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Journal of US-China Medical Science Volume 9, Number 3, March 2012 (Serial Number 88)

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Publication Information: Journal of US-China Medical Science (ISSN 1548-6648) is published monthly in print and online by David Publishing Company located at 9460 Telstar Ave Suite 5, EL Monte, CA 91713, USA.

Editorial Board Members: Dr. George Kweifio-Okai (Australia), Prof. Andrew Paul Zbar (Australia), Prof. Xiaodong Tan (China), Prof. Qiyong Gong (China), Prof. Huixiong Xu (China), Prof. Nargis Albert Labib (Egypt), Dr. Mohamed Ebrahim Abd EL-Hamid Abou El-Ghar (Egypt), Dr. Itzik Harosh (France), Prof. Géza. László. Lukács (Hungary), Dr. Mohd Ibrahim Masoodi (India), Dr. Mari Cheraghi (India), Prof. Thamer A. Hamdan (Irak), Prof. Mohammad Esmaeil Akbari (Iran), Prof. Michele Spinelli (Italy), Khalid M. Bofares (Libya), Assi.Prof. Oana-Cristina Arghir (Romania), Assi.Prof. G. Chandramohan (Saudi Arabia), Prof. Esther Uña Cidón (Spain), Assi.Prof. Chun-Chieh Tseng (Taiwan), Prof. Kıvılcım Gucuyener (Turkey), Dr. Ghulam Sarwar Pirkani (Pakistan), Prof. Ram B Singh (Poland), Dr. Douglas Wilson (UK), Prof. Robert Eduard Suter (USA), Assi.Prof. Yang Xia (USA), Prof. El-Sheikh Enas (Yemen), Jin-ichi Sasaki (Japan) Manuscripts and correspondence are invited for publication. You can submit your papers via Web Submission, or E-mail to [email protected]. Submission guidelines and Web Submission system are available at http://www.davidpublishing.org Editorial Office: 9460 Telstar Ave Suite 5, EL Monte, CA 91713, USA Tel: 1-323-984-7526 Fax: 1-323-984-7374 E-mail: [email protected], [email protected] Copyright©2012 by David Publishing Company and individual contributors. All rights reserved. David Publishing Company holds the exclusive copyright of all the contents of this journal. In accordance with the international convention, no part of this journal may be reproduced or transmitted by any media or publishing organs (including various websites) without the written permission of the copyright holder. Otherwise, any conduct would be considered as the violation of the copyright. The contents of this journal are available for any citation; however, all the citations should be clearly indicated with the title of this journal, serial number and the name of the author. Abstracted / Indexed in: Database of EBSCO, Massachusetts, USA Chinese Database of CEPS, Airiti Inc. & OCLC Chinese Scientific Journals Database, VIP Corporation, Chongqing, P. R. China Ulrich’s Periodicals Directory Cambridge Science Abstracts (CSA) Subscription Information: Price: US$420 (print), US$320 (online), US$560 (print and online) David Publishing Company 9460 Telstar Ave Suite 5, EL Monte, CA 91713, USA Tel: 1-323-984-7526 Fax: 1-323-984-7374 E-mail: [email protected]

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DAVID PUBLISHING

David Publishing Company www.davidpublishing.org

Journal of US-China Medical Science Volume 9, Number 3, March 2012 (Serial Number 88)

Contents Technical Papers 121

Antihypertensivetherapy and Adherence to It of Patients with Hypertension and with Combination of Hypertension and Diabetes Mellitus Sergeyeva Victoria, Glukhova O. E. and Magomedova H. M.

130

Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit on Tumor Cell Lines In Vitro Asaad Abdulwahed B. Al-Asady, Khesar H. K. and Saadi S. M. Barwari

144

Human T-Lymphotropic Virus-1/2 Detected in Drug Abused Prisoners Imprisoned in Correctional Facilities in Central of Java Indonesia Afiono Agung Prasetyo, Paramasari Dirgahayu, Hudiyono and Seiji Kageyama

150

Manipulation of the Sacroiliac Joint under General Anesthesia versus Other Conservative Treatment for the Management of Post Labor Backache due to Sacroiliac Subluxation Haider Wehab Ali, Mohamed Bahjat A. Rabea and Ali H. Khudhair

157

Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program Bidyadhar Sa, Vijay Naraynsingh, A. V. C. Rao and Stella Williams

Technical Resports 165

Turkish Version of the Dutch Eating Behaviour Questionnaire: In Evaluation of Eating Behaviour among a Group of Turkish University Student Lale Sariye Akan, Ayşe Özfer Özçelik and Metin Saip Sürücüoğlu

169

A Touch-Controlled Laparoscope Manipulator: Preliminary Trial to Evaluate the Performance on Female Porcine Pelvic Surgery and an Initial Experience in A Human Robot-Assisted Laparoscopic Segmental Salpingectomy Kovit Khampitak, Yuthapong Werawatakul, Amornrat Supokhen, Suchat Wattanachai, Panisara Kunkitti and Sirivit Techajedchadarungsri

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The Proposal of QMS Implementation in Healthcare Office Stefan Markulik and Anna Nagyova

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Mar. 2012, Volume 9, No. 3 (Serial No. 88), pp. 121–129 Journal of US-China Medical Science, ISSN 1548-6648, USA

DAVID

PUBLISHING

Antihypertensive Therapy and Adherence to It of Patients with Hypertension and with Combination of Hypertension and Diabetes Mellitus Sergeyeva Victoria, Glukhova O. E. and Magomedova H. M. Department of Hospital Therapy, the Medical Faculty, Saratov State Medical University of V.I. Razumovskiy, Saratov, Russia Abstract: Among patients with hypertension and with a combination of hypertension and diabetes mellitus the majority does not reach target values of blood pressure levels. There is a number of lacks in ambulatoryantihypertensive therapy and adherence to it. The considerable number of patients continues to accept therapy nonregularly, the choice of antihypertensive drugs and their combinations is not always adequate, non-medicamental actions aren’t realized by all patients. At the same time the powerful negative contribution is associated with low adherence of patients to ambulatoryantihypertensive therapy. Key words: Hypertension, antihypertensive therapy, adherence.

1. Introduction  The arterial hypertension (AH) is the most widespread disease all over the world, its role in development of cardio-vascular complications (CVC) determines the relevance of timely and adequate antihypertensive therapy (AT) which main objective consists in achievement of target blood pressure (BP) level and the maximum decrease in risk of development СVC and death from them. Tactics of conducting each patient select individually after cardiovascular risk rating. Thus monotherapy at start of treatment can be chosen only for patients with low or average risk [1]. Combined AT allows influencing simultaneously at the set of various elements of pathogenesis AH: activation reninangiotensin-aldosterone and sympathoadrenal systems, disturbance of endothelial and kidneys function, myocardial and vessel wall’s hypertrophy.In this context combined AT has the big advantage before monotherapy and it is recommended for all patients with high and very high risk of CVC [1]. The Corresponding author: Sergeyeva Victoria, PhD, research fields: cardiology, therapy. E-mail: [email protected].

combination of diabetes mellitus (DM) and AH is a special clinical situation in which the risk of microand macrovascular defeats essentially increases. In this case combinations angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) with calcium channel blockers (CCB), thiazide diuretics (TD) in low doses, highly selective β -blockers (β-B) are most suitable. In addition tomedicamental correction all patients with AH should follow the actions for lifestyle changes (LC). They allow decreasing the BP, to reduce requirement in antihypertensive drugs (AD) and to raise their efficiency, favorably to affect at available risk factors (RF), to carry out primary preventive of AH in patients with high normal level of BP and in patients with RF. Adherence to treatment is degree of conformity of patient’s behavior (concerning reception of preparations, observance of a diet and other measures of lifestyle changes) to the recommendations received from the doctor [2]. Taking incorrect dose of the recommended medication or during incorrect time, admissions in reception and-or rejection of treatment represent various forms of disturbance of adherence.

Antihypertensivetherapy and Adherence to It of Patients with Hypertension and with Combination of Hypertension and Diabetes Mellitus

As a rule, the most frequent variant of inadequate adherence is reception of insufficient doses of medicines and admissions within 2–3 days [2]. Correlation between success in treatment of AH and adherence of the patient to therapy is obvious fact [3]. The probability of successful normalization the BP directly depends on a regularity of reception AD. The relevance of this problem is confirmed by prognostic researches executed rather recently which have shown relationship between insufficient adherence to treatment and cardiovascular risk. Besides, it is necessary to consider that bad adherence to medicinal treatment, as a rule, means also bad adherence concerning non-medicamental methods of treatment that even more interferes with decrease of BP [4]. At last, insufficient adherence to the treatment, accompanied by frequent cancellation and the subsequent renewal of treatment, increases probability of the complications connected with the first dose of reception of preparations and a withdrawal syndrome [2]. The complex estimation of ambulatory AT (both non-medicamental, and medicamental) and adherences to it of various categories of patients, including in patients with combination AH and DM became the purpose of our research.

2. Patients and Methods 190 patients with AH and with combination of AH and DM type 2 which were hospitalized in cardiological and endocrinological departments of the regional hospital of the Saratov city are surveyed. Group of patients with AH were 90 persons (69% women, 31% men), with AH and DM -100 persons (70% women, 30% men). Groups were comparable on age and sex. The average age of all surveyed patients was 57.61±0.70 years. Dominated were patients with stages II and III of AH. The average age of onset hypertension in patients with AH and DM was significantly lower than that in the group without DM (44.7±0.20 years and 47.6±0.41 years, respectively, p

122

< 0.05), that testifies to earlier onset of hypertension in patients with diabetes. Crisis course of AH prevailed in both groups (56% of patients in group AH without DM and 60% — in group AH and DM). On duration of anamnesis of AH patients were divided into groups of up to 5 years, from 5 to 10 years and more than 10 years. In group of patients with AH there was a greatest quantity of patients with the experience of disease from 5 to 10 years (37%), in group of combination AH and DM — with the experience more than 10 years — 61%. For a number socially — demographic indicators of our patients was dominated by married (77% of patients in the group AH without DM, and 90% in the group AH and DM), and on an educational level — patients with secondary education in the group with AH and DM (48%); specialized secondary education (32%) and school education (32%) — in the group AH without DM. By place of residence — 38% in the group AH without DM were inhabitants of the regional center, 36% — of towns in the region; in the group with AH and DM —51%— the inhabitants of towns in the region. The remaining patients are represented by residents of countryside. At the first investigation phase was carried out surveys of patients about lifestyle modification and drug actions to correct hypertension. The questionnaire included questions on activities of lifestyle changes, about medications received by them, their dosage, duration of therapy, the addition carried out a detailed anamnesis about the features of hypertension, its course and then the laboratoryinstrumental examination of patients to identify the stage of disease and risk. Evaluation of adherence to therapy was conducted specially developed questionnaires, including questions about the disease and its complications, character of the current therapies, including nonmedicamental correction and self-monitoring of BP. When the number of points scored 12 and above —

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Antihypertensivetherapy and Adherence to It of Patients with Hypertension and with Combination of Hypertension and Diabetes Mellitus

the commitment was considered high, 8-11- the average, less than 8 points -low or insufficient. Statistical processing of data produced with packages Microsoft Exel 2010, Stat Plus 2009 Professional.

3. Results Non-medicamental correction of AH includes a number of well-known measures. According to 4th revision of National recommendations about treatment and diagnostics of AH it includes: normalization of body weight, quitting smoking, increasing physical activity, a complex modification of diet. Many studies have confirmed the effect of overweight on the development of AH. Relevant for today is a complex modification of the diet with increasing consumption of plant foods in the diet increased potassium, calcium and magnesium, as well as a decrease in consumption of animal fats. The American Heart Association recommends a DASH diet. Its distinguishing feature is the combination of products such as fruits, vegetables and low fat dairy products. This food can enrich the body with potassium, calcium and magnesium, which is acting jointly; have a powerful effect on normalizing BP. In addition, modification of diet aims to reduce the level of total cholesterol in serum and thus prevent the progression of atherosclerosis. In the group of AH without DM in 61% of identified high cholesterol, 37% excess body weight. Despite this, only 21% of patients in this group followed a diet. In the group of AH and DM — diet complied with the majority of patients (78%), however, more than half were identified excess body weight (59%), while 78% had hypercholesterolemia (Fig. 1). That suggests that the ongoing activities not fully effective in this patient group. Low physical activity is one of the most common circumstances o of modern person, its increase is simple non-medicated influence on AH with a proven effect. Physical activity in patients was assessed by

questionnaire Godin G., Sheppard R.J. In both groups of patients it’s inadequate in more than half of cases (53% in the group AH without DM and 55% in the group AH and DM) and the correction in this direction was carried out only by 28% of patients with AH and 47% — with AH and DM (Fig. 1). The role of smoking as a negative factor in the development and progression of AH is a proven factor. In both groups, the number of smokers approximately identical: in the group of patients with AH —19% and in the group of patients with AH and DM — 15%; 53% refused this bad habit in the group of AH and 47% of patients in the group of AH and DM (Fig. 1). In general, its low level of smoking, however, considering the prevalence of patients with high and very high risk of CVC in our investigation, there should be no smokers at all. The estimation of drug therapy began with the start of therapy in both groups of surveyed patients. In the group of patients with AH monotherapy as the starting was appointed in 63%, combined therapy in 37% of patients. In the group of — AH and DM — monotherapy — at 58%, combined therapy — at 42% of patients (Fig. 3A). A detailed study of starting monotherapy in the group of patients with AH without DM found that ACEI usage is dominated (63%), β-AB is —18%, other groups of drugs — prescribed less often. Among them still there are such medicaments as Adelfan, clonidine. Monotherapy in the group of patients with AH and DM also is presented by group ACEI (75%), β-AB accounted for 9.5% of appointments, in 8.2% outdated drugs were prescribed. In appointing of the starting combined therapy in the group of AH were given preference: ACEI and diuretics — 27%, ACEI and β-AB — 20%, ACEI + β-AB + diuretic — 17%, β-AB + diuretic — 10%, the others were more rare. Combinations of drugs in the patients with AH and DM were represented mainly by imidazoline receptor agonists with other drugs (36%), and ACEI with diuretics — 33%, other combinations were less common.

Antihy ypertensiveth herapy and Adherence A to It of Patients s with Hyperte ension and w with Combina ation of H Hypertension n and Diabete es Mellitus

1244

A 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

78% 59%

61%

53%

55%

37% 19%

15%

Patien nts with AH

Patients with h AH and DM

90% 78%

80%

B

70% 60% 50%

53% % 47%

47%

40% 28%

30% 21% 20% 10% 0% quittting smoking Patients with AH H

diet

physiical activity

Patientts with AH annd DM

Fig. 1 Modiffied risk factorrs in groups off patients (A) and a level of theeir correction (B). (

Correctionn of AT ( thhe group of AH A without DM) D and taking into i account the t unachievved control off the disease was undertaken in 63% of casses, which waas as follows: in 71% — additional a m medications w were addedto theerapy, 16% of patients transferredd to long-acting form of thhe medicatioons, in 7% —

repllaced by anoother groupss of medicattions. 6% off patiients requireed reductionn of AD number n (Fig.. 2A)).Correction of o AT in the group with AH and DM M wass conductedd in 75% of cases. Change off med dication’s grroups was carried out in 45% off patiients, in 44% % — to primaary prescriptio on additionall

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Antihy ypertensiveth herapy and Adherence A to It of Patients s with Hyperte ension and w with Combina ation of H Hypertension n and Diabete es Mellitus

medications was addedd, 11% traansferred to the long-acting form of thhe medicatioons. In 54% % of patients witth AH withouut DM initiaally attempted to correct theraapy by increaased doses prrimary prescrribed drugs. In the group withh AH and DM M, such attem mpts were made at a 34% (Fig. 2B). 2 At currennt therapy estimation e inn the groupp of patients with AH despitte the absencce of BP conntrol achieved monotherapy m is maintainned in 41% % of patients, com mbined theraapy is carriedd out in 59% %; in the group with AH and DM monotherapyy is maintained in i 32%, 68% of patients taake combinattions of drugs (Figg. 3B). A detailedd study of prresent therapyy in the grouup of patients witth AH under mono thherapy as innitial therapy ACE EI is dominatted (62%), inncreased the share of CCB andd β-AB whichh accounted for 8% and 20% 2 of prescripptions, resppectively. Under U combined therapy: com mbinations off ACEI with diuretic d (30% %), 6%

Patients w with AH (A)

16%

Starting AT (A)) 80 0%

40 0%

37%

0 0% Patientts with  AH Monotherrapy

Pattients with  AH H and DM Combiined therapy

Current A AT (B) 68% 70 0% 60 0% 50 0% 40 0% 30 0% 20 0% 10 0% 0 0%

59% 4 41% 32%

Patientss with AH Patiients with AH  and DM Monotherapy Fig.. 3

transition to o the prolong A AD change to another group o of AD adding more AD reduction in n the number of AD o

Paatients with A AH and DM (B) 11% 44% 45%

traansition to the prolong AD change to anothe er group of AD ad dding more AD Correection of Atinggroups of patieents.

42%

20 0%

71%

Fig. 2

58%

60 0%

7%

0

6 63%

Combined therrapy

Therapy estimation e in th he group of pa atients.

ACEI with β-A AB (22%), ACEI with h β-AB andd diurretics (17%)) are dominnated. The analysis off assiignments in AH and DM M group show wed that thee pred dominant prroportion off ACEI (53% %), but thee num mber of presccriptions deccreased as co ompared withh starrting therapyy, but the shhare of CCB Bs increasedd (12%), ARBs haave appeared in the assign nments (18%)). In combined therapy 30% % of assig gnments aree com mbinations ACEI and diurretic — as in n the startingg therrapy, this combinationn is domiinant, otherr com mbinations baasically are ppresented by combinationn ACEI with otherrs medicationns. In 54.2% of the total num mber of patieents failed too ach hieve target BP.

Antihy ypertensiveth herapy and Adherence A to It of Patients s with Hyperte ension and w with Combina ation of H Hypertension n and Diabete es Mellitus

As noteed above, in additionn to adeqquate medicamenttal AT andd lifestyle modificationn a significant roole in controllling AH playys an adherencce of the patient too treatment. Adherence A to treatment caan be defined as “the “ degree to t which thee behavior off the patient conccerning prepaaration recepption correspoonds to the acccepted recom mmendations received from f physicians”.. All the facttors of low adherence a cann be divided as foollows: • features off the nature off therapy, • factors relaated to physiccian, • factors relaated to the paatient, • socio-econnomic factors. The reasoons for low adherence a to antihypertennsive therapy weree studied quitte extensivelyy, they are: • a large num mber of presccribed drugs, • ineffectivee monitoring of o blood pressure, • high risk or o the presence of side effeects, • no symptom ms in increassed blood pressure, • lack of aw wareness of patients p aboutt the necessitty of continuous constant c takinng AD, • high cost of o drugs. Within thhe limits of an a estimationn of adherencce to AT we havee studied the regularity r of AD A taking byy our patients. It was found that in the group with AH without DM M irregularly take t prescribed medicatioon as nearly half of o surveyed patients p — 47%, in the grroup with AH andd DM 39% adhered to nonnregular modde of taking the drugs (Fig. 4). In assesssing the facctors influencing the nonregullar receptionn in the groupp of nondiabetic hypertensivee patients, 48% % pointed to lack of compliancce with the dooctor, 18% — in good statte of health durinng increased blood pressuure, 14% — high h cost of druggs, the necesssity to receive drugs sevveral times a day indicated 11% % of surveyeed, side effectts — only 9% of patients p (Fig. 5). In the grooup of patiennts with AH and a DM are also among the main m obstacles to a constannt mode of takking drugsprevaills the lack off compliance with a physiician (41%), well-being duringg increased blood b pressurre in 20% of caases, side efffects — in 144%, necessityy to

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Paatients with h AH (A) 47% %

53% Regulaar AT Nonreegular AT

Patients with AH and DM M (B) 39% % 61% %

Regulaar AT Nonreegular AT

Fig.. 4 Mode of Atin A groups of p patients.

receeive the druggs a few timees a day is an n obstacle too keeep their admisssion in 10% of patients, an a inattentionn to th he health — in i 10%, the high cost of drrugs — in 5% % of the t surveyed this t group (Fig. 5). In n general, a high level oof was found d in 38% off patiients in the grroup with AH H and 43% — in the groupp of AH A and DM. The average level of adheerence was — in 42% 4 of the group with AH and in 51% of thee exaaminees in thee group of AH H and DM. Th he remainingg patiients have a low adherencee to AT. There T have been b some rregularities on o adherencee leveel in various groups of pattients: it was significantlyy high her in womeen (11.8±0.5 points comp pared to menn 8.9± ±0.6 points, p < 0.05), iin unemployeed (12.0±0.77 poin nts comparedd with workinng patients 10.5±0.7, 1 p< 0.05 5), in inhabittants of townns of the region (12.1±0.66 poin nts) compareed with residdents of otherr settlementss (thee inhabitantss of Saratoov 10.2±0.7 points, thee inhaabitants of viillages – 8.7± ±0.4 points, p < 0.05). Inn add dition, significcant differencces (p < 0.05 5) in terms off adh herence to theerapy emergeed between the groups off patiients with higher education (12.1±0.8 8 points) andd school educatioon (10.1±0.1 points). Diifferences inn marrital status in terms of adheerence are no ot obtained. A

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Antihy ypertensiveth herapy and Adherence A to It of Patients s with Hyperte ension and w with Combina ation of H Hypertension n and Diabete es Mellitus

5% high cost o of drugs

10% 14%

Patients w with AH and D DM

inattentio on to health

20% 41% %

necessity of multiple dru ug reception 

14%

side effectts

11% 9%

P Patients with A AH

well‐beingg at an elevated d pressure

18%

Insufficien nt compliance

48% 0% Fig. 5

10% %

20%

30 0%

40%

50%

60%

Factoors affecting th he nonregular reception. r

higher level of adherennce among women mayy be indicative of greater attention to their health, organizationn, and greatter confidencce to physiccian. Inhabitants of cities inn the regionn are also more m committed to therapy than t inhabitaants of Saraatov, which may indicate i a greeater employm ment of people in the city, lackk of free tim me may also explain e the loower adherence inn the treatmeent of patientts in the worrkers compared too unemployed. Educated people are more m informed abbout their diseease and in fully fu aware off the necessity forr constant theerapy. A more detailed d studdy of adherennce in groupps of patients withh different staages of hyperrtensions shoowed that the low west adherence was in stagge I hypertennsive patients (10..2±0.8 points), it was also lower in patiients with stage IIII of hypertennsion (10.9±00.5 points) thaan in patients witth hypertension with staage II (11.5± ±0.9 points), how wever, signiificant differrences with the previous grooups weren’t obtained (p > 0.05). It should be noted that t patients with the lowest levell of adherence was w in the maajority of the group with stage s III of AH — 19%. Andd patients wiith high leveel of adherence prrevailed in grroup with II stage s АГ (42% %).

There T were siignificant diff fferences (p < 0.05) in thee adh herence to AT T between patiients with crissis (12.3± 0.88 poin nts) and non-ccrisis course ((10.16±0.4 po oints) of AH. In n assessing the adhereence to AT T in groupss dep pending on the lasting of A AH obtained the t followingg resu ults. In the grroup of patieents with AH without DM M the highest found in patiients with hypertensionn exp perience from m 5 to 10 yeears (11.9±0.4 points), inn grou ups of up to 5 years and more than 10 0 years, ratess werre nearly equaal (10.5±0.4 ppoints and 10.3±0.1 pointss, resp pectively, p > 0.05). In patients with AH and DM M with h increasing length of hyypertension th he adherencee rosee. In the grouup with the exxperience of AH A to 5 yearss its meaning was 10.3±0.1 ppoints, in thee group withh hyp pertension from m 5 to 10 yearrs — 11.6±0.9 points, withh the experience off more than 10 years — 13 3.2±0.6 pointss (Fig g. 6). In addiition, in the ggroup of patieents with AH H and d DMrising off adherence too AT was asssociated withh incrreasing lengthh of insulinothherapy. In pattients withoutt insu ulinotherapy adherence too AT was 11.1±0.8 points.. In th he group withh insulinotherrapy to 5 yearss, its meaningg wass 12.3±0.1 pooints, from 5 to 10 years, — 12.9±0.44 poin nts, more 10 years — 14.1±0.6 po oints (Fig. 7).

Antihy ypertensiveth herapy and Adherence A to It of Patients s with Hyperte ension and w with Combina ation of H Hypertension n and Diabete es Mellitus

Fig. 6 Adheerence to ATin n groups of patients dependin ng on the lasting of hypertension.

14.1

14.5 14 13.5 13 12.5

12.9 12.3

12 11.5 11 Up to 5  U years

5 to 10  5 years

More than  1 10 years

Fig. 7 Adheerence to AT in the group p of patients with insulinotheraapy.

The last ratte of adhereence was onee of the higghest among all grroups of patieents.

Despite D thatt the positiive effect of lifestylee mod dification on the course off hypertension and relatedd risk k factors, as well as patiient’s adhereence to drugg therrapy is a provven fact, therre is not enou ugh attentionn is given g to nonn-medicamenntal treatmen nts, which iss possible due to lack of awaareness of paatients aboutt theiir disease and the uundoubted benefits b thesee actiivities. The T adherennce of antihhypertensive therapy inn gen neral proved to t be insufficiient, and it co orresponds too the middle ratee. The mostt committed to therapy,, patiients with stages II and III of AH, crisis c course,, exp perience diseaase from 5 tto 10 years, presence off con ncomitant inssulinotherapyy in case of combinationn with h diabetes, suggesting s thhat patients begin b to payy atteention to their health witth advanced pathologicall process with thee target orgaan damage an nd associatedd clin nical conditioons, which siggnificantly im mpairs healthh and d causes more m attentivve to theirr treatment.. Und doubted role is played by education off patients, thee avaailability of free time, tthe material aspect, thee avaailability of thhe pharmacy nnetwork. Among A the reasons of nonregular reception off prep parations thee most impoortant are co ompliance too docctor and insuffficient awareeness of patiient’s diseasee and d the necessitty of correct its treatmentt, which alsoo app plies to patiients who nnonregularly take drugss because of the satisfactoryy state of health h duringg incrreased blood pressure.

References [1] [2]

4. Conclussions The main disadvantagees of antihypertensive therrapy in studied patients is irrational chhoice of drrugs, including thhose for the starting therrapy, the use of combinations of insufficient doses and non-rational n medications, and in soome cases, on o the contrrary, polypharmaccy.

1288

[3]

[4]

Diagnostics and Treatmennt of Hyperten nsion: Russiann Recommendaations (4th revission), 2010. M. Hill and N. Houston, A Adherence to an ntihypertensivee therapy, Chappter 131, pp. 3990–392. B. Waeber, M. Burnier aand H. R. Bru unner, How too improve addherence withh prescribed treatment inn hypertensive patients? J CarrdiovascPharmacol 36 (2000)) (suppl. 3) S233–S26. H. Horvathoova, K. Kimlikkova, I. Balazzovjech and I.. Kyselovic, Compliance C annd the therapeeutic effect inn patients withh arterial hyperrtension, BratisslLekListy 1044 (4–5) (2003)1149–154.

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Antihypertensivetherapy and Adherence to It of Patients with Hypertension and with Combination of Hypertension and Diabetes Mellitus T. Morozova and I. Yudina, The modern strategy for improving adherence to treatment in patients with arterialhypertension: A fixed combination of drugs, Consil Med. 12 (2010) 22–27. T. S. Lahdenpera, C. C. Wright and H. A. Kyngas, Development of a scale to assess the compliance of hypertensive patients, Int J Nurs Stud 40 (7) (2003) 677–684. M. A. Strelec and A. M. Mion, The influence of patient’s consciousness regarding high blood pressure and patient’s attitude in face of disease controlling medicine intake, Arc Bras Cardiol 81 (2003) 349–354. K. Port, K. Palm and M. Viigimaa, Self-reported compliance of patients receiving antihypertensive treatment: Use of a telemonitoring home care system, J TelemedTelecare 9 (2003) (Suppl. 1) S65–S66. B. Waeber, Treatment strategy to control blood pressure optimally in hypertensive patients, Blood pressure 10 (2001) 62–73. G. A. Hamilton, Measuring adherence in a hypertension clinical trial, J Manag Care Pharm 9 (5) 424–429. The major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic, ALLHAT, JAMA 288 (2002) 2981–2997. P. J. Murlow, Detection and control of hypertension in the population: the United States Experience, Am J Hypertens 11 (1998) 744–746. N. Col, J. E. Fanale and P. Kronholm, The role of medication non–compliance and adverse drug reactions in hospitalizations of the elderly, Arch Intern Med. 150 (1990) 841–845. T. Howard, P. Stang and E. Lydick, Increased morbidity and mortality associated with discontinuation of oral antidiabetic therapies, in: Program and Abstracts of the 35th Annual Meeting of the European Association for the Study of Diabetes, Sep. 28–Oct. 2, 1999, Brussels, Belgium. M. Pawar, Five tips for generating patient satisfaction and compliance, FamPractManag 12 (6) (2005) 44–46. D. Goleman, A. McKee and R. E. Boyatzis, Primal Leadership: Realizing the Power of Emotional Intelligence, Boston: Harvard Business School Press, 2002.

[17] C. Cuspidi, L. Lonati and L. Sampieri et al., To better know hypertension: Educational meetings for hypertensive patients, Blood Pressure 9 (2000) 255–259. [18] A. Filippi, A. Sabatini and L. Badioli, Effects of an automated electronic reminder in changing the antiplatelet drug-prescribing behavior among Italian general practitioners in diabetic patients: an intervention trial, Diabetes Care 26 (5) (2003) 1497–1500. [19] R. H. Frerdman, L. E. Kazis and A. Jette et al., A telecommunications system for monitoring and counseling patients with hypertension: Impact on medication adherence and blood pressure control, Am J Hypertens 9 (1996) 285–292. [20] B. R. Haynes, D. L. Sackett and E. S. Gibson et al., Improvement of medical compliance in uncontrolled hypertension, Lancet I (1976) 1265–1268. [21] B. Vrijens and E. Goethebeur, Comparing compliance patterns between randomized treatments, Controlled Clinical Trials 18 (1997) 187–203. [22] B. S. Bloom, Continuation of initial antihypertensive medication after 1 year of therapy, ClinTher 20 (1998) 1–11. [23] P. Rudd, Clinicians and patients with hypertension: Unsettled issues about compliance, Am Heart J 130 (1995) 572–589. [24] D. L. Sackett, R. B. Haynes and E. S. Gibson et al., Randomized clinical trial of strategies for improving medication compliance in primary hypertension, Lancet 1 (1975) 1205–1207. [25] E. Jokasalo, H. Enlund and P. Halonen et al., Factors related to poor control of blood pressure with antihypertensive therapy, Blood Pressure 12 (2002) 22–27. [26] J. O. Prochaska, C. A. Reddong and K. E. Evers, The transtheoretical model and stages of change, in: K. Glanz (Ed.), Health Behavior and Health Education: Theory, Research, and Practice (2nd ed.), San Francisco, Jossey-Bass, 1997. [27] J. Benson and N. Britten, Patients decisions about whether or not to take antihypertensive drugs: Qualitative study, BMJ 325 (2002) 873.

D

Mar. 2012, Volume 9, No. 3 (Serial No. 88), pp. 130–143 Journal of US-China Medical Science, ISSN 1548-6648, USA

DAVID

PUBLISHING

Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit on Tumor Cell Lines In Vitro Asaad Abdulwahed B. Al-Asady, Khesar H. K. and Saadi S. M. Barwari Department of Anatomy, School of Medicine, Faculty of Medicine, University of Duhok, Iraq Abstract: The present study aims to prepare two types of extracts; ( methanolic and aqueous) crude extracts and (polyphenol and rutin) secondary metabolite extracts of immature fruit of Capparis spinosa to evaluate the cytotoxic effects of all these prepared extracts on Human larynx carcinoma (Hep-2) and Human cervix adenocarcinoma (HeLa) tumor cell lines in vitro. The data of immature fruit extracts in present study was compared with that obtained by the same investigators in previous study for mature fruit extract to evaluate which one is more effective against the proliferation of tested tumor cell lines. The results of present study showed that the yield of extraction % of methanol and aqueous crude extracts; 16.1% and 15%, respectively, whereas that of polyphenol and rutin secondary metabolite extracts were 12.7% and 12.1%, respectively. The results revealed that the more effective extracts against the proliferation of Hep-2 tumor cell line was aqueous extract after 24 hrs treatment. After 48 hrs treatment each of methanol, aqueous, and rutin was more effective than polyphenol extract. Methanol and rutin extracts were more effective after 48 hrs than 24 hrs treatment. All types of immature fruit extracts had CC50 values on Hep-2 cell line > 10000 μg/ml for both periods of exposure. The result revealed that the effect of both methanol and rutin on proliferation of HeLa cell line after 24 hrs treatment was more than that of aqueous and polyphenol extracts. After 48 hrs treatment the activity of methanolic extract and aqueous against the proliferation of HeLa cell line more than that of polyphenol and rutin, the values of CC50 on HeLa cell line treated with methanol extract after 48 hrs was 9700 μg/ml. Aqueous extract was more effective after 48 hrs than 24 hrs. The present study shows that HeLa tumor cell line was more effective than Hep-2 tumor cell line. There were some notable cytotoxic activities of mature fruit extract of C. spinosa against the tumor cell lines than for that of immature fruit extract as compare with the previous study that done by the same investigators. Key words: Cytotoxicity, crude extracts, capparis spinosa, fruit, tumor cell lines.

1. Introduction  Worldwide there are about 274,000 women deaths in 2002, because of cervical cancer [1]. In Iraq the cancer of the cervix is 2.1% [2]. Cancers of the mouth, pharynx, and larynx, together, are the seventh most commonly occurring types of cancer worldwide. Most of the cancers of the larynx begin in cells that line the inner walls of the larynx [3]. In the last three decades, cancer has been transformed from a fatal disease to one in which the majority of people diagnosed with cancer

Corresponding author: Asaad Abdulwahed B. Al-Asady, PhD, assistant professor, research field: animal cytogenetics. E-mail: [email protected].

receive highly effective treatments that result in either cure or long-term survivorship [4]. The medical plants are used by people for medical purposes to build or maintain health, because the plants are an important source of molecules that may be useful as a drug [5]. Use of medicinal plants comes from ancient especially in the Africa, Asia and Latin America where the majority of the world’s people live. Every day, a new study is published in the world journals to confirm pharmacological effects of medicinal plants that have been used traditionally. If one search for the key word of medicinal plants and pharmacology together in a general search engine like google, about 1,180,000 records would be found [6]. It is estimated that 30–40% of all pharmaceutical

Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit 131 on Tumor Cell Lines In Vitro

preparations that are used nowadays are derived from or based on plant metabolites [7]. Over 80,000 species of plants are in use throughout the world and the traditional and folk medicinal practice based on the use of plants and plant extracts is known as herbalism [8]. Capers belonging to the family Capparidaceae the genus Capparis comprise 250 species including shrubs, trees and woody climbers [9]. Probably it originated in the dry regions in west or central Asia [10]. Known and used for millennia, capers were mentioned by Iosco rides as being a marketable product of the ancient Greeks. Capers are also mentioned by the Roman scholar Pliny the Elder. More rarely, mature and semi-mature fruits are eaten as a cooked vegetable. Additionally, ash from burned caper roots has been used as a source of salt [5]. Capers contain considerable amounts of the antioxidant bioflavinoid, rutin [11, 12]. Peter [5] suggests that these antioxidants play a role in limiting cardiovascular disease and cancers. Caper seeds yield about 35% pale yellow oil containing palmitic, stearic, oleic and linoleic acids [13]. Two (6S)-hydroxy-3-oxo-alpha-ionol glucosides, together with corchoionoside C (6S, 9S)-roseoside) and a prenyl glucoside, were isolated from mature fruits of C. spinosa [14]. Capparis spinosa is said to be native to the Mediterranean basin, but its range stretches from the Atlantic coasts of the Canary Islands and Morocco to the Black Sea to the Crimea and Armenia, and eastward to the Caspian Sea and into Iran. Capparis spinosa is one such plant established to have highly diverse economic and medicinal value in different system of medicines. Seeds of C.spinosa contain glucocapparin, glucocleomin [15, 16]. palmitic, oleic acid and linoleic acid [17]. A dimeric 62-KDa lectin exhibiting a novel N-terminal amino acid sequence was purified from C. spinosa seeds [18]. Glucosinolates like sinigrin, glucoiberin and glucocleomin were isolated from the seeds and leaves of C. spinosa [19]. Capparis spinosa fruits contain alkaloids, glucosides, reducing sugar,

fats, resins, ascorbic acid [13] and isothyiocyanate [11]. Alkaloids have been isolated and identified from C. spinosa fruits [20]. Triterpenoids like α-amyrin, sterols, β-carotene, saponins were found in the preliminary phytochemical screening [21]. Aqueous and methanolic root extract of C. spinosa possess considerable inhibition of AMN3 cells, whereas Hep-2 tumor cell line is sensitive to aqueous root extract as well as aqueous leave extract in vitro [22]. Aqueous and methanolic root extract of C.spinosa has ability to reduce the tumor volume in vivo [22]. The total alkaloids of C. spinosa can inhibit the growth of human gastric adenoma cells SGC-7901 [23]. The lectin potently that isolated from seeds of C.spinosa inhibited the proliferation of both hepatoma HepG2 and MCF-7 cell lines [18]. Recently, the study of AL-Asady et al. [24] revealed that the secondary metabolite extract polyphenol from mature fruit extract of C. spinosa has inhibition activity against Hep-2 tumor cell line after 24 and 48 hrs treatment, and against HeLa tumor cell line after 48hrs treatment, the CC50% of Hep-2 cells was 6400 and 6800 µg/ml after 24 and 48 hrs, respectively. The CC50% of HeLa cells was 7100 µg/ml after 48 hrs. According to the prevalence of C. spinosa in Iraq, and there are no reports on the cytotoxicity of immature fruit of this plant on tumor cell lines in Iraq. Hence, this work was conducted to evaluate the cytotoxic effects of Aqueous, Methanolic and Secondary Metabolites Extracts of C. spinosa immature fruit on Human larynx carcinoma (Hep-2) and Human cervix adenocarcinoma (HeLa) tumor cell lines in vitro.

2. Materials & Methods 2.1 Plant Collection Capparis spinosa was collected from Duhok governorate/Iraq in September 2008. The whole plant was deposited to be identified, the identification done by Prof. Dr. Salem Shahbaaz plant taxonomist, Department of Forestry, College of Agriculture, University of Duhok, Duhok, Iraq. Then whole

132 Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit on Tumor Cell Lines In Vitro

immature fruits were dried at room temperature.

pipetting in growth medium then 0.2 ml of cells

According to Harborn [25]. the fruit was ground into

suspension was mixed with 0.2 ml of trypan blue

powder by electrical grinder (mesh No. 0.5 mm), and

solution and 1.6 ml phosphate buffer (PBS), and a

the powdered parts were kept in plastic tubes in deep

sample of cells counted by using an Improved Double

freeze

Crude

Naubauer Ruling Counting Chamber. Magnification

extracts( aqueous & methanol) from whole immature

powers of 100X and 400X were used to count the cells,

fruit of C.spinosa were prepared according to Harborn,

viable cells do not stain, but dead cells stain blue. The

[25]. Extraction of Secondary Metabolites Polyphenol

following formula was then used to calculate the

from immature fruit as described by Yu and Dahlgren, [26]. Whereas rutin was extracted from immature fruit

number of cells per unit volume (cells/ml) (31): C = N × D × 104

of C. spinosa according to Kim et al. [27]. Chemical

Where C is the number of viable cells per milliliter, N

test for plant extracts both Wagner’s Reagent and

is the number of viable cells counted, and D is the

Hager’s Reagent was used to test the presence of

dilution factor (D = 10). About 200 μl of cells

alkaloids in extracts, whereas Ferric Chloride Solution

suspended (55000 cells/ml) in growth medium was

according to Gayon [28] and lead acetate solution

seeded in to each well of a sterile 96-well

according to Harborn [25] was used to test the presence

micro-titration plate. The plates were sealed with a

of polyphenol (tannins). The presence of flavonoids in

self-adhesive film, lid placed on and incubated at

extracts was tested according to AL- Shahaat [29]. The

37°C. When the cells are in exponential growth

identification of rutin according to Harborn [25].

(approximately 70–80% confluent monolayer), the

Liebermann-Burchard test was used to test the

medium was removed and serial dilutions of each

presence of triterpenoids, whereas Peptides and Free

aqueous, methanolic crude extracts and secondary

Amino Group Test used to test the presence of peptides,

metabolites extracts (polyphenol & rutin) of immature

primary or secondary amino groups [25]. To test the

fruit, separately in maintenance medium (10000, 5000,

presence of carbohydrate compounds Molish reagent

2500, 1250, 625, 312.5, 156.25, 78.125, and 0 µg/ml)

was used [30]. The presence of glycosides was

were added to the wells. Three replicates were used

detected according to AL- Shahaat [29]. Saponins were

for each concentration of either extract, and the plates

identified according to Harborne [25].

were re-incubated at 37°C for the selected exposure

-20°C

until

the

time

of

use.

times (24 or 48 hrs). 2.2 Cell Line

Cytotoxic effect of each extract on both tumor cell

Human Larynx Carcinoma (Hep-2) tumor cell line

lines using neutral red dye assay according to Freshney,

Passages 220-223 in RPMI-1640 medium (Sigma,

[31]. The optical density (O.D) of each well after

USA) and Human Cervix Adenocarcinoma (HeLa)

treatment

passage 240-243 tumor cell line in Eagles MEM

Immunosorbent

(Sigma, USA) supplemented with L-glutamine,

transmitting wavelength of 492 nm [31, 32]. The

non-essential amino acids and 10% FBS, was kindly

percentage of cytotoxicity was calculated as (A-B)/A

supplied by Tissue Culture Unit/Iraqi Center for

X100, where A was the mean O.D of untreated wells

Cancer and Medical Genetic Researches (ICCMGR)/

and B is the O.D of wells with plant extracts (33).The

Baghdad, Iraq. To determine the viability of tumor cell

cytotoxic concentration 50% (CC50%) for each extract

lines,

was calculated from concentration-effect-curves after

confluent

monolayer

were

treated

with

trypsin-versene and cells were further dispensed by

was

read Assay

using

Enzyme

(ELISA)

linear regression analysis [34].

reader

Linked at

a

Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit 133 on Tumor Cell Lines In Vitro

2.3 Statistical Analysis Analysis of variance (ANOVA) and the least significant difference (LSD) were used for the statistical analysis of the results and P-values at levels (P < 0.01) was considered to be statistically significant. These calculations were carried out according to SAS system [35].

3. Results The Properties of C. spinosa Immature Fruit Extracts, Yield of Extraction, and Qualitative Chemical Analysis: The results of C. spinosa; Aqeous, Methanol crude extracts and secondary metabolites Polyphenol and rutin from Immature fruit with respect to the nature and color of the obtained extract, color of each extract solution, yield of extraction %, and qualitative chemical analysis for each extract are summarized in Tables 1 and 2.

Thin Layer Chromatography (TLC) of Rutin Extract Rutin extract from Immature fruit of C.spinosa was analyzed by TLC. The identification of rutin was done by comparison rate of flow (Rf) for each extract with Rf of standard rutin as well as the color of spot under U.V. light Table 3. Cytotoxic Effect of Aqueous, Methanol crude Extracts and Secondary Metabolites (Polyphenol and Rutin) Extracts of Immature fruit of C. spinosa on Hep-2 Tumor Cell Line in vitro: Table 3 The results of TLC for rutin extract (Rf and color of spot under U.V. light) and comparison with standard rutin. Color of spot under Compound Rate of flow (Rf) U.V. light Rutin standard (a) 0.58 Yellow Immature rutin 0.48 Yellow extract (b)

Table 1 The nature and color of dried product extracts and solutions of immature fruit extracts of C. spinosa, and the yield of extraction %. Part of plant

Type of Extract Methanol Crude extracts Aqueous Im.f. Secondary Polyphenol metabolite Rutin extracts Im.f = immature fruit.

Nature & color of Extract Viscous→ dark brown Viscous→ dark brown Viscous → dark brown Solid →

brown

Color of Solution Green Brown Greenish brown

Yield of extraction % 16.1 15 12.7

yellowish brown

12.1

Table 2 The results of qualitative chemical analysis for Aqueous, Methanol, and Polyphenol Extracts of Immature fruit of C. spinosa. Im.f Extracts Methanol

Compound group

Aqueous Alkaloids a- Wagner’s reagent + b- Hagers reagent + Tannins a-lead acetate + b-Ferric chloride + Flavonoid test + Triterpenoid Peptides&Free amino group + Carbohydrate + Glycosides a-before hydrolysis + b- after hydrolysis Saponin + Im.f = immature fruit; +=The extract contain the designated phytochemicals; - =The extract does not contain the designated phytochemicals.

Polyphenol

+ +

+ +

+ + + + + +

++ + + + + +

+

+ +

134 Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit on Tumor Cell Lines In Vitro

after 48 hrs were effective with 5000 and 10000 µg/ml only. The same table also shows that the Methanolic extracts was more effective than Polyphenol extract (Figs. 2a and 2b), whereas it exhibit the same inhibition activity of Aqueous and Rutin extract, the value of O.D were 0.230±0.006, 0.250±0.006, 0.246±0.005 and 0.241±0.004, respectively. Statistical analysis revealed significant effect (p ≤ 0.01) of exposure time of Hep-2 tumor cell line to (Methanol and Rutin) extracts, whereas non significant of exposure time of cells to each of Aqueous and Polyphenol extract of Immature fruit (Table 6). Methanol and Rutin extracts were more effective after 48 hrs than 24 hrs, the value of O.D. were 0.230±0.006, 0.281±0.004 and 0.241±0.004, 283±0.005, respectively. Other extracts (Aq. and P.) exhibit the same effect in both time of treatment, the value of O.D. were 0.264±0.004, 0.246±0.005, 0.279±0.006, 0.250±0.006 (Table 7). All types of Immature fruit extracts had CC50 values on Hep-2 cell line (>10000 µg/ml) for both periods of exposure.

The results demonstrate a highly significant difference (p ≤ 0.0001) among all crude and secondary metabolites extracts and among concentrations after 24 hrs treatment. The differences among extracts and among concentrations were significant (p ≤ 0.01) after 48hr treatment. The interaction between extracts and concentrations were not significant after 24 hrs and 48 hrs. Table 4 shows that the concentrations of Immature fruit crude extract and secondary metabolites extracts after 24 hrs started their effects from 312.5 µg/ml up to 10000 µg/ml as compare with control group (Fig. 1a). The more effective extracts on the proliferation of Hep-2 tumor cell line was Aqueous extracts after 24 hrs treatment (Fig. 1b), the value of O.D. was 0.264±0.004, other extracts (Methaanol, Polyphenol, and Rutin) seem to have the same inhibition activity, the O.D. were 0.281±0.004, 0.279±0.006 and 0.283±0.005, respectively as shown in (Figs. 1c and 1d). Table 5 shows that the concentrations of Immature fruit crude extract and secondary metabolites extracts

Table 4 Mean ± SE for the effect of different concentrations of (Aqueous, Methanol, Polyphenol and Rutin)Immature fruit extract of C .spinosa on the growth of Hep-2 tumor cell line after 24 hrs treatments in vitro: (Observations of O.D). Concentration µg/ml Over all concentrations

Extracts

0

Aqueous

0.254±0.017

0.261±0.034 0.245±0.006 0.248±0.006 0.246±0.01 0.238±0.007 0.234±0.007 0.232±0.005 0.233±0.005 0.246±0.005

Methanol

0.254±0.017

0.247±0.019

78.125

156.25

312.5

625

1250

2500

5000

10000

0.249±0.01 0.246±0.012 0.240±0.006 0.222±0.02 0.241±0.012 0.174±0.013 0.194±0.004 0.230±0.006

Polyphenol 0.254±0.017 0.242±0.028 0.266±0.016 0.269±0.018 0.265±0.005 0.260±0.015 0.242±0.016 0.248±0.01 0.209±0.015 0.250±0.006 Rutin Over all extracts

0.254±0.017

0.248±0.01

0.247±0.011 0.245±0.014 0.246±0.011 0.245±0.005 0.248±0.014 0.222±0.01 0.219±0.019 0.241±0.004

0.254±0.007

0.254±0.01

0.252±0.005 0.252±0.006 0.250±0.005 0.242±0.007 0.242±0.006 0.219±0.009 0.214±0.007

Effectors

Extracts

Concentrations

Extracts and Concentrations

L.S.D(0.01)

0.0182

0.0273

-

Table 5 Mean ± SE for the effect of different concentrations of (Aqueous, Methanol, Polyphenol and Rutin )Immature fruit extracts of C .spinosa on the growth of Hep-2 tumor cell line after 48 hrs treatments in vitro (Observations of O.D). Concentration µg/ml

Aqueous

Over all concentrations 0.307±0.016 0.271±0.005 0.266±0.004 0.263±0.007 0.255±0.009 0.268±0.003 0.251±0.008 0.249±0.006 0.245±0.003 0.264±0.004

Extracts

0

78.125

156.25

312.5

625

1250

2500

5000

10000

Methanol

0.307±0.016 0.293±0.003 0.288±0.004 0.292±0.011 0.286±0.01 0.286±0.007 0.266±0.003 0.251±0.002 0.259±0.001 0.281±0.004

Polyphenol

0.307±0.016 0.295±0.005 0.294±0.004 0.290±0.003 0.281±0.044 0.280±0.003 0.278±0.005 0.266±0.006 0.244±0.008 0.279±0.006

Rutin

0.307±0.016 0.298±0.009 0.300±0.008 0.297±0.008 0.293±0.008 0.277±0.001 0.274±0.008 0.266±0.005 0.234±0.006 0.283±0.005

Over all extracts 0.307±0.007 0.289±0.004 0.287±0.005 0.286±0.005 0.274±0.011 0.278±0.003 0.268±0.004 0.258±0.003 0.246±0.004 Effectors

Extracts

Concentrations

Extracts and Concentrations

L.S.D(0.01)

0.014

0.0204

-

Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit 135 on Tumor Cell Lines In Vitro

a

c

b

d

Fig. 1 Hep-2 tumor cell line (250X) after 24 hrs treatment: (a) Control confluent monolayer, (b) cells treated with 10000 µg/ml Aqueous immature fruit extracts, (c) cells treated with 10000 µg/ml Methanolic immature fruit extracts, (d) Cells treated with 10000 µg/ml Polyphenol immature fruit extracts.

a

b

Fig. 2 Hep-2 tumor cell line (250X) after 48 hrs treated with: (a) 10000 µg/ml Methanolic immature fruit extracts, (b) 10000 µg/ml Polyphenol immature fruit extracts. Table 6 Analysis of variance for the effect of exposure time to Immature fruit extracts of C. spinosa on the growth of Hep-2 tumor cell line In vitro. S.O.V

F value d.f

Time

1

Aq. 5.37

Meth. NS

42.24

P. *

6.58

R. NS

32.09 *

Error 52 S.O.V = source of variance, d.f = degree of freedom, NS = non significant * = (P ≤ 0.01). Table 7 Mean ±SE for the effect of exposure time to Immature fruit extracts of C. spinosa on the growth of Hep-2 tumor cells in vitro (Observations of O.D). Time/hrs Extract

24 Aqueous 0.264±0.004 Methanol 0.281±0.004 Polyphenol 0.279±0.006 Rutin 0.283±0.005 SE = standard error.

48 0.246±0.005 0.230±0.006 0.250±0.006 0.241±0.004

L.S.D 0.029 0.028

Cytotoxic Effect of Aqueous, Methanolic Crude Extracts and Secondary Metabolites (Polyphenol and Rutin) Immature fruit extracts. of C.spinosa on HeLa Tumor Cell Line in vitro:

The result of present study shows highly statistical differences among all extracts as well as concentrations (p ≤ 0.0001) after 24 and 48 hrs of treatment. The interaction between concentrations and extracts were also highly significant (p ≤ 0.0001) after 24 and 48 hrs. The effective extract on proliferation of HeLa cell line after 24 hr was methanol, which revealed more inhibition activity than Aqueous and Polyphenol extracts, Rutin extract exhibit similar effect with Methanolic extract. Rutin extract was more effective than Aqueous extract, while it had the same effect with polyphenol extract (Table 8). The same table shows that the concentrations of Immature fruit extracts have started their effects after 24 hrs from 78.13 µg/ml to the highest concentration 10000 µg/ml. Aqueous extract was effective only with concentration 10000 µg/ml as compare with control group (Figs. 3a and 3b). The concentrations that made of Methanol extracts effective were 2500 5000 and 10000 µg/ml, the higher concentration exhibits more inhibition activity (Fig. 3c), the value of O.D. were 0.231±0.005, 0.228±0.003

136 Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit on Tumor Cell Lines In Vitro

the value of O.D. were 0.153±0.014 and 0.107±0.004, respectively. Polyphenol extract appeared its effect with concentration 10000 µg/ml only (Fig. 4c), Rutin extract revealed its effect with concentration 5000 µg/ml which exhibit less activity than 10000 µg/ml with value of O.D. 0.184±0.011 and 0.137±0.004 (Fig. 4d). The effect of exposure time was not significant on the growth of HeLa cell line when these cells are subjected to Immature fruit extracts (Table 10) except in Aqueous extract which showed significant effect. Table 11 shows that Aqueous extract was more effective after 48 hrs than 24 hrs, the values of O.D. were 0.194±0.003 and 0.272±0.003, respectively. The values of CC50 on HeLa cell line treated with Immature fruit extracts were more than 10000 µg/ml for each extracts in both times of exposure with exception that methanol extract after 48 hrs had CC50% 9700 µg/ml.

and 0.18±0.003, respectively. This effect was also pronounced in Polyphenol extract, whereas these concentrations have the same effect. Rutin extract shows similar effect with concentrations 1250, 2500, 5000 and 10000 µg/ml (Fig. 3d). The growth of HeLa cells was affected after 48 hrs with all concentrations started from 78.13 µg/ml up to 10000 µg/ml (Table 9). Methanolic extract was more effective than Polyphenol and Rutin extracts. It had similar effect with Aqueous extracts. Aqueous extracts were more effective than Polyphenol extracts, while it exhibit the similar effect with Rutin extract. Aqueous extract starting its inhibition activity from 2500 up to 10000 µg/ml and all concentrations revealed the same activity against the proliferation of HeLa cells (Fig. 4a), the value of O.D. were 0.188±0.004, 0.182±0.009 and 0.183±0.07, respectively. Methanolic extract was effected with concentrations 5000 and 10000 µg/ml the activity of extract increased with higher concentration (Fig. 4b),

Table 8 Mean ± SE for the effect of different concentrations of (Aqueous, Methanol, Polyphenol, and Rutin) Immature fruit extracts of C .spinosa on the growth of HeLa-2 tumor cell line after 24 hrs treatments in vitro: (Observations of O.D). Concentration µg/ml Extracts

0

78.125

156.25

312.5

625

1250

2500

5000

10000

Over all concentrations

Aqueous

0.283±0.009 0.270±0.007

0.279±0.007

0.279±0.002

0.276±0.004

0.277±0.002 0.277±0.003 0.273±0.01 0.242±0.009 0.272±0.003

Methanol

0.283±0.009 0.257±0.003

0.256±0.004

0.256±0.006

0.255±0.005

0.255±0.006 0.231±0.005 0.228±0.003 0.180±0.003 0.244±0.006

Polyphenol 0.283±0.009 0.265±0.006

0.264±0.003

0.264±0.009

0.262±0.003

0.258±0.004 0.247±0.02 0.253±0.003 0.235±0.001 0.259±0.003

Rutin

0.283±0.009 0.269±0.005

0.256±0.024

0.265±0.007

0.266±0.003

0.245±0.006 0.242±0.004 0.240±0.006 0.236±0.013 0.252±0.004

Over all extracts

0.283±0.004 0.265±0.003

0.263±0.007

0.266±0.004

0.265±0.003

0.259±0.004 0.249±0.006 0.249±0.007 0.224±0.008

Effectors

Extracts

Concentrations

Extracts and Concentrations

L.S.D(0.01)

0.0097

0.015

0.0292

Table 9 Mean ± SE for the effect of different concentrations of (Aqueous, Methanol, Polyphenol,and Rutin) Immature fruit extracts of C .spinosa on the growth of HeLa tumor cell line after 48 hrs treatments in vitro: (Observations of O.D). Concentration µg/ml Extracts

0

78.125

156.25

312.5

625

1250

2500

5000

Aqueous

0.221±0.01 0.201±0.004 0.201±0.005 0.192±0.007 0.191±0.001 0.191±0.004 0.188±0.004 0.182±0.009

10000

Over all concentrations

0.183±0.07

0.194±0.003

Methanol

0.221±0.01 0.202±0.003 0.204±0.003 0.203±0.004 0.198±0.007 0.198±0.011 0.200±0.006 0.153±0.014 0.107±0.004 0.187±0.007

Polyphenol

0.221±0.01 0.218±0.021 0.218±0.006 0.218±0.013 0.217±0.002 0.217±0.01 0.213±0.007 0.199±0.018 0.140±0.005 0.207±0.006

Rutin

0.221±0.01 0.210±0.006 0.210±0.007 0.209±0.013 0.209±0.005 0.205±0.007 0.208±0.002 0.184±0.011 0.137±0.004 0.1996±0.005

Over all extracts

0.221±0.01 0.208±0.005 0.208±0.003 0.206±0.005 0.204±0.004 0.203±0.005 0.203±0.004 0.180±0.008 0.142±0.008 Effectors

Extracts

Concentrations

Extracts and Concentrations

L.S.D(0.01)

0.0107

0.016

0.032

SE = Standard Error.

Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit 137 on Tumor Cell Lines In Vitro

a

b

d

c

Fig. 3 HeLa tumor cell line (250X) after 24 hrs treatment: (a) Control confluent monolayer, (b) cells treated with 10000 µg/ml Aqueous Immature fruit extracts, (c) cells treated with 10000 µg/ml Methanol Immature fruit extracts, (d) cells treated with 10000 µg/ml Rutin Immature fruit extracts.

a

b

c

d

Fig. 4 HeLa tumor cell line (250X) after 48 hrs treated with: (a) 10000 µg/ml Aq. Im.f. Es, (b) 10000 µg/ml Methanol Immature fruit extracts, (c) 10000 µg/ml Polyphenol Immature fruit extracts, (d) 10000 µg/ml Rutin Immature fruit extracts. Table 10

Analysis of variance for the effect of exposure

time to Immature fruit extracts of C. spinosa on the growth of HeLa tumor cell line in vitro. S.O.V

F value d.f

Time

1

Aq. 34.48

Meth. **

0.82

NS

P. 2.82

R. NS

1.68 NS

Error 52 S.O.V = source of variance, d.f = degree of freedom, NS = non significant ** = (P≤ 0.0001). Table 11 Mean±SE for the effect of exposure time to Immature fruit extracts of C. spinosa on the growth of HeLa tumor cells in vitro (Observations of O.D). Time/hrs

were 0.227±0.003 and 0.259±0.002, respectively (Table 13). Comparison between the biological activity of immature and mature fruit extracts of C. spinosa against the proliferation of tumor cell line. To compare between the cytotoxic effect of immature fruit extracts and mature fruit extracts of C.spinosa on both tested tumor cell lines ,the data of present study statistically analyzed with that of mature fruit (Tables 14–16) those obtained from previous study by the same investigators (AL-Asady et al., 2011).

Extract

24

48

L.S.D

Table12

fruit extracts of C. spinosa on the types of cell lines.

Analysis of variance for the effect of Immature

Aqueous

0.272±0.003

0.194±0.003

0.068

Methanol

0.244±0.006

0.187±0.007

-

S.O.V

d.f

SS

MS

F value

Polyphenol

0.259±0.003

0.207±0.006

-

Cell line types

1

0.126

0.115

401.5*

Rutin 0.253±0.004 SE = standard error.

0.199±0.005

-

The Effect of Immature fruit extracts of C. spinosa on the Type of Tumor Cell Lines Table 12 shows statistical differences (P ≤ 0.01) of Immature fruit extracts effect on cell lines types. The result revealed that HeLa tumor cell line was more effective than Hep-2 tumor cell line, the value of O.D.

Error 286 0.084 0.0002 S.O.V = source of variance, d.f = degree of freedom, SS = summation square, MS = mean square, *= (P ≤ 0.01). Table 13

Mean±SE for the effect of Immature fruit

extracts of C. spinosa on the types of cell lines.

Cell lines Immature fruit Extract

Hep-2

HeLa

L.S.D

0.259±0.002

0.227±0.003

0.023

SE = standard error

138 Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit on Tumor Cell Lines In Vitro

Statistical analysis shows highly significant difference between (Mature and Immature) fruit extracts of C. spinosa. Mature fruit extracts were more effective than immature fruit extracts, the value of O.D. were 0.213±0.002 and 0.234±0.001, respectively (Table 17). Table 14

Mean ±SE for the effect of exposure time to

(aqueous, methnol, polyphenol, rutin, and alkaloids)mature fruit extracts of C. spinosa on the growth of Hep-2 tumor cells in vitro (Observations of O.D). Time/hrs

Extract

24

48

L.S.D

Aqueous

0.265±0.003

0.240±0.002

0.01

Methanol

0.257±0.008

0.227±0.008

0.012

Polyphenol

0.236±0.014

0.218±0.011

-

Rutin

0.257±0.005

0.242±0.006

-

Alkaloid 0.260±0.005 SE = standard error.

0.237±0.003

0.008

Table 15 Mean ±SE for the effect of exposure time to (aqueous, methnol, polyphenol, rutin, and alkaloids) mature fruit extracts of C. spinosa on the growth of HeLa tumor cell line in vitro. (Observations of O.D). Time/hrs

Extract

24

48

L.S.D

Aqueous

0.191±0.003

0.169±0.003

0.034

Methanol

0.214±0.006

0.165±0.007

0.012

Polyphenol

0.191±0.003

0.154±0.006

0.032

Rutin

0.206±0.004

0.172±0.005

0.014

Alkaloid 0.204±0.00 SE = standard error.

0.162±0.00

0.015

Table 16

Mean±SE for the effect of mature fruit extracts

of C. spinosa on the types of cell lines.

Cell lines Mature fruit Extract

Hep-2

HeLa

L.S.D

0.244±0.0024

0.183±0.0022

0.0213

SE = standard error. Table 17

Mean ± SE for the effect of mature and

immature fruit extracts of C. spinosa on tumor cell lines. Cell lines Extract

M.f. Es.

Im.f. Es.

L.S.D

0.213±0.002

0.234±0.001

0.02

4. Discussion 4.1 The C. Spinosa Immature Fruit Extracts The reasons for the importance of Capparis genus has been a subject of interest from the phytochemicals that included particularly due to its glucosinolate content. Most of the species reported positive for triterpenoids (alpha-amyrin), sterols, beta-carotene, saponins and some tested positive for flavanoids, glycosides and alkaloids [21]. The result of extraction in the present study reveals that the yield of extraction is varied according to the types of solvents those used in extraction method, and the method of extraction. This result agrees with that obtained by Henning et al. [37] in which they find that the proportion of crude product is variable and depending on the method of extraction as well as the part of the plant. In the present study, some of chemical tests used to detection of alkaloids, tannins, flavonoids, glycosides, triterpenoids, carbohydrates as well as saponins qualitatively in the crude and secondary metabolites extracts that are prepared from the immature fruits of C. spinosa. The result shows that the chemical compounds are varied due to the solvent of extraction. The results of qualitative chemical tests differ according to the type of extract. The qualitative variation can be attributed to the fact that, the crude and secondary metabolites extracts of immature fruit contain different constituents that vary considerably in their relative concentrations. Study of Howard et al. [38] on the Capsicum species, revealed that the concentration of chemical constituents such as carotenoids, flavonoids, phenolic acids and ascorbic acid increased as the Capsicum annuum, C. frutescens and C. chinese reached maturity. In addition to the previous compounds, rutin extract is qualified as a flavonoids secondary metabolites by comparison of its Rf value with that of standard. The yield of rutin extraction for Immature fruit was 12.1, while Ramezani et al. [39] purified rutin from different parts of C. spinosa , and they demonstrate that the yield

Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit 139 on Tumor Cell Lines In Vitro

of rutin extract from leaves, fruits and flowers are 18.22, 18.42 and 25.40% respectively. Aqueous and methanolic fruit extracts was prepared in the present study, because each crude extract containing several different compounds and revealed high activity against the proliferation of tumor cells. The study of Gold et al. [40] indicate that unpurified whole plant extract containing several different compounds these can interact together where the effect of the whole plant is greater than its individual compound. Mayalen et al. [41] report that crude extracts of bifurcata, Cystoseira tamariscifolia, Desmarestia ligulata, Dictyotadichotoma, and Halidrys siliquosa exhibited strong cytotoxic activities against three different Human leukemic tumor cells lines; Daudi, Jurka , and K562. Chung et al. [42] suggested that aqueous extracts from plants used in allopathic medicine are potential sources of antiviral and antitumor agents.Usually methanolic extract has cytotoxic properties, because most of the biological active compounds are extracted with methanol. Since methanol has high polarity, it could dissolve both the polar and non polar compounds in it [36]. Rajendra and Ramakrishnan [43] reported that methanolic extract of Artocarpus heterophyllus has cytotoxic effect against the proliferation of Hep-2 cells. Study of Al-Asady [22] indicated that methanolic root extract of C. spinosa posses inhibition activity against AMN3 tumor cell line in vitro and in vivo. Recently the study of AL-Asady et al. [24] revealed that the secondary metabolite extract polyphenol from mature fruit extract of C. spinosa has inhibition activity against Hep-2 and HeLa tumor cell lines. Extraction of polyphenols that performed may isolate large number of polyphenol compounds. Decker [44] mentioned that whole variety of phenolic compounds, are widely distributed in grains, fruits, vegetables and herbs. Gadgoli and Mishra [45] reported that C.spinosa contain hydroxy cinnamic acid like caffic acid, ferulic acid, cumaric acid. Pierpoint [46] reported that high concentration of flavonoids are

present in the skin of fruits and have important and varied roles as secondary metabolites. Rutin was extracted from C. spinosa fruit as a flavonoid, it may have antioxidant, anti-inflammatery and anticarcinogenic activities [47, 48]. The presence of alkaloids in C. spinosa reported by Sadykov et al. [49], they estimated about 0.86% was found in seeds. Total alkaloids of C. spinosa inhibit the growth of human gastric adenoma cells SGC-7901 in vitro [23]. 4.2 Cytotoxic Effect of Aqeous Methanolic Crude Extracts and Secondary Metabolites (Polyphenol and Rutin) Extracts of Immature fruit of C. spinosa on Hep-2 and HeLa Tumor Cell Lines in vitro The results of Immature fruit extracts on the proliferation of Hep-2 cell line revealed that the more effective extracts on the proliferation of Hep-2 tumor cell line after 24 hrs over all concentration was Aqueous extract. Other extracts (Methanol, Polyphenol and Rutin) seem to have the same inhibition activity. After 48 hrs, Methanolic extract, posses more inhibition activity than Polyphenol extracts. Methanolic extract exhibit the same effect with Aqeous and Rutin extracts. Methanolic and rutin extracts are more effective against the proliferation of Hep-2 cells after 48 hrs treatment, whereas Aqeous and Polyphenol extracts were effective at both time 24 and 48 hrs similarly. The results of Immature fruit extracts on proliferation of HeLa cell line show the more effective extract after 24 hrs is methanol with concentration 10000 µg/ml, which reveal more inhibition activity than Aqueous, Polyphenol, and Rutin extracts. Rutin extracts is more effective than Aqueous extract, while it has the same effect with polyphenol extract. After 48 hrs Methanolic extract is more effective than Polyphenol and Rutin extract, whereas it possesses similar effect with Aqueous extract. Aqueous extract is more effective than Polyphenol extract, while it exhibit the similar effect with Rutin extract. Methanolic extract that prepare in the present study contains several

140 Cytotox xic Effects of Aqueous, Me ethanolic and d Secondary Metabolites M E Extracts of Ca apparis Spino osa Fruit on Tumorr Cell Lines In n Vitro

phytochemiccals includding alkalloids, tannnins, flavonoids, triterpenoidss, saponins, therefore such s extracts is foound to have this highly acctivity against the proliferationn of both teested cell lines. This reesult supported by b Ahn et all. [50], theyy mentioned that methanolic extract havve anticanceer activity, and antioxidant activity [51]. Arpornsuwaan and Punjannon, [52] reporteed that the methanolic m extract of Morinda citrifolia fruuit is much more m effective on breast caancer cells and neeuroblastomaa cells. The highest phennolic content is foound in methaanol extract of o mulberry fruit. f Total phenoolic content of plant exxtracts is higghly correlated with w the radiical scavengiing activity. The antiproliferaative effect off mulberry paarts on humann cell lines is diffeerent and connnected to the concentrationns of the extract [553]. Statisticall analysis shoows that each type of Methhanol, Polyphenol, and Rutin has the same effect e againstt the growth of HeLa H cell linne at both tim me of treatm ment, except in Aqqueous extraact that is moore effective after a 48 hrs. The CC50 valuees on HeLa cell line are more m than 10000 µg/ml for all extracts inn both periodds of exposure wiith exception that methanool extract afteer 48 hrs have CC C50% 9700 µg/ml, this demonstrate that Immature fruuit extracts are not highlyy effective agaainst both cell linnes, the extraacts became effective agaainst both cell linees slowly, maay be that Imm mature fruit of o C. spinosa conntains a trace amount of biological acctive compounds or may conntain highly concentrationn of tannins whicch alone do not appear too have sufficcient effect. It meeans that thee extracts of C. spinosa have h specifity inn its activityy according to its conteents. Crozier et all. [54] demonnstrated that many m unripe fruits fr have very high tannin content, whhich is typiccally concentratedd in the outer cell layers. Tannin leevels and/orr the associaated astringeency decline as the fruits mature m and the t seeds riipen. Herbalists claim c that unnpurified whoole plant extrracts containing several s differrent compouunds can inteeract together where the effectt of the wholle herb is greeater than its inddividual compponents [40]]. The resultts of

Imm mature fruit extracts in tthe present study s do nott agreee with that obtained froom Yu et al.. [55]. Theyy dem monstrate thatt immature fruuit of P. saliccina L. can bee regaarded as a saffe and promising new dietaary source forr decreasing the risk of deeveloping brreast cancer,, because the extrract of immatture fruit from m P. salicinaa con ntained higherr levels of tootal phenolicss than maturee fruiit. 4.3 The Effect of Immaturre Fruit Extracts of C. spin nosa on the Type T of Tumorr Cell Line The T result revvealed that HeeLa tumor celll line is moree effeective than Hep-2 H tumor ccell line. Thee activities off plan nt extracts aggainst the prooliferation off tumor cellss difffer due to the properrties of theeir chemicall com mpounds [56] as well as ceell membranee receptors off tum mor cells [57]]. Morrissey [58] demonsstrated that a relaatively small number of prrocesses havee been shownn to be b the targets of plant metabolites and these t includee elecctron transpoort chains, miitochondrial function andd mem mbrane integrity. It is now w emerging, however, h thatt otheer specific ennzymes and pprocesses may also be thee targ gets of particcular metaboolites. There is a generall hop pe that modeern genomic approaches will identifyy new w targets and modes of acction of plantt metabolites.. Molecules, esppecially tritterpenoids that t triggerr apo optosis or autoophagy in tum mor cells are of particularr inteerest in this regard. Theree is a limited evidence forr diettary componeents to influeence late stag ges of cancer.. Ressveratrol, queercetin, curcumin, and genistein g cann inhiibit one or more m matrix m metalloprotein nase (MMPs).. Vitaamin C can innhibit MMP pproduction by y a number off hum man cancer ceell lines and prevent invaasion of thesee linees in vitro [599]. The T difference between M Mature and Im mmature fruitt extrracts of C. spinosa sp is alsso detected. Mature fruitt extrracts are moree effective thaan immature fruit f extracts,, may y be accordinng to the presence of high h quantity off terp penoids and essential e oilss in mature fruits f than inn imm mature fruit. This T result suppported by Matthhaus M andd Ozccan [60]. Penntacyclic triterrpene from Betula spp [61]

Cytotoxic Effects of Aqueous, Methanolic and Secondary Metabolites Extracts of Capparis Spinosa Fruit 141 on Tumor Cell Lines In Vitro

and from Zizyphus spp. [62, 63] displayed selective cytotoxicity against human melanoma cell lines [64]. Study of Howard et al. [38] on the Capsicum species, indicated that the concentration of chemical constituents such as carotenoids, flavonoids, phenolic acids and ascorbic acid increased as the Capsicum spp. plant reached maturity.

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Human T-Lymphotropic Virus-1/2 Detected in Drug Abused Prisoners Imprisoned in Correctional Facilities in Central of Java Indonesia Afiono Agung Prasetyo1, 2, 3, Paramasari Dirgahayu2, 3, 4, Hudiyono 1, 3, and Seiji Kageyama5 1. Department of Microbiology, Faculty of Medicine, Sebelas Maret University, Jl. Ir. Sutami 36A, Surakarta, Indonesia 2. Biomedic Laboratory, Faculty of Medicine, Sebelas Maret University, Jl. Ir. Sutami 36A, Surakarta, Indonesia 3. Center of Biotechnology and Biodiversity Research and Development, Sebelas Maret University, Indonesia 4. Department of Parasitology Faculty of Medicine, Sebelas Maret University, Jl. Ir. Sutami 36A, Surakarta, Indonesia 5. Department of Microbiology and Immunology (Division of Virology), Faculty of Medicine, Tottori University, 86 Nishi cho Yonago, Japan Abstract: Introduction: Human T cell lymphotropic virus types 1 and 2 (HTLV-1/2) has been believed not circulate in Indonesia yet. This study evaluated the prevalence of HTLV-1 and 2 in drug abused prisoners imprisoned in correctional facilities in Central of Java Indonesia, to track the presentation of HTLV-1/2 in Indonesia. Methods: A cross-sectional study was conducted in two prisons (Kedung Pane Male Prison Semarang and Women Prison Semarang) in Central of Java Indonesia between August 2009 and October 2009. All drug abused prisoners in both prisons were enrolled in this study (n = 148). Questionnaires were retrieved and bloods were tested in the period using enzyme linked immuno sorbent assays. The serological positive results were then confirmed by RT-PCR nested addressed the part of HTLV-1 LTR and HTLV-2 LTR region, respectively. Results: The average seroprevalence in the period was 1.4% (2/148). All positive serological samples were confirmed by nested RT-PCR. Of these, one was HTLV-1 positive and one was HTLV-2 positive. Molecular analysis of positive PCR products revealed that the HTLV-1 isolate had close relationship with HTLV-1 isolated in Japan while the HTLV-2 isolate with that of isolated in USA. Conclusions: HTLV-1 and HTLV-2 were detected in drug abused prisoners imprisoned in correctional facilities in Central of Java Indonesia indicated that these viruses were circulated in Indonesia. Key words: HTLV-1/2, correctional facilities, Indonesia.

1. Introduction  Human T cell lymphotropic virus type 1 and 2 (HTLV-1/2) were the first human retroviruses to be discovered. HTLV-1 is associated with adult T-cell leukemia (ATL), HTLV-associated myelopathy/ tropical spastic paraparesis (HAM/TSP), and HTLV associated uveitis (HAU) [1]. Phylogenetic studies suggest that HTLV-1 arrived in South America through fairly recent, multiple introductions, probably during African slavery. All South American countries have Corresponding author: Afiono Agung Prasetyo, MD, PhD, research field: virology. E-mail: [email protected].

reported the presence of HTLV-1, but the prevalence varies greatly between and within countries and population groups. The reasons for HTLV-1 clustering remain unknown. Classically, a pattern of age and sex dependence occurs for HTLV-1 seroprevalence among blood donors, with prevalence higher in females and increasing steadily with age, similar to patterns observed in endemic areas of southern Japan and the Caribbean basin [1]. HTLV-1 has been estimated infected 15 to 20 million people worldwide. The virus is endemic in southern Japan, the Caribbean basin, central Africa, Central and South America, the Melanesian Islands in

Human T-Lymphotropic Virus-1/2 Detected in Drug Abused Prisoners Imprisoned in Correctional Facilities in Central of Java Indonesia

the Pacific basin, and in the aboriginal population in Australia. The seroprevalence of HTLV-1 varies from 0.1% to 30% within endemic populations. Sporadic HTLV-1 infection occurs among at-risk groups from non endemic regions, including metropolitan areas in the United States and western European countries [2]. No molecular epidemiology data of HTLV-1/2 based on correctional facilities have ever been published, for the best of our knowledge. Little is known about HTLV-1/2 infections in Indonesia especially in drug abused prisoners in correctional facilities. The seroprevalence of HTLV in the healthy blood donors in Jakarta area, which was also reflected in the western part of Indonesia, was very low; however, there was no evidence of the presentation of the viruses. No seropositive individuals were found in healthy Irian Jaya people [3, 4]. However, there is no data about the presentation of HTLV-1/2 in the high risk communities in Indonesia, including the injecting drug users, people with sexual commercial activities, etc. Drug abused prisoners is usually associated with the high risk activities and they will be released into the general community after they finish their punishment, therefore, it is important to screening the presentation of infectious agent like HTLV-1/2 in the prisoners. Thus, the present study aimed to add information concerning HTLV-1/2 in drug abused prisoners imprisoned in correctional facilities in Central of Java Indonesia. We searched for the presence of HTLV-1- and HTLV-2-specific antibodies followed by molecular detection to detect the presentation of the viruses, and tried to role out the risk factor related with HTLV-1/2 infection in the prisoners.

2. Materials and Methods 2.1 Study Population We conducted a cross-sectional study in two prisons (Kedung Pane Semarang and Women Prison Semarang) in Central of Java Indonesia between August 2009 and October 2009. These facilities serve as the

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incarceration venue for adult with illicit drug allegations, as well as for adult accused of many other crimes. A list of the drug abused prisoners was obtained from the staff of the correctional facilities, and all of these individuals were recruited (n = 148). All subjects were informed that the study was voluntary and that there would be no negative consequences for refusal. Prisoners had full authority to accept or refuse to take part in the study. Only after the written consent was signed (all prisoners could sign their names), the questionnaire was administered by the interviewer. Approval was obtained from the institutional ethical committee review boards of the Faculty of Medicine of Sebelas Maret University and DR. Moewardi General Hospital Surakarta Indonesia. 2.2 Data Collection Data were collected at the time of blood drawing by questionnaires prepared by the investigator in order to determine socio-demographic characteristics and risk factors related to blood borne virus infection. A face to face verbal interview was conducted in a private room with a trained interviewer. Staff from the correctional facilities did not participate in the study and were not present in the room during the interviews. The questionnaire was administered anonymously and confidentially. After each interview, participants were asked to provide blood samples. Questionnaires included questions on socio-demographic characteristics, travel, incarceration and medical histories, drug use and sexual behaviors, especially that of related to risk factors for HTLV-1/2 infection. Other transmission routes were also assessed, such as receipt of therapeutic injections. 2.3 Serological Assay A 5 ml blood sample was collected from willing participants and then fractionated, aliquoted, and stocked in -80°C until further study. Specimens were tested at Biomedical Laboratory Faculty of Medicine

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Sebelas Maret University Surakarta Indonesia, analyzed for the presence of specific antibodies to HTLV-1/2 using an ELISA kit that employs HTLV-1/2 viral lysates plus recombinant proteins from HTLV-1/2 as antigens (HTLV-I/II ELISA 4.0, MP Diagnostics, Durhan, DC). The reactions were conducted according to manufacturer instructions. 2.4 Molecular Biology Approaches to Confirm HTLV-1 and -2 Infections Samples who presented reactive or indetermined results on ELISA assay were confirmed by molecular assay. The peripheral mononuclear blood cells (PBMC) were used for nucleic acid extraction and reverse transcriptase polymerase chain reaction (RT-PCR). LTR segments of HTLV-1 and HTLV-2 were amplified to confirm HTLV-1 and HTLV-2 infection, as previously described. Briefly, the segment of LTR regions of the HTLV-1 genome was amplified using primers LTR1/LTR3 in the first round and LTR1/LTR2 in the second round while the segment of LTR regions of the HTLV-2 genome was amplified using primers VS1/VS2 in the first round and VS3/VS4 in the second round [5]. 2.5 Determination of Nucleotide Sequences and Phylogenetic Analysis The PCR products were subjected to the determination of nucleotide sequences directly with the primers of LTR1/LTR2 for HTLV-1 LTR region and VS3/VS4 for HTLV-2 region, respectively. Sequences were then submitted to the BLAST program in order to check their similarity to related strains deposited in Genbank/EMBL/DDBJ. The reference strain with the highest homology score to each analyzed strain was retrieved from the GenBank/EMBL/DDJB database and then was aligned with the tested sequences by ClustalW [6]. The frequency of nucleotide substitution in each base of the sequences was estimated by the Kimura two-parameter method. A phylogenetic tree was constructed by the neighbor-joining method, and

its reliability was estimated by 1000 bootstrap replications. The phylogenetic tree was constructed using the MEGA version 4 software package [7]. 2.6 Statistical Analysis All analyses were performed using SPSS version 16 (SPSS, Chicago, IL, USA). Descriptive statistics were generated. For univariate analysis, frequencies and medians of all variables and measures were calculated. Comparisons between groups were performed using the Chi-square tests for proportions and the Student’s t-test for proportional and continuous variables.

3. Results Out of 148 blood samples, two (1.4%) were resulted HTLV-1/2-positive in screening tests conducted by ELISA HTLV-1/2. Both anti HTLV-1/2 positive samples were from Women Prison Semarang. For the two reactive samples in the serologic screening, it was possible to perform PCR in all cases (100%), of which all samples confirmed the presence of HTLV-DNA in the PBMC for the LTR regions of the genome. Of these, one was HTLV-1 and the other was HTLV-2 positive. Based on 317 nucleotides part of HTLV-1 LTR region, the HTLV-1 isolate (09IDSKAH-1-1, GenBank Accession Number JN247455) was shared 100% homology with B1033-2009 (HTLV-1 isolated in Japan; GenBank Accession Number AB513134) (Fig. 1). Based on 666 nucleotides part of HTLV-2 LTR region, 09IDSKAH-2-1 (GenBank Accession Number JN247458) had shared 99% homology with HTLV-2 isolated in USA (GenBank Accession Number: AF412314) (Fig. 2). There no significant difference in socio-demographic characteristics was observed in both correctional facilities. In addition, no relationship with factors associated with HTLV-1/2 infection was detected, except for both individuals with anti HTLV-1/2 positive were reported had piercing and tattooing. The piercing and tattooing were performed in local parlors with a possibility of sharing needles and/

Human T-Lymphotropic Virus-1/2 Detected in Drug Abused Prisoners Imprisoned in Correctional Facilities in Central of Java Indonesia BRRJ127-93 Ni1.Peru 09IDSKAH-1-1 B1033-2009 TBH-5 BD89517 0.001

Fig. 1 Phylogenetic tree of HTLV-1 isolated from drug abused prisoner in Women Prison Semarang Indonesia. Nucleotide sequences of partial HTLV-1 LTR were aligned using ClustalW. Support for nodes was estimated by bootstrap resampling of 1,000 pseudoreplicate data sets. Numbers at the nodes represent the bootstrap support from 1000 replicates. The length of horizontal lines is proportional to the number of substitutions/site. The HTLV-1 B1033-2009 (GenBank Accession Number AB513134), Ni1.Peru (GenBank Accession Number Y16484), BRRJ127-93 (GenBank Accession Number DQ323788), TBH-5 (GenBank Accession Number L76027) and BD89517 (GenBank Accession Number DQ235699) were also included in the phylogenetic tree. 09IDSKAH-2-1 64 95

AF412314 Y09148 AF032992

AF401494 Z46838 0.0005

Fig. 2 Phylogenetic tree of HTLV-2 isolated from drug abused prisoner in Women Prison Semarang Indonesia. Nucleotide sequences of partial HTLV-2 LTR were aligned using ClustalW. The HTLV-2 isolated in USA (GenBank Accession Number AF412314), Belgium (GenBank Accession Number Y09148), Ireland (GenBank Accession Number AF032992), Brazil (GenBank Accession Number AF401494) and Cameroon (GenBank Accession Number Z46838) were also included in the phylogenetic tree, respectively.

or unsterile needles used since both positive individuals were not sure about the needles condition. Both positive individuals were married with no unmarried sexual activities history. We could not found any significant contribution of socio-demographic characteristics, travel, incarceration and medical histories, drug use and sexual behaviors, especially that of related to risk factors for HTLV-1/2 infection.

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4. Discussion HTLV-1 and -2 are transmitted in three ways: (1) between sexual partners, mainly from man to woman; (2) through blood transfusion with HTLV-infected cells; and (3) from mother to child during prolonged breastfeeding. In areas where the virus is highly endemic, mother-to-child transmission is sometimes the predominant route. In Japan, an area where HTLV-1 infection is highly endemic, antenatal screening and a recommendation for formula feeding of infants of HTLV-1-seropositive mothers have been instituted successfully since 1987 [8]. Similar recommendations were proposed in Europe and the Caribbean [9]. The seroprevalence varies considerably by sex, age, and region (5% in urban adult’s areas, 8.5 to 10.5% in rural adults) [10, 11]. The huge number of HTLV-1-infected men among blood donors could be a consequence of the high number of donors of this gender. An age-and-gender-cohort effect due to the characteristics of blood donors worldwide could not be excluded [12]. The prevalence of HTLV-1 infection among pregnant women was estimated to be 5.5 to 6.8%. Most previous studies, however, have been carried out in only one region of the country, the southeast, and the results may therefore not reflect the national prevalence, due to possible regional foci, a hallmark of HTLV-1 infection. Furthermore, the reported rate might be under- or rather overestimated, as in most cases HTLV-1 detection by confirmatory testing with strict Western blot criteria and/or PCR was not done. Since 2009, our group began screening the high risk communities for human blood borne viruses’ infection for HIV, hepatitis B, hepatitis C, hepatitis D, Torque Teno Virus, and HTLV-1/2. In our present study, the seroprevalence of HTLV-1/2 was low. A possible explanation for the low prevalence is the improvement of ELISA test quality, with reduction in the number of false positive tests. The low return rate for the confirmatory test demonstrated the need to reevaluate the current methods of dealing with reactive samples.

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Another improvement could be the use of WB testing in the first ELISA positive screening sample. However, we did not use the Western Blot test since the variations verified in the WB test indeterminate results can be caused by the different methods used during the period, by the possibility of cross reaction with new varieties of HTLV-1/2, cross reaction with other viruses, such as the dengue virus, chickenpox and herpes simplex, severe acute respiratory syndrome virus (SARS), malaria and by the presence of individuals in the initial stages of HTLV infection [13-17]. Regarding the sensitivity and specificity of the HTLV screening kits employed in the present study, all samples positive by ELISA kits were confirmed by PCR, therefore the kits was highly sensitive in detecting HTLV-1 and HTLV-2 antibodies. However, this work was limited by its cross-sectional design, and follow-up of such individuals was not done. Finally, the main result that emerges from this study is the HTLV-1 and HTLV-2 was detected in drug abused prisoners in Indonesia. The possible transmission route(s) on the two positive persons were piercing and or tattooing since both of the positive individuals were not sure about the needles-used condition and no risk factors related to the blood borne virus infection could be found. However, the possibility of other potential transmission routes (e.g., transversal infection and or sexual transmission from their husband) could not be neglected and need further study. The correct diagnosis of HTLV-1/2 is important for prompt attention and counseling these individuals to avoid vertical and sexual virus transmission. Indeed, the results obtained suggest that HTLV-1 and HTLV-2 has probably been introduced in healthy persons in Indonesia.

Acknowledgments The authors would like to thank Faqihuddin Ahmad, Nicola Uecker, Rochmali Zultan, and Alexius Purwoko for technical assistance. This work was supported by grants from Indonesian Directorate of Higher

Education (No. 322/SP2H/PP/DP2M/VI/2009 and 440/SP2H/PP/DP2M/VI/2010).

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F. A. Proietti, A. B. Carneiro-Proietti, B. Catalan-Soares and E. Murphy, Global Epidemiology of HTLV-1 infection and associated diseases, Oncogene 24 (2005) 6058–6068. [2] M. Matsuoka and K. T. Jeang, Human T-cell leukemia virus type I at age 25: A progress report, Cancer Res 65 (2005) 4467–4470. [3] Y. Tanggo, S. P. Gultom, T. Simanjuntak, W. H. Sibuea, H. Matsuzaki and K. Yamaguchi, Human T lymphotropic virus I in Indonesia: Very low seroprevalence in the Jakarta area: antibodies in healthy blood donors and in various nonhematological diseases, Intervirology 43 (2000) 77–79. [4] S. Takao, T. Ishida, K. K. Bhatia, N. Saha, A. Soemantri and O. W. Kayame, Seroprevalence of human T-lymphotropic virus type 1 in Papua New Guinea and Irian Jaya measured using different western blot criteria, J Clin Virol 16 (2000) 129–133. [5] H. K. Morimoto, A. A. Morimoto, E. M. V. Reiche, L. T. Ueda, T. Matsuo and F. L. Reiche et al., Difficulties in the diagnosis of HTLV-2 infection in HIV/AIDS patients from Brazil: Comparative performances of serologic and molecular assays, and detection of HTLV-2b subtype, Rev Inst Med trop S Paulo 49 (2007) 225–230. [6] J. Thompson, D. Higgins and T. Gibson, CLUSTAL W: Improving the sensitivity of progressive multiple sequence aligment through sequence weighting, position-specific gap penalties and weight matrix choice, Nucleic Acids Research 22 (1994) 4673–4680. [7] K.Tamura, J. Dudley, M. Nei and S. Kumar, MEGA4: Molecular Evolutionary Genetic Analysis (MEGA) software version 4.0, Molecular Biology and Evolution 24 (2007) 1596–1599. [8] Kashiwagi, The effects of breastfeeding and presence of antibody to p40tax protein of human T cell lymphotropic virus type-I on mother to child transmission, Int J Epidemiol 21 (1992) 989–994. [9] B. Hanchard, Adult T-cell leukemia/lymphoma in Jamaica: 1986–1995, J Acquir Immune Defic Syndr Hum Retrovirol 13 (1996) S20–S25. [10] P. F. Berteau, J. Mention, J. Tissedre, B. Narraido, C. Grall and E. Glowaczover et al., Evaluation of the seroprevalence of human immunodeficiency virus (HIV) and human T-cell lymphotropic virus (HTLV) in Haut Ogooue´ Province in Gabon in pregnant women and blood

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donor control groups, Bull Soc Pathol Exot 86 (1993) 12–15. P. F. Berteau, Y. Martin-Prevel and I. Bedjabaga, Vertical transmission of the human T-cell leukemia virus in an endemic area. An epidemiological study in children from 0 to 5 years in Gabon, Bull Soc Pathol Exot 87 (1994) 217–221. M. R. Dias-Bastos, C. D. L. Oliveira and A. B. F. aCarneiro-Proietti, Decline in prevalence and asymmetric distribution of human T cell lymphotropic virus 1 and 2 in blood donors, State of Minas Gerais, Brazil, 1993 to 2007, Rev Inst Med trop S Paulo 43 (2010) 615–619. S. M. F. Carvalho, M. S. Pombo-de-Oliveira, L. C. S. Thuler, N. P. Leite, A. O. Santos and R. M. P. Nogueira et al., Cross-reactivity between Human T-cell Leukemia-Lymphoma Virus indeterminate Western Blot and Dengue Virus in individuals from Rio de Janeiro, Brazil, J Acquir Immune Defic Syndr Human Retrovirol 20 (1999) 4. T. J. Santos, C. M. Costa, P. Goubau, A. M. Vandamme, J. Desmyter and S. Van Doren et al., Western blot

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seroindeterminate individuals for human T-lymphotropic virus I/II (HTLV-I/II) in Fortaleza (Brazil): A serological and molecular diagnostic and epidemiological approach, Braz J Infect Dis 7 (2003) 202–209. [15] K. C. Tsao, W. Chen, C. G. Huang, Y. L. Huang, J. Y. Lin and C. K. Mok et al., False positive antibody results against human T-cell lymphotropic virus in patients with severe acute respiratory syndrome, J Med Virol 77 (2005) 331–336. [16] R. Mahieux, P. Horal, P. Mauclère, O. Mercereau-Puijalon, M. Guillotte and L. Meertens et al., Human T-cell lymphotropic virus type 1 gag indeterminate western blot patterns in Central Africa: Relationship to Plasmodium falciparum infection, J Clin Microbiol 38 (2000) 4049–4057. [17] A. M. Mangano, M. Remesar, A. del Pozo and L. Sen, Human T lymphotropic virus types I and II proviral sequences in Argentinian blood donors with indeterminate western blot patterns, J Med Virol 74 (2004) 323–327.

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Manipulation of the Sacroiliac Joint under General Anesthesia versus Other Conservative Treatment for the Management of Post Labor Backache due to Sacroiliac Subluxation Haider Wehab Ali1, Mohamed Bahjat A. Rabea2 and Ali H. Khudhair2 1. Department of Surgery, Al-Samawa General Hospital, Iraq 2. Department of Surgery, Basrah Medical College, Iraq Abstract: A prospective comparative study conducted on 12 patients with post labor backache (after 3 days of vaginal delivery till the end of puerperium) in Al-Basrah General Hospital, during the period from July 2009 till October 2010. The aim of this study is to compare between the results of manipulation of sacroiliac joint under general anesthesia and other conservative treatment for the management of post labor backache due to sacroiliac subluxation. The 12 patients included were those who met the diagnostic criteria for sacroiliac subluxation [pain in the sacral region, a positive Piedallu’s sign (asymmetrical movement of the posterior superior iliac spine upon forward flexion), a positive pelvic compression test, and asymmetry of the anterior superior iliac spine] plus confirmatory signs of sacroiliac subluxation (straight leg raise, flexion block, positive Patrick’s test, pain at Baer’s point). The patients were divided into two groups A and B, 6 patients in each , those in group A were treated by NSAID, special pelvic belt and physiotherapy while those in group B were treated by manipulation of the sacroiliac joint under general anesthesia. In group A, pain was relieved partially in 4 patients (66.7%) and in 2 patients (33.3%) there was no improvement after 12 weeks of treatment. While in group B, pain was relieved totally in 5 patients (83.4%) and partial pain relieve in one (16.6%). In conclusion, manipulation of the sacroiliac joint under general anesthesia is superior to other conservative options for the management of post labor sacroiliac subluxation. Key words: Sacroiliac joint, conservative treatment, general anesthesia, post labor backache, sacroiliac subluxation.

1. Introduction  Postpartum backache is the pain that women experience it in the lower back immediately after labor [1]. Postpartum back pain is less common than pregnancy back pain. The usual temporary causes of back pain associated with pregnancy often end with the birth. For many mothers backache resolves in the first few weeks after delivery, but for some it may continue for months, and for a few it first presents postpartum [2]. Immediately after delivery, up to two thirds of mothers may suffer back pain. This is sometimes Corresponding author: Ali H. Khudhair, PhD, assistant medical. E-mail: professor, research field: [email protected].

attributed to epidural analgesia in labor. Regrettably, many investigators have failed to distinguish between localized trauma at the site of insertion of epidural needle, which is not uncommon but usually causes transient pain, and generalized backache or sacroiliac strain, which may be reported by 40% of mothers who do not receive regional analgesia. Such symptoms may be a continuation of antepartum back pain or may result from excessive straining during the expulsive phase of labor [3].

2. Patients and Method This prospective comparative study was conducted in orthopedic department in Al-Basrah General Hospital , during the period from July 2009 till October

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2010 on 21 female patients, their age were ranging from 20–42 years, with post labor backache (after 3 days of vaginal delivery till the end of puerperium). The patients were evaluated by detailed history, thorough physical examination in addition to relevant laboratory and radiological investigations to diagnose the cause of post labor backache. Special emphasis was placed upon the age, occupation, parity, onset of post labor back pain, site, severity & radiation of pain in addition to other neurological symptoms like numbness & parasthesia were asked about. A visual-analog (VA) scale of pain intensity was used [4]. This scale was a 10 cm long horizontal unstratified line spanning the entire experience of pain, ranging from 0 = no pain to 10 = severe intolerable pain. Each patient indicated how she experienced the pain intensity by making a mark on the line. The distance between the start of the line and her mark was registered as a measure of severity of pain. In addition, the location, distribution and quality of pain were also noted in each visit after treatment. Visual analog pain scale

Physical examination: (1) Measuring the weight and height of the patients, then the body mass index (BMI) were calculated according to special formula (Qutetelet’s index) [5]. BMI = (Weight (kg)/2.205)/(Height (cm)/39.37)2. The patients were classified into three groups according to this formula: (1) Normal weight: BMI = < 25, (2) Over weight: BMI = 25-30 and (3) Obese: BMI = > 30. (2) Examination of lumbar spine and hip joints to role out any pathology in these two regions as a cause of low back pain.

(3) Sacroiliac joint examination (local sacral tenderness; pelvic stress tests; diagnostic criteria of sacroiliac subluxation which includes  absence of lumbar spine and hip pathology  pain in the sacral region  a positive Piedallu’s sign (Fig. 1) (asymmetrical movement of the posterior superior iliac spine upon forward flexion)  a positive pelvic compression test  a symmetry of the anterior superior iliac spine (Fig. 2 ). Confirmatory signs of sacroiliac subluxation includes:  straight leg raise  flexion block (With the patient in a supine position, the knee is flexed at 90 degree and then passively pressed towards the chest. Flexion is blocked to one-half the expected range on the painful side).  positive Patrick’s test (Placing one heel on the opposite knee, in the recumbent position, and simultaneously rotating the leg outward provokes pain).  pain at Baer’s point (A point of acute tenderness just to the side and below the umbilicus on the painful side, which is about one- third of the way between the umbilicus and the ASIS).

Fig. 1 Piedallu’s or locking sign [6].

 

152 Manipulation of the Sacroiliac Joint under General Anesthesia versus Other Conservative Treatment for the Management of Post Labor Backache due to Sacroiliac Subluxation

 

Fig. 2 Examination of ASIS with the left spine being higher than the right [7].

(4) Signs of general joint hypermobility. Investigation included: (1) Laboratory tests including: Hb%, PCV%, Hb electrophoresis, blood sugar, CRP. (2) Pelvic X-ray (AP view) in weight bearing position and lumbo-sacral spine X-rays were taken. (3) CT scan was requested for 3 patients & MRI for another 4 patients in whom the diagnosis was unclear. Only twelve out of 21 women, met diagnostic criteria for sacroiliac subluxation, were included in this study, the other 9 patients were excluded because a herniated nucleus pulposus was diagnosed in three, symphysis pubis separation in four & coccydynia in the remaining two patients as the causes of low back pain rather than SIJ subluxation. The 12 patients were divided blindly into two groups A and B, each group consisted of 6 patients. Group A were treated for 6 weeks by NSAID (Diclofenac sodium 100 mg daily ) and sacroiliac belt for 2 weeks, followed by physiotherapy for another 4 weeks in form of heat, infrared and physical exercise to encourage movement of the PSIS in supine & standing positions. At the end of 6 weeks we re evaluate the patients by assessing there response of pain in addition by repeating the above mentioned tests to assess for improvement in SIJ alignment. The pain either totally relieved (0-1 on VA pain scale), partially improved (2-8 on VA pain scale) or not improved (9-10 on VA pain scale).

If there is no improvement we repeat the same regimen of treatment for another 6 weeks then second reassessment at the end of 12 weeks. Patients in group B were treated by manipulation of SIJ under general anesthesia. The technique is repeated in the same session in obese patients or at other time if there is partial or no response to first trial. Three high-velocity low-amplitude (HVLA) thrust techniques of manipulation were used in current study depending on the findings & patient’s built as following: (1) Rotation of the pelvis up/anteriorly on the painful side was applied after confirming that the PSIS is rotated down or posteriorly on the painful side in relation to the other PSIS (Fig. 3). (2) Thrusting the innominate posteriorly on the painful side was applied after confirming that the ASIS is rotated up or anteriorly on the painful side in relation to the other ASIS (Figs. 4–5). (3) Rotation of the pelvis down/posteriorly on the painful side was applied after confirming that the PSIS is rotated up or anteriorly on the painful side in relation to the other PSIS (Fig. 6). Following manipulation patients were re evaluated for pain relieve and for improvement of SIJ alignment. The patients were categorized in to:  The pain was completely relieved either immediately or within one week (0-1 on VA pain scale).  The pain was partially relieved (2-8 on VA pain scale).

 

Fig. 3 Sacroiliac joint, thrust the right innominate anteriorly on the painful side in side-lying position [14].

Manipulation of the Sacroiliac Joint under General Anesthesia versus Other Conservative Treatment for 153 the Management of Post Labor Backache due to Sacroiliac Subluxation

(a)

  Fig. 7 Exercise in supine-lying, encouraging movement of the PSIS (15) .

 

 

(b) Fig. 4 Sacroiliac joint, thrust the left innominate posteriorly on the painful side in supine position [14].

  Fig. 8 Exercise in standing, encouraging movement of the posterior superior iliac spine [15].

  Fig. 5 Sacroiliac joint, thrust the left innominate anteriorly on the painful side in prone position [14].

hospital if the pain had not totally subsided within one week or if they had any recurrence of pain within 12 weeks after first manipulation for re-evaluation and re-manipulation. After second manipulation, the results were recorded as final results which were no improvement, partial relieve and complete relieve.

3. Results   Fig. 6 Rotation of the pelvis posteriorly or downwards on the painful side [15].

 The pain was not relieved (9-10 on VA pain scale) within one week.  Recurrence of the symptoms (9-10 on VA pain scale) after complete improvement and the time of recurrence. Patients were instructed to use back belt as a sacroiliac belt& to do the physical exercises as a maintenance program to maintain stability and to prevent recurrence (Figs.7–8) and to return to the

Among twelve women with post labor sacroiliac joint subluxation who were included in current study 8 patient (66.6%) lie in age group 21–30 years old especially in 7(58.3) multipara mother (para3+). Three quarters (75%) of studded patients had low back pain started during pregnancy (after 24 weeks of gestation). Four patients (33.3%) were obese, 7 (58.3%) were over weight and one was normal body weight. Post labor sacroiliac joints subluxation affecting left side more frequently than in right side & was recorded in 7 women (58.3%) of cases (Table 1).

154 Manipulation of the Sacroiliac Joint under General Anesthesia versus Other Conservative Treatment for the Management of Post Labor Backache due to Sacroiliac Subluxation Table 3 response of group A patients.

Table 1 Risk factors of sacroiliac subluxation. Risk factors

No. of patients Percent

Abnormal body weight

11

91.6

Medically assisted vaginal delivery

8

66.7

Multiparity

7

58.3

General joint hypermobility

3

25

After 6 weeks After 12 weeks Pain relieve

Piedallu’s sign

Total

0

0

Partial

3

4

No

3

2

+

6

4

_

0

2

Pelvic compression test

+

3

2

_

3

4

asymmetry of ASIS

+

6

4

_

0

2

All women (100%) were presented with positive criteria of sacroiliac joint subluxation (Sacral pain, Piedallu’s sign, pelvic compression test, asymmetry of ASIS) & positive Patrick’s test, eight women (66.7%) had positive straight leg raise test, nine women (75%) had positive Flexion block test while pain at Baer’s point was recorded in three women (25%) only so it was a poor indicator in our study (Table 2). Pelvic X-ray in weight bearing didn't show any abnormality in 8 patients (66.7%) but asymmetry of sacroiliac joints was detected in 4 patients (33.3%), left SIJ affected in 3 and right SIJ in one patient. The outcome of treatment: Group A (Table 3): At the end of 6 weeks 3 patients (50%) had partial pain relieve while the other 3 (50%) had no improvement. Piedallu’s sign& asymmetry of ASIS were positive in all patients (100%) & pelvic compression test was positive in 4 (66.7%) patients & negative in 2 (33.3%) patients. The same regimen was repeated for another six weeks for all group A patients. At the end of 12 weeks the results were as follow: One additional patient got partial improvement and the figure rises from 3 to 4, Piedallu’s sign& asymmetry

of ASIS changed to negative in 2 (33.3%) patients and pelvic compression test in 4 (66.7%) patients. Regarding the outcome in group A four women (66.7%) had partial improvement & two women (33.3%) had no improvement at all. Group B: Regarding the response of women in group B for manipulation of the painful side of sacroiliac joint under general anesthesia, three women had immediate total relief of pain, one of them had recurrence of pain after 3 weeks and second manipulation was performed resulted in total relief of pain. The other three women got partial relief after the first manipulation so a second manipulation was required; the pain was relieved totally in two and partially in one. So complete pain relieve was achieved in 5 patients after single or double sessions of manipulations while the pain was partially relieved in the sixth patient even after 2 trials.

Table 2 Distribution of patients according to the diagnostic

4. Discussion

criteria of sacroiliac joint subluxation.

Twenty one females with post-labor backache were evaluated for diagnosis of sacroiliac joint subluxation. The average age was 30.4 years (ranging between 20–42 years). In this study twelve females (57.1%) met diagnostic criteria of sacroiliac subluxation, (95.6%) reported by Fraser [8] while (11%) reported by Daly [7]. These studies support the connection that sacroiliac subluxation is a common cause of severe low back pain in pregnancy.

Sign and Symptoms

Negative

%

positive

%

Sacral pain

-

-

12

100

Piedallu’s sign

-

-

12

100

pelvic compression test

-

-

12

100

Asymmetry of ASIS

-

-

12

100

Patrick’s test

-

-

12

100

Flexion block test

3

25

9

75

Straight leg raise

4

33.3

8

66.7

Pain at Baer’s point

9

75

3

25

Manipulation of the Sacroiliac Joint under General Anesthesia versus Other Conservative Treatment for 155 the Management of Post Labor Backache due to Sacroiliac Subluxation

The onset of backache due to sacroiliac subluxation took place during antepartum, and continued after labor in (75%) in the current study, (66%) in Berg [9] and (55%) in Daly [7] studies. Regarding risk factors of sacroiliac subluxation, general joint hypermobility was found in (25%) of cases, obesity (33.3%) and multiparity in (58.3%), in our study these risk factors not affect our selection of groups but we faced difficulties during applying manipulation in obese patients in whom repeated manipulation is required in the same session. Women that delivered by medically assisted normal vaginal delivery (66.7%) were more prone to post labor sacroiliac subluxation than those delivered with out medical assistant (33.3%). We believed that the effect of analgesia and sedation made women free of pain and excessive thigh abduction during labor with concomitant relaxation effect of oxytocin resulting in excessive stressing of SIJ and sacroiliac subluxation. Left SIJ involved more than the right one, but this had no significant effect on the outcome in both groups this result goes with that of Daly [7]. X-ray plays insignificant role in the diagnosis of SIJ subluxation as asymmetry of both sacro-iliac joints was detected in 4 patients only on weight bearing AP view of the pelvis while NAD was the result in two thirds of patients. This fact also raised by Gupta AD [10]. Spiral CT scan & MRI should be requested in doubtful cases to role or role out other causes. Regarding the outcome of the manipulative treatment, pain was relieved totally in 5 (83.3%) of 6 women, Daly [15] reported relieve of pain totally in 10 (91%) of 11 pregnant women & got obvious clinical improvement in pelvic alignment correlated with alleviation of pain. In response to NSAID, pelvic belt and physiotherapy, pain was relieved partially in 4 (66.7%) women and 2 (33.3%) women got no improvement even after 12 weeks extension of the regimen. Gupta AD [10] study used NSAID and sacroiliac belt; other studies used sacroiliac belt [9] and physical therapy [11–13] as a

conservative treatment with approximate outcome to our results. Current study consistent with other [7, 8, 11–13] in that manipulation of sacroiliac joint is superior to conservative treatment for the management of post-labor sacroiliac subluxation. Recurrence of symptoms after second time manipulative treatment was not recorded in this study as the use of support belt after manipulation produced more stability& minimal recurrence rate & this agrees with Golighty [12].

5. Conclusions Post labor backache is distressing problem in considerable number of pregnant women with a lot of causes, Sacroiliac subluxation is one of the most important one .The diagnosis of sacroiliac subluxation can be made depends mainly on clinical bases as plain radiograph have a limited role . Women with generalized joint hypermobility, obesity and multiparity are more prone to have post-labor sacroiliac subluxation especially if delivered by medically assisted vaginal delivery. Treatment by manipulation under general anesthesia is superior to other conservative modalities.

References [1]

[2]

[3] [4]

[5]

F. M. Kovacs, N. Mufraggi and M. Gestoso, MT.Gil del Real: Expectant mothers, available online at: http://www.espalda.org/english/divulgativa/su_espalda/e mbarazadas.asp, accessed on 19/05/2010. S. A. Rostocki, Postpartum Back Pain, available online at: http://www.cure-back-pain.org/postpartum-back-pain.htm l, accessed on 30/03/2010. R. Russell and F. Reynolds, Back pain, pregnancy, and childbirth, BMJ 314 (1997) 1062–1063. F. Turgut, M. Turgut and M. Cetinsahin, A prospective study of persistent back pain after pregnancy, European Journal of Obstetrics & Gynecology and Reproductive Biology 80 (1998) 45–48. National Institutes of Health (NIH), The practical guide: Identification, evaluation, and treatment of overweight and obesity in adults, Calculator: Body Mass Index (Qutetelet’s index), Bethesda: National Institutes of

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[16]

Health, 2000, NIH publication 00-4084, Up-to-date desk top 17,1 . A. B. Lippitt, Recurrent subluxation of the sacroiliac joint: Diagnosis and treatment, Bull Hosp Jt Dis 54 (1995) 94–102. K. M. Daly, P. S. Frame and P. A. Rapaza, Sacroiliac subluxation: A common, treatable cause of low back pain in pregnancy, Fam. Pract. Res. J. 11 (1991) 149–159. D. M. Fraser, Post-partum backache: A preventable condition, Can Fam Physician 22 (1980) 1434–1436. G. Berg, M. Hammar, J. Moller-Nielsen, U. Linden and J. Thorblad, Low back pain during pregnancy, Obstet Gynecol 71 (1) (1988) 71–75. A. D. Gupta, Sacroiliac joint pathologies in low back pain, Journal of Back and Musculoskeletal Rehabilitation 22 (2009) 91–97. R. X. Sands, Backache in pregnancy, Obstet Gynecol 12 (1958) 670–676. R. Golighty, Pelvic arthropathy in pregnancy and puerperium, Phys Ther. 68 (1982) 216–220. R. L. Don Tigny, Function and pathomechanics of the sacroiliac joint, Phys Ther. 65 (1985) 35–44. P. Gibbons, Tehan p. Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective (3rd ed.), Churchill Livingstone, 2005, Part c, HVLA thrust techniques-pelvis, pp. 239–252. E. Atkins, J. Kerr and E. Goodlad, A practical Approach to Orthpaedic medicine: Assessment, Diagnosis and Treatment (3rd ed.), Churchill Livingstone 14 (2010) 411–432. M. Lynagh, R. Burton and R. Sanson-Fisher, A systematic review of medical skills laboratory training: Where to from here? Med Educ 41 (2007) 879–887.

[17] D. R. Woods, Problem-based Learning: How to Gain the Most from PBL, Canada: Waterdown, 1996. [18] A. Barman, A. Jaafar and N. N. Naing, Perception of students about the problem-based learning sessions conducted for medical and dental schools’ students of Universiti Sains Malaysia, Education for Health 19 (2006) 363 –368. [19] R. W. Sanson-Fisher and M. C. Lynagh, Problem-based learning: A dissemination success story? MJA 183 (2005) 258–260. [20] B. Trapper, Integrated problem-based learning in the neuroscience curriculum — the SUNY Downstate experience, BMC Med Educ 6 (2006) 47. [21] V. S. Singaram, D. H. J. M. Dolmans, N. Lachman and C. P. M. van der Vleuten, Perceptions of problem-based learning (PBL) group effectiveness in a socially-culturally diverse medical student population, Education for Health 21 (2) (2008), available online at: http://www.educationforhealth.net/. [22] G. C. H. Koh, H. E. Khoo, M. L. Wong and D. Koh, The effects of problem-based learning during medical school on physician competency: A systematic review, CMAJ 178 (2008) 34–41. [23] G. Peeraer, A. J. J. A. Scherpbier, R. Remmen, B. Y. De Winter, K. Hendrickx, P. Van Petegem, J. Weyler and L. Bossaert, Clinical skills training in a skills lab compared with skills training in internships: Comparison of skills development curricula, Education for Health 20 (3) (2007), available onlie at: http://www.educationforhealth.net/. [24] D. G. Nielson, A. M. Moercke, G. Wickmann-Hansen and B. Eika, Skills training in laboratory and clerkship: Connections, similarities, and differences, Med Educ 8 (12) (2003), available online at: http://www.med-ed-online.org.

D

Mar. 2012, Volume 9, No. 3 (Serial No. 88), pp. 157–164 Journal of US-China Medical Science, ISSN 1548-6648, USA

DAVID

PUBLISHING

Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program Bidyadhar Sa1, Vijay Naraynsingh2, A. V. C. Rao3 and Stella Williams1 1. Centre for Medical Sciences Education, Faculty of Medical Sciences, UWI, St Augustine, Trinidad and Tobago 2. Department of Surgery, Faculty of Medical Sciences, UWI, St Augustine, Trinidad and Tobago 3. Departemnt of Paraclinical Sciences, Faculty of Medical Sciences, UWI, St Augustine, Trinidad and Tobago Abstract: Background: This study investigates medical students’ level of satisfaction with the effectiveness of PBL and Skills Lab training. It also seeks students’ opinions on the duration of the Phase I Programme and whether the pre and para clinical courses appropriately prepare them for ward-readiness. Method: An anonymous questionnaire was administered to 4th and 5th year medical students seeking the outcome of a PBL approach, effectiveness of Skill Lab Training and duration of the pre and para-clinical offered in phase I. The collected data was subjected to mean and standard deviation; and percentages were presented in graphs. Results: Our results on students’ ranking of the effectiveness of PBL reflect a below average rating. Students prefer skills training in both ward and laboratories rather than in skills laboratories only. The study also reveals that the majority of students prefer to have a 2-Year Phase I programme. Conclusion: Although PBL is a widely popular approach to teaching, our results show that it is always contextual. It is also observed that students prefer a blended form of skills training. Students’ preference of a 2 year Phase I Programme needs to be seriously considered with a paradigm shift from the present curriculum. Key words: Problem based learning, MBBS, skills training, effectiveness.

1. Introduction  Problem Based Learning (PBL) in medical education was first introduced at McMaster University; Canada in 1969[1]. It has been variously described as a “complex mixture of general teaching philosophy, learning objectives and goals and faculty attitudes and values” [2]. It is also seen as a general learning strategy rather than a mere teaching approach [2]. Experts in the field view PBL as not just a method but as a way of learning and also as simulative, integrated and progressive [3, 4]. In the forty or so years since its introduction there has been continuing concern among medical educators about whether or not to adopt PBL as a teaching/learning approach. Corresponding author: Bidyadhar Sa, MA, Mphil, PhD, lecturer, research fields: assessment in medical education; emotional intelligence. E-mail: [email protected].

Consistent with medical schools elsewhere, and also in the Caribbean, in 1989 [5], the Faculty of Medical Science (FMS), University of West Indies St. Augustine Campus, adopted an approach in which one third of the teaching time was devoted for PBL to deliver Phase I (First 3 years) MBBS curriculum and more than two decades later (2010), the FMS continues to use PBL as part of its curriculum. In addition, the FMS also offers skills laboratory training during the Phase One so that students might be better equipped with the practical skills necessary for the clinical phase of the program. Of the three years that are devoted for Phase One, the “preclinical” training is done in the first and second, and “Para clinical” training is done in the third year. Twenty years after implementing PBL, there is now a need to investigate student perceptions of this hybrid PBL approach as well as their opinions of skills

158

Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program

laboratory training. Researchers at the FMS therefore took the question of level of satisfaction and perception of the effectiveness of PBL directly to the stakeholders, the students. The researchers also asked whether the time allotted for the pre and Para clinical courses was appropriate to prepare students to be ward-ready. This paper details the Years four and five students’ levels of satisfaction, with the hybrid PBL approach along with their suggestions on ways to make the programme at the FMS more meaningful. A large body of published literature exists on the PBL, now promoted as a philosophy of education and an appropriate strategy for professional education [6, 7]. Yet the effectiveness of PBL and the level of satisfaction that medical students who are taught and who learn from this “philosophy of education” is still largely unclear. There is a common perception that assessment drives learning, yet it is strongly believed that since PBL involves learning through handling problems, that the approach acts as a trigger to do so. The educational philosophy behind PBL aims to build self directed learners, to develop positive team behavior, as well as to develop and nurture critical thinking skills among the students. Informed by this philosophy, the major objectives of PBL are therefore to strengthen student’s foundational knowledge about basic sciences, to develop critical, problem solving and clinical reasoning skills, to instill independent learning skill and to cultivate effective group behavior [8]. The FMS PBL process follows the steps of the Maastricht 7 Jump Method, outlined below. (Box 1) [9]: Box 1 Steps in the PBL Process at FMS Step 1: Identification and clarification of the unfamiliar words and phrases Step 2: Problem analysis and identification of the main issues Step 3: Problem summarization Step 4: Hypotheses formulation Step 5: Identification of student generated learning objectives Step 6: Self directed study Step 7: Problem resolution and knowledge consolidation

PBL research studies usually provide information that is neither rigorous nor formal enough to contribute to making evidence based medical decisions. Perhaps this is a reason why medical education scholars are still uncertain whether the PBL approach creates better physicians when compared with traditional learning. Uncertainty also exists as to whether the PBL approach is superior to didactic, basic and clinical teaching. Implementing PBL is not without challenges. One major challenge is the self directed nature of it. More than one- third of medical educators had a neutral stance on PBL as a student oriented educational approach and the value of PBL students’ confidence level while questioning and interacting in the class [10]. Moreover, early in medical training, students remain unclear as to what they need to learn in order to solve the given problem. Medical educators also remain neutral about whether knowledge is better acquired in a PBL based course rather than on a course based on lectures [10]. Further, there is no evidence that shows how a hybrid curriculum can make better doctors when compared to other methods that are used to train doctors. According to Norman and Schmidt [11], setting up PBL groups provides students with the opportunity to develop skills but in itself contributes nothing to actually develop either their: problem solving abilities or their group and self directed learning skills. And the desired target goal of skill development is only met when there is a learning cycle of practice and feedback [12]. In short, Kinkade [13] recommends the PBL curriculum should be based on carefully selected and designed problems that demand critical knowledge acquisition, problem solving proficiency, self directed learning strategies and teacher participation skills. Furthermore, Major & Palmer [14] established there was no difference between the knowledge that PBL students and non-PBL students acquire with respect to the medical sciences. Tan [15] explored students’ experiences on the following issues on a 10 point scale with the mean

Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program

scores in parantheses reflecting the effectiveness of PBL related issues: I learned much about problem solving process (7.2); I learned to become a more independent learner and self directed learner (6.2); I learned to take different perspectives and to think more deeply (7.2), I learned to access and employ a variety of resources and information (7.0), Through the PBL process I am more prepared and ready to solve more complex and new problems (6.0). Medical schools are making extensive use of Skill Laboratories and centers that provide an excellent setting for such training [16]. A physician can take effective and timely therapeutic decisions only when he or she has an authentic and accurate diagnosis. Prospective practitioners must be well versed in such skills as history-taking, observation, and physical examinations. For when assessed by simulator performance and immediate post training, skill laboratories are known to lead to improvement in procedural skills [17]. The UWI FMS, realizing the effectiveness of skill training has been offering clinical and practical skills training during Phase I (Years 1-3). But, to what extent is this skill laboratory successful in achieving its objectives in meeting the needs of the graduates? Is the time devoted for the skill training adequate and what, if any, suitable alternatives to this type of training exist? After years of training medical students in necessary skills, it became necessary to investigate the relevance and effectiveness of skills training.

open-ended allowing students to express opinions on pertinent issues relevant to the delivery of Phase: I curriculum. However one forced-choice question was dropped because of ambiguity. The questionnaire was administered to 162 (60.22% of the total 269) year 4 and year 5 clinical students. Data collected on 7-point semantic differential scale were subjected to the calculation of Mean and SD. The maximum score for each item is 7 and minimum is 1. The higher the mean score, the higher the students’ more-positive view becomes on the issue. Data collected on forced choice items were subjected to percentage technique and presented in graphs Students’ opinions on the issues in the open-ended question were collated and organized under three major categories: PBL; skills laboratory training and curriculum in pre and Para clinical years. Relevant excerpts from students’ responses to the open-ended question are detailed in the ‘discussion’ section of this paper.

3. Results Out of the available 269 (118 Year 4, Female 80 & Male 38, and 151 Year 5, Female 89 & Male 62); 162 (60.22% of the total) year 4 and year 5 participated in the study. Thus the total sample of 162 comprised of 56 (34.6%) year 4 and 106 (65.4%) year 5 students; female students outnumbered male (i.e., 64.2%, n = 104) as shown in the Fig. 1.

2. Method An anonymous questionnaire was designed to get students’ opinions on their perceptions and levels of satisfaction with 3 years of PBL experience and skills laboratory training, and the duration of Pre & Para clinical programs at FMS. This questionnaire originally contained 16 items, 10 of which were placed on a 7 point semantic differential scale where the respondents rated their agreement or disagreement. Five questions were forced-choice, and one item was

159

Fig. 1

Characteristics of the selected sample.

160

Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program

From the Table 1 the result shows that the mean score for item no 1, 5, 7 (4.12, 4.91 and 6.23 respectively) only crossed the mid score of 4. Further as shown in Fig. 2; 128 (79%) students indicate a preference for learning clinical skills using a combined approach (both skill laboratory and clinic). Particularly for the purpose of history taking 144 (88.9%) (Fig. 3) students prefer to work with real rather than with simulated patients. As shown in Fig. 4, 96 (59.3%) students are of the view that Pre & Para clinical course materials can be Table 1 Mean and SD for issues relating to PBL and skills laboratory training Issues relating to PBL & skill laboratory Mean SD training Q1. Relevance and usefulness of PBL session Q2. Change in learning approach because of PBL Q3. Change in team skills/behaviors because of PBL Q4. Change in cognitive and critical thinking skills because of PBL Q5. Relevance and Usefulness of PBL problem discussed in PBL session Q6. Whether the PBL approach should be abandoned or maintained as it is Q7. Clinical skills can be better learned with real patient in ward or clinic than simulated patient in skills laboratory Q8. Relevance and usefulness skills laboratory training during Pre & Para clinical years Q9. Whether skills laboratory training during Pre & Para clinical years should be abandoned or maintained as it is Q10. By the start of clinical studies; the rating of basic science knowledge

Fig. 2

4.12

1.51

3.89

1.61

3.82

1.58

3.94

1.45

4.91

1.47

3.81

1.57

6.23

1.37

3.77

1.86

3.51

1.70

3.93

1.21

I could learn clinical skills more effectively in.

Fig. 3 with.

For the purpose of history taking I prefer to work

Fig. 4

I could learn Pre & Para clinical materials in.

Fig. 5

I would prefer.

Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program

covered in a two-year period while only 57 (35.2%) endorsed the current 3 year programme. Further, a majority of the students 118 (72.8%) (Fig. 5) prefer 2 years of Pre & Para clinical & 3 Years of clinical training.

4. Discussion 4.1 Problem Based Learning (PBL) PBL training is considered to be able to: (a) develop an effective clinical reasoning process; (b) synthesize knowledge base for use in clinical contexts; (c) develop effective self-directed learning skills; and (d) increase motivation for learning [12]. Contrary to findings from similar studies by Tan [15], our results reflect a negative perception on most features studied. Our students’ rating fell below the average on: learning approach, team skills and behavior and also critical thinking skills. This is of serious concern. Even though there is no evidence that a PBL approach provides a better knowledge base, meta-analyses have revealed better socio-cultural attributes and critical thinking, encourage problem solving that promote self directed learning skills in students. The possible reasons for negative perception in our study could be: (1) PBL methodology in our Hybrid system contributes to less than 10% of the curriculum contact hours. Students’ comments: (a) The (PBL) curriculum is too time consuming – this wastes time and the schedule only allows time for cramming (b) Too much time is spent on PBL problems (c) We learnt theory in a vacuum for 3 years, unable to relate to real patients… (2) Large group size, which is usually about twice the number recommended. For PBL teaching it is recommended that no more than 10 students should participate in any one tutorial group [18]. Students’ comments: (a) To some extent PBL helped us to learn about the topic but one lecture with everybody [all students] on the topic would be more efficient way of doing that

161

because all the critical thinking aspects and team approach doesn’t happen.” (3) There is a lack of facilitator training, a lack of interest in the tutors in the PBL process and selection of inappropriate tutors. Students’ comments: (a) PBL tutors need to be better prepared… some don’t even seem to know the material. (b) Tutors should be trained in order to maximally benefit the learning process. (c) Please get lecturers who are dedicated to the task. (4) Lack of reliable and appropriate assessment method for PBL (a) PBL is subjective and people [(students] only go for [(to get]) marks. (b) This is not an equal or fair marking scheme, there should be clinical assessment of the cases. (c) … fairness in PBL is needed. (d) “I think that PBL is subjective, it depends on the tutor as some give you a really good experience.” (5) Heterogeneity of the student grouping and tutors could result in dysfunctional groups, variability in learning outcomes and unsatisfactory assessment Students’ responses: (a) Better teachers, more resources and fairness in PBL is [are] needed. (6) Students can find it frustrating to determine their own learning objectives without proper guidance and can also experience uncertainty on the extent they must study a given topic. Students’ comments: (a) PBL in year one and up to semester two in year two is a waste with no real direction. (b) “PBL should be revised but maintained… it proved to be very beneficial especially in year three”. (7) Inability to study all the core topics through the PBL process Students’ comments: (a) Too theory based and not patient oriented (b) Topics should be covered in lectures; students should go back to the ward, check patients and then present in PBL.

162

Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program

Considering various comments by the students, it may be inferred that PBL can be stressful to both students and staff [19]. Although the response is not overwhelming, it is remarkable that students responded positively on the question of relevance of the problem and the usefulness of the PBL session. Students’ comments: (a) PBL was very helpful, a good learning tool and effective for discussion, but it needs to be reformatted, revised, reduced and restructured. The problems selected generally included key essential topics that would have relevance to students’ assessment and overall learning. Undoubtedly the increasing adoption of PBL in the medical curriculum even without substantial and robust objective evidence that it is superior to conventional approaches, can be attributed to the strong philosophy, innovation and successful dissemination by the protagonists of PBL who always see the “glass being half full” [10, 20]. The possible reason for our students’ overall negative response indicates failure of implementation. This failure could be attributed to a combination of administrative and resource problems such as a lack of understanding and apathy of staff towards PBL. Besides, failure of satisfactory implementation, short-comings and problems inherent to PBL is generally overlooked. PBL classes at FMS are usually large and large-size classes are not recommended for it involves enormous resources and increased heterogeneity. Another possible reason for our students’ responses is the claim that PBL encourages truly self directed learning. This is a myth as in many schools the learning outcomes and objectives are determined by Faculty. The boundary for the breadth and depth of learning outcomes cannot be defined accurately and could lead to confusion [21]. Accurate and reliable tools of assessment for PBL methods are yet to be determined. Our students’ responses relevant to their perceptions

that PBL consumes too much time, is disproportionate to the understanding and presentation of a given topic. Further, the results do not reveal overall substantial achievement in cognitive and critical thinking and team skills. Indeed, cultural and social factors, group dynamics and previous learning experiences all play an important role in the PBL process [22]. Collectively, the drawbacks and problems listed above regarding PBL are evident and applicable to our context. The large-class size approximates 400 students in Year I, which results in a burden on infrastructure, resources, and finances and leads ultimately to poor implementation of PBL [23]. Remarkably, few schools adopt Pure PBL as a mode of delivery of the curriculum. Conversely, a significant number of schools adopt hybrid or add variable component of conventional methods. This raises an important question, “If PBL is reforming the teaching-learning in medical schools then why are traditional methods still being used?” Based on our findings and analysis of existing literature in our context, we state that PBL plays a limited role in our curriculum. We face many challenges in appropriate implementation of PBL and its impact on our system is less than satisfactory. Consequently, we recommend a critical review of PBL in our so called Hybrid model. 4.2 Skills Laboratory Training The results of our study infer that the students have a preference to learning clinical skills in the real clinical or ward situations rather than in the laboratory. Here are some of their comments: (Skills lab training should incorporate real life patients so we can understand what clinical signs we would have to look for in particular conditions”. “More time is needed with patients in order for students to be comfortable”) our data also emphasize both the skills laboratory training and clinical clerkship would be more effective if combined. “Clinical should be incorporated with Preclinical.”

Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program

Students felt more time with real patients, smaller groups and close supervision by doctors is necessary to make a meaningful change to their lab experience. (Smaller skills lab groups with more sessions will be helpful; … More time needed with patients in order for students to be comfortable with those things that are risky; not everyone had the chance to examine with a doctor's guidance; Skill labs should be more interactive and should tackle a greater variety of technical skills Reasons for implementation of skills training include: to compensate for short period clinical training in the wards and to prepare medical graduates with ability to perform required skills [24]. Students believe that skills laboratory training during early years of pre and paraclinical studies prepares them for their subsequent early clinical clerkship and also builds the bridge and confidence between the two components of clinical skill training. (“Skills lab in the first year should be more clinically oriented and should occur more often. Clinical exposure should ideally start by the second year, if not the first. “Clinical exposure enables students to actively learn and gain a greater appreciation for the field of medicine and surgery.”) Introduction of clinical training in early years would be motivating and would give students a better feel of becoming doctors and also provide scope to integrate Phase One studies with clinical material. Increasing demand of clinical spaces, shortage of quality staff and requirement of uniform structured clinical training and assessment favors rational and balanced use of skills laboratory training along with satisfactory implementation of training in our curriculum. The skills achieved during Skills laboratory should be easily transferable and acceptable in the real clinical setting. A study by Nielsen et al. indicates improved outcomes in clinical clerkship by those who underwent skills lab training and significant transferability of skills to real patient situations [25]. Students cannot rely on clinical clerkship training alone due to varying work routines [24] and a variation in patient type and

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numbers during the year. This results in a lack of uniformity among clinical clerkship groups. 4.3 Duration of Phase I MBBS Programme Students’ preference of having a 2-Year Phase I programme instead of an existing three (3) years is an eye opener. The following students’ comments are relevant to duration of the Phase I: “Pre clinical should be reduced to year one only and Para clinical should be six months to a year”. “If Pre and Para clinical were to be integrated together it would be easier to learn and [should] take two years instead of the three”. Thus Students’ preference of a 2 year Phase I Programme needs to be seriously considered with a paradigm shift from the present curriculum.

5. Conclusion In our hybrid model, PBL contributes to a minor component of teaching learning and assessment. Our students’ overall negative perception of PBL warrants a critical analysis and review of status of PBL in our existing curriculum. The problems identified in this study could be attributed to not only unsatisfactory implementation and but also to those inherent to the PBL approach itself. Our results revealed a preference for clinical training in the real clinical situation. However a combined (Hybrid) skills laboratory training and clinical clerkship was considered to be more effective in achieving the desired learning outcomes. We recommend that the role of skills training should be rationalized and balanced in the right context. An urgent evaluation must be made of the suggestion of a paradigm shift towards three years of clinical training. We also recommend a comprehensive review of the curriculum through open debate, referendum and a retreat.

References [1]

H. S. Barrows and R. M. Tamblyn, Problem Based Learning: An Approach to Medical Education, New York, NY: Springer Publishing Company, Inc., 1980.

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[7]

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[10]

[11]

[12]

[13]

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Students’ Rating on Effectiveness of Problem Based Learning and Skills Laboratory Training in the Phase I MBBS Program D. T. Vernon and R. L. Blake, Does problem-based learning work? A meta-analysis of evaluative research. Acad Med 68 (1993) 550–563. C. E. Engel, Not just a method but a way of learning, in: D. Boud, G. Feletti (Eds.), The Challenge of Problem Based Learning, London: Kogan Page, 1991. D. Boud and G. Feletti (Eds.), The Challenge of Problem Based Learning, London: Kogan Page, 1991. L. M. Pereira Pinto, B. V. Telang, K. A. Butler and S. M. Joseph, Preliminary evaluation of a new curriculum-incorporation of problem based learning (PBL) into the traditional format, Med Teach 15 (1993) 351–364. M. Newman, A pilot systematic review and meta-analysis on the effectiveness of problem based learning, available online at: http://citeseerx.ist.psu.edu/viewdoc/download? doi= 10.1.1.133.6561&rep= rep1&type=pdf. F. J. Veldman, M. A. De Wet, N. E. I. Mokhele and W. A. J. Bouwer, Can South African higher education afford to avoid problem based learning? Available online at: http://www.sefi.be/wp-content/abstracts/1082.pdf. H. S. Barrows, A taxonomy of problem based learning methods, Med Educ 20 (1986) 481–486. J. Wilson and B. Sa, An introductory guide to problem based learning for first year students in the faculty of medical sciences the university of the west indies, St Augustine, St Augustine, Trinidad: the University of the West Indies, 2008. M. Tayakol, R. Dennick and S. Tayakol, A descriptive study of medical educators’ views of problem-based learning, BMC Medical Education 9 (2009) 66, available online at: http://www.biomedcentral.com/ 1472-6920/9/66. G. R. Norma and H. G. Schmidt, The psychological basis of problem-based learning: a review of the evidence, Acad Med 67(1 992) 557–565. E. Yeung, S. Au-Yeung, T.Chui, N. Mok and P. Lai, Problem design in problem-based learning: evaluating students’ learning and self-directed learning practice, Innovations in Education and Teaching International 40 (2003) 237–244. S. Kinkade, A snapshot of the status of problem-based learning in U.S. medical schools, 2003–2004, Acad Med. 80 (2005) 300–301. C. H. Major and B. Palmer, Assessing the effectiveness of problem based learning in higher education: Lessons from

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the literature, Academic Exchange Quarterly 5 (2001) 134–140. O. S. Tan, Students’ experiences in problem-based learning: Three blind mice episode or educational innovation, Innovations in Education and Teaching International 41 (2004) 169–184. General Medical Council, Tomorrow’s doctors, available online at: http://www.gmc-uk.org, 2003. M. Lynagh, R. Burton and R. Sanson-Fisher, A systematic review of medical skills laboratory training: Where to from here? Med Educ 41 (2007) 879–887. D. R. Woods, Problem-based Learning: How to Gain the Most from PBL, Canada: Waterdown, 1996. A. Barman, A. Jaafar and N. N. Naing, Perception of students about the problem-based learning sessions conducted for medical and dental schools’ students of Universiti Sains Malaysia, Education for Health 19 (2006) 363 – 368. R. W. Sanson-Fisher and M. C. Lynagh, Problem-based learning: A dissemination success story? MJA 183 (2005) 258–260. B. Trapper, Integrated problem-based learning in the neuroscience curriculum — the SUNY Downstate experience, BMC Med Educ 6 (2006) 47. V. S. Singaram, D. H. J. M. Dolmans, N. Lachman and C. P. M. van der Vleuten, Perceptions of problem-based learning (PBL) group effectiveness in a socially-culturally diverse medical student population. education for health, 2008, Vol. 21, Issue 2, available online at: http://www.educationforhealth.net/. G. C. H. Koh, H. E. Khoo, M. L. Wong and D. Koh, The effects of problem-based learning during medical school on physician competency: A systematic review, CMAJ 178 (2008) 34–41. G. Peeraer, A. J. J. A. Scherpbier, R. Remmen, B. Y. De Winter, K. Hendrickx, P. Van Petegem, J. Weyler and L. Bossaert, Clinical skills training in a skills lab compared with skills training in internships: Comparison of skills development curricula, Education for Health, 2007, Vol. 20, Issue 3, available online at: http://www.educationforhealth.net/. D. G. Nielson, A. M. Moercke, G. Wickmann-Hansen and B. Eika, Skills Training in Laboratory and Clerkship: Connections, Similarities, and Differences, Med Educ, 2003, Vol. 8, Issue 12, available online at: http://www.med-ed-online.org.

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Mar. 2012, Volume 9, No. 3 (Serial No. 88), pp. 165–168 Journal of US-China Medical Science, ISSN 1548-6648, USA

DAVID

PUBLISHING

1Turkish Version of the Dutch Eating Behaviour Questionnaire: In Evaluation of Eating Behaviour among a Group of Turkish University Student Lale Sariye Akan, Ayşe Özfer Özçelik and Metin Saip Sürücüoğlu Ankara University Faculty of Health Sciences, Department of Nutrition and Dietetics, Cebeci 06260, Turkey Abstract: Objective: This study aims at examining eating behaviours according to the Dutch Eating Behaviour Questionnaire (DEBQ), among a population of normal-weight university students. Methods: The study was conducted among Ankara University students. The questionnaire was administered to 500 subjects. The participants were given a questionnaire form. A reliability test was performed to determine the extent the 33-item questionnaire can measure eating behaviors of individuals. Items 31, “Can you resist eating delicious food?”, and 32, “Do you eat more than usual when you see others eating (do you eat even if it is not meal time)?” were removed from the questionnaire since their factor loading values were below 0.30. “Varimax Factor Analysis” was performed to determine if the survey questions used in this research have the same structure. Results: The analysis resulted in three factors. This study demonstrated the factorial validity and reliability of its Dutch version. Key words: Dutch Eating Behavior Questionnaire (DEBQ), external eating, emotional eating, restrained eating.

1. Introduction  Research studies on eating behaviour are necessary to increase our understanding of the aetiology of obesity and contribute to improve therapeutic programs. These investigations require valid and reliable scales to assess and quantify factors associated with eating behaviour. The development of questionnaires usually relies on underlying theories of eating. The Dutch Eating Behaviour Questionnaire (DEBQ) [1–3] was originally elaborated in order to test the relevance of suchtheories in understanding the development and maintenance of human obesity. The first one, the so called “psychosomatic theory” [3] emphasizes the role of “emotional eating” in the aetiology of obesity. The second one, the “external theory” developed by Schachter and colleagues (1968), refers to eating in response to food-related stimuli, regardless of the internal state of hunger or 

Corresponding author: Lale Sariye Akan, PhD, research fields: food and nutrition, nutrition culture. E-mail: [email protected].

satiety [4]. The third one, the theory of “restrained eating” [5], reflects the degree of conscious food restriction, carrying the imminent risk of disinhibition. During youth, feeding needs are adequate and appropriate for the requirements of the body. However, studies conducted in our country reveal that university students have eating disorders, not being able to eat an adequate and balanced diet. That university students have right eating habits is of social importance on accounts of their own health and this group being a role model [6, 7]. During this period, eating behaviors of the young changed [8, 9]. This study aims at examining eating behaviours according to the Dutch Eating Behavior Questionnaire (DEBQ), among a population of normal-weight university students.

2. Material and Methods This study was designed to determine eating behaviors of university students with normal body

166 Turkish Version of the Dutch Eating Behaviour Questionnaire: In Evaluation of Eating Behaviour among a Group of Turkish University Student

weight (those with BMI values of 18.5–24.9 kg/m2 were included in the study). The research subjects consisted of 500 volunteer students who study at various universities in Ankara. The Dutch Eating Behaviour Questionnaire (DEBQ) was used to determine eating behaviors of the students [1, 2, 10]. 2.1 The Dutch Eating Behavior Questionnaire (DEBQ) In its original version, the DEBQ is a 33-item selfrating questionnaire. All items have the same response format: never (l), seldom (2), sometimes (3), often (4) and very often (5). Restrained and external eatings are both assessed with a 10-item scale; emotional eating may either be assessed with a 9-item scale and a 4item scale, referring to clearly defined and diffuse emotions, respectively, or with a combined 13-item scale. The questionnaire was collected by interview. An average of ten minutes was necessary to fill in the form. 2.2 Reliability As the questionnaire was completed once, reliability was assessed by internal consistency. Coefficients used were Cronbach’s alpha coefficients, calculated separately for each sub-scale. Mean alpha was calculated to be 81.98±16.71. 2.3 Statistical Analysis Numerical and percentage tables were constructed for general information. Varimax Factor Analysis and reliability tests were performed.

3. Results 3.1 Characteristics of the Sample

The study included a total of 500 subjects (260 female, 240 male). Mean age was 20.34±2.01 years for females and 21.50±1.87 years for males. Mean body mass index was found to be 23.02±2.05 kg/m2 for females and 24.08±2.91 kg/m2 for males. Age and BMI (means and standard deviations, SD) are presented in Table 1. 16.2% of the female students included in the research eat 2 times a day, 35.0% 3 times, 37.7% 4 times, and 11.2% 5 times or more. For male students, it is 10.0%, 30.4%, 45.8%, and 13.8% (for 2, 3, 4, and 5 or more meals per day, respectively). The meal that is skipped most is breakfast, at a rate of 29.2% for females and 25.0% for males. It is followed by lunch (Females: 12.3%, Males: 7.1%) and dinner (Females: 7.7%, Males: 5.4%). Students skip breakfast because they don't have time (Females: 44.2%, Males: 43.8%). Females said they skip lunch to stay thin (to avoid a big belly) (20.4%) and males because they don't have appetite (17.9%). Since most of the students don't skip dinner, the rate of students who skip it because they don’t have appetite is the highest (F: 11.2%, M: 7.9%). 3.2 Varimax Rotated Factor Matrix After the factor analysis was applied to the data (5-, 4-, and 3-factor solutions), it was found that the best interpretable matrix is the three-factor solution. The factor loadings found in this analysis are presented in Table II. The three factors account for 40.6%, 47.3%, and 43.5% of the variance, respectively. Factor 1 corresponds to all items in the emotional eating scale (loadings above 0.36). Factor 2 is based on all items in the restrained eating scale. And factor 3 corresponds to all items in the eating scale (except for items 31 and 32) (Table 2).

Table 1 Means and standard deviations for students’ weight, height, and body mass index. Gender n Weight (kg) Height (cm) S

S

BMI (kg/m2) S

Female

260

 56,9846

1,13274

 163,8038

3,30956

 23,0294

Male

240

75,1583

2,77732

176,5250

4,01279

24,0853

2,91656

Total

500

65,7080

3,23249

169,9100

2,44088

23,5362

2,62628

2,05924

Turkish Version of the Dutch Eating Behaviour Questionnaire: In Evaluation of Eating Behaviour among 167 a Group of Turkish University Student Table 2 Varimax Rotated Factor Matrix (three-factor solution) on the 33 items, in the Turkish version of the DEBQ for the total sample. Factor I Eigenvalue

Factor 2

Facfor 3

4.06

6.15

3.48

40.6%

47.3%

43.5%

1. If you have put on weight, do you eat less than yocl usually do?

,757

,064

-,193

2. Do you try to eat less at mealtimes than you would like to eat?

,361

,057

,004

3. How often do you refuse food or drink offered because you are concerned about your weight? 4. Do you watch exactly what you eat?

,642

,066

-,169

,537

,019

-,071

5. Do you deliberately eat foods that are slimming?

,659

,200

-,134

6. When you have eaten too much, do you eat less than usual the following days?

,733

,101

-,106

7. Do you deliberately eat less in order not be become heavier?

,773

,026

-,132

8. How often do you try not to eat between meals because you are watching your weight?

,537

,044

-,006

9. How often in the evening do you try not to eat because you are watching your weight?

,510

,048

,001

10. Do you take into account your weight with what you eat?

,615

,152

,028

11. Do you have the desire to eat when you are irritated?

,177

,649

,083

12. Do you have a desire to eat when you have nothing to do?

,176

,417

,263

13. Do you have a desire to eat when you are depressed or discouraged?

-,009

,455

-,002

14. Do you have a desire to eat when you are feeling lonely?

,074

,705

,199

15. Do you have a desire to eat when somebody lets you down?

,167

,777

,103

16. Do you have a desire to eat when you are cross?

,074

,751

,079

17. Do you have a desire to eat when you are approaching something unpleasant to happen?

,119

,752

-,018

18. Do you get the desire to eat when you are anxious, worried or tense?

,054

,713

,009

19. Do you have a desire to eat when things are going against you or when things have gone wrong? 20. Do you have a desire to eat when you are frightened?

,059

,793

,034

-,048

,561

-,018

Percent of variance Restrained eating

Emotional eating

21. Do you have a desire to eat when you are disappointed?

,172

,734

,047

22. Do you have a desire to eat when you are emotionally upset?

,117

,615

,176

23. Do you have a desire to eat when you are bored or retless?

,040

,739

,090

24. If food tastes good to you, do you eat more than usual?

,014

-,063

,628

25. If food smells and looks good, do you eat more than usual?

-,091

,081

,745

26. If you see or smell something delicious, do you have a desire to eat it?

-,116

,000

,616

27. If you have something delicious to eat, do you eat it straight away?

-,095

,108

,661

28. If you walk past the baker, do you have the desire to buy something delicious?

-,106

,077

,717

29. If you walk past a snackbar or a cafe, do you have the desire to buy something delicious?

-,062

,112

,725

30. If you see others eating, do you also have the desire to eat?

-,041

,190

,549

33. When preparing a meal, are you inclined to eat something?

-,129

,083

,491

External eating

168 Turkish Version of the Dutch Eating Behaviour Questionnaire: In Evaluation of Eating Behaviour among a Group of Turkish University Student

4. Discussion Strong similarities were found between the Dutch and French versions of the DEBQ. The validity of the high acceptability and the general comprehension of the items were good. The presence of three factors (“emotional”, “restrained”, and “external eating”) indicates a good factorial validity. This analysis has shown similarities to our study as well. However, only normal-weight individuals were used in our study. The three factors individualized with the French version are close to the Dutch version. The same three factors were also found by the French version of the DEBQ presents a good reliability, which is equivalent to the original Dutch version of the questionnaire. There is a good reliability in our study too (except for items 31 and 32). This study demonstrates the factorial validity and reliability in its French version, by replicating the factor structure of the DEBQ and founding a high internal consistency. Applied to larger groups in our country, the DEBQ should be a useful tool to identify personality factors related to individual eating patterns implicated in eating disorders.

References [1]

T. Van Strien, J. E. R. Frijters, G. P. A. Bergers and P. B. Defares, The Dutch Eating Behavior Questionnaire for

assessment of restrained, emotional and external eating behavior, Int J Eat Disorder 5 (1986) 295–315. [2] T. Strien, J. E. R. Frijters, G. P. A. Bergers and P. B. Defares, The Dutch Eating Behavior Questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behavior, Int. J. Eating Disorders 3 (2006) 12–15. [3] H. I. Kaplan and H. S. Kaplan, The psychosomatic concept of obesity, J Nerv Ment Dis. 125 (2007) 181– 201. [4] S. Schachter, R. Goldman and A. Gordon, Effects of fear, food deprivation and obesity on eating, J Person Sot Psychof. 92 (1968) 210–215. [5] C. P. Herman and D. Mack, Restrained and unrestrained eating, J Personality 43 (1975) 64740. [6] J. Tashiro, Exploring health promoting lifestyle behaviors of Japanese college women: perceptions, practices, and issues, Health Care Women International 23 (2002) (1) 59–70. [7] P. Tokgöz, M. Ertem, F. Çelik, Ş. Gökçe, G. Saka and R. Hatunoğlu, Üniversite öğrencilerinin beslenme alışkanlıklarının saptanmasına ilişkin bir araştırma, Beslenme ve Diyet Dergisi. 24 (1995) (2) 229–238. [8] D. O. Nnanyelugo and E. C. Okeke, Food habits and nutrient intakes of Nigerian University students in traditional halls of residence, J Am Coll Nutr. 6 (1987) (5) 369–374. [9] T. A. Wadden and A. J. Stunkard, Social and psychological consequences of obesity, Ann. Intern Med. 1995 (1995) (103) 1062–1067. [10] A. Lluch, J. P. Kahn, A. Stricker –Krongrad, O. Ziegler, O. Drouin and L. Mejean, Internal validation of a Fench version of the Dutch Eating Behaviour Ouestionnaire, Eur Psychiatry 11 (2006) 198–203.

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Mar. 2012, Volume 9, No. 3 (Serial No. 88), pp. 169–173 Journal of US-China Medical Science, ISSN 1548-6648, USA

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PUBLISHING

A Touch-Controlled Laparoscope Manipulator: Preliminary Trial to Evaluate the Performance on Female Porcine Pelvic Surgery and an Initial Experience in A Human Robot-Assisted Laparoscopic Segmental Salpingectomy Kovit Khampitak1, Yuthapong Werawatakul1, Amornrat Supokhen1, Suchat Wattanachai2, Panisara Kunkitti2 and Sirivit Techajedchadarungsri3 1. Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand 2. Faculty of Veterinary Medicine, Khon Kaen University, Khon Kaen 40002, Thailand 3. Faculty of Engineering, Khon Kaen University, Khon Kaen 40002, Thailand Abstract: Background: A laparoscope manipulator enables the surgeon to perform an advanced surgery by offering the ability to stabilize and control the visual field. However, there are several problems to be solved such as difficulties to control and a long set-up time causing prolonged operating time. The novel laparoscope manipulating robot (KhonKaen-LMR) was introduced to overcome these problems. Methods: To evaluate the feasibility and safety of KhonKaen-LMR in real robot-assisted pelvic surgeries, the study was divided into 2 experiments. The first experiment was performed in live porcine robot-assisted pelvic surgeries and the second was in a robot-assisted human laparoscopic segmental salpingectomy. Results: The first experiment was performed in ten operations in three-month-old female pigs. The horizontal motion of the scope was from -25 degrees to +30 degrees (55 degree span) and the vertical motion of the scope was from 24 degrees to 51 degrees (27 degree span). The median optimal depth of the laparoscope position was 9.5 cm (range 6 –12.5 cm). The median duration of machine set-up was 3 min (range, 2-11 min). The incised wounds showed no accessory tears and were completely healed in 7 days post-operation. The second experiment was scheduled in a 38 year-old woman for robot-assisted segmental salpingectomy. The duration of setting up was 7 min. The total operating time was 22 min. The surgeon and assistants were very impressed on the convenience of the control system. The laparoscope could move directly to the target point without image rotation which was similar to being moved by an assistant. No adverse effects that were related to the range or speed were noticed. A complete recovery was encountered in 7-day follow up. Conclusion: This new laparoscope manipulator was safe and feasible to operate in humans. It seemed to be quick to set-up and easy to control. Key words: Laparoscopic surgery, robotically assisted surgery, camera assistant, minimally invasive surgery.

1. Introduction  Robot-assisted laparoscopic surgery, which is at the forefront of technology, has encompassed various technological fields. Specialty knowledge and new capabilities enable surgeons to practice new or more Corresponding author: Kovit Khampitak, MD, associate professor, research fields: robotic surgery. E-mail: [email protected].

difficult types of operations such as non-traumatic brain surgery, precision tumor resection or intrauterine fetal surgeries. Despite advanced laparoscopic procedures for gynecologic surgery that have been developed for nearly 20 years, laparoscopic procedures have not been widely adopted in clinical practice [1–3]. The evolution of laparoscopy from a monocular view to the video screen has enabled all in the operating room to see the procedure in real time. This has meant

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A Touch-Controlled Laparoscope Manipulator: Preliminary Trial to Evaluate the Performance on Female Porcine Pelvic Surgery and an Initial Experience in A Human Robot-Assisted Laparoscopic Segmental Salpingectomy

the surgeon must rely on an assistant to hold the scope which has many drawbacks [4]. Many surgeons have embraced the da Vinci robotic surgical system over conventional laparoscopy because of its technologic advantages such as the autonomy of camera control [1]. Laparoscope manipulating robot (LMR), one such technology, enables the surgeon to perform advanced minimally invasive procedures by offering the ability to stabilize and control the visual field [5–9]. In addition, it allows solo surgery in easy operations such as segmental salpingectomy either for female sterilization or unruptured tubal pregnancy by reducing some of the difficulty resulting from the assistant’s scope movement. Although the advantages of robot-assisted laparoscopy are well documented, there are several problems to be solved such as difficulties to control, a long set-up time resulting in a prolonged operating time and significantly high initial and maintenance cost. In addition, a large apparatus can interfere with surgical space. This novel laparoscope manipulating robot (KhonKaen-LMR), which received a very encouraging the gold medal award from the International Federation of Inventors’ Associations, was introduced to overcome these problems. This study was designed to evaluate the performance of KhonKaen-LMR by performing in real pelvic operations.

2. Patients and Methods To measure the feasibility and safety of the KhonKaen-LMR, the study was divided into 2 experiments. The first experiment was in a live porcine robot-assisted pelvic surgery model. The experiment was to evaluate the robotic set-up time, optimal position for uterine horn operation, and the safety of the operations. The second was to assess the implementation of the LMR in a robot-assisted human laparoscopic segmental salpingectomy for female sterilization. The evaluation included the set-up time, total operating time, the impression of the surgeon and

assistant on the performance and the safety of the robot-assisted surgery. The operations were performed by an experienced laparoscopic gynecologist. The study was approved by the Animal Care and Use Committee of Khon Kaen University and the Khon Kaen University Ethics Committee (Reference No:AE 02/53). 2.1 Instrument and Control The KhonKaen-LMR is composed of two separate parts: (1) a high dexterity positioning mechanical component and (2) a high performance control system. The positioning part is composed of four rigid components. The first component (A) is a stand on the floor close to operative table. A-B, B-C and C-D are connected with mechanical joints. The camera holding component (D) was moved spherically in three mutually perpendicular directions (3-DOFs, x,y,z) over the umbilical port (pivot point). A laser source was attached to the first component (A) as a guide in the set-up processes (Fig. 1). A high performance control system is composed of two types of intuitive interfaces. First the control system is a touch user controlled interface. In the surgery room, the interface control system must be operated by using the surgeon’s index finger to touch on the screen sensor, displaying the surgical view from the scope, at the selected view-point. Then the corresponding motors of the robotic arm will move the laparoscope until that view-point is moved to the center of the touch screen monitor. The second control is a remote controlled joystick which can be operated by an assistant during the time that the operator cannot drop an instrument to free his hand. 2.2 First Experiment In the first experiment, ten consecutive robot-assisted pelvic surgeries were scheduled on three-month old female pigs. The robot was positioned on the right side of the operating table, opposite to the surgeon. After induction of pneumo-peritoneum,

A Touch-Controlled Laparoscope Manipulator: Preliminary Trial to Evaluate the Performance on Female Porcine Pelvic Surgery and an Initial Experience in A Human Robot-Assisted Laparoscopic Segmental Salpingectomy

171

Fig. 1 (Left) The robot is composed of four rigid components (A,B,C,D) which is moved in three spherically perpendicular directions (x,y,z). Left upper figure is a touch user controlled interface. (Right) The range of motions which is commensurate with typical motions is from -30 degrees to +30 degrees in the left to right direction (X). The optimal up/down direction(Y) is 28 degrees and the optimal in/out motion (Z) is 9.5 cm. A laser pointer which is attached to the component A is used as a guide in positioning set-up.

setting up the robot and insertion of all surgical ports, each uterine horn was explored and dissected with the help of the robot in manipulation of the scope video camera. The time to set-up the machine was recorded. The three-dimensional moving parameters were then taken at the point where the surgeon had located and clearly identified the uterine horns. Finally, after the laparoscope camera port was removed, the incised wounds were explored to identify any unexpected trauma caused by unexpected motion of the robotic arm. Seven days after the operation, a followed up for the post-operative health and the surgical wound healing was conducted. 2.3 Second Experiment The second experiment was performed ten months later in a human patient after receiving permission from the University Ethics Committee (Reference No: HE 531191). The control software was rewritten to make it easier to use. The range of motion was limited according to the results of the first experiment for the safety of human operation. The details of the new system were carefully explained to the patients and their informed consent

was obtained. The operation with assistance by the LMR was performed as follows: First, a skin incision about 12 mm long was made on the upper side of the patient’s umbilicus. The laparoscope was inserted through a port applied to the incision. Second, the robotic arm which was covered with a sterilized plastic bag was then set. By using the laser beam guide, the robotic arm was moved until the beam was pointed at the umbilical port. Third, the laparoscope was then fixed to the robotic arm and tested to move in all directions by using the touch user controlled interface. The segmental salpingectomy was then performed by use of a 5 mm port in the left umbilical aspect for the surgeon’s right hand and a 5 mm port in the left lower quadrant for the left hand. While grasper forceps were used to control the fallopian tube by the surgeon’s right hand, a 5 mm pulse-modulating electrocoagulator and cutting device (Gyrus PK) which was controlled by the surgeon’s left hand, was then used to coagulate and cut a tubal segment of 2–3 cm long and removed. The operator controlled the desired operative view by pointing the left hand index finger on the selected view-point showing on the screen sensor. Then, the other side was performed by the same processes. The

A Touch-Controlled Laparoscope Manipulator: Preliminary Trial to Evaluate the Performance on Female Porcine Pelvic Surgery and an Initial Experience in A Human Robot-Assisted Laparoscopic Segmental Salpingectomy [4] M. K. Chmarra, W. Kolkman, F. W. Jansen, C. A. tubal sections were submitted in 10% buffered Grimbergen and J. Dankelman., The influence of formalin for pathological evaluation. The operating experience and camera holding on laparoscopic instrument time was measured in three categories; the time from movements measured with the TrEndo tracking system, skin incision to closure for the total operating time, the Surg Endosc. 21 (2007) 2069–2075. [5] C. Vara-Thorbeck, V. F. Munoz, R. Toscano, J. Gomez, J. time for setting up the robot anduded that in order to Fernandez, M. Felices and A. Garcia-Cerezo, A new reach the optimal angle for the pelvic operation in robotic endoscope manipulator: A preliminary trial to 3-month pigs, which was very close to human pelvic evaluate the performance of a voice-operated industrial field, the LMR needed to move from -30 degrees to robot and a human assistant in several simulated and real endoscopic operations, Surg Endosc. 15 (2001) 924–927. +30 degrees(a 60 degree span) in the left to right [6] J. E. Jaspers, P. Breedveld, J. L. Herder and C. A. direction (X) , from +20 degrees to +60 degrees (a 40 Grimbergen, Camera and instrument holders and their degree span) in the up/down direction(Y) and 15 cm clinical value in minimally invasive surgery, Surg range for the in/out motion (Z). The results will lead the Laparosc Endosc Percutan Tech. 14 (2004) 145–152. [7] J. E. Jaspers, K. T. Den Boer, W. Sjoerdsma, M. Bruijn inventors to build a small and ergonomic camera and C. A. Grimbergen, Design and feasibility of PASSIST: holding robot. In addition, the limitations of robotic A passive instrument positioner, J Laparoendosc Adv Surg movement will ensure safety during operations. Tech A. 10 (2000) 331–335. Future experiments and development will be [8] S. S. Kummu, P. Rimington, C. Anderson, A. Rane, Initial experience with the EndoAssist camera-holding robot in targeted toward a smaller apparatus and is expected to laparoscopic urological surgery, J Robotic Surg. 1 (2007) generate capability for more complex surgical 133–137. procedures. The robotic arm will move in a spherical [9] B. Herman, B. Dehez, K. T. Duy, B. Raucent, E. Dombre slide motion in limited range which can provide more and S. Krut., Design and preliminary in vivo validation of work space on the operating table. The small-size robot a robotic laparoscope holder for minimally invasive surgery, Int J Med Robot. 5 (2009) 319–326. can mounted on the standard railing of the operating [10] J. M. Sackier and Y. Wang, Robotically assisted table with no need to reposition it when the operative laparoscopic surgery: From concept to development, Surg table was tilted or move up-down. In addition, it will Endosc. 8 (1994) 63–66. also be modified to allow easy fixation or removal of [11] J. Heemskerk, R. van Dam, W. G. van Gemert, G. L. Beets, J. W. Greve, M. J. Jacobs and N. D. Bouvy, First results the laparoscope to the robot-holding part for scope after introduction of the four-armed da Vinci Surgical cleaning [15, 24]. System in fully robotic laparoscopic cholecystectomy, Dig Surg. 22 (2005) 426–431 Acknowledgements [12] M. Lehnert, B. Richter, P. A. Beyer, K. Heller., A prospective study comparing operative time in We thank all our colleagues for the participation in conventional laparoscopic and robotically assisted Thal this experiments and the National Research Council of semifundoplication in children, J Pediatr Surg. 41 (2006) Thailand for supporting fund in this study. 1392–1396. [13] G. Muhlmann, A. Klaus, W. Kirchmayr, H. Wykypiel, A. References Unger, E. Holler, H. Nehoda, F. Aigner and H. G. Weiss, [1] R.W. Holloway, S. D. Patel and S. Ahmad., Robotic DaVinci robotic-assisted laparoscopic bariatric surgery: is surgery in gynecology, Scand J Surg. 98 (2009) 96–109. it justified in a routine setting? Obes Surg. 13 (2003) [2] M. Mitsuishi, N. Sugita and P. Pitakwatchara, 848–854. Force-feedback augmentation modes in the laparoscopic [14] P. Iranmanesh, P. Morel, O. J. Wagner, I. Inan, F. Pugin minimally invasive telesurgical system, IEEE/ASME and M. E. Hagen, Set-up and docking of the da Vinci Transactions on Mechatronics 12 (2007) 447–454. surgical system: prospective analysis of initial experience, [3] J. Sroga and S. D. Patel, Robotic applications in Int J Med Robot. 6 (2010) 57–60. reproductive endocrinology and infertility, J Robotic Surg. [15] S. S. Kommu, P. Rimington, C. Anderson and A. Rane., 2 (2008) 3–10. Initial experience with the EndoAssist camera-holding 172

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173 A Touch-Controlled Laparoscope Manipulator: Preliminary Trial to Evaluate the Performance on Female Porcine Pelvic Surgery and an Initial Experience in A Human Robot-Assisted Laparoscopic Segmental Salpingectomy robot in laparoscopic urological surgery, J Robotic Surg. 1 IEEE/RAS-EMBS International Conference on (2007) 133–137. Biomedical Robotics and Biomechatronics, Tokyo, Japan, J. F. Martins Rua, F. B. Jatene, J. R. de Campos, R. 2010, p. 65. Monteiro, M. L. Tedde, M. N. Samano, W. M. Bernardo [21] C. Ren, W. Jing and W. Yi, Robotic endoscopic system and J. C. Das-Neves-Pereira, Robotic versus human with compliance effect including adaptive impedance and camera holding in video-assisted thoracic sympathectomy: velocity control for assistive laparoscopic surgery, The 3rd A single blind randomized trial of efficacy and safety, IEEE/RAS-EMBS International Conference on Interact Cardiovasc Thorac Surg. 8 (2009) 195–199. Biomedical Robotics and Biomechatronics, Tokyo, Japan, K. Tanoue, T. Yasunaga, E. Kobayashi, S. Miyamoto, I. 2010, p. 48. Sakuma, T. Dohi, K. Konishi, S. Yamaguchi, N. Kinjo, K. [22] B. Herman, K. T. Duy, B. Dehez, R. Polet, B. Raucent, E. Takenaka, Y. Maehara and M. Hashizume, Laparoscopic Dombre and J. Donnez., Development and first in vivo cholecystectomy using a newly developed laparoscope trial of EvoLap, an active laparoscope positioner, J Min manipulator for 10 patients with cholelithiasis, Surg Inv Gyne. 16 (2009) 344–349. Endosc. 20 (2006) 753–756. [23] C. A. Nelson, X. Zhang, B. C. Shah, M. R. Goede and D. S. Aiono, J. M. Gilbert, B. Soin, P. A. Finlay and A. Oleynikov, Multipurpose surgical robot as a laparoscope Gordan., Controlled trial of the introduction of a robotic assistant, Surg Endosc. 24 (2010) 1528–1532. camera assistant (EndoAssist) for laparoscopic [24] A. Minor, R. Ordorica, J. Villalobos and M. Galan, Device cholecystectomy, Surg Endosc. 16 (2002) 1267–1270. to provide intuitive assistance in laparoscope holding, Ann N. Halin, P. Loula, P. Aarnio, Experiences of using the Biomed Eng. 37 (2009) 643–649. EndoAssist-robot in surgery, Stud Health Technol Inform. 125 (2007) 161–163. R. Reilink, G. de Bruin, M. Franken, M. Mariani, S. Misra and S. Stramigioli, Endoscopic camera control by head movements for thoracic surgery, The 3rd

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Mar. 2012, Volume 9, No. 3 (Serial No. 88), pp. 174–178 Journal of US-China Medical Science, ISSN 1548-6648, USA

DAVID

PUBLISHING

The Proposal of QMS Implementation in Healthcare Office Stefan Markulik and Anna Nagyova Department of Safety and Quality Production, Faculty of Mechanical Engineering, Technical University of Kosice, Slovak Abstract: Background: Application of Quality Management System (hereinafter QMS) according to ISO 9001 is a good precondition for increase of process efficiency inwards and customer confidence outwards. QMS application in the field of healthcare is less common than in other areas. However, the less common it is, the more doctors’ offices and hospitals should attempt to increase the standard of management of activities and also their quality. Methods: Process of implementation can be divided into 3 separate phases, where each of one has its own characteristic. The main step is to implement requirements of ISO 9001 into the organization processes and help to meet customer /in this case patients/ demands. During this process is possible to use software tool, called MS Project which helps organization to get early perspective about system implementation. Results: After quality management implementation into the dentist office, the processes were clearly identified and all nonconformities according to ISO 9001 were noticed and reported. Conclusion: Processes in dentist office were clearly identified and the system provides the possibility to obtain customer feedback. Key words: Quality, process approach, MS project, healthcare.

1. Introduction  Any change in management of any organization carries a great aversion from employees. Nevertheless, the aversion consequently lowers and new changes become a part of common life of an organization. Moreover, the fewer employees an organization has, the easier changes are applied into practice. It is not uncommon that there are some organizations which are so small that it is peculiar to address them as organizations, such as different doctors’ offices in policlinics or dentists’ offices. Particularly doctors’ offices are specific because they do not have more than two employees, usually a treating physician and supplementary health assistance such as a nurse or a medical assistant. It is a commonly known fact that QMS implementation brings benefits for any organization, inwards or outwards. However, it is not clear how functioning of an organization differs if

Corresponding author: Anna Nagyova, Ing., PhD, lecturer, research fields: quality management system, project management. E-mail: [email protected].

QMS is applied in an environment which has a minimal number of employees [1]. 1.1 Patient as a Customer For understanding of quality management principle it is necessary to comprehend the term costumer orientation and the term customer. It is a common problem of an organization to identify its customers. To understand this point in the conditions of a dentist’s office, it is important to answer the following question: Who is the customer of our dentist’s office? However, there is not just one answer to this question. Customer identification is not always as easy as it may seem because the view of a provider is limited (restricted), not seeing the broader relations which the dentist’s office has with its customers. Customer can generally be defined as a person (natural or legal) to whom the dentist’s office provides the results of its work. It is undeniable that dentist’s office costumer is its patient — the person to whom professional medical care is provided (Fig. 1). What happens if a patient comes into a dentist’s office for a health check required by their employer? In

The Proposal of QMS Implementation in Healthcare Office

this case the employer must also be considered as a costumer. Regarding these questions, another group of (usually legal) persons has to be considered. The group consists of persons who are not direct costumers of dentists’ offices but they are highly interested in the relation between the dentist’s office and its patient. These are, for example, the Ministry of Health of the Slovak Republic, medical chamber, professional and trade unions etc. (Fig. 2). What does it mean ‘interested party’ in the following context? This term represents all subjects which are interested in (accurate) functioning of a dentist’s office.

2. Methods — Quality Management System Implementation QMS implementation in a dentist’s office does not differ significantly from implementation in large organizations. However, there could appear differences in time horizon as well as division of tasks within this kind.

The implementation is divided into three basic parts: (1) Current status analysis; (2) QMS documentation settings; (3) Verification of QMS implementation; Each step of implementation can be transformed into the software application, calls MS Project, which is designed to assist project managers in developing plans, assigning resources to tasks, tracking progress, managing budgets and analyzing workloads. Schedules can be resource leveled, and chains are visualized in a Gantt chart [4]. Planning of the implementation was performed with utilization of MS Project. Implementation time schedule, as an outcome of this program, was designed in the form of Gantt diagram (Fig. 3). 2.1 Current Status Analysis Current status analysis examined control activities of the dentist’s office hitherto, documentation management appropriateness and record keeping suitability. This phase identified the costumers and interested parties of the dentist’s office as well as the necessity of vocational education of the dentist and supplementary health assistance in the field of quality management. Specific education of personnel is necessary for the right function of QMS. Base of this education is to appropriate manage record documentations.

Fig. 1 Closer costumer-supply relationship.

Fig. 3 Fig. 2 Wider costumer-supply relationship.

175

Gantt diagram.

176

The Proposal of QMS Implementation in Healthcare Office

The analysis also included a budget estimate which outlined probable QMS implementation costs. Each implementation phase was assigned resources which were consequently included in budget. The implementation process was coordinated with an external counseling organization what, of course, influenced overall costs — they were higher than if the implementation was self-performed (Fig. 4). The implementation was planned for 78 days, what is a standard period of implementation process in organizations with such low number of employees. Total costs of mentioned process reached €1.848 (Fig. 5). 2.2 QMS Documentation Setting QMS documentation setting began with identification of all processes of the dentist’s office, their sorting into three groups (major, managerial, supportive) and their demonstration on following map (Fig. 6). This map illustrates relation and interaction between particular processes. The map completion was followed by preparation of documents (directives) for

accomplished process standardization. Mentioned documentation included two sets of rules (work and organizational), which, e.g., provide description of particular responsibilities and competences attached to concrete positions (of a dentist and a nurse). EN ISO 9001 standard requires documented procedures for:  Control of documents,  Control of records,  Control of nonconforming product,  Internal audit,  Corrective action,  Preventive action [1]. The form for control of documents and control of records were coupled into one regulation because both are closely linked. Give strict rules for all documents. Furthermore, control of nonconforming product is covered in a separate directive while internal audit management is described in a quality manual. Because the dentist’s office does not have its own auditor it has to outsource this process. By contrast, internal resource planning was performed by the dentist himself. The dentist’s office cannot get rid of responsibility only because some activities are performed by an external person (auditor). Similarly to the control of documents and records, corrective and preventive actions were also coupled into one directive [2].

Fig. 4 Financial costs by phase.

Resource management process, which is depicted in the process map, is outlined in a separate directive which describes the competence of employees (the dentist and the nurse), training plans and evaluation of their

efficiency.

It

moreover

determines

the

infrastructure which is necessary for an accurate nursing performance. The term infrastructure in the conditions of the dentist’s office includes care for its interior, equipment and software used for record keeping. description

Resource of

management

work

also

environment

involves conditions

(temperature, lighting, cleanness, sterility) [3]. Fig. 5 Time schedule and financial plan of the implementation.

The key documentation of implemented QMS was dental treatment documentation. It presents procedures

The Proposal of QMS Implementation in Healthcare Office

177

of professional advice (which is depicted as a separate

that patients are not used to expressing their

process in the process map). This directive standardizes

satisfaction in a formal way (the questionnaire). Many

the dental treatment procedure, i.e., it specifies its steps

patients understand their satisfaction expression in

starting with registration of a patient, consultancy

paying the surcharge for treatment in the dentist’s

about following treatment and determination of its

office. Within satisfaction evaluation (once in six

procedure if it is necessary.

months) the dentist draws three patients who are

The treatment cannot be performed if a patient does

awarded with beforehand selected benefits. The

not state a clear agreement with the procedure.

benefits represent discounts of different value on

Dentist’s office should highly focus on the social

services offered by the dentist’s office. Their character

aspect of examination. Since the visit of a dentist is

changes every six months in order to keep them

generally connected with unpleasant feelings, dentist’s

interesting for patients. Generally, according to the

perception of a patient is very important, especially in

dentist’s opinion, activities in the dentist’s office are

the case of patient’s discomfort. In the end of the

better arranged. Processes are understood as mutually

examination the patient is advised on dental and mouth

dependant actions which outcome is satisfied customer

hygiene.

(patient).

Purchasing and Contractual Relationship directives describe procedures for performance of these processes

4. Conclusion

with regard to quality of provided services. The

QMS implementation is a difficult process from time

Purchasing process includes purchasing of different

and organizational point of view because it requires

material ranging from office supplies to tools for dental

knowledge on ISO 9001 standard and understanding its

treatment. The Contracting relation directive outlines

consequences for the dentist’s office.

the providing of incorporated procedure within these

Computer support (MS Project) used within QMS

relations, their evaluation or facture and recovery of

implementation is really helpful for dentist’s office

claims which could arise within the functioning of the

owners. The main advantage of this kind of software

dentist’s office.

application is the fact that it displays outline of drawn

3. Results — Implementation

Verification

of

QMS

resources and completed actions in contrast with the plan. During project realization it also enables to control the “substantial” performance, i.e., which of

The most important benefit of QMS application in

planned actions have been completed or phase of their

the dentist’s office is the change of customer’s

completion – created value and real cost incurred so far

perception. The change was positive because customer

within their implementation.

orientation, the key aspect of QMS, is visible immediately after entering the dentist’s office. The

Acknowledgements

dentist is focused on communication with customer

The research which lead to these results, achieved

from beginning till the end of the visit. The customer

financial capital from Seventh Frame program

(patient) can declare their (dis)satisfaction in a

iNTegRisk based on Grand agreement Nr. CP-IP

questionnaire which is easily accessible and visibly

213345-2 and along with fund up Slovak Research and

marked. Due to low interest of patients in expressing

Development Agency accordung to Agreement Nr.

their opinion, customer satisfaction is evaluated once in

DO7RP-0019-08.

six months. During the evaluation the dentist found out

178

The Proposal of QMS Implementation in Healthcare Office

References [1] [2]

[3]

Š. Markulik and A. Nagyová, Quality Management System, Košice, 2009. S. Markulik and A. Nagyová, Quality as a main aspect of Healthcare, in: YBERC 2010 Young Biomedical Engineerings and Researchers Conference, July 1–3, 2010. A. Sütőová and M. Šolc, Utilization of statistical methods within the European performance satisfaction index (EPSI)

[4]

rating methodology, in: Kvalita Inovácia Prosperita. Roč. 13, č. 1 (2009), s. 77-82. A. Nagyová and H. Pačaiová, Quality evaluation methodology for research projects, in: DAAAM International Scientic Book 2010, 21th International Conference, 2010, pp. 219–226.

[5] B. Hayes, Measuring Customer Satisfaction, United States of America: ASQ, 2008.