#jcrmhs

Abstract

Methods A computerized literature searches (Google Scholar, PubMed, Science Direct, Springer Link, Elsevier, Semantic Scholar, and HINARI) was used to collect studies addressing the OCD in Palestine.

Results and Conclusion OCD in Palestine is widely presented in adolescence and children at a young age. The most common type of OCD in Palestine is checking type. Set of risk factors increases developing OCD, including sexual abuse at any age as well as anxiety, depression, phobia and somatization disorders. In addition, the family incomes play a big role in presenting OCD, especially low income families. Most of the patients who have OCD were depressed and complaining of stigma and ignorance. Recommendations include getting rid of the stigma, creating a chance for low income families, further studies into OCD in Palestine, ending of the occupation and preventing children from following TV programs and war results.

Key words OCD, Obsessive compulsive disorder, Palestinians Mental Health, Palestine, Gaza Strip, West Bank

Background

In this section the researchers highlighted the meaning of health, mental health and mental illness. Also, they showed the impact of Israeli occupation on Palestinians people since 1948 and lastly in 2019. Besides, the state of mental health services in Palestine. A complete condition of physical, social and mental well-being and not purely disability or disease absence are the definition of the health, according to World Health Organization (WHO)(1). According to American Psychiatric Association (APA) the mental health is the foundation for learning, communication, emotions, thinking, self-esteem and resilience, also, it is the key to personal and emotional well-being, relationships, personal and contributing to the community or society(2). Therefore, the combination of behavioral, emotional or thinking process changes, or involving a change in one of them is called a mental health illness which is common and can be treatable(3). Historically, Palestinians health affected because of the Israeli occupation of Palestine, which was divided into two areas (West Bank and Gaza Strip)(4). Those two areas were occupied by Israel in 1948, related to that about 60 percent of the Palestinians living in villages with 27 percent of them in refugee camps(5). Accordingly, Israel attacks the civilians in their places and they experience infringement of their human rights which impact their health(6). Because of affection on the civilian health, especially the mental health, there is a need to develop mental health services(7). Therefore, in 2004 the mental health policy officially adopted for West Bank and Gaza Strip by Palestinian Ministry of Health (MoH) and in 2002-2003 it was formulated(5). As a result, Palestinians need to meet them human rights and develop the mental health policies and services(8). In summary, the history that the researchers mentioned above about Palestine’s political condition, clearly showed that there are major challenges faced the civilians’ mental health, as well as, their social and economic state.

Methodology

A computerized literature searches (Google Scholar, PubMed, Science Direct, Springer Link, Elsevier, Semantic Scholar, and HINARI) was used to collect studies addressing the OCD in Palestine. Search terms included “obsessive-compulsive disorder,” “obsessive compulsive” “OCD Palestine” “Palestinians mental health” “Health in Palestine” “Mental health Palestine” in both Arabic and English languages. Additional papers, which did not appear clearly in the electronic database while searching, were obtained via an examination of reference lists of published papers. Relevant empirical studies are summarized and presented hither. This study included all studies about OCD in Palestine and excluded the studies talked about anxiety, PTSD, or other disorders. The search identified 33 articles. Duplicates and irrelevant articles were removed. Nine articles related to OCD in a Worldwide, fifteen in Arabic countries and nine articles related to OCD in West Bank and Gaza Strip in Palestine. Also the researcher used some Arabic studies and translated them to English language. Studies selected after critically appraised.

An overview of OCD

In this following section the researchers explained the origin of Obsessive Compulsive Disorder (OCD) by writing its definition and clarified main class of OCD and from where it came. Also, this review showed studies about mental health in a worldwide then Arabic world later in Palestine. Moreover, the following sections focused on OCD in Palestine.

Definition of Obsessive Compulsive Disorder This part of the study focused on the definition of Obsessive Compulsive Disorder as both of the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defined it. According to ICD-10, the essential feature of OCD is recurrent Obsessional thoughts and Compulsive act(9), but according to DSM-5, OCD is the presence of obsessions, compulsions, or both of them(10). Obsessional thoughts are images, impulses, or ideas that enter the patient's mind repeatedly in a vulgar form. They are almost fixedly distressing and the patient often tries, unsuccessfully, to endure them, this definition according to ICD-10(9). But DSM-5 defined the Obsessional thoughts as an intruder, unwanted and recurrent thoughts or impulses that most patients cause marked anxiety or distress and the patient trials to ignore such thoughts or images by performing a Compulsion(10). Additionally, ICD-10 about Compulsive, an acts or rituals are stereotyped behaviors that are repeated over and over, these acts are not enjoyable, nor do they result in the completion of useful tasks(9). Also, the repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) is aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation, this definition according to DSM-5(10). As the researchers mentioned above, the OCD is a mental health disorder associated with a change in behaviors and acts, as well as with thoughts changes.

History of Obsessive Compulsive Disorder

In this part the researchers showed the historical sequence of Obsessive Compulsive Disorder. Al-Balakhi was the first one in the world mentioned a mental illness and he put the differentiation of OCD from other forms of mental illnesses nearly a millennium earlier(11). Historically, as with any mental health condition, over time the conceptualization and treatment of OCD has changed(12). In the centuries sixteenth, seventeenth, eighteenth, nineteenth and the first half of the twentieth century the OCD passed through different conceptualizations. Religious melancholy was in seventeenth century the description of Obsession and Compulsion(13), but they have likely been around since humans first roved the earth(12). OCD was associated with moral and spiritual issue in the seventeenth century. Later, in eighteenth century many doctors saw that the Obsessions and Compulsions were caused by intellectual disordered(12).After this view, in the nineteenth century a modern concepts of OCD began to evolved(14),which is ‘neurosis’ implied a neuropathological condition. In the last quarter of the nineteenth century OCD was engulfed along with numerous other disorders(13). Supplementally, in the twentieth century the OCD became with a new concept. Sigmund Freud (1856-1939) and Pierre Janet (1859-1947) isolated OCD from neurasthenia(14).Freud’s view highlighted that this mental health disorder related to subconscious problems, and he sawed that both of obsessions and compulsions were often treated via psychoanalysis(14). Throughout the first half of the twentieth century Freud’s view dominated the mental health field(13). Finally, the researchers back in the time since the appearance of Obsessive Compulsive Disorder until the new concept were appeared.

OCD in a worldwide

In this section the researchers showed a review of OCD from the worldwide view by showing the prevalence of OCD in a worldwide, also the effect of it on the patient’s life, as well as its types and the prevalence of each one. Later the researchers showed risk factors. In the world, at some points in peoples’ lives, they have obsessive thoughts with or without compulsive behaviors, but that does not mean that all of them suffer from Obsessive Compulsive Disorder(15). Approximately 2% is the prevalence of in the general population in a worldwide(16). During the past year, OCD in the U.S affected 1.2% of adults. But now it affects approximately 1 in 40 adults and 1 in 100 children in the U.S. According to the National Institute of Mental Health (NIMH)(17). In Australia around 2% of people have OCD(18). But in the UK population, OCD affects about 12 in every 1,000 people (1.2% of the population) from young children to adults, regardless of social, cultural background or gender(19). In China the prevalence of OCD is 3.17%, according to a study done by Guo et al., its title is “Meta-analysis of the prevalence of anxiety disorders in mainland China from 2000 to 2015”(20). In this condition the patient has an obsessive need to repeatedly do certain things and may have unwanted ideas, impulses or images(21). People with OCD are usually aware that their symptoms are illogical and excessive, but they find the obsessions ungovernable and the compulsions unattainable to resist(18). There are many forms of OCD, Checking, Contamination/Mental Contamination, Symmetry and ordering, Ruminations/Intrusive thoughts and Hording(22). About the prevalence of each type the checking obsessive has the highest prevalence which is 79.3%, the second high prevalence is Hoarding obsessive which has 62.3%, later Ordering 3%, Morality 5%, Sexual/Religious 2%, Contamination/Washing 3%, Harming/Aggression 5% and Illness ratios 8% to 10% (23). A study done by J. Henderson and C. Pollard in greater ST. Louis showed that the overall prevalence rate of OCD was 2.8%. The most prevalent type of Obsessive Compulsive Disorder involved checking (1.6%), followed by a multiple category that included counting, repeating and collecting rituals (1.0%) and, finally, washing compulsions (0.8%)(24) According to National Comorbidity Survey Replication (NCS-R), many people with Obsessive Compulsive Disorder have more than one OCD form(23). The risk factors which may increase the incidence of getting an OCD are divided into three ranks, factors that the person born with, factors outside human control and modifiable risk factors(25). Factors person born with like genetics 50%, gender male at more risk to develop childhood OCD than female, brain structure and socioeconomic status as a study showed that there is an association between OCD and low socioeconomic status(25). But about the factors outside human control are included age life events and mental illness. The risk of OCD drops with age and the late adolescence has the greater risk(25). Those who have stressful life and suffer from physical or sexual abuse are a major risk factor to get OCD, also having another mental illness such as anxiety or depression increase the risk of having OCD (26). According to Owen and Adrian, the third rank is the modifiable risk factors such as drugs, marital status and employment. Drug uses cans causing a neurotransmitter changes in the brain, which create a chance for developing OCD, and being unmarried increase the risk too as well as being unemployed. However, there are many risk factors may increase the incidence to develop an OCD. OCD at higher risk to present comorbid major depression or another anxiety disorder across all areas(27). Peoples suffering from OCD also end up suffering from a lack of self-esteem and self-confidence, relationship problems, very weak willpower, and social withdrawal(28).

OCD in the Arabic countries

In this section the researchers showed a review about OCD in Arabic countries. From one hand, they pointed out that the first one highlighted the OCD was an Arabian psychiatrist and he wrote about it since 1000 years ago. And from other hand, they reviewed different studies about OCD prevalence, Islamic view, culture view and stigma in the Arabic world. Statistics mentioned that the frequency of most mental disorders does not have much difference from country to country around the world(32). The prevalence of OCD in Egyptian adolescent population is 2.2%(33). Also, 0.1 % in Lebanon(34). In Iraq, the peak age for OCD was from 21 to 30 years old, females were predominating (63.2%), singles were (47.3%) and the family history of OCD and any mental illness was observed in 20.5% and 52.9%, respectively(35). The few statistics coming out of certain Arab countries assert the reality of having no difference from country to country in the frequency of mental disorders specially OCD(32). The issue in the Arab world is more to do with stigma and ignorance than it is lack of mental health problems(32). Despite the complication and the importance of the mental health problems, the Arab world still shows a lack of awareness; patients in Arab countries tend to express their psychological issues in terms of physical symptoms, thereby avoiding the stigma attached to mental illness(36). A study done by Mohamed et al., 2015 in Egypt showed the following result: “Religious patients receiving religious psychotherapy showed significantly more rapid improvement and required lower dosage of medications and for periods less than others. The role of religion as CBT could be significant in the Islamic culture.”(37). Recently, the relationship between mental health, religiosity, and personal beliefs (Such as magical ideation) has been studied Psychiatry is depending on culture more than any other medical discipline, therefore, it is not well known in developing countries the frequency of mental illness such as anxiety, OCD or depression, even doctors themselves may not know the problem size, on the contrary of the developed countries which are well characterized in determining mental diseases(32).

An overview of OCD in Palestine

In this section the researchers showed a review of OCD in Palestine. They mentioned the prevalence of OCD in Palestine, and showed the all available studies about OCD. A 15.3% is the prevalence of Obsessive Compulsive Disorder among Palestinian university students in Gaza Strip, in assessing OCD and sociodemographic variables such as family income and type of college, study showed that the OCD is more in students coming from families earning 250$ and leases more than students from families earning 500-750$ and there is no statistical significant in OCD and type of college. In addition to that, this study showed there is no statistically significant correlation between OCD and age and grade average of the students. Also, this study clarifies that the OCD correlate with anxiety (R=0.63), with depression (R=0.66, P=0.001), with Phobic anxiety (R=0.44) and with Somatization (R=0.51). However, in assessing the OCD statue with sex, the T independent test according to the same study showed statistically significant in female than in male (Mean 15.39 vs. 15.20) (T= -50)(39). Additionally, a descriptive study done by Amira Abu Shaban in Jerusalem zone by using self-reported questionnaire and the Yale-Brown Obsessive Compulsive Scale (CY-BOCS) among Palestinian school children grade 11 (public and private), this study showed that the prevalence of OCD among Palestinian school students is 15.6%: 19.1 for females and 10.2 for males. Also, the study showed significant associations among OCD and females, students with low academic level, school achievements and less educated parents. Moreover, this study showed a strong relationship between OCD and social-demographic variables and a weak relationship with social environmental factors(40). 20.6%, according to Spence anxiety scale reported Obsessive Compulsive Disorder problems among children working due to low family income. This study, which was done by Mater et al (2007), aimed to identify the impact of work on children general mental health and anxiety in a total number of 789 children in the Gaza Strip. Also, it showed that 79.2% of children rating themselves as a psychiatric patient(42). The study sample included 99 women and their ages ranged between 16 years to 42 years with mean age 25.5. In this study pre and post assessment for women who got counseling and vocational training. Accordingly, the study showed that there was improvement in Obsessive Compulsive Disorder for the women(45). In the summary for the OCD in Palestine, the OCD is higher in women than men, in adolescent and children than older ages. The risk factors that increase the OCD separation between Palestinians are low income families, stigma, and Israeli occupation, and violence, sexual abuse of the children, depression disorder and anxiety disorder.

Discussion

In this section the researchers discussed the reviewed studies about OCD worldwide, in Arabic countries, and in Palestine by showing the differences in prevalence, stigma, and risk factors.

Prevalence

The studies showed that the prevalence of OCD in a worldwide is 2%-3% (16) Convergent to the prevalence in Arabic countries 2.2% (32), but there is no general prevalence of OCD in Palestine because of lack in studies. But some studies showed 15.3% the prevalence of Obsessive Compulsive Disorder among Palestinian university students in Gaza Strip (16, 32). Checking Obsessive is the most common type in the world, 79.3% of the OCD patients are checking obsessively and 62.3% suffer from Hording Obsessive (23). The studies in Arabic countries also support this prevalence of checking obsessive 1.6%, then hording then contamination obsessions (23, 22), after that the contamination obsessions in Arabic countries and in Palestine (22, 34).

Stigma

The issue in the Arab world is more to do with stigma and ignorance than it is lack of mental health problems and the stigma attached to the illness (34, 35). Also the Palestinians studies showed that the patients suffer from community view to them and their mental health (38). The Arab world still shows a lack of awareness; patients in Arab countries tend to express their psychological issues in terms of physical symptoms, thereby avoiding the stigma attached to mental illness (36).

The risk factors

The risk factor which may increase the incidence of getting an OCD are divided into three ranks, factors that the person born with, factors outside human control and modifiable risk factors (26). The genetic factor prevalence is 50% and the male more than female in childhood (25, 28) in the world view, but in comparison with Arabic countries view the risk factors were in female more than in male in ages between 21 to 30 years old (34, 31) . Finally, in Palestine the low family income earning 250$ and less were the basis for having an OCD among Palestinians, also the studies in Palestine showed that the female more than male with mean age 15.39 for female Verses 15.20 for male(38, 31). In addition to the OCD risk factor in Palestine the sexual abuse at any age play a major role in having OCD as well as Anxiety, depression, Phobic anxiety and Somatization disorders (31, 38, 40, 44).

Definition

They are almost fixedly distressing and the patient often tries, unsuccessfully, to endure them while DSM-5 defined the Obsessional thoughts as an intruder, unwanted and recurrent thoughts or impulses that most patients cause marked anxiety or distress and the patient trials to ignore such thoughts or images by performing a Compulsion (15).

Results and Conclusion

In this section, the researchers conclude the results of this review. According to the studies that the researchers reviewed and discussed above, they found that there is a difference between the prevalence of OCD in Palestine in comparing with Arabic countries as well as with a worldwide. Also, they discovered that there is a lack of studies about OCD in Palestine especially in West Bank. The most common type of OCD in Palestine is checking type; in addition to that, OCD patients suffer from the stigma so the prevalence of it was significantly high related to fear from the community. However, there is a religious view about OCD as well as cultural view. Palestinians because of Israel occupation faced a lot of barriers standing in front of their mental health status. OCD in Palestine is widely presented in adolescence and children at a young age. The family incomes play a big role in present of OCD, especially low income families as well as a stigma. In concluding, Palestinians with OCD have a related disorder, the most common one is depressed. Also the researchers found that there was a lack in studies about OCD in Palestine and other mental health disorders, and they discovered that there is a study in specific areas of Palestine such as Gaza Strip

Recommendations

Recommendations include get rid of the stigma and create a work chances for a low income family, apply more and more studies about OCD in Palestine, ending of the occupation and prevent the children from following TV programs and war.

Limitations

The literature review has discussed an Obsessive Compulsive Disorder in Palestine. Palestine is a state that is seeking independence with a scare of resources; therefore, the research is underdeveloped. As a result, there is a lack of detailed data regarding Obsessive Compulsive Disorder in Palestine. Due to lack the complete data, all literature that was found, including a thesis study done in Al-Quds Open University about the OCD among school students in 11 grade was included.

Acknowledgments

Special thanks to all authors in the field of mental health in Palestine who equipped us with the relevant information for this literature.

ABSTRACT

Antipsychotics are the first-line treatment for psychotic disorders, which have antagonistic effects on the D2 dopamine-receptor, reducing dopamine mediated transmission. Long-term use of antipsychotics can potentially lead to a likely irreversible disorder called tardive dyskinesia (TD). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) defines tardive dyskinesia as a medication-induced movement disorder that persists despite discontinuation or change of the medications.[1] While it is typical to see the development of TD with long-term use of antipsychotics, there are few reported cases reports of the development of TD with the withdrawal of antipsychotics. The development of TD symptoms with withdrawal of antipsychotics leads to the discussion of a phenomenon known as supersensitivity psychosis (SP). Supersensitivity psychosis was first defined as the emergence of psychotic symptoms with TD following the discontinuation of certain medications, typically antipsychotics. The following article presents the case of a patient diagnosed with schizoaffective disorder who developed TD after withdrawal of long standing administration of a second-generation antipsychotic, risperidone, whose symptoms began to improve after introduction and increased titration of clozapine. Furthermore, the following article summarizes the literature on supersensitivity psychosis in patients who were discontinued on antipsychotics and current practices for the treatment of SP.

INTRODUCTION

Antipsychotics are the first-line treatment for psychotic disorders, which have antagonistic effects on the D2 dopamine-receptor, reducing dopamine mediated transmission. Over time, however, the antagonistic effects of antipsychotics can lead to an upregulation of the D2 receptors to produce receptor supersensitivity in the striatum. The enhanced affinity of dopamine for its receptors is thought to contribute to the phenomenon of dopamine supersensitivity psychosis (SP). In patients with schizophrenia and other psychotic disorders, these neuroadaptations could lead to a compromise in treatment efficacy, promote a relapse to psychosis, and trigger movement disorders, such as tardive dyskinesia. These effects have been seen in patients treated with either first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs), with a prevalence of 30% in schizophrenia and 70% in treatment resistant schizophrenia in patients treated with SGAs.[1] The following case report presents a patient with a diagnosis of schizoaffective disorder who develops supersensitivity psychosis symptoms after changes in her antipsychotic regimen and summarizes the literature on management for SP.

CASE DESCRIPTION

We present the case of  a 60 year-old female  with a medical history of generalized anxiety disorder, schizoaffective disorder – bipolar type, hypertension, hyperlipidemia, chronic kidney disease and congestive heart failure who was admitted under involuntary status for delusions and psychosis that began a few days prior to admission. Collateral information obtained from the patient’s husband revealed that the patient had been “manic” as demonstrated by a decreased need for sleep. He also states that the patient seemed to be mentally decompensating as demonstrated by displaying disorganized behaviors and speech including finding the patient standing on a stool in the closet staring at the ceiling and trying to turn on a television using a keychain. He reported the patient also had delusions that the world is ending, that she died and is currently in heaven, and that everyone around her is deceased. He also denied any suicidal ideation (SI) or attempts that they had observed.  The patient’s husband also reported her mentation became acutely worse over the past few days, which prompted her presentation to care. This was demonstrated by disorientation to the day and time, repeatedly asking the same questions, and forgetting her doctor’s names, whom she is usually able to identify. The patient is a poor historian as demonstrated by stating she is unsure why she is in the hospital, but believes she was admitted because of a stomach ache. She did however endorse a depressed mood, poor sleep, poor appetite, low energy, and poor concentration; she denied any guilt.

Collateral information was obtained regarding the patient’s psychiatric history up to the point of this admission.  The patient’s husband reported four months prior to this admission, the patient was expressing delusional thoughts and had auditory hallucinations. This behavior prompted admission to a behavioral health facility. While in treatment, the patient became catatonic and was transferred to a different behavioral health facility where she received eleven electroconvulsive therapy (ECT) treatments. He further stated that the patient was no longer catatonic after receiving ECT and was stable to be discharged home where the patient continued to receive ECT as an outpatient. He stated that the patient had been in her normal state of mental and physical health until development of her current symptoms a few days before this admission.

On mental status examination, the patient was calm on approach. Patient stated her mood is “fair and tired” and her affect was depressed and blunted. She was not oriented to place, time, or situation, but was oriented to self. She denied current suicidal or homicidal ideation. Her attitude was cooperative, calm, but unengaged as demonstrated by decreased eye contact and disinterest in conversation. There was no psychomotor agitation observed at that time. Speech was minimally coherent with one worded answers and low volume. Her thought process was slow and impoverished as demonstrated by increased latency of speech and looseness of association. She denied auditory, tactile, and visual hallucination to the best of her ability. She displayed overt delusions as demonstrated by stating she thought she was dead and everyone surrounding her was an angel. Memory was impaired as demonstrated by not being able to recall the events surrounding her hospital admission.

The patient’s psychiatric medications included trazodone 50 mg at bedtime (QHS), clonazepam 0.25 mg twice daily (BID), and risperidone 2 mg BID. The patient’s husband confirmed these medications and stated she had been taking them regularly for many years as prescribed. The patient’s course was complicated by progressively worsening psychosis. She became acutely agitated with disorganized behavior demonstrated by screaming in common rooms, walking around her room naked, and urinating and defecating in her bed. The internal medicine team was consulted to potentially rule out causes secondary to nonpsychotic origin. The medicine team evaluated the patient and determined her behavior and decompensating mental status was not due to any medical causes; complete blood count, comprehensive metabolic panel, and urinalysis showed no abnormalities. Neurology was also consulted and had no recommendations for changes in current management. The decision was made to begin clozapine 12.5 mg QHS for treatment resistant psychosis. After five days of administering clozapine, the patient continued to demonstrate disorganized behavior as displayed by yelling in common rooms and expressing delusions. The decision was made to taper risperidone over the next ten days and immediately increase clozapine to 25 mg QHS for treatment resistant psychosis.

The patient’s hospital stay was further complicated by extrapyramidal symptoms (EPS) witnessed by the nursing staff. Upon evaluation of the patient, she appeared to have symptoms consistent with tardive dyskinesia (TD) as demonstrated by abnormal movements of the mouth and jaw with lip smacking. It was noted by the patient’s nurse that these symptoms were not present at initial admission, but now seen for the first time. Patient also did not appear restless nor with other symptoms that would otherwise suggest akathisia at the time of exam. Tardive dyskinesia is made worse with benztropine (cogentin) and benadryl / antihistamines, and is typically treated with valbenazine or tetrabenazine, neither of which are available at the facility the patient is currently admitted to.  Of note, risperidone was recently tapered over the past ten days with the final dose being the morning of TD symptom onset. Clozapine is less likely to cause tardive dyskinesia when compared to other antipsychotics. As such, the plan was to continue with current medications, avoiding benztropine (cogentin) and benadryl / antihistamines, and re-evaluate the patient for ongoing treatment decisions. The patient was subsequently examined the next day, physical examination showed signs and symptoms of TD including irregular movement of mouth / tongue and an irregular blink. Clozapine 25 mg was increased to BID. The patient subsequently began to show improvement in signs and symptoms of TD six days after the increase of clozapine including less irregular movements of the mouth and tongue. There was no dystonia, akathisia, or EPS tremor. The patient’s TD symptoms continued to improve by evidence of less lip smacking and less irregular blinking until she was discharged with close outpatient follow up.

DISCUSSION

Antipsychotics are the first-line treatment for psychotic disorders, which have antagonistic effects on the D2 dopamine-receptor, reducing dopamine mediated transmission. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) defines tardive dyskinesia as a medication-induced movement disorder that persists despite discontinuation or change of the medications.[1] The disordered movements seen in tardive dyskinesia (TD) are thought to be caused by the blockade of D2 dopamine-receptors. The movement disorders include akathisia, dystonia, buccolingual stereotypy, chorea, tics, and other abnormal involuntary movements of the face, mouth, jaw, and extremities.[2] Most often, these dyskinetic disorders precipitate following chronic antipsychotic administration, however, there are reported cases of patients developing symptoms consistent with TD after withdrawal of antipsychotic medications.[3]

Supersensitivity psychosis (SP) was first defined as the emergence of psychotic symptoms with tardive dyskinesia and a decrease in prolactin levels following the discontinuation of certain medications. In the context of antipsychotics, there are four main clinical characteristics used to define medication-induced SP, including: 1) rapid relapse of symptoms following the discontinuation, dosing change, or a change in antipsychotic medication; 2) new onset tolerance after previously having therapeutic effects; 3) presence of TD; and 4) psychotic exacerbations due to life stressors. Additionally, in order to diagnose SP, a patient must also have been taking an antipsychotic for 3 months. It is hypothesized that what was previously described as “treatment resistant schizophrenia” is in fact SP, with SP being observed in 70% of treatment-resistant schizophrenic patients versus 30% in non-treatment resistant patients.[4]

Second-generation antipsychotics (SGAs) are widely used to treat a variety of psychotic symptoms, having largely replaced first-generation antipsychotics (FGAs) due to their more favorable side effect profile. Psychosis is believed to be due to excess dopamine signaling in the striatum, therefore both FGA and SGA work by blocking dopamine transmission in the striatum via the dopamine D2 receptors.[5] The D2 receptor is important with its involvement in SP, as antipsychotics are antagonists of this receptor postsynaptically.[6] It has been shown that the D2 receptor is prone to plasticity and remodeling. The effect of prolonged antipsychotic use on the intracellular system leads to an increased number of postsynaptic D2 receptors within the striatum, leading to hypersensitivity over time.[4]Our patient had been receiving chronic antipsychotic treatment for schizoaffective disorder for several years prior to her admission to the hospital. Therefore, it can be postulated that at this time she would have had an increased density of dopamine receptors in her striatum, which would have put her at increased risk for SP.  Shortly after a change to her medications, she developed TD symptoms such as lip-smacking, which was not experienced previously. This illustrates the possibility that our patient was experiencing SP due to prolonged use of her antipsychotics, which led to negative symptom development when her mediations were adjusted. As studies have demonstrated previously, as patients continue to take antipsychotics, the density of these receptors increase causing the need for increased levels of antipsychotics in order to control the increased dopamine levels to maintain symptom control.[7] This further perpetuates tolerance and increases the risk for SP.[4]

Similar to our case, another case report described a female patient who experienced TD after being abruptly withdrawn from risperidone, with resolution of symptoms occurring after starting a new antipsychotic medication. While TD can occur in all ages, it has been shown to be most common in elderly patients, particularly elderly female patients.[8] The patient we presented in this case was an elderly female, and given the previous findings of high-risk of TD and SP in this age group, greater care and monitoring should be taken when adjusting antipsychotic medications.

Due to the risk of severe psychosis and TD, it has been proposed that intermittent dosing, use of long-acting antipsychotics, and controlled tapering can help prevent SP. Furthermore, it is widely accepted that SGAs are less likely to invoke supersensitivity and drug-induced movement disorders when compared to FGAs, and therefore are the preferred first choice of medication when treating psychosis.[4] With this being said, many studies suggest the use of long-acting injectables, such as risperidone to prevent and reduce the incidence of SP.[4,9] A 12-month study evaluating treatment resistant patients (TRP) and dopamine supersensitivity patients (DSP) found that DSP had a significant improvement of symptoms while on long-acting risperidone, when compared to TRP. DSP patients at baseline had more severe extrapyramidal symptoms, however they had a 62% higher response rate to long-acting risperidone compared to 21% of non-DSP patients.[9] The long-acting and high-potency injectables have shown to stabilize the receptors and minimize fluctuations of dopamine, thereby decreasing the incidence of SP.[4]

When considering treatment for the symptoms of SP, medications should aim to reduce the increase in D2 receptor density.  One study suggests the use of anti-seizure medications such as valproate, carbamazepine, or phenytoin. The early addition of these medications with an antipsychotic has shown to potentiate the effects of the antipsychotic, thereby reducing the need for increased doses, and decreasing the likelihood of the patient developing SP.[10] Electroconvulsive (ECT) therapy has also illustrated the ability to normalize the density of D2 receptors, which was also found with our patient who had resolution of her catatonia after eleven ECT treatments.[4]

Another possible treatment option is the use of clozapine for SP symptoms. A study of 15 patients experiencing SP symptoms found that 13 of the 15 patients experienced no further SP symptoms after the initiation of clozapine for the duration of the 2.65 year follow-up.[11] The efficacy of clozapine on SP symptoms has been thought to be due to its role on GABAergic neurons and its potency on D2 receptors, however, this has not been clearly defined. Initially, our patient had no symptom relief upon starting Clozapine 25 mg once daily, but upon increasing the dose to twice daily dosing and tapering down off risperidone, her TD symptoms improved within six days. While our patient did not have complete resolution of her TD symptoms, she did experience symptomatic improvement. It is shown that only 33% of patients will have complete resolution of TD symptoms within two years, so it was not expected for her to have had complete resolution of the symptoms during our time frame of care for her.[3]

CONCLUSION

This case report highlights the importance of close medication follow-up and management with patients on long-term antipsychotics. The abrupt cessation or change of such medications can have deleterious consequences, with the most dangerous being tardive dyskinesia (TD). Therefore, it is important when considering medical management for patients with antipsychotics that consideration be placed into long-term injectables, such as risperidone, along with use of a second generation antipsychotics over first generation antipsychotics in order to prevent TD and supersensitivity psychosis (SP) from occurring. This is especially important in patients who need long-term management with antipsychotics. In addition, if a patient needs to be switched to another antipsychotic, slow tapering and close management is important in order to quickly identify TD symptoms and prevent the occurrence of SP. Finally, SP should be considered in patients who appear to be treatment resistant, as increasing doses of antipsychotics in this case can have continued damaging effects due to tolerance and hypersensitivity to the medications. The use of antipsychotics has been demonstrated to cause supersensitivity psychosis, with the most extreme form being tardive dyskinesia as highlighted in this case report. It is therefore important to carefully monitor patients when adjusting or tapering off any antipsychotics, especially those at higher risk, in order to prevent supersensitivity psychosis symptoms. It is recommended to use long-acting injectables, such as risperidone, as previous studies have shown it to reduce the risk of this phenomenon.

For more information: https://jmedcasereportsimages.org/about-us/

ABSTRACT

Nausea and vomiting are distressing and serious problems for cancer patients receiving chemotherapy despite the fact that they are receiving antiemetics according to the standard guidelines which this problem is a huge challenge to nurses involved in cancer care.

Purpose: To explore and assess the effectiveness of using acupressure as a non-pharmacological intervention in addition to pharmacological interventions in reducing nausea and vomiting in cancer patients receiving chemotherapy.

Method: A literature review was conducted of 8 articles published between 2006 and 2014. These included one study of a randomized, double-blind, placebo controlled trial; one quasi-experimental model with a control group; four articles reporting on randomized control trials (RCTs); one systematic review study; and one review study. Key Findings: Seven of the articles we read supported the effect of an acupressure P6 Wristband in reducing chemotherapy induced nausea and vomiting in cancer patients and other databases also supported that finding. The one article with neutral results showed that there was no difference between a combination of acupuncture and acupressure treatment at P6 and at the sham point for the nausea score, but the level of nausea was very low in both groups.

Conclusion: We conclude that the acupressure P6 wrist band when applied to acupuncture point P6 is effective, safe, convenient, cost effective, and provides an easy, self-administrated, non-pharmacological intervention that can be used to reduce chemotherapy induced nausea and vomiting.

Keywords: Acupressure, Chemotherapy, Nausea and Vomiting, Cancer patients, Chemotherapy-induced nausea and vomiting.

INTRODUCTION

Nausea and vomiting are serious and troublesome side effects of cancer therapy. We chose this research topic in order to become familiar with the topic of the nausea and vomiting facing cancer patients during their chemotherapy treatment, which we have observed during our experience in the Oncology departments.

As nurses, we normally use updated and standard guidelines for managing clinical challenges. We reviewed the literature to explore whether there are alternative approaches to pharmacological management that might reduce or eliminate this problem. We found there are many interventions, such as music, acupuncture, acupressure, and yoga. We decided to assess the effectiveness of using acupressure to reduce the nausea and vomiting in cancer patients receiving chemotherapy. Acupressure is a type of complementary and alternative medicine which the National Cancer Institute (NCI Dictionary of Cancer Terms) defines as follows: “Acupressure is the application of pressure or localized massage to specific sites on the body to control symptoms such as pain or nausea".

THE RESEARCH QUESTION

Can acupressure reduce nausea and vomiting in cancer patients receiving chemotherapy?

We have chosen to use the definitions of the NCI Dictionary of Cancer Terms:

“Nausea is an unpleasant wavelike feeling in the back of the throat and/or stomach that may lead to vomiting", and “Vomiting is throwing up the contents of the stomach through the mouth”.

Nausea and vomiting affect the patient’s whole life. These side effects lead to metabolic imbalance, fatigue, distress, and lowered quality of life. We would like to fine a simple, effective and cost effective way to manage these problems so we can put it to use in our hospital.

METHOD

A literature study is, “A critical presentation of knowledge from various academic written sources, and a discussion of the sources in view of a particular research question" (Synnes 2014). There are many challenges when doing a literature study. There are many databases and much literature and our search process had to find the correct, scientific and relevant databases. It required a lot of time and effort to find the full text of all relevant articles. Fortunately, we received excellent help from the librarian at the Betanien University High school.

We started the search process by making a PICO outline to narrow down the search and to find the correct key words and mesh terms.

P: (Population or participants) Cancer patients experiencing chemotherapy-induced nausea and vomiting.

I:  (Intervention or indicator) Acupressure.

C: (Comparator or control) No comparison or placebo.

O: (Outcome) Reduce nausea and vomiting.

We used PUBMED, Google scholar, scholar.najah.edu and other search engines. When we used Acupressure as a search word we found more than 800 studies. When we added chemotherapy, cancer patients, and nausea and vomiting, we brought this down to 14 articles. We read these and decided to use 8 articles only, one of which was a systematic review. We also used an unpublished Master’s thesis from An Najah National University. This thesis was cited in one of the articles that we decided to review. The key words used were: Acupressure, Chemotherapy, Nausea and Vomiting, Cancer patients, Chemotherapy-induced nausea and vomiting, with Acupressure as a mesh term.

We then critically appraised all the articles according to our checklist. We included only those articles that followed the IMRAD style (i.e. those including an introduction, method, results and discussion section). We excluded all articles that were more than ten years old (i.e. published before 2004), except for two articles: one was about the mechanism of acupressure, which seemed to be directly relevant to our research topic, while the second article was used in the discussion section to discuss certain factors related to the topic. We also excluded one of the review articles because its method appeared to be weak. One of the Cochran reviews was also dropped because it had not been updated.

Despite applying these strict criteria, we were still concerned lest we had left out some important articles or included an inappropriate one. However, we were reassured by the fact that the librarian at Betanien had guided us in our search.

THEORETICAL PART

Nursing Need Theory and basic human needs

The Nursing Need Theory was developed by Virginia A. Henderson to define the unique focus of nursing practice. The theory focuses on the importance of increasing the patients’ independence to hasten their progress in the hospital. Henderson’s theory emphasizes the basic human needs and how nurses can assist in meeting those needs.

The 14 components of Need Theory present a holistic approach to nursing that covers the patient’s physiological, psychological, spiritual and social needs.

Physiological components

Breathe normally.

Eat and drink adequately.

Eliminate body wastes.

Move and maintain desirable postures.

Sleep and rest.

Select suitable clothes – dress and undress.

Maintain body temperature within normal range by adjusting clothing and modifying the environment.

Keep the body clean and well groomed and protect the integument.

Avoid dangers in the environment and avoid injuring others.

Psychological aspects of communicating and learning

Communicate with others in expressing emotions, needs, fears, or opinions. Spiritual and moral

Worship according to one’s faith. Sociologically oriented to occupation and recreation

Work in such a way that there is sense of accomplishment.

Play or participate in various forms of recreation.

Learn, discover, or satisfy the curiosity that leads to normal development and health, and use the available health facilities.

There is much similarity between Henderson’s 14 components and Abraham Maslow’s Hierarchy of Needs. Henderson’s Components 1 to 9 are comparable to Maslow’s physiological needs, with the 9th component also being a safety need. Henderson’s 10th and 11th components are similar to Maslow’s love and belonging needs, while her 12th, 13th and 14th components match Maslow’s self-esteem needs (Vera 2014).

The second of Henderson’s physiological needs is the need to “Eat and drink adequately”. Only the need to breathe is given a higher priority than the need for adequate nutrition. For cancer patients receiving chemotherapy and suffering from chemotherapy-induced nausea and vomiting, this need is the most critical.

Cancer prevalence and treatment

Cancer is a group of diseases characterized by uncontrolled growth and the spread of abnormal cells. It may be caused by internal factors, such as an inherited mutation, or a hormonal or immune condition, or it may result from a mutation from metabolism, or from external sources, such as tobacco use, radiation, chemicals and infectious organisms. Cancer is prevalent all over the world, in both developed and developing nations; it affects both sexes at all ages (Said 2009). The American Cancer Society (2010) estimated that 1,529,560 new cases of cancer were diagnosed in 2010 and that 80 % would be treated with chemotherapy; this means more than 1 million patients will be undergoing chemotherapy in any given year (Lee et al. 2010).

Cancer treatment may be based on chemotherapy, radiotherapy and surgical interventions. Chemotherapy is an important treatment in cancer care but it is associated with several side effects, such as bone marrow suppression, increased susceptibility to infection, diarrhea, hair loss, appetite changes, nausea and vomiting, among others (NCI Chemotherapy Side Effects Series, 2014).

Chemotherapy-induced nausea and vomiting (CINV) is the most prevalent and one of the hardest side effects to manage (Suh 2012).

Nausea and vomiting

Nausea and vomiting (N&V) can be acute or delayed. The incidence of acute and delayed N&V was investigated in highly and moderately emetogenic chemotherapy treatment regimens. Patients were recruited from 14 oncology practices in six countries. Overall, more than 35% of patients experienced acute nausea, and 13% experienced acute emesis. In patients receiving highly emetogenic chemotherapy, 60% experienced delayed nausea and 50% experienced delayed emesis. In patients receiving moderately emetogenic chemotherapy, 52% experienced delayed nausea and 28% experienced delayed emesis. CINV was a substantial problem for patients receiving moderately emetogenic chemotherapy in ten community oncology clinics. Thirty-six percent of patients developed acute CINV, and 59% developed delayed CINV (NCI, Nausea and Vomiting, 2015).

Chemotherapy is the most common treatment-related cause of N&V. The incidence and severity of acute emesis in persons receiving chemotherapy varies according to many factors, including the particular drug, dose, schedule of administration, route, and individual patient variables.

Risk factors for acute emesis include:

Poor control with prior chemotherapy

Female gender

Younger age

Emetic classification:

The American Society of Clinical Oncology has developed a rating system for chemotherapeutic agents with their respective risk for acute and delayed emesis.

High risk: Emesis has been documented to occur in more than 90% of patients on the following chemotherapeutic agents:

Cisplatin (Platinol).

Mechlorethamine (Mustargen).

Streptozotocin (Zanosar).

Cyclophosphamide (Cytoxan), 1,500 mg/m2 or more.

Carmustine (BiCNU).

Dacarbazine (DTIC-Dome).

Moderate risk: Emesis has been documented to occur in 30% to 90% of patients on the following chemotherapeutic agents:

Carboplatin (Paraplatin).

Cyclophosphamide (Cytoxan), less than 1,500 mg/m2.

Daunorubicin (DaunoXome).

Doxorubicin (Adriamycin).

Epirubicin (Pharmorubicin).

Idarubicin (Idamycin).

Oxaliplatin (Eloxatin).

Cytarabine (Cytosar), more than 1 g/m2.

Ifosfamide (Ifex).

Irinotecan (Camptosar).

Low risk: Emesis that has been documented to occur in 10% to 30% of patients on the following chemotherapeutic agents:

Mitoxantrone (Novantrone).

Paclitaxel (Taxol).

Docetaxel (Taxotere).

Mitomycin (Mutamycin).

Topotecan (Hycamtin).

Gemcitabine (Gemzar).

Etoposide (Vepesid).

Pemetrexed (Alimta).

Methotrexate (Rheumatrex).

Cytarabine (Cytosar), less than 1,000 mg/m2.

Fluorouracil (Efudex).

Bortezomib (Velcade).

Cetuximab (Erbitux).

Trastuzumab (Herceptin).

Minimal risk: Emesis that has been documented to occur in fewer than 10% of patients on the following chemotherapeutic agents:

Vinorelbine (Navelbine).

Bevacizumab (Avastin).

Rituximab (Rituxan).

Bleomycin (Blenoxane).

Vinblastine (Velban).

Vincristine (Oncovin).

Busulphan (Myleran).

Fludarabine (Fludara).

2-Chlorodeoxyadenosine (Leustatin).

In addition to the emetogenic potential of the agent, the dose and schedule used are also extremely important factors. For example, prescribing a drug with a low emetogenic potential to be given in high doses may cause a dramatic increase in its potential to induce N&V. For example, standard doses of cytarabine rarely produce N&V, but these often occur with high doses of this drug. Another factor to consider is the use of drug combinations. Because most patients receive combination chemotherapy, the emetogenic potential of all of the drugs combined needs to be considered, and not only that of individual drug doses.

Delayed (or late) N&V is that which occurs more than 24 hours after chemotherapy administration. Delayed N&V is associated with cisplatin and cyclophosphamide, and with other drugs (e.g., doxorubicin and ifosfamide) when given at high doses, or if given on 2 or more consecutive days.

Delayed emesis: Patients who experience acute emesis with chemotherapy are significantly more likely to have delayed emesis as well.

Risk factors: All the predicative characteristics for acute emesis are also considered risk factors for delayed emesis (NCI, Nausea and Vomiting, 2015).

The nausea and vomiting that are often associated with chemotherapy are a serious problem for cancer patients. Despite recent improvements in pharmaceutical technology, about 60% of cancer patients who receive antiemetic medications with their chemotherapy still suffer from nausea and vomiting, and as many as 20% of patients refuse to continue chemotherapy due to the severity of the nausea and vomiting (Shin et al. 2004). Early studies reported that patients cited nausea and vomiting as the most distressing symptoms when receiving chemotherapy. The distressing effect of severe nausea and vomiting can lead to nutritional deficiencies, dehydration, electrolyte imbalance, fatigue, depression and anxiety; they can also disrupt the activities of daily living and cause a lot of work time to be lost (Said 2009).

Uncontrolled nausea and vomiting can interfere with adherence to treatment regimens, and may cause the oncologists to reduce chemotherapy doses. Chemotherapy-induced nausea and vomiting is classified as being either “acute” if it happens within 24 hours post chemotherapy, or “delayed” if it occurs on days 2–5 of the chemotherapy cycle. The latter is particularly troublesome because there is no reliable pharmacological treatment for this problem. The American Society of Clinical Oncology’s (ASCO) recommendations include giving 5-HT3 (5-hydroxytryptamine, or serotonin) receptor antagonists plus corticosteroids before chemotherapy to patients who are at high risk for emesis. Nevertheless, many patients still experience nausea and vomiting related to chemotherapy, and approximately one-third of patients have nausea of at least moderate intensity, resulting in a significant reduced quality of life (QOL). Therefore, the experts emphasize the need for an evaluation of additional ways to reduce these symptoms (Said 2009).

Pharmacological interventions for the management of nausea and vomiting

Historically, antiemetic treatment has steadily improved since the introduction, in 1981, of high-dose metoclopramide which reduced the amount of emesis. This was followed by the development of serotonin (5-HT3) antagonist in the early 1990s, and the 5-HT3 antagonists proved to be more effective than the prior medications in preventing CINV. The concomitant use of corticosteroids was found to further improve the control of emesis. Despite these improvements, nausea and vomiting still remain a problem for many patients. Recently, a new drug, the neurokinin NK (1) receptor antagonist has been shown to be more effective at preventing both acute and delayed CINV for patients treated with highly emetogenic chemotherapy (Said 2009).

Non-pharmacological intervention for management of nausea and vomiting

Traditional Chinese medicine offers a possible intervention for the non-pharmacological treatment of nausea and vomiting in cancer patients. Traditional Chinese medicine (TCM) is a system of medical care that was developed in China over thousands of years. It looks at the interaction between mind, body and environment, and aims to both prevent and cure illness and disease.

TCM is based on Chinese views and beliefs about the universe and the natural world. It is a very complex system. In this essay we can only give a brief overview of what TCM involves. It is very different from Western medicine; Chinese medicine practitioners believe there is no separation between the mind and body and that illness of every kind can be treated through the body. They use a combination of various practices that may include:

Herbal remedies (traditional Chinese medicines).

Acupuncture or acupressure.

Moxibustion (burning moxa – a cone or stick of dried herb).

Massage therapy.

Feng shui.

Breathing and movement exercises called qi gong (pronounced chee goong).

Movement exercises called tai chi (pronounced tie chee).

TCM practitioners say that TCM can help to:

Prevent and heal illness.

Enhance the immune system.

Improve creativity.

Improve the ability to enjoy life and work in general.

Beliefs behind TCM

According to traditional Chinese belief, humans are interconnected with nature and affected by its forces. The human body is seen as an organic whole in which the organs, tissues, and other parts have distinct functions but are all interdependent. In this view, health and disease relate to the balance or imbalance between the various functions. TCM treatments aim to cure problems by restoring the balance of energies.

There are important components that underlie the basis of TCM:

Yin-yang theory is the concept of two opposing but complementary forces that shape the world and all life. A balance of yin and yang maintains harmony in the body, the mind and the universe.

Qi (pronounced chee) energy or vital life force flows through the body along pathways known as meridians, and it is affected by the balance of yin and yang. It regulates spiritual, emotional, mental, and physical health. If there is a blockage or an imbalance in the energy flow, the individual becomes ill. TCM aims to restore the balance of qi energy.

The five elements – fire, earth, metal, water, and wood – is a concept that explains how the body works, with the elements corresponding to particular organs and tissues in the body.

The TCM approach uses 8 principles to analyse symptoms and puts particular conditions into groups: cold and heat, inside and outside, too much and not enough, and yin and yang (Cancer Research, UK, 2015).

In summary, chemotherapy related nausea is not well controlled by pharmacological agents and identifying methods to prevent and alleviate treatment-related nausea remains a major clinical challenge. Non-pharmacological interventions such as music, progressive muscle relaxation (Said 2009), and ginger herbal therapy (Montazeri A et al. 2013) have all been shown to reduce CINV. Among the non-pharmacological interventions that reduce CINV are acupuncture and acupressure, based on the assumption that the individual’s welfare depends on a balance of energy in the body and their overall energy level (Said 2009). Yarbro et al. (2011, p. 645) also indicate in Cancer nursing: principles and practice book that acupuncture and acupuncture-related interventions (electroacupoint stimulation, acupressure, acustimulation wrist bands, and electroacupuncture) can be used to control nausea and vomiting in cancer patients.

Molassiotis et al. (2007) claim that the need for additional relief has led to the interest in non-pharmacological adjuncts to drugs, such as acupuncture or acupressure, since combining anti-emetics with other non-pharmacological treatments may prove to be more effective, safe and convenient in decreasing nausea than antiemetics alone.

From the National Cancer Institute website we found that acupressure is recognised as one of the non-pharmacologic strategies used to manage nausea and vomiting (Nausea and Vomiting, 3 September 2014). We used this website to get up to date, relevant information.

Acupressure

Acupressure involves putting pressure with the fingers, or with bands, on the body’s acupoints and is easy to perform, painless, inexpensive, and is effective. The P6 (Pericardium 6) point (Nei-Guan) refers to a point located on the anterior surface of the forearm, 3-finger widths up from the first wrist crease and between the tendons of flexor carpiradialis and Palmaris longus (figure1). P6 can be stimulated by various methods. The most well-known technique is manual stimulation by the insertion and manual rotation of a very fine needle (manual acupuncture). An electrical current can be passed through the inserted needle (electroacupuncture). Electrical stimulation can also be applied via electrodes on the skin surface or by a ReliefBand, a wristwatch-like device providing non-invasive electrostimulation. Pressure can be applied either by pressing the acupoint with the fingers or by wearing an elastic wristband with an embedded stud (acupressure).

Figure 1: Done by M.Battat & I.Amro 2015 The Acupressure P6 point determined in the picture And showing the SEA BAND acupressure

Acupressure is based on the ancient Eastern concept that Chi energy travels through pathways known as meridians. Along the meridians are acu-points, which are controlling points for the Chi energy flow. If the energy flow in meridians is slowed, blocked, or hyper-stimulated, it can be rebalanced or re-stimulated either by applying pressure (acupressure) or by inserting a needle (acupuncture) into one or more of these acupoints. Two points are known for relieving nausea and vomiting: the Nei-Guan point (P6) and the Joksamly point (ST36, located at 4-finger breadths below the knee depression lateral to the tibia).

Patients tend to prefer the P6 point over the ST36 point, Because of its ease of access and the freedom from restriction. When these points are correctly located and pressure applied, either through acupressure or acupuncture, the Chi energy flow is rebalanced, resulting in relief from nausea and vomiting.

The practice of acupressure requires some training and experience, but the technique is widely accessible to any healthcare professionals, particularly to clinical nurses. This acupressure technique is an approach that should be tried not only by healthcare professionals but also by family members or the patients themselves (Shin et al. 2004).

According to the teaching of traditional Chinese medicine, illness results from an imbalance in the flow of energy through the body. This energy or Qi (chee) is restored through the use of acupuncture and acupressure at certain points on the body that have been identified through critical observation and testing over 4000 years. In scientific terms, the neurochemicals that are released after needling or pressure at a specific point may be responsible for this effect. The most commonly used point for nausea and vomiting is Pericardium 6 (Neiguan or P6), located above the wrist (Molassiotis et al. 2007).

The literature review on acupressure

Acupressure for chemotherapy-induced nausea and vomiting in breast cancer patients: a multicentre, randomised, double-blind, placebo-controlled clinical trial. (Said 2009)

For a master degree in public health from An-najah National University, Said (2009) described a randomized, double-blind, placebo controlled trial that was done in Palestine with 126 women on chemotherapy for breast cancer. In this study the researcher divided the patients into 3 groups: the first group (n=42) received acupressure with bilateral stimulation of P6, the second group (n=42) received bilateral placebo stimulation, and the third group (n=42), which served as a control group, received no acupressure wrist band, but all groups received pharmacological management of their nausea and vomiting. Acupressure was applied using a Sea-Band (Sea-Band UK Ltd, Leicestershire, England) that patients had to wear for five days following the administration of chemotherapy. Assessment of acute and delayed nausea and emesis, quality of life, patients’ satisfaction, recommendation of treatment and requests for a rescue antiemetic were obtained. Said (2009) concluded that the acupressure showed benefits for delayed nausea and the mean number of delayed emetic episodes. Acupressure may therefore offer an inexpensive, convenient, and self-administered intervention for patients on chemotherapy to reduce nausea and vomiting at home during days 2-5 after chemotherapy. In addition, the percentage of patients who were satisfied with the treatment (≥ 3 on a 0-6 scale) was 81% (35/42) in the P6-acupressure group, and 64% (27/42) in the placebo group (p= 0.0471). The percentage of patients who would recommend acupressure treatment was 79% (34/42) in the P6-acupressure group, and 62% (26/42) in the placebo group (p= 0.0533). We used this study because it had a lot of essential information, it used the IMRAD system and was also mentioned in the literature (Genç and Tan 2014). This study demonstrated that the mean scores for the acupressure group were lower for both acute and delayed nausea.

Review of Acupressure Studies for Chemotherapy-Induced Nausea and Vomiting Control. (Lee et al. 2008)

In the Journal of Pain and Symptom Management Jiyeon Lee et al. (2008) reviewed ten controlled studies on acupressure in order to evaluate the effects of a non-invasive intervention, acupressure, when combined with antiemetics for the control of CINV. The review evaluated one quasi-experimental and nine randomized clinical trials, which included two specific acupressure modalities, namely, an acupressure band and finger acupressure. The effects of the acupressure modalities were compared study by study. Four of the seven acupressure band trials supported the positive effects of acupressure, whereas three acupressure band trials did not support the effects of acupressure. However, all the studies with negative results had methodological issues. In contrast, the one quasi-experimental and two of the randomized finger acupressure trials all supported the positive effects of acupressure on CINV control. The reported effects of the two acupressure modalities produced variable results at each stage of CINV. Acupressure bands were most effective in controlling acute nausea, whereas finger acupressure controlled delayed nausea and vomiting. The overall effect of acupressure was strongly indicative but not conclusive. We used this article because it is relevant, a review study, and is from a known journal.

The effects of P6 acupressure in the prophylaxis of chemotherapy-related nausea and vomiting in breast cancer patients. (Molassiotis et al. 2007)

As reported in the journal Complementary Therapies in Medicine, acupressure was applied using wristbands (Sea-Band™) in a randomized controlled trial conducted in two centres in the UK. Patients in the experimental group had to wear these bands for the five days following their chemotherapy administration. Assessments of nausea, retching and vomiting were obtained from all patients, daily, for five days. Molassiotis et al. (2007) evaluated the effectiveness of using acupressure on the Pericardium 6 (Neiguan) acupoint in managing CINV. Thirty-six patients took part in the study, with 19 patients allocated to the control group and 17 to the experimental group. The results showed that nausea with retching, nausea, and vomiting with retching, and the accompanying distress were all significantly lower in the experimental group as compared to the control group (p < 0.05). The only exception was the vomiting, where the difference was close to significance (p = 0.06). We used this article because it had a strong study design and also used an IMRAD system.

Acupuncture and acupressure for the prevention of chemotherapy-induced nausea- a randomized cross-over pilot study. (Melchart et al. 2006)

In a randomized, cross-over trial, Melchart et al. (2006) studied 28 patients receiving moderately or highly emetogenic chemotherapy and a conventional standard antiemetic for one chemotherapy cycle, followed by a combination of acupuncture and acupressure at point P6 for one cycle, and for another cycle a combination of acupuncture and acupressure at a close sham point. The results showed that there was no difference in the nausea score between the combined acupuncture treatment at P6 and at the sham point, but the level of nausea was very low in both cases. We used this study because the article had neutral results and because we trusted the source of article, coming as it did from a cancer support care journal.

The efficacy of acupoint stimulation for the management of therapy adverse events in patients with breast cancer: a systematic review. (Chao et al. 2009)

This is a systematic review of 26 articles published between 1999 to 2008 examining the efficacy of acupressure, acupuncture or acupoint stimulation (APS) for the management of adverse events due to the treatment of breast cancer. Published online on 17 September 2009 in the Breast Cancer Research and Treatment journal, 23 trials reported revealed that APS on P6 was beneficial in treating CINV. Chao et al. (2009) also presented the findings from three high quality studies comparing APS groups with control groups, which indicated that APS is beneficial in the management of CINV and especially in the acute phase, even with the non-invasive intervention. Health care professionals should consider using APS, and in particular acupressure on the P6 acupoint, as an option for the management of CINV. Furthermore, as a cost effective intervention, it warrants further investigation. We used this article because it used the IMRAD structure.

'Until the trial is complete you can’t really say whether it helped you or not, can you?’: exploring cancer patients’ perceptions of taking part in a trial of acupressure wristbands. (Hughes et al. 2013)

In Complementary and Alternative Medicine, Hughes et al. report on qualitative research undertaken with patients receiving chemotherapy in the UK. A convenience sample of 26 patients volunteered to participate in the clinical trial and to explore their experiences of using acupressure wristbands. Participants were recruited from three geographical sites: nine were recruited from Manchester, nine from Liverpool, and eight from Plymouth and the surrounding regions. Ten of the participating patients received true acupressure during the trial, 9 received sham acupressure, and 7 received no acupressure. Hughes et al. (2013) concluded that the research provided insights into cancer patients’ motivations and experience of taking part in a clinical trial for a complementary alternative medicine intervention, in which the participants perceived acupressure wristbands to reduce the level of nausea and vomiting experienced during their chemotherapy treatment. This article is important because it includes the benefits experienced by the patients taking part in the trial. This is also the first qualitative study to explore patients’ experiences of using acupressure wristbands and their perceptions of the effects. In the study, the patients perceived the wristbands as reducing their level of nausea and vomiting experienced due to their chemotherapy treatment. The study was an RCT.

The effect of acupressure application on chemotherapy-induced nausea, vomiting, and anxiety in patients with breast cancer. (Genç and Tan 2014)

Genç and Tan (2014) reported on a quasi-experimental study in Turkey with 64 patients with stages 1–3 breast cancer who received two or more cycles of advanced chemotherapy. Thirty two patients were in the experimental group, and thirty two in the control group. To determine the effect of acupressure P6 on CINV and anxiety in these patients, the P6 acupressure wristband was applied to the experimental group. Genç and Tan (2014) concluded that the total mean scores for patients in the experimental group, for nausea, vomiting and retching, were lower than those of the patients in the control group over the five days of application. We used this article because it is a recent and quasi-experimental study and used the IMRAD system.

The effects of P6 acupressure and nurse-provided counselling on chemotherapy-induced nausea and vomiting in patients with breast cancer. (Suh 2012)

Suh (2012) reported in the Oncology Nursing Forum on a RCT in South Korea with 120 women who were receiving chemotherapy for breast cancer. These patients had all had more than mild levels of nausea and vomiting during their first cycle of chemotherapy. The participants were assigned randomly to one of four groups: a control group (a placebo on a specific location on the hand); a counselling only group; a P6 acupressure only group; and a P6 acupressure plus nurse-provided counselling group. The purpose of the study was to evaluate the effects of pericardium 6 (P6) acupressure and nurse-provided counselling on CINV in patients with breast cancer. Suh (2012) concluded that nurse-provided counselling and P6 acupressure were together the most effective in reducing CINV in patients with breast cancer. We used this article because it is the first RCT evaluating the isolated and combined effects of P6 acupressure and counselling in reducing CINV among non-Western patients. The findings of the study support the use of P6 acupressure together with counselling that is focused on cognitive awareness, affective readiness, symptom acceptance, and the use of available resources as an adjunct to antiemetic medicine for the control of CINV. The article used the IMRAD system.

DISCUSSION

Can acupressure reduce nausea and vomiting in cancer patients receiving chemotherapy?

In our experience, we have usually used metoclopramide (pramin) plus serotonin (5-HT3) antagonist (as Ondansetron and Granisetron), plus Dexamethasone plus neurokinin NK (1) (as Emend - aprepitant) for moderate to high ematogenic chemotherapy, yet some of the patients have still suffered from nausea and vomiting. After reviewing the literature we would like to use the acupressure P6 wrist band to solve this problem as the findings of our literature review confirm that the acupressure P6 wrist band reduces CINV in cancer patients receiving chemotherapy. This result is corroborated by 7 of the articles reviewed.

The National Cancer Institute website supports the finding that acupressure is one of the non-pharmacologic strategies that may be used to manage nausea and vomiting (NCI Dictionary of Cancer Terms). Said (2009) adds that acupressure may offer an inexpensive, convenient, and self-administered intervention for patients on chemotherapy, helping to reduce nausea and vomiting at home on days 2-5 of chemotherapy. Genç and Tan (2014) conclude that the total mean scores for CINV in patients in the experimental group to whom they applied the P6 acupressure wristband were lower compared to patients in the control group over the five days of application. Lee et al. (2008) found that the two acupressure modalities produced variable results in each phase of CINV: acupressure bands were effective in controlling acute nausea, whereas acupressure controlled delayed nausea and vomiting. Molassiotis et al. (2007) showed that the experience of nausea and vomiting was significantly lower in the experimental group than in the control group. Chao et al. (2009) found that P6 acupoint stimulation was an option for the management of CINV. In the study reported by Hughes et al. (2013) the participants perceived that acupressure wristbands reduced the levels of nausea and vomiting experienced during chemotherapy treatment. Suh (2012) concluded that the synergistic effects of P6 acupressure together with nurse-provided counselling appeared to be effective in reducing CINV in patients with breast cancer.

Five of the seven articles investigating breast cancer patients, namely Said (2009), Chao et al.( 2009), Molassiotis et al. (2007), Suh (2012) and Genç and Tan (2014), involved breast cancer patients receiving highly ematogenic chemotherapy (e.g. Cisplatin and cyclophosphamide), and moderate risk ematogenic chemotherapy (like doxorubicin).

It is necessary to mention other therapeutic regimens that can also be used in cancer treatment that contain other types of chemotherapy that cause nausea and vomiting, for example, doxorubicin-containing regimens like ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine), CHOP (Cyclophosphamide, Adriamycin, Vincristine, Prednisone) and FAC (5-Fluorouracil, Adriamycin, Cyclophosphamide), and ACT (Adriamycin, Cyclophosphamide, Taxol) (Said 2009) and from our experience cisplatin-containing regimens which that classified as highly ematogenic chemotherapy we noticed the patients still experienced nausea and vomiting after they received the antiemitecs. We think it is necessary to use additional intervention like acupressure to be included in the nausea and vomiting management.

Based on the reviewed findings we plan to use acupressure for cancer patients receiving chemotherapy, because the acupressure in the studies conducted in breast cancer patients reported was used with highly ematogenic chemotherapy in addition to the standard antiemetic treatment, so it is reasonable to conclude that it will work equally well with other less ematogenic types of chemotherapy.

We prefer the use of the acupressure wrist band at P6 acupoint because it is an inexpensive, convenient, and self-administered intervention involving pressure instead of needles at the same point as that used in acupuncture. Furthermore it is safer than acupuncture and patients can easily learn to put pressure on their own wrists, whereas the acupuncture involves using needles that are about the diameter of a hair and can cause temporary discomfort during insertion (Said 2009; Molassiotis et al. 2007). Acupressure seems to be a good way to complement antiemetic pharmacotherapy as it is safe and convenient, with minimal (with bands) or no (finger acupressure) costs involved. It is thus an easy to use, cost-effective, non-invasive intervention (Lee et al. 2008; Melchart et al. 2006).

There was no study result that showed any negative effect from the acupressure wrist band at P6 point, except the review by Lee et al. (2008), which mentioned that three of the ten reported acupressure band trials did not support the possible positive effects of acupressure, but these studies all had methodological issues, such as a small sample size, no true control group, and a concern about the sham acupressure band having a possible antiemetic effect. Melchart et al. (2006) said that no difference was detected in the nausea score between the acupuncture treatment at P6 acupoint, and that at the sham point. Said (2009) mentioned that the acupressure showed no benefit in relation to the incidence of delayed vomiting, early vomiting, or acute nausea, but Melchart and Said’s studies were done with breast cancer patients and it could be that the acupressure benefits were not evident due to the breast cancer patients having had axillary lymph node resection that may have affected the meridian pathway or caused damage to the median nerve as mentioned by Roscoe et al. (2003). Consequently, we think that the evidence suggesting that there is no benefit from the acupressure method for reducing CINV is weak.

Regarding the placebo effect in the articles reviewed here, Melchart et al. (2006) indicated that there was no difference in the nausea score for the combined acupuncture treatment at p6 or that at the sham point, although the level of nausea was very low in both cases. Molassiotis et al. (2007), Said (2009) and Roscoe et al. (2003) all suggested that the placebo effect may be the result of psychological factors.

Application of acupressure in clinical practice

It is important to put this theory into practice, and health care professionals could consider using APS, in particular acupressure on the P6 acupoint, as an option in the management of CINV (Chao et al. 2009). Melchart et al. (2006) said acupressure bands can easily be used in busy oncological wards, while Suh (2012) supported the use of P6 acupressure with counselling focused on cognitive awareness, affective readiness, symptom acceptance, and the use of available resources as an adjunct to antiemetic medications for the control of CINV. Hughes et al. (2013) concluded that the research provides an insight into cancer patients’ motivations for and experiences of taking part in a clinical trial for a complementary alternative medical intervention in which the participants perceived the acupressure wristbands as reducing their level of CINV. Said (2009) suggests that oncology nurses should include acupressure in their list of options for the management of CINV, and especially delayed nausea and vomiting. Special recommendations by oncology nurses are not only useful but are also much appreciated by patients as shown in a study in which the patients were satisfied with the antiemetic treatment given by both P6-acupressure, and placebo-acupressure. The percentage of patients who were satisfied (≥ 3 on 0-6 scale) with their treatment was 81% (35/42) in the P6-acupressure group, which was in agreement with Roscoe et al. (2003), and 64% (27/42) in the placebo group (p= 0.0471). The percentage of the patients who would recommend acupressure treatment was 79% (34/42) in the P6-acupressure group, which again was in agreement with the results of Roscoe et al. (2003) and Hughes et al. (2013), compared to 62% (26/42) in the placebo group (p= 0.0533). This study presented the patients’ compliance with the use of acupressure. Acupressure is easily learnt and taught and patients should be informed about its potential role and taught how to apply it. Leaflets about acupressure for the management of nausea and vomiting could be available in chemotherapy units so that patients who are interested to use such a technique would be encouraged to come forward and learn more from nurses or other health professionals. This could add to the patients’ options for antiemetic approaches and empower them to be involved in the management of these distressing side effects. Acupressure offers a no-cost, convenient, self-administered intervention for chemotherapy patients to reduce acute nausea. Acupressure devices (i.e. Wrist Bands, travel bands, and acupressure bands) have been developed to provide passive acupressure on P6. Acupressure can be administered by healthcare providers, family members, or patients themselves, and does not involve puncture of the skin.

We therefore found that the acupressure wristband is a good way to reduce nausea and vomiting for cancer patients receiving chemotherapy by applying it in the correct position with the stud over the pericardium 6 acupoint located on the anterior surface of the forearm, 3-finger widths up from the first wrist crease, and between the tendons of flexor carpiradialis and Palmaris longus.

Lee et al. (2008) encourage the application of acupressure bilaterally, rather than unilaterally, in CINV control. They recommend three minutes of finger acupressure once daily, with additional acupressure as needed, as the optimal intervention, because both three and five minute trials have succeeded in achieving positive effects. On the other hand, Molassiotis et al. (2007) claimed that there is no correlation between the frequency of pressing the studs and the level of nausea and vomiting. Lee et al. (2008) and Molassiotis et al. (2007) therefore claim opposite results in the relationship between CINV and the frequency of pressing the stud of an acupressure P6 wrist band. But when applying the acupressure P6 wrist band bilaterally, Lee et al. (2008), Said (2009), Molassiotis et al. (2007), Suh (2012), and Genç and Tan (2014) all reported a positive effect with P6 stimulation in reducing CINV.

We would like to discuss some factors related to CINV in relation to nausea and vomiting: expectancy and gender: Roscoe et al. (2003) argued that patients who received the acustimulation bands and expected them to be effective did report having a higher quality of life and less nausea, and in relation to gender, that women are more likely to experience nausea when receiving chemotherapy. Lee et al. (2008) say this may be caused by classical conditioning and also that breast cancer patients may have had a damaged median nerve due to axillary lymph node removal, but Lee et al. (2008) also mention that P6 acupressure in younger women had a significantly greater positive effect on delayed nausea than those on a placebo or those in the no-intervention control group. On the other hand, Molassiotis et al. (2007) mentioned that younger age is associated with greater nausea. We think that men may have tolerated greater stimulation of the acupressure points, and therefore experienced greater symptom relief, so it may be that the acupressure is more effective for men than for women, but these questions of gender, age and the frequency of pressing the studs would need further investigation.

Based on the reported studies, we support the belief that acupressure on P6 is applicable in clinical practice for CINV for cancer patients provided the required education, training and counselling is given to maintain the acupressure benefits.

Acupressure side effects

The study by Molassiotis et al. (2007) found that there were no side effects from the use of the wristbands, but one patient reported that she had to take the bands off because they were too tight and left her with marks for a few days. Chao et al. (2009) also mentioned that very few minor adverse events were observed.

Melchart et al. (2006) did report adverse effects from the treatment in five cases. One suffered a hematoma when wearing the acupressure band at P6. In the sham group, one hematoma was reported after acupuncture, and another three adverse effects from the acupressure band were reported (one hematoma, one skin irritation, one eczema). Hughes et al. (2013) also reported that participants had not experienced any restrictions from wearing the wristbands in terms of everyday activities, other than when washing and bathing. As one female participant commented, for most participants the wristbands were found to be comfortable to wear. However, a few participants reported that they had experienced minor irritation, such as the wristbands feeling tight or painful, or their wrists becoming itchy. Reported adverse side effects were generally deemed minor and acceptable. In the study by Said (2009), no side effect or discomfort was noticed from wearing the acupressure wristband. Said told the patients that if the bands caused discomfort, they could be removed for 30 minutes every two hours. In this way, by taking it off for regular periods, we can prevent the side effects of acupressure, even its minor and rare effects.

Acupressure reduces CINV in cancer patients, in addition it reduces anxiety (Genç and Tan 2014) and that affects overall quality of life (Said 2009). Quality of life is defined by the NCI Dictionary of Cancer Terms as “The overall enjoyment of life and the individual’s sense of well-being and ability to carry out various activities”. Based on the physiological components of the Virginia Henderson’s theory of basic human needs and Abraham Maslow’s Hierarchy of Needs, the patient needs to eat and drink adequately, and sleep and rest (Vera, 2014). This means that when we are providing the required management for distressing symptoms, such as nausea and vomiting, by including the acupressure wrist band in addition to standard antiemetics, the patient’s appetite will improve, leading the patient to eat and drink adequately and improve their sleeping pattern. These may then also improve other aspects of the cancer patient’s life. According to the Henderson Nursing Need Theory, when we meet a patient’s needs, it results in an improved quality of life for the cancer patient receiving chemotherapy. Another way of expressing this is that it restores the balance of Yin and Yang energy that leads to reduced nausea and vomiting and improves the patient’s ability to enjoy life and work in general through a maintaining of the harmony of body and mind, as described in traditional Chinese medicine (Cancer Research UK, 2015).

We believe that it is essential for cancer patients undergoing chemotherapy treatment to have adequate nutrition to maintain their strength to fight the cancer. Different nursing actions are necessary to maintain adequate nutrition including the relieving of CINV. From this we extrapolate that using the acupressure P6 wrist band to reduce CINV improves the patient’s quality of life.

CONCLUSION

Chemotherapy-induced nausea and vomiting may be life threatening and is therefore a huge challenge to nurses involved in cancer care. Even with the best pharmacological management of CINV, patients continue to experience nausea and vomiting.

From a review of eight articles with strong methodology, seven supported the positive effect of an acupressure P6 wristband in reducing CINV for cancer patients. This was also supported by other databases. The one article with neutral results showed that there was no difference between a combined acupuncture and acupressure treatment at P6 and at a sham point in relation to the nausea score, but the level of nausea was very low in both groups. We conclude that the acupressure wrist band applied to acupuncture point P6 is effective, safe, convenient, cost effective, an easy and self-administrated non-pharmacological intervention from traditional Chinese medicine that reduces CINV. Solving the problem of CINV is a fundamental nursing task that can lead to improved quality of life and nutritional status, reduced anxiety and increases patient compliance. In the light of these results, and due to the effectiveness and inexpensiveness of acupressure, together with its ease of use, we suggest that it should be used in conjunction with pharmacological agents for CINV prophylaxis. To maintain the effectiveness of the acupressure, special education and training is needed to reassure the patient that the acupressure is at the correct point (P6) and counselling by the nurse is required.

We recommend the use of acupressure P6 in oncology departments and that future research should be conducted to include cancer patients receiving radiotherapy, and to investigate more about the relationship between the frequency of pressing the stud on the wrist band for acupressure P6 and CINV, and the relationship between gender and CINV, and whether it is better to apply it unilaterally or bilaterally.

For more information: https://jmedcasereportsimages.org/about-us/

Abstract

Identifying and tracking the recovery of patients with mild traumatic brain injuries (mTBI) has remained elusive due to the lack of non-invasive, objective neuroimaging techniques. The purpose of this case study was to provide a proof of concept for performing a combined functional near-infrared spectroscopy (fNIRS) and 60-s psychomotor vigilance testing (60-s PVT) that can identify and track the recovery of a patient with a mTBI. The patient was a 19-year-old female acrobatics and tumbling athlete who was kicked in the left temple by a teammate. Video footage of the injury was utilized to determine the region of impact and weekly fNIRS and 60-s PVT assessments were performed throughout the 10 weeks of recovery. The patient was cleared for activity based upon symptoms at week 7; however, the patient reported increased symptomology during weeks 7 and 8 following exercise. Our fNIRS neuroimaging technique was able to detect the systemic physiological responses associated with mitochondrial dysregulation and oxygen extraction fraction at weeks 1 to 8. Based on our findings, the patient remained injured at week 8, and that the physical activity performed at weeks 7 and 8 may have regressed recovery and induced additional dysfunction resulting in increased recovery time. In conclusion, we were able to identify and track the recovery of our patient with a mTBI using our non-invasive combined fNIRS and 60-s PVT approach. Results provided real time physiological responses associated with the injury throughout the recovery process.

Introduction: Identifying and tracking the recovery of patients with mild traumatic brain injuries (mTBI) has remained elusive due to the lack of non-invasive, objective neuroimaging techniques and that each injury may be unique in its severity, signs and symptoms.1 This present case provides an overview of a novel utilization of functional near-infrared spectroscopy (fNIRS) combined with a 60-s psychomotor vigilance test (60-s PVT) for the monitoring of a patient with a severe mTBI. fNIRS examines the hemodynamic responses in brain tissue by using specific wavelength light absorbance rates to quantify the oxygenated (O2Hb), deoxygenated (HHb), and total hemoglobin (tHb) within a targeted region of the brain.2–4 mTBI’s with associated cerebral damage (e.g., cerebral hemorrhage), require increased nutrient exchange to heal causing greater blood flow to the damaged region when under load.5–8 Furthermore, following a mTBI, moderate to severe cognitive tasks are often contraindicated as they induce a worsening of symptoms.9–11 As a result, complex screening tools may induce greater severity scores immediately following a mTBI or place the patient at increased risk of adverse events such as headaches, nausea, or malaise.12,13 The 60-s PVT utilized in this case study mildly stimulates the major regions of the brain through visual, motor, and cognitive stimuli to induce a hemodynamic shift over the damaged region which would otherwise be undetectable.14,15 To our knowledge this is the longest published tracking of the recovery of a patient with an mTBI using fNIRS following injury onset.16–18 In addition, the present case is novel in that neuroimaging began within 72-hr from the onset of injury, weekly tracking was performed, and the exact time and location of injury was established through video footage of the injury’s occurrence which allowed for precise neuroimaging and tracking of the patient during their recovery. 

Our fNIRS technique is ideal for real-world monitoring as it is not as impacted by movement or environmental conditions as the traditionally used electroencephalograms (EEG). In addition, fNIRS is more portable than functional magnetic resonance imagining (fMRI) techniques which are costly and cannot be performed on the field during sporting events.5,19 The fNIRS technology has been shown to have greater spatial resolution than EEG, similar to that of fMRI.2,4,20,21 In addition, fNIRS has slightly lower temporal resolution than EEG, but much greater than that of fMRI. Thus, the portability and unique blend of spatial and temporal neuroimaging resolution makes the use of fNIRS ideal for identifying and tracking mTBI in real-world environments.2,4,20,21 However, previous studies using fNIRS have shown mixed results in its ability to identify mTBI’s.17,18,22–24 We hypothesized that these conflicting results were the result of methodological approaches that included unoptimized post-processing neuroimaging data fusion and mTBI-specific analysis algorithms for regional injury determinations.17,25,26 Furthermore, other fNIRS studies have utilized O2Hb hemoglobin measures in their statistical analyses. However, many studies have reported HHb and tHb as more robust in detecting alterations in cognitive load and neuroplastic changes.3,18,27,28 Therefore, the purpose of this case study was to provide a proof of concept for performing weekly fNIRS (O2Hb, HHb, and tHb) and 60-s PVT monitoring of a unique mTBI patient suffering from severe symptoms. 

Methods

Patient: The patient was a 19-year-old female acrobatics and tumbling athlete. Prior to enrollment in college, the patient had a history of concussions with prolonged recovery periods. During a synchronized tumbling pass the patient was kicked in the left temple by a teammate, followed by hitting her forehead on the mat during landing. Immediately following the impact, the patient presented with signs and symptoms (e.g., headache, altered mental status) warranting a referral to an emergency department (ED) for further evaluation. At the ED a head computerized tomography (CT) scan revealed that the patient was suffering from a severe mTBI. However, results of the CT scan did not identify a skull fracture or hemorrhaging. An assessment completed by the school’s medical staff after being released from the hospital found the patient was suffering from headaches, visual disturbances, and disorientation. Further, neurocognitive testing revealed substantial deficits in processing speed, reaction time, and executive functioning. The patient was then re-evaluated the day after the initial injury where she reported headaches, disorientation, and fatigue.

In total, the patient was symptomatic for 10 weeks following injury. Video footage of the injury was utilized to determine the region of impact and weekly neuroimaging assessments were performed throughout the 10 weeks. Recovery from the mTBI during this time was marked by a slow and steady decrease in symptoms (e.g., headaches, difficulty sleeping, sensitivity to light/noise, vision issues, dysphasia, emotional disturbances). The patient did not return to any physical activity until seven weeks after the initial injury. However, her activity was early threshold aerobic exercise primarily consisting of cycling while being monitored for increases in reported mTBI signs and symptoms. Due to the prolonged recovery and previous concussion history, the medical team and patient decided that further participation in the sport was not feasible. Thus, the patient medically disqualified from further participation. This project was approved by the institutions IRB (Approval ID#: 2012044), is aligned with the Declaration of Helsinki, and the patient’s consent was provided to publish the data within this case study. This study.29

Functional Near-Infrared Spectroscopy Signal Analysis:

The overall fNIRS-derived hemodynamic responses were monitored each week for 10 weeks of the patient’s recovery beginning after the onset of the injury. The location of placement for the fNIRS sensors were determined based on video footage of the injury and athletic trainers present at the time of injury. fNIRS hemodynamic monitoring were collected over left (Injured) and right (Control) superior temporal region of the patients’ head using a 4x1 optode to receiver layout which was secured to the head with a full head neoprene cap, chin strap, and pressure relief system to maintain sensor placement (OxyMon MKII, Artinis Medical Systems, Einstinweg, Netherlands). The centerpoint of the 4x1 sensor grid was the location of impact and the identical location on the opposing side of the head. Each of the 4 optodes on each region of the head were sampled at 10 Hz for each of the 762 and 848 nm wavelengths utilized to monitor the hemodynamic responses. Each wavelength penetrates through the skull and into the cerebral cortex at a distance of ~2.5 cm. The thickness of the skull was estimated based on the patients age and utilized to calculate a correction factor for the differential pathlength factor (DPF) caused by the refraction of the skull fNIRS signals were performed by filtering for Mayer waves, respiration, and heart pulsation by examining the power density spectrum prior to the continuous wavelet (CWT) analysis. A Morlet Wavelet was utilized for the CWT transform using time-step coefficients without any overlap was then performed. The Wavelet coefficients were determined from the culmination of all the CWT data over each weeks 60-s PVT test and was used to further analyze the CWT Multiscale Peak Detection to quantify the amplitude of each CWT. This analysis allowed for the calculation of fNIRSamp values for O2Hbamp, HHbamp, and tHbamp. Together, these metrics provide the regional cerebral blood flow (tHbamp), metabolic stress (HHbamp), and available oxygen (O2Hbamp) in the Control and Injured regions of the brain. Each hemisphere’s 4 optode grid channels were then summated to provide an individual activation level for each locations site of interest during each week’s 60-s PVT.

Three exploratory t-tests were performed on the mean Control and Injured tHbamp, HHbamp, and O2Hbamp measures, collapsed across the 10 weeks for sufficient data points, to determine the gross differences in hemodynamics throughout the 60-s PVT. 

Psychomotor Vigilance Test: 

A 60-s PVT was performed each week while wearing the fNIRS neuroimaging sensor on the injured and control regions of the patient’s brain. The 60-s PVT test was performed on a touch screen tablet (iPad 10.2in 9th generation, Apple, Cupertino, CA) using the Research Buddies software (Research Buddies Version 1.53). During to quantify injury severity as it has been suggested that a PVT has difficultly determining differences in patient injury severity scores.14 In a previous study31 that examined healthy, military non-TBI patients suffering from extreme hypoxemia and physical fatigue reported an average 60-s PVT time ranging from 380-450-ms. Taken together, the findings of these previous studies suggest that a 60-s PVT can help to identify deficits and potentially severity, but the 60-s PVT alone is unable determine if an mTBI occurred and its injury severity. However, the addition of our fNIRS neuroimaging technique coupled with the 60-s PVT results may allow for a methodology of tracking the occurrence and severity of mTBI patients. 

Functional Near-Infrared Spectroscopy: Neuroimaging:

Neuroimaging the contralateral side of the brain as a Control was effective for identifying the hemodynamic and metabolic differences from the Injured region of the brain in our patient as a pre-injury image was unavailable. The relatively consistent tHbamp, HHbamp, and O2Hbamp metrics across the 10 weeks for the Control compared to the Injured side reflects a low neurophysiological load placed on the Control region of the brain typical of a non-mTBI patient during the 60-s PVT (Figure 4).2,26 Furthermore, Figure 5 illustrates the similarities in the neurophysiological load placed on the Control and Injured regions of the brain at the initial 0 to 10-s of the 60-s PVT, however, after 30-s of load a greater hemodynamic and metabolic responses occurred in the Injured but not the Control region of the brain. Thus, the 60-s PVT load placed on the brain was minimal enough to not impact the Control region of the brain while sufficient at stimulating a response from the Injured region of the brain. Therefore, the utilization of a Control region was effective and allowed us to develop a target recovery threshold for the Injured region of the brain to match the tHbamp, HHbamp, and O2Hbamp of the Control region. The combined tHbamp, HHbamp, and O2Hbamp pattern of responses throughout the 10 weeks of recovery indicated maintenance of the patients Oxygen Extraction Fraction (OEF) in the Injured region of the brain. 32 The HHbamp and O2Hbamp ratio remained relatively constant in the Injured region of the brain with a concomitant increase in tHbamp which suggested that greater oxygenation utilization was required in the Injured region of the brain compared to the Control (Figure 4). The overall increased blood flow to the Injured region and increased metabolic demand, as indicated by the greater HHbamp, likely aimed to offset the mTBI associated Ca2+ overload within the patient. Increasing of the patients overall regional blood flow (tHbamp) to the Injured region may reflect a protective mechanism to avoid the catabolic effects of a Ca2+-induced intracellular dysregulation that has been shown to result in the overproduction of free radicals, activation of cell death signaling pathways and stimulation of inflammatory responses.33–35 That is, the fNIRS responses captured throughout the recovery of this patient tracked with the expected systemic physiological responses associated with the maintenance of OEF. Furthermore, it has been well established that mTBI’s result in mitochondrial dysregulation which result in a greater hemodynamic shift to the injured region of the brain to provide sufficient oxygen, dilution, and clearance rates for the metabolic byproducts.33,34 It is hypothesized that the combined mitochondrial dysregulation induced hemodynamic shift was likely the driving factor for the increased metabolic stress (HHbamp) while OEF further stimulated a greater hemodynamic flow to the Injured region of the brain to avoid further injury associated with a buildup of metabolic byproducts. The combined regional cerebral blood flow regulation pattern (tHbamp) and increased metabolic demand captured in this patient indicated that the damage to the patient’s brain was detectable using our fNIRS approach. Furthermore, the combined utilization of our CWT tHbamp, HHbamp, and O2Hbamp methodology allowed for identification of the hemodynamic shifts associated with the injury and increased load induced by the 60-s PVT. 

In our patient, all fNIRS metrics that were elevated from weeks 1 to 8 improved to within Control values at week 9 and remained at the Control levels at week 10 (Figure 4). The tracked improvements in all fNIRS measures suggest that this patient’s recovery became physiologically improved at week 9, however, the patient reported minimal symptomology at rest at week 7 which cleared the patient to begin light physical activity. During weeks 7 and 8 the patient reported increased symptomology when exercising which was her rate limiter to perform physical activity. Considering the onset of the symptomology due to exercise and the fNIRS detected hemodynamic shifts associated with mitochondrial dysregulation coupled with OEF, the patient may have been less symptomatic if exercise was resumed at week 9.32,34 Specifically, the improved fNIRS and 60-s PVT metrics at week 9 were closely aligned with the Control and expected reaction time values, respectively, suggesting that our fNIRS approach could track the physiological recovery in this patient (Figure 4). Early physical activity in patients with mTBI’s has been linked to increase metabolic byproduct accumulation, greater hemodynamic shifts, potential reduced recovery rates, and increased symptomology.32,34,36,37 Thus, the elevated tHbamp, HHbamp, and OxyHbamp values at week 8 suggest that the physical activity performed at weeks 7 and 8 may have regressed recovery and induced additional dysfunction, lengthening recovery time. Therefore, further development of this non-invasive neuroimaging approach will provide clinicians with a useful assessment tool to make more informed decisions on the rate of recovery and activity a patient may be prescribed.

Limitations: This was an exploratory case study performed on a single patient to examine the clinical feasibility of the fNIRS and 60-s PVT analysis approach which will need greater refinement and development prior to clinical adoption. We acknowledge that greater data from a larger population should be studied to make this technology useable when real-time accounts or video footage of the injury site is unavailable. Thus, data from this study should not be applied to a broader patient pool until further studies focusing on the refinement and application of this approach is completed. The data from this case study does provide the foundational information needed to replicate the study methodology and highlights the relevance to the clinical community aiming to develop non-invasive mTBI monitoring devices.   

Conclusion: In conclusion, the 60-s PVT was capable of detecting deficits in our patient, however, the 60-s PVT alone was unable to determine injury severity. The addition of our fNIRS neuroimaging technique was able to detect the systemic physiological responses over the injured region of the brain that align with mitochondrial dysregulation induced hemodynamic shifts and increased metabolic stress (HHbamp). In addition, tHbamp and HHbamp identified OEF which further stimulated a greater hemodynamic flow to the Injured region of the brain to avoid a buildup of metabolic byproducts. The neuroimaging from the contralateral side of the brain was effective as a Control in our patient as a preinjury image was unavailable. Using the Injured and Control region neuroimaging, we determined the elevated tHbamp, HHbamp, and OxyHbamp values at week 8 suggest that the physical activity performed at weeks 7 and 8 may have regressed recovery and induced additional dysfunction, lengthening recovery time. Therefore, this case study showed that a combined 60-s fNIRS neuroimaging and PVT technique was capable of detecting the patients mTBI and tracked her recovery better than subjective assessments. Furthermore, the physiological data obtained through our non-invasive neuroimaging approach was able to identify the patient’s physiological response including potential mitochondrial dysregulation and OEF. Therefore, the physiological responses and recovery state capture in our patient indicates that the weekly assessments of a combined 60-s fNIRS and PVT approach could provide clinically relevant data on the recovery status and injury severity. Future research should focus on the development of fNIRS threshold values that can be utilized to better identify the severity of a mTBI and its associated physiological responses in a large sample of mTBI patients. 

Abstracts

Objective: To investigate the availability of seven serum cytokines, interleukin-4 (IL-4), interleukin-6 (IL-6), interleukin-10 (IL-10), interleukin-17 (IL-17), interleukin-12-70 (IL-12P70), tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ) changes and significance in Common and lobular community acquired pneumonia (CAP). 

Methods: Fifty-three patients admitted to our hospital from April 2022 to July 2023 were selected as the observation group. According to the degree of pneumonia, they were divided into common pneumonia group (observation group 1), lobular pneumonia group (observation group 2), and children with fever (acute upper respiratory tract infection) during the same period were selected as the control group. The clinical data of the subjects in three groups (observation group 1, 2 and control group) were retrospectively analyzed. Temperature, length of stay, chest CT and other basic information were recorded. Fasting venous blood of three groups of children was collected and 7 cytokines levels were detected. The cytokine levels of the three groups were compared by one-way analysis of variance. 

Results: The hospital stay of lobar pneumonia group was significantly longer than that of common pneumonia group and fever group. There were no significant differences in IL-4, IL-6,IL-10, IL-17, IL-12P70, TNF-a and IFN-γ among lobular pneumonia group, common pneumonia group and fever group (P > 0.05). 

Conclusion: Lobar pneumonia prolongs the hospital stay of children. The cytokines IL-4,IL-6,IL-10,IFN-γ, IL-17,TNF-a and IL-12P70 showed no significant difference in lobular pneumonia group, common pneumonia group and fever group. According to the World Health Organization, pneumonia killed 920,000 children under the age of five in 2016, 98% of whom were in developing countries. Pneumonia is also one of the main causes of death among children < 5 years old in China, and most of them are lobular community acquired pneumonia (CAP)[1]. At present, there are few studies on biomarkers used to assess disease severity and prognosis [2]. Cytokines are major regulatory factors of inflammatory response, which play a role in amplifying, transducing and coordinating pro-inflammatory signals, leading to synchronous expression of molecular effectors and regulating autoimmune responses [3]. Previous studies have shown that the prognostic value of changes in cytokine levels is correlated with the severity of pneumonia [4]. The objective of this study was to retrospectively analyze and compare cytokine levels in children with common pneumonia and lobar pneumonia.

Data and methods

General Information:The medical records of 53 children with CAP who were hospitalized in the pediatric respiratory department of our hospital from April 2022 to July 2023 were collected. According to the degree of pneumonia, they were divided into common pneumonia group and lobar pneumonia group. Children with fever during the same period were selected as the control group, and basic information such as temperature at admission, length of stay, duration of medical history and chest CT were recorded. Cytokine levels were determined by the key Laboratory of hematological Pathology of our hospital. This study was approved by the Ethics Committee of Henan Provincial People's Hospital (2023) No. 65.

Inclusion and exclusion criteria for children with pneumonia:

Inclusion criteria: 1) The diagnostic criteria of community-acquired pneumonia and lobar pneumonia in children in the 8th edition of Zhufutang Practical Pediatrics were met; 2) Complete clinical data; Exclusion criteria: 1) combined with other lung diseases, such as asthma and tuberculosis; 2) Previous immune disease, unexplained long-term fever, joint swelling and pain; 3) A recent or longterm history of glucocorticoid use; 4) Immunomodulators and immunosuppressants such as immunoglobulin and interferon have been applied in the past 2 months.

Statistical Processing:

All the data of the patients were recorded, and the differences of each index between the two groups were analyzed using Graphpad Prism 8. Counting data is expressed as example (%); The measurement data were expressed as mean ± standard deviation (x±s), and the cytokine levels of the three groups were examined by one-way ANOVA for inter-group comparison. P < 0.05 was statistically significant. 

Results: Compared with the other 2 groups, the length of hospital stay in the lobar pneumonia group was significantly increased, with statistical significance (P < 0.05), while there was no statistical significance in other general data (P > 0.05). Compared with lobular pneumonia group, common pneumonia group and fever group, there were no significant differences in serum cytokines in IL-4,IL-6,IL-10, IL-17, IL12P70, TNF-a and IFN-γ (P > 0.05).

Discussion: CAP is a common infectious disease in childhood, especially in infants and young children. It is the most common cause of hospitalization in children and the first cause of death in children under 5 years old. For hospitalized children or areas with good conditions, the evaluation of CAP severity should also be based on the scope of lung lesions, the presence of hypoxemia, and the presence of internal and external pulmonary complications[5]. This study was mainly based on the clinical symptoms of pneumonia and the range of chest imaging lesions as a grouping basis to determine the severity of pneumonia. The results of this study found that the length of hospital stay in the fever group, the common pneumonia group and the lobular pneumonia group was different in pairwise comparison, and the length of hospital stay in the lobular pneumonia group was significantly longer than that in the other two groups, indicating that the scope of chest imaging lesions may affect the length of hospital stay and treatment time, which has guiding significance for our clinical evaluation of the length of hospital stay for pneumonia.

Abstract

An important pathology that affects the cardiovascular system is venous thromboembolism (VTE), a disease characterized by the formation of clots in veins. VTE is divided into two clinical presentations: pulmonary thromboembolism (PT) and deep vein thrombosis (DVT). The general objective of the present work is to describe the profile of patients hospitalized for venous thromboembolism and other venous diseases, in the state of Bahia between the years 2010 and 2020. The specific objectives are the following: describe the demographic characteristics of hospitalized patients; describe the epidemiological trend of venous thromboembolism over the period. Based on data extracted from the SUS Hospital Information System (SIH/SUS), it was possible to analyze the following variables: annual frequency; race/color; sex; age range; health macro-region of the state of Bahia. Of the 21,450 hospitalizations for phlebitis, thrombophlebitis, embolism and venous thrombosis in Bahia, between 2010 and 2020, for patients from 20 years of age, it was noticed that 63.09% (13,533) are women, of which 42.14% (9,040) are self-declared as black or brown and that 43.39% (9,308) are concentrated in the East 2915 macro-region (NRS – SALVADOR). The profile of patients admitted between 2010 and 2020 was identified as being composed of brown women between 40 - 49 years old.

Keywords: Venous Thromboembolism; Pulmonary Embolism; Venous Thrombosis; Embolism and Thrombosis

Introduction

Diseases of the cardiovascular system have been seen for many years as important factors in the population's illness. According to data from the Ministry of Health, in 1999, such comorbidities led to approximately 1,100,000 hospitalizations through the Unified Health System 1. Within this scenario, Venous Thromboembolism (VTE) stands out, a pathological condition marked by the development of a clot in the veins, which leads to impairment of blood circulation.

The physiological changes that precede venous thromboembolism are grouped by Virchow's Triad, which encompasses endothelial lesions, stasis or turbulent blood flow, and blood hypercoagulability. Injury to the endothelial cell is a procoagulant factor, as it increases the expression of thrombomodulin, a thrombin modulating agent, stimulating platelet adhesion. Hemodynamic alterations, such as stasis and turbulence, by modifying normal blood flow, stimulate contact of platelets with the endothelium of vessels and reduce the elimination of coagulation factors, by decreasing flow. The state of hypercoagulability, which can have hereditary and genetic causes, also promotes an imbalance between clotting factors by activating procoagulant substances and inhibiting anticoagulants. two

VTE has two distinct clinical presentations, which are closely related: Deep Vein Thrombosis (DVT) and Pulmonary Thromboembolism (PTE) 3. DVT consists of the formation of clots in the deep veins of the lower limbs, which have the potential to reach the pulmonary circulation 3. This mechanism results in PTE, a condition marked by the migration of an embolus to the pulmonary circulation, which compromises the irrigation of this organ and is generally associated with a more serious situation 4.

Manifestations in Deep Vein Thrombosis are pain, heat, redness, swelling of the affected limb, cramps and, in some cases, greater predisposition to the formation of ulcers 2-5. The edema, due to the venous obstruction, is normally of the tense type, causing a swelling, only in the calf or in the whole affected leg. The redness, heat and pain at the site are caused by inflammation of the vessel wall. The pain may be permanent or be related to orthostasis or physical exertion, such as the Hormans Sign, in which the foot is dorsiflexed to assess whether there is severe pain in the calf 6. However, certain patients may not have symptoms or only some of them 5. Pulmonary embolism is characterized by distinct manifestations, namely: chest pain, usually of a pleuritic nature, tachypnea, dyspnea on exertion and in some cases cough 5. In more serious situations, dyspnea at rest, hypotension and syncope, due to low cardiac output and hypoxemia 5. Cases of pulmonary infarction are uncommon complications and, when they exist, are associated with extensive events and previous diseases or comorbidities, such as pulmonary infections and heart failure 7.

The diagnosis of venous thrombosis is complex, as no sign or clinical manifestation presented by the patient is predictive for confirmation or exclusion of condition 8. Thus, the patient is classified according to the pre-test probability (i.e. [suspected presence of a certain disease based on anamnesis, physical examination findings and epidemiology 9]) through validated risk assessment models for deep vein thrombosis or pulmonary embolism using the Wells or Geneva diagnostic criteria, which have similar diagnostic accuracy 10. These scores are important, as they eliminated situations of intermediate probability, dichotomously characterizing patients into situations of low probability (“probable PTE”) and high probability (“unlikely PTE”) 5,10.

This predictive model can be complemented using other tests such as D-dimer. Its values can be measured in whole blood or plasma, however it should be noted that complementary tests are only performed when it is not possible to confirm the suspicion of VTE with clinical examination, which occurs in most cases 11. As it is highly sensitive ( 95%) 10, but little specific (40%) 10 for VTE, its use is related to its high negative predictive value 5 (i.e. [probability of disease absence when the test is negative])9. Thus, if the result is negative, the diagnosis of VTE can be excluded in patients with a low to moderate pre-test probability of DVT or embolism 5. However, in situations where there are strong indications of a case of VTE , treatment can be started even without the results of complementary exams 12. Treatment consists of three main categories 13: medication (use of anticoagulants paying attention to the risk of bleeding 14) thrombolysis (through an injection of a substance into the bloodstream of the patient)15,16 and vena cava filter (the insertion of devices in the inferior vena cava, indicated for patients with DVT who cannot use anticoagulation)17.

Thus, the presentation of signs and symptoms, which are often nonspecific and common to other pathologies, as well as clinical diagnoses with specificity lower than 50%, lead to underreporting of the disease 18. As a result, knowledge of the disease is significantly hampered. real incidence of venous thromboembolism.

Due to this worldwide epidemiological problem, estimating the prevalence of VTE is a challenging task, and for this reason, the numbers are variable. In the United States (USA), for example, it is estimated that the prevalence of PTE is between 3.4% and 14.8%, while in Asia, this number is around 2.0% to 4. 7% 19. In Brazil, in turn, the numbers that characterize the epidemiology of VTE are also not very precise. According to certain references, the incidence of the disease is 1 to 2 episodes per 1000 inhabitants 18, while others describe it as 0.6 per 1000 inhabitants.20

The analysis of the relationships between VTE and different health variables also allows understanding the impacts of this disease on the Brazilian population. From an epidemiological study carried out at the Hospital das Clínicas of the Federal University of Uberlândia, MG, between September and December 2005, it was concluded that the most frequent risk factors found for VTE were prolonged surgery (85.2%), anesthesia general (46.2%), age equal to or above 60 years (42.3%), prolonged restriction to bed (27.4%) and age between 40 and 59 years (24.9%) 20. age and factors that promote immobility are crucial for the development of VTE. There are also the following variables intrinsically associated with the prevalence of VTE: obesity, increasing the risk by 2 to 3 times, in cases of BMI greater than 30Kg.m2; 21 neoplasms, with an increase in risk of 5 to 7 times 22; in addition to pregnancy (increase in risk by 10 times) and the puerperium (25 times).23

Objectives

Primary objective: to describe the profile of patients hospitalized for venous thromboembolism and other venous diseases in the state of Bahia between 2010 and 2020.

Secondary objectives:

Describe the demographic characteristics of hospitalized patients;

Describe the epidemiological trend of Venous Thromboembolism over the period

Methods

The present work constitutes a descriptive observational study of secondary data, extracted from the SUS Hospital Information System (SIH/SUS), available in the DataSUS database, referring to patients hospitalized in Bahia between the years 2010 to 2020, according to the ICD chapter -10: IX. Diseases of the circulatory system, in the category Phlebitis, thrombophlebitis, embolism and venous thrombosis.

The data obtained were then treated in Microsoft Excel software, where mean and median calculations were performed. This data can be verified through the TabNet portal, at the following access link: https://datasus.saude.gov.br/.

To describe the profile of hospitalizations, Venous Thromboembolism and associated conditions in Bahia, the variables used were:

Annual frequency;

Race/Color:

the White;

or Black;

the Brown;

the Yellow;

the Brown;

the Indigenous; It is

o No information.

Gender:

the Male;

the Feminine; It is

the Ignored.

Age range:

20 to 29 years old;

30 to 39 years old;

40 to 49 years old;

50 to 59 years old;

60 to 69 years old;

70 to 79 years old; It is

80 years and over.

Health macro-region of the state of Bahia:

the North;

the Center-north;

the Northeast;

the East;

the Central-East;

the West;

the Southwest;

the South; It is

the extreme south.

System

Public services

Private services

Results

Between 2010 and 2020, 21,450 hospitalizations for Phlebitis, Thrombophlebitis, Embolism and Venous Thrombosis were recorded throughout the state of Bahia, for patients aged 20 years and over. The macro-region 2915 East (NRS – SALVADOR) had the highest number of hospitalizations, totaling 9,308 (43.39%), followed by the regions 2910 South (NBS - ILHÉUS) and 2911 Southwest (NBS - VITÓRIA DA CONQUISTA) with 2,360 (11 %) and 2303 (10.74%), respectively.

There were also 880 deaths reported throughout the period, led by 2915 EAST - (NRS – SALVADOR) with 300 (Median (M) = 27; first quartile (Q1) = 23.5; third quartile (Q3) = 32.5) , followed by 2910 SOUTH (NBS – ILHEUS) with 123 (M = 11; Q1 = 9; Q3 = 14) and 2917 CENTER-EAST (NRS – FEIRA SANTANA) with 111 (M = 12; Q1 = 6.5; Q3 = 12.5). The trend of the curve in the period suggests stability, with an annual average of 80 deaths, with a peak of 97 deaths in 2019.

The general panorama of the period demonstrates a significantly higher number of women hospitalized for phlebitis, thrombophlebitis, embolism and venous thrombosis, so that of the 21,450 hospitalized patients, 63.09% (13,533) are women and 36.91% are men (7,917) . Men had M = 717, with Q1 = 692 and Q3 = 727, and women M = 1173, with Q1 = 1145 and Q3 = 1261, demonstrating the difference in the absolute value of cases.

The central tendency values also show the density of hospitalizations over the years, which indicates that there were no alarming fluctuations between groups or between individuals of the same sex, except for the year 2019. There were 2630 hospitalizations recorded, of which 905 were men (34 .41%) and 1725 women (65.58%), absolute numbers that differ from the general average, male and female, respectively, of 1950, 719.73 and 1230.27.

When evaluating the data according to the race/color criterion, of the patients who had this information collected, the black population stands out, since in this category self-declared black and brown patients are considered, which totaled 9,040 (42.14%) in the studied period , followed by the white population with 1027 (4.79%). However, there is a greater emphasis on patients whose race/color criterion was ignored, totaling 11,669 (54.4%) between 2010 and 2020.

The regime-based analysis revealed that the sum of hospitalizations for public services (7391) significantly exceeds those for private services (3564). The numbers of hospitalizations in which the type of regime was not registered were very expressive (11089). From 2010 to 2014, there were no records of hospitalizations classified as ignored. However, between 2016 and 2020, the nature of the regime was not distinguished in any hospitalization.

During the period in which the types of regimes were considered, the median number of admissions for the public regime was 1247.5, while for the private regime it was 611.5. During the same period, the average hospitalizations by the public and private regime were, respectively, 1231.8 and 594.

Distribution by age group revealed a higher incidence among patients aged 40 to 49 years, with an annual average of 404.18 patients. Then, the ranges from 50 to 59 years old (339.64) and 30 to 39 years old (327).

Discussion

Distribution by macro-regions reflects the impacts of disparities in sociodemographic factors, such as differences in income, access to health services, as well as the number of inhabitants in each region. According to the data obtained, the macro-region 2915 East (NRS – SALVADOR) stood out, in relation to the others, in terms of the number of hospitalizations, as well as the number of deaths (34%). This information is in line with results shown in the literature, which state that the Brazilian regions with the highest proportion of cases of VTE hospitalization (south and southeast) have the lowest mortality rate due to the disease 19. that, despite the disparities regarding access to health and income being important, the significantly higher number of inhabitants in the East macro-region (NRS - SALVADOR) was able to determine it as the leader in terms of the highest rates of hospitalization and death from illness.

The profile in relation to gender corroborates the literature, since women correspond to the majority of hospitalizations. Intrinsic factors may be favorable to this arrangement, such as the use of oral contraceptives, eventual pregnancy, puerperium or gynecological surgery, as well as greater search for health services by the female population compared to the male population 23, 24 . Regarding the use of oral contraceptives, although pills currently have a lower concentration of estrogen, especially ethinyl estradiol, their use increases the risk of VTE by up to six times compared to those who do not use hormonal contraceptives. The absolute risk, however, in women aged less than 35 years and without associated risk factors remains between low and moderate 25.

When analyzing the occurrence of this condition in relation to age, it is noted that the probability of involvement grows according to the patient's age, some authors consider that this growth is directly related to longevity, however the analysis showed that this pattern is not directly proportional to the age factor 19. In research carried out by other researchers, it is noted that from the age of 40 19 the occurrence rate increases considerably, with greater risk, but other authors consider that this occurs from 50 years 26. It is important to highlight that prophylactic methods are being developed with the objective of preventing the occurrence of DVT, since this is one of the causes of PE, a serious complication. Preventive diagnostic methods, especially in older patients and after surgical procedures, rely on tests such as: daily gammagraphy with fibrinogen labeled with I125 and Doppler ultrasonography, which is easier to perform, while the treatment uses anticoagulants, which have dubious efficacy. as they increase the chances of bleeding 27.

The body of evidence, including the results of this work, suggests that VTE is more frequent in the population of African ancestry 28. Epigenetic factors help justify this arrangement, such as obesity, which increases the risk two to three times, together with greater activity of the factor VIII in this ethnic group, which may favor thromboembolic events; 10% of healthy people have values above 228 IU/dl 29,30. However, the genetic basis of this increase in the population of African origin is still unknown.

During data collection, it was noticed that the studied MORB ICD-10 list does not distinguish notifications of phlebitis and thrombophlebitis from those of embolism and venous thrombosis. This bias may have compromised the analysis of the data obtained, by including phlebitis and thrombophlebitis in the analyzed variables.

Conclusion