Medical and Health Sciences

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THE COMPARISON OF DEXMEDETOMIDINE AND MIDAZOLAM USED FOR SEDATION OF PATIENTS UNDERGOING UPPER GASTROINTESTINAL ENDOSCOPY: A PROSPECTIVE COMPARATIVE STUDY
(2022-03-21) Ibrahim Ghoul
Background: Endoscopic procedures are essential for diagnostic testing, examining, and treating a wide range of disorders like gastrointestinal tract blood loss, foreign object removal, and many other complicated procedures such as Endoscopic retrograde cholangiopancreatography. An endoscope is an irritating and painful procedure. during which patients should be anesthetized to avoid mobility, pain, coughing, gagging, and nausea. So, sufficient analgesia and sedation agents should be given and monitored with minimal side effects or complications. These agents can keep patients'response to pain and verbal stimuli without failing respiratory or cardiovascular function. Objectives: The current study aims to compare and investigate the efficacy and safety of Midazolam versus Dexmedetomidine in terms of respiratory, hemodynamic, analgesia, sedation, patient satisfaction, endoscopist satisfaction, and adverse effects in patients undergoing upper endoscopy at An-Najah National University Hospital. Methodology: A prospective observational study was performed on 68 patients (aged 18-60) undergoing upper endoscopy using theAmerican Society of Anesthesiologists (ASA) Physical Status Classification System (grades one and two). The study was conducted at An-Najah National University Hospital, Nablus-Palestine, between October 2021 and January 2022. All subjects received information about the purpose of the study, the study protocol, and the consent form was obtained from each subject. Results: Regarding patient satisfaction, the Dexmedetomidine demonstrated much higher satisfaction, minor discomfort, and less anxiety than Midazolam with P<0.05. Regarding endoscopy specialists, the satisfaction, discomfort, gagging, retching, and technical difficulty showed that Dexmedetomidine outperformed the Midazolam with P<0.05. Dexmedetomidine patients recovered faster than Midazolam patients with p <0.05, Midazolam needs 2.4 ± 7.7 minutes to be sedated while Dexmedetomidine needs 9.5 ± 1.1 minutes , and this difference is significant since the p <0.05. Regarding side effects occurrence, Dexmedetomidine had fewer side effects than the Midazolam, but with no statistically significant difference. Regarding vital signs, there is no significant difference between Midazolam and Dexmedetomidine. Conclusions: Dexmedetomidine outperformed Midazolam in recovery time, patient satisfaction, endoscopy specialist satisfaction, discomfort, anxiety, and retching; Dexmedetomidine appears to be a useful alternative to Midazolam for sedating patients during upper endoscopy because it is both safe and effective. Keywords: Dexmedetomidine, Midazolam, sedation, upper endoscopy.
DEXMEDETOMIDINE AS A BLOCKING AGENT FOR INTERCOSTAL BLOCKS IN PATIENTS WHO UNDERGO VIDEO -ASSISTED THORACOSCOPIC SURGERY
(2022-06-29) Mousa Mohammed Mousa Ma’rouf
Background: Local or regional anesthesia is one major fields in anesthesia. One technique to apply regional anesthesia is intercostal block, a type of regional anesthesia used in thoracic and upper abdominal surgeries to provide analgesia and to relieve pain due to rib-fracture, cancer, thoracic procedures and lung surgeries. Video -assisted Thoracoscopic Surgeries (VATS) has been began the late 20th century. They have now become one of the most common preferred procedures for lung surgeries. Applying intercostal blocks in these surgeries yield good outcome on pain level post operatively. Many anesthetic blocking agents are used in regional anesthesia such as lidocaine and Marcaine. Dexmedetomidine is an alpha-2 adrenergic antagonist that works on the smooth muscles of viscera and has unique effect on pain control and sedation. Adding 1 microgram per kilogram of Dexmedetomidine for the formula has a strong effect on controlling level of pain. Objectives: This study has assessed the effect of Dexmedetomidine as intercostal block agent on the level of pain, analgesia requirements, stability of hemodynamics and nausea and vomiting. Methodology: randomized control clinical trial double-blinded design was used to assess 30 patients with a category of anesthesia (ASA 1, ASA 2 and ASA 3) who underwent VATS in referral center in Palestine. These patients were divided into two groups: intervention (experimental) and control. The control group (15 patients) was given Marcaine 1 mg/kg while, the intervention group was given 1 microgram/kg Dexmedetomidine with 1 mg/kg Marcaine on intercostal space. Results: According to the results, there was an effect on the level of pain in the 3rd (p-value=0.04) 5th (p-value=0.01) 15th (p-value=0.1) minute post operation and after 24 hours of the procedure (p-value=0.01). Conclusion: Using Dexmedetomidine as adjunct in intercostal block deceased the intensity of pain, conserved the vital signs (hemodynamics) on the normal lower limits for patient, and needed less analgesic requirement post-operatively. There was also no incidence of nausea and vomiting for patients who were administered Dexmedetomidine with Marcaine. Keywords: Dexmedetomidine, intercostal block, regional anesthesia, pain, analgesia, hemodynamics.
SURVIVAL RATE AND OUTCOMES AMONG CRITICALLY ILL COVID-19 PATIENTS REQUIRING INVASIVE MECHANICAL VENTILATION (IMV) IN PALESTINE
(2022-07-26) Fadi Saliba Jeries Assi
ABSTRACT Introduction: COVID-19 is a respiratory infectious disease and can deteriorate to ARDS and respiratory failure, which necessitates the need of invasive mechanical ventilation. The varying treatment strategies and outcomes warrant the need to further explore patient characteristics and treatment plans, and their potential associations with morbidity and mortality. Aim: To designate the survival rate and outcomes of COVID-19 patients who underwent IMV, as well as impact of their clinical characteristics and treatment strategies. Method: A retrospective observational cohort design. All COVID-19 patients who were admitted to targeted hospitals between 1/8/2020 to 30/4/2021, older than 18 years and required IMV were enrolled. Data was gathered from the hospital information system and include Characteristics (demographic data, comorbidities, lab values), Treatment strategies (respiratory support, proning, intubation timing, mechanical ventilator settings and pharmacological treatments) and Outcomes (complications, length of stay on IMV, and mortality). Comparisons were then drawn between two subsets divided by mortality using the variables mentioned above using SPSS. Results: 150 patients required IMV which represents 39.8% of COVID-19 patients and 13 (8.7%) of which survived to hospital discharge. The mean age was 64 years old and younger age was associated with lower mortality (OR 0.948, p=0.006). Cardiovascular Disease and peak creatinine were significantly higher in deceased patients (p=0.041, p=0.008) respectively. Patients who underwent pressure mode ventilation, with lower FiO2 and inspiratory pressure had a higher rate of survival (OR 4.416, 0.883, 0.478, respectively, p<0.05), as well as who were submitted to tracheostomy. Remedsivir had a significant correlation with survival (p-value=0.001). ICU median length of stay was 27 days for patients who survived and 11 for those who died (p-value <0.001), while IMV median LOS for survivors and deceased patients was 15 days vs. 6 days, respectively (p-value <0.001). Patients developed complications such as AKI (60.7%) and cardiovascular (45.3%) which are significantly correlation with deceased patients. Conclusion: Survival rate among COVID-19 patients who underwent IMV was low (8.7%). Evidence based practice and multidisciplinary management are recommended in treatment of critically ill COVID-19 patients depending on research, to improve their outcomes. Keywords: COVID-19, IMV, Mortality, Characteristics, Survival rate, Outcomes.
THE EFFECT OF NATIONAL EARLY WARNING SCORING SYSTEM (NEWS2) IMPLEMENTATION ON IDENTIFYING THE RISK OF CLINICAL DETERIORATION AND OUTCOMES AMONG COVID-19 HOSPITALIZED PATIENTS
(2022-08-15) Islam Mohammad Salem Tukhi
ABSTRACT Background: Coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, has been declared a pandemic by the World Health Organization (WHO), and it is associated with high rates of mortality and morbidity, prolonged hospital stays, and increased needs for Intensive Care Unit (ICU) admission. It is crucial to predict clinical deterioration in COVID-19 patients. Objectives: To find out the efficacy of the National Early Warning Scoring System (NEWS2) application in predicting the risk of clinical deterioration and outcomes in hospitalized patients who had COVID-19 at Martyrs Medical Military Complex and Palestinian Red Crescent hospital. Methods: A quasi-experimental design was applied. A sample of 384 adult patients was divided into a research group (192 patients) and a control group (192 patients). Before and after implementation (NEWS 2), all study participants were observed until death or hospital discharge, and the results of the two patient groups were compared and assessed. Results: Comparing the control group (Pre NEWS phase) to the study group (Post NEWS phase), a significant decrease was found in the mean length of hospital stay (8.1 ± 5.5 vs 6.4 ± 5.3, p = 0.002), as well as a reduction in the mortality rate from 38 (19.8 %) during the pre- NEWS phase to 24 (12.5 %) during the post-NEWS phase (p = 0.071).The predictive value of NEWS was found to be an excellent predictor of admission to the ICU as indicated by an AUROC of 0.91 (95% CI: 0.87-0.96, p < 0.001). Also, a significant difference in the frequency of monitoring patients' vital signs was observed between the control group (Pre NEWS phase) and the study group (Post NEWS phase) following clinical deterioration (10.1 ± 7.8(Pre NEWS2) vs 23.4 ± 0.7(Post NEWS2), p = <0.001). Conclusion: Implementation of NEWS2 showed a significant improvement in hospitalized COVID patient outcomes (length of stay, predicted ICU admissions, mortality rate and frequency of vital signs measurements, which indirectly raised the number of medical reviews following patient clinical deterioration) and this was attributed to a significant prediction of patient deterioration. Keywords: COVID19; NEWS2; clinical deterioration; patient outcomes; and early warning scores.
THE EFFECT OF PROPHYLACTIC PREOPERATIVENEBULIZED KETAMINE VS. NEBULIZED DEXAMETHASONE ON POSTOPERATIVE SORE THROAT IN PATIENTS UNDERGOING SURGERY UNDER GENERAL ANESTHESIA: A RANDOMIZED, PLACEBO-CONTROLLED, DOUBLE-BLIND TRIAL
(2022-08-18) Mohammad Moufeed Mahmoud
ABSTRACT Background: Postoperative sore throat is a minor undesirable complication following general anesthesia with endotracheal intubation, causing discomfort and decreasing satisfaction to the delivered anesthetic care. An injury related to direct tracheal mucosa trauma and decreased humidity because of the ETT cuff pressure are the main cause behind POST, which means it’s almost unavoidable and therefore an appropriate prophylactic intervention is needed to decrease its incidence. Many studies proved promising results of ketamine and dexamethasone nebulizers to decrease and prevent the incidence and severity of POST with other laryngeal morbidities like cough and hoarseness. Objectives: To determine if preoperative nebulization of ketamine or dexamethasone has a significant influence on POST and other laryngeal morbidities incidence and severity in patients undergoing elective surgeries under GA with ETT, and to determine if it has a significant effect on endotracheal intubation condition and hemodynamic response to laryngoscopy. Methodology: Ninety nine patients allocated for surgeries under GA enrolled in thisprospective double-blind, randomized, placebo-controlled study. Every participant received a nebulizer for 15 minutes and just 15 minutes before the anesthesia induction as follows: 33 participants in the control group received 5 ml nebulizer of normal saline, 33 participants in the dexamethasone group received a nebulizer of 8 mg of dexamethasone in volume of 5 ml and 33 participantsin ketamine group received a nebulizer of 50 mg of ketamine in volume of 5 ml. Results: Ketamine and dexamethasone nebulizers were effective in preventing POST (p-value < 0.001) and hoarseness postoperatively with a maximum efficacy in the ketamine group. Ketamine nebulizer was effective in preventing cough and PONV, while dexamethasone wasn’t. Also, patients in ketamine group were more satisfied in comparison to dexamethasone and saline groups (p-value < 0.001). There was a significant elevation in SBP and HR in ketamine group after nebulization but no serious systemic adverse effects were noted. Conclusions: Nebulizing 50 mg of ketamine or 8 mg of dexamethasone is an effective way to prevent and to decrease the incidence of POST and other laryngeal morbidities with a maximum efficacy in the ketamine. Keywords: Ketamine, Dexamethasone, Nebulizer, Sore Throat.
THE INCIDENCE OF LONG COVID-19 SYMPTOMS IN COVID-19 PATIENTS AND THEIR RELATIONSHIP WITH RETURN TO WORK IN TULKARM DISTRICT: A FOLLOW-UP STUDY
(2022-12-15) Bayan Jamal Ahmed Abu Hamdh
Background: many COVID-19 patients complain of persistent symptoms post-recovery that affect their health status. This study aims to find the incidence rate of long COVID-19 symptoms, the most common associated risk factors, and to assess its impact on returning to work among COVID-19 patients. Method: a prospective cohort study was done to follow up on 669 positive COVID-19 patients diagnosed between September 16th and October 5th, 2021, in the Tulkarm district. The socio-demographic information was extracted from the EHR, and other information was collected using a semi-structured questionnaire, making a phone call interview for patients to evaluate their persistent symptoms on Day 10, Day 30, Day 60, and Day 90. Results: the incidence of long COVID-19 symptoms was 41.6%; (95%CI: 37.8-45.4%). The most common persistent symptoms were dyspnea, fatigue, headache, insomnia, and loss of smell or taste. Female sex [aOR=1.5 (95%CI:1.1-2.3)], age > 30 [aOR=4.8 (95%CI:2.0-11.3)],and those who required hospitalization [aOR= 5.0 (95%CI:1.3-3.7)] were at a higher risk of developing long-COVID-19 symptoms, dyspnea at day ten[aOR:2.7 (95%CI:1.8-4.0)], and fatigue at day 60 [aOR:2.9 (95%CI:1.6-5.1] are considered predictors of long COVID-19 symptoms. On the other hand, the COVID-19 vaccination was found to be protective against long COVID-19 symptoms; non-vaccinated patients were seven times more likely than vaccinated patients to develop long COVID-19 [aOR:7.1 (95%CI:4.3-11.8)]. For sick leave more than ten days, it was found that the mean days of sick leaves was 11.64 ± 2.50, which was more among governmental employees and non-vaccinated patients. Conclusion: Females and older ageconsidered the high-risk group to develop long COVID-19 symptoms, hospitalized patients,dyspnea on day ten and fatigue on day 60 predicted long COVID-19, at the same time non-vaccinated patients were more likely to have prolong sick leave. WhileCOVID-19 vaccination was considered a protective factor. The best way to avoid developing long-lasting symptoms from COVID-19 infection is to prevent it through vaccination or other protective measures. More research is needed to gain knowledge more about long COVID-19 symptoms and their consequences. Keywords: Dyspnea; Fatigue; Long COVID-19; Sick leave ; Return to work.
THE EFFICACY OF ADMINISTRATION OF TRANEXAMIC ACID PRE AND POST CARDIOPULMONARY BYPASS VERSUS PLACEBO IN REDUCING BLOOD LOSS TRANSFUSION IN CARDIAC SURGERY: A PROSPECTIVE, RANDOMIZED, PLACEBO- CONTROLLED, DOUBLE-BLIND TRIAL
(2022-12-21) Mariam Sharakah
Cardiopulmonary Bypass (CBP) provides a blood–free field surgery, but it has complications. One of these complications is blood loss and bleeding. Therefore, to save blood in cardiac surgery, antifibrinolytics, agent, like Tranexamic Acid (TXA), can be used. The Study aim to assess TXA clinical efficacy and safety to reduce blood loss, and the need for blood transfusions of the patient during Coronary Artery Bypass Grafting (CABG), using CPB. A sample of Ninety -nine patient was included in this study. A prospective, randomized, placebo–controlled, double-blind study of patients received placebo (n= 33) or TXA 15 mg/ kg before CPB, then was infused 1 mg\kg\h and stopped after termination of CBP and reversal of heparin. This was followed by a TXA infusion of 1 mg /kg / h for 5 hours (n = 33) or TXA 15 mg\kg after CPB, and by infusion TXA 1mg\kg\h for 5 h. The results showed that the mean of the RBC units in control group (Mean=1.42) was significantly higher than both the means of the RBC units in Pre –CPB TXA group (Mean=0.61) and Post- CPB TXA group (Mean=0.64), p<0.001. Pertaining to the 48 h. post-op (Mediastinal chest drainage (MCTD)). The results showed that the mean of the 48 h. post-op (MCTD) in the control group (Mean=209.45) was only significantly higher than the mean of the 48 h. post-op (MCTD) in Post-CPB TXA group (Mean=110.52), P= 0.005. Concerning 72 h. post-op MCTD), the results showed that the mean of the 72 h. post-op (MCTD), in control group, (Mean=41.67) was only significantly higher than the mean of the 72 h. post-op (MCTD) in Post-CPB TXA group (Mean=14.87), P= 0.006. In patients undergoing cardiac surgery and at risk for postoperative bleeding, the study has demonstrated that post-CPB TXA has profoundly favorable hemostatic and blood conservation benefits. Giving TXA post CPB has the best hemostatic effects. When compared to placebo, it reduces both blood loss over the course of 48 and 72 hours and the need for blood product administration. Pre-CPB TXA's positive impact, however, is less obvious. Keywords: Cardiopulmonary Bypass; Coronary Artery Bypass Grafting; Tranexamic Acid; bleeding; blood transfusion.
DEVELOPMENT OF AN OPTIMIZED SCAFFOLD FOR TISSUE ENGINEERING BASED ON THE NON-COVALENT FUNCTIONALIZATION OF CARBON NANOMATERIALS
(2022-12-29) Salsabeel Mamon Odeh
One of the main approaches for tissue engineering for therapeutic purposes involves the utilization of primary cells that are cultured on a biocompatible scaffold with appropriate characteristics. Such tissues aim to maintain and/or restore normal tissue functions. Over the past few years, significant attention has been given to carbon nanomaterials, like carbon nanotubes (CNTs), and their potential applications in generating tissue scaffolds as they tune some of the tissue's physical characteristics such as flexibility, elasticity, and porosity. A major obstacle to the employment of CNTs in biological applications was the poor limited water dispersibility and cytotoxicity, however, it was found that the functionalization of CNTs adequately with polar functional groups can solve this problem and improve their biocompatibility. Similar benefits could be achieved by coating the CNTs with chitosan, which is biodegradable, biocompatible, and can form porous structures that are appropriate for cell growth. Therefore, in our project, we aimed to investigate the characteristics of an engineered connective tissue (ECTs) that is composed of primary dermal fibroblasts and collagen hydrogel that is enriched by varying concentrations of noncovalently functionalization multiwall CNTs (MWCNTs) with pyrene moiety and coated with chitosan. The tested concentrations were 0.025%, 0.05%, and 0.1%. Our data demonstrated that the enrichment of the ECTs with the functionalized MWCNTs significantly increased the electrical conductivity of the tissues in a kind and concentration-dependent manner. Furthermore, the conductivity enhancement was greater with MWCNTs- COOH compared to MWCNTs-NH2, the concentration of 0.025% of MWCNT-COOH was enough to sufficiently enhance the electrical conductivity of the tissue compared to the control tissue. however, this concentration was still associated with some cytotoxicity where it reduces the cell viability by around (20-30) % relative to the control, while there was no significant reduction in viability when adding chitosan to 0.025%MWCNT-COOH, which indicates that chitosan might have a cytoprotective effect against CNT-induced toxicity, in addition to electrical conductivity enhancement. Keywords: carbon nanomaterials, tissue engineering, chitosan, MWCNT, primary fibroblast.
EARLY PRONE POSITION FOR NON-INTUBATED COVID-19 PATIENTS WITH SEVERE HYPOXIA
(2023-01-17) Najla Butros Abusahlia
Background: COVID-19 is an emerging infectious disease that was first recognized in Wuhan, China, and had then spread rapidly in the whole globe. Around 29 percent of patients with COVID-19 may develop ARDS. Previous research indicated that the average ratio of arterial oxygen tension to the fraction of inspired oxygen (PaO2/FiO2) can be increased by prone positioning and mortality in moderate to extreme ARDS can be decreased. Aim: The study aims to evaluate the effect of early prone position on non-intubated COVID-19 patients with severe hypoxia. Method: A Randomized Controlled Trial (RCT) design was used in this study. The population of the study was COVID-19 patients aged 18 years or more, with severe hypoxia. The sampling method was simple random sampling. Patient checklist was introduced in the present study for data collection. Results: The gender were matched between experimental and control (25 (50%) and female (25 (50%)). The mean of experimental group was significantly higher than control group for Partial pressure of oxygen "PaO2" (mmHg) at 2 hours (79.6±17.6 vs. 67.9±12.3, t=3.87 & P< 0.001), Partial pressure of oxygen "PaO2" (mmHg) at 4 hours (87±19 vs. 66.9±14.3, t=5.969 & P< 0.001), Oxygen saturation "SpO2" at 0 minute (84.9±7.6 vs. 80.5±10.3, t=2.426 & P< 0.001), Oxygen saturation "SpO2" at 2 hours (91.3±6.2 vs. 83.4±8.7, t=5.202 & P< 0.001), Oxygen saturation "SpO2" at 4 hours (94.7±5.8 vs. 82.8±9.7, t=7.39 & P< 0.001) and total number of cycles: (13.9±10.8 vs. 0.4±3.1, t=8.44 & P< 0.001). Early prone positioning of non-intubated COVID-19 patients with severe hypoxia is associated with lowering complications and there is statistically significantly different between experimental group and control group regarding discharged to home, transfer to ICU department (60% vs. 8.0%, P <0.05) and death (0.0% vs. 8.0%, P<0.05). While there is not statistically significantly different in others complication resulting from prone positioning of the non-intubated COVID-19 patients with severe hypoxia. Conclusion: Early prone position on non-intubated COVID-19 patients is associated with elevated partial pressure of oxygen "PaO2" (mmHg) at 2 hours, Partial pressure of oxygen "PaO2" (mmHg) at 4 hours, Oxygen saturation "SpO2" at 0-minute, Oxygen saturation "SpO2" at 2 hours, Oxygen saturation "SpO2" at 4 hours & Total number of cycles. As well as it associated with lowering respiratory rate "RR" (breath per minute) at 4 hours. However, early prone position on non-intubated COVID-19 patients is associated with decreased complications. Key words: Prone position, non-intubated, COVID-19, hypoxia, Palestine.
PHYTOCHEMICAL COMPOSITION, ANTIMICROBIAL AND CYTOTOXIC ACTIVITIES OF CLINOPODIUM INSULARE ESSENTIAL OIL FROM PALESTINE
(2023-02-05) Ziyad Bader Salman
ABSTRACT Clinopodium insulare (Calamintha incana) is one of the medicinal aromatic plants that is dominant in the eastern Mediterranean regions, including Palestine, and has a distinctively pleasant mint-like smell. Traditionally, C. incana leaves are used as a spice and herbal tea. The current work's goal is to examine the potential pharmacological characteristics of chemical constituents. The essential oil of the plant was extracted using the hydrodistillation (Clevenger method) technique. The use of gas chromatography–mass spectrometry (GC–MS), the chemical components of the plant's essential oil were determined. The essential oil's antioxidant capacity was evaluated by inhibiting 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical. The 3,5-dinitrosalicylic (DNSA) assay was used to assess anti-amylase activity. Anti-lipase activity was assessed using the p-nitrophynel butyrate method. Antimicrobial activity was assessed using the broth microdilution method for antibacterial testing and the poisoned food technique for fungal testing. Six bacterial strains were used: four Gram-negative: Escherichia coli, Pseudomonas aeruginosa, Proteus vulgaris, and Klebsiella pneumonia; and one yeast: Candida albicans. Two were gram-positive: MRSA (Methicillin-Resistant Staphylococcus aureus); in addition, the oil was tested against three dermatophytes: Microsporum canis, Trichophyton rubrum, and Trichophyton mentagrophyte. Anti-cancer activity was evaluated by using the MTS assay on HeLa cells. Plant essential oil yield was 0.213 percent (w/w). GC-MS analysis detected the presence of sixty compounds, which accounted for 98% of the total oil composition. The major compound was piperitone oxide, representing 41.178%. C. incana showed anti-oxidant activity with an IC50 of 390 μg/mL.. Essential oil has a moderate amylase inhibitory effect with an IC50 value of 120 μg/ml and a moderate anti-lipase inhibitory effect with an IC50 value less than 800 μg/ml. The sample showed broad antimicrobial activity, potent against Gram-negative bacteria with MICs ranging between 0.4883 ug/ml and 62.5 ug/ml , between 26.041 ug/ml and 31.25 ug/ml for Gram-positive bacteria, and yeast with a MIC of 0.2441 ug/ml. The antifungal activity against Microsporum canis, Trichophyton rubrum, and Trichophyton mentagrophyte was observed, with MICs ranging from 0.15 μl/ml against Trichophyton mentagrophyte to 0.37 μl/ml against Trichophyton rubrum. The anticancer activity of the oil was tested against HeLa cells and showed promising results with an IC50 dose of 50 μg/mL. The plant's essential oil contained varying percentages of various phytochemicals, which provided various potential biological activities such as antioxidant, anti-lipase, anti-amylase, anti-cancer, and antimicrobial effects. Keywords: Essential oil; Antibacterial activity; Antifungal activity; Clinopodium insulare.
CHEMICAL DERIVATIZATION OF ZIDOVUDINE BASED ON CLICK REACTION FOR NOVEL ANALYTICAL METHOD DEVELOPMENT
(2023-03-19) Kyan Bransi
ABSTRACT Zidovudine is a drug used for the treatment of patients that are infected with the human immunodeficiency virus. It inhibits HIV-reverse transcriptase. Zidovudine has significant dose-limiting toxicities drug-specific, resulting in a small therapeutic window between the minimum and the maximum effective and tolerated doses, respectively. Serious adverse effects among them include hepatic abnormalities, myopathy, and bone marrow toxicity. Hence, a demand exists for analytical technologies that enable efficient and accurate measurements of Zidovudine. The adapted analytical techniques must have sufficient sensitivity, selectivity, or both in order to have more manageable and accurate measurements of various chemical procedures. Converting functional groups within a molecule is one of the adaptive techniques used in chemical derivatization. In this study, the development of a new analytical method for the chemical derivatization of Zidovudine was proposed. To that end, a click reaction with azide-conjugated alkyne was employed, resulting in a five-membered heterocycle (1,2,3-triazole) and an extended conjugation. The aim is to develop a sensitive and selective analytical method. The proposed analytical method has been developed using HPLC with UV/Vis detector and validated according to the International Conference of Harmonization and the Food and Drug Administration guidelines and with the use of the parameters such as accuracy, linearity, range, precision, limit of detection, and limit of quantitation. The developed method adapted max=260 nm for the measurement of the derivatized Zidovudine. The method used HPLC using mobile phase Water-ACN 70:30 v/v. The eluted peak of the derivatized Zidovudine was separated from other used derivatization reagents. The analytical method was then validated, and validation parameters were found to be within the accepted limits. The developed method was found to be linear (R2 = 0.994), precise (RSD = 0.59), and accurate (% recovery = 101.17). Moreover, the developed method was sensitive to LOD (4*10-8 mg/ml) and LOQ (4*10-7 mg/ml). Therefore, the developed method is simple and feasible with high sensitivity and selectivity. Zidovudine may be analyzed in a variety of dosage forms and raw materials, including active pharmaceutical components. This line of research may be pursued further in the future, and the technique that has been established may be adopted in the testing of Zidovudine in biological systems. Keywords: Zidovudine; Click Reaction; HPLC; Derivatization.
THE EFFECT OF PSYCHIATRIC PATIENTS AGGRESSION AND VIOLENCE ON PSYCHIATRIC NURSES: A STUDY FROM BETHLEHEM PSYCHIATRIC HOSPITAL OF PALESTINIAN TERRITORIES
(2023-06-01) Saleh Ibrahim Abed Al Hadi Sayara
Abstract The nature of psychiatric nursing work is demanding and can be stressful, in comparison to other professions, psychiatric nurses suffer greater levels of stress. Related research has revealed that psychiatric nurses in work have a higher incidence of aggression and violence. According to evidence, the psychiatric nursing staff is often subjected to violence and aggressiveness, resulting in the affected nurses physical and mental well-being harmed. The aim of the study is to evaluate the effect of psychiatric patients aggression and violence on psychiatric nurses in Bethlehem Psychiatric Hospital in Palestinian. A descriptive quantitative cross-sectional study design was conveyed during November-December 2021 at Bethlehem Psychiatric Hospital in Palestine. The data was collected by using a questionnaire containing two sections (Demographic data, Impact of Event Scale-Revised, Eysenck Personality Questionnaire-Revised). The Data was analyzed by using SPSS version 26. The results showed the prevalence of diagnosed PTSD nurses was (14.7%), and among participants who had partial PTSD and some symptoms was (20.0%). Furthermore, the number of people who outlived post-traumatic stress (enough to suppress the immune system) was (42.7%). Furthermore, it was clear that the impact of post-traumatic stress disorder on the personality among the nurses involved in the study, as the prevalence of neuroticism among the participating nurses was (48.0%), this means that participants are characterized by sadness, mood swings, and emotional instability. In addition, individuals with a high score for this trait tend to experience mood swings, anxiety, speed, and sadness, while the extroverted ratio reached (85.3%), and this degree indicates that the person is social, loves parties, has many friends, needs many people around them, loves to talk a lot, does not like to read, and seeks excitement. They patient aims to do things thay are not supposed to do, acts quickly without thought, is generally impulsive, is fond of making pranks for others, answer is insightful and quick witted, loves change, takes things, prefers to be always active and moving, does different actions and tends to aggression. In addition to being impatient easily, the patient cannot control their feelings and gets irritated quickly. The study concluded that the aggressive and violent behaviors of the psychiatric patient on the nurses have negative impact on the psychological state of the nurses, and most of the participants suffer from PTSD. Furthermore, participants who are diagnosed with PTSD are more likely to suppress their immune system. Moreover, post-traumatic stress disorder was reflected on the personality state or personality dimensions of the nursing participants in the study. This reflection led to the emergence of neuroticism that manifests in the form of anxiety, difficulty sleeping, headaches, digestive disorders, back pain, and mood swings. The Palestinian Ministry of Health must be aware of the difficulty of the work provided by these psychiatric nurses as well as to providing psychological supervision and counseling programs for these nurses. Keywords: Psychiatric Patient, Psychiatric Nurse, Aggression, Violence, Psychological State, Bethlehem Psychiatric Hospital.
COMPARISON OF THE NEUROLOGICAL ADVERSE EVENTS AND CHANGES IN ELECTROLYTES LEVELS BETWEEN PANTOPRAZOLE AND FAMOTIDINE: A PROSPECTIVE OBSERVATIONAL STUDY
(2023-06-13) A'mer Nawwaf Zidan
Abstract Background: Proton-pump inhibitors (PPIs) have recently become more commonly used in patients with functional gastrointestinal illnesses or for primary prophylaxis of drug-related gastro duodenal damage, despite the fact that their benefits for those conditions have not been thoroughly confirmed. In a few studies, significant acute neurological symptoms related to PPI-induced hypomagnesemia have been observed; and histamine-2 Receptor Antagonist (H2RAs) are more strongly associated with increased delirium than PPIs. However, severe hypomagnesaemia has not been linked to usage of H2RAs. Aim: The study aim was to compare the effects of Pantoprazole (Proton pump inhibitor) and Famotidine (histamine-2 Receptor Antagonist) on electrolytes disturbances and other neurological adverse events among critically ill patients. Method: A prospective observational study was conducted between August 2022 and December 2022 included 100 critically ill patients in intensive and cardiac care units of Al- Watani Hospital. The response rate was 91.75%. The data sheet consisted of several sections, including sociodemographic data, health information, data about administration of Pantoprazole and Famotidine, clinical outcomes, neurological complications including delirium degree. Results: The highest age group for the total participants was over 60 years old (60%), and more than half of the total participants were male (57.0%). The findings pointed out that the percentage of Acute Kidney Injury was higher in Pantoprazole compared with Famotidine (38% vs. 10%, respectively). The results also showed that the blood urea nitrogen was significantly higher in Pantoprazole group compared to Famotidine group (40.0±29.6 vs. 27.8±24.3 mg/dl; P < 0.05). Similarly, creatinine was significantly higher in Pantoprazole group compared to Famotidine group (2.2±2.0 vs. 1.5±1.5 mg/dl; P < 0.05). In contrast, the average albumin in Pantoprazole group were significantly lower than that in Famotidine group (2.8±0.5 vs. 3.1±0.6 g/dl; P < 0.05). The Mean±SD of serum Magnesium (2.0±0.3 mg/dl in Pantoprazole vs. 2.1±0.2 mg/dl in Famotidine; P > 0.05). The results pointed out that the percentages of neurological complication among Pantoprazole group compared to Famotidine were agitation (12% vs. 24%, P=0.118), hallucinations (10% vs. 4%, P=0.24), dizziness (4% vs. 6%, P=0.646), nausea (4% vs. 4%, P=1.000), vomiting (2% vs. 2%, P=1.000), numbness (2% vs. 2%, P=1.000), muscle spasms (2% vs. 0%, P=0.315), seizures (0% vs. 2%, P=0.315), convulsions (2% vs. 0%, P=0.315), however, nobody has loss of consciousness, death, tetany, and tremors. Conclusion: There was no significant association between patients who were treated by Pantoprazole and who were treated by Famotidine with regards to serum magnesium level, occurrence of neurological complications, and mean delirium degree. But the Pantoprazole group were associated with elevated levels of creatinine and blood urea nitrogen, and lower levels of albumin and hematocrit compared to Famotidine group. Keywords: Pantoprazole; Famotidine; electrolytes; neurological adverse events.
DEVELOPMENT OF NON-COVALENTLY FUNCTIONALIZED MULTIWALLED CARBON NANOTUBES BASED-SUBSTRATE FOR SUPPORTING IN VITRO NEURONAL GROWTH
(2023-06-22) Rama Sahem Hendawi
Abstract Background: Nerve injuries are considered the first leading cause of disabilities and one of the leading causes of deaths globally, which add a huge burden on socioeconomics. Many interventions have been developed to treat nerve injures, the golden standards are neurorrhaphy when suturing is possible, and autologous nerve transplantation, although promising results were obtained, functional recovery from chronic injuries remains a challenge. As a result, nerve tissue engineering emerged to find innovative solutions. In this study, the researcher aimed to develop neuronal growth by enhancing multiwall carbon nanotubes (MWCNT) dispersion and use it as a substrate. Objectives: This study aimed to test the effect of CNT substrate on neuronal functions and morphology, by first enhancing the MWCNT dispersion and form a substrate allows neuronal growth. Methods: in order to enhance MWCNT dispersion, the researcher functionalized it with poly-l-lysine (PLL) and chitosan by sonication, the cells were primary isolated from cortical rat embryo and seeded on PDMS polymer, and then we analyzed the substrate was analyzed by Raman spectra and scanning electronic microscope (SEM). Then we tested neuronal synchronicity was tested by calcium dye staining florescence, the recorded videos were further analyzed by SyincAnalysis software, the cellular viability, and synchronicity percentages were statistically analyzed by student T test. The neuronal morphology was analyzed by staining actin and tubulin, the main cytoskeletal filaments engaged in neuritogenesis, the recorded images were further analyzed by special software, and the results were statistically analyzed by one way ANOVA. Results and conclusions: PLL enhanced MWCNT dispersion better than chitosan, with 0.05% PLL-MWCNT as our working concentration. For neuronal synchronicity the researcher tested the substrate against PLL-ECM as a control, and it was that there is found no significant difference between active cell number percentage and synchronicity cell percentage which indicates the substrate ability to sustain neuronal activity. Furthermore, we tested neurite branching against PLL and PLL-ECM as controls, and we found significant difference between PLL-MWCNT and others, we hypothesized this increase due to nanoscale topography that are in the favorable size for focal adhesion attachment, and that PLL-MWCNT increased substrate stiffness. Keywords: Carbon nanotubes; poly-l-lysine; chitosan; synchronization; neuritogensis; nerve tissue engineering; substrate.
FREQUENCY OF RED CELL ALLOIMMUNIZATION IN HEMATOLOGICAL MALIGNANCIES IN WEST BANK, PALESTINE
(2023-06-23) Ikram Yousef AbdAlrahman AlSheikh Qasem
Abstract Background: Patients with malignant hematological diseases frequently have anemia. Blood transfusion therapy is fundamental in management in these patients. Repeated blood transfusions may cause the development of alloantibodies against one or more red cell antigens, which complicates subsequent transfusions. Objectives: This study aimed to investigate the frequency and characteristics of RBC alloimmunization as well as the related risk factors among patients diagnosed with hematologic malignancies (mainly leukemia and multiple myeloma) in Palestine. Materials and Methods: This cross-sectional study was performed between February and August, 2022 on oncohematological patients from clinics or admitted to the hospitals from three hospitals located north, middle and south of West Bank, Palestine: An-Najah National University Hospital in Nablus, the Istishari Arab Hospital in Ramallah and the Beit Jala Governmental Hospital in Bethlehem. A total of 94 of multi transfused patients were included. Demographic, medical data and history of transfusion were retrieved from patients` files. Alloantibody screening (indirect coomb’s test) and identification (panel test) were performed from plasma samples of patients ,who have never done the test using commercial Capture-R Ready-screen and ID, IMMUCOR. In order to exclude autoantibodies, a patient's RBCs were analyzed in combination with each screen for autoantibodies. Results: Twenty-nine participants had alloantibodies. The rate of alloimmunization observed in the present study was 30.85%. The most frequent alloantibodies were against Kell system antigens (Anti-K) (20.7%), followed by Anti-E (13.8%), and Anti-D (6.9%). One participant had multiple antibodies, and six participants (23.9%) had two antibodies: Anti-E and K (6.9%), Anti-Jka and Kpa (6.9%), Anti-E and Fya (3.4%), and Anti Fya and S (3.4%). Autoantibodies were found in this study (6.9%). Conclusion: This study showed a high rate of alloimmunization among hematological malignancies mainly leukemia and multiple myeloma in different regions of West Bank, Palestine. The most frequently detected alloantibodies were against the Kell and Rh antigens. RBC compatibility in ABO, Rh, and Kell system as well as phenotyping of antigens may reduce the risk of the most of alloimmunizations. Keywords: Red Blood Cell Transfusions; Antibody Screening; Hematological Malignancies; Palestine.
CHEMICAL DERIVATIZATION OF NORETHINDRONE BASED ON CLICK REACTION FOR NOVEL ANALYTICAL METHOD DEVELOPMENT
(2023-06-25) Rawan Saymeh
Abstract Norethindrone is a synthetic progestin, which mimics female natural progesterone's effects but with a greater potency. Norethindrone-only progestin pill is mainly used as birth control pills by increasing uterine lining thinning and cervical mucus thickening. It is also used as hormonal replacement therapy alongside other steroidal hormones in treating conditions caused by abnormal hormonal levels. Norethindrone has significant dose-limiting properties, resulting in a small therapeutic window. Consequently, there is a need for analytical methods that allow for effective and reliable measurements of norethindrone. The adapted analytical methods must have enough sensitivity, selectivity, or both in order to evaluate different chemical processes more easily and accurately. One of the adaptive strategies utilized in chemical derivatization involves converting functional groups within a molecule. In this thesis, we made a proposal to create a novel analytical technique for norethindrone’s chemical derivatization. This was accomplished by using a click reaction with an azide-conjugated alkyne, which produced a five-membered heterocycle ring (1,2,3-triazole) and an extended conjugation. Our goal was to create a sensitive and selective analytical method. The analytical method has been created using HPLC with a UV/Vis detector and validated using parameters like accuracy, linearity, range, precision, Limit of detection, and Limit of quantitation in accordance with the ICH and the FDA's guidelines. The developed method adapted λmax= 245 nm for the measurement of the derivatized norethindrone. The method used HPLC using mobile phase MeOH-Water 60:40 v/v. The eluted peak of the derivatized norethindrone was separated from other used derivatization reagents. The analytical method was then validated, and validation parameters were found to be within the permitted limits. The developed method proved to be linear (R2 = 0.9995), precise (RSD = 1.07), and accurate (% recovery = 106.5%). Moreover, the developed method was sensitive to LOD (2*10-6 mg/ml) and LOQ (2*10-4 mg/ml). Therefore, the developed method is simple and practical and has excellent sensitivity and selectivity. Norethindrone may be analyzed in a variety of dosage forms and raw materials, including active pharmaceutical components. The good sensitivity values of our developed method suggest that it may be applied to analyze norethindrone in biological systems. Keywords: click chemistry, chemical derivatization, norethindrone, analytical method development, high-performance liquid chromatography.
COMPARISON OF NON-INTENSIVE CARE UNIT (ICU) VERSUS ICU NURSES’ PERCEPTIONS AND SATISFACTION WITH THE USE OF THE SITUATION, BACKGROUND, HOSPITAL ASSESSMENT, AND RECOMMENDATION (SBAR) TOOL: A MULTICENTER RESEARCH
(2023-07-06) Rasheed Darawsheh
Abstract Background: Patient safety is crucial for the delivery of effective, high-quality healthcare, and poor communication is found in many different healthcare settings, including handovers, shift exchanges, rounds, and team meetings. The SBAR tool was used for effective communication between nurses and between nurses and other HCPs. Therefore, the purpose of this study was to examine perception, satisfaction, and perceived barriers among Palestinian nurses working in the ICU regarding the use of the SBAR tool for effective communication. Methods: This cross-sectional study was conducted in Palestinian hospitals. Data were collected from 208 participants through a questionnaire that was adopted from previous studies in this field. Data were collected by convenience sampling. The nurses answered a questionnaire covering social demographics, satisfaction, perception and perceived barriers. IBM-SPSS software was used for all analyses, and median utility indices used a Bloom cut-off point for positive satisfaction and satisfied perceptions were equal or high. Results: Overall, 208 nurses completed the study questionnaires. The median age of the study participants was 27 years, with an IQR of 25.0-29.0. The median satisfaction score was 95, with an interquartile range of 89.0 to 102.0. Approximately fifty percent (n = 106) of the respondents scored 95 (median). The median perception score was 36.0, with an interquartile range of 33.0 to 39.0. A total of 55.3% (n = 115) of the respondents scored 36 (median). The 25-29 age group showed better satisfaction than the other age groups, with a median satisfaction of 97 (p < 0.001). Additionally, nurses with 3 to 5 years in the field showed good satisfaction, with a mean satisfaction of 98 (p < 0.001). Additionally, participants did not share any direct barriers to SBAR, but approximately 42.3% did not know when asked about time constraints. Additionally, 41.8% were unaware of the physician's delay in response. Conclusions: Our study revealed that participants of the SBAR framework as a communication tool had negative satisfaction and unsatisfied perceptions. Future research should provide more evidence of its viability and effectiveness compared to conventional handover tools and in other healthcare scenarios. Keywords: SBAR; perceptions; nurses; satisfaction; perceived barriers; safety; patient safety.
SYNTHESIS OF DOXORUBICIN-URSODEOXYCHOLIC ACID CONJUGATES FOR TARGETED LIVER CANCER THERAPY
(2023-09-05) Ansam Sous
Abstract Liver cancer is a highly aggressive disease with high mortality rates. Doxorubicin has been utilized to treat hepatocellular carcinoma due to its broad-spectrum anticancer effect. However, due to the potential of cardiotoxicity and the development of multidrug resistance, it is typically dose-limited in therapeutic use, limiting its long-term usefulness. Ursodeoxycholic acid is a hydrophilic bile acid that binds to the bile acid receptors with higher affinity than any other type of bile acids. The primary objective of this project is to develop a UDCA-DOX conjugate and evaluate its targeting capabilities in vitro to specifically deliver DOX to HCC cells. With these objectives, we aim to exploit the affinity of UDCA for HCC cell lines to minimize DOX toxicity on normal cells, while maintaining enough cytotoxicity against liver cancer cells. UDCA-DOX conjugate was synthesized with an acid-labile linkage, then, its characteristics and release profile were studied by the HPLC. After that, the cytotoxicity of this conjugate was investigated by the MTS test in vitro in HepG2 ,Hep3B hepatic cancer cell lines, LX-2 cells the normal hepatic cells, and the none hepatic cells 3T3. The targeted cellular uptake of UDCA specifically by hepatic cancer cells was studied by fluorescence microscopy. UDCA-DOX can spontaneously hydrolyze in acidic media. This conjugate showed significant cytotoxicity in hepatic cancer cell lines (HepG2 and, Hep3B). The successful delivery of DOX into the cancerous cells was confirmed by fluorescence microscopy. However, the cytotoxicity of UDCA-DOX was limited in non-cancerous cell lines (LX-2 and 3T3), suggesting that the delivery of UDCA-DOX into the cells is dependent on specific features in the hepatic cancer cells. Moreover, the observed cytotoxicity of UDCA-DOX was less than that of free DOX, suggesting that the drug reached the cell via a rate-limited process, which endorses the hypothesis that the internalization of UDCA-DOX could be through bile acid receptor-mediated endocytosis. This study demonstrated valuable insights into the potential of UDCA-DOX as a targeted therapeutic strategy for HCC to reduce the adverse effects associated with DOX therapy. Further investigations are required to test the in vivo efficacy and safety of this conjugate. Keywords: Hepatocellular Carcinoma; Ursodeoxycholic acid; Doxorubicin; Cancer targeting; Acid-labile Linkage; Fluorescence.
MOLECULAR CHARACTERIZATION OF CLOSTRIDIUM DIFFICILE TOXIGENIC STRAINS AND ANTIBIOTIC SUSCEPTIBLY PATTERNS AMONG PALESTINIANS IN PARTS OF NORTH WEST BANK
(2023-10-01) Deema Rasim Khouli
Abstract Introduction: Clostridium difficile is a Gram-positive, spore-forming bacillus that causes gastrointestinal sickness C. difficile infections (CDIs). C. difficile infection is considered as an opportunistic infection that develops after spores are acquired by fecal-oral route, and germinate into vegetative cells, start producing virulent toxins (A, B, and binary) that are responsible in symptoms and clinical presentation of the infection. Inflammatory diarrhea is the main manifestation among infected patients. It can be moderate and self-limiting, but it can also be severe and lead to serious complications, such as toxic megacolon and pseudomembranous colitis. Irrational use of broad-spectrum antibiotics, age above 65 years, lengthy hospital stays, and immunocompromised state, are the main risk factors for infection Objectives: This study aimed to molecularly characterize toxigenic C. difficile strains, find the prevalence of C. difficile and associated risk factors among Palestinians in the northern part of West Bank, in addition to antibiotic susceptibility pattern against first line choices antibiotics, and finally highlight C. difficile in children population. Methods: A cross- sectional study design was selected, a total stool diarrheal samples collected from patients in governmental hospitals, molecular characterization was done by multiplex PCR and gel electrophoresis, followed by isolation of C. difficile on C. difficile agar base with supplement, antibiotic susceptibility was performed using disk diffusion method on Brucella blood agar supplemented with hemin and vitamin k. Results: The prevalence of C. difficile in prevalence group was 15.7, and incidence of 5.8 per 10,000 diarrhea patient, and prevalence in children group was 10.6. Risk factors in prevalence was antibiotic and PPI use, hospitalization history and comorbidities, in the children group risk factors were antibiotic use and hospitalization history. Isolated toxigenic C. difficile strains was susceptible in 96 %, 89 % against vancomycin and metronidazole respectively. Conclusion: 15.7 prevalence is considered as warning sign, especially when dealing with spore forming bacteria, and CDI in children group, in most cases, masked with amoeba as they result in similar presentation and treated with same antibiotic. Increased awareness about infection prevention practices in hospital and community, in addition to antibiotic stewardship programs are main recommendations to control spread of CDI Keywords: Clostridium difficile; CDI; Toxins A, B; Binary; diarrhea.
ENVIRONMENTAL AND GENETIC RISK FACTORS AMONG TYPE 1 DIABETES MELLITUS / CASE CONTROL STUDY IN NABLUS CITY
(2023-10-03) Bara'a Khaleel Rawajbeh
Abstract Type 1 diabetes is a result of an autoimmune reaction in which the body immune system attack himself the exact risk factors that enhance this mechanism are not as clear as for type 2. In this study, a questionnaire for risk factors (environmental and genetic factors) for type 1 diabetes mellitus at maternal and child level. The study is aiming for identifying the risk factors (environmental & genetic) at maternal and patient level associated with type 1 diabetes mellitus in Nablus city West Bank, Palestine. A case control study design was adopted to find the risk factors associated with type 1 diabetes occurrence 68 cases and 50 control filled a questionnaire that was developed by the researcher, then the data was analyzed by SPSS. A total of 118 participants included in the study: 68 cases (57.6%), 50 controls (42.4%), mean age in cases 8.8703 ±5.2053, mean age of controls 8.5600±5.83938. 53.4% males and 46.6% females. The comparison between case and control groups showed significant association with multiple risk factors. BMI pre pregnancy (p 0.009), hypertension during pregnancy (p 0.077, OR 5.623, 95%CI 0.8294 – 1.4206), exposure to hair salon chemicals (p 0.033, OR 4.632, 95%CI 0.9269 – 1.3808), passive smoker (p 0.002, OR 3.458, 95%CI 1.1415 – 1.3868), consumption of soft drinks (p 0.051, OR 2.217, 95%CI 1.1516 – 1.4484), and family history of T1DM (p 0.000, OR 42.690, 95% CI1.4095 – 1.6109). T1DM is associated with genetic and environmental risk factors. Recommendation for further studies about the result founded in this study, with more sample size, and more details Keywords: Diabetes and risk factors; T1DM.

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