Chronic stress can interrupt personal life and cause fatigue, inability to concentrate, and irritability. This study aims to determine the prevalence of stress and its associated factors among medical students in Syria and whether social support could be a protective factor against stress.A cross-sectional study was conducted in the faculty of medicine of five Syrian universities. The Medical Student Stressor Questionnaire (MSSQ) was used to evaluate the stress caused by the possible sources of stress. And Social Support Questionnaire – short version (SSQ – short version) was used to assess the social support that medical students received from family, friends, and their fellow medical students using six questions.n = 745) and moderate  stress levels. Academic-related stressors were the most important cause of stress among undergraduate medical students. Social support was provided equally to both genders, and genders reported the same degree of satisfaction.A total of 1472 medical students participated in the study. Among the total participants, 671 (45.6%) were males, and 801 (54.4%) were females. The majority of the participators had mild (50.6%; Our results emphasize the importance of improving the curricula, providing mental health consultants for students, and paying more attention to the mental health of female students. Finally, students in their clinical years should also receive mental health care, decreasing their duties and providing more self-free time. Anxiety is the feeling of fear that occurs when faced with stressful situations. It is a normal response when confronted with danger, while fear is always associated with subsequent physical changes, like elevated blood pressure and increased heart rate , 2. ChroDifferent studies showed higher rates of stress among medical students when compared to the general population . MedicalSyria has an exceptional situation due to the ongoing civil war. Many studies have documented the harmful effects of the Syrian war on mental health , 9. DuriIt is evident that social support from family and colleagues could prevent and even improve stress symptoms . TherefoThe largest and most important public universities are Damascus, Aleppo, Tishreen, and Al Baath. Regarding the fifth university, only three private universities were eligible for the study based on our inclusion criteria; Syrian Private University, University of Kalamoon, and Al Andalus. A random selection was done to choose only one university (the Syrian Private University). Data were collected from March 1st to March 31st, 2022.We targeted students who were studying at previous universities. Male and female students in their second, third, fourth, or fifth year of college were included. No restriction to age was defined. Students in their 1st year were excluded as this year is a preparatory year, and it determined whether students are going to the medical college based on their academic performance. Students in this year experience different stress-related factors such as massive curricula, the choice they have to make regarding their future, and the surrounding environment. Contrary, students in the sixth year also experience different stress factors as this year is clinical, and students have additional responsibilities toward patients, which is not experienced with their peers in earlier years. Therefore, students in the first and sixth years were excluded; to make a baseline match with all students. Incomplete surveys were also excluded. The G*Power 3.1 software  was usedWe designed the demographic section to obtain the general characteristics of medical students, which included: gender, year of birth, educational level of parents, and whether one or both of them is a doctor. Financial status, source of income, experience in volunteer work , the current year in college, and grades of the last year were acquired. Financial status was assessed as follows, low: not sufficient to provide basic family needs; medium: sufficient to provide basic family needs; good: to provide basic needs with some luxuries; excellent: provides comfort and luxury. We also asked the participants whether they were living inside or outside Damascus.Yusoff et al. –15 constArabic version of the social support questionnaire—short version (SSQ6)  was usedThis cross-sectional study measured the perceived stress and social support as dependent variables. Data were collected using Microsoft excel 2016 and included demographic and dependent variables. Responses were processed using the Statistical Package for Social Sciences (SPSS) version 23. Descriptive analysis was conducted for variables, categorical variables were presented as frequency and percentages, and continuous variables were expressed as mean ± standard deviation. A cross-tabulation was performed to determine the differences between the types of Medical Student Stressors (MSS) and demographic variables. We performed a Chi-square T-test to study the association between the stress caused by academic, intrapersonal, and interpersonal, teaching and learning, drive and desire, group activities, and qualitative variables. We validated each subscale and Cronbach's Alpha coefficient for the subscales was calculated. Fisher’s exact test was used whenever any of the expected cells were less than five. The test was two-tailed, and values less than 0.05 were considered statistically significant.n = 271) were in their 2nd year, 23.8% (n = 351) in the 3rd year, 26.5% (n = 390) in the 4th, and 31.3% (n = 460) in the 5th year. 14.9% (n = 219) of the mothers’ students had an elementary educational level, 21.3% (n = 314) had a high school degree, 20.2% (n = 297) had institutional degree, and 43.6% (n = 642) had a university degree. Whereas 10.5% (n = 155) of the fathers’ students had an elementary educational level, 18.9% (n = 278) had a high school degree, 12.3% (n = 181) had an institutional degree, and 58.3% (n = 858) had a university degree (Table n = 745) and moderate  stress levels.The non-response rate of this study was 7.3%. A total of 1472 (92.7%) medical students participated in the study, of which 671 (45.6%) were males, and 801 (54.4%) were females. Regarding year of study, 18.4% of students (n = 745). In addition, the overall prevalence of moderate stress was reported in more than one-third of the participants . Low and severe levels of stress were reported in a minority of participants, 8.8% and 3.6%, respectively . Severe levels of stress were reported in 17.4% (n = 139) of females and 11.3% (n = 76) of males, while moderate levels were reported in 53% (n = 424) of females and 50.4% (n = 338) of males. On the other hand, low and mild levels of ARS were predominant in males, 4.0% (n = 27) and 43.3% (n = 230), respectively. Students who lived in Damascus city had significantly moderate levels of stress compared to those who lived outside Damascus, 57.9% (n = 287) and 48.7% (n = 475). A significant relationship was found between last semester's grades and ARS. Severe levels of stress were reported in 18.1% (n = 38) of students with a grade of 70% or less, 16.8% (n = 89) of those with a grade of 70%-79%, 11.2% (n = 66) of those with grades of 80%-89%, and 14.9% (n = 13) of students who had a grade above 89%  compared to their peers in the other universities, 11.8% in Syrian private university; 9.5% in Tishreen; 9.1% in Aleppo; 7.3% in Al-Baath. Students who lived in Damascus city had significant severe and moderate levels of stress caused by IRS  compared to those who lived outside Damascus . A significant relationship was found between IISs and study year (p < 0.5). Severe levels of stress were noted between 14.2% (n = 50) of the third-year students and 11.0% (n = 34) of the fourth-year students  experienced a significant severe degree of stress compared to their peers in the other universities, 9.5% in Syrian private university; 8.1% in Al-Baath; 7.2% in Damascus; 7.0% in Aleppo. However, students in Damascus University reported higher rates of moderate stress  compared to their peers in other universities, 34.1% in Syrian Private University; 31.7% in Al-Baath; 26.1% in Aleppo; 21.0% in Tishreen  and moderate TLRS (35.7% vs. 26.7%) compared to their peers outside Damascus  of females and 1.8% (n = 12) of males, while mild levels were reported in 51.8% (n = 415) of females and in 45.5% (n = 305) of males. Students in Tishreen university had significant levels of severe stress  compared to their peers in the other universities, while students of Aleppo University had the lowest prevalence of severe stress (1.0%). Living outside Damascus had a greater impact on SRS; students who lived outside Damascus city had significant levels of low, mild, and severe stress, 26.8% (n = 262), 49.0% (n = 478), and 2.7%(n = 26), respectively. On the other hand, living in Damascus was associated with moderate levels of stress .Severe levels of stress were reported in 2.7% , while those who had grades between 70%-79% and 80%-89% reported lower levels of severe stress, 6.3% and 3.2%, respectively. Students who had volunteer experience had a lower prevalence of moderate (16%) and severe (3.1%) stress compared to those who did not, 18.0% and 6.9%, respectively  and severe (5.4%) stress compared to those who did not, 41.2% and 8.7%, respectively  in stress levels between students in public (2.84 ± 0.59) and private (2.73 ± 0.57) universities. Kumar et al. [Our results showed that 87.6% of Syrian medical students had mild to moderate levels of stress and academic-related stressors were the leading cause of stress among Syrian medical students. A major contributor to this finding is the demanding curricula of medical schools that require students to spend lots of time studying and put them in competition with each other; as a result, students feel overwhelmed and stressed. Eva et al.  and manyp < 0.001) [Positive social support from family and colleagues is believed to be a crucial aspect of psychological adjustment that could help buffer the pathogenic effects of stress , 31. Kje< 0.001) . Therefo< 0.001) , 39, 40.Our study has its strengths and limitations. This study is the first to identify stress factors among Syrian medical students. It included students from the major universities in the country with specific criteria in an attempt to make the results more generalizable and accurate. In addition, our study was not limited to a specific stressor; instead, we assessed the six possible causes of stress to come out with transparent results and recommendations. However, some reporting bias may exist as the results were based on the information reported by the students themselves. Another limitation is that we possibly created some report bias when we informed the students about the study aims and how it was designed to measure the stress levels among them. In addition, further studies need to be conducted to compare the stress among medical students and doctors in their residencies. In conclusion, our study found that mild stress is the most frequent among medical students (50.6%), that the most common cause of stress was academic-related stressors and that females were most affected by these factors. This emphasizes the importance of improving the curricula and providing mental health consultants for students. In addition, the female predominance of academic, social, and group-related stressors makes us pay more attention to the mental health of female students. Finally, students in their clinical years should also receive mental health care, decreasing their duties and providing more self-free time.


Peribacillus frigoritolerans S2313 by 16S rDNA sequence analysis. The capacity of the strain to degrade PBAT film was optimized by adjusting the cultivation conditions such as nitrogen source, pH, and inoculum volume. After 8 weeks of cultivation, the actual degradation rate of the strain to PBAT mulch film reached 12.45%. SEM (scanning electron microscopy) coupled with EDX (energy dispersive spectroscopy) analysis showed that microbial degradation is an oxidation process and is mainly due to the amorphous regions of the PBAT film. The biodegradation of PBAT film by Peribacillus frigoritolerans may provide a promising method for regulating the degradation progress of PBAT film in the farmlands.In recent years, PBAT  mulch has become one of the most commonly used biodegradable mulching films. In this paper, five potential strains of PBAT film degrading bacteria were screened from the soil sample using PBAT film as the sole carbon source. A highly efficient PBAT degrading strain JZ1 was isolated by comparing the degradation performance of PBAT mulching film identified as  In 2017, the amount of plastic film used in China exceeded 1.5 million tons and the area covered exceeded 20 million hmion tons , accountion tons ,5.In recent years, the biodegradable mulching films including PLA (polylactic acid), PCL (polycaprolactone), PBS (polybutylene succinate), PBAT, and their mixtures have been widely used in farmlands in an attempt to combat plastic film contamination . PBAT muIn this paper, a highly efficient PBAT degrading bacterium was determined by comparing five potential bacteria by the weight loss method and identified by the 16S rDNA method. The degradation conditions were optimized by adjusting the cultivation conditions such as the content of nitrogen source, the pH value, and the inoculum amount. Then, the PBAT degradation potential was assessed under the optimal degradation condition in 8 weeks. Finally, SEM-EDS analysis was applied to characterize the degraded PBAT film by this strain. The type of film sample used in this test is PBAT biodegradable film, provided by Xinjiang Lan Shan Tun He New Materials Co., Ltd. . The strain was isolated from the soil of an agricultural cotton field in Shihezi City, which had been polluted by the plastic film for a long time.The required instruments include a vertical pressure steam sterilizer , thermostatic oscillator , air drying oven , biochemical incubator , ultrasonic cleaner , PCR instrument (SimpliAmp), microplate reader (Epoch), electrophoresis instrument (Powerpac Basic), and a gel imager (BioradGel Imager).2PO4 1.0, Na2HPO4 1.5, NH4Cl 2.0, CaCl2 · 2H2O 0.1, KCl 0.2, MgSO4 · 7H2O 0.2, pH 7.2–7.4.Inorganic salt medium (g/L): KHScreening medium (g/L): inorganic salt medium + PBAT pieces (1 cm×1 cm) 1.0.LB medium (g/L): peptone 10, yeast powder 5, NaCl 10, pH 7.0.Solid medium (g/L): LB medium 18, agar 20.The soil sample was collected from an agricultural cotton field in Shihezi city, Xinjiang region, China by using a narrow stainless shovel. Approximately 5 kg of soil specimens were collected from a depth of 15 cm in different locations and thoroughly mixed. The mixed soil sample was promptly brought to the laboratory, passed through a 60-mesh sieve, placed in a vacuum tube, and stored at 4 °C.Film pretreatment: firstly, the biodegradable mulching film was cut into square sizes of 1 cm × 1 cm and 5 cm × 5 cm (weight 20.2 ± 0.2 mg), and soaked in 75% ethanol for 0.5 h before rinsing with deionized water 3 times. Then, the pieces were put in the digital display ultrasonic cleaner for 5 min before drying them in the air-drying oven for 24 h at 60 °C. In the end, the pieces were put under the ultraviolet sterilization lamp for 15 min for sterilization [1.0 g of a soil sample was added to 99.0 mL of inorganic salt medium with 0.1 g of pretreated PBAT film (1 cm × 1 cm), and shaken at 28 °C, 130 rpm for 7 days. The supernatant was taken from the soil suspension in the previous step and inoculated to LB solid medium by using the dilution coating method, and incubated in the biochemical incubator for 48 h at 30 °C. Then, well-separated single colonies with different colors and shapes observed on the plates were picked, and further purified by repeat streaking ,26. FinaV—degradation rate of the mulch film (%);Inorganic salt medium with 1% tryptone was prepared and 3 pieces of pretreated biodegradable mulching film (5 cm × 5 cm) were added into each medium. The purified strains were inoculated into the culture medium one by one with glass rods, sealed with gauze and transferred into the thermostatic oscillator, and cultivated at 28 °C, 130 rpm for 7 days. The biodegradable mulch film was taken out after the degradation process and cleaned with the same pretreatment method mentioned above before measurement. The quality of the mulch film was accurately measured by using an electronic balance after drying. The degradation rate of the mulch film was calculated as follows (See Formula 1).V0—weight of biodegradable mulching film (mg);V1—weight of biodegradable mulch film after 7 days of degradation (mg).600  of the inoculum was adjusted to 1.0.The strain with the highest degradation rate was finally selected for further study by comparing the degradation rates of the strains. Preparation of inoculum: the selected strain was inoculated into 100 mL of LB medium and cultured for 12 h on a shaker at 28 °C and 130 rpm. The OD2+) 2.5 μL, dNTP (2.5 mM) 1.0 μL, Taq Plus DNA Polymerase (5 U/Μl) 0.2 μL, 27 F/1492 R (10 μM) 0.5μL, ddH2O 25.0 μL. PCR reaction temperature was 95 °C for 5 min; 94 °C for 30 s, 57 °C for 30 s, 72 °C for 5 min; 72 °C for 10 min, 30 times. The amplified products were sequenced by Biotech (Shanghai) Co., Ltd., and the sequencing results were sent to the ribosome database for homology comparison. A phylogenetic tree was established by combining MEGA6 software with the adjacency method [The 16S rRNA sequence of strain JZ1 was sequenced. Common primers 27 FAGTTTGATCMTGGCTCAG and 1492 RGGTTACCTTACTACTACTACTAT were used to amplify the 16S rRNA gene. The PCR reaction system is: template (DNA 20–50 ng/μL) 0.5 μL, 10 × Buffer  of tryptone as a nitrogen source were added to the basic salt medium, respectively. Then, the pretreated biodegradable mulch film was added and inoculated with strain JZ1. PBAT film was taken out after 7 days of shaking at 28 °C, 130 rpm. The degradation rate was calculated after cleaning and drying by the above methods. After determining the optimal amount of tryptone, the pH value of the culture medium was adjusted to 4, 5, 6, 7, 8, and 9, respectively, and the optimal pH value was determined by calculating the degradation rate of the PBAT film after 7 days cultivation. Then, the optimal inoculum amount of the strain was determined by changing the inoculation amount in the culture medium  with the optical tryptone content and pH. Finally, the degradation experiment of PBAT film was carried out over a period of 8 weeks to analyze the degradation capacity of strain JZ1 on biodegradable mulching film under optimal conditions. The PBAT film was soaked in 75% ethanol for 0.5 h, rinsed with deionized water 3 times, and put in the air-drying oven for 24 h at 60 °C before SEM-EDX analysis. A scanning electron microscope  was used for analyzing the morphological changes on the surface of the PBAT film samples. Then, an energy-dispersive X-ray spectrometer  was applied to confirm the changes in the elemental composition and content of the film samples.Stainless steel or glass materials were used in the sampling, processing, and analysis. All dishes, flasks and beakers used in the experiment were washed three times with deionized water. PBAT films were stored in closed spaces to prevent contamination from airborne contaminants. All PBAT film pieces were soaked in 75% ethanol, and washed 3 times with deionized water before and after the degradation tests. All experiments were performed in triplicate. t-test statistical method was applied to determine whether there were significant differences among different groups. The significance level for the analysis was set at p < 0.05. Data analysis was performed using Microsoft Office 2016  and OriginPro 9.1 . The p < 0.05). Therefore, strain JZ1 was identified as the dominant degradation strain and selected for further study.PCR amplification was carried out with universal primers of bacteria, and the amplified products were sequenced by using the genomic DNA of strain JZ1 as the template. The obtained 16S rRNA gene sequence length was 1201 bp after splicing. The 16S rDNA sequence of strain JZ1 was registered in the ribosomal database (NR117474.1), and Blast similarity analysis was carried out with the sequence in the NCBI database. It was found that the nucleotide sequence homology of strain JZ1 and Peribacillus frigoritolerans strain LPB69 was 99.4%. The phylogenetic tree was constructed by selecting 10 16Sr RNA gene sequences with high similarity and using MEGA6.0 software and the neighbor-joining method, as shown in As shown in p > 0.05) with further increases in tryptone content (2.0% and 2.5%). This trend is basically consistent with the growth trend of strain JZ1 under the conditions of different tryptone content (see p < 0.05) when the tryptone content increased from 0% to 1.5%. The biomass increases were not significant with the further increases in the tryptone content to 2.0% and 2.5%, indicating that the degradation process of biodegradable mulch film by strain JZ1 is a growth-associated process.tent see B. The bip < 0.05). This changing of the trend of the film degradation rate is consistent with the OD600 changes in different pH values  and kept at this level until the inoculation amount increased to 1.5 mL before slightly decreasing to 1.92 and 1.87 (p > 0.05) when the inoculum amount further increased to 2.0 mL and 2.5 mL. Therefore, the inoculum amount of 1.0 mL was chosen in this study.As shown in Brevibacterium frigoritolerans in 1953 [Peribacillus frigoritolerans later [Peribacillus frigoritolerans. Most plastic-degrading bacteria can degrade plastics by secreting degrading enzymes such as urease, laccase, peroxidase, and lipase. The enzyme genes can use oxygen molecules to introduce unstable oxygen-containing functional groups into the stable chemical structure of plastics [Brevibacterium frigoritolerans GD44 from the radioactive soil in the Xinjiang region and identified the genes encoding enzymes related to the degradation of organophosphorus compounds such as esterase, phosphotransferase, C-P lyase, and alkaline phosphatase by sequence analysis [The PBAT-degrading bacterium we isolated from the soil sample in our research was first defined as  in 1953  and reclns later . This bans later ,32,33,34ns later  in the lplastics ,37. The plastics ,39. Jin analysis , which iSphingopyxis ginsengiso) from the soil samples of Shule County in Xinjiang. The degradation rate of PBAT was 0.92% after 60 days of degradation [Delftia tsuruhatensis) from a cotton field soil sample and the degradation rate reached 6.87% at 37 °C in 7 days [Paraphoma Chrysanthemicola B47-9 had a 99.2% of PBAT film degradation rate in 7 days [Cryptococcus sp. MTCC 5455 achieved complete PBAT film degradation at 25 °C within 9 days [In our research, the degradation rate by this bacterium on PBAT film at an ambient temperature reached 4.30% in 7 days in neutral conditions and increased to 12.45% after 8 weeks of cultivation. So far, a few microorganisms have been reported to be capable of degrading PBAT or PBAT mixed materials. For instance, Kasuya et al. found that the degradation rates of PBAT film by bacteria NKCM2511 and NKCM2512 isolated from soil were 1.4% and 1.2%, respectively . Muroi eradation . Liu Jiaradation . The hign 7 days . Hao Jian 7 days . In compn 7 days , while tn 9 days . To sum Peribacillus frigoritolerans S2313. SEM images showed that the PBAT film surface was damaged and irregular cracks and defects appeared on the surface. EDX analysis showed that the content of oxygen elements significantly increased after 8 weeks biodegradation. The increase in oxygen atom content led to the decrease in hydrophobicity and the increase in roughness and fracture on the PBAT surface [In order to further study the degradation characteristics of the PBAT film, we used SEM-EDS to analyze morphological and elemental changes before and after 8 weeks of degradation by  surface ,45. The induction period of PBAT mulch film is very important for the growth of crops and vegetables, and the necessary longevity depends on the growing crop types. If the induction period is too short, the mulch film breaks too early and its moisture and temperature-keeping functions vanish when the plant growth still needs them. If the induction period is too long, the mulch film degrades too slowly and the film residues will affect plantation and soil function . An induPeribacillus frigoritolerans S2313 isolated from a cotton field could effectively degrade PBAT film. Under optimized conditions of nitrogen source, pH, and inoculum amount, the degradation rate by this strain on PBAT film reached 12.45% in 8 weeks. The substantial increase in the PBAT film degradation in the eighth week indicated that the PBAT film entered its induction period, which is suitable for main crops like cotton and maize in Xinjiang’s arid areas. SEM-EDX analysis showed that microbial degradation is an oxidation process and is mainly due to the amorphous regions of the PBAT film. However, in field conditions, the degradation process of the mulch film is affected by many factors including temperature, radiation, moisture, soil and crop types, and film composition. Therefore, the isolated strain Peribacillus frigoritolerans S2313 should be demonstrated in larger-scale field experiments considering the above-mentioned environmental factors and used to mediate the PBAT film degradation process in the field.Our results demonstrated that the bacterial strain


BackgroundUpper gastrointestinal bleeding (UGIB) represents a substantial clinical and economic burden and rebleeding is one of the most important predictors of morbidity and mortality. Identifying patients who are likely to rebleed is a critical component of effectively managing patients with bleeding peptic ulcers. So, the study was undertaken to look for predictors of rebleeding in patients with bleeding peptic ulcers and try to find out the new scoring system to predict rebleeding in our population.Material and methodsA retrospective analysis of prospectively maintained hospital data of UGIB patients was done and 480 patients of endoscopically documented peptic ulcers whose complete data was available were taken for study.ResultsAmong the studied patients, men constituted 84.6%, and most of the patients were in the third to sixth decade of life with a mean age of 40.9±15.9 years, 76% were from rural areas. Only males with a mean age of 38.4±19.8 rebled with a rebleeding rate of 2.9% only. Half of the patients who rebled were in shock at the time of presentation. Those who rebled received more units of blood transfusion (mean 3±1.8), had a large mean ulcer size of Forest class IIa and IIb and epinephrine injection monotherapy group with varied statistical significance. Among rebleeders (n=14), eight patients were managed by a second endoscopic therapy, and six (42.8%) rebleeders and 1.25% of patients in total needed surgery. Two patients ultimately died giving overall mortality of 0.4% and mortality of 14.3% among rebleeders.ConclusionOur study found a very low rebleeding rate and mortality which could be explained by a young population with fewer co-morbidities and better response to proton pump inhibitor therapy. The significant parameters related to rebleeding were shock at presentation, degree of smoking, units of blood transfused, ulcer size, and high-risk endoscopic stigmata. Upper gastrointestinal bleeding (UGIB) represents a substantial clinical and economic burden . BleedinVarious scoring tools have been devised to identify patients with non-variceal bleeding at the greatest risk for mortality and rebleeding. These tools could be used to triage patients to a higher level of hospital care or more urgent endoscopy. They can be divided into those that use purely clinical parameters available on patient’s presentation to the hospital and those that incorporate clinical parameters and endoscopic findings. The Blatchford  and pre-Furthermore, studies have shown that parietal cell mass is much lower in Indian patients than those in western countries . Also, tA retrospective analysis of prospectively maintained hospital data of UGIB bleeders was done and 480 patients of endoscopically proven peptic ulcers whose complete data was available were taken for analysis. The study was approved by the institutional ethics committee (IEC number 246).The patient population management protocolAll patients admitted to this hospital with UGIB manifested in the form of hematemesis and/or malena or both are managed as per the departmental protocol. After receiving the patient in the emergency department and checking vital parameters; the patient is resuscitated, and complete history and clinical examination are recorded. Those patients suspected to have UGIB because of peptic ulcer are given pantoprazole 80 mg intravenous stat followed by 8mg per hour continuous infusion which is subsequently stopped or continued as per endoscopic findings. After discussing the endoscopic therapy with the patients and/or their relatives, written informed consent is obtained. All patients undergo endoscopy within 12 hours (max. of 24 hrs) of presentation and preferably immediately after resuscitation in patients with massive bleeding or shock. Endoscopic hemostasis is achieved using epinephrine injection or epinephrine injection in combination with heat probe coagulation or hemoclip application at the discretion of the endoscopist. Epinephrine  is injected in aliquots of 0.5-1.0 mL into and around the bleeding area. Heat probe thermocoagulation is given to ulcers using the Olympus heat probe unit. The energy output of the heat probe is set at 25 Joule and co-aptive pulses (minimum of three) are applied until cavitation and adequate coagulation are obtained. In the case of an adherent clot, removal of the clot is tried either by vigorous flushing or snaring at the discretion of the endoscopist. Endoscopic therapy is given either after clot removal or with an intact clot. At the time of endoscopy, the size of the ulcer is estimated by placing biopsy forceps alongside the ulcer, the fully opened cup of forceps is approximately 5mm in diameter. Patients with low-risk stigmata ulcers in the form of clean-based ulcers or flat pigmented spots are discharged from the hospital and are asked to report back in case of fresh hematemesis, malena, or cold sweats associated with postural symptoms. Those with high-risk stigmata are observed in a high-care facility of the gastroenterology ward and they continue pantoprazole 8mg per hour infusion for 72 hours. Patients’ vital signs are checked every hour during the first 12 hours, every two hours for the next 12 hours, and four hours thereafter until they were discharged. The hemoglobin level and hematocrit are checked at least once daily, and a blood transfusion is given if the hemoglobin levels drop to 7g/dL or less or any time when vital signs deteriorate.During the whole period, patients are closely observed for rebleeding which is defined by fresh hematemesis, malena, or both with either shock ; or a fall in hemoglobin of 2 g/dL or more over 24 hours after initial stabilization of vital signs. Patients meeting these criteria undergo emergency endoscopy within four hours to confirm the rebleeding diagnosis. Rebleeding was managed with repeat endoscopic therapy as before.Those confirmed to have bleeding from the stomach or duodenal ulcer by having active bleeding  or stigmata of recent hemorrhage (non-bleeding visible vessel or adherent clot) or ulcer with flat pigmented spot and clean-based ulcer without another obvious source of bleed constituted the study group. Patients with severe coagulopathy  and platelet count < 50,000/cmm and patients bleeding from a suspected malignant ulcer, and terminally sick patients were excluded from this study.Indication for surgery1. Failure of endoscopic re-treatment, i.e., those patients who continued to bleed despite second endoscopic therapy.2. Those who rebled after the second endoscopic therapy.Follow-up protocolAfter three days, all patients received pantoprazole 40mg orally once daily for six weeks; those positive for Helicobacter pylori (H. pylori) are treated with triple therapy. Patients undergo repeat endoscopy if clinically indicated for duodenal ulcer. For stomach ulcers, repeat endoscopy is done approximately after eight weeks to look for healing of the ulcer and or biopsy if clinically indicated.Statistical methodsData were analyzed using the statistical package for social sciences (SPSS) version 19  using standard analytical and statistical methodology accepted for observational studies. Number and percentage were calculated for categorical data. Pearson’s Chi-square test and Fisher’s exact test were applied to examine the difference between proportions. For continuous quantitative data, values were expressed as mean ± standard deviation. Data were checked for normal distribution with the Kolmogorov-Smirnov test. For normally distributed data, an unpaired t-test was applied; for skewed data, the Mann-Whitney U test was used to compare the difference between means. Two-tailed tests were performed and a P-value of less than 0.05 was considered significant. Multivariate analysis was done using logistic regression analysis.This study was conducted on 480 consecutive patients. Men constituted 84.6% of studied patients. Most of the patient population were in the third to sixth decade of life; 114 (23.7%), 95 (19.8%), 84 (17.5%), and 69 (14.3%), respectively, were in the third, fifth, sixth, and fourth decade of life in decreasing order of frequency. Most of the studied subjects were from rural areas. Out of the total 480 patients, 361 (75%) were from rural areas and only 119 (25%) were from urban areas as shown in Table Only 14 out of 480 patients rebled giving a rebleeding rate of 2.9%. The mean age was 38.4±19.8 years and 40.9±15.8 years in rebleeding and non-rebleeding groups respectively which was not statistically significant. All the rebleeders were males. Overall, 19.8% of patients were smokers and only eight (1.7%), 50 (10.4%), 14 (2.9%), and one (0.2%) of patients were taking alcohol, non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet and anticoagulants, respectively, with none significantly associated with rebleeding. The studied population had a fewer number of co-morbidities with mean of 2±0 and 1.6±0.8 co-morbidities in the rebleed and non-rebleed groups, respectively. Co-morbidities seen in our patients were hypertension (8.3%), diabetes mellitus (DM) (3.3%), chronic kidney disease (CKD) (1%), stroke (6%); malignancy (0.62%), and chronic obstructive pulmonary disease (0.8%) as shown in Table The main clinical presentation of our patients was malena (71%), hematemesis + malena (17%), and hematemesis 11.3%). Seven out of 14 (50%) patients who rebled were in shock at the time of presentation in comparison to only 76 out of 466 patients (16.3%) in the non-rebleed group. Mean hemoglobin (Hb.), hematocrit, and creatinine at presentation were 9.2±2.4 g/dL, 28.5±7.1, and 1.6±0.33 mg/dL, respectively, which were not significantly associated with rebleeding as shown in Table %. Seven The mean ulcer size was higher (1.57±0.36 cm) in the rebleed group. In the rebleed group ulcer size was 1-2 cm compared to <1cm in the non-rebleed group. The majority 74%) had duodenal ulcers. Most of the patients were in Forest class III (39.8%) as shown in Table % had duoEndoscopic procedures were done in 267 out of 480 patients 54.8%); 146/267 (54.7%) received epinephrine whereas 121/267 (45.3%) received epinephrine + mechanical/thermal therapy. As expected, the mean hospital stay was more in the rebleed group as compared to the non-rebleed group (4.86±2.68 days vs. 2.14±0.93 days) as shown in Table 4.8%; 146A total of 480 consecutive patients of acute UGIB of ulcer etiology were studied. 406/480 (85%) of the patients in this study were men, making men the majority of the study group. Our patients were younger compared to contemporary studies and majority were in the third to sixth decade of life with a mean age of 40.9±15.9 years. This is in comparison to other studies by Villanueva et al. , DanielaAlthough only 95 (19.8%) of patients were smokers, equally distributed between two groups (rebleed and non-rebleed group); the mean number of cigarettes smoked per day was significantly more in the rebleed group (16.7±11.5 vs. 8.3±2.9). We could not find any study for comparison. Alcohol consumption and intake of non-steroidal anti-inflammatory drugs, antiplatelets and anticoagulants were not associated with rebleeding risk which is consistent with studies by Wong et al.  and TravOur patient population being young had less frequency of various co-morbidities with a mean number of 1.7±0.8 co-morbidities. Major co-morbidities were hypertension, coronary artery disease (CAD), DM, and CKD. Various studies have found a significant association between cirrhosis, CKD, malignancy, and congestive cardiac failure (CCF) with risk of rebleeding and mortality ,9,15,16;The main clinical presentation was malena in 341/480 (71%), hematemesis in 54 (11.3%) and hematemesis + malena in 85 (17.7%) patients which corresponds to the study done by Guglielmi et al.  who founAlthough more patients in the rebleeding group in our study had hematemesis 7/14) than in the study by Guglielmi et al. , where h than in Mean hemoglobin levels of 9.2±2.4 g/dL and 8±2.2 g/dL in the non-rebleed and rebleed groups, respectively; had no significant correlation with rebleeding in our study. Travis et al.  found a  Regarding endoscopic findings, high mean ulcer size was significantly associated with rebleed; with a mean ulcer size of 1.57± 0.36 cm vs. 1.2±0.28 in the rebleed and non-rebleed group respectively corresponding to other studies ,15. CompOne of the important predictors of rebleeding is the endoscopic stigmata of ulcers given by the Forest class. We had more number of patients in Forest class III 39.8%) followed by Ib (32%) and IIa 15.6%) which is higher as compared to 29%, 36.4%, and 25% ,11,15 fo.6% which% followeSeven percent of patients in class IIc comparable to 9.7%; 10.5% in class IIb which is lower than 17%; 6.6% in class IIa, lower than 19.5%; 1.9% in class Ib, lower as compared to 19% and 11% in class Ia, lower than 23% in our study and study by Guglielmi et al. , respectEndoscopic therapy was given in 267 (55.7%) patients; epinephrine-only therapy in 146(54.7%) and epinephrine+ mechanical/thermal in 121 (45.3%) as per the endoscopist’s discretion. Although more of the patients in epinephrine-only therapy rebled compared to epinephrine + mechanical (nine [69%] vs. four [31%]), it was not statistically significant.Although we did not randomize endoscopic therapy in our patients; meta-analysis of various studies has shown that monotherapy with epinephrine injection is more effective than medical therapy in patients with high-risk stigmata, but it is inferior to other monotherapies or combination therapy that uses two or more methods .Patients with high-risk stigmata after endoscopic therapy were observed for 72 hours and were continued on high-dose proton pump inhibitor therapy. Fourteen out of 480 patients rebled as per definition; 13 among the high-risk stigmata group and one from the low-risk group (IIC) giving an overall rebleeding rate of only 2.9% compared to 8%, 21%, 7.7%, 10.8%, 13%, and 17%, in other studies ,12,15,18All rebleeders were taken for a second look at endoscopy and endoscopic therapy. Eight patients were managed by second endoscopic therapy whereas six  patients continued to bleed or rebled after second endoscopic therapy and needed surgery. Two patients died subsequently among bleeders managed by second endoscopic therapy giving overall mortality of 0.4% (2/480) and a mortality of 14.3% (2/14) for rebleeders which is lower than the overall mortality rate of 10%, 5.3%, 3.1% and 8.09% in studies done by Guglielmi et al. , Joseph For multivariate analysis, we put parameters which showed a p-value of less than 0.05 in univariate analysis like the presence of shock, degree of smoking, units of blood transfused, ulcer size and high-risk endoscopic stigmata. However, none of the parameters showed significance possibly because of the overall low rebleeding rate. At this point, we could not develop a new model for predicting rebleed due to our study's smaller number of rebleeders. Applying the Rockall score to our patients showed that the Rockall score of ≥5 has 84% specificity, 57% sensitivity and 98.5% negative predictive value for rebleeding.This hospital-based retrospective study found a very low rebleeding rate and mortality compared to the literature. The low rebleeding rate in our study could be explained by the young population, with fewer co-morbidities and a better response to proton pump inhibitors. The significant parameters related to rebleeding included shock at presentation, degree of smoking, units of blood transfused, ulcer size, and high-risk endoscopic stigmata.


Introduction: The prevalence of myocardial infarction (MI) among young Indian adults is on the rise with reports suggesting 32.7% of all deaths in men and 32.6% of all deaths in women between 2010-13 were due to cardiovascular diseases (CVDs). Though various long-term cohort studies have established risk assessment scores none of them are specific to the Indian population. In this study, we look to establish which scoring system among the American College of Cardiology (ACC), Joint British Society (JBS3) and Framingham Risk Scores (FRS) would be reliable for the Indian population. A timely intervention based on the most reliable score can help mitigate cardiovascular diseases.Materials and methods: In this cross-sectional study, we included Indian adults, aged more than 40 years, with first MI. Patients previously on lipid lowering drugs were excluded. Demographic data, history, clinical information, laboratory data and other investigations were noted. Subsequently the predicted cardiovascular risk scores based on JBS3, ACC, and FRS were calculated and divided into low risk, intermediate and high risk based on the categorization of the risk scores individually.Results: There were 102 (79.1%) males and 23 (17.8%) females with a mean age of 51.01 years . There was considerable prevalence of type 2 diabetes mellitus with 56 (47.1%) of the subjects being known diabetics.The mean 10-year risk of MI based on ACC was 12.42% (SD=10.45), mean JBS3 score was 14.45% (SD=12.67) and mean FRS score was 15.75% (SD=14.71). FRS scores when categorized, 48 (40.3%) patients had low risk, 30 (23.3%) had medium risk and 43 (33.3%) had high risk. As for ACC score, 39 (35.8%) patients were in low risk and 29 (26.6%) in intermediate risk, borderline in 18 (16.5%) and high risk in 23 (21.1%). In JBS3 scores, 53 (46.5%) patients were in low risk, 32 (28.1%) were in moderate risk and 29 (25.4%) in high risk.Conclusion: The absolute value of 10-year risk scores was highest for FRS scores. The proportion of patients whose scores were under the category of high risk was highest for FRS. As a developing nation, India is facing an epidemiological transition in the pattern of diseases. The major burden of diseases have shifted from communicable to non-communicable diseases , with th has shown the precision in terms of estimating high cardiovascular risk of different assessment models to be 13.5% (FRS), 20.2% (JBS3), 55.9% (ACC), 38.3% . Based on the above findings of the study, to exhibit statistical significance, we included a minimum of 125 subjects for the study with 95% confidence, with 7% precision.This is a cross sectional study with a retrospective method of data collection. The subjects included in this study were Indian adults, aged above 40 years, with first MI admitted in a tertiary medical college hospital. The patients who were previously on medications that alter the blood lipid profile, such as statins, were excluded. A study carried out by Bansal et al.  has showData were collected after obtaining written informed consent. Demographic data, history of presentation and risk factors were noted. Vital parameters such as heart rate, blood pressure, and oxygen saturation (SpO2) were measured. Clinical examination findings, electrocardiogram findings and 2D echocardiography (ECHO) findings were noted too. Diagnosis of MI was defined based on the 4th Universal definition of MI ) as compared to 23 (17.8%) females. Type 2 diabetes mellitus was present in 56 (47.1%) cases. Nine subjects (7.6%) had a previous family history of MI. Seventy-five (58.1%) patients were active smokers while 38 (31.9%) patients admitted having smoked previously but have abstained from smoking now. Thirty-five (29.9%) patients were on antihypertensive medication. Other comorbidities seen were as follows: history of atrial fibrillation in 14 (10.9%) patients, chronic kidney disease (CKD) in three (2.6%) patients and five (4.3%) patients were known cases of rheumatoid arthritis. These variables are tabulated in Table The mean age of the subjects was 51.01 years SD=12.82 years). The variation in the ages was significant among the patients with a p value <0.001. The pulse rate on an average was 87 beats per minute (SD=18.74) with average BP of systolic 131 mmHg (SD=26.01) and diastolic 80 mmHg (SD=14.58) which surprisingly falls in the bracket of normal range despite hypertension being an established risk factor. The mean arterial pressure on average was 94 mmHg (SD=20.55) and respiratory rate was 19 cycles/minute (SD=2.65). These statistics however were significant when tested with a p value <0.001. The above-mentioned statistics are tabulated in Table .82 yearsMean values of lipid profiles were as follows: total cholesterol levels were 170.79 mg/dL (SD=52.49). Triglycerides were 169.50 mg/dL (SD=99.66). Mean HDL cholesterol was 37.65 (SD=10.26) while non-HDL cholesterol was 128.88 mg/dL (SD=54.15) and LDL cholesterol was 104.02 mg/dL (SD=48.58). Mean of total cholesterol to HDL ratio was 4.84 (SD=2.09). The components of the lipid profile among all the subjects were tested to be statistically significant . Mean values of random blood sugar (RBS) were 214 mg/dL (SD=76.39). This however when tested for statistical significance was found to be not significant . This data on lipid profiles are represented in Table Risk scores were calculated using standardized calculators officially published by the respective institutions. Patients’ average ACC score was 12.42% SD=10.45), mean JBS3 score was 14.45% SD=12.67), and mean FRS score was 15.75% (SD=14.71). The difference in the mean value of various risk scores was not statistically significant. FRS score was calculated in all 125 patients, 48 (40.3%) patients were in the low-risk category, 30 (23.3%) were in medium-risk and 43 (33.3%) were in the high-risk category. As for ACC score, 39 (35.8%) patients were in low-risk and 29 (26.6%) in intermediate-risk, borderline in 18 (16.5%) and high-risk in 23 (21.1%). In JBS3 scores, 53 (46.5%) patients were in low-risk, 32 (28.1%) were in moderate-risk and 29 (25.4%) in high-risk , the predictive accuracy of the contemporary risk models has not been adequately evaluated in Indians. The JBS3 score, which has been confirmed in ethnic Indians, is actually more prevalent among non-resident Indians. This study attempted to examine these several risk indicators in order to determine which of them has the best predictive value for identifying high-risk individuals. There were 149 patients without prior cardiac illnesses who presented with their first acute MI .The FRS, WHO risk prediction charts, ACC pooled cohort equations and JBS3 were used to estimate what would have been their predicted 10-year risk of cardiovascular events if these patients had presented just prior to suffering an acute MI. The results of the present study showed that the FRS cardiovascular risk assessment tool could identify the maximum number of patients as high risk for future cardiovascular events. The results are similar to a study done by Garg et al. . HoweverIn terms of limitations of the study, substantial evidence derived from such studies most often require a long-term cohort study with prospective data collection and follow up. However in our study we have tried our best to eliminate this factor. Demography and lifestyle before and after the acute cardiac event do not differ. Since parameters such as lipid profile do not change over a course of a few hours, the values before and after a cardiac event would be the same. Other variables such as vital parameters are expected to be deranged in a majority of the patients but the margin of error is comparable in all patients. Hence the bias gets nullified here and the level of precision is high. We have hence actively overcome the statistical bias except for the sample size and have arrived at a valuable conclusion regarding which risk score is more relevant for our contemporary Indian population. However, our study is not a population-based study and further studies with larger sample sizes are the need of the hour to be able to initiate primordial prevention of cardiovascular disease. Males with diabetes who have a history of smoking or are currently smoking and are on treatment for hypertension have the highest risk of developing MI. The absolute values of 10-year risk scores were the highest for FRS scores. The proportion of patients whose scores clearly indicated high risk was highest for FRS. Though these results when compared to ACC and JBS3 were not statistically significant, it is important to take these into absolute consideration. Further, the implication of this is that patients presenting to the OPD with cardiovascular symptoms or are known diabetics, hypertensives or patients with dyslipidemia can be assessed using FRS i.e implementation at ground level. Despite apparently normal clinico-laboratory parameters, in case of high-risk scores the patient can be initiated on appropriate means of primordial prevention of MI which may include lifestyle modifications with or without pharmacological agents.


Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in bipolar disorders(BD). The heart age of patients with BD was found to be 8.5 years higher than gender-age matched health controls. Metabolic side effects of antipsychotics, poor diet, insufficient physical activity, smoking and sedentary life style increase the risk of cardiovascular disease in bipolar patients. QRISK-3 is an approved risk classification that calculates the 10-year risk of developing a heart attack or stroke.This study aims to determine whether there is a difference between cardiovascular disease risk scores and clinical stages of bipolar disorder35 outpatients that were followed up in Selcuk University Medical Faculty were evaluated. The clinical stages and qrisk3 scores were calculated.68.6% (n:24) of the patients were female. 42.9% of patients were in stage 3b . The mean age was 36.94 ±10.46 years. The mean heart age was 50.54±17.35. The mean Q risk3 score was 5.59±8.18. There was no difference between bipolar patients at stage 2 and stage 3 in terms of age(p=0.36 and gender(p=0.73). When we compared the qrisk3 total socres and heart age of the patients in stage 2 and 3, we could not find any difference between groups .Even though we could not find any difference of qrisk scores at different clinical stages of patients with BD, the CVD risk increases with the age. Prospective longitudinal follow-up studies are required to evaluate dual interaction of clinical stages and CVD risk in BD.No significant relationships.


The role of medical personnel in promoting vaccination and pro-health attitudes seems to be of key importance for protection against COVID-19. The aim of the study was to assess the attitudes of health care workers and students of medical faculties towards preventive vaccinations against COVID-19. A cross-sectional online self-administered survey was conducted among 497 people. The questions concerned attitudes towards vaccination as well as concerns about the side effects of the vaccine and contracting COVID-19. A positive attitude to vaccination was observed in 82% of the respondents. More than 54% respondents were concerned about side effects after COVID-19 vaccination. Medical students under 26 years had a more positive attitude towards COVID-19 vaccination, twice as high as among health care workers OR (95%Cl): 2.20 (1.03–4.66) vs. 4.06 (2.54–6.48), respectively. Students were more concerned than nurses about adverse effects of COVID-19 vaccine 3.8 (3.2–4.1) vs. 3.0 (2.7–3.5) and contracting the virus (1.7 (1.2–2.5) vs. 1.2 (1.0–2.0). Medical students had a more positive attitude toward vaccination than nursing students 4.2 (3.9–4.3) vs. 3.7 (3.3–4.3). In conclusion, predictors of positive attitudes toward vaccination were medical student status and young age. COVID-19 is a new disease caused by the coronavirus first detected in Wuhan, China, called SARS-CoV-2 [So far (January 2022) infection with the coronavirus causing the COVID-19 disease has been confirmed in 12% of Poland’s inhabitants, which corresponds to about 4.55 mln cases with a confirmed positive test for the presence of the SARS-CoV-2 virus. Since the beginning of the pandemic in Poland to January 2022, the number of deaths due to COVID-19 is 103,844.At the beginning of 2021, new vaccines against COVID-19 began to appear successively. The first WHO-approved vaccine was COMIRANTY, manufactured by Pfizer and BioNtech. Currently (January 2022) the WHO has approved 10 COVID-19 vaccines . The avaHealthcare workers who carry out vaccinations, care for those infected with SARS-CoV-2 and educate patients in hospitals and clinics, have an impact on decisions regarding the implementation of mass vaccinations and the participation of citizens in preventive vaccinations. The behavior of Health Care Workers (HCWs) and medical students is a model for the rest of society. Constantly increasing awareness as well as building promotional potential among medical personnel who act as leaders and educators is crucial to the success of preventive pro-health actions ,9.Therefore, we decided to check the attitude of HCWs and medical students towards vaccination against COVID-19. It is important to determine what factors may influence the patient’s decision to participate or not participate in the mass vaccination program. In addition, the study researched the same subject among medical students who represent the future of the healthcare system, including its educational potential. Previous studies found that factors that may positively influence willingness to vaccinate against COVID-19: socioeconomic status, young age, female gender, perception of likely COVID-19 infection during a pandemic, and COVID-19 prosocial behaviors were facilitating factors .The aim of the study was to assess the attitudes of HCWs and medical students towards preventive vaccinations and to determine what factors influence decisions regarding vaccination. In addition, a comparative analysis of the level of knowledge between HCWs, medical students and the impact of the respondents’ age was assessed.The study used an original questionnaire, which was based on questions that were previously used in questionnaires assessing attitudes towards influenza vaccination ,12. To cDuring the questionnaire development and pilot testing phase, none of the respondents made any comments regarding the design of the questions or problems with understanding the survey. The next step was to use the questionnaire to study the target population—health care workers and students.The survey showed good psychometric properties. Cronbach’s alpha coefficient was 0.75 which means that the survey is a good research tool. Data were gathered in an anonymized fashion. The study received a positive opinion from Wroclaw Medical University’s Bioethics Committee No. 52/2021.A cross-sectional online self-administered survey was conducted among 497 people. Participation was voluntary. The participants provided informed consent on the survey platform before they could proceed to the questionnaire. The criterion for inclusion in the study was work in a medical center or medical student status. The exclusion criterion was lack of consent to participate in the study.n = 328);Medical students (n = 169).Health care workers  and the compliance of their distributions with a theoretical normal distribution was checked using the Shapiro–Wilk’s W test. Comparisons were Performed with the Mann–Whitney U test for independent groups, or Kruskal–Wallis tests. Each categorical variable is presented as numbers and percentages. Spearman’s rho was used to estimate the correlation between the two variables. When comparing the attitudes of respondents towards vaccination, contingency tables and Chi-square tests of independence were used. The fractions in two groups were compared. It was assumed that the fraction differences will be significant when they amount to at least 20%. Assuming Type I error alpha = 0.05 and 1-beta test power = 0.80, the minimum size in each group should be N1 = N2 = 76.The statistical analysis was performed using STATISTICA v. 13.3 . The response rate was 71% because 700 people were invited to participate in the study and 497 of them successfully completed (entirely) and returned the questionnaire. In the whole study group, the median (Q1–Q3) age was 24 (21–28), with the youngest participant being 18 and the oldest 64. The characteristics of the study group were as follows: every third respondent (35.0%) was a medicine student. The second largest group were people who had either completed or were in the course of nursing studies (22.3%). Less numerous groups were students of dentistry (17.7%) and pharmacy (12%). The remaining 12.9% were people declaring graduation or participation in the following courses: obstetrics and public health, dietetics, medical analysis. Among the employed, the largest number was nurses (21.5%), midwives (3.8%) with the least number of doctors (2.6%) and paramedics (0.4%). The results are presented in The results of the responses to individual questions showed that the respondents had a more positive attitude to vaccination against COVID-19 4.1 (3.6–4.3) than to vaccination in general 3.4 (2.9–3.9). On the other hand, they were also more concerned about vaccination adverse effects 3.6 (3.0–4.0). than they were about developing COVID-19 1.5 (1.0–2.3). . The conThe attitude towards vaccination was generally dominated by worries about vaccination among patients with allergies and the chronically ill, followed by concerns about the rapid introduction of vaccines for the benefit of pharmaceutical companies. In terms of COVID-19 specifically, the respondents supported the validity of mass vaccinations 3 (2–3) and their health benefits 5 (4–5), though some respondents believed that the risk of falling ill is so low that vaccination on such a scale is not necessary 3 (2–4) .p < 0.001). Midwives had a less positive attitude towards vaccination against COVID-19 (domain 2) than students 3.4 (3.0–3.8) vs. 4.1 (3.8–4.3); p < 0.001). Moreover, nurses had a less positive attitude towards vaccination against COVID-19 than students 3.7 (3.3–4.3) vs. 4.1 (3.8–4.3); p < 0.001). Students were more concerned about the adverse effects of the COVID-19 vaccine than nurses 3.8 (3.2–4.1) vs. 3.0 (2.7–3.5); p < 0.001 and contracting the virus 1.7 (1.2–2.5) vs. 1.2 (1.0–2.0); p = 0.023. Nursing students had a significantly less positive attitude towards vaccination (domain 1) than those studying pharmacy 3.1 (2.6–3.6) vs. 3.6 (2.9–4.0); p = 0.027 and medicine 3.1 (2.6–3.6) vs. 3.6 (3.3–4.0); p < 0.001. On the other hand, students at the faculty of medicine had a more positive attitude towards COVID-19 vaccination than those studying nursing 4.2 (3.9–4.3) vs. 3.7 (3.3–4.3); p < 0.001.A number of correlations were found between the results assessing attitudes towards vaccination against COVID-19 and the age, profession, gender, status and field of study of the respondents . No statp < 0.001. The situation was slightly different in domain 3 (concerns about the effects of the COVID-19 vaccine), as participants aged 18–24 were more afraid of the effects of the vaccination compared to the 55–64 age group 3.7 (3.2–4.0) vs. 3.1 (2.4–3.4) p < 0.001.In an age-related analysis, people aged 55–64 showed less willingness to be vaccinated against COVID-19 (domain 2) compared to the group aged 18–24, median (Q1–Q3) 3.8 (3.3–3.9) vs. 4.2 (3.7–4.4); n = 5) of people had a strong negative attitude towards vaccination in general (domain 1), with some being rather negative 17.7% (n = 72), neutral 37.1% (n = 183), and most people, as much as 47.2% (n = 237) rather positive. There were no people with an overwhelmingly positive attitude towards vaccination. In domain 2 (positive attitude towards vaccination against COVID-19), most people had a rather positive (67.1%) or strongly positive (14.9%) attitude towards vaccination against COVID-19, while approximately 14% of respondents could not take a position on this matter, and the remaining few people expressed a negative attitude: either strongly (0.8%) and rather negative (3.2%)  .n = 220), lack of concern—33.5% (n = 168), did not know or had no opinion—17, 1% of the respondents (n = 83). A total of 4.4% (n = 22) of the respondents had concerns of getting sick, and only 0.8% (n = 4) (In domain 3 (concerns about the adverse effects of the COVID-19 vaccine), the largest group was represented by people with concerns about the adverse effects of vaccination (50.2%), another 30.3% were people who did not have an opinion, only 1.2% of respondents showed a strong lack of concern. However, in domain 4, which represented the fear of falling ill with COVID-19, the distribution was as follows: strong lack of concern—44.2% ( (n = 4)  had stroThe selected variables were analyzed on the basis of the results of the general attitude to vaccination studies. The study took into account: age and professional status.Positive attitudes towards vaccination were considered to be average scores of 4 points or more (corresponding to „yes” and „definitely yes” answers) in the first, second and third domains. For domain 4 (fear of COVID-19), 3 points was adopted as the cut-off value. A statistically significant negative correlation was observed between the level of positive attitude to vaccinations  and the age of the respondents .The results of the ROC curve analysis  were useThe chance of a positive attitude towards vaccination in the first and second do-mains in the group of students of the medical faculty is more than twice as high as among health care workers .In conclusion, the study showed many significant relationships between positive attitudes towards vaccination and individual health professions and age under 26. In addition, a group of medical students had better attitudes toward vaccination than health care workers. There were no significant differences between the level of knowledge about vaccinations and gender.Reluctance by parts of the public to accept the COVID-19 vaccine varies from country to country. The most common reasons for resistance towards vaccination are concerns about side effects or fear of the vaccination’s long-term impact that could deteriorate one’s health. A large part of the public expresses a desire to vaccinate, but at a later date, wanting to wait for reactions among those relatives and friends who already underwent the procedure. As reported by Grochowska et al. in a study conducted on a group of 419 Polish doctors, nurses, medical students, and other allied health professionals, safety and efficacy of COVID-19 vaccinations would persuade 86.3% of hesitant and those who would refuse to be vaccinated, while only 3.1% of all respondents claimed that no argument would convince them to get vaccinated . In a stIn our own research, 82% of people asked had a positive attitude towards vaccination against COVID-19, while another study showed that 92.1% of doctors were willing to accept this vaccine, while among pharmacists only 64.7% showed such willingness . Addition = 376, 62.7%) were not willing to be vaccinated against COVID-19. The most cited reasons for not taking up the vaccine were concerns about safety  and having heard or read negative information about the vaccine . Of those that reported having heard negative information about the COVID-19 vaccine , the most frequently mentioned sources were social media , and friends . In our research, only 5.2% were afraid of the negative consequences of falling ill with COVID-19. Fear of vaccine side effects was similarly assessed, with only minor concerns identified. However, 32.14% of this research group indicated concern about the long-term effects of the COVID-19 vaccine. Students specifically were more concerned about the adverse effects of the COVID-19 vaccine compared to nurses, while remaining generally positive about the COVID-19 vaccine, with nursing students being the least positive and emergency medicine students the most positive. On the other hand, a study of 793 undergraduate nursing students from 12 Polish universities revealed that in the spring of 2021, 77.2% of study participants were already vaccinated against COVID-19 and approximately 50% of students in the unvaccinated group declared willingness to get a vaccination [In turn, in the work of Kanyike et al.  on a grocination . A studyfety n = 2, 64.4% Though compared to students in our study, doctors had a more positive attitude towards vaccination in general and vaccination against COVID-19, medical students were more willing to accept both vaccines in general and the COVID-19 vaccine than all the other HCWs in the study . A total of 98.41% of physicians declared that in their lives they had taken compulsory vaccinations against other diseases. Another study showed physicians were more willing to be vaccinated against COVID-19 (94.44% vs. 91.99%), less concerned with vaccine side effects, as well as less frequently believed in conspiracy theories (3.17% vs. 8.69%) compared to medical students . To compThe age of the participants and their attitude towards vaccination as well as the fear of possible side effects of the COVID-19 vaccine shows similar trends as the occupation analysis with younger study participants being more positive about vaccines, while at the same time displaying a considerably greater fear of vaccine side effects. In contrast to our findings, a study by Papagiannis et al. reports that older age of Greek healthcare workers was associated with the likelihood of COVID-19 vaccination acceptance , while aInterestingly, in our own study, it was shown that 47.2% of people had a positive attitude towards vaccination, while almost twice as many people declared a positive attitude towards vaccination against COVID-19. According to the study by Lazarus et al. , in the The conducted study showed numerous dependencies between the willingness to receive the COVID-19 vaccine and the profession, student status and age. Compared to the rest of the study participants, students had a significantly more positive attitude towards vaccination compared to the rest of the respondents, which confirms the important role of medical students not only in future patient care, but especially in present prevention and promotion of pro-health behaviors. Other factor showing positive attitudes toward vaccination was young age. There were no correlations between attitudes toward vaccination and gender of the subjects.n = 497). The number of people included in the study is lower than the originally assumed 700 people, but some participants withdrew from the study and some questionnaires were eliminated from the study due to either not signing the informed consent agreement or numerous missing answers to individual questions. Another limitation is the different numerical values of participants between students and healthcare professionals. People taking part in the study worked in different health institutions or studied at different universities, however, the study was conducted only in one region. The study used an original questionnaire due to the lack of standardized research tools assessing attitudes towards vaccination against COVID-19.The study is limited by the relatively small group of respondents (We can suggest that COVID-19 vaccination campaigns should attend to raising awareness and the role of medical students and focus on promotion the vaccination against COVID-19. Minimizing the fear of vaccine side effects should be a part of this promotion. Another important stage of a potential social campaign is targeting and adjusting awareness activities to those areas of ignorance or fear that constitute the biggest problem in a given social group, preventing the implementation of mass vaccinations against COVID-19. Sharing information about vaccination through local health care professionals or medical students, can help support the mass COVID-19 immunization process.


Sputum differentia! is the most comprehensive, and non-invasive investigation for evaluating airway inflammation because of its reliability, reproducibility and responsiveness. The interpretation of the results of induced sputum examination depends on knowledge of normal values from a healthy population. So far, the reference values of sputum differential cells in Nepalese population are not reported. Neutrophil and eosinophil are used to assess the inflammatory response of the airway. The aim of our study was to detect the eosinophil level in the sputum of healthy individuals with normal pulmonary function.A descriptive cross-sectional study was conducted in a tertiary care hospital, from November 1, 2021 to December 31, 2021 after taking ethical clearance from Institutional Review Board (Reference number: 1507202106). Convenience sampling was done. Collected data was entered and analysed using Statistical Package for the Social Sciences version 24.0. Point estimate at 95% was calculated along with mean and standard deviation for continuous data.Among 139 induced sputum samples, 7 (5.03%) had eosinophils present in their sputum . The age range of the participants was 18 years to 79 years with mean age of 39.5 ± 15.06. Prevalence of eosinophilia (percentage of eosinophil >3) was 4 (2.88%).The prevalence of eosinophilia in our study was found to be similar to published literature. The results of the present study show that there is a paucity of eosinophils with predominance of neutrophils, macrophages and lymphocytes in induced sputum samples of healthy non-smoker adults with normal pulmonary function test. Ethical clearance was taken from the institutional review board of Kathmandu Medical College and Teaching Hospital with reference number: 1507202106.Study population was individuals visiting the outpatient department of Internal Medicine of Kathmandu Medical College and Teaching Hospital. Inclusion criteria for participants in the study are:Healthy non-smoker adult of age >18 years who provide consent for the study,No history of any chronic respiratory conditions,No history of respiratory infection within four weeks before the recruitment,No history of contact with patients with respiratory illness within four weeks before the recruitment,No history of atopy,Individual with normal radiological findings in chest X-ray, and18Normal pulmonary function according to European Respiratory Society (ERS)/American Thoracic Society (ATS) guideline i.e. Forced expiratory volume in 1 second [FEV1] >80% predicted, and FEV1 to forced vital capacity [FVC] ratio >0.7.Convenience sampling was done and sample size was calculated using the formula:2 × p × q) / e2n = (Z2 × 0.5 × 0.5) / 0.0852  = p = prevalence taken as 50% for maximum sample size calculationq = 1-pe = margin of error, 8.5%Hence, the total sample size was calculated to be 133. However, 139 samples were taken.19The participants who fulfilled the inclusion criteria underwent induced sputum collection with the help of inhalation of 3% hypertonic saline. The procedure was stopped if the subject experienced respiratory distress. Those with unsuccessful sputum collection or inadequate sputum after induction were excluded from the study. Treatment with inhaled bronchodilator was given to those subjects who developed respiratory distress during the procedure. Sputum sample was then preceded for examination of cytology. Sputum differential of neutrophil, macrophage, lymphocyte, and eosinophil was obtained from each sample in percentage. Eosinophilia is defined as ≥3% eosinophils in sputum.th and 90th percentiles. Point estimate at 95% Confidence Interval was calculated.Statistical Package for the Social Sciences (SPSS) version 24.0 was used for data entry and analysis. The percentage of sputum differential cell counts were expressed as arithmetic mean±SD, median and interquartile range (IQR). The normal range was expressed by 10Total 139 healthy adults who fulfilled the inclusion criteria were included in the study among which 7 (5.03%) had eosinophils present in their sputum . There were 88 (63.3%) male and 51 (36.7%) female. The age range of the participants was 18 years to 79 years with mean age of 39.50 ±15.06. The FEV1 / FVC among the participants were 0.83±0.05 .The eosinophil count among induced sputum samples was mostly zero percent in 132 (94.96%), two percent in 3 (2.16%), three percent in 3 (2.16%) and eight percent in 1 (0.72%) individuals . PrevaleNeutrophils were predominant cells in induced sputum with a mean of 56.54±16.65% and median of 60% .Aside from eosinophils, on sputum examination neutrophils were present in 139 (100%), macrophages in 127 (91.4%), lymphocytes in 139 (100%), and eosinophils in 7 (5%) individuals. .In this study, we found the eosinophil level and normal sputum differential cell percentage in the sputum of healthy non-smoker adults visiting medicine OPD of KMCTH with normal pulmonary function test by studying the sputum characteristics of 139 participants who fulfilled the inclusion criteria. Compared with previous studies, this study includes a larger number of participants and a broad range of all ages (18 to 79 years); moreover, the numbers of subjects are comparable in all ages.16 The results of our study show that neutrophils predominate in sputum of healthy adults; macrophages and lymphocytes are less common, while eosinophils are seldom present which is similar to those in literature.The mean values in our sample are in agreement with the findings with other studies with healthy subjects.16 Belda J, et al. (0.4%),11 and Spanevello A, et al. (0.6%).12 The reference values of percentage of eosinophil in sputum are lower than 2.0% in most studies,16 but the values from Canada13 and Korea15 are above 2.5%, which may attribute to the inclusion of subjects with allergy history. Therefore, it is reasonable to define the abnormality of eosinophil counts if the percentage is above 2.5%, which might be suggestive of airway eosinophilic inflammatory conditions.In our study, the percentage of eosinophils ranged from zero percent to 8%. The mean reference value of eosinophils was 0.16% which was comparable to studies conducted by Veras TN, et al. (0.1%),11 Luo W, et al. (38.3%),14 Davidson WJ, et al. (50.3%),13 Spanevello A, et al. (27.3%),12 and Veras TN, et al. (23.4%).16 However, the percentage of lymphocytes in our study is 21.36% which is much higher than that reported in previous studies including Belda J, et al. (1.0%),11 Spanevello, et al. (1.0%),12 Davidson WJ, et al. (2.6%),13 and Veras TN ,et al. (3.1%).16 It suggests that reference values might vary by geographic location. In our study, the mean reference value of macrophages was 21.96% which is lower compared to previous studies conducted by Belda J, et al. (58.8%)," Luo W, et al. (58.9%)14, Spanevello A, et al. (69.2%),12 and Veras TN, et al. (68.4%).16In our study, the proportion of neutrophils is 56.54%, which is higher than that reported in previous studies including Belda J, et al. (37.5%),Limitation of our study was the way of recruitment. Participants were recruited from hospital visitors, which could not exclude the possibility of comorbidities other than asthma, respiratory diseases, or recent systemic infection. However, due to methodological considerations, sputum induction and processing should be performed with specialised instruments and very near to laboratories, making community based sampling difficult. Also, since our study was a singlecentred study, with convenience sampling, the results cannot be generalised to the whole population.1 and FEV1/FVC may vary according to age group. Since participants included in our study are of various age groups, fixed cut-off values of predicted FEV1 >80% and FEV1/FVC >0.70 defining normal pulmonary function may not hold true for all the participants.Another limitation of our study is that cut-off values of FEVThe prevalence of eosinophilia in our study was found to be similar to published literature. The present study is the first attempt to determine the eosinophil level of sputum differential counts in healthy Nepalese adults with a normal pulmonary function. The results of the present study show that there is a paucity of eosinophils with predominance of neutrophils, macrophages and lymphocytes in induced sputum samples of healthy nonsmoker individuals with normal pulmonary function. It is recommended to conduct a national multi-center study to establish the reference value of sputum cell counts for the Nepalese population.