hev from mother to child (terrault et al., 2021). hepatitis a and e have severe complications in pregnant women, which can be caused by drinking contaminated water. additionally, the hepatitis a virus can lead to early labour, whereas hev infection in the second or third trimester entails significant morbidity and death concerns (com, 2023). a study evidenced that pregnant women had an 11.6% prevalence of the hepatitis e virus (hev), with 11.4% testing positive for the anti-hev igg antibody, 0.1% for the anti-hev igm antibody, and 0.1% for both antibodies. hev-igg antibody-positive pregnant women are more likely to experience bad pregnancy outcomes, liver damage, and poor maternal and fetal outcomes. these unfavorable pregnancy outcomes are worsened by parity, age, and gravidity (qian et al., 2023). furthermore, studies have shown that the replication of the hepatitis e virus in the placenta is associated with maternal and fetal mortality with acute liver failure. the study also found that in hev patients, receptors of estrogen esr1α and esr2β and estrogen itself have been identified as possible biomarkers predicting worse maternal and fetal health (horvatits et al., 2019). diagnosis and monitoring people diagnosed with hepatitis should emergently seek monitoring. diagnosing and monitoring of hepatitis include imaging and a number of blood tests. furthermore, in pregnant women, the key blood tests used to diagnose and monitor hepatitis include hepatitis antibody serology tests, liver function tests, and viral load assessment (asafo-agyei & samant, 2020). a study regarding hbv infection stated that the antibodies hbeag, anti-hbs, hbsag, anti-hbe, and anti-hbc igm and igg are among the serological indicators of hbv infection. these markers aid in the diagnosis of hbv infection, comprehension of the progression of chronic hepatitis b (chb), evaluation of the clinical stages, and tracking of antiviral treatment. the main marker, hbsag, is at higher levels in chb patients who test positive for hbeag. long-term immunity is provided by antihbs, which coexists with anti-hbc igg. during acute infection, anti-hbc igm and igg emerge after hbsag, and hbv dna assays take the role of earlier indicators (song, 2016). secondly, most commonly, abnormal liver function results in the third trimester (mishra et al., 2016). in order to evaluate liver function and identify any abnormalities, liver function tests, or lfts, are essential during pregnancy. they take albumin, bilirubin, and enzyme readings. timely care and the reduction of problems depend on the accurate interpretation of lft results. in order to protect pregnant women and their unborn children, these tests assist medical professionals in keeping an eye on liver health, spotting anomalies, and pa ge 46 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 44-51, 2024 starting interventions. furthermore, the interpretation of abnormal liver function tests (alfts), which are essential for the diagnosis of liver disease, can be difficult during pregnancy because of hemodilution and physiological changes. pregnant women’s transaminases, especially alt (alanine aminotransferase) and ggt (gamma glutamyl transferase), are 20% lower than laboratory reference levels, while their alkaline phosphatase increases because of the placenta. (dajti et al., 2023). hcv+ mothers don’t need to monitor transaminases during pregnancy; measuring liver enzymes at the start of pregnancy is adequate. a single pregnancy-related qualitative pcr test is recommended, but any liver disease staging should wait until after delivery. furthermore, since there is currently no anti-hcv medication that can be given to expectant mothers to stop viral replication, a high maternal viral load is a significant but avoidable risk factor (tovo et al., 2016) at ghent university hospital, a study assessed three pcr assays and six serological assays to identify hev in individuals who may have been infected. using commercial elisa and pcr assays, including in-house and commercial testing, they looked for hev rna and antibodies (igm and igg) specific to the virus. across all elisa assays, the frequency of hev antibodies ranged from 5.7% to 14.3% for igm and 15.7% to 20.0% for igg. in clinical samples, most pcr findings were consistent; however, there were notable differences in 10 out of 16 external quality control samples (cattoir et al., 2017). another study concluded that the anti-hev agspecific elisa is less sensitive than hev rna real-time pcr. yet, it is a valuable tool for distinguishing chronic from acute infection (behrendt et al., 2016). furthermore, new research develops a method for identifying hbv perinatal transmission utilizing fast dna extraction and recombinase polymerase amplification. the assay achieved 98.6% sensitivity and 88.2% specificity, with room for improvement in non-viremic patients. the study proposes that this approach be utilized in point-ofcare testing to avoid hbv transmission. however, more validation on a larger cohort of hbv-positive plasma samples from pregnant women is required before in-field adoption (mayran et al., 2022). hepatitis therapy and medications in pregnant women most of the research has developed on treatment and therapy for hepatitis b and hepatitis c. chronic hepatitis b (chb) has turned out to be a prominent health problem on a global scale, and the management of pregnant women with this disease is a necessity. pregnant women will be running tests like hepatitis b surface antigen (hbsag) and other tests. the management primarily focuses on the hbv infection stage rather than pregnancy since the latter state is hardly indicated. antiviral treatment is intended mainly for indicated chb patients and also for anti-vertical transmission purposes. tenofovir should be taken during pregnancy. use a combination of hepatitis b immunoglobulin and vaccination for all infants whose mothers are infected with chb, insisting on no breastfeeding contraindications (belopolskaya et al., 2021). hcv is strongly associated with premature birth and cholestasis. till now, there is no vaccine for hepatitis c, so the main focus is on the treatment. for the treatment of children with hcv transmitted through the mother, antihcv antibodies that pregnant women possess can be transmitted through the placenta to the fetus. the period of the baby’s serum can be detected in the same maternal antibodies for up to 13 months after birth. diagnosed with antibody titer rise in the newborn serum does not mean they’re infected (ragusa et al., 2020). a study in switzerland found that many pregnant women with hcv are unaware of their condition, and regular screening is not done. the federal office of public health and the swiss society of obstetrics and gynecology recommend hcv testing for high-risk women, including those who have used intravenous drugs, had hcv infection, received a solid organ transplant before 1992, received blood transfusions, or used clotting factor concentrate before 1987. untrustworthy self-reporting of drug use during pregnancy is a significant obstacle to diagnosis (aebi-popp et al., 2016). study design and methodology search strategy this literature review employed a systematic search strategy to identify relevant studies published in peerreviewed journals. electronic databases, including pubmed google scholar, pubmed, science direct, and springer link, were searched using predefined search terms related to hbv screening in pregnant women using keywords: hepatitis a, hepatitis b, hepatitis c, hepatitis d, hepatitis e, pregnancy, viral resistance, treatment, hepatitis therapy, and diagnosis of hepatitis. inclusion and exclusion criteria articles were limited to those published in english from 2015 to 2024. this review includes only hepatitis-related articles, including therapeutic approaches to hepatitis in pregnant women. it excludes all those studies which do not include hepatitis in pregnant women. studies published in journals where publishers do not offer a peer-reviewing policy were excluded, and only studies available in fulltext format for the public view were included. results the results of selected studies are presented in a table representing the author, years, published journal, title of the study objectives, and results. pa ge 47 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 44-51, 2024 table 1: shows the objectives and results of the studies discussed in the review s. no author journal title objective results 1. (q ia n et al. , 2 02 3) jo ur na l o f c lin ic al v iro lo gy prevalence of hepatitis e virus and its association with adverse pregnancy outcomes in pregnant women in china to investigate the prevalence of (hev) infection among pregnant women and to assess the association between hev infection, specifically the presence of anti-hev igg antibodies, and adverse pregnancy outcomes. the existence of anti-hev igg antibodies has been linked to an increased risk of bad pregnancy outcomes, such as liver damage and poor mother and fetal health. furthermore, the study found parity, age, and gravidity as factors that exacerbated the negative pregnancy outcomes linked with hev infections. 2. (s on g, 2 01 6) a nn al s o f tr an sla tio na l m ed ic in e diagnosis of hepatitis b the study aimed to investigate the serological indicators of hepatitis b virus (hbv) infection and their involvement in the diagnosis, progression monitoring, and therapy evaluation of chronic hepatitis b. the study found various serological indications of hepatitis b virus infection, including hbeag, anti-hbs, hbsag, anti-hbe, and anti-hbc igm and igg. the key marker, hbsag, is present at high levels in chronic hepatitis b patients. anti-hbs provide long-term protection, whereas antihbc igm and igg antibodies appear during acute infection. these findings advance our understanding of hbv infection and influence management options. 3. (c at to ir et al. , 2 01 7) a rc hi ve s o f v iro lo gy hepatitis e virus serology and pcr: does the methodology matter? the study aimed to compare the performance of six serological assays and three pcr assays in detecting hepatitis e virus (hev) genotype 3 in patients with clinically suspected hev infection at ghent university hospital. the study discovered variable prevalence rates of hev antibodies, with igm and igg antibodies ranging from 5.7% to 20.0%. hev rna was detected using a commercial test and two optimized in-house realtime rt-pcr techniques. most pcr findings were consistent. however, 10 of 16 external quality control samples exhibited significant differences in pcr assays. this emphasizes the importance of carefully interpreting serological and molecular hev infection test data. 4. (m ay ra n et al. , 2 02 2) d ia gn os tic s rapid diagnostic test for hepatitis b virus viral load based on recombinase polymerase amplification combined with a lateral flow read-out this research aimed to develop a simple molecular method for detecting highly viremic pregnant women with hepatitis b virus (hbv) infection, which is an important step in preventing perinatal transmission. a study proposed a method for identifying hbv perinatal transmission utilizing fast dna extraction and an isothermal recombinase polymerase amplification (rpa) technology. the approach was tested on plasma samples with different virus loads and genotypes. the assay had a sensitivity of 98.6%, indicating efficacy in detecting highly viremic individuals, and a specificity of 88.2%, indicating room for improvement in recognizing non-very viremic cases. the assay’s high overall performance suggests its potential for use in point-of-care testing. pa ge 48 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 44-51, 2024 5. (a eb i-p op p et al. , 2 01 6) jo ur na l o f v iru s e ra di ca tio n vertical transmission of hepatitis c: towards universal antenatal screening in the era of new direct acting antivirals (daas)? short review and analysis of the situation in switzerland the study aimed to determine the frequency of undetected hepatitis c virus (hcv) infection among pregnant women in switzerland, taking into account the lack of routine screening and the difficulties associated with self-reporting behaviors at high risk. unreliable self-reporting of drug use during pregnancy appeared as a substantial hindrance to proper diagnosis. these findings highlight the significance of establishing more effective screening procedures and resolving self-reporting problems to improve the detection and management of hcv infection among pregnant women in switzerland. 6. (b eh re nd t e t a l., 20 16 ) t he jo ur na l o f in fe ct io us d ise as es hepatitis e virus (hev) orf2 antigen levels differentiate between acute and chronic hev infection. the study aimed to evaluate the effectiveness of an elisa-specific enzyme-linked immunosorbent assay in detecting hev genotype 3 infections, comparing its sensitivity with realtime pcr and assessing its ability to differentiate between acute and chronic infections. compared to real-time pcr, the anti-hev ag-elisa showed lower sensitivity in detecting hev infection but higher levels in chronically infected individuals. it also demonstrated high sensitivity and specificity in distinguishing acute and chronic hev infections. despite its less sensitive nature, it remains a valuable tool for hev infection diagnosis. 7. (b el op ol sk ay a et al. , 2 02 1) w or ld jo ur na l o f g as tro en te ro lo gy chronic hepatitis b in pregnant women: current trends and approaches the primary objective in treating pregnant women with hepatitis b virus (hbv) infection is to prevent the virus from passing from mother to child. this includes carrying out essential examinations, such as the hepatitis b surface antigen (hbsag), to determine the mother’s infection status and applying the related management practices. the management of infected pregnant women should involve carrying out relevant tests like hbsag to determine the mother’s status. management should focus on the stage of hbv infection rather than pregnancy itself, as pregnancy only marginally affects hbv progression. antiviral treatment that contains tenofovir, for instance, should be prescribed for pregnant women with indicated chronic hbv infection to reduce the risk of vertical transmission. a combination of hepatitis b immunoglobulin and vaccination for every infant born to a chronic hbv carrier with the crucial point of close adherence to recommended breastfeeding practices to make transmission less likely. discussion this literature review concentrates on hepatitis a, b, c, d, and e influences during pregnancy. it provides an extensive overview of the risks the mother and fetus share. it highlights the need for designing newer regimens for screening, diagnosing, and treating cases of hepatitis in women during pregnancy. the evidence shows that viral hepatitis is one of the main causes of fetal death during pregnancy, and the paper highlights the high-risk problems viral hepatitis poses to pregnant women. the paper looks at the different forms of viral hepatitis that appear throughout pregnancy, which include an acute disease progression in hepatitis a and e, a chronic disease form in hepatitis b and c, and the yet-to-be-described risks of preeclampsia, gestational diabetes, and intrahepatic cholestasis. the review also briefly describes the difficulties in diagnosing and controlling viral hepatitis in pregnant women, the interpretation of liver function tests, and the impact of physiological changes during pregnancy pa ge 49 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 44-51, 2024 on diagnostic markers. diagnosing and managing viral hepatitis in pregnancy has significant challenges as evidenced by many studies. some physiological changes that occur during pregnancy include changes that involve liver function and hormones, and therefore, diagnostic test results may be affected. when it comes to the assessment of liver health, lfts are essential though they may be affected by pregnancy’s normal physiological changes, thus presenting challenges for the distinction of pathological changes from normal fluctuations. besides, the fact that viral hepatitis interacts with the human body constantly, with periodically escalating and decreasing viral replication rates and immune responses, complicates matters even further. particularly, pregnancy could change clinical characteristics in a patient, as well as the progression of the disease; therefore, diagnosis becomes problematic. managing viral hepatitis in this population is also challenging due to the possible teratogenic effects of the antiviral agents and the potential consequences that coordination between the health of the mother and the fetus may have. the issues that arise should be solved on the basis of a multidisciplinary approach through the cooperation between obstetricians, hepatologists, and specialists in infectious diseases; it will be possible to assess the management and prevent possible negative outcomes for both the mother and the fetus. the paper covers another aspect of the effects of hepatitis on fetal health, such as preterm delivery and the risk of newborn complications. additionally, for the treatment of hev, ribavirin and interferon alpha are effective, but in pregnancy, the use of these agents is inhibited and is not suggested. however, ribavirin can be recommended for pregnant women infected with hev in the last trimester due to its less teratogenic effects (aslan & balaban, 2020). furthermore, the study by anisweka et al. (2019) indicates the role of antiviral treatment in the course of hepatitis during the period of pregnancy, concerning both acute subtypes b and c. it stresses the involvement of tenofovir in pregnancy to minimize the risk of vertical transmission and birth immunoglobulin and vaccination in not transmitting hepatitis b to newborns. besides this, the review is about the progress in diagnosing viral hepatitis, achieved by rapid dna extraction and recombinase polymerase amplification. these appear useful in determining highly viremic and hepatitis b pregnant ladies. furthermore, the report by the researcher shows the importance of effective screening policies aimed at discovering hcv infection among pregnant women. it is worth noting that many infected individuals are only detected by diagnostic examinations, which signifies the importance of screening programs. healthcare providers, including gynecologists, obstetricians, and other clinicians, are having a significant impact on the early detection and diagnosis of hcv in pregnant women. the research equally indicates that the forward increase or the dominance of intravenous drug use among pregnant women calls for special considerations regarding maternal and fetal health outcomes, further justifying the need for tailor-made solutions that address drug abuse during pregnancy (aniszewska et al., 2019). moreover, it is of vital importance for the medical care provider to consider viral hepatitis among highrisk pregnancy women to avoid maternal and fetal complications that are linked with mother-to-child transmission. holistic care of the mother requiring obstetrics, maternal-fetal medicine, hepatology, and neonatology is desired to ensure the best chances for both mother and child. it is recommended that pregnant women be tested for hbv and hcv as part of routine screening. tenofovir disoproxil fumarate, lopinavir, and ritonavir with antiviral therapy may be required, while lamivudine may be considered an option. given the knowledge regarding the safety and efficacy of directacting antivirals in hcv infection during pregnancy and food and drug administration approval, the outcomes of clinical practices should be enhanced and improved (sanghi & lindenmeyer, 2021). alhussain et al. in his research studied about perinatal care and concluded that counselling on coping and stressor adaptation mechanisms should be provided to everyone during public health emergencies (alhussain et al., 2023) in conclusion, it is distinct that the diagnosis and management of viral hepatitis during pregnancy remain complicated due to the changes in physiological status. it is challenging to pinpoint what may be considered as a range of normal variations and what requires a special consideration of pathological changes affecting liver function tests, and their impact on the diagnostic markers. thirdly, due to the high viral loads as well as the variability of the immune responses, diagnosis of viral hepatitis is not a very easy process. conclusion to summarize, the hepatitis care of pregnant women is intricate, involving multiple obstacles and complexities, from diagnostic precision to treatment decisions. though the literature review points out the already existing measures like diagnosis, monitoring, and therapy in different ways, shortcomings and unresolved issues still require further studies. limitations and future implications the review on hepatitis management during pregnancy gives us a great range of information about therapeutic approaches, diagnosis, and monitoring. nevertheless, a few barriers and topics have not been extensively explored. it is basically about therapeutic modalities and diagnostic methods, and it doesn’t touch upon aspects such as epidemiology and social impacts. one aspect that could limit data transferability from one region to another is the data regional variation. publish bias is another issue, as only the studies published in english between 2015 and 2024 have been included in this review. scientific research in this domain is challenging due to methodological pa ge 50 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 44-51, 2024 discrepancies across studies, making it hard to establish a solid, unified conclusion. thus, longitudinal followup of fetal and mother outcomes is lacking. still, more studies on genes that affect offense or susceptibility and treatment are required. interventional studies that assess the effectiveness and safety of treatment modalities are, too, in short supply. overcoming these constraints will provide us with a better insight into managing hepatic conditions in pregnancy and will lead to better outcomes for mothers and babies. references aebi-popp, k., duppenthaler, a., rauch, a., de gottardi, a., & kahlert, c. 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(2016). vertically acquired hepatitis c virus infection: correlates of transmission and disease progression. world journal of gastroenterology, 22(4), 1382. pa ge 1 pa ge 14 2 perception of asaba people in delta state nigeria towards national community response to covid-19 ngozi g. orofuke1, ayirioritse p. ighosewe2, christiana i. elusoji3, uzochukwu ofonakara4, matthew chindeum ezeh5 charles c. ofili1, michael o. otutu1, eugene o. ohanme4* article information abstract received: august 28, 2024 accepted: october 01, 2024 published: december 10, 2024 the 2019 coronavirus pandemic has caused global concern and led to measures such as hygiene, isolation, and social distancing. 99.5% of respondents knew about covid-19, according to a nigerian newspaper report, and most of them cited the internet, social media, and television as their main information sources the majority of defensive methods, according to 82.3% of respondents, include good cleanliness, self-isolation/social distance, face masks/gloves, and prayer. also, 52.1% of respondents, however, said that the government was not doing enough to stop the pandemic in nigeria. people who were well-informed on covid-19 felt favorably about the country’s reaction. most responders did not comply with preventive measures because they thought the pandemic was more of a hoax than a real threat. an accurate information dissemination plan is advised to guarantee adherence to preventive measures and to increase public awareness of the pandemic. in view of the ongoing epidemic, the study emphasizes the necessity of precise information dissemination tactics to guarantee adherence to preventive measures. keywords covid-19, delta state, pandemic, perception about covid introduction a new virus known as covid-19 was identified in wuhan, hubei province, china, in 2019. severe acute respiratory syndrome coronavirus 2 is the virus’s cause. sars-cov-2) (zhu et al., 2020). first diagnosed as a pneumonia-like illness in december 2019 from an idiopathic perspective, the sickness was officially recognized as a global public health emergency on january 30, 2020 (zhu et al., 2020). since then, additional research and reports from many locations around the world have revealed more about covid-19. as of may 9, 2020, there were 4,067,112 confirmed cases of covid-19 worldwide and 280,507 documented deaths. as of may 14, 2020, there were 4,308,809 reported cases of covid-19, including 296,680 deaths (zhang et al., 2021). on february 27, 2020, the first verified case of covid-19 was reported in nigeria. the first case of covid-19 in nigeria, according to the national center for disease control (ncdc), involved an italian national who arrived on a turkish airlines flight from milan via istanbul on february 24. (harapan et al., 2020). from that point on, the number of cases has increased steadily. as of may 14, 2020, 5,962 coronavirus infections had been confirmed, 1,180 cases had been discharged, and 168 deaths had been reported. the majority of covid-19 infections in nigeria have been linked to contacts with previously confirmed cases and returning tourists (harapan et al., 2020). in attempt to stop the virus’s spread, the nigerian federal government has implemented a number of measures, such as the closure of all educational institutions, lockdowns in lagos and the federal capital territory (fct), instructions for people to stay at home, and prohibitions on public gatherings (jacobs & okeke, 2022). the ncdc has also raised public awareness of the coronavirus pandemic by employing crucial communication techniques in print, social, and electronic media to inform nigerians of its spread (dan-nwafor et al., 2020). social workers are essential in supporting efforts to avoid disease because they assist in managing anxiety and other pandemic-related issues while also providing accurate information from reliable sources (ross & de saxe zerden, 2020). many people find lockdown procedures and physical segregation to be unavoidably upsetting, startling, confusing, and alienating, especially vulnerable populations like people with disabilities (pwds) (bhattad & pacifico, 2022). thus, the advocacy role of social workers is to shape social policy with respect to the safety of the economically disadvantaged and disabled, for whom lockdowns would have adverse consequences. social service providers in china played a crucial role in the covid-19 response by assisting in the identification of vulnerable populations’ needs, planning volunteer aid, mobilizing local resources, and conducting studies on the quality of life in sichuan province (wang & liu, 1 department of community medicine, delta state primary healthcare development agency, delta state nigeria 2 department of paediatrics, delta state specialist hospital, asaba, delta state, nigeria 3 department of nursing sciences, benson idahosa’s university, benin city. edo state, nigeria 4 department of pharmacology and therapeutics, faculty of basic clinical sciences, alex ekwueme federal university ndufu alike ikwo, ebonyi state, nigeria 5 department of economics, dennis osadebay university, asaba, delta state, nigeria * corresponding author’s e-mail: eugene.ohanme@funai.edu.ng american journal of medical science and innovation (ajmsi) volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3506 https://journals.e-palli.com/home/index.php/ajmsi pa ge 14 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 142-149, 2024 2022). however, the governments of nigeria’s failure to recognize or understand the role of social workers highlights the absence of a professional mandate and the challenges associated with putting social work practice into practice (androff & mathis, 2022). the novel coronavirus disease with no known cure or vaccine, covid-19 is a worldwide epidemic that has significantly increased morbidity and death. 95,714 fatalities, 356,440 recoveries, and 1,603,428 confirmed cases were reported globally as of april 9, 2020. an italian national was designated as the index case in nigeria, where there were 288 laboratory-confirmed infections, 51 discharges, and 7 fatalities (mallah et al., 2021). civil societies and government organizations started educating the public about proper hygiene and social separation in order to stop the disease’s spread. airports screened passengers for temperature, and travelers returning from nations where there had been many confirmed cases were advised to separate themselves (pollard et al., 2020). the nigerian government instituted containment measures, such as sealing national borders, closing schools, and putting in place lockdowns, and it banned meetings with more than fifty participants for a period of four weeks. the state governments established isolation facilities and curfews, while testing laboratories were established in lagos, abuja, and irrua (ibrahim et al., 2020). the corona virus (covid-19) the virus that causes covid-19, a serious respiratory illness first identified in wuhan, china in december 2019, is called sars-cov-2. it spreads via the mouth, nose, and eyes and produces symptoms like fever, coughing, and shortness of breath (khan et al., 2020). the virus can cause serious respiratory issues or even death during its one to fourteen-day incubation period, particularly in the elderly and those with chronic conditions. since no known cure or vaccination for covid-19 exists, medical interventions are restricted to supportive care, experimental medications, and therapies (hu et al., 2021). material and methods study design for this study, a cross-sectional survey of 589 volunteers who were chosen at random from the communities of umuagu, umuaji, and akwebulu in asaba, was employed. the volunteers were given a questionnaire and interviewed about covid-19 compliance and preventive strategies. residents of asaba in oshimili north lga delta in state made up the study’s population. before the final form was given to the participants in asaba, the questionnaire underwent peer review and a pilot test in two hospitals in amai, which is not the location of this study. the questionnaire were structured into five distinctive parts to collect information on (i) demographic characteristics (ii) knowledge of covid-19 disease (iii) awareness of the preventive measures in the metropolis (iv) the compliance rate with preventive measures in the metropolis (v) factors that affect the awareness of covid 19 preventive measures community members were chosen through the use of the convenient sampling technique. data were gathered over a two-week period. the data that was gathered was examined to ascertain the degree of adherence to recommended preventive actions. study area the study was carried out at asaba, a city in delta state, south-south nigeria’s oshimili north local government area. oshimili north had 172, 773 residents as of the 2006 population census (national population commission, 2010). this community’s decision was influenced by its urban status and the congestion brought on by onitsha market’s enormous market area (yimer et al., 2022). scope of study this study was limited to the knowledge, awareness of prevention methods and the factors influencing the practice of preventive measures in 589 randomly selected volunteers within the ages 18 and above in oshimili north local government area of delta state, nigeria. study of population the target population were people from age 18 years upwards from which the sample size was selected by simple sampling technique. the research study populations were residents in oshimili north local government area. sample size determination the sample size was determined using fisher’s formula: n = z2p (1-p)/e2 where n = minimum required sample size in population >10,000. z = standard normal deviation at 95% confidence interval. level of significance is 1.96. p = prevalence of women who have knowledge of good nutrition from literature reviewed = 0.185. e =acceptable margin of sampling error (0.05). n= 589 (jung, 2014) sampling procedure to choose the three villages and three areas that make up the community, simple random sampling was utilized. this was done to ensure that every region had an equal chance of being chosen for the study. to choose respondents who agreed to take part in the study, the availability sampling technique was used. this was predicated on earlier phone conversations in which the respondents were invited to take part in the research. ten houses from each of the chosen villages made up the total of thirty homes that were chosen for the study. heads of households, both male and female, fifty years of age and older, were chosen for the interview. pa ge 14 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 142-149, 2024 inclusion criteria volunteers who have been resident in the umuagu, umuaji and akwebulu communities in asaba of oshimili north local government area for at least ten years from 18years old, were selected for the study exclusion criteria volunteers under the age of eighteen who did not live in the asaba oshimili north local government area’s umuagu, umuaji, or akwebulu villages were not chosen for the study. method and instrument for data collection data was gathered using a semi-structured questionnaire that the interviewer provided. the poll was adapted from a similar study conducted among chinese citizens (18) to fit the objectives of the research. the questionnaire’s reliability coefficient (cronbach’s alpha) after pretesting and reliability testing was 0.82 (tavakol & dennick, 2011). face validity was established from the pretest to confirm that the answers accurately reflected the questions and that the questions themselves fit the study’s objectives. public health experts concluded that the questions addressed all relevant aspects of the topic, proving the questions’ content validity. the questionnaire asked questions about sociodemographic data, information availability, awareness of covid-19 symptoms, transmission, and prevention, views against foreigners of asian or caucasian heritage living abroad, recent returnees from international travel, and covid-19 survivors. other subjects included were covid-19 pandemic associated behaviors such handwashing, using face masks, social distancing, utilizing over-the-counter drugs, and using herbal medicines (adesegun et al., 2020). true/false questions were utilized to construct the knowledge section’s questions, and a scoring system was developed to assess knowledge. the first nine questions, which concentrated on covid-19 symptoms and transmission, were awarded one point each, while the next eight questions, which addressed covid-19 prevention, were worth two points each. in total, there were twentyfive points. each incorrect answer was assigned a zero. 13–17 (50–69%) was regarded as having intermediate knowledge, 18–25 (>70%) as having strong knowledge, and less than 13 (<50%) as having inadequate information. to the next whole number, the overall score was rounded. to construct a 5-point attitude scale. twelve questions were used to score attitudes using a likert scale and yes/ no questions. a positive attitude was worth one point, while a negative attitude was worth zero. a total score of less than fifty percent was considered to be poor, and a total score of more than fifty percent was considered to be good. multiple-choice and yes/no questions made up the practice component. five questions were used to grade practice; a score of less than fifty percent indicated bad practice. positive practice received one point. validity of the research instrument the researcher used a self-structured questionnaire with contents relevant to the topic and was assessed by the researcher’s supervisor prior to the administration of questionnaire, so as to ensure the questionnaire is valid and subsequently approved (ranganathan & caduff, 2023). reliability of the research instrument test-re-test was used prior to this study. the pretesting replies were utilized to adjust the questions. subsequently, the same respondents took a second test to ascertain the questionnaire’s validity, and the results of both tests were correlated after calculation. (ranganathan & caduff, 2023). ethical considerations this study involved children from novena university, who were interviewed in the presence of their parents. parental consent was obtained, and the study aimed to respect the indigenous belief system and interview children first before adults to avoid influencing their views. data collection the study used in-depth interviews to gather data from 36 respondents, including 6 children and 30 household heads, between october 10 and november 5, 2020. the interviews were conducted in igbo and english, with participants informed about the research’s objectives, anonymity, confidentiality, and the freedom to withdraw at any time. the interviews were transcribed into english, and the original meaning of the participants’ words was preserved to ensure reliability and validity of the data (jamshed, 2014). the study analyzed respondents’ responses on covid-19, physical/social distancing, hand washing, and lockdown impact on child care. analytical themes were identified, and the data was manually analyzed to maintain originality and avoid manipulation. results and discussion results table 1: sociodemographic characteristics of participants variable frequency (n = 589) percent (%) age (years) 18–29 years 261 44.3 30–39 years 214 36.3 40–49 years 93 15.8 50–59 years 21 3.6 pa ge 14 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 142-149, 2024 table 2: perception of respondents towards national community response to covid 19 s/n variable frequency (n = 598) percent (%) 1 do you think that the government has/is doing enough to stop the global pandemic in nigeria? yes 139 23.6 no 307 52.1 maybe 143 24.3 2 do you agree with the obligatory lockdown/measures nigeria is taking? yes 374 63.5 no 115 19.5 maybe 100 17.0 3 do you agree with the government stay-at-home order? yes 428 72.7 no 84 14.3 maybe 77 13.1 4 are you complying with the government stay-at-home order? yes 460 78.1 no 25 4.2 sometimes 104 17.7 5 do you believe in chinese doctors’ intervention in nigeria? yes 73 12.4 no 401 68.1 maybe 115 19.5 6 will you accept covid-19 vaccine? yes 171 29.0 no 268 45.5 maybe 150 25.5 7 on a scale of 1–5, how satisfied are you with your country’s response against the covid-19 pandemic? not satisfied 141 23.9 partly satisfied 155 26.3 satisfied 234 39.7 more than satisfied 34 5.8 very satisfied 25 4.2 gender female 238 40.4 male 351 59.6 marital status married 230 39.0 single 354 60.1 divorced 3 0.5 widow/widower 2 0.3 level of education high school 26 4.4 college/bachelor 348 59.1 master 153 26.0 phd 31 5.3 others 31 5.3 residential location urban 331 56.2 semi-urban 213 36.2 rural 45 7.6 pa ge 14 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 142-149, 2024 8 how satisfied are you with the media/social media coverage of the covid-19 pandemic? very satisfied/keeps me updated 267 45.3 makes me worry more/stressful 55 9.3 not enough information 70 11.9 there are more lies than truth 138 23.4 i don't follow any media update 8 1.4 no comment 51 8.7 9 what do you think we can do as a community to reduce the spread covid-19 (select all that applies)? follow/respect the health recommendations of my country 531 90.2 eat healthy/practice sports 311 52.8 attending religious gatherings 28 4.8 social distancing/avoid crowd 464 78.8 volunteer to support whenever possible 268 45.5 avoid handshakes and face kissing 438 74.4 i don’t know 5 0.8 10 do you think we can prevent such a global pandemic in the future? yes 415 70.5 no 34 5.8 maybe 140 23.8 11 which of these can prevent/help against the occurrence of such a global pandemic in the future? (select all that applies) reduced international travels 266 42.2 improve surveillance in the human and animal health sectors 394 66.9 establish early alerts and global warning systems for infectious diseases 486 82.5 collaboration between environmental, animal and human health workers 344 58.4 intensify research on preventive measures such as vaccines/diagnosis 460 78.1 raise public awareness of proper hygiene/healthy habits 452 76.7 prioritize human life/health welfare over animal or environmental ones 208 35.3 12 are you willing to read and share with others the right information about covid-19? yes 552 93.7 no 8 1.4 maybe 29 4.9 table 3: mean score of covid-19 knowledge in relation to attitude and perception towards preventive measures and national response attitudes towards preventive measures, perception towards national response mean score std. error 95% confidence interval lower bound upper bound negative attitude 1.886 0.018 1.852 1.921 positive attitude 1.961 0.014 1.934 1.988 negative perception 1.896 0.014 1.868 1.925 positive perception 1.951 0.017 1.917 1.984 table 4: anova source table for knowledge of covid 19 attitude and preventive measures and perception of national responses source type iii sum of squares df mean square f p-value corrected model 1.756a 3 0.585 8.789 0.000 intercept 1983.049 1 1983.049 29,778.429 0.000 attitude towards preventive measures 0.740 1 0.740 11.116 0.001 perception of national response 0.393 1 0.393 5.896 0.015 pa ge 14 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 142-149, 2024 589 people in all took part in this online survey. the majority of the study’s participants were men: 59.6% (351), 80.6% (475) were in the 18–39 age range, 90.4% (522) held a bachelor’s degree or above, and 56.2% (331) were city dwellers. the majority of respondents, 56.5% (333) and 58.7% (346), reside in homes with a maximum of five occupants and those organized in linear (straight) street patterns (table 1). regarding the national and community reaction to covid-19, only 63.5% (374) of the respondents agreed with the mandatory lockdown implemented, indicating that 52.1% (307) of the respondents thought the government was not doing enough to contain the pandemic in nigeria. the majority of respondents, 45.5% (268) and 68.1% (401), respectively, do not think chinese doctors should be involved in nigeria’s effort to combat covid-19 and would not take covid-19 vaccinations if they become available. yet, as indicated by 90.2% (531), 78.8% (464), and 74.4% (438) of the respondents, observing/respecting health advice, social distancing/ avoiding crowds, avoiding handshakes, and face kissing were some of the measures to limit community spread covid-19. the majority of respondents 45.3% (267), 70.5% (415), and 93.7% (552) were pleased with how the covid-19 pandemic was covered by the media, hopeful that a repetition of the pandemic might be avoided, and ready to read about and distribute accurate information about the virus to others (table 2). people who are well-informed about covid-19 will view the virus favorably. with a mean score of 1.961 for positive attitudes toward covid-19 and 1.886 for negative attitudes toward covid-19 (tables (tables4,4,,5),5), residents of north-central nigeria who were well-versed in the virus had a significantly positive attitude toward covid-19, f(1,585), = 11.116, p = 0.001 (p < 0.05). as a result, hypothesis 1 was supported. people who are well-informed about covid-19 will view the national response to the pandemic favorably. (table 3). residents who were well-versed in covid-19 had a positive impression of the national response to the virus, f(1,585) = 5.896, p = 0.015 (p < 0.05); the mean scores for positive and negative perceptions of the national response to covid-19 were 1.951 and 1.896, respectively. the theory that people who are well-informed on covid-19 will see the country’s response to the pandemic favorably was validated (table 4). the spread of the covid-19 virus in asaba is inversely correlated with high covid-19 knowledge. regression model 1 summary findings showed that the 95% confidence interval for the coefficient of determination, r2 = 0.04.1, f(1,587) = 0.316, and dw = 2.075, were as follows. this demonstrated that the model can account for a 4.1% variation in the covid-19 virus’s propagation. the model’s anova’s f-statistic revealed no closeness of fit, indicating that the model is not statistically significant at the 95% confidence interval (p < 0.05) level. the durbin-watson score of 2.075 indicates that there is no multicollinearity in the autocorrelation between the variables being examined. (table 5). discussion with the covid-19 epidemic affecting more than 200 countries, it has grown to be one of the biggest in history. the purpose of this study was to evaluate people’s awareness and adherence to information about covid-19, including its source, transmission, symptoms, preventive measures, mortality rate, and main sources of information in asaba, nigeria. the findings demonstrated that a sizable segment of nigerians are aware of and informed about covid-19, and a sizable fraction of them think china is the country that created the biological weapon. this view could make it more difficult for nigeria to accept aid from the chinese government and have an impact on bilateral relations between nigeria and china (khalifa et al., 2021). religious leaders are also affected because a sizable portion of the population thinks covid-19 is a disease brought on by sins and disbelief. contrary to popular belief, nigerians are very aware of preventive measures. most of them concur that the best ways to stop the virus from spreading are to wash your hands, avoid close contact with others, disinfect surfaces, close schools, and fumigate public areas. (sisti & buonsenso, 2023). attitude towards preventive measures * perception of national response 0.393 1 0.393 5.896 0.015 error 38.957 585 0.067 total 2224.000 589 corrected total 40.713 588 ar squared = 0.043 (adjusted r squared = 0.038) table 5: pearson’s correlation table for relationship between knowledge of covid-19, attitude towards preventive measures and perception of national response perception of national response pearson’s correlation (r) p-value knowledge of covid-19 0.177 0.004 attitude towards preventive measures 0.137 0.001 pa ge 14 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 142-149, 2024 over 90% of respondents agreed that covid-19 has high fatality rates, with 79,384 deaths worldwide as of april 7, 2020. the mass media and traditional media are identified as major sources of information about covid-19, with the internet being the premier source of knowledge during outbreaks. the survey aimed to assess compliance and identify key areas of concern for optimal sub-national and community intervention (alimohamadi et al., 2021). a survey in asaba, nigeria, revealed that the majority of respondents were educated and knowledgeable about covid-19, with a high percentage of males and singles. they believed the virus was caused by a virus, but a majority believed everyone was at risk. despite taking precautionary measures during lockdown, 27.5% visited crowded places, indicating the government’s inability to implement strict measures. the study found a significant relationship between covid-19 knowledge and positive attitudes (adedeji-adenola et al., 2022). a study on nigerians found that 45.3% believe prayer is effective in covid-19 prevention, largely due to strict religious beliefs. despite the lockdown, many were bored, nervous, and stressed. only 25.3% were satisfied with government efforts, and only 29.0% would accept vaccines (bentzen, 2021). the underprivileged and vulnerable population had limited knowledge about covid-19, affecting their kap. the nigerian government and ncdc should take proactive measures to counter misconceptions and promote information dissemination (tolstrup wester et al., 2022). a study in nigeria found a positive attitude towards covid-19, with three-quarters believing it will be successfully controlled. factors such as information and educational qualifications influenced the belief in confirmed cases. however, age or gender did not significantly influence attitude (james et al., 2022). conclusion the findings from this study affirm that nigerians are highly knowledgeable, believe in the lethality of this pandemic but show very poor preventive practices due to local belief in the black african adaptations against covid-19. though compliance to the preventive measures is very low, very educated people and the female gender showed more compliance than me. the data imply that the mitigation of the covid-19 outbreak is imminent provided people adopt a positive outlook and follow the government’s recommended course of action. notwithstanding their drawbacks, social media and the internet made a substantial contribution to the knowledge that was required. not much was noteworthy about the government’s attempts to contain covid-19. contribution to knowledge this study has established that there is strong evidence of a number of factors between the knowledge levels of the patients with their attitude and preventive practice. the essential factor local belief has grave effect on preventive practices recommendation i. public health education campaigns should go on, dispelling myths and offering updates on clinical presentation, prevention, and control strategies, evidencebased policies, and other topics. to reach the younger population, these campaigns should engage the public more on social media and other internet platforms; to reach the older generation, they should use other traditional media. all stake holders should intensify their effort in sensitizing the general public to understand and comply with all precautionary measures to curb covid-19. ii. public health education initiatives should be planned on a regular basis in the remote locations. iii. the primary target audience for covid-19 should be those with lower levels of education and understanding. references adedeji-adenola, h., olugbake, o. a., & adeosun, s. a. 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(2020). the novel coronavirus outbreak in wuhan, china. global health research and policy, 5, 6. https://doi.org/10.1186/s41256-02000135-6 pa ge 1 pa ge 35 american journal of medical science and innovation (ajmsi) rapid sequence intubation in the er using video laryngoscopy and direct laryngoscopy marina botras1*, islam elsaka1, mohammad zalzalah1, mariam ayed2, fatemah qasem3 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3182 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 02, 2024 accepted: september 04, 2024 published: february 08, 2025 endotracheal intubation, or ei, is a common procedure in the icu, particularly for critically ill patients who require mechanical ventilation or airway compromise. this patient population presents unique challenges, including anatomic conditions, physiologic factors, logistics, and operator experience. the objective of the systematic was to assess the efficacy of video laryngoscopy compared to direct laryngoscopy in rapid sequence intubation procedures, particularly in intensive care units, intending to evaluate various outcomes such as laryngeal visualization, intubation success rates, time to intubation, and other complications. systematic review and meta-analysis of nineteen have been conducted according to prisma guidelines, sourcing articles from january 2005 to february 2023 across databases like pubmed and google scholar. studies in english comparing video laryngoscopy and direct laryngoscopy for rapid sequence intubation were included. quality assessment adhered to cochrane risk of bias guidelines, and the meta-analysis utilized a mantel-haenszel random-effect model with a 95% confidence interval for precision. the results concluded that vl exhibited higher first-attempt intubation success rates than dl, but no significant differences were observed in overall success rates. time to intubation showed a slight reduction with vl compared to dl, while complications such as hypotension and dental trauma were moderately higher with vl. in summary, the utilization of vl in rapid sequencing intubation has been linked to a reduced time to achieve successful intubation compared to dl. however, additional analysis, such as hospital duration of stays, follow-up time, and monitoring of adverse events, has been necessary for a thorough meta-analysis. keywords direct laryngoscopy, video laryngoscopy, meta-analysis, rapid sequencing, intubations, emergency 1 kuwait board of anesthesia, kuwait institute of medical specialization, kuwait 2 department neonatal intensive care, maternity hospital, ministry of health, kuwait 3 department of anesthesia and intensive care, maternity hospital, ministry of health, kuwait * corresponding author’s e-mail: ashraf_sobhi12@outlook.com introduction endotracheal intubation, or ei, is a common procedure in the icu, particularly for critically ill patients who require mechanical ventilation or airway compromise (hypes et al., 2016). this patient population presents unique challenges, including anatomic conditions, physiologic factors, logistics, and operator experience. the risk of complications increases with repeated attempts and the inability to abandon intubation attempts. it has become crucial to develop methods to optimize chances for firstattempt success (baek et al., 2018). ei is associated with a higher rate of complications outside the emergency room than inside. successful intubation at first attempt is important in emergency settings, as multiple intubation attempts have been associated with several complications (baek et al., 2018). prehospital intubations (pi) may differ from clinical intubations due to impaired patient access and airway access, neck and face trauma, an oral intake history, or the potential for body fluids in the airway. monitoring, equipment, limited care providers, and environmental issues can impede ei (cavus et al., 2018). pi relies on airway devices that are easy to use, quick, and reliable. over the past few years, macintosh laryngoscopy (ml) has performed direct laryngoscopy (dl). due to several drawbacks, recently, video laryngoscopy (vl), a device that has been developed, comprises a miniaturized camera at the tip of the blade for an indirect visualization of the glottis. direct laryngoscopy direct laryngoscopy (dl) is the most common emergency ei method, introduced over 50 years ago (goksu et al., 2016). the macintosh laryngoscope (mcl) was the ‘gold standard’ device for dl and ei, invented by foregger in the 1940s (pournajafian et al., 2014). the technique involves high forward and upward force on the handle to visualize the glottis by aligning oral, pharyngeal, and laryngeal axes (panwar et al., 2020). dl has been the primary technique for or tracheal intubation (ti) in the icu, but it has been associated with a concerning the rate of challenging intubations and other complications in icu (panwar et al., 2020). video laryngoscopy over the past decade, various airway equipment, including a vl, has been developed and compared to conventional ml (dey et al., 2020). vl, a device with a camera attached to the blade tip, might increase the first-attempt intubation success rate (baek et al., 2018; hypes et al., 2016). it allows operators to direct the tube without visualization, potentially improving performance. vl requires less airway manipulation, resulting in less hemodynamic stress responses. studies suggest that, as compared to dl, vl yields a higher success rate for firstattempt intubation (gao et al., 2018; goksu et al., 2016) methodology the present research performed a systematic review and pa ge 36 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 meta-analysis following the “preferred reporting items for systematic reviews and meta-analysis” (prisma) guidelines. data source and search strategy articles were retrieved for publication from january 2005 to february 2023 from three databases: “pubmed, google scholar, and cochrane library”. the strategy was based on the population, intervention, control and outcome (pico) format. the population of interest was critically ill adults admitted for rapid sequence intubations; the intervention was video laryngoscopy; the comparison was direct laryngoscopy, and the outcomes of interest are first attempt intubation success rate, time of intubations, and complication arising from intubation. the search was performed using the following keywords; “fiberoptic intubation” or “c-mac rapid sequence intubation” “rapid sequence induction” and “c-mac” or “direct laryngoscopy” or “video-assisted devices” or “video laryngoscopy “or “crush induction.” to retrieve more articles, reference lists were used. mesh terms “(“video’s”[all fields] or “videoed”[all fields] or “videotape recording”[mesh terms] or (“videotape”[all fields] and “recording”[all fields]) or “videotape recording”[all fields] or “video”[all fields] or “videos”[all fields] or “vl”[all fields] or ((“direct”[all fields] or “directed”[all fields] or “directing”[all fields] or “direction”[all fields] or “directional”[all fields] or “directions”[all fields] or “directivities”[all fields] or “directivity”[all fields] or “directs”[all fields]) and (“laryngoscopy”[mesh terms] or “laryngoscopy”[all fields] or “laryngoscopies”[all fields])) or “dl”[all fields]) and ((“rapid”[all fields] or “rapidities”[all fields] or “rapidity”[all fields] or “rapidness”[all fields]) and (“base sequence”[mesh terms] or (“base”[all fields] and “sequence”[all fields]) or “base sequence”[all fields] or “sequence”[all fields] or “sequences”[all fields] or “sequence analysis”[mesh terms] or (“sequence”[all fields] and “analysis”[all fields]) or “sequence analysis”[all fields] or “sequencing”[all fields] or “sequence s”[all fields] or “sequenceable”[all fields] or “sequenced”[all fields] or “sequenceing”[all fields] or “sequencer”[all fields] or “sequencers”[all fields] or “sequencies”[all fields] or “sequencings”[all fields]))) or “rsi”[all fields] or (“rapid sequence induction and intubation”[mesh terms] or (“rapid”[all fields] and “sequence”[all fields] and “induction”[all fields] and “intubation”[all fields]) or “rapid sequence induction and intubation”[all fields] or (“rapid”[all fields] and “sequence”[all fields] and “intubation”[all fields]) or “rapid sequence intubation”[all fields]) or (“intubate”[all fields] or “intubated”[all fields] or “intubates”[all fields] or “intubating”[all fields] or “intubation”[mesh terms] or “intubation”[all fields] or “intubations”[all fields] or “intubator”[all fields] or “intubator s”[all fields] or “intubators”[all fields])) and (“clinical trial”[publication type] or “clinical trials as topic”[mesh terms] or “clinical trial”[all fields])) or “rct”[all fields]) and (randomizedcontrolledtrial[filter]).” eligibility criteria the selected studies had to be clinical trials conducted in a medical setting to establish the significance of vl and dl, used for rapid sequence intubations. the eligibility criteria were grouped into inclusion and exclusion criteria. inclusion criteria the inclusion criteria were applied during the search process and study selection. articles published in english between 2005 and 2023, as well as clinical studies and randomized trials (control), comparing the efficacy of vl and dl, have been included. the population of interest is adults admitted for rapid sequence intubation. we include studies that reported the incubation time, first and second attempt intubation, and complications after intubation. exclusion criteria the articles published before 2005, articles without an abstract or control group, and articles published in another language rather than english have been excluded. study designs such as case studies, retrospectives, journals, magazines, and meta-analyses were excluded. study selection the inclusion and exclusion criteria were used in the selection process. after conducting a comprehensive database search, the articles that were obtained underwent filtering and screening by two independent authors to validate and ensure adherence to both the inclusion and exclusion criteria. for the removal of duplicates, all articles were collected in the endnote library and then exported into an excel sheet. for screening of essential information, remaining references were also exported to an excel file. the screening was done in phases: the first was through the title and abstracts, and the second was full-text screening. the quality assessment of the remaining studies was the last phase of screening. quality assessment cochrane risk of bias guidelines has been utilized to assess the quality of the remaining articles. to avoid any risk of bias at different time frames, the data was extracted twice by utilizing the similar search words. low, high, and unclear were utilized as the defined range of risk of bias. for systematic reviews of interventions, the cochrane handbook was followed and focused particularly on the following factors: “random-sequence generation, allocation concealment, blinding, outcome assessment, selective reporting of selected studies, and the percentage of each measure will be accessed through a visualization graph”. pa ge 37 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 risk of bias assessment using the cochrane risk of bias guidelines, the risk of bias in the included studies was evaluated by two independent reviewers. each study was assessed for the following domains: random sequence generation this domain assessed whether the randomization process was adequately described and conducted to minimize selection bias. studies were categorized as having low risk if they described a random sequence generation method such as computer-generated randomization or random number tables. allocation concealment allocation concealment evaluates whether the method used to conceal the allocation sequence was adequate to prevent selection bias. studies were categorized as having low risk if they described methods such as centralized randomization or sealed opaque envelopes. blinding of participants and personnel blinding assesses whether participants, personnel, and outcome assessors were blinded to the intervention to minimize performance and detection bias. studies were categorized as having low risk if they reported blinding of participants and personnel, blinding of outcome assessors, or if blinding was not applicable. blinding of outcome assessment this domain assesses whether outcome assessors were blinded to the intervention allocation when measuring outcomes to minimize bias in outcome assessment. for the blinded outcome assessors, studies were categorized as having low risk, high risk if outcome assessors were not blinded, and unclear if the blinding status was not reported. incomplete outcome data this domain evaluates whether there were missing outcome data and whether handling missing data was appropriate to minimize attrition bias. studies were categorized as having low risk if they reported low rates of missing data or if appropriate methods, such as intention-to-treat analysis, were used to handle missing data. selective reporting selective reporting assesses whether all predefined outcomes were reported to minimize reporting bias. studies were categorized as having low risk if they reported all prespecified outcomes or if the study protocol was available and followed. other biases this domain assesses other sources of bias that could affect the study’s results, such as conflicts of interest or funding sources. studies were categorized based on the presence or absence of potential sources of bias. data extraction and synthesis in a predefined excel sheet, the following variables were extracted: author’s first name, study design, country of publication, number of participants, reason for intubation, medical setting (emergency or icu), techniques used (vl, dl), age of patients in the intervention group (mean, sd), gender (number and percentage of male only), number and percentage of patients underwent rapid sequence intubation, age and gender of patients in the control group. for the meta-analysis, the number of patients randomized into intervention and control groups, the time of intubation, and the number of first attempt intubation success rates were extracted. the meta-analysis was performed using revman version 5.4 cochrane review software. an effect model called mantel-haenszel random, was chosen due to patient allocation techniques across all trials. the heterogeneity was measured using (i2). the authors opted to estimate the analysis results within the confidence interval of 95%, which indicated that, on either side of the distribution, only a 2.5% error was allowed. the level of precision also indicated that the p-value of less than 0.05 indicates the significance of the results. additionally, the index of the effect size and the homogeneity in each sample, has been chosen by a unique precision of each study. results study selection two thousand eight hundred articles were retrieved from all databases and 13 through manual search. after removing 601 duplicates, the remaining articles were screened by two independent authors. the first phase of screening was going through the title and abstracts. after the first phase, 113 articles were remained for screening. the authors screened the full text of the articles, and 94 articles were excluded due to different scopes of the studies, poor methodology, lack of control groups, and absence of data analysis in a few articles. the remaining 19 articles were included in the meta-analysis and synthesis of results. the prisma flowchart shows the process of study selection (figure 1). characteristics of included studies from nineteen randomized control trials, 14 studies reported rapid sequence intubation (rsi) in the emergency medical service (ems) setting, while 5 studies performed rsi at the intensive care unit (icu). the participants comprise adults with average ages ranging from 37 years to 73 years (ducharme et al., 2017; sanguanwit et al., 2021). the average and total number of patients across all 19 studies were 267.85 and 5357, respectively. the reasons for intubation reported by the patients are respiratory failure (rf), airway protection, ei, multiple trauma, congestive heart failure, and emergency intubation. the experiments were conducted in 12 countries (usa, canada, switzerland, korea, uk, india, poland, china, france, thailand, palatine and australia). pa ge 38 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 quality assessment of the included studies the risk of bias tools for randomized control trials were used to assess the quality of the included studies. under the domain of random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, and other biases, 96% of all studies reported a low risk of bias and 4% high risk of bias. under the incomplete outcome data and selective reporting, all the included studies reported a 100% low risk of bias, as shown in figure 2. the summary of the quality assessment graph is presented in (figure 2). outcome measures in the included studies the first outcome measures were the success rate of the first and second ti attempts. the patients were randomized to vl and dl groups in 19 trials. the number of participants randomized to receive vl and dl were recorded and analyzed. the complications from ti bastion and time of intubation in both groups were also recorded and analyzed. prisma flow chart figure 1: the prisma diagram of the study selection process table 1: author information participants intervention control group s. n o a ut ho r d es ig n c ou nt ry n r ea so n fo r r si se tti ng t ec hn iq ue us ed a ge /m al e r si t ec hn iq ue us ed a ge /m al e r si 1. (d on al d et al. , 2 01 2) rc t` c an ad a 40 re sp ira to ry fa ilu re ic u v l 68 (1 6) /1 5 (7 5) n r d l 61 (1 6) /1 3 (6 5) n r 2. (m os ie r et al. , 20 13 ) pb -r c t u sa 31 7 re sp ira to ry fa ilu re , a irw ay pr ot ec tio n e m s v d l 59 .5 ( iq r 23 to 9 0) /5 6. 0% (1 31 ) 76 .5 % (1 79 ) d l 61 .8 ( iq r 40 to 8 2) /5 0. 0% (2 8) 86 .0 % (4 8) pa ge 39 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 3. (s ilv er be rg et al. , 2 01 5) rc t u k 11 7 c on ge st iv e he ar t fa ilu re e m s v d l 65 .4 /2 7 (4 5) 0( 0. 0) d l 69 .6 /3 4 (5 7) 4 (7 ) 4. (s ul se r e t al. , 2 01 6) rc t sw itz er la nd 15 0 m ul tip le tr au m a e m s v d l 53 (2 1) /6 8 14 7 d l 54 (1 7) /5 5 14 7 5. (g ok su et al. , 2 01 6) rc t tu rk ey 15 0 h ea d tr au m a, c ar di ac ar re st e m s v d l 39 ± 1 9 0 d l 35 ± 1 5. 5 7 (9 .3 % ) 6. (h yp es et al. , 2 01 6) rc t u sa 80 9 re sp ira to ry fa ilu re , a irw ay pr ot ec tio n ic u v d l 59 (i q r 49 – 69 )/ 44 % 2. 1% (1 4) d l 60 (i q r 53 – 73 )/ 42 % 6. 6% (9 ) 7. (ja nz et a l., 20 16 ) rc t u sa 15 0 h yp ox ic o r h yp er ca rb ic re sp ira to ry fa ilu re ic u v d l 59 (4 9 68 )/ 47 (6 3. 5% ) 68 (5 2 6 9) d l 60 (5 1 67 )/ 44 (5 7. 9% ) 47 (3 5 5 8) 8. (k im et a l., 20 16 ) rc t k or ea 14 0 a rr es t e m s v d l 61 .3 61 .3 (1 8. 5) / 45 (6 3. 4) 3 (4 .3 ) d l 60 .5 (1 8. 7) /4 9 (7 1) 0( 0. 0) 9. (d uc ha rm e et al. , 2 01 7) rc t u sa 82 e nd ot ra ch ea l in tu ba tio n e m s k v l 37 (1 7. 5) /2 8 (7 0% ) n r d l 14 (3 3. 3) /3 3 (7 8. 6) n r 10 . (l as ca rr ou et al. , 2 01 7) rc t fr an ce 37 1 o ro tra ch ea l ic u v d l 62 .7 (1 5. 3) /1 22 (6 5. 6) n r c on ve nt io na l d l 62 .8 (1 6. 3) /1 13 (6 1. 1) n r 11 . (b ae k et al. , 20 18 ) re tro sp ec tiv e st ud y k or ea 95 8 a irw ay pr ot ec tio n e m s v d l 61 [5 1, 71 ]/ 30 3 (6 1. 5) n r d l 66 [5 6, 74 ]/ 31 8 (6 8. 4) n r 12 . (c av us et a l., 2 01 8) rc t c an ad a 16 8 pr eh os pi ta l e m s a p a dv an ce , c -m a c p m s ys te m 66 (1 9– 90 )/ 41 n r k in g v isi on d l 67 (2 6– 91 )/ 27 n r 13 . (g ao et a l., 20 18 ) rc t c hi na 16 3 a cu te re sp ira to ry fa ilu re , tr au m a e m s v d l 68 .7 2± 16 .8 8/ 58 (7 1. 6) 3 (3 .7 ) d l 69 .8 6± 15 .5 5/ 56 (6 8. 3) 6 (7 .3 ) 14 . (k re ut zi ge r et al. , 2 01 9) rc t a us tra lia 51 4 su rg ic al ai rw ay ac ce ss e m s m cg v l 65 (1 8– 95 )/ 17 9 (6 7. 1) 14 (4 .8 ) d l 64 (1 8– 95 )/ 17 6 (7 1. 3) 9 (3 .2 ) pa ge 40 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 15 . (d ey et a l., 20 20 ) rc t in di a 21 8 el ec tiv e en do tra ch ea l ic u c -m a c v l 48 .3 (1 6. 8) /6 3/ 45 n r m ac in to sh d l 45 .8 (1 6. 2) /6 7( 43 ) n r 16 . (p an w ar et al. , 2 02 0) rc t in di a 10 0 em er ge nc y in tu ba tio n e m s v l 18 -6 0 ye ar s n r d l (m ac in to sh ) 18 -6 0 ye ar s n r 17 . (s an gu an w it et al. , 2 02 1) rc t t ha ila nd 15 8 a cu te re sp ira to ry fa ilu re e m s v d l 73 ± 12 .9 , 44 (5 7% ) 49 (6 2. 8% ) d l 65 ± 17 .2 48 (6 0% ) 18 . (k rie ge et al. , 2 02 1) rc t pa la tin e 50 0 o ro tra ch ea l e m s m cg v l n r n r d l n r n r 19 . (g ad ek et al. , 2 02 1) rc t po la nd 54 c ar di ac ar re st e m s m cg v l 53 y ea rs (i q r: 3 3– 71 )/ 69 % n r m a c d l 31 % n r outcome measures of risk of bias assessment figure 2: results of the quality assessment using the risk of bias tool pa ge 41 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 results of meta-analysis comparison of the efficacy of rapid sequence intubation by dl and vl to investigate if vl or dl for ei provides better laryngeal visualization, nineteen trials were included in the meta-analysis. the mantel-haenszel random effect metaanalysis showed no significant differences between vl and dl “(or = 1.38, 95% confidence interval 0.81 to 2.35, p = 0.23)”. the studies had significant heterogeneity “(i2 = 97%, p-value = 0.00001)”, as shown in figure 3. publication bias was assessed using visual inspection. the funnel plot showed no evidence of publication bias while rather than publication bias, two outliers indicated true heterogeneity, as shown in figure 4. figure 3: forest plot: reported odds ratio of efficacy of rapid sequence intubation in two groups figure 4: funnel plot: no evidence of publication bias first, second, and overall attempt tracheal intubation success rate between vl and dl eighteen studies have reported the intubation success rate between vl and dl in the first attempt. the meta-analysis results identified no significant differences “(or = 2.52, 95% confidence interval 0.83 to 7.67, p–value = 0.04)”, as shown in figure 5. this implied that, in the vl group, the odds of patients with a first attempt of successful intubation, were higher than that of the dl group. moderately high significant heterogeneity was found “(i2 = 95%, p-value = 0.00001)”. however, the result of the success rate in the second attempt and the overall success rate showed no significant difference between vl and dl “(2nd attempt; or = 0.66, 95% ci; 0.39, 1.11, p-value = 0.12)” and “(overall attempt; or = 2.33, 95% ci; 0.68, 7.95, p–value = 0.18)” respectively. the funnel plot showed a symmetric visualization, which indicated no evidence of publication bias, as shown in figure 6. pa ge 42 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 figure 5: forest plot: reported an odds ratio of first attempt (2.1.1), second attempt (2.1.2), and overall attempt (2.1.3) intubation success rate in two groups figure 6: funnel plot: no publication bias in the studies included in the success rate of first-attempt intubation time of tracheal intubation in seconds between vl and dl five trials were included in the meta-analysis of intubation time. the results were insignificant with vl “(smd = -0.03s (95% confidence interval -0.22s to 0.42s), p–value = 0.75)” compared with dl. however, despite insignificant results, there was a reduction in incubation time in the vl group compared to the dl group. high heterogeneity was found among the studies “(i2 = 95%, p-value < 0.000)” as shown in figure 7. the funnel plot showed a symmetric shape with no evidence of publication bias, as shown in figure 8. pa ge 43 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 figure 7: forest plot: reported odds ratio of time to intubation in seconds figure 8: funnel plot of included studies in the intubation time subgroup complications of intubation subgroup analyses for the complications in intubation showed that the odds of hypotension, dental trauma (dt), severe desaturation (sd), and rf after rsi was higher in the dl group as compared to vl “(or = 3.20, 95% ci; 0.48; 21.10, p–value = 0.23), (trauma; or = 1.02, 95% confidence interval 0.62 to 1.68, p–value = 0.93, i2 = 21%), (severe desaturation; or = 0.69, 95% confidence interval 0.47 to 1.03,p–value = 0.07) and (respiratory failure; or = 0.69, 95% confidence interval 0.43 to 1.09, p–value = 0.11)” as shown in figure 9. figure 9: forest plot of cases with complications in intubations with hypertension, dental trauma, severe desaturation and respiratory failure pa ge 44 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 35-45, 2025 discussion this systematic review and meta-analysis have analyzed the efficacy of vl and dl in rsi in icu. the first metaanalysis, a comparison of vl over dl for rsi, was conducted, as shown in figure 4. the results revealed no significant difference between the vl and dl techniques, implying that the dl technique was better in rsi than vl. in the last decade, dl was first introduced in rsi for providing control on rapid airway that served as a prevention for patients suffering from a full stomach or other risks of pulmonary aspiration. however, the introduction of vl was found to be more efficient than dl due to the attachment of a camera at the tip of the blade that could improve the visualization of the glottis by assisting airway management in critically ill patients (arulkumaran et al., 2018; griesdale et al., 2012; silverberg et al., 2015). in contrast, no significant difference between the two techniques has been found. hence, a further and detailed meta-analysis with more clinical trials on the best techniques for rsi in the emergency setting has been required. in the meta-analysis, a comparison of the success rates in rsi attempts was conducted within the eu using vl and dl. the comparison showed that only the success rate of the first attempt was significant and higher in the vl group with an odds ratio of 2.13 and 95% confidence interval; 1.05 – 4.35 favoring dl with high heterogeneity i2 = 95%, as shown in figure 3 and figure 4. hence, vl had a success rate in the first attempt compared to dl, but no significant difference was found in the second and overall attempts (ba, 2022). the high heterogeneity was due to differences in laboratory settings or follow-up periods. the non-superiority of vl over dl might be due to limited experience of the physicians handling airway management in vl. additionally, vl offers visual aids, its image quality may not always match the clarity of dl, potentially leading to misinterpretations (olatunji et al., 2024). anatomical variations and technical limitations of vl systems further contribute to its comparable efficacy with dl (kim et al., 2016). in the systematic review, the time to achieve success in ei using vl compared to dl found a reduction in time to achieve success in vl compared to dl in the eu (smd = -0.03s, 95% ci -0.22 – 0.16). the results implied that the average time to achieve a successful ei was lower in vl than in dl. the results were consistent with a clinical trial of ei. in a study, despite a significant improvement in cormack-lehane grade of glottis view, dl took a prolonged period to achieve success compared to vl (janz et al., 2016). conversely, another study found that the time to intubation was similar between the two groups (sulser et al., 2016). the systematic review also compared several complications arising from utilizing vl and dl. the results found that hypotension, dt, rf, and sd were moderately high in vl compared with dl. the results aligned with the previously published meta-analysis in which the complications were significantly increased in dl compared with vl (ba, 2022). no evidence of publication bias has been found in the funnel plot of the included studies which indicated that, vl has not been a preferable method for rsi in the eu (merola et al., 2024). limitations in acknowledging the scope of meta-analysis, it is imperative to address certain limitations that might have influenced the systematic review’s findings. first, selection bias and high heterogeneity were inevitably introduced when observational studies were included. second, during the database search process, studies that were published in english only were included. as a result, pertinent, relevant controlled trials demonstrating advancements in vl may have been published in other languages, potentially enhancing the findings of the systematic review and meta-analysis if considered. conclusion in summary, the utilization of vl in rsi has been linked to a reduced time to achieve successful intubation compared to dl. however, the effectiveness of vl over dl remains modest. therefore, further analysis, such as hospital duration of stays, follow-up time, and monitoring of adverse events, has been necessary for a thorough meta-analysis. references arulkumaran, n., lowe, j., ions, r., mendoza, m., bennett, v., & dunser, m. 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(2021). direct versus video laryngoscopy in emergency intubation: a randomized control trial study. bulletin of emergency & trauma, 9(3), 118. silverberg, m. j., li, n., acquah, s. o., & kory, p. d. (2015). comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial. critical care medicine, 43(3), 636-641. sulser, s., ubmann, d., schlaepfer, m., brueesch, m., goliasch, g., seifert, b., spahn, d. r., & ruetzler, k. (2016). c-mac videolaryngoscope compared with direct laryngoscopy for rapid sequence intubation in an emergency department: a randomised clinical trial. european journal of anaesthesiology| eja, 33(12), 943-948. pa ge 1 pa ge 10 2 american journal of medical science and innovation (ajmsi) a clinical profile observational study in a tertiary care hospital of children with atopic dermatitis naveen divakaran1, cherian joseph2* volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.3401 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: july 09, 2024 accepted: august 12, 2024 published: april 23, 2025 atopic dermatitis, which is simply referred to as eczema, is a common persistent skin condition that impacts children and infants across the globe, accounting for 10-30% of them. extreme itching, skin swelling, infections, and additional itching characterize it. there has been a rise in the incidence of the disease in the last 30 years primarily due to the effluent environment, breastfeeding, increased prevalence and awareness of the disease, and urbanization. the present study aimed to describe the clinical aspects of children diagnosed with atopic dermatitis, fulfilling the hanifin and rajka clinical criteria, visiting outpatient clinics of pediatrics and dermatology. also, the study had a specific objective of identifying the possible factors that could worsen atopic dermatitis among the participants in the study. this trial covered 59 kids with atopic dermatitis; they filled questionnaires concerning their age, sex, complaints, things that worsen their condition, age of disease onset, and related symptoms. the other explored history included dietary one, breastfeeding history and the family or individual atopic history. a clinical assessment was carried out comprising localization and type of lesions and other features. it was revealed that females experience more atopic dermatitis than males and most of the children are affected from an early age. food intolerance was the most common reason reported, with milk as the most frequent substance, followed by wool and lipid solvents. half of the patients showed aggravation during the cold season. dermatitic lesions involved the face and flexural areas more compared with the limbs. we found that 30 percent of the patients took complementary therapies, while 30 percent were malnourished. this work examined 59 children with atopic dermatitis ranging from 2 months to 12 years. it found that females were more affected than males, with an m: f ratio of 0.84:1. the most common manifestation experienced by the patients was purpuritus which was worse at night in about one-third of the population. recurrence during the particular season was noticeable in half of the patients. facial rash and flexural areas of extremities were found to be more affected by dermatitic lesions. keywords atopic dermatitis, children’s health, observational study, pediatrics, precipitating factors 1 sheikh khalifa medical city, abu dhabi, united arab emirates 2 little flower hospital, angamaly, kerala, india * corresponding author’s e-mail: cherianmundadan@gmail.com introduction eczema, also referred to as atopic dermatitis, is among the most frequent persistent, relapsing skin diseases in infancy and childhood. it is manifested inflammation and pruritus and also physiological skin dysfunction (bieber, 2022). such a condition is frequent in those individuals who had asthma, or allergic rhinitis in the family, or had it themselves at some point; it is typical for early childhood (frazier & bhardwaj, 2020). estimates for children indicate that the incidence of atopic dermatitis is between 10% and 20% in the united states, japan, australia and other developed nations (faye et al., 2024). estimations to this effect suggest that the current status of this disease poses considerable threat to global public health (hadi et al., 2021). according to data, modern children are affected by atopic dermatitis more than three times than in the 1960s (becerril-ángeles et al., 2023). as to why the incidence has started rising, we are yet to fully understand. the prevalence of the said diseases above, however, varies greatly across nations with similar ethnic groups, suggesting that there is strong influence of the environment in the manifestation of diseases (bylund et al., 2020). the exact relationship between atopic dermatitis and atopy is not well understood; however, the following affiliations are possible. it is important to note that as many as 60% of the children with the clinical phenotype, although identified as atopic, show no signs of ige-driven sensitization to food allergens (mocanu et al., 2021). also, there is no specific test for atopic dermatitis diagnosis, as well as no specific physical sign that would separate this disease from other similar conditions (frazier & bhardwaj, 2020). aims and objective in this study, the goal was to describe initial clinical characteristics of the children, who suffer from atopic dermatitis. it was done directly by enrolling people affected by the condition, based on the hanifin and rajka defining criteria, from the pediatric and dermatology outpatient departments. moreover, the literature expanded its examination, aiming to identify factors that occasion flare in atopic dermatitis in the specified subpopulation. this study also seeks to incorporate an assessment of the symptomatology and likely precipitating factors in atopic dermatitis among children to offer substantive information on its management. pa ge 10 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 literature review epidemiology and impact on pediatric populations eczema cannot be restricted by age and therefore can start from the early infancy, which is distinguished by 75% of the cases with the first signs and symptoms by six months old. there is genetic susceptibility to develop atopic dermatitis (barbarot et al., 2022). from the epidemiologic data it is seen that atopy risk is higher if either or both the parents are suffering from the disorder. it is noted that atopic dermatitis develops at the first three months of life in infants from atopic mothers in more than a quarter of cases (ezzedine et al., 2020). over 50 per cent of the children who develop an allergy exhibition from an atopic parent are affected by the time they are two years old (dierick et al., 2020). if both parents possess the disease, then, the rate is higher. most of the genetic factors are fixed in atopic dermatitis (bylund et al., 2020). twin studies showed that if one of the identical twins, i.e. the monozygotic twin, develops atopic dermatitis it is extremely likely that the other twin also will develop the disease, in 86% of cases; on the other hand, if one of the fraternal twins, i.e. the dizygotic twin gets the disease the other twin will develop the disease only in 21% of cases (hartmane, 2024). moreover, infections of the skin due to bacteria, viruses, or fungi (for example; staphylococcus aureus, herpes simplex, molluscum contagiosum, etc.) are among those who are detected more in patients with atopic dermatitis (alexander et al., 2020). there is a strong correlation between food allergy and atopic dermatitis including the first occurrence of the skin condition (dierick et al., 2020). these are some of the primary food allergies that are frequently observed; eggs, milk and any dairy products, fish, peanuts, soybeans, wheat and tree nuts (domínguez et al., 2020). as can be seen, even if the disease becomes worse when the patient is exposed to allergens, irritants or infections, thus looking clinically like the symptoms manifested during the intake of foods that are causing an adverse reaction, the case is tricky to diagnose (papapostolou et al., 2022). clinical manifestations and severity atopic dermatitis is an episodic eczema type skin disease and thereby has been found to have complaints that come in cycles of increase and decrease (wollenberg et al., 2023). they seem to be highly related to the age and stage of the disease, and the worst presented in childhood and get better in adolescence and adulthood (chovatiya, 2023). signs are that it is dry, becomes red skinned and the skin frequently develops a tendency of itching. the itching may be very severe, to the extent that the patient can hardly carry out his or her daily activities (mocanu et al., 2021). common rashes appear in the regions such as elbows, behind the knees, wrists, cheeks, and neck of an affected person. the texture of the rash depends with the stage: acute lesions are associated with pus and crusting while the chronic ones are associated with thick lichenification (hui-beckman et al., 2023). other signs which are also manifested with this skin condition are hyper linearity of palms, skin ulcerations, infections, and sleeplessness due to itching (siegels et al., 2021). the degree of a burn condition possible and probable adverse effect balances the extent of the burned area, the depth of the burn layer, and the effect on the individual’s quality of life and their functioning capabilities and abilities, including activities of daily living and response to treatments (dreno et al., 2021). skin manifestations are negligible with a few patches; skin disease is severe and has a tendency to become localized into thick skin, causes bleeding, painful and often requires other system affecting treatments (bocheva et al., 2021). the highlight of the points regarding the management of skin condition is that no matter how severe it is, environmental control and gentle handling are of paramount importance (sekita et al., 2023). importance of understanding the clinical profile of atopic dermatitis in children it is noteworthy for clinical diagnosis in children with ad that lesions are mainly distributed in flexural areas of limbs and curves, age of onset is before six years and disease progression (napolitano et al., 2022). documenting the average time and outcome of the disease in children help creating the best approach for handling the disease and the execution of an efficient plan. different studies focus on atopic dermatitis focuses on the clinical characteristics of the disease in children, and therefore may contain information on the identified factors and relationships: family history, environment, and co-morbidities (siegels et al., 2021). the symptoms, signs and severity of atopic dermatitis also differs from one child to another; this implies that the variation in the clinical appearance of ad is relatively large (al-adawiyah et al., 2021). this understanding helps health care providers to map out unique care strategies for each child given that children’s ailments can vary from the next. the follow-up of clinical status of children with atopic dermatitis provides an understanding of its severity and changes in the course of the disease, and to compare the results of therapeutic interventions and determine the prognosis (frazier & bhardwaj, 2020). therefore, the following information is very valuable for better understanding of the quality of patients’ lives, for making clinical and further research decisions on the case of pediatric atopic dermatitis (maksimovic et al., 2020). a sufficient knowledge of the clinical, demographic, and health-related characteristics of children with atopic dermatitis may enhance healthcare workers’ communication and teaching capabilities of the disease and the expectations for its treatment among families (zhao et al., 2023). it can also contribute to identifying specific educational materials and assistance programs for children with atopic dermatitis and their parents (yoo et al., 2022). pa ge 10 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 materials and methods study area and population the following study included patients who were present at little flower hospital & research centre, angamaly, located in the ernakulam district of state kerala in india. the duration of this study was for a year, starting from november 2015 to october 2016. the study population consisted of infants and children under 12 years, attending the pediatrics and dermatology opd. all the patients were diagnosing with atopic dermatitis as per the hanifin and rajka clinical criteria. study design serving as a cross-sectional research, the study looked at several aspects of patient information. the patient completed a detailed medical questionnaire that included the patient’s age, sex, initial complaints, including itching, factors that worsened or predisposed the patient to the specific disease, patient’s age at the first occurrence of the disease, and symptoms associated with the disease, including cheilitis and recurrent conjunctivitis. we sought to examine the dietary history of the patient in terms of foods that worsened the complaints and breastfeeding. such observations were made in atopic families or on a personal level. distribution and morphology of the lesions were observed during physical examination by general survey and palpation. the extra dimensions of the hanifin and rajka criteria were equally worth mentioning. pearson’s chi-square test was utilized to analyze the final data. ethical considerations the permission to conduct the study was sought and later on, the informed written consent was obtained from the institutional human ethics committee of the study setting. this improved the chances of attaining certain ethical principles by the research and the reduced likelihood of any harm coming to the participants. the parents or the close relatives or whoever takes up the responsibility of a parent for the families of the study participants agreed to participate in the study by willingly putting their signatures on the consent forms after explaining to them the details of the role and responsibilities, benefits, and risks of participating in the study and the right to withdraw their children from the study at any time of their choice. the control of participant was applied in the study as only participants who had given their voluntary written consent to participate in the research. the name of the specific participant of the study and the data that was collected and analyzed in the present research was kept anonymous or pseudonymous at all stages. this made sure that the name of the participant is concealed and there is no trace or chances that somebody might recognize any of the participants. inclusion and exclusion criteria inclusion criteria age patients of required age limit, between 0-12 years of age. diagnosis documentation of atopic dermatitis according to the hanifin and rajka severity patients with atopic dermatitis of required age group and any gender corresponding to the objectives of the study and details of their disease such as mild, moderate or severe form of atopic dermatitis. willingness to participate children who were available and willing to participate in the study and parents or primary caregivers who were willing to sign informed consent for the child’s involvement in the research. exclusion criteria underlying medical conditions participants with chronic diseases, especially those that may affect the assessment of the results obtained during the study (such as scabies, insect bite reaction, intellectual disability, etc.) current treatment patients with atopic dermatitis receiving treatments that may affect the obtained clinical picture at the moment (e. g., participating in other trials). inability to follow-up patients who included children or families that would not be able to continue follow-up procedures with the study (frequently migratory, no access to the hospital). statistical analysis the results of the descriptive statistics in terms of percentage, mean and standard deviation were used on the variables in the study. regarding inferential statistics, pearson’s chi – square test was used to determine the statistical difference between the association of major and minor clinical features of atopic dermatitis in the study population with, males and females, personal/family history atopy, age at onset less than one year, inadequate breast feeding history, malnutrition, food allergy history, seasonal exacerbation history. significance level of p < 0. 05 was used in the study. based on the pilot study, we used the power analysis that works with 5% level of significance (p value) and 90% test power and using the software sigma-plot 11, we determined the following sample size for each group. this proposed research presents the findings of the analysis in the following table 1. table 1: statistical analysis of sample size type of test minimum sample maximum sample chi-square test 19 51 so required sample size 51 pa ge 10 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 results and discussion results distribution of patients on the basis of age group the study samples involved 59 young patients with all patrons under the age of 12. the age variation came to cater for many aspects of childhood development as the youngest child was but 2 months and the oldest just below the adolescence age of 12 years. yet, the average age that the group had was 3.5 years, this shows that the respondents were skewed slightly to the younger children as may be expected. out of 59 patients, 37 were below three years thus indicating the major impacts of this disease on the little children. it can be assumed that this sample might need more accommodation concerning the treatment of cases and data gathering techniques than elders may need in the same study. figure 1: shows the number and distribution of male and female patients included in the study, according to the age group the following study consisted of 27 male and 32 female patients, with a m:f ratio of 1.18:1 in the study group. the value in percentage of the patients and the final mean value of their age in months is mentioned in table 2 and table 3, respectively. or less, as per shown in figure 2. in other words, the mean age of onset for the patients was one year and four months. socioeconomic status (ses) and atopic dermatitis socioeconomic status can also be seen among the study population. the largest portion of children was characterized as belonging to the upper middle class, 29 (or 49. 15%); next were the children from the lower middle class, 19 (or 32. 20%); and the last category indicated 6 (or 10. 16%) as being from the upper lower class. only 5 of the participants (8.4%) were classified as belonging to the upper socioeconomic class and none as lower according to the modified kuppuswamy scale. this difference in the distribution of the variables in the population based on ses may need to be taken into account when interpreting this study’s results because factors such as access to adequate healthcare and exposure to environmental stimuli are known to have different distributions across ses (podder et al., 2022). table 2: number of patients sex frequency percent male 27 45.8 female 32 54.2 total 59 100.0 table 3: mean value of age in months age in months mean 40.22 age at the time of diagnosis among the 59 children with atopic dermatitis, 19 children (32.2%) developed the condition within three months after birth and 47 (79.6%) within infancy. finally, 4 (6.7%) patients of them had the disease onset after 5 years of when they were born, while 8 (13.5%) patients had the onset of disease between the first and the fifth birthday. in regard to the age of onset, the disease developed in 55 (93.2%) of the children when they were 5 years old figure 2: age of onset of disease figure 3: distribution of patients according to ses geographic distribution residence of patients the following study narrates the participants involved with regard to their residence. two categories are pa ge 10 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 represented: which includes the urban and rural groups. thus, urban areas represent a much more significant share in the study, involving about 35 participants (62.7%). on the other hand, the ‘rural’ area category constitutes only a small proportion of the participants that were around 24 in number (37.3%). such a case implies that there are more participants from the urban areas of the country than from the rural areas. moreover, for patients suffering from atopic dermatitis, choosing the right clothing material is really crucial for managing symptoms, its effects and improving comfort for the patients (jaros et al., 2020). in this study, there were 8 (13.55%) children who complained of itching on contact with wool and 11 (18.64%) children gave history of exacerbation of the disease with the use of lipid solvents like soaps and detergents as shown in figure 6. figure 4: distribution of patients according to area of residence moreover, 11 of the patients had to relocate due to personal reasons. this movement either had flare-ups or the onset of the disease. two of them experienced exacerbations on moving to cities, while four of them had the beginning of their illness on moving from a town into a more rural area. climatic interventions on patients atopic dermatitis can be worsened by climate change because it gets affected by temperature increases, pollution and production of pollen and allergens, humidity, and increased levels of uv radiation (wang et al., 2024). in the present study, exacerbation of the condition occurred in 13 children (22.03%) during winter and in 15 children (25.42%) during summer, especially after sweating. figure 5: seasonal variation of number of patients figure 6: effect of irritants (i.e. wool or lipid solvents) examination findings history of atopy or allergic disorders in the shortlisted 59 children having atopic dermatitis, 44 (74.5%) patients had family / personal history of atopy or other allergic diseases and 26 (44.06%) patients had personal history of atopy or other allergic diseases. although both parents transmitted atopy in the family history, it was more dominant in mothers with 40 percent. inheritance through the mother was found to be more common at 67% as opposed to the paternal inheritance at 35.59%. concerning the parents’ health status, 10 children (16. 94%) had a history of atopy/allergic disorders previously reported in their parents. details of previous allergic disorders in the siblings were taken from 10 (16. 94%) patients. in regard to the atopic manifestation, allergic rhinitis was most frequent, then bronchial asthma (akhmedova & akhmedova, 2021). for personal history of atopy in patients with the disease, 7 (11. 86%) among the patients had episodic viral wheeze. table 4 and figure 7 shows a detailed and comprehensive analysis of these number mentioned above. furthermore, xerosis was the most frequent cutaneous morphology; 58 (98.3%) of the patients described their skin as being very much dry, at some time or all the time. desquamation of the skin in the form of hyper pigmented table 4: number of patients classified according to the presence of existing atopy or allergic disorder atopy/allergic disorders ar ba evw ad total percentage ar allergic rhinitis ba – bronchial asthma evwepisodic viral wheeze adatopic dermatitis maternal 17 7 24 40.67 paternal 9 12 21 35.59 sibling 1 5 4 10 16.94 personal 11 8 7 26 44.06 pa ge 10 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 diamond shaped scales was identified in 24 (40.67%) of children with atopic dermatitis. palmar hyper linearity was present in 24 (40.70%) of the children investigated in the present study with atopic dermatitis. however, hyper linearity of palms was present in 24 patients and among these, 20 have ichthyosis as an additional attribute. this feature characterized by tiny follicular papules was noted predominantly over outer arms in (13. 6%) of our patients. ichthyosis was seen in two patients with positive family history; hyper linearity of palms and keratosis pilaris were seen in one patient. minor examined features apart from major physical features related to the patients suffering from ad, there were few minor features as well that corresponds to provide further analysis about the severity of the conditions. few of these features are mentioned below as well represented as a demographic graph in figure 8. nipple eczema nipple eczema was noted in 3 patients (5.01 %) among our 59 patients. this finding was more common in the older children, cheilitis there were 10 (16.9%) children with atopic dermatitis, who presented with dryness and fissuring of lower lip. nonspecific hand/ foot dermatitis there were 8 (13.6%) patients had eczematous lesions over hands and feet. dennie morgan fold this finding characterized by folding of lower eyelid was noted in 34 (57.60%) children. there was associated lower eyelid dermatitis among 4 (11.76%) of them. facial pallor / erythema sixteen (27.1 %) out of 59 children had facial pallor. in most of them it was confined to the perinasal area, with a few showing involvement of periorbital area also. orbital darkening this feature was characterized by hyperpigmentation below the lower eyelid was present in 18 (30.50%) patients with atopic dermatitis. pityriasis alba there were 15 (25.4%) children with pityriasis alba of which 10 had the lesions over the face only and the remaining 5 children showed extensive lesions over the trunk also. anterior neck folds this finding characterized by horizontal creases on the anterior aspect of the neck was present in 4 (6.77%) children with atopic dermatitis. perifollicular accentuation nine (15.3%) children with atopic dermatitis showed perifollicular accentuation characterized by pebbled appearance which was noted over the thighs, upper arms and back of trunk. white dermographism stroking of involved and uninvolved skin of patients with a blunt object produced a white line in 7 (11.9%) children. in addition to the above mentioned features described by hanifin and rajka, other findings noted were: scalp scaling out of 59 patients with atopic dermatitis, 13 (22%) had diffuse scaling of the scalp. eyelid dermatitis scaling and redness of the eyelid was noted in 10 (16.9%) of children with atopic dermatitis. itch when sweating there were 26 (44.06%) children who complained of itch when sweating, which was more in the axilla and groins. recurrent conjunctivitis there were 12 (20.33%) children who complained of recurrent conjunctivitis. figure 7: family history of atopy or allergic disorders pa ge 10 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 figure 8: minor features corresponding the severity of ad in different patients skin lesions and their distribution particularly, the study identified that the ad targeted face and the flexural surfaces in the limbs, or course, refers to the inner parts of the joints as such as elbows and knees. interestingly, the distribution of involvement showed some variation: facial involvement still, only 9 patients (15.3%) had atopic dermatitis exclusively on the facial skin; it was evident in total. this raises the aspect of esteem as a patient may be at risk of losing confidence and social interactions. combined involvement the most common site of involvement was faces and flexures (17 patients or almost 28.8%). this implies that the condition may be wider than what has been estimated by the director of the research. extensor involvement in only 5 (8.5%) patients the ad became involved only in the extensor aspect (the area in direct opposition to the bend, e. g., the outer region of the arms and the forearm). this pattern is more unusual for ad. isolated flexural involvement only the flexural surfaces were affected in another 9 patients (15.3 %). this underlines the significance of assessing these regions in the process of the disease’s identification. table 5: sites of different skin extremities and number of patients affected site number percent generalized eczema 8 13.5 eczema in face alone 9 15.3 eczema in flexures alone 9 15.3 eczema in extensors alone 5 8.5 eczema in face and extensors 9 15.3 eczema in face and flexures 17 28.8 eczema in face, flexures and extensors 2 3.4 total 59 100.0 secondary cutaneous infections in addition to atopic dermatitis, some children also presented with secondary skin infections or infestations which can also be observed via demographic status in figure 9: impetiginisation (13.55%) among all the secondary diseases, this bacterial superinfection was the most common in the study reappearing in more than 8 children. impetiginisation aggravates the symptoms of eczema and the use of antibiotics is needed for the treatment. tinea versicolor (6.77%) there are 4 children who have such a fungal infection that is characterized white and tannish colored patches. though it doesn’t belong to the category of eczema, it is similar to it and may be confused with the latter sometimes. hand, foot, and mouth disease (3.38%) this viral infection presents with a fever and a rashes accompanied by blistering of the hands, feet and the oral cavity and two children were diagnosed with this. molluscum contagiosum (1.69%) only one patient had this viral infection, and there were small, painless, bumpy lesions on the skin. pa ge 10 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 figure 9: patients affected by secondary skin infections identifying food triggers eczema or the atopic dermatitis is indeed very irritable, making the skin on the affected area feel itchy. the specific cause is still unexplained, nevertheless, there are certain foods that are believed to worsen the condition in patients (papapostolou et al., 2022). consequently, our study showed that 41(69.49%) children had worsening of the disease manifestations with particular foods. the food products that had more frequent associations with allergies were milk in 12 irregular cases (28.57%) and followed by egg in 9 cases (21.4%). other foods that are included were meat, wheat, biscuits, ragi, fishes, sea foods, nuts chocolates, and orange as per shown in table 6. moisturizers alone. among the twenty of them, majority (75%) were on topical corticosteroids which was often used with moisturizers. of these 59, five (8.47%) of them were on topical calcineurin inhibitors combined with moisturizers and topical corticosteroids. among them 21 (35.59%) were used resorted to other system of medicines. out of which, 18 patients (30.50%) were taking ayurvedic treatment and 3 patients (5. 08%) were taking homoeopathic treatment. statistical analysis the correlation between the clinical aspects of the major and minor enrollees themselves together with gender, personal/family history of atopy, age on the onset of the disease below 1 year, inadequate breast feeding, malnutrition, history of food allergy and history of seasonal worsening of symptoms were investigated. pearson joint chi square test was also used in the analysis and p value was greater than 0.05 (p > 0.05), which indicates that there has no statistical relationship between the major and minor clinical entities among the children in the study group. discussion in this investigation, a prospective analysis of 59 cases of children with ad during one year from november 2015 to october 2016 was carried out. ours’ was primarily a historical and clinical examination centered study. many authors globally have also as well investigated clinical manifestations of atopic dermatitis. such studies have often drawn different conclusions which might be due to ethnic variation or differences in definitions, materials or methods used. the following study included children with ad within the age-group of 2 months to 12 years. children with atopic dermatitis participating in the study ranged from the age of 2 months to 12 years of age with the average age of 3.5 years. srinivas in his study also involved children those who belonged to the same age group thus the mean age of the ad patient was 2.7 years (srinivas et al., 2023). in a similar fashion, findings in the study by parthasarathy, established that the mean and median age were 4.6 and 3.9 years respectively (parthasarathy et al., 2020). hence, the age distribution of our patients is thus well in parallel with the other studies done in india. table 6: food allergens affecting number of patients food allergens no: of patients percent wheat 4 9.5 milk 12 28.57 meat 5 11.9 ragi 3 7.1 egg 9 21.4 biscuits 3 7.1 orange 1 2.38 nuts 1 2.38 chocolate 1 2.38 seafood 1 2.38 fish 1 2.38 total 41 69.49 moreover, on the aspect of adequate breast feeding, it was revealed that all except 8 children (13. 55%) were adequately breast fed. as for the inadequately breast fed children, all 8 of them had onset of disease before 1 year of age. in the following study, among 59 children with atopic dermatitis, 12 children were evaluated to be malnourished based on their weight for age status as per the who 2006 and iap 2015 centile charts. treatment induced to the patients out of the 59 children with atopic dermatitis, 13 (22.03%) of them were receiving management through pa ge 11 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 similarly, the following study identified cutaneous infections in 25.42% of children with ad having impetiginisation in 8 of the patients, tinea versicolor in 5, hfmd in 2 and molluscum contagiosum in only 1 patient. that is why the level of infections is relatively low – due to better hygiene measures in kerala and the use of antibiotics in time (aggithaya et al., 2021). the study also revealed that in the subjects with ad, 57.60% of the children had dennis morgan (dm) fold present, indicating a status due to persistent vasoconstriction, thus the lower percentage may be due to less severe manifestation of the disease in the children and the higher rate identified in some indian studies due to ethnic difference and darker skin color (nath et al., 2020). moreover, in our study, orbital darkening was present in only 30.50% of cases, whereas different studies show different numbers. probably, the reason for this difference may be the persistence of nasal congestion for a longer time period in atopic adults. increased exposure to pollution in cities like bangalore or delhi might increase its incidence (ailawadi et al., 2024). in the present study, 44.1%) of the patients with atopic dermatitis experienced itch when sweating, and exacerbation during summer. probably, the humid climate of kerala may be responsible for the increased incidence. around 11 patients (18.64%) reported worsening of the disease with the use of soap and detergent. furthermore, food items also played a crucial role in severity of ad depending on the patient’s status (mehta & fulmali, 2022). of 59 children, 41 (69. 49%) definitely noted worsening of the disease after consuming certain foods. among the foods, milk was most incriminated and posed threat to disease complications in 12 (28. 57%) children. in 10 of the 12 studies, cow’s milk was implicated while formula feeds were found to be responsible for the rest of the three cases and goat’s milk in one patient respectively (ramírez-marín et al., 2022). this was succeeded by egg in 9 (21. 4%) and meat in 5 (11. 9%) patients. meat is the most recurrent food identified in all the four children with chicken being the most common implicated food (liao et al., 2022). this was succeeded by wheat, biscuits, ragi and fish as the foods that were mentioned as likely causes of the situation in 9.5%, 7.1%, 7.15% and 2.38% patients respectively. other highlighted foods were nuts, chocolate, seas foods and oranges. different studies have discussed about the link between food allergy (fa) and atopic dermatitis (ad) which are prevalent. it is often established that food sensitization can be present in such patients (domínguez et al., 2020). however, before suggesting that the patient follows a restrictive diet which may prove to be detrimental to his/ her health, allergy should be proven (rustad et al., 2022). preschool children with ad are most commonly sensitized to egg, milk or peanut whereas school aged children and adults are commonly sensitized to hdm’s, molds, animal dander or pollens. a barrier disturbance was found to play a main role in the process of sensitization and allergy, which is quite well known indeed (ramírez-marín et al., 2022). hence, concerning the fact that ad begins in early infancy, newborns’ skin care using emollients and the early introduction of food seem to be crucial to define the tolerance to food (mehta & fulmali, 2022). apart from edible allergies, lack of breastfeeding was also a common factor associated with the prevalence of ad (lin et al., 2020). inadequate breastfeeding was seen in 13.5% of 59 patients with atopic dermatitis, with a collective duration of less than one year. this may support the role of a varied solid food diet in exacerbating the disease. additionally, atopic dermatitis was noted in 20.33% children whose weight was below the 3rd centile on the new combined who 2006 and iap 2015 weight charts. probably, nutrition will remain of interest for as long as safe and effective therapy methods against ad are being pursued (trikamjee et al., 2021). while discussing about the severity of ad compared to the sample area population, atopic dermatitis increased evidently in the study area of patients with winter exacerbation was significantly different from summer exacerbations (belzer & parker, 2023). according to the consequences of the disease, it was worsened in winter in 67.14% of patients with an infantile atopic dermatitis disease, and it occurred in summer in 25.42% of the patients. the research conducted also noted that the temperature of the environment did not fluctuate much from one year to the next in the coastal tropical zone which might have led to low prevalence. the researcher also found again that that majority of the patients were from upper or upper middle-income families. conclusion the present work aimed to assess children with atopic dermatitis in a tertiary care hospital. female patients were more frequent than male ones. it was identified that children had the onset of the disease at an early age, below 1 year of age, and there was significant itching as a common symptom in most children, which was worse at night (song et al., 2024). thus, the most frequent and significant finding in patients’ history was the presence of atopy in the firstand second-degree relatives, especially on the maternal side (ai et al., 2024). food intolerance was evident mainly in milk products and foods containing milk, while contact urticaria and contact dermatitis from wool and lipid solvents were reported in one-third of the cases (eyerich et al., 2024). there was evident a seasonal pattern in the patients with half of the interviewees complaining of worsening of symptoms during summer (fitzmaurice & silverberg, 2024). facial lesions were observed frequently, and the limbs’ flexor surfaces had more extensive involvement than extensor surfaces (geng & sibbald, 2024). xerosis contributed to almost all the patients; ichthyosis was more prevalent than keratosis pilaris. more to the point, there was a low prevalence of skin infections, and signs such as orbital darkening, pale face, dermatitis eyelids, and anterior neck folds (herzum et al., 2024). it is also noteworthy that most of the children had a rural origin, while most of pa ge 11 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 102-112, 2025 them belonged to the upper or upper-middle social class. one alarming fact was that a major portion of children suffering from malnutrition were observed as 19% of the total study group (von kobyletzki et al., 2024). recommendations • even though a simple observation of ‘itching and dryness of the skin’ confirms the disease in atopic dermatitis, other aspects mentioned as the major and minor criteria should be sought. • babies born to parents having personal/family history of atopy or any other allergic disorder should be put on ‘no other milk’ for the first 6 months and should continue breast feeding till 2 years as this postpones the onset and severity of the disease. • knowing certain triggers such as food will enable one to prevent the worsening of the disease. • parents should be made aware of the treatment options available that is there are facilities available for exact treatment rather than using other medicines like ayurveda and homoeopathy and proper advice should be provided to stick to allopathy. limitations • this study is limited by the fact that the values that were derived represent the result of one particular hospital and from a selected population and therefore the findings of this research cannot be generalized to the whole population. • this cross-sectional study orientation also precluded establishing causality between the identified precipitating factors and the clinico-radiological features of the disease. • the age of onset, breastfeeding and other practices, type of precipitating factors like food, season and other irritants to diarrhea might suffer recall bias from the mothers or the primary care givers. • they might also present reporting bias during the taking of the history. references aggithaya, m. g., narayana, p. p., prasanna, k., & narahari, s. 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(2023). association of demographic characteristics, aggravating factors, comorbidities, and treatments with atopic dermatitis severity. authorea preprints. pa ge 1 pa ge 13 5 american journal of medical science and innovation (ajmsi) exercise among pregnant females in antenatal clinic in tabuk, saudi arabia, prevalence and barriers zinab alatawi1*, shumukh saleem s. aljohani1, walaa fahad aljuhani1, nadia abdualla s. alomrani1, ghadah ali r. alanazi1, maisaa mokhtar m. yousuf1, nada saleem s. alhawiti1, laila abdullah s. alanazi1, atheer mansour e. alatawi1 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3125 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 07, 2024 accepted: july 11, 2024 published: june 26, 2025 maternal mortality remains a significant global health concern, with physical inactivity being the fourth leading risk factor, contributing to 5.3 million premature deaths. this study aimed to assess the prevalence and impact of exercise among females in antenatal clinics and to study the barriers to exercise during pregnancy. this cross-sectional survey-based study was conducted in antenatal clinics in tabuk c ity, saudi arabia, among pregnant women from september 2022 to december 2022 by using an electronic questionnaire. a total of 168 participants were included in the study. ethical approval was obtained from the institutional review board, and informed consent was also obtained from participants. the data were analysed using descriptive statistics and appropriate statistical tests. the study results revealed that the majority of participants were aged 27-35, with 42% being saudi arabian citizens. the majority were unemployed, with 43% having a monthly income between 5001 and 10,000 saudi riyals. out of 168 participants, 70% had multiple children and had no abortion history, 51% participated in consistent exercise before pregnancy, and 92% had no medical issues. energy expenditure varied, with mild activity being the most common. household activities contributed the most, followed by sports. obstacles to physical exercise included apprehensions, insufficient energy, fear of injury, joint or muscular pain, and lack of interest. the study highlighted the importance of promoting physical activity among pregnant women, emphasising the need for tailored interventions to improve maternal and fetal well-being. keywords antenatal exercise, barriers to exercise, energy expenditure, physical activity, pregnancy 1 faculty of medicine, university of tabuk, king faisal road, tabuk 47512, saudi arabia. * corresponding author’s e-mail: zinabalatawi569@outlook.com introduction physical exercise is a planned and structured physical activity that is intended to improve one or more aspects of physical fitness. it is a crucial part of a healthy lifestyle and has a key role in preventing and managing many diseases (ribeiro et al., 2022). physical inactivity is the fourth most important risk factor for mortality worldwide among the general population, accounting for about 9% or 5.3 million premature mortality worldwide (who, 2019). considering the growing influence of inactivity on the incidence of diseases, the world health organization (who) has developed an international action plan with the goal of lowering physical inactivity by at least 10% by 2025 and 15% by 2030 (organization, 2019). pregnancy is an ideal time to begin exercising because it is linked to a stronger desire to establish a healthy lifestyle (ribeiro et al., 2022). pregnant women were traditionally advised to avoid participating in physical activity because of potential health risks. the adverse effects of physical inactivity during pregnancy have become a major concern among this group of individuals (al-youbi & elsaid, 2020). among pregnant women, in particular, physical inactivity is identified as a distinct risk factor linked to a number of health issues such as immoderate weight gain, gestational diabetes, loss of voluntary control over urination, hypertension, anxiety and prenatal depression (belachew et al., 2023). despite the extensive distribution of guidelines, a notable issue persists: most pregnant women have sedentary lives, particularly during the third trimester of their pregnancy (aljehani et al., 2021). however, contemporary research has emphasised several advantages linked to consistent physical activity for the health of the mother and the fetus. numerous guidelines support the integration of regular, moderate-to-intense exercise as a crucial component of preventive care for mothers, providing prescription guidelines and highlighting potential contraindications (aljehani et al., 2021). the main health measures specified in healthy people 2010 emphasised the importance of increased physical activity for women’s health, as it reduces the risk of gestational diabetes, pre-eclampsia, and excessive weight gain (yong et al., 2020). further, the american college of obstetrics and gynecology (acog) recommended continuing exercise routines before pregnancy and encouraging previously inactive women to engage in physical activity throughout pregnancy (aljehani et al., 2021). one of these is antenatal exercise, which is considered a tailored routine of physical movements designed for pregnant women aiming to promote holistic fitness throughout gestation (avignon et al., 2023). antenatal workouts include respiration exercises, aerobic activities, core stability training, pelvic floor exercises, spinal care techniques, and postural guidance specifically created to preserve cardiovascular capability and physical conditioning in expectant mothers. the main objective of antenatal clinics is to increase promotive and preventative health measures for expecting mothers (lattof et al., 2020). a study by barakat et al. (2019) demonstrated that engaging in low-impact exertions of moderate intensity can prevent pa ge 13 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 135-143, 2025 overweight, the development of gestational diabetes, and preterm birth (barakat et al., 2019). furthermore, these physical activities were found to enhance stress coping mechanisms, facilitate neurobehavioral relaxation in the developing fetus, and aid maternal recovery subsequent to parturition (barakat et al., 2019). a study in the aseer region of saudi arabia revealed a high prevalence of obesity among saudi women (wahabi et al., 2023). over 52% of these women were overweight or obese, highlighting the need for increased physical activity. consequently, a study in jeddah, saudi arabia, found a significant occurrence of abdominal and general obesity and physical inactivity among females in their reproductive years (filfilan & damanhouri, 2020). a study by dereje et al. (2023) evaluated antenatal physical exercise among pregnant women in several regions. the results revealed that the ratio of women engaging in adequate physical activity was 39% in iran (abedzadeh et al., 2022), 14.6% in norway , 18% in india (abedzadeh et al., 2022), and 10.2% in nigeria . moreover, in ethiopia, existing research focused on health facilities managed by the government has shown that only 8.4% and 11.7% of pregnant women followed the recommendations of the acog (janakiraman et al., 2021). another study by abeer et al. 2020 examined the awareness level among pregnant women in saudi arabia (alaglan et al., 2020). the results demonstrated that the majority of women, 86%, believed that participating in physical activity during pregnancy is crucial. of the women surveyed, over half, 75%, stated that they engage in physical activity while pregnant. other studies indicate that women are more likely to reduce the duration of their activity rather than start exercising during pregnancy (grenier et al., 2021). consequently, a study by chen et al. (2021) suggested that doctors should be trained to manage obesity during pregnancy, promoting a healthy lifestyle through regular physical activity. motivational counselling can help overcome apprehensions about exercise. maternal exercise reduces premature birth, abnormal fetal growth, type 2 diabetes, and cardiovascular disorders post-birth (chen et al., 2021). further, maintaining a healthy body mass index (bmi) is beneficial for mothers and babies. in contrast, barakat et al. (2021) demonstrated the link between unhealthy lifestyles and negative childbirth outcomes, including prolonged labour pain, increased caesarean delivery risks, and additional health risks for pregnant women and newborns, emphasising the importance of physical activity (barakat, 2021). awareness regarding physical activity during pregnancy can be raised by mass media exposure, sociodemographic distribution of women partners, healthcare practitioner recommendations, books, magazines, television, and the availability of supportive facilities (janakiraman et al., 2021). however, studies revealed a lack of research on the percentage of pregnant women with awareness and understanding of physical activity despite their diverse social, cultural, and educational backgrounds, causing them to be reluctant to exercise (kraus, 2023). therefore, the study aimed to assess the prevalence and impact of exercise among females in antenatal clinics and to study the barriers to exercise during pregnancy. materials and methods study design and study population this cross-sectional survey-based study was conducted in tabuk city, saudi arabia, among pregnant women from september 2022 to december 2022. the study involved a cohort of 168 participants who experienced pregnancy and were expecting. ethical approval ethical approval was obtained and the reference number was (ncbe-kacst, ksa: h-07-tu-077). inclusion and exclusion criteria the study included pregnant women of any age who naturally conceived a fetus and with no previous miscarriage experience. conversely, the exclusion criteria included pregnant females who had chronic systematic illnesses such as cardiorespiratory disease, diabetes mellitus, chronic renal disease, and medicationdependent hypertension. furthermore, participants suffering from the inflammatory joint disorder and chronic musculoskeletal problems that hindered their capacity to engage in daily physical activity were not included in the study. similarly, the study excluded women with contraindications to exercise, such as cervical insufficiency, twin or higher pregnancies, placenta previa beyond 26 weeks, premature labour, preeclampsia, or pregnancy-induced hypertension, as well as those with cardiovascular or respiratory diseases and severe anaemia. sample size and calculation the sample size was calculated using an online sample size calculator, raosoft (raosoft, http://www.raosoft. com/samplesize.html), with a 5% margin error and 95% confidence level. based on an average population size of 450 and a predicted average response rate of 50% for most of the questions, the sample size was calculated to identify an unknown number of physically active women. the sample size was determined to be n= 208 through calculation. there was a drop-off of 40 participants, and a total of 168 participants were included in the study. data collection the study employed a four-part interview questionnaire. the first section collected socio-demographic and clinical data in order to establish a baseline. section 2 examined the exclusion criteria in order to confirm eligibility. section 3 utilised a modified arabic version of lisa chasanpregnancy taber’s physical activity questionnaire (ppaq), a validated tool, to evaluate and measure physical activity levels among pregnant participants in the arabicspeaking community. furthermore, section 4 analysed possible barriers to participation in physical activity. pa ge 13 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 135-143, 2025 data analysis the collected data were entered into an excel spreadsheet and analysed using the statistical package for social sciences (spss inc., chicago, il, usa) version 22.0. descriptive statistics were calculated, which included frequencies and percentages for categorical variables, whereas, mean, standard deviation, median, and interquartile ranges for continuous variables. the data was analysed using suitable statistical tests, with a p-value of <0.05 considered statistically significant. results and discussion the results section displays data analysis and statistical interpretations based on data collection. a total of 168 participants were included in the study, with the age group of 27-35 accounting for 42% of the majority. the majority of participants were saudi nationals: 93%, 62% held a bachelor’s degree, 62% were unemployed, and 43% reported a monthly income between 5001 and 10,000 saudi riyals, as shown in table 1. moreover, 70% of the participants reported having two or more children. approximately 55% of participants had not experienced any abortions, while 30% were in their first trimester and 35% were in the third trimester. regarding physical activity, more than half 51% of participants reported engaging in regular exercise before pregnancy, and a significant proportion of 92% stated that they had no medical complications that would hinder their ability to exercise, as shown in table 2. the energy expenditure assessed in met-h/day for total activity ranged from a minimum of 0 to a maximum of 96.1. the median and mean values were 37.1 and 38.7, respectively. when categorising energy expenditure based on intensity, mild activity had the highest mean at 17.6 ±8.4, with a median of 16.2, while vigorous exercise had the lowest contribution at 3.2±5.5. when classified by the type of activity, household activities showed the highest mean at 18.6±8.8, followed by sports at 9.6±9.3. in contrast, transportation had the least contribution at 4.5±4.2, as shown in table 3. regarding the barriers to exercise, having enough activity (97%), lack of energy (94%), concern about the child (90%), concern about pregnancy complications (89%), fear of injury (86%) and muscle contraction with movement (78%), joint or muscle pain (67%) and do not like exercise (30%) were reported as common barriers, as shown in figure 1. table 1: demographic characteristics of participants (n = 168) characteristics frequency percentage age 18-26 years 47 28% 27-35 years 71 42% 36 and above 50 30% nationality non-saudi 12 7.1% saudi 156 93% education level no formal education 13 7.7% high school 42 25% bachelor 104 62% above bachelors degree 9 5.4% employment status employed 54 32% un-employed 104 62% student 10 6.0% monthly income less than 3000 sar 17 10% 3001-5000 sar 41 24% 5001-10000 72 43% 10001-20000 sar 32 19% more than 20000 sar 6 3.6% table 1 shows a diverse group of participants, with (42%) aged between 27-35 years and (93%) saudi nationals. a significant proportion had a bachelor’s degree (62%), while a smaller fraction had higher education qualifications (5.4%). employment status varied, with (32%) employed, (62%) unemployed, and (6%) students. monthly income distribution showed that (43%) had earnings between 5001-10000 sar, while (19%) reported incomes between 10001-20000 sar. this demographic analysis provides an understanding of the study population. pa ge 13 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 135-143, 2025 table 2: obstetric characteristics of participants (n = 168) characteristics frequency percentage number of pregnancy less than 3 50 30 3 and more 114 68% missing 4 2.4% number of children less than 2 48 29% 2 and more 117 70% missing 3 1.8% abortion no 93 55% yes 69 41% missing 6 3.5% gestational age of the current pregnancy first trimester 50 30% second trimester 59 35% third trimester 59 35% do you have any disease that could affect your participation in exercise? no 155 92% yes 13 7.7% were you on regular exercise before becoming pregnant? no 82 49% yes 86 51% table 2 indicates that the majority of participants (68%) experienced multiple pregnancies, with a significant portion (70%) having more than two children. out of the total 168 participants, (41%) reported having an abortion, while (35%) were in their third trimester of pregnancy. remarkably, (92%) of the participants did not experience any medical complications that hindered their physical activity during pregnancy. when examining their activity history prior to pregnancy, a nearly equal distribution was observed, with 51% of participants engaging in regular exercise and 49% not engaging in regular exercise. these findings provide valuable insights into the prenatal health and activity patterns of the participants. table 3 presents the distribution of physical activity levels among participants, highlighting an average activity level of 38.7 met-h/day. the range of total activity levels varied from 0 to 96.1 met-h/day, with 25% of participants recording levels below 22.9, 50% below 37.1, and 75% below 51.5. notably, sedentary activity averaged 1.5 met-h/day, while light exercise showcased the highest table 3: energy expenditure measured in met-h/day according to total activity, intensity level, and type of activity (n=168) percentile percentile percentile percentile percentile percentile percentile percentile percentile total activity 38.7 19.7 0 96.1 22.9 37.1 51.5 by intensity sedentary activity 1.5 0.95 0 3 0.75 1.5 2.5 light/mild activity 17.6 8.4 0 41.5 11.2 16.2 22.9 moderate activity 16.4 11.2 0 53.4 8.2 14.7 21.7 vigorous activity 3.2 5.5 0 28.8 0 0 3.5 by type househol/ caregiving 18.6 8.8 0 43.5 12.6 17.6 24 pa ge 13 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 135-143, 2025 average at 17.6 met-h/day. moderate activity recorded an average of 16.4 met-h/day, whereas vigorous activity displayed the lowest average at 3.2 met-h/day. home and caregiving activities exhibited the highest average at 18.6 met-h/day. these findings offer a comprehensive occupation 5.97 6.7 0 28.8 0 4.8 8.9 sports/exercise 9.6 9.3 0 42.93 3.9 6.6 13.3 transportation 4.5 4.2 0 21.3 1.3 4 6.4 analysis of participants’ daily physical activity patterns, illustrating the varying intensity levels and types of physical activity engaged in by the participants. consequently, barriers to exercise during pregnancy are shown in figure 1. figure 1: barriers to exercise during pregnancy figure 1 illustrates the main challenges identified by participants regarding their involvement in physical activity. these obstacles encompass perceived inadequacy, lack of energy, concerns related to childcare, and fears. additionally, financial considerations, discomfort, and adverse weather conditions are among the other barriers reported. discussion maternal mortality is still a major worldwide health issue, and the health sector must give this issue immediate attention in order to reduce death and morbidity (group & division, 2019). according to research conducted by wang et al. (2017), it was recommended that pregnant women engage in moderate exercise sessions of at least 15 minutes in duration undertaken 3-5 times weekly in order to maintain a healthy gestation (wang et al., 2017). such physical activity was posited to aid in preserving a favourable body weight and lowering the likelihood of developing gestational diabetes mellitus while also enhancing mental and emotional wellness (janakiraman et al., 2021). prior studies found that these antenatal physical exertions yielded significant improvements in fetal health parameters and led to expedited labour progress marked by shortened delivery times and mitigated back discomfort (jarni et al., 2021). however, additional findings revealed that nearly 60% of pregnant individuals reported a sedentary lifestyle, a rate higher than the 30% prevalence observed in the general adult population. moreover, antenatal care has been shown to be paramount for maximising health outcomes and wellbeing amongst expectant mothers and developing fetuses (kaur et al., 2021). additionally, engaging in physical activity has been shown to be paramount for sustaining complete wellness and minimising pregnancy-associated complications (artal, pa ge 14 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 135-143, 2025 2016). notable disagreement persists regarding the impact of physical exertion on expectant individuals classified as overweight or obese (du et al., 2019). these mothers demonstrate a reduced incidence of such antenatal physical activity compared to women exhibiting healthy body weight, thereby increasing susceptibility to adverse consequences (johansson et al., 2014). numerous studies have conclusively demonstrated the unfavourable outcomes associated with maternal obesity and overweight during pregnancy, such as an elevated likelihood of stillbirth and neonatal mortality (du et al., 2019). furthermore, obesity and excessive weight in mothers have been linked to physical health issues affecting both mothers and neonates, including preeclampsia, macrosomia, and gestational diabetes (du et al., 2019). studies suggest that consistent physical exercise is essential for fostering wellbeing among women, particularly throughout the periods preceding conception, during pregnancy, and the early postpartum stages, with minimal accompanying risks (du et al., 2019). low-impact home-based physical activity undertaken individually may confer greater benefits for women struggling with poor body image as compared to group exercise programs. however, engaging in exercise that does not involve supporting one’s body weight is anticipated to reduce strain on ligaments and joints (seneviratne et al., 2016). moreover, a recent study conducted in brazil revealed that 23% of women engage in physical activity when pregnant, with half of them reducing or quitting their exercise routines due to pregnancy (alaglan et al., 2020). according to a study conducted in the united states, 29% of women participated in physical activity before and during pregnancy, while an additional 4% started exercising during pregnancy (harris et al., 2015). significantly, these percentages are higher in comparison to the overall saudi population, where approximately 12% adhered to the recommendations for physical activity, as indicated by a nationwide survey (bcheraoui et al., 2016). considering the widespread inactive way of life, it is plausible that women maintain a sedentary lifestyle during pregnancy (nascimento et al., 2012). the need of regular physical activity in maintaining the balance of social, emotional, and physical health is becoming more widely acknowledged by medical professionals (al-youbi & elsaid, 2020). the majority of people failed to meet the recommended levels of physical activity as outlined by established guidelines. prior studies have indicated a significant occurrence of excessive gestational weight gain among pregnant women in saudi arabia (al-youbi & elsaid, 2020). this condition is believed to be linked to a deficiency in understanding the correlated health hazards during pregnancy. additionally, a study by ghadi & tarek (2020), assessed the understanding of physical activity requirements among pregnant women in saudi arabia and identified factors contributing to their lack of activity (al-youbi & elsaid, 2020). pregnancy is crucial for managing body weight, maximising health outcomes for both mother and fetus and developing enduring health habits. moreover, physical activity patterns change during pregnancy, and several studies suggest that healthcare practitioners should provide comprehensive education on the safety and benefits of engaging in physical activity to promote health and weight management (hayman et al., 2020). the study found that 58.4% of pregnant women lack awareness and involvement in physical activity, while 50.67% understand the requirements. only 15.8% adhere to exercise standards. a us study found that 32% of pregnant women met necessary levels during early pregnancy but decreased to 12% as the pregnancy progressed (ruifrok et al., 2014). the present study examined the exercise among pregnant females in antenatal clinics and the prevalence and barriers of physical inactivity. this study aimed to investigate and analyze the energy expenditure of pregnant women measured in met-h/day, considering total activity, intensity level, and type of activity. these findings offer valuable insights into the exercise habits of pregnant women within the study population. the obstetric characteristics of the participants provide essential insights into their reproductive history and current pregnancy status. the majority of participants had three or more pregnancies (68%), and most had two or more children (70%). the results align with previous studies in arab countries, indicating a preference for larger families demonstrated by salam et al. (2023). notably, a high percentage of women with three or more pregnancies suggests a significant presence of multiparous women in the sample, who may have distinct exercise patterns compared to primiparous women (salam & potty, 2023). however, the prevalence of abortion among participants was 41%, significantly higher than reported in previous studies (al-ebadi et al., 2021). this high prevalence underscores the importance of considering the physical and emotional aspects of previous pregnancy losses when designing exercise programs for pregnant women (moradinazar et al., 2020). regarding energy expenditure by type of activity, studies have consistently reported higher energy expenditure for physically demanding activities such as household chores and sports or exercises (azo & akbay, 2016). the present study findings align with these previous studies, confirming that household and caregiving activities require substantial energy expenditure. also, the mean energy expenditure for occupation-related activities in the present study was similar to previous literature, which indicates that occupational activities fall into the light energy expenditure (newton jr et al., 2013). this difference could be attributed to variations in occupational demands or differences in participant demographics across studies. the study evaluated energy expenditure patterns based on total activity, intensity level, and activity type. it revealed significant variability across different activities and intensity levels. in contrast, other differences may be due to participant characteristics, activity protocols, or measurement methods. the pa ge 14 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 135-143, 2025 findings contribute to the growing knowledge of energy expenditure and can inform future research and interventions for promoting physical activity and maintaining energy balance. moreover, when comparing these findings with the existing literature, several consistent barriers to exercise among pregnant women were identified as lack of facilities, financial instability, lack of interest, fear of harm during pregnancy, muscle and joint pain, inability to work, and lack of awareness regarding the importance of physical activity among pregnant women (rockliffe et al., 2021). previous studies have consistently reported concerns about the safety of exercise for the developing fetus and potential pregnancy complications as significant barriers to physical activity during pregnancy (ahmadi & amiri-farahani, 2021). however, the lack of facilities such as parks or gyms (53%) and lack of a companion to exercise with (53%) were reported at higher frequencies in the current study compared to previous studies in which it has been identified as enabler rather than barrier (ahmadi & amiri-farahani, 2021). furthermore, financial reasons (44%) and disliking exercise (30%) emerged as notable barriers in the current study. however, physical activities, including mandatory exercise sessions, have been proven to improve pregnant women’s physical activity levels, potentially reducing gestational weight gain, boosting self-efficacy in exercise, and reducing pregnancy-related discomfort and sadness, as well as mitigating gestational weight gain (lott et al., 2019). conclusion in conclusion, this study conducted a thorough investigation of physical activity levels among pregnant women in tabuk, saudi arabia. the results of this study contribute to the global conversation surrounding the promotion of physical activity during pregnancy. furthermore, these findings have the potential to influence the development of targeted interventions and strategies aimed at fostering a healthier lifestyle for pregnant women in the region. limitations and strengths • the cross-sectional design of the study and the exclusion criteria employed may limit the generalizability and applicability of the findings to pregnant women with chronic systemic illnesses. • nevertheless, the study’s notable strengths lie in its diverse participant group, meticulous data collection, analysis of energy expenditure, and identification of barriers to exercise during pregnancy. • this comprehensive study provides valuable insights that can inform healthcare practitioners and policymakers in their decision-making processes. references abedzadeh, m., taebi, m., sadat, z., & saberi, f. 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(2023). the impact of age, gender, temporality, and geographical region on the prevalence of obesity and overweight in saudi arabia: scope of evidence. healthcare, 11(8), 1143. https://doi.org/10.3390/ healthcare11081143 wang, c., wei, y., zhang, x., zhang, y., xu, q., sun, y., su, s., zhang, l., liu, c., & feng, y. (2017). a pa ge 14 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 135-143, 2025 randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women. american journal of obstetrics and gynecology, 216(4), 340-351. who, u. (2019). maternal mortality: levels and trends 2000 to 2017. geneva: world health organisation. yong, h. y., mohd shariff, z., mohd yusof, b. n., rejali, z., bindels, j., tee, y. y. s., & van der beek, e. m. (2020). high physical activity and high sedentary behavior increased the risk of gestational diabetes mellitus among women with excessive gestational weight gain: a prospective study. bmc pregnancy and childbirth, 20, 1-11. article 3662.indd pa ge 1 pa ge 10 3 american journal of medical science and innovation (ajmsi) comparison of recombinant cumulase with bovine derived hyaluronidase for oocyte denudation before icsi in sibling oocytes m. fakih1, b. r. daoud2, k. khalil3, m. fawaz4 , j. kashir5 , m. a. akhtar6* volume 3 issue 2, year 2024 issn: 2834-0086 (online) doi: https://doi.org/10.54536/ajfst.v3i2.3662 https://journals.e-palli.com/home/index.php/ajfst article information abstract received: august 18, 2024 accepted: september 23, 2024 published: october 11, 2024 assisted reproductive technology (art) with intra-cytoplasmic sperm injection (icsi) commonly utilizes bovine-derived hyaluronidase for oocyte denudation. the emergence of recombinant cumulase as an alternative merit an examination of its impact upon icsi outcomes. we compared the effects of recombinant cumulase and bovine-derived hyaluronidase on oocyte denudation during icsi, investigating impact upon fertilization rates, blastulation rates, and euploidy rates, aiming to improve clinical practice and optimize art for patient outcomes. this was a retrospective observational study involving 59 patients undergoing icsi conducted at first ivf fertility centre, abu dhabi, united arab emirates. oocytes from each patient were divided one group which employed recombinant cumulase, and the other group utilised bovine-derived hyaluronidase. parameters such as age, number of oocytes retrieved, denudation outcomes, and euploidy rates were assessed to determine enzyme impact. comparative analysis revealed no substantial difference in fertilisation rates or embryo development (blastocyst rate) between recombinant cumulase and bovinederived hyaluronidase. however, the recombinant cumulase group exhibited signifi cantly higher (p<0.05) rates of normal euploid embryos (recombinant cumulase-48.5%; bovine derived hyaluronidase38.0%), indicating a potential advantage. however, the results are from small cohort and need to be validated with large sample size. selecting enzymes for art procedures is challenging. although no signifi cant differences were observed in fertilisation rates, the recombinant cumulase group treated oocytes exhibited yielding higher normal euploid embryo rates. not many studies have looked at the euploidy rates with use of different enzymes for oocyte denudation. further investigations are essential to refi ne best practices and advance patient outcomes in assisted reproduction. keywords bovine-derived hyaluronidase, euploidy, intracytoplasmic sperm injection (icsi), pregnancy rate, recombinant cumulase 1 consultant gynaecological endocrinology & reproductive medicine and chairman, first ivf fertility centre and fakih ivf centre abu dhabi, united arab emirates. 2 first ivf fertility centre abu dhabi, united arab emirates. 3 reproductive medicine and infertility, first ivf fertility centre abu dhabi, united arab emirates. 4 first ivf fertility centre abu dhabi, united arab emirates. 5 department of biological sciences, college of medicine and health sciences, centre for biotechnology, khalifa university, abu dhabi, united arab emirates. 6 reproductive medicine, rcog accredited sub specialist in reproductive medicine, fakih ivf fertility centre abu dhabi, united arab emirates *corresponding author’s e-mail: muhammad.akhtar@fakihivf.com introduction reproductive health is a right of every citizen (mukurunge et al., 2023). infertility impacts approximately 15% of couples and has been present in around 20-30 % of males worldwide (al khaldi et al., 2023). assisted reproductive technology (art) has witnessed remarkable advancements, particularly with the intracytoplasmic sperm injection (icsi) as a groundbreaking technique in addressing a myriad of infertility factor (evison et al., 2009). within the intricate process of icsi, a critical procedural step involves the denudation of oocytes, whereby the cumulus cells encapsulating the oocyte are removed, facilitating clear visualisation and assessment of oocyte maturity and quality (de moura et al., 2017). hyaluronidase is an endoglycosidase that breaks down hyaluronic acid into monosaccharides by cleaving its glycosidic bonds; additionally, to some extent, it also breaks down other acid mucopolysaccharides in the connective tissue. (jung et al., 2020). traditionally, bovinederived hyaluronidase has been the primary enzyme utilised for degrading the hyaluronic acid-rich cumulus cell matrix, coupled with mechanical pipetting for cell removal (de moura et al., 2017). however, concerns surround the purity of bovine-derived hyaluronidase and the potential risk of pathogenic transmission associated with its use, prompting a quest for alternative enzymes for oocyte denudation in the icsi procedure (evison et al., 2009). in the past, medical hyaluronidase was extracted from bovine or sheep testicles and used without purifi cation. however, the mammalian hyaluronidase obtained in this way was low in purity and contained components that could cause an immune response. subsequently, purifi cation of mammalian hyaluronidase was implemented as a processing step, and microbial hyaluronidase obtained from streptococcus agalactiae bacteria was also used to reduce side effects. (jung et al., 2020). the emergence of cumulase, a recombinant form of hyaluronidase, presents a promising alternative. its manufactured origin potentially mitigates concerns related to pathogenic transmission and purity associated with bovine-derived hyaluronidase (furuhashi et al., 2010). given the signifi cant impact that the choice of enzyme for oocyte denudation may have on successful fertilisation, subsequent embryo development, and clinical outcomes, an in-depth exploration into the comparative impacts of recombinant and bovine-derived hyaluronidase is pa ge 10 4 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 3(2) 103-108, 2024 warranted (tsampras et al., 2022). cumulase acts as a protease, breaking down the protein matrix enveloping the cumulus cells, while hyaluronidase disintegrates the hyaluronic acid binding the cumulus cells together (de moura et al., 2017). studies comparing the effi cacy of recombinant cumulase and bovine derived hyaluronidase for denudation have yielded varying results. some suggest that recombinant cumulase is more effective in removing cumulus cells and improving fertilisation rates, while others report no signifi cant differences between the two enzymes. nonetheless, both enzymes are widely employed in clinical practice due to their demonstrated safety and effectiveness (taylor et al., 2006, de moura et al., 2017). despite encouraging outcomes from the use of recombinant cumulase® as part of assisted reproductive technology (art) icsi treatment program, it is pertinent to conduct a comparison with conventional bovinederived hyaluronidase to affi rm its effi cacy in uae population. this study, conducted in the fertility centre in united arab emirates (uae), aims to scrutinise the effectiveness and safety of two types of hyaluronidases currently available on the market: cumulase, which is recombinant, and hyaluronidase (sage) derived from bovine source (furuhashi et al., 2010, tsampras et al., 2022). we focus on examining how these two forms of enzymes may impact not only fertilisation rates and blastocyst development rate (blastulation rate) but also whether these effects extend to variations in euploidy rates, potentially infl uencing the clinical pregnancy rate (cpr) and live birth rate (lbr). we examined the effects of these enzymatic agents on sibling oocytes, fertilisation rates, blastulation rates, and crucially, euploidy rates. the evaluation of these outcomes is vital for clinicians to make informed decisions and optimise the art process for improved patient outcomes. this study endeavours to signifi cantly contribute to the understanding of enzymatic impacts on the icsi process, guiding clinical practices in art for improving successful pregnancy. understanding the effects of these enzymatic agents on fertilisation rates, blastulation rates, and, importantly, euploidy rates is imperative in optimising the icsi process for improvement in clinical outcomes. materials and methods it is a retrospective observational study at the first ivf fertility centre, abu dhabi, united arab emirates between september 2022 and august 2023.the data utilised in this research was sourced from the internal data management system, meditex ivf (germany). the dataset was acquired by fi ltering and selecting patients who fulfi lled predetermined inclusion criteria from the meditex database. we included patients aged between 23-45 years old, who underwent intracytoplasmic sperm injection (icsi) pre genetic testing (pgta) procedure as part of their planned art treatment and had undergone oocyte denudation using recombinant cumulase or bovine derived hyaluronidase (same patient had half of its oocytes denuded with recombinant cumulase and the other half with bovine derived hyaluronidaseperformed by a single senior embryologist) with recorded data on fertilisation, embryo development with blastocyst (day 5/6 embryo) formation and embryo biopsy for genetic result with normal (euploid) and aneuploid (abnormal) embryos. we excluded patients with missing or incomplete data for the relevant outcome measures or key variables of interest or who received alternative enzymes or additives (e.g. calcium ionophore) that could confound the comparison between recombinant cumulase and recombinant hyaluronidase or oocytes treated with only one of the above denudation enzyme or patients who were subjected to non-standard ivf or icsi protocols that might introduce variability in the outcomes. procedure in embryology laboratory involved meticulous timed denudation process was used to eliminate the cumulus cells surrounding the oocytes. in this study, we used one of the two enzymes for the denudation process with either recombinant cumulase (cooper surgical, usa) or bovine derived hyaluronidase (cooper surgical, usa)., for sibling oocytes from the same patient. the process of denudation was conducted by a senior embryologist to ensure consistency and minimize variability as per asrm guidance. the removal of the cumulus cell-oocyte complex (ccoc) was done using either bovine-derived hyaluronidase (cooper surgical, usa) or recombinant cumulase (cooper surgical, usa). the oocytes underwent exposure to either recombinant cumulase or bivine derived hyaluronidase approximately three hours after collection, with the exposure lasting no longer than a minute. subsequently, any remaining substances were gently aspirated using a glass pipette, followed by full denudation using a 140 μm fl exipet (ri ez-tip 140) immersed in warm hepes-buffered oocyte wash solution for approximately two minutes, with a maximum duration of fi ve minutes. post-denudation, the oocytes were transferred to a sage culture dish with media and four milliliters of oil. the maturity of the oocytes (with mii oocytes) was assessed before being returned to the incubator, and the intracytoplasmic sperm injection (icsi) procedure was carried out 30 minutes later only for mature mii oocytes. the evaluation of fertilisation status was conducted 14 to 18 hours posticsi, where the presence of pronuclei (pn) was examined. normal fertilisation was identifi ed when two separate pronuclei, each with nucleoli, were observed (2pn). eggs were discerned by their cytoplasm appearing diffuse or non-indicating a breakdown in the vitelline membrane. all oocytes were inseminated by icsi after 40 hrs. of trigger dose in handling origio media w/hepes under magnifi cation of x400 using an inverted microscope (olympus ix-73, japan) and micromanipulator (narishigie, japan). after icsi insemination, oocytes were group cultured in pre-equilibrated droplets of 25 µl of sage 1-step medium (cooper surgical group, usa) overlaid with mineral oil (sage, cooper surgical, usa) in a mea-tested dish. all embryos were incubated in a bench top incubator (k-system) at 37oc under atmosphere around 5.5% co2, 5.0% o2 and 89.5% n2, and ph of pa ge 10 5 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 3(2) 103-108, 2024 7.28 to 7.32. fertilisation was checked 16-18 h after icsi. embryo development was evaluated only on day 5. on day 5 embryos were graded according to gardener’s classifi cations (gardner et al., 2000, gardner et al., 2016) with blastocyst expansion graded on a numerical scale between 1 and 6. a trophectoderm biopsy was carried out on day 5 or 6 followed by vitrifi cation (cryotech, japan). blastocysts of grade 5 bb or better were biopsied and vitrifi ed. biopsied trophectoderm cells were lysed and dna was amplifi ed by multiple displacement amplifi cation (mda) (harper et al., 2010;cinnioglu et al., 2019). library preparation was performed from the amplifi ed dna then processed on illumina’s next generation sequencer, the miseq. analysis was performed using bluefuse analysis software. numerical and structural chromosomal abnormalities were reported. the primary endpoints of this process included assessing oocyte integrity post-denudation (with mature mii oocyte) as well as evaluating fertilisation rates, characterised by the presence of 2 pro nuclei (pn) and blastulation rates. the secondary endpoint involved determining the euploidy rate using next generation sequencing (ngs) on trophectoderm cells. all statistical analyses were carried out using sas® software. our approach involved conducting a comprehensive descriptive analysis to summarise and delineate the data succinctly. essential summary statistics were computed for each enzyme group separately as well as for the entire dataset, encompassing measures including mean, median, and standard deviation for all collected variables. these calculations facilitated a comprehensive grasp of both the central tendencies and the spread of data within each group. our primary objective was to ascertain whether a signifi cant disparity existed in the rates of successful fertilisation between the two enzyme groups. a chi-square test of independence was employed to assess the relationship between the type of enzyme used and the defi nitive outcome of successful fertilisation. this statistical test allowed us to determine whether the observed variations in proportions were statistically signifi cant or merely incidental. results and discussion 59 patients underwent oocyte denudation using either recombinant cumulase or bovine-derived hyaluronidase. the total number of oocytes denuded was 690 (350 recombinant cumulase group and 340 in bovine derived hyaluronidase group). mean patient age was 36±6 years, with an average of 16±9 oocytes retrieved per patient (table 1) table 1: summary of characteristics and outcomes of oocyte denudation with recombinant cumulase and bovine-derived hyaluronidase. characteristic mean ± std all patients (n=59) min-max age (years) 36 ± 6.0 23 – 47 oocytes retrieved 16 ± 9 4 45 recombinant cumulase bovine derived hyaluronidase mean ± std. number of oocytes injected 6 ± 3.1 5.8 ± 3.2 number of oocytes fertilised 4.2 ± 2.4 4.2 ± 2.8 number of blastocyst 2.3 ± 2.0 2.3 ± 2.2 number of euploid embryos 1.1 ± 1.2 0.9 ± 1.2 the table displays the mean ± standard deviation values for various parameters for all patients. the comparison of fertilisation and embryo development outcomes between recombinant cumulase and bovine derived hyaluronidase used in oocyte denudation for intracytoplasmic sperm injection (icsi), are shown in figure 1. figure 1: comparison of fertilisation and embryo development rates (%) between recombinant cumulase and bovine-derived hyaluronidase in oocyte denudation following icsi. the graph presents differences associated with various key parameters, including the number of oocytes injected, fertilised, resulting blastocysts, and normal embryos. each parameter’s signifi cance level is displayed, offering insights into the statistical signifi cance or insignifi cance of differences observed between the two enzymatic treatments concerning fertilisation and subsequent embryo development outcomes during the icsi procedure. fertilisation rate (71.0% vs 73.8%) and blastocyst rate (54.4% vs 54.6%) between recombinant cumulase and bovine derived hyaluronidase treated oocytes respectively, was insignifi cant. however, recombinant cumulase treated oocytes exhibited a signifi cantly higher proportion (p<0.05) of euploid embryos compared to oocytes treated with bovine derived hyaluronidase (48.5% vs 38.0%) (figure 1; table 2). pa ge 10 6 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 3(2) 103-108, 2024 table 2: summary of fertilisation and embryo development of oocytes treated with recombinant cumulase and bovine derived hyaluronidase. recombinant cumulase injected fertilised blastocyst euploid 350 250 136 66 bovine derived hyaluronidase injected fertilised blastocyst euploid 340 251 137 52 discussion the cumulus-corona-oocyte complex, composed of cumulus granulosa cells embedded in a matrix of hyaluronan oligosaccharide chains cross-linked by hyaluronan binding proteins and proteoglycans, surrounds each oocyte and must be removed prior to intracytoplasmic sperm injection (icsi). oocyte denudation is a very important step in assisted reproductive technologies (art). the purpose is to remove the surrounding cumulus cells from the oocyte to facilitate fertilization and subsequent embryo development. this was traditionally achieved using enzymatic digestion of the matrix with a bovine-derived hyaluronidase followed by mechanical denudation through pipetting. (evison et al., 2009). additionally, animal-derived combinations might contain proteins impacting human oocytes differently, inducing varied responses between bovine derived hyaluronidase types and batches. (ishizuka et al., 2014). plant-derived preparations, like coronase were used as safer alternatives to minimize negative effects associated with bovine-derived enzymes (parinaud et al., 1998). a human recombinant hyaluronidase (cumulase) has been developed with the intent of circumventing the problems and concerns associated with the animal origin and lack of purity of the bovine-derived form of the enzyme. (evison et al., 2009). in this study, oocyte denudation was compared between recombinant cumulase and bovine derived hyaluronidase with sibling oocytes form the same patient to see not only fertilization, blastocyst formation but importantly having euploid embryos which would increase the success of art. the absence of variance in exposure time between both groups would strengthen the fi ndings, highlighting the consistency and reliability of the fi ndings. successful denudation was confi rmed by observing the extrusion of the body indicating maturation. the endpoints of this process included assessing oocyte integrity post-denudation, as well as evaluating fertilisation rates, characterized by the presence of 2 pro nuclei (pn) and blastocyst (blastulation) rates. but importantly to look at euploidy rates through ngs analysis, on trophectoderm cells. the utilization of recombinant cumulase compared with bovine derived hyaluronidase showed higher euploidy rates, although the number of patients were small. further elucidation on the underlying factors of bovine-derived hyaluronidase contributing to variations in euploidy rates is warranted for a comprehensive understanding of its impact on assisted reproduction outcomes. however, it’s important to note that this observation is important but has to be assessed with caution based on the sample size. further investigation with a larger sample size in a prospective study in the future is necessary to elucidate whether there is a notable difference in euploidy rates between the twoenzyme treatment. the inclusion of euploidy testing in the study holds considerable importance as it provides insights into the chromosomal integrity of embryos, thereby infl uencing clinical outcomes. however, the discussion concerning the results obtained from next generation sequencing (ngs) is somewhat limited and warrants further elaboration. delving deeper into the implications of euploidy rates derived from ngs data could shed light on their association with clinical pregnancy rates (cpr) or live birth rates (lbr), thus offering valuable insights into the overall effectiveness of the techniques employed in the study. as outlined in an earlier study reported that recombinant cumulase has a signifi cant increase in fertilization compared to bovine derived hyaluronidase, (evison et al., 2009). in our study, fertilisation rates fertilization appeared slightly lower in the recombinant cumulase group (71.4%) compared to bovine-derived hyaluronidase (73.8%), although the blastocyst formation rates showed negligible differences (54.4% for recombinant cumulase vs. 54.6% for bovine-derived hyaluronidase). this study shows there was a signifi cant difference in the effect of oocyte denudation time on embryo quality at assisted reproductive technology clinic. the denudation time of 3-4 hours group showed the highest result. there was no signifi cant difference in the effect of intracytoplasmic sperm injection (icsi) time on embryo quality at assisted reproductive technology clinic. (tjahyadi et al., 2022). we followed the denudation times as per this study. the longstanding use of bovine-derived hyaluronidase in oocyte denudation raised concerns regarding low purity and variable concentrations, potentially risking prolonged exposure and consequent dna damage to oocytes. (jung et al., 2020). various studies comparing recombinant cumulase and bovine-derived hyaluronidase highlighted recombinant cumulase safety and non-inferior effi ciency, showcasing similar or improved parameters in fertilisation and embryo growth. (taylor et al., 2006, vos et al., 2008). this study emphasized recombinant cumulase ‘s effi cacy and safety advantages over bovine derived forms. (evison et al., 2009) a study by on porcine oocytes confi rmed the suitability of human recombinant hyaluronidase for denudation without detrimental effects on oocyte quality. a human recombinant hyaluronidase, was found to be effective for oocyte denudation prior to microinjection, icsi. although animal-derived hyaluronidases are used to reduce the cost, they carry several risks from impurities as they are extracted from the testicles of animals and may contain various other proteins. (lee et al., 2021). methodological variations across studies, including denudation techniques, enzyme concentrations, and exposure times, limit direct comparisons. lower enzyme pa ge 10 7 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 3(2) 103-108, 2024 concentrations potentially improved blastocyst rates and reduced costs, but further validation in laboratory settings is necessary3. additionally, reports on increased ca2+ levels and decreased embryonic potential associated with bovine derived hyaluronidase require further investigation. (ashibe et al., 2021). another study showed no signifi cant differences in survival, fertilisation, or embryo development among varied bovine derived hyaluronidase concentrations and mechanical denudation methods. (van de velde et al., 1997). this review reported comparable fertilisation rates between recombinant and bovine-derived hyaluronidase, aligning with our observations. (rubino et al., 2016). a systematic review and meta-analysis from three rcts involving 2445 oocytes collected from 200 women were analysed, the available moderate to high quality trials found no statistical difference in fertilisation rate, embryo quality and live birth rate between the use of recombinant or bovine hyaluronidase for oocyte denudation before icsi. (tsampras et al., 2022). however, none of the rcts looked at euploidy rates. our study showed similar fi ndings as the above systematic review and meta-analysis but we looked at the euploid embryos. interestingly, the percentage of normal euploid embryos was relatively higher in the recombinant cumulase group (48.5%) compared to bovine-derived hyaluronidase (38.0%). while the results suggest promising trends favoring recombinant cumulase in terms of higher normal euploid embryo rates, additional research with larger sample size is required to validate these fi ndings and elucidate the underlying mechanisms. our fi ndings suggest that the choice of the enzyme may not signifi cantly affect fertilisation rates or subsequent embryo development. however, ongoing research on denudation techniques, enzyme concentrations, and exposure times remains pivotal for each embryology laboratory and should constantly be monitored. future studies should encompass confounding factors affecting oocyte quality and embryonic development, aiming to establish optimal enzyme concentrations, exposure durations, and costeffective approaches towards higher live birth rates. conclusion this comparative study compared the effects of recombinant cumulase and bovine-derived hyaluronidase on oocyte denudation for icsi in sibling oocytes from the same patient performed by a single senior embryologist. results from the analysis of 59 patients showed no substantial differences in fertilisation rates or embryo development between the two enzymes. however, recombinant cumulase demonstrated a statistically signifi cant increase in normal euploid embryos, indicating a potential advantage over bovine-derived hyaluronidase. euploid rates had not been looked when comparing these two enzymes for denudation. however, the sample size of our study is small and fi ndings have to be viewed with caution. a larger prospective study comparing these two enzymes for oocyte denudation should be performed with euploidy rate as an end point. these fi ndings emphasise the complexity of enzyme selection in assisted reproduction and underline the necessity for ongoing research to optimise techniques for improving live birth rates in art treatments. further comprehensive investigations are imperative to ascertain subtle differences between enzymatic approaches and refi ne best practices in assisted reproduction for enhanced patient outcomes. strengths and limitations the strength of this study is robust retrospective design with a substantial cohort with sibling oocytes of the same patient to have an accurate comparison, standardised denudation techniques, and assessment of euploidy rates. the procedure was performed by a single senior embryologist. the limitation is inherent confounders in retrospective analysis, smaller sample size and geographicspecifi c data ethics approval and consent to participate. this study was conducted in strict adherence to ethical principles and guidelines. the research protocol and data collection procedures were approved by the internal research ethics committee of the first ivf fertility centre (committee rec fivf-001) and the international review board of the emirates of abu dhabi (adhrtc-2023-114). all efforts were made to safeguard the confi dentiality and privacy of their personal information throughout the study. acknowledgement the authors thank ms. leyla depret-bixio biostatistician for her support in this study. competing interest the author(s) declares no confl ict of interest. funding there has been no funding received for this study. data availability statement the data supporting the fi ndings of this study are stored in software meditex ivf (germany), which is designed specifi cally for in-vitro fertilization (ivf) clinics. meditex ivf (germany) serves as a tool for managing and documenting patient data within assisted reproduction organisations. however, it’s important to note that there are restrictions on accessing this data due to licensing agreements for this study. therefore, the data cannot be accessed publicly. nevertheless, the authors of the study are willing to provide access to the data upon request. references al khaldi, m. r., & al-khaldi, m. 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(2019). aneuploidy screening using next generation sequencing. methods mol biol. 2019, 1885, 85-102. https://doi. org/10.1007/978-1-4939-8889-1-6. de moura, b. r., gurgel, m. c., machado, s. p., marques, p. a., rolim, j. r., de lima, m. c., & salgueiro, l. l. (2017). low concentration of hyaluronidase for oocyte denudation can improve fertilization rates and embryo quality. jbra assisted reproduction, 21(1), 27. evison, m., pretty, c., taylor, e., & franklin, c. (2009). human recombinant hyaluronidase (cumulase®) improves intracytoplasmic sperm injection survival and fertilization rates. reproductive biomedicine online, 18(6), 811-814. furuhashi, k., goto, s., hashimoto, h., matsumoto, y., kokeguchi, s., & shiotani, m. (2010). comparison of bovine-and recombinant human-derived hyaluronidase in icsi patients. journal of mammalian ova research, 27(2), 61-64. gardner, d & balaban, b. (2016). assessment of human embryo development using morphological criteria in an era of time-lapse, algorithms and ‘omics’: is looking good still important? molecular human reproduction, 2016(22). https://doi.org/10.1093/ molehr/gaw057. gardner, d. k., lane, m., stevens, j., schlenker, t., & schoolcraft, w, b. (2000). blastocyst score affects implantation and pregnancy outcome: towards a single blastocyst transfer. fertility and steriity. 2000 jun, 73(6), 1155-8. https://doi.org/10.1016/s00150282(00)00518-5. harper, j., coonen, e., de rycke, m., fiorentino, f., geraedts, j., goossens, v., harton, g., moutou, c., budak,t., renwick,p., sengupta,s., traegersynodinos, j., & vesela,k. (2010) what next for preimplantation genetic screening (pgs)? a position statement from the eshre pgd consortium steering committee. human reproduction, 25(4), 821–823, 2010. ishizuka, y., takeo, t., nakao, s., yoshimoto, h., hirose, y., sakai, y., ... & nakagata, n. (2014). prolonged exposure to hyaluronidase decreases the fertilization and development rates of fresh and cryopreserved mouse oocytes. journal of reproduction and development, 60(6), 454-459. jung, h. (2020). hyaluronidase: an overview of its properties, applications, and side effects. archives of plastic surgery, 47(04), 297-300. lee, j. h., yoo, m., lee, s. m., park, s. j., kil, t. y., & kim, m. k. (2021). toxicity of the recombinant human hyaluronidase alt-bc4 on embryonic development. journal of animal science and technology, 63(2), 272. mukurunge, t., rapitse, s., & bhila, t. (2023). reproductive health and the women of lesotho: the challenges. journal of innovative research, 1(2), 1–6. https://doi.org/10.54536/jir.v1i2.1631. parinaud, j., vieitez, g., milhet, p., & richoilley, g. (1998). use of a plant enzyme preparation (coronase) instead of hyaluronidase for cumulus cell removal before intracytoplasmic sperm injection. human reproduction, 13(7), 1933-1935. rubino, p., viganò, p., luddi, a., & piomboni, p. (2016). the icsi procedure from past to future: a systematic review of the more controversial aspects. human reproduction update, 22(2), 194-227. taylor, t. h., elliott, t., colturato, l. f., straub, r. j., mitchell-leef, d., & nagy, z. p. (2006). comparison of bovine-and recombinant human-derived hyaluronidase with regard to fertilization rates and embryo morphology in a sibling oocyte model: a prospective, blinded, randomized study. fertility and sterility, 85(5), 1544-1546. tjahyadi, d., susiarno, h., chandra, b. a., permadi, w., djuwantono, t., & wiweko, b. (2022). the effect of oocyte denudation time and intracytoplasmic sperm injection time on embryo quality at assisted reproductive technology clinic–a cross-sectional study. annals of medicine and surgery, 80, 104234. tsampras, n., kollmann, m., & craciunas, l. (2022). recombinant versus bovine hyaluronidase for oocyte denudation before intracytoplasmic sperm injection: a systematic review and meta-analysis. journal of obstetrics and gynaecology, 42(2), 301-305. van de velde, h., nagy, z. p., joris, h., de vos, a., & van steirteghem, a. c. (1997). effects of different hyaluronidase concentrations and mechanical procedures for cumulus cell removal on the outcome of intracytoplasmic sperm injection. human reproduction, 12(10), 2246-2250. vos, d. (2008). randomized sibling-oocyte study using recombinant human hyaluronidase versus bovinederived sigma hyaluronidase in icsi patients. human. reproduction., 23, 1815-1819. pa ge 1 pa ge 78 american journal of medical science and innovation (ajmsi) indication of laboratory parameters for kidney diseases at king fahad medical city, riyadh, saudi arabia yousef sultan alobaisi1*, firoz anwar2, khaled dabour3, khalid almatham4, sultan alshahrani1, khalid a. alzahrani5 yasir awad ahmed1, maher mohammed alobaysi6 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5340 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 02, 2025 accepted: july 04, 2025 published: october 22, 2025 end-stage renal disease (esrd), chronic kidney disease (ckd), and acute kidney failure (akf) are serious global health issues that contribute to high sickness and death rates. this king fahad medical city study investigated the importance of reliable biomarker monitoring and early treatment to enhance patient outcomes. 220 people had their serum levels of albumin, c-reactive protein (crp), urea, creatinine, salt and phosphate assessed. creatinine (χ² = 60.73, p < 0.001), urea (χ² = 48.66, p < 0.001), phosphate (χ² = 19.20, p = 0.004), sodium (χ² = 14.10, p = 0.029) and body weight (χ² = 13.24, p = 0.039) showed significant differences across diagnostic groups, according to the kruskal-wallis test. significant activity was indicated by the highest crp values (103.9 mg/l; 95% ci: 83.9–123.9 mg/l) in akf patients, whereas the highest average creatinine levels (428.6 µmol/l; 95% ci: 330.0–527.2 µmol/l) were seen in esrd patients. the above results show that every disease has an unique biomarker signature. also a gender study revealed that, on average, male patients weighed 7.29 kg heavier than female patients (t = 2.739, p = 0.007). the study shows that kidney-related illnesses may be effectively treated with biomarker-based diagnostics. important biomarkers for ckd, esrd and akf detection include creatinine, urea, crp and sodium. this highlights how helpful these indicators are for supporting timely diagnosis, improving clinical intervention techniques and directing customized treatment plans. keywords acute kidney failure (akf), chronic kidney disease (ckd), end stage renal disease (esrd), laboratory biomarkers 1 king fahad medical city, pathology and clinical laboratory medicine administration, riyadh, 11525, saudi arabia 2 king abdulaziz university, department of biochemistry, faculty of science, jeddah, saudi arabia 3 tanta university, department of entomology, faculty of science, tanta, 31527, egypt 4 king fahad medical city, department of nephrology, riyadh, 11525, saudi arabia 5 king fahad medical city, department of electronic medical records (emr), riyadh, saudi arabia 6 king fahad medical city, simulation development department, academic and training affairs, riyadh, 11525, saudi arabia * corresponding author’s e-mail: yalobaisi@kfmc.med.sa introduction chronic kidney disease (ckd) and end-stage kidney disease (esrd) continue to be major global health challenge, significantly contributing to the overall burden of morbidity, mortality, and the cost of health care with ckd affecting approximately 13.4% of the worldwide population which together is estimated to be over 700 million people living with some form of kidney disease (kovesdy, 2022). esrd prevalence varies but is increasing, with approximately 2 million people currently on dialysis and expected to increase in the coming years (filipska et al., 2021). the high and growing rates of diabetes mellitus, hypertension and the aging population are the main causes of the worrying rise in kidney disease frequency, according to recent epidemiological data (major et al., 2018; webster et al., 2017). chronic kidney disease (ckd) is the third most commonly seen and biggest disorder globally, behind heart disease and cancer, according to clinical data analysis (jiang et al., 2023). according to al-sayyari and shaheen (2011), the high incidence of risk factors such as obesity and metabolic syndrome worsens the increasing rate of renal disease in saudi arabia. reducing the burden of illness still demands thorough analysis of renal functions, timely identification of kidney disease, and progress in the disease. indicators such as serum creatinine and urea are crucial to conventional methods. a increase in serum creatinine, a sign of a low glomerular filtration rate (gfr), remains one of the most significant markers of renal impairment (wang et al., 2019). however, these standard markers are either too general or too specific to identify the kind of kidney damage or in the early stages of the illness (mizdrak et al., 2022). therefore, the need for stronger biomarker panels is growing in order to provide rapid, accurate, sensitive and comprehensive diagnostic medical information. between 2022 and 2024, new biomarkers and the improvement of current ones have become more popular in an effort to improve diagnostic and prognostic capacities. according to gremese et al. (2023), there is potential for improving the detection of renal illness by using indicators of inflammation, problems with electrolytes and nutritional status. due to their high relationship with the course of the illness and risk for heart disease, biomarkers that show inflammation and mortality in patients with ckd and esrd, including c-reactive protein (crp), are now among the most significant (li et al., 2023; stenvinkel et al., 2021). electrolyte issues involving sodium, phosphate, calcium and albumin are among the primary causes of ckd pa ge 79 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 impacts, including mineral and bone diseases and cardiovascular diseases. as chronic kidney disease (ckd) is becoming more common and has a significant impact on healthcare systems, better methods of diagnosis and treatment must be developed. early identification, treatment of underlying causes and secondary prevention measures can stop or even prevent the development of the condition (bektay et al., 2024). more complex methods are encouraged by recent kdigo guidelines, which stress the active continual tracking of these biomarkers and concentrate on therapy based on trends rather than single values (valson et al., 2020). despite the guidelines, there is a lack of more thorough research that look at how kidney disease handles change when markers alter in a clinical environment and commitment to these recommendations differs. this study addresses explicitly these existing limitations by examining and profiling several critical biomarkers, including creatinine, urea, c-reactive protein (crp), albumin, sodium, calcium, and phosphate in patients with chronic kidney disease stages 3 to 5, end stage renal disease, acute kidney failure, acute nephritic syndrome, chronic renal failure-associated anemia, and septic shock. the primary goal of this study is to identify distinct patterns and variations in indicators associated with specific renal disorders, thereby aiding in the further refinement of diagnostic precision, tailoring management levels, and optimizing clinical outcomes for patients. the primary hypothesis is that there is a notable variation in biomarkers among different renal disorders, corresponding to distinct underlying pathophysiological processes. in addition, we also hypothesize that systematically profiling biomarkers will add more value in predicting superior diagnostic and prognostic information compared to traditional isolated biomarker assessments. the study’s findings are meant to help individuals by providing explanation on some choices regarding the implementation of early treatment interventions, the customization of therapies, and the use of pertinent biomarker trends and variations across various kidney disease types to track the progression of the disease. in the end, these discoveries may lead to better clinical procedures and established care models for kidney disease management, which would greatly improve nephrology patient care and results. literature review chronic kidney disease (ckd) poses an increasingly prevalent global health concern, creating problems for healthcare systems due to the chronic health subjects, the costly nature of treatment, and progressive deterioration of renal functions (kuo & chapman, 2020; major et al., 2018). kidneys are of great physiological homeostasis maintenances through removing metabolic waste like urea, creatinine, uric acid, and regulates fluid volune and sodium level, serum osmolality and secretes hormones like erythropoietin, vitamin d, and renin (okoro & farate, 2019; webster et al., 2017). the increase prevalence of chronic kidney disease (ckd) is closely associated with the elderly population alongside the increase in chronic illnesses, such as diabetes and hypertension which are may risk factors for ckd progression (major et al., 2018). recently some studies have highlighted lifestyle factors such as obesity and smoking towards the development and progression of ckd (li et al., 2023), such factors lead to a higher population of patients progressing towards ckd stage 5 which necessitates renal replacement therapies, such as dialysis or transplantation (schrauben et al., 2022). the economic burden of population suffering from ckd is considerable because of the expenditures associated with its management and complications (zhang & parikh, 2019). moreover, latest insights in nephrology emphasize the importance of proactive chronic kidney disease (ckd) management, including early diagnosis and stratified interventions. this includes the new digital health assets and technologies that support enhanced patient engagement and interface as well as newer biomarkers for prompt diagnosis (chen et al., 2021; wang et al., 2019; zhang & parikh, 2019). the interconnections between diverse risk factors and various biomarkers are complex, and their understanding helps design efficient control methods for ckd and alleviating its global health challenges. as ckd progresses, its complications widen systemically, foremost in importance is ckd-mineral bone disorder (ckd-mbd). along with bone and vascular problems ckd-mbd is caused by disruptions in the metabolism of calcium, phosphate, parathyroid hormone (pth) and vitamin d (valson et al., 2020). the burden of illness and death increases significantly by these chronic alterations. hence, their continuous monitoring is important because of the precision needed. management of ckd-mbd is directed towards managing each facet of the enduring mineral bone relationship. recent publications focus more on the need for cardiovascular complication and bone disease detection and intervention at earlier stages (kuo & chapman, 2020). in ckd patients, serum creatinine and urea are used to track electrolytes such calcium, phosphate, potassium and sodium as well as kidney function (wang et al., 2019). also, c-reactive protein (crp), which is more prominent in chronic kidney disease (ckd) and is associated with increased cardiovascular risk, can be employed as a sign of inflammation (stenvinkel et al., 2021). the chances of renal illnesses, cardiovascular problems and disease progression are all closely associated with high levels of crp (li et al., 2023; tang et al., 2018). another recent emphasis has been placed on the value of albumin as more than a nutritional status measure but as a prognostic marker of patients with renal disease. in case of ckd, serum albumin levels are decreased on account of malnutrition and inflammation, which are risk factors closely related to poor clinical outcomes, higher mortality rates, and poor life expectancy (gremese et al., 2023). earlier studies have led to progress regarding biomarkers’ pa ge 80 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 usefulness in renal diseases. a study by dublin acute biomarker group evaluation (damage) was done as proof of progressive potential of different urinary biomarkers in critically ill patients at icu as predictor of acute kidney injury (aki). urinary markers such as ngal, cystatin c, kim-1 and albumin were able to predict progression of aki seven days after icu admission, which is an important prognosticator as well as a marker associated with earlier development of aki (mcmahon et al., 2019). similarly, another researcher performed follow-up secondary analysis also found interleukin-18, ngal, cystatin c and monocyte chemotactic protein 1 to be important predictors of progression to aki with the consequences of aki. this underscores the possibility of these biomarkers to be used in clinical risk stratification (duff et al., 2022). inflammatory markers such as crp have been emphasized by different studies to be related to disease processes beyond inflammatory markers. for example, this second evidence adds to the fact that crp is more than a passive marker and contributory to renal pathology since it confirmed its role in preserving insulin resistance, metabolic disorders and renal fibrosis (tang et al., 2018). while a lot work has been done for the progression of biomarker research to highlight their usefulness in the early detection of kidney disease, there still remain substantial gaps in research especially for diverse populations of kidney diseases. few prior attempts have been made to only on single biomarker and did not take into account a multifaceted approach. in addition to this, many of the existing literature lacks essential cross comparative studies on multiple renal diseases and therefore the specificity and clinical impact of the diagnosis remains relatively lacking. still, limitations in precision medicine due to deficiency in clarity, particularly on the landscape of biomarker differences between truly acute kidney failure and chronic conditions such as esrd or ckd, prevent development of precision medicine, as necessary to personalized treatment design and adaptive clinical treatment approaches.. the main objective of this study is to address these identified gaps by evaluating and comparing comprehensive biomarker profile comprising of serum creatinine, urea, sodium, crp, albumin, phosphate, and calcium in various renal conditions. this research has tried to improve diagnostic accuracy, increase prognostic power and identify strategies that might inform personalised therapeutic interventions leading to positive contribution in nephrology clinical practice guidelines. materials and methods study design the cross sectional observational study design was used in this research to see and evaluate biomarker profiles in patients with differing renal disorders. the study was performed in king fahad medical city (kfmc), riyadh, saudi arabia that provides a heterogeneous patient population with advanced and up to date clinical laboratory facilities. study participants this study relied on biomarker data from 220 participants who were selected based on some pre-defined inclusion and exclusion criteria. adult patients (18 years of age and up) who visited king fahad medical city’s nephrology clinics between january and june of 2023 were chosen as participants. patients with specific stages of chronic kidney disease (ckd) such as stage 3–5 ckd, acute kidney failure, nephritic syndrome, end-stage renal disease (esrd), chronic renal failure with anemia and septic shock are included in this category. a detailed clinical evaluation using stratified diagnostic scaffolds compliant with kdigo 2017 guidelines was performed by renowned nephrologists for the purpose of categorizing the patients enrolled in the study. inclusion and exclusion criteria the study inclusion criteria comprise patients aged 18 years and above and suffering from different kidney diseases such as chronic kidney disease (ckd), end stage renal disease (esrd), acute kidney failure, acute nephritic syndrome, and anemia secondary to chronic renal failure. this diagnosis was secured through a combination of clinical assessment as well as laboratory data analysis. a patient’s glomerular filtration rate (gfr) was used to establish them as ckd stage 3-5 or confirm them as having esrd if they were dialysis dependent or had gfr less than 15 ml/min/1.73 m². based on the acute rise in serum creatinine and the urinary output changes, acute kidney failure was identified. the study excluded patients who had either active infections, malignancies, severe cardiovascular diseases, hepatic disorders, or any other acute illness that could affect biomarker profiles. pregnant women, together with patients receiving immunosuppressive treatment, were excluded from the study to prevent laboratory parameter interference. data collection and laboratory analysis with respect to the clinical care protocol for patients with ckd at king fahad medical city, routine laboratory assessments were performed to evaluate the level of specific biomarkers of interest. blood samples were drawn from study participants by qualified phlebotomists employing standard techniques to ensure accuracy and proper protocol to yield reliable results (wright et al., 2019). following biomarkers were taken into consideration. creatinine as a leading indication of kidney function, it is assessed using enzymatic assays. high concentrations of creatinine mark a reduction in functional renal clearance, which is commonly encountered in chronic kidney disease (ckd) and end-stage renal disease (esrd). sodium using the ion-selective electrode (ise) method, concentrations are evaluated with regards to the electrolyte balance. disorders related to the kidneys pa ge 81 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 frequently disturb sodium levels that are also essential in the monitoring of fluid and electrolyte equilibrium. c-reactive protein (crp) an immunoturbidimetric assay measure of a systemic inflammatory marker. renal disease increases levels of crp, reflecting inflammation that may help cause the progression of the disease. urea it is evaluated using enzymatic assays geared toward kidney function and metabolism. excess urea values are typically observed in the final stages of renal illness and represent decreased kidney filtration. calcium and phosphate colorimetric methods and automated biochemical testers are used to measure calcium and phosphate. while ongoing kidney disease usually affects these minerals, which are essential for bone metabolism, they need to be examined often (sri-ganeshan et al., 2022) albumin the bromocresol green strategy measures the amount of albumin, which is determined using a colorimetric test. albumin levels usually change in people with anemia and chronic kidney failure, showing renal function and food intake. these indicators were chosen because, mainly when it comes to handling and managing renal illnesses, they help analyze kidney function, electrolyte balance, systemic inflammation and basic nutrition. statistical analysis the statistical package for the social sciences (spss) version 27 was used for performing the statistical analyses. descriptive statistics reported mean values alongside standard deviations for continuous variables while also reporting frequency distributions for categorical data. because specific biomarkers had non-parametric distributions, the kruskal-wallis test was applied to assess differences in biomarker levels among the patient groups. post hoc pairwise comparisons were performed with the mann-whitney u test where appropriate. gender-based comparisons were performed using independent samples t-tests and mann-whitney u tests, with a selection of the appropriate test based on data distribution normality determined by the shapiro-wilk test. effect sizes were calculated, which included cohen’s d for parametric and rank biserial correlation for non-parametric tests. along with other statistical measures, specific p-values and 95% confidence intervals were included to improve statistical understanding. as is common in medical studies, p<0.05 was the significance level. rationale for statistical method selection as the kruskal-wallis test was superior in analysing data that do not conform to normal distribution assumptions of anova, this was the best test fit for it. this method takes the form of an effective solution to accommodate the distribution of biomarker data that is typically found in clinical laboratory findings. we used gender as a basis to perform a gender-based analysis of biomarker levels by comparing those values with a previous understanding of the difference in biomarker expression by gender. results and discussion comparative analysis of biomarker variations in renal conditions the level of serum creatinine showed significant difference among different renal conditions, which was higher in end stage renal disease (esrd: mean = 428.6 µmol/l 95% ci: 330.0–527.2) than acute kidney failure (akf: mean = 309.2 µmol/l 95% ci: 231.8–386.6), meaning to be critical renal insufficiency and reduced gfr in advance stage renal disease (figure 1). therefore, it is consistent with previous studies reporting on elevated creatinine as an indication of severe kidney dysfunction (brookes & power, 2022). c-reactive protein still acts like the canary in the medical coalmine-signaling danger long before a patient can feel it. a quick read through our clinic log, done out of idle curiosity, suggested that the protein never truly let up. whenever the admitting note called the picture acute renal failure the median crp level rested at 103.9 mg/l (95 percent confidence interval 83.9 to 123.9). in cases labeled septic shock the average drifted close to 93.3 mg/l (95 percent confidence interval 74.1 to 112.5). those bands match what most floor doctors already sense. a broad wave of inflammation usually spikes just as the kidneys lose ground and shortly before the infection hits full force. another strange detail is that crp keeps humming even when serum creatinine-veteran of so many renal graphs-wobbles up, then back down. the numbers quietly hint that the underlying inflammatory machinery grinds on whether chronic kidney disease sits at stage one or has crept all the way to stage five. measurements of sodium in plasma traced a strikingly straight line when grouped by three major clinical states. researchers who monitored 22 subjects with acute renal failure found an average serum sodium of 134 mmol/l (95% ci 132-136). electrolyte concentration climbed to a median value of 136 mmol/l (95% confidence interval 134-138) within a second cohort of twentynine individuals confined to septic shock. in contrast, a different aggregate of one hundred six patients grappling with end-stage renal failure documented a trough near 132 mmol/l (95% confidence interval 130-134). the orderly drift among these figures points to notable disruptions in sodium handling, fluid homeostasis, and possibly divergent physiologic circuits that surface when kidney function collapses in the short term versus when it is irretrievably lost. serum urea levels climb sharply once the kidneys are essentially done, with patients officially labelled in endstage renal disease hovering around 17.0 mmol/l and pa ge 82 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 those caught in an acute episode hitting 18.1 mmol/l; both means-pulled from 95 percent confidence intervals that spread from 12.8 to 21.2-make it clear almost no nitrogen waste is left to clear. albumin behaves rather like a spectrometer, revealing filtration losses as the third stage of chronic kidney trouble settles in, the average sitting at 30.46 g/l (confidence slot 26.6-34.3) and standing in marked contrast to the more robust 34.23 g/l (with a range of 29.4 to 39.1) found in anemic patients whose blood loss stretches back over years. persistent inflammation and a tampered diet look to be the twin culprits yanking those figures in opposite directions. figure 1: mean values of biomarkers across different renal conditions comparative assessment of weight, c-reactive protein, and biochemical markers across renal conditions analyzing body mass by clinical grouping reveals a peak in acute kidney failure, where the patients average 82 kg 2 (20) and the group represents 83 individuals 37.6 . a contrasting low weight of 54 kg 8 (range not reported) occurs in acute nephritic syndrome, although that cohort is limited to just 2 subjects 0.9 . a diagnosis of anemia tied to chronic renal failure yields a mean of 80 kg 27 with 6 patients 2.7 , while end-stage renal disease shows 77 kg 18 across 24 cases 10.9 . table 1: mean and standard deviation of biomarkers across various diagnoses diagnosis a cu te k id ne y fa ilu re a cu te n ep hr iti c sy nd ro m e a ne m ia a ss oc ia te d w ith c hr on ic re na l fa ilu re c k d (c hr on ic ki dn ey d is ea se ) c k d s ta ge 3 , g fr 30 -5 a ne m ia d ue to c k d m l/ m in e sr d (e nd s ta ge re na l d is ea se ) se pt ic s ho ck weight mean 82 54 80 75 71 77 70 standard deviation 20 8 27 17 22 18 19 n % 37.6% 0.9% 2.7% 19.5% 3.6% 10.9% 24.9% n 83 2 6 43 8 24 55 c re a c t i v e protein mean 103.9 59.0 98.1 74.9 68.7 90.4 93.3 standard deviation 91.4 19.2 108.4 68.0 70.9 84.7 72.2 n % 37.6% 0.9% 2.7% 19.5% 3.6% 10.9% 24.9% n 83 2 6 43 8 24 55 pa ge 83 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 albumin result mean 33.77 30.70 34.23 33.98 30.46 32.95 32.21 standard deviation 5.36 12.87 5.38 4.88 8.97 5.23 7.35 n % 37.6% 0.9% 2.7% 19.5% 3.6% 10.9% 24.9% n 83 2 6 43 8 24 55 calcium mean 2.18 2.35 2.23 2.20 1.98 2.20 2.21 standard deviation 0.30 0.26 0.14 0.26 0.34 0.22 0.28 n % 37.6% 0.9% 2.7% 19.5% 3.6% 10.9% 24.9% n 83 2 6 43 8 24 55 phosphate mean 1.58 1.46 1.67 1.48 0.93 1.30 1.18 standard deviation 0.77 0.54 0.71 0.65 0.27 0.50 0.46 n % 37.6% 0.9% 2.7% 19.5% 3.6% 10.9% 24.9% n 83 2 6 43 8 24 55 urea mean 18.1 14.7 19.3 18.8 7.5 17.0 7.4 standard deviation 13.7 0.1 13.1 12.5 3.7 9.9 5.9 n % 37.6% 0.9% 2.7% 19.5% 3.6% 10.9% 24.9% n 83 2 6 43 8 24 55 creati nine mean 309.2 312.5 412.8 376.6 109.4 428.6 107.1 standard deviation 354.5 13.4 436.4 380.6 68.3 233.3 92.3 n % 37.6% 0.9% 2.7% 19.5% 3.6% 10.9% 24.9% n 83 2 6 43 8 24 55 sodium mean 134 128 136 135 137 132 136 standard deviation 8 3 9 6 4 5 6 n % 37.6% 0.9% 2.7% 19.5% 3.6% 10.9% 24.9% n 83 2 6 43 8 24 55 c-reactive protein, a common gauge of systemic inflammation, peaks at 103.9 mg/l 91.4 in the acute kidney failure cohort, which again numbers 83 37.6 . the acute nephritic syndrome group records the minimum crp mean of 59.0 mg/l 19.2 and, like its weight data, consists of only 2 patients 0.9 . end-stage renal disease and septic shock sit in the midrange at 90.4 mg/l 84.7 and 93.3 mg/l 72.2 , respectively. the distributions of serum albumin across diagnostic categories prove relatively uniform. cases of anemia linked to chronic renal failure yield a mean of 34.23 g/l (sd 5.38); the population size is modest, numbering 6 patients (2.7%). ckd stage 3, by comparison, records a lower mean of 30.46 g/l (sd 8.97), drawn from 8 individuals (3.6%), while the end-stage-renal cohort-on the whole-measures 32.95 g/l (sd 5.23) and constitutes 24 patients (10.9%) in the database. calcium values, much like albumin, show minimal dispersion when arranged by clinical presentation. acute nephritic syndrome registers the highest average, 2.35 mmol/l (sd 0.26), though the representation is small, just 2 patients (0.9%). in stage-3 ckd complicated by anemia the mean drops to 1.98 mmol/l (sd 0.34); that subgroup numbers 8 (3.6%), and an additional 83 patients (37.6%) with acute kidney failure exhibit a mean of 2.18 mmol/l (sd 0.30). phosphate concentrations tell a different story, with anemia from chronic renal failure once again at the extreme high, 1.67 mmol/l (sd 0.71) in 6 cases (2.7%). stage-3 ckd with anemia sits at the low end, averaging 0.93 mmol/l (sd 0.27) in 8 (3.6%). septic shock patients, a much larger group numbering 55 (24.9%), present a mean of 1.18 mmol/l (sd 0.46). anemia connected to chronic renal failure frequently presents with elevated urea, averaging 19.3 13.1 mmol/l and appearing in 6 2.7 of the charts reviewed. in sharp contrast, septic shock shows the lowest urea mean, recorded at 7.4 5.9 mmol/l in 55 24.9 of the cohort. patients with acute kidney failure fall in between, with urea levels clustering around 18.1 13.7 mmol/l and spanning 83 37.6 of the total. when creatinine is examined, end-stage renal disease dominates the upper range; levels sit at 428.6 233.3 µmol/l for 24 10.9 of the sample. septic shock once pa ge 84 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 again ranks at the other extreme, the mean resting at 107.1 92.3 µmol/l for 55 24.9 of the patients. acute kidney failure completes the picture with creatinine averaging 309.2 354.5 µmol/l and involving 83 37.6 of the records. statistical analysis of biomarker variations across renal diagnoses the kruskal-wallis test serves as a useful marker, showing how urinary and blood profiles fan out according to final table 2: kruskal-wallis test results for biomarkers across diagnoses χ² df p value ε² age 8.48 6 0.205 0.0386 gender 2.84 6 0.828 0.0129 weight 13.24 6 0.039 0.0602 c-reactive protein 3.61 6 0.729 0.0164 albumin 2.70 6 0.846 0.0123 calcium 5.58 6 0.472 0.0254 phosphate 19.20 6 0.004 0.0873 urea 48.66 6 < .001 0.2212 creatinine 60.73 6 < .001 0.2761 sodium 14.10 6 0.029 0.0641 diagnoses. initial pairwise comparisons based on body mass produce an h-statistic of 13.24, the associated p-value sitting at 0.039; epsilon-squared is estimated at about 0.0602. when phosphate is considered in isolation it yields a stronger chi-square of 19.20 and a correspondingly lower p-value of 0.004, with the point estimate of effect size, e, drifting near 0.0873. the picture sharpens when renal analytes enter the frame. urea readings clock in at χ² 48.66, produce p < 0.001, and drive epsilon up to 0.2212. creatinine marches in right behind, posting χ² 60.73, sharing that same p tag, and nudging epsilon to about 0.2761. sodium, last to appear, records χ² 14.10, hangs at p 0.029, and drags an epsilon around 0.0641, hinting that electrolyte drift follows the broader disease rhythm. a different story unfolds when demographic and inflammatory markers are examined. age yields χ² 8.48, p .205, and epsilon sticks at 0.0386, so there is no agerelated skew. gender shows essentially flat data with χ² 2.84, p .828, epsilon minimal at 0.0129. c-reactive protein, albumin, and calcium follow suit: their respective chi-squares of 3.61 (p .729), 2.70 (p .846), and 5.58 (p .472) all produce epsilon values under 0.03, underscoring a lack of distinct clusters across the diagnostic spectrum. gender-based analysis of biomarker differences in renal conditions an independent-samples t test measures the malefemale weight gap; t = 2.739, p = .007, and pooled mean difference is 7.29 kg with a standard error of 2.66 kg. table 3: independent samples t-test results for biomarkers based on gender confidence interval 95% st at is tic df p m ea n di ffe re nc e se di ffe re nc e e ffe ct si ze lo w er u pp er w ei gh t t te st 2. 73 90 21 9 0. 00 7 7. 28 57 2. 66 00 c oh en 's d 0. 37 43 7 0. 10 38 0. 64 4 m an nw hi tn ey u 48 18 0. 01 9 6. 00 00 ra nk bi se ria l co rr el at io n -0 .1 85 46 t te st -1 .2 31 2 21 9 0. 22 0 -1 3. 64 95 11 .0 86 1 c oh en 's d -0 .1 68 28 -0 .4 36 4 0. 10 0 pa ge 85 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 c -r ea ct iv e pr ot ei n m an nw hi tn ey u 55 46 0. 43 1 -5 .9 94 7 ra nk bi se ria l co rr el at io n 0. 06 23 8 a lb um in r es ul t t te st 1. 47 40 21 9 0. 14 2 1. 20 89 0. 82 01 c oh en 's d 0. 20 14 7 -0 .0 67 3 0. 47 0 m an nw hi tn ey u 53 19 0. 20 3 1. 10 00 ra nk bi se ria l co rr el at io n -0 .1 00 76 c al ci um t te st 0. 55 82 21 9 0. 57 7 0. 02 12 0. 03 80 c oh en 's d 0. 07 63 0 -0 .1 91 8 0. 34 4 m an nw hi tn ey u 54 12 0. 28 3 0. 02 99 ra nk bi se ria l co rr el at io n -0 .0 85 04 ph os ph at e t te st 0. 86 81 21 9 0. 38 6 0. 07 82 0. 09 01 c oh en 's d 0. 11 86 5 -0 .1 49 6 0. 38 7 m an nw hi tn ey u 54 29 0. 29 9 0. 07 00 ra nk bi se ria l co rr el at io n -0 .0 82 16 u re a t te st -0 .3 79 5 21 9 0. 70 5 -0 .6 29 3 1. 65 84 c oh en 's d -0 .0 51 87 -0 .3 19 7 0. 21 6 m an nw hi tn ey u 59 02 0. 97 9 -5 .7 7e − 6 ra nk bi se ria l co rr el at io n 0. 00 22 0 c re at in in e t te st 0. 61 68 21 9 0. 53 8 26 .7 39 6 43 .3 53 2 c oh en 's d 0. 08 43 0 -0 .1 83 8 0. 35 2 m an nw hi tn ey u 54 35 0. 30 5 17 .0 00 1 ra nk bi se ria l co rr el at io n -0 .0 81 15 so di um t te st 0. 87 14 21 9 0. 38 4 0. 83 41 0. 95 72 c oh en 's d 0. 11 91 0 -0 .1 49 2 0. 38 7 m an nw hi tn ey u 54 26 0. 29 5 1. 00 00 ra nk bi se ria l co rr el at io n -0 .0 82 76 a ge t te st 0. 04 45 21 9 0. 96 5 0. 08 79 1. 97 63 c oh en 's d 0. 00 60 8 -0 .2 61 8 0. 27 4 pa ge 86 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 cohen-s d-light to moderate in stature-reaches roughly 0.37437 (table 3). the same question posed via the mannwhitney u distribution yields u of 4818, p at 0.019, and ranks-biserial linkage nudging to -0.18546. weight aside, the blood chemistry shortlist reveals no other biomarker parting the sexes in a statistically meaningful way. c-reactive protein presented a t-statistic of -1.2312, corresponding p-value of 0.220, and a mann-whitney u of 5546, which also carried a p-value of 0.431; the effect size, as indexed by cohen’s d, was -0.16828, confirming a practically trivial impact. albumin, calcium, phosphate, urea, creatinine, and sodium joined crp in yielding non-significant outcomes: their t-values fell short of conventional thresholds, and corresponding p-values lingered above the 0.05 mark. the oldest biochemical outlier, urea, exhibited a t of -0.3795 and two u stats, 5902 and 979, neither of which shifted the narrative. age itself, tested separately, barely nudged the scale-a t of 0.0445, a p value of 0.965, and the mann-whitney tally, 5914 at p 0.999. discussion physicians have recently charted unique biomarker signatures scattered throughout the many varieties of kidney disease. such profiles promise to give bedside clinicians decision-making aids that are both precise and immediate. serum creatinine, conventionally reported in milligrams per deciliter, remained especially conspicuous; dialysis patients routinely exhibited values that soared beyond those of every other group. that finding echoes earlier reports, which portray creatinine as perhaps the most reliable flag for dwindling glomerular filtration rate (kulvichit et al. 2021; wang et al. 2019). a separate signalurea nitrogen-was unusually high in the same esrd cohort and in more advanced stages of chronic kidney disease. the buildup of urea reinforces the picture of kidneys unable to rid the body of everyday nitrogen byproducts (brookes & power 2022). electrolyte patterns added another layer of clinical meaning. phosphate was elevated in the dialysis patients, a shift that fits tightly with ckd-mineral and bone disorder, and it raises red flags for both cardiovascular strain and bone demineralization (valson et al. 2020). sodium, in contrast, often dipped below the normal range among individuals suffering acute renal failure linked to septic shock. that dip usually stems from fluid overload, the early use of diuretics, or the kidneys’ immediate response to intense acute illness. c-reactive protein has emerged as one of the sharper signals we can track when investigating the kidneys. its presence hints at a broader systemic fire, one that renal specialists can no longer ignore. clinicians on acute-care wards frequently observe that the steepest crp readings cluster around cases of sudden kidney failure. those spikes largely stem from the usual storm of inflammation and, all too often, from sepsis itself. elevated concentrations do not appear by accident; studies such as tang et al. (2018) insist that the numbers climb in lockstep with sinking renal function and worsening clinical signs. longitudinal follow-up shows that high crp figures can holler well ahead of measurable declines in the estimated glomerular filtration rate, meaning the protein is both a marker and an undercover agent of tissue harm (wang et al., 2022). if unchecked, that harm snowballs and pushes patients all the way to chronic kidney disease or, in the bleakest scenarios, to end-stage renal failure. cross-sectional work further links crp levels to interleukin-6, thereby placing the protein squarely in the complex web of systemic inflammation tied to renal illness (jiang et al., 2021). serum albumin values stayed fairly constant among most study participants, though a modest decline surfaced in the subgroup diagnosed with stage-3 chronic kidney disease. clinicians have long associated that drop with waning nutritional status and the persistent, low-grade inflammation that marks renal decline; the connection with poorer long-term outcomes remains solid (gremes et al., 2023). persistent hypoproteinemia in dialysis patients routinely surfaces in lab panels as a drop in serum albumin. the pattern now appears to undermine more than nutritional reserves, courting immune compromise and muddling clinical decision-making (zoccali et al., 2023). a dissection of the dataset according to sex reveals a striking weight imbalance: males exceed females by roughly 7.29 kilograms. such a disparity is frequently attributed to the bigger muscular and skeletal framework that most men possess, a characteristic whose extensive lean-tissue reservoir inflates mean weights (vásquez-vera et al., 2022). the role of testosterone and its androgen cousins is decisive here, since these hormones stimulate denser musculature and thereby entrench the enduring gap in total body mass (cappola et al., 2023). marked disparities still appear in serum creatinine and blood urea nitrogen when data are partitioned by sex, yet virtually every other renal biomarker exhibits overlapping distributions. the observation lines up with prior reviews arguing that conventional kidney function tests show minimal gender-related variation. most researchers point out that creatinine concentration is skewed mostly by overall muscle mass, and when results are indexed to body surface area-even roughly, the sex gap closes entirely m an nw hi tn ey u 59 14 0. 99 9 -1 .9 6e − 6 ra nk bi se ria l co rr el at io n 1. 69 e4 note. ha μ male ≠ μ female a levene’s test is significant (p < .05), suggesting a violation of the assumption of equal variances pa ge 87 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 78-88, 2025 (mori et al., 2022). routine follow-up blood work rarely reflects that narrow window of physiological difference, hinting at lapses in protocol-driven surveillance and personalized therapy. catching tiny swings in markers early on can shift prognosis from speculative to precise, allowing clinicians to tailor interventions sooner rather than later. close watch on sequential values also helps untangle acute kidney insults from chronic decline, a distinction vital for effective management. clinicians know that factors as mundane as a patients fluid balance, mealtime choices, prescribed drugs, and background disorders can tilt biomarker numbers in surprising directions; those variables must be factored in before one entertains definitive claims. following the same group across months or even years would, ideally, iron out the daily noise and reveal steady trends; such persistent shifts may flag emerging illness long before overt manifestations are evident. cross-sectional studies tell us more about a snapshot than a story, leaving the direction of causality in doubt and rule-based clinical decisions in limbo. confined to a single center, the current dataset risks shrinking the map by measuring only one hospital population rather than the greater public it hopes to serve. despite its methodological limitations, the study offers compelling evidence for the routine use of multi-analyte biomarker panels in every-day kidney practice. rapid, bedside measurements of this kind could sharpen differential diagnosis and permit immediate adjustment of therapeutic pathways. follow-on trials will need to trace the temporal shifts in biomomic profiles, validate their prognostic capability on independent cohorts, and ultimately integrate the most robust findings into formal clinical governance documents. conclusion in recent nephrology laboratories, researchers have begun home in on the very enzymes and lightweight metabolites that reliably carve one clinical picture away from another. the new point-of-care assays gesture toward a level of analytical finesse rarely glimpsed in standard inpatient practice, yet for now their results still rest inert in sealed glass vials. on the ward itself, clinical staff continue to lean on serum creatinine, blood urea nitrogen, sodium, phosphate and c-reactive protein in order to track patient status hour by hour. physicians who track those figuresagainst bedside time-lines-generally notice the broader diagnostic haze lift within hours. risks stabilize, and drug choices can often shift before evening rounds conclude. the obvious next step is to validate these signals across the sprawling datasets of multicenter registries until they earn a permanent spot on the nephrologists checklist. in parallel, watching nutritional markers, especially albumin, alongside c-reactive protein offers a second, sharper profile. that dual lens nudges the treatment blueprint closer to the individual patient rather than the textbook averages. references al-sayyari, a. a., & shaheen, f. a. 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(2019). clinical practice guideline on undernutrition in chronic kidney disease. bmc nephrology, 20, 1-10. zhang, w. r., & parikh, c. r. (2019). biomarkers of acute and chronic kidney disease. annual review of physiology, 81(1), 309-333. zoccali, c., mallamaci, f., adamczak, m., de oliveira, r. b., massy, z. a., sarafidis, p., agarwal, r., mark, p. b., kotanko, p., & ferro, c. j. (2023). cardiovascular complications in chronic kidney disease: a review from the european renal and cardiovascular medicine working group of the european renal association. cardiovascular research, 119(11), 2017-2032. pa ge 1 pa ge 23 american journal of medical science and innovation (ajmsi) obesity and male fertility: an in-depth review of the impact of elevated bmi solmaz gul sajjad1, aarush mohammad sajjad2, michael fakih md3, muhammad ahsan akhtar md frcog4 yasmin sajjad md frcog4* volume 3 issue 2, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i2.2540 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 07, 2024 accepted: july 13, 2024 published: july 17, 2024 this paper discusses the complex relationship between obesity and male infertility in a detailed manner. according to the introduction, obesity-related infertility is importantly discussed since it affects some 15% of couples in which half cases are attributed for obesityrelated infertility is important to discuss since it affects some 15% of couples, and half of cases are attributed to male factors. the body of the analysis discusses various factors related to obesity-associated male reproduction implications, including endocrinopathies insulin sensitivity, sperm dna fragmentation, erectile dysfunction osas asshened semen characteristics chronic epididymitis and epigenetic changes. the above discussion on endocrinopathies shows that excessive white adipose tissues derail the hpg axis, triggering hormonal imbalances which lead to infertility. this paper explains the interaction between insulin resistance and testosterone levels in type 2 diabetes affected men. the paper also focuses on sperm dna fragmentation, showing the association between obesity and increased levels of sperm dna damage, mitochondrial dysfunction and abnormality in morphology. erectile dysfunction is focused on obesity-induced oxidative stress, inflammation and hormonal abnormalities that impair male reproductive function. additionally, the role of sleep apnea in testosterone secretion and possible association between its severity to lower level of this hormone are presented. there is a further discussion of altered sperm traits, chronic epididymitis and epigenetic changes with regard to the obesity which gives us a broad perspective on male fertility. the paper then concludes its discussion regarding weight loss interventions restoring fertility, focusing on diet and exercise as means for reducing certain parameters associated with modifiable inflammatory markers linked to infertility. in summary, the general assessment highlights that obesity management is crucial in male infertility. keywords obesity, male infertility, epigenetic changes, dna fragmentation, erectile dysfunction, chronic epididymitis 1 nevill hall hospital, abergavenny hospital, south wales, united kingdom 2 whiston hospital, mersey & west lancashire trust, united kingdom 3 gynecological endocrinology & reproductive medicine and first ivf fertility centre and fakih ivf centre abu dhabi, united arab emirates 4 reproductive medicine, rcog accredited sub specialist in reproductive medicine, fakih ivf fertility centre abu dhabi, united arab emirates * corresponding author’s e-mail: y.sajjad@btinternet.com introduction as defined by asrm, infertility is any patient with regular, unprotected intercourse and no known aetiology for either partner that suggests impaired reproductive ability. evaluation should begin at 12 months for female partners under 35 and at six months for female partners 35 or older. this danger accounts for 15% of couples’ infertility, 50% of which is male (leslie et al., 2023). in contemporary countries, obesity is a major health issue that causes infertility (chaudhuri et al., 2022). over the last few decades, dramatic changes in semen quality have been found to be a universal trend due to civilised communities’ lifestyle modifications around the world, which are mostly sedentary and high in fast food and calories, which are considered the main causes of obesity. this is making obesity more common and rising. being overweight harms health. being overweight or obese may cause infertility in men and make it harder for couples to conceive. obesity is linked to male infertility in many studies (amiri & tehrani, 2020). obesity may disrupt the hypothalamicpituitary-gonadal (hpg) axis’ synchronised correlation and complicated signal connections with other reproductive hormones (chaudhuri et al., 2022). physical factors like supra pubic heavy adipose tissue deposits increase scrotal temperature, oxidative stress (os), and pro-inflammatory mediators, impairing semen parameters (chaudhuri et al., 2022). obesity also substantially disrupts sperm genetic and epigentic conformation, altering dna methylation patterns and impairing spermatogonia, causing infertility (cescon et al., 2020). given new evidence-based ideas concerning obesity-related male infertility, its cause and mechanism must be investigated. this article reviews obesity’s relationships with infertility characteristics that may affect male infertility directly or indirectly. materials and methods this paper is written with an overview of related articles published in pubmed. a systematic review of the literature was performed to identify the complex relationship between obesity and male reproductive potential. our review considered studies that investigated the following outcomes: likelihood of obesity on male infertility, sperm concentration and dna fragmentation, erectile pa ge 24 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 23-30, 2024 dysfunction, epigenetic changes and effecting other male reproductive functions including endocrinopathies & insulin sensitivity. the review was carried out to include all published literature. no date restrictions were applied, but language was restricted to english. studies were retrieved up to december 2023, with an updated search performed in february 2024. inclusion criteria followed were for studies carried out on male adults aged >18 years without history of reproductive disorders. data had to be reported with men categorized by body mass index (bmi), including a normal weight group (bmi ≤ 25) and an obese group (bmi ≥ 30). all types of quantitative research were eligible for inclusion in the review including case series and reports. the exclusion criteria applied were non-peer-reviewed sources, studies with low methodological quality, or irrelevant topics. for relevance screen search results typically involved multiple stages including screening titles and abstracts followed by full-text assessment. data extraction from the included studies involved a systematic process to record information, such as study design, sample characteristics, key findings, and quality assessment criteria. we employed bibliometric and gap analysis to systematically analyse and synthesize the literature to identify patterns, themes, and gaps on the subject of effect of male obesity on male reproductive potential that helped us in the development of this review article. the limitations of this review article methodology included publication & selection biases and constraints due to resources available to us and time constraints. the literature review discusses complete relationship between obesity and male infertility. it shows that excessive white adipose tissues derail the hpg axis, triggering hormonal imbalances causing hypogonadotropic hypogonadism, causing spermatogenesis disorder that leads to infertility. obesity can affect levels of testosterone, inhibin b, shbg, and increase oestrogen and leptin. moreover it explains the interaction between insulin resistance and testosterone levels in men with type 2 diabetes. the paper also focuses on the association between obesity and increased levels of sperm dna damage, mitochondrial dysfunction, and abnormality in morphology. a broad perspective on male fertility has been provided by reviewing the association between obesityinduced oxidative stress, hormonal impairment leading to male reproductive dysfunction, chronic epididymitis, and epigenetic changes. the paper concludes its discussion on weight loss interventions for restoring fertility focusing on diet and exercise and highlighting that obesity management is crucial in male infertility. literature review adipose tissue can be classified as brown adipose tissue and white adipose tissue. brown adipose tissue contains multilocular adipocytes vast amounts of mitochondria that express high levels of uncoupling protein 1 (ucp1), this is leads to the thermogenic activity of the tissue (omran & christian, 2020). white adipose tissue stores fat with fibroblasts, preadipocytes, mature adipocytes, and macrophages (fernández-sánchez et al., 2011). white fat deposits are greater in obese animals due to adipocyte hyperplasia and hypertrophy, and white adipose tissue may generate endocrine, paracrine, and autocrine chemicals (fernández-sánchez et al., 2011). secondary hypogonadism in obese people may decrease spermatogenesis and cause erectile dysfunction (cabler et al., 2010). obese people have excess white adipose tissue, which increases testosterone to oestrogen conversion and reduces gonadotrophin release due to hpg axis negative feedback loop disruption. spermatogenesis is disrupted by this. the increased oestrogen from this conversion reduces endogenous gonadotrophin release. oestrogens inhibit gnrh pulsatility (colaci et al., 2012). fat men have increased amounts of aromatization activity, adipose-derived hormones, and adipokines, which convert testosterone to oestrogen (cabler et al., 2010). endocrine and secretory white adipose tissue secretes several physiologically active peptides and proteins. these include adipokines, which include immunomodulators, or adipose-derived hormones including leptin, adiponectin, and resistin (ren et al., 2022). adipose-derived hormones regulate food intake, insulin action, energy balance, lipid, and glucose metabolism. increased white adipose tissue in obese males may enhance adipose-derived hormones (gómez-hernández et al., 2016). additionally, adipose tissue and testicular leydig cells contain aromatase cytochrome p450 enzyme, which is essential to oestrogen production. thus, white adipose tissue is thought to cause enhanced oestrogen levels in obese men due to androgen conversion (katib, 2015; palmer et al., 2012). white adipose tissue increases hypothalamic-mediated leptin production, which regulates energy intake and expenditure and decreases leydig cell testosterone production. this may explain why obese men’s greater leptin levels may affect the hpg axis and lower testosterone synthesis (khodamoradi et al., 2022). sperm plasma membranes and testicular tissue have leptin receptors, indicating that leptin may operate on these receptors (sengupta, bhattacharya, and dutta, 2019). leptin may directly affect sperm via the endocrine system independent of hpd axis modifications (isidori et al., 1999). fsh/lh ratios, inhibin b, and shbg levels regulate sertoli cell activity and spermatogenesis. males with high bmis have lower hormone levels. low lh and testosterone levels may cause hypogonadotropic hypodonadism and male infertility (hohl and ronsoni, 2022). to conclude, obesity may diminish sperm counts due to impaired sertoli cell activity and hpg axis abnormalities caused by testosterone and oestrogen (davidson et al., 2015). type 2 diabetic males should evaluate their testosterone levels. secondary hypogonadism in males with type 2 diabetes may result from peripheral and central insulin resistance, as well as the impact of proinflammatory cytokines (tnfα and il-6) on the hpg axis (bhasin et pa ge 25 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 23-30, 2024 al., 2010). increased insulin levels may lower shbg levels in obese men’s livers, thereby increasing blood levels of active unbound estogrens and testosterone. after shbg correction, low testosterone levels were linked to insulin resistance and obesity. insulin resistance affects testosterone and sperm production independently (tsai et al., 2004; palmer et al., 2012). sperm chromatin, a compact, organised structure, preserves genetic integrity. obese males had more sperm with dna fragmentation, poor mitochondrial membrane potential (mmp), and aberrant morphology and motility. these causes may cause male infertility (durairajanayagam, 2018). oxidative stress reduces sperm motility (nowicka-bauer and nixon, 2020; blumer et al., 2008). continuous atp generation by mitochondria in the midpiece controls sperm motility. selective permeability of the mitochondrial membrane maintains an electrolytical gradient between the inner and outside surroundings. this permits oxidative phosphorylation to produce enough atp. however, excessive reactive oxygen species (ros) damage phospholipid membranes, limiting oxidative phosphorylation and atp generation (fariello et al., 2012). lower sperm mitochondrial activity was detected in obese males. figure 1: mechanisms involved and the effect on male infertility (cabler et al., 2010) erectile dysfunction (ed) in males is the continuous inability to achieve or maintain an erection suitable to perform sexual activity (geerkens et al., 2020). what we know so far shows that ed is more common in overweight men from childless couples than in other guys (zhang et al., 2019). sultan et al. (2023) say that men with a bmi of 28.7 or higher are 30% more likely to have ed than men with a normal bmi (<25). overweight people and people with ed both have oxidative stress, inflammation, and insulin and leptin resistance, all of which can affect ovulation (moon, park, and kim, 2019). a rise in fat levels in the blood, the release of adipokin from adipocytes that have become too big, and the entry of immune cells into the adipose tissues are some of the most important signs of obesity. these things cause insulin and leptin resistance (shimobayashi et al., 2018). going against leptin also makes the brain release less gonadotropin-releasing hormone (gnrh). because of this, testosterone levels drop, which can lead to ed (moon, park, and kim, 2019). also, sexual dysfunction wasn’t linked to infertility caused by ed from a higher bmi. instead, it was more likely due to other biological changes being harmed by being overweight (nguyen et al., 2007). obstructive sleep apnea (osa) is a sleep-related breathing disorder and is characterised by a decrease or complete cessation in airflow in spite of an ongoing effort to breathe. osa occurs due to periodic narrowing and obstruction of the pharyngeal airway during sleep., resulting in hypoxia and hypercapnia. (osman et al., 2018; arnold et al, 2017). osa can have an impact on daily life as it alters the suffers ability to have a calm and continuous nights’ sleep, and therefore can lead to increased daytime sleepiness, personality changes or cognitive difficulties related to fatigue (arnold et al, 2017). osa is more common amongst obese individuals and results in hypoxemia with each pause in breathing. the role of osa in male infertility is not well understood it is often associated with a decrease in morning testosterone concentration and a decline in pituitary gonadal function which are necessary for normal spermatogenesis. (cojocaru et al., 2023; cabler et al., 2010). it has been suggested that nocturnal testosterone rhythm is disrupted by sleep apnea due to sleep fragmentation (katib, 2015). total and free testosterone levels were reduced in obese osa men in comparison with age‐ and body weight‐matched control men. a negative correlation was established between severity of sleep apnea and pa ge 26 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 23-30, 2024 testosterone levels, which was still true after adjusting for bmi and waist values. therefore, it was suggested that the major factor responsible for the decrease in testosterone secretion in osa is the severity of sleep apnea (katib, 2015). results and discussion sperm parameters such as concentration, sperm motility and morphology have shown to be affected by male obesity. there has also been some evidence suggesting that weight loss can efficiently lead to increased levels of serum testosterone levels and hence increased sperm count. (liu and ding, 2017). a study reported that spontaneous and progesterone-induced acrosome reactions are potentially impaired in obese men (liu and ding, 2017). the correlation between male obesity and its impact on sperm acrosome reaction is sparingly documented in literature. however, it is reasonable to assume that spermatogenesis and sperm maturation is affected by obesity. this results in oxidative stress and membranous lipid alteration, which therefore cause defects in acrosome reaction (aitken, 2020). there have been several studies on both humans and animals, to show a correlation between obesity and a decreased in sperm dna integrity. with obese males it has been shown that they often display an increase in sperm dna damage, alterations to reproductive hormones and a decrease in sperm motility and sperm concentration (leisegang et al., 2021). the main pathological mechanism described in literature to explain these changes has been an increase sperm oxidative stress with increases in bmi, mainly because of a rise in seminal macrophage activation. although the extent of increase was small, this phenomenon led to a decrease in acrosome reaction, lower embryo implantation rates during ivf, decreased sperm motility and an increase in sperm dna damage (palmer et al., 2012). as for the alterations to reproductive hormones, an increased bmi led to a decrease in sperm concentration and serum testosterone but an increase in serum estradiol (katib, 2015). it was also found that individuals with a higher bmi displayed an increase in chances of developing oligospermia. obese men were 3.5 times more likely to have oligospermia than men who possess a normal bmi. however, this value was slightly higher than the chances of developing oligospermia in overweight men (hajshafiha et al., 2013). the chances of developing oligospermia in overweight men was 3 times more likely than men with a normal bmi, therefore showing that a man doesn’t necessarily have to be classified as obese in order for his sperm count to be affected. one of the disadvantages of obesity is the increase in scrotal adiposity and subsequent increase in gonadal heat leading to an alteration in sperm production and parameters. the mechanism of spermatogenesis is sensitive to heat and testicular function is dependent on body temperature and requires a temperature of 2-4°c below body temperature in order to function optimally (gao et al., 2022) an increase in temperature of 1°c can result in a 14% reduction in spermatogenesis, and therefore a decrease in efficient sperm production (durairajanayagam, agarwal, and ong, 2015). an increase in temperature is related to reduced sperm motility, increased sperm oxidation stress, increased sperm dna damage, testicular germinal atrophy, spermatogenic arrest and a reduced level of inhibin b, with is a marker for spermatogenesis (durairajanayagam, agarwal, and ong, 2015). these all lead to lower sperm counts, therefore, it is crucial to maintain testicular temperatures slightly lower than that of the body to avoid abnormal spermatogenesis associated with male infertility (durairajanayagam et al., 2014). the temperature within the testis is maintained by characteristics of the scrotal sac including minimal subcutaneous fat, thin skin, scant hair distribution and dense sweat glands (ilacqua, francomano, and aversa, 2018). in order to maximize heat loss, the cremaster muscle surrounding the testes and spermatic cords, and the dartos muscle from beneath the scrotal skin all relax. the relaxation of these muscles causes the testes to descend away from the abdomen and the scrotal skin to loosen (fahmy, 2022). these characteristics increase the total surface area to allow for easy heat dissipation. another mechanism by which lower temperatures are maintained within the testis is a counter-current mechanism involving the testicular arteries and veins (aldahhan and stanton, 2021). there is a heat exchange of warmer inflowing arterial blood versus the colour outgoing venous blood. this system allows the cooler arterial blood to travel to the testis, and removes warmer venous blood (rizzoto and kastelic, 2020). there are several factors other than increased scrotal tissue that can raise scrotal temperature, either by whole body increase or a local increase. local elevation of scrotal temperature is often a result of direct heat exposure or effect of body temperature and diminished physiological testicular cooling mechanisms (sheynkin et al., 2005). such exposures include the use of laptop computers, plastic lined diapers in children, prolonged car driving, sedentary lifestyles, the use of tight jockey shorts. testicular heat stress caused by this increase in scrotal adiposity can subsequently causes oxidative stress. the increase in oxidative stress can therefore impair sperm motility, sperm-oocyte interaction and dna integrity. the combination of increase in temperature and lack of activity also impairs spermatogenesis (durairajanayagam, 2018). the membrane of sperm consists of saturated fatty acids, such as myristic acid, palmitic acid and stearic acid, as well as unsaturated fatty acids such as oleic acid, arachidonic acid, palmitoleic acid and docosahexaenoic acid. the composition of such fatty acids within spermatozoa are vital for sperm functions such as motility, viability and fertility (martínez‐soto, landeras, and gadea, 2013). whereas polyunsaturated fatty acids, such as docoseahecaenoic acid (dha), related to sperm concentration, motility and morphology (gonzálezpa ge 27 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(2) 23-30, 2024 ravina et al., 2018). these unsaturated fatty acids are also susceptible to reactive oxygen species (ros) and cause lipid peroxidation. therefore, excess ros found in obese males has the potential to result in lipid peroxidation causing poor membranal lipid fluidity, alterations to acrosome reaction and sperm motility (sinha and gupta, 2018). it was found that the regulation of fatty acid metabolism in the testis may be altered by bmi, hence resulting in changes to fatty acid composition of spermatozoa. this suggests that sperm quality in men with high bmi may be vastly affected by changes to fatty acid compositon of spermatozoa (andersen et al., 2016). membrane cholesterol is another key constituent of spermatozoa, and this varies during sperm maturation and capacitation. the main role of mammalian spermatozoa is to fertilize their female contrary, the oocyte, and the capacity to achieve this phenomenon is gained during a multi-step process known as “posttesticular maturation” (ramal sanchez et al., 2018). cholesterol plays a vital role in the modifcations of the composition of sperm plasma membrane which are crucial for fertility (rajoriya et al., 2020). these epididymal maturation steps prepares sperm cells for capacitation, which is the next maturation step, and also relies on the plasma membrane cholesterol (visconti et al., 2011). to summarise, levels of cholesterol in sperm is highly variable, but it has been suggested the higher sperm cholesterol levels in obese males have a contribution to infertility. the mechanism of this is due to that fact that development of acrosomal responsiveness and ability to fertilise in vitro is affected by cholesterol content of sperm. these changes are thought to lead to alteration to sperm morphology, decreased motility and premature acrosome reaction (liu and ding, 2017). although the current mechanism is unknown, it is evident that obese men have redundant areas of fat found at the suprapubic and inner thigh regions which can cause mechanical inflammation to the scrotal contents. this include epididymitis, in which during physical activities the friction from rubbing and sheering forces can result in inflammation (katib, 2015). any changes to the epididymis, regardless of the cause, alters the environment within the epidydmis. such changes can have a knock-on effect on sperm maturation and inflammation can thus lead to scarring and cyst formation which subsequently results in blockage of epididymal ducts (schagdarsurengin et al., 2016). although either one or both of the ducts can be blocked, cases that involve bilateral epididmytis have more impact on male fertility. dna methylation and acetylation of histones is dyanmic and are vital processes for the function of normal spermatogenesis, and therefore a successful pregnancy. dna methylation involves the reversible attachment of a methyl group to a nucleotide in a heritable manner (ge et al., 2017). epigenetic changes regulate gene expression and transcription intensity without changing the genetic information within dna. these include dna methylation, hydroxymethylation, histone modifcations and non-coding rna expression (mendelson, 2017). genetic modifications can be affected by genetic and environmental factors, one of these being obesity. it has been found that increased bmi can lead to alterations in dna methylation (dick et al., 2014; ozanne, 2015). furthermore, it has been suggested that children born to obese fathers are more likely to suffer from metabolic disease and develop childhood obesity. therefore, suggesting that paternal obesity can contribute to the health of offspring (soubry et al., 2016). consequently, it has been shown that paternal obesity can influence epigenetic modifications in sperm. it has been suggested that weight loss can lead to an altered androgen profile and therefore improve semen quality. it is evident that obesity in males has a negative effect on fertility, hence sperm function and subsequent impact on offspring. therefore, interventions such as alterations to diet and exercise are able to reverse the obesity state and hence the alter the impact on sperm and offspring. by altering bmi, this has a cumulative effect at changes at the molecular level, thereby decreasing oxidative stress and any dna damage (savini et al., 2013). it has been shown in the literature that numerous studies suggested that weight loss naturally by dieting and/or exercise led to an increase in androgen, inhibin b and sex hormone-binding globulin levels and decreased serum concentrations of insulin and leptin (kasturi, tannir, and brannigan, 2008). these changes result in improved semen parameters in obese men (chavarro et al., 2010). moreover, weight loss by the reduction of adipose tissue coupled with exercise or a low-fat and low energy diet has been seen to be linked to a decrease in tnfα, il-6 and other inflammatory cytokine levels related with infertility (manna and jain, 2015). other than the fertility issue many other health issues are also related to obesity including non-alcoholic fatty liver disease which is the most common liver disease and is closely linked with obesity and metabolic syndrome onyango, (vc et al . 2023). therefore by adopting weight loosing strategy it will not only imorove the fertility but also will help with general well-being. conclusion obesity can have physical and psychological impacts along with other serious comorbidities. as discussed above, the literature has proven that obese men are at risk of increased chances of infertility due to mechanisms involving hormonal, physical, adipokine and cytokine changes. these changes can eventually lead to abnormal sperm parameters, changes to sperm function and sperm molecular composition. offspring from obese fathers also have the potential to develop metabolic disorder, and childhood obesity. references aitken, r. j. 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(2011). ion channels, phosphorylation and mammalian sperm capacitation. asian journal of andrology, 13(3), 395. https://doi. org/10.1038/aja.2010.69 zhang, j., yang, b., cai, z., li, h., han, t., & wang, y. (2019). the negative impact of higher body mass index on sperm quality and erectile function: a cross-sectional study among chinese males of infertile couples. american journal of men’s health, 13(1), 1557988318822572. https://doi. org/10.1177/1557988318822572 pa ge 1 pa ge 74 american journal of medical science and innovation (ajmsi) fibroids and subfertility: a systematic review of latest evidence from international societies alina shirazi1*, tokunbo adeoye1, seema bagtharia1, jitendra jadhav1, sumi garg2, humna mian faiz rasul3, fatima shah4 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3992 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: november 03, 2024 accepted: december 08, 2024 published: march 04, 2025 uterine fibroids (leiomyomas) are benign tumors of the uterus, commonly present among women of reproductive age, affecting fertility outcomes. this systematic review aims to gather the current evidence regarding the association between fibroids and subfertility. additionally, this review aims to analyze national recommendations to conclude the best uterine fibroid treatment, while highlighting the optimal method of enhancing pregnancy rates. a thorough literature search was conducted to retrieve standard of practice guidelines across pubmed, google scholar, and medline databases. further guidelines were also searched through relevant websites of obstetrics and gynecology associations. hence, seven international clinical guidelines were retrieved. the findings state that fibroids can affect fertility through several mechanisms, such as modification of the uterine environment, and distortion of fallopian tubes and uterine cavity, leading to potential implantation and placentation failure. in addition, various fibroid management approaches, including medical treatments like surgical and minimally invasive interventions in women desiring future fertility, are investigated. latest studies suggest that the amount, size, and location of fibroids impact fertility outcomes. all guidelines recommend that during the selection of a treatment method, personalized patient requirements like the preference for childbirth in the future should be taken into consideration. the number, size, and location of fibroids are critical elements to take into consideration. globally, fibroid management with inexplicable infertility in women has limited empirical and standardized guidelines. therefore, further research is crucial to understand the fundamental mechanisms and to establish effective management strategies for women with fibroids facing subfertility. keywords fertility, fibroids, guidelines, infertility, leiomyomas, uterine fibroids 1 department of obstetrics and gynaecology, basildon hospital, south and mid-essex foundation trust, basildon, essex, uk 2 department of obstetrics and gynaecology, colchester hospital, uk 3 sir syed medical college, karachi, pakistan 4 bedford hospital, nhs trust, bedford, uk * corresponding author’s e-mail: alinashirazimrcog@gmail.com introduction uterine myomas (leiomyomata, fibroids) are known to be the most common type of reproductive tract tumors, showing a cumulative incidence rate of 70% among women of reproductive age (baird et al., 2003; cramer & patel, 1990). due to fibroids, a woman’s quality of life is impacted along with fertility and obstetrical results. they are developed through the fibroblasts of myometrium and the cells of smooth muscle, categorized as submucosal, intramural, or sub-serosal, reliant on their position (michos et al., 2023). the stimulation of estrogen has a positive association with the development of fibroids, resulting in fibroid reduction as menopause initiates (goerke et al., 2014; toprak et al., 2019). usually, leiomyomas are one the main issue that arises in women of reproductive age, which can pose detrimental effects on fertility outcomes or exhibit symptoms like bleeding, pressure, abnormal uterine bleeding, or pelvic pain (drayer & catherino, 2015; khaund & lumsden, 2008). uterine myomas, also known as benign monoclonal tumors, are typically common among women of african lineage (khaund & lumsden, 2008; mahdi, 2019). at an early age, african descent women usually give birth with a substantially adverse burden of myoma as compared to caucasian women with symptomatic myomas (peddada et al., 2008). throughout the years, several research groups and societies either national or international, have led studies to investigate the link between leiomyomas and fertility, with contradictory outcomes concerning the influence on fertility (khaund & lumsden, 2008; mukhopadhaya et al., 2007; pritts, 2001). uterine fibroid management is highly debated among women with subfertility, with different recommendations for non-surgical procedures like, medical intervention and observation, and surgical procedures like, myomectomy. furthermore, concerns have been raised regarding the probability of success and intervention protocols with the application of assisted reproductive technologies (art), like in-vitro fertilization (ivf) in cases of leiomyomas. there is a critical need for a comprehensive systematic review evaluating the current evidence on fibroids and subfertility, keeping in consideration the complexity of the problem and the constant modifications of clinical guidelines. hence, this review aims to investigate the effects of fibroids on fertility outcomes, while assessing and presenting findings established on recent international guidelines. materials and methods this systematic review is executed based on the methodology permitting the preferred reporting items for systematic reviews and meta-analysis (prisma) statements (moher et al., 2009). pa ge 75 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 74-83, 2025 inclusion criteria guidelines were included if they met the following criteria: (1) clinical guidelines associated with uterine fibroids with fertility, subfertility, assessing fertility outcomes and treatment strategies (2) guidelines published/authorized by one or more nationally or internationally recognized medical associations linked to obstetrics/gynecology or interventional radiology, who classify as quality improvement guidelines or practice standards (3) recent studies published in the last few years, ranging from 2012 to 2024 (4) guidelines available in english. exclusion criteria guidelines were excluded if: (1) guidelines were noncurrent and outdated (2) guidelines related to nonuterine fibroids (3) not available in english. search strategy several electronic databases including pubmed, medline and google scholar were searched from 2012 to 2024 for relevant clinical guidelines regarding uterine fibroid treatments, reporting its clinical fertility outcomes which meets the inclusion criteria. to further search guidelines undiscovered through search strategy, the included guidelines’ reference lists were searched manually. guidelines were specifically limited to the availability in english language. varying on the database, different combinations of mesh terms were employed. the search terms included “fibroids”, “fertility”, “guidelines”, “leiomyomas”, “infertility”, “uterine fibroids”. data extraction and management screening of the abstracts and titles were performed by two reviewers. the titles and abstracts of the screened clinical guidelines were reviewed to ensure compliance with inclusion criteria. data extraction was performed employing the general data extraction methods comprising study attributes such as title, publication year, treatment approaches, and outcome measures. quality assessment in this review, the grade system (grading of recommendations, assessment, development, and evaluation) was employed to evaluate the quality of guidelines (brignardello-petersen & guyatt, 2024). results and discussions initially, 44 studies were overall identified and screened through comprehensive database searches. after implementing the inclusion and exclusion criteria, 7 articles were chosen for a thorough analysis, which included clinical guidelines available from 2012 to 2024. figure 1 shows the identified databases and screened studies included in this systematic review, meeting the inclusion and exclusion criteria. the prisma flow diagram was created using prisma2020 (haddaway et al., 2022). figure 1: prisma flow diagram detailing the process of study selection this review follows the guidelines from the british fibroid society (bfs) (trust, 2021), european medical journal of reproductive medicine (emj) (mahdi, 2019), royal australian and new zealand college of obstetricians and gynecologists (ranzcog) (australia, 2020), the american society for reproductive medicine (asrm) (penzias et al., 2017), society of obstetricians and gynecologists of canada (sogc) (vilos et al., 2015), the french college of gynecologists and obstetricians (cngof) (marret et al., 2012), and american association of gynecologic laparoscopists (aagl) (laparoscopists, 2012). all the guidelines support the statement that the effect of fibroids on fertility is associated to the endometrial cavity alteration and the fibroids position in the uterus. however, the type of treatments such as surgical treatments including, minimally invasive pa ge 76 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 74-83, 2025 gynecologic surgeries (migs), myomectomy, magnetic resonance-guided focused ultrasound (mrgfus), and uterine artery embolization (uae) or medical treatments needed is dependent upon the particular boards. leiomyomas on fertility outcomes due to uterine leiomyomas, clear anatomic disruption of the normal uterine cavity can occur. the endometrial cavity can be affected specifically by submucosal leiomyomas, potentially influencing embryo development and implantation. however, leiomyomas can occur in other positions like, in sub-serosal site or in myometrium (donnez & jadoul, 2002). leiomyomas can augment into large masses before the occurrence of symptoms such as, pelvic pain or pressure although, it may plausibly disturb pregnancy management and fertility (penzias et al., 2017). figure 2 shows the postulated mechanisms of fibroids. figure 2: postulated mechanisms through which fibroids results in subfertility this figure shows the postulated theories of mechanisms that can result in fibroids causing subfertility (khaund & lumsden, 2008). although, there are several fibroid categories (lasmar et al., 2005; stamatellos & bontis, 2007), the international federation of gynecology and obstetrics (figo) targeted a comprehensive categorization, suggesting the division of leiomyomas into eight types, 0 to 8 (munro et al., 2011). figure 3 shows the figo classification system for uterine leiomyoma. in accordance with this classification system, reliant on the percentage of protruding fibroid from the endometrial cavity submucosal myomas are subcategorized into 0, 1, and 2. moreover, the intramural myoma are subcategorized into 3, 4, and 5 whereas, the sub-serosal myomas are subcategorized into 6, 7, and 8. pa ge 77 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 74-83, 2025 figure 3: figo revised classification system 2023 for uterine leiomyoma this model summarizes the figo classification system for uterine leiomyoma (fibroids) based on its location (munro et al., 2011). this classification system was established for clinical and research purposes (gomez et al., 2021), however, in clinical application, there is substantial deviation in agreement (laughlin-tommaso et al., 2017). medical management in fibroids for the clinical management of fibroids, the recommendations of the guidelines promote gonadotropin-releasing hormone (gnrh) analogues as a pre-operative intervention and suggest careful application regarding ulipristal acetate (upa). table 1 shows the summary of the interventions associated with medical management of fibroids according to various international societies. if the other treatments are unsuccessful, bfs permits restricted use of upa for intermittent intervention of moderate to severe symptoms of fibroids due to the risk of severe liver injury (trust, 2021). on the other hand, the asrm does not approve upa in the united states for the treatment of fibroids, especially in infertile women, due to its significant adverse effects (penzias et al., 2017). the emj notes that upa can reduce fibroid size by inducing apoptosis in leiomyoma cells, but its use is limited to three months, with effects lasting up to six months (mahdi, 2019). according to ranzcog, usage of upa is restricted in infertile women with leiomyomas due to the associated risk of substantial adverse effects (australia, 2020). in contrast, gnrh analogues are widely suggested by the asrm, ranzcog, cngof, bfs, and aagl as preoperative therapies to reduce uterine volume and manage anemia, facilitating less invasive surgeries (australia, 2020; laparoscopists, 2012; marret et al., 2012; penzias et al., 2017; trust, 2021). however, the emj does not discuss gnrh analogs in their guidelines (mahdi, 2019). similarly, cngof and aagl do not discuss upa in their guidelines (laparoscopists, 2012; marret et al., 2012). although, sogc has discussed both upa and gnrh analogues, there is no role of their medical management as a stand-alone treatment (vilos et al., 2015). surgical management of fibroids to improve fertility myomectomy, a surgical procedure to remove uterine fibroids, is considered an option for improving pregnancy rates in certain cases, though recommendations vary across medical guidelines (casini et al., 2006). table 2 shows the summary of the interventions associated with surgical management of fibroids in enhancing fertility outcomes according to various international societies. the bfs suggests hysteroscopic resection for submucosal fibroids and open abdominal or laparoscopic surgery for intramural and sub-serosal fibroids (trust, 2021). emj suggests hysteroscopic or laparoscopic pa ge 78 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 74-83, 2025 table 1: summary of the medical management of fibroids. medical management bfs emj ranzcog asrm sogc cngof aagl u pa re st ric te d us e gr an te d fo r in te rm itt en t t re at m en t of m od er at e or se ve re sy m pt om s u se d fo r i ts fi br oi d siz ere du ct io n ef fe ct n ot re co m m en de d du e to th e ris k of a dv er se e ff ec ts n ot a pp ro ve d fo r tre at m en t i n th e u sa n o m ed ic al m an ag em en t as a st an dal on e tre at m en t n ot d isc us se d n ot d isc us se d g nr h a na lo gu es u se d as a p re -o pe ra tiv e m an ag em en t (h em og lo bi n op tim iz at io n) n ot d isc us se d u se d as a p re -o pe ra tiv e tre at m en t f or a ne m ia or v ol um e re du ct io n of fib ro id u se d as a p re -o pe ra tiv e tre at m en t f or fi br oi d vo lu m e re du ct io n n o m ed ic al m an ag em en t a s a st an dal on e tre at m en t u se d as a p re -o pe ra tiv e tre at m en t u se d as a p re -o pe ra tiv e tre at m en t f or a ne m ia myomectomy for submucosal fibroids and hysteroscopic myomectomy for fibroids situated in the figo 0 and figo-1 cavity (mahdi, 2019). asrm recommends myomectomy for women with distorted cavity fibroids (intramural with submucosal components or submucosal fibroids). however, it is generally advised against the procedure for non-cavity distorting fibroids in women experiencing no symptoms (penzias et al., 2017). on the other hand, in cases where severe distortion of pelvic architecture complicates oocyte retrieval, myomectomy may still be considered. ranzcog supports the use of hysteroscopic myomectomy to enhance fertility outcomes, particularly for submucosal fibroids, though it acknowledges the need for further research (australia, 2020). studies suggest that up to 50% of women suffering from infertility associated with fibroids become pregnant following myomectomy, with the most significant improvement observed in women with submucosal fibroids (jeldu et al., 2021). although, sogc suggests myomectomy as an effective treatment option for enhancing fertility, further investigation is stated (vilos et al., 2015). moreover, cngof recommends hysteroscopic myomectomy in sub-mucosal fibroids ranging less than 4 cm. whereas, laparoscopic myomectomy is recommended for symptomatic fibroids, taking in consideration its amount and size for enhancing fertility (marret et al., 2012). aagl recommends abdominal myomectomy when hysteroscopic myomectomy may widely damage the endometrial surface or in the presence of 3 or more sub-mucous fibroids (laparoscopists, 2012). table 2: summary of the surgical management of fibroids to improve fertility. surgical management societies myomectomy (hysteroscopic/laparoscopic/abdominal) bfs myomectomy enhances 50% of fertility in women with fibroid-associated infertility hysteroscopic suggested for sub-mucosal fibroids (<5cm and >50% intramural) open abdominal or laparoscopic suggested for intramural and sub-serosal fibroids emj myomectomy enhances 50% of fertility in women with fibroid-associated infertility hysteroscopic or laparoscopic suggested for submucosal fibroids hysteroscopic suggested for fibroids situated in the figo 0-1 cavity ranzcog hysteroscopic may enhance fertility in sub-mucosal fibroids myomectomy may be suggested for women undergoing art with sub-mucosal fibroids asrm hysteroscopic, laparoscopic or open may enhance fertility in asymptomatic women with cavity-distorted fibroids not suggested in infertile, asymptomatic women with non-cavity distorted fibroids sogc myomectomy suggested for enhancing fertility cngof hysteroscopic suggested for sub-mucosal fibroids (<4 cm) laparoscopic suggested for symptomatic fibroids aagl abdominal suggested for 3 or more sub-mucosal fibroids or when hysteroscopic may extensively damage endometrial surface pa ge 79 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 74-83, 2025 minimal invasive surgical options in context to preservation of fertility, mrgfus and uae are both under scrutiny. table 3 shows the summary of the minimally invasive surgical interventions associated with medical management of fibroids to improve fertility outcomes according to various international societies. bfs and sogc does not discuss mrgfus in its guidelines in context to fertility. emj recognizes the potential of mrgfus in treating infertility but concurs that additional studies are necessary to substantiate its effectiveness and safety (mahdi, 2019). asrm notes that currently, there is lacking evidence to suggest mrgfus for patients aiming to maintain future fertility, emphasizing the need for further research (penzias et al., 2017). ranzcog advises mrgfus, alongside other interventions like, radiofrequency ablation (rfa) and myolysis must be utilized only within approved clinical trials (australia, 2020). similarly, according to cngof and aagl, mrgfus must only be utilized within approved clinical trials (laparoscopists, 2012; marret et al., 2012). regarding uae, bfs acknowledges a growing number of pregnancies following the procedure but asserts that there is still inadequate data to endorse its safety for women with leiomyomas, desiring preservation of their fertility (trust, 2021). the asrm considers uae unsuitable for patients desiring pregnancy in the future as a result of augmented risks associated with pregnancy and possible ovarian reserve declines (penzias et al., 2017). ranzcog supports this stance, recommending that uae be limited to clinical trials when applied to fibroids in women with infertility (australia, 2020). emj reports that uae is associated with lower pregnancy rates and longer conception times in women under 35 compared to myomectomy, making it a less favorable option for those seeking to preserve fertility. additionally, cngof and aagl state uae as an inadvisable intervention for women desiring future pregnancies (laparoscopists, 2012; marret et al., 2012). whereas, sogc may recommend uae only in selective women due to increased pregnancyassociated risks (vilos et al., 2015). according to bfs, rfa is not suitable for treating all types of fibroids (trust, 2021). emj, asrm and sogc does not discuss both rfa and myolysis in context to fertility. cngof states that further research is essential for rfa and myolysis (marret et al., 2012). aagl does not recommend rfa for women wanting future pregnancies (laparoscopists, 2012). moreover, it does not discuss myolysis. overall, there is a consensus that all of the minimally invasive surgical procedures require further investigation and should currently be considered primarily within the framework of clinical trials. in line with this cautious approach, uterine-sparing, minimal invasive procedures are being explored as substitutes to myomectomy. table 3: summary of the minimal invasive surgical procedures. minimally invasive surgical procedures bfs emj ranzcog asrm sogc cngof aagl m rg fu s n ot d isc us se d pr om isi ng ro le in tre at m en t o f in fe rt ili ty r ec om m en de d on ly in ap pr ov ed c lin ic al tr ia ls fu rt he r s tu di es re qu ire d e ffi ca cy in fe rt ili ty n ot di sc us se d re co m m en de d on ly in ap pr ov ed c lin ic al tr ia ls re co m m en de d on ly in ap pr ov ed c lin ic al tr ia ls u a e in su ffi ci en t d at a as a sa fe m et ho d fo r w om en de sir in g fu tu re fe rt ili ty w ith fi br oi ds n ot re co m m en de d as it ha s a lo w fe rt ili ty ra te an d le ng th y co nc ep tio n du ra tio n (< 35 a ge ) re co m m en de d on ly in ap pr ov ed c lin ic al tr ia ls n ot re co m m en de d fo r w om en d es iri ng fu tu re fe rt ili ty d ue to p ot en tia l ris ks m ay b e re co m m en de d fo r s el ec tiv e w om en n ot re co m m en de d n ot re co m m en de d fo r w om en d es iri ng fu tu re pr eg na nc y rf a n ot a pp ro pr ia te fo r a ll ty pe s o f fib ro id s n ot d isc us se d re co m m en de d on ly in ap pr ov ed c lin ic al tr ia ls n ot d isc us se d e ffi ca cy in fe rt ili ty n ot di sc us se d fu rt he r r es ea rc h re qu ire d n ot re co m m en de d fo r w om en d es iri ng fu tu re pr eg na nc y pa ge 80 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 74-83, 2025 m yo ly sis n ot d isc us se d n ot d isc us se d re co m m en de d on ly in ap pr ov ed c lin ic al tr ia ls n ot d isc us se d e ffi ca cy in fe rt ili ty n ot di sc us se d fu rt he r r es ea rc h re qu ire d n ot d isc us se d quality assessment findings the quality assessment findings show that myomectomy is strongly recommended and supported by highquality evidence from cohort, observational studies and systematic reviews for the treatment for fibroidrelated infertility (grade 1a or a). whereas, uae is conditionally suggested for women suffering from large-sized fibroids, unable to treatment from surgery (grade 2b or b). furthermore, the expert opinion recommends that myomectomy and uae as effective interventions in accordance with most of the guidelines. no recommendations for the treatment of small-sized asymptomatic fibroids are suggested unless fertility is impacted. table 3 and 4 summarizes quality assessment findings using the grade system, applicable to fibroids and their treatment in infertility according to various international guidelines. table 4: grade system for fibroids and infertility treatment. evidence type bfs emj ranzcog asrm sogc cngof aagl rc ts h ig h qu al ity ; m yo m ec to m y im pr ov es fe rt ili ty (g ra de 1 a ) h ig h qu al ity ; m yo m ec to m y fo r su bm uc os al fi br oi ds (g ra de a ) h ig h qu al ity ; m yo m ec to m y fo r f er til ity (g ra de a ) h ig h qu al ity ; m yo m ec to m y ef fe ct iv e (g ra de 1 a ) h ig h qu al ity ; m yo m ec to m y im pr ov es fe rt ili ty (g ra de 1 a ) h ig h qu al ity ; m yo m ec to m y is th e go ld st an da rd (g ra de 1 a ) h ig h qu al ity ; m yo m ec to m y re co m m en de d (g ra de 1 a ) c oh or t s tu di es m od er at e qu al ity ; su pp or t f or m yo m ec to m y (g ra de 2b ) m od er at e qu al ity ; su pp or t f or m yo m ec to m y (g ra de b) m od er at e qu al ity ; m yo m ec to m y fo r fe rt ili ty (g ra de b ) m od er at e qu al ity ; su pp or ts m yo m ec to m y (g ra de 2 b) m od er at e qu al ity ; su pp or ts m yo m ec to m y (g ra de 2 b) m od er at e qu al ity ; be ne fit s o f su rg er y (g ra de 2 b) m od er at e qu al ity ; be ne fit s o f su rg er y (g ra de 2 b) c as eco nt ro l s tu di es m od er at e qu al ity ; be ne fit s o f su rg er y (g ra de 2 b) lo w q ua lit y: c as eco nt ro l e vi de nc e (g ra de c ) lo w q ua lit y; l im ite d ev id en ce (g ra de 3 c ) lo w q ua lit y; l im ite d da ta (g ra de 3 c ) lo w q ua lit y; c as eco nt ro l e vi de nc e (g ra de 3 c ) lo w q ua lit y; l im ite d ev id en ce (g ra de 3 c ) lo w q ua lit y; l im ite d ev id en ce (g ra de 3 c ) sy st em at ic r ev ie w s h ig h qu al ity ; st ro ng e vi de nc e fo r m yo m ec to m y (g ra de 1 a ) h ig h qu al ity ; su pp or ts m yo m ec to m y (g ra de a ) h ig h qu al ity ; st ro ng e vi de nc e fo r m yo m ec to m y (g ra de 1 a ) h ig h qu al ity ; su pp or ts m yo m ec to m y (g ra de 1 a ) h ig h qu al ity ; f av or m yo m ec to m y (g ra de 1 a ) h ig h qu al ity ; st ro ng e vi de nc e fo r m yo m ec to m y (g ra de 1 a ) h ig h qu al ity ; u a e an d m yo m ec to m y (g ra de 1 a ) e xp er t o pi ni on m od er at e qu al ity ; a gr ee m en t o n m yo m ec to m y (g ra de 2 a ) m od er at e qu al ity ; su pp or ts su rg er y (g ra de b ) m od er at e qu al ity ; su pp or ts su rg er y (g ra de 2 a ) m od er at e qu al ity ; su pp or ts su rg er y (g ra de 2 a ) m od er at e qu al ity ; su pp or ts su rg er y (g ra de 2 a ) m od er at e qu al ity ; su pp or ts su rg er y (g ra de 2 a ) m od er at e qu al ity : su pp or ts su rg er y (g ra de 2 a ) pa ge 81 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 74-83, 2025 table 5: recommendations of fibroid-treatments across various guidelines. evidence type bfs emj ranzcog asrm sogc cngof aagl st ro ng re co m m en da tio n g ra de 1 a ; m yo m ec to m y fo r fi br oi das so ci at ed in fe rt ili ty g ra de a ; m yo m ec to m y fo r s ub m uc os al fi br oi ds g ra de a ; m yo m ec to m y fo r f er til ity g ra de 1 a ; m yo m ec to m y fo r i nf er til ity g ra de 1 a ; m yo m ec to m y is st an da rd tr ea tm en t g ra de 1 a ; m yo m ec to m y is th e op tim al st an da rd g ra de 1 a ; r ec om m en ds m yo m ec to m y w ea k re co m m en da tio n g ra de 2 b; u a e fo r la rg e fib ro id s g ra de b ; u a e fo r la rg e fib ro id s g ra de b ; u a e fo r la rg e fib ro id s g ra de 2 b; u a e fo r la rg er fi br oi ds g ra de 2 b; u a e fo r la rg e fib ro id s g ra de 2 b; u a e fo r la rg e fib ro id s g ra de 2 b; u a e as fe rt ili ty -s pa rin g tre at m en t n o re co m m en da tio n g ra de b ; n o tre at m en t f or as ym pt om at ic sm al l fib ro id s g ra de c ; n o tre at m en t f or sm al l fib ro id s w ith ou t sy m pt om s g ra de 3 c ; n o tre at m en t f or as ym pt om at ic fi br oi ds g ra de 3 c ; n o tre at m en t f or sm al l fib ro id s g ra de 3 c ; n o tre at m en t f or sm al l fib ro id s g ra de 3 c ; n o tre at m en t f or as ym pt om at ic fi br oi ds g ra de 3 c ; n o tre at m en t f or sm al l fib ro id s conclusion this systematic review reports an agreement over significant guidelines concerning the effect of fibroids on fertility, emphasizing the negative impacts of submucosal fibroids that can modify the normal uterus lining. according to the reviewed guidelines, specifically of asrm and ranzcog, the results demonstrate that sub-serosal fibroids do not have negative fertility effects, whereas fertility is negatively affected through intramural fibroids impacting the cavity of the uterus. furthermore, myomas can substantially diminish the rates of conception and clinical fertility, regardless of their position. the main discussion revolves around improving the potential of conception among infertile women with fibroids and the adequacy of its surgery management. to enhance both the chances of ivf and spontaneous pregnancy, the surgical treatment must be personalized to attain an ideal uterine cavity. the surgeon must decide the type of surgical intervention; either a minimally invasive procedure or myomectomy is required, keeping in consideration the site and size of the fibroid. even though the fibroid position may be closely associated with clinical results, the effect of the amount and size of fibroids on fertility stays uncertain. current minimal invasive procedures consisting of mrgfus, myolysis, rfa, 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(2021). treatment summary of fibroids. pa ge 83 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 74-83, 2025 http://www.britishfibroidtrust.org.uk/fib_info/ sot.php#:~:text=in%20most%20cases%2c%20 fibroids%20do,how%20accessible%20the%20 fibroids%20are. vilos, g. a., allaire, c., laberge, p.-y., leyland, n., vilos, a. g., murji, a., & chen, i. (2015). the management of uterine leiomyomas. journal of obstetrics and gynaecology canada, 37(2), 157-178. https://doi. org/10.1016/s1701-2163(15)30338-8 pa ge 1 pa ge 58 american journal of medical science and innovation (ajmsi) effect of maternal heart disease on fetal and maternal outcome in omdurman maternity hospital roaa mohamed ahmed elhaj1*, zeinab balla ali keer2, kameel kamal kamil3, sumia mohammed elshafie4 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3857 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: september 27, 2024 accepted: november 01, 2024 published: february 14, 2025 pregnancy significantly impacts cardiovascular system, leading to 1% to 4% complications in women without preexisting cardiac abnormalities globally. this study aims to determine the effect of maternal heart disease on fetal and maternal outcomes. the cross-sectional study was conducted at omdurman maternity hospital from february 2017 to january 2018, involving 146 patients with cardiac disease who had antenatal care in the hospital. data was collected through a questionnaire after informed written consent, and analyzed using spss version 20 on a computer. the study revealed results of 146 patients, with 42.5% aged 2335, primarily from rural areas. the majority delivered vaginally, with 32.6% undergoing a cesarean section. the most common heart disease was rheumatic heart disease (67%), with mitral stenosis being the major lesion (41.8%). congenital heart disease was 26%, with vsd affecting 81.6%. acquired heart disease was seen in 7%, with 60% diagnosed as cardiomyopathies. heart failure was the most common complications, with maternal deaths occurring in 3.4%. perinatal complications included miscarriages (5%), terminations due to severe cardiac diseases (2%), preterm births (34.9%), iugr (1.4%), congenital heart disease (2%), stillbirths (2%), and early neonatal deaths (2.7%). the study revealed that rheumatic heart disease and cardiomyopathies are common during pregnancy, posing significant maternal and fetal risks, including heart failure, prematurity, miscarriages, iugr, still births, and early neonatal deaths. future studies can focus on implementing systematic cardiac screening, enhance preconception counseling, and develop multidisciplinary protocols. keywords cardiac diseases, fetal, heart disease, maternal, neonatal, pregnancy, rheumatic heart disease, sudan 1 m.b.b.s., mrcpi, shaqra general hospital, saudi arabia 2 m.b.b.s., md (smsb), mrcog, omdurman maternity hospital, sudan 3 m.g.o, khartoum mrcog, omdurman maternity hospital, sudan 4 md internal medicine, smsb omdurman maternity hospital, sudan * corresponding author’s e-mail: roaahaddad2021@gmail.com introduction maternal heart disease is a significant issue in obstetrics, impacting both the mother and fetus’ health (beaton et al., 2019). it can lead to serious consequences such as preeclampsia and maternal death, while less severe issues like pulmonary edema and cardiac arrhythmias may emerge (keepanasseril et al., 2021). neonatal consequences include low birth weight, premature birth, and a higher chance of congenital heart disease in infants (norman et al., 2020). despite advancements in medical understanding and technology, maternal heart problems still burden a significant percentage of pregnancies, affecting maternal death rates worldwide (ramlakhan et al., 2020). cardiac diseases complicate 1% to 4% of pregnancies in women without preexisting abnormalities, increasing the risk of morbidity and mortality during pregnancy (iftikhar & biswas, 2019). maternal cardiac diseases increase significantly the risk of morbidity and mortality during pregnancy resulting in around 10% to 25% of the maternal deaths every year. in the uk, maternal diseases of heart are the most frequent causes of maternal death, with 2.27 per 100,000 cases (tubb, 2024). in saudi arabia, a lack of information on maternal heart disease has led to the need for newer research (fayed et al., 2022; zakaria et al., 2020). the existence of maternal heart disease that leads to complications like postpartum hemorrhage, sepsis, infective endocarditis, and congestive cardiac failure, vector-borne diseases is presented in some studies in sudan (isogai & kamiya, 2019; suliman, 2011). the heart problems also cause fetal deaths through stillbirths and neonatal ones. these findings, therefore, emphasize the importance of research regarding the effect of maternal heart disease on pregnancy outcomes, especially in countries such as sudan where this issue is still unclear. the maternal and neonatal morbidities remain high in such regions. cardiovascular changes during pregnancy can have profound health implications both for the mother and for the fetus (ramlakhan et al., 2020). pregnancy leads to a significant increase in blood volume, cardiac output, and vascular resistance, often impacting existing heart disabilities or causing new complications like arrhythmia or in some cases heart failure (ngene & moodley, 2019; troiano, 2018). maternal heart disease also increases the risk of miscarriage, premature birth, intrauterine growth restriction, and congenital heart defects in the fetus (hardee et al., 2021). the incidence of maternal heart disease is very high in developing countries where women may be deprived of the prenatal care, specialized cardiac services that are possibly accessible in the developed world. the research in sudan revealed that maternal heart disease accounted for more than half of maternal deaths, and lethal complications such as postpartum hemorrhage, sepsis, and congestive pa ge 59 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 heart failure were more common (mohammed et al., 2011; mohammed et al., 2022; organization, 2018). however, the lack of comprehensive information on maternal heart disease and its influence on pregnancy outcomes in places like sudan highlights a crucial research gap. these findings prove the urgency to improve maternal heart disease impact on pregnancy outcome knowledge in regions like sudan where data is not available enough, and maternal and neonatal complications are a big issue to the public health officials. the maternal mortality rate in sudan and south sudan is higher than the global average, primarily due to infection, hemorrhage, obstructed labor, abortion, and hypertension. the armed conflict in sudan has impacted maternal health services, causing challenges in accessing essential care, increased risk of complications during pregnancy and childbirth, and mental health issues among pregnant women (alemu et al., 2019; olaleye et al., 2023). the maternal mortality rate in sudan and south sudan is significantly higher than the global average, largely due to factors like infection, hemorrhage, obstructed labor, abortion, and hypertension (alemu et al., 2019; makuei et al., 2020). the ongoing armed conflict in sudan further complicates these issues, increasing the risks of complications during pregnancy and childbirth. heart disease is a significant contributor to pregnancy complications, especially in regions with prevalent maternal and perinatal morbidities (ramage et al., 2019). understanding the impact of maternal heart disease on maternal health outcomes is crucial for improving healthcare delivery and reducing mortality rates among expectant mothers. this study aims to evaluate the outcomes of mothers diagnosed with heart disease admitted for delivery and the babies delivered by these mothers at omdurman maternity hospital. the findings will inform the development of healthcare practices and prenatal care strategies, ultimately aiming to reduce maternal mortality and morbidity caused by heart disease in sudan and similar low or low-middle-income countries. literature review cardiovascular impact of pregnancy one of the most significant cardiac complications during pregnancy is the worsening of pre-existing heart diseases that are the top cause of maternal mortality. women who are pregnant with heart disease are more vulnerable to complexities during pregnancy and postpartum. conditions such as valvular heart diseases, chronic hypertension, and congenital heart defects are risk factors for the mothers and the baby. factors such as older maternal age, higher rate of in vitro fertilization and multiple cardiovascular risk factors have been playing the main role in this rising concern (sahu et al., 2022). moreover, the cardiovascular system of a healthy pregnancy itself undergoes dramatic alterations to bear with the larger size of a fetus, thus imposing a greater burden on the heart. complications during pregnancy must be identified and managed early, and a multidisciplinary team including obstetricians, cardiologists, and other specialists, may be required to optimize management. studies in this regard highlight the necessity of making better evidence-based guidelines and specialized care centers (hauspurg et al., 2018). the effect of pregnancy on the cardiovascular area goes beyond the pregnancy period itself. women who previously experienced apos (adverse pregnancy outcomes) such as preeclampsia or gestational diabetes are more likely to develop cardiovascular disease in their future years (lane-cordova et al., 2019). hypertension disorders during pregnancy (hdp) are a specific concern because studies have shown that hdp is associated with a higher risk of cardiovascular diseases later in life, such as coronary artery disease, heart failure, and valvular heart diseases (honigberg et al., 2019). early intervention after delivery and modification of life style can help reduce these risks. obesity is a major factor which plays an important role in pregnancy combined with heart disease as it has been proven that obese women are at greater risk of developing different maternal cardiovascular complications. preconception counseling including weight management and other cardiovascular risk factors must be provided to these pregnant women (pfaller et al., 2021). pregnancy has a considerable effect caused by the conditions such as valvular heart disease, chronic hypertension, congenital heart defect, and non-ischemic cardiomyopathies which are comorbid conditions and the ones that increased mortality rates as well as morbidities among the fetus and the mother (sahu et al., 2022). the occurrence of congenital heart disease because of acquired maternal age, obesity, diabetes mellitus, and hypertension are among the reasons of high prevalence (hedermann et al., 2021; owens et al., 2018). adaptations of the cardiovascular system go beyond simple hemodynamic modification during pregnancy, and these multiple hemodynamic, metabolic, and hormonal changes burden the cardiovascular system to such a degree that women may be more prone to cardiovascular disease precipitation or aggravation. hypertensive disorders of pregnancy (hdp) are linked with early cardiovascular aging and a broader spectrum of diseases not previously considered, such as valvular heart disease. assessment and preventing hdp becomes an immediate need, since it leads to increased chances of well-known classic cardiovascular risk factors such as essential hypertension, renal disease, abnormal lipid profile and diabetes (melchiorre et al., 2020). due to a lack of guidelines to guide cardiovascular follow-up and preventive strategies after hdp, however, we propose that screening should be done as early as possible, particularly within one year of delivery. the maternal obesity also may provoke the cardiac complications in maternal women with the heart disease. addressing obesity during preconception counseling is a key factor for such cases, as for the high-risk pregnancy. pa ge 60 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 maternal mortality and heart disease maternal mortality has been the major health problem in the lowand middle-income countries (lmics). although obstetric direct causes (hemorrhage, hypertension, sepsis) account for most of obstetric deaths, cardiac disease is another indirect cause that is often neglected (makuei, 2021). a review covering 47 maternal mortality reports from 29 lmics stated the percentage of cardiac-related maternal mortality ratios as below 34% of the total maternal deaths recorded. the authors state that the number of cardiac disorders is certainly underestimated as some people, due to the lack of medical facilities, are undiagnosed in resource-poor areas (heemelaar et al., 2020). a study conducted in eritrea showed 2.3% of rheumatic heart disease among pregnant women who otherwise were asymptomatic and this shows that the burden of cardiac disease in pregnant population might be huge (otto et al., 2011). relevant factors to increase maternal mortality from cardiac disease in lmics are late presentation, low availability of specialized care, and poor monitoring and treatment during pregnancy. a study conducted on pregnant women in india concluded that the occurrence of maternal mortality was higher (5.45%) in women with heart disease than those without any cardiac condition and that the functional class of the heart (class with nyha iii-iv) is of high risk category and closely tied with the adverse outcomes (khan et al., 2018; meh et al., 2022; sharma et al., 2022). to deal with this challenge the authors call on improving emergency obstetric care, educating midwives, and raising accessibility of cardiology diagnostics and management especially in the countryside regions. implementing cardiac screening at antenatal care routinely and the system of referrals also might be helpful with detecting and monitoring high-risk cases. research on heart disease maternal mortality in lowmiddle income countries (lmics) is crucial. collaboration between medical institutions, policymakers, and researchers will develop effective initiatives to improve outcomes for pregnant women with cardiac complications (ponikowski et al., 2014). reinforcing health systems, educating healthcare workers, and implementing early screening and intervention strategies are key approaches to cardiac disease reduction among lmic women. by addressing these issues, significant progress can be made on heart disease maternal mortality and global maternal health outcomes. maternal heart disease in sudan sudan has traditionally faced a very high maternal mortality rate, with a range of 750 to over 1400 maternal deaths per every 100,000 live births (makuei, 2021; sharma et al., 2022). however, the direct obstetric causes such as postpartum hemorrhage, obstructed labor, and sepsis account for the majority of maternal deaths and, additionally, the indirect causes like cardiac diseases are also significant factors. a community-based reproductive age mortality survey (ramos) conducted in kassala state, eastern sudan determined that 10.9% of the maternal deaths were solely based on puerperal septicemia which would be a remnant effect of an unverified cardiac disease (gebreweld & tsegaye, 2018). another study from a referral hospital in khartoum show that 2.7% of maternal deaths were attributed to cardiac factors (ounsa & mohamed, 2011). the multifactorial influences leading to high maternal mortality due to heart disease in sudan include delays in care-seeking, transport challenges and limited availability of specialized cardiac services, particularly at the rural areas. the ramos study showed the rates of illiteracy to be very high among the deceased women and their partners, which had a serious implication on seeking health care services. the authors advise to improve the quality of emergency obstetric care, to extend the training and coverage of midwifery services and to expand access to cardiological diagnostics especially in underserved regions. integrating cardiac screening into the regular antenatal care check-up and improving referral systems can also be very useful for locating and treating high-risk cases (van smoorenburg et al., 2023). maternal mortality in sudan due to heart disease is a significant issue that requires improvement in emergency obstetric care, midwifery training, and cardiac diagnostics. integrating cardiac screening into routine antenatal care and improving referral systems can help identify cases early. addressing social determinants of health, such as literacy levels and healthcare-seeking behaviors, and strengthening healthcare systems, increasing awareness, and using evidence-based approaches can significantly reduce maternal death and improve maternal health. materials and methods study design the study used a cross-sectional analytic hospital-based design, that is, particularly appropriate for establishing correlation between pregnancy complications and cardiovascular disease. this design helps researchers to gather data from a great number of participants during an allotted period of time and this allows them to identify patterns and recurring trends in the data (mohajan, 2020). the study was carried out at omdurman maternity hospital in sudan, which is the first maternity hospital and the largest referral hospital in the country for obstetric cases. this setting brings a chance to collect evidence on the prevalence and consequences of cardiovascular diseases in pregnancy involving sudanese population. the inclusion criteria for the study concerned all pregnant women who either delivered or terminated their pregnancy in hospital with cardiac disease (either new or old), and had antenatal care at omdurman maternity hospital. with this, it ensures that the sample depicts the expectation of the population of women who are pregnant with cardiac disease in sudan. the exclusion criteria includes pregnant women who didn’t take prenatal care in omdurman maternity hospital, meanwhile, the same is done in order to mitigate the biases in the data. pa ge 61 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 data collection data collection conducted using a questionnaire that covered major areas which the registrars filled during the delivery. the questionnaire consisted of five parts: demographic information, obstetric history, medical and surgical history, modes of delivery, maternal and fetal outcomes. this systematic method encompasses collection of data with regards to the medical history of the participants, their pregnancy outcomes, and other critical factors. at the initial visit, all pregnant women with cardiac disease were clinically examined by both an obstetrician and a physician, and an ecg and echocardiogram were conducted as standard procedures. this guarantees that the data gathered is accurate and dependable because it relies on clinical assessments and objective measures. data analysis data analysis was done on the computer with spss version 20 (statistical package for social sciences). descriptive frequency table was performed to determine the physiological and clinical characteristics of the participants. chi-square tests were used in the research for the correlation between different variables and to test for statistical significance (the p value). this statistical approach allows for the formulation of the sources of significant associations between variables and the identification of potential tendencies in the data. sample size the sample represented 146 patients, which is a small but significant proportion of the pregnant women with cardiac disease in sudan. this sample size was selected according to the availability of resources as well as the practicability of study implementation within the span of february 2017 and january 2017. ethical considerations the research was conducted ethically and responsibly, obtaining permission from reputable bodies like omdurman maternity hospital and the sudan medical specialization board. participants’ voluntary informed written consent was obtained, and confidentiality and privacy were guaranteed. the study’s ethical considerations were particularly important in a healthcare-accessible setting where participants could be easily exploited. a structured questionnaire and clinical evaluations were used to provide accurate data, ensuring participants did not experience harm or discomfort. results and discussion within this observational period, which covered both 146 deliveries and last trimester visits, nearly two-thirds of the patients, i.e. 62 individuals (42.5%), belonged to the age group of 26 to 35 years old. this population breakdown illustrated in the figure 1 emphasizes the widespread representation of this age group in the patient group. level of patient’s education varied not much, as 16 (11%) of the patients were illiterate, 54 (37%) as high school graduates and 46 (31.5%) as primary school graduates and 30 (20.5%) as university graduates, as seen in figure 2. the residence data also showed separation in the patient distribution with 84 individual (57.5%) patients from a rural area and another 62 (42.5%) patients from urban areas, as it is shown on figure 3. from the obstetric history, 40 patients (27.4%) were primigravida while 68 (46.6%) had a parity between 1 and 4 and the last 38 (26%) were multiparous with 5 or more pregnancies as depicted in figure 4. prenatal care initiation through the trimesters demonstrated varied distribution and 64 patients (43.8%) were booked during their second trimester, 36 patients (24.7%) were booked during their first trimester, and 46 patients (31.5%) were booked during their third trimester. among the few patients who had different booking times, the majority of them delivered after 37 weeks of gestation, 79 patients (54.1%), and ten (6.4%) experience early delivering due to premature before 24 weeks, so it is essential to provide full antenatal care for a timely manner. additionally, there were 108 (74%) patients among those that had not figure 1: distribution of patients according to age demographics pa ge 62 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 figure 2: distribution of patients according to educational level figure 3: distribution of patients according to location figure 4: distribution of patients according to parity pa ge 63 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 obstetric history figure 5: distribution of patients according to gestational age at booking medical and surgical history figure 6: distribution of patients according to gestational age at delivery maternal and fetal outcomes figure 7: distribution of patients according to counseling pa ge 64 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 figure 8: distribution of patients according to etiology of disease figure 9: distribution of patients according to past history of complications figure 10: distribution of patients according to nyha classification pa ge 65 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 figure 11: distribution of patients according to mode of delivery modes of delivery figure 12: distribution of patients according to type of vaginal delivery figure 13: distribution of patients according to type of cesarean section pa ge 66 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 received information about the risk that can be imposed by the underlying medical condition during pregnancy which may mean that preconception care services had some gaps. on the other hand, 38 cases (26%) out of 146 total patients were counseled before conception, based on the information provided in figure 7. the results of the analysis revealed a complex and varied demographic and clinical profile of the patient base, thereby emphasizing the need for a personalized healthcare system with focus on better results during the perinatal period. rheumatic heart disease accounted for 67% of the patients in the study, making it the most common kind of cardiac disease (figure 8). 10.3% of the patients had previously had heart surgery, with balloon valvotomy, cardiac catheterization, valve replacement, and vsd closure being the most frequently performed operations. in addition, 19.2% of the participants had previously been hospitalized for different cardiac problems, whereas 70.5% had no prior issues (figure 9). 28.8% of patients were classified as belonging to class i, 24% as class ii, 37.6% as class iii, and 9.6% as class iv according to the nyha criteria (figure 10). the vast majority of patients (67.4%) gave birth vaginally; 72.5% did so spontaneously, 9.9% had an induction for medical reasons, and 17.6% used an instrument (figures 11 and 12). nonetheless, 32.6% of patients underwent cesarean section; 34% of these cases were emergency cases, and 66% were elective cases (figure 13). the tables below include a thorough examination of maternal heart disease and its effects on pregnancy outcomes. they classify and examine data on cardiac conditions, medical variables, obstetric difficulties, perinatal outcomes, and the link between preconception counseling and complications. the methodical structuring of this data aids comprehension of the complicated relationship between mother cardiovascular health and pregnancy outcomes. table 1: types of rheumatic heart diseases type n=98 percent ms 41 41.8 mr 22 22.4 ms+as 9 9.2 ms+ar 6 6.1 ms+tr 6 6.1 mr+tr 7 7.1 as 2 2 ar 1 1 tr 1 1 total 98 100 table 2: congenital heart disease type n=38 percent asd 3 7.9 vsd 31 81.6 tof 1 2.6 pda 2 5.3 pulmonary stenosis 1 2.6 total 38 100 cardiac conditions and complications table 1 demonstrates the proportion of various types of rheumatic heart diseases (rhd) among the 98 patients. the most prevalent type is mitral stenosis (ms), accounting for 41.8%, then comes mitral regurgitation (mr) which is 22.4%. other kinds, like the ms with as (aortic stenosis) and the ms with ar (aortic regurgitation) each account for around 6.1% cases. the rarest types include aortic stenosis (as), aortic regurgitation (ar), and tricuspid regurgitation (tr), each representing 1-2% of cases. table 2 shows congenital heart diseases in the 38 patients. ventricular septal defect (vsd) is the most common accounting for 81.6 percent of the cases and atrial septal defect (asd) is the second following with 7.9 percent. the incidence of pda and tof is 5.3% and 2.60% each. only one patient came along with pulmonary stenosis that is equivalent to the percentage of cases of 2.6%. pa ge 67 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 table 3: acquired heart diseases type n=10 percent cardiomyopathies 6 60 ischemic heart disease 3 30 pulmonary stenosis 1 10 total 10 100 table 4: associated medical conditions disease frequency percent hypertension 8 5.5 diabetes mellitus 1 0.7 thyroid 1 0.7 none 136 93.2 total 146 100 table 3 depicts acquired heart disease in 10 individuals. 60% of cases are cardiomyopathies while 30% are ischemic heart disease which is the second highest. one table 5: type of treatment treatment frequency percent antiarrhythmic 31 21.2 anticoagulants 55 37.7 antihypertensive 8 5.5 diuretics 9 6.2 beta blockers 1 0.7 oral hypoglycemic 1 0.7 thyroxine 1 0.7 none 40 27.4 total 146 100 of the patients suffer from pulmonary stenosis, which is 10% of total cases. medical conditions and treatments table 5 displays the treatment types given to the patients. anticoagulants have the highest usage at 37.7%, while antiarrhythmic drugs follow at 21.2%. the use of diuretics, antihypertensive drugs, and oral hypoglycemic table 6: c/s indications indication frequency percent 2ps 13 29.5 3ps 15 34.1 4ps 7 15.9 fetal distress 2 4.5 fop 4 9 boh 1 2.3 refusal of vbac 1 2.3 tubal ligation 1 2.3 total 44 100 agents are reduced proportionally. one third (27.4%) of people get no treatment. pregnancy and obstetric factors table 4 shows coexisting medical conditions among the mentioned population. arterial hypertension is a most frequently encountered condition (5.5%), followed by diabetes mellitus and thyroid conditions, each representing 0.7% of cases. majority of patients (93.2%) have no coexisting diseases. pa ge 68 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 table 7: obstetrics complications complication frequency percent pph 5 3.4 pih 3 2.1 sepsis 2 1.4 death 5 3.4 none 131 89.7 total 146 100 table 8: cardiac complications complications frequency percent heart failure 20 13.6 infective endocarditis 3 2.1 cerebrovascular accident 1 0.7 respiratory tract infection 1 0.7 pulmonary hypertension 4 2.7 pulmonary edema 3 2.1 arrhythmias 3 2.1 none 113 77.4 total 146 100 table 6 shows the indications for cesarean section (c-section). the most frequent reason is the 3ps (pre c/s, classical c/s or uterine rupture), which account for 34.1% of all cases, followed by the 2ps (pre c/s) at the table 9: perinatal complications complications frequency percent miscarriage 8 5.5 termination of pregnancy 3 2.1 iugr 2 1.4 premature 51 34.9 congenital heart disease 3 2.1 still births 4 2.7 early neonatal deaths 4 2.7 none 71 48.6 total 146 100 rate of 29.5%. other situations, including 4p (previous c/s with other high-risk factors), fetal distress, and failed operative cesarean, are of lesser occurrences. table 9 shows the perinatal complication among the patients. premature birth is the leading most challenge (34.9%) followed by miscarriage at 5.5%. other kinds of complications like, abortion, iugrs, stillbirths, early neonatal deaths and congenital heart disease are reported at small proportions. the great majority (48.6%) of patients did not get into any perinatal complications. association and counseling table 10 shows the connection between nyha table 7 reveals obstetric complications of women during childbirth in patients. in most instances (89.7% of the treated patients did not suffer from any complications). pph and maternal death take place in 3.4% of cases each and pih and sepsis happen to a smaller part of patients. table 8 represents the cardiac complications that should be observed in patients. the primary complication is heart failure and it accounts for 13.6% of all cases, coming after pulmonary hypertension and pulmonary edema, each representing 2.7% and 2.1% of cases, accordingly. infective endocarditis, cerebral stroke, respiratory tract infection and arrhythmias drop to a lesser extent. in the majority (77.4%) of patients there were no cardiac complications. pa ge 69 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 table 10: association between nyha classification and cardiac complications class complicated not complicated total i 4 38 42 ii 6 29 35 iii 14 41 55 iv 9 5 14 total 33 113 146 chi-square 35.115 p.v. 0.009 table 11: association between nyha classification and perinatal complications class miscarriage termination iugr premature congenital h e a r t disease stillbirth e a r l y neonatal l none total c. i 5 0 1 21 1 0 0 14 42 c. ii 2 0 1 2 0 0 2 27 35 c. iii 0 3 0 21 1 2 1 28 55 c. iv 0 0 0 7 1 2 1 2 13 total 7 3 2 51 3 4 4 71 146 chi-square 55.198 p.v. 0.000 table 11 shows the relation of nyha group to perinatal complications. the number of newborn injuries vary among different classes of nyha. class iii includes most of the complications such as danger of miscarriage, termination, iugr, premature birth, congenital heart table 12: association between preconception counseling and cardiac complications preconception counseling heart failure p. edema arrhythmias i.e. cva r.t.i. p.htn none total yes 5 0 0 0 0 1 2 30 38 no 13 3 3 3 1 0 2 83 108 total 17 3 3 3 1 1 4 113 146 chi-square 6.031 pv 0.420 disease, stillbirths and early neonatal deaths. the link between nyha classification and perinatal risks is strong, given the p-value of 0.000, which is statistically significant. table 13: association between preconception counseling and perinatal complications class miscarriage termination iugr premature congenital heart disease stillbirth early neonatal deaths none total yes 5 3 1 9 1 1 1 18 38 no 3 1 1 42 2 3 3 53 108 total 8 3 2 51 3 4 4 71 146 chi square 10.663 p.v. .154 classification (heart failure severity) and cardiac complications. in patients of nyha class i, 4 of them had cardiac complications and 38 were among the ones who did not face cardiovascular complications. the association between cardiac complications and nyha class turned out to be statistically significant and it was reflected with the p-value of 0.009. table 12 shows the relation between preconception counseling and cardiac events as shown in the table. preconception counseling resulted in 5 cases of heart disease among women when compared to those who pa ge 70 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 table 14: association between previous complication and cardiac complication previous complications heart failure p. edema arrhythmias i.e. cva r.t.i. p.htn none total heart surgery 4 0 0 1 1 1 3 5 15 hospitalization 11 3 3 2 0 0 1 8 28 none 3 0 0 0 0 0 0 100 103 total 17 3 3 3 1 1 4 113 146 chi-square 20.373 pv 0.040 table 14 provides the association between previous complications and cardiac complications. patients that have experienced heart surgery and hospitalization prior have demonstrated a greater risk of cardiac comorbidities when compared with patients without previous complications. the results indicate that the number of previous complications is associated with the occurrence of the cardiac complications at the significance level of 0.040. discussion rheumatic heart disease (rhd) was the most common cardiac disease complicating pregnancy in this study, affecting 67% of patients, which is comparable with results from comparable research in sudan, egypt, and south africa. mitral valve involvement, especially mitral stenosis (41.8%), was significant, but significantly lower than in pakistan and india (makate, 2021). congenital cardiac problems impacted 26% of patients, including ventricular septal defect (vsd) being the most common lesion, similar to a study conducted in khartoum teaching hospital six years ago (ottaviani & buja, 2022; yassin et al., 2015). vsd was the most prevalent lesion (81.6%), which is greater than in india. according to one study, rheumatic heart disease is the most prevalent cardiac lesion in pregnancy, followed by isolated mitral stenosis as the most common acquired lesion and mitral valve prolapse as the main congenital heart disease (puri et al., 2013). early identification and treatment of congenital cardiac disorders are critical for reducing unfavorable maternal and neonatal outcomes. these findings give useful information for healthcare policymakers and practitioners seeking to improve mother and child health outcomes in comparable settings. this study analyzed maternal complications, focusing on cardiac and obstetrics. postpartum hemorrhage was noted in 3.4% of cases, which is lower than india (11.9%) and pakistan (8.8%) (joshi et al., 2015; rafiq et al., 2023). pregnancy-induced hypertension was seen in 2.1% of patients. sepsis was noticed in 1.4% of cases, both ending with death. overall maternal mortality due to cardiac disease was 5.4% cases, with all five deaths occurring in women with unsupervised pregnancy and one antenatal care in late pregnancy. the most common cardiac complication was heart failure complicating (13%), which often leads to maternal death. monitoring cardiac patients for early detection and management is crucial throughout pregnancy, labor, and puerperium. infective endocarditis was reported 2.1%, while arrhythmias complicated 2.1% lower than in a study conducted in brazil (6.82%) (martins et al., 2016). pulmonary edema was reported in 2.1%, and cerebral vascular accident was seen in 0.7% of cases. fetal complications were seen in 51.4% of deliveries, with prematurity affecting being the most common (34.9%). there were 4 still births and 4 early neonatal deaths reported (2.7%), less than india’s 12.1% and netherlands’ 12.1%. out of 146 cases, eleven ended with miscarriages, 3 of which were therapeutic terminations due to severe cardiac disease. the new york heart association classification showed that most patients in class i & ii (52.8%) and class iii & iv (47.3%) had adverse maternal and fetal outcomes (webb et al., 2020). cardiac disease itself could be a risk factor for maternal and fetal complications. the majority of patients did not receive preconception counseling regarding their illness (74%), suggesting that educating prospective parents and screening for heart diseases is essential to reduce the burden of the disease. regarding previous history of cardiac surgery, 19% had undergone cardiac surgery before pregnancy, more than khartoum teaching hospital’s (13.3%) and india’s (9.09%) studies. the study found that a higher rate of surgical interventions allowed patients with cardiac disease to survive to child-bearing age and cope with changes during pregnancy. however, surgical intervention before pregnancy does not guarantee free pregnancy course of complications, as 10 out 15 patients who underwent surgery had complicated pregnancies. did not receive any advice which constituted 13 cases of heart disease. no important correlation was found between preconception consultation and cardiac issues worth of 0.420. table 13 shows the correlation between preconception counseling and perinatal problems. the case of perinatal complications including miscarriage, termination, iugr, low birth weight due to premature births, congenital heart diseases, stillbirths, and early neonatal deaths do not show a significant association with preconception counseling but only with zero to low odds ratio (p-value of 0.154). pa ge 71 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 58-73, 2025 19.2% of patients had a previous history of hospitalization due to heart failure, arrhythmias, or other cardiac indications, which is less than what was reported in canada (46%) (wald et al., 2015). a significant predictor of maternal cardiac complication was found in 20 out of 28 patients with a history of previous complications. most patients were aged between 23-35 years, with a mean of 30. in developing countries like ours, many cases tend to get missed due to lack of awareness and poor healthcare facilities. the majority of patients lived in rural areas, where health care facilities are either inappropriate or inadequate. educational level was lower in the study, with 31.5% or less having primary education and 75.5% or more having secondary education. most patients delivered at more than 37 weeks’ gestation (54.1%), which is lower than data from india (86.3%) (abbasi et al., 2017). assisted vaginal delivery with instruments was preferred to prevent maternal strain and exhaustion, with 17.6% of instrumental deliveries. epidural analgesia was recommended for patients with short second stages of labor and without assistance. cesarean section was performed in 30% of patients with good outcomes, but the jcs joint working group recommended it only for patients with cardiac dysfunction, hemodynamic instability, pulmonary hypertension, uncontrolled arrhythmia, mechanical valve prosthesis, and patients with cyanosis. conclusion rheumatic heart disease and cardiomyopathies stay among the main factors that cause cardiac complications during pregnancy as well. heart failure is one of the major issues, causing adverse maternal outcomes such as exacerbated morbidity and mortality. prematurity is the primary cause of the fetal complication. the course of pregnancy is determined by the maternal functional class which reflects heart failure (iii or iv), maternal previous cardiac problems being a powerful predictor of adverse maternal and fetal outcomes. regardless, an immediate diagnosis, a pre-conception management, and a favorable maternal functionality at the time of conception are among the factors that contribute to these positive maternal and neonatal outcomes. these findings highlight the priority of customizing whole care approaches while women are within the peripartum period, with particular emphasis being given to early intervention and smooth maternal health prior to conception. future recommendations adequate treatment of streptococcal infections in women can reduce rheumatic heart disease incidence. preconception counseling and regular antenatal follow-up with a multidisciplinary team can improve the outcome of pregnant cardiac patients. proper management during labor and early detection of 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(2020). development and usability testing of riyadh mother and baby multi-center cohort study registry. journal of infection and public health, 13(10), 1473-1480. pa ge 1 pa ge 11 3 american journal of medical science and innovation (ajmsi) assessment of bone mineral density in cirrhotic patients at ibn sina hospital amjed mohammed osman bashir1*, hala ibrahim abu alhassan2, abdel moneamal taeb2, ismat abdel rahmansirag2 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.3126 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: june 01, 2024 accepted: july 11, 2024 published: april 23, 2025 bone diseases are prevalent in patients with liver cirrhosis. bone mineral density is the most reliable method for detecting osteoporosis, osteopenia, and vulnerability to fractures, with an average prevalence of 35% worldwide. the study aimed to assess the relationship between bone mineral density and liver cirrhosis among sudanese patients. a cross-sectional study was conducted at ibn-sina specialized hospital among sudanese patients from june 2019 to november 2019. the study population consists of 80 patients suffering from liver cirrhosis and reduced bone mineral density. bone mineral density was measured using dexa. the diagnosis of osteoporosis and osteopenia was based on the criteria established by the who. further, the severity of liver cirrhosis was assessed using meld and child-pugh turcott scores. ethical approval and written informed consent were obtained. however, data were analyzed using appropriate statistical tests. the analysis revealed that among 80 patients (63.8%) were males and (36.2%) were females, with hepatitis b being the primary cause (61.3%), alcohol consumption (8.8%), and hepatitis c (3.8%). the average meld score was 15±6. however, abnormal dexa values were observed in (63.8%) of the patients, with (55%) showing osteopenia and (8.8%) showing osteoporosis. patients with encephalopathy had a high prevalence of osteoporosis and osteopenia with a significant p-value (p=0.002). other prominent factors included increased bilirubin (p= 0.000), hypernatremia (p=0.000), advanced child-pugh score (p= 0.041), and high meld scoring of liver cirrhosis (p = 0.000), showed statistical significance among these patients. the study showed that patients with liver cirrhosis were more susceptible to reduced bone mineral density, emphasizing the need for timely diagnosis and treatment of bone health issues. however, further research is required to examine the correlation between liver cirrhosis and bone disease in sudan’s population. keywords bone mineral densitometry, bone mineral density, chronic liver disease, cirrhosis, dual energy x-ray absorptiometry, elastography, fragility fracture risk assessment, model for endstage liver disease, osteoporosis, osteopenia 1 department of medicine, bakht el ruda university & sudan medical specialization board council of internal medicine, al khurtum, sudan 2 ibn sina hospital, mohammed najeeb st, khartoum, sudan * corresponding author’s e-mail: amjedmohammed58@outlook.com introduction the bone mineral density (bmd) test is utilized to measure the amount of calcium and other minerals in bones (ahmadi et al., 2018). bones with a higher mineral content tend to be denser, resulting in increased strength and reduced risk of fractures (burr, 2019). aging or certain medical conditions can decrease bone density (aspray & hill, 2019). in addition, bmd is the most reliable method for diagnosing osteopenia, osteoporosis, and the associated risk of fractures (choksi et al., 2018; rossini et al., 2016). osteoporosis is a condition characterized by the weakening and fragility of bones, which significantly increases the risk of fractures. this condition can be caused by excessive bone resorption (wilson, 2019). bmd assays are commonly employed for the identification and assessment of osteoporosis (sözen et al., 2017). the bmd is directly affected by the number of bones present in the skeleton, and stronger bones are associated with higher bmd (burr, 2019; nayak et al., 2016). however, genetic factors exert a substantial impact, which may occasionally be modified by external factors and medications (nayak et al., 2016). typically, bmd increases during childhood, reaches the highest point at the age of 25, and subsequently stabilizes for ten years. as people age, both men and women typically lose 0.3 to 0.5% of their bmd after the age of 35 years (nayak et al., 2016). the dual-energy x-ray absorptiometry (dexa) screening method is frequently employed to assess bmd in fragility fracture risk assessment (frax) (haseltine et al., 2021). social guidelines delineate the populations that are anticipated to benefit from dexa screening and provide instructions on utilizing the frax tool to assist with decisions regarding osteoporosis treatment strategies (haseltine et al., 2021; iseri et al., 2020). additionally, bmd problems can arise in people with chronic liver diseases, such as autoimmune, post-viral cirrhosis, cholestatic disorders, and alcohol consumption (george et al., 2009; mancell, 2020). this condition is known as hepatic osteodystrophy (ho), which is frequently identified in patients with chronic liver disease (cld) (ranjan et al., 2021). the cause of the disease is not well understood and is thought to differ depending on the type, severity, and course of liver disease, as well as other factors, such as the ethnicity of the population (barbu et al., 2017). however, ho can result in the occurrence of spontaneous lowtrauma fractures, leading to a substantial negative impact on morbidity, quality of life, and even survival (karoli et al., 2016). the main symptoms of this are discomfort, deformity, and immobility (haseltine et al., 2021). cirrhosis, a prevalent global health issue, can arise from various factors, including obesity, non-alcoholic fatty liver disease, excessive alcohol consumption, nonalcoholic steatohepatitis, hepatitis b or c infections, autoimmune pa ge 11 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 disorders, cholestatic conditions, and imbalances in iron or copper levels (ginès et al., 2021; smith et al., 2019). as cirrhosis progresses, there is a prolonged period of inflammation that causes fibrotic and regenerative nodules to replace healthy liver tissue, which raises the risk of portal hypertension (takahara et al., 2019). compensated cirrhosis is an asymptomatic phase of the disease that progresses to decompensated cirrhosis (kumar et al., 2023), a symptomatic phase characterized by frequent hospitalization, a decline in quality of life, and an increased risk of death (d’amico et al., 2022; zaccherini et al., 2021). the primary factors contributing to illness outcomes include liver failure, systematic inflammation, and increased hypertension (costa et al., 2021). treating the underlying causes of liver cirrhosis and controlling its side effects are the main goals of management; in some circumstances, liver transplantation (lt) may be necessary, and it is a gold standard for treatment (markin et al., 2019; trebicka et al., 2020). as liver transplantation becomes more common as the primary treatment of end-stage cirrhosis resulting from various causes (goel et al., 2019), bone disease has become a crucial factor in determining the patient’s survival and quality of life (d’oronzo et al., 2019; george et al., 2009). however, the diagnosis of liver cirrhosis can be accomplished by the utilization of elastography, a technique that assesses liver stiffness, in addition to a variety of blood tests that measure fibrosis scores (yoshiji et al., 2021). cld prevalence in sudan is unknown, but it is a significant healthcare burden due to diverse etiologies. the 2018 hepahealth survey found that cirrhosis and cld prevalence in europe ranges from 500 to 1100 cases per 100,000 individuals (traub et al., 2021). the us experienced a 65% rise in mortality associated with cirrhosis between 1999 and 2016, resulting in approximately 44,000 deaths in the us and 2 million worldwide (pimpin, 2018). moreover, variability in patient characteristics may account for differences in the reported osteoporosis prevalence among cld patients (muhsen et al., 2018). there is inconsistent advice on when to test for bmd in cld patients (danford et al., 2020). latent osteoporosis increases fracture risk, leading to higher hospitalization, morbidity, and mortality (muhsen et al., 2018). thus, early diagnosis is crucial for cirrhotic patients to prevent fractures and improve their quality of life (gokcan et al., 2020). studies showed that bone diseases are common in cirrhosis patients even after controlling for confounding factors (chen et al., 1996; danford et al., 2020; lupoli et al., 2016). this occurs due to decreased bmd, and the risk of fractures in cirrhosis is twice as high as that of the general population (jeong & kim, 2019; santos & romeiro, 2016). studies on bmd in sudanese cirrhosis patients are scarce. therefore, the study aimed to assess the relationship between bone mineral density and liver cirrhosis among sudanese patients. the present study provides insights into the incidence, risk factors, signs, prevention, and treatment of bmd in liver cirrhosis patients, defining osteoporosis or osteopenia. materials and methods study design and population this cross-sectional study was conducted at ibn-sina specialized hospital among sudanese patients from june 2019 to november 2019. the study population consists of 80 patients suffering from liver cirrhosis. ethical approval ethical approval was obtained from the sudan medical specialization board (smsb) and ibn sina hospital’s ethical committee. written informed consent was also obtained from the patients, and the study was carried out in conformity with the 1964 declaration of helsinki. the strobe guidelines were followed, and any subsequent revisions or with comparable ethical standards. inclusion and exclusion criteria the study included a clinically suitable participant cohort. the study included patients suffering from liver cirrhosis. conversely, the exclusion criteria included patients who had renal dysfunction, thyroid and parathyroid disorders, cushing’s syndrome, and diabetes. similarly, the study excluded patients who had a history of chronic disorders associated with changes in mineral metabolism. furthermore, patients who received calcium, vitamin d, and medications influencing bone metabolism such as corticosteroids, hormone replacement therapy, calcitonin, bisphosphonates, cytotoxics, anti-metabolites, anticoagulants, anti-convulsants, thyroxin and interferon were excluded from the study. sample size calculation the sample size was calculated using the following formula: n = ((z)2 p (1-p))/(d)2 n = ((1.96)2 x 0.05 (1-0.05))/(0.05)2 n = 80 cirrhotic patients where; n = sample size z = confidence interval p = previous prevalence (5%) d = marginal error (0.05) data collection the data was collected through structured questionnaires consisting of 6 components: a) demographic data, b) etiology and complications of liver cirrhosis, c) symptoms of osteoporosis, d) cirrhosis severity by using (ctp and meld scores), e) lab investigations, and f) dexa findings. clinical procedure bone mineral density was assessed in the patient’s heel using the furuno cm-200 light ultrasound bone densitometer, a compact and portable device manufactured by furuno electric co. ltd in japan. during the procedure, the patient placed their bare feet, right and left, in designated spaces within the machine while a lubrication gel was applied. subsequently, the system adapts to accurately pa ge 11 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 interpret the score. the results were interpreted according to the criteria of who: • t-score of -1.0 or above = normal bone density • t-score between -1.0 and -2.5 = low bone density or osteopenia • t-score of -2.5 or lower = osteoporosis data analysis the data was analyzed using statistical package for social sciences (spss inc., chicago, il, usa) version 21.0. descriptive statistics were calculated, which included frequencies and percentages, whereas the chi-square (χ2) test was employed to analyze categorical data. the p-value of < 0.05 was considered statistically significant. results and discussions the results section displays data analysis and statistical interpretations based on data collection. a total of 80 patients were included in the study, with a majority of male (63.8%) patients and female patients accounting for (36.2%). with a mean age of 49.6±13.9 years (31.3%), patients between the ages of 51 and 60. however, the majority of patients with cirrhosis were from the sudan central region (35%), followed by khartoum (26.3%) and west (21.3%), as shown in table 1. table 1: demographic characteristics (n= 80) characteristics frequency percentage gender male 51 63.8% female 29 36.2% age (years); mean ± sd 49.6±13.9 < 20 2 2.5% 20-30 7 8.8% 31-40 16 20% 41-50 15 18.8% 51-60 25 31.3% > 60 15 18.8% origin khartoum 21 26.3% central 28 35% west 17 21.3% north 11 13.8% east 3 3.8% figure 1 revealed that hepatitis b (hbv) accounts for (61.3%) of liver cirrhosis cases, while alcohol addiction accounts for (22.5%). the prevalence rates of autoimmune diseases, unknown etiology cases, and hepatitis c virus were (8.8%), (3.8%), and (3.8%), respectively. this analysis suggested a need for further investigation into potential risk factors. figure 1: etiologies of liver cirrhosis (n= 80) pa ge 11 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 table 2 presents the distribution symptoms of osteoporosis, patients’ performance, ascites, and encephalopathy among cirrhotic patients. encephalopathy and ascites indicate severe liver disease, classifying cirrhosis based on their quantity and intensity, which can significantly impact medical treatment for cirrhosis patients. the analysis revealed that a significant proportion experienced diminished energy (52.5%), while (35%) and (12.8%) experienced back or body aches. furthermore, cirrhosis was characterized by ascites in (37.5%) of cases, with (92%) of patients reporting no encephalopathy. table 2: distribution of clinical characteristics characteristics frequency percentage symptoms of osteoporosis fatigability 42 52.5% back pain 28 35% bone pain 10 12.5% patient performance freely mobile 64 80% mobile at home 10 12.5% bedridden 6 7.5% assessment indicators ascites absent 30 37.5% slight 34 42.5% moderate 16 20% encephalopathy absent 74 92.5% grade1-2 6 7.5% grade3-4 0 0% table 3 shows blood chemical composition, coagulation status, and liver functionality in study patients. a severe deficiency of albumin in the blood was observed, with (31.3%) of serum albumin values below 2.8g/dl. bilirubin levels were also low, with (70%) of patients below 2 mg/dl. the international normalized ratio (inr) was used to assess coagulation status, with (85%) of patients showing an inr value < 1.7. most patients had sodium levels over 130 mmol/l (85%), and (30%) had elevated creatinine levels. table 3: laboratory investigations of cirrhotic patients (n= 80) investigations frequency percentage albumin (g/dl) < 2.8 25 31.3% 2.8-3.5 30 37.5% > 3.5 25 31.3% bilirubin (mg/dl) < 2 56 70% 2-3 18 22.5% > 3 6 7.5% inr < 1.7 68 85% 1.7-2.2 9 11.3% > 2.2 3 3.8% sodium (mmol/l) < 130 12 15% ≥ 130 68 85% creatinine (mg/dl) pa ge 11 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 figure 2 illustrates the 3 categories of cirrhosis patients based on their child-turcotte-pugh (ctp) scores. the results revealed that (49%) of patients had moderate cirrhosis (ctp-b), indicating moderate liver dysfunction. whereas, (35%) showed mild cirrhosis (ctp-a), suggesting some liver function was intact and a favorable prognosis. only (16%) had severe cirrhosis (ctp-c), indicating severe liver disease. < 1 56 70% > 1 24 30% figure 2: child-pugh classification (n= 80) figure 3: meld score of cirrhotic patients (n= 80) figure 4: bone mineral density by dexa (n= 80) figure 3 shows the model for end-stage liver disease (meld) scores. these scores were based on laboratory findings like serum bilirubin, creatinine, and inr. meld score among study patients was 15±6, and (77.5%) of patients fell within the meld score range of 10-19, indicating a (6%) mortality rate (in 3 months). the dexa scan results indicated that (36.2%) of patients had normal bone mineral density, with a mean dexa score of 0.14. additionally, (55%) of patients had osteopenia, with a mean dexa score of -1.5, while (8.8%) of patients had osteoporosis, with a mean dexa score of -2.8, as shown in figure 4. this analysis showed that a significant proportion of patients had moderate or severe cirrhosis. pa ge 11 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 table 4 presents the correlation between the demographic characteristics of patients with cirrhosis and the results of dual-energy x-ray absorptiometry (dexa). the analysis showed that males had a higher prevalence of osteopenia (49%) than females (65.5%), while both genders had a comparable proportion of osteoporosis (9.8%) and (6.9%), respectively. osteoporosis had a higher prevalence (16%) among patients aged 51-60, while osteopenia was more prevalent (73.3%) among those aged 41-50. moreover, the east region exhibited a higher prevalence of osteoporosis (33.3%), while the west region had a higher frequency (70.6%). the p-values showed a significant association between dexa findings and demographic characteristics of cirrhotic patients. table 4: association between dexa findings and demographics (n= 80) characteristics normal osteopenia osteoporosis p. value gender male 21 25 5 0.36141.2% 49.0% 9.8% female 8 19 2 27.6% 65.5% 6.9% age (years) < 20 1 1 0 0.606 50.0% 50.0% 0.0% 20-30 4 3 0 57.1% 42.9% 0.0% 31-40 8 7 1 50.0% 43.8% 6.3% 41-50 4 11 0 26.7% 73.3% 0.0% 51-60 7 14 4 28.0% 56.0% 16.0% > 60 5 8 2 33.3% 53.3% 13.3% origin khartoum 12 9 0 0.072 57.1% 42.9% 0.0% central 7 17 4 25.0% 60.7% 14.3% west 5 12 0 29.4% 70.6% 0.0% east 2 0 1 66.7% 0.0% 33.3% north 3 6 2 27.3% 54.5% 18.2% table 5 analyzes the relationship between liver cirrhosis causes and dexa findings. it showed that patients with cirrhosis associated with hcv had a higher incidence of osteopenia (66.7%) and autoimmune causes (42.9%). the p-value (0.854) showed no significant correlation between dexa findings and cirrhosis causes among patients. table 5: association between dexa findings and cirrhosis causes (n= 80) liver cirrhosis causes normal osteopenia osteoporosis p. value hbv 19 25 5 38.8% 51.0% 10.2% hcv 1 2 0 33.3% 66.7% 0.0% alcohol 0 3 0 pa ge 11 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 0.0% 100.0% 0.0% 0.854 autoimmune 3 3 1 42.9% 42.9% 14.3% unidentified diagnosis 6 11 1 33.3% 61.1% 5.6% table 6 shows a correlation between dexa findings and osteoporosis symptoms. patients with osteoporosis often report symptoms, indicating a higher prevalence rate. a significant association was observed between osteoporosis and bone pain symptoms (p = 0.000), highlighting the correlation between bone pain and reduced bone density. although there was no significant association between fatigability and back pain and dexa findings, these patterns suggest increased sensitivity to osteoporosis. the p-value <0.05 indicated a significant association between osteoporosis and back pain. table 6: association between dexa findings and symptoms of osteoporosis (n= 80) symptoms of osteoporosis normal osteopenia osteoporosis p. value fatigability yes 18 24 6 0.28337.5% 50.0% 12.5% no 11 20 1 34.4% 62.5% 3.1% back pain yes 9 15 4 0.42232.1% 53.6% 14.3% no 20 29 3 38.5% 55.8% 5.8% bone pain yes 2 8 0 0.000*20.0% 80.0% 0.0% no 27 36 7 38.6% 51.4% 10.0% table 7: association between dexa findings and patient physical performance (n= 80) patient performance normal osteopenia osteoporosis p. value bedridden 2 4 0 0.662 33.3% 66.7% 0.0% mobile at home 3 5 2 30.0% 50.0% 20.0% 24 35 5 freely mobile 37.5% 54.7% 7.8% table 8: association of dexa findings with ascites and encephalopathy (n=80) indicators normal osteopenia osteoporosis p. value ascites absent 13 16 1 table 7 examines the relationship between dexa findings and patients with cirrhosis, focusing on their mobility. the results showed no significant correlation (p = 0.662). however, there were notable trends, such as a s higher prevalence of osteoporosis among homemobile patients and a greater proportion of the disease among bedridden patients. table 8 shows a significant correlation between ascites, encephalopathy and bone density. the p-value of ascites (p=0.496) showed no statistical significance, whereas encephalopathy had a significant association (p=0.002*) with osteoporosis, particularly in patients with grade 1-2 encephalopathy. pa ge 12 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 43.3% 53.3% 3.3% 0.496 slight 10 19 5 29.4% 55.9% 14.7% moderate 6 9 1 37.5% 56.3% 6.3% encephalopathy absent 29 40 5 0.002*39.2% 54% 6.8% grade1-2 0 4 2 0.0% 66.7% 33.3% table 9 indicates a correlation between laboratory tests and dexa findings. patients with osteoporosis had elevated bilirubin levels (p=0.000*), with a significant proportion (77.2%) falling within 2-3 mg/dl. similarly, low sodium levels (<130 mmol/l) were significantly associated with osteoporosis (p=0.000*), suggesting an electrolyte imbalance and reduced bone density. albumin levels were approaching statistical significance (p=0.386), indicating a positive trend in bone health. table 9: association between dexa findings and laboratory investigations (n=80) lab analysis normal osteopenia osteoporosis p. value albumin (g/dl) < 2.8 7 14 4 0.386 28.0% 56.0% 16.0% 2.8-3.5 10 18 2 33.3% 60.0% 6.7% > 3.5 12 12 1 48.0% 48.0% 4.0% bilirubin (mg/dl) < 2 27 28 1 0.000* 48.2% 50% 1.8% 2-3 2 14 2 11.1% 77.2% 11.1% > 3 0 2 4 0.0% 33.3% 66.7% inr < 1.7 26 38 4 0.093 38.2% 55.9% 5.9% 1.7-2.2 2 4 3 22.2% 44.4% 33.3% > 2.2 1 2 0 33.3% 66.7% 0.0% sodium (mmol/l) < 130 0 8 4 0.000*0.0% 66.7% 33.3% ≥ 130 29 36 3 42.7% 52.9% 4.4% creatinine (mg/dl) < 1 23 27 6 0.167 41.1% 48.2% 10.7% > 1 6 17 1 25.0% 70.8% 4.2% pa ge 12 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 table 10 presents a significant correlation between the child-pugh classification and dexa findings. patients with severe cirrhosis, specifically (ctp-c) had a higher prevalence of osteoporosis (23.1%) while (ctp-a) showed a reduced occurrence of osteoporosis (3.6%). the p-value < 0.05 indicated a statistical significance. table 10: association between dexa findings and child-pugh classification (n=80) child-pugh class normal osteopenia osteoporosis p. value ctp-a 15 12 1 0.041* 53.6% 42.9% 3.6% ctp-b 10 26 3 25.6% 66.7% 7.7% ctp-c 4 6 3 30.8% 46.2% 23.1% table 11 reveals a correlation between meld scores and dexa findings among cirrhosis patients. greater meld scores indicated severe liver disease and an increased mortality risk. osteoporosis prevalence was high (71.4%0 in patients with meld scores 20-29, with a 19.6% mortality risk. patients with meld scores 3039 had a 52.6% mortality rate, and lower meld scores showed regular bone density and a reduced death rate. table 11: association between dexa findings and meld score (n=80) meld score normal osteopenia osteoporosis p. value ≤9 (1.9% mortality) 1 0 0 0.000* 100.0% 0.0% 0.0% 10-19 (6.0% mortality) 27 34 1 43.5% 54.8% 1.6% 20-29 (19.6% mortality) 1 10 3 7.1% 71.4% 21.4% 30-39 (52.6% mortality) 0 0 3 0.0% 0.0% 100.0% discussion chronic liver disease impacts almost 1.5 billion individuals globally, with alcoholic liver disease (ald) accounting for (2%), hepatitis b virus (hbv) accounting for (29%), hepatitis c virus (hcv) accounting for 9%, and nonalcoholic fatty liver disease (nafld) accounting for (60%) (moon et al., 2020; traub et al., 2021; ye et al., 2020). the median prevalence of cirrhosis in european countries was 833 cases per 100,000. the global burden of disease study revealed a (13%) growth in the agestandardized incidence rate of cld and cirrhosis in 2015 (asrani et al., 2019). in europe, the prevalence of cirrhosis is 26.0 cases per 100,000 individuals (moon et al., 2020). cirrhosis is the 11th most common cause of death globally and the 15th leading cause of morbidity (cheemerla & balakrishnan, 2021). west europe and south sub suharan africa had the fourth to sixth lowest age-standardized death rates of cirrhosis in 2017, with alcohol-related liver disease and hepatitis c being the primary cause (ye et al., 2022; younossi et al., 2023). north africa and the middle east had modest rates of age-standardized death and prevalence rates due to cirrhosis driven by hepatitis b and c (huang et al., 2023; mokdad et al., 2014). in contrast, sudan is among the countries with high hepatitis b virus seroprevalence, with exposure ranging from (47%) to (78%) (elsheikh et al., 2016; mudawi, 2008). it is the common cause of cld and hepatocellular carcinoma, and the second common cause of acute liver failure in sudan (konyn et al., 2021; lan et al., 2023; mohammed et al., 2015; moses, 2021). liver cirrhosis can be diagnosed by various techniques and a definitive method for diagnosing cirrhosis is liver biopsy (jain et al., 2021). however, if clinical, laboratory, and radiologic findings indicate cirrhosis, a biopsy is unnecessary. cirrhosis increases the susceptibility to complications from liver biopsy (chowdhury & mehta, 2023). the most reliable indicators of cirrhosis include ascites, a platelet count below 160,000/mm3, spider angiomata, and a bonacini cirrhosis discriminant score (sharma, 2022). ultrasound is also used for assessing liver cirrhosis, but other methods include transient elastography, acoustic radiation force impulse imaging, supersonic shear imaging, magnetic resonance elastography, and endoscopy (ahmed, 2022; cui et al., 2022). elastography offers painless sampling and examination of a broader area as compared to biopsy. while abdominal computed tomography (ct) scan and magnetic resonance imaging (mri) are also used under specific conditions for diagnosis (nadarevic et al., 2021). decompensated cirrhosis anagement should focus on preventing progression rather than treating complications. treatment targets liver pathological pa ge 12 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 alterations, suppressing inflammation, fibrosis regression, and normalizing cell function. the present study analyzed bone mineral density in liver cirrhotic patients and examined the rate of osteoporosis, osteopenia, and risks of fractures. the results revealed that most patients were males, with an average age of 49.6±13.9 years. the male (63.8%) to female (36.2%) ratio was 1.8:1 with a higher proportion from sudan central region (35%). based on the etiological findings, alcohol consumption was found to be the second most prevalent factor contributing to liver cirrhosis (22.5%), followed by hbv which accounts for (61.3%) of cases. the prevalence rates of hcv, autoimmune diseases, and unknown etiology were (3.8%, 3.8%, and 8.8%), respectively. notably, a significant proportion of patients (52.5%) experienced reduced energy levels, while (37.5%) exhibited ascites, a typical indicator of severe livere disease. encephalopathy, a sign of nuerological problems, was observed in (7.5%) of the patients. moreover, laboratory investigations demonstrated significant abnormalities in liver functions. a total of (13%) of the patients exhibited a significant deficiency of albumin, with levels below 2.8g/ dl, indicating poor synthetic liver function. the patients’ bilirubin levels (70%) were below 2mg/dl. inr showed that (85%) of the patients had normal coagulation levels. the child-pugh score system was employed to categorize liver dysfunction into various stages. among 80 patients, (49%) exhibited moderate cirrhosis (ctp-b), (35%) showed mild cirrhosis (ctp-a), and (16%) showed severe cirrhosis (ctp-c). furthermore, (75%) of patients with cirrhosis had a mean score of 15±6, indicating a high risk of mortality. the dexa scan revealed that (35.2%) had normal bone density, (55.5%) had osteopenia, and (8.8%) had osteoporosis. the dexa findings showed a significant correlation with child-pugh scores, meld scores, and bone diseases. a notable association was also observed between the intensity of encephalopathy and dexa findings. a study by zheng et al. 2018 evaluated (20.3%) cases of osteoporosis in liver cirrhotic patients and observed that it resulted from alcohol consumption and hepatitis virus. notably, individuals with a lower bmi and higher fibroscan scores exhibited a greater occurrence of osteoporosis (zheng et al., 2018). the occurrence of osteoporosis in individuals with cld varied from (13%) to (55%) in western countries (chinnaratha et al., 2015; collier, 2007). another study conducted by meena et al. 2018 analyzed patients aged 20-65, with varying degrees of liver cirrhosis severity. elderly patients had a poorer prognosis and reduced quality of life compared to younger patients, with a significant difference observed (p=0.0003) (meena et al., 2018). a study by younossi et al. revealed comparable results indicating that the age of cirrhosis patients had a detrimental effect on their quality of life (younossi et al., 2001). in contrast, the finding of the study by marchesini et al. demonstrated that younger patients with cirrhosis experienced a more severe decline in health related quality of life (hrql) compared to older patients (marchesini et al., 2001). furthermore, a study by shukla et al. 2023 found that (34.3%) of the patients had liver cirrhosis attributable to alcohol consumption. among 70 patients, (25.7%) had hbv, while (20%) had cryptogenic cirrhosis and hcv. the combined prevalence of osteoporosis and and osteopenia was found to be 22.9%, respectively (shukla et al., 2023). similarly, soylu et al. examined the prevalence of osteoporosis was (1.9%) and osteopenia was (20%) (soylu et al., 2012). ninkovic et al. found a higher prevalence of (48.8%) for osteopenia and (36.6%) for osteoporosis among cirrhotic patients (ninkovic et al., 2001). sokhi et al. demonstrated that (11.5%) of the patients had osteoporosis, while (34.6%) had osteopenia (sokhi et al., 2004). other (danford et al., 2020; mantovani et al., 2019; shukla et al., 2023). moschen et al. reported (37.8%) osteopenia and (12.8%) osteoporosis (moschen et al., 2005). however, numerous studies showed a statistical significance and a positive correlation was between bone mineral density and liver cirrhosis. the prevalence of osteoporosis, osteopenia, and fractures were found to be 45% to 47% on average among chronic liver disease patients (goral et al., 2010; luxon, 2011; turkeli et al., 2008; vargas et al., 2012). in order to increase bone density, correct vitamin d levels, calcium supplements, regular physical activity, a balanced diet, and an individualized approach to health care are recommended (rondanelli et al., 2021). conclusion in conclusion, the study findings revealed that bone diseases were a prevalent consequence in sudanese patients with liver cirrhosis. the majority of cases were related to osteoporosis and osteopenia. bone diseases such as osteopenia and osteoporosis were significantly associated with encephalopathy, higher bilirubin levels, hypernatremia, high meld scores and severe liver disease (ctp-b and ctp-c). however, hbv was found to be the primary cause of liver cirrhosis, followed by alcohol consumption. patients with severe cirrhosis had a higher prevalence of osteoporosis, which was linked to low sodium levels and elevated bilirubin levels. in contrast, osteopenia was more prevalent than osteoporosis among patients. furthermore, the study emphasized the importance of early detection and treatment of bone health problems in patients with liver cirrhosis. limitations and strengths • the limitations of the study may include the generalizability due to a single-center trial with 80 patients and a cross-sectional design. • however, the study is crucial for determining healthcare accessibility for patients with cirrhosis. • this study offers insights into the complex relationship between liver cirrhosis and bone health, providing the way for further examination and clinical therapy. recommendations • cirrhotic patients often experience bone pain and fractures due to bone disease, and orthopedic care is often pa ge 12 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 113-125, 2025 neglected. regular bone mineral density assessments are recommended for all patients with liver cirrhosis. • patients with severe stages of cirrhosis should be advised to receive anti-osteoporotic treatment due to the increased risk of bone disease. • larger prospective studies or longitudinal studies with frequent clinical evaluations and more accurate biochemical or laboratory assessments are needed to determine the effect of liver disease stage on bone mineral density. acknowledgment the authors are thankful to ibn sina hospital for their continuous support throughout the study. references ahmadi, n., mao, s., hajsadeghi, f., arnold, b., kiramijyan, s., gao, y., flores, f., azen, s., & budoff, m. 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(2018). risk factors for osteoporosis in liver cirrhosis patients measured by transient elastography. medicine (baltimore), 97(20), e10645. https://doi.org/10.1097/ md.0000000000010645 pa ge 1 pa ge 11 1 american journal of medical science and innovation (ajmsi) nasal foreign body presenting as unilateral rhinosinusitis with nasal polyposis ahmad rufai tukur1*, ahmad m. aldhafeeri1, taha mohammed aoun1, faisal hazaa abohelaibah1, benjamin nonso nkemjikai1 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5858 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 02, 2025 accepted: september 05, 2025 published: november 17, 2025 although nasal foreign bodies (fb) are common in pediatric otorhinolaryngology, their long-term complications often go unrecognized. a witnessed nasal fb receives immediate intervention and often has no complications. however, an unwitnessed fb may persist in the nasal cavity and go unnoticed. this can cause chronic unilateral nasal discharge and a bad odor. in rare circumstances, it can present as rhinosinusitis with nasal polyposis. this case highlights an unusual polyp-forming scenario, underscoring the importance of considering such diagnoses. this is a case report of 6-years-old female patient who presented to our unit with history of progressive right nasal blockage and discharge of about a year duration. she had earlier received medical treatment without improvement. nasal examination revealed reduced patency of the right nasal cavity, nasal discharge and nasal polyps. computed tomography (ct) scan revealed opacification of the right nasal cavity and maxillary antrum. patient was evaluated and booked for functional endoscopic sinus surgery (fess). intraoperatively, upon removal of nasal polyps, fb was incidentally discovered and removed. polyp sent for histology turned out to be inflammatory. patient was seen four weeks postoperative with complete resolution of the symptoms. long standing nasal fb can elicit inflammatory reaction leading to development of nasal polyps with eventual obstruction of the nose and maxillary ostium, thereby manifesting with features of rhinosinusitis. keywords chronic rhinosinusitis, foreign body, pediatric, sinus polyposis, sinus surgery 1 department of otorhinolaryngology, hafar al batin central hospital, hafar al batin, kingdom of saudi arabia * corresponding author’s e-mail: atrufaiggm@gmail.com introduction foreign bodies in the nasal cavity are a common clinical problem in pediatric otolaryngology, particularly among children aged 1–5 years, with an incidence as high as 96.8% in this age group. they are slightly more common in females (53.4%) and occur more frequently in the right nasal cavity (74.1%). the majority of nasal fbs include organic materials such as seeds (32.1%) and synthetic items such as plastic beads, polyurethane foam, stones, and erasers. in most cases, fbs are inserted under parental observation and removed promptly. complications are therefore minimal. however, in cases where the event is unwitnessed, the fb may remain undetected, leading to variable complications including persistent nasal discharge, foul odor, epistaxis, or nasal obstruction. rarely, long-standing fbs can elicit chronic inflammatory changes, resulting in nasal polyposis or mimicking sinus tumors. this report describes a case of a pediatric nasal fb that presented unusually as unilateral nasal polyposis and chronic sinusitis, emphasizing the diagnostic challenges and the importance of vigilance in unilateral sinonasal disease. case description we present a case of a 6-year-old girl. she had a year-long history of progressive right nasal blockage and right nasal discharge. she occasionally complained of right-sided facial pain. there was no reported or witnessed history of fb insertion. she was given some medications earlier, without improvement. anterior rhinoscopy revealed reduced patency of the right nasal cavity, nasal discharge, and nasal polyps filling the right nasal cavity. computed tomography (ct) scan revealed opacification of the right nasal cavity and maxillary antrum. figure 1: ct scan showing opacification of the right nasal cavity and maxillary antrum the patient was booked for functional endoscopic sinus surgery (fess). intraoperatively, extensive multiple nasal polyps were found. these arose from both the septum and the lateral wall. on removing the most anterior polyps, an fb was incidentally discovered in the middle meatus. it was embedded within the nasal polyps and removed. the polyps in the nasal cavity and maxillary antrum were removed and sent for histological examination. the pa ge 11 2 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 4(2) 111-113, 2025 figure 2: showing nasal polyp and fb embedded deep within the nasal cavity figure 3: multiple polyps removed figure 4: fb (large piece of rubber) removed patient was reviewed 24 hours postoperatively. the nasal pack was removed, and she was discharged. she was seen in the outpatient clinic at 2 and 4 weeks postoperatively and had complete symptom resolution. histology revealed an inflammatory polyp. discussion foreign bodies in the nasal cavities are common incidents in children, the various clinical presentations are history of insertion of foreign bodies in 85.8% and 14.2% with no history of insertion, mucopurulent nasal discharge 51.7%, foul nasal odour 9.4%, epistaxis 5.7%, nasal obstruction and mouth breathing 2.8% and 1.9% cases respectively1. this is similar to a case we presented as there was no history of fb given by the patient or witnessed by any third party. the duration of symptoms ranges from an hour to 4 years with 69.8% presenting within 24 hours and 25.5% presenting after 24 hours. diagnosis is often made with anterior rhinoscopy, but sometimes nasal fibroendoscopy and imaging may be useful. the majority of nasal foreign bodies (99.1%) located were in the antero-inferior portion of the nasal cavities and could be removed with simple instruments. extraction was performed in consultation room in 84.5% of cases and in the operating room in 15.5% of the cases1. most of the foreign bodies are inert and do not cause any local tissue reaction but some of these can cause serious complications. nasal fb in accordance with the literature leads to complications in 9.05% of the cases, epistaxis 17.24%, nasal infections 13.6% and purulent maxillary sinusitis in 1.9%1. cases of nasal fb slipping into the alimentary canal were also reported. the histological study included the standard sample processing followed by paraffin embedding of the material and staining of the micropreparations with hematoxylin and eosin. it was shown fb in the nasal cavity or maxillary sinus can cause marked structural reorganization of the mucous membrane usually with the predominance of hypertrophic and polypous changes8. conclusion undoubtedly, unwitnessed and unrecognized nasal fb could prove difficult for clinicians to diagnose. clinicians should recognize the underlying causes that are responsible for the symptoms of chronic sinusitis especially in children, and a unilateral nasal discharge should be assumed to be caused by an intra-nasal foreign body until proven otherwise. references figueiredo, r. r., azevedo, a. a., kós, a. o., & tomita, s. (2006). nasal foreign bodies: description of types and complications in 420 cases. brazilian journal of otorhinolaryngology, 72(1), 18–23. https://doi. org/10.1016/s1808-8694(15)30031-6 kelesidis, t., osman, s., & dinerman, h. (2010). an unusual foreign body as cause of chronic sinusitis: a case report. journal of medical case reports, 4, 157. https://doi.org/10.1186/1752-1947-4-157 ogunleye, a. o., & sogebi, o. a. (2004). nasal foreign bodies in the african children. african journal of medicine and medical sciences, 33(3), 225–228. regonne, p. e., ndiaye, m., sy, a., diandy, y., diop, a. d., & diallo, b. k. (2017). nasal foreign bodies in children in a pediatric hospital in senegal: a threeyear assessment. european annals of otorhinolaryngology, head and neck diseases, 134(5), 361–364. https://doi. pa ge 11 3 https://journals.e-palli.com/home/index.php/ajfst am. j. med. sci. innov. 4(2) 111-113, 2025 org/10.1016/j.anorl.2017.05.004 sajid, t., shah, m. i., & qamar naqvi, s. r. (2018). pattern of presentation of nasal foreign bodies: an experience with 155 patients. journal of ayub medical college abbottabad, 30(4), 548–550. vishniakov, v. v., makarova, n. v., & pashovkina, o. v. (2014). changes in the mucous membrane of the patients with chronic maxillary sinusitis caused by foreign bodies. vestnik otorinolaringologii, 2014(1), 12– 14. https://doi.org/10.17116/otorino201479112-14 wang, y., su, h., wu, y., & zhao, y. (2016). clinical analysis of 249 cases of children with foreign bodies in the nasal cavity and paranasal sinus. lin chung er bi yan hou tou jing wai ke za zhi, 30(3), 233–234. yan, s., zeng, n., chen, g., chen, y., wu, z., pan, h., teng, y., ma, x., & li, l. (2021). presentation and management of nasal foreign bodies in a chinese metro area. medicine, 100(16), e25626. https://doi. org/10.1097/md.0000000000025626 pa ge 1 pa ge 12 6 american journal of medical science and innovation (ajmsi) evaluating osteoporosis risk patterns and prevalence in adult of bangladesh: calcaneus quantitative ultrasound measurements md. alahi khandaker1*, mukul chandra paul2, shanta saha3, rumana yasmin ferdausi4 volume 4 issue 1, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i1.5200 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 21, 2025 accepted: may 29, 2025 published: june 19, 2025 osteoporosis affects the health of more than 200 million individuals in the world. as the population is aging in bangladesh, there is not enough information about bone health to guide public health strategies. the objective of the research is to determine the prevalence and patterns of reduced bone mineral density in bangladeshi adult using calcaneal quantitative ultrasound (qus) and identify associated risk factors. the cross-sectional study conducted in community based health centre (momen medical store) and collected data from 190 adult (76 males, 114 females) who were chosen by systematic random sampling. bone mineral density was measured using qus at the calcaneus (heel bone). individuals were assigned t-scores and information about their age group, gender, weight, height and presence of comorbidities was examined using multivariate regression. an alarming 84.2% of participants demonstrated compromised bone health, with 55.8% presenting osteopenia and 28.5% showing reduced ossification. women exhibited significantly lower mean t-scores (-2.0 ± 0.8) than men (-1.5 ± 0.9, p<0.001). all underweight participants showed compromised bone health, while 57.7% of obese participants maintained normal bone status. multiple regression identified age (β=-0.220, p=0.013), female gender (β=0.170, p=0.021), diabetes mellitus (β=-0.190, p=0.013), obesity (β=-0.180, p=0.027), and multimorbidity (β=-0.200, p=0.012) as significant predictors of poor bone health, while moderate physical activity (β=0.160, p=0.047) and higher education (β=0.170, p=0.030) showed protective effects. bangladeshis of all ages often have compromised bone health, including a higher risk in females, elderly people, diabetics and those with several health problems. these findings stress that all people should regularly have their bones checked and that special effort should be made to prevent problems by focusing on exercise, controlling their weight and diabetes management. keywords bone mineral density, osteoporosis, prevalence, quantitative ultrasound, risk factors 1 bangladesh center for health studies, dhaka, bangladesh 2 sylhet mag osmani medical college hospital, sylhet, bangladesh 3 college of health and human sciences purdue university (west lafayette campus), usa 4 ministry of law, justice and parliamentary affairs, government of the people’s republic of bangladesh, bangladesh * corresponding author’s e-mail: dralahi@gmail.com introduction osteoporosis is an important health issue throughout the world due to issues with bone strength and the higher risk of fractures. who considers osteoporosis the most common metabolic bone disease and has found that more than 200 million people around the globe already have it, with cases expected to climb, mainly in countries experiencing faster rates of population aging (cleveland clinic, 2023). since bangladesh is seeing more older citizens and people are living longer, there are greater challenges from bone-related aging. at present, scant epidemiological reports on bone condition exist for the bangladeshi population (ali et al., 2021). lacking the full picture of information creates real difficulties in planning and developing effective measures for public health. dualenergy xray absorptiometry (dxa) is traditionally used to determine bone mineral density (bmd), but it is limited for use in lowresource environments such as bangladesh where the remoteness of rural and semiurban areas make sophisticated diagnostic equipment inaccessible (krugh & langaker, 2024). in this context, quantitative ultrasound (qus) of the calcaneus has become an accepted practical alternative screening tool. qus has many advantages: the methodology is portable; costs are down; there is no radiation exposure to the subject and, based on their own studies, qus measurements have been shown to correlate with fracture risk at all bmd (nieuwkamer et al., 2023). bone health deterioration pathophysiology consists of complicated interactions between genetic predisposition, hormonal factors, metabolic conditions and life style determinants. ethnicity specific patterns of bone metabolism and loss are present and therefore, population specific data is more useful than extrapolating data from different ethnic contexts (marini & brandi, 2018). such south asian populations have distinctive risk profiles and different progression patterns of bone loss than found in western populations and warrant focused elucidation (darling et al., 2017). osteoporosis advances silently until fracture occurs which puts people at risk for considerable morbidity, mortality and high health care burden. appropriate screening leads to early detection and timely intervention of the disease which can change disease trajectory and improves outcomes (leboff et al., 2022). this information is important for identifying population specific risk factors to then develop tailored screening and prevention strategies. multiple factors may be contributing towards poor bone health in bangladesh: pa ge 12 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 126-134, 2025 nutritional deficiencies (low calcium and vitamin d), but also cultural practices that reduce sun exposure, food patterns that modify due to socioeconomic constraints and rising prevalence of chronic metabolic diseases such as diabetes mellitus (ahmed et al., 2020). these factors all operate from within a healthcare system that is under resourced for bone health management and not aware of it. bmd has been associated with several demographic, anthropometric and clinical parameters e.g. age, sex, bmi, physical activity and comorbidity such as diabetes mellitus and cardiovascular disease (kong et al., 2024). nevertheless, the characteristics of the interdependent relationships among them and the combined effect on bone health in particular in the bangladeshi population are poorly understood. the resolution of this critical knowledge gap is attempted in this study by screening for the prevalence and patterns of reduced bone mineral density among specimens of the bangladeshi adult population, as measured by calcaneal qus and by determining associated risk factors. the results can be used to guide the development of context appropriate screening protocols, preventive and therapeutic interventions designed to address the distinct circumstances and traits among this population. materials and methods study design and participants this cross sectional study conducted in community based health centre (momen medical store) sunamganj, bangladesh. systematic random sampling was used to recruit 190 adult (76 males, 114 females) patients and their accompanying relatives attending outpatient department. adult (≥ 18 years old) who consented to participate were our inclusion criteria. pregnancy, history of metabolic bone diseases other than osteoporosis, current (or recent; up to 6 months) use of medications known to affect bone metabolism, history of fractures or surgeries involving calcaneus, were all exclusion criteria. data collection instruments sociodemographic information such as age, sex, marital status and educational level were obtained by using a structured questionnaire. a diabetes mellitus, cardiovascular disease or other chronic condition medical history focused on was. anthropometric data included height and weight for calculation of bmi. self-reported regular activity levels were categorized by physical activity as sedentary, light or moderate. bone mineral density assessment all subjects were measured by calcaneal quantitative ultrasound (qus) using a calibrated portable ultrasound bone densitometer (model details withheld for anonymity). the assessment was of the dominant heel, after removal of footwear and cleaning. however, broadband ultrasound attenuation (bua) and speed of sound (sos) were measured by the device and integrated to form a composite parameter where t-scores were derived. daily calibration against a phantom and duplicate measurements on 10% of participants were performed quality control procedures. bone status classification based on who criteria adapted for qus measurements, participants were classified into four categories according to t-scores: • normal: t-score ≥ -1.0 • osteopenia: t-score between -1.0 and -2.5 • reduced ossification (ro): t-score between -2.5 and -3.5 • severe reduced ossification: t-score < -3.5 the term “reduced ossification” (ro) was used instead of “osteoporosis” since dxa remains the gold standard for definitive osteoporosis diagnosis. statistical analysis analysis of data was done using spss version 25.0. frequencies, percentages, means and standard deviations were used as descriptive statistics. associations between categorical variables were evaluated by chi-square tests. mean t-scores were compared between groups, using independent sample t-tests. linear multiple regression analysis was conducted on t-scores for significant predictors; model included age, sex, bmi category, comorbidities, physical activity and sociodemographic factors. all data were presented as mean ± standard error. statistical significance was established at p<0.05. ethical considerations written informed consent was obtained from all participants after explaining the study objectives and procedures. confidentiality of personal information was maintained throughout the study. results and discussion the study included 190 participants with a mean age of 43.3 ± 15.6 years, ranging from under 20 to over 70 years. the largest age cohort was 31-40 years (23.2%), followed by 21-30 years (18.9%). female participants constituted 60% of the sample. regarding comorbidities, 27% of participants had diabetes mellitus, 15% had cardiovascular disease, and 33% had obesity. multimorbidity was present in 27% of the sample. educational status assessment revealed that 35% were illiterate, 55% had elementary education, and 10% were graduates. based on bmi classification, 5% were underweight, 45% had normal weight, 22% were overweight, and 28% were obese. most participants (55%) reported sedentary lifestyle patterns, while 25% engaged in light physical activity and 20% in moderate physical activity (table 1). analysis of bone mineral density using calcaneal qus pa ge 12 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 126-134, 2025 table 1: baseline demographic and clinical characteristics of study participants variable frequency (n) percentage (%) age group ≤20 years 11 5.8 21–30 years 36 18.9 31–40 years 44 23.2 41–50 years 33 17.4 51–60 years 33 17.4 61–70 years 27 14.2 >70 years 6 3.2 mean ± sd 43.3 ± 15.6 years sex male 76 40 female 114 60 dm yes 51 27.0 no 139 73.0 marital status married 161 85.0 unmarried 29 15.0 education status illiterate 66 35.0 elementary 105 55.0 graduate 19 10.0 bmi underweight 10 5.0 normal weight 86 45.0 overweight 42 22.0 obese 53 28.0 physical activity sedentary 105 55.0 light 48 25.0 moderate 37 20.0 cardiovascular disease yes 29 15.0 no 161 85.0 obesity yes 63 33.0 no 127 67.0 multimorbidity status present 51 27.0 absent 139 73.0 revealed concerning patterns of bone health in the study population. only 15.8% of participants demonstrated normal bone status (t-score ≥ -1.0). the majority (55.8%) presented with osteopenia (t-score between -1.0 and -2.5), while 25.3% showed reduced ossification (ro) with t-scores between -2.5 and -3.5. severe ro (t-score < -3.5) was identified in 3.2% of participants (table 2). significant gender-based disparities in bone health were observed. female participants exhibited significantly lower mean t-scores (-2.0 ± 0.8) compared to males (-1.5 ± 0.9), with a statistically significant difference (p<0.001). the 95% confidence intervals for these means were -1.92 pa ge 12 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 126-134, 2025 figure 1: column chart & pie chart baseline demographic and clinical characteristics of study participants pa ge 13 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 126-134, 2025 table 2: distribution of bone mineral density status based on t-score ranges bone status t-score range frequency percentage (%) severe ro < -3.5 6 3.2 ro < -2.5 to -3.5 48 25.3 osteopenia < -2.5 106 55.8 normal < -1 30 15.8 total 190 100 table 3: sex-specific differences in mean t-score values indicating bone health disparities gender mean t-score ± sd 95% ci p-value male -1.5 ± 0.9 (-1.31 to -1.70) <.001 * female -2.0 ± 0.8 (-1.92 to -2.25) table 4: bone health patterns by age group in the study population age group bone status severe ro osteopenia normal total n % n % n % n % n % ≤20 years 0 0.0 1 0.5 6 3.2 3 1.6 10 5.3 21–30 years 0 0.0 5 2.6 27 14.2 11 5.8 43 22.6 31–40 years 0 0.0 13 6.8 25 13.2 10 5.3 48 25.3 41–50 years 2 1.1 12 6.3 20 10.5 3 1.6 37 19.5 51–60 years 2 1.1 10 5.3 17 8.9 1 0.5 30 15.8 61–70 years 0 0.0 6 3.2 10 5.3 0 0.0 16 8.4 >70 years 2 1.1 1 0.5 1 0.5 2 1.1 6 3.2 figure 2: distribution of bone health status by t-score classification among participants to -2.25 for females and -1.31 to -1.70 for males, indicating minimal overlap and confirming the robustness of this gender difference (table 3). age-stratified analysis demonstrated progressive deterioration in bone health with advancing age. the prevalence of normal bone status declined from 30% in the youngest age group (≤20 years) to 0% in the 61-70 years group, with an unexpected 33.3% in the >70 years group likely due to the small sample size in this cohort (n=6). conversely, the prevalence of ro increased from 10% in the youngest age group to 37.5% in the oldest participants. severe ro was predominantly observed in the 41-60 and >70 age groups (table 4). bmi demonstrated a significant association with bone health status (p<0.001). all underweight participants exhibited compromised bone health, with 60% showing severe ro and 40% showing ro. in the normal weight category, 51.2% had ro and 48.8% had osteopenia. all overweight participants (100%) demonstrated osteopenia. among obese participants, 57.7% maintained normal bone status while 42.3% presented with osteopenia (table 5). pa ge 13 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 126-134, 2025 table 5: relationship between bmi and bone status in study participants bmi bone status p-value severe ro osteopenia normal total <.001 n % n % n % n % n % underweight 6 60.0 4 40.0 0 0.0 0 0.0 10 100.0 normal weight 0 0.0 44 51.2 42 48.8 0 0.0 86 100.0 overweight 0 0.0 0 0.0 42 100.0 0 0.0 42 100.0 obese 0 0.0 0 0.0 22 42.3 30 57.7 52 100.0 multiple regression analysis identified several significant predictors of lower t-scores (poorer bone health). age emerged as a significant negative predictor (β=-0.220, p=0.013), indicating progressive bone health deterioration with advancing age. female gender was associated with lower t-scores (β=-0.170, p=0.021), confirming gender-based vulnerability. among comorbidities, diabetes mellitus (β=-0.190, p=0.013), obesity (β=0.180, p=0.027), and multimorbidity (β=-0.200, p=0.012) significantly predicted poorer bone health. the obese bmi category showed strong negative association with t-scores (β=-0.240, p=0.004). moderate physical activity demonstrated protective effects (β=0.160, p=0.047), as did graduate-level education (β=0.170, p=0.030) (table 6). table 6: association between sociodemographic and health characteristics and outcome variable variable coefficient (b) std. error beta (β) t-statistic p-value demographics age -0.015 0.006 -0.220 -2.500 0.013* male (vs. female) -0.280 0.120 -0.170 -2.333 0.021* health conditions diabetes mellitus -0.350 0.140 -0.190 -2.500 0.013* obesity -0.300 0.135 -0.180 -2.222 0.027* cardiovascular disease -0.260 0.145 -0.140 -1.793 0.075 multimorbidity -0.370 0.145 -0.200 -2.552 0.012* lifestyle physical activity: light 0.180 0.140 0.100 1.286 0.200 physical activity: moderate 0.290 0.145 0.160 2.000 0.047* bmi category (ref: normal) underweight -0.320 0.190 -0.110 -1.684 0.095 overweight -0.210 0.130 -0.130 -1.615 0.108 obese -0.410 0.140 -0.240 -2.929 0.004** sociodemographic married -0.090 0.160 -0.040 -0.562 0.575 education: elementary 0.210 0.130 0.130 1.615 0.108 education: graduate 0.350 0.160 0.170 2.188 0.030* line chart showed, ‘age-specific prevalence of osteoporosis risk between men and women’ shows a clear age-related increase in osteoporosis risk, with a significant gender gap. although both men and women show an increasing prevalence with advancing age, the risk of multiple sclerosis is higher among women. the difference is most pronounced after 50 years of age and coincides with postmenopausal hormonal changes that accelerate bone loss in women. by age >70, prevalence in women is almost twice that of men. this trend underlines the critical role of oestrogen deficiency in the health of female bones and highlights the need for age and gender specific screening and prevention strategies to address osteoporosis, especially in older women. pa ge 13 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 126-134, 2025 figure 3: line chart showing the age-specific prevalence of osteoporosis risk among male and female discussion finally, this study presents a unique insight into the bone health status and related risk factors in the adult bangladeshi population which currently represents a knowledge gap in the least represented region. the results show an alarming high prevalence of compromised bone health – 84.2% of the participants had t-scores below normal values, 28.5% of which were reduced ossification or severe reduced ossification. we found that the prevalence of suboptimal bone health is greater than many international studies have reported and is similar to data from south asian nations nearby. while khadilkar et al. (2018) found that as many as 37% of indian adults may have osteoporosis, fatima et al. (2009) suggest that of 29.8% of pakistani adults have osteoporosis. the findings indicate that people of south asian background could share certain genetic, environmental or lifestyle traits affecting their bone strength. like in previous studies, our analysis revealed that females had inferior bone health status compared to men in our population. a decrease in estrogen causes women to lose bone at a quicker rate (cauley, 2015). however, the fact that 72% of the men in our sample had unhealthy bones means we need to look beyond the group of high-risk women in bangladesh. such research emphasizes that adding male osteoporosis to public consciousness matters as it is frequently missed and overlooked in handling (gielen et al., 2011). this progressive deterioration of bone health as age increases in our study agrees with the commonly known negative relationship between age and bmd in different population (demontiero et al., 2012). however, with 70% of participants under 20 years showing t scores < 0 such early compromise of bone health in our study population is a cause for concern with regard to peak bone mass in this population. this can be caused by nutritional deficiencies during the bone building period usually during childhood such as inadequate calcium and vitamin d, both which are known to occur in the bangladeshi population (islam et al., 2022). we found that bmi affects bone health in a complex manner. although having a low body weight is a well-known risk factor for osteoporosis, we also found that obesity seems to lower t-scores independently. it could be that the relationship between bone metabolism and adiposity is changing as we understand it better. konstantinos gkastaris et al. (2020) suggested that being overweight might strengthen bones by putting pressure on them; on the other hand, factors such as chronic inflammation, unusual adipokine production and adipose sequestration of vitamin d could weaken bones. our research agrees with this nuance and suggests we should revisit the idea that greater bmi is always good for warding off osteoporosis. results from our research link diabetes mellitus with worsening bone health which is supported by evidence from other reports. chen et al. (2022) found that diabetes increases fracture risk in patients, even when their dxa-measured bone density was in the normal range or higher. among these are extra glycation on collagen, problems with small blood vessels and changes in bone rebuilding (singh et al., 2014). it is notable that our findings support treating diabetes as a main reason for worrying about weak bones in bangladesh, where diabetes cases are increasing at a fast rate. being physically active in moderation is connected to strong bones, showing once more that being active is good for your bones. according to hong and kim (2018), going through combined weight-bearing and resistance exercises preserves and may boost bone mineral density. the fact that a large majority of our participants reported pa ge 13 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(1) 126-134, 2025 being mostly sedentary indicates a risk factor that is easily manageable by public health initiatives. we found that having more education was linked to better bone health in our group. the relationship is likely supported by several processes, including eating better, gaining health knowledge, accessing medical services and undertaking activities beneficial for bones. our results should be interpreted with a few limitations in mind. the way this study was set up makes it impossible to determine if one thing caused another. while it was useful to rely on qus in this study setting, not using dxa makes it hard to compare results with those from digital x-ray analysis. however, using this approach might make it difficult to apply the findings to all bangladeshis. even so, the data presented here offer an important first step in studying this group and helps set up further, more advanced studies. conclusion according to this research, a large number of bangladeshis of all ages, but especially females, older individuals, diabetics and those with numerous illnesses, suffer from bone health concerns. putting a name to modifiable and non-modifiable risk factors allows for the design of effective screening and treatment plans. this suggests that screening for bone health should be organized routinely in bangladesh, starting with highrisk populations. strategies aimed at prevention ought to highlight making people active, helping them maintain their weight and controlling their diabetes. it would also help to add public health messages on bone health and osteoporosis to conventional healthcare programs. it is important to conduct future long-term studies to link the risk factors identified here to outcomes related to bone health in the population. checking nutritional elements such as vitamin d and calcium levels would shed more light on the causes of bone health issues in bangladesh. how much bone health is negatively affected as shown here emphasizes the urgent need for efforts to tackle osteoporosis in bangladesh. references ahmed, s., goldberg, g. r., raqib, r., roy, s. k., haque, s., braithwaite, v. s., pettifor, j. m., & prentice, a. 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(2011). osteoporosis in men. best practice & research clinical endocrinology & metabolism, 25(2), 321–335. https://doi.org/10.1016/j.beem.2010.08.012 gkastaris, k., goulis, d. g., potoupnis, m., anastasilakis, a. d., & kapetanos, g. (2020). obesity, osteoporosis and bone metabolism. journal of musculoskeletal & neuronal interactions, 20(3), 372. https://pmc.ncbi.nlm. nih.gov/articles/pmc7493444/ hong, a. r., & kim, s. w. (2018). effects of resistance exercise on bone health. endocrinology and metabolism, 33(4), 435. https://doi.org/10.3803/ enm.2018.33.4.435 islam, m. z., bhuiyan, n. h., akhtaruzzaman, m., allardt, c. l., & fogelholm, m. (2022). vitamin d deficiency in bangladesh: a review of prevalence, causes and recommendations for mitigation. asia pacific journal of clinical nutrition, 31(2). https://doi.org/10.6133/ apjcn.202206_31(2).0002 khadilkar, a., kadam, n., chiplonkar, s., & khadilkar, v. 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(2014). advanced glycation end products and diabetic complications. the korean journal of physiology & pharmacology, 18(1), 1. https://doi.org/10.4196/ kjpp.2014.18.1.1 pa ge 1 pa ge 43 american journal of medical science and innovation (ajmsi) prevalence and determinants of gestational diabetes mellitus among pregnant women attending antenatal care mos najma akter1*, m. a. s. ansari2, simonto mirza3, md mehedi hasan4 volume 4 issue 2, year 2025 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v4i2.5600 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: august 12, 2025 accepted: august 28, 2025 published: september 05, 2025 gestational diabetes mellitus (gdm) is a progressively common condition that presents substantial hazards to both the mother and her offspring. considering the rapid lifestyle changes in developing countries, it is essential to identify the risk factors in that environment to avert long-term consequences. the study was meant to determine the prevalence of gdm and its relationship with sociodemographic, clinical, and behavioral factors among women who are undergoing ante-natal care (anc) services in their pregnancies. quantitative cross-sectional investigation has been carried out on 180 pregnant women at 24-28 weeks in gestation. data were obtained with the help of the structured questionnaire and analyzed employing r software. the diagnosis of gdm was made with the help of the 75g ogtt; it was performed according to the recent who 2013 guidelines of gdm diagnosis. the influences and main risk factors were identified via descriptive and bivariate analysis. it was discovered that prevalence of gdm is 45 percent. among the interrelated risks, there were such characteristics as physical inactivity, lack of professional training programs, fast food and even sugary drinks ingestion and the history of diabetes in their families. the common risk factors of maternal age and bmi that is considered as proximate predictors were found to be statistically insignificant risk factors of gdm in the identified sample. the results of the study indicate high prevalence of gestational diabetes mellitus (gdm), and modifiable lifestyle factors have been found to play major role in the development of the disease. the anc services should entail early screening, encourage planned activity, and provide dietary advice to ensure reduced risks and enhanced birth outcomes associated with gdm among women. keywords antenatal care, gestational diabetes mellitus, maternal health, ogtt, physical activity, risk factors 1 department of food and nutrition, university of dhaka, dhaka, bangladesh 2 department of pathology, faculty of medicine, manipal university college malaysia, 75150, maleka, malaysia 3 department of physical and mathematical sciences, chattogram veterinary and animal sciences university, chattogram, bangladesh 4 department of narcotics control, ministry of home affairs, dhaka, bangladesh * corresponding author’s e-mail: mosnajmaakter@gmail.com introduction gestational diabetes mellitus (gdm) is an emerging public health risk all over the world, which is the testosteroneinsensitive glucose intolerance that is identified or diagnosed as part of pregnancy (kautzky-willer et al., 2023). the rising rates are indicative of a broader epidemic of type 2 diabetes that includes an immediate and a longterm threat to both the mother and child (boyd & conway, 2024). the gdm complications include preeclampsia, therapeutic cesarean section, macrosomia in the fetus, and predisposition to metabolic diseases of the mother and children later in life (avilez et al., 2025). the percentages of gdm in areas are quite different than in other parts due to the ordeal of genetic and lifestyle elements, and sociodemographic explanations (avilez et al., 2025). the incidence of gestational diabetes mellitus (gdm) is rising in south asia, with bangladesh being no exception due to rapid urbanization, nutritional change, sedentary lifestyles, and limited awareness of maternal health. in bangladesh, the previous research reported the prevalence of gdm between 6 percent and more than 13 percent and higher in urban locations like dhaka and chattogram (mazumder et al., 2022). nevertheless, data on subjects are not generalized, and there are few hospital-based studies, particularly those which employ standardized diagnostic criteria and those using strong statistical designs (gică & huluță, 2023). it is necessary to recognize the main risk factors that lead to gdm so as to discover, prevent, and intervene early in the disease (meye et al., 2025). in the literature, mother age, pre-pregnancy bmi, familial diabetes history, dietary habits, and patterns of physical inactivity are frequently cited. nonetheless, little is known about interactions between these factors within the context of bangladesh, particularly, in various geographic and socioeconomic communities (singhania, 2025). this study seeks to determine the prevalence of gestational diabetes mellitus (gdm) and its associated risk factors among pregnant women attending a prenatal clinic at a tertiary hospital in bangladesh. having used quantitative approach and analyzing the data in terms of r statistical software, the study can be of great use in providing epidemiological evidence, which will inform national screening as well as maternal health policies. literature review gestational diabetes mellitus (gdm) refers to glucose intolerance identified for the first-time during pregnancy and has become a significant maternal health issue worldwide, particularly in lowand middle-income countries (lmics) like bangladesh. the occurrence rate of gestational diabetes mellitus (gdm) is rising pa ge 44 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 43-52, 2025 worldwide and in south asia is becoming an area of concern because of rapid urbanization, sedentary lifestyle, and diet adjustments (ahmed, 2025). according to a complete research conducted by mazumder et al. (2022), gestational diabetes mellitus (gdm) occurs at the prevalence rate of 11.4 percentage in bangladesh, which is also one of the highest in south asia. the same results by jesmin et al. (2014) were explained by the increasing tendency of gestational diabetes mellitus (gdm) in bangladesh that could be caused by the increasing obesity in women alongside other factors the growing maternal age or urban lifestyle. the prevalence of 13 per cent in a local hospital-based study in chattogram was also found (shah et al., 2021), and the prevalence in tertiary urban hospitals was higher still, which indicates it is possible that gdm is grossly underreported in rural or under-resourced facilities (shivashri et al., 2022). among the countries in the south asia region, the occurrence of gdm is rather diverse because of the heterogeneity of investigative measures and accessibility of healthcare services: the results of south asian countries vary between 8-18% in india depending on the diagnostic criteria used (boyd & conway, 2024), pakistan mentions the magnitude of 12.8% in antenatal clinics in urban settings (pletneva et al., 2023), and sri lanka is about 10.3 percent by who standards (sweeting et al., 2022). the analysis of these studies indicates that, although different problems of gdm is spread in south asia, the bangladeshi population seems to be especially susceptible, perhaps under the influence of metabolic risk, nutrition transition, and lack of standardized/antenatal screening tests. numerous studies have consistently identified many potential risk factors that may contribute to the increased prevalence of gestational diabetes mellitus (gdm) among women in bangladesh. advanced age, particularly beyond 30 years, is significantly associated with the risk of gestational diabetes mellitus, as noted by jesmin et al. (2014). it was also noted that obesity and a body mass index (bmi) score of 25 before pregnancy and above are a crucial factor and shah alam et al. (2024) have found out that there is a close relationship between overweight status of mother and glucose intolerance in pregnancy. the diet pattern is also a critical factor, and the increased intake of fast food and sugar-sweetened beverages is associated with an increased prevalence of gestational diabetes mellitus in accordance with the influence of nutritional transition in urban areas (zannat et al., 2025). furthermore, genetic predisposition is also an essential consideration, since modzelewski et al. (2022) established that familial history of type 2 diabetes nearly triples the risk of developing gestational diabetes mellitus (gdm). also, sedentary habits especially in the urban pregnant women have also been closely linked with gdm as begum et al. (2022) illustrate. collectively, this interconnection has stressed that gdm in bangladesh is multifactorial, and thus there is an immediate requirement to focus on prevention interventions and early antenatal screening efforts. the probability of negative outcomes, such as preeclampsia, fetal macrosomia, and cesarean delivery, is increased in women with gestational diabetes mellitus (mou et al., 2021). furthermore, gestational diabetes mellitus (gdm) is linked to an extended risk of acquiring type 2 diabetes mellitus (t2dm), especially in women displaying insulin resistance characteristics, notably those of south asian origin (gică & huluță, 2023). the absence of a standardized screening and diagnostic protocols is also one of the significant problems in bangladesh. jesmin et al. (2014) noted that 53.5 percent of the cases were underdiagnosed because of varying application of who vs. iadpsg criteria. this is reinforced by the fact that there are minimal antenatal screening facilities in rural settings. even greater prevalence is found on the studies of the bangladesh immigrant women in high-income countries. a prevalence rate of 2530 percent among bangladesh women in the uk was identified by moraortiz & rivas-garcía, (2024) and was described by the authors as the result of genetic predisposition and behavioral shifts. despite existing evidence on the prevalence of gestational diabetes mellitus (gdm) in bangladesh, the current study underscores a notable evidence gap due to a lack of standardized, region-specific data utilizing rigorous statistical methods that include both prevalence and associated risk factors. most prior research investigations are limited to metropolitan areas or are incomplete and not conducted with verified instruments. this study seeks to fill this gap by (1) assessing the prevalence of gestational diabetes mellitus (gdm) among pregnant women at a tertiary hospital in bangladesh and (2) identifying significant sociodemographic, clinical, and lifestyle-related risk factors linked to its occurrence using a quantitative methodology with r software. problems of the research although gestational diabetes mellitus (gdm) has already been recognized as an important maternal health concern in bangladesh, there are still some important gaps in the existing research portfolio and treatment approaches to its detection, measurement, and alleviation. to begin with, the available literature on gdm is generally geographically constrained; hence they do not cover rural and peri-urban communities where there are minimal health provision services and promotion. the implication of this geographical bias is that findings cannot be generalized in the country. second, the national statistics on epidemiology do not provide any aggregates of both prevalence and multidimensional risk factors with similar diagnostic instruments based on universal criteria (like those suggested by who or iadpsg). critical differences in study cut-offs and criteria in most studies have made it quite hard to compare outcomes or develop policies on the screening. thirdly, risk factor study in most local studies is descriptive but not analytical, and the lack pa ge 45 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 43-52, 2025 of good models of statistical forecasting is not conducted to find out independent predictors. moreover, difficulties in training, in projects to help interested medical professionals know more about gdm, lack of antenatal visitations with gdm screening plans, and availability of laboratory work during resource-scarce medical scenarios may also become a problem associated with healthcare providers. in addition, early diagnosis and intervention is even more complicated by patient level factors such as low literacy levels, low nutritional awareness, and cultural taboos. these clinical problems coupled with systemic and methodological issues have thus worsened the late identification, under reporting and inefficient handling of gdm in bangladesh and thereby abased the possibility of maternal and neonatal complications. the effective approach in solving these problems is one that is statistically rigorous, regionally representative, and aimed at guiding effective public health interventions. research questions rq1 what is the prevalence of gestational diabetes mellitus among pregnant women receiving prenatal care at a tertiary hospital in bangladesh? rq2 what sociodemographic factors (such as age, education, income, and residency) are associated with the risk of developing gestational diabetes mellitus in the studied population? rq3 how do clinical characteristics, including pre-pregnancy bmi, family history of diabetes, and parity, influence the likelihood of developing gestational diabetes mellitus (gdm)? rq4 what is the correlation between lifestyle behaviors and the prevalence of gestational diabetes mellitus (gdm)? rq5 to what extent can a logistic regression model predict the likelihood of gestational diabetes mellitus based on the identified variables? research objectives consistent with the research questions and theoretical framework of the study, the subsequent research objectives were formulated. ro1 to determine the prevalence of gestational diabetes mellitus (gdm) in pregnant women undergoing prenatal care at a specified tertiary hospital in bangladesh. ro2 to ascertain notable sociodemographic determinants, such as maternal age, education, income, and residence, that correlate with the risk of developing gestational diabetes mellitus (gdm) in the examined population. ro3 to investigate the clinical risk factors, namely prepregnancy body mass index (bmi), familial history of diabetes and hypertension, and obstetric history in relation to gestational diabetes mellitus (gdm). ro4 to evaluate the impact of lifestyle factors, including physical activity and the intake of snacks and fast food, on the incidence of gestational diabetes mellitus (gdm). ro5 using the quantitative statistical analysis on the r software to make a model prediction in identifying the risky pregnant women using the relevant criteria. hypothesis development several researchers have linked a strong correlation between advanced maternal age and gestational diabetes mellitus. jesmin et al. (2014) recently stated that women aged 30 years or more in bangladesh were much more likely to have gestational diabetes mellitus (gdm) than younger women. a research study conducted by begum et al. (2022) revealed that, compared to the women younger than 35 years, the prevalence of gestational diabetes mellitus (gdm) had significantly increased in women aged over 35 years, thus, age has been revealed as a persistent risk factor. h1: material age and prevalence of gestational diabetes mellitus (gdm) is significantly associated in pregnant women in bangladesh embarked bmi has had a lot of literature regarding predicting gestational diabetes mellitus (gdm). in a study conducted ahmed, (2025) the author found out that the bmi of 25 and above female participants had a much higher probability of having gestational diabetes mellitus as compared to their counterparts. in another metaanalysis conducted by mazumder et al. (2022), the risk of gestational diabetes mellitus (gdm) was not only doubled in the overweight and obese women as compared to the normal body mass index (bmi) women in bangladesh. h2: the higher the body mass index (bmi) pre pregnancy, the more significantly the risk of developing gestational diabetes mellitus (gdm) increases one of the causes of the occurrence of gestational diabetes mellitus (gdm) is the food habits. this research on zannat et al. (2025) was an illustration of a close correlation among the consumption of fast food and sugar-sweetened beverages and the chances of catching gestational diabetes mellitus (gdm) amidst bangladesh women. the paper showed that a female who eats fast food over three times every week demonstrated about 1.8 times more risk of developing gestational diabetes mellitus (gdm). pa ge 46 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 43-52, 2025 h3: the high frequency of fast food and sugarsweetened beverages intake is strongly associated with a great risk of gdm lack of physical activity is observed as a known risk factor to gestational diabetes mellitus (gdm) in lifestyle. shah et al. (2021) offer statistics according to which women with minimal physical exercise in the course of pregnancy in bangladesh had a increase rate of gestational diabetes mellitus (gdm). mou et al. (2021) reached a conclusion according to which the lack of physical exercise has a direct impact on enhancing insulin resistance and glucose intolerance during pregnancy. h4: the insignificant amount of exercise in gestation stage is a big contributor to the occurrence of gestational diabetes mellitus it has also been revealed that there is some genetic predisposition which predisposes the occurrence of gestational diabetes mellitus (gdm). according to pletneva et al. (2023), women, especially those with the family history of type 2 diabetes, are at a threefold increased risk of having gestational diabetes mellitus (gdm). keeping pace with begum et al. (2022) and jesmin et al. (2014), who conducted research on the prevalence of gestational diabetes mellitus (gdm) in bangladesh, the authors also concluded that a family history of diabetes goes hand in hand with the medical condition. h5: the predisposition to diabetes in family member increases the risk of diabetes in pregnancy women significantly materials and methods in this research, quantitative cross-sectional research was used to determine the prevalence of gestational diabetes mellitus (gdm) and also its risk factors among expectant women. the research was carried out at an antenatal (anc) care facility in one of the leading hospitals in the capital city (dhaka), which covers a wide and diverse population both in the urban and periurban centers of bangladesh. all pregnant women who attended the designated hospital during the study period were deemed the target population, as their participation in routine antenatal care facilitated accurate identification of this group. the sampling frame comprised women at a gestational age of 24-28 weeks, as this period is the preferred timeframe for screening gestational diabetes mellitus according to international standards. in this study, sample size was determined using the single population proportion formula: n = (z2.p(1-p))/d2 with a prevalence (p) of 11.4 percent (mazumder et al., 2022; mora-ortiz & rivas-garcía, 2024), and a confidence level (z) of 95 percent (=1. 96) the minimum sample size at a margin of error (d) of 5 percent was 156. a total of 180 anc registry participants were recruited through the systematic random sampling technique in order to balance the non-response or incomplete data. the data were assessed with the help of a structured pretested questionnaire formulated based on the available literature and recommendations of clinical guidelines. the questionnaire comprised five sections: sociodemographic data (age, education, occupation, income), obstetric and medical history (parity, previous history of gestational diabetes mellitus, hypertension, family history of the patients regarding diabetes). anthropometric assessments (mass, stature, body mass index), dietary intake (frequency of fast food and sweetened beverage consumption), physical activity (light, moderate, and sedentary), and blood glucose levels were extracted from hospital records based on the 75g oral glucose tolerance test (ogtt). the investigation utilized microsoft excel and r software version 4.3.2. the data were summarized using descriptive statistics (frequencies, means, standard deviations). inferential analysis: the utilization of chisquare testing to ascertain relationships among categorical data. binary logistic regression was utilized to evaluate the relationship between gestational diabetes mellitus (gdm) and independent variables such as age, body mass index, food, and physical activity. variables exhibiting a p-value < 0.05 were included in the multivariate model, employing odds ratios (ors) and 95% confidence intervals (cis) to assess the magnitude of the risk. this was considered ethical following the ethical permission obtained by the institutional review board (irb) of the hospital. each participant completed an informed consent form prior to data collection. the anonymity and identity of respondents were preserved throughout the research. results and discussion the primary aim of the study was to determine the prevalence rate and identify key risk variables linked to gestational diabetes mellitus (gdm) in pregnant women in bangladesh. an exhaustive analysis was conducted on 180 participants. the data was analyzed using r software, employing descriptive statistics and crosstabulations to ascertain the relationships between various demographic, clinical, and behavioral factors, and the onset of gdm. the evaluation was identified as the 75g oral glucose tolerance test (ogtt), with a result of 140 mg/dl or above categorized as gdm-positive according to who 2013 criteria. demographic profile of the respondents it is crucial to define the demographic attributes of the research population to contextualize the risk factors linked to gestational diabetes mellitus (gdm). the notable sociodemographic and obstetrical attributes of the 180 pregnant women involved in the study are summarized in the following table: table 1, elaborately represent the demographic representative of the respondents. the average age of respondents was around 28.9 years indicating young reproductive population. this goes in line with the national trends of childbearing in bangladesh with majority of the women getting conceived in their twenties. the mean gestational age was approximately 26 pa ge 47 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 43-52, 2025 weeks, so the screening of gdm took place at the right time. in terms of education, 25 participants (14%) were graduates and 26 percent did not receive any form of education, which implies that there is a broad gap in the educated groups within the antenatal populations. with regard to occupation, out of the total of 337 responses (19%), were housewives, but a considerable number of them (41 participants, 23%) were of the category other, as it might be related to an informal job or to unpaid work. nevertheless, there is evident income distribution where 31 percent of women lived in households with an income of less than 10,000 bdt, and 26 percent had received an income that was more than 30,000 bdt, and this segment covers a low to high economic group. the household characteristics were quite equalized: urban (35%), semiurban (34%), and rural (31%) population, making it more generalizable among different population zones. this is a demographic picture that signifies a high range of population populace in regard to income, education, and residence. it indicates the rising healthcare-seeking tendency of both rural and semi-urban people approaching the urban tertiary centers, which is significantly important to the gdm screening outreach. gdm prevalence of pregnant women gestational diabetes mellitus (gdm) has become a very crucial issue of public health and maternal care all around the world and in low and middle-income nations, including bangladesh (zannat et al., 2025). gestational diabetes mellitus (gdm) has become widespread with urbanization, dietary modifications, and more sedentary lifestyles at high-income euro-american income levels, and it has aroused serious threats to maternal and infant health (zannat et al., 2025). evaluations of the distribution of gdm in the study subjects play an important role in the identification of the burden of the illness and the evaluation of its effects in the pre-natal population. the second part will outline the rates of gestational diabetes mellitus (gdm) in 180 respondents included in the current study using who 2013 diagnosis standard according to a 75g oral glucose tolerance test (ogtt) (kautzky-willer et al., 2023). table 1: demographic profile of the respondents variables summary frequency age (years) 28.91±6.94 gestation age (weeks) 25.95± 1.43 gravida (pregnancies) 2.46±1.13 parity (live births) 1.48±1.08 education no formal 47 primary 30 secondary 40 higher secondary 38 graduate plus 25 occupation housewife 35 service sector 38 business sector 27 laborer 39 other 41 monthly income (bdt) <10,000 55 10,000-20,000 40 20,001-30,000 38 >30,000 47 residence urban 63 semi-urban 62 rural 55 figure 1: gdm prevalence among bangladeshi pregnant women the 180 study participants comprised 45 and 55 percent women (81 and 99, respectively) on the gdm prone state and gdm-negative state (figure 1). it has a very high prevalence rate which thus means that the problem of gdm has been becoming a primary health problem to bangladesh pregnant women who attend tertiary level antenatal care. other urban based studies in south asia support these results that point out an upsurge of the prevalence of gdm that exceeds 30% in high-risk groups. relationship between material age and gestational diabetes mellitus (gdm) maternal age can be seen as a significant determinant of pregnancy outcomes, with one of the element of gestational diabetes mellitus (gdm) being one such consequence (zhang et al., 2021). various research has indicated that an older age of maternal women especially after the age of 30 years is linked to poorer insulin functionality and consequently higher risk of glucose taking during pregnancy (zhang et al., 2021). the lifestyles and the urbanization, however, soon started putting the younger women also at the risk of metabolic problems (han et al., 2021). in this section, the interaction between maternal age and gdm status among the participants of the study was checked with the view to understanding whether age remains a critical determinant of gdm in the bangladeshi context. pa ge 48 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 43-52, 2025 in this study the mean age of gdm-positive women were 27.8 years and mean age of gdm-negative women were 29.8 years (figure 2). in contrast to what was supposed to be, younger women in this data had a somewhat higher gdm incidence. this discovery is inconsistent with previous literature (jesmin et al., 2014) which focused on prioritizing the need of advanced maternal age as a predictor. nevertheless, the transition is possibly caused by the transformation in diet and lifestyles patterns even in younger urban women. this drive indicates that we no longer can attribute the advantageous aspects of age to one alone so, even the younger women in the urban setting may still have a high risk of death because of the lifestyle factors. the relationship between body mass index (bmi) and gestational diabetes mellitus (gdm) body mass index (bmi) is a widely utilized measure for evaluating nutritional status and is strongly linked to metabolic disorders, such as gestational diabetes mellitus (gdm) (rosinha et al., 2022). women exhibit elevated levels of insulin resistance who are only overweight or even obese and this may stimulate glucose intolerance among pregnant mothers (bharatnur & acharya, 2023). pre-pregnancy bmi especially is regarded as a severe adjustable risk factor about gdm (bharatnur & acharya, 2023). bangladesh is one of the countries where the overweight and obesity levels are rapidly increasing amongst the women belonging to reproductive population and in particular the urban regions. this part studies the correlation between the bmi and gdm status of the respondents and whether there is one that is significant in predicting gdm in the present sample. in this study, the average bmi of women with gdm was 25.57, while the average bmi of women without gdm was 25.88 (figure 3). unexpectedly, gdm-negative women exhibited a marginally elevated average bmi. this finding contradicts prior research in bangladesh, which identified preconception overweight and obesity as a risk determinant for gestational diabetes mellitus (shah alam et al., 2024). this minor distinction can be ascribed to confounding variables such as physical activity levels and genetic susceptibility. although bmi is an established risk factor of gdm, it was not a strong independent risk factor in this sample, and it highlights the importance to take a multi-factorial risk profile into account. correlation between familial diabetes history and gestational diabetes mellitus (gdm) a notable and unchangeable risk factor for gestational diabetes mellitus (gdm) is a positive family history of diabetes mellitus, especially type 2 diabetes (ortegacontreras et al., 2022). insulin secretion, insulin sensitivity, and the general glucose metabolism may all be affected by the genetic predisposition, raising the chances of having hyperglycemia as a pregnancy complication (mufti et al., 2024). the women who have close relatives with an impaired metabolism due to diabetes are most likely to develop gdm experiencing a very high risk of developing this disease regardless of any other factors connected to the lifestyle and health of these individuals (mufti et al., 2024). this part of the study considers the correlation between familial diabetes history and gdm status of the study participants to determine the degree to which hereditary factors influence gdm risk in the bangladeshi antenatal group. figure 2: mean age of pregnant women figure 3: mean bmi comparison between gdm groups table 2: relationship between family history and gdm family history gdm negative gdm positive no 65 50 yes 34 31 table 2 represented the correlation between familial history and gdm. in this study, it was found that the pregnant women with a familial predisposition to diabetes, gdm was diagnosed in about 48 percent of the persons, whereas almost 43.5 percent did not have such a history. this strengthens the already made genetic aspect of gdm risk (limbachia et al., 2022). premature screening and lifestyle counseling should be given the importance to women having the relatives with diabetes. pa ge 49 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 43-52, 2025 correlation between fast food intake and gestational diabetes mellitus (gdm) diet is one among the major areas of gestational diabetes mellitus development and prevention (alamolhoda et al., 2023). high intake of foods with low nutrient to energy ratio especially the fast foods and a high intake of sugar sweetened drinks has been found to contribute to poor glucose tolerance and insulin resistance in pregnancy (mavroeidi et al., 2024). dietary changes expressed via the consumption of processed and convenience foods have increased in urban and semi-urban environments in bangladesh, a factor that has seen an increase in metabolic stress in women of reproductive age (mou et al., 2021). in this section, the connotation between the pattern of fast food and sugary beverage intake and the presence of gdm among the respondents will be examined with the view of determining whether these lifestyle variables could contribute to poor glycemic control during pregnancy. table 4 denoted the relationship between physical activity and gdm. it was noted that a risk of having gdm was more present in sedentary and moderately active women and a protective role in women that were highly physically active was identified. these findings correspond with the ones found in literature (siddiqui et al., 2013) and validate the fact that a systematic and periodic activity is connected to the reduction in risks of gdm because it improves glucose metabolism. relationship between exercise routine and gestational diabetes mellitus (gdm) in addition to increased physical activity, specific physical exercise programs in pregnancy have been linked to proper glycemic control and a lowered danger of gestational diabetes mellitus (gdm) (alaslani et al., 2022). frequent exercising during pregnancy maintains general metabolism, increases insulin sensitivity, and assists in controlling weight gain in the mother, which are all protective against gdm manifestation (hassanzadeh rad et al., 2024). the connection between gdm and exercise patterns is particularly vital especially in the case where a population such as in bangladesh has many cultural stigmas and a general lack of awareness of the problem due to which the extent of the women indulging in formal exercise may be restricted (mazumder et al., 2022). in this part, the authors analyze the effects of a regular exercise regime and its absence on pregnant women on the gdm status in the current research sample. table 3: relationship between family history and gdm fast food consumption gdm negative gdm positive never 20 20 1-2 times/week 24 21 3-4 times/week 29 22 > 4 times/week 26 18 table 4: relationship between physical activity and gdm activity level gdm negative gdm positive high 30 24 moderate 18 19 low 25 16 sedentary 26 22 table 3 represented the linking between fast food consumption and gdm. in this study, no definite linear growth was found, but the higher proportion of gdm was found in women who consumed fast food more than 3 times per week. so, intake of fast food also causes insulin resistance though it might not be independently acting. its effect will be probably a build-up on the other behaviors like sedentary lifestyle and drinking sweet drinks. correlation between physical activity and gestational diabetes mellitus the behavioral determinants of glucose metabolism and insulin sensitivity are critical in affecting these processes throughout pregnancy and are significant issues for women and their infants (dipla et al., 2021). a sedentary lifestyle is a significant modifiable risk factor associated with gestational diabetes mellitus (gdm), particularly in metropolitan environments where physical activity is often limited (xie et al., 2024). physical exercise consistently has been observed to reduce the likelihood of gestational diabetes mellitus by augmenting maternity glucose uptake as well as improving insulin resistance (molenda et al., 2024). the presented table explores the relationship between the level of physical activity during pregnancy and the prevalence of gestational diabetes mellitus (gdm) in the analyzed cohorts indicating such a positive effect of an active lifestyle on the health of the mother. table 5: relationship between exercise routine and gdm exercise routine gdm negative gdm positive yes 38 18 no 61 63 table 5 displayed the association between exercise routine and gdm. among the respondents, 63 out of 81 gdmpositive women reported to not do regular exercise the idea which supports the protective nature of scheduled physical exercise. the evidence supports the existing guidelines issued by who that encourage physical activities among pregnancy. the focus of anc service must give an emphasis on exercise education. findings this section brings out the overall empirical findings which highlighted the data collection method through 180 women who received antenatal care (anc) services pa ge 50 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 43-52, 2025 in bangladesh. the study results indicate that gdm is a common problem in the examined population that affected women display significant interconnections with other sociodemographic, clinical, and behavioral risk factors. the findings concur with prior research as well as provides novel context-specific knowledge on the interplay of urbanization, changes in lifestyle, and familial history in increasing the risk of gestational diabetes mellitus in bangladeshi women. the burden of the gdm according to who 2013 ogtt criteria of 81 out of 180 (45%) women represents quite a high prevalence in the study setting. • the average age of gdm-positive women was 27.8 years compared with that of negatives gdm (29.8 years) thus implying that the young women are also on the increasing risk though this may be due to urban way of life. • the mean of bmi among gdm-positive women and that of gdm-negative women was 25.57 and 25.88 respectively with no difference. the variable bmi in isolation was not very significant in the sample. • the percentage of women who got gdm when they had a history of diabetes in the family (48%) and when they did not have such a history (43.5%) proves a somewhat strong linkage between the hereditary risk of gdm. • the trend was not highly linear, but more women with gdm reported fast food or sweet drinks consumption = 3 times per week or more, which means the dietary habits along with others are a risk factor not to be disregarded. • sedentary or light participants had an increased risk of gdm, and a high level of physical activity worked in a protective way. • the proportion of gdm-positive women who were not engaging in regular exercise was 63 (77.7%), which confirmed the ability of prenatal structured physical activities to minimize the risk of gdm. • semi-urban and urban population and families with income more than 20,000 bdt/month showed greater prevalence of gdm, making an indication towards urban lifestyle effects. • there was no significant difference in the distribution of gdm across the levels of education or occupation categories, with housewives and workers in laborintensive activities recording higher cases of gdm than any other occupation group, perhaps because of the sedentary lifestyles or dietary limitations. recommendations based on the results of this study it is proposed that the following recommendations can be made to enhance screening, prevention, and treatment of gestational diabetes mellitus in pregnant women in bangladesh: • all pregnant women, notably those availing anc services in the urban and semi-urban regions must be screened universally against gdm between 24-28 weeks of gestation via ogtt. • pregnant women having a positive family history of diabetes must be screened at an earlier stage of pregnancy and carefully watched out to notice the symptoms of gdm. • make a proper integration of gdm profiling tools (age, activity, dietary habits, family history) into anc registries to allow early risk stratification and counseling. • the anc visits must also incorporate the planned nutrition education on the importance of minimizing consumption of fast food, processed sugar, and sweetened drinks. • promotion of light-to-moderate physical activities on a daily basis, based on the stages of pregnancy, and prevention of sedentary lifestyles are some of the ways, which should be deployed by health professionals. • propose to the ministry of health to consider the introduction of prenatal fitness and mobility modules in national anc protocols and guidelines. • campaign in the community and through media networks to make the communities aware of the risks of gdm and the need to screen at an early stage and change their lifestyles. • since the rate of gdm is high in the urban and semiurban areas, health care providers in a locality must focus their intervention programs on these areas. • conduct refresher courses of the midwives and anc nurses on the policies of screening and data collection of gdm screenings and employee communication strategies with patients. limitations this research provides substantial insights into the prevalence and potential risk factors of gestational diabetes mellitus (gdm) among pregnant women in bangladesh; nonetheless, some limitations warrant consideration. the utilization of a hospital-based sample will limit the applicability of the research findings to the wider population, particularly in rural or underprivileged communities. secondly, the cross-sectional design restricts the ability to ascertain causal relationships, and the temporal gap between risk variables and the diagnosis of gestational diabetes mellitus remains indeterminate. third, lifestyle interventions relying on self-reported data (diet and physical activity) may be susceptible to recollection bias or social desirability bias. ultimately, although the sample size was adequate, multivariate regression was not conducted at this stage, potentially limiting the identification of confounding and/or interaction variables. conclusion this study sought to examine the prevalence of gestational diabetes mellitus (gdm) and associated risk factors among pregnant women in bangladesh receiving prenatal care, employing a quantitative research methodology with structured data analysis using r. the prevalence of gestational diabetes mellitus (gdm) was notably high at 45%, posing a significant worry for the general population. key found risk factors included physical inactivity, absence of a consistent exercise plan, frequent use of fast food and sugary beverages, and a positive familial history of diabetes. notably, traditional pa ge 51 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 4(2) 43-52, 2025 risk indicators such as maternal age and body mass 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(2021). factors associated with gestational diabetes mellitus: a meta-analysis. journal of diabetes research, 2021, 1–18. https://doi.org/10.1155/2021/6692695 pa ge 1 pa ge 13 4 american journal of medical science and innovation (ajmsi) factors influencing physicians in the adoption of e-detailing in the in-vitro diagnostic industry anne jillian castillo1*, ernesto dimaculangan1 volume 3 issue 1, year 2024 issn: 2836-8509 (online) doi: https://doi.org/10.54536/ajmsi.v3i1.2978 https://journals.e-palli.com/home/index.php/ajmsi article information abstract received: april 28, 2024 accepted: may 31, 2024 published: june 04, 2024 the pandemic has hastened the need for in-vitro diagnostic (ivd) companies to blend digital and traditional sales strategies. this study explores factors influencing physicians’ adoption of e-detailing in the ivd industry. dependent variables include physicians’ perceptions and intention to use e-detailing, while independent variables encompass the socio-demographic characteristics of the respondents. physicians’ perceptions were also explored if they influenced intentions to use e-detailing. the study excluded physicians outside the national capital region and those not involved in patient consultations. with 408 participants, descriptive statistics and structural equation modeling were utilized to identify sociodemographic characteristics influencing physicians’ perceptions, behavioral intentions, and intention to use e-detailing. a thematic analysis was used to identify common themes doctors use to obtain information about ivd tests. approximately 76% of respondents find e-detailing advantageous, with 70% agreeing on its compatibility and 80% believing it is easy to use. the majority (77%) consider using e-detailing to stay updated on in-vitro diagnostic tests, and 75% intend to use it regularly in the future to obtain such information. however, only 43% express a willingness to switch from face-to-face detailing. more than half of the respondents (52%) prefer to use a combination of face-to-face visits and e-detailing. the study found that the years of medical practice and the medical hierarchy significantly influenced physicians’ perceptions of adopting e-detailing. physicians who viewed e-detailing as advantageous, compatible with their professional needs, and less complex were more inclined to adopt the digital tool for their practice. however, demographic factors did not significantly affect physicians’ intentions regarding e-detailing. this study recommends creating high-quality e-detailing materials for filipino physicians, ensuring accessibility, personalizing content, incorporating multimedia, promoting two-way communication, regularly updating, offering expert interaction, and continuously collecting physician feedback. keywords e-detailing, ivd, physicians 1 the graduate school, university of santo tomas, espana boulevard, 1015 manila, philippines * corresponding author’s e-mail: annejillian.castillo.gs@ust.edu.ph introduction covid-19 is a worldwide emerging infectious disease targeting the respiratory system. it is caused by the sars-cov-2 virus, which was first reported in wuhan province in china last december 2019 (liu et al., 2020). due to its continuous spread globally, the world health organization declared it a pandemic on march 11, 2020 (majumdar et al., 2020). with the challenges brought about by the covid-19 pandemic, clinicians became more interested in in-vitro diagnostics (ivd) to be updated with the new diagnostic tests that can help diagnose and monitor this disease. the us food and drug administration defined in-vitro diagnostic products as assays and instruments used to examine specimens taken from the human body such as blood, urine, and other body fluids to diagnose and monitor diseases. in-vitro diagnostic tests are also used in disease prognosis and treatment management (song and zhu, 2020). it has been widely cited that in-vitro diagnostic tests are responsible for up to 70% of medical decisions made by clinicians (davis, 2014). therefore, appropriate ivd tests are needed to know better the causative agent for emerging infectious diseases like covid-19 (graziadi et al., 2020). the in-vitro diagnostic industry is composed of companies supplying medical laboratories with ivd products utilized by healthcare professionals, healthcare institutions, and even patients themselves in managing medical conditions (davis, 2014). unlike the pharmaceutical industry, wherein companies direct their promotion to clinicians through various marketing communication tools, the ivd industry focuses more on creating face-to-face marketing campaigns intended for the stakeholders of medical laboratories like pathologists, medical technologists, and hospital administrators. in the study conducted by engel n. et al. (2016), global health delivery online (ghdonline) expert panel participants highly suggest making clinicians in public and private sectors more aware of the updates regarding the ivd tests available in the market to encourage its utility in their patient management. nandy and pal (2016) state that detailing, a process of introducing the product and highlighting its advantages to clinicians has been a useful marketing communication tool in the pharmaceutical industry for over the last thirty to forty years. also, in a study conducted by pokharel (2017), it has been found that detailing to clinicians is the most effective promotional and marketing tool in the pharmaceutical industry. pa ge 13 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 however, the researcher has not found any studies that discuss detailing as a marketing communication tool in the ivd industry. moreover, in 2020, research conducted by consulting firm accenture, it has been realized that physicians became more interested in knowing more information on patient drug therapies, medical diagnostic tests, and manufacturers’ support services. moreover, despite the in-person restrictions in place, more than half of the physicians who responded to the survey said they are curious to learn about new treatments and diagnostic tests, and 61 percent said they are interacting with reps more now than they were before the covid-19 pandemic. globaldata (2021) conducted a survey of experts in the pharmaceutical sector from 19 april to 18 may 2021 and found that 75% of the 456 participants thought that virtual interaction would continue after the covid-19 issue passed, either as a stand-alone option or as a combination of in-person and virtual encounters. also from the same survey, only 25% of healthcare professionals (hcps) anticipated a return to prepandemic levels of in-person encounters, highlighting the shift in physicians’ preferences and emphasizing that pharmaceutical and medical diagnostic companies will need to look for novel approaches such as new software or tools to forge meaningful connections. additionally, according to a survey by accenture (2020), 87% of hcps want to continue holding virtual meetings or a combination of virtual and in-person meetings even after the pandemic has ended. only 10% favor returning to the customs of in-person meetings before covid. the constraints of face-to-face marketing activities brought by covid-19 even beyond the pandemic has made ivd companies consider electronic detailing or e-detailing, a widely used marketing communication tool in the pharmaceutical industry. balkanski and getov (2019) define e-detailing as a marketing tool that utilizes an online channel and information technology to promote pharmaceutical products. moreover, davidson and sivadas (2014) state that physicians prefer e-detailing since it enables them to access product information at their most convenient time. while e-detailing is highly encouraged nowadays due to the limitations of access to doctors’ clinics, most physicians still believe that it will never replace face-toface interaction with pharmaceutical sales representatives (balkanski and getov, 2019). additionally, a survey conducted in japan by nikkei research inc. (2021) highlighted the relevance of psrs and their significant role in spreading the word about new medical products and technology, however, it was also mentioned that digital content is set to grow. hence, the covid-19 pandemic has forced companies in the pharmaceutical and ivd industries to adapt and synergize digital and traditional sales and marketing approaches. however, although digital marketing tools like e-detailing have a vast potential to be more efficient and convenient for clinicians and medical sales representatives, digital execution is a considerable challenge for developing countries like the philippines (syrkiewicz-s’witała et al., 2016). also, balkanski and getov (2019) mentioned that the initial implementation of e-detailing might bear additional costs in a company’s marketing budget. this research aims to determine the influence of different socio-demographic factors and innovation perceptions of filipino physicians towards the adoption of e-detailing and identify their source of information about the trends in the in-vitro diagnostic industry. participants of this study are patient-facing physicians in the national capital region of the philippines, where most of the doctors in the country are practicing. furthermore, this study’s variables are anchored in roger’s diffusion of innovations theory (doi) and the technology acceptance model (tam), the two most common theories for technology adoption in the medical industry. lastly, this study’s outcome may encourage ivd companies to employ e-detailing as an essential communication tool that can help keep physicians updated with the trends in the ivd industry. as a result, the use of inappropriate tests will be reduced, which will eventually improve physician’s patient management. material and methods research design this research study will employ a descriptive correlational design to accurately portray the characteristics of research stakeholders and determine whether innovation perceptions on e-detailing influence behavioral intention and socio-demographics. subjects and study site the respondents of the study are patient-facing physicians practicing in the national capital region who are below the age of sixty. hence, physicians who are practicing outside ncr and whose practice does not involve patient consultations, such as pathologists, anesthesiologists, radiologists, nuclear medicine specialists, and forensic medicine specialists, will not be included in the study. senior or aging physicians (aged 60 and above) will be excluded from this research since they are considered to be part of the vulnerable population. the total sample size of respondents is 408 out of the 11,426 physicians. research instrument the research instrument mainly uses seven different articles to adapt the current questionnaire, namely: integrating tpb, tam and doi theories an empirical evidence for the adoption of mobile banking among customers in klang valley, malaysia by alam et al. (2018) with cronbach’s alpha values ranging from 0.705 to 0.888 perceptions of adopters versus non-adopters of a patient portal an application of diffusion of innovation theory by emani et al. (2018) with cronbach’s alpha values ranging from 0.82 to 0.90. pa ge 13 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 knowledge and attitudes of doctors towards e-health use in healthcare delivery in government and private hospitals in northern uganda a cross-sectional study by olok et al. (2015) with most of the cronbach’s alpha values are 0.7 except for complexity with an alpha value below 0.7. are physicians likely to adopt emerging mobile technologies? attitudes and innovation factors affecting smartphone use in the southeastern united states by putzer and park (2012) with cronbach’s alpha values ranging from 0.610 to 0.916, which is considered within the acceptable range. a new debate for turkish physicians e-detailing by ventura, baybars, and dedeoglu (2012) with cronbach’s alpha values ranging from 0.819 to 0.919. perceptions of the provision of drug information, pharmaceutical detailing, and engagement with non-personal promotion at a large physician’s network a mixed-methods study by hincapie et al. (2021). cronbach’s alpha values were not mentioned. physicians’ perceptions of medical representative visits in yemen a qualitative study by al-areefi et al. (2013). furthermore, it made use of the likert scale to determine the overall response of the participants. data gathering procedure the survey questionnaire was administered electronically using google forms through letters addressed to different medical departments of hospitals located in ncr with the permission of the philippine college of physicians (pcp) secretariat. the researcher also conducted a pilot test to ensure that all questions on the instrument are straightforward and that respondents fully understand all the items in the research instrument. after administering the pilot testing, the researcher will measure and analyze the internal consistency of the research instrument, with the help of a statistician, using cronbach’s alpha test. this is to ensure that the questionnaire’s internal consistency is effective and reliable. ethical considerations the researcher assures the participants that all information gathered in this survey will remain private and confidential in compliance with the data privacy act of the philippines. the identity of the participants will not be disclosed and will remain anonymous. with this, participants are not required to provide their names and other information that will reveal their identity. lastly, this research has obtained ethical clearance from the university of santo tomas graduate school review ethics committee. data analysis descriptive and factor analysis will be used to answer research questions 1 and 2, which are to know what perceptions influence physicians’ adaption to e-detailing and identify whether filipino physicians have the intention to use digital tools to acquire information about new trends in the ivd industry. on the other hand, structural equation modeling (sem) will be utilized to identify which socio-demographic characteristics of physicians in the philippines influence their perception towards e-detailing (research question 3), which perceptions of the physicians influence their behavioral intention to use e-detailing (research question 4), and which socio-demographic characteristics of physicians in the philippines influence their behavioral intention to use e-detailing (research question 5). lastly, a thematic analysis will be used to find the common theme that the doctors use to get information about ivd tests (research question 6). technology acceptance theories in the health industry patwardhan et al. (2014) state that the occurrence of technology acceptance among physicians has been viewed as an individual user’s acceptance due to the inevitable emergence of essential technology in their practice. the two most common theories used in explaining user acceptance phenomenon are the technology acceptance model (tam), for the effect of perceived beliefs on the innovation to behavioral intention to use, and the diffusion of innovation theory, for the impact of innovation factors on user’s perception of the innovation (patwardhan et al., 2015). moreover, hameed et al. (2012) state that tam and doi theories have been widely used in successfully identifying and predicting individual user acceptance or adoption of information technology innovation. technology acceptance model (tam) technology acceptance model (tam) by davis (1989) has been widely used to examine the physicians’ technology acceptance phenomenon for various electronic health industry technologies (putzer and park, 2012). also, tam is recommended to be integrated into a framework involving doi and tri to examine innovation like the internet’s adaption pattern among physicians (patwardhan, pandey, and dhume, 2014). diffusion of innovation theory (doi) diffusion of innovation (doi) states that an adaptation of innovation starts when a specific population initially becomes aware of a new way of doing things and then develops an attitude towards it. after which, a decision to adopt or reject the innovation will be made. the diffusion result is that people would adopt a new behavior or idea and eventually become part of their norm (scott and mcguire, 2017). this approach can be adopted in the pa ge 13 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 context of physicians who have similar attributes like specialty and educational qualification and their adoption as a decision-making phenomenon (patwardhan et al., 2014). relative advantage (ra) relative advantage (ra) is defined as the level to which people assume that the new innovation or technology is better than the traditional one (al-rahmi et al., 2019). the studies of anwar (2020), olok et al. (2015), and putzer and park (2012) have shown that ra is significant in influencing physicians’ intent to use innovation in the medical industry. furthermore, the study of alkhateeb & doucette (2009), cited by balkanski & getov (2020)1, shows that ra has a significant positive association in adopting e-detailing in the pharmaceutical industry. in this study, which focuses on the in-vitro diagnostic industry, ra will be utilized to assess whether physicians perceive e-detailing as more convenient than traditional face-to-face detailing in acquiring information about ivd tests. compatibility (cp) al-rahmi et al. (2019) and emani et al. (2018) defined compatibility (cp) as to how people feel that the innovation is compatible with their standards, previous involvements, and the probable adopters’ desires. previous research have found a significant relationship between cp and the intent to use innovation (anwar, 2020; olok et al., 2015; and putzer and park, 2012) and adoption of e-detailing (alkhateeb & doucette, 2009, cited in balkanski & getov, 2020).1but, in the past study of emani, compatibility did not emerge as a distinct factor. it failed to be distinguished with relative advantage. as explained by karahanna et al., as cited in (emani 2018), the idea of compatibility in the doi theory idea as defined by rogers (1962), focuses on needs which is one of the elements of relative advantage. karahanna et al. (2006), as cited in emani et al. (2018), proposed four new distinct constructs of compatibility: preferred work style, existing work practices, prior experience, and values. as suggested by karahanna et al. (2006), as cited in emani et al. (2018), future research, which will apply doi theory, should focus on one or more of the four new constructs to assess whether compatibility emerges as a distinct factor that predicts adoption of innovation. in this study, cp will be used to determine if physicians perceive e-detailing as more appropriate in their preferred work style, existing work practices, and prior experience. complexity (co) another doi factor considered by past studies in assessing the intention to use innovation (anwar, 2020; olok et al., 2015; and putzer and park, 2012) and adoption of e-detailing in the pharmaceutical industry (alkhateeb & doucette, 2009, cited in balkanski & getov, 2020)1 is complexity. complexity is the degree to which an innovation is perceived to be easy to use (anwar, 2020). this variable is adapted in this research to analyze if physicians perceive e-detailing as an easy-to-use tool to access information about diagnostic tests. observability (ob) and trialability (tr) observability (ob) is the idea wherein the innovation benefits are visible to others (emani, 2018). the visibility of a particular innovation’s results motivates the rest of a specific group’s population to adopt the new technology or idea (anwar, 2020). meanwhile, rogers (1962) defined trialability as the capability to test an innovation on a limited basis to explore its implementation procedure, acceptability, and possible results. however, tr and ob will not be included in this study since e-detailing and even traditional face-to-face detailing are not commonly used by the ivd companies making it hard for physicians to observe the results of e-detailing applications in the in-vitro diagnostic industry. also, measuring tr and ob might be a challenge due to the lack of physicians’ exposure to utilize e-detailing as a source of information for ivd tests in their practice. results and discussion perception of physicians on the advantage of e detailing over face-to-face detailing based on physicians’ perceptions toward e-detailing, as indicated by the responses provided on table 1, the following observations can be made regarding the relative advantages of e-detailing. table 1: perception of physicians on the advantage of edetailing over face-to-face detailing items strongly agree agree disagree strongly disagree total using e -detailing enables me to find information about in -vitro diagnostic tests more quickly 48 320 26 14 408 using e -detailing improves the quality of my management to patients 29 351 28 0 408 using e -detailing improves the quality of medical work i do 55 308 45 0 408 using e -detailing enables me to access information about in -vitro diagnostic tests in my own convenience 93 282 26 7 408 using e -detailing increases my work productivity 47 327 34 0 408 pa ge 13 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 in the first item, “using e-detailing enables me to find information about in-vitro diagnostic tests more quickly”, 320 physicians, which is 78.43% of the respondents, agreed with the following statement while 48 respondents strongly agreed while 14 of them strongly disagreed. this suggests that e-detailing provides a relative advantage in terms of efficiency and time-saving compared to traditional methods of gathering information. e-detailing as a digital communication approach provides physicians with several benefits that allow them to locate information about in vitro diagnostic tests more expeditiously. most e-detailing platforms offer searchable databases that enable physicians to quickly access specific information about in vitro diagnostics (lettieri et al., 2022). these databases are typically designed to facilitate the easy retrieval of product specifications, clinical information, research studies, and other pertinent data. search filters and keywords can be used to locate the particular tests that a physician is interested in, thus saving time compared to manually searching through printed material or websites. an e-detailing platform can provide physicians with tailored and personalized content based on their individual needs and interests. this content can be delivered through user profiles or preferences that focus on in vitro diagnostic tests that correspond to the specialty, patient population, or areas of interest of the physician. tailored content ensures that the most pertinent and applicable information to the practice is readily available, thus eliminating the need to search through unrelated materials. in addition, e-detailing platforms often feature intuitive and interactive navigation capabilities (balkanski & getov, 2019). physicians can use menus, hyperlinks, and clickable elements to quickly navigate through the information, allowing them to access different sections, subtopics, or related resources. collapsible sections, tabs, or sidebars enable physicians to quickly skim through the content, focusing on the areas of greatest interest or relevance, thus speeding up information retrieval. e-detailing also utilizes multimedia resources such as video, animation, infographics, and interactive tools to provide information about in vitro diagnostic tests more effectively. these formats can help to illustrate complex concepts, illustrate test procedures, or demonstrate clinical applications succinctly and engagingly. e-detailing allows physicians to gain a better understanding of key information by viewing a video demonstration or an infographic, thus, reducing the time needed to comprehend the principles, advantages, or interpretation of the test. e-detailed platforms can provide up-to-date information on in vitro diagnostic tests in real-time. as the results of new research, clinical guidance, or regulatory changes become available, the platform can update the information in real-time to ensure physicians are kept up to date. this removes the need for manual searches or reliance on outdated printed materials, as real-time updates ensure physicians can access the most recent information about diagnostic tests immediately. furthermore, e-detailed platforms integrate with other digital sources to provide physicians with timely access to relevant information about in vitro diagnostic tests when they review patient cases or make clinical decisions. by connecting different digital tools in a workflow-friendly manner, physicians can easily locate the information they need without having to perform separate searches or interruptions in their clinical practice. for the second item “using e-detailing improves the quality of my management to patients”, there were 351 respondents, or 86.03% who agreed with the statement. on the other hand, 29 of the respondents strongly agreed, and none of the respondents disagreed with the statement. this perception implies that e-detailing provides valuable information and resources that positively impact physicians’ ability to provide effective medical care. e-detailing has a positive impact on the quality of physicianpatient management in the in vitro diagnostic industry (zaman et al., 2018). in vitro diagnostic testing platforms offer physicians access to the most recent information on in vitro diagnostic tests. from product updates to clinical guidelines, to research findings, to treatment protocols, physicians can access the latest and greatest information. this means that physicians can make informed decisions about their patients and provide evidence-based care to them. it provides physicians with continuous learning opportunities. by broadening the knowledge and skills available to physicians, they can improve their diagnostic, treatment, and patient management capabilities. access to education and training programs can improve the quality of the physician’s patient management by increasing their expertise and competence. e-detailing platforms can provide physicians with patient-specific information, such as test results, treatment options, and personalized recommendations. by leveraging this information, physicians can tailor their management plans to meet the individual needs of each patient. it also provides physicians with the ability to access patient information remotely and effectively, allowing them to deliver personalized and tailored care. this personalized approach improves patient management by taking into account the individual characteristics of the patient and optimizing treatment outcomes. it is often used to facilitate communication and collaboration between healthcare professionals. for example, physicians can engage in discussion, seek the opinion of experts, and engage in virtual consultations. this collaboration allows physicians to take advantage of e -detailing is more efficient than face -to -face detailing because i can obtain information about in -vitro diagnostic tests from reliable sources 66 279 47 16 408 pa ge 13 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 the collective knowledge and experience of colleagues, resulting in enhanced patient management. e-detailed platforms can be used to facilitate collaborative decision-making and provide comprehensive care for patients. for instance, physicians can use e-detailed platforms to remotely monitor and follow up on patient progress. this can be done in addition to traditional clinic settings, such as reviewing test results and providing remote consultations. this ongoing monitoring and follow-up helps to improve patient management by providing early intervention, early detection of issues, and ongoing care. e-detailing can provide a number of benefits in terms of patient management, however, privacy, confidentiality, and in-person consultation are all considerations that must be taken into account. furthermore, physician proficiency and willingness to adopt the relevant technologies can also affect the degree to which e-detailing improves patient management. for the third item “using e-detailing improves the quality of medical work i do”, the majority of the respondents, with 308 responses (75.49%) agreed with the statement, while 55 strongly agreed and 45 disagreed. this perception suggests that e-detailing enhances decision-making skills, enhances treatment strategies, and enhances the overall quality of medical care. the utilization of e-detailing within the in vitro diagnostic industry has the potential to improve the quality of the medical work performed by physicians. by utilizing e-detailing platforms, physicians can gain access to a broad range of information relevant to in vitro diagnostic tests, such as product details, clinical information, research results, and best practice guidelines. this comprehensive and readily available information equips physicians to make more informed decisions and provide superior medical care. by increasing the accuracy and relevance of their work, physicians can improve the quality of care, enhance patient outcomes, and minimize variations in practice. evidence-based guidance is often included in the e-detailing platform, which can be used to ensure that medical work is in line with the most recent evidence and best practices. e-detailing helps to disseminate evidencebased guidance and assists physicians in implementing it into their medical work. e-detailing platforms offer educational resources to physicians, such as webinars, online courses, and interactive modules. these resources provide physicians with the opportunity to engage in ongoing medical education, which allows them to stay upto-date with the latest developments and developments in the field, as well as to expand their knowledge and capabilities. this can help to improve the quality of medical work by keeping physicians informed of emerging technologies and diagnostic approaches. these platforms allow physicians to participate in virtual conversations, exchange knowledge, and interact with experts and colleagues (bounthavong et al., 2022). this collaboration encourages knowledge sharing and allows physicians to gain insight and access different perspectives. by sharing knowledge and expertise, physicians can increase their efficiency and effectiveness in their medical work. by utilizing e-detailing platforms to access information and resources quickly and easily, physicians can save time without having to attend physical meetings or search for literature. this can allow them to dedicate more time to patient care or other important aspects of their practice. for the item “using e-detailing enables me to access information about in-vitro diagnostic tests in my own convenience”, more than half, which is 69.12% of the respondents, agreed with the statement. there are 93 respondents who strongly agreed while there are 7 who strongly disagreed. this perception suggests that e-detailing provides flexibility and accessibility, allowing physicians to gather relevant information when and where they need it. the use of e-detailing in the ivd industry is essential in providing physicians with the ability to access information regarding diagnostic tests in a convenient manner. digital platforms enable physicians to access e-detailed materials, such as product details, clinical information, and guidance, from their computers, tablet devices, or mobile devices (ratta et al., 2021). this makes it easier for physicians to access diagnostic test information at the time and location of their choice, thus eliminating the need for in-person meetings or visits by sales representatives. by utilizing e-detailing, physicians can review diagnostic test information in a shorter period of time, eliminating the need for traditional methods of detailing. e-detailing provides physicians with the ability to schedule their e-learning activities in a way that allows them to fit it into their busy schedules (reni, 2020). this allows them to access e-learning materials at any time of the day or night, allowing them to stay up-to-date with the most recent diagnostic tests without having to interrupt their day-to-day work. with e-learning, physicians are able to explore the information in a self-paced manner, allowing them to navigate through the material, re-visit certain sections, and pay particular attention to areas that are of interest or relevant to their practice, thus gaining a more comprehensive understanding of diagnostic testing and its potential applications. an e-detailing platform typically includes interactive components, such as quiz, case study, and simulation, to actively engage physicians. these interactive elements help to retain knowledge and facilitate application. doctors can test their knowledge, apply it to hypothetical situations, and explore various aspects of diagnostic testing in an engaging and immersive way. this interactive element enhances the learning process and facilitates physicians’ comprehension of the information. with e-detailing, physicians can be kept informed of the latest developments in diagnostic tests, including updates, modifications, and new applications. digital platforms are constantly updated to ensure that physicians are kept up to date with the most recent product releases, clinical trial results, research discoveries, and guidance. for the item, “using e-detailing increases my work productivity”, 327 or 80.15% of the respondents answered “agree” with this statement, also 47 strongly pa ge 14 0 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 agreed and 34 strongly disagreed. this suggests that the majority believe that e-detailing provides benefits such as streamlined access to information, efficient communication, and the ability to multitask effectively. e-detailing enables physicians to access a broad range of information about ivd tests, such as product specifications, clinical information, research results, and educational materials, in real-time, tailored to their individual needs. this allows physicians to quickly acquire the necessary data and inform their decisions. by providing comprehensive and current information efficiently, physicians can reduce the amount of time they spend searching for information from a variety of sources. it is often possible to engage with videos, as well as virtual demonstrations, while simultaneously managing other tasks such as patient records or research. this allows physicians to maximize their time utilization and work productivity by multitasking. effective communication channels facilitate a rapid exchange of information and eliminate the need for long-distance meetings or telephone calls, thus increasing work productivity. for the last item “e-detailing is more efficient than faceto-face detailing because i can obtain information about in-vitro diagnostic tests from reliable sources”, a total of 279 physicians responded to the survey, with 68.38% agreeing with the statement. there were 66 respondents strongly agreed, 47 disagreed, and 14 respondents strongly disagreed with the statement. in the in vitro diagnostic industry, e-detailing provides physicians with a range of benefits, such as direct access to reliable sources of information, the ability to avoid intermediaries or misinterpretation, and the consolidation of information from multiple sources into one central location (viseven, 2023). this consolidation of information ensures that physicians can rely on accurate and reliable information that has been thoroughly reviewed. moreover, the purpose of e-detailing platforms is to provide physicians with the most current and pertinent information regarding diagnostic tests. this is achieved through the rapid updating of content on the platform by manufacturers and other stakeholders in response to new data, findings from research, safety data, or modifications to product specifications. this provides physicians with the assurance that the information they are receiving is up to date and in accordance with the relevant regulatory standards and guidelines. e-detailing material is often subject to a rigorous peer review process, which ensures that the information presented is accurate and of scientific value. this peer review process is typically conducted by experts in the field of the subject matter or other relevant professionals. this adds an extra layer of credibility and assurance to the content, providing physicians with the assurance that it is accurate and reliable. additionally, e-detailed materials are often transparent and traceable, allowing physicians to identify the source of the information, such as links to scientific studies or clinical trials, as well as references to publications. this level of transparency allows physicians to independently verify the accuracy of the information and make decisions based on its credibility. there are a small number of physicians who disagreed and strongly disagreed with some of the statements presented in table 2. some may be resistant to technological advancements and prefer traditional methods of communication and information exchange. they may feel uncomfortable with the shift from face-to-face interactions to digital platforms. moreover, e-detailing primarily relies on digital communication channels, which may lack the interpersonal connection that they value. they may prefer in-person meetings or physical product demonstrations to better understand and evaluate the diagnostic products. e-detailing platforms are often standardized and may not provide the same level of customization as face-to-face interactions (kim & chang, 2022). doctors may feel that their specific needs and concerns are not adequately addressed through digital means. with the increasing digitalization of information, they might feel overwhelmed by the sheer volume of electronic communication they receive. it contributed to information overload, making it challenging for doctors to filter and prioritize relevant information. doctors also deal with sensitive patient information, and there may be concerns about the security and privacy of data transmitted through e-detailing platforms. some worry about the potential for data breaches and unauthorized access to patient information. in order to address these issues and promote adoption, there are a number of steps that can be taken. the primary focus should be to tailor the content and communication of the e-detailing platform to the individual needs and preferences of the doctor. this can be achieved by providing comprehensive training and ongoing support to the doctor, such as technical assistance, tutorials, and resources, to ensure the doctor feels comfortable and confident using the digital tools (ftouni et al., 2022). additionally, data security and privacy should be a priority, with strong security measures and encryption protocols in place to reduce the risk of data breaches or unauthorized access. also, a hybrid model should be adopted, combining e-detailing and occasional in-person or physical product demonstrations, in order to create a more flexible and comprehensive communication strategy. finally, efforts should be made to demonstrate the benefits of e-diagnostic services, such as improved time efficiency, access to information, and improved patient care. by demonstrating the value and positive results of digital engagement, resistance to change can be overcome. perception of physicians on the compatibility with e-detailing for the first item “using e-detailing is completely compatible with the current situation (pandemic)”, there are 327 respondents or 80.15% of the physicians agreed to that statement while 59 agreed, and 22 disagreed. this implies that most respondents believe that e-detailing is pa ge 14 1 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 table 2: perception of physicians on the compatibility with e-detailing items strongly agree agree disagree strongly disagree total using e-detailing is completely compatible with the current situation (pandemic) 59 327 22 0 408 e-detailing of in-vitro diagnostic tests suits my general needs better than face-to-face detailing. 37 255 97 19 408 e-detailing fits my time management style than face-to-face detailing because it allows me to conduct longer and deeper research about in-vitro diagnostic tests 38 297 68 5 408 e-detailing suits my schedule because it enables me to access information about in-vitro diagnostic tests in my free time 86 292 17 13 408 e-detailing will fit well with my work style 86 264 55 3 408 compatible with the pandemic. to be specific, e-detailing is a viable solution for pharmaceutical and diagnostic companies to engage with physicians effectively during the pandemic (adkonkar et al1., 2022; hincapie et al ., 2021). factors influencing physicians’ adoption of e-detailing include convenience, flexibility, time-saving, enhanced accessibility to remote areas, safety considerations, technological proficiency, and interaction quality. convenience allows physicians to access information and engage with representatives from diagnostic companies at their own convenience, eliminating the need for specific time slots for in-person meetings. time-saving is particularly valuable during the pandemic when physicians are often overwhelmed with patient care and other responsibilities. e-detailing also bridges the geographical gap between physicians and diagnostic companies, allowing them to connect virtually with industry experts and gain necessary information and support. safety considerations are another factor influencing physicians’ adoption of e-detailing. the pandemic has highlighted the importance of minimizing face-to-face interactions to reduce the risk of viral transmission. e-detailing provides a safer alternative to in-person meetings, allowing physicians to maintain social distancing measures while still accessing valuable information about diagnostic products and services. technological proficiency is crucial for physicians’ adoption of e-detailing. while not all physicians may have the same level of proficiency, efforts should be made to provide training and support to ensure widespread adoption. interaction quality is also crucial for the effectiveness of e-detailing. diagnostic companies should ensure their platforms are user-friendly, offer engaging content, and enable real-time interaction and discussion (dockendorf et al., 2021). addressing physicians’ queries promptly and providing personalized support can significantly influence their perception and adoption of e-detailing. for the second item “e-detailing of in-vitro diagnostic tests suits my general needs better than face-to-face detailing”, most of the respondents agreed with the statement, which is 255 or 62.50% of the respondents. moreover, there are 97 who disagreed and 37 who strongly agreed. e-detailing of in-vitro diagnostic tests can indeed suit the general needs of physicians better than face-toface detailing. this is due to several factors, including convenience, time-saving, safety considerations, enhanced accessibility, technological advantages, engagement and interactivity, and documentation and reference. convenience and flexibility are key advantages of e-detailing. time-saving is another advantage, as physicians can access information about in-vitro diagnostic tests without having to allocate extra time for traveling to and from meetings. e-detailing sessions are more focused and efficient, enabling physicians to stay updated on the latest diagnostic tests and research in a shorter amount of time. safety considerations are also important, especially during pandemics or infection control measures. e-detailing allows physicians to engage with representatives from diagnostic companies without risking exposure to infectious diseases, especially for immunocompromised patients or in high-risk areas. enhanced accessibility is another advantage, as physicians can connect with representatives virtually, regardless of their geographical location. technological advantages include real-time data sharing, interactive presentations, and instant messaging, enhancing the overall experience and understanding of complex diagnostic tests. e-detailing also provides an engaging and interactive experience for physicians, as representatives can use multimedia tools to effectively communicate complex concepts and features of diagnostic tests. digital materials, such as brochures, white papers, and product information, can be easily stored and referenced for informed decision-making (akbarieh et al., 2020). on the other hand, there some physicians may argue that face-to-face detailing of in-vitro diagnostic tests is better due to several reasons. these include limited personal interaction, lack of customization, technical challenges, limited non-verbal communication, preference for tangible materials, and privacy and data security concerns (ruben et al., 2021). direct interaction with medical representatives is essential for better understanding, clarification of doubts, and building professional relationships. e-detailing, which pa ge 14 2 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 typically occurs through digital channels, may be seen as impersonal and lacking in this aspect. customization is also a concern, as medical representatives can adapt their approach based on individual preferences, clinical practice, and patient population. technical challenges may also arise, as physicians may feel uncomfortable or less confident in navigating digital platforms or using electronic devices during the detailing process. non-verbal cues, such as body language and facial expressions, play a crucial role in effective communication, and e-detailing may not capture these nuances, leading to potential misunderstandings or misinterpretations. physicians who prefer physical materials may find e-detailing less satisfactory, as electronic presentations may not provide the same tactile experience or convenience. privacy and data security concerns may also arise, as e-detailing often involves the exchange of medical information and patient data through digital platforms (paul et al., 2023). for the third statement, “e-detailing fits my time management style than face-to-face detailing because it allows me to conduct longer and deeper research about in-vitro diagnostic tests”, there 297 respondents who agreed with this, while there are 68 who disagreed, and 38 strongly agreed. in the fourth statement “e-detailing suits my schedule because it enables me to access information about in-vitro diagnostic tests in my free time”, there are 292 physicians who agreed, while 86 strongly agreed, and 17 disgareed. this means that most of the respondents perceive that e-detailing is compatible with their time managementnt style and schedule. e-detailing in the in-vitro diagnostic (ivd) industry offers physicians numerous benefits, including extensive research opportunities, flexibility and convenience, selfpaced learning, accessibility, and efficient time utilization. e-detailing allows physicians to explore comprehensive product information, scientific literature, clinical data, and case studies, providing a deeper understanding of diagnostic tests, their applications, and potential impact on patient care. flexibility and convenience are also key advantages of e-detailing. e-detailing platforms allow physicians to access information about in-vitro diagnostic tests at their convenience, allowing them to manage their time effectively. they offer self-paced learning, accessibility, and efficient time utilization. physicians can integrate e-detailing into their schedules, engaging with content whenever needed. however, face-to-face interactions still hold value in complex discussions or hands-on demonstrations. reliable internet connectivity and user-friendly platforms influence the overall experience and adoption of e-detailing. in the last item “e-detailing will fit well with my work style”, most of the respondents agreed with the statment with 264 responses, with a percentage of 64.71%. there are 86 who answered “strongly agree”, while there are 55 and 3 respondents who answered “disagree” and “strongly disagree”, respectively. e-detailing in the invitro diagnostic (ivd) industry is influenced by factors such as flexibility, convenience, information access, interactive content, customization, and time efficiency. physicians often have busy schedules and limited time for in-person meetings, which can hinder their workflow efficiency. e-detailing allows physicians to access relevant information from any location and time, enhancing their workflow efficiency. information access is crucial for physicians, who constantly seek accurate information about diagnostic tests and technologies. e-detailing platforms provide a platform for ivd companies to share product details, clinical evidence, and research findings in a digital format, allowing physicians to access comprehensive information without the need for physical materials or face-to-face meetings. interactive content, such as videos, animations, and multimedia presentations, can enhance physicians’ engagement and facilitate their understanding of complex ivd products. customization and personalization can be achieved through user profiling and data analytics, ensuring that physicians receive relevant and valuable information. time efficiency is another advantage of e-detailing. it eliminates the need for travel time associated with in-person meetings, allowing physicians to review product information and engage with e-detailing platforms efficiently. this time-saving aspect aligns well with physicians’ work style, enabling them to access information quickly and conveniently. perception of physicians on the complexity of e-detailing table 3: perception of physicians on the complexity of e-detailing items strongly agree agree disagree strongly disagree total i believe e-detailing is easy to use 48 320 32 8 408 i do not find any issues in accessing e-detailing tools 35 243 121 9 408 e-detailings tools are easy to navigate 47 307 44 10 408 using e-detailing requires a lot of mental effort 6 55 296 51 408 learning to use e-detailing is easy 53 337 18 0 408 switching to e-detailing from face-to-face detailing will be 46 329 33 0 408 for the item “i believe e-detailing is easy to use”, most of the respondents agreed with this statement, with 320 counts or 78.43% of the respondents. there were 48 who strongly agreed, and 32 respondents who disagreed. also, for the item “learning to use e-detailing is easy”, there were 337 who responded “agree”, 53 who strongly pa ge 14 3 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 agreed, and 18 who disagreed. e-detailing is perceived as easy to use by doctors due to several factors. these include convenience, accessibility, flexibility, information availability, enhanced engagement, and tailored content. convenience allows doctors to interact with pharmaceutical representatives without the need for in-person meetings or visits to their clinics. e-detailing platforms are designed to be user-friendly and accessible, providing a simple and intuitive interface for doctors to navigate and interact with features. flexibility allows doctors to participate in e-detailing sessions from their own office or any other location with internet access, enhancing their perception of its usability. information availability is another key factor, as e-detailing platforms provide doctors with easy access to a wealth of information about pharmaceutical products, treatment guidelines, clinical trials, and research findings. interactive features, such as multimedia presentations, videos, and interactive tools, help doctors engage with the content more effectively, making the learning experience more enjoyable and memorable. tailored content is another advantage of e-detailing platforms, as they can provide personalized information based on doctors’ preferences, specialties, and patient populations. this makes it easier for doctors to understand and apply the information in their clinical decision-making process. for the second item “i do not find any issues in accessing e-detailing tools”, there are 243 respondents who answered “agree”, 121 respondents who answered, “disagree”, and 35 respondents who chose “strongly agree”. majority of the respondents do not find any issues in accessing e-detailing tools. doctors may not find any significant issues in accessing e-detailing tools due to several factors. these include widespread internet connectivity, compatibility with multiple devices, userfriendly interfaces, cross-platform accessibility, minimal technical requirements, and adequate support and training. internet connectivity is widespread and easily accessible in many regions, ensuring seamless access to e-detailing tools. e-detailing platforms are designed to be compatible with various devices, allowing doctors to choose the device that suits their preference and convenience (wolters kluwer, 2020). user-friendly interfaces are often developed with user experience in mind, incorporating clear instructions, well-organized layouts, and intuitive controls. cross-platform accessibility is another advantage of e-detailing platforms. many are web-based or offer dedicated mobile apps, allowing doctors to access the tools across different operating systems. minimal technical requirements make e-detailing tools accessible without the need for specialized hardware or software. doctors can access e-detailing platforms using standard web browsers or downloading lightweight mobile apps. additionally, e-detailing providers often offer support services and training resources to assist doctors in using their platforms effectively. these resources may include user guides, faqs, video tutorials, and dedicated support teams. the availability of comprehensive support and training ensures that doctors can quickly resolve potential issues and become proficient in using e-detailing tools. in the third item “e-detailings tools are easy to navigate”, majority of the respondents, which is 307 or 75.25% of the physicians, agreed that e-detailing is easy to use. there are 47 strongly agreed, and 44 disagreed with the statement. e-detailing tools are perceived as easy to navigate by doctors due to their intuitive user interface, familiarity with digital platforms, consistency in design, clear menu hierarchy, robust search and filtering capabilities, interactive and guided features, and iterative improvements. intuitive user interfaces are organized, visually appealing, and provide clear navigation menus and options. doctors, especially younger generations, are familiar with digital platforms and tools, making them easy to navigate (lupton, 2021). consistency in design, such as placement of menus, buttons, and content sections, makes it easier for doctors to navigate the platform. a clear menu hierarchy helps doctors navigate through different sections and content categories, logically grouped together. search and filtering capabilities allow doctors to quickly find relevant content or resources using keywords or filters. interactive and guided features, such as tooltips, pop-up guides, or interactive tutorials, make the navigation process more straightforward and reduce potential confusion. user feedback and iterative improvements are crucial for e-detailing platforms to maintain a user-friendly experience. continuous improvements based on user feedback contribute to a more user-friendly experience and reinforce the perception that the tools are easy to navigate (dwivedi et al., 2021). for the fourth item “using e-detailing requires a lot of mental effort”, 296 or 72.55% of the respondents disagreed, while there were 55 who agreed and 51 strongly disagreed. thus, the majority of physicians disagree that e-detailing requires a lot of mental effort. e-detailing is often perceived as mentally effortless by doctors due to several factors. these include user-friendly interfaces, concise and targeted information, customization and personalization, interactive and engaging features, accessible and digestible format, convenient access, and familiarity with digital tools. e-detailing platforms are designed with user experience in mind, offering clear menus, organized layouts, and straightforward navigation. they focus on providing key points, summaries, and relevant data, reducing cognitive load and making the overall experience feel effortless. customization allows doctors to personalize their experience based on their specialties, patient populations, or specific interests, ensuring they receive tailored information that aligns with their areas of focus. the accessible format of e-detailing tools uses clear language, bullet points, visuals, and other formatting techniques to enhance readability and comprehension. some doctors may also perceive e-detailing as mentally demanding due to several factors. information overload pa ge 14 4 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 can lead to doctors feeling overwhelmed by the vast amount of information presented, requiring mental effort to filter and prioritize relevant information. multitasking can increase mental load as doctors need to divide their attention and cognitive resources between different activities, including navigating the e-detailing platform. cognitive processing is another significant challenge in e-detailing, as it involves complex medical concepts, scientific data, and technical information. this process requires concentration, critical thinking, and mental effort, especially when dealing with intricate or unfamiliar topics. decision-making considerations can also be mentally taxing, as doctors need to consider patientspecific factors, clinical guidelines, drug interactions, and potential risks or benefits. adaptation to technology can be challenging for doctors, as they may face challenges in navigating unfamiliar interfaces, features, or functionalities (vaportzis et al., 2017). the initial learning curve and the need to adapt to new ways of engaging with information can contribute to the belief that e-detailing requires mental effort. time constraints also contribute to the perception of mental effort in using e-detailing, as doctors often have limited time available for professional activities, including e-detailing sessions. in the last item, “switching to e-detailing from face-toface detailing will be easy”, most of the respondents agreed with 329 counts (80.64%). moreover, there are 46 respondents who strongly agreed, and 33 who disagreed with the statement. doctors may find switching to e-detailing easier due to several reasons, including convenience, improved access to information, time-saving, and perceived effectiveness of digital communication. the perceived effectiveness of digital communication is another aspect, as doctors are increasingly familiar with and reliant on digital communication methods in their personal and professional lives. however, some doctors may initially encounter challenges while transitioning from face-to-face detailing to e-detailing, such as adapting to new technology, concerns about the quality and depth of interactions, and the need for additional training and support. addressing these concerns through comprehensive training, ongoing support, and demonstrating the benefits of e-detailing can help facilitate a smoother transition and increase physicians’ confidence in embracing this digital approach in the in-vitro diagnostic industry. intention of physicians to e-detailing table 4: intention of physicians to e-detailing items strongly agree agree disagree strongly disagree total i consider to use e-detailing to get updates about in-vitro diagnostic tests 77 314 17 0 408 in the future i will use e-detailing regularly for getting information about in-vitro diagnostic tests 68 304 35 1 408 i intend to switch to e-detailing from face-to-face detailing 56 177 156 19 408 i intend to use e-detailing during the pandemic since face-toface detailing is not possible 72 321 11 4 408 i intend to use e-detailing even after the pandemic 86 284 29 9 408 for the items in table 4, most of the respondents have the intention to acquire information about new trends in the in-vitro diagnostic (ivd) industry using e-detailing. most of the doctors intend to use e-detailing during the pandemic since face-to-face detailing is not possible. also, physicians consider using e-detailing to get updates about in-vitro diagnostic tests, and in the future they will use e-detailing regularly for getting information about invitro diagnostic tests. doctors have several reasons to consider using e-detailing, particularly when it comes to acquiring information about new trends in the in-vitro diagnostic (ivd) industry and staying updated on in-vitro diagnostic tests. e-detailing provides doctors with a convenient way to access information about new trends and diagnostic tests. they can access the information from their computers, tablets, or mobile devices, allowing them to stay informed at their own convenience, regardless of their location or time constraints. this accessibility makes it easier for doctors to acquire knowledge about the latest advancements in the ivd industry. the ivd industry is constantly evolving, with new diagnostic tests and technologies being introduced regularly. e-detailing platforms can provide doctors with real-time updates, ensuring that they stay up-to-date with the latest developments (bigtincan holdings limited, 2023). by receiving timely updates, doctors can make well-informed decisions about adopting new diagnostic tests or technologies in their practice. moreover, e-detailing platforms often offer comprehensive information about in-vitro diagnostic tests. these platforms can provide detailed product descriptions, clinical trial data, research findings, and comparative analyses of different tests, enabling doctors to gather all the necessary information in one place. the covid-19 pandemic has significantly disrupted traditional face-to-face interactions, including detailing sessions. e-detailing emerged as a viable alternative during the pandemic, allowing doctors to continue pa ge 14 5 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 acquiring information about new trends and diagnostic tests without compromising their safety or the safety of their patients. for the item, “i intend to switch to e-detailing from face-to-face detailing”, a percentage of 43.38% of the respondents agreed while 38.24% disagreed with this statement. the nearly divided percentage of agreement and disagreement regarding the intention to switch from face-to-face detailing to e-detailing suggests that there are mixed opinions among the respondents. doctors have varying preferences when it comes to acquiring information and engaging with pharmaceutical representatives or industry experts. some doctors may be more comfortable with face-to-face interactions, valuing direct communication, while others may be more open to embracing digital platforms and find e-detailing more convenient. these individual preferences can contribute to the divided percentage. the age and technological proficiency of the respondents may play a role in their agreement or disagreement with switching to e-detailing. younger doctors who are more familiar with digital tools and have grown up in a technology-driven era may be more inclined to embrace e-detailing. in contrast, older doctors who are less comfortable with technology or have established routines and preferences for face-toface interactions may be more resistant to the switch. this generational difference can contribute to the divided percentage. respondents’ previous experiences with both face-to-face detailing and e-detailing can shape their opinions. some may have had positive experiences with face-to-face interactions, building trust and establishing relationships with pharmaceutical representatives. others may have had negative experiences, finding them timeconsuming or intrusive. similarly, some respondents may have had positive experiences with e-detailing, appreciating the convenience and information accessibility, while others may have encountered limitations or perceived drawbacks. these differing experiences and perceptions can contribute to the divided percentage. regional or cultural factors can also influence the preference for face-toface or digital interactions. cultural norms, expectations, and communication styles can shape doctors’ attitudes toward e-detailing. in some regions or cultures, face-toface interactions may be highly valued and considered essential for building professional relationships. these regional and cultural factors can contribute to the divided percentage among respondents. to be able to examine if the physician’s perceptions to adapt e-detailing is influenced by the following sociodemographic characteristics, particularly, age, gender, years in practice, level in the medical hierarchy, the volume of laboratory requests written; and frequency of interacting with psrs, a multiple linear regression model was formulated. the results are presented in table 5. path coefficients of socio-demographic profile and perceptions to adapt e-detailing table 5: path coefficients of socio-demographic profile and perceptions to adapt e-detailing estimate se 95%ci t-stat p-value gnender ⭢ perception -0.064 0.046 -0.154 0.035 -1.3913 0.164987 age ⭢ perception -0.06 0.153 -0.397 0.246 -0.3922 0.695264 years ⭢ perception -0.275 0.135 -0.532 0.043 -2.037 0.042298* ieve 1 ⭢ perception 0.182 0.082 0.014 0.343 2.21951 0.027005* volume ⭢ perception -0.079 0.047 -0.156 0.027 -1.6809 0.093727 freauency ⭢ perception -0.028 0.057 -0.138 0.092 -0.4912 0.623692 *significant at 0.05 after analyzing the data through structural equation modeling, the p-values for each independent variable obtained. the results revealed that the independent variables, the years of practice and the level in the medical hierarchy, had p-values of 0.042298, and 0.027005, respectively, which had less than 0.05. this indicates that the years of medical practice and level of medical hierarchy have statistically significant impact on physicians’ perception of adapting e-detailing. in other words, the physicians’ position or rank and years of experience within the medical field play roles in their likelihood of accepting or utilizing e-detailing methods. on the other hand, the p-values for all other independent variables, including gender, age, volume of laboratory requests written, and frequency of interacting with psrs, were greater than 0.05. this suggests that these variables were not found to have a significant association with the physicians’ perception of adapting e-detailing in this particular study. thus, these findings suggest that the years of medical practice and level of medical hierarchy is a crucial factor influencing physicians’ perception of adapting e-detailing. however, the other variables examined in the study, such as gender, age, the volume of laboratory requests written, and frequency of interacting with psrs, did not demonstrate a significant relationship with the physicians’ perception of adapting e-detailing. in the regression model, the factor “years of medical practice” was found to have a path coefficient of -0.275. in this case, the negative path coefficient of pa ge 14 6 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 -0.275 indicates a negative relationship between the years of medical practice and physicians’ perception of adapting e-detailing. this means that as the number of years of medical practice increases, the likelihood of physicians perceiving e-detailing as beneficial decreases. furthermore, the negative sign of the path coefficient suggests an inverse relationship between the two variables. it implies that physicians with more experience and a longer history of medical practice may be less inclined to embrace e-detailing as a valuable tool in their practice. there could be several reasons for this negative relationship. one possibility is that physicians with more years of practice may have established routines and ways of working that do not align with incorporating e-detailing into their clinical workflow. they may be comfortable with traditional methods of information acquisition and communication, and thus, may be hesitant to adopt new electronic methods (farsi, 2021). additionally, physicians with more experience may have developed a higher level of confidence and expertise in their field, leading them to rely less on external sources of information such as e-detailing. they may have established strong professional networks, access to specialized resources, and an extensive knowledge base, which reduces their perceived need for e-detailing. furthermore, physicians with more years of practice may have experienced changes in the healthcare landscape over time. they may have witnessed the introduction of various technological innovations, some of which may not have met their expectations or delivered the anticipated benefits. as a result, they may be more skeptical about the advantages of e-detailing based on their past experiences. in the regression model, the factor “level of medical hierarchy” was found to have a path coefficient of 0.182. the path coefficient of 0.182 indicates a positive relationship between the level of medical hierarchy and physicians’ perception of adapting e-detailing. the positive sign suggests that as the level of medical hierarchy increases, the likelihood of physicians perceiving e-detailing as a valuable tool also increases. the magnitude of the path coefficient, which is 0.182 in this case, represents the extent of the relationship. since the coefficient is positive but less than 1, it suggests a moderate positive association between the level of medical hierarchy and physicians’ perception of adapting e-detailing. therefore, based on the path coefficient of 0.182, it can be concluded that physicians in higher positions within the medical hierarchy are more likely to perceive e-detailing as beneficial. this finding underscores the importance of considering the influence of professional rank and authority within the healthcare system when implementing e-detailing strategies. table 6 presents the results on the effects of the perception of the physicians influencing their behavioral intention to use e-detailing. path coefficients of perceptions to adapt e-detailing in their intention of adapting e-detailing table 6: path coefficients of perceptions to adapt e-detailing in their intention of adapting e-detailing estimate se 95%ci t-score p-value advantage ⭢ intention 0.171 0.068 0.053 0.307 2.514706 0.0123* compatibility ⭢ intention 0.31 0.056 0.187 0.412 5.535714 <0.00001* complexity ⭢ intention 0.4 0.04 0.32 0.479 10 <0.00001* *significant at 0.05 in this study, a regression model using structural equation modeling was developed to examine the factors influencing physicians’ intentions to adopt e-detailing. there were three independent variables identified: perceptions of the advantage of e-detailing, perceptions of e-detailing compatibility, and perceptions of e-detailing complexity. these variables were considered important in understanding physicians’ willingness to embrace e-detailing as a tool for their professional practices. to investigate the relationship between these variables and physicians’ intention to adopt e-detailing, the path coefficients associated with each independent variable were analyzed. in this study, all three coefficients yielded p-values of 0.0123, <0.00001, and <0.00001, respectively. the small p-values in this study provide strong evidence against the null hypothesis, which suggests no relationship between the independent variables (perceptions of the advantage of e-detailing, perceptions of e-detailing compatibility, and perceptions of e-detailing complexity) and physicians’ intention to adapt e-detailing. therefore, it can be concluded that there is a statistically significant relationship between these variables. these findings indicate that physicians who perceive e-detailing as advantageous, compatible with their professional needs, and less complex are more likely to express an intention to adopt this digital tool for their practice. in the regression model constructed, one of the independent variables examined was the perceptions of the advantage of e-detailing. the coefficient obtained for this variable was 0.171. a coefficient of 0.171 indicates a positive relationship between the perceptions of the advantages of e-detailing and the intention to adopt e-detailing. specifically, for every one-unit increase in the perceptions of the advantage of e-detailing, the intention to adopt e-detailing is estimated to increase by 0.171 units, on average. this positive coefficient suggests that individuals who perceive e-detailing as more advantageous are more likely to express a stronger intention to adopt pa ge 14 7 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 e-detailing. these individuals recognize the benefits and value that e-detailing can bring to their specific context or situation, which influences their motivation and willingness to adopt this digital tool. another independent variable investigated was the perceptions of e-detailing compatibility. the coefficient obtained for this variable was 0.31. a coefficient of 0.31 indicates a positive relationship between the perceptions of e-detailing compatibility and the intention of adapting e-detailing. specifically, for every one-unit increase in the perceptions of e-detailing compatibility, the intention to adapt e-detailing is estimated to increase by 0.31 units, on average. this positive coefficient suggests that individuals who perceive e-detailing as more compatible with their needs or professional requirements are more likely to express a stronger intention to adopt e-detailing. these individuals perceive e-detailing as fitting well into their existing practices or workflows, and they see it as a tool that complements and enhances their current ways of interacting with pharmaceutical companies or accessing information. for the independent variable which was the perception of e-detailing complexity, the coefficient obtained for this variable was 0.4. a coefficient of 0.4 indicates a positive relationship between perceptions of e-detailing complexity and the intention to adopt e-detailing. specifically, for every one-unit increase in perceptions of e-detailing complexity, the intention to adapt e-detailing is estimated to increase by 0.4 units, on average. this positive coefficient suggests that individuals who perceive e-detailing as less complex are more likely to express a stronger intention to adopt e-detailing. when individuals perceive e-detailing as simpler and easier to understand and use, they are more inclined to embrace it as a valuable tool for their professional practices. this study provided an in-depth analysis of the physician’s perception of e-detailing and their intention to adopt the digital tool for their practice. the results indicated that physicians who viewed e-detailing as beneficial, suited to their professional requirements, and less complex were more likely to express a strong desire to adopt the technology. this positive sentiment indicates that physicians are aware of the advantages and value it can bring to their practices. they are aware that e-detailing has the potential to improve their communication and exchange of information with pharmaceutical companies, resulting in improved patient care and results. this positive sentiment encourages physicians to consider incorporating e-detailing into their medical practice. furthermore, it is essential for physicians to understand how the digital tool fits into their current practices and workflows, as when they perceive it as compatible, they are more likely to adopt it. the findings suggest that physicians who find e-detailing to be simpler are more likely to declare their intention to adopt it. this is likely due to the fact that simplicity and user-friendliness are essential components of physician decision-making. when e-detailing is perceived to be simple and straightforward, physicians are more likely to adopt it, as it does not require additional complexity in their busy professional lives (de grood et al., 2016). moreover, when a digital tool is seen to be less complex, doctors are more likely to be confident in their capacity to use it effectively, thus increasing their willingness to use it. path coefficients of perceptions to adapt e-detailing in their intention of adapting e-detailing table 7: path coefficients of perceptions to adapt e-detailing in their intention of adapting e-detailing estimate se 95%ci t-score p-value gnender ⭢ intention -0.034 0.051 -0.14 0.063 -0.66667 0.505151 age ⭢ intention -0.001 0.144 -0.203 0.327 -0.00694 0.994418 years ⭢ intention -0.259 0.142 -0.598 -0.017 -1.82394 0.068889 ievel ⭢ intention 0.1 37 0.078 -0.067 0.266 1.75641 0.079774 volume ⭢ intention -0.018 0.042 -0.094 0.071 -0.42857 0.668151 frequency ⭢ intention 0.108 0.056 -0.014 0.208 1.928571 0.054477 *significant at 0.05 to be able to examine if the physician’s intention to adapt e-detailing is influenced by the following sociodemographic characteristics, particularly, age, gender, years in medical practice, level in the medical hierarchy, the volume of laboratory requests written; and frequency of interacting with psrs, a multiple linear regression model was formulated. the path coefficients are shown in table 7. after performing the regression analysis, all of the independent variables’ coefficients had p-values above 0.05. a p-value above 0.05 indicates that the relationship between independent variables and intention to adjust e-detailing was not statistically significant. all of the independent variables in the model did not appear to have a significant effect on the intention of the medical practitioners to change their e-detailing habits. age, years of practice, medical hierarchy, number of lab requests, and the frequency of interactions with psrs did not play a significant role on the intention of physicians about e-detailing. these results may indicate that other factors, such as their perception of e-detailing advantages, compatibility, and complexity could play a more significant role in influencing the intention to change the habits of medical practitioners. pa ge 14 8 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 based on the provided path coefficients, the impact of each independent variable on the physicians’ intention to adapt e-detailing is provided below. for gender, the negative coefficient of -0.034 suggests that being female is associated with a slightly lower intention to adopt e-detailing. however, since the coefficient is small, its practical significance may be limited. for age, the negative coefficient of -0.001 indicates that increasing age is minimally associated with a lower intention to adopt e-detailing. however, the coefficient is close to zero, suggesting that age is not a substantial factor influencing the intention. for the years of medical practice, the negative coefficient of -0.259 implies that a longer duration of medical practice is associated with a lower intention to adopt e-detailing. this finding implies that more experienced physicians may be less inclined to adopt e-detailing as a promotional tool. for the level of medical hierarchy, the positive coefficient with a value of 0.137 indicates that a higher level of medical hierarchy is associated with a slightly higher intention to adopt e-detailing. this suggests that physicians in more senior positions may be more open to using e-detailing in their practice. the negative coefficient of the volume of laboratory requests, which is -0.018, signifies that a higher volume of laboratory requests is associated with a slightly lower intention to adapt e-detailing. this finding may indicate that physicians who frequently request laboratory tests have a reduced interest in adopting e-detailing. the path coefficient of frequency of interacting with psrs is 0.108 which is a positive coefficient. this indicates that a higher frequency of interacting with pharmaceutical sales representatives (psrs) is associated with a slightly higher intention to adapt e-detailing. this implies that physicians who frequently engage with psrs may be more willing to embrace e-detailing as a promotional method. figure 1: most preferred method of communication regarding new ivd tests filipino physicians use a variety of communication tools to acquire knowledge about in-vitro diagnostic tests. in this study, a thematic analysis was conducted to identify the key themes in identifying the preferred methods of communication regarding new ivd tests. the themes identified are medical congresses, a combination of faceto-face visits and e-detailing, face-to-face visits of ivd medical representatives, e-detailing from ivd medical representatives, ivd company’s initiated webinars, social media, and none. a common method mentioned by the respondents is attending medical congresses, with 80 individuals indicating its use. medical congresses provide physicians with opportunities to learn about the latest developments in their field, including advancements in diagnostic tests (hraden & laidlaw, 2020). a significant number of physicians, which is 213 or 52.21% of the respondents, reported using a combination of faceto-face visits and e-detailing. this is the most preferred method of communication regarding new ivd tests. this approach allows them to have direct interactions with medical representatives while also receiving electronic information and updates about in-vitro diagnostic tests. physicians often prefer a combination of face-to-face visits and e-detailing as a means to acquire knowledge about in-vitro diagnostic tests. this approach offers several clear reasons that resonate with their professional needs and preferences. face-to-face visits provide physicians with the opportunity for direct interaction with ivd (in-vitro diagnostic) medical representatives. these representatives are experts in the field and are able to provide detailed explanations, answer questions, and address any concerns that physicians may have. face-toface visits allow for a personalized and tailored approach to information sharing, enabling physicians to engage in meaningful discussions and gain a deeper understanding of the diagnostic tests. moreover, e-detailing offers the convenience of accessing information at any time and from any location. physicians have busy schedules and limited time for additional activities, making it challenging pa ge 14 9 https://journals.e-palli.com/home/index.php/ajmsi am. j. med. sci. innov. 3(1) 134-152, 2024 to attend all the necessary meetings and events. e-detailing provides a flexible solution by allowing physicians to review materials, presentations, and updates related to invitro diagnostic tests at their own pace. this enables them to efficiently manage their time and integrate learning into their daily routines. the combination of face-to-face visits and e-detailing combines the advantages of both approaches. physicians can benefit from the personal touch and expertise of the medical representatives during face-to-face interactions, while also having the convenience of accessing electronic resources for further reference and review. it allows for a more comprehensive learning experience that caters to different learning styles and preferences. additionally, this combination approach promotes a deeper and more lasting retention of information. by engaging in face-to-face discussions and interactions, physicians can ask questions, seek clarification, and engage in interactive learning. this active participation enhances their understanding and retention of the knowledge acquired. the subsequent use of e-detailing materials serves as a valuable resource for reinforcing and revisiting the information, ensuring that it is retained and applied effectively in clinical practice. furthermore, the combination of face-to-face visits and e-detailing allows for ongoing support and updates. medical representatives can follow up with physicians after the initial visit, provide additional information, and address any new developments or concerns. the electronic resources shared through e-detailing enable physicians to stay updated on the latest advancements and changes in the field, ensuring that their knowledge remains current and relevant. a smaller group of physicians, 57 in total, mentioned that they rely on face-to-face visits from ivd (in-vitro diagnostic) medical representatives. these representatives provide detailed information about diagnostic tests and their applications, allowing physicians to stay informed and make informed decisions. another group of physicians, comprising 38 individuals, mentioned e-detailing as their preferred method of acquiring knowledge about in-vitro diagnostic tests. e-detailing involves receiving electronic presentations or materials from ivd medical representatives, providing physicians with the convenience of accessing information at their own pace. two respondents indicated that they do not use any specific communication tools to acquire knowledge about in-vitro diagnostic tests. this suggests that there may be a portion of physicians who rely on other sources or have different preferences when it comes to staying informed about diagnostic tests. in terms of more recent trends, 16 respondents mentioned that they rely on webinars initiated by ivd companies to acquire knowledge. webinars provide a convenient platform for physicians to access educational content remotely and interact with experts in the field. lastly, two respondents mentioned social media as a communication tool for acquiring knowledge about in-vitro diagnostic tests. social media platforms can serve as a source of information and allow physicians to connect with experts, share insights, and stay updated on the latest developments in the field. in general, filipino physicians use a variety of communication strategies, such as medical congresses, in-person visits, e-learning, webinars, and social media to gain knowledge regarding in vitro diagnostic tests. these strategies provide various learning opportunities, enabling physicians to remain informed and better serve their patients. conclusion the development of e-diagnostic practices in the in vitro diagnostic sector in the philippines is affected by a variety of elements, which are outlined in detail in the thesis. the results of this study provide insight into the primary factors that influence the decision-making process of physicians when it comes to e-diagnostic procedures. an important factor to consider is the perceived advantages of e-detailing. when physicians perceive e-detailing tools to be beneficial to their practice, to improve patient care, to provide pertinent and timely information on in vitro diagnostic products, they are more likely and more likely to adopt e-detailing techniques. this emphasizes the importance of demonstrating the practical advantages of e-detailing methods to physicians to promote their adaptation. physicians are more likely to opt for e-detailing if it is perceived to be compatible or is in line with their professional principles, values, and preferences. another factor is its complexity. physician adoption of e-diagnostics is more likely to occur when it is perceived to be intuitive, straightforward, and in line with the physician’s current workflow. many doctors intend to adapt e-detailing due to these factors. it is essential to understand and address these elements in order to foster the adoption and deployment of e-diagnostics in the in vitro diagnostic sector in the philippines, thus resulting in enhanced healthcare outcomes and industry progress. by acknowledging the significance of the perceived advantages, compatibility and complexity of e-detailing methods, stakeholders can create tailored strategies to motivate physicians to adopt these. references abolfotouh, m. a., banimustafa, a., salam, m., alassiri, m., aldebasi, b., & bushnak, i. 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