Medical Journal in Usa

Psychology as Support for Medicine on Lung Cancer: A Literature Review

Psychology is currently in a growth phase, although it has yet to fully achieve recognition comparable to other sciences, such as medicine. However, it plays a significant role in the human experience. Scientific advances in this area have revoked Cartesian dualism, demonstrating that the mind and body act interconnectedly, exerting direct and indirect influence on each other (Levy, L 2010). Diagnoses previously addressed exclusively from a medical point of view began to be considered by psychology, not through drug interventions, but by offering emotional support to face the condition (Deitas [1]). This approach is particularly relevant when chronic diseases require continuous adaptation throughout life. It is especially evident in more severe cases, such as lung cancer, which not only raises uncertainty about the future, but also poses significant challenges to existence itself, both for the affected individual and those around them (Sofia & Grilo, 2023). Currently, through the media and other sources, it is possible to access statistical data on cancer, observing its rapid evolution until the often fatal outcome. However, we recognize that medicine does not act in isolation in this scenario. Hospitals and health centers increasingly rely on multidisciplinary teams, integrating doctors, nurses, healthcare professionals, and mental health specialists, such as psychologists and psychiatrists, who adopt a biopsychosocial approach (Deitas [1]). This perspective recognizes that all problems have biological, psychological and social foundations.

Lung cancer emerges as one of the leading causes of death globally (Global Cancer Observatory [2,3]), requiring an in-depth understanding of its evolution and associated triggering factors. In addition to analyzing demographic data to understand its impact, it is crucial to explore the psychological and emotional side that the diagnosis can have on the life of the affected individual, as well as on family dynamics and the system as a whole (Grilo [1,4,3]).

Method

The methodology adopted for this study began with an extensive literature review conducted through online searches on PubMed, Google Scholar, and B-On platforms, covering 22 articles. The inclusion criteria were based on the presence of the intended topic in the title or keywords, followed by an analysis of the abstract to assess its relevance for the development of the work. The selection prioritized articles from the last 20 years (2003-2023), conducting research in both English and Portuguese. Statistical data from reliable sources were incorporated, including the World Health Organization (WHO), the Institute for Health Metrics and Evaluation, the Global Cancer Observatory, and the Portuguese League Against Cancer. The exclusion criteria were strict, eliminating articles outside the established period, those lacking relevant information about the intersection between lung cancer and psychology, and those that did not make the full text available. The literature search was conducted using keywords in English, such as “psychological impact of lung cancer,” “emotions and feelings arising from a lung cancer diagnosis,” “quality of life in cancer patients,” “psychological changes in lung cancer,” and “family and social support in coping with lung cancer,” with a parallel approach in Portuguese. This meticulous process ensured a robust and comprehensive basis for analyzing and discussing the proposed topic.

Lung Cancer

According to the Portuguese League Against Cancer, lung cancer is among the most prevalent neoplasms, being categorized into two distinct groups: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). The prevalence of SCLC is observed in approximately 20% of lung cancer cases. At the same time, the more common NSCLC is characterized by slower growth and dissemination, showing less aggressiveness in approximately 70-80% of cases (European Lung Foundation [5]). This categorization encompasses three distinct subtypes: squamous cell carcinoma, adenocarcinoma and large cell lung cancer. In contrast, small-cell lung cancer, which is less common, exhibits rapid growth and a greater propensity to metastasize to other organs (Liga et al. o Cancro). The leading causes of this type of cancer are associated with tobacco consumption, accounting for more than 80% of cases (European Lung Foundation [5]). However, the probability of developing a tumor is influenced by the age at which smoking began, the duration of the habit, the daily number of cigarettes, and the depth of inhalation (Liga [6]). Furthermore, cases of passive smokers, that is, individuals constantly exposed to tobacco smoke, can also develop lung cancer. Environmental pollution is another relevant factor, triggering the diagnosis, primarily through inhalation of combustion fumes, exposure to radon, asbestos, arsenic and industrial metals such as chromium (Liga [5,6]).

Early identification plays a crucial role, requiring careful observation of clinical signs, such as persistent cough, chest pain, hemoptysis, dyspnea, asthmatic conditions, hoarseness, pneumonic manifestations, bronchitis, facial and neck edema, weight loss, and asthenia (Portuguese League Against Cancer). Diagnosis usually requires the intervention of procedures such as chest radiography (or X-ray) or sputum cytology, with biopsy playing a crucial role in analyzing lung tissue and confirming the presence of cancer (Liga [6]). On the other hand, the prognosis is generally not optimistic, given the tendency for late diagnoses, resulting in a reduced probability of cure. The standard survival rate is five years, although it is essential to consider the individual variability of each case, as some patients may have a more limited survival time (European Lung Foundation [5]). In the early stages of the disease, the primary treatment involves removal through surgery; however, when this is not possible, treatment is usually done through chemotherapy and radiotherapy. Chemotherapy aims to cure cancer through drug interventions, while radiotherapy uses high-energy X-rays to eliminate cancer cells. Although they are different approaches, both have common side effects, such as nausea, vomiting, fatigue and hair loss (Cancro [5,6]). On the other hand, when the disease is already at a very advanced stage, and cancer has already metastasized, the “objective is to prolong survival, alleviate symptoms and improve quality of life through the use of chemotherapy and immunotherapy” (World Health Organization [7]).

Epidemiology of Lung Cancer in the World and Portugal

As indicated by the World Health Organization (WHO), lung cancer represents the leading cause of mortality on a global scale (Dumitrascu [3]), leading to high death rates in both men and women (World Health Organization [7]). According to data from GLOBOCAN 2020, this type of cancer occupies the highest prevalence among men, with an incidence of 31.5% and a mortality rate of 25.9% per 100,000 inhabitants. In the female population, it ranks third in the table as the most prevalent cancer, only surpassed by breast and colorectal cancer, with an incidence rate of 14.6% and a mortality rate of 11.2% per 100,000. Inhabitants (Global Cancer Observatory [2]). It is essential to highlight that there is a predominant incidence of lung cancer cases north of the equator, with notable emphasis on the United States of America (USA), Europe and the Asian continent, although some regions to the south also have a considerable incidence among inhabitants (Global Cancer Observatory [2]). In this context, the mortality rate follows incidence patterns, highlighting regions such as Russia, Oceania and the whole of Europe, which did not show such a high incidence of (Global Cancer Observatory [2]). Considering these data, the literature has shown a higher prevalence of cases in highly industrialized countries, which justifies the incidence in the above mentioned nations.

Furthermore, it is highlighted that, increasingly, due to these countries being more developed, there is greater availability of socioeconomic resources and easier exposure and access to risk factors, such as tobacco (European Lung Foundation [5]). Smoking, being the main predisposing factor to lung cancer, has been increasingly consumed by females, resulting in an increase in cases among women compared to previous years, in which men were the primary tobacco consumers (FGM [8]). In Portugal, based on the most recent data from 2020, it is observed that lung cancer occupies the third position in prevalence among men, recording an incidence of 35.4% and a mortality rate of 31.4% for every 100,000 inhabitants. This classification places lung cancer in a lower position only than prostate and colorectal cancer. Regarding females, this type of cancer ranks fourth in prevalence, with an incidence of 10.8% and a mortality rate of 8% per 100,000 inhabitants. In this context, lung cancer is surpassed in prevalence by breast, colorectal and thyroid cancers. (Global Cancer Observatory [2]). It is essential to highlight that, compared to other European countries, Portugal has the lowest incidence of lung cancer cases, occupying the thirty-fifth position (35th) in a group of 40 countries (Global Cancer Observatory [2]). It is important to note that Portugal – compared to other countries highlighted by the Cancer Observatory, with high lung cancer incidence rates – has a numerically smaller population.

It is worrying to note that, instead of decreasing, the current trend is for an increase in the daily number of cases, even in the face of significant technological advances in medical and scientific areas. It is expected that, with the progress of these sciences, there will be a reduction in cases, as recommended by the objectives of the National Health Plan until 2030, which aim to improve the population’s quality of life and reduce the daily and annual incidence of cancer deaths in general (National Health Plan). Due to the recognition of the significant global repercussions – and considering the data above – the World Health Organization (WHO) also adopted multiple initiatives to deal with this disease. The central purpose is to expand smoking control, promote cancer prevention and early detection, and improve access to high-quality treatments and care (World Health Organization [7]).

Psychology as Support for Medicine and the Patient

In addition to the conventional medical approach, it is currently recognized that psychological support plays an essential role in various multidisciplinary teams present in hospital environments and health centers (Deitas [1]). Historically dominated by medical and nursing professionals, these teams have evolved to include psychological professionals. In response to this change, the World Health Organization (WHO) adopted the concept of health, starting to consider health problems from a biopsychosocial perspective. In this approach, health is defined as a “state of complete physical, mental and social well-being and not merely the absence of disease” (World Health Organization [1,7]). After this recognition of psychology as a science capable of contributing to improving the quality of life of patients diagnosed with lung cancer, we now understand that the impact of this diagnosis, given the magnitude of the disease, is extraordinarily challenging, both for the patient and for the family. Even if the family is not directly affected by the disease, it is impacted by the need to adapt to the situation and the uncertainty associated with the diagnosis (Murillo [1,9]). In this context, the family plays a crucial and of significant importance in the life of the patient diagnosed with lung cancer (Deitas [1,10]). Emotional support from friends, colleagues and individuals considered as part of the family, even if there are no blood ties, reveals that It is incredibly vital for the patient to realize that they are not facing this new stage alone and that they will always have someone to lean on (Dumitrascu [3,4]).

Furthermore, we understand that the diagnosis of a disease, such as cancer, regardless of the type, causes deep sorrow and guilt in the patient, in addition to feelings of uncertainty about the future and cure, about death and survival, leading to feeling different from others. Questions often arise, such as “Why me?”, “what did I do to deserve this?” and “Will I be condemned to death?” (Grilo [4,10]). The literature points out that support from peers and family has a very positive impact, not directly on healing, as this does not depend on desire or support, but on an emotional level, consequently enabling greater adherence to treatments and a greater sense of hope that the disease will be overcome (Querido [11]). Psycho-oncology is an “interdisciplinary science that crosses the areas of psychology, medicine, psychiatry and sociology” (Ordem [12]), aiming to provide psychological support to individuals faced with a cancer diagnosis, to restructure them emotionally and reintegrate them into society (Silva [10,13]). Given the alarming statistics of annual diagnoses of lung cancer and the shocking number of deaths associated with this disease on a global scale (Global Cancer Observatory [2]), psychology must make decisive progress in this field in order to serve a significant contingent of people who need psychological support to preserve their mental health and quality of life in the face of the overwhelming impact of a diagnosis of this nature (Murillo [9]).

Such a diagnosis raises uncertainty about the individual’s survival and profoundly challenges their meaning in life (Silva [1,10]). Lung carcinoma generates diagnoses of anxiety and, sometimes, depressive states (Silva [10]) due to the direct impact it has on the individual’s body, resulting in damage that, consequently, leads to the loss of essential functions for activities. A characteristic intrinsically associated with lung cancer, a vital organ of the respiratory system, is the manifestation of shortness of breath or decreased respiratory capacity (Liga [6]). Although this ramification may not become immediately evident, it is imperative to highlight that, according to Psychology, any reduction or loss of respiratory capacity, regardless of its magnitude, requires adaptation. Additionally, the diagnosis requires readjustment and adaptation to the new situation and the presence of something new (Basso [13,14]).

Generation X and the Impact of their Ideals on Tackling Lung Cancer

According to the 2019 National Oncological Registry (RON-2019), the age group most commonly affected by the diagnosis of lung cancer in Portugal is between 50 and 75 years old, with the majority of cases occurring between 50 and 66 years old, characterizing this population as part of generation X (Veloso [15]). Various sources state that generations are influenced by historical events that shape their values and worldviews. In the context of Generation X, two particular characteristics that significantly impact several domains stand out. First, many members of this generation were raised by parents with extensive professional commitments, resulting in a family dynamic in which older siblings assumed caregiving roles from a young age (Veloso [15]). Secondly, in the professional sphere, generation ensures job retention (Veloso [15]). The influence of these characteristics becomes evident when we consider the diagnosis of lung cancer in this specific age group. The literature suggests that generation, the family is impacted by intense feelings of sadness (Murillo [1,9,10]), especially for the patient who sees his family life as an achievement and who now faces the possibility of destruction by a potentially fatal disease. This psychological impact can trigger feelings of anguish, depression and anxiety, as well as internal and external conflicts (Murillo [9,10,16]).

The change of roles, from caregiver to dependent on children, can generate feelings of weakness and shame as the patient perceives a change in the family dynamics they were building. This scenario can result in emotional and mental conflicts, increasing the challenge faced by these patients during treatment and living with the disease (Grilo [4]). It implies considering the dynamics between parents and children and recognizing the existence of several family subsystems, each with specific roles and dynamics. In the marital context, the relationship between husband and wife is distinguished by different interactions, being particularly susceptible to both physical and psychological repercussions caused by the disease (Silva [10]). Therefore, it is crucial to consider the preservation of physical health and mental health, recognizing that both aspects play a significant role in the effective functioning of the family and marital relationship (Grilo [4]). Maintaining emotional stability helps the patient to cope with the disease without being overwhelmed by anxiety and other feelings arising from uncertainty about the future, allowing them to live with the best quality possible given the circumstances (Grilo [4]). In the professional sphere, the need for a feeling of usefulness in the work environment is characteristic of the generation, resulting in competition to stand out from others, aiming to ensure the maintenance of their positions and longevity in employment (Veloso [15]).

Considering the age group in which lung cancer predominates, it is possible to infer that a large part of this population is active and employed, often with financially and emotionally dependent children. Not only is the diagnosis of lung cancer impactful in itself but the difficulties and consequences associated with it also have a strong influence. A striking characteristic of lung cancer is the loss of respiratory functions, combined with the side effects of treatments, which include symptoms such as fatigue, malaise and nausea (European Lung Foundation [5]). These factors, almost inevitably, compromise the patient’s ability to maintain their work activities, leading to a temporary interruption or cessation of their functions. In a generation that profoundly values work and a sense of usefulness, this loss of capabilities affects the professional sphere and the family’s role (Grilo [4]). The change in routine and perceived contribution to the work community results in feelings of uselessness, exacerbated by the possibility of financial difficulties faced by the family due to the loss of income resulting from the disease (Grilo [4]). Changing roles and breaking expectations generate not only physical pain but also more intense psychological pain. In this context, the role of psychology and Psycho-oncology is crucial to help the patient adapt, encourage resilience and overcome these feelings, promoting the understanding that the diagnosis is not a punishment, could not be predicted and that the patient cannot feel guilty about something that is beyond control (Silva [10]).

The psychological and emotional impact of Lung Cancer on the patient and family and family support as a guarantee of emotional stability. Psychology is vital in shedding light on aspects often less highlighted by medicine. One of these critical aspects is the emphasis on maintaining a positive perspective, demonstrating to the patient that emotional stability contributes significantly to a better quality of life (Silva [10]). This approach not only improves living with the disease but also comprehensively impacts various aspects of the individual’s life, influencing their self-perception and social interactions. Thus, it is clear that mental health promotion is intrinsically linked to physical well-being, following the premise that a healthy mind contributes to a healthy body (Deitas [1,10]). In this context, it is essential to direct attention to the family sphere since the patient is significantly affected by the presence of the disease, although not physically, but psychologically (Deitas [1,10]). It is essential to highlight that, when referring to “family,” we are not restricting ourselves just to the nuclear family, although this is undeniably the most impacted. We encompass all contemporary concepts of family, extending to the extended family and friends considered as family members. Studies have shown that the family plays a facilitating role throughout the process, from diagnosis to treatments, as well as in the final phase of the disease, whether death or cure (Deitas [1]).

It is undeniable that support, an essential element to feel safe, is crucial in this scenario. When receiving a diagnosis of lung cancer, the patient needs support from family, together with a support network that includes close friends or colleagues. The straightforward certainty of having someone to count on when they feel sad and helpless becomes extremely important for the patient.

Quality of Life and Stigma

When an individual is diagnosed with lung cancer, they are often subject to stigma (Sanguedo [17]), both from themselves and their surroundings. The stigma associated with this condition is often influenced by the widespread belief that lung cancer is directly linked to bad habits, mainly tobacco consumption, even though this is just one of the risk factors, not excluding other possible causes. This misconception, often perpetuated by a lack of information, creates a harmful stigma for the patient and society. The automatic association between lung cancer and smoking leads to an immediate perceived death sentence, contributing to the stigmatization of the patient from the moment of diagnosis (Sanguedo [17]). The stigma associated with lung cancer, primarily when related to smoking, often results in feelings of guilt on the part of the patient, especially if they are or have been a smoker. The search for quality of life is a universal aspiration; however, human nature often focuses on dissatisfactions to the detriment of achievements already made (Sanguedo [17]). In contexts such as lung cancer, characterized by high mortality rates and low probabilities of cure, the objective of psychological intervention is to promote the patient’s mental well-being throughout the entire process, regardless of the outcome [18]. The literature highlights the overwhelming emotional burden of the diagnosis and the fear of the outcome for patients (Deitas [1]). While medicine plays its role in the fight against illness, the patient’s mental health dimension often lacks adequate support.

In this sense, psychology emerges as a fundamental tool to ensure the patient’s emotional stability, providing them with an optimized quality of life (Basso [14,19]) within limits imposed by the condition and encouraging the understanding of that part of the coping process is also under the patient’s control (Deitas [1,10,17]). Furthermore, the objective, taking into account the feelings of guilt that arise, is to try to provide the patient with the vision that he is not to blame for what is happening to him and that he is much more than that illness (Basso [14,20,21]).

Final Reflection

An in-depth study of lung cancer and the application of positive psychology prove crucial to understanding the emotional complexity surrounding this condition. Throughout this analysis, we highlight the importance of family support as a fundamental element in coping with a lung cancer diagnosis. The presence and support of the family emerge as an essential pillar for the patient, not only in the physical sphere but, above all, in the psychological one. The positive influence of the family support network is reflected in the patient’s ability to deal with the emotional challenges inherent to the diagnosis, providing crucial support for effectively coping with the disease. The psychological impact of a lung cancer diagnosis is vast and profound, affecting the patient and their families. Psychology highlights the need to cultivate an optimistic outlook even amid adversity. It does not imply ignoring difficulties, but instead recognizing the resilience, strength and possibilities for personal growth that can emerge from the coping process. Integration of psychology in lung cancer treatment plays a crucial role in promoting emotional well-being. Family support, as a central element, offers emotional comfort and contributes to building a more positive approach to a challenging diagnosis. This work reinforces the continuous need to integrate the principles of psychology in the clinical monitoring of these patients, aiming not only at physical survival but also at quality of life and psychological flourishing in the face of adversity.

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Free Medical Journal

Renal Cell Carcinoma: A Review on Patients’ Quality of Life

Kidney cancer occurs due to the abnormal growth and division of cells. This phenomenon occurs when an injured cell grows and multiplies, giving rise to several abnormal cells forming a tumor (Alberts, et al. [1]). Renal carcinoma originates in the kidneys, essential organs for normal and healthy functioning. The kidneys belong to the urinary system and have several functions, including the excretory function, responsible for filtering the blood and producing urine, which expels substances that in large quantities would be harmful to the body; the regulatory function of internal volume and acid-base balance, responsible for internal homeostasis through the excretion of water and electrolytes; the hormonal function, which plays a role in the internal secretion of hormones that regulate various processes related to the organ and the catabolic function, which ensures that no essential substances are lost. Kidney cancer represents 2-3% of all malignant tumors in adults, with an increase in incidence in recent decades (Karki, et al. [2]), and is one of the most common cancers of the urinary system (Liu, et al. [3]). This diagnosis has a higher incidence in males, and it has been shown that they have worse initial tumor characteristics and worse mortality specific to this cancer (Ajaj, et al. [4]). It is estimated that 90% of kidney cancers are represented by Renal Cell Carcinoma (RCC), and this is divided into three types: clear cell RCC, which represents 70% to 85% of cases; papillary RCC, which represents 10 to 15% of cases and chromophobe RCC, which represents less than 5% of cases (Motzer, et al. [5]).

A set of risk factors is associated with kidney cancer, meaning that a risk factor implies any aspect that interferes with the probability of having a specific disease but does not incorporate a direct causal relationship in cancer development (Hancock & Georgiades [6]). Firstly, we have smoking as one of the main risk factors associated with renal carcinoma. The risk increases proportionally to the number of cigarettes smoked; however, if the individual stops smoking, the risk decreases. The incidence in males can be explained by the fact that, in the past, men were the biggest tobacco consumers (Lopaz-Beltran, et al. [7]). Additionally, obesity also incorporates a considerable risk factor, with the risk increasing exponentially with excess weight. It may be due to the hormonal changes characteristic of excess weight, which can lead to hormonal imbalance (Lopaz-Beltran, et al. [7]). Professional exposure to certain chemicals has also been shown to be a risk factor, specifically trichloroethylene, as well as prolonged exposure to cadmium, benzene, herbicides, and vinyl chloride, among others (Lopaz-Beltran, et al. [7]). CRC does not have a constellation of defined symptoms and is usually asymptomatic in its earliest stages, often discovered at a late stage of the disease, affecting the individual’s prognosis and chance of survival (Hancock & Georgiades [6]). Patients with metastatic CRC have a more unfavorable prognosis, with a survival rate that varies between 2 and 3 years. However, there is a constant attempt and effort to develop ways to regularly track and effectively manage distress, as an essential component of patient care, to help improve patients’ quality of life (Bergerot, et al. [8]).

Method

A systematic review of the literature published between 2003 and 2023 was carried out in the B-on database to find out what the literature says about the quality of life in patients with CRC. The research protocol used was: (“kidney cancer” OR “renal cell carcinoma”) AND (“intervention plan” OR “therapy” OR “psychology” OR “psychoeducation”) AND (“adults” OR “elderly people”) AND (“anxiety” AND “trauma” OR “distress” AND “depression” OR “coping” OR “death anxiety” AND “future planning” AND “quality of life”). The Boolean Operators “AND” were used to ensure that the topics were all included in the search, and the “OR” was used to increase the possibility of obtaining more results within the same topics. The inclusion criteria are studies

(a) Academic articles,

(b) Published between 2003 and 2023,

(d) That mentioned the quality of life,

(e) That focused on the psychological perspective of cancer, and

(f) That focused on kidney cancer.

The exclusion criteria are articles that

(a) Did not mention psychology,

(b) Were unavailable for consultation,

(d) Were more focused on the medical perspective, and

(e) Focused on testing for cancer symptoms.

First, 50 articles were collected, and, considering the exclusion criteria, 36 articles were removed, leaving 14 articles to be used in this review (Figure 1).

Results

Firstly, after applying the research protocol, 50 articles were collected, but only 14 articles were considered eligible for the systematic review after applying the exclusion and inclusion criteria mentioned above. Although the number is small, this fact only highlights the importance of more research in psycho-oncology and kidney cancer, specifically on the topic of quality of life, which is the central theme of this systematic review. All articles used in this systematic review are included in Annex 1. Additionally, all literature used in this systematic review included a psychological perspective on the quality of life in the context of kidney cancer, including topics such as resilience, self-efficacy, self-management, hope, the consequences of treatments and experiencing cancer, physical activity, psychopathologies, psychological suffering, and positive affect.

Discussion

Quality of Life of Patients with CRC

For cancer patients, quality of life (QoL) is an essential factor, and the literature shows that there is a correlation between a high symptom burden and poor QoL. There is a constellation of symptoms associated with cancer; however, among individuals with cancer, fatigue, pain, and depression are the three most frequently reported symptoms related to the disease and subsequent treatment. This phenomenon, together with the fact that 50% of patients who suffer psychosocial impacts do not disclose them to their healthcare team, can immensely affect their QoL. Therefore, the emotional and psychological impact of cancer on patients is likely not well understood (Carlos, et al. [9]). QoL is a subjective perception at various levels that changes over time as it reflects an individual’s current situation. Deterioration in QoL is associated with an increased risk of suicide and depression. In particular, the QoL of patients with metastatic kidney cancer deteriorates significantly as a result of treatment due to the stress imposed on their body and mind (Liu, et al. [3]). More specifically, kidney cancer patients are faced with multiple stressors, including pain, fatigue, significant bodily changes, and changes in sexual/urinary function (Yang et al., 2016). Furthermore, due to the adverse effects of altered self-image/body image and altered sexual/urinary function, individuals may withdraw from friends and other people because they are afraid of losing people due to their condition and do not know how to ask for help due to their embarrassment, which may lead to them receiving insufficient support from their loved ones and friends (Yang et al., 2016).

Furthermore, intense physiological, psychological, and interpersonal challenges may arise in the first year after diagnosis, which may decrease QoL and increase the likelihood of developing psychopathologies such as anxiety, depression, or posttraumatic stress disorder (PTSD) (Moretto et al.) (Thekdi, et al. [10]). In kidney cancer patients, the prevalence of depression, anxiety, and PTSD is 77.5%, 69.3%, and 25.2%, respectively (Yang et al., 2016). Psychopathologies can affect the patient’s judgment and decision-making capacity, which is crucial in their treatment (Karki, et al. [2]). Indeed, concerns about the recurrence of cancer or the possibility of never being able to overcome it can worsen these psychopathologies if they are not correctly regulated (Liu, et al. [11]). Furthermore, these psychological disorders can lead to a decrease in the immune response, prolonged recovery times, difficulties in controlling symptoms, poor adherence to treatment and, possibly, a reduction in survival time. Therefore, regular screening and adequate management of these psychological disorders are an essential aspect of psycho-oncology, as they not only affect the patient’s psychological aspect but can also reduce their survival rate and the success of their treatment (Yang et al., 2016). Although currently available drug treatments (sunitinib, interleukin-2, interferon-α, among others) can improve overall survival and alleviate some of the symptoms to a certain extent, at the same time, they also produce toxic side effects, which can also affect their QoL (Liu, et al. [11]).

Additionally, in patients with advanced cancer, fatigue is often a priority symptom. It can hurt QoL because it affects physical and social functioning, activity level and emotional well-being. Fatigue is also a joint adverse event (AE) associated with advanced cancer treatments, including targeted therapies (such as those approved for advanced RCC). It is reported as an AE in approximately 40% to 70% of patients with advanced RCC. (Cella, et al. [12]). In fact, due to physical exhaustion and restrictions imposed on activities, these patients have difficulty performing activities they previously enjoyed, which can worsen their psychological suffering (Liu, et al. [3]). Psychological distress refers to non-specific symptoms that include stress, anxiety and depression. Increased levels of psychological suffering may indicate the beginning of diagnostic severe conditions, such as the psychological disorders already mentioned above. In practice, it is often found that many patients deny any symptoms of psychological distress and often self-medicate with ethanol and recreational drugs. It is assumed that the impact of psychological distress on therapeutic adherence and long-term well-being is significant. However, this field is poorly explored (Bartolomei et al., 2022). Additionally, it has been shown that female cancer patients suffer more from psychological distress. In contrast, men suffer more from symptoms of physical distress, and it has also been shown that younger people are more susceptible to experiencing psychological distress (Ajaj, et al. [4]).

While QoL deteriorates through treatments and the various difficulties a patient faces, optimism and resilience work as protective factors for their QoL. Resilience is the ability to restore one’s original state when faced with an essential stressful event and can be a process or a result of coping. Characteristics of resilience include resilience, flexibility, self-determination, self-esteem/self-efficacy, a sense of humor, and the ability to maintain positive relationships (Liu, et al. [3]); Yang et al., 2016). In the conceptual framework for recovering the health and well-being of cancer survivors, cancer-related self-efficacy refers to the degree of self-confidence of survivors about self-management of problems caused by cancer or treatment after completion. of primary treatment; that is, these patients are confident in their ability to avoid symptoms or health problems that interfere with what they want to do, believe that performing their self-care activities would reduce their need to see a doctor and can improve psychological distress caused by treatment (Liu, et al. [3]). This self-efficacy mediates the relationship between negative emotional states and resilience; the fewer negative states, the greater self-efficacy and, consequently, the better resilience (Liu, et al. [3]). Additionally, a high level of self-confidence is beneficial so that individuals can adopt self-management behaviors to improve their symptoms or health problems and reestablish their health and well-being. Thus, the emotional state of cancer patients affects their self-efficacy about cancer, which, in turn, affects their resilience and QoL.

A negative emotional state may lead to low self-efficacy, while a positive one will have the opposite effect. Resilience plays a crucial role in this process, as it can help resist the influence of a hostile state on QoL, thus implying that patients with better resilience have better QoL (Liu, et al. [3]). As a product of resilience, coping appears, defined as continuous cognitive and behavioral efforts to manage specific external and internal demands that overload or exceed the individual’s resources (Lazarus [13]). Coping helps patients live with the demands placed on them by the disease and experience a general sense of well-being. The main coping styles identified are problem-focused, emotion-focused and avoidance-focused. These mechanisms can be great protectors of QoL, as they increase the individual’s resilience if used correctly. However, avoidance-focused coping may have a negative association with QoL, so not all coping styles will benefit all patients (Beisland, et al. [14]). Another concept associated with QoL is hope; a high level of hope in a cancer patient can increase their ability to find solutions to the problems caused by cancer and feel confident that they can use ways to solve or deal with these problems. Problems. Additionally, hope showed a negative association with PTSD, which may provide valuable information for the development of targeted psychotherapy for PTSD in cancer patients (Yang et al. 2016).

Furthermore, the psychological impact of cancer not only increases levels of negative emotions but also reduces the positive affective experience; that is, patients may not necessarily have an abundance of negative emotions, but rather a lack of positive emotions. Positive and negative affect mechanisms contribute differently to biological and psychological processes, such as blood pressure, heart rate, creativity and stress perception (Prinsloo, et al. [15]). Positive affect was also associated with a 10% reduction in mortality; survival outcomes were substantially better for patients who simultaneously reported high positive affect and low depressive symptoms, thus affecting QoL (Prinsloo, et al. [15]). Finally, physical activity (PA) and sleep have been associated with better health and QoL outcomes in many cancer groups (Tabaczynski, et al. [16]). Light-intensity PA has also been associated with positive health outcomes for cancer survivors, as it can be performed in many domains as part of daily living activities. Additionally, kidney cancer survivors spend a lot of time sedentary, which is defined as any behavior, including sitting, reclining, or lying down, performed during waking hours. Sedentary behavior is linked to adverse health outcomes for kidney cancer survivors, including decreased physical functioning, increased pain and fatigue, decreased well-being, and reduced QoL (Tabaczynski, et al. [16]) Furthermore, sleep disturbances are also one of the symptoms most cited by cancer patients during and after treatment [17,18].

Therefore, better sleep quality and longer sleep duration are associated with positive health and well-being and are fundamental to maintaining QoL during the process. Reorienting sedentary time to PA of any intensity or sleep can lead to successful symptom management in kidney cancer patients, increasing QoL (Tabaczynski, et al. [16]).

Conclusion

After the systematic review of the literature, we can note that this subject has not yet been explored much, as most articles mentioned the quality of life of cancer patients in general, and few delved into the experience of patients with CRC. However, it cannot be said that the experience of an individual with cancer is not the same as that of an individual with CRC, as the processes are similar. One of the limitations of this study is the number of keywords used in the research protocol; in a future review, it would be relevant to try to reduce some keywords. Finally, resilience and self-efficacy play an essential role in maintaining and protecting the quality of life of patients with CRC.

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Open Access Medical journal

Semicircular Lipoatrophy of Occupational Origin (SLOO): Proposal of a Clinical History Sheet for Data Collection and Implementation of Corrective Factors

Semicircular lipoatrophy (SL) is defined as a benign disorder of the subcutaneous tissue that manifests as atrophy of the adipose tissue and is characterised by semicircular banded depressions affecting mainly the thighs on the anterolateral aspect and, to a lesser extent, the forearms and abdomen uni or bilaterally [1,2], with asymptomatic lesions, and with intact skin and muscle (Figure 1). Where an occupational cause is demonstrated, it most commonly affects females in a 6:1 ratio and in an age range of 30 40 years and in office workers [3]. The course is reversible, be nign and without sequelae, remitting within months or years after

cessation of exposure to risk factors. This rare disorder has been linked to the workplace since 1974, when cases of LS were reported in workers in certain buildings in Germany, and since 1 995, when new cases have been published in France, Italy, the United Kingdom and the Netherlands, including the appearance of 900 cases in a bank in Brussels [2]. In Spain, the first cases appeared in 2007, causing a health scare with great media coverage among the working population in Catalonia, and cases were subsequently reported in other autonomous communities [4]. Although there is insufficient scientific evidence on the causes, in the studies reviewed, it is associated with repeated microtrauma due to repeated pressure from office furniture, tight clothing, electromagnetic fields and static electricity (work environment factors such as low relative humidity and the influence of computer equipment and wiring) [5].

Common characteristics and a Etiology

Most of the cases described have the following common features:

• The incidence is not universal. Not all workers in the same building are affected, but it is common to find several cases in the same group.
• It is usually associated with office work with computer equipment, although not always administrative (also cleaning and maintenance).
• Most cases have occurred in modern buildings Most cases have occurred in modern buildings — smart, airtight, lacking natural ventilation, or smart, airtight, lacking natural ventilation, or following changes or moves to new buildings equipped with new furniture and/or renewal of IT following changes or moves to new buildings equipped with new furniture and/or renewal of IT equipment.
• In most cases, a significant reduction in the relative humidity of the environment has been observed, and it is common for affected workers to report frequent episodes of electrostatic discharges in their work area.
• Once the environmental conditions or factors have been corrected, the clinical signs of lipoatrophy progressively disappear between 9 months and 4 years.
• It is predominantly observed in women, who are more susceptible to accumulate electrostatic charges, possibly due to a laxer structure of the superficial adipose tissue.
• Affected workers do not present other general alterations. • There is no current scientific evidence of specific effects on the embryo or foetus in case of pregnancy.

Causal Hypothesis

There is insufficient scientific evidence on the causes of LSOL. However, the main risk factors identified, and which should be prevented from the design of workstations are: microtrauma due to repeated pressure on the affected area, low relative humidity and electromagnetic fields [6-8]:

1. Low relative humidity below 45% (objectively measurable).
2. Presence of electrostatic charge higher than 2 KV (objectifiable)
3. Electromagnetic fields of weighted values with respect to the limit curve of the ICNIRP98 (International Commission on Non-Ionizing Radiation Protection) limit curve for the public > 100% (objectifiable)
4. Pressure, compression in injury areas (subjective objective) The current hypothesis on the causes of LSOL is based on the induction of lipolysis by electric and magnetic fields generated by computer equipment and its cabling. The greater or lesser presence of lipoatrophy in other areas would be due to the different bioelectrical properties of the skin, depending on the region. Is possible that electrical stimulation of macrophages causes a release of tumour necrosis factor (TNF α) that would damage adipocytes and facilitate lipid phagocytosis.

Diagnosis

SLOO is currently considered to be primarily diagnosed clinically (visual inspection and palpation of the skin lesion) and has no evaluated complementary diagnostic test that would substantially improve the diagnosis. In cases of suspected SLOO, when visual inspection and palpation are doubtful, a new examination should be performed a few weeks after the first visit to confirm or rule out the diagnosis.

Treatment

There is no specific treatment. The lesions reverse after elimination of the triggering factors [5,8-12]:

Ensure a relative humidity level of not less than 50% throughout the working day.

• Avoid contact with the edges of worktable tops by re viewing the design and work procedures. Adjust the height of the chair to avoid contact of the thighs with the tables, by resting the feet on the floor or footrest. Do not rest your feet on the legs of the chair.
• Avoid materials that generate or accumulate static electricity. Antistatic products can also be applied to surfaces susceptible to retaining electrostatic electricity (chairs, tables, etc.) in the form of a spray or varnish.
• Improve the electrical insulation of the wiring with respect to the metal structures of the furniture. Collect all electrical cables that may be under the tables and remove any cables that may be in contact with the tables.
• Replace thin edges with rounded edges. This would increase the contact surface. This would increase the contact surface and reduce the intensity of the shock.
• Get up from the chair and walk around at least every hour.
• Maintain good, seated ergonomics.

Do not wear fabrics with artificial fibres (acrylic) when the accumulation of static electricity is important and avoid tight fitting clothing as far as possible.
• Maintain good hydration with water.
Most cases show progressive resolution over a period ranging from 3 months to 4 years.

Material and Method

Proposed Assessment and Anamnesis

Take a medical history with assessment of pathological antecedents in order to determine other pathologies that may be related to semicircular lipoatrophy, such as systemic panniculitis, scleroderma, lipoatrophy caused by antiretrovirals, or by injection of insulin or corticoids; the latter are compatible with linear skin atrophy and hypopigmentation due to this intra articular injection given the antiproliferative effect that alters the metabolism of the proteins of the extracellular matrix (3,4). There is no evidence of personal history that could be relevant. However, some studies link a congenital defect of the lateral femoral circumflex artery as a predisposing factor. It is important to detail the characteristics of the onset of the lesions, time of onset, coexistence with other symptoms and whether similar lesions were previously present and their evolution, as well as the involvement of other coworkers. If a case of lipoatrophy is detected, information should be sought on the areas frequented by the affected person affected person [4,8,11,13]

• Air conditioning, ventilation, and humidification system.
• Electrical installation around the table where the case occurred. In this case
• The installation is understood to include the wiring of any consumer appliances that may be present.
• Type of flooring and treatments carried out.
• The presence of telecommunications signal amplifiers or possible emitters of electromagnetic fields.
• Electromagnetic fields.
• Shape of the furniture with which it is in contact. Observing the edges and checking for the presence of wiring inside.
• Check that chairs have antistatic treatment.
• Checking that work equipment is in good condition (operation, earthing, appearance, etc.).
• Check that work equipment is in good condition (operation, earthing, appearance, etc.).
• Check that the relative humidity of the air is at least 50%.
• When it is considered that the values of electromagnetic fields may be higher than those of the European regulations, it will be necessary to measure in the spaces closest to the person affected.
• Electrostatic charges should be measured when occupants report electrostatic discharges. The aim is to ensure that the person concerned does not become electrostatically charged or frequently discharged.
• The conductivity of materials in space should be checked to ensure that they assist in dissipating electrostatic charges [14,15].

Results

After the collection of data based on health risk factors such as physical, chemical, biological factors or due to situations in the building or construction and the environment and workplace and their influence on the clinical variables and the occurrence of injuries, the following proposal for a clinica l data collection form has been detailed (Table 1).

Conclusion

When dealing with semicircular lipoatrophy of occupational origin, it is important to consider the health risk factors that may have led to its development and its consequences, which can be found in documentation produced by official bodies (WHO, State Public Health Agencies, etc.). These factors are sometimes intangible to the naked eye, but they affect our health, their effects are rarely immediate, and it is difficult to associate them with any symptomatology. Based on the exposure risk factors and the results of the checks and data collected, technical proposals for correction can be established to be taken into account in the development of the work activity in the work environment and workplace.

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Journal on Medical Science

Is it what we See with the Eyes?

Euglena is a single-celled organism that represents the first organism with a light-sensitive structure with numerous chloroplasts, which is truly the first step in history towards the human eye. Transduction is the mechanism in which photoreceptors transform the optical energy of light into electrical energy as part of the evolution of the eye. In such a way that the human eye captures shapes and images, converts them into an electrical signal, which passes to the optic nerve and from there to the brain in the visual cortex, in this way the image is processed and thus allows its interpretation in the medium [1].

Radiological Anatomy

Only 25% of the content of the bony orbit corresponds to the eye, the eyeball on average measures 23 mm while its wall is 2 mm thick, it is made up of three layers from the outside in, the outermost layer is the cornea and the sclera, the middle layer or uvea, are composed of the ciliary body and the choroid. This choroid is the layer that is enhanced with the injection of intravenous contrast given its constitution with abundant blood vessels and the deepest or inner layer. formed by the retina, which in turn is the composite portion of the neuroepithelial type. Inside the eyeball there are also three chambers: the most superficial chamber, the anterior chamber that is located between the cornea and the iris where the anterior angle is located for the drainage of the aqueous humor, the posterior chamber that is located between the iris and the iris. anterior part of the vitreous body that contains the lens and the ciliary body that are producers of the aqueous humor and the vitreous chamber, a segment that is occupied by the vitreous humor, of gelatinous consistency with approximately 99% water content. From a functional ophthalmological point of view, it can be considered only the anterior segment that includes the cornea, the anterior chamber, the iris, the ciliary body and the lens. Posterior segment that includes sclera, choroid, retina and vitreous body [2-4].

The retinal axons travel backwards through the orbit, entering the brain through the optic canal to form the chiasm, where the temporal retina is ipsilateral and the nasal retina is contralateral, from there it goes to the optic tracts until it synapses with the cells of the retina. lateral geniculate body and finally to the occipital visual cortex Images 1A- 1E. For anatomical and didactic purposes, the retina can be divided into four retinas: the nasal retina, which receives information from the temporal field, the temporal retina, which receives information from the nasal visual field, the upper and lower retina, so that the upper visual field Its information is processed by the lower retina and the information from the lower visual field by the upper retina Images 2A & 2B. The cones and rods are photoreceptors located in the retina, responsible for the synapse with the bipolar cells, which in turn form the second synapse with the ganglion cells, the axons of these cells form the fibers of the optic nerve. The optic nerve is covered by the meninge, cerebral extension and instilled by cerebrospinal fluid [3-5,6]. Light enters the eye and crosses the optically active components until it reaches the retina. These components pass through all layers of the retina to stimulate the photoreceptors in its outermost layer. Here the impulses are modified by the accessory cells of the retina that are before passing to the proximal external of the ganglion cells. Once activated, the ganglion cells transmit the action potential of their distal axons that go from there to the nerve fiber layer of the retina, then the axons converge to form the optic nerve. The optic nerves go from the posterior pole of the eye, run intraconally towards the superior orbital fissure in the chiasm, join the contralateral optic nerve, only the nasal retina crosses, while the temporal retina continues ipsilateral in the chiasm the ganglion cells that arise from the nasal retina join the axons of temporal ganglion cells [7,6].

The optic tracts arise from the chiasm and pass posterolaterally around the brain stem. Each of the optic tracts contains axons from the contralateral nasal hemiretina and the ipsilateral temporal hemiretina. Most of the fibers end up synapsing in the lateral geniculate body. Lateral geniculate body constitutes a small oval thickening of the pulvinar of the thalamus, consists of six layers of cells in which the axons of the optic tracts synapse. Each layer of the lateral geniculate body contains a complete and ordered representation of the contralateral visual field, here the information of luminosity and colors of the retina is processed, the axons of the nerve cells of the lateral geniculate body exit to form the optic radiation. The superior quadrigeminal tubercle located on the posterior surface of the midbrain. part of the fibers that do not end in the lateral geniculate body, pass through the brachia pontis and go to the superior colligeminal tubercle, its circuits generate movements of the head and eyes or movements to objects of visual interest, it connects with the spinal nerves, the trigeminal nerve, the visual cortex, the periaqueductal gray matter, and the inferior quadrigeminal tubercle [8]. The Nucleus of Edinger Westphal is a parasympathetic nucleus located at the level of the periaqueductal gray matter. Its preganglionic axons run next to the third cranial nerve and at the orbital level they synapse in the ciliary ganglion. Through the short ciliary nerves, they innervate the ciliary muscle for accommodation of the lens and the sphincter of the iris for pupillary contraction Images 1A-1E.

Optical Radiation

The fibers of the optic radiation are the axons of the nerve cells of the lateral geniculate body. The beam subsequently passes through the retrolenticular part of the internal capsule and terminates in the visual cortex.

Primary Visual Cortex

The primary visual cortex is located at the level of the calcarine fissure on the medial surface of the brain, which corresponds to Brodman’s area 17. Higher-order visual areas are located in Brodmann areas 18 and 19 that surround area 17. Retino is organized topically. It emits projections to higher-order visual areas of the occipital, parietal, and temporal lobes. These functional pathways are intended for the perception of the shape of the stimulus, the color and the movement of the stimulus [7].

“I see you with my eyes!”.

It is a common phrase, but false. The function of seeing is a global function of the nervous system and only neurons intervene in it. Other types of structures participate in seeing well. To see is to be aware of the information that the visual pathways collect, conduct and deliver, interpret it, recognize it, be able to store it in memory and call it when you want or when you need it, with the possibility that the latter may occasionally occur. that we neither want it nor need it. An individual, who has lost his eyes, does not see

But another person with healthy eyes, but with damage to very precisely defined structures and regions in the brain, does not see either. If this damage is not total, it is possible that you receive light and images, but you cannot interpret or recognize them, which does not allow a cerebral visual function, it is not seeing, in the final and complete sense of the term [9-11]. Let’s see what this is like. The optic pathways run from the retina, inside the eye, to the back of the brain, the occipital lobes. Images 2A & 2B Optical images are analog when received on the retina(to), which is a nervous structure. There they are encoded to convert light energy into electrical energy, that is, a stream of electrons (digital images) that travel at high speed through the optic nerves [12-15]. (b)And Optical Tapes (c) Until reaching the thalamus (d), Where they make a neuronal relay to arrive, through optical radiation(and), to the primary visual area in the cortex of the occipital lobe(F). Image 3 But digital images are not visible. To do this, once we reach the primary visual cortex. (F) are analyzed, identified, decoded and retransformed to analog through two synaptic steps to neighboring secondary visual areas. (g) and tertiary (h) and then they see each other. That means we see with the brain and not with the eyes. (scheme 3).

The image above shows the similarities between viewing with optical pathways and viewing images captured by a video camera on a television screen. The camera receives analog images that its computer systems encode and transform into digital (electron flow). In that format they travel to the VCR where they are analyzed, identified and encoded to continue to the television where they are finally decoded and transformed into analogue, that is when we see them. There are some problems left to solve, not for us, but for our entire vision system. [14,15] The first is the inversion of images, a problem known for a long time in so-called dark cameras. Images 4A & 4B. A closed box that allows the passage of light Images only through a small perforation on one of its faces will project, on the opposite face, the image of the object presented, but inverted: from top to bottom and from left to right. That’s a camera obscura. If we place a plate of sensitive photographic film on the back of that camera obscura, the image presented is fixed on it, with the inversion already described. This is a camera. Images 5A-5C Human eyes are dark chambers with the characteristics we already described.

The image shows the inversion of the letterFand the inversion of the place of the colors also occurs, horizontally and vertically. Humans have two eyes in front, which allows us to have stereoscopy, to see in third dimension, to know the depth of the different objects that are offered to us. A single, large central image, which occupies the entirety of our visual field, is received by each eye almost completely, excluding the lateral extreme portions, each of which is only perceived by the eye on the same side. But the single image is received in each eye inverted horizontally and vertically. Images 5A-5C If we see them from above, the same thing finally happens, but with a different strategy. At the level of the optic chiasm, the fibers that go externally in the optic nerves thus continue through the optic tracts and to the occipital cortex. Those that come from the inside are crossed in the chiasm and are placed inside in the bands and up to the occipital cortex, but on the opposite side. The final result is that, to the visual areas of the brain, the occipital lobes, inverted images arrive horizontally and vertically and in separate quadrants, since there is no physical communication, at that level, between the cerebral hemispheres and the visual areas. cortices above and below the calcarine fissure From all this it turns out that the image of this dancer, image 6, when it reaches its final destination to be seen and recognized (gnosia), does so divided into quadrants and inverted in the horizontal and vertical planes (Image 6).

Conclusion

From here and from this moment, how do you do it, what are the steps and pathways that the brain takes to reconstruct the images so that we see them well? I don’t know, but I also know that no one knows for sure. I won’t have to know anymore.

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Journal on medical science

Is it what we See with the Eyes?

Introduction

Radiological Anatomy

Figure 1

Figure 2

Optical Radiation

Primary Visual Cortex

“I see you with my eyes!”.

Figure 3

Figure 4

Figure 5

Figure 6

Conclusion

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Open Access journals on surgery

The Impact of Early Warning Sign (EWS): Perception of Nursing Staff at Aster Sanad Hospital, Riyadh City, Kingdom of Saudi Arabia

Introduction

Early Warning Signs (EWS) Score systems are based on seven parameters using an assessment of the patient’s physiological response. The seven parameters include respiration, systolic blood pressure, temperature, pulse, oxygen saturation, additional oxygen, and the level of patient awareness [1]. Patient safety relies on nurses’ timely assessment and actions. Thus, EWS has been recommended and implemented to enhance patient safety by ensuring that patient deterioration is recognized and addressed in health care [2,3]. Deterioration is a risk to all in‐hospital patients and includes the risk of suffering a Serious Adverse Event (SAE) such as cardiac arrest, unplanned admission for intensive care, and unexpected death. The majority (84%) of patients have abnormal vital signs prior to SAE, suggesting that some can be prevented if abnormal vital signs are detected and acted upon by nurses and clinicians [4]. Kruisselbrink et al in Uganda found that after using the EWS, the mortality rate of patients’ critical illness in 7 days was only 5.5% and 41.4% of the patients could be discharged. This also showed that EWS contributes greatly to improving the quality of health services [5]. A previous study conducted by Janwar O et al recruited 48 nurses at a private hospital in Eastern part of Indonesia, revealed that nurses’ knowledge about EWS significantly influenced their actions. In this case, related to patients’ management [6].

Despite the use of the EWS, there are still problems in nurses’ detection of patient deterioration and of errors in the EWS and non-adherence to referral protocols has been highlighted.

It is argued that the effectiveness of the EWS is dependent on its users [3]. Factors influencing the use of the EWS have been highlighted, such as motivation, clinical relevance, meaningfulness [7], recording of vital signs, communication, practitioner engagement [8], ward culture, staffing, skills and knowledge [9]. Although there are some studies of the EWS implementation process [7,10,11], little is known about how hospital nurses perceive and react to the EWS in clinical practice and how the working context. By exploring the introduction of the EWS to nursing practice, with a focus on nurses’ perceptions and reactions as potential factors that affect the use of such a system, gaps in knowledge of the implementing of the EWS system will be illuminated. Therefore, the aim of this study was to assess hospital nurses’ perceptions to EWS at Aster Sanad Hospital in Riyadh, KSA.

Methods

Sample and Participants

The study was carried out using a quantitative approach, involving a cross sectional study from November 2021 until February 2022. There were 88 nurses involved from Aster Sanad Hospital in Riyadh, KSA. The convenient sampling method is used in this study with inclusion criteria of the nurses that include work in the wards that utilize EW.

Data Collection

Data collection was conducted through electronic-based questionnaires consisting of two parts. Part A involves socio-demographic data on years of experience, area of practice and educational level. Part B of the questionnaire contained queries regarding statements related to EWS. The answers on self-perceived 21 perception items were reported in 5-choices categories such as “strongly disagree”, “disagree”, “neutral”, “agree”, and “strongly agree” and scaled from 0 to 5. Then, perception assessments were performed by using Likert’s scaling system as follow: positive perceptive (promoter) (scores: 71-105), neutral perceptive (passive) (scores: 36-70) and negative perceptive (detractor) (scores ≤ 35)

Ethical Considerations

The study was approved by Committee from Aster Sanad Hospital. Participant’s anonymity and guaranteed confidentiality of any delivered information were emphasized as well as insurance about declining participation would not have managerial consequences.

Data Analysis

Data was analyzed by using a computer program called Statistical Package for Social Sciences (SPSS V. 21.0). The analyzed data presented in tables and figures designed by Microsoft Excel 2010. Frequencies with proportions (percentages) were reported for categorical variables and means with Standard Deviations (SDs) were reported for continuous variables. One-way ANOVA was used to compare the perception score’s mean values between more than two independent categorical variables. All P. value considered as significant if less than 0.05.

Results

In total this study recruited 88 nurses and their working units were detailed in Figure 1. Figure 2 revealed that, 54(61%) were registered nurses, 20(23%) were head/administrative nurses and 14(16%) were charge nurses as shown in Table 1, the majority of the nurses had diploma degrees (n= 53; 60.2%) and more than 5 years working experience (n= 56; 63.3%) Table 2 showed the nurse’s perceptions toward EWS, in technical aspects the majority of the participants mentioned they aware about EWS policy and procedure (n=44; 50%) and the action for each EWS score (n=46; 52.3%), able to interpret EWS criteria (n=55; 62.5%), confident enough to utilize EWS criteria (n=45; 51.1%), fully engaged with EWS criteria (n= 53; 60.2%), competent to complete EWS documentation (n=54; 61.4%), competent enough to escalate EWS score if met its criteria (n=5; 64.8%) and competent enough to follow each intervention based on EWS criteria (n=57; 64.8%). Concerning to patient’s related aspects, the majority of the respondents agreed with that EWS criteria increase patient safety (n=50; 56.8%), reduce unplanned ICU transfer (n=50; 56.8%), prevent deterioration to code blue (n=46; 52.3%), prevent further deterioration to death (n=44; 50%), and not prefer follow patients vital sign records without EWS (n=37; 30.7%). According to the training and educational aspects, the most of the nurses stated they were received enough training of EWS criteria (n=56; 63.6%), interested to share their experience in EWS criteria (n=48; 54.5%), capable to training EWS as a speaker (n=36; 40.9%), confident to teach EWS to new staff (n=48; 54.5%), recommend other hospital to implement EWS (n=51; 58%), and nursing quality provide them with the appropriate feedback with the knowledge and skills during the audit (n=53; 60.2%) As demonstrated in Table 3, by using Likert’s scaling system, the average perception scores of our study group was 86 points (range= 61-105 points), and the vast majority of them 82(93.2%) were positively perceptive toward EWS criteria (Table 3).

Figure 1

Figure 2

Table 1: The education degrees and experience years of nurses (N=88).

Table 2: The nurses’ perceptions to Early Warring Sings statements (N=88).

Table 3: The nurse’s perception scores by Likert’s scaling system (N=88).

Table 4: The correlation between perception scores and nurse’s characteristics.

Note: a By ANOVA test.

The correlation between nurse’s characteristics and perception scores illustrated in Table 4, in which the highest scores were significantly associated with supervisors as well as obstetric and gynecological wards nurses (P. value= 0.008), master’s degrees (P. value = 0.025) and more than 5 years’ experience (P. value = 0.045).

Discussion

This study explored hospital nurses’ perceptions and reactions to EWS in the working context among 88 respondents. In general, the overall perception gained by study participants was encouraging since the vast majority of them (93.2%) answered positively toward EWS, which indicates EWS showed to be important to the nurses in different traits. This is in line with findings of recent Swedish study of Spångfors M et al who also reported that the nurses positively perceptive toward EWS criteria in their hospitals [12]. The effectiveness of EWS is dependent on user engagement with the tool and compliance [3]. Technical wise, the majority of our study respondents agreed with the statements of that they are aware, confident and competent regarding EWS policies, utilization, documentation, interpretation, engagement and also escalating, this condition is probably caused by the nurses’ initiative to participate in internal training. Therefore, training is needed to improve the level of knowledge of the nurses which eventually generates good quality professional nurses. This is a huge concern as the nurses are part of healthcare delivery team, so they need to become knowledgeable and aware about EWS to prevent medical malpractice or promote better care for patients. Although, Ludin S identified that the nurses in her study were lacked knowledge in EWS scoring and consequently detecting the risk of deterioration by patient’s condition. The researcher suggested that nurses must improve their skills and awareness of EWS criteria [13].

On the other hand, it is important to note that more than one-half of the nurses (51.1%) stated EWS consume the nursing care time, and this could be attributed to their busy schedule or presumably maybe due to the lack of understanding EWS criteria as reported in the study of Anati L and Salizar M in Malaysia [14], and this issue should be considered by nursing staff administration. EWS has been recommended and implemented to enhance patient safety by ensuring that patient deterioration is recognized and addressed in health care [2,3]. This fact was confirmed in this study since most of the nurses stated that EWS is meaningful and significant in identifying patient deterioration in different scopes such as increasing patient safety, reducing unplanned ICU transfer, preventing deterioration to code blue and even the death. Consistently, Jørghild K et al found that the overall perception gave by the nurses was they have a strong commitment to EWS criteria and scores to achieve optimal patient safety and thus prevent deteriorations [3]. Also, nurses in the study of Caroline S et al mentioned that the EWS criteria are expressive and important in identifying patient deterioration [15]. In systematic review of Saab M, et al. who analyzed 10 studies, the perception of nurses is that EWS scoring is important to detect patients’ health problems, then, to identify the intervention needed to reduce the incidences of medical emergency and serious adverse events of patients [16].

For no doubt, training and education are cornerstones for any medical management and intervention. Therefore, it is important to improve the practice of EWS among nurses through training or further information/ education provided by institutions or hospitals. Most of the nurses in our study stated they were received enough training and education about EWS criteria and they capable of training and teach this criterion. Also, they underlined the particular utility value of EWS for new and inexperienced nurses by sharing their experiences and described it as a tool that could enable them to more readily identify patient’s condition. These observations were consistent with the findings of Jørghild K, et al. study [3] Significantly, the present study showed that, the highest perception scores towards EWS were encountered among supervisors, advanced educational degree (master’s degree), and more than 5 years experienced nurses (P. value< 0.05). These findings were in agreement with the studies of Peter G, et al. [17] Mackintosh, et al. [18] in United Kingdom those reported that the senior/supervisor nurses more tend to have positive attitude and perceptions towards EWS. In same line, Janwar O, et al. reported good knowledge and perceptions to EWS was associated with longer experience years above 2 years [6]. When categorizing nurses according to their workplaces and units, this study showed positive EWS perceptions were associated with obstetric and gynecological wards nurses (P. value< 0.05).

However, Spångfors M et al reported the good adherence and positive perceptions to EWS were highest in surgery and orthopedics and lowest in the cardiac high dependency unit [12]. The limitations of this study could be summarized in a single-center study design that could not permit us to generalize these findings. Also, we did not examine the direct influence of EWS practicing on patients’ outcomes, therefore further studies are needed to examine the actual effects of this criteria on patients by measuring incidences of death and adverse side effects among them.

Conclusion

The presents study concluded that, the vast majority of our nurses were positively perceptive toward EWS criteria, and agreed with EWS criteria are meaningful and significant in identifying patients’ deterioration, as well as they recommend other hospital to implement it. Moreover, the highest perception scores towards EWS were encountered among supervisors, obstetric and gynecological wards nurses, advanced educational degree (master’s degree), long experience years above 5 years. Furthermore, sustainable nurses training of modified and updated EWS criteria are recommended to ensure knowledgeable, aware and professional nursing staff.

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Journals on Medical drug and therapeutics

Outpatient Pharmacy Service Delivery on Hypertensive Patients in St Elizabeth, St Patrick, and Holy Family Hospitals

Introduction

Globally, there has been a drastic change from product-oriented to patient-oriented care in the provision of pharmaceutical care [1]. The relevance of understanding the satisfaction of patients is widely recognized in providing responsive, quality healthcare delivery. Satisfaction, therefore, becomes essential, as selective choices are made by patients themselves and by institutional healthcare providers. According to Jackson and Kroenke [2] healthcare quality is an indicator that needs to be redesigned or restructured to improve patient satisfaction. Many studies have emphasized the significance of patient opinions as an important instrument for tracking and handling as well as enhancing the quality of service. In Ghana, the Ministry of Health (MoH [3]), in a five-year programme identified patient’s satisfaction as a key to quality healthcare and service delivery (MoH [3]). The Ministry in addition acknowledged the improvement of patient’s satisfaction and quality healthcare as one of the prime objectives of health sector reforms in Ghana [3]. Reports confirm that various factors such as income, insurance statuses and perceived health are predictors of patient’s satisfaction for healthcare services provided (Lee, et al. [4]). Other factors identified are the availability of prescription of medicine, accessibility, patient’s experience of health facility visits as well as attitude of service providers at the pharmacy (Eshetu and Gedif, Ahmad, et al. [5]).

According to the World Health Organization (WHO), hypertension is a worldwide public health concern that leads to cardiac complications such as stroke, renal impairment, premature deaths, and disability [ 6]. Current global hypertension data have also shown that its occurrence and casualties have increased between 1990 and 2015 (Forouzanfar, et al.[7]). In Ghana, hypertension incidence and its noticeable effect on disease and death have been increasing in the last four decades according to population studies Wiredu & Nyame, [8]. Reported evidence shows that hypertension is placed second on the causes of morbidity in outpatients aged 45 years and older (Addo, et al.[9]). Sanuade, et al. [10] in their study further remarked that knowledge of hypertension, therapy and control with medications among the populace is still poor. The Ghana Health Service in 2014 thus estimates a prevalence rate of 29.9% males and 27.6% females with hypertension among adults, 18years and above (Obirikorang, et al. [11]). Apart from human causes, the poor management of hypertension has been associated with a weak healthcare scheme. Service delivery, and specifically pharmaceutical care, that is satisfactory to patients, play an essential role in promoting adherence to medications and ultimately, improved health outcomes. Thus, a failure in the quality-of-service delivery could significantly impact the extent to which medication regimes are poorly adhered to, thereby resulting in medical complications, which tend to drain health care funds greatly (Oswald, [12]). This study, therefore, seeks to assess the impact of outpatient pharmacy service delivery regarding hypertensive patients’ satisfaction in some selected hospitals in Ghana.

Research Problem

The failure to adhere to medicine therapy is a growing concern in the healthcare sector, relating to poor treatment failures, which results in a rise in blood pressure that cannot be controlled. The World Health Organization (WHO) estimates that approximately 50% of medication non-adherence occurs in patients who have chronic disease and about 25% of patients who undergo medication therapy for a rise in blood pressure, do not achieve the optimum blood pressure (De Geest & Sabaté, [13]). The situation in Ghana does not differ, as a study indicated that 66.7% of patients with hypertension comply with their medications (Boima, et al. [14]). Furthermore, Jimmy and Jose [15] stated that, medication non-adherence occurs as a result of several factors such as inaccessibility and frequent medication shortage, apathy of pharmacy staff, increase in medication cost, long waiting time, poor patient-provider communication and relationship among others. Subsequently, research by IFPMA [16], revealed that the non-adherence to hypertensive medication therapy results in reduced health outcomes such as hypertension complications, causing about 9.4 million deaths each year. The IFPMA further specified that deaths resulting from cardiovascular complications such as heart diseases and stroke are approximately about 45% and 51% respectively [16]. Non-adherence, therefore, negatively affects health systems, families, patients, and the state as a whole. Frequent hospitalizations associated with such complications deprive patients of working; making them a financial burden to their relatives and the public at large. Likewise, their quality of life is decreased because complications like stroke causes restricted body movements, which could further lead to depression. Additionally, the funding of health facilities becomes a big issue due to frequent hospitalization, resulting in shortage of medications and a reduction in human-resource efficiency. It is therefore necessary to enhance compliance to avoid complications and decrease the adverse effects on health systems, relatives and patients (Brown & Bussell, [17]). Bajorek, et al. [18] suggest the active participation of pharmacists in hypertension management by improving treatment and the quality of life of their patients thereby decreasing chronic disease burden.

Numerous researchers have evaluated the satisfaction derived by patients from healthcare services and have found a correlation between overall patient fulfillment and the five dimensions of quality of service (Aghamolaei, et al. [19-23]). However, studies by some scholars suggest that little is known about the satisfaction derived by patients from pharmaceutical services offered to patients with chronic conditions such as hypertension (Al-Jabi, et al. [24, 25]), and Ghana is no exception. In addition, authors such as Swanson, et al. [26], Assefa, et al. [27] and Kelly [28] confirmed scanty research carried out between the overall satisfaction of patients and in healthcare service delivery. This current study thus, will seek to evaluate outpatient pharmacy service delivery on hypertensive patients’ satisfaction provided by at Hwidiem St Elizabeth Hospital, Techiman Holy Family Hospital and Offinso St. Patrick hospital in Ghana based on the five service quality parameters of the SERVQUAL model using Reliability, Assurance, Tangibility, Responsiveness and Empathy as independent variables and the dependent variable being Hypertensive Patient Satisfaction.

Research Aim

The aim of this study will be to assess the impact of outpatient pharmacy service delivery on hypertensive patients’ satisfaction in three hospitals, namely: St Elizabeth Hospital, Hwidiem, the Holy Family Hospital, Techiman and St. Patrick hospital, Offinso in Ghana.

Research Objectives

The Specific Objectives are:

1. To evaluate the effect of reliability of outpatient pharmacy service delivery on hypertensive patients’ satisfaction.

2. To assess the level of assurance of outpatient pharmacy service delivery on hypertensive patients’ satisfaction.

3. To investigate the level of responsiveness of outpatient pharmacy service delivery on hypertensive patients’ satisfaction.

4. To examine the degree of empathy of outpatient pharmacy service delivery on hypertensive patients’ satisfaction.

Research Questions:

1. How does reliability of outpatient pharmacy service delivery affect hypertensive patients’ satisfaction?

2. To what extent has the level of assurance of outpatient pharmacy service delivery affected hypertensive patients’ satisfaction?

3. How does the level of responsiveness of outpatient pharmacy service delivery affect hypertensive patients’ satisfaction?

4. What is the degree of empathy of outpatient pharmacy service delivery on hypertensive patients’ satisfaction?

Assumptions

The researcher adopted the explanatory sequential mixed method approach (qualitative and quantitative) since that appropriately addressed the research questions and achieved the research objectives. The qualitative part of the study was achieved through interviews while the quantitative approach focused on self-administered closed-ended questions. According to Bryman & Bell (2015) the quantitative approach is used by positivists; believing that studies with a deductive approach follow the path of Theory, Hypothesis, test, and Confirmation/rejection. This approach uses deductive logic in which the researcher started with a hypothesis or a set of hypotheses and collected data, which was used to determine whether empirical evidence existed to support that hypothesis or set of hypotheses. It is also believed to be more scientific and objectively oriented, by making its replication easier. Therefore, for the set of hypotheses formulated for this study to be accepted or otherwise, a quantitative approach was used. Subsequently, the researcher is of the belief that, the use of both the quantitative and qualitative approaches, assisted to a large extent in achieving the study’s objectives and answered the research questions.

Significance of the Study

This study highlighted the degree of fulfillment offered to hypertensive patients and how efficient management of these patients resulted in a better health outcome. In addition, the research outlined the shortcomings pertaining to patient’s satisfaction of services delivered by the outpatient’s department. It further served as the basis for appropriate reforms to be made by other hospitals and healthcare facilities in terms of policy. Again, the study is beneficial to researchers, serving as a reference source in conducting comparable future studies.

Scope of the Study

The study covered St. Elizabeth Hospital, Hwidiem, Holy Family Hospital, Techiman and St. Patrick hospital, Offinso, which serve as the main referral points for all major health facilities in the area, providing specialist healthcare services. The research, therefore, focused on the impact of outpatient pharmacy service delivery on hypertensive patients’ satisfaction of these hospitals, in relation to the five service quality dimensions. More so, Pharmacy staff, specifically pharmacists and pharmacy technicians, were selected for interviews during the research period. This was restricted to those that have worked at the outpatient pharmacy for at least one (1) year, where their work roles and service delivery involved direct contact with outpatients.

Review of Relevant Literature

This section reviewed a number of articles, reports and books discussed by various scholars on service delivery in the outpatient pharmacy department on hypertensive patients, which answered the research questions outlined by this study. Accordingly, the empirical studies assessed and summarized different findings, conclusions, methods and recommendations from literature, which centered mainly on the area of study. After reviewing the literature, further research gaps were identified which this research somewhat addressed through the research questions. Moreover, an operational model was constructed, which discussed variables (dependent and independent as well as the moderating variables) relating to outpatient pharmacy service delivery and hypertensive patients’ satisfaction. Variables in this construct served as the main guide in realizing the objectives of the study.

Theoretical Framework

(Defee, et al. [29]) postulated that every good research should be grounded in theory. As a result, this study will align itself with Principal-Agent theory and confirmation and disconfirmation theory of customer satisfaction which will resonate very well with this study.

Principal-Agent Theory

Economists developed the principal-agent theory or model in the 1970s that deals with situations in which the principal is in the state to induce the agent −to perform some tasks in the interest of the principal− but not necessarily the agent’s [30]. The theory aids to investigate the role of Outpatients Pharmacy Staff and record the management of patients’ compliance and satisfaction as agents of the healthcare service delivery. Donahue (1989) elucidates that patients as agents must play their roles as elected agents. As cited by Krawiec [31], compliance with the directives by health professionals may resolve a principal-agent problem (Langevoort, 2002). Waterman & Meier [32] posits that despite the widespread referencing of the principal-agent model, the model and how its assumptions fit the problem to be studied are barely discussed. The reverse may also hold true in certain circumstances. The principal-agent model, as applied in disciplines such as sociology, political science and public administration is, in essence, a theory about contractual relationships between buyers and sellers (Ross, 1973; Zeckhauser, [33]). Essentially, the execution of quality health care will require the application of the contractual relationship between the institution providing the service (principal) and the receiver of the service (agent). It is a known fact that information irregularity exists, which is an advantage to service providers (a Physician or Pharmacist) over the agent (a Patient).

Principals, therefore, seek to manipulate and mold the behavior of agents, so they will act in a manner consistent with the principals’ preferences (Waterman & Meier, [32]). This is, however, seen as a weakness of the principal-agent theory, where the principal or the agent takes advantage of each other due to distorted information. The contractual arrangement played a critical role in Mitnick (1973 and 1975) establishment of an institutional or regulatory principal-agent model. Rather than focusing on buyers and sellers, in exchange the author, Mitnick, examined the relationship between agents in the regulatory bureaucracy and their political principals (legislator and interest groups). This relationship is prevalent in the public sector administration where in the implementation of the Quality Health Care, State Institutions acts as agents on behalf of the principal (Ministry of Health for the Government) in the execution of the tenets of the principal. The agent is required to represent the interest of the government in the course of discharging their duties. Further to this, Mitnick (1980) framework included a network of agency relationships generated from such dimensions at the level of consent between agent and principal regarding the agent’s actions (whether or not a contract exists, a contract which may be formal or informal), the sources of requirements of the agent’s acts, and the level of discretion disclosed by the agent. The author added that agents could be motivated by the public interest or by their peculiar narrow interest. The author stressed that since agents enjoy information advantages over political principles, the regulators are thus seen as agents to be policed to adhere to the public interest goals of some principals (Ministry of Health). This study is, therefore, deeply rooted in the principal-agent theory because it resonates well, in principle, and in practice.

Expected Service, Perceived Service and Customer Satisfaction Theory

Parasuraman, et al. (1985) in their research, established a very strong relationship between quality of service and customer satisfaction. When perceived service quality is less than expected service quality customer will be dissatisfied (Jain & Gupta, [30]). High perceived service quality will therefore result in increased customer satisfaction (Saravanan & Rao, [34,35]) since service quality is a precursor to satisfaction. Subsequently, a positive influence on a customer’s satisfaction will motivate the customers to patronize the services constantly. Parasuraman, et al. (1988) posited that if expected quality of service and actual perceived performance is equal or approximately equal, customers experience satisfaction. It is further presumed that a negative discrepancy between perceptions and expectations (performance-gap), causes dissatisfaction while a positive discrepancy leads to consumer delight. This study is, therefore, deeply rooted in the Customer Satisfaction theory because it resonates well, in principle, and in practice. The American Customer Satisfaction Index (ACSI) model of customer satisfaction, establish the relationship between service quality, expectation and perception as demonstrated in Figure 1 below. This framework according to Fornell, et al. [35], shows that the measure of perceived quality is based on two key components of consumption experience: customization and reliability.

Figure 1

Empirical Studies

A number of research works conducted in the healthcare sector has found a relationship between patient’s satisfaction and healthcare quality. A summary of these reviews is represented in Table 1 below.

Table 1: A summary of empirical studies.

Research Gaps

A careful review of extensive literature on patient satisfaction based on the service quality dimension using the SERVQUAL model shows that most studies, which focused on this area, lumped together all departments of the hospitals; Mahmoud et al. [36], Wesso [37], Sathish, et al. [38], Tharanga, et al. [39], Zarei, et al. [40], Al-Damen (2017), Haryeni and Yendra (2019), Naik Jandavath and Byram (2016), Pekkaya et al. (2019), Fufa and Negao [41] and Sie [23]. The results from these studies might therefore be regarded as biased since the differences in business activities of the various healthcare departments were not taken into consideration in the analysis of results. Studies by other scholars suggest that little is known about the satisfaction derived by patients from pharmaceutical services offered to patients with chronic conditions such as hypertension (Al-Jabi, et al., [24]; OPAGS, [25]), and Ghana is no exception. Furthermore, authors such as Swanson, et al. (2007), Assefa, et al. [28] and Kelly [28] confirmed scanty research carried out between the overall healthcare service delivery and patients’ satisfaction.

Conceptual Framework

In this section, a conceptual framework constructed in Figure 2 below, shows the relationship between the independent or explanatory variables: reliability, assurance, tangibility, responsiveness and empathy, the dependent variable (patient satisfaction) as well as the moderating variables; mode of payment and number of antihypertensive medicines prescribed. This relationship established will direct the researcher in confirming or rejecting the hypothesis set.

Figure 2

Explanatory Variables

Reliability: It reflects the ability of businesses to perform the promised service dependably and accurately. According to (Parasuraman, et al. [42] this dimension shows whether a company is reliable in providing the service, as promised. More so, reliability reflects a company’s consistency and certainty in terms of performance, which Yousapronpaiboon and Johnson [43] recognized as the most important dimension for the consumer of services.

Assurance: Assurance includes knowledge and courtesy of employees and their ability to inspire trust and confidence. This dimension quantifies the knowledge, skill and technical abilities of the service provider from the client’s view. It is a combination of the following components from the original SERVQUAL model, communication, credibility, security, competence and courtesy. Employee attitude towards the patient: their friendliness, politeness among others is also a key factor (Daniel & Berinyuy, [29]).

Tangibility: In this regard, Parasuraman, et al. [42] describes tangibility, mainly as how the service provider’s physical installations, equipment and people are. In relation to the health sector, it makes reference to how the physical environment of the hospital appears to the patient- the neatness, how it looks good and modern, accessibility, staff appearance and attire among others. The physical atmosphere may have a psychological impact on the patient either positively or negatively. This is arguably the least important dimension for the client according to some literature from the use of the SERVQUAL model (Yousapronpaiboon & Johnson, [43]).

Responsiveness: It indicates the willingness to help customers and to provide prompt service. The main issue raised is whether company employees are helpful and capable of providing fast service without wasting time. This dimension is critical to the customer’s satisfaction of the quality of care (Yousapronpaiboon & Johnson, [43]).

Empathy: It is the provision of care and individualized attention to customers and regarded as a function of the interactions between client and employee. This dimension deals with the capacity of a person to experience another’s feelings. Most customers expect that the delivery of services is not done in a robotic manner, which does not take into account their presence or feelings. Subsequently, their expectation is that the employee relates to them in an amiable manner with courtesy, serenity and calmness.

Predictor Variable

Patient Satisfaction of Quality Healthcare: The WHO, therefore, defines quality care as the extent to which health care services provided to individuals, and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable, affordable and people centered. Similarly, the Institutional Care Division of Ministry of Health, Ghana, defines quality of health care as the proper performance (according to standards) of interventions that are known to be safe, affordable to society and impact positively on morbidity, disability and mortality. Hospitals have always been a place that provides the population with complete healthcare, both curative and preventive. In the hospitals, quality of care is measured with two metrics: patient outcomes and patient satisfaction. As a result, a patient’s satisfaction increases his or her willingness to recommend, improves trust, loyalty and the rate of patient compliance and in addition decreases the number of lawsuits. Shan, et al. [44] argued that service quality is usually regarded as the antecedent of patient satisfaction. However, according to Kravitz [45], a patient’s perspective of quality, effective service is often dissimilar to that of healthcare providers, administrators, and family supporters. A patient’s view of care thus, influences their overall treatment outcome (Berghofer, et al., 2001). Generally, patients are satisfied by the quality of healthcare given, based on a range of factors such as promptness of care, a healthy personnel attitude, regard for and rights of patients, privacy and confidentiality, appropriate data, accessibility of medications and safe environmental conditions (Boateng, [46]). Consequently, the need for patients’ opinions coupled with quality assurance of treatment outcome data has increased the demand for patient surveys in the past decade (Meehan, Bergen, & Stedman, [47-110]). Ultimately, survey responses are used as an effective tool to assist healthcare providers in developing interventions in order to increase patient satisfaction and improve treatment outcomes. This is increasingly being used to assess the competence of healthcare providers and the quality of care. Patient satisfaction surveys need to be conducted from time to time to determine the indicators of patient satisfaction so that health facilities can continue to modify their service delivery to suit the patients’ needs.

Methodology

The methodology focused on the research approach, research paradigm, research design, population, sampling size and technique, data-collection tool, method of data analysis, validity and reliability, limitation of the study and ethical considerations.

Research Approach

According to Creswell (2007) and Johnson & Christensen [9], adopting the explanatory sequential mixed method approach is appropriate for conducting a high-quality study. The explanatory sequential mixed method approach was adequate in answering the research questions in addition to the corresponding hypothesis. The researchers found it necessary to seek the views of experts at the Pharmacy Unit at selected hospitals on “Impact of Hypertensive Patients’ Satisfaction Regarding Outpatient Pharmacy Service Delivery.” Again, the five-point Likert Scale questions were applied in assessing the opinions of the study population through a well-structured questionnaire. Moreover, this approach brought together both convergence and divergence views and further consolidated the findings to satisfactorily achieve the objectives outlined in the study.

Research Paradigm

The pragmatic philosophical stance was adopted for this research because it aligns well with the explanatory sequential method of both quantitative and qualitative approach. Pragmatics is of the opinion that the appropriate and right research method and approach very well answers the research questions and hypothesis. It is worth mentioning that the pragmatic philosophical stance is considered a problem-oriented approach that takes care of the limitation of both the qualitative and quantitative approach. The study under investigation (Outpatient Pharmacy Service Delivery on Hypertensive Patients’ Satisfaction: A case study of Selected Hospitals in Ghana) is a multi-faceted case and therefore, adopting just the positivist paradigm will not be appropriate hence the adoption of the two approaches because of the complexity of the study. This assertion is strongly affirmed by Creswell (2007) and so the adoption of closed-ended questions and in-depth interviews from the targeted management staff to evaluate Hypertensive Patients’ Satisfaction Regarding Outpatient Pharmacy Service Delivery was good for this research work, to get varied views in analyzing and discussing the convergence and divergence views to enrich the findings. In a nutshell, the pragmatic philosophical stance stresses perceptions and diversity of events and people, which aligned well with the study in terms of the problem outlined in the study organizations.

Research Design

The study adopted the explanatory sequential design based on the complex nature of the case. The explanatory sequential design combines data from secondary sources such as articles, textbooks, newsletters, official records, dissertation, online journal along with closed-ended questions and primary data gathered through interviews as suggested by (Berman, 2017). For the primary data, in-depth interview was gathered from key experts from the selected hospitals, to evaluate Hypertensive Patients’ Satisfaction Regarding Outpatient Pharmacy Service Delivery while closed-ended questions were collected in addition to the primary data, thus the qualitative data. The design met the expectation of the study by addressing the case study problem and appropriately answering the research questions alongside the hypotheses.

Research Population

The study population comprised of patients and experts from St Elizabeth Hospital, Hwidiem, St. Patrick’s Hospital, Offinso and Holy Family Hospital, Techiman The distribution of the study population is illustrated in Table 2 below.

Table 2: Population, Sample Size and Technique.

Sampling Size and Technique

The study adopted the pragmatic philosophical stance, which aligns with the mixed method approach. As such, this research applied different sampling techniques. With regards to the quantitative method, the study employed the stratified random technique. This technique was adopted since the staff considered for this study were in different stratums of the Hospitals. This gave each stratum an equal chance of being selected. Likewise, to ensure a high degree of transparency and fairness regarding the quantitative approach, the researchers employed the Research Advisors (2006). A sample size of one hundred (100) was appropriate for a with a confidence level of nine five percent (95%) and a margin of error of approximately two and half percent (2.5%). Again, a purposive sampling technique was applied to the qualitative aspect of this study. This technique was employed to elicit the views of top management (experts), at the Pharmacy Unit having comprehensive knowledge on Hypertensive Patients’ Satisfaction Regarding Outpatient Pharmacy Service Delivery, to consolidate with the quantitative data. The principal investigator (PI)) was the Hospital Administrator responsible for the general running and supervision of (Finance, Stores, plants & grounds, secretarial, transport departments) at the St Elizabeth Hospital Hwidiem, which is a non-profit making Catholic Health Institution and is duly registered under the Christian Health Association of Ghana (CHAG). Essentially, the researcher’s years of experience make her understand and is mindful of the fact that Hypertensive Patients’ Satisfaction Regarding Outpatient Pharmacy Service Delivery is one of the clinical issues in recent times. Thus, the researcher’s drive and curiosity on this problem led to this study. The researchers’ interest is to examine how the variables in the study are being adhered to and implemented in the face of Outpatient Pharmacy Service Delivery of the selected hospitals. The researchers’ position is therefore a mere investigator wanting to probe into and further gain a better understanding and appreciation of the problem under investigation. Finally, the researchers’ comprehension of the subject area helped in asking insightful questions on the qualitative aspect of the research work, and consolidate the quantitative data, making this study more robust.

Discussion (Main Findings)

Understanding the satisfaction of patients is widely recognized in providing responsive, quality healthcare delivery. Satisfaction, therefore, becomes essential, as selective choices are made by patients themselves and by institutional healthcare providers. As identified in the research gabs of several principal investigators, the SERVQUAL model was useful for this research with 98 respondents participating in the research from the three hospitals out of 100 people planned. The study revealed that a high number of respondents from the three hospitals where the research was conducted were very satisfied with the service at the pharmacy departments. In St Elizabeth Hospital, 88% of respondent indicated that, staff of the pharmacy department understand hypertension very well and they are always ready to help when attending to them. Some of the respondents indicate that, at times, they are offered alternative drugs when the prescribed drugs are not available. One respondent indicated that the pharmacy staff also offer pieces of advice on how they should live in terms of diet. In Holy Family hospital 82% of respondents also stated that they were satisfied with the services of the pharmacy department when it comes to services rendered to hypertension patients. At the St Patrick Hospital, 87% of respondents expressed happiness about the services of the pharmacy staff. When it comes to gender 71 % of the respondents were male whiles 29 % were female. This seems to indicate that, when it comes to hypertension, many adult males have the condition more than adult females. The minimum age recorded in this study was 33 years adult male. The oldest was 81 years adult male. Three respondents indicated that the staff of the pharmacy department have time for them more than the clinic staff, because there are so many people at the clinic.

Another interesting finding was that some of the respondents indicated that, because they come for review frequently, the pharmacy staff know them or are familiar with their condition. As compared to the staff at the clinic, the respondent said that there is a frequent change of staff at the clinic and therefore they are not familiar with the patients. This is significant and answers research questions one and two. The services at the pharmacy department is reliable and assuring for hypertension patients. Again, because the three hospitals are in semi-rural communities, 31% of the respondents say their faces are familiar and that made them have good interactions with the pharmacy staff. “They dare not treat us badly as I know 4 of them very well. We attend the same church”, said one respondent. The smaller the community, the good interaction they had together. The three pharmacists of the three hospitals interviewed stated that, their staff cannot afford to give bad service because they have a monitoring system to check services rendered to their clients. “Hypertensive patients are mainly adults and, in our culture, adults are respected, therefore it will be strange for our staff to treat them badly in this small community despite our established protocol in the department”, a pronouncement from a pharmacist”. One interesting thing mentioned was that, because the three hospitals are sister institutions under the Christian Health Association of Ghana (CHAG), they have a common monitoring system that help them to operate at optimal service level for all their patients and not necessarily, the hypertension patients alone.

Conclusion

This study has highlighted the fulfillment offered to hypertensive patients and how efficient management of these patients is resulting in a better health outcome. Respondents who participated in the research stated that they are happy with the services rendered to hypertensive patients. The services are reliable and assuring. Some major factors that account for the reasons is that the staff at the pharmacy departments spend a lot of time on hypertensive patients, educating them on the medication. Another factor was that they go to the hospitals frequently for review and have become familiar with the staff. The staff at the pharmacy department work there more permanently than staff at the clinic who are changed sometimes. This makes the patients more familiar with the staff at pharmacy departments and brings cordiality as well as satisfaction. Again, the common monitoring system of health facilities under the Christian Health Association of Ghana also plays a significant role in offering hypertensive patients good service.

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Journals on Medical Casereports

Undesirable Transformations of Certain Nutrients During Pre-Processing and Protection Against them

Introduction

Such transformations occur in the content of protein, simple carbohydrates, vitamins and other substances. The main reasons for them include improper thermal regime, atmospheric oxygen, various types of microflorae, high water content, hydrogen ion concentration, sunlight, composition of packaging material, etc., and the consequence is a change in the quality of food and the appearance of undesirable, and sometimes harmful substances. Such a wide variety of factors and completely different chemical composition of food make the researcher look for optimal solutions for processing and storing certain types of food. Based on the above, we approached this issue primarily taking into account their chemical composition, in particular, understanding the possible reaction of the factors listed above to the substances (Protein, carbohydrates, excess moisture, etc.) included in their composition.

Results of the Research

Features of Processing and Storage of High-Protein Foods

In this case, the subject of our research was pollen – pollen grains, that bees collect as a source of basic nutrients (except carbohydrates), a product with high biological activity, perishable under natural conditions, with moderate (20-30%) moisture content and abundantly infected with yeast fungi [1]. The bee itself solved this issue in the process of evolution by carrying out lactic acid fermentation in a product placed in honeycombs, but it is quite difficult for a person to remove the product stored in a honeycomb and already turned into bee bread, not to mention its ecological purity, the volume of a marketable product is reduced due to the sharp seasonality of work. Man has developed simple methods to collect raw pollen from bees (see Figure 1- pollen collector) and dry it (Figure 2). For the last operation, it is recommended to use a simple drying cabinet with a thermal regime of 35-40°C. Obviously, this regime makes the drying process much longer (20-48 hours, taking into account its initial humidity) (Figure 3). A negative consequence of this process is the low stability of labile ingredients, especially in terms of preservation of carotene and amino acids (lysine, phenylalanine, arginine). During the comparative testing of drying units of different designs, we preferred a vacuum dryer. In addition, it was observed that: if the residual pressure does not exceed 0.05 kg/cm², and the temperature ranges from 60-65°C, then the drying process lasts 75-90 minutes, and the residual moisture content is 4 wt.% on average.

Figure 1

Figure 2

Figure 3

It should be noted that under these conditions, the temperature in the material to be dried does not rise above 45°C, which is explained by the increased release of heat and water vapor from the vacuum dryer. The fact that the negative effect of atmospheric oxygen on the preservation of carotene and amino acids is significantly weakened in vacuum conditions cannot be regarded as a factor contributing to the improvement of drying, in particular, the carotene content in the test sample of pollen (drying in vacuum) was 8.5 mg%, in the control of the sample (drying in a conventional drying cabinet 40-45°C) this indicator was 7.94 mg%, of Lysine- 3.23 and 2.55 mg%, respectively; of Arginine -4.21 and 1.27; of Phenylalanine -1.94 and 1.35. In the test group of bee colonies, which were given vacuum-dried pollen mixed with candy, the area of an adult brood at the end of the experiment was 29.4 dm², the same indicator of the control group was 25.5 dm². Furthermore, it should be noted that volatile essential oils – an important biologically active substance – are much more intensively lost in vacuum, which can be considered a disadvantage of this method. At the next stage of the work, we made bee bread from dry pollen without a bee colony (honeycombs).

The advantages of this step include clearly the best ecological purity of the pollen, the opportunity to do work literally all year round, and for the collection of pollen – during 5-7 months of the active season, reduction of labor costs by almost 40%, the duration of conservation of bee bread has been reduced from 2.5 weeks to 50 hours, using selective strain of lactic acid bacteria. This was also due to the fact that the mixture created the necessary minimum of simple sugars for the functioning of lactic acid bacteria, and also used a neutral gas-carbon dioxide was used both during incubation and storage of the finished product. Accordingly, the market price of finished bee bread has decreased from $100 to $64 per kg, which will significantly increase the consumption of the product by the population with the results obtained. To determine the biological activity of the bee bread made by the above technology, the sample was incubated with Clostridium botulinum spores, placed in a thermostat at 37°C for 10 days, after which a sample of bee bread was given together with the main feed to an experimental group of white mice. The control group received regular food (without bee bread) [2]. During the experiment, all numbers of mice were maintained, i.e. the bee bread inhibited the ability of Clostridium botulinum to multiply and produce toxin (Report of R.Lugar laboratory, Tbilisi) [3].

This product was also tested in the Microbiological Laboratory of “Biotex” LLC by including it in a meat-peptone agar on which strains of Escherichia coli and Staphylococcus aureus were incubated. Within 24 hours, the diameter of their inhibition zones was 33 and 31 mm, respectively. Unfortunately, we did not have the opportunity to determine the effect of bee bread made in this way on the condition of patients with the Covid-19. Due to technical difficulties, we were also unable to determine the level of carotene retention compared to the initial product using an improved research method (Biehler, et al. [4]). In addition, it would be very interesting to implement the entire process of product preparation (including final humidity conditioning) in the neutral gas zone.

Processing and Storage of Foods Rich in Simple Carbohydrates

Such products include fruits and honey. The water content in fruits is very high, and the fructose-rich raw materials almost do not emit water at low temperatures (<45°C) during the drying process. Prolonged low-temperature drying and the same process in short-term, but high-temperature conditions dramatically worsen the appearance of the product; Due to the oxidation of phenolic compounds, Badagi (grape juice) darkens, and 5-hydroxymethylfurfural, harmful to health, is formed. Under these conditions, it is very difficult to produce high-quality canned fruits, and conditioning of unripe honey (concentration 75-79 wt.%) takes several hours (Tew [5]), which leads to a further increase in the above-mentioned harmful substances. According to our observational data (certificate #5870, 2014), the intensity of thickening of solutions or liquid mechanical mixtures increases dramatically due to an increase in the surface area of liquid evaporation (a decrease in water content by 15-17% every hour) [6]. In this case, the intrinsic temperature of the solution becomes a secondary factor, due to the installation of a special device in a standard-sized boiler, this area can be increased several times, which allows to achieve intensive evaporation of the solvent at a temperature of 50-60°C.

Following this regime, at the beginning of the research, we developed a technology for the production of honey substitute – invert sugar for bees, in which the temperature required for concentration starts from 62°C and ends at 68°C, reaching a concentration of 82-83 wt.%. According to the testing laboratory “Multitest” (Georgia), the content of 5-hydroxymethylfurfural in invert syrup made using this technology did not exceed 5 mg/kg [7]. The same indicator ranged from 83 to 713 mg/kg in canned fruit brought from the International Food Exhibition in Istanbul (2017), as well as from Georgian enterprises. Below are photos of jams and purees prepared using these technologies, clearly indicating a sharp increase in the oxidation of phenolic compounds (Figures 2-4). Relatively low temperature used for canning (<70°C) excludes the possibility of the formation of caramelans.

Figure 4

Grape Juice Processing

When using grape juice in production of Churchkhela, Georgian delicacy, by traditional technology, a radical change in its color is observed- intensive oxidation of phenolic compounds above a temperature of 50°C, which indicates a high content of these substances in juice. Substances successfully used as antioxidants by various authors: sulfuric anhydride, polyacrylamide, and others (Tsereteli, 1995) (Shatirishvili [8]), protected this product from darkening. Sulfuric anhydride, used by us for a similar purpose, effectively purified juice from sediment for 36 hours, although sometimes granular Clinoptilolite (3-5 mm in size) had to be used for the same purpose. At the completion of this process, grape juice thickened to 82-83 wt.% at a temperature of 52-57°C was characterized by sufficient transparency and crystallized in a short time (2 weeks) (the result of excess glucose) to form a gray-white, fairly dense dough. This gives us an opportunity to make the Churchkhela production process permanent, that is, to get rid of seasonality (more equal provision of the market), while hydrogen ion concentration in juice before treatment and after concentration was almost the same and was pH 3.9.

This indicates that SO₂ is removed along with water vapor during the concentration of juice. As for 5-hydroxymethylfurfural, we conducted a qualitative analysis of it by the effect of hydrochloric acid resorcinol on diethyl ether extract (after evaporation of the ether) (Fiehe’s test). The control sample was presented by the Churchkhela dough prepared in the traditional way (50% juice+ a mixture of wheat flour as a result of prolonged cooking). The results of the analysis are given below (Figures 5 & 6). In the production of Churchkhela, it is worth noting that the product made in the traditional way, after drying in natural conditions, becomes very dense, which negatively affects its commercial qualities. It can be seen that there is no substance in grape juice that can break down starch, which is present in large quantities (48-57%) in flour. The enzyme α-amylase was used to correct the condition. As a result of carrying out a certain amount of experimental works, we achieved the formation of saccharides of a simpler structure in the required amount in the flour suspension maintaining sufficient elasticity of the dough in the finished product without violating the integrity of the surface: The internal rotation angle of the product was reduced from 1800 to 1460, which turned out to be a satisfactory indicator in terms of increasing the attractiveness of the product for the consumer [9].

Figure 5

Figure 6

Reducing the content of simple sugars in canned fruits has become very relevant in the current century, because their excess in the human body is accompanied by undesirable complications, especially when using folk methods: as a rule, the proportion of food sugar in the finished product significantly exceeds the amount of dry matter of the main raw material. In our research, we focused on the use of invert syrup (>67 wt.%) instead of crystal sugar, given that invert syrup penetrates more easily into the product to be processed, thereby contributing to the removal of excess water from the fruit. Immediately after the initial processing of the fruits, they were carefully put into a heated (> 400°C) syrup, to which the antioxidant SO₂ was previously added, the mixture placed in a container was kept in a thermostat at 65 ± 2⁰C for 2 hours, after which the syrup concentration was reduced to 50-54 wt.%. The syrup drained from the container was condensed to 70-72% and poured back onto the fruit in the container. Through such step-by-step processing (with an increase in the concentration of syrup in the intervals up to 83-84%), the total concentration of jam increases to 81-82 wt.%, not accompanied by a decrease in the quality of jam during the shelf life. At the end of the process, the fruits were separated from the syrup and dried by enhanced aeration, and after transfer to the commercial vessel, the atmospheric air was replaced by carbon dioxide, providing complete preservation of the appearance, taste properties (absence of excessive sweetness) and, accordingly, pH (Figures 7 & 8) of the finished product.

Figure 7

Figure 8

Conclusion

1. To remove excess moisture from a food product with low heat resistance, solid, granular structure, it is preferable to limit the drying process to vacuum drying, with a residual pressure of no more than 0.05 kg/cm2 in a move that provides the desired temperature within 45-50°C and a duration of 75-90 minutes. This makes it possible to preserve biologically active substances (carotene, amino acids), antimicrobial properties of the product as much as possible, to use neutral gas (for example, CO2) for the incubation of anaerobic microbes for the same purpose, during the drying and storage of the finished product;

2. To process liquid low-concentrated fruit juices containing simple sugars and phenolic compounds, it is advisable to use an antioxidant (sulfur anhydride), for concentration – innovative technology based on an increased evaporation surface area that prevents the formation of substances harmful to health (5-hydroxymethylfurfural, caramelans);

3. To preserve a product with a high protein content and a relatively low water content while maintaining its biological activity, it is advisable to use lactic acid fermentation by specific bacteria, with the necessary minimum of simple sugars, with their further conversion into organic acids, which makes it possible to create the necessary amount of hydrogen ions (pH) in the product to be canned to avoid the process of protein decomposition.

4. Making jams from various fruits with minimal consumption of food sugar is facilitated by using concentrated (>67% by weight) invert syrup, which more easily replaces the water in the fruit. By gradually concentrating the syrup used, the total concentration of jam increases to 81-82 wt.%, which ensures the shelf life of fruits by preserving their presentation without syrup, which is enhanced by placing fruits in an oxygen-free vessel.

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Journals on Medical Microbiology

Comparison of Two Mandibular Advancement Devices in the Treatment of Obstructive Sleep Apnea: The Effect of the Vertical Mouth Opening

Introduction

Obstructive sleep apnea is a sleep respiratory disorder that is characterized by total (apnea) or partial (hypopnea) obstruction of the upper airway during sleep, causing snoring, sleep fragmentation and intermittent hypoxia [1]. Clinically, it is characterized by daytime hypersomnia, snoring and pauses in breathing during sleep. This disease, with time, may produce important health problems like arterial hypertension, cerebrovascular accidents, infarctions, immune alterations, cognitive and sexual disturbances, and higher mortality [2,3]. OSA is a prevalent disease that could be present in more than 50% of the population, as estimated by Heinzer, et al. [4]. The main symptom of OSA, daytime hypersomnia, has serious consequences on the familiar, social, and professional life of the patients [5]. For that, obstructive sleep apnea is an important public health problem. Mandibular advancement devices (MADs) have been considered a simple, silent, minimally invasive, tolerable, and effective treatment for snoring and mild to moderate sleep apneas [6,7]. They are also an alternative treatment for those patients who cannot tolerate or do not want to use continuous positive airway pressure (CPAP) machines [8]. MADs support the mandible in a forward position and prevent it from falling backwards, bringing forward the base of the tongue, causing pharyngeal stretching and reducing the collapse of the upper airways [9].

In addition, recent studies confirm their efficacy in improving daytime sleepiness, AHI, cardiovascular health, improved arterial oxygen saturation levels and arousal frequency [6]. In adult patients, MADs can achieve an estimated mean reduction in AHI of 13.60 events/h (95% confidence interval (95%CI): 15.57-12.20) [6]. They have a modest improvement in minimum oxygen saturation (a mean of 3.09% (95% CI: 2.43-3.76)) and reduction in oxygen desaturation index. They also reduce the rate of micro-arousals but do not appear to have a significant effect on sleep architecture or efficacy [6]. MADs also improve quality of life and reduce blood pressure (between 2- and 3-mm Hg), which is like the blood pressure reduction obtained by CPAP [6]. The design of the MADs could be a factor that may influence their efficacy, safety, or the adherence to therapy. The range of mandibular advancement, the degree of mouth opening, the type of material and the process of fabrication of the MADs are factors that may affect their efficacy, safety, and patient’s adherence to therapy [10,11]. For example, the degree of mouth opening should be optimized not to increase the risk of mandible falling backwards and thus altering the device efficacy [10]. The risk of having side effects is increased by the increase in the magnitude of mandibular advancement [12,13]. For that, there is a need to personalize the optimal mandibular protrusion that results in the highest reduction in the Apnea-hypopnea index (AHI) and in producing the least side effects.

The adherence of the patients to the treatment with MAD would be the net outcome of patient’s subjective enhancement, comfort, and side effects. Currently more than 100 different oral appliance designs exist on the market that differ in the type of material used, the position of the junction between the upper and lower part of the appliance, the possibility of titration, the degree of customization, the magnitude of the vertical opening and the lateral movements of the jaw [14]. Therefore, there is a need for comparative studies that assess the efficacy, side effects and adherence to therapy of different MAD. Two of these devices are BTI DIA and Orthoapnea device. Both devices share several characteristics including the control of mouth opening, pull mechanism, occlusal stability, and freedom of lateral movement. However, they differ in the degree of vertical mouth opening required to fabricate the device, the initial advancement, the anteroposterior freedom of movement and the position of the coupling mechanism. For that the purpose of this study has been the comparison of these two types of MADs in the treatment of OSA.

Materials and Methods

This observational and retrospective study has been performed following the STROBE guidelines for observational studies. The study was performed in a single private center (Clinica Bisheimer, Madrid, Spain) between January 2018 and December 2021. It was performed according to the 1964 Helsinki declaration and its later amendments. All patients signed informed consent. Patients were selected according to the following criteria: diagnosis of obstructive sleep apnea, treatment with BTI DIA (BTI Biotechnology Institute, Vitoria, Spain) or Orthoapnea device (Orthoapnea, Malaga, Spain), had finalized the titration of the mandibular advancement device and had at least two sleep studies (one before treatment and one after titration). Patients who did not fulfill these criteria were excluded from the study. Patients starting treatment between January 2018 and December 2019 were treated with Orthoapnea device and patients starting treatment between January 2020 and December 2021 were treated with BTI DIA.

Type of devices

BTI DIA (BTI Biotechnology Institute, Vitoria, Spain): the device was prepared using thermoforming plastic sheets and vacuum pressure (1.5 mm in thickness for the mandible and 1 mm for the maxilla). For each splint, two metallic buttons (one on each side) were fixed on the lateral surface of the splint. During titration, 2 plastic retainers (of different lengths) were connected to the ipsilateral buttons of the upper and lower splints. The starting position was set at maximum retrusion + 3 mm (in anterior direction). This corresponded to 25% of maximum mandibular protrusion. During titration, 2 plastic retainers (of different lengths) were connected to the ipsilateral buttons of the upper and lower splints. Orthoapnea (Orthoapnea, Málaga, Spain): the device was prepared using thermoforming 3 mm thick hard/soft sheets and vacuum pressure. The two splints were connected by inverted rod screw as described previously [15]. The starting position was set at maximum retrusion + 8 mm (in anterior direction). This corresponded to 60% of maximum mandibular protrusion. Both devices were fabricated to allow balanced occlusal forces. They controlled and limited the vertical mouth opening to avoid mandibular retrusion during sleep. They also allowed for lateral mandibular movements but only the DIA device allowed for protrusion (Figure 1).

Figure 1

Titration

After 4 weeks of the delivery of the device at the starting position, subjective (patients reported symptoms and comfort) and objective (Apnea-hypopnea index) titration was performed. Additional mandibular advancement was made at a rate of 1 mm every 2-3 weeks. The final therapeutic position was defined by the mandibular position that resulted in the maximum improvement in subjective symptoms and maximum reduction of the AHI. Thence after, the patients were recalled after 3 months to review the side effects (muscles, TMJ, device, the occlusion). A validated respiratory polygraphy (BTI APNiA, BTI Biotechnology Institute, Vitoria, Spain) was employed to perform the sleep study at the patient’s own home according to the criteria of the American Academy of Sleep Medicine. [16] The following data were extracted from the patients’ records: Type of MAD, demographic data (age and sex), body mass index (BMI; Kg/m2), neck perimeter (mm), smoking (yes/No), snoring (yes/No), excessive daytime somnolence (EDS; yes/No), observed apnea (yes/No), over jet (mm), over bite (mm), percentage of mandibular protrusion, mandibular advancement (mm), maximum mouth opening (mm), lateral mandibular ranges of movement (mm), maxilla-mandibular protrusion (mm), apnea-hypopnea index (AHI; events/h) and frequency of symptoms (muscles, TMJ) and type of symptoms management.

Statistical Analysis

The Shapiro-Wilk test was applied to verify the normal distribution of the variables. Descriptive statistics were performed. Quantitative variables following the normal distribution were described by mean and standard deviation otherwise, the median and range were used. Frequency was calculated for qualitative variables. The comparison between qualitative variables was performed by the Chi square test. Student tests and repeated measures ANOVA were used to compare quantitative data following the normal distribution. Mann-Whitney, Wilcoxon and Friedman tests were selected to compare the quantitative data not following the normal distribution.

Results

Table 1 shows the demographic data of the study groups. Sixty- one patients received the Orthoapnea device, and 56 patients received the BTI DIA device. The results show similarity between the two groups in age, BMI, smoking, ESD and observed apnea. However, the patients in the Orthoapnea group had lower neck perimeter.

The use of both intraoral devices had induced changes due to mandibular positioning in more forward position. Indeed, patients treated with the Orthoapnea device had 66% of mandibular protrusion and those treated with BTI DIA had 25% (Table 2). The median of the total mandibular advancement was 8 mm for the Orthoapnea device and 3 mm for the BTI DIA device. Moreover, the increase in the vertical dimension was higher in the Orthoapnea device (median: 9 mm) compared with the BTI DIA (median: 4 mm). Both devices showed no significant differences in relation to jaw movements although individually they increased the MMO and the left mandibular excursion (Table 2). The use of both devices had a significant effect in reducing the AHI with no significant differences between them (Table 3). The reduction in the AHI for both devices were higher than 75%. BTI DIA reduced the AHI by more than 50% in 94.5% of the patients. This value was 88.5% for the Orthoapnea device. Furthermore, 41% and 86% of patients treated with BTI DIA had an AHI < 5 and AHI < 10 events/h, respectively. Orthoapnea device had achieved these threshold values in 38% and 75% of the patients, respectively.

Table 1: Demographic data.

Note:
SD: Standard deviation
a: Student test
b: Chi square test
c: Mann-Whitney test

Table 2: Occlusion-related variables.

Note:
SD: standard deviation
a: Mann-Whitney test
b: Student test
c: Friedman test
d: Repeated measures ANOVA
e: Wilcoxon test
f: Paired Student test

Table 3: Obstructive sleep apnea data

Note: AHI: Apnea-hypopnea index
a: Mann-Whitney test
b: Chi square test
c: Wilcoxon test

Table 4 shows the changes in the severity of the OSA before and after treatment. The BTI DIA showed a statistically significant effect but not the Orthoapnea device. Interestingly both devices had a positive effect in patients reporting muscles and TMJ symptoms (Table 5). On one hand,10 patients in each group had symptoms related to temporalis and masseter muscles at baseline. Absence of these symptoms was reported by 9 patients in the BTI DIA group and 5 in the Orthoapnea NOA group. On the other hand, 13 and 12 patients reported symptomatic TMJ in the BTI DIA and Orthoapnea NOA groups, respectively. At the end of the follow-up, all the patients in the BTI DIA were asymptomatic while 4 patients in the Orthoapnea were still symptomatic (Table 6). Jaw relaxation exercises were needed in 4 and 11 patients in the BTI DIA and Orthoapnea groups, respectively. None of the patients in both groups required any occlusal adjustments, morning positioner or medications.

Table 4: Changes in the severity of the OSA.

Note:
MAD: Mandibular advancement device
OSA: Obstructive sleep apnea
a: Chi square test

Table 5: Number of patients with symptomatic muscles.

Note: a: Chi square test

Table 6: Patients with TMJ symptoms.

Note: a: Chi square test

Discussion

This study has shown the clinical efficacy and safety of the two mandibular advancement devices (BTI DIA and Orthoapnea device) for the treatment of OSA. The BTI DIA has a mean reduction of the baseline AHI of 23.1 events/h (95% confidence interval: 18.6 – 27.7 events/h). Similarly, the Orthoapnea device has achieved a mean reduction of 24.1 events/h (95% confidence interval: 19.7 – 29.1 events/h). Data from meta-analysis in adult patients has shown that the MADs can achieve an estimated mean reduction in AHI of 13.60 events/h (95% confidence interval (95%CI): 15.57-12.20) [6]. The mean difference of AHI reduction of both devices in this study has been -1.3 events/h (95% confidence interval: -7.8 – 5.2 events/h). This mean difference has a range of -5.0 to 1.9 events/h in studies that compared different MADs [17-22]. Furthermore, 41% and 86% of patients treated with BTI DIA had an AHI < 5 and AHI < 10 events/h, respectively. Orthoapnea device had achieved these threshold values in 38% and 75% of the patients, respectively. The good function of both devices could be related to the efficacy of both devices in avoiding mandible falling backwards by limiting the vertical mouth opening and retaining the mandible in the therapeutic position during sleep. Attali et al. have reported an AHI < 5 events/h in 56% and AHI < 10 events/h in 67% of treated patients [23]. Haesendonck, et al. have reported the achievement of these thresholds in 31% and 57% of the patients, respectively [24]. Furthermore, similar results have been obtained by Byun et al (31% and 64.4%, respectively) [25].

The BTI DIA device resulted in lower mandibular advancement compared to the Orthoapnea device. BTI DIA has achieved a reduction of at least 50% of the baseline AHI in 94.5% of the patients while the Orthoapnea device has achieved it in 88.5%. Indeed, the changes (toward lower degrees) in the severity of OSA has been statistically significant only in the case of BTI DIA. One of the main differences between the two types of devices is the minimum vertical mouth opening required to fabricate the device. To manufacture the Orthoapnea device a minimum increase of vertical dimension by 5 mm is required between the edges of the upper and lower incisors. This distance is needed to accommodate the screw, and the upper and the lower splints. However, in the case of the BTI DIA device, the vertical mouth opening is only needed to accommodate the upper and lower splints (Figure 1). Such a difference may explain the differences between the two devices in the amount of mandibular advancement required to treat the OSA. Mayoral et al., who used a MAD with similar characteristics to the Orthoapnea (5 mm vertical mouth opening), have shown that an 8 mm of anterior advancement of the mandible only achieved a forward displacement of the mandible by only 1.98 mm (from maximum intercuspation position) [26]. Moreover, the morphological characteristics (overbite) of the patient may influence the amount of mandibular advancement needed to treat the OSA. This is related to the effect of the overbite on the degree of vertical mouth opening.

For that, it could be better in patients with deep vertical overbite, the use devices whose design opens less the vertical dimension. Moreover, the degree of vertical mouth opening may also affect the device efficacy [10,26,27]. Excessive increase of the vertical dimension may induce posterior rotation of the mandible compressing the upper airway and worsening the treatment outcomes. To optimize the therapeutic efficacy of MADs, several studies have indicated the interest of monitoring the mandibular movements and controlling/titrating the mouth opening [26,28,29]. Indeed, Mayoral et al. have estimated a reduction of the effective mandibular advancement by 0.3 mm for every 1 mm increase in the vertical mouth opening [26]. The higher mandibular advancement in the Orthoapnea device made more pronounced the changes in the over jet and overbite. The over jet at the last follow-up was almost twice the baseline value in Orthoapnea device. Similarly, the overbite increased 1.6-fold the baseline value. BTI DIA had provoked minimal increase in over jet and minimal decrease in the overbite. Figure 2 shows the tracing of lateral cephalometric images of one patient that used both devices but was not included in the present study, wearing no device, the Orthoapnea device and the BTI DIA device (Figure 2). The tracings corresponded to the devices at their therapeutic position (final mandibular position after titration).

Although the amount of mandibular forward displacement was different (8 mm for the Orthoapnea device Vs 3 mm for the BTI DIA), it could be observed that the area of the symphysis and the lower incisors was in the same anteroposterior position. Several factors may influence the occurrence of adverse effects such as the vertical mouth opening, the distance of mandibular advancement, and the device design [12,13]. Titration of the mandibular advancement is a key element to place the mandible in the least anterior position that is effective in the treatment of OSA. In this regard, using a device that needs lower mandibular advancement would be advantageous [12,13]. The number of patients with symptomatic TMJ and muscles have been reduced in both devices but more in the BTI DIA. The good occlusal stability and freedom of lateral movements may help explain the low rate of adverse effects at the muscular and TMJ level [30]. This study has several limitations. The retrospective design, the short follow-up time, and the absence of polysomnography study at the baseline should be considered. The study included patients with severe OSA (32% in the BTI DIA and 43% in the Orthoapnea device) that may hamper its comparison with other studies. The inclusion of severe OSA could increase the feasible margin of improvements.

Conclusion

BTI DIA and Orthoapnea devices have been effective and safe in the treatment of obstructive sleep apnea. The differences in the vertical mouth opening have significantly affected the degree of mandibular advancements to treat the obstructive sleep apnea (higher for Orthoapnea device). BTI DIA has been effective in achieving a statistically significant reduction in the severity of obstructive sleep apnea. The lower degree of advancement necessary to achieve the therapeutic position by the BTI DIA makes more comfortable the use of the appliance for the patients and reduces risk factors for muscular and TMJ adverse effects.

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Journals on Biomedical Imaging

Dynamics of Height and Weight Indicators in Children and Adolescents with Type 1 Diabetes Mellitus as a Marker of Treatment Effectiveness

Background

Type 1 diabetes mellitus (DM -1), an autoimmune disease, is becoming widespread, affecting approximately 490,000 children worldwide. There are various etiological factors that contribute to the spread of its incidence in different geographical locations [1-4]. According to a multicenter study carried out in Germany in 2018, deterioration in metabolic control and dynamics of weight status in adolescent girls indicate eating disorders in the first years after the onset of DM-1 [5]. A total of 31,556 girls aged >6 months and <23 years with DM- 1 from the diabetes cohort were analyzed, including 155 (0.49%) girls with anorexia nervosa, 85 (0.27%) girls with bulimia nervosa, 45 (0 .14%) girls with binge eating disorder and 229 (0.73%) girls with unspecified eating disorders. Patient characteristics, weight changes, number of patients with severe hypoglycemia and diabetic ketoacidosis (DKA), changes in HbA1c levels, pump use. Significant differences in HbA1c levels, prevalence of DKA and severe hypoglycemia between girls with and without eating disorders were found already in first years after the onset of DM- 1. A decrease in body mass index (BMI)-SDS increased the risk of developing comorbid anorexia nervosa (7.1 times [95% CI 3.6–14.3] compared with stable BMI-SDS, 6. 9 times [95% CI 3.4–14.1] compared to the increase in BMI-SDS) [5]. The authors concluded that poor metabolic control, increased incidence of DKA, and severe hypoglycemia in the early years after onset of DM -1 may indicate eating disorders in girls with DM-1, and weight loss is specific to anorexia nervosa. These clinical features should lead to screening for eating disorders, especially in late puberty.

Authors from the USA emphasized that Weight control in DM-1 can be successfully achieved in real clinical practice. Dietary therapy, however, involves reducing energy intake and providing a structured meal plan that is lower in carbohydrates and glycemic index and high in fiber and lean protein. The training plan should include a combination of stretching, as well as aerobic and resistance exercises to maintain muscle mass. Dynamic adjustment of insulin doses is necessary during weight control. Adding anti-obesity medications may be considered. If medical weight loss is not achieved, bariatric surgery may be considered [6]. The authors noted that patients with DM-1 who exhibit clinical features of DM-2, such as obesity and insulin resistance, are considered to have “double diabetes.” Although patients with DM-1 were traditionally thought to have a lower BMI, current research has shown the opposite [5]. The trend towards increasing obesity prevalence is increasing at a faster rate in patients with DM-1 compared to the general population [6]. Currently, about 50% of patients with DM-1are overweight or obese. They also have higher waist and hip circumferences compared to healthy controls [7]. In the Pittsburgh Epidemiologic Study of Diabetes Complications (EDC), which followed adults with DM-1 for an average of 18 years, the prevalence of overweight increased from 29 to 42%, and the prevalence of obesity increased sevenfold from 3 to 23% [8]. Weight gain does not appear to be related to aging but to clinical factors such as insulin therapy [8].

Comorbid diseases, often associated with excess body weight, reduce the benefit of good metabolic control [9]. Thus, weight control in patients with DM-1is necessary due to the well-known relationship between obesity and cardiovascular disease (CVD) [10]. Metabolic disturbances associated with obesity, such as a pro-inflammatory state, are likely to alter the risk of cardiovascular disease in this population [10]. Until now, complications associated with cardiovascular diseases have been the leading cause of death in patients with DM-1 [11]. The above was the reason for our study. In this regard, we have formulated the following goal of research work.

The Aim of the Study

Study the dynamics of height and weight indicators in children and adolescents with DM-1 during treatment.

Material and Research Methods

Based on outpatient observation in Republican Specialized Scientific and Practical Medical Center of Endocrinology of the Ministry of Health of the Republic of Uzbekistan named after academician. Y.H. Turakulov, from 2021 to 2023, 50 patients with DM-1 were examined. At the same time, 23 boys and 27 girls. The average age of boys was 12.7 years, girls 11.8 years. The patients were divided into 2 groups: group 1-30 patients on intensive insulin therapy (IIT), group 2-20 patients on insulin pump injection (PII). The control group consisted of healthy children, 20 individuals.

Inclusion Criteria

Children and adolescents with DM-1.

Exclusion Criteria

Adults, type 2 diabetes mellitus, severe somatic diseases.

Research Methods

General clinical, biochemical (fasting blood glucose, blood glucose 2 hours after a meal, glycemic profile, urea, creatinine, bilirubin, direct, indirect, ALT, AST, PTI, coagulogram, CRP, glycated hemoglobin, etc.), hormonal (TSH, free thyroxine, insulin, C-peptide) and instrumental: ECG, ultrasound of the thyroid gland, internal organs, chest x-ray, fundus examination, etc. Age, sex, height, weight, age at diagnosis, number of insulin injections, total daily insulin dose, number of severe hypoglycemia events (i.e. seizures or loss of consciousness) in the past 3 months, family composition and ethnic status are all filled out by us in a specially designed questionnaire. Statistical software. Microsoft Excel and STATISTICA_6was used for statistical analysis, and p < 0.05 was considered a significant difference. Normally distributed quantitative data were expressed as mean and standard deviation (M ± SD). Analysis and results. Table 1 shows the distribution of patients by gender and age.

As can be seen from Table 1, sick children aged 8 to 12 years were most often observed: 32 cases (64%). Table 2 shows the average indicators of objective examination of boys by group. As can be seen from Table 2, the patients had significant differences in height and weight in boys of both groups compared to the control group (p < 0.05). No significant differences were found in other indicators. Table 3 shows the average indicators of objective examination of girls by group. As can be seen from Table 3, the patients had significant differences in height and weight in girls of both groups compared to the control group (p < 0.05). Table 4 shows the average values of biochemical studies of patients before treatment. Table 5 shows the average values of hormonal studies of patients before treatment. As can be seen from Table 5, patients had significant differences in the content of insulin and C-peptide of both groups in comparison with the control group (p < 0.05). Next, we studied the dynamics of objective examination data one year after treatment in boys and girls of both groups. Table 6 shows the average indicators of objective examination of boys by group.

Table 1: Distribution of patients by gender and age.

Table 2: Average indicators of objective examination of boys by group.

Note: * – significance of differences compared to control, where * – p <0.05

Table 3: Average indicators of objective examination of girls by group.

Note: * – significance of differences compared to control, where * – p <0.05

Table 4: Comparative characteristics of biochemical studies of patients in the study groups before treatment.

Note: P1 – significance of differences in comparison with control group 1, P 2 – group 2

Table 5: Comparative characteristics of indicators hormonal studies of patients in the study groups before treatment.

Note: P1 – significance of differences in comparison with control group 1, P 2 – group 2.

Table 6: Average indicators of objective examination of boys by group one year after treatment.

Note: * – significance of differences compared to control, where * – p <0.05

As can be seen from Table 6, the patients had significant differences in height and weight in boys of both groups compared to the control group (p < 0.05). No significant differences were found in other indicators. Table 7 shows the average indicators of objective examination of girls by group. As can be seen from Table 7, the patients had significant differences in height and weight in girls of both groups compared to the control group (p < 0.05). Moreover, the best height and weight indicators were in group 2 after a year of treatment. Here, patients in group 1 grew by an average of 7-8 cm, and in the second by 9-10 cm. Next, we studied the dynamics of biochemical and hormonal data one year after treatment (Tables 8 & 9). In terms of biochemical blood parameters, there was a tendency to reduce the average values of fasting blood glucose and glycated hemoglobin and 2 hours after a meal in comparison with the control level, although these values decreased significantly in group 1. At the same time, in group 2, the achievement of the target values of these indicators was reliable both in relation to the control group and with the data before treatment.

Table 7: Average indicators of objective examination of girls by group one year after treatment.

Note: * – significance of differences compared to control, where * – p <0.05.

Table 8: Comparative characteristics of biochemical studies of patients in the study groups1 year after treatment

Note: P1 – significance of differences in comparison with control group 1, P 2 – group 2.

Table 9 shows the average values of hormonal studies of patients before treatment. As can be seen from Table 9, in patients there were no significant differences in the content of insulin and C-peptide of both groups in comparison with the control group (p < 0.05). We see that in group 2 patients, the target levels of glycemia on an empty stomach, 2 hours after meals, the level of HbA1C, and insulin were significantly closer to normal than in group 1 (P<0.05). Our study showed that the dynamics of anthropometric data is an effective means of monitoring the effectiveness of treatment for children and adolescents with type 1 diabetes, along with laboratory and instrumental studies.

Table 9: Comparative characteristics of indicators hormonal studies of patients in the study groups after 1 year of treatment.

Note: P1 – significance of differences in comparison with control group 1, P 2 – group 2.

Conclusion

1. The use of insulin pump therapy has a significantly greater positive effect on all physical development compared to intensive insulin therapy.

2. The best results of anthropometry indicators (average height, average weight) were observed in patients of group 2 who received pump insulin therapy.

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