issn: 1755 -6783 internationally indexed journal 3.3.pdf · table 2 shows that 17 (34%) patients...

Annals of Tropical Medicine & Public Health-Special February 2018 Vol 3.3

ISSN: 1755-6783

Internationally indexed

journal

The journal is registered with the following abstracting partners: Baidu scholar, CNKI,

EBSCO Publishing’s Electronic databased, Google Scholar, National Library, ProQuest, and

African Index Medicus.

It is indexed with DOAJ, EMASE, ESCI, Index Copernicus, Scimago Journal Ranking, and

SCOPUS

Impact factor for 2018: 2.75

Annals of Tropical Medicine & Public Health-Special Issue February 2018 Vol 3.3

i

Title Page Relationship between hypertension and restless leg

syndrome in elderly population in IIlam

SP52-18

Comparing stress, coping strategies, and quality of life

among nurses working in ICU and emergency ward

with other hospital departments

SP53-18

Effect of physical activity promotion program on life

satisfaction among the rural elderly

SP54-18

Comparison of effectiveness of shock index score and

trauma and injury severity score in predicting

mortality in patients

SP55-18

The effect of hope therapy on improving life

expectance and general health among cancer patients

SP56-18

The barriers of unlearning for nurses employed in

hospitals: a qualitative study

SP57-18

Pleural lipid profile in differentiating exudative pleural

effusion

SP58-18

A review on knowledge and attitude of medical

students to communication skills at Mazandaran

University of Medical Sciences

SP59-18

Analysis of determinants of physical activity to prevent

osteoporosis among pre-university female students in

Rafsanjan, 2015-16: Applying health belief model

SP60-18

The effect of topical cyclosporine A in patients with

dry eyes referring to Vali-e-Asr Hosptial in Birjand

SP61-18

A new approach to idiopathic scoliosis correction

SP62-18

Investigating the relation between hemoglobin A1C to

left ventricular hypertrophy and left ventricle mass in

children with type 1 diabetes mellitus

SP63-18

Study of total RNA circulation and tryptase activity

levels in heart failure in patients

SP64-18

Evaluating the effectiveness of cognitive behavioural

group psychotherapy on psychological well-being of

under treatment addict patient

SP65-18


SP52-18

Relationship between hypertension and Restless Leg Syndrome in

Elderly population in Ilam

Milad Borji1, Sedighe Molavi*2

, Asma Tarjoman3, Abbas Nasrollahi

4

1-Department of Nursing, Faculty of Nursing and Midwifery, Ilam University of Medical Science, Ilam, Iran

2- Department of Nursing, Faculty of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord , Iran

3- Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran

4-Researchcenter of prevention of psychosocial injuries , Ilam University of Medical Science, Ilam, Iran

Corresponding author: Sedighe Molavi, - Department of Nursing, Faculty of Nursing and Midwifery, Shahrekord

University of Medical Sciences, Shahrekord , Iran, [email protected]

Introduction: Hypertension is one of the most prevalent diseases in the elderly, and the restless leg syndrome

(RLS) is a possible concomitant hypertension-related condition with estimated high prevalence among the

elderly. Therefore, this study was conducted to determine the relationship between hypertension and RLS in the

elderly.

Materials and methods: In the present case-control study, 250 elderly participants (50 with high blood pressure

and 200 with normal blood pressure) in Ilam, Iran, were enrolled. Data were collected using a demographic

questionnaire, the Berlin questionnaire, the RLS screening questionnaire, and the blood pressure chart. The

questionnaires were completed through interviews, and the blood pressure measurements were recorded by the

researchers, who were nurses. Data were analyzed using the SPSS version 16 software. The independent t-test,

regression, Mann-Whitney, and Chi-square tests were conducted, and p-values < 0.05 were considered

statistically significant.

Results:The findings indicated that 17 (34%) of the participants with hypertension had RLS, while 33 (66%) did

not have RLS. Further, 66 (33%) of the participants with normal blood pressure did not have RLS while 134

(67%) had no RLS. In addition, there was no relationship between hypertension and RLS (P>0.05).

Conclusion: Considering that no significant relationship was found between RLS and hypertension in the

present study, further studies are needed in different cities in Iran, to obtain more accurate and reliable

information.

Keywords: Restless Leg Syndrome, Hypertension, Elderly

INTRODUCTION:

Over the past 30 years, advances have been made in the prevention, diagnosis, treatment of cardiovascular

diseases and in associated rehabilitation techniques (1). Despite the decline in the associated mortality rates,

cardiovascular diseases are still one of the most common causes of deaths worldwide (2, 3). In 1910, only 10%

of deaths were due to cardiovascular disease. However, this value is projected to reach 75% by 2020 (4). In Iran,

cardiovascular disease cause death, with 138007 people (45.3%) affected, half of which are due to myocardial

infarction (5).

The elderly population continues to increase because of improved health and therapeutic conditions (6-8).

Hypertension is one of the most prevalent diseases associated with old age (9), and accounts for 13.5% of deaths

worldwide (10). The findings of previous studies have revealed some complications associated with


SP52-18

hypertension in the elderly (9, 11 and 12). The restless leg syndrome (RLS) is a hypertension-related

complication with a recorded high prevalence among the elderly (13, 14). Patients with RLS have an irresistible

urge to move their legs and describe it as an unpleasant feeling that exacerbates with inactivity courses (15-17).

This syndrome affects the patient’s ability to enjoy life, and has negative effects on social activity, family life,

and occupation (18).Moreover, it is also associated with an increase in the incidence of depression, anxiety,

sleep disorders, daily fatigue, functional impairment, and social isolation, as well as a decrease in the quality of

life of the patients (19, 20).

Studies performed on patients with heart diseases have produced different results. For instance, Farajzadeh et al.

showed a relationship between hypertension and RLS in elderly people in Saqqez, Iran (9). Alternatively, some

studies have found no statistical relationship between these two variables (21, 22). Considering the important

association between aging and increased prevalence of cardiovascular diseases, and the varying findings of

different studies on the relationship between hypertension and RLS, This study (2017) aimed to determine the

relationship between hypertension and RLS in elderly people in Ilam, Iran.

MATERIALS AND METHODS:

In the present case-control study, 250 elderly participants (50 with high blood pressure and 200 with normal

blood pressure) in Ilam, Iran, were enrolled. For each elderly person with high blood pressure in the case group,

four elderly people with normal blood pressure were considered as controls. The subjects were included in the

study by a two-stage cluster sampling. For this purpose, six community health centers in Ilam were randomly

chosen, and an equal number of participants were selected from each center, using convenience sampling. The

inclusion criteria consisted persons of age, 65 years and older, those who consciously consented to participate in

the study, persons with no history of depression and antidepressants use, those with no history of admission to a

psychiatric institution, and those with absence of physical disabilities, such as blindness and deafness. The

exclusion criteria included having sleep apnea based on the Berlin questionnaire (11), history of

antihypertensive use, and neurological disease.

Data were collected from a demographic questionnaire, the Berlin questionnaire, the RLS screening

questionnaire (RLSSQ), and the blood pressure chart. The RLSSQ was designed by the International RLS Study

Group. The questions inquired regarding: 1. repeated movement of the legs, causing uncomfortable sensations

on the skin of the legs, 2. temporary relief of unpleasant symptoms by moving the legs, 3. the symptoms RLS

begin or worsen of inactivity or rest, and 4. the symptoms begin or worsen in the evening or at night. If any

participant had all four symptoms, they were considered as having RLS (16). The blood pressure of patients was

measured from the dominant hand, using a mercury sphygmomanometer after 15 minutes of rest in a sitting

position. In this study, systolic BP ≥ 140 mmHg and diastolic BP ≤ 90 mmHg was regarded as hypertension

(23).

Initially, the research objectives were explained to the participants, and their informed consent obtained for

patients. Participation in the study was voluntary. They were assured of the confidentiality and anonymity of the

information provided. Data were analyzed by the SPSS version 16 software using independent t-test, regression,

Mann-Whitney, and Chi-Square tests. Level of significance was considered at p ≤ 0.05.

RESULTS:

According to the findings of the present study, of 250 elderly people, 86 (34.4%) were males while 164 (65.5%)

were females; 163 (65.2%) were married while 87 (34.8%) were not. Regarding the state of drug abuse, 119

(47.6%) used cigarettes while 131 (52.4%) did not use cigarette. Also, 88 (35.2%) had jobs, while 162 (64.8%)

were unemployed. The mean age of participants was 71.62 ± 7.97 years, there was no significant difference

between the demographic characteristics of the elderly in the high BP and normal BP groups (P>0.05).


SP52-18

Table 1- Demographic profiles of the elderly in the city of Ilam, 2017

Variable High blood pressure Normal blood

pressure p-Value

Gender

Man 15(30) 71(35.5) 0.55

Female 35(70) 129(64.5)

Marital status

Married 29(58) 134(67) 0.24

No wife 21(42) 66(33)

smoking

Yes 24(48) 95(47.5) 0.99

No 26(52) 105(52.5)

job

Working 20(40) 68(34) 0.52

Unemployed 30(60) 132(66)

Table 2- Frequency and odds ratio of units According to on the presence or absence of RLS in

elderly with high and normal blood pressure

Variables High blood pressure Normal blood pressure

N (%) N (%)

RLS

Yes 66(33) 17(34)

No 134(67) 33(66)

p-value 0.58

Table 2 shows that 17 (34%) patients with hypertension had RLS while 33 (66%) had no RLS. Regarding

subjects with normal blood pressure, 66 (33%) were without RLS and 134 (67%) had no RLS. According to

Table 2, there was no relationship between hypertension and RLS (P>0.05).

DISCUSION:

This study determined the relationship between hypertension and RLS in elderly people in Ilam, in 2017. The

findings revealed no significant relationship between high blood pressure and RLS in elderly people. A study by

Ulu et al. (2015) in Turkey showed was no significant relationship between BP during sleep and RLS in

participants, 50 years and above (24). Devito et al. (2014) also found no significant relationship between

hypertension and RLS (25). Winkelmann et al. (2006) also observed no correlation between these two variables

(22). These are all consistent with the results of the present study.

However, several other studies have showed relationships between RLS and hypertension, which are

inconsistent with the results of this study. For example, Farajzadeh et al. reported a relationship between

hypertension and RLS in elderly people in Saqqez, Iran (26). In studies by Swanson et al (2011), on participants

with the mean age of 47 years (27) and by Sabic et al. (2015) on participants with mean age of 55 years (28), a

significant relationship was observed between hypertension and RLS.

One limitation of the present study was that RLS was diagnosed based on data obtained from the questionnaire

only, while in a previous study (26), a neurologist was recruited to diagnose RLS, in addition to data from the

questionnaire. Some strengths of this study included the matching of demographic profiles of participants, to

control any confounding effect, and excluding participants on antihypertensive, and those with sleep apnea

syndrome.


SP52-18

In conclusion, no significant relationship between RLS and hypertension was observed in the present study;

further studies are needed to be performed on participants from different cities in Iran to obtain more accurate

and reliable information.

Conclusion: Considering that no significant relationship was found between RLS and hypertension in the present study,

further studies are needed in different cities in Iran, to obtain more accurate and reliable information.

References :

1. Ali-Akbari F, Khalifehzadeh A, Parvin N. The effect of short time telephone follow-up on physical conditions and

quality of life in patients after pacemaker implantation. Journal of Shahrekord University of Medical Sciences.

2009;11(3):23-8. 2. Farzadmehr M, Fallahi Khoshknab M, Hosseini M, Khankeh H. The Effect of Nursing Consultation on

Anxietyand Satisfcation of patient's Family in Cardiac Surgical Intensive Care Unit. Journal of Nursing Education.

[Research]. 2016;4(2):57-64. 3. Tajbakhsh F, Hosseini MA, Rahgozar M. The Effect of Religious-Spiritual Care on Stress Post Surgery Coronary

Artery Bypass Graft Patients. Iranian Journal of Rehabilitation Research in Nursing. [Research]. 2016;2(4):57-65. 4. Oshvandi K, Keshmiri K, Salavati M, Emkanjoo Z, Musavi S. Effectiveness of education based on Orem’s self-

care model in self-care activity of patients with implantable cardioverter defibrillators. Journal of hayat. 2013;19(3):47-55. 5. Saki A, Hooshmand Bahabadi A, Asadi Noghabi AA, Mehran A. Comparison of face-to-face and electronic

education methods on anxiety in patients with acute myocardial infarction. Journal of hayat. 2014;20(1):6-14. 6. Borji M, Motaghi M. The Effect of Collaborative Care Model on Social Support and General Self-Efficacy of the

Elderly. Journal of Nursing Education. [Research]. 2017;5(1):22-9. 7. Borji M, Asadollahi K. Comparison between Perceived Misbehavior by Urban and Rural Elderlies. Journal of

Nursing Education. [Research]. 2016;4(3):41-50. 8. Borji M, Moradi M, Mahdian K, Bahman Pour K, Navkhasi S, Salimi E. Comparison of Social Participation Level

Between Older Adults With Assistive Mobility Devices and Those Without These Devices. Iranian Journal of Rehabilitation

Research in Nursing. [Research]. 2017;3(2):38-44. 9. Gheshlagh RG, Parizad N, Zahednezhad H, Sarokhani M, Sayehmiri K, Baghi V. Prevalence of Restless Leg

Syndrome in Iran: A Systematic Review and Metanalysis. Journal of Sleep Sciences. 2016;1(3):131-8. 10. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United

States, 1988-2000. Jama. 2003;290(2):199-206. 11. Farajzadeh M, Hosseini M, Mohtashami J, Chaibakhsh S, Zaghari Tafreshi M, Hajnasiri H. Studying relationship

between body mass index and obstructive sleep apnea in depressed elderly patients in Saqqez city in 2014. Medical Science

Journal of Islamic Azad Univesity-Tehran Medical Branch. 2016;26(2):116-22. 12. Woo E-k, Han C, Jo SA, Park MK, Kim S, Kim E, et al. Morbidity and related factors among elderly people in

South Korea: results from the Ansan Geriatric (AGE) cohort study. BMC Public Health. 2007;7(1):10. 13. Ferini-Strambi L, Walters AS, Sica D. The relationship among restless legs syndrome (Willis–Ekbom Disease),

hypertension, cardiovascular disease, and cerebrovascular disease. Journal of neurology. 2014;261(6):1051-68. 14. Tison F, Crochard A, Leger D, Bouee S, Lainey E, El Hasnaoui A. Epidemiology of restless legs syndrome in

French adults A nationwide survey: The INSTANT Study. Neurology. 2005;65(2):239-46. 15. Sforza E, Mathis J, Bassetti C. Restless legs syndrome: pathophysiology and clinical aspects. Schweizer Archiv für

Neurologie und Psychiatrie. 2003;154(7):349-57. 16. Farajzadeh M, Hosseini M, Ghanei Gheshlagh R, Ghosi S, Nazari M, Nahid K. Investigating the association

between Restless Leg Syndrome and depression in elderly. Iranian Journal of Rehabilitation Research in Nursing.

[Research]. 2016;2(3):18-26. 17. Atkinson M, Allen R, DuChane J, Murray C, Kushida C, Roth T. Validation of the Restless Legs Syndrome

Quality of Life Instrument (RLS-QLI): findings of a consortium of national experts and the RLS Foundation. Quality of Life

Research. 2004;13(3):679-93. 18. Kushida C, Martin M, Nikam P, Blaisdell B, Wallenstein G, Ferini-Strambi L, et al. Burden of restless legs

syndrome on health-related quality of life. Quality of Life Research. 2007;16(4):617-24.


SP52-18

19. Ghanei Gheshlagh R, Lanjavani T, Lazari N, Moslemi B. Comparison of the quality of life in pregnant women

with and without restless legs syndrome. Journal of Clinical Nursing and Midwifery. 2014;3(1):54-61. 20. Cotter PE, T O’Keeffe S. Restless leg syndrome: is it a real problem? Therapeutics and clinical risk management.

2006;2(4):465. 21. Ussavarungsi K, Kaplan J, Burger C, Arunthari V. Survey of restless legs syndrome in a pulmonary hypertension

population. The clinical respiratory journal. 2015;9(1):98-103. 22. Winkelman JW, Finn L, Young T. Prevalence and correlates of restless legs syndrome symptoms in the Wisconsin

Sleep Cohort. Sleep medicine. 2006;7(7):545-52. 23. Ghanei Geshlagh R, Baghi V, E A. The Relationship between Sleep Apnea and Hypertension in Women with

Gestational Diabetes. Iranian J Obstet Gynecol Infertil. 2014;16(85):18-24. 24. Ulu SM, Ahsen A, Akcı Ö, Yaman F, Demir K, Yaman G, et al. The relationship between dipping-non-dipping

arterial blood pressure pattern and frequency of restless leg syndrome with related factors. Anatol J Cardiol. 2015;15:284-8. 25. Vito K, Li Y, Batool‐Anwar S, Ning Y, Han J, Gao X. Prospective study of obesity, hypertension, high

cholesterol, and risk of restless legs syndrome. Movement Disorders. 2014;29(8):1044-52. 26. farajzadeh m, Ghanei Gheshlagh R, Zarei M, Fakhrooyan E, Rashadi H, Rezaei K. Investigating the Association

between Hypertension and Restless Legs Syndrome in Elderlies of Saqqez City in 2016. Iranian Journal of Rehabilitation

Research in Nursing. [Applicable]. 2017;3(3):48-55. 27. Swanson LM, Arnedt J, Rosekind MR, Belenky G, Balkin TJ, Drake C. Sleep disorders and work performance:

findings from the 2008 National Sleep Foundation Sleep in America poll. Journal of sleep research. 2011;20(3):487-94. 28. Sabic A, Sinanovic O, Sabic D, Galic G. Restless Legs Syndrome in Patients with Hypertension and Diabetes

Mellitus. Medical Archives. 2016;70(2):116.


SP53-18

Comparing Stress, Coping Strategies, and Quality of Life among Nurses Working in ICU

and Emergency Ward with Other Hospital Departments

Giti Shahbazi1, Masoumeh Otaghi2, Shabnam Shahbazi

3, Mohammad Parvaresh-Masoud

1- Psychology Department, Piam-Noor University of Ilam, Iran.

2-Nursing & Midwifery Faculty, Ilam University of Medical Sciences, Ilam, Iran

3- Nursing & Midwifery Faculty, Ilam University of Medical Sciences, Ilam, Iran.

4-Faculty of Paramedical sciences, Qom University of Medical Sciences, Qom, Iran.

*Corresponding Author E-mail: Shabnamshahbazi73gmail.com

Abstract

Background and objectives: Doing therapeutic jobs in which human relationships and individuals’ health status are

of importance can bring about a lot of stress. Among those working in healthcare centers, nurses are can suffer from

the highest levels of pressure at work. Thus, this study aimed for comparing stress, coping strategies, and quality of

life among nurses working in intensive care units, emergency wards, and other hospital departments.

Materials and Methods: The present study was of casual-comparative research type. Thus, the statistical

population of this study included all the nurses working within hospitals of the city of Ilam in Iran in 2016. To

conduct this study, a total number of 253 nurses (103 individuals from emergency wards, 47 people from intensive

care units, 103 nurses from other hospital departments) were selected using multi-stage cluster sampling method. To

meet the research objectives; Perceived Stress Scale (PSS) developed by Cohen et al., Coping Inventory for

Stressful Situations (CISS) by Endler and Parker, and World Health Organization Quality of Life (WHO-QoL)

instrument were used. Accordingly; MANOVA and ANOVA were employed to test the research hypotheses. The

data obtained were also analyzed through the SPSS Version 24 Software.

Results: Analysis of tests at a level of P=0.05 showed a significant relationship between the variables of task-

oriented coping style, stress, mental health, social relationships and environment among nurses working in intensive

care units, emergency wards, and other hospital departments; however, no significant difference was observed

between emotion-oriented coping style, avoidance-oriented coping style, and physical health among nurses working

in intensive care units, emergency wards, and other hospital departments.

Conclusion: Given that stressors and efficient coping styles can have impacts on the quality of life of nurses,

adoption of effective strategies by managers to improve working conditions and to reduce stress at work are of

paramount importance.

Keywords: Stress, Coping Strategies, Quality of Life, Nurses

Introduction

Doing therapeutic jobs in which human relationships and health status of individuals are of utmost importance can

cause a lot of stress. Among those working in healthcare centers, nurses can thereby suffer from the highest levels of

pressure at work (1). Although stress can be observed in all professions, this issue is of utmost significance in ones

associated with human health. Given its nature and quality, there is also evidence that nursing is considered as a

stressful profession (2) which has made stress as one of the issues of interest in nursing profession (3). It should be

also noted that stress not only imposes economic costs on society but also affects physical and emotional health

status. Besides, there is no doubt that not dealing with stress that is constantly affecting nurses can over time make

an organization deprived of well-motivated and high-spirited workforce and as a result damage and wear down the

existing talents fostered over the years(4). In fact, research studies have also demonstrated that one of the most

important factors threatening individuals’ mental health status is stress (mental pressure). Moreover, psychologists


SP53-28

believe that individuals pass through three stages of “warning”, “resistance”, and “collapse” as they are encountered

with mental stress and those who are not able to cope well with a variety of stressors can go further beyond the point

of tension and collapse in terms of physical and mental health and thus feel threatened (5). According to the theory

raised by Lazarus and Folkman (1988), coping indicates to a series of cognitive and behavioral activities and

processes to prevent, manage, or reduce stress and in this respect the ways of coping with stress and how to respond

it are more important than its nature (6). In this respect, Endler and Parker (1990) proposed three dimensions of

coping including task, emotion, and avoidance-oriented ones(7). Thus, decision-making to make use of a particular

type of such strategies are influenced by factors such as how people perceive events, how they feel dangers and

threats, and also how individuals understand the extent of exercising personal control over stressful situations. In

fact, when people feel that they have nothing to do in order to change the stressful situations that are out of their

control, they almost always adopt emotion-oriented approaches and change emotional responses to stressors. In

addition, when they find an opportunity to change such situations, they prefer to adopt task-oriented strategies in

order to reduce the stress raised by these situations through making changes into the given situations. The

avoidance-oriented strategy is also used when a person escapes from problems or denies their existence(8). One of

the variables associated with perceived stress and coping strategies among nurses is their quality of life which is one

of the fundamental concepts developed in positive psychology. The belief from the issue that scientific, medical, and

technological developments can improve life to the one related to personal, familial, and social welfare in which

society is combination of such developments along with values and individuals’ perceptions of welfare and

environmental conditions is among the primary sources of tendency towards quality of life(9). The quality of life is

also an extensive concept encompassing all dimensions of life including health. This expression is employed in

various political, social, and economic fields and it is of utmost use in medical studies containing different physical,

physiological, social, and spiritual dimensions from the views of most experts (10). The quality of life also refers to

the degree of an individual’s feeling of their ability to perform physical, emotional, and social functions. For

example, Pazhoiuheshpour (2013) in a study entitled “Investigating mental stressors considering the moderating role

of perceived social support in female nurses working in hospital emergency wards” found a significant relationship

between the variables of stress arousal, perceived social support as well as the one between job satisfaction and

perceived social support. Given that stressors can have an impact on efficiency and quality of life of nurses; it was

argued that adoption of effective strategies by managers to improve working conditions and reduce work-related

stress through involvement of the staff in decision-making, supervision support, lowered work shifts, and improved

working environment were of utmost importance (11). The research study by Fathi Ashtiani et al. (2014) entitled

“The effect of stress management and communication skills training on improved mental health status among nurses

and hospital staff” also revealed that stress management and communication skills training program could result in a

significant reduction in the mean scores of stress and anxiety among the individuals in the experimental group

compared with those in the control group (p˃0.01). However, there was not a significant difference between two

groups for the variable of depression (p=0.0861) (12). Besides, Khalvandi (2012) in an investigation in the same

field argued that hospital staff with task-oriented coping styles had more control over the amount of their stress and

also reported less stress at work. Nevertheless, the other group of the staff using emotion-oriented and avoidance-

oriented coping styles reported more work-related stress (13). In another study in 2006, Erfani reiterated that the

stress associated with hard work in both groups of nurses working in the ICU and other hospital departments did not

lead to any different effects; however, nurses experienced higher levels of stress compared with normal individuals

(4). Improved working environment were of utmost importance. In this respect in a research study, Takashi (2012)

suggested no relationship between individuals’ coping styles and varying degrees of perceived stress; however,

emotion and task-oriented coping styles had effects on understanding the severity of perceived stress (14). Nurse can

improve health status, so their role is very important (15-19) and skill nurse is importance (20). In the meta-analysis

study by Valizadeh et al in Iran, the prevalence of depression was high (21).In the few recent decades and due to

financial and global crises as well as endangered economic security worldwide, quality of life and promotion of

living standards in numerous countries have drawn a lot of attention to themselves especially among nurses living

away from their family environment in hospitals. Accordingly, the present study was to compare stress, coping

strategies, and quality of life among nurses in ICUs, emergency wards, and other hospital departments.


SP53-38

Materials and Methods

The method was of casual-comparative type. The statistical population were all nurses working in public hospitals in

the city of Ilam in 2016. To conduct this study, Similar to previous studie a total, number of 253 nurses (103

individuals from emergency wards, 47 people from the ICUs, 103 nurses from other hospital departments) were

selected using multi-stage cluster sampling method. To meet the research objectives, Perceived Stress Scale (PSS)

developed by Cohen et al., Coping Inventory for Stressful Situations (CISS) by Endler and Parker, and World

Health Organization Quality of Life (WHO-QoL) instrument (SF-36) were used.

Research Instruments

To measure the variables of this study; Perceived Stress Scale (PSS) developed by Cohen et al., Coping Inventory

for Stressful Situations (CISS) by Endler and Parker, and World Health Organization Quality of Life (WHO-QoL)

instrument (SF-36) were employed.

Perceived Stress Scale (PSS): The given scale was developed by Cohen et al. (1993). This questionnaire contains 14

items and each item is graded from 0 to 4 based on five-point Likert-type scale in which respondents are asked to

spell out their feelings and thoughts during one month. The minimum and the maximum scores obtained from this

scale are 0 and 56, respectively. The given scale is also a useful tool for measuring the overall levels of stress in

different age groups. In this respect, Mimura and Griffith (2004) in their research study on Japanese university

students found a Cronbach’s alpha coefficient equal to 0.88 for this scale(22) . Furthermore, Amin Yazdi (1998) in a

study reported the Cronbach’s alpha coefficient of 0.81(23) .

Coping Inventory for Stressful Situations (CISS) The given questionnaire was developed by Endler and Parker

(1999) and then it was translated by Akbarzadeh (1997) into Persian. It also contains 48 items whose responses are

set based on a Likert-type scale from Never (1) to Always (5).

The CISS covers three main themes of coping behaviors:

1. Task-oriented coping or active dealing with a problem for managing and solving it

2. Emotion-oriented coping or concentrate on emotional responses to a problem

3. Avoidance-oriented coping or escape from a problem

Given that this questionnaire is graded based on five-point Likert-type scale, the maximum and the minimum scores

for each item are from 5 to 0, respectively. The subjects are similarly required to answer all the items. If subjects do

not provide answers to 5 items or below, the researcher can choose 3 for these items but the questionnaire is not

scored if over 5 items are left without responses. The variation range of the scores assigned to the three coping

behaviors i.e. task-oriented, emotion-oriented, and avoidance-oriented is from 16 to 80. In other words, the

prevailing coping style for an individual is specified based on the score they receive from the given questionnaire. It

means the behaviors receiving higher scores are taken into account as an individual’s coping style. Endler and

Parker (1990) also reported the values between 0.8 and 0.9 for the internal consistency coefficients for this

questionnaire for varied normal samples(7) .

Reliability and Validity: To obtain the reliability of the CISS among university students, Cronbach’s alpha method

was used in which the values of task-oriented coping style for male and female participants were 0.092 and 0.085,

respectively. Such values for emotion-oriented coping among male and female participants were 0.082 and 0.085,

respectively; and they were 0.085 for male and 0.082 for female respondents in terms of avoidance-oriented coping

style. Using Cronbach’s alpha method, the validity coefficient of this questionnaire was also obtained in the study

by Ghoreishi at a high level (0.08133). Moreover, the given questionnaire was confirmed in the related studies


SP53-48

conducted in Iran. It should be noted that Pearson Correlation Coefficient was also employed to determine the

correlation of the factors in this questionnaire and thus the following results were obtained.

World Health Organization Quality of Life (WHO-QoL) Instrument: To measure the level of quality of life, the

WHO-QoL (short form) instrument was used. This scale examines four dimensions of individuals’ quality of life

including physical health, mental health, relationships with others, and perceived life environment (24). It should be

noted that the two dimensions of relationships with others and perceived life environment were considered in the

present study. To measure social relationships and life environment, 3 and 8 items were taken into account;

respectively. Moreover, one of the items associated with the dimension of social relationships was crossed out due to

cultural inconsistencies i.e. the item for the evaluation of the quality of sexual relationships among individuals. Each

item was also assigned with scores from 1 to 5. Therefore, the scores of the dimension of social relationships and

those for the dimension of life environment were from 2 to 10 and 8 to 40, respectively. The score for the validity of

the whole test and the scores for its sub-scales compared with the total scores and those for the sub-scales of the

General Health Questionnaire (GHQ) were reported to be at a desirable level in terms of their concurrent validity

(24).Furthermore, the internal consistency coefficient of the test measured by calculating the correlation coefficient

of each item with its relevant dimension was equal to 0.062 and 0.087 for the dimensions of social relationships and

perceived life environment, respectively. The Cronbach’s alpha coefficient was also reported between 0.073 to

0.089 for the four sub-scales and the whole scale (Nasiri & Razavi, 2006). In Iran, Nasiri (2006) similarly used three

methods of test-retest reliability (with three-week intervals) for 45 items (0.065), split-half reliability for 302 items

(0.087), and Cronbach’s alpha for 302 items (0.084) which all showed a desirable reliability. In the present study,

Cronbach’s alpha coefficient equal to 65% for 2 items within the dimension of social relationships and 0.077 for 8

items in the dimension of life environment as well as 0.088 for 23 items considering the whole scale were

calculated(25).

Method of Analysis: For analyzing the data, descriptive statistics (mean and standard deviation) and inferential tests

(MANOVA and ANOVA) were used. The data were also statistically analyzed through the SPSS 24 Software.

Findings

Table 1: Means and SD for the variables

Variable ICUs emergency wards Other departments

Mean Standard deviation Mean Standard deviation Mean Standard deviation

Task-oriented 33.97 5.038 28.61 3.064 31.27 4.216

Emotion-

oriented

29.55 3.341 32.74 3.867 28.12 3.960

Avoidance-

oriented

31.82 5.207 34.65 5.389 29.84 4.013

Stress 28.31 3.246 32.86 4.562 23.81 2.970

Mental health 15.38 2.927 10.57 2.147 15.97 3.538

Physical health 14.86 2.143 11.76 2.503 13.75 2.803

Social

relationships

12.77 3.795 9.20 1.576 11.84 2.629

Environment 12.63 2.867 9.38 1.986 11.32 2.271

The Table 1 illustrated mean and standard deviation for the variables of the study in three groups of nurses working

in ICUs, emergency wards, and other departments.


SP53-58

Table 2: Results of Kolmogorov-Smirnov test (K-S) to check the assumptions of normality of variables

Variable ICUs Emergency wards Other departments

Mean Standard deviation Mean Standard deviation Mean Standard deviation

Task-oriented 0.786 0.165 0.273 0.477 0.757 0.619

Emotion-

oriented

0.869 0.574 0.771 0.786 0.672 0.757

Avoidance-

oriented

0.678 0.289 0.596 0.557 0.777 0.582

Stress 0.572 0.351 0.695 0.633 0.828 0.826

Mental health 0.488 0.474 0.393 0.957 0.956 0.320

Physical health 0.592 0.262 0.762 0.375 0.987 0.258

Social

relationships

0.262 0.593 0.467 0.483 0.964 0.311

Environment 0.660 0.655 0.559 0.252 0.763 0.606

The results shown in Table 2 confirmed the Kolmogorov-Smirnov test results for examining the normality of the

dependent variables with a non-significance level (P>0.05).

Table 3: Results of the significant test of MANOVA for the main effect of the dependent variables

Variable est Value Significance level

Group

Pillay-Bartlett 0.616 37. 274 0.00

Wilks’ Lambda 0.597 37.274 0.00

Lali’s Hotelling 1.386 37.274 0.00

Roy’s Largest Root 1.386 37.274 0.00

The results in Table 3 revealed that the Wilks’ Lambda test on the effect of the group on the combination of the

components of the dependent variables was significant (P<0.001; F=37.274, Wilks’ Lambda=0.597). In other words,

there was a significant difference in at least one of the dependent variables among the nurses working in ICUs,

emergency wards, and other departments.

Table 4: Results of ANOVA on the scores for the dependent variables

Dependent variable

Sum of squares Degrees of freedom Mean squared F Significance level

Task-oriented 693.58 2 346.79 22.63

Emotion-oriented 756.48 2 378.24 24.86 0.053

Avoidance-oriented 792.31 2 396.15 23.89 0.061

Stress 538.61 2 269.30 18.96 0.001

Mental health 421.66 2 210.83 14.24 0.058

Physical health 452.34 2 226.17 15.28 0.000

Social relationships 463.26 2 231.63 16.31 0.003

Environment 520.63 2 260.315 18.32 0.002

A significant relationship was shown in Table 4 showed between task-oriented coping style, stress, mental health,

social relationships, and environment among nurses working in ICUs, emergency wards, and other departments.


SP53-68

However, no significant difference was observed between emotion-oriented coping style, avoidance-oriented

copying style, and physical health among nurses working in ICUs, emergency wards, and other departments.

Conclusion

This study aimed to compare stress, coping strategies, and quality of life among nurses working in ICUs, emergency

wards, and other departments. Thus, a significant relationship was shown between task-oriented coping style, stress,

mental health, social relationships, and environment among nurses involved in ICUs, emergency wards, and other

departments. Given that any changes in human life, both pleasant and unpleasant, require re-adjustments; the ways

adopted by individuals to cope with such changes are different depending on various situations. In general, coping

strategies are a set of efforts by an individual in order to change, interpret, and modify a stressful situation which can

consequently lead to reduced suffering caused by stress. The strategies employed by individuals to solve or

eliminate stressors include task, emotion, and avoidance oriented copings. The task-oriented coping is due to

changes in management as problems causing stress. This type of coping is focused on action and encompasses a

number of strategies such as information acquisition and collection, conflict resolution, planning, and decision-

making for change. Emotion-oriented coping style refers to efforts by an individual to regulate the emotional

consequences of stressful events and to achieve emotional and affective balance (24). Avoidance-oriented coping is

also a set of cognitive and behavioral efforts for reducing, denying, or ignoring intensive situations. In this regard, it

is argued that task-oriented coping can reduce mental stress; and vice versa, avoidance-oriented coping can increase

it. On the other hand, emotion-oriented coping is associated with reduced and increased levels of mental stress.

However, sources of stress can take many forms which sometimes affect individuals due to various situations and

sometimes stem from inner experiences such emotions. Although low levels of stress can have positive effects and

raise motivation and coping with problematic situations; its higher degrees can bring about anger, fear, frustration,

and depression (26). The severity of perceived stress is also considered as one of the major components of

explaining the possibility of coping strategies adopted by individuals in stressful situations. Thus; with regard to the

severity of perceived stress, a person adopts specific coping strategies when they believe in the negative physical,

social, and psychological effects of stress and its important consequences. Based on the two above-mentioned

variables, it is concluded that the higher the severity of perceived stress, the higher the possibility of coping actions

(5). Moreover, another component associated with the personal life of nurses is quality of life. In this respect; it is

argued that if nurses are endowed with better quality of family life, they can enjoy a better quality of life both in

their current life and within hospitals. Considering the issue of quality of life, health is of top priority even though

the concept of quality of life should be widely examined and reviewed in all dimensions. Given the negative

consequences of stress and working problems of nurses, administrators of hospitals and healthcare centers are

suggested to have specific programs such as holding psychotherapy workshops for stress management, adopt

strategies to lower stress including biofeedback and appropriate exercises, and also take steps in terms of stress

coping and reducing its damaging effects on nurses as a vulnerable group in society.

Acknowledgements

We hereby express our thanks and gratitude to the respected authorities in the School of Nursing as well as all

nurses working in public hospitals of the city of Ilam who sincerely cooperated during this project.

References

1. Li J, Lambert V. Job satisfaction among intensive care nurses from the People's Republic of China. International

Nursing Review. 2008;55(1):34-9.


SP53-78

2. Yousefi R, Namdari K, Adhamian E. A COMPARISON OF DEPRESSION AND OCCUPATIONAL STRESS IN PSYCHIATRICS

AND NON PSYCHIATRICS UNIT NURSES AND OFFICIAL EMPLOYEES. Journal of Nursing and Midwifery Urmia University of

Medical Sciences. [Research]. 2006;4(2):80-90.

3. Jex SM, Beehr TA. Emerging theoretical and methodological issues in the study of work-related stress. Research in

personnel and human resources management. 1991;9(31):l-365.

4. SAFAEE PZM, AREFI M. THE RELATION BETWEEN COPING STYLES AND PERCEIVED STRESS IN NURSES OF

EDUCATIONAL HOSPITALS IN KERMANSHAH UNIVERSITY OF MEDICAL SCIENCES. 2015.

5. Hudd SS, Dumlao J, Erdmann-Sager D, Murray D, Phan E, Soukas N, et al. Stress at college: Effects on health habits,

health status and self-esteem. College Student Journal. 2000;34(2):217-28.

6. Jafari A, Amiri Majd M, Esfandiary Z. Relationship between personality characteristics and coping strategies with job

stress in nurses. Quarterly journal of nursing management. 2013;1(4):36-44.

7. Endler NS, Parker JD. Multidimensional assessment of coping: a critical evaluation. Journal of personality and social

psychology. 1990;58(5):844.

8. Bond FW, Dryden W. Handbook of brief cognitive behaviour therapy: John Wiley & Sons; 2005.

9. Schalock RL, Brown I, Brown R, Cummins RA, Felce D, Matikka L, et al. Conceptualization, measurement, and

application of quality of life for persons with intellectual disabilities: Report of an international panel of experts. Mental

retardation. 2002;40(6):457-70.

10. Park K. Park's textbook of preventive and social medicine. 2007.

11. Adib-Hajbaghery M, Khamechian M, Alavi NM. Nurses’ perception of occupational stress and its influencing factors: A

qualitative study. Iranian journal of nursing and midwifery research. 2012;17(5):352.

12. Mazlom Sr, Darban F, Vaghei S, Modarres gharavi M, Kashani lotfabadi M, Shad M. The effect of Stress Inoculation

Program (SIP) on nurses’ Perceived stress in psychiatric wards. Evidence Based Care. 2012;2(1):35-44.

13. Vaezfar S, Azadi M, Akbari Balootbangan A, Rahimi M. The role of coping styles and self-efficacy in nurses job stress in

hospital. Iranian Journal of Psychiatric Nursing. 2014;2(2):22-32.

14. Takashi. Examine the relationship between coping styles with stress. New York: MC Grow Hil. 2012;782(6):520-9.

15. Borji M. Investigating the effect of home care on death anxiety in patients with gastrointestinal cancer. Govaresh.

2017;22(2):131-2.

16. Motaghi M, Borji M, Moradi M. The effect of orange essence aromatherapy on anxiety in school-age children with

diabetes. Biomedical and Pharmacology Journal. 2017;10(1):159-64.

17. Ghadiri M, Motaghi M. Homeopathy Impact on Physical Health Aspects of Quality of Life of Patients with Chronic

Headache in Isfahan in 2015. Biomedical and Pharmacology Journal. 2016;9(1):269-74.

18. Salehi M, Motaghi M. The Effect of Continuous Care Model on Care Burden and Coping Behavior of Diabetic Older

Adults’ Caregivers in Poldokhtar City. Indian Journal of Forensic Medicine & Toxicology. 2018;12(2):204-9.

19. Kazeminezha B, Taghinejad H, Borji M, Seymohammadi R. The Effect of Self-Care on Glycated Hemoglobin and Fasting

Blood Sugar Levels on Adolescents with Diabetes. J Compr Ped. [Research Article]. 2018;In Press(In Press):e62661.

20. Borji M, Tarjoman A, Taghi Nejad H, Meymizade M, Nariman S, Safari S. Relationship between Knowledge-Skill and

Importance of Physical Examination for Children Admitted to Infectious Wards: Examining Nurses’ Points of View. J Compr Ped.

[Research Article]. 2018;9(1):e63292.

21. Valizadeh R, Veisani Y, Delpisheh A, Kikhavani S, Sohrabnejad A. Major Depression and Psychiatric Disorders in Iranian

Prisoners Based on a Clinical Interview: A Systematic Review and Meta-Analysis. Shiraz E-Medical Journal. 2017(Inpress).

22. Ghorbani N, Bing MN, Watson P, Davison HK, Mack DA. Self-reported emotional intelligence: Construct similarity and

functional dissimilarity of higher-order processing in Iran and the United States. International Journal of psychology.

2002;37(5):297-308.

23. Mohammadi-Yeganeh L, Bastani F, Feizi Z, Agilar-Vafaie M, Haghani H. Effect of stress management education on

mood and perceived stress among oral contraceptive pill users. Iran Journal of Nursing. 2008;21(53):63-73.

24. Vahedi S. World Health Organization Quality-of-Life Scale (WHOQOL-BREF): analyses of their item response theory

properties based on the graded responses model. Iranian journal of psychiatry. 2010;5(4):140.

25. van Berkel HK. The relationship between personality, coping styles and stress, anxiety and depression. 2009.

26. Holahan CJ, Moos RH, Holahan CK, Brennan PL, Schutte KK. Stress generation, avoidance coping, and depressive

symptoms: a 10-year model. Journal of consulting and clinical psychology. 2005;73(4):658.


SP54-18

Effect of Physical Activity Promotion Program on Life

Satisfaction among the Rural Elderly

Zahra Hori1, Sima Mohammad Khan Kermanshahi2, Robabe Memarian3

1. MS in Geriateric Nursing, School of Medical Sciences, Tarbiat Modares University, Tehran, Iran

2*.Associate Professor of Nursing Department, School of Medical Sciences, Tarbiat Modares University,

Tehran, Iran

3. Assistant Professor of Nursing, Department, School of Medical Sciences, Tarbiat Modares University,

Tehran, Iran

* Corresponding author, Email: [email protected]

Abstract

Introduction: Huge differences exist in aging between rural and urban populations currently in most

communities, and villages have usually older age structure. The life satisfaction (LS) decreases slowly with age,

which can be affected by physical activity. The purpose of this study is to investigate the effect of physical

activity promotion on the life satisfaction among the rural elderly.

Materials and methods: The present quasi-experimental study was conducted on two case (n = 30) and control

(n = 32) groups with non-random selection of elderly people from two villages of Chalab and Changuleh in

Mehran County, Ilam Province, Iran, in 2016-2017. Data collection tools were demographic information

questionnaire and Life Satisfaction Index-Z (LSI-Z) questionnaire whose validity and reliability were measured.

The physical activity promotion program was accomplished in four steps including identification, planning,

implementation and evaluation. The designed physical activity promotion program was implemented for the

case group, and resulting data were gathered before and three months after intervention and then analyzed using

SPSS 16 software.

Results: Based on the Chi-square test, the case and control samples were homogeneous for demographic

variables (P>0.05). Paired t-test showed a significant difference in the mean life satisfaction score before

intervention (11.90) and after three months (15.33) in the case group (P<0.05) and no significant difference in

the mean life satisfaction score before intervention (15.33) and after three months (14.91) in the control group

(P>0.05).

Conclusion: The level of life satisfaction was increased in elderly people who performed the physical activity

program (case group) compared to those who did not (control group). It is recommended to apply the program

designed to promote local physical activity for the elderly in different regions of the country.

Keywords: Rural Elderly, Physical Activity, Life Satisfaction (LS)

INTRODUCTION

Old age is a biological process common to all living beings. In fact, all humans start aging from birth(1). Aging

is one of the human life cycles along with a kind of biological, physical and mental maturity. In other words, the

aging is a biological fate with a reality longer than history(2).

Population aging is a pervasive phenomenon affecting all countries with different severity and weakness(3).

There were nearly 205 million elderly people around the world in 1950; the population of elderly people was

tripled 50 years later and reached 606 million. In the first half of the current century, it is projected that the

world's elderly population will reach two billion by 2050. The UN estimations for the period 2025-2030 show

that the elderly population in this period will have a growth rate equal to 3.5 times more than the total

population growth (2.8% vs. 0.8%)(3). Today, many developed countries have an aging population structure

while some developing countries are on the verge of entering the aging population and many of these countries

mailto:[email protected]


SP54-18

still have a very young population structure(4). However, in the population transfer process, these countries are

expected to undergo such a process(5, 6). The census in 2011 in Iran revealed that the elderly accounted for

8.2% of the country's population.

Since an active old age is a challenge today, all dimensions of physical, mental, social, economic, and spiritual

health of life should be considered in order to achieve active and healthy aging. It is insufficient to pay attention

only to promote the life expectancy and longevity, but the quality of life should be regarded as well (7). The life

satisfaction is one of the mental dimensions of quality of life and expresses the positive attitude of the individual

towards the world of life (2, 8, 9). Actually, the life satisfaction describes an individual's assessment of various

aspects of life.

Most people in old age and disability experience several problems, including the reduction of opportunities for

social communications and loneliness, reduced physical abilities, physical illnesses, changing the body's

response to drugs, reducing income and economic difficulties, experiencing important events such as retirement,

staying in nursing homes, and so on. These conditions influence their life satisfaction(10, 11). In fact, the life

satisfaction decreases slowly with age, due to the descending trend in physical and mental health status in the

elderly(9, 12). Many factors affect the level of life satisfaction such as individual, economic, social, cultural,

physical activity and physical health.

In addition, in assessing the factors effective in the life satisfaction of the elderly, although the role of physical

activity has been proven in promoting the optimal health(13), but the promotion of physical activity of the

elderly should be based on a holistic approach according to the physical, psychological and social conditions.

Meanwhile, according to World Health Organization (2008), physical inactivity rate in countries such as the

United States and the Eastern Mediterranean region (including Iran) has been found higher than other regions of

the world. Reportedly, 50% of women had inadequate physical activity while the proportion of physical

inactivity in men was 40% in the United States and 36% in the Eastern Mediterranean region(14). Estimation of

the statistics in 2008 in Iran on the risk factor of inactive behavior on average was about 35.7% (25.2% of men

and 46.5% of women); as well, 72% of deaths were due to non-communicable diseases (which can be reduced

effectively by the physical activity)(15), which is higher than the global mean. Therefore, it is essential and vital

to increase the level of physical activity.

Studies have demonstrated that rural elderly differ from the elderly in urban areas in various aspects, such as

educational level, economic status, access to health care services and access to clean air(16). On the other hand,

the specific economic and social factors of the rural environment, the inappropriate use of health services and

the low standard of living in rural elderly lead to an increase in their lack of life satisfaction than in their urban

counterparts (17). Nursing intervention can improve patient (18, 19). While the general belief is that rural elders

have good physical activity, the rural elderly people in some regions currently have incomplete rural and

traditional life and have no access to urban amenities such as elderly community and cultural centers, decreasing

physical activity of the rural elderly. Since the results of the study of urban elderly life cannot be generalized to

rural elderly, this study aimed to investigate the effect of the physical activity promotion program on the level of

life satisfaction in rural elderly people.

MATERIALS AND METHODS

The present quasi-experimental study was conducted in 2016-2017 on 64 elderly aged over 65 years (with

medical and health records) at the health centers from two villages of Chalab and Changuleh in Mehran County,

Ilam Province, Iran. These two villages, located 10 km from each other, were selected non-randomly (by

convenience sampling method) according to the same climate and geographical location, lifestyle and dialect.

Randomly, the village of Changuleh was then considered as the control group and the village of Chalab as the

case group. Pre and post interventions were done in the two groups to determine the effect of the physical

activity promotion program as an independent variable on the level of rural elderly life satisfaction as a

dependent variable. In this study, the sample size was estimated to be about 15 people, according to the results

of a similar study by Heidari et al. aiming to investigate the effect of self-care training program on quality of life

of elders in 2012 (20)and using the Pukak Formula. In order to perform statistical analyses and consider

probability of attrition, 64 subjects According to previous reviews (32 people in each control and case group)

were enrolled in the study based on the inclusion criteria, including willingness to participate in the research,


SP54-18

age 65 or older, having medical records in the rural health centers, residing in the village during the intervention,

mental health (referring to elderly medical records) and physical ability to participate in activities designed for

program. In the case group, two people were excluded from the study; one because of catching malignancy and

leaving the village for treatment and the other due to the death of daughter and unwillingness to participate in

activity program. Thus, the case group consisted of 30 subjects.

In this research, the data collection tools were: 1- Demographic information questionnaire designed by using

previous studies on the life satisfaction and relevant factors affecting elderly living conditions including age,

marital status, educational level, occupational status, how to live the elderly with other family members, elderly

income level, type of insurance support, history of specific disease, history of hospitalization, history of

smoking and drug use. 2- The 13-item life satisfaction index-Z (LSI-Z) questionnaire that is widely used to

measure the life satisfaction of elderly people, scoring as 0, 1 and 2. Hence, the life satisfaction score as

calculated between 0-26. Higher scores mean more satisfaction. A score between 0 and 9 expresses a low level

of life satisfaction, a score between 9 and 13 indicates a level of moderate life satisfaction, and a score higher

than 13 states a high level of life satisfaction. The validity and reliability of the tool were measured. Tagharrobi

et al. (2010) studied the life satisfaction index-Z on 75 Iranian elderly people over 60 years referring to two

health centers in Kashan and applied the method of known-groups comparison as a kind of construct validity to

determine the validity of the questionnaire.

The questionnaire reliability coefficient was 0.79 using Cronbach’s alpha coefficient and unequal spearman

brown, as well as was calculated 0.78 using the two-step cluster method with Guttman's formula. In this study,

the reliability coefficient of the questionnaire was calculated to be 0.74 using Cronbach's alpha method with

unequal spearman brown formula. In the present research, after obtaining approval from authorities of the two

rural health centers of Chalab and Changuleh, the medical records of the elderly were firstly reviewed and then

the names and phone numbers of the research units were extracted to contact with one of the family members

for attending the center. Blood pressure and FBS were measured in order to attract the participation of the

elderly in both groups and were registered in their medical records. Informed consent to participate in research,

demographic profile and life satisfaction questionnaires were completed in both groups. No intervention was

performed for the control group and the program designed to promote physical activity was carried out for 3

months from 25 January 2017 to 26 April 2017 for the case group.

The physical activity promotion program was fulfilled in four steps including identification, planning,

implementation and evaluation.

First step: identification

1- The living environment, rural amenities and supportive resources were explored. Then, clergymen, physicians

and health providers in the rural health clinical centers and rural municipality were identified to cooperate as

well as to encourage elderly for participating in the physical activities of this study, and their collaboration was

used to carry out the program.

2- The physical activity of each elderly was recognized quantitatively and qualitatively using the PASE

(Physical Activity Scale for Elderly) questionnaire and asking questions on type of related favorites and desires.

Thus, it was found that the elderly favorite activities included handicrafts (including Jajim weaving, spinning,

wool weaving and Chit weaving), planting vegetables, exercising, walking and group travel. Almost all elderly

people preferred group sports and recreational activities compared to individual ones. The ongoing activities of

the elderly included treating livestock or pets, housekeeping, reading the Quran or other books, watching local

TV channels, baking or preparing local yogurt and doogh, participating in voluntary and benevolent activities

outside the home such as shopping, shopkeeping, helping neighbors in constructing concrete masonry unit and

handling livestock. The results of studying the physical activity of the elderly according to the PASE

questionnaire showed that most elderly people had no regular physical activity on a daily basis. All case group

elderly in this study received the score less than 1.3 of physical activity. Concerning the barriers to perform

these activities, the elderly referred to items such as skeletal pain, vision problems, fear of injury and falling,

feeling disability to perform physical activity and disagreement with the children.

3- The health status and individual limitations of the elderly were studied by the researcher as a nurse using the

elderly recognition survey form. According to the study results, the elderly who needed caregivers or the use of


SP54-18

a cane or an inhaler or other drug during the course of the activity were identified in order to provide conditions

for the use of these items.

Second step: planning

According to the first step summary, three categories of activities included leisure activities, housekeeping, and

voluntary and occupational activities were designed in the form of the physical activity promotion program to

offer seniors (Table 1). The elderly were divided into 4 groups of 8 to facilitate group programs.

Third step: implementation of the program:

This phase included all interventions to maintain, promote and initiate new physical activities for the elderly as

educational, emotional and instrumental supports. The nurse provided the training program to the elderly and

caregivers at this phase to develop mental fitness and positive attitude to physical activity, to be aware of its

benefits in physical and mental health, and to maintain independence. A group of caregivers was requested to

accompany the elderly in out-of-home activities in order to prevent damage. The family in this study had a

supportive role that made the opportunity for the elderly to do some homemaking activities performed

previously by elderly who had been forbidden now because of aging or thinking of disability or difficulty in

doing activities to help promote the physical activity of elderly. The clergymen in addition to lectures

encouraged the elderly and their family members to collaborate with them. The physicians and health care

providers at the health clinical centers visited the elderly to examine the health status, if necessary, cooperated

with the study on the need for individual activities and recommended exercises for the elderly. The rural

municipality also contributed to the program for the provision of vegetable seeds and vehicles for group travels.

The group actions arranged for the elderly included weekly group exercising, as well as group walking and

travelling programs every two weeks. During activities, the elderly people with problems such as skeletal pain

or other barriers were trained to use the necessary medications, the use of knee brace, suitable shoes, canes and

other supportive devices as well as inform the researcher in case of fatigue or other physical discomfort to solve

these problems through the rest and the necessary support.

Individual activities were based on the personal differences of the elderly in terms of type of activities (exercises

trained to the elderly at least twice a week), sitting activities (watching TV and local channels or handicrafts),

gardening activities (irrigation and harvesting and planting), walking in the courtyard or outdoors and

homemaking.

Table 1- Elderly physical activity program The main groups of physical activities

Activities related to each group

Leisure activities and

exercises

Handicrafts: mat weaving and black tent fabric (the required equipment and materials were prepared by

families and rural municipality based on the coordination)

Planting vegetables or cucurbits that were provided by seeding in the courtyard of small gardens

constructed at the elderly house

Walking: jugging out of the house, walking in the courtyard, group walking for about 1 km (roundtrip) held

on Thursdays every two weeks

Pet walking

Individual and group daily exercise (in collaboration with the rural health clinics at the health center one

day a week for the male elderly and one day for the female elderly)

Participation in a group travel special for elderly people (coordinated with Basij)

Homemaking activities

Light homemaking activities such as dishwashing and dusting

Heavy homemaking activities like washing windows and carrying wood and sweeping

Home repairs

Caring for another person

Voluntary or occupational

activities

Helping others in dealing with livestock, etc. (if possible by group assistance)

Assistance in carrying out religious affairs and occasions (in the mosque and Husseinieh of village)

Handling livestock and pets

Fourth step: evaluation

Elderly people were evaluated during the study by the PASE tool. The physical activity level of the elderly was

measured one week, two weeks, one month, two months and three months after the interventions and compared


SP54-18

with the baseline PASE score to follow up the trend of the elderly physical activity. Elderly problems related to

program were identified and resolved by receiving their feedback. To assess the effect of the program on the life

satisfaction of the elderly, the LSI-Z questionnaire was completed in two case and control groups before and

after intervention. Data were analyzed by SPSS version 16 software using Chi-square, independent t-test, paired

t-test. In order to consider ethical considerations, the physical activity promotion program was implemented

after the research in the control group and the necessary training was provided for them.

RESULTS

In order to control the confounding factors, the case and control groups were matched for demographic profile

such as age, sex, marital status and educational level. As shown in Tables 2 and 3, the Chi-square and

independent t-test showed no statistically significant difference in the demographic variables between the two

groups. As shown in Table 4, the mean life satisfaction scores in the control group before and after the

intervention indicated no significant difference based on paired t-test (P>0.05). The mean life satisfaction scores

in case group before and after intervention was significantly different (P<0.05) by using paired t-test. In other

words, the mean life satisfaction score in the case group increased from 11.90 before the intervention to 15.33

after the intervention.

Table 2- Mean and standard deviation of elderly in two groups of control and case based on age, sex,

height and weight

Variables Groups

Independent t-test Control (mean±SD) Case (mean±SD)

Age 73.25±5.59 73.13±6.15 P=0.94

Sex 161.24±29.89 163.23±8.83 P=0.33

Weight 70.39±11.80 63.80±11.76 P=0.87

Table 3- Absolute and relative frequency of elderly people in two groups of control and case based on study demographic variables

Demographic variables

Control Case Chi-

square test Absolute

frequency

Relative

frequency

Absolute

frequency

Relative

frequency

Sex Male 21 66 20 67

P=0.93 Female 11 34 10 33

marital status

Married 24 75 20 67

P=0.47 Deceased

spouse 8 25 10 33

Educational

levels

Illiterate 28 88 29 97

P=0.19 Primary

school 4 12 1 3

Table 4- Comparison of mean and standard deviation mean life satisfaction scores of rural elderly before and after intervention in each control and case group

Groups Control

Paired t-

test

Case

Independent t-

test Time of

study

Before

intervention

After

intervention

Before

intervention

After

intervention

mean±SD mean±SD mean±SD mean±SD

Life

satisfaction 15.13±4.48 14.91±4.71 P=0.165 11.90±4.25 15.33±3.92 P=0.000

Based on the results of Table 4, the mean life satisfaction in the control group was 15.13 ± 4.48 before the

intervention and 14.91 ± 4.71 after the intervention. According to the paired t-test, there was no significant

difference in the mean life satisfaction score in the control group before and after the intervention (P>0.05) and


SP54-18

the level of life satisfaction score in this group was the same before and after the intervention. Moreover, the

mean life satisfaction in the case group before and after the intervention was 11.94 ± 4.25 and 15.33 ± 3.92,

respectively. According to the paired t-test, there was a significant difference in the mean life satisfaction score

in the case group before and after the intervention (P<0.05). In other words, the life satisfaction score in this

group was not the same before and after the intervention.

DISCUSSION

The aim of this study was to determine the effect of physical activity promotion program on the level of life

satisfaction of rural elderly within two case and control groups before and after interventions. The dependent

variable in this research is life satisfaction of elderly people. Since some variables such as sex, age, educational

level and occupation affect life satisfaction, the samples were homogenized in terms of demographic

characteristics.

According to Table 4, there is a significant difference in the mean life satisfaction score of the case group before

and after the intervention (P<0.05). The mean life satisfaction score respectively before and after the

intervention was 11.90 ± 4.25 and 15.33 ± 3.92 in the case group as well as 15.13 ± 4.48 and 14.91 ± 4.71 in the

control group.

The physical activity is considered to be a health-promoting factor that can affect the physical and mental health

of individuals, including the elderly(21). The health is a means by which human beings can achieve life

satisfaction(22). The life satisfaction is one of the mental dimensions of quality of life. Many studies examining

the quality of life also pointed out to the level of life satisfaction (23). The results of some studies have reported

greater in older people with the ability to perform physical activities, daily activities of life, regular walking,

recreational activities and leisure(24, 25).

Concerning the level of life satisfaction of the elderly, the majority of subjects in this study had moderate and

high level of satisfaction. In general, 53% of the elderly had high level of satisfaction and 23% had moderate

satisfaction before intervention, as well as 63% had high satisfaction and 27% had moderate satisfaction after

intervention.

The study of Sanaee et al. (2013) on the type of physical activity expressed that the physical activities in leisure

time had an effect on all life quality indices such as life satisfaction [49]. Therefore, this conclusion suggests

that the active participation of the elderly in leisure time has a greater effect on their life satisfaction. Older

people usually have less physical activity due to their higher age and physical condition, allowing them to spend

further hours without physical activity. Lack of the physical activity at such times leads to adverse physical and

psychological complications. If they can spend their leisure time thoroughly as planned activity, their life

satisfaction will be increased and thus they will provide a good quality of life. Additionally, Sanaee et al.

determined that leisure time physical activity have the greatest impact on the quality of life. This result shows

that regular physical activity and sports help the elderly to achieve the satisfactory level of the quality of life

[49]. In the present study, the physical activities related to leisure time and then exercises were most welcomed

by the elderly. Almost all elderly in the case group welcomed leisure activities, including group travel to

religious sites and recreational places, and the activity of planting vegetables, as well as 85% of these elderly

people achieved the level of physical activity necessary for the program by participating in group exercise and

group walking. It appeared to have had the greatest impact on increasing the life satisfaction after three months

of intervention.

In this study, the support of family, health care providers and physicians from physical activity promotion

program in the villages by encouraging the elderly, creating opportunities to promote physical activity in the

elderly and increasing their self-efficacy and independency predisposed increasing life satisfaction of the

elderly. Borhaninejad et al. (2015) found that positive changes in the level of physical activities could increase

the self-efficacy and independence of the elderly and contribute them to control the many complications of old

age and various treatments.

During the current study, 50% of elderly women with the restart of handicrafts performed previously achieved

desirable physical activity throughout the day. Following the physical activity, they expressed the feeling of

pleasure and happiness aroused by a product-related activity, which seems to have been effective in increasing


SP54-18

the level of female satisfaction. Soury et al. (2016) by investigating the effect of physical activity on quality of

life in older women in Kermanshah Province (Iran) demonstrated that the physical activity could promote the

quality of life of the elderly. Furthermore, the active older women had better general health compared to inactive

group [48].

On the basis of our results, 80% of the elderly participating in the study performed the regular physical activities

and group exercise and 65% of them conducted individually the trained physical activities at home. Ross et al.

(2009) (26) and Reid et al. (2010) reported that elderly people with regular physical activities had better quality

of life and more independence in their lives. Also, Aghanoori et al. (2011) by assessing the quality of life of

elderly people in Markazi Province (Iran) showed that active elderly people had better physical and mental

health than those who did not exercise, improving the level of life satisfaction and quality of life in these elderly

people(27). One of the out-of-control limitations of this study was the elderly emotional and mental states when

answering questions on the life satisfaction.

CONCLUSION

According to the present findings, the level of life satisfaction was increased in the elderly of case group who

performed the physical activity program compared with the control group. In other words, increasing the level

of physical activity in the case group led to improved level of life satisfaction. Regarding the results of this

study, it is suggested that the physical activity promotion program should comply with the health status,

concerns and interests of the elderly, should be designed in a local and cost-effective manner, and should be

used at elderly activity centers, elderly care centers and other communities in different regions of the country.

Additionally, it is proposed to establish facilities for physical activities and camps, sports and group walking

programs suitable for the elderly to promote their physical activity. The evaluation of the effect of the physical

activity promotion program on any of these factors affecting the life satisfaction (such as mental health, social

roles, etc.) and their relationship with the life satisfaction in the rural elderly could be considered in future

researches.

ACKNOWLEDMENT

The current research has been adopted from the M.Sc. thesis in Geriatric Nursing with tracking code of

1296063. Hereby, the authors would like to thank and appreciate the Deputy of Research, School of Medical

Sciences, Tarbiat Modares University, Tehran, Iran, and the elderly living in the two villages of Chalab and

Changuleh in Ilam province, as well as those who collaborated in the implementation of this research.


SP54-18

References

1. Borji M, Tarjoman A. Investigating the effect of religious intervention on mental vitality and sense of loneliness among the elderly referring to community healthcare centers. Journal of religion and health. 2018:1-10.

2. Salehi M, Motaghi M. The Effect of Continuous Care Model on Care Burden and Coping Behavior of Diabetic Older Adults’ Caregivers in Poldokhtar City. Indian Journal of Forensic Medicine & Toxicology.

2018;12(2):204-9.

3. Laatar R, Baccouch R, Borji R, Kachouri H, Rebai H, Sahli S. Ramadan fasting effects on postural control in the elderly: a comparison between fallers and non-fallers. Journal of religion and health. 2019;58(1):28-40.

4. Bakhtiari A, Yadollahpur M, Omidvar S, Ghorbannejad S, Bakouei F. Does Religion Predict Health-

Promoting Behaviors in Community-Dwelling Elderly People? Journal of religion and health. 2018:1-13.

5. Motalebi SA, Loke SC. Efficacy of progressive resistance tube training in community dwelling older adults: a pilot study. International Journal of Gerontology. 2014;8(4):213-8.

6. Morgan LA, Perez R, Frankowski AC, Nemec M, Bennett CR. Mental illness in assisted living: challenges for quality of life and care. Journal of housing for the elderly. 2016;30(2):185-98.

7. Masoudi R, Soleimani M, HASHEMI NA, Qorbani M, POUR DA, Bahrami N. The effect of family centered empowerment model on the quality of life in elderly people. 2010.

8. Ghadiri M, Motaghi M. Homeopathy Impact on Physical Health Aspects of Quality of Life of Patients with Chronic Headache in Isfahan in 2015. Biomedical and Pharmacology Journal. 2016;9(1):269-74.

9. Hatefi MAAT, A, Borji, M, Prevalence of Depression and Pain among Patients with Spinal Cord Injury in Iran: a systematic review and meta-analysi, Trauma Monthly Journal, 2019, In press.

10. Bazargan R. Health facilities and welfare of elderly homes. Master's thesis of nursing science: Tehran

University of Medical Sciences (In Persian). 1991.

11. Bishop A, Martin P, Poon L. Happiness and congruence in older adulthood: A structural model of life satisfaction. Aging and Mental Health. 2006;10(5):445-53.

12. Meléndez JC, Tomás JM, Oliver A, Navarro E. Psychological and physical dimensions explaining life satisfaction among the elderly: A structural model examination. Archives of Gerontology and Geriatrics.

2009;48(3):291-5.

13. McNaughton SA, Crawford D, Ball K, Salmon J. Understanding determinants of nutrition, physical activity and quality of life among older adults: the Wellbeing, Eating and Exercise for a Long Life (WELL) study. Health and quality of life outcomes. 2012;10(1):109.

14. Organization WH. Physical inactivity: a global public health problem. 2010. URL www who int/dietphysicalactivity/factsheet_inactivity/en/ Part I APPENDIX. 2012.

15. Organization WH. Global health risks: mortality and burden of disease attributable to selected major risks: World Health Organization; 2009.

16. Ahn YH, Kim MJ. Health care needs of elderly in a rural community in Korea. Public Health Nursing. 2004;21(2):153-61.

17. Cleary KK, Howell DM. Using the SF-36 to determine perceived health-related quality of life in rural Idaho seniors. Journal of allied health. 2006;35(3):156-61.

18. Abdi A, Tarjoman A, Borji M. Prevalence of elder abuse in Iran: a Systematic review and meta-analysis. Asian Journal of Psychiatry. 2018;39:120-7.

19. Hatefi M, Tarjoman A, Borji M. Do religious coping and attachment to god affect perceived pain? Study of the elderly with chronic back pain in Iran. Journal of religion and health. 2019:1-11.

20. Heidari M, Shahbazi S. Effect of self-care training program on quality of life of elders. Iran Journal of Nursing. 2012;25(75):1-8.

21. von Wichert P. The importance of atmospheric heat waves for health service in already altered people.

Medizinische Klinik (Munich, Germany: 1983). 2008;103(2):75-9.

22. Ghaffari G, Omidi R. Quality of life, social development indicator. Tehran: Shirazeh. 2009.

23. Campbell A, Converse PE, Rodgers WL. The quality of American life: Perceptions, evaluations, and satisfactions: Russell Sage Foundation; 1976.


SP54-18

24. Osada H, Shibata H, Haga H, Yasumura S. Relationship of physical condition and functional capacity to

depressive status in person aged 75 years. [Nihon koshu eisei zasshi] Japanese journal of public health. 1995;42(10):897-909.

25. Subaşı F, Hayran O. Evaluation of life satisfaction index of the elderly people living in nursing homes. Archives of Gerontology and Geriatrics. 2005;41(1):23-9.

26. Ross KM, Milsom VA, Rickel KA, DeBraganza N, Gibbons LM, Murawski ME, et al. The contributions of weight loss and increased physical fitness to improvements in health-related quality of life. Eating behaviors. 2009;10(2):84-8.

27. Reid KJ, Baron KG, Lu B, Naylor E, Wolfe L, Zee PC. Aerobic exercise improves self-reported sleep and

quality of life in older adults with insomnia. Sleep medicine. 2010;11(9):934-40.


SP55-18

Comparison of effectiveness of Shock Index Score and Trauma and Injury

Severity Score in Predicting Mortality in Patients

Azita bandani1, Rostam jalali

2, Mohammad Rasoul Khazaei

3 ,Mansour Resaei

4

1MSc Critical care Nurse, Faculty of Nursing and Midwifery, Kermanshah University of Medical Sciences,

Kermanshah-Iran.

2 PhD of Nursing, Faculty of Nursing and Midwifery, Kermanshah University of Medical Sciences,

Kermanshah-Iran.( corresponding author: email: [email protected] )

3 Fertility and Infertility Research Center,Kermanshah University of Medical Sciences, Kermanshah, Iran

4 PhD of Biostatistics, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah-Iran.

Abstract

Introduction: The damage caused by acute energy transferor lack of heat and oxygen, defined as trauma, which

leads to the death of people under44years.

Objective: determining the performance of Shock index and Trauma and Injury severity score in predicting

mortality in patients referred to the Ayatollah Taleghani hospital in Kermanshah .Materials and Methods: This

retrospective cohort analysis was carried out on the files of the patients with trauma admitted to the emergency

ward of Taleghani hospital Kermanshah in 1392-1391. All data about trauma patients were collected using

questionnaires of demographic and Trauma and Injury severity score and shock index by visiting the files of the

patients. Average shock Index, Trauma and Injury severity score, observed mortality and predicted mortality

were calculated by two measures and analyzed using SPSS version 18.

Results: The causes of trauma in74% items is accident. The average Shock Index and the Trauma and Injury

Severity Scorewererespectively0.789and92.104.Comparingthe area under the ROC curve in shock index criteria

and TRISS showed insignificant difference.

Conclusion: The results showed that the shock index to predict mortality in trauma patients was better but did

not show statistically significant superiority.

Keywords: trauma, shock index, Trauma and Injury Severity Score


SP55-18

Introduction:

Damage caused by acute transfer of energy (mechanical, thermal, electrical, chemical, and radiation)or the lack

of heat and oxygen was defined as trauma(1, 2). In the United States, trauma is the leading cause of death in

people under 44 years, causing the loss of 30 percent of years of life that this figure equals the sum of years of

life lost due to cancer (16%), heart disease (12%) and HIV (2%)(3). Trauma causes temporary or permanent

disability as well as imposing the burden on emergency departments and trauma care systems (approximately

3.1% of patients admitted to the emergency department and 8% hospitalized in hospital)(4)and billions of

dollars are annually imposes on the health care system(3). The physical, emotional and financial effects due to

trauma can have effects on person's life, family and community(4). So the importance of decreasing mortality

and disabilities is raised here(5, 6) which is required using precise instruments and scales in order to immediate

identifying and immediate treatments in trauma patients including the shock index(7), scoring system of Trauma

and Injury Severity Score(8), RTS(9), ISS(10), APACHE II, adjusted APACHE II(8), GCS(11), ASCOT(12)

and other criteria.

According to previous studies Shock index was used for the first time in1967(5). The score of Shock index is

calculated by dividing the heart rate on systolic blood pressure (13-16), which isnormallybetween0.5-0.7(13,

14). The measure is a good guide to determine the severity of hypovolemia in blooding(13), septic shock(14),

and rupture of the ectopic pregnancy(17).

Scoring system of Trauma and Injury Severity Score is an merged index based on anatomical and physiological

multi-indices(12) in which some criteria such as the Trauma and Injury Severity Score to different parts of the

body (head, neck, face, chest, abdomen and pelvic organs, limbs and exterior parts) as a result of trauma, RTS

and age of the patient are used to determine the patient's survival. Several studies have been conducted to

determine better and more accurate tool among which the study of Amini et.al used all three models of

APACHE II, adjusted APACHE II and TRISS ability to predict mortality in patients hospitalized with

concussion in ICU, but were not statistically superior to each other(8). However, the results of the study

conducted by Moradi Lakeh showed that the most ability to predict death was related to TRISS and

ASCOT(18). On the other hand, Heydari and his colleagues concluded that the shock index can be used as a

triage tool to predict mortality in trauma patients used to prioritize care(5). However, the study of Lorenzo et.al

demonstrated that the diagnostic performance of shock index was partially better than the heart beat (19). One of

the things that needs a shock for a patient is heart disease. The incidence of heart disease is on the rise (20-22),


SP55-18

and the importance of heart disease is increasing, given that Iran is exposed to aging. Nursing care is important

for health promotion (23-27). Given different point of views in studies and the lack of superiority of tools on

other tools, the present study was conducted in order to compare shock index and Trauma and Injury severity

score in predicting the mortality of patients in the first two days of hospitalization.

Material and Method

This study is a retrospective analysis (Retrospective) on trauma patients ‘files admitted to the Ayatollah

Taleghani hospital in Kermanshah in 1392-1391. The study population included all patients with trauma cases

admitted to Ayatollah Taleghani hospital in Kermanshah in 1391-1392. The sample of study were the files of

the patients who were qualified for the study (not partial). The sampling of the study was availability sampling.

To determine the population sample of the study calculating formula of sample size minimum to compare the

ratios in both samples in which the number of population was calculated 122 and in order to reach the accuracy

and strength of the test the population increased to 150.

Inclusion criteria was completeness of records, a score of ISS more than10 (major trauma) Exclusion criteria

was duration of hospitalizing less than14 days.

Data collection was done through using the existing data as well as using the two-platforms. Different parts of

the information sheets are as follows:

The first part includes demographic information such as age, gender and marital status as well as information on

trauma, injured limbo body and the kind of trauma.

Part II: Determination of the patient's death two weeks after hospitalization, and shock index TRISS

questionnaire.

At first the ISS criteria was calculated for patients and then patients with ISS greater than 10 (major trauma)(28)

entered the study and the information about the questionnaire and the early biographies and the record of vital

signs of the patients were taken .the score of Shock index, TRISS, and mortality were calculated for each. The

average of the scores of the shock index, TRISS, observed mortality after two weeks of hospitalization and

mortality predicted by the standard shock index and TRISS were calculated and entered into SPSS 18 software.

According to the scores of each criterion and comparison with observed outcomes, prediction of criteria was

written as for positive true and false, and negative true and false and sensitivity, specificity, positive and


SP55-18

negative predictive value and accuracy were measured for each tool . Data were analyzed using the chi-square

test and calculating the area under the ROC curve.

Results:

In the present study which was carried out to determine the effectiveness of shock index and Trauma and Injury

Severity Score in predicting mortality in trauma patients, 150 cases of trauma patients admitted to the

Kermanshah Ayatollah Taleghani hospital in 1391-1392 were reviewed. Of these, 110 were male and 40 were

female.

The minimum age was 1 and the maximum one was 88 and the mean age was 19-38 years, with standard

deviation of 20.224.

The average age of males was 37.10 with a standard deviation of 19.977 and that of females was 41.20 years,

with SD = 20.846.

The majority of patients were married. Trauma occurred in males more than females and most patients were in

the age group of 15- 54. Distribution of demographic of the trauma patients were examined in Table (1).

Table 1-Distribution of demographic of the trauma patients

Frequency Percent

110 73.3 Male Gender

40 26.7 Female

60 40 Single marital status

90 60 Married

10 6.5 >15 Age

104 67.1 15-54

36 23.2 54<

The most common cause of trauma was accidents (74%). Most patients were suffering from multiple trauma.

18% of the total of 150 patients died due to trauma and its complications. 92.7% of patients were affected by


SP55-18

penetrating trauma. Most patients were hospitalized in the orthopedic and neurosurgery department. Distribution

of absolute and relative variables are listed in Table (2).

Table 2-Distribution of absolute and relative variables

Percent Frequency

18 27 Death Outcome

82 123 Improvement

74 111 Accident Etiology

17.3 26 Falling

3.3 5 Gunshot

1.3 2 Suicide

4 6 Wall

16.7 25 Head and face Damage zone

2.7 4 Abdominal and pelvic organ

4 6 Chest

18.7 28 Extrimities

58 87 Multi Trauma

7.3 11 Penetrating Type of trauma

92.7 139 Blunt

28.7 43 Orthopedic Inpateint portion

19.3 29 Surgery

24 36 ICU

28 42 Neurosurgery

18.2% of male patients and 17.5% of female patients died. Table 3-4 shows the absolute and relative frequency

distribution of life and death according to gender.


SP55-18

Of the in 27 cases of death, 13 cases related to the accident and 9 caused by the crash. So traffic accidents and

falls are the leading cause of death from trauma.

Of the 27 deaths, 13 cases of trauma related to the head and neck, and 11cases were related to multi-trauma.

36.4% of penetrating trauma and (16.5%) blunt trauma were fatal.

Table (3) shows the distribution of mean, standard deviation, minimum and maximum criteria of shock index

and the Trauma and Injury Severity Score.Theshockindexscorewas0.3and the highest score was 1.7.

Table 3-the distribution of mean, standard deviation, minimum and maximum criteria of shock index

and the Trauma and Injury Severity Score

Minimum Maximum Mean Standard deviation

0.3 1.7 0.789 0.21 shock index

0.21 0.99 0.92 0.13 TRISS

80 trauma patientshadSI≤0.7of that 12 patients died and 68 recovered.43patients had an index score more than

0.9 of which11 people died. Distribution of life and death, according to the shock index are listed in Table (4).

Table4-Distribution of life and death, according to the shock index (P-value=0.31, df=1)

Shock Index

0.7≥ 0.89≥SI≥0.71 0.9≥

percent Frequency percent Frequency Percent Frequency

15% 12 15% 4 26% 11 Death Outcome

85% 68 85% 23 74% 32 Improvement

100% 80 100% 27 100% 43 Total


SP55-18

4 patients who died had the scoreTRISS≤0.5.Table (5) shows the frequency distribution of life and death based

on the Trauma and Injury Severity Score caused by trauma.

Table 5-frequency distribution of life and death based on the Trauma and Injury Severity Score

caused by trauma (P-value=0.000, df=1)

TRISS

<=0.50 >0.50

Frequency Percent Frequency Percent

4 100 23 15% Death Outcome

0 0 123 75% Improvement

4 100 146 100 Total

Table (6) shows the sensitivity, specificity, accuracy, positive predictive value and negative indices of shock and

Trauma and Injury Severity Score caused by trauma. Shock index had higher sensitivity and specificity. Both

the Trauma and Injury Severity Score and shock index had a negative predictive value almost the same however

the positive predictive value of the Trauma and Injury Severity Score was higher compared to shock index.

Table 6-the sensitivity, specificity, accuracy, positive predictive value and negative indices of shock

and Trauma and Injury Severity Score

Shock Index TRISS

%85 15% Sensitivity

%19 %100 Specificity

%31 %31 Accuracy


SP55-18

%19 %100 Positive predictive value

%87 %84 Negative predictive value

ROC curve shows the relationship between sensitivity and specificity in figure 1 and helps with choosing the

optimal model by setting thresholds for required criteria. The ROC curve is also a useful tool for selecting the

optimal cut-off point(29). The area under the ROC curve represents the power of diagnostic criteria that the

much power of diagnostic criteria, the greater the ROC curve on top of the diameter of the square and to the

ideal state (the area of 1)(30). The area under the ROC curve in SI models and TRISS were respectively, 0.067 ±

0.579 and 0.04 ± 0.828 is (Figure 1).


SP55-18

Figure 1Roc Curve

Table (7) shows the sensitivity and specificity of the shock index and Trauma and Injury Severity Score

according to cut-off point. The best cut-off point of shock index was 0.4 and in the Trauma and Injury Severity

Score was 52.55.

Table 7-sensitivity and specificity of shock index and the Trauma and Injury Severity Score based on cut-off

points

cut-off points sensitivity specificity

1.1 1 1 TRISS

17.2 1 .963

37.15 1 .926

43.95 1 .882

52.55 1 .852

-.7 1 1 Shock Index

.4 1 .992

The results of the study showed that the number of deaths were 27 however the number of expected deaths

according to the index shock and the Trauma and Injury Severity Score was respectively 4 and 23.


SP55-18

Discussion:

The criterion for measuring the Trauma and Injury Severity Score is an international standard to evaluate the

Trauma and Injury Severity Score. This criteria are used by the patients with damage to different parts of the

body(13). ASCOT can be noted as the criteria used to estimate mortality in patients. ASCOT is the criteria in

which the anatomical and physiological characteristics and the patient's age are used in order to determine the

Trauma and Injury Severity Score(11).

TRISS is a composite index that is used for this purpose. In MoradiLakehet.al study ASCOT and TRISS criteria

had greatest ability to predict mortality(18). In the present study the ability of shock index was greater in correct

diagnosis of the disease.

In this study, most deaths occurred in patients who had a shock index less than 0.7 and greater than 0.9. So that

the shock index of 85% of those who died were in the theses two ranges. Heydariet.al found that in there is a

relationship between shock index and mortality rate of trauma patients in the first 24 hours of hospitalization (p

<0.001) and most deaths occurred in patients who had a shock index greater than 0.9(5). Connonet.al also found

that increasing the shock index greater than 9.0 is associated with increased mortality(31).

In this study, 85% of deaths occurred in those whose TRISS score was more than 0.50. However, due to the low

number of patients with TRISS score less than 0.50 in this study, this needed to be investigated further.

Thanapaisal et .al also found in their study that TRISS index had the ability to predict death(32).

The mean of shock index was 0.789 with a standard deviation of 0.21. This figure was 0.209 with a standard

deviation of 0.71 in Heydari et.al study(5).

The results showed that the majority of trauma patients were male that is consistent with the results of the

studies (9, 32, 33). Given that the most cases were the cases duo to accidents and crash and the majority of

trauma patients were male thus it is expected to have more males than females and as a result increasing

mortality.

In the United States, trauma is the leading cause of death for people under 44 years(3). In this study, 67.1% of

patients were in the age group of 54-15.Traumaalso caused the death of 18% of the study population with an

average age of 38.19, but no significant relationship between age and outcome of trauma found (P-value =

0.52).

The results of this study showed that among the injured part due to trauma and its consequences, there is a

significant correlation (P-value = 0.019). So that the traffic accidents with (74%) were the major cause of


SP55-18

trauma which is consistent with other studies (7, 12, 18, 28, 34, 35). Given that the majority of patients were

male, thus, most of the accidents can be related to activities related to the accident.

The results of this study show that there is a significant relationship between the injury and its consequences so

that the most common cause of death in these patients is trauma to the head and neck and multiple trauma ( P-

value = 0.000), which can be due to the lack of protection of this area and the trauma in this area . In the study

of Heydari et.al(5)no relationship was found between damaged part and death. However, in studies conducted

by Rahman(36), Shahla(34) and Nazari(37)the most common cause of mortality in patients was head injury.

In this study Blunt trauma with 92.7% was the most common type of trauma. However, no significant

correlation was found between the type of trauma and its consequences (P-value 0.1).Kondo study (Kondo) et.al

also showed that the most common type of trauma was blunt trauma (94.6%)(38). ROC curve analysis showed

that the area under the ROC curve in SI and TRISS models, were respectively, 0.067 ± 0.579and0.04 ± 0.828

that indicates better prediction of Trauma and Injury Severity Score criteria caused by trauma compare to the

shock index.

The best cut-off point of shock index was0.4and in the Trauma and Injury Severity Scorewas52.55.

In discussing the sensitivity and specificity of the considered criteria both sensitivity and specificity are

considered as the appropriate function. The most favorable case is when the criteria for both sensitivity and

specificity iscloseto100%(39). In this study the sensitivity criteria of TRISS was 15%and the specificity

was100%, while the sensitivity of shock index was 85%and specificity was 19%. Ability of shock index in the

correct diagnosis of the patient’s greater than TRISS and the ability of TRISS was correct diagnosis of healthy

people. TRISS sensitivity and specificity Shahla study was 95% and 100% respectively. This criterion is

suitable for evaluating the function of trauma centers (34). The positive predictive value of the criterion TRISS

(100%) was greater compared to the SI (19%).So TRISS criteria is valuable in prioritizing patients and their

need for special medical care. Both criteria have the same negative predictive values. So both criteria have the

same value in identifying patients without problem.

Conclusion

According to the findings of the present research which was carried out to examine the effectiveness of shock

index score and the Trauma and Injury severity score in predicting the mortality of the trauma patients it can be

concluded that the criteria of Trauma and Injury Severity Score had better predictive value of death in trauma


SP55-18

patients compared to shock index thus it is recommended as a useful tool in predicting mortality in trauma

patients.

The most common cause of death in these patients was trauma to the head and neck and multiple trauma and

accidents (74%) was identified as the most important cause of trauma. traffic education and enforcement of

helmet can be helpful in this regard.

Limitations of the study

One of the limitations of this study was the less amount of the patients with TRISS scoreless than 0.25. That

could make it difficult to analysis data thus individuals divided into two groups, with a score of more than0.50

and less than 0.50, until the analysis could be possible. Other limitations of the study include the lack of

information in the profiles (vital signs, GCS, type and Trauma and Injury Severity Score, demographic) so the

incomplete records were excluded from the study.

Suggestions for the further research:

Recommendations in the area of research:

There was no significant relationship between the two measures in predicting mortality in trauma patients. So, in

order to confirm the results of the study it is recommended to conduct a study with a larger sample size.

-In This study, effectiveness of shock index score and Trauma and Injury severity score in predicting mortality

in trauma patients were studied. It is suggested that in future studies the difference between the two measures to

be examined at the scene of accident and the beginning of the emergency.

Suggestions in training and in the area of management: one way of doing successful triage is the use of accurate

tools. Therefore, it is recommended that nursing managers improve the quality of work with training on how to

use these tools.

Recommendations within the clinical scope:

- Use of precision instruments to triage can improve the performance of the nurses.

References

1. Measham AR, Alleyne G, Mills A, Musgrove P, Claeson M, Jamison DT, et al. Disease control priorities in

developing countries: Washington, DC: World Bank and Oxford University Press; 2006.

2. Bagheri SHS, Iranmanesh S, Rayyani M, Dehghan M, Tirgari B, Hosseini SH. Post-traumatic stress and growth

among CPR survivors in the southeast of Iran. International journal of adolescent medicine and health. 2018.

3. Trauma Statistics. Centers for Disease Control and Prevention.


SP55-18

. Available at: http://wwwnationaltraumainstituteorg/home/trauma_statisticshtml.

4. World Health Organization, Violence and Injury Prevention. Available at:

http://wwwwhoint/violence_injury_prevention/disability/en/.

5. Heydari Khayat N, Sharifi Poor H, Mohammadinia N. The relationship of shock index (SI) with trauma patients’ mortality after the first 24 hours of admission at Khatam-aL-Anbia Hospital in Iranshahr. Journal Of Evidence Based Care.

2012 Aug;2(3):61-7.

6. Bagheri SHS, Rayyani M, Iranmanesh S, Dehghan M, Tirgari B, Hosseini SH. Growth: A Journey from Experience to

Higher Perception Among Iranian Muslim CPR Survivors. Journal of religion and health. 2018:1-11.

7. McNab A, Burns B, Bhullar I, Chesire D, Kerwin A. A prehospital shock index for trauma correlates with measures

of hospital resource use and mortality. Surgery. 2012 Sep;152(3):473-6.

8. Amini S, Safari Malekabadi M, Roudbari M. Comparison of APACHE II, Adjusted APACHE II and TRISS Scores in

Predicting Mortality Rate in Head Trauma Patients Admitted to ICU at Khatam-al-Anbia Hospital of Zahedan. Zahedan

Journal of Research in Medical Sciences. 2009 Jul;11(3):25-31.

9. Watts HF, Kerem Y, Kulstad EB. Evaluation of the revised trauma and injury severity scores in elderly trauma

patients. Journal of emergencies, trauma, and shock. 2012;5(2):131.

10. Goris R. The injury severity score. World journal of surgery. 1983;7(1):12-8.

11. Senkowski CK, McKenney MG. Trauma scoring systems: a review. Journal of the American College of Surgeons.

1999;189(5):491-503.

12. Rabbani A, Moini M. Application of “Trauma and Injury Severity Score” and “A Severity Characterization of

Trauma” Score to Trauma Patients in A Setting Different from “Major Trauma Outcome Study”. Archives of Iranian

Medicine. 2007 July;10(3):383-6.

13. AKDUR O, ÖZKAN S, SÖZÜER EM, AVŞAROĞULLARI L, AKPINAR G, İKİZCELİ İ. Use of the shock index to diagnose

acute hypovolemia. 2009.

14. Berger T, Green J, Horeczko T, Hagar Y, Garg N, Suarez A, et al. Shock index and early recognition of sepsis in the

emergency department: pilot study. West J Emerg Med. 2013 Mar;14(2):168-74.

15. Liu Y-c, Liu J-h, Fang ZA, Shan G-l, Xu J, Qi Z-w, et al. Modified shock index and mortality rate of emergency

patients. World. 2012;3(2):114-7.

16. Yussof SJ, Zakaria MI, Mohamed FL, Bujang MA, Lakshmanan S, Asaari AH. Value of Shock Index in

prognosticating the short-term outcome of death for patients presenting with severe sepsis and septic shock in the

emergency department. Med J Malaysia. 2012 Aug;67(4):406-11.

17. Faraji R, Mirbolok F, Heydarzadeh A. Diagnostic Value of Shock Index in Predicting Ruptured Ectopic Pregnancy.

Iranian Journal Of Surgery. 2009 Jan;16(4):15-21.

18. Moradi Lakeh M, Tehrani Banihashemi SA, Varasteh Kia GR, Roohipour MR. COMPARISON OF TRAUMA SCORING

SYSTEMS FOR PREDICTION OF PATIENTS’ PROGNOSIS. Joural Of Iran University Of Medical Sciences

9(28):129-38.

19. Paladino L, Subramanian RA, Nabors S, Sinert R. The utility of shock index in differentiating major from minor

injury. Eur J Emerg Med. 2011 Apr;18(2):94-8.

20. Otaghi M, Qavam S, Norozi S, Borji M, Moradi M. Investigating the effect of lavender essential oil on sleep quality

in patients candidates for angiography. Biomedical and Pharmacology Journal. 2017;10(1):473-8.

21. Borji M, Otaghi M, Salimi E, Sanei P. Investigating the effect of performing the quiet time protocol on the sleep

quality of cardiac patients. Biomedical Research. 2017;28(16).

22. Borji M, Ebrahim Salimi MO. Effects of continuous care model on blood pressure in patients with type ii diabetes.

Journal of Clinical and Diagnostic Research [serial online]. 2018.

23. Otaghi M, Bastami M, Borji M, Tayebi A, Azami M. The effect of continuous care model on the sleep quality of

hemodialysis patients. Nephro-urology monthly. 2016;8(3).

24. Borji M, Tavan H, Azami M, Otaghi M. The effect of continuous care model on blood pressure and quality of life in

patients on hemodialysis. Biomedical and Pharmacology Journal. 2016;9(2):689-95.

25. Borji M. Investigating the effect of home care on death anxiety in patients with gastrointestinal cancer. Govaresh.

2017;22(2):131-2.

26. Khoshnood Z, Rayyani M, Tirgari B. Theory analysis for Pender’s health promotion model (HPM) by Barnum’s

criteria: a critical perspective. International journal of adolescent medicine and health. 2018.

27. Salehi M, Motaghi M. The Effect of Continuous Care Model on Care Burden and Coping Behavior of Diabetic

Older Adults’ Caregivers in Poldokhtar City. Indian Journal of Forensic Medicine & Toxicology. 2018;12(2):204-9.

28. Khosravi A, Ebrahimi H. To Evaluate the Outcomes of Patients with Truma Admitted to the Imam Hossein

Hospital, Shahrood Using the Trauma and Injury Severity Score (TRISS). Iranian Journal Of Epidemiology. 2008 9;4(2):35-41.

29. Zhu W, Zeng N, Wang N. Sensitivity, specificity, accuracy, associated confidence interval and ROC analysis with

practical SAS® implementations. NESUG proceedings: health care and life sciences, Baltimore, Maryland. 2010.

30. Sadat Hashemi SM GR, Kavei B. ROC curves to compare medical diagnostic tests. Koomesh.2:145-50.

31. Cannon CM, Braxton CC, Kling-Smith M, Mahnken JD, Carlton E, Moncure M. Utility of the shock index in

predicting mortality in traumatically injured patients. The Journal of Trauma and Acute Care Surgery. 2009;67(6):1426-30.


SP55-18

32. Thanapaisal C, Saksaen P. A comparison of the Acute Physiology and Chronic Health Evaluation (APACHE) II score

and the Trauma-Injury Severity Score (TRISS) for outcome assessment in Srinagarind Intensive Care Unit trauma patients. J

Med Assoc Thai. 2012 Nov;95 Suppl 11:S25-33.

33. Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A, editors. Comparisons of the outcome prediction performance of

injury severity scoring tools using the Abbreviated Injury Scale 90 update 98 (AIS 98) and 2005 update 2008 (AIS 2008).

Annals of Advances in Automotive Medicine/Annual Scientific Conference; 2011: Association for the Advancement of

Automotive Medicine.

34. Shahla A. TRISS SCORING OF THE MULTI-TRAUMA PATIENTS DURING APRIL 2005-MARCH 2006 IN URMIA

UNIVERSITY OF MEDICAL SCIENCES. Urmia Medical Journal. 2008;18(4):665-9.

35. Singh J, Gupta G, Garg R, Gupta A. Evaluation of trauma and prediction of outcome using TRISS method. Journal

of Emergencies, Trauma and Shock. 2011;4(4):446.

36. N ARN, M HH. The pattern of death related to trauma cases presented to the emergency department of a tertiary

university hospital. Med J Malaysia. 2013 Apr;68(2):148-52.

37. Nazari RB, A. Haji Hosseini, F. Beheshti, Z. Sharifnia, S.H. Hojati, H. Mortality and Injury Sevirity in the Accident

Victims Referred to the Hefdah Shahrivar Hospital of Amol. J Babol Univ med sci. 2011;13(1):76-81.

38. Kondo Y, Abe T, Kohshi K, Tokuda Y, Cook EF, Kukita I. Revised trauma scoring system to predict in-hospital

mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score. Crit Care.

2011;15(4):R191.

39. Yaseri M, Yekaninejad S, Pakpour A, Rahmani S, Rangin H, A. A. Learning concepts of diagnostic tests by graphical

approach: sensitivity, specificity, positive predictive value and negative predictive value. North Khorasan University of

Medical Sciences. 2011;3:1-9.


SP56-18

The Effect of hope therapy on improving life expectancy and

general health among cancer patients

Atefeh Fahami, Minoo Motaghi*

1- Department of Nursing, Faculty of Nursing and Midwifery, Shahre Kord University of Medical Science, Shahre Kord, Iran

2-Nursing Department, Faculty of nursing and Midwifery, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran

* Corresponding author: Nursing Department, Faculty of nursing and Midwifery, Isfahan (Khorasgan) Branch, Islamic Azad

University, Isfahan, Iran. Email:[email protected]

Abstract

With alarming statistics of the number of people suffering from cancer, numerous studies have been conducted

in the field of medicine. However, according to many researchers, many diseases including cancer have achieved to

some patterns to treating, reducing the disease process and improving the quality of life; hope therapy methods are

among these patterns that many reports have been presented about their roles. This is a quasi-experimental study

with pre- and post-test with control group. The statistical population includes patients with the age range of30 to 65

years being treated in August 2016 in Ayatollah Kashani hospital in Shahrekord. General Health and Miller Hope

questionnaires were used to collect data. Subjects were randomly selected from among 50 patients, 30 patients who

had the lowest scores in these tests were selected (15 in the experimental and 15 for control group). The training of

Snyder hope therapy was done in 8 sessions each session lasted 90 minutes. After finishing sessions, posttest was

administrated to experimental and control group. The results showed that hope therapy had a positive impact on life

expectancy and general health in cancer patients; as the mean scores of life expectancy before and after intervention

were 107/66 and 123/33 respectively and general health were 37/98 and 28/72 respectively. In fact, the higher life

expectancy, the quality of life will be better and vice versa. As a result, we can anticipate the quality of a better life

through the life expectancy.

Keywords: Cancer, Hope therapy, General health

Introduction

Quality of life has a multidimensional and complicated concept and includes objective and subjective factors; it is

often considered as a personal understanding of life satisfaction, physical health, social health and family, hope,

etiquette and patient’s mental health(1, 2).

According to the defined standards by the World Health Organization, human health includes a physical-mental and

social welfare. So, paying attention to the mental aspect is a certain requirement (3). As the age increases, the

amount of cancer increases(4, 5). Iran is an elderly country(6, 7). Over the past few decades, the incidence of cancer

has increased (5, 8-11). This incurable disease with unpredictable developments will lead to a lot of mental and

physical disorders in cancer patient’s quality of life and certainly their family and friends (5). The nature of cancer

can cause a stressful event in terms of the personal health of patient (physical, mental) and family. Patients suffering


SP56-18

from all kinds of cancers are afflicting with different and disappointed degrees of mental disorders of depression,

lack of adjustment to disease, low self-esteem, emotional disorders and fear of disease recurrence and death (12, 13).

As hope considers the inner part (thoughts and feelings) of a person suffering from cancer, numerous studies have

been done in this case (10, 14). Among the proposed psychological treatments, Snyder hope therapy, treatment is

based on hope. The main parameters of this type of treatment include the ability to design pathways for suitable

goals despite obstacles and the ability to design agency parameter or necessary motivation to use these pathways. In

fact, this type of treatment is an inner challenge with strong and self-made motivation that external factors are its

stimulator (15).Werner (2012) states that hope as a healing force in welfare and health must be considered as the

basis of personality and the source of human life. It is also known that hope is related to therapeutic efficacy and it is

basically considered as an essential element for treating patients(16). In another study, Baljaniet al. (2011) have

shown that considering some factors such as success in life and hope to care cancer patients can improve the quality

of life and their treatment process(17). Mehmet et al. (2009) demonstrated that hope in steady state is inconsistent

with depressive symptoms (18). Schrank et al. (2008) showed in a review article that hope therapy can be tested and

examined as a predictor variable in mental health conditions (19) .

Nurses have important role in improving health promotion. It has been found from studies that hope therapy has a

potential in the field of mental health problem and because few studies have been done about cancer, it requires

significant quasi-experimental studies in our country that has the highest death rate due to cancer.

Methodology

This is a quasi-experimental study with pre-test (before using research interventions) and post-test (after using

research interventions).The statistical population with methodology before studies, includes two categories of

hospitalized and non-hospitalized cancer patients in Ayatollah Kashani hospital in Shahrekord agreed to continue

participating in this research project. The age range of patients is between 30-65 years (they don’t suffer from any

other long-term disease except cancer) that have earned the lowest score (28) in general health. Then patients were

randomly become equal in the experimental and the control groups with standard and sufficient numbers of 15

persons. With a period of consultation and explanation of the research objectives, hope therapy process was

implemented and post-test was taken by both groups. The collected data were analyzed by SPSS software and

descriptive (mean, standard deviation) and inferential statistics (analysis of covariance).Statistical analysis was done

based on the fact that the significance level is less than or equal to 0/05 (15). To examine the validity of general

health questionnaire, Chen and Chen (1983) simultaneously used the multidimensional Minnesota questionnaire and

correlation coefficient was found 0/54. In the study conducted by Chen (1985) and Keyes (1984), internal

consistency was reported as 0/93 by using Cronbach’s alpha. To determine the validity of this questionnaire,

Taghavi (2001) used test-retest, split half, and Cronbach’s alpha method that validity coefficients were obtained

0/70, 0/93, and 0/90 respectively(20). In their study, Nazifi et al. (2013) reported Cronbach’s alpha coefficient for

the total scale equal to 0/92 (21). In the current study, Cronbach’s alpha validity coefficient was 0/65. In another

study conducted to assess the validity of Miller hope scale, reliability was obtained 0/75 through using content


SP56-18

validity method; Cronbach’s alpha coefficient was used to determine the internal consistency that it was found 0/81

(22).

Procedure

The group training of Snyder hope therapy (2000) was done in 8 sessions each session lasted 90 minutes (19). The

intervention group participated in these sessions but no intervention was given to control group. After introducing

objectives of the study, patient consent was orally received and all necessary explanations were given to all

participants that participating in the study was voluntary and they were allowed not to participate in the study

without time limitation. Because of the type of questionnaire that required patient comfort regarding the

confidentiality of personal information during completing form, it was ensured that patient’s personal information

will be perfectly preserved. General health questionnaire is based on a self-report method and it is a powerful tool

for answering one of the major concerns of experts in the field of mental health to provide criteria and measure in

terms of mental health. The 28-item version with 4 subscales (somatic symptoms, anxiety and insomnia, social

performance disorder and depression) in 1979 by Goldberg & Hillier was considered more popular than other ones

because of the number of questions and good psychometric properties suitable for all members of society(23, 24).

Miller hope scale (1988) with the original version of 40 questions is one of the most powerful measurement tools for

hope and optimism in psychological field that was increased to 48 questions in next versions. Grading in this way is

a total coverage range named Likert scale that includes strongly agree (score 5) to strongly disagree (score 1). Miller

reported the favorability of the questionnaire and according to Cronbach’s alpha coefficient he mentioned to its

reliability above 0/80 (25).

The content of meetings

Each session consisted of four sections. In the first section, it was discussed about the activities done in the last few

days. In this process, people were encouraged to help each other to resolve the problems relating to the requested

activities and tasks in order to practice coexistence between themselves.

The second part consisted of mental training and learning skills related to hope in three areas of objectives, pathways

and factors. In the third part that required a longer process, it was discussed about some methods to use hope skills

in person’s daily life. The audiences were encouraged to discuss clearly about the problems and to help each other to

understand and solve them through hope skills. In the final section, the activities and tasks related to the next

meeting were presented. The general trend included the following sessions. The first session: it is related to the

implementation of the questionnaire and the introduction of the sessions, the objectives of the educational program

based on hope theory; the second session: it is about explaining how hope and its necessity affect hopelessness,

depression and feelings of futility; the third session: in this session the respondents are allowed to tell and hear

stories of each other's personal life (help members to get hope bonding); the fourth session: it is the explanation of

mentioned stories based on three main principles of hope and reformatting them with hope recognition approach and

available success and discovering factors and pathways of these successes; the fifth session: it is about presenting a

list of current events and identifying the important aspects of people’s life and their consent with each of these

events; the sixth session: it is about encouraging people to select appropriate targets and presenting the properties of


SP56-18

suitable targets (practice to increase hope in the respondents); the seventh session: it refers to consider the

characteristics of appropriate pathways and to train them in breaking pathways in a series of small steps and to

determine substitute pathways (it is aimed to preserve hope in people); the eighth session: it is about presenting

strategies to make and protect the proposed factor through encouraging the respondents in mental imagination and

positive self-talks to achieve personal objectives (19). Regarding the sessions, it is concluded that the respondents

are being taught to be a hope therapist and to use hopeful thinking during the day as the person can determine the

objectives and obstacles, he/she can make and preserve the necessary factors to achieve the objectives in him/herself

and detect the necessary pathways. Finally, post-test was simultaneously implemented for both the experimental and

the control group. In this study, response time is 10 minutes (the average of standard time. Data analysis was done

through SPSS software version 22.

Statistical Results

According to both descriptive and inferential perspectives, the results of the study have been presented. 80% of

the experimental group and 60% of the control group were married. In terms of education, 40% of the experimental

group had a high school education or less than it and 20% had diploma, associate diploma and bachelor's degree. In

the control group, 20% of individuals had high school education or less, 60% had diploma, and 20% had associate

diploma. All subjects were a little literate and able to read and understand the questionnaires in primary steps.

According to Chart 1, out of the total population of the experimental group and the control group, the highest and

the lowest density are showed in the age ranges of 40-50 and 30-40 respectively.

Chart1. Subjects’ data according to age ranges

In this study, Cronbach's alpha coefficient was used to determine the internal consistency that was equal to

0/73. Descriptive outputs consisting of mean and standard deviation derived from the obtained data of health

questionnaire named as general health and hope questionnaire for both the experimental and the control group have

been shown in Table 1.


SP56-18

Table 1.Findings of mean and standard deviation in the experimental groups in both

pre-test and post-test level

Control group Experimental group Post-test Pre-test Post-test Pre-test

1.63±7.66 1.65±7.80 1.39± 6.66 2.03± 8.53 Pulse physical

symptoms 2.18±8.93 2.66±8.60 1.20±8.80 1.84±10.86 Pulse anxiety 1.67±7.66 2.01±7.06 1.46±7.00 2.16±9.46 Pulse social

performance 1.53±9.93 1.64±11.53 1.16±6.26 2.13±9.13 Pulse

depression 5.98±34.18 4.48±34.99 3.12±28.72 4.55±37.98 General

health

4.41±108.66 6.46±102.40 8.79±123.33 9.92±107.66 Life

expectancy

According to the results, it is clear that there is a difference between mean scores of pre-test and post-test in the

experimental and the control group. Analysis of covariance was used to inferential analysis and to determine the

significant differences obtained in the results of Table (1). The necessary conditions to use analysis of covariance

are lack of significant relationship in homogeneity of variance and regression slope (25). Table 2 shows that the

significance of Levine test in total score of general health and its subscales and hope is more than the significance

level of 0/05. So covariance analysis was used for inferential analysis.

Table2. Examining the assumptions of the homogeneity of slopes and homogeneity of variance

in presenting analysis of covariance

Homogeneity of variance Homogeneity of slopes

Parameter Levene Test Significance

level F Significance level

0.19 0.65 1.23 0.30 The quality of life

with Pulse health

Table 3 shows the results of the analysis of covariance. According to the results of Table (2), the significance level

is less than 0/05 that it shows the significant relationship between hope therapy and general health of subjects. In

fact, the research hypothesis i.e. the effect of hope therapy on life expectancy and general health among cancer

patients has been implemented.


SP56-18

Table3. Findings of the analysis of covariance of sub pulses in general health and

life expectancy (parameters related to health and quality of life)

Eta Significance level F Mean Square Factor 0.2 0.001 26.31 42.26 Pre Sub pulse

Physical

symptoms 0.43 0.017 6.53 11.48 Group 0.51 0.045 4.42 46.39 Pre Sub pulse

anxiety 0.74 0.002 11.25 117.90 Group 0.51 0.001 7.50 18.09 Pre Social

performance subscales 0.65 0.001 8.93 64.57 Group

0.55 0.001 15.52 18.67 Pre Depression Subscales

0.64 0.001 12.13 43.78 Group 0.33 0.008 8.13 147.68 Pre General

Health 0.74 0.001 37.51 681.22 Group

0.12 0.04 1.80 440.37 Pre Life expectancy 0.79 0.001 9.70 5316.59 Group

Discussion and conclusion

Because of the psychological effect in the diagnosis and treatment of cancer, self-motivation and self-regulatory

on patients’ thoughts is a new trend in the field of hope therapy that positive results from many research projects

have been reported. The findings showed that training hope therapy has caused to increase the life expectancy in

cancer patients. In their study, Ghahari et al.(2012) reported the effect of positive hope therapy in reducing

psychological aspects and factors also they showed the improvement of treatment process and life quality in a 90-

item list of questions about mental symptoms in cancer patients(26). In the study done by Haffman et al. (1991) that

was based on group effectiveness of hope therapy approach they concluded that hope training and improving it in

people will reduce the psychological challenges because hopeful people have more factors and pathways (principles

of Snyder hope theory) to follow their objectives and when they get into trouble they maintain the motivation and

use alternative pathways. By having less factors and pathways, hopeless people lose their motivation when they get

involved in difficulties and experience negative emotions(27).In the study dealt with the effect of hope therapy on

improving the life of teenagers suffering from cancer, Bahramian et al. (2014) stated that in comparison to the

control group, there was a significant difference in the quality of life in subjects with hope therapy sessions (p

<0/0001) and the quality of life in these subjects, compared with the control group, showed a greater

improvement(28)..In their study titled as the effect of hope therapy on cancer patients, Rostamizadeh et al. showed

that after implementing the therapy sessions and in comparison to the control group, a significant difference was

seen in the quality of life in the experimental group and the quality of life in the experimental group, compared with

the control group, had a greater improvement(29) .Duggleby et al. (2007) studied the hope therapy program which

consisted of the interventions and psycho-social supports in increasing the quality of life and improving the

treatment of cancer patients. During the process of training for a few weeks, both factors of hope and the quality of


SP56-18

life were evaluated. The subjects who received life program with hope have significantly showed hope and the

quality of a better life(30). Hope as a strong internal factor gives value to the concept of life that directs human

toward a perspective beyond his/her conditions. Being goal-directed and trying to achieve goal, emerging the

additional energy in doing things, feeling an inner peace and real happiness, adjusting to the current situations,

having self-confidence in decision making and trying significantly to maintain life are the outcomes of appearing

hope in human. When hope is added to the life of cancer patients through developing recognition and determination

methods, treatment and control are undeniable(31). In the study dealt with increasing hope in the early stages of

cancer recurrence, Herth (2000) planned and implemented some interventions based on hope to increase hope and to

improve the quality of life. The obtained results showed a positive significant difference between hope and the

quality of life between the experimental and control groups (32).In his report, Snyder (2000) states that

implementing hope therapy is a suitable way to improve the quality of life in chronic diseases. He said that

increasing hope lead to increase the level of self-care, the quality of life and promotion of general health in these

types of patients. In fact, he considers hope as one of the meaningful components in life that causes to certain

goals(23). According to Feldman and Snyder (2005), having a hopeful thinking and having sufficient sources to

achieve goals cause the significance in life. In other words, there is an interactive relationship between these two

variables; it means increasing hope leads to increasing the significance in life and increasing significance leads to

increase hope or targeted thought(33). In the same way, King (2006) has shown that hope is interactively leading to

increase psychological well-being and positive emotions and satisfaction of life that are consistent with the findings

of this study(34). In their study, Sotodeh-Asl et al. (2010) showed that in comparison to drug therapy, hope therapy

is more effective in improving the quality of life in patients with hypertension(35). Improving hope has been

considered as an important factor in predicting disease process. According to Benzein et al. (2005), hope to life

helps the cancer patients by considering their physiological and emotional aspect. Thus it tries to adjust the patient to

tolerate disease(36). The reported results from Groopman (2005) on patients suffering from chronic physical

disorders showed that positive beliefs have positive effects on central nervous system. For this reason, due to having

positive beliefs about treatment results, patients hoped to be better have been improved more rapidly (37). In a

study conducted by Hall et al. (2009), they showed that after doing positive psychological interventions and

considering them for eight weeks, the quality of life in patients with chronic diseases would be improved (38).

Limitations of the study

- Because the distribution of the patients in the age range was abundant and many patients or their families were

not willing to cooperate or accessing to patients who agreed to participate was impossible, the statistical

population was less than 50 persons.

- According to this matter that subjects are 15 based on the acceptable standard, therefore, due to low population

distribution, extending it to the entire community takes a precautionary process.

Suggestions


SP56-18

- Consistent willing should be taken in training and supporting steps of hope therapy plan in all fields of diseases.

- Since cancer patients are involving with a strong internal challenge, it had better repeat Snyder intervention

process during persons’ disease process until the patient reaches the certainty of hope test.

- According to the results of the study, clinical experts and cancer patients’ close relatives can benefit from this

treatment plan in improving patients’ life expectancy and general health.

- According to Snyder approach, in positive psychology literature, positive factors such as hope are considered

as a protective factor against stressful factors seen in many teenagers.

Therefore, developing training programs in educational places is considered a suitable matter. This program can

be used by staff in education.

References

1. Otaghi M, Bastami M, Borji M, Tayebi A, Azami M. The effect of continuous care model on the

sleep quality of hemodialysis patients. Nephro-urology monthly. 2016;8(3).

2. Hatefi, M. Abdi AR. Tarjoman, A, Borji, M, Prevalence of Depression and Pain among Patients

with Spinal Cord Injury in Iran: a systematic review and meta-analysi, Trauma Monthly Journal, 2019, In

press.

3. Borji M, Molavi S, Rahimi Z. The Effect of Sexual Satisfaction on the Quality of Life on Patients with Cardiovascular Disease. Health Sciences. 2016;5(12):70-5.

4. Pouy S, Peikani FA, Nourmohammadi H, Sanei P, Tarjoman A, Borji M. Investigating the effect of

mindfulness-based training on psychological status and quality of life in patients with breast cancer.

Asian Pacific journal of cancer prevention: APJCP. 2018;19(7):1993.

5. Borji M. Investigating the effect of home care on death anxiety in patients with gastrointestinal

cancer. Govaresh. 2017;22(2):131-2.

6. Hatefi M, Tarjoman A, Borji M. Do religious coping and attachment to god affect perceived pain?

Study of the elderly with chronic back pain in Iran. Journal of religion and health. 2019:1-11.

7. Abdi A, Tarjoman A, Borji M. Prevalence of elder abuse in Iran: a Systematic review and meta-

analysis. Asian Journal of Psychiatry. 2018;39:120-7. 8. Borji M, Nourmohammadi H, Otaghi M, Salimi AH, Tarjoman A. Positive Effects of Cognitive

Behavioral Therapy on Depression, Anxiety and Stress of Family Caregivers of Patients with Prostate

Cancer: A Randomized Clinical Trial. Asian Pacific journal of cancer prevention: APJCP. 2017;18(12):3207.

9. Al-Wassia R, Al-Zaben F, Sehlo MG, Koenig HG. Religiosity and Beliefs About the Transmission of

Cancer, Chemotherapy, and Radiation Through Physical Contact in Saudi Arabia. Journal of religion and

health. 2018:1-15.

10. Goudarzian AH, Boyle C, Beik S, Jafari A, Nesami MB, Taebi M, et al. Self-Care in Iranian Cancer

Patients: The Role of Religious Coping. Journal of religion and health. 2018:1-12.

11. Parenteau SC, Hurd K, Wu H, Feck C. Attachment to God and Psychological Adjustment: God’s

Responses and Our Coping Strategies. Journal of religion and health.1-21. 12. Hamule MM, Vahed AS. The assessment of relationship between mental health and quality of

life in cancer patients. Scientific Journal of Hamadan University of Medical Sciences. 2009;16(2):33-8.

13. Lee SJ, Fairclough D, Parsons SK, Soiffer RJ, Fisher DC, Schlossman RL, et al. Recovery after stem-

cell transplantation for hematologic diseases. Journal of Clinical Oncology. 2001;19(1):242-52.


SP56-18

14. Sarafyno A. Health psychology. translated by: Mirzaee. Tehran: Roshd publication. 2005.

15. Snyder CR. Coping: The psychology of what works: Clarendon Press; 1999.

16. Werner S. Subjective well-being, hope, and needs of individuals with serious mental illness.

Psychiatry research. 2012;196(2):214-9.

17. Slife BD, Hope C, Nebeker RS. Examining the relationship between religious spirituality and psychological science. Journal of Humanistic Psychology. 1999;39(2):51-85.

18. Mehmet A, Rozien M. You've got to have hope: Studies show" hope therapy" fights depression.

Atlanta: News RX. 2009:68.

19. Schrank B, Stanghellini G, Slade M. Hope in psychiatry: a review of the literature. Acta

Psychiatrica Scandinavica. 2008;118(6):421-33.

20. Fathi-Ashtiani A, Dastani M. Psychological tests: Personality and mental health. Tehran: Besat.

2009;46.

21. Taghavi S. Validity and reliability of the general health questionnaire (ghq-28) in college students

of shiraz university. Journal of psychology. 2002;5(4):381-98.

22. Nazifi M, Mokarami H, Akbaritabar A, Faraji Kujerdi M, Tabrizi R, Rahi A. Reliability, validity and factor structure of the persian translation of general health questionnire (ghq-28) in hospitals of kerman

university of medical sciences. Journal of Fasa University of Medical Sciences. 2014;3(4):336-42.

23. Snyder CR. Handbook of hope: Theory, measures, and applications: Academic press; 2000.

24. Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O, et al. The validity of two

versions of the GHQ in the WHO study of mental illness in general health care. Psychological medicine.

1997;27(1):191-7.

25. Werneke U, Goldberg DP, Yalcin I, Üstün B. The stability of the factor structure of the General

Health Questionnaire. Psychological medicine. 2000;30(4):823-9.

26. Farhadi M, Reisi-Dehkordi N, Kalantari M, Zargham-Boroujeni A. Efficacy of group meaning

centered hope therapy of cancer patients and their families on patients’ quality of life. Iranian journal of nursing and midwifery research. 2014;19(3):290.

27. Ghahari S, Fallah R, Bolhari J, Moosavi SM, Razaghi Z, Akbari ME. Effectiveness of cognitive-

behavioral and spiritual-religious interventions on reducing anxiety and depression of women with

breast cancer. Article in Persian] Know Res Appl Psychol. 2012;13(4):33-40.

28. Elliott TR, Witty TE, Herrick SM, Hoffman JT. Negotiating reality after physical loss: hope,

depression, and disability. Journal of personality and social psychology. 1991;61(4):608.

29. Klausner EJ, Clarkin JF, Spielman L, Pupo C, Abrams R, Alexopoulos GS. Late‐life depression and functional disability: the role of goal‐focused group psychotherapy. International journal of geriatric psychiatry. 1998;13(10):707-16.

30. Duggleby WD, Degner L, Williams A, Wright K, Cooper D, Popkin D, et al. Living with hope: initial evaluation of a psychosocial hope intervention for older palliative home care patients. Journal of pain

and symptom management. 2007;33(3):247-57.

31. Farran CJ, Herth KA, Popovich JM. Hope and hopelessness: Critical clinical constructs: Sage

Publications, Inc; 1995.

32. Herth K. Enhancing hope in people with a first recurrence of cancer. Journal of advanced

nursing. 2000;32(6):1431-41.

33. Feldman DB, Snyder CR. Hope and the meaningful life: Theoretical and empirical associations

between goal–directed thinking and life meaning. Journal of Social and Clinical Psychology.

2005;24(3):401-21.

34. King LA, Hicks JA, Krull JL, Del Gaiso AK. Positive affect and the experience of meaning in life. Journal of personality and social psychology. 2006;90(1):179.


SP56-18

35. Sotodeh-Asl N, Neshat-Dust H, Kalantari M, Talebi H, Khosravi A. Comparison of effectiveness of

two methods of hope therapy and drug therapy on the quality of life in the patients with essential

hypertension. Journal of clinical psychology. 2010;1(5):27-34.

36. Benzein EG, Berg AC. The level of and relation between hope, hopelessness and fatigue in

patients and family members in palliative care. Palliative medicine. 2005;19(3):234-40. 37. Groopman J. The anatomy of hope: How people prevail in the face of illness: Random House

Trade Paperbacks; 2005.

38. Hall S, Edmonds P, Harding R, Chochinov H, Higginson IJ. Assessing the feasibility, acceptability

and potential effectiveness of Dignity Therapy for people with advanced cancer referred to a hospital-

based palliative care team: Study protocol. BMC palliative care. 2009;8(1):5.


SP57-18

The barriers of unlearning for nurses employed in hospitals:

a qualitative study

Abbas Heydari 1, Kokab Basiri Moghaddam

2*, Zahra Sadat Manzari

3, Behrooz Mahram

4

1Professor at Department of Medical- Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical

Sciences, Mashhad, Iran 2PhD candidate at Department of Medical- Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical

Sciences, Mashhad, Iran Correspondence: Kokab Basiri Moghaddam, PhD candidate, School of nursing and midwifery,

Mashhad University of Medical sciences, Mashhad, Iran. E-mail: [email protected] 3Assistant Professor at Department of Medical- Surgical Nursing, School of Nursing and Midwifery, Mashhad University of

Medical Sciences, Mashhad, Iran 4Assistant Professor at Department of education, faculty of education and psychology, Ferdowsi university of Mashhad,

Mashhad, Iran.

Abstract

Introduction: In the complex world of today, learning is very important. Lifelong learning survives the standard

and quality of performance and promotes a sense of well-being in patients. But the fact is that to learn new

things in a better way and more efficiently, the previous ineffective lessons or those in conflict with the new

knowledge should be removed beforehand. The concept of Unlearning refers to this issue. Objective of study

was exploring the barriers that affect the Unlearning process in nurses.

Materials & Methods: this study was Qualitative Content Analysis .The Participants included nurses having at

least six months of clinical practice and had experienced changes in the healthcare implementation methods.

Sampling was done purposefully and continued till data saturation. 29 interviews with 25 participants were

conducted. The duration of interviews was about 15-135 minutes. The data was analyzed using qualitative

content analysis with conventional approaches.

Results: The analysis of the interview data and field notes led to the emergence of 1260 initial codes, 16

categories and 3 themes. The resulting themes include: inefficient and defective education, unlearning

debugging mediators and hidden inner domination.

Conclusion: Our study showed that there are several obstacles in the way of unlearning in the clinical settings.

Discovering and explaining the obstacles will help policy-makers and managers to plan and intervene with

regards to facilitating the unlearning so that they allocate a section to the important matter of continued staff

education.

Key words: unlearning- nurses- barriers- content analysis

Introduction

In keeping with the increasing advances of technology and the unprecedented growth that is taking place in the field

of medical sciences, the need for training nurses has become even more inevitable in the present situation (1). To this

end, numerous research studies have been carried out in the field of different methods and types of learning to see

which one is more effective and under what conditions. But the fact is that to learn new things in a better way and

more efficiently, the previous ineffective lessons or those in conflict with the new knowledge should be removed

beforehand (2&3).

Rushmer and Davies stated that: With regard to the importance of learning to improve the quality of care, we have

an acceptable amount of literature on learning – its concepts and how learning takes place and the various forms and

procedures within the organization, including further education, etc., yet the link which is missing in this case is

Unlearning (4). There is very little information about the process and nature of Unlearning. Unlearning is often


SP57-18

overlooked and neglected though it is very difficult and almost impossible to acquire new knowledge without

Unlearning (5).

The issue now taken into consideration in health organizations worldwide is the necessity of continuous training

and updating of information. Medical personnel are trained with new knowledge and clinical practices unaware of

the fact that the new information is added to the massive amount of old and outmoded information, and instead of old

knowledge being removed and replaced by new knowledge, the new knowledge gets mounted on it, thus the old

knowledge gets nested more firmly and cannot ever be removed (5). In this regard Coombs states that unlearning is a

relatively neglected and unknown dimension of the processes of change and learning (6). Rushmer and Davies also

cite in their study that when new learning occurs, healthcare workers become confused as sometimes a mass of new

information contradicting old information causes mental confusion and reduces efficiency and performance;

therefore raising a major challenge in the quality of patient care and increasing the risk of medical errors (4).

Despite the importance of Unlearning in its opposite process of Learning, very few studies have been carried out in

this regard. In Iran and other countries, the researches carried out on the same have just been reviews and have

normally reported from the analyses of other papers.

Since the Unlearning path is neither simple nor convenient and in fact it may be very difficult (7-9), it is important to

know what factors impede it or act as a barrier in this process. Therefore our research was undergone with the aim of

exploring the barriers that affect the Unlearning process in nurses.

Methodology

For better focusing on the goal of the research, to obtain a deep understanding of the barriers to Unlearning,

Qualitative Content Analysis was used. The research environment was Mashhad and Gonabad teaching hospitals.

There were two groups of participants: the Main Participants included nurses having at least six months of clinical

practice and had experienced changes in the healthcare implementation methods. The other group of participants

consisted of superintendents, educational supervisors, nurse educators, residents and medical groups, hospital

matrons and educational experts. In all, 25 participants took part in this study - 19 of whom were nurses or the main

participants. Four Supplementary interviews were also conducted. The location of the interviews was selected by the

participants, mostly in hospital or the School of Nursing and Midwifery. Sampling was done purposefully.

The study lasted from December 2014 and culminated in December 2015. Sampling continued till data saturation,

meaning it continued until a new code was gained in the last 4 interviews. Accordingly, 26 formal and in-depth face

to face unstructured interviews with open-ended questions and three informal unplanned and random interviews were

conducted with the participants (a total of 29 interviews were conducted).

The main method of data collection in this study was in-depth interviews of unstructured type with face to face and

open ended questions; and the subordinate method used by the researcher was field notes. The duration of the formal

interviews was about 40-135 minutes while the informal ones lasted about 15-45 minutes. The Researcher was

committed to maintaining a state of openness towards the thing that was constantly occurring, to not censoring the

data by default and pre-suppositions, to being impartial and to not having any bias in listening and observing, as well

as to discovering the participants’ main desire in the work environment and their approaches in dealing with

problems or solving them.

In this regard, an interview typically first started with open-ended questions, and recalling experiences, clinical

workshop memories, etc., next updating information were used to enter into the interview phase and then the focus

was turned onto the discussion of Unlearning and the mode of people’s performance. The main question that was

asked of the nurse or interviewee was: “when you encounter a new caring technique in the clinical field, how do you

implement it?”

During the interviews, participants were encouraged to continue the discussion by speaking of their clinical-care

experiences and memories. In addition, further questions were asked according to the participants’ conversations to

direct the interviews, such as: What problems did you face with its implementation? Do you know of another example


SP57-18

in this regard?

As the study progressed, interviews were executed following the lead of the topics that came up and the researcher

directed the questions according to the prominent and significant categories.

The data was analyzed using qualitative content analysis with conventional approaches. Thus, each interview was

immediately after transcribed verbatim alongside the participants’ non-verbal communication, such as, crying, tears,

smiles, sighs, silence, etc. The text of each interview was reviewed several times and expressions unrelated to the

study were removed. Then the data was broken into meaning units (code) in the form of sentences and paragraphs

with the original meaning as a central idea. These semantic units were reviewed several times then proper codes were

written for each semantic unit. After that the codes were classified based on conceptual and semantic similarity and

were compressed as much possible. The process of data reduction was pursued in all units and in the main and

sub-categories of the analysis. Then, the codes were placed in main categories which were more general and

conceptual, and finally the themes were abstracted. It is worth noting that during analysis, the necessary changes

about content and the categories indicating these contents were labeled. The process of analyzing was repeated

regularly for every interview and categories were modified.

Ethical permission for this research was obtained through the approval of the Medical Research Ethical Committee

of Mashhad University of Medical Sciences. A Consent of Participation form was filled in and signed by the

participants and their permission was taken in order to record their statements. Moreover, participants were assured

that their statements would be kept confidential and would not be made available to anyone but the researcher.

In addition three professors in the field of qualitative research monitored all the stages of the study process.

Utilization of a combination of methods (interviews and field notes) along with sampling with maximum variance

meaning interviews with various individuals (in terms of age, gender, employment status, employment history, work

place and position) increases validity, approval and transferability of data. Allocation of adequate time to the study,

open communication and empathy with the participants were also other factors increasing the validity of the study

data.

Results

The analysis of the interview data and field notes led to the emergence of 1260 initial codes, 16 categories and 3

themes. The resulting themes include: inefficient and defective education, unlearning debugging mediators and

hidden inner domination.

Theme 1: Inefficient and Defective Education

This theme was extracted from two categories of non-effective educator and undesirable unlearning training

practices.

“When I asked the trainer, he just played with words and couldn’t answer my question. I didn’t get anything so I

couldn’t accept the rest of the content.”

“Once a workshop for AKG reading was held for us, the trainer said things hastily and went. We remembered

nothing and I didn’t learn anything from that workshop. “

Theme 2: Unlearning Debugger Mediators

This theme means any obstacles be it individuals or events, etc that may act as mediators between the different

factors obstructing unlearning and affecting its outcomes. This theme was extracted from two categories. They

include personal turmoil and structural limitations.

Personal turmoil included the zealous guardians, fear of ambiguity, indifference due to a lack of motivation and

concern, and getting caught in the trap of relaxation and whirlpool of scientific immaturity.

“The previous training was much better than the new one, I’ve been working with the old method for many years


SP57-18

now and it is really good; I really trust old medical care practices.”

“The first time that I heard CPR has been changed, I didn’t accept it. It was strange, I had a sense of fear, I didn’t know what it was … was it right or wrong?”

Structural Limitations

This consisted of an unpleasant feeling of sudden change, withdrawal from the training because of the dissatisfaction

with the workshops, lack of financial benefits for employees, the non-unlearning nature of medical care methods, and

ineffective professional relationships.

Thus despite the unlearning process being started for nursing staff and their understanding its necessity, the above

obstacles made unlearning to be postponed or stricken by confusion and skepticism or deviated it from its path and

did not initiate unlearning at all; or even stopped the staff from trying to go after it or even refrained them from

entering the unlearning process.

“They suddenly came and said that the method has been changed and you should do like this from now on. We were

in great stress, so we resisted accepting it and opposed it, instead.”

“The clinical dominance of our job is increased by this method, and it makes lots of trouble for us but doesn’t have

any profit for us. It is like as if they are misusing us.”

Theme 3: The hidden inner domination

This content points to the individual, personality and psychological features of people and represents the inner

inhibiting character of individuals. The inner inhibitor refers to the features that do not easily accept change and

make unlearning difficult. Such people are strong and stubborn and do not accept new training easily. They usually

like being slow and steady and feel comfortable doing routines.

Some of the resisting staff are too meticulous and cautious and are too skeptical about new methods. They constantly

seek for verification and validation of new training contents and, this does not allow easy acceptance and

implementation of new methods. Although change is often stressful for most people, some people experience severe

threat and panic in facing with any change and this could include a feeling of complete disorientation. This sort

possess intellectual rigor. They lay too much emphasis on previous experiences and feel that old education is

absolute, and they therefore oppose new training in any form.

“I oppose a new method at first and don’t accept it easily. I think that it is wrong. I can’t help it, it’s in my nature.

Although they explain that what are its effects I can’t accept it easily and usually oppose it at first. I am the same at

home, as well, I oppose everything at first.”

Discussion

The results of this study indicate that the most important barriers to unlearning in nurses are inefficient and faulty

training, non-unlearning mediators and hidden inner domination. Review of the studies shows that although the

details and dimensions of all the themes were mentioned sparsely in the study, the overall content of most of the

categories formed in the present study in fact are consistent with results of other studies. None of the unlearning

debugger contents: non-unlearning mediators, hidden domination and some sub-categories like the non- unlearning

nature of medical care method, being caught in the trap of relaxation, and biased or even zealous guardians; none of

them formed a basic concept or independent theme on their own in these studies.

In addition, our article emphasizes unlearning at the individual level and the barriers in nurses which has been

covered only in a few studies. In the study of Hadavinejad and Tamaddon identifying personality traits of behavior

resistance to change has been discussed. In the current study the inner hidden domination category investigated these

personality characteristics that is consistent with Hadavinejad study. However, in our study two other effective

factors in unlearning were detected which did not appear in Hadavinejad study(10).


SP57-18

Although our study comes to more important obstacles in the field of unlearning, non unlearning mediator theme that

is in line with the results of various research reports like in Becker’s and other researchers’(11&12). The Becker

study indicated the length of change implementation and how to start it is effective for people’s unlearning. This

study also showed that sudden and explosive changes have a negative effect on the unlearning process and causes

individual resistance (11).

Also ineffective professional relations was in line with the results of other studies. Armson and Whiteley in Australia,

Pianes and Taghlioventi etal in the United States introduced the importance of interaction in the implementation of

new learning and changes as a key factor among the various effective factors in applying the new learning(13-15).

Becker's study and yildiz & fey study showed that understanding the need for change, positive experiences and

emotions and individual expectations is one of the most important reasons for performing unlearning which are in

consistence with the current study(16&17). Fear of the unknown considered as another barrier of unlearning that

appears in the srithika study is seen in our study as well (18). Moreover, the concept of habit pressure is proposed as

an affecting factor on people’s resistance towards new training. In Pighin and Marzona’s study, being caught in the

trap of peace is expressed as one of the unlearning inhibitors and is found as a category in the present study, too (19).

Lack of motivation is a condition in which resistance to unlearning forms and this too emerged in this study as a

sub-category. This finding is consistent with Pianes study (14).

It is worth mentioning that the category of the nature and characteristics of the method of care was not reported in

any study and the reason for this could be the fact that the other studies had not been carried out to examine

individual experience in the field of unlearning within the nursing context. In addition to this, the withdrawal from

training category is not mentioned in any of the studies.

Conclusion

Our study showed that there are several obstacles in the way of unlearning in the clinical settings. Therefore, in order

to facilitate the unlearning process in clinical settings and to continue educating nurses, these barriers must be

understood first and by considering them further education can be reinforced and the barriers rendered ineffective.

Discovering and explaining the obstacles will help policy-makers and managers to plan and intervene with regards to

facilitating the unlearning so that they allocate a section to the important matter of continued staff education. Also we

can use the findings of this study that identifies and defines the nature of the effectual barriers in unlearning to design

an exclusive tool to assess and measure such obstacles in organizations.

Acknowledgment

It is deserves the thanks of all participants in the study who patiently recounting their experiences. Also the report is

part of the PhD thesis is approved by the School of Nursing and Midwifery, Mashhad University of Medical Sciences

that It is necessary to appreciate the support of the University.

Conflict of interest

The authors declare that there is no conflict of interest.

References:

Gillis DA. nursing management. A system approach, 3r ed, philadelphia: W.B saunders,1998.

Klein E J. Learning, Unlearning, and Relearning: Lessons from One School’s Approach to Creating and Sustaining Learning

Communities. TEQ 2008; 35(1):79-97.

Akgun AJ, Byrne JC, Lynn GS, Keskin H. Organizational Unlearning as Changes in Beliefs and Routines in Organizations. JOCM 2007;

20 (6): 794-812.

Rushmer R, Davies H T. Unlearning in health care. Qual Saf Health Care 2004; 13(Suppl II):ii10–ii15. Doi: 10.1136/qshc.

T sang E, Zahra S. Organizational unlearning. Human Relations 2008; 61(10):1435—1462.

Coombs CR, Hislop D, Holland J, Bosley SLC, E Manful. Exploring types of individual unlearning by local health-care managers: an

original empirical approach. HS&DR 2013;1(2).DOI 10.3310/hsdr01020.

Adli F. Unlearning; strategy to learn more. Iranian Journal of Educational Strategies 2010; 3( 1): 17-21.

Kiefer T. Understanding the Emotional Experience of Organizational Change: Evidence from a Merger. Adv Develop Hum Resour.


SP57-18

2002; 4: 39-61. DOI: 10.1177/1523422302004001004.

Becker K.Individual and Organisational Unlearning: Directions for Future Research. International Journal of Organisational

Behaviour 2005; 9(7):659-670.

Hadavinejad M, Tamaddon S.Exploring Personality Traits of Behavioral Resistance to Change: A Phenomenological Study.

Strategic Management Thougth 2014; 8(1): 157-189.

Becker K. Unlearning as a Driver of Sustainable Change and Innovation: Three Australian Case Studies. IJTM 2008; 42 (1/2):

89-106. DOI: 10.1504/IJTM.2008.018062

De Holan, PM, Phiiips N, Lawrence T B.Managing Organizational Forgetting. MIT Sloan Management Review 2004; 45(2): 45-51.

Armson G, Whiteley A. Employees’ and managers’ accounts of interactive workplace learning: A grounded theory of “complex

integrative learning. J of Workplace Learning 2010; 22(7): 409-427. DOI: http://dx.doi.org/10.1108/13665621011071091.

Pianes A. Journey to chaos and back: unlearning in workplace training programs. The systems thinker 2009; 20(5).

Tagliaventi M R, Bertolotti F, Macri DM. A Grounded Theory for Resistance to Change in a Small Organization. J of Organizational

Change Management 2002; 15(3):292-310. DOI: http://dx.doi.org/10.1108/09534810210429327.

Becker KL. Facilitating unlearning during implementation of new technology. J of Organizational Change Management 2010;

23(3):251 – 268. DOI: http://dx.doi.org/10.1108/09534811011049590.

Yildiz EH, Fey CF. Compatibility and unlearning in knowledge transfer in mergers and acquisitions. Scandinavian Journal of

Management 2010; 26(4): 448–456. DOI:10.1016/j.scaman.2010.09.010.

Srithika TM, Sanghamitra B. Facilitating Organizational Unlearning using Appreciative Inquiry as an Intervention. Vikalpa: The

Journal for Decision Makers 2009; 34(4):67-77.

Pighin M, Marzona A.Unlearning/Relearning in Processes of Business Information Systems Innovation. JIOS 2011; 35(1): 59-72.


SP58-18

Pleural lipid profile in differentiating exudative pleural

effusion

Majid Golestani Eraghi 1, Mihan Pourabdollah Toutkaboni

2, Niloufar Dadashpour

3, Seyed Mohamad Masoud

Moosavinasab4, Mohammad Khabiri

5, Behrooz Farzanegan

*6

1Department of Anesthesiology and critical care, Fellowship in critical care, Anesthesiologist

Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid

Beheshti University of Medical Sciences, Tehran, Iran 2 Pediatric Research and Chronic Respiratory Disease Research Center. Shahid Beheshti University of Medical Sciences,

Tehran, Iran 3 Anesthesiology Research Center, Lorestan University of Medical Sciences, Lorestan, Iran 4 Anesthesiology Research Center, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 5 Anesthesiology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 6 Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid

Beheshti University of Medical Sciences, Tehran, Iran

Corresponding authors: Email: [email protected]

Address: Masih Daneshvari Hospital, Darabad Ave, Tehran, Iran.

Tel: 00982127122525

Fax: 00982127122537

Abstract:

Objective: Diagnostic approaches to patients with a pleural effusion must be precise because many procedures

depend on the nature of the fluid in the effusion. To date, Light criteria is common criteria to differentiate

transudate and exudate pleural effusion, no biochemical test is considered an appropriate. The aim of present

study was to assess sensitivity and specificity, positive and negative predictive value of pleural and

pleural/serum value of lipid profile.

Material & Methods: In this case series, 44 patients with exudative pleural effusion based on light’s criteria

were enrolled to the study. Definitive diagnosis was based on pathological and cytological final diagnosis.

Pleural and serum level of cholesterol, TG, HDL and LDL were measured and P/S ratio was calculated. Sensitivity

and specificity, positive and negative predictive value of pleural and pleural/serum value of lipid profile were

calculated.

Results: A total of 31 patients (70.5 %) were definitively diagnosed with an exudative effusion. Sensitivity and

specificity of pleural cholesterol were 32.26 and 53.85 % respectively and positive and negative predictive value

of pleural cholesterol were 32.26 and 46.15 % respectively. LDL, HDL and TG were not valuable diagnostic

biomarkers.

Conclusion: according to the result of present study it seems pleural HDL, LDL and TG has no enough Sensitivity

and specificity to differentiate transudate and exudate pleural effusion. Further investigation with greater

sample size is recommended.

Key Words: cholesterol, exudative effusion, pleural effusion, light’s criteria.

Introduction:

Pleural effusion (PE) as an abnormal collection of fluid in pleural space, is a frequent medical challenge in many

diseases due to imbalance of secretion and drainage of pleural fluid. Light et al. introduced criteria for differentiating

exudative PE from transudative ones with specificity of 70-86% in different investigations (1, 2). Light’s criteria is

based on plural and serum protein and LDH and their ratios. About 25% of transudative PEs misclassified especially

in patients with heart failure treating with diuretic medications using light’s criteria (2). Some other biomarkers such


SP58-18

as pleural cholesterol (3), plural albumin (4), and plural bilirubin (5) were studied but consistent result was not

found.

In this study, we aimed to assess accuracy and specificity of measuring plural and serum lipid profile (LDL, HDL,

TG, and cholesterol) in classification of pleural effusion.

Materials and Methods:

In this case series, patients with exudative pleural effusions (PE) based on Light’s criteria who attended our Chronic

Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases

(NRITLD), were studied from 2015-09-23 to2015-12-23.

Inclusion criteria was as follow:

Age≥18.

A chest sonography with pleural effusion.

A diagnosis with the etiology of an exudative PE.

The possibility of thoracentesis (≥10 cc of pleural fluid in lateral decubitus chest radiograph or chest sonography).

And Exclusion criteria was as follow:

Transudative PE.

Hemodynamic instability.

A bilateral PE with an established renal, hepatic or cardiac failure.

Renal failure or diuretic medication.

Coagulopathy.

Patients not willing to participate in the study.

Patients without definite diagnosis or more than one possible etiology.

Missed data or death before data collection.

The results of detailed medical history and clinical examination of all of the patients were recorded and diagnostic

tapping of the pleural fluid was done in every case and tested for appearance, cell count, protein, glucose, LDH,

lipid profile, Gram stain, bacterial culture, acid fast stain and cytology. Concomitant blood sample was tested for

similar parameters. Pleural effusion was localized using CXR and other imaging modalities if needed. In our center,

National Research Institute of Tuberculosis and Lung Diseases, further investigations such as computed tomography

are also done routinely based on patients’ situation and differential diagnosis.

We used pathological and etiological diagnosis for differentiating exudative and transudative pleural effusion in

studied patients as a gold standard. Pleural effusion due to malignancy, pneumonia, tuberculosis, pulmonary

embolism, fungal infections, pancreatic pseudo-cyst, intra-abdominal abscess, after coronary artery bypass graft

surgery, post cardiac injury syndrome, pericardial disease, Meigs syndrome, ovarian hyperstimulation syndrome,

rheumatoid pleuritis, Lupus erythematosus, drug induced pleural effusion, Yellow nail syndrome, uremia, trapped

lung, chylothorax, pseudochylothorax, acute respiratory distress syndrome, chronic pleural thickening, malignant

mesothelioma, and hypothyroidism were considered exudative effusions.


SP58-18

The results of using Light’s criteria and pleural lipid profile for categorizing exudative and transudative PE were

compared with etiological results and the specificity, sensitivity and positive and negative predictive value were

calculated. Plural effusion with cholesterol level ≥ 50 mg/dl or pleural /serum cholesterol ratio ≥ 0.4 were classified

as exudative PE (6).

For pleural HDL and LDL and their pleural/serum ration, the cutoff values were established as the best

discriminating level. The statistical significance was considered at p<0.05.

(Registration code: IRCT2015083112642N18)

Results:

Forty four of 144 patients had exudative plural effusion based on Light’s criteria and fulfilled the study criteria

which 27 (61.36%) were men. The average of age was 53.57 (16.91) years old.

The diagnosis are listed in Table 1. Based on definite etiological diagnosis, as our gold standard, 31 (70.45 %)

patients had exudative PE, and 13 (29.54 %) had pleural effusion misclassified using Light’s criteria who had

transudative PE. Malignant effusion was the most common PE in our study (16 cases of 31, 51.61%) followed by

tubercular effusion (9 cases of 31, 29.03%).

The average of serum level of cholesterol in exudative patients was 177.81± 38.60 mg/dl. The serum level of

cholesterol ≥ 200 mg/dl was seen in 4 (12.9%) patients. The average of pleural cholesterol were 62.73 ± 26.84 and

62.57 ± 28.15 mg/dl in exudative and transudative patients respectively. The cholesterol of pleural fluid > 50 mg/dl

was considered as exudative cutoff value, and 29 (65.9%) patients had exudative pleural effusion based on pleural

cholesterol. The mean of pleural/ serum cholesterol ratio were 0.370 ± 0.164 and 0.374 ± 0.169 in exudative and

transudative PE respectively. The specificity, sensitivity and positive and negative predictive value of pleural and

pleural / serum ratio of cholesterol were reported in Table 2.

The pleural and serum level of triglyceride and HDL, and their pleural/serum ratio were compared between

exudative and transudative patients (Table 3). There was no significant differences between groups, and pleural and

serum level of triglyceride and HDL, and their ratio could not differentiate exudative and transudative pleural

effusions.

The pleural and serum level of LDL were compared between exudative and transudative patients too which, no

significant differences was seen between groups but it’s pleural/serum ratio in transudative PE was significantly

higher than exudative PE (Table 3). ROC curve was designed for P/S LDL ratio but this variable was not able to

differentiate transudative and exudative PE.

Discussion:

In this case-series, 44 patients with exudative pleural effusion (based on light’s criteria) were studied, so we were

not able to calculate specificity and sensitivity of light’s criteria, but about 29.5 % misclassification (13 patients)

was seen in our study. Thirty percent misclassification of transudative PE was reported using light’s criteria, which

cause additional aggressive diagnostic approaches such as thoracentesis with biopsy, surgery, or thoracoscopy (6- 8).

Diuretics may cause biochemical changes in pleural fluid and misclassification. We excluded all of patients on

diuretic medications. Repeated thoracentesis could alter pleural fluid characteristics.

Malignancy was the most cause of exudative PE followed by tubercular effusion. Rufino and his colleges and some

other studies reported tubercular effusion as the most common cause of exudative PE (1, 6, and 9) which shows high

incidence of TB in their studied population but we chose patients from Chronic Respiratory Diseases Research

Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD) with more incidence of

malignancy.

In recent meta-analysis including 20 studies (3496 patients), specificity and sensitivity of pleural cholesterol were

96% and 88% respectively with area under curve of 0.97 and for P/S ratio were 87%, 94% with area under curve of

0.97. Authors conclude that both pleural cholesterol and P/S cholesterol ratio are helpful for differentiate exudative


SP58-18

and transudative PE along with the results of traditional tests and clinical information (10). The lower specificity and

sensitivity of pleural cholesterol (64.52 % and 69.23 % respectively) in present study may be due to difference of

sample size, ethnicity, laboratory methods and errors, and difference in clinical situation of studied population.

We assess pleural TG, LDL, and HDL and their P/S ratio, but we could not find any acceptable cutoff value to

differentiate transudative and exudative pleural effusion.

In conclusion, it seems pleural cholesterol in cutoff level of >50 mg/dl is more accurate than light’s criteria but

pleural TG, LDL and HDL and their P/S ratio are unable to diagnose of exudate and transudate PE. Pleural level of

LDL was significantly different in exudative and transudative PE, it seems further investigations with bigger sample

size is needed to better understanding of lipid profile differences in transudative and exudative pleural effusions.

Acknowledgment

This article is written based on approved projects at Vice Chancellor for Research and Technology Shahid Beheshti

University of Medical Sciences.

Funding statement

The Vice Chancellor for Research of the Shahid Beheshti University of Medical Sciences provided the financial

resources

Conflict of interest

The authors state that they have no conflict of interest.

References:

Hamal AB, Yogi KN, Bam N, Das SK, Karn R. Pleural fluid cholesterol in differentiating exudative and transudative pleural

effusion. Pulmonary Medicine. 2013. http://dx.doi.org/10.1155/2013/135036.

Chakko SC, Caldwell SH, Sforza PP. Treatment of congestive heart failure. Its effect on pleural fluid chemistry. Chest. 1989;

95(4): 798-802.

Hamm H, Brohan U, Bohmer R, Missmahl HP. Cholesterol in pleural effusions. A diagnostic aid. Chest 1987; 92(2):296-302.

Roth BJ, O’Meara TF, Cragun WH. The serum-effusion albumin gradient in the evaluation of pleural effusions. Chest 1990;98(3):

546-549

Meisel S, Shamiss A, Thaler M, Nussinovitch N, Rosenthal T. Pleural fluid to serum bilirubin concentration ratio for the

separation of transudates from exudates. Chest 1990; 98(1):141-144.

Rufino R, Marques BL, Azambuja RL, Mafort T, Puglise JG, da Costa CH. Pleural cholesterol to the diagnosis of exudative

effusion. The Open Respiratory Medicine Journal. 2014; 8: 14-17.

Hooper C, Lee YC, Maskell N, BTS Pleural, Guideline Group. Investigation of a unilateral pleural effusion in adults: British

Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010; 65: ii4-17.

Romero- Candeira S, Hernandes L. The separation of transudate and exudate with particular reference to the protein gradient.

Curr Opin Pulm Med. 2004; 10 (4): 294-8.

Laim CK, Kim-Hatt LIM, Wong CMM. Causes of pleural exudates in a region with a high incidence of tuberculosis. Respirology.

2000; 5(1): 33-38.

Shen Y, Zhu H, Wan C, Chen L, Wang T, Yang T. Can cholesterol be used to distinguish pleural exudates from transudates?

Evidence from a bivariate meta-analysis. BMC Pulmonary Medicine. 2014; 14:61-69.

Table 1: Causes of pleural effusions Etiology No. %

Transudative 13 29.54

Congestive heart failure 11

Liver cirrhosis 2

http://dx.doi.org/10.1155/2013/135036


SP58-18

Exudative 31 70.45

Malignancy 16

Tuberculosis 9

Empyema 2

Para-pneumonic 2

Post heart transplant 2

Table 2: The specificity, sensitivity and positive and negative predictive value of pleural and pleural / serum ratio of

cholesterol Diagnosis based on Pleural cholesterol ≥50mg/dl Diagnosis based on P/S cholesterol ≥ 0.4

Exudative PE Transudative PE Exudative PE Transudative PE

Definite Exudative PE 20 9 10 7

Definite transudative PE 11 4 21 6

Positive predictive value 64.52 32/26

Negative predictive value 30.77 46.15

Sensitivity (%) 64.52 32.26

Specificity (%) 69.23 53.85

Table 3: the comparison of TG, HDL, and LDL in exudative and transudative pleural effusion Variable Exudative Transudative P-value

Serum TG 151.81±39.5 189.0±88.0 0.1

Pleural TG 24.52±12.82 28.54±13.01 0.3

P/S TG 17.51±10.88 15.74±5.42 0.5

Serum HDL 42.32±14.62 39.54±7.14 0.5

Pleural HDL 14.06±6.39 12.77±5.64 0.5

P/S HDL 35.73±18.19 32.66±12.89 0.5

Serum LDL 105.12±27.00 91.20±24.69 0.1

Pleural LDL 41.16±23.46 50.45±27.59 0.2

P/S LDL 40.22±20.98 62.53±41.94 0.02*

*statistically significant


SP59-18

A Review on Knowledge and Attitude of Medical Students to

Communication Skills at Mazandaran University of Medical

Sciences

Abbas Masoudzadeh 1, Pezhman Hadinezhad

2

1Associate Professor of Psychiatry, Faculty Member of Mazandaran University of Medical Sciences 2Psychiatric Assistant, Mazandaran University of Medical Sciences (Corresponding Author)

Abstract

Introduction: The ability to communicate is a fundamental skill for human. Communication is one of the most

important characteristics essential for people working in health care systems. The present paper aims to review

the knowledge and attitude of medical students to communication skills in Sari Medical School.

Materials and Methods: The present study, which is conducted by descriptive method, evaluated the

apprentices, interns and residents at Sari Medical School during one academic year using communication skills

questionnaire including 25 questions on knowledge and 50 questions on attitude.

Findings: 140 people participated in this study including 63.6% female, 69.3% married persons, 22.84 %

residents, 30% interns and 45.71%, apprentices. In general, 41.3% of participants had positive attitude. There

was low level of knowledge in this study and a significant relation was observed between attitude level and

residents’ specialty field and history of having clinic (P=0.027 & P=0.02). The level of psychiatric residents’ attitude was higher than other fields.

Conclusion: The present study indicated that the knowledge and attitude condition of apprentices, interns and

residents related to communication skills were undesirable. With regard to the importance of this issue, it is

proposed that appropriate planning would be conducted in this area.

Key Words: Communication skills, attitude, medical students

Introduction

The ability to communicate is a fundamental skill for human and similar to many other skills, some people show

more talent and ability in this regard than others (1). It could be said that communication is a set of physical and

psychological processes established between several people in order to achieve particular objectives and includes

complicated procedures from giving and receiving oral messages and even body language. To have a successful

relationship and develop it, it is necessary to know different cultures and recognize their impact on communication

(2). To emphasize the importance of communication, it could be said that all social activities require exchange of

information and the appropriate way of this exchange is the basic condition of human relations (3).

Communication has been proposed as one of the most important characteristics required for people working in

health care systems (4, 5) in a way that Medical Education Accreditation Council (ALGHE) has defined

communication skills as key parts of public competencies of physicians (6). Communication with patient is the core

of the clinical skill to practice medicine (7). Communication skills are defined as specific and visible behaviors

including interview to obtain family history, explanation about diagnosis and prognosis, therapeutic strategies and

patient counseling (8, 9). Establishment of proper communication has positive effects on patients such as recovery

of vital signs, reduced pain and anxiety, increased satisfaction and improvement of health outcomes. It also leads to

positive contribution of doctor in working environment and more relation with patient and so increased self-esteem


SP59-18

of physician. On the other hand, lack of proper communication between doctor and patient leads to higher rate of

diagnostic errors, reduced participation by patient in treatment and provision of patient’s profile by patient as well as

reduced participation of physician in various occupational scenes on one hand which will entirely lead to patients’ dissatisfaction (10, 11).

Medical training in less developed countries is mainly based on evaluation of scientific promotion of physicians

which merely focuses on scientific and abstract content of communication in some cases. However the training

programs in developed countries include several parts for improvement of communication skills which are

increasing both in terms of number and complexity of procedures (12).

Communication skill is not proposed as a course to students and there is no specific program to teach such skills to

learners. Besides, few studies have been conducted in this area and no study has been implemented on medical

students in Sari at different educational levels. Therefore, the present paper aims to review the knowledge and

attitude of students to communication skills in different educational levels so that we could take a step to achieve

appropriate educational programs and improve communication skills.

Materials and Methods

In present study which was conducted based on descriptive-survey method, the population consisted of 200 people

including all apprentices, interns and residents at Sari Medical School (except pathology and radiology residents)

who were qualified to be included in the study through primary examination of statistical population and have been

evaluated for census. The assessment tool in this study was communication skills questionnaire including 25

questions on knowledge and 50 questions on attitude.

The questions on knowledge were multiple-choice with one correct answer. The questions on attitude included

positive and negative attitudes which were organized with 5-item scale from strongly agree to strongly disagree.

Therefore, the most positive and the most negative attitudes were respectively scored by 5 and 1. The rating order

was reversed in negative questions and total results were similar to other questions. The highest and lowest scores

were respectively allocated to the most positive and most negative attitudes.

Each correct response of knowledge questions had one point and participants’ points determined their status of

knowledge in which 20-25 was good knowledge status, 15-19 was average knowledge and lower than 14 was little

knowledge. This questionnaire was used in the study by Heidarzade et al. (14) and its reliability amongst medical

students was 0.71 for knowledge questionnaire and 0.67 for attitude questionnaire.

Participants’ personal information included age, gender, marital status and history of having clinic which were

inscribed in their profile form.

The data were recorded in SPSS statistical software and were examined and compared using descriptive statistics

indices (mean and frequency), t-test and square test. The values lower than 0.05 were regarded as statistically

significance level.

Findings

From 200 people (apprentices, interns and residents), 140 people with regression coefficient of 0.7 completed and

returned the questionnaire. Participants were in the age range of 22 to 40. The distribution of demographic variables

and frequency of positive attitude, mean attitude and knowledge are shown in Table 1.

Table 1- Distribution level of demographic variables, frequency status of positive attitude, mean attitude and mean knowledge

Frequency % Positive

Attitude P Mean

Attitude P Mean

Knowledge P Variable

89 63.6 42.7 0.8 1.47 0.9 8.26 0.7 Female

SP59-18

51 26.4 41.2 1.47 8.11 Male 64 45.71 91.2

0.3 1.47

0.14 8.09

0.18 Apprentice

42 30 38.1 1.44 8 Intern 32 22.84 100< 1.48 8.9 Resident* 97 69.3 42.3 0.96 1.46 0.7 8.12 0.4 Married 43 30.7 41.9 1.47 8.41 Single 11 34.3 63.6

0.027 1.49

0.7 8.45

0.7 Yes History of

having clinic 21 65.7 23.1 1.46 8.76 No

*Resident refers to total residents of one to third academic year.

In general, from 140 participants, 41.3% had positive attitude and 58.7% had negative attitude. All participants had

little level of knowledge in present study. Mean knowledge score had no significant relation with contextual factors

such as age, gender, marital status, history of having clinic and educational level.

There was no significant relation between level of attitude and contextual factors such as age, gender, marital status

and educational level. There was significant relation between overall attitude and positive attitude of residents based

on their field of specialty and need to communication skills (P=0.041, P=0.02): diagrams 1 and 2

1/3

1/35

1/4

1/45

1/5

1/55

1/6

Psychiatry Pediatrics Internal

Medicine

Gynecology Surgery

Diagram 1: Mean attitude of residents based on their field of specialty

Diagram 2: Frequency of attitude level of based on their field of specialty

Psychiatry Pediatric woman Internal Surgery


SP59-18

0

2

4

6

8

10

12

Internal

Medicine

Pediatrics Gynecology Psychiatry Surgery

Diagram 3: Level of knowledge based on their field of specialty

The highest and lowest positive attitude were respectively related to psychiatry residents and surgery residents.

There was significant difference between positive attitude of residents in terms of communication skills and history

of having clinic (P=0.027). Residents with history of having clinic had more positive attitude to communication

skills.

Level of knowledge in different fields of residency had no significant difference. However internal resident and

surgery resident groups respectively had the most and least knowledge about the importance of communication

skills.

Discussion and Conclusion

In present paper which was conducted to examine knowledge and attitude of medical students on communication

skills in Sari medical school, the participants had generally low level of knowledge.

In general, from 140 people under study, 41.3 % had positive attitude.

In the study by Heidarzade et al., in Gilan, the participants had little level of knowledge which was consistent with

the results of present study. In overall review, 65.5% of the subjects had positive attitude (13). In the study by

Neimati et al., faculty members were examined in addition to residents and interns, however the individuals from

apprenticeship to residency were studied in this research. It seems that the reason for higher negative attitude in

present study compared to the study by Neimati was that the faculty members did not participate in present study. In

the study by Neimati, only the history of having clinic had significant relationship with the level of knowledge and

positive attitude however, besides to history of having clinic, type of specialty field had significant relation with

level of knowledge and positive attitude in present study. The highest score was related to internal residents in terms

of level of knowledge and the most positive attitude was related to psychiatry in terms of attitude.

In the study by Shankar et al. (2006), 213 people were examined in which only the attitude of medical students were

evaluated. In this study, participants took communication skills training during educational course prior to

completing the questionnaire. Female students had more positive attitude than male students in to learning

communication skills. Besides, freshmen students compared to interns had more positive attitude to learning

communication skills (14).

In the study by kuffman et al. (2001) (15), female students compared to male students had more positive attitude to

communication skills. Also in this study, it was shown that the first and second year students had more positive

attitude compared to fourth year students. However in present study, there was no significant difference between

knowledge and attitudes about communication skills and gender and educational level.

SP59-18

In the study by Liddle et al., 357 internship students were evaluated in terms of communication skills after

completing a training course which showed increased positive attitude of students to communication skills (16).

Generally, there was more negative attitude towards communication skills in present study which could be due to

little knowledge in this area and lack of communication skills training courses compared to other studies. Another

important controversial point which in present study is that the main focus has been on the evaluation of

communication skills in most of the studies while the knowledge of medical students has not been measured.

Despite the more positive attitude of psychiatry residents towards the need to learn communication skills, their level

of knowledge was lower than residents of internal medicine. So, with regard to importance of communication skills

in this field it is recommended to implement more comprehensive researches and educational interventions.

Major limitations of this study included small number of participants, lack of trial communication skills course

before completing the questionnaire for further and more proper examination of students’ knowledge and attitude

and lack of awareness of students’ situation in other fields.

For additional studies in order to achieve appropriate educational programs and improve communication skills, it is

recommended to present one course on communication skills to medical students and examine the effectiveness of

different ways of teaching communication skills in order to select the most proper method.

References

World health organization. Mental health department. Physician-patient communication. Ghadir ashkajani F, zolfaghari M,

translation. Tehran institute of psychiatry: educational and development center of Iran university of medical science. 2000,6.

Mirzakhani M, Sheik federeaski T, tabatabae M, soltrani arabshahi K. A survey on communication skill of under graduate

student of Shahid Beheshti University of medical science, faculty of rehabilitation in the academic year 2011-2012. J Rehab

Med. 2014; 3(1):51-57.

Bali lashki N. Communication and patient treatment. Mazanadaran university of medical sience, 2002:1-4

Holt A. Professional communication skills. Scandinavian Journal of primary health care. 1990; 8(3):131-132.

Moin A, Anbari akmal K. The doctor-patient communication. Daneshvar Med. 2009;17(85):71-80

Wehhe-Danek H, Song J, Shabunhang M. An evaluation of the usefulness of standardizes patient methodology in the

assessment of surgery resident communication skills. J surg Educ. 2011; 68(3)172-177.

F Daniel Duffy, Geoffrey H Gordon, Gerald Whelan, Kathy Cole-Kelly, Richard Frankel, Natalie Buffone, et al. Academic

Medicine: Journal of the Association of American Medical Colleges 2004, 79 (6): 495-507

Coulhan Jl, Block MR. The medical interview: mastering skills for clinical practice. 4th

ed. Phiadelphia; F.A davis company. 2001.

Cole A, Bird J. Medical interview: the three function approach. Phladelphia, 2000:7-13.

Lavasani F. Interpersonal skill communication. Tehran institute of psychiatry. 2004:5-7.

Javaher A, khaghanizade M, Ebadi A. Study of Communication Skills in Nursing Students and its Association with Demographic

Characteristics. Iranian Journal of Medical Education. 2014; 14 (1):23-31[Persian].

lynn S, Bilckly, Bates' Guide to Physical Examination and History-Taking. 11th

ed. Lippincott-Raven Publishers, 2009. PP: 1-5.

The Interns, Residents and Faculty Members\' Knowledge and Attitudes toward Communication Skills Heidarzadeh A , Dadkhah

Tirani H , Asadi A , Nemati M Research in Medical Education, Guilan University of Medical Sciences 138631-26 : (9)- ؛

Shankar RP. Et all. Student attitudes towards communication skills training in a medical college in western Nepal. Educ health

(Abingdon) 2006; 19:71-84.

Kaufmann DM, et al. Differences in medical students attitudes and self-efficacy regarding patient-doctor communication. Acad

med.2007; 76: 188-192.

Liddle MJ, Davidson SK. Student attitudes and their academic performance in there any relationship. Med Teach, 2004; 26: 52-

56.

http://health.barakatkns.com/article/135055/%D8%A8%D8%B1%D8%B1%D8%B3%D9%8A-%D9%85%D9%87%D8%A7%D8%B1%D8%AA%D9%87%D8%A7%D9%8A-%D8%A7%D8%B1%D8%AA%D8%A8%D8%A7%D8%B7%D9%8A-%D9%83%D8%A7%D8%B1%D9%88%D8%B1%D8%B2%D8%A7%D9%86-%D8%AF%D8%B3%D8%AA%D9%8A%D8%A7%D8%B1%D8%A7%D9%86-%D9%88-%D8%A7%D8%B9%D8%B6%D8%A7%D8%A1-%D9%87%D9%8A%D8%A6%D8%AA-%D8%B9%D9%84%D9%85%D9%8A-%D8%A8%D8%A7%D9%84%D9%8A%D9%86%D9%8A-%D8%AF%D8%A7%D9%86%D8%B4%DA%AF%D8%A7%D9%87-%D8%B9%D9%84%D9%88%D9%85-%D9%BE%D8%B2%D8%B4%D9%83%D9%8A-%DA%AF%D9%8A%D9%84%D8%A7%D9%86-%D8%AF%D8%B1-%D8%B3%D8%A7%D9%84-13

http://health.barakatkns.com/author-indexedarticles/607263/heidarzadeh-a

http://health.barakatkns.com/author-indexedarticles/607264/dadkhah-tirani-h

http://health.barakatkns.com/author-indexedarticles/607264/dadkhah-tirani-h

http://health.barakatkns.com/author-indexedarticles/607265/asadi-a

http://health.barakatkns.com/author-indexedarticles/607266/nemati-m

http://health.barakatkns.com/author-indexedarticles/607266/nemati-m

http://health.barakatkns.com/issue-articles/11837


SP60-18

Analysis of Determinants of Physical Activity to Prevent Osteoporosis among

Pre-University Female Students in Rafsanjan, 2015-16: Applying Health

Belief Model

Kazemi Safieh Sadat1, Salim Abadi Yaser

2, Asadpour Mohammad

2, Aligol Mohammad

3,

Nasirzadeh Mostafa2*

1. Researcher, Student Research Committee of School of Health, School of Health, Rafsanjan University of Medical

Sciences, Rafsanjan, Iran.

2. Assistant Professor, Department of Health Services and Health Promotion, School of Health, Rafsanjan

University of Medical Sciences, Rafsanjan, Iran.

3. Ph.D. in Health Education and Promotion, Health Deputy, Qom University of Medical Sciences, Qom, Iran.

Corresponding Author: Nasirzadeh Mostafa, Assistant Professor, Department of Health Services and Health

Promotion, School of Health, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.

Email: [email protected] Tel: +989131067118

Running Title: Determinants of Physical Activity among Pre-University Female.

Abstract

Introduction: Osteoporosis is one of the health problems, in which relatively 1 out of 3 Iranian women is involved.

This study conducted with the aim of identification of determinants of physical activity of students in field of

osteoporosis based on health belief model.

Methods and materials: The descriptive-analytical research is conducted among 470 female students in pre-

university grade in Rafsanjan City, using simple random sampling. Data collection instrument in this study is 4-part

questionnaire containing 8 items about demographic information; 15 items on knowledge; 24 items on structures of

health belief and 11 items measuring the status of physical activity during weekdays per minute. Data analysis in

this study is done using SPSS-14 and using Pearson Correlation test, Independent t-test and one-way ANOVA at the

significance level of 0.05.

Results: The average age of participants was 17.8±0.6 years old. Mean and Standard Deviation (M.SD) physical

activity was equal to 178.52±285.29 minutes per week and majority of students (53.7%) had moderate physical

activity. Significant correlation was between physical activity and perceived barriers (p<0.001); although showed no

significant correlation with other structures and demographic information (p>0.05).

Conclusion: Only 18% of participants had favorable physical activity. The knowledge level of students was also

unfavorable. There was significant correlation between physical activity and perceived barriers. According to gender

of participants, analysis of social determinants such as family and environments is required for purpose of

comprehensive identification of perceived barriers. Moreover, analysis of other determinants of preventing

osteoporosis like nutrition is also suggested.

Key words: Osteoporosis, Physical Activity, Health Belief Model, Pre-University Female Students



SP60-28

Introduction

Osteoporosis (OP) is one of the general health problems and has affected millions of people across the world (1).

The disease is the most common metabolic bone disease diagnosed with reduction of bone mass and bone tissue

construction tangle (2-4). Nowadays, Osteoporosis is a big threat at the world and its annual mortality is higher than

different types of cancer (5). The disease is also common in Iran, so that about 1 out of 3 women and 1 out of 12

men suffer from osteoporosis (6). Specialists believe that the best strategy for the disease is prevention, since the

existing treatments can just prevent loss of bone tissue and can't reconstruct the lost tissues (7). The main

recommendations of World Health Organization (WHO) to prevent osteoporosis is increasing physical activity (PA)

and exercise (8). Taking physical activity in young age can help increase in bone mineral mass and the evolution of

that and continuing physical activity can prevent reduction of bone density during lifetime (9). Although

epidemiologic, clinical and empirical studies show that taking regular physical activities is vital to protect and

increase bone mass and body strength and can help people to prevent fractures caused by OP (10), the reports show

unfavorable status of physical activity in adolescents and youths, especially girls (11, 12). Physical activity is

reduced in adolescents and is increased progressively in high school students and this process is continued to

adulthood (13). Educational plans to enhance knowledge and educational interventions should be taken based on the

realities and needs of patients and based on the traits of different social classes (14). It is important to know that why

and how people accept new behaviors and how change in behavior happens and what factors can cause that? One

common reason for lack of acceptance of OP prevention behaviors is the wrong belief such as the disease is not

serious. According to health belief model, people change their behavior when they understand that the disease is

serious, since they otherwise rarely are directed towards healthy behaviors and lifestyle. Health belief model tries to

explain that why some people use preventive behaviors and some others don't use that. According to this model, the

probability of taking healthy behavior is depended on two issues: first, the perception of person of the risk of disease

(perceived susceptibility and severity) and second, the perception of person of health behavior barriers and benefits

(perceived barriers and benefits) (15). Relevant studies have shown that factors such as lack of time and sport space,

lack of social support, job and educational business, lack of believe in advantages of exercise and low self-efficacy

and feeling lazy are the most important perceived barriers to exercise (1, 2, 17, 18, 19, 20). According to high spread

of OP in women and necessity of preventing it in this group based on the documents of WHO and the possibility of

enhancement of physical activity behavior as one of the most important variables affecting OP, this study has been

conducted with the aim of identification of determinants of students' physical activity in field of OP based on health

belief model and the results obtained from this study are presented to the authorities for purpose of planning and

codification of interventions and taking supportive policies.

Methods and materials


SP60-38

This study is a descriptive-analytical work conducted on 470 pre-university female students in Rafsanjan selected

using simple random sampling during academic year 2015-16. Data collection instrument in this study is 4-part

questionnaire. The first part contains 7 items on demographic information (age, marital status, education level and

parent job and income level); second part contains 15 items on knowledge; third part contains 24 items on structures

of health model and fourth part contains 11 items derived from findings of Baheiraei et al on physical activity status

(walking, cycling, swimming, exercise, basketball, etc.) of students during weekdays per minute (9). The scale of

answering items was 4-option knowledge measurement and the range of scores was 0-5. The true answers get point

1 and false answers get point Zero. Out of 24 items in part 3, each structure including perceived susceptibility,

severity, benefits and barriers on OP possessed 6 items. The answering scale of each structure was based on 5-point

Likert scale from totally agree to totally disagree. The answer "totally agree" got point 5 and the option "totally

disagree" got point 1. The range of scores in each part was from 6 to 30. In regard with perceived susceptibility,

severity and benefits, higher points showed higher perception of these concepts. Moreover, getting lower points in

the section of perceived barriers showed higher perception of these barriers. Validity and reliability of items of

health belief model was confirmed by Baheiraei et al and Cronbach’s alpha was reported to 0.82 (9). Moreover, in

the study conducted by Shojaeizadeh et al (2011), reliability of the questionnaire based on health belief structures

was confirmed and Cronbach’s alpha for perceived susceptibility, severity, benefit and barriers was respectively

obtained to 0.78, 0.8, 0.77 and 0.7 (16). Reliability of the questionnaire of measurement of physical activity was

confirmed by Tavassoli and the Cronbach's alpha was reported to 0.78 and the validity of questionnaire was also

confirmed by sport specialists (21). Physical activity less than 150 minutes per week was considered as weak PA,

150 to 300 minutes as moderate PA and more than 300 minutes as severe PA. The procedure was as follows: the

author referred to classrooms of students and after explaining the research objectives, they were asked to study the

questionnaire carefully and fulfill that if they were satisfied by that. The collected data were analyzed using SPSS-

14 and due to role of research variables. Also, normality of data distribution (using Kolmogorov-Smirnov test) was

analyzed using Pearson correlation test, independent t-test and one-way ANOVA. Sig level was considered lower

than 0.05.

Results

Number of students participated in this study was equal to 470 people and the average age range of participants was

equal to 17.8±0.6 years old (16-21 years old). Number of single students was equal to 416 (87.2%) and number of

married students was equal to 61 people (12.8%). Education level of parents was respectively in academic level in

119 (25.4%) and 104 (21%) parents. 380 (79.5%) mothers of participants were housewives and 211 (44.1%) fathers

of students were self-employed. Only 7.6% of students described the income level of their parents in weak level

(table 1). Mean score of physical activity of students was equal to 178.52±285.29 minutes per week. Majority of

participants (53.7%) had moderate physical activity (figure 1). M.SD of knowledge level is equal to 6.8±2.5;

perceived susceptibility of participants is equal to 15.8±4.2; perceived severity is equal to 16.8±4.5; perceived


SP60-48

benefits and barriers are respectively equal to 24.1±3.7 and 15.1±4.8. There was significant correlation between

M.SD of physical activity and perceived barriers in field of physical activity (p<0.001). No significant correlation

was observed between physical activity per week and other structures (p>0.05)(table 2). Moreover, no significant

correlation was observed between physical activity and demographic information (p>0.05).

Table 1: Frequency Distribution of Students' Demographic Characteristics Variable Name Variable Status Number Percent Marital status

Single 416 87.2 Married 61 12.8

Mother's education

level

illiterate 26 5.5 primary 72 15.1 Guidance 101 21.2 Diploma 174 36.5 Academic 104 21.8

Father's level of

education

illiterate 28 6 primary 65 13.9 Guidance 100 21.3 Diploma 157 33.5 Academic 119 25.4

Father's job

Unemployed 34 7.1 The worker 54 11.3 Free 211 44.1 Employee 161 33.7 Others 18 3.8

Mather's job

housewife 380 79.5 Employee 88 18.4 Others 2 2.1

Income status**

Weak 36 7.6 Average 127 27 Good 307 65.4

** Poor income: Lack of living expenses; Middle income: Less than

Living expenses; Good income: The provider of living expenses

Table 2: Correlation between Physical activity of Students with other Structures of Health Belief

Model

Variable Name Mean and Standard

Deviation

Pearson correlation

X1 X2 X3 X4 X5 X6

X1=physical activity 178.5±285.2 1

X2=Knowledge 6.8±2.5 0.03 1

X3=Perceived susceptibility 15.8±4.2 -0.06 -0.08 1

X4=Perceived severity 16.8±4.5 0.004 -0.01 0.3** 1

X5=Perceived benefits 24.1±3.7 -0.03 0.2** -0.1* 0.04 1

X6=Perceived barriers 15.1±4.8 -0.1** 0.009 0.2** 0.2** -0.09 1

* Significant at the level of 0.05 ** Significant at the level of 0.01


SP60-58

Discussion

Osteoporosis (OP) or reduced bone mineral density across the world and in all populations has increased burden of

diseases (22). The lifestyle plays key role in occurrence of such disease (23). The main recommendation of World

Health Organization to prevent OP is increasing the amount of exercise and physical activity (24). The most

important solutions to design plans to change behavior could be to perceive the reason for function of people and

recognizing the factors affecting change in behavior (14). Accordingly, this study has been implemented with the

aim of determining status of physical activity of pre-university female students of Rafsanjan City and relevant

determinants based on health belief model. The results obtained from this study showed that majority of students

had moderate physical activity, Similar to Asadpour's research results (25); only about 18% of participants had

favorable physical activity. Development of technology and availability of welfare facilities and using TV and

computers has directed life of adolescents towards inactivity (26). Hence, taking regular physical activity is

recommended at least 30min per day to compensate the reduced physical activity (27). The first variable studied has

been the knowledge score of students in field of physical activity, which is lower than average level in this study and

this result is in consistence with findings of Niazi et al and Kamjoo et al (2, 28) before intervention. The highest lack

of knowledge of students is reported in field of least time required for exercise to prevent OP. Despite to importance

of preventing OP in girls and women, their knowledge was not in favorable level and this needs implementation of

educational interventions in this field. Second studied variable is mean value of perceived benefits of students in

field of physical activity, which was reported in favorable level similar to findings of Ghaffari et al and Aghamollaei

et al (1, 29). It should be noted that why students have unfavorable physical activity even with existence of high

perceived benefits? Accordingly, it is essential to conduct more comprehensive and holistic studies with the aim of

28,1

53,7

18,2

Figure 1: Frequency Distribution of Students' Physical

Activity per Week in Minutes

Weak (less

than 150

minutes)

Medium (150-

300 minutes)


SP60-68

identification of other determinants of lack of physical activity in this group. Third variable is perceived barriers of

students in field of physical activity, which is reported to average level similar to other relevant studies (29, 31).

Similar to other works (32-34), this study has determined perceived barriers as the strongest predictor of taking

physical activity among the studied variables. The most important perceived barrier of students in this study to take

physical activity is disappointing them by their family. According to the emphasis on family in Iran and emotional

and financial attachment of adolescents to family in these ages, strong effect of family support on physical activity

of girls is logical (35). Accordingly, it is essential for further studies to identify other barriers in individual and

social level and provide the outputs for the planners, so that they can make short-term and long-term plans to meet

the barriers to enhance physical activity. In this study, mean value of perceived susceptibility of students on OP is

reported in moderate level similar to findings of Ghaffari et al (1). However, Shojaeizadeh et al reported the mean

value of perceived susceptibility lower than average level (36) and the most important causes of the differences

could be the area of study and different target groups and heterogeneity of applied instruments. The last variable in

this study is perceived severity of students on OP, which is reported in average level similar to findings of Ebadifard

Azar et al and Ghaffari et al (37, 1). According to obtained results from this study, it seems that other factors are also

involved in unfavorable physical activity of students. Therefore, it is essential to conduct further studies in more

comprehensive and holistic way and beyond just individuals. It should be mentioned that according to analysis of

individual factors and perceptions of individuals, the results obtained from this study are mostly compared to

domestic works and this is strength of this study. The next strength of this study is using a regular and logical

framework in the research process. The limitations of this study include studying girls and the way of answering

questions by students (self-report).

Conclusion

In this study, average time of taking physical activity by students is reported to 178.52±285.29 minutes per week

and majority of students were in moderate level. Moreover, students had average perceived barriers in field of

physical activity, average susceptibility and severity in field of OP and favorable perceived benefits in field of

physical activity and also weak knowledge lower than average level in field of physical activity. In this study, there

was significant correlation between value of physical activity and perceived barrier and no significant correlation

was observed between this variable and other variables. Perceived barrier is determined as the strongest predictor to

take physical activity. It is recommended to conduct further studies with holistic attitude and to study other variables

affecting taking physical activity such as analysis of facilities and equipment, spaces and places for sports of

women, effect of others like family and their attitude and behavior in field of physical activity. Moreover, the studies

can analyze other dimensions of 6 strategies of World Health Organization in field of osteoporosis and bone density

measurement such as the nutrition status as one of the most important factors affecting this issue.

Acknowledgments


SP60-78

The authors would like to appreciate authorities of Rafsanjan University of Medical Sciences, Education and

Training Ministry of Rafsanjan, managers and teachers of Female schools and the students who helped to

implementation of this research project. This research is derived from Research project (Code 1329 that supported

by Rafsanjan University of Medical Sciences).

References

1. Ghafari M, Nasirzadeh M, Aligol M, Davoodi F, Nejatifar M, Kabiri S, Nezhadmohammad S. Determinants of physical

activity for prevention of osteoporosis among female students of Shahid Beheshti University of Medical Sciences:

Application of health belief model. Pejouhandeh 2014; 19(5):244-250. (In Persian)

2. Niazi S, Ghafari M, Noori A, Khodadoost M. Impacts of a health belief model-based education program about

osteoporosis prevention on junior high school students’ physical activity, Kalaleh, Iran, 2012. The Journal of Hakim Seyyed

Esmaeil Jorjani 2013; 1(1): 1-9. (In Persian)

3. Andreoli T, Grygz R, Carpenter CH, Laskalzv J. Principles of internal medicine, Cecil / musculoskeletal and connective

tissue disease. Teranslated by: Raisi M, Ghaziani M, Khavaran K, 6th ed. Tehran. Teimoorzadeh Institute Press. Publishing

Tabib; 2004:54-61.

4. Prevention and management of osteoporosis: report of a WHO scientific group. Geneva: World Health Organization. 1st

ed. 2004; 1-120.

5. Sambrook P, Cooper C. Osteoporosis. Lanset 2006; 367 (9527): 1010-2008.

6. Foroutan R, Shahidi L. Orthopedic nursing. Tehran: Salemi Publication, 2004:78-79.

7. Shahram F. Osteoporosis (guidelines for diagnosis, prevention and treatment). Publications General Department Disease

Control and Prevention. Ministry of Health and Medical Education; 2005: 24-36.

8. World Health Organization. Diet, nutrition and the prevention of chronic diseases. Available from: http://whqlibdoc.

who.int/trs/who_trs_916.pdf.

9. Baheiraei A, Ritchie JE, Eisman JA, Nguyen TV. Psychometric properties of the Ppersian version of the osteoporosis

knowledge and health belief questionnaires. Maturitas 2005; 14(50): 134-9. (In Persian)

10. KarimzadehShirazi K, Niknami S, Heydarnia AM, Wallace L, Torkaman G, Faghihzadeh S. Effects of a TTM-based

osteoporosis preventive physical activity education, on increasing muscle strength and balance in women aged 40-65.

Hakim Res J 2007; 10(2): 34- 42. (In Persian)

11. Bener A, Hammoudeh M, Zirie M, Heller Rf. Is obesity a protective factor for osteoporosis? Aplar J Rheumato 2005; 8(1):

32- 38.

12. Derakhshan S, Salehi R, ReshadManesh N Prevalence of osteoporosis, osteopenia and their related factors in post-

menopausal women referring to Kurdistan densitometry center. Scientific Journal of Kurdistan University of Medical

Sciences 2006; 40(11): 59- 67 .(In Persian) 13. Gillman MW, Pinto MB, Tennstadt S, glanz K, Marcus B, Fridman RH.

Relationship of physical activity with dietary behavior among adults. Pre Med 2001; 32(2): 295- 301.

14. Heidarnia E. Discussions In the process of health education. Tehran: ZamaniNaser Publishing; 2003. p. 92-109. (In

Persian)

15. Glanz KA, Rimer BA, Viswanth K. Health behavior and health education theory, research and practice. 4th ed. San

Farancisco: Josey-Bass Publisher; 2008. p. 8-30.

16. Shojaeezadeh D, Mehrab Beik A, Mahmoodi M, Salehi L. The effect of education on knowledge, attitude and practice of

women clients Imam Khomeini Relief Foundation about preventing osteoporosis using the health belief model. Iran J

Epidemiol 2011; 7(2): 30-7. (In Persian)


SP60-88

17. Veugelers PJ‚ Fitzgerald AL. Effectiveness of School program in preventing childhood obesity: a multilevel comparsion.

Am J public Health. 2005:95(3): 432-5.

18. Noreen E. Mehon‚Thomes J. Yarcheski‚ Adela yarcheski the revised personal lifestyle questionnaire for early

Adolescents. West J Nurs Res. 2002; 25(5): 553-547.

19. Levers – Landis CE‚Burant C‚Drotar D. Social Support Knowlage, and self-efficacy as correlates of osteoporosis

preventive behaviors among preadloescent female. J pediatr psychol. 2003:28(5): 335-45.

20. Bauman A. Criag CL. The place of physical activity in WHO global strategy on diet and physical activity. Int J Behave

Nutrphys Act. 2005:242-10.

21. Tavasoli E. The effect of education based on health belief model on the improvement of osteoporosis preventive

behaviors of second grade middle school girls in Isfahan, 2010 (MS Dissertation in Health Education).

22. World Health Organization. Tobacco and osteoporosis: Tobacco free initiative (TFI), 2013; Accessed 2013 October 20.

Available from: http://www.who.int/tobacco/research/osteoporosis/en/.

23. Gibbs TS, Fleischer AB, Jr., Feldman SR, Sam MC, O'Donovan CA. Health care utilization in patients with migraine:

demographics and patterns of care in the ambulatory setting. Headache. 2003; 43(4): 330-5.

24. World Health Organization. Diet, nutrition and the prevention of chronic diseases. Available from: http://whqlibdoc.

who.int/trs/who_trs_916.pdf.

25. Asadpour M, Sheikh Fathollahi M, Goujani R, Razi S, Torkashvand F, Hassanloei B, Bahador S. Survey on Physical Exercise

Among Paramedical Students of Rafsanjan University of Medical Sciences Based on Stages of Changes Model and Its

Association with Self-Efficacy in 2011-2012. J RafsanjanUniv Med Sci 2014; 13(4): 349-60. (In Persian)

26. Wagner A, Klein-Platat C, Arveiler D, et al. Parent-child physical activity relationships in 12-year old French students do

not depend on family socioeconomic status. Diabetes Metab 2004 Sep; 30(4): 359-66

27. Mcinnis KJ, Franklin BA, Rippe JM. Counseling for physical activity in overweight and obese patients. Am Fam Physician

2003 Mar 15; 67(6): 1249-56

28. Kamjoo A, Shahi A, Dabiri F, Abedini S, HosseiniTeshnizi S, PormehrYabandeh A. The effectiveness of education about

osteoporosis prevention on awareness of female students. Hormozgan Med J 2012; 16(1): 60-5. (In Persian)

29. Aghamolaei T, Tavafian SS, Hassani L. Exercise self-efficacy, exercise perceived benefits and barriers among students in

Hormozgan University of Medical Sciences. Iran J Epidemiol 2008; 4(2): 9-15. (In Persian)

30. Gharlipour Gharghani ZA, Sayarpour SM, Moeini B. Associated factors with regular physical activity among emergency

medical personnel in Hamadan: applying health belief model. J Health Sys Res 2011; 7(6): 710-7. (In Persian)

31. Solhi M, Ahmadi L, Taghdisi MH, Haghani H. The Effect of Trans theoretical model (TTM) on exercise behavior in

pregnant women referred to Dehaghan Rural Health Center. Iran J Med Educ 2012; 11(8): 942-50. (In Persian)

32. Charkazi A, Nazari N, Samimi A, Kouchaki GM, Badeleh MT, Shahnazi H, et al. The relationship between regular physical

activity and the stages of change and decisional balance among Golestan University of Medical Sciences’ Students. J Gorgan

Bouyeh Faculty Nurs Midwifery 2012; 9(2): 74-81. (In Persian)

33. Taymoori P, Falhahi A, Esmailnasab. Application of the health promotion model in studying physical activity behavior of

students in Sanandaj, Iran. Sci J School Public Health 2011; 9(1): 35-46. (Full Text in Persian)

34. Hashemi SZ, Rakhshani F, Navidian A, Mosani SR. Effectiveness of educational program based on Trans-theoretical

model on rate of physical activity among household women in Zahedan, Iran. J Health Sys Res 2013; 9(2): 144-52. (In

Persian)

35. Lubans D, Foster C, Biddle S. A review of mediators of behavior in interventions to promote physical activity among

children and adolescents. PM 2008; 47(5): 463-70

http://www.who.int/tobacco/research/osteoporosis/en/


SP60-98

36. Shojaezadeh D, Sadeghi R, Tarrahi MJ, Asadi M, Lashgarara B. Application of health belief model in prevention of

osteoporosis in volunteers of Khorramabad City health centers, Iran. J Health Syst Res 2012; 8(2): 183-92. (In Persian)

37. Ebadi Fard Azar F, Solhi M, Zohoor AR, Ali Hosseini M. The effect of health belief model on promoting preventive

behaviors of osteoporosis among rural women of Malayer. J Qazvin Univ Med Sci (JQUMS) 2012; 16(2): 58-64. (In Persian)


SP61-18

The effects of topical cyclosporine A in patients with dry

eyes referring to Vali-e-Asr Hospital in Birjand

Gholamhossein Yaghoobi1*, Zohrea Nobakht2, Shabnam Ghavam Ahmadi3

1. MD, Ophthalmologist Professor of Birjand University of Medical Science, Social Determinant

Health Research Center, Department of Ophthalmology, Birjand, Iran (Corresponding author)

2. Assistant Professor of Birjand University of Medical Science, Department of Medicine, Birjand, Iran

3. Student Research Committee, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran

*Corresponding Author E-mail:[email protected]

ABSRACT

Introduction & Objective: Dry eye is one of the most common complaints of patients referred to

ophthalmologists. The dry eye syndrome is a multifactorial disease that affects millions of people around

the world. The prevalence of dry eyes was 14.5% (17.9% in women and 10.5% in men). In this study, to

remove the confounding dermographic variables, the cases and control group of a person was considered

to investigate the effects of topical cyclosporine a in patients with dry eyes referred to the clinic of Vali-e-

Asr Hospital in Birjand.

Materials and Methods: In this clinical trial study, 31 patients who referred to ophthalmology clinic of Vali-

e-Asr Hospital in Birjand who were eligible to participate in the study were evaluated for eye drops by

questionnaire and test. Schirmer test taken before the first visit,one month and three months therafter. The

right eye of the subjects was considered as the experimental group and their left eye as a control group.

Then, for the right eye, cyclosporine A drops were given, and for both eyes the patients were given an

artificial tear drops. The data were analyzed by SPSS software 26, and Chi-square, Fisher, Friedman and

Manwitney statistical tests were analyzed.

Results: In this study, 31 patients participated in this study, which included 26 women and 5 men with an

average age of 49.67 ± 11.6 years. The results showed that pain or burning in the experimental group and

the age group of 46 to 55 years was significantly decreased (p = 0.02). Other symptoms were not

significantly different in different age groups (p> 0.05). The results of examining the changes in the severity

of the disease in the experimental group by sex showed that the fatigue in the men was significantly (p =

0.03). Compared to the changes in the lingerie test for each separate group and the comparison of the two

groups in three time intervals showed no significant changes (p> 0.05). Also, the results of the comparison

of the average score of the Schirmer test of breast milk in the three age groups showed that there was a

significant difference between the score in the next month and three months later in the three age groups

(p = 0.05) and in the age group of 46 to 55 years was significantly lower (P = 0.006). Comparison of disease

severity in the experimental group at different times showed that individuals with underlying disease who

were treated with ciclosporin had a significant reduction in their eye dryness (p = 0.05).

Conclusion: The findings of this study indicate that the use of cyclosporine is a benefecial tool indeed of

Artificial tear to relieved patients dry eye discomfort with rheumatological origin, so it can be helpful in

Treating these patients at a cost and frequency (ease of use).

Keywords: Dry eye, cyclosporine, artificial tears, treatment.

Introduction:

Dry eye is one of the most common complaints in patients referred to ophthalmologists. (1) Dry eye syndrome is a

multifactorial disease that affects millions of people around the world. (2) But due to the variety of definitions the

disease and the lack of a single diagnostic test for diagnosis, the exact extent of the outbreak of dry eye disease is

unknown.


SP61-18

In some studies, the prevalence of dry eye was 14.5% (17.9% for women and 10.5% for men) (3)

Chronic dry eye disease, with symptoms of eye discomfort, is described by patients as burning, dryness, foreign

body sensation, eye pain or other symptoms. This condition can affect visual acuity, photophobia and eye fatigue.

(4). this condition is associated with signs and symptoms including abnormal lacrimal layer and eye inflammation

(5). If these symptoms are not treated in a timely manner and persist for a long time, symptoms of exophthalmia,

including pain, severe photophobia with corneal ulcer and infection, will occur. Infection usually with gram-positive

bacteria and can be dangerous. Previous history of corneal surgery, the use of topical steroids, and eye contact lenses

are predisposing factors for infection (6). Dry eye disease has a wide range of symptoms and symptoms that make it

very complex and categorized. For this reason, several terms are used, such as dry eye syndrome, chronic dry eye

disease, dysfunctional tears syndrome, and cicatricial keratoconjunctivitis (7).

The tear layer eliminates ripples in the epithelial surface of the cornea, and the tear combination prevents the growth

of microorganisms on the cornea and conjunctiva. The tear movement helps to distinguish the peripheral and

microorganisms from the cornea and the conjunctiva. Corneal epithelium and conjunctiva help to survive these cells,

and part of the glucose, oxygen and other materials needed for the life of the epithelial cells Tears are provided by

the lacrimal gland, facilitating the movement of the eyelids on the eyeball, and also making inflammatory cells, such

as neutrophils and lymphocytes, easily reach the affected cornea. (4)

This disease is associated with a change in the composition of the teardrop, including decreased mucin content,

changes in cytokine balance and growth factors, increased active protease concentrations and inflammatory markers,

and increased osmolality. (4)

Diagnostic tests for the disease include: 1-Shirmer test: The taper strip is placed in the center of the outer lobe and in

the middle of the 3rd and 3rd, and the patient closes his eyes. After 5 minutes, the paper soaking time is read and

recorded. Positive test, Soaking less than 15 mm in 5 minutes in cases without local anesthetic and less than 10 mm

in cases of numbness (8) .2-Eye coloring: Corneal epithelial cell damage and conjunctiva with vital colors Such as

Rosebangal, the color of the affected areas is tested in this test. Because the use of Rose Bengal staining in pain-

affected patients is painful, fluorosine is the color of the cornea and the Lysamine Green have been replaced for

conjunctiva coloring. (9) 3-Tear film break up time test: At first, the patient's eyes are painted with fluorescein

strips, then the interval between the last blinking to the appearance of dots on the cornea is measured. In this case,

the patient is examined by a slit lamp. Less than 10 seconds later, the probability of the disease is posed (10). 4.

Salivary gland biopsy. Salivary gland biopsy is an important diagnostic tool in patients suspected of having

Syndrome syndrome. )

The goal of the current treatment for dry eye disease is to increase the production of tears, reduce the evaporation of

tears, and reduce the absorption of tears. Two of the treatments include artificial tears and cyclosporine. (11)

Artificial tear: Includes cellulose to maintain viscosity, polyethylene glycol or polyvinyl alcohol to prevent

evaporation and a preservative to prevent contamination. Artificial tears are in liquid form, gel and ointment. (12)

Cyclosporine A belongs to a group of immunosuppressive compounds that were first isolated in Norway from fungi

(13). Cyclosporine has a molecular formula of C62H111 N11O12 and a molecular weight of 1202.6 g / mol. which

is a non-ribosomal peptide and contains an amino acid D (14)

This drug reduces the immune response by decreasing T cell activity. (2) Cyclosporine has other effects, such as

inhibition of apoptosis. These effects of cyclosporine are linked to two cytoplasmic intermediate proteins called

cyclophilin A and cyclophilin D.Cyclophilins are propyl pyridine isomerase that has chaperonin activity capable of

catalyzing the reversal of protein from twisted-wrong proteins. Cyclosporine binding to cyclophilin A ultimately

inhibits the activity of lymphocyte T (15).

Cyclosporine is used to treat many inflammatory diseases such as psoriasis, rheumatoid arthritis, ulcerative colitis,

and ocular inflammation. (2)


SP61-18

Eye Restoration Emulsion cyclosporine 0.05% (Restasis, Allergan, Inc., Irvine, CA) is available as a treatment

approved by the Food and Drug Administration (FDA) for dry eye diseases since 2003. But usually, dry eyes are

treated with antihistamines, mast cell inhibitors and topical or systemic steroids. (14)

Topical use of cyclosporine due to low penetration of the drug into the bloodstream, following topical

administration, allows the therapeutic effect to occur without causing complications. (2)

Since this study was not don in this place this study specify was, the case and control group of in one person to

eliminate demographic confounding variables.

Method:

In this clinical trial study, 31 patients who referred to ophthalmology clinic of Vali-e-Asr Hospital in Birjand, or

referred to the Rheumatology Clinic of the mentioned hospital and were eligible to participate in the study,

evaluated the external parts of the eye and symptoms the eyes are dry. All patients referred to the eye clinic who had

clinical and paraclinical symptoms of dry eye who were willing to participate in the study, were required to

participate in the study and completed the questionnaire. Exit conditions included: visual impairment of one eye to

Other causes include conjunctivitis of one eye, external vision of the eye, eye closeness to causes such as recent

surgery, those who have been traumatized or burned by the eyes.

For the right eye of all patients, cyclosporine A dropped every 12 hours, and for both patients, artificial tear drops

were administered every 6 hours. The right eye was considered as the experimental group and the left eye of the

referring patients as the control group. The evaluation was done by means of the subjective and objective symptoms

through a questionnaire (SPEED scale). Subjective criteria include: Feeling of dry eye, Feeling of gravel in the eye,

Itching, Pain and burning eyes, Falling water and eye fatigue due to the duration of the symptoms, the frequency and

severity of symptoms in the first visit, one week later, one month Next and three months after the first visit, another

examination was performed through the schirmer test, which is presented as a breast milk strip that is placed in the

lower lip in the middle and the outer one, and the patient closes his eyes, after 5 minutes The wetting of the paper is

read and recorded. Positive test, wetting less than 15 mm in five minutes in cases without local anesthetic and less

than 10 mm in cases using numbness. This test was performed before the first visit, one month and three months

later. Patient information including dermographical data was recorded in the information form. Data were analyzed

using SPSS-26 software and Chi-square, Fisher, Friedman and Manuwetni statistical tests.

Results:

The study included 31 participants, including 26 women and 5 men. The ranges were from 23 to 81 years old with a

mean age of 49.87 ± 11.6 years. Of these, 7 were employees, 21 were housewifes and 3 were workers. (Table 1)

In determining the severity of the disease in the control and experimental group, the Friedman test was used to

compare the incidence of symptoms in different times of study the frequency of distribution of dry eye feeling,

exhaustion in the eye, distribution of pain or burning, before of installation, One week later, one month later and

three months after taking cyclosporine compared in the experimental and control groups was not significant (p>

0.05). (Table 2)

The schirmer test used to compare two groups in each of the three measuring times using Mann-Whitney

nonparametric test showed that there was no significant difference between the cases and control mean of test. (P>

0.05) (Table 3)

The results of Friedman and Mann-Whitney tests showed that no significant changes were observed in the Schirmer

test of the two sexes from the first visit to three months later. Also, the results of the comparison of mean score of

Schirmer test in men and women three times measured showed no significant difference between the two groups. P>

0.05)) (Table 4)

The results of Friedman and Kruskal-Wallis tests showed that the Schirmer test in the age group of 46-55 years was

significantly reduced one month after the first visit (p = 0.02). Also, the results of the comparison of the average

score of the test of Schirmer in three age groups at three times showed that there was a significant difference


SP61-18

between the sclerectomy score in one month after and three months later in three age groups (p = 0.05) and the age

group of 46 to 55 years There is a significant difference (p = 0.006) (Table 4)

The results of the Friedman test and Kruskal-Wallis tests were used to investigate the changes in the Schirmer test in

different occupations. There was no significant difference in any of the jobs (p> 0.05) (Table 4)

Comparison of the severity of the disease by Schirmer test in the subjects before, one week, one month and three

months after cyclosporine A was evaluated based on the field of rheumatoid diseases in the experimental and control

groups using Friedman and Mann-Whitney tests. The results showed that patients with underlying disease who were

treated with cyclosporine A had a significant reduction in their dry eye (p = 0.05) (Table 5)

Discussion:

In this study, we observed that in 31 patients, both treatments, i.e., artificial tears, used as a control group in one eye

of the patients, and cyclosporine, used as the case group in the other eye of the same patients, were studied in A

follow-up of 3 months in patients has, over time, reduced the symptoms of patients but it was not statistically

significant.

Comparing the efficacy of these two treatments, it was found that both had the same efficacy. Patients were

categorized according to the severity of the symptoms in 5 categories: no problem, tolerant, uncomfortable, painful

and intolerable, and it was observed that in the case of any of the symptoms also, including: dry eye, foreign body

sensation in the eye and Eye pruritus, pain and eye irritation, tears and eye fatigue at the start of the study, one week

later, one month later, and three months later, there was no significant difference between the two groups.

Also, there were no significant differences between the two treatment groups in the frequency of occurrence of each

of the mentioned symptoms (never, sometimes, often and continuously), and also in the categorization of patients

with symptom and asymptomatic feeling. These findings suggest that cyclosporine has had similar efficacy in all the

criteria for artificial tears.

In examining the severity of symptoms in patients with cyclosporine over time, it was found that the treatment

reduced the symptoms in all age ranges, including dry eye, pain and burning, tearing and fatigue decreased after 3

months that it was only significant in the severity of pain and burning in the age range of 45 to 55 years.

In the past decade, only one drug has been approved for the treatment of DED by the US Food and Drug

Administration (FDA) in the USA (ie, Restasis® by Allergan, Inc.). A large number of these drugs are designed to

target a specific cause of dry eye and some of these drugs will be approved for clinical use in the next 10 years.)16.

The Cyclosporine topical administration was effective in controlling symptoms and signs of dry eye

disease.)17Although there was methodological difference between our study and above demonstration, the severity

of the disease in the subjects according to the field of rheumatic diseases in the experimental group showed that

those with underlying hematological diseases who were treated with cyclosporin had a dry eye reduction during the

study.

In a study by Hyunseung Kang, and colleagues, cyclosporine was prescribed at 0.05% for patients with artificial tear

drops for the treatment of dry eye disease in 2015, and after 1, 3, and 6 months it was found that patients

Significantly have improvement on symptoms and other commonly used signs of dry eye disease for 3 months.

Also, other measurements, such as the schirmer test, ocular suface gade and d increased osmolarity of tears it

showed improvement, and however the observed difference was not significant in these cases. It can be seen that in

spite of the large difference in this study with our study on the methodology especially regarding the unilaterality of

this study and the use of cyclosporine after treatment with artificial tear in comparison with our study as well as the

criteria for judging response to treatment, both studies showed cyclosporine’s good efficacy in the treatment of dry

eye.; however, the tear osmolarity values were not significantly improved. (18)


SP61-18

In a study by Karl G. Stone cipher, and colleagues (19), in 2015, they examined the maintenance of visual acuity in

cyclosporine treatment in dry eye patients. For this, cyclosporine was given topically twice a day for 6 months. The

distribution of gender (87.5% female) and mean age (59.5 ± 9.05) patients were consistent with our study (83.5%

female). After 6 months of follow up, corneal fluorescence staining decreased significantly. People also reported

significant improvement in visual acuity including blurred vision, visual impairment, reading, driving at night,

working with computers and watching TV, and in all measurements, eye discomfort decreased significantly.

Therefore, this study also confirms the efficacy of cyclosporine treatment.

In a review study by Marta Sacchetti et al. (20) in 2013, 18 clinical trials were reported that all cyclosporine

formulations are safe for DED treatment. Improvement in tear function was observed in 72% (13.18) and ocular

surface diseases in 53% (9.17).

Huélya Devecı et al. (21) also examined the effect of topical cyclosporine A in comparison with normal saline in dry

eye disease caused by Sjögren's syndrome they showing that all of the subjective symptoms (including burning and

tingling sensation, light sensitivity and pain ) And all objective symptoms (including the schirmer test, tear break of

time and redness analysis) were significantly decreased after one week and one month.our finding have not showed

significant meaning that it may be due to dry eye pathology.

Prabhasawat P et al. (22) evaluated the effect of ocular cyclosporine in comparison with carboxymethylcellulose

(control group) in the treatment of mibomian glandular dysfunction. In the 3-month evaluation, the mean OSDI,

non-invasive tear analysis (NIBUT) and (FBUT), eyelid marginal inflammation, mibobmian gland secretion and

intra-eyelid infusion were significantly improved compared to baseline, in the cyclosporine group. While in control

group only OSDI was significantly improved from baseline in 3 months. Our cases were stratified according history

of rhumatological diseases and dry eye that it is not comparable with this study.

Pinnita Prabhasawat et al. In order to investigate the effect of cyclosporine eye drops in Steven Johnson with

chronic dry eye, 30 patients with Steven Johnson syndrome who developing dry eye have been treated with

cyclosporine A daily for 6 months 17 patients (56.67%) completed the study 8 (26.67%) were excluded due to

unbearable side effects of Cyclospoin; including pain, redness and swelling of the eyelids. Five cases were also

removed due to no attendant in follow up. But all 17 cases showed a marked improvement in the symptoms of dry

eye, conjunctiva, corneal staining and the schirme test. (23)

Some studies reported somewhat contradictory results. For example, in a study by Hoehn ME et al,with the aim of

investigating the effect of cyclosporine ocular emulsion on the treatment of children with radionuclide induced dry

eye 11 children consumed cyclosporine emulsion 0.05% two times of day after the failure of conventional treatment.

After 6 months, dry eye symptoms improved in 3 children (27.3%). The remaining 8 children showed no

improvement with cyclosporine ocular emulsion 0.05%.This finding could be concluding the inflammatory rule of

cyclosporine effect. . (24),

In other studies, the therapeutic effect of cyclosporine on eye dryness has been evaluated by the use of a schirme

test, most of them confirmed a significant improvement in the test result, although none of methodology of those

study exactly was similar to our study. Among Sall et al. (25), compared with cyclosporine A with 0.05 and 0.1%

grains and vehicle, patients treated with cyclosporine had a meaningful improvement as a result of the sterilization

test. Also, over the course of the follow-up period of 3 and 6 months, the results were clearly improved in

cyclosporine-treated groups.

In another similar study by Milner and coleagous the Clinical evidence indicates that once-daily administration

following 1 year of twice-daily administration may still suppress the signs and symptoms of DED (level II) [112]

.

Members of the DTS Panel have used topical cyclosporine therapy for 2 years or more for patients with aqueous

deficiency. Limited safety information is available from the published studies evaluating long-term and/or a reduced

administration regimen of topical cyclosporine. (26)

Conclusion:

http://journals.lww.com/co-ophthalmology/Fulltext/2017/01001/Dysfunctional_tear_syndrome__dry_eye_disease_and.2.aspx#R112-2


SP61-18

The findings of this study indicate that the use of cyclosporine in treating patients with dermatological eye, which

has a rheumatologic disease such as Sogrener, is efficient and can be used at a cost and frequency less than artificial

tears (easy to use). Can help cure these patients

Reference:

1) Shokoohi Rad S. Alteration of tear secretion after vitrectomy surgery, and factors influencing it, in patients of Khatam

hospital.Mashhad. Mashhad University of Medical sciences.School of Medicine.2005-2006

2) C Schultz.Safety and Efficacy of Cyclosporine in the Treatment of Chronic Dry Eye. Ophthalmol Eye Dis. 2014; 6: 37–42.

3) Paulsen AJ, Cruickshanks KJ، etal. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related

quality of life.Am J Ophthalmol. 2014 Apr; 157(4):799-806

4) GM Salib, MB McDonald, M Smolek. Safety and efficacy of cyclosporine 0.05% drops versus unpreserved artificial tears in

dry-eye patients having laser in situ keratomileusis. Journal of Cataract & Refractive Surgery.2006, Pages 772–778

5 Massingale ML, Li X, Vallabhajosyula M, Chen D, Wei Y, Asbell PA. Analysis of inflammatory cytokines in the tears of dry eye

patients. Cornea 2009; 28:1023-7

6) Mortaji S, Haghighi A, Pakdel F. Evaluation of the frequency of dry eye and sjogren's syndrome in patients with rheumatoid

arthritis and correlation between dry eye and rheumatoid arthritis activity, Arak Medical University Journal (AMUJ): 2014;

17(86): 79-86

7) M. Rodriguez-Aller a, B. Kaufmann a, D. Guillarme a,etal. In vivo characterisation of a novel water-soluble Cyclosporine A

prodrugfor the treatment of dry eye disease. European Journal of Pharmaceutics and Biopharmaceutics2012, 544–552

8) Zakeri Z, Parsa M, Zanjani H. Comparison the frequency of dry eye syndrome in patients with newly diagnosed rheumatoid

arthritis with healthly people in Zahedan. J Shahrekord Univ Med Sci. 2013; 14 (6):124-129

9) Whitcher JP, Shiboski CH, Shiboski SC،et al. A simplified quantitative method for assessing keratoconjunctivitis sicca from the

Sjögren's Syndrome International Registry. Am J Ophthalmol. 2010 Mar; 149(3):405-15. Epub 2009 Dec 29

10) van Bijsterveld OP. Diagnostic tests in the Sicca syndrome. Arch Ophthalmol. 1969; 82(1):10.

11) Lee M, Rutka JA, Slomovic AR, McComb J, Bailey DJ, Bookman AA. Establishing guidelines for the role of minor salivary gland

biopsy in clinical practice for Sjögren's syndrome. J Rheumatol. 1998; 25(2):247

12) Laflamme MY, Swieca R. A comparative study of two preservative-free tear substitutes in the management of severe dry

eye.1988; 23(4):174

13)el Tayar N, Mark AE, Vallat P, Brunne RM, Testa B, van Gunsteren WF. Solvent-dependent conformation and hydrogen-

bonding capacity of cyclosporin A: evidence from partition coefficients and molecular dynamics simulations. J Med Chem. 1993;

36(24):3757–64

14) Eric Donnenfeld, Stephen C. Pflugfelder Topical Ophthalmic Cyclosporine: Pharmacology and Clinical Uses.Survey of

Ophthalmology. May 2009, Vol. 54, No. 3: 321-338

15) Zarrinpar A, Busuttil RW. Immunomodulation options for liver transplant patients. Expert Rev Clin Immunol. 2012; 8(6):565–78. ; quiz 578.

16) Ridder III WH,Kaesolia. A New drugs for the treatment of dry eye disease; Clinical Optometry 2015, 7:91-102

17) Corneal confocal scanning laser microscopy in patients with dry eye disease treated with topical cyclosporine.B Iaccheri, G

Torroni, C Cagini, T Fiore, A Cerquaglia, M Lupidi, S Cillinoand H S Dua. Eye; 2017, 31(5): 788-794

18) Hyunseung Kang, MD, San Seong, MD, Chul Myong Choe, MD.et al. The Effect of Topical Cyclosporine 0.05% on Tear

Osmolarity for Dry Eye Syndrome. J Korean Ophthalmol Soc. 2015 Feb; 56(2):174.

19) K Stonecipher -.Maintaining Visual Performance with Topical Cyclosporine Therapy in Patients with Dry Eye. KIOSKS. April

17, 2015

20) M Sacchetti, F Mantelli, A Lambiase.et al.Systematic review of randomised clinical trials on topical ciclosporin A for the

treatment of dry eye disease. Br J Ophthalmol 2014; 98:1016-1022

21) Devecı H1, Kobak S. The efficacy of topical 0.05 % cyclosporine an in patients with dry eye disease associated with

Sjo¨gren’s syndrome. Int Ophthalmol. 2014; 34(5):1043-8.

22) Prabhasawat P1, Tesavibul N, Mahawong W. A randomized double-masked study of 0.05% cyclosporine ophthalmic

emulsion in the treatment of meibomian gland dysfunction. Cornea. 2012 Dec; 31(12):1386-93

23) Prabhasawat P1, Tesavibul N, Karnchanachetanee C, Kasemson S.Efficacy of Cyclosporine 0.05% Eye Drops in Stevens

Johnson Syndrome with Chronic Dry Eye.J Ocul Pharmacol Ther. 2013 Apr; 29(3):372-7. 24) Hoehn ME1, Kelly SR, Wilson MW, Walton RC. Cyclosporine 0.05% ophthalmic emulsion for the treatment of radiation-

associated dry eye in children. Pediatr Blood Cancer. 2013 Jul; 60(7):E35-7

http://www.sciencedirect.com/science/journal/08863350

http://www.sciencedirect.com/science/journal/09396411

http://www.ncbi.nlm.nih.gov/pubmed/?term=Devec%C4%B1%20H%5BAuthor%5D&cauthor=true&cauthor_uid=24442759

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kobak%20S%5BAuthor%5D&cauthor=true&cauthor_uid=24442759

http://www.ncbi.nlm.nih.gov/pubmed/?term=The+efficacy+of+topical+0.05+%25+cyclosporine+A+in+patients+with+dry+eye+disease+associated+with+Sjo%C2%A8gren%E2%80%99s+syndrome

http://www.ncbi.nlm.nih.gov/pubmed/?term=Prabhasawat%20P%5BAuthor%5D&cauthor=true&cauthor_uid=23135530

http://www.ncbi.nlm.nih.gov/pubmed/?term=Tesavibul%20N%5BAuthor%5D&cauthor=true&cauthor_uid=23135530

http://www.ncbi.nlm.nih.gov/pubmed/?term=Mahawong%20W%5BAuthor%5D&cauthor=true&cauthor_uid=23135530

http://www.ncbi.nlm.nih.gov/pubmed/?term=A+randomized+double-masked+study+of+0.05%25+cyclosporine+ophthalmic+emulsion+in+the+treatment+of+meibomian+gland+dysfunction

http://www.ncbi.nlm.nih.gov/pubmed/?term=Prabhasawat%20P%5BAuthor%5D&cauthor=true&cauthor_uid=23289903

http://www.ncbi.nlm.nih.gov/pubmed/?term=Tesavibul%20N%5BAuthor%5D&cauthor=true&cauthor_uid=23289903

http://www.ncbi.nlm.nih.gov/pubmed/?term=Karnchanachetanee%20C%5BAuthor%5D&cauthor=true&cauthor_uid=23289903

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kasemson%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23289903

http://www.ncbi.nlm.nih.gov/pubmed/?term=Efficacy+of+Cyclosporine+0.05%25+Eye+Drops+in+Stevens+Johnson+Syndrome+with+Chronic+Dry+Eye

http://www.ncbi.nlm.nih.gov/pubmed/?term=Efficacy+of+Cyclosporine+0.05%25+Eye+Drops+in+Stevens+Johnson+Syndrome+with+Chronic+Dry+Eye

http://www.ncbi.nlm.nih.gov/pubmed/?term=Hoehn%20ME%5BAuthor%5D&cauthor=true&cauthor_uid=23335290

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kelly%20SR%5BAuthor%5D&cauthor=true&cauthor_uid=23335290

http://www.ncbi.nlm.nih.gov/pubmed/?term=Wilson%20MW%5BAuthor%5D&cauthor=true&cauthor_uid=23335290

http://www.ncbi.nlm.nih.gov/pubmed/?term=Walton%20RC%5BAuthor%5D&cauthor=true&cauthor_uid=23335290

http://www.ncbi.nlm.nih.gov/pubmed/?term=Cyclosporine+0.05%25+ophthalmic+emulsion+for+the+treatment+of+radiation-associated+dry+eye+in+children


SP61-18

25) Sall K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology 2000; 107:631-639.

26) Milner MS, Beckman KA, Luchs JI, Allen QB, Awdeh RM, Berdahl J,

Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment.

Curr Opin Ophthalmol. 2017; 28 (1):3-47.

Table 1.Distribution of respondents by age, gender, occupation

Age Frequency Percent Cumulative frequency

Under 0f 45 yeas 11 5/35 5/35

55 years 46- 14 2/45 6/80

Upper of 56 years 6 4/19 100

Total 31 100

Sex Frequency Percent Cumulative frequency

Female 26 9/83 9/83

Male 5 1/16 100

Total 31 100

, Frequency Percent Cumulative frequency

Employee 7 6/22 6/22

House hold 21 7/67 3/90

Worker 3 7/9 100

Total 31 100

Table 2: Comparison of the symptoms of the first referral, one month and three months later in the control and

test groups

Symptom Average rating Cases Control

Foreign body sensation First attendance

After one week

After one month

After three month

53/2

53/2

40/2

53/2

53/2

53/2

40/2

53/2

Chi 2 tese

P-value 0

1

80/0

1

80/0

Pain or burning First attendance

After one week

After one month

After three month

73/2

47/2

33/2

47/2

73/2

47/2

33/2

47/2

Chi 2 tese

P-value

8/3

28/0

8/3

28/0

Lacrimation First attendance

After one week

After one month

After three month

63/2

50/2

50/2

37/2

73/2

47/2

47/2

33/2

Chi 2 tese

P-value

2

57/0

33/6

09/0

Fatigue eye First attendance

After one week

After one month

After three month

5/2

5/2

5/2

5/2

5/2

5/2

5/2

5/2

Chi 2 tese

P-value

https://www.ncbi.nlm.nih.gov/pubmed/?term=Milner%20MS%5BAuthor%5D&cauthor=true&cauthor_uid=28099212

https://www.ncbi.nlm.nih.gov/pubmed/?term=Beckman%20KA%5BAuthor%5D&cauthor=true&cauthor_uid=28099212

https://www.ncbi.nlm.nih.gov/pubmed/?term=Luchs%20JI%5BAuthor%5D&cauthor=true&cauthor_uid=28099212

https://www.ncbi.nlm.nih.gov/pubmed/?term=Allen%20QB%5BAuthor%5D&cauthor=true&cauthor_uid=28099212

https://www.ncbi.nlm.nih.gov/pubmed/?term=Awdeh%20RM%5BAuthor%5D&cauthor=true&cauthor_uid=28099212

https://www.ncbi.nlm.nih.gov/pubmed/?term=Berdahl%20J%5BAuthor%5D&cauthor=true&cauthor_uid=28099212

https://www.ncbi.nlm.nih.gov/pubmed/?term=Dysfunctional+tear+syndrome%3A+dry+eye+disease+and+associated+tear+film+disorders+%E2%80%93+new+strategies+for+diagnosis+and+treatment+Milner%2C+Mark+S.a%2Cb%2C*%3B+Beckman%2C


SP61-18

Table 3. Comparison of the schirmer tests of the first referral, one month and three months later in the control

and test groups

Stage Groups Manvitni test

Cases Control Chei 2 P-value

First attendance

After one week

After one month

After three month

63/2±74/3 29/2±60/3

26/2±53/4

34/2±79/3 68/3±33/4

29/3±60/4

15/0 001/0

18/0

69/0 98/0

67/0

05/5 08/0

73/2 25/0

15/0 001/0

18/0

69/0 98/0

67/0

Table 4: Comparison of changes in the schirmer test of the first refferal, one month and three months

later in the control and test groups by sex, age, flame

Stage Male Female

First attendance

After one week

After one month

After three month

56/3±8/3 58/0±33/2

15/1±33/3

51/2±73/3 47/2±92/3

41/2±83/4

Chi2-test

P-value

8/0 67/0

93/4 08/0

Stage Age range

Under 45 years 46-55 years

First attendance

After one week

After one month

After three month

48/2±18/4 93/2±83/4

9/1±4

46/2±29/3 63/0±2

82/0±67/3

Chi2-test

P-value

81/1 40/0

18/10 006/0

Stage Job Govermental House hold Worker

First attendance

After one week

After one month

After three month

19/2±14/3 58/0±5/2

1±5/3

84/2±19/4 74/2±33/4

55/2±33/5

1±2 71/0±5/2

41/1±3

13/4 13/0

29/2 32/0

001/0 99/0


SP61-18

Table 5. Comparison of disease severity in subjects before, one week after, one month after and three months after cyclosporine A

in terms of the field of rheumatoid diseases in the experimental and control groups

Rheumatological diseases

Mean of No Yes

Cases Control Cases Control

Foreign body

sensation

First attendance

After one week

After one month

After three month

5/3

5/2

5/2

5/1

25/3

25/2

25/2

25/2

81/2

92/2

38/2

88/1

85/2

54/2

62/2

2

z=-1.15, p=0.29

Z=-0.35, P=0.81

Z=-0.99, P=0.38

Z=0.07, P=0.11

Chei 2

P-value

4

26/0

3

39/0

76/7

05/0

49/5

14/0

---

Pain or burning First attendance

After one week

After one month

After three month

3

3

2

2

3

3

2

2

73/2

81/2

31/2

15/2

85/2

38/2

38/2

38/2

Z=-0.17, P=0.88

Z=-0.21, P=0.88

Z=-1.45, P=0.23

Z=-1.48, P=0.23

Chei 2

P-value

3

39/0

3

39/0

94/5

11/0

52/3

32/0

---

Lacrimation First attendance

After one week

After one month

After three month

5/2

5/2

5/2

5/2

5/2

5/2

5/2

5/2

85/2

42/2

54/2

19/2

81/2

38/2

65/2

15/2

Z=-1.15, P=0.39

Z=-0.06, P=0.96

Z=-0.73, P=0.69

Z=-0.57, P=0.80

Chei 2

P-value

--- --- 77/5

12/0

22/6

10/0

---

Eye fatigue First attendance

After one week

After one month

After three month

5/3

5/2

5/2

5/1

5/3

5/2

5/2

5/1

3

69/2

08/2

23/2

92/2

46/2

5/2

12/2

Z=-2.15, P=0.04

Z=-0.75, P=0.53

Z=-0.27, P=0.80

Z=-0.46, P=0.69

Chei 2

P-value

4

26/0

4

26/0

20/6

10/0

97/4

17/0

---


SP62-18

A New Approach to Idiopathic Scoliosis Correction

*Maryamsadat Lesani1,

1- Corrective Exercises and Sports Injuries, Department of Physical Education and Sports Sciences, University of Tehran-

Kish International Campus, Iran

*Corresponding Author E-mail: [email protected]

ABSTRACT

Background

Idiopathic scoliosis is a 3D spinal deformity. Brace and exercises are typical treatments known for such

problems. But brace is mostly used for prevention aims and exercises for reducing the scoliosis and spinal

deformity angle. In case kyphosis occurs with scoliosis, it will be called kyphoscoliosis which the treatment will

be more difficult. Up to now, different types of rehabilitation and treatment approaches (surgical and non-

surgical types) were proposed. Nevertheless, very few studies showed decreased angle deformity as becoming

close to a normal angle form. Therefore, the purpose of this study was to present a case report through

Directed Both Side Corrective Exercises (DBSCE)

Case Presentation

In this study, radiographs were taken in 3 stages. The first stage was done prior to initiation of the training

program. The second stage was taken 3 months later, and the last stage was demonstrated 6 months after the

onset of training program. Furthermore, we included a 1-year follow-up for the present study. R.B, a 12-year-

old boy was the subject of this research. Within 3 months, the scoliosis and kyphosis angle were decreased

from 28˚ to 9 and from 51 to 40 respectively. 6 months later, scoliosis and kyphosis were completely corrected.

Conclusion

3 components may lead to a scoliosis curve including; structural bony, ligamentous components, and a postural

one (counts up to 9˚ in children). According to the results of the present study, DBSCE was beneficial once

stretching and strengthening exercises were combined together. Plus, main features of training program

including stretching both sides of spine, with higher focus of same exercises on concave side, and strengthening

both sides, with intense focus on convex side, were probably the most important key factors to the significant

effectiveness of the above mentioned exercises.

Keywords: Scoliosis, Kyphosis, Exercise

INTRODUCTION

Lateral curvature of the spine with a more than 10 degrees Cobb angle and vertebral rotation condition is called

Adolescent idiopathic scoliosis (AIS). Only 0.3 to 0.5 percent of progressive curves require treatment, whereas

scoliosis progresses appear in about 3 percent of children younger than16 years of age (1). These statistics are

almost quasi in different in articles, in spite o small differences. AIS prevalence is approximately 3%, whilst 10% of

individuals with AIS require treatments including; generally, observation or physiotherapeutic scoliosis-specific

exercises (PSSE) for mild curves (less than 20˚ Cobb angle), brace could be suggested for moderate curves (between

20˚ and 40˚) and spinal surgery for severe curves (more than 40˚). Severe curves are more prevalent among females

(2-4)).Typically, Scoliosis between 25˚ and 50˚ spinal orthosis (rigid or dynamic types) may be generally considered

as a prevention method (5).


SP62-18

Idiopathic Scoliosis can be sub-classified as infantile (from birth to 3 year-olds), juvenile (3 to 10 year-olds), and

adolescent (above 10 years of age). Scoliosis development in adults may be due to degenerative disk disease.

If the curve progresses, spinal bracing will be considered as the prior treatment. In spite of bracing, if the curve

progresses, spinal fusion may be recommended (6).

large scoliotic curves can negatively impact the pulmonary function and in most severe cases, it may lead to

corpulmonale condition, which is a type of heart failure (Good, 2009). For several decades, AIS has been strongly

suspected as a familial disorder. Researchers showed that 97% of the individuals with AIS were of families with AIS

(7). Studies reported a 10% prevalence for individuals with first-degree relatives with scoliosis (6); this suggested a

genetic basis for this condition; although specific genetic determination has still remained unclear (8). However,

there are studies which allocate a great percentage of idiopathic scoliosis to environmental effects. Grauers ET. Al,

reported the effects of genetic was 38% of the observed phenotypic variance, and 62% was related to environmental

influences (9).

Based on the report of Negrini ET. Al, demonstrated on 74 patients with AIS (mean Cobb angle of 15˚, mean age of 12.1 years), which compared the effect of 2 different approaches including; scientific exercises approach to scoliosis

(SEAS) and usual physiotherapy, it was concluded that SEAS could improve Cobb angle, but usual physiotherapy

effects it negatively. SEAS led to improvements in 23.5% of patients and worsened11.8% o those; whilst usual

physiotherapy improved 11.1% of the subjects and 13.9% got worsen. However, these changes could not be

considered as clinically significant. All patients got followed-up after 6 and 12 months from the onset of research

program (10).

It is crystal clear that AIS is a 3D spinal deformity. Scoliotic spinal deformity progression occurs during the

adolescent growth spurt, and there could be a correlation between curve progression and rapid spinal growth period

(11).Lin Shi ET. Al, concluded that accelerated growth profiles may encourage supplementary scoliotic progression

and, thus, may pose as a progressive risk factor (11).

Adolescents with thoracic scoliosis were characterized taller, leaner, and with hypokyphoticthoracic spines,

compared to the healthy subjects (11).

Effect of brace on scoliosis was controversial. Papadopoulos suggested combined exercises and brace for correction

aims. According to his study, 67% of patients experienced improvement in their posture and appearance, 53% of

patients had about 9% to 23%improvement in Cobb angle, no changes remained in 18% of the subjects and 29% of

patients had an aggravation of 7% to 15%. Also, Papadopoulos stated that in some cases he noticed exercises and/or

brace alone could result in decreased pain or improved posture. In general, he concluded that combination of brace

and exercises yielded excellent results (12). Based on previous studies, primary use of brace was to try avoiding

fusion and help progressing the angle of scoliosis (12-15). Sanders ET. Al, reported that bracing had not been

effective in preventing necessity of surgery unless the patient was highly compliant with brace wear. High

compliance of patients was considered based on the hours they wore the brace per day (14).

An early study showed Scoliosis prevalence could be associated with age, but not gender, and curve severity was

reported to be associated with race but not with either age or gender (16).

Kyphosis occurred in sagittal plane in spine, is a deformity which sometime can be associated with scoliosis and

such deformity is called kyphoscoliosis (17). Rate of Idiopathic kyphoscoliosis was reported in about 80% of cases.

This deformity, usually, begins during late childhood and the severity of it can progress during the period of rapid

skeletal growth (18). Kyphoscoliosis commonly associates with restrictive impairment of pulmonary function,

chronic pain and reduced vitality. Prevalence of this deformity rise with aging and varies from 2% in adolescent

population to 15% in elderly population with the higher ratio in women (19).

Physiotherapeutic Scoliosis Specific Exercise (PSSE) is known as a valuable tool in AIS treatment. In a study

conducted by Marti ET. Al, 22% of patients with AIS responded to Physiotherapeutic Scoliosis Specific Exercises

https://www.ncbi.nlm.nih.gov/pubmed/?term=Sanders%20JO%5BAuthor%5D&cauthor=true&cauthor_uid=24740661


SP62-18

(20). Purpose of these treatments were preventing curve progression, minimizing respiratory dysfunction, preventing

spinal pain syndromes, and improving aesthetics via postural correction (20). Bettany-Saltikov ET. Al, stated no

evidence of superiority in effectiveness of operative interventions compared to non-operative ones among patients

with severe AIS, and available literature reported no clear evidence to suggest that a specific type of treatment

superiors other types of treatment (21). Morningstar ET. Al conducted an exercise-based study on scoliosis with a 9-

year follow-up. They reported decreased pain in all patients (3 patients with different types of angle and pain), and

improvements in their daily activities as well. From the onset of the project, to the end of the 9th year, an

approximately 9 degree mean reduction was seen in scoliosis of the patients (patient 1: 63˚ to 54˚, patient 2: 41˚ to 31˚, patient 3: 47˚ to 34˚) (5). Considering results of the previous studies, present procedures could decrease

scoliosis and kyphoscoliosis angle, and that patients with high angle still dealt with their condition after completion

of the treatment period. Therefore, finding a more effective method to reduce the severity of scoliosis and

kyphoscoliosis seems necessary.

METHODS

Scoliosis and kyphosis angle were measured by MRI taken in 3 stages. The first stage was done before the DBSCE,

the second one was taken 3 months after, and the third MRI was done 6 months after the onset of study. A 1-year

follow-up was demonstrated after completion of the third stage. Every month the patient got examined by an

orthopedist. All the training sessions were held at home and under the supervision of a personal trainer (researcher).

Directed Both Side Corrective Exercises (DBSCE):

This training program included stretching and resistance training. However, stretching exercises (both passive and

active types) were actually the basis of this program. All exercises were designed for both sides, with the only

difference that stretching exercises emphasis was on the contacted side and resistance exercises emphasized on the

weak side. This program was designed by Ms. Maryam Lessani.

Case Report:

Mr. R.B's Mother noticed something wrong about his appearance once he was a child and, when he was eight, she

became certain of the existence of impairment. At the time, according to the physician's recommendation, it needed

to be controlled (because the degree was not very remarkable). At the age of 10, R.B received 2 series of

physiotherapy sessions, each consisted of 12 sessions; however, none of them were found effective on the patient's

condition.

At the age of 11, the scoliosis reached up to 28

degrees. Then, the patient received corrective

exercises and brace. The brace which was

prescribed for this patient was Lyonnais Brace

type (figure 1).

Figure 1


SP62-18

Patient's mother did his first MRI when he was 11. Since he was at the rapid growth age period, there was a risk for

increasing severity. The first assessment showed a 28-degree scoliosis. Plus, he had a 51 kyphosis.

Warm Up:

The entire warm up protocol takes about 10 to 15 minutes.

The warm-up training included following exercises:

Exercise 1: Stretching upwards – stand on tiptoes – reach both arms high in the air in the shape of a letter “V”- hold

position for 4 seconds with four repetitions.

Exercise 2: Stretch up and stand on tiptoes – hands cling together.

Exercise 3: Stretch side flanks: right side, 2 repetitions -hold position for 4 seconds- and left side 6 repetitions – hold

position for 4 seconds.

Exercise 4: Flex abdominal muscles and constricted hip muscles- hold the position 4 seconds- then relax the

muscles, perform 10 repetitions.

Exercise 5: Stretching with a ball – place hands shoulder width apart on the ball- knees perpendicular to the

ground, hips up high- with four 10 seconds of repetition sets.

Exercise 6: Stretch with the ball towards the right and the left. Right side stretch includes 2 ten seconds repetition

sets and Right side stretch with 4 ten seconds repetition sets.

Exercise 7: Flex abdominal muscles whilst holding the ball in hands – stand on tiptoes- raise the ball up and lift the

body up to the maximum possible, with 10 sets of repetition.

Exercise 8: Lean to the right with the ball - 4 repetitions- lean to the left with the ball -8 repetitions- (Supervisor

must keep the pelvis still) bend into sides without inclining forward or backward.


SP62-18

Exercise 9: One leg should remain bent with the foot flat on the floor, and the other straight out- body weight begins

to be loaded backwards- keep stretching your front leg toes upward for 10 seconds. Return to start and repeat poses

on both sides.

Exercise 10: stretch quadriceps femoris muscle of both legs for ten seconds.

Exercise 11: Lie down on a matt with toes stretched. Intensely but slowly stretch the ball from the thigh towards the

top of head, and then contact the ball with the floor right above the head. Keep the arms flat during the whole

exercise.

Exercise 12: Lie flat supine, with your knees bent and both feet kept on the floor. Flex and then relax abdominal

and hip muscles –perform three sets of 10 repetitions-.

Training Protocol:

Exercise 1: lies down on a matt with both tiptoes stretched out towards outside the matt. Gently move a one-

kilogram ball (a 10 cm diameter) from chest towards head until the ball gradually contacts the floor.

Exercise 2: Hold a pair of half Kg dumbbells by one hand straight on top of the head and keep the other hand flat on

the floor. Hand excursions should be performed.

Exercise 3: Keep feet on the floor with knees bent and hands behind the head between the chin and the chest (fixed

length as long as your fist). Raise the trunk to a point where the lower hinge angle separates from the floor. Perform

four sets of 8 repetitions with 5 seconds rest in between.

Exercise 4: Hold two half Kg dumbbells in hands at chest level along your body; palms facing forward. Raise the

dumbbells until they are side by side on top of you and slowly lower them back after a short pause. Perform two sets

of 8 repetitions.

Exercise 5: Raise the dumbbells straight up with a 90-degree angle – perform two sets of 8 repetitions.

Exercise 6: Lie supine on a matt and hold a pair of 500 grams’ dumbbells with both hand palms towards the right

hip. Raise the dumbbells in the shape of the letter “V” and lower hands back until reaching the floor. Perform two

sets of 8 repetitions.

Exercise 7: Lie down on your left side (The supervisor holds the pelvic and upper leg of the subject, still), then move

upward. (The study subject performed 8 reputations during the first two weeks followed by two sets of 8 repetitions

in the third week of the training program).


SP62-18

Exercise 8: Lie down on your left on the floor with your right hand perpendicular to the ground and your right knee

at 45 degrees angle towards the floor, and the left leg extended towards your body. Keep your left arm besides the

ear (the left arm to be extended still). Left side of your body must be stretched. Perform two sets of 10 seconds.

The supervisor tried to correct the participant’s position during few first weeks of the program and extended

stretching by pulling his left arm.

Exercises 7 and 8 were performed as combined. An eight repetition strengthening set was initially done followed by

stretching the left side for ten seconds. This process was performed twice.

Exercise 9: Lie prone on the matt and hold dumbbells side by side, then rise about 3 cm from the floor and lie down

again. Perform two sets of 8 repetitions.

Exercise 10: Lie prone. The supervisor must place a Thera-band in front of the subject’s hands with a distance then,

places it further as soon as he could reach it, so that he tries harder to stretch his muscles (The subject was asked to

stretch both arms equally to reach the Thera-band in the first four repetitions, but then he was asked to strive more

with the left hand to reach it in the second 4 repetitions set).

Exercise 11: Lie prone, holding dumbbells with palms facing each other, and then move both arms concurrently

towards the body. Keep elbows still during the entire workout.

Exercise 12: Lie prone Raise both arms 3 cm and lower them back again.

Exercise 13: Lie down on your stomach, holding a pair of 500 grams’ dumbbells at a 90 degrees angle in hands.

Straiten hands forward and rotate back again at a 90 degrees’ angle. Perform two sets of 6 repetitions.

Exercise 14: This exercise must be performed without dumbbells. The supervisor holds both arms of the subject,

stretches for two seconds and unhands whilst the participant straitens arms (elbow & shoulder) of the 90 degrees

angle forward. Perform ten repetitions with 2 seconds pause.

Exercise 15: Lie down on your stomach, concurrently raise the right arm and the left leg and lower back to the floor.

Perform 2 sets of 8 repetitions.

This exercise was done on the opposite side as well.

Exercise 16: Lie prone with your thighs on top of the exercise ball, legs and back fully extended, trying to keep

balance with hands. Raise your right leg (two sets of 8 repetitions) and then perform the same with your left leg.

Two sets of 8 repetitions with 10 seconds pause between each set.

Exercise 17: Pushup exercises were performed on the wall during the first month of the program (one set of 8

repetitions), and then it was performed on a matt during the second month (Started with 4 exercises and reaching 8

exercise max, based on capability of the subject).

Exercise 18: Lie on one side on a bed with upper body outside the bed and the supervisor must hold subject’s lower

body still. The subject moves upward in the same position (Perform 8 repetitions whilst on the left side and 4, for the

right side of the body).

Exercise 19: Keep elbows at 90 degrees angle with shoulder and flex abdominal muscles and with palms stretching

upwards. Perform 2 sets of 6 repetitions.

Exercise 20: Move arms straight up, until they are side by side (arms must not move higher than shoulders).

Exercise 21: Firstly, keep arms straight forward at 90 degrees and then move upwards (Perform two sets of 8

repetitions).


SP62-18

Exercise 22: Stand completely close to the wall with abdominal muscles flexed and move shoulders and elbows at

90 degrees upwards. Perform one set of 6 repetitions.

Exercise 23: Hold arms straight above the head and the supervisor must draw a line 10 to 15 cm higher than the

subject’s hands. Try to reach the drawn lines. The supervisor could then stretch the participant’s hands upward for

assistance.

Exercise 24: Stand completely close to the wall with abdominal muscles flexed whilst holding a one Kg ball on the

left hand and bending towards the right. Stand still for 15 seconds. The supervisor must correct the subject’s

position. Perform 2 repetitions of 15 seconds.

Exercise 25: Initially, hold the exercise ball straight forward with hands extended. Move the ball upwards to the top

of your head, and then roll it to your left side. Roll the exercise ball to the same route back (Perform one set of 8

repetitions).

Exercise 26: Perform the above showed stretch for two sets of 10 seconds.

Exercise 27: Perform chest stretch using a door frame (perform two repetitions of 10 seconds).

Exercise 28: Hang on horizontal bar and the supervisor must pull the subject downwards for reinforcing his stretch

(3 repetitions of 10 seconds).

Exercise 29: Bend forward with hands kept on a shelf. The supervisor must correct his position and pulls the

subject’s pelvic backwards. Both knees need to be bent, for being able to keep the back straight better. The height

changes in accordance to the shelves (Knees straiten and stretching the back of legs was added, as the arms reach a

higher spot). Perform two repetitions of 10 seconds.

Exercise 30: The subject is stretched by the supervisor in both positions of prone and supine (one set of 10 seconds

for each).

Exercise 31: As shown in the picture, the subject sat down and the supervisor pulled his both arms backwards and

she kept her leg next to the subject’s spinal cord, to remain still.

Exercise 32: The supervisor holds subject’s pelvic still and assists him by pushing his feet (Perform one repetition,

30 seconds pause).

Exercise 33: Kneel down and put hands on the edge of the bed. The supervisor must hold the subject’s pelvic still.

Then band towards your right side.

Exercise 34: This exercise is done in three directions including; right, left and forward. Perform 2 repetitions of

stretch on the right side and one on the rest sides.


SP62-18

Exercises 9 and 10 must replicate at the end of the protocol.

Exercises 5 and 6 must replicate after every 4 exercises right after the warm-up stage.

The supervisor corrects the subject’s position during all exercises.

RESULTS:

The initial assessment showed a 28-degree scoliosis and 51-degree kyphosis right before the training program. 3

months later, the second assessment was conducted, and the results reported a 15-degree reduction (13 degree) in

scoliosis and a 7-degree reduction in kyphosis (44 degree). Eventually, six months after the measurement of

radiology picture, assessments showed a 9-degree scoliosis and 40-degree kyphosis which was considered as

complete correction due to the hospital report. The correction was still remained after a one-year follow-up.


SP62-18

DISCUSSION:

The main finding of the current study was noticeable effectiveness of DBSCE. However, the child used brace at

nights. Corrective exercises, according to the results of this study, led to noticeable correction of kyphoscoliosis

(normal scolios and kyphos) in the case that we have studied. According to the DBSCE characteristic, both sides of

spine were stretched, and strength exercises were applied on both sides too. But the emphasis of stretching was on


SP62-18

the left side, and the strength exercises were demonstrated more on the right side. Stretching of Pectoralis major and

minor and resistance training for back muscles were applied for hyper kyphosis.

Previous studies were not able to determine cause of idiopathic scoliosis, but the majority of cases could be found in

adolescent population. EMG studies have shown muscle imbalance and stretch receptors asymmetry in the region of

paraspinal muscles in individuals with AIS which this, can play an importance role in developing and producing

deformities (22). According to the paraspinal muscle biopsies, there were alternatives in fiber type distribution

(increased percentage of type II fibers) on the apex of the curved spine on the concave side. Alternations on the

convex side have got some- not so extreme- similar nature and direction. This may be due to inactivity of the back

muscles in general (23). According to biomechanical, neurological, and molecular mechanisms, the increase in

ROM often occurs after passive stretching. A stretching muscle adaptation could result in more sarcomeres in series

and may lead to longer muscle (24) . A prolong muscle spindle stretch can inhibit afferent activities which result in

decreased muscle tension. Plus, Golgi tendon organs and nociceptors, which inhibit muscle tension, are induced by

prolong static stretch (25).

Regarding the spinal stabilization, core stability exercises could be more effective than general fitness exercises. The

superficial and deep core muscles coordination was crucial for core stability (26). Core muscle release technique

(CRT) is a therapeutic technique with focus on muscle imbalance through proper strengthen and relaxation of global

stability and local stability while the patient is in supine and sitting positions (27). Lee ET. Al compared 3 types of

treatment for scoliosis (CRT, Exercise therapy and Electrotherapy). They stated that “Cobb angle was improved

regardless of the treatment method. The core muscle release technique provided better results than other treatments.

Thus, CRT can be considered as an effective treatment for the correction of scoliosis” (26). Bracing can reduce

progression, and prevent necessity of surgery, and once combined with exercises according to Society on Scoliosis

Orthopedic and Rehabilitation Treatment (SOSORT) criteria, it could also increase treatment efficacy (28). In Tsai’s

study,it has been proved that during isokinetic back exercises, there was no symmetry in bilateral Paraspinal muscle

(PSM) seen among healthy subjects. The dominant lumbar PSM played the main role in healthy subjects and

individuals with small curve scoliosis. During resistance exercises, for individuals with scoliosis, compensated

muscle activities was needed in the mid-back. In fact, there was a shifting of muscle activities from the lumbar

domain (concave) side to thoracic side. This compensation and protection is needed higher in patients with large

curve scoliosis while doing resistance exercise (22). Increased tension and stress (increased EMG activities) on the

convex side was aimed to keep the posture in balance (22). The resistance training was one of the elements of the

training program in the present study; thus, the training program of this research focused on stretching exercises

(although, stretching exercises applied on both sides of spine, the emphasis was on concave side mainly).

Stretching exercises were more effective in treatment of idiopathic scoliosis, rather than mechanical traction of the

spine. Mechanical traction actually applies equal stretching force on both sides of the spine. Stretching exercises for

tight concave could reduce spasm and hyperactivity of concave side and lengthen short muscles. In order to create

muscle balance and normal path gravity line, strengthening the convex side and stretching the concave side is

necessary. Furthermore, having strong enough abdominal muscles considered as the anterior wall of the spine, is

necessary for this aim as well .In the study of Zakaria ET. Al, decreased rate for the stretching group was 10 degrees

(28 to 18.85) and mechanical traction rate was 3 degrees (27.2 to 24.8) (Zakaria et al., 2012).

Otman ET. Al showed that Schroth’s 3-dimentional exercise therapy had a positive effect on AIS. It could be

effective on Cobb angle, vital capacity, strength and postural defects in outpatient adolescents. This procedure was

based on kinesthetic and sensorimotor systems which consist of scoliosis posture correction and correct breathing

pattern techniques with assistance of proprioceptive stimulation and mirror control. On average, it could reduce

proximately 9 degrees after 1 year (26.10 to 17.85) (29). Fowles ET. Al stated “prolonged stretching of a single

muscle decreased voluntary strength for up to 1 hour after the stretch, as a result of impaired activation and

contractile force in the early phase of deficit and by impaired contractile force throughout the entire period of deficit

(30).”

Exercises used in the present study along with higher intensity stretching exercises and various exercises for

stretching can reduced the strength on shorten muscle and reduce the muscle stiffness. Stretching could be effective


SP62-18

on muscle stiffness. According to Nakamura ET. Al, a 5 minute static stretch on gastrocnemius may reduce muscle

stiffness which could remain for at least 10 minutes after the static stretch (31). Nakamura ET. Al, concluded that

within 4 weeks of static stretch training program, the range of motion and myotendinous junction (MTJ)

displacement increased significantly; however, they did not observe any significant increase in muscle fascicle

length. So, static stretch training program could change the muscle-tendon unit flexibility without making any

changes in muscle fascicle length (32).

PERSPECTIVE:

Results of this study showed that DBSCE could make corrections and improve scoliosis and kyphosis to normal

angle. Although, the exercises were on both sides, the spot of emphasis was different. Concluding the above

mentioned, we realized that brace could just prevent the progress of the scoliosis severity, and an exercise training

program, consisting of stretching and resistance training, could correct the spinal misalignments (kyphoscoliosis).

*Author claims no conflict of interest.

**A written consent form was collected from the study participants prior to the onset of research demonstration.

REFERENCES:

1.Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. New England Journal

of Medicine. 2013;369(16):1512-21.

2.Bettany-Saltikov J, Parent E, Romano M, Villagrasa M, Negrini S. Physiotherapeutic scoliosis-specific exercises for adolescents

with idiopathic scoliosis. Eur J Phys Rehabil Med. 2014;50(1):111-21.

3.Scherrer S-A, Begon M, Leardini A, Coillard C, Rivard C-H, Allard P. Three-dimensional vertebral wedging in mild and moderate

adolescent idiopathic scoliosis. PLoS One. 2013;8(8):e71504.

4.Tsiligiannis T, Grivas T. Pulmonary function in children with idiopathic scoliosis. Scoliosis. 2012;7(1):7.

5.Morningstar MW, Siddiqui A, Stitzel C, Dovorany B. Chiropractic Rehabilitation of a Scoliosis Family: Results from a 9-Year

Follow-Up. Rehabilitation. 2017;5:29-35.

6.Hresko MT. Idiopathic scoliosis in adolescents. New England Journal of Medicine. 2013;368(9):834-41.

7.Ogilvie JW. Update on prognostic genetic testing in adolescent idiopathic scoliosis (AIS). Journal of Pediatric Orthopaedics.

2011;31:S46-S8.

8.Gorman KF, Julien C, Moreau A. The genetic epidemiology of idiopathic scoliosis. European Spine Journal. 2012;21(10):1905-

19.

9.Grauers A, Rahman I, Gerdhem P. Heritability of scoliosis. European Spine Journal. 2012;21(6):1069-74.

10. Negrini S, Zaina F, Romano M, Negrini A, Parzini S. Specific exercises reduce brace prescription in adolescent

idiopathic scoliosis: a prospective controlled cohort study with worst-case analysis. Journal of rehabilitation medicine.

2008;40(6):451-5.

11. Shi L, Wang D, Driscoll M, Villemure I, Chu WC, Cheng JC, et al. Biomechanical analysis and modeling of different

vertebral growth patterns in adolescent idiopathic scoliosis and healthy subjects. Scoliosis. 2011;6(1):11.

12. Papadopoulos D. Adult scoliosis treatment combining brace and exercises. Scoliosis. 2013;8(2):O8.

13. Lusini M, Donzelli S, Minnella S, Zaina F, Negrini S. Brace treatment is effective in idiopathic scoliosis over 45: an

observational prospective cohort controlled study. The Spine Journal. 2014;14(9):1951-6.

14. Sanders JO, Newton PO, Browne RH, Herring AJ. Bracing in adolescent idiopathic scoliosis, surrogate outcomes, and

the number needed to treat. Journal of Pediatric Orthopaedics. 2012;32:S153-S7.

15. Sanders JO, Newton PO, Browne RH, Katz DE, Birch JG, Herring JA. Bracing for idiopathic scoliosis: how many patients

require treatment to prevent one surgery? JBJS. 2014;96(8):649-53.

16. Kebaish KM, Neubauer PR, Voros GD, Khoshnevisan MA, Skolasky RL. Scoliosis in adults aged forty years and older:

prevalence and relationship to age, race, and gender. Spine. 2011;36(9):731-6.

17. Liu Z, Qiu Y, Yan H, Hu Zs, Zhu F, Qiao J, et al. S2 Alar‐iliac Fixation: A Powerful Procedure for the Treatment of Kyphoscoliosis. Orthopaedic surgery. 2016;8(1):81-4.

18. Kokane DM, Hingole P. Spinal anaesthesia in a case of kyphoscoliosis. International Journal of Advances in Medicine.

2017;2(1):67-70.

19. Talarico Jr EF, Vlahu AC. Characterization of kyphoscoliosis and associated giant hiatal hernia in a 97-year-old female

cadaver. Eur J Anat. 2015;19(3):257-68.


SP62-18

20. Marti CL, Glassman SD, Knott PT, Carreon LY, Hresko MT. Scoliosis Research Society members attitudes towards

physical therapy and physiotherapeutic scoliosis specific exercises for adolescent idiopathic scoliosis. Scoliosis. 2015;10(1):16.

21. Bettany-Saltikov J, Weiss H-R, Chockalingam N, Kandasamy G, Arnell T. A comparison of patient-reported outcome

measures following different treatment approaches for adolescents with severe idiopathic scoliosis: A systematic review. Asian

spine journal. 2016;10(6):1170-94.

22. Tsai Y-T, Leong C-P, Huang Y-C, Kuo S-H, Wang H-C, Yeh H-C, et al. The electromyographic responses of paraspinal

muscles during isokinetic exercise in adolescents with idiopathic scoliosis with a Cobb’s angle less than fifty degrees. Chang

Gung medical journal. 2010;33(5):540-50.

23. Mannion A, Meier M, Grob D, Müntener M. Paraspinal muscle fibre type alterations associated with scoliosis: an old

problem revisited with new evidence. European Spine Journal. 1998;7(4):289-93.

24. De Deyne PG. Application of passive stretch and its implications for muscle fibers. Physical therapy. 2001;81(2):819-

27.

25. Nakamura K, Kodama T, Mukaino Y. Effects of active individual muscle stretching on muscle function. Journal of

physical therapy science. 2014;26(3):341-4.

26. Lee M, Hwang J, Seo B, Im G, Jeon N, Yang H, et al. The effects of the core muscle release technique on scoliosis.

Journal of Physical Therapy Science. 2013;25(4):445-8.

27. Lee M, Song C, Jo Y, Ha D, Han D. The effects of core muscle release technique on lumbar spine deformation and low

back pain. Journal of physical therapy science. 2015;27(5):1519-22.

28. Negrini S, Donzelli S, Lusini M, Minnella S, Zaina F. The effectiveness of combined bracing and exercise in adolescent

idiopathic scoliosis based on SRS and SOSORT criteria: a prospective study. BMC musculoskeletal disorders. 2014;15(1):263.

29. Otman S, Kose N, Yakut Y. The efficacy of Schroth s 3-dimensional exercise therapy in the treatment of adolescent

idiopathic scoliosis in Turkey. Saudi medical journal. 2005;26(9):1429-35.

30. Fowles J, Sale D, MacDougall J. Reduced strength after passive stretch of the human plantarflexors. Journal of applied

physiology. 2000;89(3):1179-88.

31. Nakamura M, Ikezoe T, Takeno Y, Ichihashi N. Acute and prolonged effect of static stretching on the passive stiffness

of the human gastrocnemius muscle tendon unit in vivo. Journal of Orthopaedic Research. 2011;29(11):1759-63.

32. Nakamura M, Ikezoe T, Takeno Y, Ichihashi N. Effects of a 4-week static stretch training program on passive stiffness

of human gastrocnemius muscle-tendon unit in vivo. European journal of applied physiology. 2012;112(7):2749-55.


SP63-18

Investigating the relation between hemoglobin A1C to left ventricular Hypertrophy and left

ventricle mass in children with type 1 diabetes mellitus

Mohammad Mehdi Bagheri1, ElhamMaleki

1, Sekineh Rezazade Mehrizi

1, Azam Dehghani

1

1School of Medicine, Kerman University of Medical Sciences, Kerman, Iran

Abstract: Left ventricular hypertrophy (LVH), is one of heart complications that increases the probability

of cardiac arrhythmia and heart failure. Some researchers have claimed for the effect of factors such as high

blood pressure, diabetes and kidney failure on LVH. This study investigates the relation between

hemoglobin A1c (HbA1c) and left ventricular hypertrophy and left ventricle mass (LV mass) in children

with type 1 diabetes mellitus. In this cross sectional study, the population consisted of patients referred to

Afzalipoor hospital of Kerman in years 2014-2015 who were evaluated. In order to investigate heart

diseases, Doppler echocardiography has been performed and to investigate hemoglobin A1C level, 2 ml

blood was taken from patient. Then independent t-test and Pearson test were used for the analysis of

obtained data. According to the results, the effect of HbA1c level on LVH and increase LV mass was not

significant. Only some demographic factors (age, height, weight, maximum blood pressure) had positive

and meaningful relation with left ventricular posterior wall (LVPW) (p<0.05). In this study, there was a

significant relation between systolic annular velocity (Sa) and HbA1c (P < 0.05). Since Sa is one of the

TD1 indicators, this relation shows that diastolic dysfunction is a predictor of increase LV mass. The

increasing trend of diabetes mellitus prevalence and its associated problems impose major costs to

developed and developing societies. Therefore, it calls for special attention by the medical communities and

policy makers.

Keywords: Children, diabetes mellitus, left ventricular Hypertrophy, Left ventricle mass, hemoglobin A1C

Introduction

Diabetes mellitus is one of the most common and costly chronic diseases in world. Outbreak Amount of type 1 diabetes

mellitus in people under 30 years old is about %0.3 and in Children under 5 years old is %1.2 which is increasing every year

[1, 2]. According to recent researches by increase in diabetes period, micro and macro vascular complication will also

increase. Therefore diabetes mellitus in Children and its outbreak in earlier ages increase probability of resultant

complications [3, 4].

Among resultant complications of diabetes, macro vascular disease, which caused cardiovascular disease, is the most

important and the main reason of death because of diabetes mellitus [5]. According to research in England probability of

death because of cardiovascular complication in people with type 1 diabetes is 5 times more than other people [6]. Left

ventricular hypertrophy (LVH) is one of systemic hypertension cardiovascular complication, which increases probability of

cardiac arrhythmia and cardiovascular accident [7].

Also in addition to systemic hypertension there are other factors effective in LVH. In a research by Lepira et al. on about

100 hypertensive patients it has been shown that Dyslipidemia, high blood sugar and duration of hypertension are effective

factors in LVH [8]. Also according to a research by Salmasi et al. in England it has been found that diabetes mellitus can

affect diastolic function of left ventricle [9]. LVH is an important sign to predict cardiovascular complications and death

probability in patients with cardiovascular disease [10]. In diabetic patients, left ventricle mass (LV mass) increase as

another heart disorder is also seen. It is thought that increase of LV mass due to metabolic, functional and structural

inappropriate factors can increase risk of cardiovascular diseases. For example increase of left ventricle mass can caused

1 Corresponding author: Sekineh Rezazade Mehrizi

School of Medicine, Kerman University of Medical Sciences, Kerman, Iran

Tel: +989132925716; Email: [email protected]


SP63-18

Myocardial infarction and heart failure due to need of myocardial to more oxygen. Many researches shown that impairment

of glucose tolerance (IGT) is in relation with increase of LV mass [11, 13].

Hemoglobin like other proteins of body combines with sugars such as glucose. This combination is stable (about 120

days) till red blood cell is alive. This is the base of hemoglobin A1C (HbA1c) test, since whatever the level of blood sugar in

last 2-3 months is more than normal level, percentage of combined HbA1c with glucose will be more. So measurement of

HbA1c is suitable method to determine control of blood sugar and adequacy of insulin therapy of diabetic patients [14].

Due to the content of last paragraphs, increasing outbreak of diabetes mellitus, high blood pressure and hyperlipidemia

in Children during recent decades, and also due to resultant diseases of cardiovascular which can be controlled, early

diagnosis and treatment of them is essential to reduce cardiovascular diseases and danger of death. On the other hand early

diagnosis leads to increase longevity and improvement of life quality in patients. The goal of this study is to investigate

relation of hemoglobin A1C (HbA1c) to LVH and LV mass in Children with type 1 diabetes mellitus.

Material and method

This study is a descriptive-analytical study, which had been conducted on diabetic Children referred to Afzalipoor

hospital of Kerman during 2014-2015, and Sampling was randomized.

Inclusion and exclusion criteria to participate in study

Inclusion criteria: diabetic Children more than 6 years old that is proved are suffering from type 1 diabetes mellitus at

least for more than 2 years.

Exclusion criteria: children with Hemoglobinopathies (such as major thalassemia) and diabetes mellitus resultant from

Endocrinopathy (such as Cushing syndrome, hyperthyroidism) also children with diabetic complications (such as kidney

diseases, hypertension) and resultant diseases of secondary diabetes like thalassemia and cystic fibrosis were excluded from

study.

After satisfaction of patients and their parents a questionnaire including general information such as: age, sex, elapsed

time from disease diagnosis was filled out.

Evaluation of left ventricular mass

In order to evaluate cardiac involvement, by mean of echocardiography machine (Medison, South Korea) Doppler

echocardiography was performed by one cardiologist. Corresponding to suggestion of American society of

echocardiography M-mode echocardiography has been used to evaluate end-diastolic dimension and end-systolic dimension

from size of heart cavities and valves [15]. LV mass also was determined from diameter of left ventricle by the following

formula [17].

Where: LVEDD, left ventricular end-diastolic dimension (; (PWD), posterior wall thickness ;(IVS), interventricular Septal

thickness

Evaluation of left ventricular hypertrophy

In order to evaluate interventricular septal thickness in diastole, left ventricular end-diastolic size, left ventricular

posterior wall thickness in diastole and ejection fraction doppler method was used.

Hemoglobin evaluation

Evaluation of hemoglobin was performed by photometric accuracy method on 2 ml blood of patient by means of

Selectra device (Poland), and Pishtaz-Teb kit (Iran).

Data analysis method


SP63-18

After data collection statistical analyses were performed with SPSS software .For Descriptive statistic, average central

index or relative abundance was used. Also independent t-test and Pearson test were used for analytical statistic. In this

study meaningful level was considered below 0.05.

Results

In this research 45 patients with type 1 diabetes mellitus were studied and their demographic information is shown in

table 1.

Table 1: Demographic variables

Sex Abundance

Male 26(57.8)

Female 19(42.2)

Mean

Age 12.20(4.45)

Height 143.30(23.07)

Weight 39.94(17.57)

Maximum blood pressure 103(9.90)

Minimum blood pressure 65.22(8.91)

Years of getting diabetes 5.48(3.88)

Body mass index 18.36(3.75)

Hemoglobin A1c 8.89(1.98)

By analyzing echocardiography data, mean values of LV mass, LVEDD, LVPW, Left Ventricular Posterior Wall;

LVESD, left ventricular end-systolic dimension; LVEF, Left Ventricular Ejection Fraction; E/A, E/E, Sa, Ea, Aa were

respectively 92463.62, 23.67, 8.14, 12.96, 65.14, 1.86, 5.38, 11.65, 18.72, 8.61.

Table 2 shows information about:

1- Relation of demographic information to LV mass, LVPW and LVESD

2-Relation of echocardiography information to LV mass, LVPW and LVESD

3- Relation of hemoglobin A1C to LV mass, LVPW and LVESD

According to obtained information of echocardiography, just there was a meaningful relation between LVEDD and LVESD.

Other echocardiography findings did not have relation to LVH and LVmass. Just some demographic findings such as age,

weight, height, maximum blood pressure had meaningful relation to LVPW.

Relation of LV mass and hypertrophy to sex was studied which LV mass index (male=126038.65 female=67928.03) and

LVESD (male=15.6 female=11.03) unlike LVPW index (male=8.06 female=8.21) were greater in male than female but this

difference in each of three indexes was not statistically meaningful.

http://medical-dictionary.thefreedictionary.com/Left+Ventricular+Ejection+Fraction


SP63-18

Table 2: Relation of LV mass and hypertrophy to investigated variables

Variables LV mass

Pearson coefficient (p.v)

LVPW


LVESD


age 0.154(0.313) 0.350(0.018) 0.00(0.998)

height 0.190(0.211) 0.342(0.021) 0.008(0.956)

weight 0.127(0.404) 0.309(0.039) -0.092(0.546)

Maximum blood pressure 0.001(0.995) 0.413(0.005) -0.086(0.572)

Minimum blood pressure -0.053(0.729) 0.272(0.071) -0.049(0.751)

Year of getting diabetes -0.021(0.891) 0.210(0.166) -0.169(0.267)

Body mass index -0.038(0.804) 0.160(0.293) -0.199(0.190)

Hemoglobin A1c 0.234(0.127) 0.077(0.618) 0.077(0.618)

LVEDD 0.220(0.146) -0.004(0.980) -0.365(0.014)

LVEF -0.068(0.656) -0.132(0.388) -0.124(0.419)

E/A -0.025(0.872) 0.002(0.989) -0.074(0.630)

E/E -0.179(0.240) -0.053(0.732) -0.053(0.730)

Sa 0.097(0.525) -0.065(0.673) 0.054(0.725)

Ea -0.006(0.969) 0.081(0.595) -0.124(0.417)

Aa 0.018(0.909) 0.293(0.051) -0.167(0.273)

Figure 1: Comparison of LVPW and LVESD according to sex

LVPW, LVESD: Data were presented mean ± sd. P<0.05.


SP63-18

Figure 2: Comparison of LV mass according to sex

LV mass: Data were presented mean ± sd. P<0.05

Discussion

According to this study hemoglobin A1C is not related to LV mass, LVPW and LVESD in Children suffering from type

1 diabetes mellitus. Also sex is not in relation with LV mass increase and LVH. Echocardiography results show that just

there is an inverse relation between LVEDD and LVESD. Other echocardiography findings did not have relation to LV

mass and LV hypertrophy. Also some demographic findings just had meaningful relation to LVPW.

In research by Chan Yengo et al., it is shown that hemoglobin A1C has meaningful relation to diastole function and

acoustic densitometry in patients suffering from type 2 diabetes mellitus [17]. Seravi et al. showed that Diastolic

dysfunction in patient with type 1 diabetes mellitus is more and strongly in relation to blood sugar level (HbA1c) [18]. In

another research effect of blood sugar control on LVH development and diastolic failure in children with type 1 diabetes

mellitus was investigated and results showed that 14.6 percent of patients had LVH and 47.9 percent of patients had

Diastolic failure. Diabetes period in patients with LVH was meaningfully more. LVH outbreak and diastolic dysfunction in

these patients were more and control of diabetes could not affect LVH outbreak and diastolic dysfunction [19]. In research

by Gosh et al., it is shown that diabetes period is an independent predicting factor of LV mass. Where the increase of

diabetes period significantly leads to LV mass increase [15]. Chahal et al. showed that there is a meaningful relation

between carotid intima-media thickness and LV mass in patients with type 1 diabetes mellitus. Also this relation is weak in

patients with short disease period [16]. Maybe the difference of our study with others is in following up of patients for

longer term and type of study. Also for closer examination of the issue, a comprehensive study would be useful. Low


SP63-18

number of patients can be regarded as restriction of this study which is because of the absence of referring patients to

hospital in predetermined times. Therefore these patients were excluded from study population.

Because of increasing in diabetes mellitus outbreak and resultant problems which yearly impose great costs to develop

and developing countries, special attention of medical communities and country planners is necessary. According to results

of different researches, weak control of blood sugar due to hemoglobin index, can affect echocardiography indexes.

Diabetes mellitus is associated with the risk of cardiovascular diseases, and could be control to decrease high outbreak of

cardiovascular diseases in diabetic patients. Therefore planning for diabetes prevention, making changes and effective

interference in life style of people in a country is necessary to prevent diabetes where effective treatment of type 1 diabetes

mellitus can reduce risk of cardiovascular diseases.

References

1. Lernmark A. Type I (Insulin Dependent) Diabetes Mellitus: Etiology, Pathogenesis, and Natural History. In: De Groot LJ, Jameson JH

(editors). Endocrinology, 4th edition. Philadelphia. WB Saunders; 2001.p 763-75.

2. Silink M. Childhood diabetes: a global perspective. Horm Res 2002;57:1-5.

3.Lepore G, Bruttomesso D, Nosari I, et al. Glycaemic control and microvascular complications in a large cohort of Italian type 1 diabetic

out– patients. Diabetes NutrMetab2002;15:232-9.

4. Olsen BS, Sjolie A, Hougaard P, et al. A 6-year nationwide cohort study of glycaemic control in young people with type 1 diabetes.

Risk markers for development of retinopathy, nephropathy, and neuropathy. Danish Study Group of Diabetes in Childhood. J Diabetes

Complications 2000;14:295-300.

5. Miller J, Silverstein J. Cardiovascular risk factors in childhood diabetes. The Endocrinologist 2003; 13:394-405.

6. Krolewski AS, Kosinski Y, Worram JH, et al. Magnitude and determinants of coronary artery disease in juvenile – onset, insulin

dependent diabetes mellitus. Am J Cardiol1987;59:750-5.

7. Agabiti-Rosei E, Muiesan ML. Left ventricular hypertrophy: how to influence an important risk factor in hypertension. J

HypertensSuppl 1998;16(1):S53-8.

8. Lepira FB, Kayembe PK, M'buyamba- Kabangu JR, et al. Clinical correlates of left ventricular hypertrophy in black patients with

arterial hypertension. Cardiovasc J S Afr 2005;30:1-5

9. Salmasi AM, Rawlins S, Dancy M. Left ventricular hypertrophy and preclinical impaired glucose tolerance and diabetes mellitus

contribute to abnormal left ventricular diastolic function in hypertensive patients. Blood Press Monit 2005;10(5):231-8.

10.Gasperin CA, Germiniani H, Facin CR, et al. An analysis of electrocardiographic criteria fordetermining left ventricular hypertrophy .

Arq Bras Cardiol. 2002 ;78(1):59-82.

11. Rutter MK, Parise H, Benjamin EJ, et al. Impact of glucose intolerance and insulin resistance on cardiac structure and function sex-

related differences in the Framingham Heart Study. Circulation 2003;107(3):448-54


SP63-18

12. Devereux RB, Roman MJ, Paranicas M, et al. Impact of diabetes on cardiac structure and function the strong heart study. Circulation

2000;101(19):2271-6.

13. Grossman E, Shemesh J, Shamiss A, et al. Left ventricular mass in diabetes-hypertension. Archives of Internal Medicine

1992;152(5):1001-4.

14. Laviades C, Mayor G, Diez J. Association of cardiovascular risk factors in hypertensive patients with left ventricular hypertrophy.

Rev ClinEsp 1991;189 (9):403-7.

15.Ghosh AK, Hardy R, Francis D, et al. Duration of diabetes is a significant independent predictor of elevated lift ventricular mass.

Journal of the American College of Cardiology 2012;59(13s1):1727-28.

16.Chahal H, Backlund J-YC, Cleary PA, et al. Relation Between Carotid Intima–Media Thickness and Left Ventricular Mass in Type 1

Diabetes Mellitus (from the Epidemiology of Diabetes Interventions and Complications [EDIC] Study). The American journal of

cardiology 2012;110(10):1534-40.

17.Guo C-Y, Shen L-H, Li H-W, et al. Relation of Hemoglobin A1c to myocardial acoustic densitometry and left ventricular diastolic

function in patients with Type 2 diabetes mellitus and without evident heart disease. Diabetes research and clinical practice

2009;83(3):365-70.

18.Saravi M, Moazezi Z. Relation of hemoglobin a1c to left ventricular diastolic function in patients with type 1 diabetes mellitus and

without overt heart disease. Diabetologia Croatica 2006;35(2):39044.

19.El Dayem S, Battah AA. Effect of glycemic control on the progress of left ventricular hypertrophy and diastolic dysfunction in

children with type I diabetes mellitus. Anadolu Kardiyol Derg 2012;12:498-507.


SP64-18

Study of Total RNA Circulation and Tryptase Activity Levels in Heart

Failure Patients

Nagham Qasim Kadhim1, Fawzi Hassan Zayr

2, Sabah Fadhil Al-Qurashy

3

1 Department of Biochemistry, College of Science, Tikrit University, IRAQ

2 Department of Clinical Biochemistry, College of Medicine, Wasit University, IRAQ.

3 Department of Medicine / College of Medicine / Wasit University, IRAQ.

ABSTRACT

Background: Heart Failure (HF) take place when heart muscle couldn't pump blood as it should. HF is a

clinical disorder that occurs due to structural and functional weakness in the myocardium leading to a weak

ventricle in the blood pump. Methods: Serum Tryptase and Total RNA Blood were taken from 90 samples:

45 sample with heart failure, and 45 normal healthy control. The age of individual ranged from (40-65)

years. The tryptase assay by ELISA technique. Total RNA Blood was determined by QIAamp RNA Blood

Mini Kits. Results: There are a very high significant increase in activity of tryptase and a high significant

decrease in the total RNA concentration in whole blood in heart failure patients group, in addition to a very

high significant decrease in the total RNA levels in whole blood heart failure patients group when compared

with normal subject. A highly significant in the activity of tryptase and a highly significant in the total RNA

levels in whole blood in heart failure (male, female) patients group when compared with (male, female)

normal subject. There are a highly significant in the serum activity of tryptase and highly significant in the

total RNA concentration in whole blood in patient group according to compared it with normal subject in

age 38-50 years and in age >50.

Conclusions: There was a correlation between tryptase levels and circulation total RNA levels and

development of major adverse HF events.

KEYWORDS; Heart Failure, Tryptase, Total RNA

INTRODUCTION

Heart failure (HF) is a chronic condition (syndrome) produced in which happen when exist a

structural and functional disturbances in myocardium leading to retrogradation and weakness of ventricular

padding. The greatest public cause is reducing function of left ventricular; yet, abnormality or impairment in

the function of a pericardium, great vessels alone or with HF, myocardium, endocardium or heart valves.


SP64-18

Some of the main mechanisms which produce HF are enhanced blood flow overload, ventricular rebuild,

undue neurological and humoral stimulation, anomalous myocyte calcium recycling, insufficient

reproduction of extracellular matrix, faster apoptosis, ischemia dysfunction, and genetic mutations (1).

Tryptases are enzymes that belong to the serine proteases group, tetrameric, excrete by human mast

cells , possess a molecular weight of approximately 134 kDa (monomer approximately between 26-

35kDa)(2),(3). The amount of tryptase (EC 3.4.21.59) from total protein content of mast cell granules

approximately 25%, the tryptase are stored in active shape before release through mast cell degranulation.

The tryptase working show be constrained to the extracellular milieu (4). The arranging of tryptase active

side subunits results a little oval central pore (It’s size approximately 50×30 °A), which lead to restrictive

accessibility for substrate and inhibitors (5). The tryptase monomer is coordinated with six externally

uncovered, that associated with its external circumference, inclusive its adjacent monomers, when in the

tetramer form. These domains are external loops. Named are: “37-loop”, “60-loop”, “70- to 80”, “97”,

“147”, and “173” loop. Because of this loops encircle the active site of tryptase, any alteration in these

domains can make hard modify in the specificity of this enzyme. Tryptase, also, includes a catalytic

umvirate, that is fundament for its proteolytic activity (6), (7). Multiple human tryptases have been specified,

inclusive α, β, δ, γ and ε (8), yet, suspicion occur to regardless all structures or forms are efficient and

functional. The genes that encoded human tryptases are a cluster or Located on a 2.5Mb region, on the small

arm (p) of chromosome 16, (16 p13.38).

A noncoding RNA (ncRNA) is an RNA molecule which is transcribed from DNA, but don’t use to

build proteins. Generally, ncRNAs function to organizing gene expression at the all levels. These ncRNAs

which appear to be take part in epigenetic practicability can be split into 2 major groups; ncRNAs (<30 nts -

the short) and ncRNAs (>200 nts -the long) (9),(10). Latterly, attention in ncRNAs has start increasing

because they represent the performance majority of the transcriptase (11), (12) and also because of their

relationship with cardiovascular diseases (13-15). The ncRNAs are set up to stable and determined in fluids

of body, they appear a possibilities and benefits for used as biomarker parameter for diagnostic scientific

applications. Diverse new research have found that: extracellular rRNA and miRNAs, significantly

participate to the opposite output of cardiovascular impairment. Extracellular RNAs working as new risk -

sensor linked molecular signals and powerful cofactors in thrombosis and inflammation in cardiovascular

system, particular when gather in the extracellular area around tissue- damaged or in pathological cases

(16),(17).

MATERIALS AND METHODS

Forty five patients (23 males and 22 females) suffering from heart diseases were participated in the

present study. Their ages ranged from 40 to 65 years. Samples were collected from Wasit General Hospital

and the Salah al-din Hospital (Al-Askari) in Tikrit district, during the period from April to August 2017. All

patients were diagnosed by a specialist doctor, and each patient have troponin T was positive.


SP64-18

The control group was 45 apparently healthy controls (25males and 20 females). Ages of the involved

subjects ranged from (40-65) years. Five milliliters (5ml) of blood were drown from each patient and healthy

control individuals. Serum was obtained and kept into small Eppendorf tubes capacity 1.5 ml at -20C° until

time of analysis. The tryptase assay employs by the ELIZA technique (18). Total RNA Blood was

determined by QIAamp® RNA Blood Mini Kits (19) (QIAGEN company) which designed for extraction of

total RNA from novel, human whole blood which collected in anticoagulant( EDTA tube) for estimation of

RNA concentration.

Statistical analysis: The probability (P values= significance of difference) were estimated by student T-test.

RESULTS AND DISCUSSION

The mean (±SD) of tryptase activity and total RNA in normal healthy control group and patients with

heart failure group are explained in table [1]. There are a highly significant difference in the activity of

tryptase in heart failure patients group according to compared with normal healthy group (control), and a

highly significant decrease in the total RNA concentration in whole blood heart failure patients group

compared with normal healthy group (control).

Table [1]: Mean (±SD) tryptase activity and total RNA concentration in study group

Parameters Control Heart failure p

Tryptase (ng/ml) 16.6±8.19 49.88±6.240.0001 ٭

Total RNA (ng/ml) 212±31.23 88±12.900.0001 ٭

Table [2] : Shows there are a highly significant rise in the activity of tryptase in heart failure male

patients when compared with (male) control, and a highly significant rise in the activity of tryptase in heart

failure female patients when compared with (female) normal control, while , no significant different between

male and female

Also, there are a significant decrease in the concentration of total RNA level in whole blood heart

failure male patients group as compared with (male) control group, and a significant decrease in the total

RNA level in whole blood heart failure female patients group as compared with (female) control group.

There are a significant decrease in the total RNA level in whole blood heart failure female patients group

when compared with male patients group.


SP64-18

Table [2]: Mean (±SD) tryptase activity and total RNA level in study group

according to gender.

Parameters Control Heart failure

Tryptase (ng/ml)

male 17.68±2.33 44.18±9.23٭

female 16.06±2.12 46.88±12.34٭

Total RNA (ng/ml)

male 229±21.03 101±5.50٭

female 195.01±10.20 75.99±6.63#٭

*High Significant p˂0.0001 # Significant p˂0.05 compared with males

Table [3] shows there are a significant increase in the activity of tryptase in patient group compared

with normal healthy control group in age 38-50 years, there are a significant increase in the activity of

tryptase in patient group compared them with control group in age >50 , and no significant different between

38-50 years and >50 age groups.

Also, there was a very high significant decrease in total RNA level in whole blood patient group when

compared it to control group in age 38-50 years, and significant decrease in the total RNA level in whole

blood patient group as compared to control group in age >50, and significant decrease in the total RNA level

in whole blood patients group in age>50 when compared with 38-50 years patients group.

Table [3] : Mean (±SD tryptase activity and total RNA concentration in study group

according to age.

Parameters Control Heart failure

Tryptase (ng/ml)

38-50 years 17.68±2.33 44.18±9.23٭

>50 16.06±2.12 46.88±12.34٭

Total RNA (ng/ml)

38-50 years 242±21.23 100±12.11٭

>50 181.05±24.43 76.99±18.63#

*High Significant # Significant

Mast cells consist of various excess mediators that gives them the capacity to do diverse mechanisms.

For the mast cells to work, effecting and to stimulate plaque progression (41), they require to be activated to

liberation and release mediators. Interesting: one of the main plaque damaging effects is by the mast cell–

tryptases (9). In different studies, tryptase levels in plasma have been shown relate to cardiovascular diseases.

However, another searches failed show any change in tryptase levels pending cardiovascular events (20). As

yet, serum tryptase is increasing extent used as a signature for different abnormalities in clinical exercise (4).

Despite of studies detects a positive relationship between obesity and raise mast cells number for both

animals and humans (41). Prior doings show a lineal contribution for mast cells in insulin resistance and type

2 diabetes mellitus (T2DM) in animal models (21).Numerous experimental studies have found that: tryptase

has a important role in the atherosclerosis in addition in the formation of aortic aneurysm (42). Zhang et al.

found a decrease in formations abdominal aortic aneurysm appear in tryptase imperfect animals (22). Newly


SP64-18

demonstrated that, inhibition tryptase by medications decrease abdominal aortic aneurysm (23). The

relationship between increase tryptase concentration and the development events cardiovascular could lead to

prove that: the mast cells have important role in the weakness and degradation process to heart. Others

explained that: powerful roles in activated and functioning mast cells in the growing destabilization of a

plaque (24).

In this time, many researchers have given their concern to the RNA domain. With the common use of

RNA-sequencing, the finding is ncRNAs related to disease expansion. Circulating ncRNAs are powerful

serve as index for disease valuation. Invert proteins, RNAs are more stable in the organ and also in blood

(25). Only 2% of genomes are responsibility of coding for protein. RNAs are grouped as ncRNAs (26).

Although this, ncRNAs are very important because they participate in protein silencing, modification and

promotion (27). Emerging evidence has confirmed a close correlation with pathophysiology for human heart

(28). Consecutive studies found different specific lncRNAs that are high sensitive which attached to disease

progress (29).

The existence of DNA (RNA) outside the cell and sour the DNA in blood is usually present as a result of

turnover of cells or by the formation proses of micro vesicles blood cells (30), platelets, and secretive cells

remain in tissues such as placenta, organs ,endocrine, tumors, tissue injury especially in liver (32),(32).

Considering the change in concentration of free nucleic acids, and extracellular their composition reflect to

their unequalled metabolism and disease operation (33), and identical structural sequence has been

considered beneficial for the determination of novel biomarkers (34-35). That damage to the heart tissue will

result in excess release of ncRNA similar to secretion of protein. For improvement and complementation

such as the associated biomarker, miRNA transiently and recently inRNA and potential circular IncRNA are

expected to reflect equivalently heart damage, the Engage of other organ, and generally patient disease (36,

43). Different reports supply evidence that RNAs is involved in the growing and forward of HF, the study of

circular RNA has been studied as a biologically increasing of possible heart failure has been summarized by

various references (37-39).

Conclusion: Studies are ensured to prove that blood RNA can be used as biomarkers for cardiac damage,

especially HF, we agree with other (40) which found that “blood cells act as sentinels of some disease.”

Therefore capitalize from it for the diagnosis, or follow them with cardiac diseases.

Acknowledgment: All authors disclose that they do not have any conflict of interests.

ABBREVIATION USED

Heart Failure (HF), kilo Dalton ( kDa), histamine( His), Asparagine( Asp), Serine(Ser) .


SP64-18

References

1- Dassanayaka, S.; Jones, S.P. Recent Developments in Heart Failure. Circ. Res. 2015, 117, e58–e63.

2- Payne, V., and P. C. Kam. 2004. Mast cell tryptase: a review of its physiology and clinical significance.

Anaesthesia 59:695.

3- Caughey, G. H. 2004. Genetic insights into mast cell chymase and tryptase function. Clinical and Experimental

Allergy Reviews 4:96.

4- Wang, H. W., H. P. McNeil, A. Husain, K. Liu, N. Tedla, P. S. Thomas, M. Raftery, G. C. King, Z. Y. Cai, and

J. E. Hunt. 2002. Delta tryptase is expressed in multiple human tissues, and a recombinant form has proteolytic

activity. Journal of Immunology 169:5145.

5- Fiorucci, L., and F. Ascoli. 2003. Mast cell tryptase, a still enigmatic enzyme. Cellular & Molecular Life

Sciences 61:1278.

6- Pereira, P. J., A. Bergner, S. Macedo-Ribeiro, R. Huber, G. Matschiner, H. Fritz, C. P. Sommerhoff, and W.

Bode. 1998. Human beta-tryptase is a ring-like tetramer with active sites facing a central pore. Nature 392:306.

7- Sommerhoff, C. P., W. Bode, P. J. Pereira, M. T. Stubbs, J. Sturzebecher, G. P. Piechottka, G. Matschiner, and

A. Bergner. 1999. The structure of the human betaII tryptase tetramer: for better or worse. Proceedings of the

National Academy of Sciences of the United States of America 96:10984.

8- Jenny Hallgren. The Role of Heparin in the Activation of Mast Cell Tryptase. Doctoral thesis Swedish

University of Agricultural Sciences Uppsala 2004.

9- Morris KV, ed. (2012). Non-coding RNAs and Epigenetic Regulation of Gene Expression: Drivers of Natural

Selection. Caister Academic Press. ISBN 978-1-904455-94-3.

10- Shahrouki P, Larsson E (2012). "The non-coding oncogene: a case of missing DNA evidence?". Frontiers in

Genetics. 3: 170. doi:10.3389/fgene.2012.00170. PMC 3439828. PMID 22988449.

11- Alexander RP, Fang G, Rozowsky J, Snyder M, Gerstein MB. Annotating non-coding regions of the genome. Nat

Rev Genet. 2010; 11:559–571. Doi: 10.1038/nrg2814.

12- Derrien T, Johnson R, Bussotti G, et al. The GENCODE v7 catalog of human long noncoding RNAs: analysis of

their gene structure, evolution, and expression. Genome Res. 2012; 22:1775–1789. Doi: 10.1101/ gr.132159.111.

13- Thum T, Condorelli G. Long noncoding RNAs and microRNAs in cardiovascular pathophysiology. Circ Res.

2015;116:751–762. Doi: 10.1161/ CIRCRESAHA.116.303549.

14- Uchida S, Dimmeler S. Long noncoding RNAs in cardiovascular diseases. Circ Res. 2015; 116:737–750. Doi:

10.1161/CIRCRESAHA.116.302521.

15- Vegter EL, van der Meer P, de Windt LJ, Pinto YM, Voors AA. MicroRNAs in heart failure: from biomarker to

target for therapy. Eur J Heart Fail. 2016;18:457–468. Doi: 10.1002/ejhf.495.

16- Alma Zernecke and Klaus T. Preissner, 2016, Extracellular Ribonucleic Acids (RNA) Enter the Stage in

Cardiovascular Disease, Circulation Research.;118:469–479.

17- Etheridge A, Gomes CP, Pereira RW, Galas D, Wang K.The complexity, function and applications of RNA in

circulation.Front Genet. 2013;4:115.

18- Human tryptase ELISA Kit, CUSABIO BIOTECH CO., Ltd., Catalog Number. CSB-E09012h.

19- QIAamp RNA Blood Mini Kits, QIAGEN - Sample to Insight, Catalog Number.52304.

20- Ilze Bot, Guo-Ping Shi, Petri T. Kovanen, Mast Cells as Effectors in Atherosclerosis, Arterioscler Thromb Vasc

Biol. 2015;35:265-271.


SP64-18

21- Tebeen Jamal Nadir , Zhian Salah Ramzi , Ban Mousa Rashid , Saman Hussein Noori , Taha Othman Mahwi

and Beston Faiek Nore , status of circulating serum tryptase in healthy obese and comorbidly obese conditions ,

JSMC, 2017 (Vol 7) No.1

22- Zhang J, Sun J, Lindholt JS, Sukhova GK, Sukhova GK, Sinnamon M, et al. Mast cell tryptase deficiency

attenuates mouse abdominal aortic aneurysm formation. Circ Res. 2011; 108(11):1316–27.

23- Wang Y1, Shi GP. Mast cell chymase and tryptase in abdominal aortic aneurysm formation. Trends Cardiovasc

Med. 2012; 22(6):150–5.

24- Bot I, Shi GP, Kovanen PT. Mast cells as effectors in atherosclerosis. Arterioscler Thromb Vasc Biol.

2015;35(2):265–71.

25- Shi T, Gao G, Cao Y. Long Noncoding RNAs as Novel Biomarkers Have a Promising Future in Cancer

Diagnostics. Dis Markers 2016;2016:9085195.

26- Gao J, Xu W, Wang J, et al. The Role and Molecular Mechanism of Non-Coding RNAs in Pathological Cardiac

Remodeling. Int J Mol Sci 2017;18.

27- Viereck J, Thum T. Circulating Noncoding RNAs as Biomarkers of Cardiovascular Disease and Injury. Circ Res

2017;120:381-99.

28- Yu X, Zou T, Zou L, et al. Plasma Long Noncoding RNA Urothelial Carcinoma Associated 1 Predicts Poor

Prognosis in Chronic Heart Failure Patients. Med Sci Monit 2017;23:2226-31.

29- Qiying Dai , Jose Freire , Teresa Zhang,, Circulating long non-coding RNAs as biomarkers of acute myocardial

infarction, Non-coding RNA Investig 2017;1:4

30- Klaas E. A. Max , Karl Bertram , Kemal Marc Akat , Kimberly A. Bogardus , Jenny Li , Pavel Morozov , et al.,

Human plasma and serum extracellular small RNA reference profiles and their clinical utility,PNAS, v.115 (23),

2018 , p.E5334 - E5343.

31- Momen-Heravi F, et al. (2015) Increased number of circulating exosomes and their microRNA cargos are potential

novel biomarkers in alcoholic hepatitis. J Transl Med 13:261.

32- Latreille M, et al. (2015) miR-375 gene dosage in pancreatic β-cells: Implications for regulation of β-cell mass and

biomarker development. J Mol Med (Berl) 93: 1159–1169.

33- Akat KM, et al. (2014) Comparative RNA-sequencing analysis of myocardial and circulating small RNAs in human

heart failure and their utility as biomarkers. Proc Natl Acad Sci USA 111:11151–11156.

34- Boon RA, Dimmeler S (2015) MicroRNAs in myocardial infarction. Nat Rev Cardiol 12: 135–142.

35- Klingenberg M, Matsuda A, Diederichs S, Patel T (2017) Non-coding RNA in hepatocellular carcinoma:

Mechanisms, biomarkers and therapeutic targets. J Hepatol 67: 603–618.

36- Janika Viereck, Thomas Thum , Circulating Noncoding RNAs as Biomarkers of Cardiovascular Disease and Injury,

Circ Res. 2017;120:381-399

37- Vegter EL, van der Meer P, de Windt LJ, Pinto YM, Voors AA. MicroRNAs in heart failure: from biomarker to

target for therapy. Eur J Heart Fail. 2016;18:457–468. Doi: 10.1002/ejhf.495.

38- Bronze-da-Rocha E. MicroRNAs expression profiles in cardiovascular diseases. Biomed Res Int.

2014;2014:985408.

39- Komamura K, Fukui M, Iwasaku T, Hirotani S, Masuyama T. Takotsubo cardiomyopathy: pathophysiology,

diagnosis and treatment. World J Cardiol. 2014;6:602–609. Doi: 10.4330/wjc.v6.i7.602.

40- Liew CC, Ma J, Tang HC, Zheng R, Dempsey AA. The peripheral blood transcriptome dynamically reflects system

wide biology: a potential diagnostic tool. J Lab Clin Med 2006;147:126–32.


SP64-18

41- Nagham Q. Kazim, D. H. Hadree, and Fawzi H. Zayr, “Study of Tryptase Activity and Selenium Concentration in

Cardiovascular And Diabetic Patients,” Tikrit J. Pure Sci., vol. 21, no. 6, pp. 67–71, 2016.

42- Z. Wang, X. Shen, W. Feng, and W. Qiu, “Mast cell specific immunological biomarkers and metabolic syndrome

among middle-aged and older Chinese adults,” Endocr. J., vol. 64, no. 1, pp. 1–9, 2017.

43- W. Ricart and J. M. Fernandez-real, “Circulating Tryptase as a Marker for Subclinical Atherosclerosis in Obese

Subjects,” PLoS ONE, vol. 9, no. 5, pp. 1–6, 2014.


SP65-18

Evaluate the effectiveness of cognitive behavioral group psychotherapy on psychological

well-being of under treatment addict patient

1 Aliakbar Esmaeili, 2 Reza Yaghoubi, 3 Reza dastgerdi*

1Psychiatry and Behavioral Sciences Research Centere, Assistant Professor of psychiatry, BUMS

2Master of Clinical Psychology

3Psychiatry and Behavioral Sciences Research Center, Assistant Professor of psychology. BUMS

*Corresponding Author Email: [email protected]

Abstract Introduction & Background: The people of the word especially our people of Iran are suffered from opoid addiction and its

consequently ruinous effects since many years ago. Nowadays , with development positivism of psychotherapy for

psychological problem especially addiction, progression the psychological well-being causes increase of response treatment of

addiction cognitive – behavioral group psychotherapy is one of effective and cost-benefit treatment for this purpose,

.According to past studies, psychological well-being can be effective in the treatment of addiction, this study examines the

effectiveness of psychological well-being group cognitive behavior psychotherapy on treatment of addiction.

Methods: A quasi-experimental with before and after test, of the 100 cases referred to the outpatient clinic Ferdows city treated

with methadone (MMT), the random sampling method 30 selected and divided into two experimental and control groups (each

group 15 persons). In addition to receiving drug treatment group underwent 12 sessions of group therapy was Cognitive- while

the control group did not receive any non-medicinal intervention. 84 questions for data collection questionnaire psychological

well-being Reef (RSPWB) was used and data were analyzed by t-test.

Results: In this study, the treatment group Cognitive- positive role in predicting components, "environmental control", "personal

development", "positive relationships with others," "purpose in life" and "acceptance" revealed (05 / 0P <). But in predicting

"independence" parameters, did not show a significant role (05 / 0P>)

Conclusion: According to this study, the effects of cognitive-behavior group psychotherapy on improving psychological well-

being are important predicting factor of addiction treatment.

Keywords: group therapy, Cognitive- behavioral therapy, psychological well-being, addiction

Introduction Addiction is a complex and multi-factorial phenomenon that has been studied from different perspectives

of biological, psychological, cultural, social and spiritual and as a social problem has a high prevalence in

community especially among young people. This issue can be led to various social and health

disadvantages, such as damage to an individual's economic context, increased violence, increased risk of

AIDS, delinquency, unemployment, increased mental disorders and suicidal thoughts (1) (2). To deal with

the phenomenon of opiate dependence, drug therapy is not the only tool, it is necessary to have enough

knowledge about different aspects of this phenomenon. So far, several therapeutic approaches such as

psychoanalytic, behavioral therapy, group therapy, drug therapy, and so on, has been used to treat addict

people, but each of these methods has been moderately effective (3). Most drug addicts tend to change the

drug-dependent lifestyle, but the existence of many problems during treatment, can be led to relapse and

leaving the treatment process (4). Continuity factors for addictive behaviors include craving and

dysfunction in cognitive and emotional regulation (5). However, in order to deal with opium dependency,

drug therapy alone is not feasible and requires treatments that can overshadow these different parts. That

is, beside the biosphere dimension of human beings is considered to be as much and perhaps more the

psychosocial dimensions of man be considered. The importance of the case manifests itself when addicts

abandon drug addiction over and over again, but after a while, they re-enter addiction. This suggests that

addressing the psychological problems of addicts such as restoration of self-esteem, self-confidence,

accountability (responsibility), etc., as well as social and familial problems, have a direct link to leave

addiction (6).

In drug abuse patients, recovery is potentially influenced by the success of interpersonal relationships and

the quality of social skills. Since group counseling directly emphasizes these categories, therefore has a

major potential as a therapeutic element. Most studies on the effectiveness of different approaches to

treatment of addiction have referred to cognitive-behavioral approach as an effective approach to

treatment of this disease. Studies have shown that the cognitive behavioral pattern in group maintenance

therapy has been more effective than the individual approach (7). Some believe that the group therapy is



SP65-18

the best way to treat addicts. Overall, studies on substance abuser in the past forty years have shown that

these therapies can lead to a long-term recovery that motivates the patient for treatment and use the

patient's contribution to treatment (8, 9). One of the methods with these characteristics is group cognitive

therapy. This method is a fully structured and focused on current and immediate patient problems.

Although cognitive-behavioral therapy initially developed as an individual therapy, today, a shift in

direction to its use in a group-based manner in terms of its cost-effectiveness in terms of time and

economy is seen. Positive approach to mental health has become widespread in recent years and on this

basis concept of psychological well-being has emerged that considers psychological well-being more than

a lack of disease as having positive qualities such as self-esteem, proper social relationships and

satisfaction (9). At the first glance, the belief that it is possible to experience psychological well-being

despite illness is unacceptable. However, many studies have shown that psychological well-being can be

experienced in the presence of disease. The sense of psychological well-being includes evaluations that

people act on themselves and their lives. These evaluations include life satisfaction, excitement, positive

mood, lack of depression and anxiety. The components of psychological well-being are: self-acceptance,

purposefulness in life, personal growth, dominating on environment, independence, and positive

relationships with others. These criteria are closely related to the psychological problems of addicts. In

drug addiction treatment clinics, which are composed of a team of therapists, clients are usually more than

that psychologist can counsel each of them in a proper opportunity. On the other hand, the group has

some benefits that are not individually treated, which will be referred to below. Usually in small

communities, most addicted patients often people who, due to cognitive problems and unknowingly,

become drug addicts, and are less likely to be infected with drugs in a funny way, thus, due to having

enough incentive to leave drug abuse participate in therapeutic programs, such as therapeutic group, are

more cooperative, and possibly the treatment group is effective in their treatment.

A group of psychologists have used psychological well-being instead of the term mental health because

they believe that this term brings to the mind more positive aspects (9). Ryff and colleagues, first and

foremost attempted, based on the philosophical foundations of people such as Aristotle and Russell,

determine and categorize ideal life criteria or so-called good life. Accordingly, they identified six

important factors through which they could be good: self-acceptance, commitment to life, personal

growth, having a positive relationship with others, domination of the environment and autonomy,

components of psychological well-being in the Ryff’s model (9, 10).

Ryff considers the psychological well-being as a comprehensive development that is widespread

throughout life. Therefore, they believe that well-being does not mean the acquisition of pleasure, but the

attempt to transcend and promote that manifests itself in realizing the individual talents and abilities. He

considers psychological well-being to be a quest for perfection in order to realize the real potentialities of

a person (10, 11).

Considering the importance of cognitive-behavioral psychotherapy in the process of improving addiction

and the major role that psychological well-being has in motivating the continuation of treatment, this

study evaluates the effectiveness of cognitive-behavioral group psychotherapy on psychological well-

being of patients.

Research Methodology The research method is a clinical trial, using pre-test and post-test with two groups (experimental and

control) in which the effect of group therapy as an independent variable on psychological well-being as a

dependent variable has evaluated. The statistical population consists of all male addicts who are leaving

referring to Ferdows addiction treatment clinic. The inclusion criteria were having addiction diagnosis by

semi-structured interviews and adapting it to DSM-IV-TR and a willingness to enter the study. Among

100 male patients undergoing treatment with methadone maintenance treatment, 30 individuals were

randomly selected and were divided into two groups of experiment (15 subjects) and control (15). A pre-

test was performed in two groups. Then, in the experimental group, 12 sessions of 1.5 hours of group

therapy were performed by a master's degree in clinical psychology. The method used for the treatment


SP65-18

was psycho-educational method. This means that, in addition to implementing group psychotherapy

techniques, the training of these people and increasing their general knowledge were also addressed. After

the end of the treatment group sessions, evaluation and assessment of post-test were done in two groups.

The instrument for assessing the psychological well-being and its components was the Ryff Psychological

Well-Being Scale (RSPWB).

Ryff Psychological Well-Being Scales (RSPWB): This scale was designed by Ryff in 1980 (Ryff, 1995).

The original form had 120 questions, but in the later reviews, shorter forms of 84 questions, 54 questions

and 18 questions were also suggested. In this research, based on Ryff’s recommendation to researchers,

the 84 questions form was used. Psychological well-being scales have six subscales: self-acceptance,

positive relationship with others, autonomy, purposeful life, personal growth and environmental

domination. In the form 84 questions each item (factor) has 14 questions. The subject is asked to read the

questions and express his or her opinion on one of the six options, from fully disagree to fully agree. For

each question, scores of one to six are given. A high score indicates better psychological well-being.

The questionnaire was translated into Persian by Dr. Ali Asghar Bayani, Ashour Mohammad Kuchiki and

Ali Bayani in the year 2007. The reliability coefficient using test-retest was 0.71, 0.77, 0.78, 0.77, 0.70

and 0.78, respectively which was statistically significant (p <0.001) (13). The results of confirmatory

factor analysis indicated that the test had the desired factors and structures of its makers. In fact, the

results of the factor analysis confirmed the construct validity of the test.

The group cognitive behavioral therapy that was conducted in this study is based on the protocol of the

addiction treatment group, the Mashhad well-being Faculty, and has been approved by experts. This

approach is based on the cognitive-behavioral psycho-education approach. The basis for the work of the

protocol is a group of 8 to 12 members in 12 sessions and the summary of sessions are shown in

following.

Session 1: The topic of familiarity and referrals of members with each other, icebreaking and the

description of group therapy, Second session: Addiction as a disease and the study of the dimensions of

the disease, Session 3: Role of motivation and decision in treatment, Session 4: Treatment process,

Session 5: The role of the guide in the treatment process, Session 6: Relapse and lapse, Seventh session:

craving, Eighth session: ways to cope with craving, Ninth session: Alternative materials, Tenth session:

Attitude of family members towards treatment, The eleventh session: Society and addict individuals,

Twelfth Session: Lifestyle and Summary of provided matters.

Data analysis method The Kolmogorov-Smirnov test (K-S) was used to normalize the variables. Then, independent t-test and

Mann-Whitney test were used based on the results. For statistical analysis, SPSS software 20 was used.

Results In this study, all subjects were men with an average age of 38 years. They have a minimum age of 20 and

a maximum of 59 years. Table 1 Mean and standard deviation of pre-test scores in two experimental and control groups in the test subscales

Scales Subscales Experimental group Control group

Mean SD Mean SD

Psychological wellbeing

Autonomy 53.73 5.40 54.07 6.31 Environmental dominance 52.93 9.69 54.60 10.09

Personal Growth 55.80 7.73 54.27 7.81 Positive relationship with others 52.2 7.00 56.07 8.79

Purposefulness in life 57.47 5.79 59.07 7.74 Self-acceptance 47.40 10.20 50.73 9.60

As indicated in Table 1, in the pretest stage, the mean of cognitive scores in the subscales of personal

growth in the control group is lower than the experimental group and in the other scales is more. The

mean of each subscales of psychological well-being in the post-test is higher than the mean of each

subscales of the control group.


SP65-18

Table 2 Comparison between pre-test of two groups of control and experiment in the psychological well-being sub-scales

Subscales of

psychological well-

being

Group Number Mean SD t

statistics

Degree

of

freedom

Significance

level

Autonomy

Experiment 15 53.733 5.405 -0.155 28 0.878

Control 15 54.067 6.307

Environmental

dominance

Experiment 15 52.933 9.961 -.0461 28 0.648

Control 15 54.600 10.091

Personal growth Experiment 15 55.800 7.729

0.540 28 0.593 Control 15 54.267 7.815

Positive relationship

with others

Experiment 15 52.200 7.002 -1.333 28 0.193

Control 15 56.067 8.788

Purposefulness in

life

Experiment 15 57.467 5.792 -0.641 28 0.527

Control 15 59.067 7.741

Self-acceptance Experiment 15 47.400 10.197

-0.922 28 0.364 Control 15 50.733 9.595

Total scale Experiment 15 319.533 34.597

-0.651 28 0.520 Control 15 328.800 42.945

As shown in Table (2), there is no significant difference between the two groups in the sub-scales at the

pre-test stage (P>0.05). The results show that the level of significance is greater than 0.05, so there is no

significant difference between the pre-test of two groups of control and experiment in the subscales of

psychological well-being. That is, if in the post-test, the significance level is less than 0.05, it is due to an

intervention that would be carried out in the treatment group. To evaluate the difference between the two

groups of experiment and control in the pre-test and post-test of the psychological well-being subscales

independent t-test was used that in the case of observation of a significant difference in the two stages

indicates the effectiveness of independent variable (cognitive-behavioral therapy). At first, using the

Levene's test for equality of variances of dependent variable in two groups of experiment and control was

performed and for autonomy is (P = 0.005, F = 0.986), individual growth (P = 0.0003, F = 183.293),

effective communication with others (P = 0.0008, F = 15.860), Purposefulness in life (P = 0.0004, F =

17), self-acceptance (P = 0.001, F= 12.448).

Table 3 Independent t-test values in the subscales of the two groups (experiment and control) in two stages (pre and post

test)

Subscales of

psychological well-

being

Group Number Differential

Mean SD df t

Significance

level

Autonomy Experiment 15 3.467 7.615

16.478 -1.592 0.130 Control 15 -0.200 2.274

Personal growth Experiment 15 -8.200 8.994

15.757 -3.703 0.002 Control 15 0.667 2.257

Positive relationship

with others

Experiment 15 -10.733 8.379 16.312 -5.004 0.001

Control 15 0.533 2.416

Purposefulness in life Experiment 15 -5.000 6.268

16.412 -2.885 0.011 Control 15 -0.133 1.844

Self-acceptance Experiment 15 -7.520 7.520

15.822 -4.191 0.001 Control 15 0.533 1.922


SP65-18

Considering the amount of t calculated in Table 3, regarding the components of personal growth, positive

relationship with others, purposefulness in life and self-acceptance, obtained significance level is less

than 0.05. The pre-test and post-test mean scores in the control and experimental groups show that the

differential mean of the above mentioned cases in the experimental group is significantly greater than the

mean difference of the control group, in other words, there is a significant difference between the two

groups.

Concerning the efficacy of cognitive group therapy in increasing the environmental dominance of

addicted patients undergoing treatment in the experimental group, the mean of pre-test is 52.93, the mean

of post-test is 59.13, the ranking mean is 10.53, the total ranks is 158, the Mann Withney (u) is 38.00,

Wilcoxon statistic is 158.00, the Z statistic is -3.19 and the significance level is 0.001. Since the

significance level in the Mann-Whitney test (u) is less than 0.05, there is a significant difference between

the two groups of experiment and control on levels of environmental dominance. The examination of

differential mean scores shows that the differential mean of environmental dominance in the experimental

group is significantly greater than the mean difference of the control group. In fact, the difference

between the pretest and post-test scores in the experimental group is significantly higher than the control

group.

Discussion and conclusion

On a general and in general scale, it was found that cognitive behavioral group therapy increased the

psychological well-being of addicts and had a positive and significant effect on all psychological well-

being sub-scales, except for autonomy. Therefore, examining the pre-test and post-test mean in two

groups of control and experiment in the "autonomy" component indicates that the differential mean of the

above mentioned components in the experimental group is significantly less than the mean difference of

the control group. In other words, there is no significant difference between the two groups which

suggests that cognitive-behavioral therapy isn’t effective in increasing the "autonomy" of addicts

undergoing treatment.

Usually self-actualized individuals are described as those who can act independently and resist

environmental and cultural pressures (14). The requirement to achieve self-actualization and

independence in addicts in such a way that these needs appear in a hierarchy and usually when a lower

need is met, the upward need shows itself. It is important to note that most addicts have low economic

and educational conditions. Similar problems can prevent them from achieving autonomy. An individual

with a complete or independent action or function is the owner of an inward evaluation resource and does

not look at others for approval, but measures himself according to his/her own criteria (14).

In line with this finding by Ahmadvand et al in a research entitled "explaining psychological well-being

based on cognitive therapy on the effect of psychological well-being on reducing stress and tension, one

could expect that by increasing the components of mindfulness, psychological well-being is increased and

the rate of stress and physical and psychological disorders is decreased (15). In this regard, Dabbaghi et

al., in their study entitled “the efficacy of the prevention of relapse based on the mindfulness in the

treatment of opium dependence and mental health” showed the use of the method of prevention of

recurrence based on mindfulness, dramatically improved the efficacy of medical and cognitive behavioral

therapies of opiate dependency and increase mental health of patients (16).

The results of study conducted by Brown and Rayan (2003), showed that increased mindfulness is

accompanied with increasing psychological well-being, as well as clinical intervention on cancer patients,

showed that increased mindfulness is associated with decreased mood disorder and stress (17) and in

research by Morena et al. (2008) that in their study on chronic pain patients found the practice of

mindfulness had positive effects on pain, attention, and sleep issues, as well as the results of their study

showed that mindfulness exercises increased psychological well-being in individuals. This has an

immediate effect on the increase in mood and long-term effects on quality of life. In fact they found that

increasing mindfulness is associated with increasing physical and psychological well-being [18]. Hool et

al. (2010) also examined the relationship between mindfulness and emotional well-being, psychological


SP65-18

well-being and social well-being, which showed that there is a positive and significant relationship

between mindfulness and all types of emotional, psychological and social well-being (19). This means

that cognitive-behavioral group therapy has not been able to increase the autonomy of addicts.

Cognitive-behavioral group therapy has an impact on increasing environmental domination, personal

growth, Purposefulness in life, self-acceptance of addicts undergoing treatment.

Various factors contribute to the individual's development of addicts. As Ryff (1998) states, this concept

also has a close connection with self- actualization, which means that as one develops more personal

growth, he becomes closer to self-actualization.

Some areas in cognitive-behavioral group therapy, by raising the knowledge, insight and skills of addicts,

create the right conditions for increasing individual's personal growth. This finding can also be influenced

by the fact that the group is basically a perfect model for the person who wants to change.

Sartre believes (quoted by Ryff and Singer, 2008), creating meaning and finding a path is a fundamental

challenge to life (14). While the reason of addict referring for quitting, and more importantly, the reason

for having to attend a therapeutic group is purpose and motivation. This purpose may change during the

group therapy and change its position with a higher purpose.

Acknowledgement

This research, which has been carried out at the Ferdows addiction treatment clinic, it is necessary the

technical team and the members of the clinic's treatment team and patients who have participated in the

research process to be commended and thanked. There is no conflict between the authors in this article.

References 1. Reed E, Amaro, H., Matsumoto,A.,& Kaysen,D. The relation between interpersonal violence and substance use

among a sample of university students.Examination of the role of victimis and perpetrator substance use. Addictive

behaviors, 34(3):316-80. 2009; 34(3):316-80.

2. Kaldavi A, Borjali A, Falsafi Negad MR, Sohrabi F. The Effectiveness of. 2. 2012; 3(4):69-79. (Persian)

3. Galanter M. In novations: alcohol & drug abuse, spirituality in alcoholics anony mouse, Psychiatric services.

2010; 57:307-9.

4. Ravndal PE, E. & vaglum, M. psychopathology, treatment completion and 5 years outcome a prospective study of

drug abusers. Journal of substance abuse treatment. 1998; 415(2):135-42.

5. Tiffany ST. A cognitive model of drug urges and drug-use behavior: role of automatic and nonautomatic

processes. Psychological review 1990; 92(2):147.

6. Tajeri B. Evaluating Effectiveness of Cognitive- behavior Therapy on Craving, Attitude & Compatibility in

Methamphetamine Addicts. Journal of Applied Psychology. 2015; 9(3):35. (Persian)

7. Hadadi R, Rostami R, Rahiminejad A, Akbari Zardkhaneh S. The Effectiveness of Cognitive Behavior Therapy of

Impulse Control on Reduction of Impulsiveness, Crave of Usage and Addiction Severity among Crack Users.

Research on Addiction. 2009; 3(10):29-52. (Persian)

8. Ghoudarzi Nea. The effectiveness of group contracting and behavioral activation therapy on opioid substance use

disorders Contemporary Psychology. 2008; 3(1):8. (Persian)

9. Micheili manba F. Psychological well-being scale factor structure among students of Urmia University. Tabriz

Journal of Psychology. 2011; 5(18). (Persian)

10. Ryff CD. Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of

personality and social psychology. 1989; 57(6):1069.

11. Keyes CL, Shmotkin D, Ryff CD. Optimizing well-being: the empirical encounter of two traditions. Journal of

personality and social psychology. 2002; 82(6):1007.

12. Ryff CD, Keyes CLM. The structure of psychological well-being revisited. Journal of personality and social

psychology. 1995; 69(4):719.

13. Bayani AA, Mohammad Koochekya A, Bayani A. Reliability and validity of Ryff’s psychological well-being

scales. Iranian Journal of Psychiatry and Clinical Psychology. 2008; 14(2):146-51.(persian)

14. Ryff CD, Singer BH. Know thyself and become what you are: A eudaimonic approach to psychological well-

being. Journal of happiness studies. 2008; 9(1):13-39.

15. Ahmadvand Z, Heydarinasab L, Shairi M .R. Prediction of Psychological Well –Being Based on the Comonents

of Mindfulness. Health Psychology. 2012; 1(2):60-9. (Persian)


SP65-18

16. Dabbaghi P, Asgharnejad Farida A-a, Atef-Vahidb MK, Bolharic J. Effectiveness of Group Cognitive Therapy

Based on Mindfulness and Spiritual Schema Activation in the Prevention of Opioid Abuse Relapse. Iranian Journal

of Psychiatry and Clinical Psychology. 2008; 13(4):366-75. (Persian)

17. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being.

Journal of personality and social psychology. 2003; 84(4):822.

18. Morone NE, Lynch CS, Greco CM, Tindle HA, Weiner DK. “I felt like a new person.” The effects of

mindfulness meditation on older adults with chronic pain: qualitative narrative analysis of diary entries. The Journal

of Pain. 2008; 9(9):841-8.

19. Howell AJ, Digdon NL, Buro K. Mindfulness predicts sleep-related self-regulation and well-being. Personality

and Individual Differences. 2010; 48(4):419-24.

issn: 1755 -6783 internationally indexed journal 3.3.pdf · table 2 shows that 17 (34%) patients...

Documents