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SCIENTIFIC COOPERATIONS MEDICAL WORKSHOPS

7-8 June, 2014

ANKARA-TURKEY

PROCEEDINGS BOOKLET

ORGANIZED BY SCIENTIFIC COOPERATIONS

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SCIENTIFIC COOPERATIONS PUBLICATIONS Copyright © Scientific Cooperations ISBN: 978-605-86637-2-5 All rights reserved. No part of this book may be produced, in any form or by means, without permission in writing from the publisher

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Scientific Cooperations International Workshops on Medical Topics, Ankara-TURKEY, 7-8 June 2014

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CONTENTS

IWCC-2014, International Workshop on Cardiology and Cardiothoracic Surgery 01-HBA1C IS ASSOCIATED WITH ACUTE KIDNEY INJURY IN PATIENTS UNDERGOING CABG SURGERY - A COHORT STUDY………………………………………………………………………………1 Mehmet Oezkura, Khaled Hamoudaa, Martin Wagnerb, Coralie Essicha, Carolin Weissa, Christoph Schimmera, Peter Heuschmannb,c, Rainer Leyha aDepartment of Cardiovascular surgery, University Hospital Würzburg bInstitute of Clinical Epidemiology and Biometry, University of Würzburg; Comprehensive Heart Failure Center, University of Würzburg cClinical Trial Center Würzburg, University Hospital Würzburg IWDN-2014, International Workshop on Dentistry 02- Relationship Between Oral Halitosis and Fixed Partial Dentures……………………………………………..3 Hebah Al-Juhani, Rawan Daabash, Wijdan Al-Khalid, Hamad A. Alzoman College of Dentistry, King Saud University, Riyadh, Saudi Arabia 03-A comparative assessment of the accuracy of electronic apex locator (Root ZX) in the presence of commonly used irrigating solutions…………………………………………………………………………………………...5 Osama Khattak, Ebadullah Raidullah RAK College of Dental Sciences, RAK Medical and Health Sciences University Ras Al Khaimah, UAE Shunsuke Ota 04- Effects of axial height and cement cover area on strain measurements of full gold crowns on nickel chromium dies……………………………………………………………………………………………..………7 Asbia S. (BDS(Ben,Lib), MSc(Edin,UK), PhD(Edin,UK)) Prosthodontic Department, Sirte Dental School Sirte University Sirte Libya e.mail: [email protected] Ibbetson R. (BDS MSC FDS RCS(Eng) FDS RCS(Edin) FFGDP(UK)) School of Medicine and Dentistry, Queen Mary, University of London. London,UK. e,mail: [email protected] Reuben B. (BSc, PhD). School of Engineering and Physical Sciences, Heriot-Watt University, Edinburgh, UK. e.mail: [email protected] 05- Comparison of dental age development between non-cleft children and cleft lip and palate children by panoramic radiograph……………………………………………………………………………………………15 Buddhathida Wangsrimongkol, Paramaporn Ovatakanon, Dhanabhol Riowruangsanggoon, Tanyakorn Wichettapong, Araya Pisek, Tasanee Wangsrimongkol, Poonsak Pisek Department of Orthodontics Faculty of dentistry, Khon Kaen University Khon Kaen, Thailand


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06- New Simulated Plasma for Assessing Solubility of Mineral Trioxide Aggregate…………………………...19 Mohammad Samiei1, Seyyed Mahdi Vahid Pakdel2, Hadi Valizadeh3, Zahra Aghazadeh4 1Assistant Professor, Department of Endodontics, Tabriz University of Medical Sciences, presenter 2Post-graduate Student, Student Research Committee, Department of Prosthodontics, Tabriz University of Medical Sciences 3Associate Professor, Department of Pharmaceutics, Tabriz University of Medical Sciences 4Post-graduate Student, Department of Oral Medicine, Tabriz University of Medical Sciences 07- One-stage full-mouth disinfection combined with Doxycycline: A single-center, placebo controlled, randomized, controlled clinical trial. ……………………………………………………………………………..37 Mahmoud Abu-Ta'a Department of Oral Surgery & Periodontology Arab American University Palestine 08- Relation between severity and distribution of periodontal inflammatory diseases and chronic urinary tract infections at child’s age…………………………………………………………………………………………...39 Targova-Dimitrova T. Department of Periodontology and Dental Implantology Faculty of Dental Medicine Medical University-Varna Varna, Bulgaria e-mail: [email protected] S. Angelova Department of Pediatric Dentistry Faculty of Dental Medicine Medical University-Varna Varna, Bulgaria e-mail: [email protected] D. Bliznakova Department of Clinical Medical Sciences Educational-Scientific Sector of Pediatrics and Infectious Diseases Medical University-Varna Varna, Bulgaria e-mail: [email protected] S. Peev Department of Periodontology and Dental Implantology; Faculty of Dental Medicine Medical University-Varna Varna, Bulgaria e-mail: [email protected] IWGS-2014, International Workshop on General Surgery 09- Spiradenoma Breast: A rare pathology……………………………………………………………………….45 Kamran Ahmad Malik Sultan Qaboos University Hospital, OMAN IWN-2014, International Workshop on Neurology

10- TROUSSEAU SYNDROME AS AN INITIAL MANIFESTATION OF PANCREATIC ADENOCARCINOMA: CASE REPORT………………………………………………………………………..49 A. Kaprelyan1, Al. Tzoukeva1, M. Atanasova2, D. Kalev3, B. Balev4, R. Georgiev4 1Dept. of Neurology, 2Clinic of Gastroenterology, 3Clinic of Oncology, 4Dept. of Radiology Medical University – Varna Varna, Bulgaria [email protected]

Tariq Mehmood PAKISTAN


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IWNH-2014, International Workshop on Nursing and Healthcare 11- Jordanian Women's Personal Practices Regarding Prevention and Early Detection of Breast Cancer………53 Al-Hussami, Mahmoud, D.Sc., Ph.D. The University of Jordan, Faculty of Nursing Amman 11942 Jordan [email protected] Zeilani, Ruqayya, RN., Ph.D. The University of Jordan, Faculty of Nursing Amman 11942 Jordan [email protected] AlKhawaldeh, Omar, RN, Ph.D Mu'tah University Karak – Jordan P.O.Box 7 [email protected] 12- Professionalism: An enduring insight of the nursing profession in Malaysia………………………………65 Rekaya Vincent Balang School of Human and Health Sciences University of Huddersfield Queensgate, Huddersfield, HD1 3DH UK [email protected] Dr. Rob L. Burton School of Human and Health Sciences University of Huddersfield Queensgate, Huddersfield, HD1 3DH UK [email protected] 13- Leadership Development for Nurses as Educators…………………………………………………………...71 Abeer Al-Hazmi Nursing Department Nursing Education & Development Unit King Abdulaziz University Hospital Saudi Arabia, Jeddah [email protected] 14- Predisposing Factors of Violence against Nurse in Emergency Department from Nurses', Patients', and accompanies visitors' perspective…………………………………………………………………………………73 Mohammad Ali Cheraghi, Associate Professor, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences Sanaz Javanmardi, MSc in Critical Care, Tehran University of Medical Sciences Mitra Zolfaghari, Assistant Professor, Tehran University of Medical Sciences, Fatemeh Salamati, BSc in Management, Ministry of Cooperatives, Labour and Social Welfare 15-Nurses' Perceived Job Related Stress and Job Satisfaction in the Intensive Care Environment……………...75 Sahar Younes Othman*, Samah Anwar ** * Lecturer of Critical and Emergency Care Nursing, Faculty of Nursing, Damanhour University ** lecturer of Critical and Emergency Care Nursing, Faculty of Nursing, Alexandria University 16-Gender difference in quality of life after controlling for related factors among Korean elderly……………...77 Chung, Younghae (Dongshin University, Korea) Cho, Yoo Hyang (Chodang University, Korea)


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17-Factors affecting the quality of care in cardiac outpatient departments: Patients’ perspective……………….79 1. Dr. Mahmoud Maharmeh, RN, PhD Title: Assistant Professor Affiliation: Faculty of Nursing, University of Jordan, Amman-Jordan. Telephone: 00962 6 5355000 ext. 23145 Email: [email protected] 2. Mahmoud Al-Hussami, D.Sc., Ph.D., Epidemiologist Title: Associate Professor Affiliation: The University of Jordan, Faculty of Nursing Email: [email protected] Telephone: 00962 6 5355000 ext.23138 3. Muhammad Darawad, Ph.D., RN Title: Associate Professor Affiliation: The University of Jordan, Faculty of Nursing Email: [email protected] Telephone: 00962 6 5355000 ext.23162 18-The Nursing Homes Structure and the Prevalence of Falling Down Among Old Adults in Three of Nursing Homes in Palestine……………………………..………………………………………………………..99 Rasmieh N.S. Anabtawi* *Lecturer, Nursing Department/Faculty of Allied Medical Sciences Arab American University/Jenin/Palestine [email protected] Jamal A.S. Qaddumi* *Assistant Professor, Nursing Department/ Faculty of medicine and health sciences An-Najah National University/ P.O. Box 7/ Nablus/ Palestine [email protected] 19-Development of person-centred self-assessment tool grounded on phenomenology in rehabilitation………111 Kristín Thórarinsdóttir, MSc, RN, PhD student, Faculty of Nursing, University of Iceland, Iceland; Assistant Professor, University of Akureyri, Iceland, [email protected] Kristín Björnsdóttir, PhD, RN, Professor, Faculty of Nursing, University of Iceland, Kristján, Kristjánsson, PhD, Professor School of Education and the Jubilee Centre for character and values, University of Birmingham, UK 20-Patient perspectives on constrained patient participation in health care: A framework analysis……………………………………………………………………………………………113 Kristín Thórarinsdóttir, MSc, RN, PhD student, Faculty of Nursing, University of Iceland, Iceland; Assistant Professor, University of Akureyri, Iceland, [email protected] Kristján, Kristjánsson, PhD, Professor School of Education and the Jubilee Centre for character and values, University of Birmingham, UK 21-A method for analysing the learning environment in nursing and health care………………………………115 Kristín Thórarinsdóttir, MSc, RN, Assistant Professor, University of Akureyri, Iceland, [email protected]


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22-Validation of Self-Reported Smoking and Environmental Tobacco Smoke through Urine Cotinine in Prenatal Care Visits…………………………………………………………………………………………….117 Azita Amiri College of Nursing University of Alabama in Huntsville Huntsville, Alabama, USA [email protected] Azin Nowrouzi Nell Hodgson Woodruff School of Nursing Department of Biochemistry School of Medicine Tehran University of Medical Sciences Charles A. Downs Nell Hodgson Woodruff School of Nursing Emory University Atlanta, Georgia, USA [email protected] IWPS-2014, International Workshop on Plastic Surgery 23-Modified insetting method for breast projection in breast reconstruction with free TRAM………………...121 Heeyeon Kwon Department of Plastic and reconstructive Surgery Seoul National University College of Medicine Seoul, Korea Ungsik Jin Department of Plastic and reconstructive Surgery Seoul National University College of Medicine Seoul, Korea Jihoon Park Department of Plastic and reconstructive Surgery Seoul National University College of Medicine Seoul, Korea Kyungwon Minn Department of Plastic and reconstructive Surgery Seoul National University College of Medicine Seoul, Korea 24-Implant breast reconstruction after mastectomy using CG CryoDerm® : A Comparative Study with Acellular dermal matrix (AlloDerm®)………………………………………………………………………….123 Ji Hoon Park, M.D., Jun Ho Choi, M.D., Ung Sik Jin, M.D., Kyung Won Minn, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea


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IWR-2014, International Workshop on Radiology 25-Comparison between multidetector computed tomography, histopathological findings and C-reactive protein in patients with acute appendicitis …………………………………………………………...…………125 Murat Karul1*, Cyrus Behzadi1, Maxim Avanesov1, Asmus Heumann2, Philip Stahl3, Thorsten Derlin1, Gerhard Adam1, Jin Yamamura1 1 Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany 2Department of General, Visceral- and Thoracic Surgery University Medical Center Hamburg-Eppendorf, Hamburg, Germany 3Department of Pathology University Medical Center Hamburg-Eppendorf, Hamburg, Germany 26-Performance Assessment of the GE X-ray Fluoroscopy System at King Saud University………………….129 M. A. Alnafea, K. Z. Shamma Department of Radiological Sciences, College of Applied Medical Sciences King Saud University Riyadh 11433, Saudi Arabia E-mail: [email protected] H. I. Aldossari Department of Radiological King Fahad Medical City Riyadh, Saudi Arabia E-mail: [email protected] 27-Implementation of case study in undergraduate didactic radiography clinical practice courses…………….135 M. M. Abuzaid (1), S. A. Alyafei (2), W. Elshami (1) (1) Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, UAE (2) Fatima College of Health Sciences, UAE 28-University of Sharjah (UoS) Radiography Educational Website………………………………….…………137 M. M. Abuzaid (1), S. A. Alyafei (2), W. Elshami (1) (1) Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, UAE (2) Fatima College of Health Sciences, UAE


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This study aimed to evaluate the accuracy of Root ZX in determining working length inpresence of normal saline, 0.2% chlorhexidine and 2.5% of sodium hypochlorite. Theremoval of all pulp tissue, necrotic material and microorganisms from the root canal isessential for endodontic success. On the other hand determination of an accurateworking length is also a critical step in endodontic therapy.1 Therefore properinstrumentation upto the apical constriction or also called as the cemento-dentinaljunction2 as seen earlier is also one of the vital factor for a good prognosis.

Sixty extracted, single rooted, single canal human teeth were used. Teeth weredecoronated at CEJ and actual canal length determined. Then working lengthmeasurements were obtained with Root ZX in presence of normal saline 0.9%, 0.2%chlorhexidine and 2.5% NaOCl. The working length obtained with Root ZX werecompared with actual canal length and subjected to statistical analysis.

No statistical significant difference was found between actual canal length and Root ZXmeasurements in presence of normal saline and 0.2% chlorhexidine. Highly statisticaldifference was found between actual canal length and Root ZX measurements inpresence of 2.5% of NaOCl, however all the measurements were within the clinicallyacceptable range of ±0.5mm.

The accuracy of EL measurement of Root ZX within±0.5 mm of AL was consistentlyhigh in the presence of 0.2% chlorhexidine, normal saline and 2.5% sodiumhypochlorite.


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This study signifies the efficacy of ROOT ZX (Third generation apex locator) as adependable aid in endodontic working length determination in the presence of differentcommon root canal irrigating agents.

1. Ingle JI, Himel VT, Hawrish CE, Glickman GE. Endodontic cavity preparation. In:Ingle IJ, Bakland LK, editors. Endodontics. 5th ed. Elsevier India: B.C. Decker; 2003.pp. 405–570


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Effects of axial height and cement cover area on strain measurements

of full gold crowns on nickel chromium dies

Asbia S. (BDS(Ben,Lib), MSc(Edin,UK), PhD(Edin,UK))

Prosthodontic Department, Sirte Dental School Sirte University

Sirte Libya e.mail: [email protected]

Ibbetson R. (BDS MSC FDS RCS(Eng) FDS RCS(Edin) FFGDP(UK)) School of Medicine and Dentistry, Queen Mary, University of London.

London,UK. e,mail: [email protected]

Reuben B. (BSc, PhD).

School of Engineering and Physical Sciences, Heriot-Watt University, Edinburgh, UK.

e.mail: [email protected] Abstract—The overall scope of this work is concern with the performance of the adhesives used for cementation of gold crowns onto nickel chromium under static and dynamic compression. A measurement system based on the mounting of two miniature strain gauges on the outer surface of the crowns, opposing each others, has been developed allowing an indirect, non-destructive, semi quantitative estimate of the state of adhesion. This work investigated the effect of the axial height (AH) of metallic dies with a different degrees of cementation. Ten nickel chromium dies, five for each (6mm AH &8mm AH) were fabricated. The total occlusal convergence (TOC) was 24o, the finish line was chamfer with 0.5 mm in depth. For each correspondent die, a full gold crown with a 0.5mm thickness was constructed.. Uni-axial loading between [0 Newton-220 Newton] of the crowns on their dies were repeated five times for each sample and the values for strain recorded. An ANOVA test [Single Factor] was used to compare the slope of each run at the 5% significant level. The results showed that the p values >0.05, which were not significant. The expected slope of the strain gauge was the same for all the builds [samples], apart from some partially cemented samples. The results showed a decreased in strain at the axial walls with increasing axial height (AH), providing a useful design information for the durability of restorative crowns. Additionally, with the increase of the luting cement cover, the strain decreased dramatically. These findings, along with the findings of earlier work are consistence with a simple model of load transfer between the crown and the die.

Keywords—adhesives, mechanical testing, axial height, zinc phosphate cement. Uni-axial static loading (key words)


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I. INTRODUCTION

Retention and resistance of cemented cast restoration depends on geometry form rather than adhesion, this phenomenon depends on the type of luting cement used. Zinc phosphate is non-adhesive cement which retain casting on its preparation by friction through the mechanical interlocking between the casting fitting surface and the tooth surface preparation [1]. Axial height (AH) is an important parameter for retention and resistance of crown and bridgework. The longer the preparation the more retentive the restoration. That is because of the greater surface area whilst the increased height interfaces more with the arc of the casting pivoting on the margin on the opposite side of the restoration [2]. The resistance of artificial crowns prepared on human extracted teeth have been investigated [3]. They concluded that 3mm was the minimal (AH) required for adequate resistance of crowns made for maxillary incisors and mandibular premolars that prepared with minimal (TOC). Further, other authors proposed the minimal (AH) of 3 mm for premolars and anterior teeth that prepared in a range of 10o-20o (TOC). They added that, since molar teeth are usually prepared with greater convergence than anterior teeth, they have a greater diameter than other teeth, and located under heavier occlusal forces, they supported a 4mm is the minimal (AH) [4]. The purpose of this work is to extend the finding of previous work [5], which sought to determine the relationship between strain measured on the outside of a model crown-die system as the degree of coverage by luting cement was varied. In this investigation, a new geometrical factor, axial height (AH), is introduced to investigate the effect of this factor in the light of the relationship that was already established.

II. MATERIALS AND METHOD Die, crown fabrication and strain gauge instillation:

Using lost wax technique, five nickel chromium dies of 6mm (AH) and five of 8mm (AH) were produced. The dies have 24o TOC, diameter of 10mm at the cervical area, flat top and about 0.5 mm thickness chamfer finish line “Fig. 1,”. For each fabricated nickel chromium die, a gold crown of total 0.5mm thickness was cast using lost wax technique. For each crown two miniature strain gauges (EA-06-031EC-350 , Vishay Measurements Group UK Ltd, Stroudley road, Basingstoke, Hants RG24 8FW, UK) were bonded on the opposite each other about 1mm above the margins, “Fig. 2,”.


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Fig. 1: Cylindrical preparations with Fig. 2. Finished full gold TOC angle on its of 24 and AH of crown on its die with strain gauge 6.0 mm (left) and 8.0 mm (right)

Cementation, load application and data collection :

The steps are similar to what descried in a previous work [10].

III. RESULTS The results are displayed in Graphs 1, 2, and 3 for the un-cemenetd crowns ,partially cemented crowns, and fully cemented crowns respectively.

Stress strain chart of uncemented gold crown with 6MM vis 8MM axial hieght

y = 1.3525x + 13.993R2 = 0.9962

y = 2.2463x + 13.21R2 = 0.9968

0100200300400500600

0 50 100 150 200 250

Load(Newton)

Stra

in (M

icro

stra

in)

8MM NC 6MM NC Linear (8MM NC) Linear (6MM NC)

Graph 1: Load-strain behaviour of uncemented crowns (6mm AH&8mm AH)

Stress strain chart of 6MM vis 8MM axial hieght of partially cemented crown

y = 0.6864x - 4.1651R2 = 0.9995

y = 0.2526x + 1.663R2 = 0.99950

50

100

150

200

0 50 100 150 200 250

Load (Newton)

Stra

in (M

icro

satra

in)

8MM PC 6MM PC Linear (6MM PC) Linear (8MM PC)

Graph 2: Load-strain behaviour of partially cemented crowns (6mm AH&8mm AH)


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Stress strain chart of 6MM vis 8MM axial hieght of totally cemented crown

y = 0.0618x + 5.9712R2 = 0.8362

y = 0.0709x + 2.7103R2 = 0.971

0

5

10

15

20

25

0 50 100 150 200 250

Load (Newton)

Stra

in (M

icro

stra

in)

8MM TC 6MM TC Linear (6MM TC) Linear (8MM TC)

Graph 3: Load-strain behaviour of fully cemented crowns (6mm AH&8mm AH).

The statistical analysis tables for 24oTOC and 6mm AH for a given cementation procedure are shown in Table I (uncemented) , Table II (partially cementd) and Table III (Fully cemented). The statistical analysis tables for 24oTOC and 8mm AH for a given cementation procedure are shown in Table IV (un-cemented) , Table V (partially cementd) and Table VI (Fully cemented).

TABLE I. ANOVA FOR 24o&6cm AXIAL HEIGHT UNCEMENTED

ANOVA Source of Variation SS Df MS F P-value F crit

Between Groups 0.521433 4 0.130358 0.093277 0.98035 5.192168 Within Groups 6.987678 5 1.397536 Total 7.509112 9

TABLE II. ANOVA FOR 24o&6cm AXIAL HEIGHT PARTIALLY CEMENTED

ANOVA Source of Variation SS Df MS F P-value F crit Between Groups 0.136707 4 0.034177 1.039382 0.470303 5.192168 Within Groups 0.164409 5 0.032882 Total 0.301116 9

TABLE III. ANOVA FOR 24o&6cm AXIAL HEIGHT FULLY CEMENTED


TABLE IV. ANOVA FOR 24o&8cm AXIAL HEIGHT UNCEMENTED

ANOVA Source of Variation SS Df MS F P-value F crit

Between Groups 2.659376 4 0.664844 1.718791 0.281532 5.192168 Within Groups 1.934045 5 0.386809 Total 4.59342 9


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TABLE V. ANOVA FOR 24o&8cm AXIAL HEIGHT PARTIALLY CEMENTED ANOVA

Source of Variation SS Df MS F P-value F crit Between Groups 4.678289 4 1.169572 9.006115 0.01657 5.192168 Within Groups 0.649321 5 0.129864 Total 5.327611 9

TABLE VI. ANOVA FOR 24o&8cm AXIAL HEIGHT FULLY CEMENTED


IV. DISCUSSION

The results show consistently higher strain for a given load on the axial surface of crowns for all cementation scenarios with 6mm (AH) than of the 8mm (AH) crowns. The ratios of the slopes (8mm AH:6mm AH) of the strain load graph is around 0.602 for uncemented crowns, 0.368 for partially cemented crowns, and 1.147 for fully cemented, although it might be noted that the strain levels for fully cemented crowns are rather low and the results could be affected significantly by zero drift or plastic slip at the cement interface.

Graph 1 (note the scale for Y axis) showed the highest value for 6mm was approximately 340 microstrain whilst for 8mm was 200 microstrain. Graph 2 (note the scale for Y axis, partially cemented crowns) showed that the highest mean microstrain for 6mm (AH) was approximately 125 micostrain and for 8mm was about 40 microstrain. Graph 3 (note the scale for Y axis, fully cemented crowns) showed that about 13 microstrain for 6mm (AH), whilst about 12 microstrain for 8mm(AH). Strain in the uncemented crowns was higher than for the partially cemented crowns, which in turn was higher than the fully cemented castings. The slope of the strain for the fully cemented crowns (8mm axial height) was almost similar to that 6mm axial height. The results showed that as the load increased, there was an increase in the strain on the axial surfaces of the gold crowns. Increasing (AH) from 6mm to 8mm decreased the strain under all cementation conditions. For the uncemented and partially cemented crowns, there was a linear increase in the resultant strain with the applied load. For the fully cemented crowns however, the graph showed a curved rather than a linear relationship. There was a gradual increase in the difference as the load increased the strain of both 6mm and 8mm increased until 100N where the difference between them started to decrease gradually. For the fully


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cemented crowns, the difference between 6mm and 8mm axial height was not as big as the uncemented and partially cemented samples. Additionally the graph did not show completely linear results. As the strain increased, the difference between them increased till about 100N then returned again to become similar again. It was clear from the results in graphs 1, 2, and 3 that with the increase of the (AH), there was a decrease in strain. This might have been due to the increase in the surface area.The surface area of the frustum with 24o taper and 8mm axial height was 213.336mm2 whilst the surface area for 24o taper and 6mm axial height was 168.198mm2.With the increase of the surface area, the load per square surface area will be less resulting in less strain. It might be that the luting cement would be more durable. This data indicated that maximum crown height would be advantageous. This marked decrease in the axial strain with the increased (AH) within each different cementation condition compared to dividing the (TOC) by two; this might have been related to the surface area of the die too. Dividing the angle of taper by two decreased the surface area only by (168.20/177.58) 94.72% whilst decreasing the axial wall height from 8mm to 6mm in this experiment decreased the surface area by (168.20/213.34) 78.84%. To compare the relation between the (TOC) finding that were already published [7], and current investigation (AH), there was an interesting finding that the increasing of the axial height (AH) by 2mm whilst maintaining a TOC of 24o affected the resultant strain on loading more sensitive than decreasing the (TOC) by 50% from 24o to 12o. Dividing the (TOC) by two did not affect the strain as much as increasing the axial height (AH) by 2mm. This finding emphasised the importance of (AH) compared with (TOC) during tooth preparation. However many authors have supported the importance of a low TOC, but few have written regarding the axial height (AH). This work supported indirectly the earlier work [1&8] and provided support for the clinical recommendation [3]. A previous study [6] found that as the height increased, so did the retentive ability of the crown. Two strain gauges were used for each crown. To investigate the relation between each strain gauge reading to the complete build (sample) as a whole, an ANOVA test (Single Factor) was used to compare the slope of each run. The results showed the p values >0.05, which were not significant. The hypothetical question was whether the variance between the left and right strain gauges in each build (sample) was the same, less or more than the variance between builds (samples). At the 5% significant level, the expected slope of the strain gauge was the same for all the builds (samples), apart from some partially cemented samples, in such cases, it might have


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been related to the possible spread of cement onto the occlusal surface. It was found that 40% of the partially cemented crowns showed some spread of cement beyond the axio-occlusal line angle onto the occlusal surface [5&7]. The results of the ANOVA showed that there was greater variability in the build of an individual crown compared with variability between different builds. The reasons might have been related to variations in the thickness of the luting cement and/or the gold crowns, skewing of the gold crown during seating at the time of the cementation, or a degree of non-axial loading during the experiments. The conclusion was drawn that the strain gauges on each side of the crowns behaved in the same way.

The number of the samples for each category was five, this would be considered small, however, with the presence of two strain gauges for each sample and the repetition of each run for five times would strengthen the conclusion. The loads were uni-directional. The direction of the applied axial loads used in this experiment was likely to have been favourable to the cement lute in contrast with those directed non-axially; the latter would have produced a cantilevering action with increased resultant strain. Most of the research is based on pulling a crown off a simulated prepared tooth (metallic or plastic dies) in a direction parallel to the long axis of the tooth preparation [8]. However, it was stated that forces that tend to remove cemented restorations along their path of withdrawal are small compared to those tend to seat or tilt those restorations [9]. It was concluded that true tensile forces seldom occur especially on a single unit crown in the oral environment, and when they do occur, they certainly do not compare with those produced by occluding or chewing.

V. CONCLUSION 1. The increase in the axial crown height decreased the strain on the axial

surface of gold crown. 2. The presence of cement at the interface between the crown and the die

reduced the strain in the axial walls of the crown. 3. The most strain was seen in the uncemented crowns and least in those

which were fully cemented. 4. The effect of the extent of the cement film influenced axial wall strain

more than the height of the preparation. 5. The use of miniature strain gauge method is a reproducible method to

assess the strain under a given compressive load in-invasively on the outer surface of the cast metal crowns.


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ACKOWLEDEMENT This work is a part of a PhD thesis by Dr Asbia S (Short and long-

term behaviour of cast dental restoration under compressive stresses) in Edinburgh University, UK. CORROSPONDING AUTHOR

Dr Salim Badre Asbia (BDS,MSc,PhD). Head of Prosthodontic Department, Dean of Sirte Dental School, Sirte University, Sirte Libya, PO Box [email protected] or [email protected]. Mobile phone number:+218927311661,fax number:+218545261902

REFRENCES

[1] H.T. Shillingburg, S. Hobo, L.D. whitsett, R. Jacobi, S.E. Brackett. Fundamentals of fixed prosthodontics. Quintessence publishing company, 3th Edition; 1997. [2] E.S. Smyd. Advantage thought in indirect inlay and fixed bridge fabrication. J Am Dent Assoc. 1944; 31:759-768. [3] A.W. Maxwell , L.W. Blank , G.B. Jr Pelleu .: Effect of crown preparation height on the retention and resistance of gold castings. Gen Dent. 1990;38:200-202.

[4] C.J. Goodacre .: Designing tooth preparations for optimal success. Dent Clin North Am. 2004;48:359-385.

[5] S. Asbia , R. Ibbetson, R.L. Reuben.: Occlusal convergence and strain distribution on the axial surface of cemented gold crowns. Stud Health Technol Inform. 2008;133:21-32. [6] E.D. Kaufman, D.H. Coelho, L. Colin. Factors influencing the retention of cemented gold castings: J Prosthet Dent. 1961; 11:487-502. [7] M.H. Reisbick , H.T. Jr Shillingburg .:Effect of preparation geometry on retention and resistance of cast gold restorations. J Calif Dent Assoc. 1975;3:51-59.

[8] K.D. Jorgensen. Relationship between retention and convergence angle in cemented veneer crowns, Acta Odontol Scand:1955,13;35-40.

[9] W.W. Dodge, R.M. Weed, R.J. Baez, R.N. Buchanan. The effect of convergence angle on retention and resistance form. Quintessence Int. 1985;16:191-194. [10] S. Asbia , R. Ibbetson, R.L. Reuben.: Compressive stress-strain behaviour of cast dental restorations in relation to luting cement distribution. Technol Health Care. 2006;14:439-448.


22

Comparison of dental age development between non-cleft children and cleft lip and palate children by

panoramic radiograph

Buddhathida Wangsrimongkol, Paramaporn Ovatakanon, Dhanabhol Riowruangsanggoon, Tanyakorn Wichettapong, Araya Pisek, Tasanee Wangsrimongkol, Poonsak Pisek

Department of Orthodontics Faculty of dentistry, Khon Kaen University

Khon Kaen, Thailand

Abstract— Cleft lip and palate children usually have

malocclusion with skeletal problems. To correct this malocclusion by growth modification, orthodontist needs to assess growth and development of the jawbones. The objective of this study was to clarify and compare development of dental age between cleft lip and palate children and non-cleft children. A data of total 82 from each group of cases and controls were collected. Experimental group were Thai children with cleft lip and palate with 5-14 years of age. Controls were matched by age and gender to clarify and compare. Demirjian’s method was used to determine dental maturation from panoramic radiographs. The children with cleft lip and palate in Thailand aged 5 – 14 years old have shown significant dental age difference compared to non-cleft children. When considered separately in three groups of age: 5-6, 7-9, and 10-14 years old, the mean dental age difference among groups of 5-6 and 7-9 years old were not statistically significant. However, a statistically significant delay was found in a group of 10-14 years old. In conclusion, Thai children with cleft lip and palate aged 5 – 14 years old demonstrated a delay in dental maturation compared to non-cleft children.

Keywords— Cleft lip and palate, dental age, dental maturation

I. INTRODUCTION Cleft lip and palate (CLP) is an abnormality in craniofacial

anomalies which is most likely occurs. The worldwide occurrence is 1 in 500-1,000 lives birth. The incidences are considerably varied from each part of the world. In Thailand, the highest occurrence appears to be 2.49 in 1,000 lives birth. [1]

This congenital anomaly affects several organ systems including orofacial, and respiratory system. It also affects speech development, hearing and causes malocclusion in effected individuals.[2, 3]

Orthodontic treatment in cleft lip and palate children aims to correct dental malocclusion and skeletal discrepanciess by growth modification. For effective treatment outcomes, orthodontist needs to be able to assess growth and development of the jawbones. However, there are several

methods to evaluate such developmental stages including assessment of the chronological age, weight and height, secondary sexual characteristics, cervical vertebral maturation[4], hand and wrist assessment[5], and the estimated of dental age by panoramic radiographs.[6] The estimated dental age using panoramic radiograph is of advantages in that patients with previously taken panoramic radiograph are not required to take additional x-ray, thus reduce chances of unnecessary radiographic exposure.

Therefore, the purpose of this study was to compare development of dental age between cleft lip and palate children and non-cleft children in Thailand.

II. MATERIAL AND METHOD

A. Study sample The investigation was based on retrospective analytical

study of cleft lip and palate children and non-cleft children from department of Orthodontics, Khon Kaen University. A total of 82 cleft lip and palate children and 82 of non-cleft children (42 boys and 40 girls in each group) matched by age and gender were investigated and compared.

The inclusion criteria of the CLP study samples were:

a) All patients were treated in department of Orthodontics, Khon Kaen University.

b) Aged between 5 to 14 years old.

c) Thai people.

The exclusion criteria of the CLP study samples were:

a) Patients with syndromes and other congenital malformations or diseases.

b) Patients with missing teeth on both sides of the mandible.

c) Inadequate dental records or missing radiographs.


23

B. Dental maturation The developmental stages of permanent teeth were graded

from panoramic radiographs by two examiners according to the method of Demirjian et al.[7] The method included determining maturity of seven mandibular teeth on the left side (except third molar) which were divided into eight stages (A to H), based on crown calcification and root development. (Table1)

Each stage of individual developing tooth was being converted from developmental stages into scores. Total of scores (seven left mandibular teeth) was considered as maturity score.

The maturity score was then converted to dental age using separated converting table of Demirjian et al.[7] for each gender. The dental age difference was calculated by subtracting the dental age of cleft lip and palate children from the dental age of non-cleft children, then compared the mean dental age difference between each group.

C. Statistical analysis The Wilcoxon Signed Rank test was used to calculate mean

differences of dental age between cleft lip and palate and non-cleft group. The Kappa coefficient was used to analyze for determining intra-examiner and inter-examiner reliability.

III. RESULTS

A. Demographic characteristics A total of 82 Thai cleft lip and palate children in

experimental group were 42 boys and 40 girls. Non-cleft children in control group consisted of an equal number matched by age and gender. (Table2)

B. Intra-examiner and Inter-examiner The Kappa coefficients for reliability test between two

examiners ranged from 0.72 to 1.00 and intra-examiner ranged from 0.69 to 1.00 showed moderate to almost high agreement.

C. Dental maturation of cleft lip and palate children & non-cleft children The mean dental age of cleft lip and palate and non-cleft

children were 9.77 ± 2.24 years and 10.40 ± 2.83 years, respectively. Mean dental age difference compared between experimental group and control group was 0.62 ± 1.91 years. A statistically significant delay was found (p-value = 0.004).

When considered separately in three groups of age: 5-6 (n=12), 7-9 (n=37), and 10-14 (n=33) years. The mean dental age differences in groups of 5-6 years old (0.36 ± 0.68 years) and 7-9 years old (0.40 ± 2.22 years) were not statistically significant delay (p-value = 0.18 and 0.24, respectively). However, a statistically significant delay (p-value = 0.004) was found in a group of 10-14 years old (0.98 ± 1.82 years). (Table3)

IV. DISCUSSION In this study, a delay in dental maturation was found in the cleft lip and palate group compared to non-cleft group of 10-14 years old. Other findings were also investigated by Huyskens et al., 2006 [8], Lai et al.,2008[9], Kobayashi et al., 2010[10] and Tan et al., 2012.[11] The mean dental age differences in groups of 5-6 and 7-9 years old were not statistically significant. However, a statistically significant delay was found in a group of 10-14 years old. The reason of an insignificant outcome was that the samples were too small when divided into several age ranges, as described by Heidbüchel et al., 2002.[12]

Table2: Demographic characteristics Group Male Female All

N % n % n % Cleft lip and palate

children 42 51.2 40 42.8 82 100

Non-cleft lip and palate children

42 51.2 40 42.8 82 100

Table1: Dental formation stages description of seven left mandibular teeth

of Demirjian (1973)

Stage A A beginning of calcification is seen at the superior level of the crypt in the form of an inverted cone or cones. There is no fusion of these calcified points.

Stage B Fusion of the calcified points forms one or several cusps which unite to give a regularly outlined occlusal surface.

Stage C Enamel formation is complete at the occlusal surface. The beginning of a dentinal deposit is seen. The outline of the pulp chamber has a curved shape at the occlusal border.

Stage D The crown formation is completed down to the cement-enamel junction.

Uniradicular teeth: The superior border of the pulp chamber has a definite curved form, being concave towards the cervical region. The projection of the pulp horn if present, gives an outline shapes like an umbella top.

Molars: The pulp chamber has a trapezoidal form. Beginning of root formation is seen in the form of a spicule.

Stage E Uniradicular teeth: The wall of pulp chamber now form straight lines, the root length is less than the crown height.

Molars: Initial information of the radicular bifurcation is seen in the form of either a calcified point or semi-lunar shape. The root length is less than the crown height.

Stage F Uniradicular teeth: The walls of pulp chamber now form a more or less isosceles triangle. The apex end in a funnel shape. The root length is equal to or greater than the crown height.

Molars: The calcified region of the bifurcation has developed further down from its semi-lunar stage to give the roots a more definite and distinct outline with funnel shaped endings. The root length is equal to or greater than the crown height.

Stage G The wall of root canal are now parallel and its apical end is still partially open (Distal root in molars)

Stage H The apical end of the root canal is completely closed. (Distal root in molars). The periodontal membrane has a uniform width around the root and the apex.


24

Chronological age and dental age relationship can possibly be varied among races. Since Demirjian’s samples were collected only from French Canadian population, this could provide deviation of data if being used in other populations. In this study, therefore, chronological age have not been used to compare to dental age. In addition, J. Jayaraman et al.[13] demonstrated that French Canadian dataset overestimates the age of the subjects by more than six months, hence this dataset should be used cautiously when estimating dental age among different populations.

Furthermore, a study of chronological age in comparison with dental age in Thai population should be further investigated. In the case that chronological age compare to dental age of Thai population is not significantly different from French Canandian people, we can, therefore, make an assumption that in future studies we can use the same dataset as in French Canadian population.

In this study, mean dental age difference from cleft and non-cleft group at the age of 5-6 and 7-9 were not statistically significant. According to Ngan and Jang et al., it was recommended to start treatment by growth modification in CLP patients during early stages of the mixed dentition.[14, 15] Therefore, growth modification for CLP patients should be start at the same time as non-cleft group during the age of 5-6 and 7-9.

V. CONCLUSION The dental age of Thai children with cleft lip and palate at

5–14 years of age have shown statistically significant different compared to non-cleft children. In the group of 5-6 and 7-9 years old, no difference could be detected. However, a statistically significant difference was found in a group of 10-14 years old.

ACKNOWLEDGMENT We are greatly appreciated Assist.Prof.Dr. Pipop

Suttiprapaporn to help calibrating radiographic interpretations and collecting data.

REFERENCES

[1] Chowchuen, B., Interdisciplinary care of cleft lip, cleft palate and craniofacial anomalies 2004, Khon kaen: Siriphan offset.

[2] [Lekbunyasin, O., Pradubwong , S. ,Chantachum , V. ,Udomtanasup, S. , Chowchuen, B. , Epidemiology of patients with cleft lip and cleft palate in

Srinagarind Hospital, 1984-2007 2008, Khon kaen Srinagarind hospital

[3] Wyszynski F D, Cleft lip and palate from original to treatment. 2002, New york: Oxford University Press.

[4] Franchi, L., T. Baccetti, and J.A. McNamara, Jr., Mandibular growth as related to cervical vertebral maturation and body height. Am J Orthod Dentofacial Orthop, 2000. 118(3): p. 335-40.

[5] Chertkow, S. and P. Fatti, The relationship between tooth mineralization and early radiographic evidence of the ulnar sesamoid. Angle Orthod, 1979. 49(4): p. 282-8.

[6] Maber, M., H.M. Liversidge, and M.P. Hector, Accuracy of age estimation of radiographic methods using developing teeth. Forensic Science International, 2006. 159, Supplement(0): p. S68-S73.

[7] Demirjian, A., Goldstein, H. ,Tanner, J.M., A new system of dental age assessment Hum. Biol, 1973. 45: p. 211-227.

[8] Huyskens, R.W., et al., Dental age in children with a complete unilateral cleft lip and palate. Cleft Palate Craniofac J, 2006. 43(5): p. 612-5.

[9] Lai, M.C., N.M. King, and H.M. Wong, Dental development of Chinese children with cleft lip and palate. Cleft Palate Craniofac J, 2008. 45(3): p. 289-96.

[10] Kobayashi, T.Y., M.R. Gomide, and C.F. Carrara, Timing and sequence of primary tooth eruption in children with cleft lip and palate. J Appl Oral Sci. 18(3): p. 220-4.

[11] Tan, E.L., et al., Dental maturation of unilateral cleft lip and palate. Ann Maxillofac Surg. 2(2): p. 158-62.

[12] Heidbuchel, K.L., et al., Dental maturity in children with a complete bilateral cleft lip and palate. Cleft Palate Craniofac J, 2002. 39(5): p. 509-12.

Table3: Dental maturation of cleft lip and palate & normal children

Age group N (pair)

Cleft Non –cleft Mean dental age difference

95%CI p-value

Mean±SD (year)

Mean±SD (year)

lower Upper

All 82 9.77 ± 2.24 10.38 ± 2.83 0.62 ± 1.91 0.20 1.04 0.004*

5-6 12 7.00 ± 0.46 7.30 ± 0.53 0.30 ± 0.68 -0.13 0.73 0.18

7-9 37 8.76 ± 1.30 9.15 ± 1.96 0.40 ± 2.22 -0.34 1.14 0.24

10-14 33 11.90 ± 1.40 12.90 ± 2.02 0.98 ± 1.82 0.33 1.62 0.004*

*p<.05; Mean=Mean dental age; SD=standard deviation


25

[13] Jayaraman, J., et al., The Frenchโ€“Canadian data set of Demirjian for dental age estimation: Aย systematic review and meta-analysis. Journal of Forensic and Legal Medicine. 20(5): p. 373-381.

[14] Ngan, P., Early Timely Treatment of Class III Malocclusion. Seminars in Orthodontics, 2005. 11(3): p. 140-145.

[15] Jang, J.C., et al., Controversies in the Timing of Orthodontic Treatment. Seminars in Orthodontics, 2005. 11(3): p. 112-118.


26

New Simulated Plasma for Assessing Solubility of Mineral Trioxide Aggregate

Mohammad Samiei1, Seyyed Mahdi Vahid Pakdel2, Hadi Valizadeh3, Zahra Aghazadeh4

1. Assistant Professor, Department of Endodontics, Tabriz University of Medical Sciences, presenter

2. Post-graduate Student, Student Research Committee, Department of Prosthodontics, Tabriz University of Medical Sciences

3. Associate Professor, Department of Pharmaceutics, Tabriz University of Medical Sciences

4. Post-graduate Student, Department of Oral Medicine, Tabriz University of Medical Sciences

Running title: Solubility of Mineral Trioxide Aggregate

Acknowledgments: This study was supported, in part, by the Student research committee and Office of Vice Chancellor for Research, Tabriz University of Medical Sciences, Tabriz, Iran.


27

Abstract

Introduction: Solubility of mineral trioxide aggregate (MTA) is one of its important

characteristics which affects other properties such as microleakage and biocompatibility.

Distilled water has previously been used for solubility tests. This study was aimed to compare

the solubility of MTA in distilled water (DW), synthetic tissue fluid (STF) and new simulated

plasma (NSP). Materials and Methods: In this experimental study, 36 samples of WMTA were

prepared and divided into three groups (n=12) to be immersed in three different solutions (DW,

STF, and NSP). Solubility studies were conducted at 2-, 5-, 9-, 14-, 21-, 30-, 50-, and 78-day

intervals. Welch statistics was utilized to determine the effect of solubility media and Games-

Howell approach was used for pair-wise comparisons. Repeated-measures ANOVA was used to

assess the importance of immersion duration. Results: Unequal variance F-test (Welch test)

showed significant differences in solubility rates of samples between all the different solubility

media at all the study intervals (P<0.05) except at 14-day interval (P=0.094). Mixed repeated-

measures ANOVA revealed a significant difference in solubility rate of MTA in three different

solutions at all the study intervals (P=0.000). Games-Howell post-hoc test revealed that all pair-

wise comparisons were statistically significant at all the study intervals (P=0.000). Conclusions:

Based on the findings of this study, the solubility rate of MTA in simulated plasma was less than

that in synthetic tissue fluid and distilled water in the long term.


28

Key words: Blood substitute, mineral trioxide aggregate, plasma, solubility.

Introduction

Solubility of materials used in endodontic therapies would affect treatment prognosis [1].

Solubility rate of a dental material is one of the properties that affects other features like sealing

ability and biocompatibility [2, 3]. According to International Association of Standard, the

solubility rate should be under 3% of the whole mass [4]. If a root-end filling material

disintegrates progressively in periradicular tissue fluids, subsequent leakage would lead to

treatment failure [5, 6].

Due to low solubility, low cytotoxicity, tissue biocompatibility, and ability to induce mineralized

tissue formation, mineral trioxide aggregate is indicated to seal perforations and be used as a

retrograde filling material, as a pulp capping agent, for repair of external and internal root

resorptions, as an apexification material, and as a root canal sealer [7]. MTA has been known as

a bioactive material which induces hard tissue formation. One of the by-products of MTA and

water is calcium hydroxide which is soluble in distilled water and is a major factor in MTA


29

solubility [8]. Calcium hydroxide is converted to hydroxyapatite (a water-insoluble compound in

contrast to calcium hydroxide) in contact with tissue fluid and deposits on MTA surface. Lower

microleakage of WMTA in comparison to other materials has been attributed to this

phenomenon [3].

In most previous studies on the solubility of MTA, the ISO and ADA approaches have been

employed, in which the solubility of root canal sealing materials has been assessed in distilled

water [4, 8-12]. Saghiri et al assessed solubility of MTA in deionized water and synthetic tissue

fluid [13]. However, none of above-mentioned studies mimicked compositional condition of

blood adjacent to the filling material. In clinical practice, MTA as a root-end filling material

comes in contact with human fluids such as tissue fluid and blood. Therefore, this in vitro study

was aimed to compare the solubility of MTA in distilled water, synthetic tissue fluid (STF) and

new simulated plasma (SP).

Materials and Methods

The solubility of white ProRoot MTA (Tooth-colored, Dentsply, Tulsa Dental, Tulsa, Ok, USA)

in three different solutions was assessed according to the ISO 6876 standard [4] and the

American Dental Association (ADA) specification #30 [14] with minor modifications. The

solubility was periodically determined at increasingly longer periods of time, i.e. at 2-, 5-, 9-, 14-

, 21-, 30-, 50-, and 78-day intervals.

Thirty-six metal molds (20 mm in diameter and 2 mm in height), according to the ISO standard

[4], were numbered using a diamond bur on the mold circumference and weighed with AND

analytic scale (AND GR-200 Analytical Balance, Lab Recyclers Inc., Gaithersburg MD, USA)

with 0.1-mg precision and mounted on glass slabs with sticky wax. Twelve sets of specimens


30

were prepared for each solution in one step by one operator. To this end, WMTA was mixed

with distilled water according to manufacturer’s recommendations’ and packed into the mounted

rings and the other glass slab was packed over them to obtain a flat surface. The samples were

handled at room temperature (23±2°C) and 60±5% relative humidity. For moist curing, the

samples were then placed in a heating chamber for 21 h at 37±1°C and 100% relative humidity

for initial setting. Once removed from the chamber, the specimens were dried in a desiccator

attached to a vacuum machine until they reached a constant weight; this step is necessary to

eliminate all the free water from the samples to achieve a consistent net weight reference. Each

sample was weighed again. To minimize any room humidity absorption this process was

accomplished in less than 20 seconds. After subtraction of rings’ weight from the latter weight,

the resultant weight was recorded as Initial Dry Weight (IDW).

The samples were randomly divided into three groups to be immersed in three different solutions

(i.e. DW [pH=7.2], STF, and SP). The compositions of STF and SP are shown in Tables 1 and 2,

respectively.

Table 1: Composition of synthetic tissue fluid

Ingredient Amount (mg/100 mL)

potassium hydrogen phosphate 17

disodium hydrogen phosphate 118

sodium chloride 800

potassium chloride 20


31

Table 2: Composition of simulated plasma adopted from a study by Kintner et al [15]

Ingredient Quantity (g/1000 mL)

Isoleucine 5.10

Leucine 8.90

Lysine 5.60

Methionine 3.80

Phenylalanine 5.10

Threonine 4.10

Tryptophan 1.80

Valine 4.80

Arginine 9.20

Histidine 5.20

Glycine 7.90

Alanine 13.70

Proline 8.90

Aspartic acid 1.30

Asparagine Monohydrate 3.72

Cystine 0.50

Glutamic acid 4.60

Ornithine 2.51

Serine 2.40

Tyrosine 0.30


32

Acetyl tyrosine 1.23

Albumin 40

Sodium Acetate.3H2O 3.95

Potassium Acetate 2.45

Magnesium Acetate.4H2O 0.56

Sodium Dihydrogen Phosphate.2H2O 1.40

Sodium Hydroxide 0.20

Malic Acid 1.01

Solubility tests were conducted inside an incubator at 37°C. At the predetermined time intervals

of 2, 5, 9, 14, 21, 30, 50, and 78 days the solubility media containing dissolved samples were

collected and the specimens were immersed in other bottles with 50 mL of corresponding fresh

solubility medium (37°C). The collected solubility media were then evaporated at 90‒95°C.

Bottles and residues were re-dried in an oven at 105‒110°C, cooled down in a desiccator and re-

weighed. In DW samples, differences between the final weight and the original bottle weight

were expressed as the specimens’ IDW percentages. These values are called “Solubility”

according to the ISO 6876 standard 2. In STF and SP samples, the final dry weight was

subtracted from STF/SP dry ingredients and then the IDW was calculated. The results were

analyzed by one-way ANOVA to indicate any significant difference between different solubility

media at each time interval. In order to assess the solubility process during all the study intervals,

repeated-measures one-way ANOVA was used. SPSS 17 was used for all the statistical analyses.


33

Results

Kolmogorov-Smirnov analysis revealed normal distribution of solubility rate of tested materials

in all the three solutions at all study intervals (P>0.05). Levene statistics for testing the

homogeneity of variances depicted unequal variances at all the study intervals (P<0.05). Unequal

variance F-test (Welch test) showed a significant difference in solubility rate in tested solubility

media at all the study intervals (P<0.05) except for 14-day interval (F(2,18.128)=2.708, P=0.094).

Games-Howell post-hoc test was used for pair-wise comparisons. At shorter time interval of 2

days, there was no significant difference between solubility rates between DW and SP (P=0.081).

However, pair-wise comparisons of dissolution media were all significant (P<0.05). At 5-day

interval only the difference of solubility rate was significant between DW and SP (P=0.013) and

other pair-wise comparisons did not reveal significant differences (P>0.05). At 9-, 21-, 50-, and

78-day intervals, all the pair-wise comparisons revealed statistically significant differences

(P<0.05). At 30-day interval, only the difference of solubility rate was significant between DW

and STF (P=0.000) and other pair-wise comparisons did not demonstrate significant differences

(P>0.05).

Mixed repeated-measures ANOVA revealed a significant difference in solubility rate of MTA in

three different solutions at all the study intervals (df(3.101)=22.681, P=0.000). Games-Howell

post-hoc test revealed that all pair-wise comparisons were statistically significant at all the study

intervals (P=0.000) (Chart 1).


34

Chart 1: Comparison of solubility (%) of MTA in three different solubility media as a

function of time.


35

Figure 1. Scanning electron micrographs of MTA immersed in SP (simulated plasma): A.

×1000 magnification; B. ×2000 magnification. Notice the surface of MTA covered with

plasma elements.

Figure 2. Scanning electron micrographs of MTA immersed in STF (synthetic tissue fluid):

A. ×1000 magnification; B. ×2000 magnification. Notice the surface of MTA covered with

STF elements. The surface of material has not been covered as fully as in SP.


36

Figure 3. Scanning electron micrographs of MTA immersed in DW (distilled water): A.

×1000 magnification; B. ×2000 magnification. Notice the faded view and solubility of MTA

crystals (especially needle-like ones) which are associates with a higher solubility of MTA

in DW.

Discussion

The aim of employing a root-end filling material is to prevent microleakage of irritants from the

root canal system to periradicular tissues. Therefore, an ideal root-end filling material should

provide apical seal, be non-toxic, and be tolerated by periradicular tissues, be insoluble and


37

dimensionally stable, be easily manipulated, be radio-opaque, and bear bactericidal or

bacteriostatic activity [16].

Solubility of a root-end filling material is one of its utmost important features since it would

influence other properties like sealing ability, biocompatibility, and mutual effects with

surrounding environment (2,3). Sealing ability and solubility could affect treatment prognosis

[1]. The root-end filling material should have very low solubility because the materials released

from it might have toxic effects on surrounding tissues [2]. According to International

Association of Standard, the dissolved amount should be under 3% of the whole mass (4).

Mineral trioxide aggregate is a mixture of dicalcium silicate, tricalcium silicate, tricalcium

aluminate, tetracalcium aluminoferrite, and bismuth oxide. It contains other elements such as

SiO2, CaO, MgO, Al2O3, K2SO4, FeO, and Na2SO4. Due to low solubility, low cytotoxicity,

tissue biocompatibility, and the ability to induce mineralized tissue formation, mineral trioxide

aggregate has been used in vital pulp therapy (direct pulp capping, partial pulpotomy, and

pulpotomy), repair of furcal and lateral perforations, as an apical plug in open apex non-vital

teeth and as a root-end filling material during apical surgery [17-20].

Different studies have addressed the solubility of MTA and compared it with International

Organization for Standardization (ISO) method [8, 9, 11, 12, 21, 22]. In ISO 6876 and American

Dental Association protocol, the solubility of dental materials are measured in distilled water and

the solubility of 3% is acceptable [4, 14]. In the majority of previous studies [8-12] , the

solubility of materials has been measured only in DW (according to ISO method), the solution

which does not have any similarity with the composition of periradicular tissues. However, MTA

is a biomaterial and has interactions with surrounding tissues. MTA, as a root-end filling

material, contacts with biologic tissues and fluids. Therefore, solubility tests of these materials


38

should be performed in physiologic solutions with similarity to periradicular tissue fluids. As

tissue fluid and human blood better mimic the dental surrounding media, it seems that they

would act as better solutions to test the solubility of a root-end filling material which comes in

contact with them during and after surgery. Handling human blood needs an anticoagulant (e.g.

heparin) and some other considerations that may interfere with the study results. Therefore in the

present study, the solubility of MTA was assessed in STF and SP as well as in DW. In a study

conducted by Saghiri et al, solubility of MTA was investigated in deionized water and synthetic

tissue fluid. They reported less solubility rates of MTA in STF than deionized water and

suggested STF as an alternative to distilled water for solubility studies of dental materials due to

similarity of STF to biological fluids.

The method of measuring dissolution rate in most reported studies involves determination of the

weight difference of the biomaterial before and after dissolution [8, 11, 12, 23]. Although this

method is presented as a standard procedure, in fact it indicates the material wash-out in the

solution rather than actual solubility. Solubility of a material is defined as the amount of material

which dissolves in a certain amount of a solvent. Therefore, the measurement of weight

difference of the material before and after dissolution might not show the actual solubility since

it is possible that some cement disintegrates without any dissolution [24, 25]. In other words, the

result obtained with this method is the combination of solubility and disintegration rates. Due to

the similar effect of these two phenomena (solubility and disintegration) on the properties of

root-end filling material (sealing ability, biocompatibility, etc.), there is no need for measuring

these exclusively and the measurement of the combination rate is also adequate and critical.

According to ISO protocol, solubility test should be carried out 24 hours after material setting. In

the present study, 2‒78-day intervals were used to evaluate the effect of longer time on the


39

dissolution process. Some previous studies have employed similar methods, evaluating the

dissolution rate at 28- and 78-day intervals as well as ISO protocol [9-12].

In this study, desiccant materials in a vacuum-attached desiccator (for elimination of

environmental humidity) were utilized for drying specimens before dissolution to achieve a

constant weight in each one. In some previous studies, the samples were put under a temperature

of 105ºC for this purpose [8]. Since the latter would alter the material’s crystalline structure and

interfere with measuring dissolution rate, it was not employed in the present study. In a pilot

study, the latter method had destructive effects on the samples.

Fridland et al reported that the higher the water-to-powder ratio of MTA, the higher the solubility

rate [8]. Therefore, we used the powder-to-water ratio recommended by the manufacturer to

eliminate the effect of such disruptive factors.

It has been reported that the solubility of MTA decreases with time but never reaches zero [9,

11]. In this study, the solubility rate had a descending pattern but it was somehow irregular.

Since the solubility and disintegration phenomena take place inevitably and none of the studies,

before ours, measured these exclusively, and because the disintegration is an unpredictable

process, its irregular mode seems natural.

It seems that STF and SP (particularly SP) are more similar to periradicular tissue fluids and

solubility studies on these media show the actual solubility of material in comparison to distilled

water. Therefore, it would be better to evaluate the solubility of biomaterials in these solutions.

Conclusions

Based on the findings of this study, the solubility of MTA in modified artificial plasma was less

than that in synthetic tissue fluid and distilled water in the long term.


40

Acknowledgments:

This study was supported, in part, by the Student research committee and Office of Vice

Chancellor for Research, Tabriz University of Medical Sciences, Tabriz, Iran.

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[1] Grossman LI. Solubility of root canal cements. J Dent Res. 1978;57(9-10):927.

[2] Kaplan AE, Goldberg F, Artaza LP, De Silvio A, Macchi RL. Disintegration of

endodontic cements in water. J Endod. 1997;23(439-41.

[3] Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of

the biologic properties of mineral trioxide aggregate. J Endod. 2005;31(2):97-100.

[4] Anonymous. International Organization for Standarization. Specification for dental root

canal sealing materials. ISO 6876. London: British Standards Institution, 2001.

[5] Lin LM, Skribner JE, Gaengler P. Factors associated with endodontic treatment failures. J

Endod. 1992;18(12):625-7.

[6] Johnson BR. Considerations in the selection of a root-end filling material. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod. 1999;87(4):398-404.

[7] Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature

review--Part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-

27.

[8] Fridland M, Rosado R. Mineral trioxide aggregate (MTA) solubility and porosity with

different water-to-powder ratios. J Endod. 2003;29(12):814-7.

[9] Bodanezi A, Carvalho N, Silva D, et al. Immediate and delayed solubility of mineral

trioxide aggregate and Portland cement. J Appl Oral Sci. 2008;16(2):127-31.

[10] Bortoluzzi EA, Broon NJ, Bramante CM, Felippe WT, Tanomaru Filho M, Esberard RM.

The influence of calcium chloride on the setting time, solubility, disintegration, and pH of

mineral trioxide aggregate and white Portland cement with a radiopacifier. J Endod.

2009;35(4):550-4.

[11] Fridland M, Rosado R. MTA solubility: a long term study. J Endod. 2005;31(5):376-9.


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[12] Danesh G, Dammaschke T, Gerth HU, Zandbiglari T, Schafer E. A comparative study of

selected properties of ProRoot mineral trioxide aggregate and two Portland cements. Int

Endod J. 2006;39(3):213-9.

[13] Saghiri MA, Ricci J, Daliri Joupari M, Aeinehchi M, Ahmadi K, Bahramian N. A

Comparative Study of MTA Solubility in Various Media. iran Endod J. 2011;6(1):21-4.

[14] Anonymous. ANSI/ADA. Revised American National Standard/American Dental

Association Specification N° 30 for dental zinc oxide eugenol cements and zinc oxide

noneugenol cements 7.5. ANSI/ADA, Chicago, IL, 1991.

[15] Kintner DB, Kao JL, Woodson RD, Gilboe DD. Evaluation of artificial plasma for

maintaining the isolated canine brain. J Cereb Blood Flow Metab. 1986;6(4):455-62.

[16] Xavier CB, Weismann R, de Oliveira MG, Demarco FF, Pozza DH. Root-end filling

materials: apical microleakage and marginal adaptation. J Endod. 2005;31(7):539-42.

[17] Abbasipour F, Akheshteh V, Rastqar A, Khalilkhani H, Asgary S, Janahmadi M.

Comparing the effects of mineral trioxide aggregate and calcium enriched mixture on

neuronal cells using an electrophysiological approach. Iranian endodontic journal.

2012;7(2):79-87.

[18] Sahebi S, Nabavizadeh M, Dolatkhah V, Jamshidi D. Short term effect of calcium

hydroxide, mineral trioxide aggregate and calcium-enriched mixture cement on the

strength of bovine root dentin. Iranian endodontic journal. 2012;7(2):68-73.

[19] Zarrabi MH, Javidi M, Jafarian AH, Joushan B. Histologic assessment of human pulp

response to capping with mineral trioxide aggregate and a novel endodontic cement. J

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[20] Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature

review--part II: leakage and biocompatibility investigations. J Endod. 2010;36(2):190-

202.

[21] Islam I, Chng HK, Yap AU. Comparison of the physical and mechanical properties of

MTA and portland cement. J Endod. 2006;32(3):193-7.

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pH on properties of white mineral trioxide aggregate. J Endod. 2009;35(1):98-101.

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of a new root-end filling material. J Endod. 1995;21(7):349-53.


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[24] Kazemi RB, Safavi KE, Spangberg LS. Dimensional changes of endodontic sealers. Oral

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46

Relation between severity and distribution of periodontal inflammatory diseases and

chronic urinary tract infections at child’s ageTargova-Dimitrova T.

Department of Periodontology and Dental Implantology

Faculty of Dental Medicine

Medical University-Varna Varna, Bulgaria

e-mail: [email protected]

S. Angelova

Department of Pediatric Dentistry Faculty of Dental Medicine



D. Bliznakova

Department of Clinical Medical SciencesEducational-Scientific Sector of Pediatrics and

Infectious Diseases



S. Peev

Department of Periodontology and Dental Implantology; Faculty of Dental Medicine

Medical University-Varna

Varna, Bulgaria e-mail: [email protected]

Abstract:

Periodontal inflammatory diseases at child’s age are often registered and diagnosed. A large number of predisposing factors such as poor oral hygiene, social-economic status, educational patterns are related with these clinical findings. According to literature co-relations between inflammatory diseases of periodontium and recurring urinary tract infections have already been established. In this study are involved totally 72 children, 30 of them

with no systemic diseases and 42 children suffering from recurring urinary tract infections. During the investigation was emphasized on relation between distribution and severity by these groups of disorders. A predisposition for early initiation of inflammatory periodontal processes concerning children with recurring urinary tract infections has been ascertained.

Key words: periodontal; urinary; infections; childhood;

I. INTRODUCTION

Nowadays periodontal inflammatory diseases are widely spread at child’s age. Poor oral hygiene, social-economic and educational status of family members are playing essential role of predisposing factors according to plenty of studies [1]. Asignificant part of systemic diseases afflicting the organism have their onset characterized by explicit clinical manifestation at early child’s age [2], [3]. Co-relation between periodontal and recurring urinary tract infections at childhood has already received scientifically-based confirmation [4], [5].

In our research strong emphasis is put on severity and distribution of these inflammatory processes.

II. AIM AND TASKS

The purpose of this screening study is registrationof deviations of indexes representing oral-hygieneand gingival status, clinical attachment level, levelof gingival margin, pocket probing depth bydentitions of children of age below 18, healthy and suffering from recurrent infections of urinary tract.Also, we are investigating the criteria of severity and distribution of periodontal inflammatory diseases by the means of proceeding examinations.


47

As main tasks of this paper are outlined:

Investigation of deviations in the Hygiene Index /HI/ by children of the determined groups.Registration of obtained data into aperiodontal chart and table.Records of degree of severity and extent of distribution of gingival inflammation.Records and description of periodontalstatus into the periodontal chart, followedby comparison of results concerning bothof the examined groups of children.Recommendations and instructionsaddressed to doctors providing treatmentand also to parents in conditions ofdeviations from the definite norm, as wellas advices for taking regular optimalprophylactic cares.

III. MATERIALS AND METHODS

The object of this study are children below the age of 18, 30 of them without systemic diseases and 42- suffering from recurring urinary tract infections [6], [7].

We have defined the criteria of investigation as: gender, age, type of dentition-primary, mixed and permanent, oral hygiene level, recorded by the plaque index- PI by O`Leary, gingival status by the means of BoP /bleeding on probing/ and PBI /papilla bleeding index/, number of intact teeth, number of treated teeth, number of teeth liable to treatment; registration of severity and distribution of inflammation processes, clinical attachment level, pocket probing depth, level of gingival margin, others [8], [9].

Validation of results:Assessment of the child’s periodontalhealth status based on severalmethods:

1. Affirmation of recurrent infections of urinary tract by hospitalized children, following the protocol of appropriate diagnostic procedures [10].

2. Inspection of oral mucosa aim toestablish or disprove the presence oflesions and orthodonticabnormalities; records of position of attachment of frenulum of upper and lower lips and gingival-buccal junctions [11].

3. Registration of the index of PI byO`Leary without coloration, byscraping away the accumulatedplaque using a periodontal probe ofUNC 15 and recording data into the periodontal chart; calculation of the per-cent of distribution of dental plaque [12].

4. By the means of a periodontal probeof UNC 15, applied during the wholeexamination, is marked out alsopresence or absence of bleeding byprobing. Again results are recorded into the periodontal chart. Afterwards we calculate the per-cent of distribution of gingival pockets’ activity.

5. The index of PBI is registeredmaking sweeping-out movementswith the periodontal probe onrepresentative teeth surfaces, thenmarking the obtained values into atable. Determination of degree of severity and extent of distribution of inflammation according to calculation of per-cent expression of the ratio of sites with positive bleeding and mean value of recorded indexes.

6. Measurement of pocket probing depth with a periodontal probe andregistration in the periodontal chartof six greatest values from all thetooth surfaces of each present tooth observing the rules of index registration. Calculation of a mean value for the whole dentition [13].

7. Measurement of the level of gingivalmargin with a periodontal probe,followed by registration of attainedvalues into the periodontal chart inmm, taking into considerationpresence or absence of zones ofrecessions and hyperplasia.Calculation of mean values of records of the whole dentition.

8. Registration of clinical attachment level according to pocket probing depth and level of gingival margin; records of mean value for the whole dentition [14].


48

The investigation is conducted byspecialists at Periodontology, PediatricDentistry and dental assistant.

Children without systemic diseases involved in thestudy are examined separated in classes, groups andindividually. In conditions of proper illumination of oral cavity are performed as subsequent procedures inspection, registration of deviations and recording of obtained data.

There have been examined 42 children suffering from recurring infections of urinary tract, hospitalized at First Clinics of Pediatrics, University Hospital “St. Marina”- Varna. Investigations have been conducted by the bed of patients. Established deviations are registered in the periodontal chart, and into history of illness paper are marked determined diagnosis and recommendations of adequate treatment [15]. After examination of dentition, oral cavity of each child is rinsed with mouth-rinsing solution, followed by instructions concerning improvement and optimization of personal oral hygiene. There arerecommendations addressed to parents for proper prophylactic cares and dental treatment to be provided for their children [16].

Characteristics of examined groups:

In the study are involved 72 children, separated into groups, respectively:Children without systemic diseases: 30childrenChildren suffering from recurring urinary tract infections: 42 children.Separation of examined children of pointed groups regarding type of dentition:with primary dentition: 18with mixed dentition: 26with permanent dentition: 28

IV. RESULTS AND DISCUSSION

In the process of performed examinations in all the investigated groups have been established clinical signs of a slight degree of gingival inflammation.

Concerning children of the first group, with primary dentition, these results have been marked out: PI /plaque index/: 69,63%; BoP: 0,34%; PBI:3,04%.

At children suffering from recurring urinary tract infections of the second group, with mixed dentition, have been recorded these indexes’ values: PI: 85,17%; BoP: 3,39%;PBI: 24,58%.At children of the third group, with mixed dentition, these figures have been affirmed, namely- PI:69,44%; BoP: 3,50% and PBI: 22,64%.

At children without systemic diseases, group 3, have been ascertained these values: PI: 86,69%; BoP: 16,36%; PBI: 45,79.And at children into group 2, respectively: PI: 96,13%; BoP: 35,57% and PBI: 61,22%.

No positions of loss of clinical attachment and recessions have been registered. But, into the group of healthy children /without systemic diseases/ has been recorded the state of hyperplasia of gingival margin at the rate of 0,09.At 9 of the children with recurring urinary tract infection has been diagnosed generalized gingival inflammation.

Moderate and severe forms of gingival inflammation have not been diagnosed into any of the examined groups. No data of periodontitis have been obtained during the investigation. Into all the inspected groups have been found no representatives with intact dentition /without decay lesions and/or filling/.

Comparative investigation based on specific definite criteria-graphics (1), (2):

Graph.1 Co-relation between the criteria of type of dentition /according to the age/ and periodontal and dental status by healthy children:

At children without common health problems,because of prevalence of groups 2 and 3 and greaternumber of teeth that are examined, the values ofindexes PI and BoP are higher, related withascertainment of symptoms of chronic persistentgingival inflammation. Another reason for established pathological findings is the significant

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49

portion of untreated teeth Zb, serving as plaque-retentive factor and reservoir of infection into oral cavity.

Graph.2 Co-relation between the criteria of type of dentition /according to the age/ and periodontal and dental status by children suffering from recurring urinary tract infections:

UTI – urinary tract infections; Gr.1 -primary dentition; Gr.2 - mixed dentition; Gr.3 -permanent dentition; HI -hygiene index;BoP -bleeding on probing; PBI% -papilla bleeding index-distribution; PD -probing depth; /AL/CAL –clinical attachment level; PBIs-papilla bleeding index-burden; GM -gingival margin; Zz -healthy teeth; Zb – teeth with complicated or non-complicated caries; Zl –treated teeth

Although there have been registered significantlevels of dental plaque by examined childrensuffering from recurring urinary tract infections,indexes of gingival status do not emphasize on explicit reaction of bleeding from gingival tissues. At the same time, among examined patients were diagnosed such with generalized gingival inflammation. This regularity is based on anamnesis data for oftener, compared with healthy children, provided antibiotics treatment, which suppresses the inflammatory answer by gums.Among patients with recurring urinary tract infections, subject of procedures of assessment and diagnosis, has been prevailing the portion of these with primary dentition, which explains the smaller number of untreated teeth in the context of predominant group of children with mixed dentition.

On the grounds of conducted examinations, including comparison, we take into consideration differences between values’ expression of investigated criteria by these groups of patients, seeking if received results are related with impact upon commented diseases and their severity of

clinical manifestation by children with recurring urinary tract infections.

V. CONCLUSION

At the three of the investigated age groups distribution and severity of gingival inflammation is established to be of slight degree and localized. But, in the group of examined children with recurring urinary tract infections, in the context of lower values of the hygiene index, have been diagnosed 9 patients with generalized gingival inflammation,which figures out at 20.45% of all of them [17].

Taking into account the performed study and its results, we can conclude that by children with recurring urinary tract infections there is predisposition to early initiation of inflammatory periodontal disease. There is a necessity of a moreprofound and detailed investigation, directed to clarification of reasons. As main priorities have to be outlined in-time performed prophylactic cares and adequate, throughout treatment aiming protection of dentition healthy at later age, avoiding risks of recurrence [18].

REFERENCES

[1] Frank A, Oski, MD, Principles and Practice of Pediatrics, USA, 1990[2] Klegman, Stanton, St. Geme, Nelson Textbook of Pediatrics, 2011[3] Hrair-George, O. Mesrobian, MD, MSc, Cynthia G. Pan, MD, Pediatric Clinics of North America. Recent Advances in Pediatric Urology and Nephrology, 2006[4] Foster H., Fitzgerald J., “Dental disease in children with chronic illness”, Arch Dis Child 2005; 90:703-708; [5] Fisher A. M., Borgnakke S. W., Taylor W. G., “Periodontal disease as a risk marker in coronary heart disease and chronic kidney disease”, Curr Opin Nephrol Hypertens, November 2010; 19(6): 519-526; [6] Alar H., Alar C. G., Carrero J. J., Stenvinkel P., “Systemic consequences of poor oral health in chronic kidney disease patients”, Clin J Am Soc Nephrol 6, 2011, 218-226; [7] Wahid A, Chaudhry S, Ehsan A, Butt S, Khan AA, “Bidirectional relationship between chronic kidney disease and periodontal disease”, Pak J Med Sci 2013; 29(1): 211-215; [8] Sobrado-Marinho J. S., Tomas-Carmona I., Loureiro A., Limeres-Posse J., Garcia-Caballero L., Diz-Dios P., “Oral health status in patients with moderate-severe and terminal renal failure”, Med Oral Patol Oral Cir Bucal 2007; 12:E 305-310; [9] Seraj B., Ahmadi R., Ramezani N., Mashayekhi A., Ahmadi M., “Oro-dental health status and salivary characteristics in children with chronic renal failure”, Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2011, Vol. 8, № 3); [10] Bastos J. do A., Vilela E. M., Henrique M., Daibert P. de C., Fernandes F. M. C., “Assessment of knowledge toward

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periodontal disease among a sample of nephrologists and nurses who work with chronic kidney disease not yet on dialysis”, J Bras Nefrol 2011; 33(4): 431-435; [11] Haider R. S., Tanwir F, Phil M., Momin A. I., “Oral aspects of chronic renal failure”, Pakistan Oral and Dental Journal Vol 33, №1 (April 2013), p. 87-90; [12] Alamo M. S., Esteve G. C., Perez S. G. M., “Dental considerations for the patient with renal disease”, J Clin Exp Dent, 2011, 3(2): e 112-9;[13] Ioannidou E, Swede H., “Disparities in periodontitis prevalence among chronic kidney disease patients”, J Dent Res 90(4): 2011, 730-734; [14] Bastos J. A., Diniz C. G., Bastos M. G., Vilela E. M., Silva V. L., et al., “Identification of periodontal pathogenes and

severity of periodontitis in patients with and without chronic kidney disease”, Archives of Oral Biology 56(2011), 804-811; [15] Reeves J., “Oral health problems in the renal patient”, Dental Nursing, November 2008, Vol 4, №11, p. 618-621; [16] De Rossi S. S., Cohen D. L., “Renal disease”, Burket’s Oral Medicine, 2006, p. 363-383; [17] Nibali L., Farias B. C., Vajgel A., Tu y. K., Donos N., “Tooth loss in aggressive periodontitis: a systematic review”, J Dent Res 92(10) 2013, p. 868-875; [18] Thomas Ch., “The roles of inflammation and oral care in the overall wellness of patients living with chronic kidney disease", www.dentaleconomics.com, August 2008, p. 111-118;


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52

Spiradenoma Breast: A rare pathology. Kamran Ahmad Malik1, Glyn Neades2, Matthew Barber2, Mike Dixon2.

1) Visiting Fellow Edinburgh Breast Unit, Western General Hospital, Edinburgh, United Kingdom. Currently at Sultan Qaboos University Hospital Muscat, Oman

2) Consultant Breast Surgoen,Edinburgh Breast Unit, Western General Hospital, Edinburgh, United Kingdom.

Corresponding Author: Dr Kamran Ahmad Malik.Department of Surgery, Sultan Qaboos University Hospital,Muscat,Oman.Email:[email protected] Introduction: Spiradenoma, also known as spiroma or eccrine spiradenoma, was first reported in 1956 by Kersting et al1.They are usually benign dermatological condition which are characterized, clinically, as a solitary, deep-seated, painful, slow-growing, dermal nodule of approximately one centimeter, occurring on the ventral surface of the body. It can occur in infancy but most commonly arises in persons aged 15-35 years and is seen equally in both genders. Eccrine spiradenomas are very rare in the breast and only few cases have been reported in the literature2. A defective tumor suppressor gene is believed to result in the development of spiradenomas

We report here on the case of an eccrine spiradenoma in the breast of a 47-year-old gentleman who presented to us with a painful mass in his left upper breast which was first diagnosed as an epidermal inclusion cyst based on the imaging findings and the mass's superficial location .The subsequent histopathology confirms it to be benign eccrine spiradenoma.

Keywords:

Spiroma, Eccrine Spiradenoma, Breast.

Case Report: A 47-years old gentleman was seen in breast clinic for a painful palpable lesion involving the left breast which was gradually increasing in size. The physical examination revealed a tender, immobile mass in the left upper breast. A breast ultrasound examination revealed a well defined hypo echoic mass in the subcutaneous layer. Hence it was diagnosed as an epidermal inclusion cyst based on the imaging findings and the mass's superficial location The patient underwent surgical excision for pain relief and due to patient’s worry for the lesion for the potential for malignancy. The surgical specimen showed approximately 1 cm in size lesion present in the dermis without obvious continuity with the epidermis. The histopathological examination confirmed the diagnosis of a benign, adnexal skin tumor in the breast, and this


53

was all consistent with an eccrine spiradenoma which was excised completely. Discussion: The embryologic origin of the breast is related to salivary and sweats glands. Thus, breast neoplasms may show differentiation toward these tissues. Eccrine spiradenomas may present as painful or painless solitary masses and are usually benign tumors. Most spiradenomas go unnoticed for many years to decades. Spiradenomas can occur in Brooke-Spiegler syndrome, which manifests with cylindromas, spiradenomas, and trichoepitheliomas 3. An eccrine spiradenoma is composed of two types of cells.Basaloid cells are small and stain dark while the other cells are large and stain pale. At low power magnification, a spiradenoma appears as a solid neoplasm composed of a single mass or a few masses of basaliod cells. At higher magnification, two distinct populations of neoplastic epithelial cells can be seen as dark and pale cells 4. It is very rare for this benign tumor to transform into a malignancy and they generally arise from long-standing benign eccrine spiradenomas 5. Dabska in 1972 reported first case of malignant spiradenoma 6. The cause of malignant spiradenomas is unclear. The expression of TP53 seems to be increased in malignant spiradenomas, but the significance of this observation is unclear.

A skin biopsy helps in establishing the diagnosis of these tumors. Fine-needle cytology of a spiradenoma of the breast can be performed to aid in diagnosis 7.The presence of metastatic foci in the case of malignant spiradenoma can be assessed by CT or MRI scans.

The best and really only treatment is surgical excision for both benign and malignant ones.The lesions do not tend to recur after surgery.

Due to the infrequency of occurrence of this type of malignancy, especially of the breast, no guidelines are available for the management and treatment of malignant spiradenomas.The recommended treatment at this time is complete excision and patient follow up. It may be beneficial to send the specimen for hormone receptor sensitivity to better determine the characteristics of the tumour. One case was reported where the patient received Tamoxifen as part of the treatment 8. At this time, there is no proven role of radiation and chemotherapy in management.

Conclusion: Spiradenoma is a rare condition world wide and should be considered as one of the differential diagnosis for the lesions presented in the breast .The surgical excision is the mainstay of the treatment for both benign and malignant varieties.

References:

1) Kerstein DW, Helwig EB. Eccrine spiradenoma. AMA Arch Derm. Mar 1956; 73(3):199-227.


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2) Hyun Ho Lee,Sung Hee Park,Hye Young Choi .Eccrine Spiradenoma Arising in The breast Misdiagnosed as an Epidermal Inclusion Cyst.Korean J Radiol. 2011 Mar-Apr; 12(2): 256–260.

3) Bumgardner AC, Hsu S, Nunez-Gussman JK, Schwartz MR. Trichoepitheliomas and eccrine spiradenomas with spiradenoma/cylindroma overlap. Int J Dermatol. May 2005;44(5):415-7.

4) Dijkhuizen T, van den Berg E, Nikkels PG, Hoekstra HJ, de Jong B. Cytogenetics of a case of eccrine spiradenoma. Hum Pathol 1992 Sep;23(9):1085-7.

5) Ribeiro SA,Shaletich C,Careta RS,Kazava DK,Siqueira MC,Ponton F. Spiradenocarcinoma of the breast arising in a long-standing spiradenoma.Ann Diagn Pathol 2004 Jun;8(3);162-6.

6) Dabska M. Malignant transformation of eccrine spiradenoma. Pol Med J. 1972; 11(2):388-96.

7) Bosch MM, Boon ME. Fine-needle cytology of an eccrine spiradenoma of the breast: diagnosis made by a holistic approach. Diagn Cytopathol.1992; 8(4):366-8.

8) Mirza I, Kloss R, Sieber SC. Malignant eccrine spiradenoma. Arch Pathol Lab Med. May 2002;126(5):591-4.


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56

TROUSSEAU SYNDROME AS AN INITIAL MANIFESTATION OF PANCREATIC

ADENOCARCINOMA: CASE REPORT

A. Kaprelyan1, Al. Tzoukeva1, M. Atanasova2, D. Kalev3, B. Balev4, R. Georgiev4

1Dept. of Neurology, 2Clinic of Gastroenterology, 3Clinic of Oncology, 4Dept. of Radiology

Medical University – Varna Varna, Bulgaria [email protected]

A. Kaprelyan1, Al. Tzoukeva1, M. Atanasova2, D. Kalev3, B. Balev4, R. Georgiev4

1Dept. of Neurology, 2Clinic of Gastroenterology, 3Clinic of Oncology, 4Dept. of Radiology

Medical University – Varna Varna, Bulgaria [email protected]

Abstract—Multiple ischemic cerebral strokes as the first manifestation of pancreatic carcinoma are infrequent. In recent times the term Trousseau’s syndrome must be reserved for unexplained thrombotic problems that precede or appear concomitantly with visceral malignancy. We report a case of 55-year-old female with malignancy – related thromboembolism, presented with multiple and recurrent ischemic strokes, from a recently diagnosed pancreatic adenocarcinoma in the tail.

We conclude that patients with multiple, repeated cerebral infarction, with minimal risk factors for stroke, must be further investigate for an underlying malignancy, possibly of pancreatic origin.

Keywords—Trousseau’syndrome, stroke, malignancy, pancreas

I. Introduction Multiple ischemic cerebral strokes as the first

manifestation of pancreatic carcinoma are infrequent [1,7,9,10]. In recent times the term Trousseau’s syndrome must be reserved for unexplained thrombotic problems that precede or appear concomitantly with visceral malignancy [2,6,8,12]. Migratory thromboses, which occurred in about 10% of patients with pancreatic adenocarcinomas, may be associated with chronic disseminated intravascular coagulopathy, cancer – related hypercoagulability syndrome, or tumor embolism [5,13,15,16]. Pancreatic tumor of the body and the tail tended to grow relatively silently and metastasized before diagnosis [11]. We reported a case of 55-year-old female with malignancy – related thromboembolism with multiple and recurrent ischemic strokes, from a recently diagnosed pancreatic adenocarcinoma in the tail.

II. Case reportA 55-year-old female, previously healthy, presented

with sudden-onset speech difficulties, dizziness, and right-sided leg weakness resulting in unsteady gait. Prior to admission to neurology clinic, a medical consult with gastroenterologist was done due to intermittent epigastric pain, noted after meal. She had normal vital signs and was fully awake, conversant with Glasgow Coma Scale (GCS) at 20. Neurological examination revealed partial sensory and motor aphasia, right-sided latent lower monoparesis, and hemi-hyperreflexia. The patient did not have any cranial nerves dysfunction, sensory deficit or coordination disorder. Laboratory data demonstrated anemia (Hb 116 g/l) and elevation of erythrocyte sedimentation rate 40 mm, Leucocytes 16.2 g/l, blood glucose 7.1 mmol/l, ASAT 49 U/l, ALAT 40 U/I, CRP 176 nmol/l, tumor markers: CEA - 328 ng/ml, CA 15-3 - 91.3 U/ml, CA 19-9 >1000 U/ml, CA 125(OV) >500 U/ml, proteinuria and hematouria. Hypercoagulability studies were negative, coagulation factors, and D – dimers were within normal.

Fig.1 Non-enhancing hypodense area (12.5x11 mm, 25 HU) in the left parietal and occipital lobes, and second one in the left parietal lobe.

Later on brain CT (25.09.2012) revealed one hypodense area (44x22 mm, 29 HU) in the left parietal lobe


57

and second one located near the posterior corn of the left lateral ventricle (fig.2).

Fig.2. a hypodense zone left parietal 44/42mm, with mean density 29 HU, acute ischaemic insult; b small hypodense zone 9mm left parietal above the posterior horn of the left ventricle-subacute ischemic insult

One week later the patient demonstrated progression of her neurologic deficit. Brain magnetic resonance imaging (MRI) (28.09.2012) revealed large infarction localized in the left temporal and parietal lobes, multiple punctiform areas in the right parietal lobe, both cerebellar hemispheres, and corpus callosum, as well as two encephalomalatic areas with perifocal gliosis in the right frontal and temporal lobes. MRI data confirmed multiple acute embolic ischemic strokes and two old ischemic cerebrovascular accidents (fig.3).

Fig.3.a AX T2 FLAI- multiple hyperintense zones right parietal and left parieto-temporal, which present multiple acute ischemic insults; b DWI-multiple hyperintense zones right parietal, left parieto-temporal, with diffusion restriction, due to multiple ischemic insults; c ADC map, these lesions are correspondingly hypointense on ADC map-acute ischemic insults

Fundoscopic examination discovered findings of hypertonic retinal angiopathy. Transcranial Doppler utrasonography was normal. Trans-thoracic echocardiography was normal. Chest findings were normal. Enhanced abdominal CT (26.09.2012) demonstrated multiple, different sized oval-shaped metastatic lesions in the both liver lobes, the biggest one 60x50 mm, one hypodense area in the upper pole of the spleen, and necrotic tumor mass (50x39x25) located in the pancreatic tail (fig.4).

Fig. 4 Contrast-enhanced CT of abdomen shows hypodense zone in the pancreas tail – Tu –carcinoma; multiple hypodense zones in the liver, and one hypodense area in the spleen upper pole – meta

Fine-needle aspiration liver biopsy (27.09.2012) detected cytological findings of metastases from low-differentiated adenocarcinoma. The consult with oncologist and abdominal surgeon confirmed data relevant to advanced stage IV adenocarcinoma of pancreatic tail with liver and spleen metastases.

We diagnosed Trousseau’s syndrome accompanying pancreatic cancer and performed anticoagulation (Heparin) and antiplatelet (Clopidogrel and Aspirin) treatment. Brain CT monitoring (18.10.2012) revealed hemorrhagic transformation in the previous ischemic areas (fig.5).

Fig.5 a hemorrhagic transformation, hyperdense linear foci, in the zones of the known insults; b hemorrhagic transformation, hyperdense linear foci right parietal in the new discovered insult.

The patient died of cerebral edema 1 month later.

III. Discussion In 1865, Armand Trousseau (1801 – 1865) described

that some patients presented with unexpected, unusual, or migratory thrombosis, later or concomitantly manifested a visceral malignancy [2,3,8,12,13,14]. In review of the findings – our patient suffered from multiple bihemispheric progressive ischemic stroke. Atherosclerosis, hypertension, diabetes mellitus, or nonneoplastic hypercoagulable states appear to be conventional risk factor for cerebrovascular disease, but she was not known hypertensive and/or diabetic. Ischemic stroke


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with no overt vascular risk factors should be considered for cancer screening [1,4,5,6]. For this patient CA19-9 was extremely high and a large silent necrotic mass in pancreatic tail were seen on abdominal CT. The combination of radiology with a best serum tumor marker for pancreatico-billiary cancer CA19-9, significantly increases the diagnosis sensitivity to 97.2% and the specificity to 88.7% [7]. The presented patient has necrotic stage IV adenocarcinoma of pancreatic tail with hepatic and splenic metastases and multiple acute cerebral ishemic stroke as the first symptom, wich is very rare. Adenocarcinoma of pancreatic tail often grows silently and the most common clinical manifestation is glucose tolerance disorder [11]. The underlying pathophysiological mechanisms for the presence of the cerebrovascular diseases, due to the pancreatic cancer itself, are unclear [9,10,15,16]. For this patient, except the elevated serum pancreatic carcinoma antigen and mild hepatic pathology, the coagulation factors and all of the rest blood tests were within normal limits. Ultrasonographic duplex study, trans–thoracic echocardiography and chest findings were normal. We speculate that in our case the cause of the multiple cerebral infarctions may have been due to migratory arterial tumor emboli from necrotic pancreatic cancer.

IV. Conclusion We conclude that patients with multiple, repeated cerebral infarction, with minimal risk factors for stroke, must be further investigate for an underlying malignancy, possibly of pancreatic origin.

REFERENCES

[1] Arabi M .,Saleh Z., Sawaya R. Cryptogenic stroke as a very early manifestation of pancreatic neoplasm. EXCLI Journal. 2009; 8:118-120.

[2] Chen L., Li Y., Gebre W., Lin J. Myocardial and cerebral infaction due to nonbacterial thrombotic endocarditis as an initial presentation of pancreatic adenocarcinoma. Arch Pathol Lab Med. 2004; 128:1307-1308.

[3] Dammacco F, Vacca A, Procaccio P, Ria R, Marech I, Racanelli V.Cancer-related coagulopathy (Trousseau's syndrome): review of the literature and experience of a single center of internal medicine. Clin Exp Med. 2013; 13(2):85-97. doi: 10.1007/s10238-013-0230-0.

[4] Devulapalli S, Pinto N, Gandothra C, Jayam-Trouth A, Kurukumbi M. A rare case of occipital stroke as a consequence of nonbacterial thrombotic endocarditis in ovarian clear cell carcinoma: a case report. Case Rep Neurol. 2012; 4(1):84-91. doi: 10.1159/000338811.

[5] Giray S., Sarica F., Arlier Z., Bal N. Recurrent ischemic stroke as an initial manifestation of an concealed pancreatic adenocarcinoma: Trousseau’s syndrome. Chinese Medical Journal. 2011; 124:637-640.

[6] Gokce M., Benli E., Dinc A. Arterial ischemic stroke as a first manifestation of Trousseau’s syndrome. International Journal of Clinical Medicine. 2012; 3:43-45. http://dx.doi.org/10.4236/ijcm.2012.31009.

[7] Ines P., Esposo E., Bocobo J. Multiple ischemic cerebral stroke as the initial presentation of a concealed pancreatic malignancy: Trousseau’s syndrome. Philippine Journal of International Medicine. 2012; 50:34-39.

[8] Ladizinski B, Federman DG. Trousseau syndrome. CMAJ. 2013; 185(12):1063. doi: 10.1503/cmaj.121344.

[9] Medina C, Molins T, Guarner L, Balsells J, Olsina JJ, Malagelada JR.Cerebrovascular accident as the form of presentation of a pancreatic cystadenocarcinoma: an unusual form of presentation in a rare tumor. Gastroenterol Hepatol. 2000 Mar; 23(3):132-134.

[10] Murinello A., Guedes P., Rocha G., Serrano A., Figueiredo A., Damasio H., Feire J., Cunha F., Alves L. Trousseau's syndrome due to asymptomatic pancreatic adenocarcinoma. GE J Port Gastrenterol. 2013; 20:172-176. http://www.elsevier.pt

[11] Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G. Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center. Clin Oncol. 1986; 4(4):509-514.

[12] Rigdon E. E. Trousseau’s Syndrome and Acute Arterial Thrombosis. Journal of Cardiovascular Surgery, 2000; 8 (3): 214-218.

[13] Tachihara M, Nikaido T, Wang X, Sato Y, Ishii T, Saito K, Sekine S,Tanino Y, Ishida T, Munakata M. Four cases of Trousseau's syndrome associated with lung adenocarcinoma. Intern Med. 2012; 51(9):1099-1102.

[14] Ukai K., Okajima A, Yamauchi A, Sasaki E, Yamaguchi Y., Kimura H., Aleksic B, Ozaki N. Total palliative care for a patient with multiple cerebral infarctions that occurred repeatedly in association with gastric cancer (Trousseau's syndrome). Palliat Support Care. 2013; 11(2):169-172. doi: 10.1017/S1478951512000624.

[15] Varki A. Trousseau’s Syndrome: Multiple Definitions and Multiple Mechanisms. Blood. 2007; 110:1723-1729. doi: 10.1182/blood-2006-10-053736.

[16] Woo PY, Chan DT, Cheung TC, Zhu XL, Poon WS. Middle cerebral artery infarction in a cancer patient: a fatal case of Trousseau's syndrome. Hong Kong Med J. 2014; 20(1):74-77. doi: 10.12809/hkmj133780.


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Professionalism: An enduring insight of the nursing profession in Malaysia.

Rekaya Vincent Balang School of Human and Health Sciences

University of Huddersfield Queensgate, Huddersfield, HD1 3DH UK

[email protected]

Dr. Rob L. Burton School of Human and Health Sciences

University of Huddersfield Queensgate, Huddersfield, HD1 3DH UK

[email protected]

Abstract— Professionalism has been discussed among nurses for years. Nursing in Malaysia also experience a gradual progression toward professionalism [33] despite the rapid development of nursing education [23]. Anecdotally, every nurse will rather to admit that they are professional. However, there might be possibility of speaking of it rather than doing it. This paper explores and describes the professionalism among nurses in Malaysia and also discusses briefly the important theoretical frameworks that were introduced in the recent years. Numerous literatures pertaining to professionalism in nursing were found and majority of the literatures are research papers that exploring professionalism in nursing from various paradigms. However, a marginalised amount of literatures discuss professionalism in nursing within Malaysia context. Further research to explore professionalism among nurses in Malaysia is essential.

Keywords—Professionalism:Nursing:Malaysia

I. INTRODUCTION

Professionalism has been contemporaneously deliberated among nursing scholars for many years and has becoming as one of enduring issues in the nursing profession globally [12][5][13]. Professionalism in nursing can be defined in various concepts. Among the earliest concepts of professionalism in nursing is the Miller’s Model, entitled “Wheel of Professionalism in Nursing” from 1984 [34]. This model was developed in response to nurses’ need to acknowledge attributes and behaviours necessary for nursing professionalism. Melia in 1985 [6] also stated that nurses must have the power to enable them to act professionally to patients, organisation and to their professional association to achieve and sustain professional status. In the same way, professionalism in nursing is the progression of the way nurses act and think which derived from the biological, physical, and behavioral sciences [31]. These are applied to the care, diagnosis, treatment, counsel and health teaching of persons who are experiencing changes in their normal health processes or who require assistance in the maintenance of health and the prevention or management of illness, injury or infirmity. Professionalism also can be described as an extent to which an individual identifies with a profession and adhere to itsstandard [36]. It is a contemporary conceptualisation and way of relational caring practice caters the physical and

psychological needs of health care consumer [32].Professionalism in nursing is a commitment to behaviours of compassion, caring and strong ethical values; continuous development of self and others; accountability and responsibility for insightful practice and demonstrating a spirit of collaboration and flexibility [12].

Noteworthy, professionalism is an important characteristic of careers that emphasise values and commitment in service to the community [35]. It can be arguable that professionalism is a multi-dimensional concept that provides a platform for nurses to ameliorate personally [3]. Hence, it important for nurses to elevate the image of nursing and the standard of the profession to substantially gaining the much needed simultaneously establishing themselves as an important regulator of the health care system. These goals is earned through the self-regulation of socially sanctioned goals, adherence to common social values, the maintenance of high ethical standards and a commitment to enhancement through education and the procurement of knowledge [4].

Interestingly, professionalism in the nursing practice is different from the nursing under taken by many in term of the clinical judgement, the knowledge as a basis of assessment and determination of action [31][35]. Professionalism in nursing practice does not lie only in the type of task performed, nor in the level of skill that is required to perform a particular task. The Registered Nurses of Alberta Ontario (RNAO) in 2007 has suggested the fundamental principles of professionalism comprise ethics and values, knowledge, advocacy, spirit of inquiry, innovation and visionary, collegiality and collaboration, accountability and autonomy[29]. These attributes hold an integration of attitudes, skills and behaviours, attributes and values, which are expected from those to whom society has extended the privilege of being considered a professional.

Apart from these attributes, the personal accountability for all decisions, and actions and the concrete association between nurse and patient according to the code of ethics within a statutory framework are the essentialities that create the authentication of the nursing profession [31]. It is possible that


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the nurses who are able to bring the attributes of professionalism into their practice will significantly contributepositive health outcomes and patient satisfaction [29]. Whereas, professionalism is a complex and an origin context which it is relatively easy to define yet it is not simple, and it is not easy to recognise in absolute terms whether behaviour is professional or unprofessional [21].

II. NURSING IN MALAYSIA AT GLANCE

Nursing profession in Malaysia also experience a gradual progression toward professionalism [33] despite the rapid development of nursing education in recent years [24]. Since the British colonisation of Malaya in the early 19th centuries to the evidence based nursing practice, nursing profession in Malaysia has gradually progress to the same level with other nursing profession in other developed countries [33]. The dynamic and contemporaneous of the nursing trend around the globe has brought significant impact on health sector as it resonance the overall care that has epitomised the patient outcomes and ensuring the health care system is running at its best condition [14]. In order to achieve this goal, the nursing profession must be restructured in terms of its policies and standard operating procedures and working culture. This subsequently saw a crucial need for professionalism in every aspect for the nursing profession [16].

No doubt, journey for nursing profession in Malaysia is still far from achieving its desired goals, however, there are efforts and positive evidence that this profession in Malaysia is slowly moving forward [8]. One of these positive indicators is presently accepted and in demand globally as substantial numbers of them are working abroad and increasing yearly. Approximately 10% to 20% of Malaysia's 84,000 nurses are estimated to be working overseas [30]. Majority of those working abroad were in Saudi Arabia while others went to countries like Australia and New Zealand. He further stated that Saudi Arabia chooses Malaysian nurses because of our high quality of education and being a Muslim country. Other Muslim countries look up to Malaysia as a role model and nursing was no longer a job for school-leavers but a fully-fledged profession with degree and postgraduate qualifications available. With the evidences above, nursing in Malaysia could be argued being an acceptable professional despite of these evidences can be vividly justifiable.

Evidently, there is no study that attempt to explore professionalism among nurses in Malaysia until now. Acomparative study conducted by Ahmad and Oranye in 2010,which focuses on the empowerment, job satisfaction, and organisation commitment by comparing nurses in Malaysia and England can be considered as a recent study that discuss on professionalism among nurses in Malaysia [2]. This is because empowerment and organisation commitment is one of many components of professionalism in nursing [22][34][36].Their research findings showed that nurses in one of hospital in Malaysia higher level of empowerment as to compare with the one in England. This was perhaps due to the nurses in Malaysia were likely to have better structural empowerment and organisational commitment. Having

mentioned other scholarly works on the matter in Malaysia, it is fair to say that professionalism in nursing is a huge challenge for scholars to grapple with and undoubted under research.

Eventually, nursing in Malaysia has moved forward in its recognition as a profession and currently is the biggest workforce in the Malaysian health care system [7].Statistically, 50,063 nurses work in the government hospitals and 24,725 work in the private hospitals [20]. The Malaysian Ministry of Health has made an effort to elevate the nursing profession to professional status. In order to achieve this status, the Nursing Division, Ministry of Health in Malaysia in 2009 introduced the framework of nursing professionalism in Malaysia [1]. The framework comprises five components, which are meeting client’s needs now and in the future, being supported by good governance and subject to fair fiscal treatment, making good contributions to patient safety, reducing negative impacts on people and the environment and building skills and competency of nurses. There are four main strategies have been form to succeed the nursing professionalism, which are entry qualification, mentor –mentee programme, ligature of Continuous Programme Development and Annual Practice Certificate and strengthen specialization within the profession itself.

The academic qualification for nurses to enter the profession of nursing in Malaysia was restructured in the early 2000 [17]. Nurses are trained in colleges or universities by undertaking a 3-year diploma level qualification or a 4-year degree. For the diploma, entry level is commonly the Sijil Pelajaran Malaysia (SPM- equivalent to UK GCSE) and entry to the degree, the Sijil Tinggi Pelajaran Malaysia (STPM- equivalent to UK A-Levels) [17]. Part time nursing degree courses also available for working nurses. As nurses have become more aware of the importance of this qualification the demand for a BSc qualification for Malaysian Nurses has increased tremendously [10]. The nurses are fully aware the important of upgrading their knowledge in order to achieve professional status for their profession. Through undertaking a degree course these nurses acquired knowledge as expected, yet were also exposed to new information and insights they had not anticipated [9]. The outcome was the discovery of a new conception of knowledge that saw them gain a fresh perspective on learning and a sense of achievement beyond what had been anticipated which will empower them to practice innovatively, creatively and autonomously [10][8].

Mentor Mentee programme is known as “buddy system” has started in 2007[11]. The purpose of this programme is to help new graduate nurses to become competent and to get familiarise with the clinical setting. All new graduated nurses will be attached to the senior nurses on their first year of working regardless which clinical setting that they attached to. The senior nurses who act as a mentor are expected to facilitate clinical learning for new graduate nurses and help them on the transition of being neophyte to becoming nurse. The current trend about mentoring nurses in Malaysia is that a


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mentor role and outline what is the preparation to be an effective mentor.

In spite of steady development of nursing education, instilling professionalism is essential to promote this transition as all aspects of nursing particularly within the Malaysia context eventually will be uplifted on par with the public expectation [33]. This is because the nurses are the central and the front facet for any health care system. With regards on nurses in Malaysia, they are perceived as the ‘frontline’ of Malaysia Health System [1]. Hence, the nurses should portray the element of caring, professionalism and teamwork at all times which in the line with corporate culture concept of the ministry of health.

In contrast, Webber in 2010 mentions that nursing profession is perceived as a continuous abstruse profession [15]. Heexplains further that nurse are not generally referred when it comes to contribute ideas, opinions and views on the interventions to cater the client’s needs or any form of modalities to health system problems. This scenario does not synchronously with the fact of nurses are the “around the clock” well-educated care providers and they are constitutes the largest group of profession in any form of the health care systems. Nurses also viewed as a compliment ‘package’ in the health care workforce by which they are “quick” trained caregivers to fulfill the health provider shortage. As a result, this phenomenon may threaten health outcomes at all level. A good example to predicate this state of affairs is the mushroom phenomena of private nursing colleges in Malaysia. At the moment, there are 106 institutions, 66 are private providers, 11 are public institutions and the rest are run by the Health Ministry [24]. On top of this phenomenon, nurses who graduated from the private colleges still require training at teaching hospitals before they are fully equipped to work. Consequently, the Malaysian government had initiated amoratorium of new nursing schools of colleges to prevent an oversupply graduates, doubtful quality of graduates augmentation issues and higher rate of unemployment among the graduates. Notwithstanding, the Malaysian governmentencouraged all the existence nursing institutions to enhance the quality of their education as well as to focus more to tertiary degree programmes [24].

III. REGULATING AND PROMOTING PROFESSIONALISM

The public perception of nursing standards in Malaysia have declined over the years and that present-day nurses are less skilled, less caring and less efficient compared with those of yesteryears in other words, lack professionalism in the job description[19]. Despite criticism and negative perception, there were efforts to elevate the level of professionalism in nursing particularly in Malaysia. For example, the division of nursing of Malaysia in 2007 had conducted a nationwide nursing audit, which basically focuses on the nursing skills

instead of focusing on professionalism perspectives in nursing [27].

Continuous Programme Development (CPD) also introduced by the Nursing Division, Ministry of Health, Malaysia and it is mandatory for nurses in Malaysia to participate as well as to contribute into the programmes. In 2008, the Malaysian Nurses Board endorsed that nurses are required to participate in a minimum number of hours of education which is one of the inevitable regulations for them to renew their annual practice certificate [33]. Mandating compliance reinforces the message that health care is dynamic and the nurses must update their knowledge and skills to keep pace with change [28]. As a result, majority of nurses managed to attend their CPD session with total credit points of more than 25 was 41% followed with 1 to 24 credit points of 29% [23]. The minimum accumulation of CPD credit points for them to relicensure is 20 points.

The Malaysian Ministry of Health has upgraded majority of post basic courses in Nursing to Advanced Diploma in 2012[20]. All registered nurses are encouraged in Malaysia to complete at least one of many selection of post basic or advanced diploma courses, which offered by the Ministry of Health. In addition, the Malaysian Ministry of Health other private colleges have introduced more new post basic courses every year to be par with the current and contemporaneous health trends. The purpose of the course is to improve nurses’ competencies by providing them with advanced skills and knowledge and attitude of care in specialty care areas.

Apart from improving the qualification for the nursing profession, professionalism in nursing is equally an important component of competency that enables nurses to work safely and efficiently. Hence, the nursing division of Malaysia introduced a code of professional practice in 1998 [26]. It focusses the importance of the profession by protecting the interest of society by ensuring that nurses practice safe nursing. The code guides the nurses to carry out their responsibilities in protecting, promoting and restoring of health, preventing of illness and alleviating of suffering while giving care to individuals, families and communities. Six important areas are highlighted in the codes which are professional nursing practice, neglect or disregard of professional responsibilities, abuse of professional privileges and skills, conduct derogatory to the reputation of the profession, advertising, canvassing and related professional offences and disciplinary proceedings.

IV. FUTURE OF PROFESSIONALISM AMONG NURSES IN MALAYSIA

No doubt, professionalism among nurses in Malaysia can be viewed as a questionable dispute and under researched. It remains as an ostensible issue yet no one known where does it stand. Anecdotally, nurses in Malaysia strongly refuse if there are any individuals perceives them as the “right hand” maiden to doctors or “traditionally, the doctor-nurse relationship in Malaysia is similar to a master and servant.” They also will


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rather to admit that they are professional. However, there might be possibility of speaking of it rather than doing it.Despite of these speculation and perception about the local health fraternity, the nurses in Malaysia do not have adequate evidence to prove that they are at the par in achieving the status of a profession through professionalism.

Efforts should not only focus on verifying the existence of professionalism, but substantially promoting and preserving professionalism from the level of individually to the level of the organisation. The Ministry of Health Malaysia are aware on the importance of professionalism by inducting series of mandatory rules for nurses to attend CPD session for relicensure, Mentor and Mentee programme as well funding and allowing nurses to further their tertiary education. Also, the ministry has allocated more graduate entry post for nurses in the health care system.

However, to sustain or the improve professionalism should not be lied fully to the stakeholders or the administrators. The nurses themselves should be aware the important of professionalism accents and should not only illuminated from the appearances, behaviours, attitude and the way the work but also need to consume it into the aura and persona as well as formulate their identity being health care provider in and out of their workplace [6].

The awareness of establishing professionalism is a lifelong continuum process [32]. Therefore, the nursing education sectors such as the universities and the nursing training colleges should always concern the elements of professionalism in their syllabus from day one. The student nurses should be exposed and comprehended with professionalism in nursing. The nursing educators should guide the student nurses carefully and appropriately when it comes to articulate it into their daily practice. This will ensure that it can be assimilated and gesticulated into a very positive habitual and rituals among nurses and surely to be illuminating into their practice and hence positive patient outcomes and good philanthropic nursing care are seen.

V. CONCLUSION

Further research on professionalism particularly among nurses in Malaysia is essential. This is to ensure the exploration suffice on these matters and its findings will help to improve the nursing profession in Malaysia. Conceivably, professionalism enhances recognition and improves empowerment, job satisfaction and their organisation commitment throughout their career as the front lines of Malaysia health care system [2]. Also, professionalism is a status which should be both assessed and delegated by the public [22]. Therefore, nurses should not overlook the fact that the public decides which careers are bestowed with status of being considered professional and have to strive it to achieve it.

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Factors affecting the quality of care in cardiac outpatient departments: Patients’ perspective

1. Dr. Mahmoud Maharmeh, RN, PhD Title: Assistant ProfessorAffiliation: Faculty of Nursing, University of Jordan, Amman-Jordan. Telephone: 00962 6 5355000 ext. 23145Email: [email protected]

2. Mahmoud Al-Hussami, D.Sc., Ph.D., EpidemiologistTitle: Associate Professor Affiliation: The University of Jordan, Faculty of Nursing Email: [email protected]: 00962 6 5355000 ext.23138

3. Muhammad Darawad, Ph.D., RNTitle: Associate Professor Affiliation: The University of Jordan, Faculty of Nursing Email: [email protected]: 00962 6 5355000 ext.23162

The authors have no funding of conflicts of interest to disclose

Acknowledgements: The authors express their appreciation to all patients who participated in this study. Also thanks extended to the University of Jordan for funding this research.


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Factors affecting the quality of care in cardiac outpatient departments:

Patients’ perspective.

Abstract

Purpose: The study aim at exploring cardiac patients’ perception of the factors

affecting the quality of cardiac services delivered in Out Patient Department (OPD) in

Jordanian hospitals.

Methods: Semi-structured face to face interviews were conducted with 17 cardiac

patients during their clinical appointment in two cardiac care centers in Amman,

Jordan. A framework approach was used to analyze the qualitative data.

Results: Participants identified several factors which could affect the quality of

cardiac services provided in OPD: lacks of time for physicians to spend with their

patients, inhibited physician-patient relationship which in turn limits the time

available for physician care delivered to each patient; patients information was not

adequately provided; organizational factors such as long waiting time and the

intervals between the patient’s visits.

Conclusion: Several factors were identified by cardiac patients that may influence the

quality of cardiac services provided by OPD. Healthcare professionals and decision

maker should consider patients’ views to improve the quality of cardiac care in OPD.


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Introduction

Although outcomes for patients living with heart disease are improving,

Jordan, like most countries around the world, is experiencing a major increase in the

prevalence of acute coronary syndrome. This in turn has both high human and

economic costs. Cardiovascular diseases continue to be a top health issue for

Jordanians, and are considered as one of the primary causes of death accounting for

35.92% and 15% of total deaths in Jordan in the year 2009 (Jordanian Ministry of

Health 2009). Although, healthcare system at different levels in Jordan is focused

more than ever on improving the quality of cardiac patient care, the quality and

opportunity for improvement in the cardiac out patient department (OPD) are largely

unknown. Therefore, measuring and improving care in OPD has become increasingly

important (Chan, Oetgen, & Spertus 2010).

The OPD is a basic organizational unit of the hospital, which aim to carry out

health promotion and preventive activities, and to serve as the ‘front door’ of the

hospital system for referring and admitting patients with more complex needs for

appropriate intervention. Evaluating the quality of the services provided by OPDs is

important as the performance at this level affects the whole health system. This

evaluation is part of assessing the quality of health services as a strategy that includes

meeting the basic standards (eg., performance, infrastructure, service delivery, and

operational process) and consumer consultation where they are heard, listened to and

involved in actual decision making (Hoodless, Bourke, & Evans 2008). Therefore, to

build image and maintain competitive advantage, the successful organizations

recognize the significance of delivering quality services continuously (Chahal &

Kumari, 2012).


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The present study is part of those efforts aim at improving the quality and

performance services in healthcare sector through comprehensively analyzing the

factors that affect the quality of cardiac care in OPD in Jordan. Moreover, it will

provide healthcare providers about the development of health care quality and

performance and the factors that affect this quality. To improve the quality of care,

information is needed regarding the factors that affecting care and the obstacles faced

in improving care. Therefore, the overall aim of this study is to gain a rich and

detailed understanding of the factors affecting the quality of cardiac care in OPD.

Consequently, this will help healthcare administrators in improving quality services in

the healthcare sector.

Review of literature

One of the most important topics in the health service is quality of health care.

Chahal and Kumari (2012) argued that improving and even maintaining the quality of

care is a critical dilemma that healthcare administrators face. The key components of

health service quality are “effectiveness, efficiency, accessibility, scientific and

technical development and the match between the availability of services and needs of

the population” (Marin, Silberman, & Sanguinetti, 2009, P. 284). Also, Wakerman et

al. (2008) suggested that the essential service requirement to enhance quality of care is

generally measured from a provider perspective in terms of principles, such as good

governance, management and leadership, funding and infrastructure, and a sustainable

workforce. Factors, such as “better quality, less waiting time, service guarantees, good

physical environment, and better interaction are contributing factors to positive patient

perceptions” (Chahal & Kumari, 2012, P. 189), which in turn result in patient

satisfaction, patient loyalty, and hospital profitability.


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In order to maintain and increase patients satisfaction, it is important to

measure and evaluates the quality of the health care provided to them (Johansson,

Oleni, & Fridlund, 2002). A study by Connell et al (2010) reported the perceptions of

both clients and their carers about receiving palliative care services, and the impact of

the services on their quality of life. Both clients and carers identified that long waiting

time is a major theme affecting their ability to receive treatment, which was

frustrating and seen as a waste of valuable time. Interestingly, clients and carers

expressed the need for information that is essential to enhance their understanding

about the care received and symptoms management. Clients wanted information to be

presented in a way that was easy to understand, and the consistency was crucial to

both clients and carers.

According to Rashmi and Vijaykumar (2010) hospitals are considered as a

buyers’ market, where the patient is all important. In order to achieve patient

satisfaction, the hospitals have to develop their technology and become more service

oriented. They also stated that patients are in support of quality of care. Also, it is

clear that being able to understand factors affecting the quality of cardiac patents care

will provide information to support improvements in the quality of care delivered to

cardiac patient in OPD. Therefore, information is needed regarding variables that

influence care and the obstacles faced in improving care.

Factors which influence the quality of nursing care in rural district hospitals in

South Africa were studied by Eygelaar and Stellenberg (2012). Although the study

focused on the quality of nursing care, the findings of the study revealed that the

availability of doctors played an important role in providing the patients with the

safety and prevent putting them at risk. The study found that 76% of the participants


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indicated that inadequate availability of doctors create an ethical and legal dilemma

and placed the patient’s safety at risk. This is supported by Albert et al (2005) who

found older patients to report receiving poor quality of care. However, the study relied

on recording the care to measure the quality of care provided rather than the care

delivered. Irurita (1999) further found that poor doctor-nurse-patient communication

had a deleterious effect on the patient’s care provided.

A qualitative study by Al-Azri et al (2011) involved the interview of 11

diabetic patients in the primary care setting aimed to explore the factors affecting the

quality of care. The findings of this study identified several factors that could affect

the quality of care. For instance, patients emphasized that continuity of care is

associated with better outcomes and improved the quality of care among patients.

Patients also emphasized that long appointment waiting time limits the opportunity for

the early detection, evaluation and management of a new patient’s problem.

Moreover, the patients highlighted the importance of patient education about lifestyle

changes as a good factor of controlling the patient’s problem. The findings in this

study are consistent with those of Johansson, Oleni, and Fridlund, (2002), in that the

patients who had received clear and straightforward information increased their

understanding about care provided and therefore become more satisfied. Similarly,

Irurita (1999) pointed that the level of quality of care was found to depend on the

information given to the patients which facilitate their understanding of the hospital

routine and prepared them to deal with some of the aspects of being a patient.

Therefore, reducing their uncertainty and consequently reduce their stress.

Marin et al (2009) surveyed 20% of primary care health centers (PCHCs) in

Argentina to investigate the structure, process, and results of care. The authors found


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that PCHCs provided only basic services to people who seek attention. Due to the low

of health-seeking behavior, only 13% of the populations who needed care accessed

services. The survey further found that heath team members showed a lack of clear

objectives around what was expected of them and the role of PCHCs in the healthcare

system. This affected their ability to respond to population demands due to the lack of

resources and fear of changing a model that has been used for both patients and health

team members. This is supported by Johansson and Fridlund (2002) who stated that

physical environment has an impact on the patient’s physical and mental health, and

hence affect their satisfaction. Irurita (1999) also noted that the quality of care was

affected by the services provided by the hospital. The author further found that

patients received high quality care in private and smaller hospitals than in large and

public hospitals.

To improve quality of care in cardiac OPD in Jordan, information is needed

about the factors that influence care and the obstacles faced in improving care. To our

knowledge, no such study has been undertaken in cardiac OPD in Jordan. This study

therefore aims to develop a baseline to measure the factors affecting the quality of

cardiac care aimed at improving cardiac OPD care. The purpose of the study was to

evaluate the quality of care provided by OPD in Jordan and to explore factors

affecting the quality of care provided.

Methodology

Design

A qualitative research approach was used to collect data from patients. A

qualitative methodology is proposed as the most appropriate to use in seeking to


93

understand the phenomenon of this study as it focuses on the human experience in

naturalistic settings (LoBiondo-Wood & Haber, 2002).

Sample

The participants were selected using convenience sampling method. The

sample of this study was patients who attended an appointment in the cardiac OPD.

Prospective participants were verbally invited followed by outlining the proposed

study and they were encouraged to ask questions and seek clarification if required.

During the meeting, patients were invited to participate in the study and asked to sign

a consent form if they wish to participate. The selection of the participants was guided

by a set of inclusion criteria including: (1) older than 18 years, (2) being a cardiac

patient; (3) a current OPD patient for at least one year, (4) willing to participate, and

(5) have no cognitive impairment. The selection of participants who had at least one

year of experience with OPD was because they are able to reflect and share their

experience with others. Based on the literature (Al-Azri et al, 2011, Irurita, 1999), the

number of potential participants in the three coronary OPD was (15-20), however this

was depend on data saturation.

Setting

The proposed study was conducted in the cardiac OPD in Jordan. Jordan has

four types of health services; these are: governmental, military, private and university

training hospitals. Only three cardiac centers (one military, one university, and one

governmental) were included in this study.

Data collection

The data collection process involved interviewing participants during their

appointment attendance. Interviews were performed by the primary researcher in


94

Arabic language, and recorded using an audio tape recorder. However, at the end of

the study the entire interview tapes will be destroyed and transcripts will be shredded.

The interviewer started the interviews by asking patients to complete a

demographic data and initiated a short conversation on a general topic. Then, open-

ended questions were asked to prompt the patients to tell their narrative. The starting

question used was: “Could you please explain your experiences of the different

aspects of cardiac care services provided in the cardiac clinic in your hospital”. The

interviews were conducted in the charge nurse’s office after obtaining their

permission. Each interview lasted between 20-30 minutes. The interview focused on

the following aspects of services. These were agreed upon by the investigators after a

thorough review of relative literature (Al-Azri et al, 2011):

1. the effectiveness of appointment system,

2. suitability of waiting area,

3. waiting time before consulting the doctor,

4. the role of nurses, doctors and nutritionists,

5. the efficiency of laboratory test and pharmacy procedures, and

6. the availability of cardiac health education

The researchers also asked for clarifications and prompted the patients

frequently during the interview, until they had no more to tell.

Data analysis

Polit and Beck (2004) stated that the data analysis process in qualitative research

aims to describe shared practice and common meanings. Each tape recorded

conversation was transcribed verbatim by the main researcher. Data obtained from the

transcribed interviews were analyzed by the researcher using thematic analysis.


95

According to Braun and Clarke (2006), thematic analysis referred to “a method for

identifying, analyzing and reporting patterns (themes) within data” (p.79).

Ethical approval

Approval of the study was obtained from the Scientific and Ethical Research Committee

at the Faculty of Nursing, the University of Jordan. Following their approval, permission was

gained at the selected hospitals before data collection begins. All prospective participants were

invited verbally to discuss their concerns and all questions were answered concerning the use of

data, confidentiality, and timing of interview. All participants were invited to voluntarily

participate and were informed that they could withdraw at any stage without a need to provide a

reason and any effect on their care. Confidentiality was maintained throughout the study. All

patients were provided with an information sheet outlining the study and asked to sign a consent

form. Only the primary researcher will be conducting and transcribing the interviews. All study

transcripts and demographic data were identified by code numbers. All of these documents will

be saved in the researcher’s password-protected computer, and hard copies will be stored in a

locked drawer with access restricted to the primary researcher. At the end of transcription review,

the interview tapes will be destroyed and transcripts will be shredded.

The findings

Seventeen cardiac patients, 12 males and 5 females, were interviewed during their

appointments. Their age ranged from 33 to 80 years with an average of 56 years. Eight patients

were educated up to secondary level and the remaining had graduate and post-graduate education.

Three main themes emerged from the data analysis regarding the factors affecting the quality care

from the patients’ perspective. These include: (1) physician–patient relationship and sufficient

time, (2) patient information, and (3) organizational factors.

Physician–patient relationship and sufficient time


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One of the most important findings to emerge from the study is related to the fact that the

quality of patient’s cardiac care could be affected by lack of time for physicians to spend with

patients. The inhibited physician-patient relationship limits the time available for physician care

delivered to each patient. The main reason for this lack of time was due to inadequate staffing.

This may negatively impact the quality of cardiac patients care.

An effective physician–patient relationship was considered to be central to quality of patient’s

care.

…They (physicians) did not give us enough time when we were in his office (patient 6).

Another patient commented that

…The physicians always asks us, however he does not want to be asked (patient 2)

Justifications were given for the physicians not talking to patients and for patients not

engaging the physicians in conversation (and so facilitating the development of a good

physician–patient relationship). The most common reasons put forth by the patient as inhibiting

the quality of care was hospitals being short in staff. This perceived lack of time had negatively

impacted on physician care generally.

…you just had to wait. …I saw 100 patients in the clinic and there were just 5 or 6 physician (patient 2).

They also expressed their concern regarding the long waiting time to see the physician.

…I came to the clinic at 8 am as I was told but, I waited for four hours until they called me in (patient 2).


97

The patients suggested that if there were more physicians employed there would be more time to

develop effective physician–patient relationships:

…You know, they have to add more physicians to the office (patient 9)

It was important that the physicians had enough time to sit down and talk to patients, especially

when they (patients) were worried or afraid. Nevertheless, it was perceived that the lack of time

prevents physicians from doing so.

Patient information

The possession of information, knowing what to expect and understanding the disease

process and related procedures, was found to facilitate the retention of control by patients, thus

reducing their vulnerability to emotional hurt. Being prepared enabled the participants to deal

with some of the aspects of being a patient; it reduced uncertainty and hence the stress

engendered by ‘not knowing’.

…There was no health education provided (patient 10) …No advices were given to me (patient 14)

Other patient stated

… As an old patient, I feel tired and bored (patient 13).

Whereas there was overwhelming consensus among the participants regarding the importance of

being well informed about their condition, there was a general agreement that they had been

inadequately informed. These aspects were reflected throughout these data. The importance of

adequate disease information was emphasized in the following way:

One participant elaborated on his clinic experience:


98

…No enough information was given. There were a lot of things they could tell you beforehand. I had no idea what some of my medications given to....., I think the most important thing is knowledge about your medications which they missed (patient 13)

The same participant further stated:

…Sometimes, the doctor gave me a pills for depression, when I asked the doctor about it, he told me this is what being written here (patient 13)

Examples of lack of information included:

…I was told nothing at all . . . I was told to loose weight, but was not told how to do that (patient 2).

…They (physicians) never gave any information unless someone asked for (patient 7)

Some of the participants suggested that the hospital can benefit from the television provided in

the waiting area to present information that may help the patients understand their diseases and

related procedures. One participant said:

…They (hospital) could use the TV in the waiting area to provide information about nutrition, smoking cessation, and also some lessons about exercise that may help cardiac patients (patient 14)

Another participant suggested

…They can provide information through leaflets that include information about cardiac patients (patient 11)

Information provided to the patients was considered crucial to understand their disease process

and related procedures and that the physicians should provide it in a clear and understandable

way.

Organizational factors

The study participants expressed their discomfort regarding the intervals between visits to

the cardiac clinic. They felt that their regular visit should be every month or maximum every two

months. Some of the participants stated that:


99

…The next available visit is available only after one year (patient 3),…The next appointment will be in the next 6 months or more (patient 6)

Other participants commented that the waiting area is very small compared to the number of

patients.

…The waiting area is very small and there is no enough seats for all patients (patient 6).

The same patient verbalized that some patients came to the clinic without an appointment and had

seen by the physician that lead to increasing in the waiting time to see the physician. Therefore,

some patients suggested that hospital administrators should add up more help to the consultant to

enhance the quality of medical care and speed up the service. Other participants were unhappy of

delaying their laboratory test results. Indeed, some others were sent to other healthcare

institutions.

…In reference to the lab, do not even ask. It is hectic, takes for ever, hours and hours of waiting and sometimes specimens were sent to different centers.

Whereas there was a consensus among the participants regarding the long waiting time on line in

front of the pharmacy to have their medications, some of them (old patients) highlighted the

importance of being well informed about his medications. The importance of adequate

information was emphasized by one of the patients who stated that

…They (pharmacists) just handle us the pills bags without any instructions. However, I am an illiterate, so difficult for me to figure them out (patient 13).

Discussion

The present study examined the factors affecting the quality of cardiac care in the OPD in

Jordan. The interpretations authors made of the collected data based on the transcribed


100

interviews. It was evident that several factors affected the quality of care for patients attending

their appointments in the cardiac OPD.

The findings of this study indicated that the physicians dealt with the patients in a short time

manner and they attempted to control their disease with the treatment option written to the

patient’s file previously. This raised the question that physicians’ treatment was considered to

focus on the physiological aspect rather than the whole patient’s situation. Therefore, physicians

need to value the importance of providing both physiological and psychological treatment when

dealing with patient’s cardiac problems. To care for a patient suffering from cardiac problems is a

serious challenge for physicians. Such a care requires the physicians in the OPD to assess and

interpret accurately all evidence available to confirm the patient’s health situation. This will only

occur with providing enough time for the patients. Patients in this study stressed that providing

enough time by health team members, taking their history and assessing their health problem,

making a diagnosis and provide treatment are essential parts of caring process in the cardiac

OPD. This could prevent or decrease the level of adverse effects such as anxiety and fear. The

findings of this study were consistent with that of Eygelaar and Stellenberg (2012) study, who

found the unavailability of doctors as a crucial to provide safe patient care and prevent

complications. Furthermore, Irurita (1999) stated that being short of staff was found to inhibit

the quality of care.

The physical environment of the cardiac OPD plays an important environmental factor that

was given as inhibiting quality of care. Appropriate clinical care can help assess and manage

cardiac patients without any delay. Thus, the concern about the quality of care encompasses both

clinical care services and the aspect of physical environment. Previous study by Johansson and

Fridlund (2002) suggested that patient’s satisfaction was affected by physical environment in the

hospital. This finding is consistent with the work of Irurita (1999) who stated that the quality of


101

care was affected by the services provided by the hospital, and that public hospital provided a

poor quality of care.

Participants’ emphasized that the quality of their cardiac care could be affected by long

waiting times either to see the physicians or for getting their next appointment at the cardiac

clinic. Long appointment waiting times limit the opportunity for the early detection, evaluation

and management of new cardiac problems, which may lead to poor quality of life. It would

appear that patients were aware of the performance of the physicians and that they wanted to be

reviewed to receive the appropriate treatment in a timely manner. The availability of more

physicians to manage patients with cardiac problems on a regular basis was found to improve the

process of cardiac care. The findings of this study are similar to that reported by Connell et al

(2010) who found that patients were unsatisfied with long waiting times during their appointment

and considered it as a waste of their time. This study also found that the probability of a factor

affecting the quality of cardiac care was significantly associated with the clinic services rather

than its direct measures of clinical care. The impact of these services was such that a decrease

numbers of a comfortable chairs and small waiting area were associated with low patients

satisfaction with the care provided.

Participants also highlighted the importance of utilizing the waiting room for education about

cardiac and lifestyle modifications. Using television on the waiting room for educational

purposes has been shown to be effective for patient education. Patient education has been found

to be an important factor in patient adherence to therapy (Al-Azri et al., 2011, Connell et al 2010,

Johansson & Fridlund 2002). Providing leaflet for cardiac patients has also been shown to be

effective in improving patients’ knowledge about cardiac disease. Hospitals should provide

patients with the best information available and supporting them in order to develop the capacity

to understand broader heath and wellbeing issues. Previous studies by Connell et al (2010),


102

Rashmi and Vijaykumar (2010), Johansson and Fridlund (2002), and Irurita (1999) considered

information as an important aspect of both quality of care and patient’s satisfaction. They stated

that information was crucial to assist patients understand their disease process and related

procedures. They emphasized that health care providers have to provide health information in a

clear and understanding manner. Therefore reduce patient’s vulnerability to emotional stressors.

Conclusion

The current study aimed to explore cardiac patients’ perceptions regarding the quality

of healthcare services in OPD in Jordan. The findings of this study demonstrated a number

of factors that appear to be affecting the quality of care of patients with cardiac diseases.

Several recommendations emerged from this study relevant for practice and policy of OPD

in order to improve the quality of cardiac care. An effective physician-patient relationship

was considered to be central to the quality of care. Waiting area could be used to educate

patients about their disease process and related procedures. Therefore, providing patients

with health materials by leaflets or T.V might help increasing patients’ awareness and

improve outcomes.

Acknowledgement

The authors like to thank hospital administrators and directors of nursing at the University

of Jordan and Royal Medical Services. The great thanks go to the patients who participated

in this study. Also, the authors are grateful to the Deanship of Academic Research- the

University of Jordan for funding this project.


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106

The Nursing Homes Structure and the

Prevalence of Falling Down Among Old

Adults in Three of Nursing Homes in

Palestine

Rasmieh N.S. Anabtawi* *Lecturer, Nursing Department/Faculty of Allied Medical Sciences Arab American University/Jenin/Palestine [email protected] A.S. Qaddumi* *Assistant Professor, Nursing Department/ Faculty of medicine and health sciences An-Najah National University/ P.O. Box 7/ Nablus/ Palestine [email protected]

Abstract

Background: Fall is a sudden, unintentional change in position causing an individual to land at a lower level.

Aim: This study will find out the relationship between the nursing home structure and prevalence of falling

down in nursing homes.

Method: Face to face Questionnaire for collecting information has been conducted after survey some previous

studies dealing with the same subject.

Result: The highest percentage of falling down among the studied sample of old adults was related to

polypharmacology by proportion of 79.4%.

Conclusion: This study concludes that there is a high prevalence of injuries post falling down in the Palestinian

nursing homes. The most frequent falling down was related to polypharmacology by proportion of 79.4%.

Keywords: older adult, nursing home, physical disabilities, polypharmacology, head injury, bruises, soft tissue

injury, Dementia, osteoporosis.


107

I. INTRODUCTION AND BACKGROUND

Fall was defined as a staff-reported incident of a person, who had slipped or stumbled and fallen,

collapsed or had fallen off, for example, a bed, chair or wheelchair, or was found on the floor (13).

Falling down is a common problem among old adults as a result of age-related physiological changes such

as muscle weakness, visual impairment, and balance problems. The incidence of falls and fall related injury

increase with advancing age compared to children, older person are more likely to hospitalized and die as a

result of a fall (Fuller, 2000). Each year about one out of three people older than age 65 years who is living

in the community falls; this rate increases with advanced age and is higher among people who are living in

institutional settings (11). Furthermore, as the population ages, the number of fall-related injuries will likely

continue to increase unless prevention strategies can be successfully implemented (4). In addition, the

structure of the nursing homes and lack of safety measures may increase the incidence of falling down

among old adults in nursing homes.

Although now a day there is a positive vision toward having nursing homes in the country, we still have

dearth information about falling down among old adult. And, the relationship between the nursing homes

structure and physical disabilities in Palestinian nursing homes was not explored.

The risk factors responsible for a fall can be intrinsic (i.e., age-related physiologic changes, diseases, and

medications) or extrinsic (i.e., environmental hazards). It is essential to remember that a single fall may have

multiple causes, and repeated falls may each have a different etiology. Thus, it is critical to evaluate each

occurrence separately(6).

Approximately half of nursing home residents fall annually, a proportion that is two to three times that of

community residents. About 4% of falls occurring each year result in fractures, and 11% result in soft tissue

and other types of injuries. Other consequences of falling include loss of function, self-imposed functional

limitations caused by fear of falling, and discouragement of activity by care providers. Higher healthcare

costs are another potentially serious consequence of falling; annual expenditures for fall-related fractures in

the community alone are in the billions of dollars, whereas noninjurious falls can increase the costs of

nursing home care because of staff time required for assessment, observation, and reporting(5).

Falls are a common and complex geriatric syndrome that cause considerable mortality, morbidity, reduced

functioning, and premature nursing home admission(11). Falls are extremely common among older adults.

Each year about one out of three people older than age 65 years who is living in the community falls; this

rate increases with advanced age and is higher among people who are living in institutional settings (10).

From 30 to 40 percent of community-dwelling adults older than 65 years fall each year. Rates are higher

in nursing home residents and hospitalized patients. The incidence of falls rises steadily from middle age and


108

peaks in persons older than 80 years. Between 20 and 30 percent of older adults who fall suffer serious

injuries such as hip fractures and head trauma(1).

Muscle weakness and walking or gait problems are the most common causes of falls among nursing home

residents. These problems account for about 24% of the falls in nursing homes. Hazards in the nursing home

cause 16% to 27% of falls among residents. Such hazards include wet floors, poor lighting, incorrect bed

height, and improperly fitted or maintained wheelchairs Medications can increase the risk of falls and fall-

related injuries. Drugs that affect the central nervous system, such as sedatives and anti-anxiety drugs, are of

particular concern Other causes of falls include difficulty in moving from one place to another (for example,

from the bed to a chair), poor foot care poorly fitting shoes, and improper or incorrect use of walking aids(8).

Each year, at least 10 percent of older people have a serious injury caused by a fall, such as a fracture,

joint dislocation, or severe head injury. Such falls and the injuries they cause are associated with pain, loss of

confidence, and restricted activity (15).

People living in nursing homes are considered to have a high fracture risk. Several researchers in Europe

and North America have reported a much higher hip fracture incidence in institutionalized elderly persons

than in the general population (12). Most fractures among older adults are caused by falls and the most

common are fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand (2).

Risk factors are either intrinsic or extrinsic. Intrinsic means demographic and health factors such as

advanced age, chronic disease or disability. Extrinsic means the physical and socioeconomic environment,

such as an older adult taking four or more prescription medications, poor lighting or lack of bathroom safety

equipment. Because some risk factors cannot be changed, the focus of fall-prevention activities is on

modifiable risk factors (16).

The main aims of this current study are to estimate the prevalence of falling down among old adult who

are resident in the nursing homes, find out the nursing home structures that contribute falling down among

old adults, and to determine the physical abilities of the old adult that can contribute falling down in nursing

home.


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II. METHODOLOGY

A. Research Design:

Descriptive surveying design is used based on face to face interview with old adults who are resident in the

north Palestinian nursing homes.

B. Research Sample:

The study sample consist of 34 old adult who are resident in three nursing homes in Palestinian,

(Charitable Society Committee in Jenin, Red Crescent committee in Nablus, and Grandfathers Home in

Tulkarm).

C. Data Collection Process:

The questionnaire is based on factors derived from previous studies. The questionnaire allowed for

confidentiality, in an effort to encourage more honest responses. The study conducted at three nursing

homes in North Palestine (Charitable Society Committee in Jenin, Red Crescent committee in Nablus, and

Grandfathers Home in Tulkarm.).

D. Instrumentation:

After reviewing literatures about falling down among old adults in nursing homes, a questionnaire was

build up for collecting data; the questionnaire is organized into four parts:

Part one: Include independent variable (age, Gender , Educational level, year of study ,marital status ,place

of residence, years of residency at nursing home, number of children, chronic illnesses, living situation)

Part two: type of injuries that the old adult experience and how many times.

Part three: the physical disabilities that may contribute injury

Part four: the structure design of the nursing home and the availability of safety measure.

E. Statistical analysis

The collected data for this study were analyzed and tabulated using the Statistical Package for Social

Sciences (SPSS) software. The results of the research showed the prevalence of old adults who had

different types of injuries in relation to their physical disabilities, and the structure of the nursing home. In

addition to prevalence of how many times that the old adults experience injury, and examine the

relationship between chronic illnesses and type of injuries that they exposed to.

To ensure the reliability, Cronbach's coefficient alpha was estimated to test the internal consistency among

the items included in each of the formative scales. The resulting alpha values for this study are (0.853),

which are acceptable according to Nunnally and Bernstein's (1994) guidelines for exploratory research.


110

III. RESULTS

As shown in table 1 the studied sample consists of 34 old adults (50% n=17) males and (50% n=17)

females whose ages were (26.5% n=9) 65-70 years old, (41.2% n=14) 71-75 years old, and (32.4% n=11)

above 76 years old. (23.5% n=8) of the sample had been in nursing home less than one year, (35.3% n=12)

their residency was from 1-3 years, while (41.2% n=14) of them spend more than 3 years at the nursing

homes. Most of the population sample had chronic illnesses as shown in the table, who had neurological

disorders were (70.6% n=24), (64.7% n=22) had diabetes mellitus, (50% n=17) had cardiovascular

disorders, and who had musculoskeletal disorders were (41.2% n=14).

TABLE 1. DEMOGRAPHIC DETAILS OF THE SAMPLE (N=34)

%nParticipant' Characteristics

50.0 17 Male Gender 50.0 17 Female

26.5 965-70years Age41.2 14 71-75years 32.4 11 Above 75years

11.8 44.1 4

15

Tulkarm Jenin

City

44.1 15 Nablus

23.5 8< 1 year Years of Residency at Home Nursing 35.3 12 1-3 years 41.2 14 >3 years

64.7 22 DM Chronic Illness 50.0 17 Cardiovascular 70.6 24 Neurological 41.2 14 Musculoskeletal


111

Table 2 shows the distribution of type of injuries in relation to its frequency in the nursing homes,

23.5% n=8 of old adults had head trauma for one time as a result of falling down, and 14.7% n=5 had it for

two times. 41.2% n= 14 had fracture for one time, 11.8% n=4 had fracture for two times while 5.9% n=2

had it more than two times. The third type of injuries which is common between old adults were bruises

32.3% n=11 develop bruises post falling down, 35.3% n=12 for two times, and 14.7% n=5 had bruises

more than two times.

TABLE 2. THE DISTRIBUTION OF TYPE OF INJURIES VARIABLE IN RELATION TO THE FREQUENCY OF OCCURRENCE. (N=34)

>2times

n (%)

2times

n (%)

Once

n (%)

None

n (%) Type of Iinjuries

0 (0.0) 5 (14.7) 8 (23.5) 21 (61.8) Head trauma 2 (5.9) 4 (11.8) 14 (41.2) 14 (41.2) Fracture 5 (14.7) 12 (35.3) 11 (32.4) 6 (17.6) Bruises

Table 3 shows the distribution of old adults according to their physical disabilities which can

contribute falling down in nursing home; 67.6% n=23 with muscle weakness, 73.5% n=25 had gait

disability, and the same proportion had balance problems, 64.7% n=22 had postural hypotension, 52.9%

n=18 had visual impairment, 79.4% n= 27 were taking multiple medication, 23.5% n=8 had Parkinson

disease, 29.4% n=10 had dementia, and 32.4% n=11 had D/M neuropathy.

TABLE 3. THE DISTRIBUTION OF PHYSICAL DISABILITIES VARIABLE IN RELATION TO ITS OCCURRENCE. (N=34)

Physical Disabilities n (%)

23 (67.6) 25 (73.5) 25 (73.5) 22 (64.7) 18 (52.9) 27 (79.4) 8 (23.5) 10 (29.4) 11 (32.4)

Muscle weakness Gait Balance problem Postural hypotension Visual impairment Multiple medication Parkinson Dementia D/M neuropathy


112

TABLE 4. THE DISTRIBUTION OF AVAILABILITY OF SAFETY NURSING HOME MEASURES AND ITS EFFICIENCY. (N=34)

%nNurses' Home Characteristics

(67.6) 23 Adequate Lightness

(58.8) 20 Changes in flour services

Bathroom design (58.8) 20

(67.6) 23 Grab bars in bathroom

(70.6) 24 Wide doors

Height of the sink (64.7) 22

(58.8) 20 Adequate spaces between corridors

Stairs bars (38.2) 13

(52.9) 18 Availability of elevator inside the nursing home

(61.8) 21 Availability of assistance when walk

Room spaces are adequate enough

Availability of assistive devices

(79.4) 27

(67.6) 23

The distribution of safety measures availability in nurses' homes according to the residents reports

about its availability, 67.6% n=23 reported that there is adequate lightness, grab bars in bathroom are

available, and there are availability of assistive devices. 58.8% n= 20 said there were changes in flour

services and the same number reported that there is a suitable bathroom design, and said that there is

adequate spaces between corridors. 70.6% n= 24 agree that there are wide doors in nurses' home, and

55.9% n= 19 said that the floor is maintained. 38.2% n= 13 said that the stairs bars are available, while

64.7% n= 22 said that the height of the sinks are suitable for them. 61.8% n= 21said that there are

assistance when walk, 79.4% n=27 agree about the presence of adequate room spaces in nurses' home.


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The distribution of chronic illness among nurses' home residence in relation to their gender is shown in

table 5. 66.7% n=8 males had diabetic mellitus and 33.3% n=4 were females, 41.25 n=7 males had

cardiovascular problems while 58.8% n=10 were females. Who had neurological disorders were 60% n=6

and 40% n=4 were females, 60% n=12 males had musculoskeletal diseases, and 40% n=8 females.

TABLE 5 : THE DISTRIBUTION OF THE CHRONIC ILLNESSES ACCORDING TO THE GENDER VARIABLE. (N=34)

%nChronic illness according to gender variable

66.7 8Male Diabetic Mellitus 33.3 4Female

41.2 7MaleCardiovascular 58.8 10 Female

60 40

64

Male Female

Neurological

60 40

12 8

MaleFemale

Musculoskeletal

TABLE 6: THE INCIDENCE OF INJURY IN RELATION TO THE TYPE OF CHRONIC ILLNESS THAT THE NURSING HOME RESIDENT MAY HAVE.(N=34)

>2times n (%)

2times n (%)

Once n (%) Type of Injuries Chronic Illness

0 (0.0) 3 (8.8) 1 (2.9) Head trauma

0 (0.0) 3 (8.8) 7 (20.6) Fracture Diabetic Mellitus

2 (5.9) 6 (17.6) 2 (5.9) Bruises

0 (0.0) 4 (11.8) 2 (5.9) Head trauma

1 (2.9) 3 (8.8) 11 ( 32.4) Fracture Cardiovascular

3 (8.8) 7 (20.6) 5 (14.7) Bruises

0 (0.0) 2 (5.9) 2 (5.9) Head trauma

0 (0.0) 0 (0.0) 5 (14.7) Fracture Neurological

2 (5.9) 4 (11.8) 2 (5.9) Bruises

0 (0.0) 3 (8.8) 4 (11.8) Head trauma

1 (2.9) 3 (8.8) 11 (32.4) Fracture Musculoskeletal

2 (5.9) 9 (26.5) 6 (17.6) Bruises

The frequency of falling down among old adults in relation to the nurses' home residence and type of

chronic illnesses. The nurses' home residence who had diabetic mellitus 2.9% n= 1 of them developed head


114

trauma for one time, 8.8% n=3 of them had head trauma two times. 20.6% n=7 had fracture for one time

,and 8.8% n=3 of them had a fracture for two times. 5.9% n=2 developed bruises once, 17.6% n=6

developed it for two times, and 5.9% n=2 had bruises more than two times.

5.9% n=2 of old adults who had cardiovascular illness developed head trauma for one time , 11.8% n=4 of

them had a head trauma two times, 32.4% n=11 of old adults had fractures for one time , 8.8% n=3 of them

had a fracture two times, and 2.9% n=1 had fracture more than two times. 14.7% n=5 of elderly who had

cardiovascular illness developed one time bruises, 20.6% n=7 of them had bruises two times, and 8.85 n=3

had it more than two times.

Who had neurological disorders 5.9% n=2 of them developed head trauma for one time, and the same

proportion had it for two times. 14.7% n=5 had fracture for one time. 5.9% n=2 of elderly developed one

time bruises, while 11.8% n=4 of them had bruises two times, and 5.9% n=2 developed bruises more than

two times.

11.8% n=4 of old adults who had musculoskeletal disorders developed head trauma for one time, 8.8%

n=3 of them had it for two times. 32.4% n=11 of old adults had fracture for one time, 8.8% n=3 of them

had two times, and 2.9%n=1 had fracture more than two times. 17.6% n=6 of elderly who had

musculoskeletal disorder developed bruises for one time, 26.5% n=9 of them had bruises for two times,

while 5.9% n=2 had bruises more than two times.

Table 7 shows the frequency of injuries in relation to the nurses' home characteristics. 20.6% n=7 of old

adults had one time of head trauma even there were adequate light in the nursing home, 35.1% n=12 had

fracture for one time, and who developed bruises even of adequate light 38.3% n=11 for two times.

The bathroom design contributes head injury for 11.8% n=4 of nursing home residents for one time, and the

same proportion develop two times head trauma, who develop fracture are 29.4% n=10 for one time. The

residents who had bruises are 23.5% n=8 for one time.

Grab bares in bathroom availability didn't prevent head injuries, 15.7% n=5 had head trauma for one time,

and who developed fracture were 32.4% n=11 for one time, 23.5% n=8 had bruises for one time although

the availability of grab bars in bathroom, 20.6% n=7 developed bruises for two times.

17.6% n=6 of old adult had head trauma for one time even of the available of wide doors, 38.3% n=11 of

old adult had fracture for one time even of available wide doors, and 26.5% n=9 had bruises for two times.

Even of the appropriate height of the sink 32.4% n=11 had fracture for one time, 23.5% n=8 of old adult

had bruises for one time, and the same number had bruises for two times,

Although the adequate spaces between corridors, who developed fracture for one time were 29.4% n= 10

for one time, 23.5% n=8 developed bruises.

29.4% n=10 of old adult had fracture for one time even of available strain bars , and 2.9% n=1 for two

times, and 11.8% n=4 of old adult had bruises for two times.

11.8% n=4 of old adult had head trauma for two times even of the availability of assistance when walk.

38.2% of n=13 old adult had fracture for one time, 23.5% n=8 of old adult had bruises for one time even of

available assistance when walk, and the same proportion had bruises for two times.


115

Who had head trauma for one time even of room space are adequate enough were 20.6% n=7, 35.3% n=12

of old adult had fracture for one time, and 32.4% n=11 of old adult had bruises for one time.

14.7% n=5 had head trauma for one time although the availability of assistive devices,. 38.2% of old adult

had fracture for one time even of available assistive device, and 29.4% of old adult had bruises for one

time even of available assistive device.

TABLE 7: THE INCIDENCE OF INJURIES IN RELATION TO THE NURSES' HOME CHARACTERISTICS. (N=34)

>2times n (%)

2times n (%)

Once n (%) Type of Injuries Nurses' Home

Characteristics

0 (0.0) 4 (11.8) 7 (20.6) Head trauma

2 (5.9) 4 (11.8) 12 (35.1) Fracture Adequate lightness

5 (14.7) 11 (38.3) 8 (23.5) Bruises

0 (0.0) 3 (8.8) 2 (5.9) Head trauma

1 (2.9) 4 (11.8) 9 ( 26.5) Fracture Changes in flour

3 (8.8) 7 (20.6) 7 (20.6) Bruisesservices

0 (0.0) 4 (11.8) 4 (11.8) Head trauma

1 (2.9) 4 (11.8) 10 (29.4) Fracture Bathroom design

3 (8.8) 7 (20.6) 8 (23.5) Bruises

0 (0.0) 4 (11.8) 5 (15.7) Head trauma

1 (2.9) 4 (11.8) 11 (32.4) Fracture Grab bars in bathroom

3 (8.8) 7 (20.6) 9 (26.5) Bruises

0 (0.0) 4 (11.8) 6 (17.6) Head trauma

2 (5.9) 4 (11.8) 11 (38.3) Fracture Wide doors

5 (14.7) 9 (26.5) 8 (23.5) Bruises

0 (0.0) 4 (11.8) 3 (8.8) Head trauma

2 (5.9) 4 (11.8) 11 (32.4) Fracture Height of the sink

4 (11.8) 8 (23.5) 8 (23.5) Bruises0 (0.0) 4 (11.8) 3 (8.8) Head trauma 2 (5.9) 4 (11.8) 10 (29.4) Fracture Adequate spaces

4 (11.8) 7 (20.6) 8 (23.5) Bruisesbetween corridors

0 (0.0) 3 (8.8) 1 (2.9) Head trauma 0 (0.0) 1 (2.9) 10 (29.4) Fracture Stairs bars 3 (8.8) 4 (11.8) 3 (8.8) Bruises0 (0.0) 4 (11.8) 3 (8.8) Head trauma 1 (2.9) 4 (11.8) 13 (38.2) Fracture Availability of assistance

2 (5.9) 8 (23.5) 8 (23.5) Bruiseswhen walk

0 (0.0) 4 (11.8) 7 (20.6) Head trauma 2 (5.9) 4 (11.8) 12 (35.3) Fracture Room spaces are adequate 4 (11.8) 11 (32.4) 11 (32.4) Bruisesenough 0 (0.0) 4 (11.8) 5 (14.7) Head trauma 1 (2.9) 4 (11.8) 13 (38.2) Fracture Availability of assistive 2 (5.9) 9 (26.5) 10 (29.4) Bruisesdevices


116

IV. DISCUSSION

This study consists of all of old adults who are residents in three nursing homes in Palestine (N=34),

there are many factors influence the number of old adult residency in nursing homes, such as religion

norms and circumstances. Although of the sample number there is a high incidence of falling down among

old adults in nurses' home, the most type of injury between old adults who are resident in nurses' home is

fracture 41.2%. Which is consistent with previous studies, approximately 25% to 35% of people over the

age of 65 years experience one or more falls each ear. The consequences of falls among older adults are

often devastating (14). Approximately 1 in 10 falls results in a serious injury, such as hip fracture, other

fracture, subdural hematoma, other serious soft tissue injury, or head injury(15). And there are many

variables which contribute falling down and cause injury, this study shows a high percentage of injuries

between old adults as a result of having multi medications which was 79.4%.

Polypharmacy is regarded as an important risk factor for falling and several studies and meta-analyses have

shown an increased fall risk in users of diuretics, type 1 a antiarrhythmics, digoxin and psychotropic

agents(3).

The second variables which also had a high prevalence in falling down are the gait and balance problems,

this study shows that 73.5% of old adults had either gait problems or balance problems. The broad category

of gait problems and weakness is the next commonest specific precipitating cause for falls 10-25% in most

series (10).

Most of the nurses' home residents had chronic illnesses such as diabetes mellitus, cardiovascular disorders,

neurological disorders, and musculoskeletal disorders which contribute in falling down, in this study shows

that 32.4% of old adults who have cardiovascular problems developed fracture as a result of their disease,

and the same proportion had also fracture as a result of musculoskeletal disorders. The Indian Health

Services Portland Area, 2006 reported that people in nursing homes are generally more frail than older

adults living in the community. They tend to be older, have more chronic illnesses, and have difficulty

walking (8).

This study shows a high prevalence of injuries 79.4% in nurses' home despite the adequate spaces in the

rooms, which is related to gait and balance problems among old adults. Gait and balance disorders 17%

(10). Gait and balance impairments were a significant risk factor for falls, and were associated with about a

threefold increased risk for falling.

In relation to the characteristics of the nurses' home it contribute the incidence of injuries, 38.2% of old

adults had fracture although there are availability of assistance when walk, which may indicate that the

personnel who are working in nurses' home are not qualified enough in caring for old adults, and also the

same proportion 38.2% had fracture in spite of the availability of assistive devices which indicate lack of

knowledge about using them. Which is confirmed in previous study that the use of assistive devices may

reduce the risk for falling(7).


117

V. CONCLUSION AND RECOMMENDATIONS

There is a high prevalence of injuries as a result of falling down among old adults in three of the

Palestinian nurses' homes. The most frequent type of injury is fracture with a proportion of 41.2%.

The highest percentage of falling down among the studied sample of old adults was related to

polypharmacology by proportion of 79.4%, while 73.5% were as a result of balance problem and the same

percentage for gait disorder. In addition to the relationship between the nursing home safety measures and

the prevalence of injury among old adults.

Improving nursing homes safety measures can reduce the number of falling down among old adults, regular

revision of medications must be performed, and build up educational programs for the staff who are caring

for old adults in order to give an optimal care for them in which it contribute in decrease the risk of falling

down.

REFERENCES

(1) Al- Faisal, W. (2006). Falls Prevention for Older Person .

(2) Center of Disease Control and Prevention ,National Center for Injury Prevention and Control .(2012).Falls Among Older

Adult :an Overview.

(3) Choi, H.(2008).Fall Among Older Adult in California : Public Health Surveillance Issues.

(4) Deval, L. ,Patrick.(2008). Unintentional Fall-Related Injuries.

(5) Doorn , C., Ann , L , et al.(2003). Dementia as a Risk Factor for Fall and Injuries Among Nursing Residents .

(6) George, F. ,Fuller, COL.,(2000) .Falls in the Elderly.

(7) Grace, S., Fisher,et al.(2008).Home Modification Outcomes in the Residences of Older People as a Result of Cougar

Home Safety Assessment(Version 4.0) Recommendations .journal of health promotion 6(1) p87-110.

(8) Indian Health Service Portland Area.(2012).The Fact: Trips & Falls.

(9) Handoll ,H.(2010).Prevention of Fall and Fall Related Injuries in Older People in Nursing Home and Hospitals .

(10) Laurence, Z., Rubenstein, .(2006). Falls in Older People: Epidemiology, Risk Factors and Strategies for Prevention.

(11) Laurence, Z., Rubenstein, Karen R., Josephson, M. (2006). Falls and Their Prevention in Elderly.

(12) Nakamura,k.,Oyama,M.,takahashi,s.,etal.(2010).Fracture Incidence in Nursing Home in Japan.

(13) Nurmi,I.,Luthje , P. (2002). Incidence and Cost of Falls and Fall Injuries Among Elderly in Institutional Care .

(14) Shumway -cook, A.,Baldwin , M ,etal.(2012). Predicting the Probability for Fall in Community –Dwelling Older Adults

.Journal of the American Physical Therapy Association .

(15) Tinetti, M,etal.(2007).Fall,Injuries Due to Fall , and the Risk of Admission to a Nursing Home.

(16) Show Me Falls Free Missouri (2012). Falls Among Old Adults: Anational Public Health Crisis.


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Validation of Self-Reported Smoking and Environmental Tobacco Smoke through Urine

Cotinine in Prenatal Care Visits

Azita AmiriCollege of Nursing

University of Alabama in HuntsvilleHuntsville, Alabama, USA

[email protected]

Azin NowrouziNell Hodgson Woodruff School of Nursing

Department of BiochemistrySchool of Medicine

Tehran University of Medical Sciences

Charles A. DownsNell Hodgson Woodruff School of Nursing

Emory UniversityAtlanta, Georgia, USA

[email protected]

Abstract— Introduction: Cigarette smoking during pregnancy is the most significant modifiable risk factor for adverse fetal outcomes, such as low birth weight and premature birth. Efforts to obtain accurate estimate of smoking prevalence among pregnant woman have been hindered by high rates of misreporting. Cotinine is considered a gold standard measure of exposure to cigarette smoke, but its level in urine and its influence in pregnancy vary in different populations. There is no consensus regarding urine cotinine cutoff point that matches all pregnancies and distinguishes smokers from non-smokers and environmental tobacco exposure (ETS).

Purpose: To determine the rate of cigarette smoking by self-report and the level of urine cotinine in pregnant women in the second trimester.

Method: 140 pregnant women were interviewed and one time urine sample was collected during a routine prenatal visit. The samples collected in one university related and three private obstetrics and gynecology clinics in North Alabama. Urine cotinine levels were determined using Calbiotech urinary ELISA kit and standardized based on the level of creatinine.

Results: Cigarette smoking rate during pregnancy based on self-report was 15.4%. The mean creatinine-standardized cotinine level was 153.0 (ng/ml) (SD=463.7). The rate of smoking based on the Society for Research on Nicotine and Tobacco (SRNT)’s cutoff point (50 ng/ml) was 26.1%. The sensitivity and specific of self-report were 57.6% and 97.8%, respectively.

Conclusion: Relying on self-report to determine the smoking status can result in exposure misclassification. In addition, not considering detection of and intervention for ETS would not be helpful in reducing the adverse pregnancy outcomes related to tobacco smoke.

Keywords—tobacco smoke exposure, pregnancy, self-repot, cotinine

I. INTRODUCTION

Tobacco smoke and tobacco smoking are known to be associated with adverse pregnancy outcomes and increased infant mortality and morbidity [1-4]. The most common adverse outcomes include abortion, infertility, ectopic pregnancy, low birth weight (LBW), intrauterine growth restriction (IUGR), placenta previa, placental abruption, congenital abnormalities, and sudden infant death syndrome (SIDS) [3, 4]. Tobacco smoke exposure can be measured by self-report and nicotine levels, the active ingredient in tobacco, and its metabolite, cotinine. Cotinine has a longer half-life (20 hours), which allows detection for a few days after smoking [5]. Cotinine can be transferred though the placenta to the fetus and has been measured in the meconium [6] and cord blood [7]. Based on the recent Surgeon General Report [4] and other studies, self-report may underestimate the tobacco smoke exposure status [4, 8-10]. Therefore, efforts to obtain accurate estimates of smoking prevalence among pregnant woman have been hindered by misreporting.

Many studies have reported the effect of tobacco smoke during pregnancy on birth outcomes such as LBW or IUGR through self-report of tobacco smoke exposure [11-13]. Environmental tobacco smoke (ETS), also known as second hand smoking, is prevalent [14] and has been shown to be associated with adverse pregnancy outcomes such as LBW [14, 15].

Cotinine is considered a gold standard measure of exposure to cigarette smoke, but its level in urine is influenced by gestational age and varies in different populations, which


125

affect the cutoff point for active smoking and ETS. The purpose of this study was to determine the rate of cigarette smoking by self-report and the level of urine cotinine in pregnant women in the second trimester.

II. MATERIALS AND METHOD

The Institutional Review Board (IRB) approval was obtained prior to the initiation of this study. The study used a cross-sectional, correlational study design with a nonprobability, convenience sample of 140 pregnant women from one university and 3 private obstetrics and gynecology clinics located in an urban area in the southeastern United States. The inclusion criteria was pregnant women who: (1) were capable of understanding, speaking, and responding in English, (2) were between the ages 19 to 40, (3) were pregnant with one fetus (singleton), (4) were in their second trimester of pregnancy, and (5) had no history of chronic diseases or high risk pregnancies.

Potential participants were identified from the daily patient appointment schedule in each clinic. In the university clinic, the principal investigator approached eligible participants. In the private clinics, the clinic physician determined if the participant was eligible, and then informed the principal investigator. The informed consent process and data collection procedures took place in a private room after the participant completed the physician’s appointment, in order to not interfere with standard clinical practices in the clinics. The principal investigator read the questionnaires (demographic and smoking status) to the participants due to the potential variability in participants’ reading ability. A urine sample for cotinine measurement was obtained from each participant during theprenatal clinic visit, using a portion of the urine sample collected during that visit. If a urine sample was not available at the time of data collection, the principal investigator obtained a urine sample after the interview, at a convenient time arranged by the participant, or at the participant’s next prenatal visit. All urine samples were kept at a consistent temperature (-4 ºC) (in a cooler with dry ice) prior to and during transfer to the laboratory and transferred to freezer -80 ºC within 1-2 hours after collection. Urinary cotinine levels were assessed using the Calbiotech urinary ELISA kit (solid phase competitive and standardized by creatinine level) according to the manufacturer’s instructions 2-3 weeks after collection. The detection limit of the cotinine assay was 2 ng/ml [16].

The data were entered in Epi Info TM [17] and exported to SPSS version 21.0 [18]. The variables were examined for outliers. Descriptive statistics were used to determine distribution of maternal demographic and pregnancy characteristics, the rate of tobacco smoke self-report, and the level of urine cotinine in active smokers. The cutoff point for active smokers were based on Society for Research on Nicotine and Tobacco [5] (50 ng/ml).

II. RESULTS

Urine samples from two participants were insufficient for cotinine assays. There were also missing maternal demographic

and pregnancy characteristics as shown in Table 1. Pairwise deletion of observations was used to maximize use of available data for the analysis. Demographic data and pregnancy characteristics are summarized in Table 1. The mean level of creatinine-standardized cotinine in urine was 153.0 μg/g (SD = 463.7) with a range of 0-3893.0 μg/g. Fig 1 shows that only 17.9% of participants were cotinine free. No significant difference was found between demographic characteristics with urine cotinine level.

TABLE 1.

DISTRIBUTION OF DEMOGRAPHIC CHARACTERISTICS

Variable Frequency PercentMaternal Age (N = 139)

19-2021-2526-3031-3536-40

22 53 38 20

6

15.838.127.214.4

4.3

Education (N = 136)High School or less; or GEDSome College and Higher

99 37

72.827.2

Marital Status (N = 136)MarriedSingle*

61 75

44.955.1

Race/Ethnicity (N = 140)African-AmericanWhiteOther

5265 23

37.146.416.4

Employment Status (N = 134)Employed Full timeEmployed Part-timeNot-employed

412865

30.620.948.5

Yearly Family Income (N = 119)< $10,000$10,000-$20,000$20,000-$40,000> $40,000Don’t know

3331 30 2521

23.622.121.417.915.0

Gravida (N = 140)12-34-5>5

51 66 20 3

36.047.514.42.1


126

TABLE 2

VALIDITY OF SELF-REPORTED TOBACCO SMOKE EXPOSURE DURING PREGNANCY CONSIDERING COTININE AS GOLD STANDARD

Self-reported tobacco smoke exposure

Urine cotinine level indicating smoking

Urine Cotinine

< 50 ng/ml

Urine Cotinine >50

ng/ml

Total

Smoking 2 17 19

Not-smoking 91 13 104

Total* 93 30 123

*17 missing values/ Sensitivity: 56.7%; Positive predictive value: 89.5%; Specificity: 97.8;

Negative predictive value: 87.5

III. DISCUSSION

In this study, the mean level of tobacco smoke based on creatinine-standardized cotinine in urine ELISA was 152.93 μg/g (SD = 463.7 range from 0-3893.0 ng/ml). The prevalence of smoking, based on self-report, was 15.4%, which is similar to the smoking rate of 15.9% published in the report of the Pregnancy Risk Assessment Monitoring System (PRAMS) Surveillance Report for Alabama in 2010 [19]. However, in the Selected Maternal and Child Health Statistics Alabama (2011)report, the rate of smoking during pregnancy was reported to be 10.6% in Alabama. Moreover, in 2003, the prevalence of smoking during pregnancy was reported at 10.7% in the US [20]. Therefore, the rate of self-reported tobacco smoke in this study is higher than the published surveys. This could be due to enrollment of a high number of low socioeconomic populations in this study, which is a group known to have a higher prevalence of smoking [19]. In this study no relationship was found between demographic characteristics and the level of cotinine, which is inconsistent with others that reported higher level of tobacco exposure in low socioeconomic groups. This inconsistency could be due to the recruitment of a higher number of low socioeconomic participants in this study.

Considering a cut-off point of 50 ng/ml, 10.7% of participants did not disclose their tobacco smoke exposure. Aurrekoetxea, Murcia [21] reported a prevalence rate of 18.5% by self-report and 22.5% with a cotinine cut-off point of 50 ng/ml. Gilligan, Sanson-Fisher [22] indicated that 17% of women who self-reported non-smoking were smokers based on cotinine cut-off point of 250 ng/ml. Shipton, Tappin [23] self-report prevalence rate of 24% versus 30% for smokers based on a urine cotinine cut-off point of 13.7 ng/ml. In contrast, Pickett, Rathouz [24] considered a cut-off point of 200 ng/ml for active smokers and reported a prevalence rate of 28.9% and found that self-report (26.3%) can be a valid way to characterize smokers during pregnancy. In this study, the

sensitivity and specificity of self-report were 57.6% and 97.8%, respectively, in pregnant women. However Pickett, Rathouz [24] reported higher sensitivity (88.4) and specificity (99%), which could be due to the difference in selected urinecotinine cut-off point.The inclination to not disclose tobacco smoking is higher in pregnant women [25]. Therefore, self-reported smoking prevalence can underestimate the true value [4, 26, 27]. In the view of having different cut-off points in different studies, various ethnic groups [8-10], and gestational age [7], the comparison of the prevalence rate in different studies may not reflect the real variance. The other concern is that the gestational age at the time of data collection is variable acrossstudies, which makes the comparison of different studies’ result difficult. The level of cotinine metabolism varies in different trimesters showing a pattern of elevated cotinine concentration in the plasma and urine from the beginning to the end of pregnancy [7], and that is why in this study only pregnant women in second trimester were recruited.

Considering that ETS is associated with adverse pregnancy outcomes [4], detection of any cotinine in urine could be important. Based on the results of this study, 25.3% of participants had cotinine level of 5.1-50 ng/ml and 30% had a level of 0.1-5.0 ng/ml, which means that 55.3% of pregnant women were exposed to ETS. Therefore, not-considering ETS exposure as a risk factor for fetal wellbeing would result in failure by health care providers to initiate ETS prevention practices and interventions during pregnancy. There are only a few studies that determined a cutoff point for ETS, and again the comparison is complicated due to dissimilarities in cut-off points and gestational age at the time of urine collection.The limitations of this study were a small sample size, one time urine collection, and spot urine sampling. Also, we did not measure smoking history via pack years. In addition, most of the participants in this study were from low socioeconomic groups.

Conclusion: This study, consistent with several other studies, showed that reliance on tobacco exposure self-reporting to identify pregnant smokers underestimates the number of pregnant smokers in most ethnicities [8-10, 28, 29]. In addition, concealment of ETS will not assist in reducing the complications of pregnancy due to exposure to tobacco smoke. Therefore, a reliable measurement method, such as urinary cotinine, may be appropriate to be included in routine prenatal care visits.

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[5] SRNT. Biochemical verification of tobacco use and cessation. Nicotine and Tobacco Research, 2002;4:149-59.

[6] Braun JM, Daniels JL, Poole C, Olshan AF, Hornung R, Bernert JT, et al. A prospective cohort study of biomarkers of prenatal tobacco smoke exposure: The correlation between serum and meconium and their association with infant birth weight. Environmental Health, 2010;9:53.

[7] Wu FY, Chiu HT, Wu HD, Lin CJ, Lai JS, Kuo HW. Comparison of urinary and plasma cotinine levels during the three trimesters of pregnancy. Paediatric and Perinatal Epidemiology, 2008;22:296-301.

[8] Lindqvist R, Lendahls L, Tollbom O, Aberg H, Hakansson A. Smoking during pregnancy: Comparison of self-reports and cotinine levels in 496 women. Acta Obstetricia et Gynecologica Scandinavica, 2002;81:240-4.

[9] Parna K, Rahu M, Youngman LD, Rahu K, Nygard-Kibur M, Koupil I. Self-reported and serum cotinine-validated smoking in pregnant women in Estonia. Maternal and child health journal 2005;9:385-92.

[10] Post A, Gilljam H, Bremberg S, Galanti MR. Maternal smoking during pregnancy: A comparison between concurrent and retrospective self-reports. Paediatric Perinatal Epidemiology, 2008;22:155-61.

[11] Dejmek J, Solansk y I, Podrazilova K, Sram RJ. The exposure of nonsmoking and smoking mothers to environmental tobacco smoke during different gestational phases and fetal growth. Environmental Health Perspectives, 2002;110:601-6.

[12] Horta BL, Victora CG, Menezes AM, Halpern R, Barros FC. Low birthweight, preterm births and intrauterine growth retardation in relation to maternal smoking. Paediatric Perinatal Epidemiology, 1997;11:140-51.

[13] Sclowitz IK, Santos IS, Domingues MR, Matijasevich A, Barros AJ. Maternal smoking in successive pregnancies and recurrence of low birthweight: The 2004 Pelotas birth cohort study, Brazil. Cadernos de Saude Publica, 2013;29:123-30.

[14] Kharrazi M, DeLorenze GN, Kaufman FL, Eskenazi B, Bernert JT, Jr., Graham S, et al. Environmental tobacco smoke and pregnancy outcome. Epidemiology 2004;15:660-70.

[15] Windham GC, Eaton A, Hopkins B. Evidence for an association between environmental tobacco smoke exposure and birthweight: a meta-analysis and new data. Paediatric and perinatal epidemiology 1999;13:35-57.

[16] Calbiotech. Cotinine ELISA. Calibiotech; 2008.[17] Epi Info. Epi Info Tm 7. 1. 1. 14. Atlanta, GA: CDC; 2013.[18] Statistical Package for the Social Sciences. SPSS 21.0 for Windows.

Chicago, IL2013.[19] Zheng Q, Wouolbright LA, Afgan I. PRAM surveilance report Alabama

2010. Montgomery, Al: Alabama Department of Public Health; 2012.[20] Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson

ML. Births: final data for 2002. National vital statistics reports 2003;52:1-113.

[21] Aurrekoetxea JJ, Murcia M, Rebagliato M, Lopez MJ, Castilla AM, Santa-Marina L, et al. Determinants of self-reported smoking and misclassification during pregnancy, and analysis of optimal cut-off points for urinary cotinine: A cross-sectional study. BMJ open 2013;3.

[22] Gilligan C, Sanson-Fisher R, Eades S, Wenitong M, Panaretto K, D'Este C. Assessing the accuracy of self-reported smoking status and impact of passive smoke exposure among pregnant Aboriginal and Torres Strait Islander women using cotinine biochemical validation. Drug and alcohol review 2010;29:35-40.

[23] Shipton D, Tappin DM, Vadiveloo T, Crossley JA, Aitken DA, Chalmers J. Reliability of self reported smoking status by pregnant women for estimating smoking prevalence: a retrospective, cross sectional study. Bmj 2009;339:b4347.

[24] Pickett KE, Rathouz PJ, Kasza K, Wakschlag LS, Wright R. Self-reported smoking, cotinine levels, and patterns of smoking in pregnancy. Paediatric and Perinatal Epidemiology, 2005;19:368-76.

[25] Webb DA, Boyd NR, Messina D, Windsor RA. The discrepancy between self-reported smoking status and urine continine levels among women enrolled in prenatal care at four publicly funded clinical sites. Journal of Public Health Management and Practice, 2003;9:322-5.

[26] Jhun HJ, Seo HG, Lee DH, Sung MW, Kang YD, Syn HC, et al. Self-reported smoking and urinary cotinine levels among pregnant women in Korea and factors associated with smoking during pregnancy. Journal of Korean Medical Science, 2010;25:752-7.

[27] West R, Zatonski W, Przewozniak K, Jarvis MJ. Can we trust national smoking prevalence figures? Discrepancies between biochemically assessed and self-reported smoking rates in three countries. Cancer Epidemiol Biomarkers & Prevention, 2007;16:820-2.

[28] EPA. EPA to study formaldehyde. Environmental building news. Brattleboro, VT: BuildingGreen.com; 2008.

[29] Center for Disease Control. The health consequences of involuntary smoking: A report of General Surgeon. In: Coordinating Center for Health Promotion NCfCDPaHP, editor. Atlanta, Georgia: Office on Smoking and Health; 2006.


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132

Comparison between multidetector computed tomography,

histopathological findings and C-reactive protein in patients with acute appendicitis

Murat Karul1*, Cyrus Behzadi1, Maxim Avanesov1, Asmus Heumann2, Philip Stahl3, Thorsten

Derlin1, Gerhard Adam1, Jin Yamamura1

1 Department of Diagnostic and Interventional Radiology,

University Medical Center Hamburg-Eppendorf, Hamburg, Germany

2Department of General, Visceral- and Thoracic Surgery


3 Department of Pathology


*First author, responsible for correspondence:

Murat Karul

University Medical Center Hamburg-Eppendorf

Department of Diagnostic and Interventional Radiology

Martinistr. 52

20246 Hamburg

Germany

Tel.: +49-40-7410-54023

Fax.: +49-40-7410-56799

E-mail: [email protected]


133

ABSTRACT

Background and Purpose: Acute appendicitis (AA) is the most common cause of

acute intra-abdominal pain in adults requiring emergency surgery [1,2]. The clinical diagnosis

is based upon patients` history, physical examination and elevated C-reactive protein (CRP)

levels in serum analysis, and imaging including transabdominal ultrasound (US) or

multidetector computed tomography (MDCT) may aid in establishing the diagnosis of AA.

MDCT is the imaging modality of choice in adults [3] with a sensitivity of 90-100%, a

specificity of 90-99.1%, a positive predictive value (PPV) of 83-95.7%, and a negative

predictive value (NPV) of 90-100.0% [1,4]. MDCT is superior to US in the diagnosis of AA

[5] and may show various established signs of AA [6,7]: wall thickness above 2mm with ring-

like contrast enhancement, an increased cross-sectional diameter more than 6mm,

periappendiceal edema, abscess in the right lower quadrant (RLQ) or pneumoperitoneum due

to perforation, and a calcified appendicolith. Histopathological assessment serves as the

reference standard, and AA may usually classified as either phlegmonous or ulcero-

phlegmonous or gangrenous AA, or as AA with perforation and abscess formation.

The purpose of our study was to compare findings on MDCT with both histopathology and

CRP levels in patients with AA.

Methods and Materials: The study protocol has been approved by the local Clinical

Institutional Review Board and complied with the Declaration of Helsinki. All subjects had

given written informed consent for the retrospective evaluation of their data.

The study group consisted of 76 consecutive patients (42 males; 34 females; age 56 ± 17.9

years; range 23-97years) with histopathologically proven AA. All patients had been referred

for a preoperative MDCT scan of the abdomen due to clinically suspected appendicitis

between January 2011 and January 2013. Patients were categorized into one of three groups

(GR) based on histopathologic evaluation: ulcero-phlegmonous (GR1), gangrenous (GR2),

and perforation (GR3). Two blinded readers with 5 (MK) and 3 (CB) years of experience in

abdominal imaging reviewed the transaxial as well as the coronal MDCT images in consensus

and patients were assigned into one of three GR using following criteria: Patients in GR1

showed wall thickness (2-3mm) with ring-like contrast enhancement, a cross-sectional

diameter (6-10mm), and moderate periappendiceal fat attenuation, patients in GR2 showed

wall thickness (>3mm) with ring-like contrast enhancement, a cross-sectional diameter

(>10mm), and high grade of periappendiceal fat attenuation, and patients in GR3 showed an


134

abscess formation in the RLQ. CRP levels were correlated using p-values from Mann-

Whitney’s U test and receiver operating characteristic (ROC) curve analysis was performed

for the identification of the optimal cutoff-point for perforation.

Results: According to histopathological evaluation of the surgical specimens, 49/76

patients (64.5%) were assigned to GR1, 5/76 patients (6.6%) to GR2, and 22/76 patients

(28.9%) to GR3. Using MDCT, 42/49 patients (85.7%) were correctly identified as GR1.

However, 7/49 patients (14.3%) were falsely classified as GR2. 2/5 patients (40%) were

correctly identified as GR2, while the three remaining patients (60%) were falsely classified

as GR1.

An abscess in the RLQ was correctly diagnosed in 19/22 patients (86.4%) in GR3. However,

3/22 patients (13.6%) were falsely classified as GR2 on MDCT. In total, 20 calcified

appendicoliths were diagnosed: GR1 (n=13); GR2 (n=2); GR3 (n=5).

Mean CRP levels were 56mg/l ± 99.3 (range 0-359mg/l) in GR1, 117mg/l ± 64.6 (range 32-

208mg/l) in GR2, and 139.5mg/l ± 84.3 (range 59-353mg/l) in GR3. CRP levels were

significantly different between GR1 and GR3 (p<0.03). ROC curve analysis revealed an

optimal cut-off point of >72mg/l for identification of appendiceal perforation (AUC=0.725),

resulting in a sensitivity of 86.4% and a specificity of 55.1%. CRP levels were neither

significantly different between GR1 and GR2 (p=0.206) nor between GR2 and GR3

(p=0.786). Patients with ulcero-phlegmonous appendicitis (GR1) could have normal CRP

levels whereas appendiceal perforation (GR3) with a CRP level less than 59mg/l was very

unlikely in our study cohort.

Limitations: This study had limitations. First, due to its retrospective nature, a

selection bias cannot be excluded. Second, there was an unequal distribution of patients with

histopathologically proven AA in the three groups. Finally, previously described cecal wall

changes such as the arrowhead sign, the "cecal bar" sign, and focal cecal apical thickening

could not be reliably assessed without administration of bowel contrast material in our study,

and were not included as a consequence in our CT criteria for diagnosis of appendicitis [8].

Conclusion: MDCT may not only aid in establishing the diagnosis, but may correctly

predict the clinically relevant differences in histopathological grading. The differentiation

between patients in GR1 and GR3 on MDCT may influence the therapeutic management and

could lead to a different surgical procedure (open vs. laparascopic approach).


135

Literature: [1] Petroianu A. Diagnosis of AA. Int J Surg 2012;10(3):115-9.

[2] Sieren LM, Collins JN, Weireter LJ, et al. The incidence of benign and malignant neoplasia presenting as AA.

Am Surg 2010;76(8):808-11.

[3] Reich B, Zalut T, Weiner SG. An international evaluation of ultrasound vs. computed tomography in the

diagnosis of appendicitis. Int J Emerg Med 2011;29(4):68.

[4] Pooler BD, Lawrence EM, Pickhardt PJ. MDCT for suspected appendicitis in the elderly: diagnostic

performance and patient outcome. Emerg Radiol 2012;19(1):27-33.

[5] van Randen A, Lameris W, van Es HW, et al. A comparison of the accuracy of ultrasound and computed

tomography in common diagnosis causing acute abdominal pain. Eur Radiol 2011;21(7):1535-45.

[6] Kim HC, Yang DM, Kim SW, Park SJ. Reassessment of CT images to improve diagnostic accuracy in

patients with suspected AA and an equivocal preoperative CT interpretation. Eur Radiol 2012;22(6):1178-85.

[7] Lai V, Chan WC, Lau HY, Yeung TW, Wong YC, Yuen MK. Diagnostic power of various computed

tomography signs in diagnosing AA. Clin Imaging 2012;36(1):29-34.

[8] Rao PM. Cecal apical changes with appendicitis: diagnosing appendicitis when the appendix is borderline

abnormal or not seen. J Comput Assist Tomogr 1999; 23:55-9.


136

Performance Assessment of the GE X-ray Fluoroscopy System at King Saud University

M. A. Alnafea, K. Z. Shamma Department of Radiological Sciences, College of Applied

Medical Sciences King Saud University

Riyadh 11433, Saudi Arabia E-mail: [email protected]

H. I. Aldossari department of Radiological King Fahad Medical City

Riyadh, Saudi Arabia E-mail: [email protected]

Abstract—To get optimum use of newly installed equipment, specific performance tests must take place. To evaluate the image quality as low and high contrast detection, detailed contrast and limiting resolution, Leeds test objects have been used. The aim of this work is to evaluate the performance of GE (GE Precision 500D) X-ray fluoroscopy system, recently installed at the radiological sciences department, King Saud University in Riyadh. This assessment includes dose rate and the quality of images obtained from such system. Non-invasive auto meter used to evaluate the accuracy and reproducibility of the generator. Tube and generator has also been tested, and the obtained results meet the international standards. Entrance surface dose rate, values were almost the same as the expected results published in the literatures. Values obtained have not been affected by the use of different pulse rates. The image quality evaluation has showed quite different results from those recommended by technical standards but the values are within the accepted range. This could lead to the acquisition of poor quality images besides an increase in radiation exposure level for both patients and staff. To achieve high-quality performance of the X-ray GE fluoroscopy (Precision 500D), additional tests are to be introduced, with beam quality and patient dose measurement as half value layer (HVL) evaluation.

Keywords—Performance assessment, Image intensifier, Fluoroscopy System, Test Object, Radiation meter, Ionization chamber.

I. INTRODUCTION In recent years, digital fluoroscopy X-ray systems have

almost replaced the conventional systems, this is because that it can produce improved image quality and thus become preferred by the medical imaging institutions. Such developments required relevant protocols from medical physics professions in order to assess the performance of such equipments in order to achieve optimum image quality with minimum radiation dose. Although these performance tests may be demonstrated at the manual of the medical equipment factories and even on installation, the image quality of the equipment in use is often less satisfactory. Inevitably, in time the equipment becomes poorly adjusted or faulty and requires maintenance. Eventually it will become worn out, obsolete or both and require replacement. Clinical judgments on the performance of the medical equipments may be not believed, because the degradation in the performance are often gradually,

hardly noticeable and patients do not offer a standardize assess for comparing the performance over period. What is required then is a set of tests and test tools that would enable to measure the total performance compared to factory pre installed base line measurements. That can allow users of Image intensifier or flat panel detector systems to monitor the performance, so that optimum image quality with minimum dose rate is assured during the operation life of the system, and that replacement of any part may be recommended on an objective based. Despite, there are no specific tools to assess the overall contrast in fluoroscopy but different test object can be used separately. The test methods and standards applied, are mainly derived from AAPM [1].

II. OBJECTIVES This study investigates the measurements were performed

to evaluate the tube and generator, beam quality, entrance surface dose rate (ESDR) and image quality, to evaluate the GE X-ray fluoroscopy (Precision 500D) ,carried out at King Saud university (KSU) to assess the performance.

Our main aim is to provide was to ensure that high quality diagnostic images are obtained and are consistent with the clinical use of such equipment.

III. MATERIALS AND METHODS At King Saud University in Riyadh, kingdom of Saudi

Arabia, experiments were performed on the recently installed GE (Precision 500D) X-ray fluoroscopy. High voltage generator (JEDI generator 65 kW, 80 kW), Daily Voltage Variations +/– 10%. The standard frequency is 50/60Hz with daily variation +/– 6%.In the radiograph mode kVp range (40-150) and mAs range(10-1000), while in fluoroscopy mode kVp range (60-120) and mAs range(0.35-15).The unit operates in the following pulse rates 3.75, 7.5, 15 and 30 pulses per second. Filters and wedges are 0.1, 0.2, and 0.3 mm Cu respectively. The II field sizes are 32, 22, 16 cm respectively. The unit has two video monitors within the room for visualizing the examinations. To measure the radiation factors, the multi-function meter called the Victoreen NERO™ mAx Model 8000 (NERO stands for Non-invasive Evaluator of Radiation Output) is made by Fluke Biomedical, 6045 Cochran Road Cleveland OH USA. This multi-function tool is a multi sensitive meter and can be used for radiographic, fluoroscopic,


137

Fig. 1. Plot of mR as a function of mAS

0

1000

2000

3000

4000

5000

6000

7000

0 100 200 300 400 mAs

Linearity of mAs

mR

computed tomography, mammography and dental machines. It is calibrated by factory for both tungsten and molybdenum anodes of X-ray tubes. In addition, the ionization chamber model 6000, which can be connected to the multi-function meter, was used in these experiments to act as a dosimeter. Chamber calibration factors can be stored in the NERO mAx for direct results of measurements [2]. PMMA phantom is a material used to simulate the actual interaction of X-ray with patient’s tissue. For any material to be suitable as a phantom, it should absorb and scatter photons in the same way as that of a tissue. This phantom is accredited by American college of radiology (ACR), and it is 30x30x1(cm3). Leeds test object (TOR 18 FG) was used to evaluate the image quality for low contrast and high contrast detect ability [3].

IV. RESULTS AND DISCUSSIONS

A. Tube and Generator Performance 1) kVp accuracy The procedure followed in this assessment test was that the

detector was placed on the X-ray table, at a distance of 100 cm from the X-ray source or at the clinically used focus to skin distance (FSD). By using the fluoroscopy mode, the sensitive surface of the detector was pointed toward the X-ray source and X-ray beam cantered and collimated to the detector sensitive area such that it covered the whole sensitive area of the detector.

In the kVp accuracy test for radiographic and fluoroscopic units, the different between the initiated and measured kVp should be within ±5%. The kVp accuracy was performed between 40 and 130 kVp. Table (1) summarizes the result of this performance test. The minimum percentage difference that has calculated using (1) was found to be -1.85% at 100 kVp, while the maximum percentage difference was 0.91% at 90 kVp. It is clear from these results that this machine has passed the test successfully.

2) Reproducibility Assessment of the tube output is considered one of the most

important testing elements for indicating the general performance of an X-ray tube and the generator.

The aim of this test is to measure the reproducibility of the exposure timer. Several exposures were taken within one hour as recommended by [1] and reported in [4]. and with 60 kVp and 10 mA and repeated in Table (2). Then the coefficient of variance, was calculated by using (2) from (IAEA) which Suggest that the Covariance Variance (CV) must be less than 2%, all results was as recommended.

3) Linearity and mR/mA Output of the tube The aim of this test is to assess the effect of tube current on

tube output. By using the same measurement setup as suggested in [5],with the settings presented on Table (3) at 70 kVp and mA of 2.5, 5, 10, 20, 40, 80, 160 and 320 respectively.

TABLE. 1. Radiology accuracy test kVp kVpm kVp diff kVp error diff %

40 39.7 0.3 0.76 50 50 0 0.00 60 60.3 -0.3 -0.50 70 70.6 -0.6 -0.85 80 81.3 -1.3 -1.60 90 91.7 -1.7 -1.85

100 99.1 0.9 0.91 110 109.8 0.2 0.18 120 120.4 -0.4 -0.33 130 131.1 -1.1 -0.84

TABLE. 2. Tube reproducibility test

No kVp avg msec mR

1 60.7 1998.7 302.6 2 60.7 1997.6 302.8 3 60.6 1997.3 302.8 4 60.7 1997.6 303.2 5 60.7 1997.4 303.0 6 60.6 1997.5 304.1 7 60.6 1997.3 303.9

Ave 60.7 1997.6 303.2

CV 0.001 0.000 0.002

TABLE.3. linearity and mR/mAs test sittings and mR kVp Set mAs mR mR/mAs 70 2.5 47 18.80 70 5 94 18.80 70 10 191.2 19.12 70 20 384.2 19.21 70 40 771 19.28 70 80 1544 19.30 70 160 3089 19.31 70 320 6179 19.31

CV (( mR/mAs)) = 0.0013

The result is shown in Fig. 1 which demonstrate a linear relationship with the slop equal to the average tube output per unit exposure time and the linearity variance of 0.013.The linearity of mA should not exceed the ± 10% deviation for whole mA ranges as recommended by [1] and reported in [4]. The GE precision 500D have good output linearity mR/mAs.


138

Fig. 2. Shows HVL for GE X-ray fluoroscopy Precision 500D, equal 3.6 mmAl

0

50

100

150

200

0 1 2 3 4 5 AL mm

mR

mR(Max) /2

Fig. 3. Entrance Surface Dose Rate

0 1 2 3 4 5 6 7 8 9

0 5 10 15 Thickness of the PMMA phantom

ESDR ( mGy/Min)

7.5 15 30

Fig. 4. Dose rate per min for different pulse rates, 30,15,7.5 respectively

with full FOV.

0

2

4

6

8

10

12

0 5 10 15 Thickness of the PMMA phantom

ESD (μG/P)

7.5 15 30

B. Beam quality and patient dose measurement 1) Half Value Layer (HVL) evaluation Proper filtration is necessary to remove low energy photons

from the X-ray beam. A patient’s skin dose can increase by as much as 90% if the low energy photons are not removed. The reduction of low energy beam can be achieved by HVL [6].

This test was performed in the radiographic mode of the fluoroscopic machine, and the centre of the tube was on the sensitive part of the detector and the exposure was fixed at 80 kVp and 10 mA. After the exposure, the reading was recorded with added aluminium filters of different thickness, ranging from 0 mm to 4.3 mm on each exposure until a level of 50% off of radiation density was reached. Table (4) show all exposures, an exponential decay graph will be plotted of recorded reading of the dosimeter against the attenuator thickness as shown on Fig. 2 which suggests 3.6 mmAl as HVL.

Alternatively, can be calculated the HVL from the obtained readings only by sued (3):

Where (Y1) and (Y2) are the exposure readings, with added aluminium thickness of (X1) and (X2) respectively and (Y0) correspond to the primary exposure.

We find the HVL was 3.41 , In both methods this specific value of HVL and voltage, the total filtration of this equipment is 3.5 mmAl. The useful beam HVL value should not be lower than 2.3 mmAl as national council on radiation protection (NCRP) and measurements similar to the Australian standard.

If the measured HVL is higher than the stated values may affect the X-ray quantity and such situation should be thoroughly investigated for any unnecessary added filter or excessive deposition of target material on the inside tube [1].

TABLE.4: Values of the HVL on GE Fluoroscopy on KSU

AL mm 0 1 2 3.3 4.3

mR 154.7 123.2 101.6 81.4 70.2

2) Entrance Surface Dose Rate (ESDR) At the total slab thickness used was 14 cm, the results of

the measured absorbed dose to air at the entrance surface of phantom from the ESDR and ESD/p for the same field of view size (32cm) with different pulse ratio are presented in Table (5),(6) and (7) respectively.

The relation between the ESDR and ESD/p with the PMMA thickness at this measurement with the application of preset clinical protocol dose mode and full FOV is shown in Fig. 3 and Fig. 4 respectively, we note that the ESDR increased gradually with the human thickness simulator increase depending on the pulse rate, it is the same conclusion reached by the [7]. For that some radiologists prefer to go with the highest pulse rate to get better image quality, especially in the use of moving objects.

Experimentally an average dose savings of 11% and 45%, for pulsed fluoroscopy at 15, and 7.5 rates per second, respectively are observed compared to 30 pulse rate. In contrast, the ESD per pulse is more with the lowest dose rate.


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TABLE.5. ESDR and ESD/p readings for 30 FPs

TABLE.6. ESDR and ESD/p readings for 15 FPs KV mA ESDR (mGy/min) ESD/p s 60 1 1.2 1.33 60 1 1.2 1.33 60 1 1.2 1.33 60 1.1 1.3 1.44 60 1.3 1.7 1.89 60 1.7 2.1 2.33 61 1.9 2.6 2.89 65 1.8 3.3 3.67 68 1.8 4.2 4.67 73 1.8 5.5 6.11 78 1.8 7.1 7.89

TABLE.7. ESDR and ESD/p readings for 7.5 FPs

As suggested by Den Boer , in all fluoroscopy systems,

depending on the pulse rate in the pulsed mode is enable reducing the dose of radiation during fluoroscopy procedures [8]. ALARA principle also can be optimized for fluoroscopy examinations [9]. Since the GE X-ray fluoroscopy (Precision 500D) is used for training using a variety of phantoms, so the use of only slabs of thickness 14 cm may justify our use of this range of exposure and thickness used in this test.

C. Image quality 1) Evaluation of high contrast spatial resolution and low

contrast detectability The assessments of low contrast resolution (LCR) and

high contrast resolution (HCR) were carried out with the use of Leeds test objects TOR (TVF) that have different thicknesses and materials inside.

HCR is assessed by the ability to distinguish the number of line pairs per millimeter (lp/mm). The results of tests to evaluate high contrast resolution tabulated in table 8 , this leads to high quality images and allow good diagnosis in some radiology procedures which performed in radiology services, both screens are within the range as suggested by [8]. Thus, that there is no big visualization different of some anatomical

details on images, which displayed on either the internal or the external monitors.

LCR is assessed in terms of the number of circles with different densities that are clearly visible and can be visually distinguished from their background on the screen [10], At 70 kV and 0.4 mAs, GE X-ray fluoroscopy machine can be capable of resolving not less than 11 discs for 32 cm ,22 cm and 16 cm as recommended. Depends on those results, the attendant radiologists can diagnose their patients by using the internal or the external screen.

V. CONCLUSIONS AND FUTURE WORK The results obtained suggest that the generator and tube

demonstrated the relevance of a review evaluation by means of performance assessment tests. This allowing supervising of the machine performance, finding of anomalies or operational problems, as well as an estimation of workers and patients radiation exposure levels are necessary and may be obtained by measuring surface entrance dose rate.

Similarly, the outcomes concerning images quality as one of the requirement of an assessment of the images acquisition unit of the fluoroscopy machine. The performance testing for newly installed machines give concrete data which can direct to noticeably image quality improvement, given that these data permit the reasons of possible imaging system degradation after long time.

we will be do the same performance tests on another GE fluoroscopy (Precision 500D) in clinical use for comparison purpose. Daily, weekly, monthly and yearly quality control program must be implemented on this machine to guarantee the higher performance for long time. Future study will focus on a national quality assurance (QA) program for evaluating the performance of all the digital fluoroscopy equipment installed in the Kingdom of Saudi Arabia.

ACKNOWLEDGMENT we thank the college of applied medical sciences research

centre for their support. The authors declare that there are no conflicts of interest.

REFERENCES [1] AAPM (2002) QUALITY CONTROL IN DIAGNOSTIC

RADIOLOGY. Report of Task Group #12. American Association of Physicists in Medicine by Medical Physics Publishing.

[2] FLUKE, C. (2010) Victoreen 8000M (Users Manual). [3] LEEDS TEST OBJECTS MANUAL (2010) TOR TVF. IN LIMITED,

L. T. O. (Ed.). United Kingdom, Leeds Test Objects Limited. [4] WAGNER, L. K., FONTENLA, D. P., KIMME-SMITH, C.,

ROTHENBERG, L. N., SHEPARD, J. & BOONE, J. M. (1992) Recommendations on performance characteristics of diagnostic exposure meters: report of AAPM Diagnostic X-Ray Imaging Task Group No. 6. Med Phys, 19, 231-41

[5] BOSNJAK, J., CIRAJ-BJELAC, O. & STRBAC, B. (2008) Implementation of quality assurance in diagnostic radiology in Bosnia and Herzegovina (Republic of Srpska). Radiat Prot Dosimetry, 129, 249-52.

[6] BALL, J. & MOORE, A. D. (1997) Essential physics for radiographers, Malden, Ma., Blackwell Science.

KV mA ESDR (mGy/min) ESD/p s 60 0.7 1 0.56 60 0.9 1.2 0.67 60 1.1 1.6 0.89 62 1.2 1.9 1.06 65 1.1 2.2 1.22 67 1.1 2.5 1.39 70 1.1 2.9 1.61 74 1.1 3.6 2 78 1.1 4.5 2.5 83 1.2 6.1 3.39 86 1.3 7.8 4.33

KV mA ESDR (mGy/min) ESD/p s 60 0.5 0.6 1.33 60 0.5 0.6 1.33 60 0.6 0.7 1.56 61 0.6 0.9 2 61 0.8 1.1 2.44 62 0.9 1.2 2.67 65 0.9 1.6 3.56 69 0.9 2.1 4.67 73 0.9 2.7 6 78 0.9 3.5 7.78 80 1 4.6 10.22


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[7] DIMOV, A. & VASSILEVA, J. (2008) Assessment of performance of a new digital image intensifier fluoroscopy system. Radiat Prot Dosimetry, 129, 123-6.

[8] DEN BOER, A., DE FEYTER, P., HUMMEL, W., KEANE, D. & ROELANDT, J. (1994) Reduction of radiation exposure while maintaining high-quality fluoroscopic images during interventional cardiology using novel x-ray tube technology with extra beam filtering. Circulation, 89, 2710-2714.

[9] JESKA, S. WAMBANI, GEOFFREY K. KORIR, MARK A. TRIES, IAn K. KORIR, JEDIDAH M. SAKWAL. (2014) Patient radiation exposure during general fluoroscopy examinations. Applied Clinical Medical Physics, Volume 15, Number 2.

[10] HAY, G. A., CLARKE, O. F., COLEMAN, N. J. & COWEN, A. R. (1985) A Set of X-Ray Test Objects for Quality Control in Television Fluoroscopy. Br J Radiol, 58, 335-344.


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University of Sharjah (UoS) Radiography Educational Website M. M. Abuzaid (1), S. A. Alyafei (2), W. Elshami (1)

(1) Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, UAE

(2) Fatima College of Health Sciences, UAE

Introduction (UoS) radiography education website is a research project linked between

the Picture Archiving and Communicating System in the Medical Diagnostic

Imaging Lab to the web (www), this link made through hardware and software

application. It is an open source providing educational and teaching material for

both medical imaging students and radiographer ( Radiological Technologist).

The software Application (www.uospacs.com )

www.uospcas.com is a website developed and designed in the Medical

Diagnostic Imaging Department, College of Health Sciences. UOS is abbreviation

used for University of Sharjah and PACS is referred to Picture Achieving and

Communicating System. The website is running under supervision of Medical

Diagnostic Imaging faculty members who are assure that the information provided

are trusted and reviewed before publishing it online, the medical images which are

published online are anonymous and patient and image source are removed for the

patient privacy.

The website site is used as a link between the hardware and the internet

make the hardware available to the users which allow them to use the DICOM

image and other data available anywhere and any anytime. As well as that the

www.UOSPACS.com is providing education materials in a form of teaching file


145

format, it gives clear link between the practical experiences and the basic sciences

theory. The teaching file is a real patient case demonstrated the patient

information, clinical history, diagnostic and treatment plan and the patient

prognosis. This data are well demonstrated through the evidence and the support

of the basic sciences such as anatomy, physiology, pathology and radiographic

anatomy. The diagnostic imaging role in the diagnostic process presenting at the

case in different format through the description of the imaging techniques used for

the patient, images in different format such as DICOM and JEPG and videos.

Users The website allows the health care students and professionals such as the

physicians, technologist, and Medical Imaging specialist to create an account and

become members at the website. They can participate and shared the knowledge

and experiences by discussing the various patient cases.

Educational Material The website also is providing an educational material prepared by the

Medical Diagnostic Imaging Department faculty members which it can be act as a

references for the students as well as the other professionals who would like to

refresh or update their information. The education material are available in

different format such as pdf, ppt, asw which it can be viewed online or

downloaded to be viewed offline.

The website establishing an educational area between the users who would

like to communicate and have a kind of social and education activities through

initiation of friends, sending and receiving messages from other users, sharing the

experiences between different users such as Student, Medical Imaging Specialist,

Physicians, Radiologist and many other.

Why www.uospacs.com? The education revolution from traditional to digital.


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Ability to study, discuss and take quizzes. The change from conventional films to digital images in diagnostic medical imaging. Sharing skills and experiences between professionals and students Utilization of diagnostic Imaging in study of basic sciences and radiography sciences

What is new in www.uospacs.com? It the first time in the Middle East to have educational website for the medical imaging students and professionals The great usage of medical imaging in cases explanation Sharing the knowledge between the professionals and students The ability to use the DICOM images online All cases are reviewed before published Ability to upload the cases and the department staff will complete the missing material such as anatomy, physiology, radiographic anatomy, pathology and quiz’s You can upload the images in any format and we will convert to the suitable format as well as labeling it.

What is additional in www.UOSPACS.com?The educational material:- the website contain educational material page covering various categories in radiography course such as technique, CT scan, MRI, Digital imaging & PACS, Patient care in radiography. This educational material helps the students and other professionals in the health care to update their knowledge and refresh their experiences skills. Sharing community: - the website allows the users to contact each other through the case discussion, comments as well as initiate friendship relation through sending messages and request friends. Medical Images: - the website facilitate the images uploading in different format such as DICOM, JEPG etc... Dynamic Images:- the website allow the users to upload and view the dynamic images in the video format such as fluoroscopic images, cardiac images and ultrasound images Comparison between normal and abnormal anatomy:- the cases are prepared in away help the users to study the normal anatomy and physiology before reviewing the case, this is supported by the normal radiographic anatomy


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AUTHOR INDEX

A. Kaprelyan 47

Abeer Al-Hazmi 71

Al. Tzoukeva 49

Al-Hussami Mahmoud 53

Araya Pisek 15

Asmus Heumann 125

Azin Nowrouzi 117

Azita Amiri 117

B. Balev 49

B. Reuben 7

Buddhathida Wangsrimongkol 15

Carolin Weissa 1

Charles A. Downs 117

Christoph Schimmera 1

Coralie Essicha 1

Cyrus Behzadi 125

D. Bliznakova 39

D. Kalev 49

Dhanabhol Riowruangsanggoon 15

Ebadullah Raidullah 5

Fatemeh Salamati 73

Gerhard Adam 125

Glyn Neades 45

H. I. Aldossari 129

Hadi Valizadeh 19

Hamad A. Alzoman 3

Matthew Barber 45

Mike Dixon 45

Hebah Al-Juhani 3

Heeyeon Kwon 121

Jamal A.S. Qaddumi 99

Ji Hoon Park 123

Jihoon Park 121

Jin Yamamura 125

Jun Ho Choi 123

K. Z. Shamma 129

Kamran Ahmad Malik 45


149

Khaled Hamoudaa 1

Kristín Björnsdóttir 111

Kristín Thórarinsdóttir 111

Kristín Thórarinsdóttir 113

Kristjánsson Kristján 111

Kristjánsson Kristján 113

Kyung Won Minn 123

Kyungwon Minn 121

M. A. Alnafea 129

M. Atanasova 49

M. M. Abuzaid 135

M. M. Abuzaid 137

Mahmoud Abu-Ta'a 37

Mahmoud Al-Hussami 79

Mahmoud Maharmeh 79

Martin Wagnerb 1

Maxim Avanesov 125

Mehmet Oezkura 1

Mitra Zolfaghari 73

Mohammad Ali Cheraghi 73

Mohammad Samiei 19

Muhammad Darawad 79

Murat Karul 125

Omar AlKhawaldeh 53

Osama Khattak 5

Paramaporn Ovatakanon 15

Peter Heuschmannb 1

Philip Stahl 125

Poonsak Pisek 15

R. Georgiev 49

Rainer Leyha 1

Rasmieh N.S. Anabtawi 99

Rawan Daabash 3

Rekaya Vincent Balang 65

Rob L. Burton 65

Ruqayya Zeilani 53

S. A. Alyafei 135

S. A. Alyafei 137

S. Angelova 39

S. Asbia 7


150

S. Peev 39

Sahar Younes Othman 75

Samah Anwar 75

Sanaz Javanmardi 73

Seyyed Mahdi 19

T. Targova-Dimitrova 39

Tanyakorn Wichettapong 15

Tasanee Wangsrimongkol 15

Thorsten Derlin 125

Ung Sik Jin 123

Ungsik Jin 121

Vahid Pakdel 19

W. Elshami 135

W. Elshami 137

Wijdan Al-Khalid 3

Yoo Hyang Cho 77

Younghae Chung 77

Zahra Aghazadeh 19


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scientific cooperations 7-8 june, 2014 …med-scoop.org/med_proceeding2014/med_proceeding2014.pdf7-8...

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