Monthly Archives: February 2023

COVID-19 Vaccine Hesitancy among Syrian Refugees

DOI: 10.31038/JCRM.2023611

Abstract

Background: The COVID-19 pandemic has disproportionately affected refugee populations, with refugees suffering higher rates of exposure and infection and a higher risk of severe disease and death due to socioeconomic disparities, reduced access to healthcare, and underlying medical conditions. Widespread vaccination is critical to reduce the individual morbidity and mortality as well as the public health burden of COVID-19. However, the uptake of COVID-19 vaccination among refugee populations is unknown.

Methods: We used validated surveys to quantitatively assess COVID-19-related fear and vaccine hesitancy in a population of Syrian refugees living in Turkey.

Results: COVID-19 vaccine hesitancy is critically high among Syrian refugees, with 85% of participants refusing vaccination. However, COVID-19 fear is also high, with over 90% of participants expressing fear of contracting or dying from COVID-19. Misinformation and false beliefs regarding vaccine efficacy and side effects contribute to the discrepancy between high fear of an infectious disease and low rates of acceptance of a life-saving preventive measure.

Conclusion: COVID-19 vaccine hesitancy is alarmingly high in Syrian refugee populations. Targeted interventions to improve vaccine acceptance in refugee populations are urgently needed.

Keywords

COVID-19, Vaccine hesitancy, Refugees, Syria, Turkey

Background

The COVID-19 pandemic has caused over 650 million recorded cases and over six million deaths worldwide as of December 2022 per World Health Organization statistics. Refugees and asylum-seekers have been disproportionately affected by all aspects of the pandemic. Refugees are at higher risk of initial exposure to SARS-CoV-2, are more likely to be hospitalized with COVID-19, and have a higher mortality rate compared to non-refugee populations [1]. A multitude of factors contribute to increased risk of in this population. Refugees are more likely to reside in crowded living conditions, to work low-wage public-facing jobs, to have less access to public health messaging in their native language, and to have lower health literacy compared to non-refugee individuals [2-8]. Once infected, refugees have a higher risk of severe COVID-19 symptoms, of requiring hospitalization due to COVID-19, and of death due to COVID-19. This is likely due to a higher incidence of chronic comorbidities, delays in seeking medical attention, and exclusion from the healthcare system, among other causes. Special attention to the effect of the COVID-19 pandemic on refugees is urgently needed.

Turkey harbors the world’s largest population of refugees and the world’s largest Syrian refugee population, with 3.65 million Syrian refugees and an additional 330,000 refugees from other countries [9]. Turkey has been profoundly affected by the COVID-19 pandemic, with over 12 million infections, nearly 92,000 deaths, massive inflation, and an unemployment rate of up to 40% [10]. Even prior to the pandemic, the refugee population in Turkey placed humanitarian and economic strain on the country. In 2020, the United Nations High Commissioner for Refugees (UNHCR)’s budget for refugees and asylum-seekers in Turkey was 365 million US dollars (USD); however, the sum of all available funds was only 131 million USD, a gap of 234 million USD [11].

Vaccination, combined with non-pharmaceutical methods such as social distancing and use of masks, offers the world’s best chance at curtailing the COVID-19 pandemic. Multiple effective and safe vaccinations to prevent COVID-19 have been developed and widely implemented with infection reduction rates of over 90% and excellent safety profiles. Unfortunately, vaccine hesitancy, defined by the World Health Organization (WHO) as “the reluctance or refusal to vaccinate despite the availability of vaccines,” is common in many populations. Given that refugees are at increased risk of COVID-19 exposure, infection, severe disease, and death, vaccination of this population is critically important, and vaccine hesitancy in this group is life-threatening. However, refugee and migrant populations have dismally low vaccination rates compared to non-refugee populations. Prior to the COVID-19 pandemic, vaccination rates for other preventable infectious diseases, such as measles-mumps-rubella (MMR), polio, and diphtheria-pertussis-tetanus (DPT), had been persistently low for decades in refugee populations compared to non-refugee populations [12]. With regard to the COVID-19 vaccine, as of June 2021, 85% of COVID-19 vaccine doses administered had been given in high- and middle-income countries, but 85% of refugees reside in developing countries [13]. Even within vaccine administration programs in developing countries, refugees are neglected: for example, in Lebanon in April 2021, refugees and migrants comprised 30% of the country’s population, but only 2.9% of vaccinated individuals [14].

Low COVID-19 vaccination rates among refugees are multifactorial. Some contributors are systemic, including lack of healthcare coverage or access to care for refugees, lack of vaccine information in refugees’ language, lack of transportation or financial means to obtain vaccination, and perceived fear of detention when presenting for medical care [15]. However, COVID-19 vaccine hesitancy is prevalent in refugee populations as identified by qualitative interviews [16]. These investigations identified misinformation and false beliefs as major drivers of vaccine hesitancy: for example, that COVID-19 is a hoax, that COVID-19 is a “Western disease,” that the government cannot be trusted, and that the COVID-19 vaccine contains microchips [17]. Facebook, TikTok, Whatsapp, and YouTube were cited as primary sources of COVID-19-related information [17].

Objectives

A rigorous understanding of the motivations, attitudes, and fears regarding vaccination is critically needed in order to decrease vaccine hesitancy and improve vaccination rates in refugee populations. In this study, we present the first quantitative investigation of refugee COVID-19 vaccine hesitancy using a validated questionnaire.

Methods

A cross-sectional survey was conducted in January 2022 among Syrian refugee patients in Turkey. Data were collected from patients aged 18 and older who presented for outpatient care at a public medical facility in Istanbul, Turkey. Patients who had already received any COVID-19 vaccine were excluded. Informed consent was obtained from each participant. This study was approved by the Institutional Review Board of the university hospital.

COVID-19-related fear was assessed via the Fear of COVID-19 Scale (FCV-19S). FCV-19S was developed in 2020 by a multinational group from Hong Kong, Iran, the United Kingdom, and Sweden [18]. FCV-19S assesses multiple aspects of fear related to COVID-19, including vulnerability to infection, fear of dying, and psychological and physical symptoms of anxiety. FCV-19S has robust psychometric properties and provides a reliable quantification of the severity of fear of COVID-19. Response patterns are not affected by respondent age or gender. The scale has since been implemented and validated in numerous other European, Middle Eastern, and Asian countries, including Turkey.

General vaccine hesitancy sentiment was assessed using the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization (SAGE) definition. Assessment of vaccine hesitancy by the SAGE definition can be done via as few as three questions regarding vaccine behaviors; this definition and question set have been widely employed worldwide [19].

COVID-19 vaccine hesitancy was assessed using a version of the Vaccination Attitudes Examination (VAX) scale. VAX is a measure of anti-vaccination sentiment that was initially developed in 2017 by a cooperative group from the United States and New Zealand [20]. Initially developed to measure general anti-vaccination attitudes, the VAX scale can be adapted to assess attitudes toward specific vaccines. The original VAX scale has high internal consistency and validity, and responses are significantly associated with both past vaccine behavior and future vaccine intentions. The VAX scale has been adapted to create the Attitudes toward COVID-19 Vaccine Scale to assess COVID-19 vaccine hesitancy, and has been implemented in several countries, including the United States, France, and India.

For the present study, assessments were translated from English into Arabic, and participant responses were translated back into English. A pilot with 20 participants was initially performed. The questionnaire and the logistical arrangements were found feasible by the participants.

Statistical analysis: Statistical analyses were performed using SPSS statistical software version 24 (IBM Corporation, Armonk, New York, USA). Results are presented as frequencies and percentages for categorical variables and as the mean and standard deviation for continuous variables.

Results

A total of 321 participants were recruited to the study and completed the survey. The median participant age was 43 (range: 18-75). Forty-three percent of participants identified as female. The majority of participants were illiterate (60%), were not working (62%), and lived in large households (household size of five to six, 41%; household size of seven to nine, 42%). Thirty percent of participants reported a personal history of COVID-19 infection. Twenty-seven percent of participants reported a personal history of diabetes mellitus, hypertension, and/or hyperlipidemia. Demographic characteristics of the cohort are displayed in Table 1.

Table 1: Demographic characteristics of study participants

	Median (range)
Age	43 (18-75)

	N (%)
Gender identity
Female	139 (43.3)
Male	182 (56.7)
Education
Illiterate	193 (60.1)
Primary school graduate	71 (22.1)
Secondary school graduate	57 (17.8)
Work status
Not working	200 (62.3)
Working irregularly	41 (12.8)
Working regularly	80 (24.9)
Size of household
3-4	57 (17.8)
5-6	130 (40.5)
7-9	134 (41.7)
Personal history of COVID-19 infection
Yes	94 (29.3)
No	227 (70.7)
Personal history of chronic disease (DM, HTN, and/or HLD)
Yes	86 (26.8)
No	235 (73.2)

Fear of COVID-19 was common among participants, as assessed by FCV-19S. Ninety-three percent of participants reported feeling uncomfortable when thinking about COVID-19, and 75% of participants reported fear of dying of COVID-19. Forty to 65% of participants also reported physical symptoms of anxiety (palpitations or insomnia) related to fear of COVID-19. Results of the FCV-19S assessment are displayed in Table 2.

Table 2: Fear of COVID-19

	Yes [N (%)]	No [N (%)]
I am most afraid of Coronavirus-19.	300 (93.5)	21 (6.5)
It makes me uncomfortable to think about Coronavirus-19.	300 (93.5)	21 (6.5)
My hands become clammy when I think about Coronavirus-19.	180 (56.1)	141 (43.9)
I am afraid of losing my life because of Coronavirus-19.	239 (74.5)	82 (25.5)
When watching news and stories about Coronavirus-19 on social media, I become nervous or anxious.	218 (67.9)	103 (32.1)
I cannot sleep because I’m worrying about getting Coronavirus-19.	127 (39.6)	194 (60.4)
My heart races or palpitates when I think about getting Coronavirus-19.	207 (64.5)	114 (35.5)

General vaccine hesitancy was common among participants. Seventy-one percent of participants reported refusing a vaccine for themselves or their child in the past, and 46% reported postponing a vaccine recommended by a physician. Vaccine hesitancy data are displayed in Table 3.

Table 3: Vaccine hesitancy

	Yes [N (%)]	No [N (%)]
Have you ever refused a vaccine for yourself or a child because you considered it as useless or dangerous?	229 (71.3)	92 (28.7)
Have you ever postponed a vaccine recommended by a physician?	147 (45.8)	174 (54.2)
Have you ever had a vaccine for a child or yourself despite doubts about its efficacy?	0 (0)	321 (100.0)

COVID-19 vaccine hesitancy was high among participants. Only 14% of participants stated that they would receive the COVID-19 vaccine. The remaining 86% of participants stated that they would refuse the COVID-19 vaccine. Of those respondents who refused vaccination, reasons for refusal were fear of side effects (78.5%), doubt about effectiveness (19%), and suspicion of short production timeline (2.5%). Attitudes toward COVID-19 Vaccine Scale response data are displayed in Table 4.

Table 4: Intentions regarding COVID-19 vaccination

If a vaccine against the Coronavirus was available, would you get vaccinated?	N (%)
Yes	46 (14.3)
No	275 (85.7)
If no, why?
Fear of side effects	216 (78.5)
Doubt about effectiveness	52 (19.0)
Suspicion of short production timeline	7 (2.5)

Discussion

In this study, we present the first quantitative assessment of COVID-19 vaccine hesitancy and fear of COVID-19 in a refugee population using validated questionnaires. COVID-19 vaccine hesitancy is alarmingly high in this population: 86% of participants stated that they would refuse a COVID-19 vaccine. General vaccine hesitancy is also prevalent in this population, with more than 40% of participants reporting a history of refusing or postponing a recommended vaccine.

The prevalence of vaccine hesitancy in this large cohort of refugee patients is concerning given this population is at extremely high risk in every phase of an infectious pandemic, from initial infection to death. Firstly, migrants and refugees are at higher risk of infection with the Coronavirus compared to non-refugee populations. For example, in Denmark in May 2020, the incidence of COVID-19 in the migrant population was 240 per 100,000, compared to 128 per 100,000 among native Danish individuals [21]. Similarly, in Spain in April 2020, the incidence of COVID-19 in the migrant population was 8.81 per 1,000, compared to only 6.51 per 1,000 for native Spanish individuals [22]. The living conditions of refugees, which commonly involve camp-type settings with crowding and extensive use of shared spaces, likely contribute to the increased incidence in refugee populations: outbreaks have been observed in migrant shelters in many countries. Even in non-camp settings, refugees are more likely to reside in shared or overcrowded housing. For example, in a survey of Organization for Economic Cooperation and Development (OECD) countries, migrants were twice as likely to live in an overcrowded housing setting (17%, versus 8% of native-born individuals) [1]. Occupational risks also contribute to increased risk of contracting COVID-19 among refugee populations: refugees are more likely to be employed in public-facing jobs, such as retail, delivery, hospitality, and transport, thereby increasing the risk of COVID-19 exposure compared to other, non-public-facing jobs [23]. Furthermore, refugees generally have more tenuous financial means compared to non-refugee populations and are more likely to be employed in “no work, no pay” jobs such as those mentioned above, necessitating the continuation of work even in high-risk conditions [4,5,23].

Refugees are also at higher risk of hospitalization and mortality from COVID-19. In Denmark in September 2020, migrants made up 15% of COVID-19-related inpatient admissions, despite comprising only 9% of the population [21]. In Sweden, the relative risk of ICU admission for COVID-19 was five times higher for migrants from Africa and the Middle East than for native Swedish individuals [24]. Similarly, in Norway, the incidence of hospitalization due to COVID-19 was 147 per 100,000 in migrant populations, compared to 37 per 100,000 for native Norwegian individuals [2,25]. Certain ethnic groups are at even higher risk of poor outcomes, and studies specific to Syrian refugees have found dismal COVID-related mortality rates. In Sweden, Syrian migrants had a relative risk of death from COVID-19 of 6.14 compared to native Swedish individuals [26]. Excess mortality in Syrian migrants in Sweden was 220% in 2020, due overwhelmingly to COVID-19 deaths [26].

Thus, given the high risk of initial exposure, severe disease, and death in this population, the magnitude of benefit from vaccination in this population is enormous, and the consequences of vaccine hesitancy are catastrophic. For example, the resurgence of measles in the United States, Norway, and other countries in the early 2000s as a result of increased parental refusal of MMR vaccination was notable for outbreaks heavily concentrated in migrant and refugee populations. In two outbreaks in Minnesota, USA in the 2010s, 72% of cases occurred in members of the Somali community [27,28]. During this time period, MMR vaccination rates among two-year-old Somalis in Minnesota fell to 54%, from over 90% ten years prior [29]. Similarly, in a 2011 measles outbreak in Oslo, Norway, 80% of cases occurred in members of the Somali community, in which MMR vaccine rates were also noted to be low [29,30]. Unfortunately, the present study confirms that vaccine hesitancy continues to be a major barrier to vaccination among refugee communities with regard to COVID-19 vaccination. Interventions to increase vaccine uptake in refugee populations are critically needed.

Vaccine uptake can be improved by addressing each contributing factor to low vaccination rates. Systemic factors must be addressed on the institutional level. For example, although the national COVID-19 vaccine program in Turkey, the setting of the present study, includes all individuals living in the country regardless of immigration, refugee, or asylum-seeking status, public health and vaccine programs in some countries exclude refugees, either explicitly, or indirectly due to requirements for identification or documentation to be presented at the time of vaccination. Removing systemic barriers by making COVID-19 vaccines available to all individuals regardless of legal status, improving outreach in refugees’ native language, increasing vaccine convenience, and guaranteeing protection from detention when seeking healthcare will all increase vaccination rates in individuals who desire to be vaccinated.

However, the present study identified that unvaccinated individuals who desire to be vaccinated (but may be impeded from doing so by systemic factors such as those detailed above) are a small minority among the Syrian refugee population in Turkey; the vast majority of participants are refusing COVID-19 vaccination, with concern for side effects the most commonly cited reason for refusal. Therefore, removing systemic barriers to vaccination is not sufficient to improve vaccination rates. Education on vaccine effects must be provided and misinformation and false beliefs must be addressed to improve vaccine hesitancy.

Although the present study is the first to quantitatively assess COVID-19 vaccine hesitancy in refugee populations using validated questionnaires, vaccine hesitancy in general has been well-studied. The most effective strategies for reducing vaccine hesitancy and improving vaccination rates overwhelmingly involve accessible, understandable health education from trusted sources. These strategies have been well-described by previous groups [31,32]; we briefly summarize the most common and salient points here. First, and perhaps most importantly, public health messaging must be available in refugees’ native language. In Turkey, a robust COVID-19 public health program is available via internet and a COVID-19 hotline is available via telephone, but these sources are only available in Turkish and English; 80% of Syrian refugees speak only rudimentary Turkish. An Arabic translation of the website or an Arabic language option for the telephone hotline would make this information more accessible for Syrian refugees. This model has been extremely successful in Sweden, where healthcare workers use telemedicine platforms nicknamed “Corona lines” to distribute COVID-19 educational information, triage respiratory symptoms, and instruct patients on appropriate quarantine and hygiene in Arabic, Somali, Tigrinya/Amharic, and Persian/Dari as well as the Swedish national languages. Second, vaccine development, testing, and approval information should be transparent and accessible to the public. As prior qualitative interviews cited above noted social media as the main source of COVID-19-related information for refugees, this information should be publicized via not only traditional media, but verified sources on social media as well. For example, national health ministries can use their official Facebook and other social media feeds to publicize vaccine information; this information should be in refugees’ native language, as discussed below. Specific provocative or culturally relevant false beliefs, such as concern that the vaccine contains pork products or causes infertility, should be targeted and addressed emphatically. The participants in the present study overwhelmingly indicated fear of side effects as the reason for vaccine refusal; public health information should emphasize the favorable side effect profile of COVID-19 vaccines. Third, personal storytelling from persons with whom refugee populations identify are effective means of appealing to individuals’ empathy and emotion. For example, for a target population of Syrian refugees, a public health announcement featuring a multigenerational Syrian family who accepted the vaccine can be filmed and widely publicized as described above. Fourth, community leaders, particularly religious leaders, such as imams at Syrian-majority Arabic-speaking mosques, should be partnered with for the dissemination of vaccine information. Fifth, refugee populations should be actively included in the process of public health education and information dissemination; for example, local public health committees should include at least one refugee member who participates in vaccination campaigns.

We found that fear of COVID-19 is also common in this population, with over 90% of participants reporting COVID-19-related fear. Notably, 75% of participants stated that they fear dying of COVID-19. The coexistence of high COVID-19 fear with high vaccine hesitancy seems contradictory. This contradiction emphasizes the role of misinformation, portraying the preventive measure as more harmful than the disease itself, in promoting vaccine hesitancy in this population. However, COVID-19 fear may become a motivation for participants to agree to vaccination if misinformation is replaced with accurate information about the efficacy and safety of COVID-19 vaccines.

The limitations of our study include its design as a cross-sectional survey, which represents the attitudes of the survey participants at one time point, and does not assess changes in attitudes over time. The demographic and clinical variables assessed, such as comorbidities and history of COVID-19 infection, were self-reported by participants, and were not verified by the investigators. The study was restricted to Syrian refugees in an urban metropolis. It may not be generalizable to other ethnic refugee populations, or to refugees in rural areas.

Conclusion

Refugee populations are at high risk of COVID-19 exposure, infection, severe morbidity, and mortality. Fear of COVID-19 infection is high in this population, with over 90% of participants reporting COVID-19-related fear. However, despite high levels of fear the disease, COVID-19 vaccine hesitancy is contradictorily and critically high among Syrian refugees in Turkey, with over 80% of individuals refusing vaccination. Fear of side effects is the most common reason for refusal of vaccination. Targeted public health outreach interventions are critical to improve vaccination rates in this vulnerable population.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Voice Analysis for Decisions in Clinical Practice

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DOI: 10.31038/IJNM.2022334

Verbal and nonverbal communication generates various debates and feelings between individuals, finally improving knowledge and experiences and, last but not least, influencing people’s health. Mental activity is mainly influenced by visual, sound, and smells perception. A person’s appearance, colour use, scent, and movement in a specific environment create diverse motion pictures going along with excitement, indifference, or discomfort, according to data processing. The music expresses various themes; miscellaneous musical compositions decoded by matching corresponding musical instruments or human voices determine emotions, relaxation, and even attentiveness. Verbal communication skills are necessary to improve an individual’s professional, cultural and social life; the words’ meaning and energy influence people’s well-being. The effects of the usage of the words in the written format are different from the spoken words since the speech energy, controlled by the nervous system, adds value to the words’ significance. Communication skills by terms make a difference between individuals and initiate numerous actions according to their relevance, physical characteristics of words’ transmission, intended recipient’s sensitivity, and context.

In this digital era, an individual can put an idea in a writing format or convert it into a say that instantly goes up to the intended recipients using IT devices.

Speech or the words’ ordering analysis offers information about the individual:

Level of Expertise
Skills for knowledge translation in practice
Emotions
Possible medical conditions
Well-being

Speech depicts its coordination in appearance; deficiencies at various levels for command and execution pathways indicate the voice’s signs of interest in clinical practice. Voice characteristics combined with the breathing data reflect blood flowing in the human body. Heart activity, the respiratory system’s function, and gravitational waves influence human body fluids movement; the digestive, endocrine, skeletal, respiratory system, kidney, and liver functions influence blood composition. The mind activity affects all these variables interplay, conveying the words and voice expression. Even so, the heart function and respiratory system, both under nervous system coordination, are seen as significant contributors to the voice function. Heart failure modifies the body’s fluid distribution and, subsequently, voice characteristics that change from one stage to another in its evolution.

Each person’s voice is distinctive and adaptable to various internal and external stimuli. AI supply leads to fast voice analysis and prediction of disorders in appearance or evolution. In this digital era, a video visit or only a phone call visit can offer sufficient details about individuals, including data health. For the medical team, an e-visit may be considered appropriate when necessary. For the patient, an in-person or e-visit represents a convenient option to get care in need. The patient experience can be appreciated /measured by his words’ composition to express gratitude, voice attributes, and sentiment analysis, preferably using AI supply. Subjective voice analysis and artificial intelligence utilization offer another perspective in clinical practice. Recent medical literature highlights ambitious AI projects for using the voice function in diagnosis. Therefore, according to individual financial status, there will be a wide range of options for the disease’s management in clinical practice. But only by using a mobile phone can the patient and the physician be connected to successfully control the patient’s disorders. The art of using the voice for analysis and decisions in clinical practice defines us as professionals in the community we serve.

Formative Evaluation of Trauma-informed Content Provided to Undergraduate Nursing Students in NURS 466 – Community Health

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DOI: 10.31038/IJNM.2022333

Abstract

Purpose: The purpose of this Quality Improvement (QI) project was to complete a formative evaluation of Trauma Informed Care (TIC) content delivered in a population-focused health nursing course for senior-level undergraduate nursing students.

Methods: This was a descriptive study that gathered feedback from students about the Trauma Informed Care content. A survey was disseminated via Qualtrics after the module/lecture to gather information about the effectiveness of the lecture with respect to TIC content; timing of the lecture in the semester relative to clinical; attitudes/perceptions about the importance of the content and practical application.

Results: The content provided to the students in Nursing 466 Community Health improved students’ knowledge and skills related to providing Trauma Informed Care. Twenty-five participants from the Bachelor of Science in Nursing program at Gonzaga University participated

Keywords

Bachelor of nursing students, Trauma-informed care, COVID-19, Population health

Introduction

Current times require us to reexamine the content we are teaching community/public health nursing courses. The American Association of Public Health suggests that undergraduate public health nursing education should include information on trauma-informed care. Trauma-informed pedagogy in public health is not new, but the trauma related to the COVID-19 pandemic argues for making it a priority for all educators [1]. As a result of the pandemic many in the public have experienced trauma related to stress, financial impact, mental health, and physical well-being. We are faced with increasing rates of the COVID-19 pandemic, chronic conditions, infections, violence, and extreme weather events. All these circumstances point to a growing need for including content about Trauma Informed Care. The concept of trauma can be described as the following “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual functioning and mental, physical, social, emotional, or spiritual well-being [1]. This article reports the formative evaluation of adding content about Trauma Informed Care (TIC) to a population-focused health course in a Bachelor of Science (BSN) program at a private university in the inland northwest. Trauma-informed care is grounded in a set of four assumptions and six key principles as a framework. The four Rs of this Trauma-Informed Approach framework are: realize, recognize, respond, and resist re-traumatization [1]. “A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization (wording bolded in original text). These concepts are needed when working in population health. The content that was presented to this BSN group of students was organized into three sections. Section 1 was an overview of trauma-informed care, including the definitions of trauma and passive trauma. The trauma that those who experience homelessness or living in poverty were used as exemplars. This section included an overview of neurobiology, biopsychosocial needs of those experiencing homelessness, addiction, and/or poverty, and how the brain reacts to trauma. Section two described different types of traumas as a public health issue of our time and included an overview of Adverse Childhood Effects (ACEs). Exemplars of trauma related to ACES, as well as the pandemic, and natural disasters were presented. Section two also included an overview of current statistics related to trauma and how stress affects those that experience trauma. Section three addressed addiction, stress, and homelessness, how to return to a state of hope, how to implement and “do” trauma-informed care, transformation, and post-traumatic growth, and how not to re-traumatize individuals. Today we are not only faced with increasing diseases but also other traumatic events [2]. These events can be additional sources of trauma and Post Traumatic Stress Disorder (PTSD) in public health. Although the need for nurses who can manage care along a continuum, implement evidence-based practice, work in multi-disciplinary teams, and integrate clinical expertise with knowledge of community resources is recognized, there is a lack of pedagogy that includes Trauma Informed Care [3]. This article describes the need for gathering formative information to add trauma-informed pedagogy to the current community health course. Using that formative information students provide could lead to changes made to the content before presenting it to the next group of students. The TIC content and knowledge could be implemented with the partnership between the school of nursing (SON) and local agencies where students complete public health clinicals.

Background

As a result of the COVID-19 pandemic, there is an essential need to prepare BSN students to not only care for individuals, but also for populations. According to SAMSHA “PHN practice is population-focused and requires unique competencies, skills, and knowledge. The important skills of analytic assessment, program planning, cultural competence, communication, leadership, and systems thinking, and policy are critical to the PHN role” [4]. Considering the pandemic, students’ interest may be piqued, and more students now see public health as a viable career option. It is important as faculty to recognize how Public Health will be taught in the aftermath of the COVID-19 pandemic and have awareness of the trauma students could experience as new nurses taking care of COVID patients. The pandemic will have likely affected students as well as those prone to experience trauma among the population on a personal level either because they have become ill themselves or know someone that was affected by the virus. Furthermore, we need to consider the trauma of providing nursing care as a student to COVID patients. With this comes the need for trauma-informed care. Those from marginalized communities, the homeless population, and middle-class families have all been prone to traumatic experiences. Trauma Informed Care will ensure that the students gain knowledge and learning tools to serve their community with the knowledge of what Trauma Informed care is and how to reduce the risk of re-traumatization of clients [3]. The added pedagogy included Trauma Informed Care, to an already packed course that includes Disaster Preparedness, prioritizing social determinants of health, and the use of politics and policy. As faculty teaching, this group of “post-pandemic” students requires our pedagogy to include trauma-informed care so as to not exacerbate the client’s trauma in their public health clinicals’. The students at this school of nursing work in partnership with community sites such as shelters, homeless centers, the department of health, and many other agencies that provide services to populations that experience extreme poverty. The content took on a hybrid format of teaching online and in the classroom. Study findings provide information to inform revisions to the lecture to better meet the needs of students regarding this content.

Problem

Undergraduate Nursing students in this BSN program need Trauma Informed Care content. There is a gap in practice in the literature regarding Trauma Informed Care (TIC) taught in the BSN program. As a result of the COVID-19 Pandemic, many in the public may have experienced some form of trauma. There is a recurring recommendation from the American Public Health Association to start integrating TIC into the undergraduate curricula to educate BSN students on what Trauma Informed Care is and how to apply it to practice. This Quality Improvement Project aimed to examine the formative feedback and perceived value of the TIC content integrated into the BSN Community Health content.

Methods

This was a descriptive study within one BSN program. Students were enrolled in the senior-level community health class. Participation was voluntary and consent, as well as understanding the purpose and process of this project, was presumed by completion of the survey. Approval from the university’s IRB was obtained. The survey included both scaled and open-ended questions and students could voluntarily participate post-lecture. This article describes the preliminary findings of the perceived value of the TIC content and how students responded to the content delivered. The overall goal was to gather feedback about the effectiveness of the lecture and what changes need to be made for the future integration of TIC into the community health course. Participants were invited to participate in a Qualtrics survey sent out securely to their student email addresses during class by a staff member from the Dean’s Office. The investigator did not utilize email addresses herself but had the staff member send the surveys via email during class time from a remote location. The class roster was available to the staff member in the university system. Email addresses were not stored in any other system except for Qualtrics, the survey software. Once the survey and project were completed using Qualtrics, any email addresses used by the system were deleted. The investigator/course instructor informed the class (potential subjects) about the survey and study goals immediately before the lecture was given and informed the students of their ability to opt-in/out of the survey portion of the class, which occurred after the lecture was given. The survey consisted of 9 questions Likert-type scaled responses and 5 open-ended questions that were designed to gather feedback about the effectiveness of the lecture with respect to content; timing of the lecture in the semester relative to clinicals’; perceived importance of the content and practical application; information necessary to inform revisions to the lecture to make it tailored to the population-level needs of the students A Likert scale was used to gather quantitative data. Five of the questions were open-ended so that the students could provide written feedback exploring contextual factors [5,6]. Students’ narrative responses provided essential information about how to format the content and presentation for the next group.

Results

The Trauma Informed Care content is particularly valuable. This information also provides resources and tools for clinical practice use. The formative evaluation process used in the project provided valuable feedback to increase the quality of this content and delivery in the future to the next group of participants (students). The content provided to the students in Nursing 466 Community Health improved students’ knowledge and skills related to providing Trauma Informed Care. Twenty-five participants from the Bachelor of Science in Nursing program at Gonzaga University participated. Participating evaluators indicated that the education program was effective with respect to TIC content, the timing of the lecture in the semester relative to clinical, attitudes/perceptions about the importance of the content and practical application. Overall, 52% of participants felt the content was very understandable and 64% felt the content was very important to clinical practice. 56% of participants felt that the lecture was very understandable and 64% of the participants felt that the content was important to clinical practice. Participants (54%) felt that the content was usable in their practice and 44% of participants felt that it would impact their values and beliefs.

Demographics

Thirty-six students were enrolled in the course; 25 (69%) of participants completed the survey. This section outlines descriptive statistics performed for the Likert-type items that were a part of the questionnaire. To capture the students’ perceptions about the lecture, we included in the questionnaire questions such as “How informative was the lecture content” and “How relevant is this lecture to public health.” These questions were measured utilizing a Likert-type scale ranging. 0=Unimportant, 1=Somewhat important, 2=Moderately important, 3=Important, 4=Very important, 5=I don’t know.

Qualitative feedback identified strengths in the use of the open-ended questions related to how the lecture impacted the students’ values and beliefs about people who live with homelessness and substances; the length of the presentation; timeliness of the presentation; understandability of the lecture and lastly, what changes the participants suggested to improve the lecture for future students

14 (56%) of respondents indicated that they found the lecture content to be informative, while 8 (32%) found it very informative. 21 (84%) of respondents found the lecture to be very relevant to the landscape of public health (Graph 1).

Graph 1: How informative was the lecture content

The students were asked to assess the length of the presentation. There were 25(60%) respondents that found the length of the presentation appropriate, while 5(20%) found it very appropriate (Graph 2).

Graph 2: Length of lecture

From this question, four different themes came to light. These themes are “different parts of the lecture “extending the lecture” “reduction in the lecture” and “additions to lecture.

The lecture was split up into three different sections and the students responded favorably to this and stated that “the presentation blended well together, and each section built off one another in a coherent manner”. There were some comments to extend the lecture by including more breaks and breaking apart what trauma-informed care is based on evidence-based practice and how that can be implemented in different communities. Related to the reduction in lecture the lecture was very consolidated, and students felt that there were a few slides that could be omitted. Some students suggested that perhaps it could be a multiday lecture. Additions to the lecture included suggestions to add some more videos and to include the ACE’s resources and some CDC resources.

The timeliness of the lecture relative to the student’s clinical experiences was also assessed. There were 13 (52%) respondents that indicated that the lecture was somewhat timely;7 (28%) of respondents rated it as timely with respect to how early it was offered in the course (Graph 3).

Graph 3: Timeliness of the lecture

Timeliness was very important to the students, and they noted that it would be good for students to benefit from the content much earlier in their BSN curriculum. Students suggested receiving this content earlier in the semester of their program. It was stated that if they had this before their senior practicum it would be very beneficial. Others stated that they could see this content being threaded throughout their 4-year program. It was mentioned that trauma-informed care is something they are thankful they learned in their BSN track and wished to learn about it earlier.

To assess the impact of the lecture, the following questions were asked: “How understandable was the presentation?” 14 (56%) Respondents felt the presentation was very understandable (Graph 4).

Graph 4: How understandable was the lecture

In response to this question Students mentioned that the topic was very relevant and helped them to see the “bigger picture”. Furthermore, they stated it would help them to identify paying attention to the information relating to ACEs among children, and being able to be an advocate for their patients was very important and helpful. Regarding the enjoyability of the lecture, students felt the PowerPoint was easy to follow and enjoyable to view.

“How important will this lecture be to your clinical practice,” 7 (28%) respondents felt that this was very important content for their clinical practice. 16 (64%) of respondents felt that this was very important content for their clinical practice (Graph 5).

Graph 5: Importance of lecture to clinical practice

“To what extent do you feel the content can be used by you in practice immediately?” 9 (36%) of respondents felt that the content could be used in practice immediately. 13 (52%) respondents felt that the content was usable for practice immediately (Graph 6).

Graph 6: Usability of lecture in practice

“To what extent did the lecture content impact your values and beliefs about people who live with homelessness and use substances?” 9(35%) of respondents felt that the content was very impactful and related to the above question. 11 (44%) of respondents felt it was impactful content (Graph 7).

Graph 7: Impact on values and beliefs

The first question analyzed reflects the impact that the content on the student’s values and beliefs about how people live with homelessness and substances. Students stated that the content was “extremely relevant” and is a significant component in promoting healing. Furthermore, students stated that “being educated on this topic allows us to be more aware and educate the community we work with during our community health clinical’ as future nurses, and it provides details about the struggles the homeless face since many of those experience some form of trauma that have been homeless before.” There were two sub-questions to this overall question.

The next question addressed what students’ reaction was to the details about physiological and psychological content. Students responded that neurological and biological changes are important to consider and that it was “cool” to learn more about the actual physiology and physical and chemical changes that occur during trauma. Furthermore, it was stated that “the lecture did a really good job at explaining the reasoning behind homelessness and addiction”.
Understanding what Adverse Childhood Effects (ACEs) are, was another area of this question that could influence the values and beliefs. Students state that understanding ACES “impacts the way you interact with patients in the clinical setting and broadened their perspective and strengthened their patience while working with this population and/or people who may have experienced ACEs or trauma in the past.

What changes would you make to the TIC lecture to improve it for future NURS 466 students? This question addressed any suggestions or changes to the lecture. Three themes emerged including resources, timing, and methods. Students suggested that they could offer specific resources or reference for patients or clients. They also asked how they can be sure to not re-traumatize patients. One of the students suggested asking someone who experienced trauma and overcame it to write a letter and share how they overcame their trauma. Timing again addressed the fact students wanted this content earlier in the semester, and program. Regarding methods, students mentioned more class discussions and asked for some real-life clinical examples. They also suggested part of the lecture be more interactive and include discussion.

Outcomes

Participating evaluators indicated that the education program was effective with respect to TIC content, the timing of the lecture in the semester relative to clinical, attitudes/perceptions about the importance of the content and practical application. Receiving formative evaluation to improve the development of a trauma-informed public health education program that provided evidence-based strategies and resources was the primary goal of this project. The results of the program demonstrated the effectiveness of using formative evaluation to develop a trauma-informed educational lecture for senior undergraduate Bachelor of Nursing students. The educational lecture overall demonstrated positive responses as to how the lecture impacted the students’ values and beliefs about people who live with homelessness and substances; the length of the presentation; timeliness of the presentation; understandability of the lecture and lastly, what changes the participants suggested to improve the lecture for future students. The findings of this educational lecture resonate with findings from other publications in relation to the importance of educational content on trauma-informed care for undergraduate nursing students to equip students with knowledge and understanding of trauma-informed care as it relates to public health. Emphasis on how timely this lecture was given is noted and will help change the timeliness of future lectures provided at the beginning of the student’s semester rather than toward the end.

Limitations

While the development of this Trauma-Informed care lecture reasonably provides strong evidence of the effectiveness of using formative evaluation to aid the development of the lecture within the sample population, it has some limitations. The first limitation is that it did not provide pre- and post-feedback as to what knowledge base the students had related to the content. It was limited only to one class in the undergraduate nursing program and the feedback is provided at the end of class when students are overloaded with the information they just received.

Future Directions

To overcome some of the limitations the respondents in the next part of this project will have a pre-and post-survey. The formative information provided in this project will better the lecture offered to the next student group in the Spring 2021 semester.

Funding

There was no funding involved for this project.

Conclusions

The trauma-informed care for public health lecture developed for senior undergraduate nursing students is powerfully applied by using evidence-based content and resources poised to provide an excellent delivery system for educating students. The lecture provided students with evidence-based content related to how trauma-informed care impacts public health. The student participants’ responses to the formative evaluations in developing this content were positive. In addition, the responses provided positive feedback and suggestions to improve the development of this lecture for future students.

References

SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach (2014) Retrieved from Substance Abuse and Mental Health Services Administration.
Auerbach, J, Miller F (2020) COVID 19 Exposes the cracks in our already fragile mental health system. AJPH. [crossref]
Abuelezam N (2020) Teaching public health will never be the same. AJPH 110. [crossref]
National League for Nursing. NLN. 2022.
Center for Disease Control. CDC. 2021.
S Department of health and human services (HHS) (2014) Office of women’s (OWH) health trauma informed care (TIC) training and technical assistance initiative. Participant scales. Cross-site evaluation of the national training initiative on trauma informed care (TIC) for community-based providers from diverse service systems. Abt. Associates.

Peer-to-Peer Evaluation: Kritik Pilot at Two Post- secondary Canadian Institutions

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DOI: 10.31038/IJNM.2022332

Abstract

In 2021/2022, educators at two Canadian universities chose to use a novel pedagogical approach to undergraduate program learning and instruction. Kritik, an on-line platform was selected because of its reputation for encouraging peer-to-peer learning and evaluation through use of Bloom’s Taxonomy of Learning to promote critical thinking skill development in learners. In this article, we outline our experiences while piloting use of Kritik, provide a critical assessment of its use and share our pedagogical lessons learned.

Keywords

Peer evaluation, Peer feedback, Undergraduate learning and instruction, Kritik

Introduction

The inspiration for this article originated in 2021/2022 after our pilot of Kritik, an on-line, peer-to-peer learning and evaluation platform used for the purpose of promoting student engagement in learning. Kritik allowed us to step away from being the primary source of all knowledge, and to instead use a collaborative educational approach to facilitate the learning process. In this article, we share our experiences, provide a critical assessment of Kritik use, and outline our pedagogical lessons learned.

Explication of Concepts

A peer has been defined to be one who is of equal standing with another, especially based on age, grade, or status [1]. In this article, a peer is understood to be an undergraduate student. Despite their similarities and often being used interchangeably, the terms review, assessment and evaluation have distinct meanings. A review is identified to be the act of giving one’s opinion about the quality of a product, and assessment is a systematic basis for making inferences about student learning and development, while evaluation is the determination of the value, nature, character, or quality of something [1]. Feedback is the transmission of evaluative or corrective information about an action, event, or process to the original or controlling source [1].

The terms peer feedback and peer evaluation are used for the purposes of this article. Peer feedback is the “rich detailed comments” [2 p. 280] given by peer student evaluators and communicated to students with the aim of providing “guidance on the quality of the student’s work and understanding of the subject manner” [3 p. 753]. Peer feedback is given during the process of peer evaluation; an organized, systematic process wherein students use a rubric, a standardized measurement tool to evaluate peer assignment compositions completed on the Kritik platform.

Background

We teach undergraduate courses at two Canadian universities located in the province of Manitoba. Kristen teaches DIS-2200/ WGS- 2264, Disabilities, Sexualities and Rights, cross-listed between the Disability Studies Program and Women’s and Gender Studies Department, as well as REL-2570, Sexuality in the Religious Context, in the Religion and Culture Department at the University of Winnipeg. I teach both 69:161, an introductory interpersonal communication course and 69:473, a fourth-year philosophical perspectives in psychiatric nursing course at Brandon University.

Over the past two decades, I have incorporated the use of peer evaluation into my courses. One of my previously taught fourth-year courses involved students completing peer evaluation of their seminar presentations. The assignment mark was derived from an average of peer evaluation scores and my own. In a third-year course, students conducted peer evaluation of a case study analysis, completed, and posted on an on-line platform by each student. In this case, too, the assignment mark was based on an average between peer review scores and mine. In yet another course, this time an introductory course, after viewing an assigned video, students posted their responses to questions about the video to an on-line platform for peer evaluation by fellow classmates. The assignment mark was again based on an average of student peer review scores and mine.

It is noteworthy to share that over the years, I have repeatedly encountered significant resistance to peer evaluation assignments from several students. Course end student evaluation included have comments suggesting that the majority of opposition was aligned with assumptions and beliefs that use of peer evaluation is a mechanism for offloading the course instructor’s work onto students.

Kristen had previously experimented with incorporating peer evaluation into an online REL-2507 course, using the ‘Discussions’ feature of the D2L/Brightspace platform. Having sorted students into groups, they were asked to post their near-final drafts of a visual-art analysis assignment on-line. Each group member was instructed to carefully read the other members’ submissions, and to offer actionable feedback. Completing all (four or five) of one’s peer assessments with evidence of a good degree of care and effort earned each student 5% of their final mark, though students’ drafts themselves were not graded. Students then made any changes they wished to their drafts and submitted the final papers to the instructor for assessment. The finished paper was worth 15% of students’ final grade, and assessed in a conventional, holistic way by the instructor and teaching assistant (TA). One of the limitations of this peer-evaluation activity was that the process could not be made anonymous, limiting the critical feedback some students were comfortable providing. Overall, this activity resulted in respectful and supportive engagement with peers’ work, and a reasonably high caliber of finished work, and encouraged Kristen’s interest in using peer evaluation in future courses.

Kritik

Kritik, a novel on-line platform developed with the aim of encouraging peer-to-peer learning and evaluation, integrates the use of Bloom’s Taxonomy of Learning to promote critical thinking skill development in learners [4]. A rubric developed by the course instructor, in consultation with a Kritik design specialist, accompanies each peer-to-peer learning & evaluation activity. This rubric, comprised of evaluative criteria and specific criterion measures, serves as a frame of reference for students while conducting peer review and evaluation.

Each peer-to-peer learning and evaluation activity consists of create, evaluate, and feedback stages [4]. In the create stage, students follow the activity instructions, adhere to the criteria outlined in the corresponding rubric, and create an activity composition that is uploaded to the Kritik platform. During the evaluate phase, students provide both formative and summative feedback by evaluating assigned peers’ activity compositions using the corresponding rubric and substantiate their assigned peer evaluation scores with written comments intended to be helpful when students complete their next Kritik composition. The feedback stage involves students providing each peer evaluator with feedback about how helpful their comments were [4]. Weighting is assigned to each of the three stages through use of an algorithm calibrated by a Kritik design specialist in consultation with the course instructor. A score is assigned for each of the three stages using the established algorithm with the overall Kritik activity mark being the combined score of all three stages

Motivations for Using Kritik

We do not believe that the course instructor should be the central figure in any given course; achievement of sustained, quality learning is a cooperative task. Moreover, we opine that learning is less likely to occur if students are passive recipients and not actively engaged within learning and instruction. As such, we strive to create student-centered learning environments with students actively engaged with one another while we provide guidance in the accomplishment of course learning objectives. One of the most significant advantages of Kritik, from this perspective, is that it keeps the learning process student centered. Although instructors are available to ‘step in’ to provide guidance with peer evaluations, or to override marks assigned by peer evaluators in any/all three stages, students interact primarily with each other. Further, if Kritik is used for a sequence of assignments in a course, students are teaching and learning from one another and so doing are engaged in an iterative process. Kritik levels the playing field wherein students are on somewhat more-even footing with the course instructor. Rather than being fundamental to the learning process, we consider ourselves to be facilitators of learning, readily available to assist and/or intervene if needed.

One of the more ‘pragmatic’ benefits of Kritik is the flexibility it offers to instructors in managing their grading work. While the platform does not completely take assessment duties away from the instructor, it does allow the instructor to choose how intensively they wish to be involved in the process, ranging from engaging only when students disclose a concern with a peer evaluation by submitting a ‘grade dispute’, to evaluating all Kritik compositions as well as commenting on and/or adjusting the score for students’ work themselves. For those educators dealing with large grading loads and minimal teaching assistance, this is a decidedly attractive feature.

Kritik Implementation

During the 2021/2022 academic year, Kristen piloted Kritik for DIS-2200/WGS-2264 and REL-2507 during Fall 2021 term, for DIS- 2200/WGS-2264 again in the Winter 2022 term, and once more for the latter course in the condensed Spring 2022 term; and I piloted Kritik in 69:161 and 69:473 during Fall 2021 term as well as 69:161 again in the Winter 2022 term.

Both Kristen and I had some lead time to familiarize ourselves with the platform. We each worked closely with Kritik’s instructional designers and technical-support people to navigate Kritik’s range of features and to become familiar with the processes involved in using Kritik from both the faculty and student perspectives. Despite this support, and although we had prior experience with peer evaluation as well as a significant degree of confidence with design/development of grading matrices, we both encountered steep learning curves. In saying this, it is important to acknowledge that Kritik’s support team were indispensable supports in our onboarding including platform set-up and initial use.

Kristen opted to use Kritik in REL-2507 for ‘two and a half ’ of the written assignments. Specially, the initial draft (but not final paper) of a visual-art analysis activity, the final version of the course’s media analysis and film analysis assignments. Each assignment component required students to apply their course-derived knowledge to analyze, respectively, a visual image, a media story, and a documentary film. In her first term of using Kritik in DIS-2200/WGS-2264, Kristen chose to use Kritik for most of the written assignments (weekly response papers, plus two film analyses). After receiving mixed student reviews, adjustments (described below) were made to Kritik use in subsequent terms.

In both 69:161 sections of my course, students completed five Kritik based learning activities designed to increase writing proficiency. Two weeks completion time was allocated to each of the five activities, with six days to create the composition, five days for the peer evaluation and three days for the feedback stages. A different rubric accompanied each of the five Kritik based activities. 69.474 involved short essay compositions to address a different philosophical question for each of five Kritik based activities. The same time parameters used for 69:161, outlined above, were used for this course but all Kritik based activities had the same corresponding rubric.

Kristen and I made a point of soliciting frequent feedback from students about their experiences with Kritik. We both expressed an interest in receiving feedback in several asynchronous lecture videos and distributed reminders in our weekly email updates to students. Ultimately, it was the time spent during synchronous online class inviting students to discuss and share concerns about Kritik that we found to be most productive.

Pedagogical Issues/Concerns

One of my reasons for deciding to use Kritik was its assurance of student anonymity throughout the peer evaluation process. Following completion of the first Kritik activity in 69.474, I received notification from several students that viewing the document ‘properties’ of uploaded Microsoft Word files permitted identification of the students for whom they were completing peer evaluations. After notifying Kritik technical support of this issue, I was advised that use of third party, Microsoft Word was the issue; that anonymity could only be assured by a copy and paste of student compositions directly into the Kritik application text box. I was also advised that disabling the file type submission option would prevent Word file uploads and ensure that students could only submit a composition via the copy/paste feature.

However, this copy/paste option was not without issue. None of the original formatting was retained after composition copy/paste. Those compositions that were not edited following copy/paste were difficult for peers to evaluate. Specifically, students shared difficulties with determining where paragraph breaks should be. Ultimately students disclosed their frustration with the additional time and focus required to complete an accurate peer review, when formatting was askew. Therefore, prior to third 69:474 assignment commencement, I advised all students of the necessity to pay particular attention to their composition formatting, and the need to edit submissions, after copy/ paste completion within the Kritik application textbox.

In both my 69:161 Fall and Winter term offerings, following completion of the initial assignment, several students shared their lack of understanding that assignment completion involved participation in the three Kritik stages, others indicated they did not realize that they needed to evaluate all peer compositions assigned to them and many disclosed their duress with the requirement of learning a new platform in a very short time while being concurrently required to complete an assignment for marks.

In both 69:161 sections, 10 of 35 and five of 26 students respectively did not complete the first two Kritik activity compositions by the due date/time. Acceptance of late submissions affects the assignment of completed compositions for peer review, and I believed it unfair for those students who completed their peer evaluation in a timely manner to be assigned late composition(s) to evaluate. Therefore, I made the decision not to permit late composition submissions. Students were notified of this decision from the outset of course commencement. However, in circumstances where students notified me early of their failure to complete the assignment by due date/time, I did allow these students to proceed with completing the peer review and evaluation stages. In these instances, I assigned partial marks that reflected the effort each student had invested during completion of these last two Kritik stages.

All students in both 69:161 sections and 69:474 were assigned five peer compositions to evaluate. While reviewing the first activity compositions and corresponding peer evaluations, I noted significant variation in peer evaluation scores assigned by the 69:474 students. Specifically, 10 of 36 peers had assigned full marks for many if not all rubric criteria, while other peers who had been assigned the same student compositions to evaluate, had allocated less than half mark for the same rubric criteria. Upon further examination, I noted the peer evaluations with less than full marks assigned were closely aligned with my evaluations. To ensure that use of Kritik was accurate and therefore credible, I adjusted the composition scores for students who had received inaccurate peer evaluation scores and reduced the evaluation scores of the students who completed inaccurate evaluations. All students involved were apprised of my reasons for over-riding the previously assigned scores and in particular the students who had completed inaccurate evaluations were informed of the action required by them to ensure that I did not have to over-ride scores again.

One of Kristen’s concerns, as a Disability Studies instructor and self-identified disabled person, was whether the inflexible deadlines within Kritik would create an accessibility issue for some students, including those with formal accommodations around time allowances for completing assignments, and those who encountered unexpected illnesses or personal/family circumstances. Outside of Kritik, Kristen has maintained a flexible policy of granting extensions on most assignments, especially if requested in advance. Somewhat surprisingly, despite having more than 100 students in the three courses combined, accessibility rarely became an issue. While not obvious to students, work could still be submitted late (with the instructor’s approval) via Kritik’s on-line help/support chat feature. If the work was uploaded before the deadline for the ‘evaluation’ stage, there was a good chance of its distribution for peer-assessment to those students who have left their ‘evaluate’ tasks until closer to that phase’s due date/time. Even papers uploaded too late to be peer evaluated can be assessed within Kritik by the instructor.

For the most recent offering of DIS-2200/WGS-2264, Kristen experimented with allowing late submissions automatically. In this case, Kritik requires students to provide an explanation for the delay in their submissions, and then allows the instructor to accept or reject the paper. In a class of approximately 40 students, this typically resulted in only one or two late submissions for a given activity, with improved odds of ‘slightly’ late papers being distributed to peers for evaluation because of the lack of a need to obtain pre-approval and Kritik’s assistance to upload late work.

Partway through each section of DIS-2200/WGS-2264, during discussions with students about Kritik, some of Kristen’s strongest students expressed misgivings about having their work assessed by peers, and their inability to score ‘perfect’ marks, given the way Kritik’s algorithm calculates overall activity marks. A few students showed interest in receiving more ungraded, early term training in assessing peers’ work accurately in Kritik. Some students also expressed concerns that their peers were marking too harshly. During one conversation, some students disclosed the belief that because one of the metrics during the evaluation stage asked them to rate how ‘critical’ aspects of the peer evaluation were, some believed they needed to “find faults” in the peer evaluations. Kritik’s use of the term “critical” refers to how helpful and actionable the peer evaluation was for students [4]. This misinterpretation of the term “critical” was addressed during asynchronous online class and by email.

Kritik’s ‘grade dispute’ function permits students to notify the course instructor of any peer evaluation concerns. Such ‘disputing’ promotes more focused checking by the course instructor of student work with dispute resolution accomplished by the instructor prior to finalizing activity grades. Repeatedly encouraging all students to use Kritik’s ‘grade dispute’ function to flag any concerns about peer evaluations or make comments for the instructor on a specific paper also reduced in-class complaints about inaccurate grading. Both Kristen and I think that the presence of this function builds students’ trust. For example, if students think their peers’ evaluations are too low, upon notification of a grade dispute, the instructor or TA can focus in on the issue to reassess, and perhaps regrade, the work. In response to concerns over lower-than-expected marks by midterm during her first term using Kritik, Kristen emailed her students and requested that they “err on the side of generosity” in their evaluations. This tipped the subsequent marks noticeably upwards, even somewhat beyond what Kristen would have assigned had she evaluated students’ work herself. Revision of rubrics in subsequent terms was helpful in preventing inappropriately low averages.

Also worrisome were the views, expressed by several students in the Fall DIS-2200/WGS-2264-section course evaluations that use of Kritik reflected “laziness” on the part of the instructor; that because the instructor’s spot-checking papers was not visible to students unless marks were changed, or additional comments left, students perceived they were doing this work with no oversight. These concerns were addressed through changes made in implementing Kritik in the following winter and spring-term sections of the same course, with both a reduction in the number of course assignments for which Kritik was used, and instructor comments left on all spot-checked papers; a process that involved approximately a third of submitted papers each week, while recording which papers had been checked in any given week.

Pedagogical Lessons Learned

My lessons learned include the necessity to include both a Kritik orientation for students and a strategy to promote student anonymity, as well as provision of clear expectations about the scoring and commentary required of peers during the evaluation stage. I did not anticipate the need for providing an orientation to Kritik at the beginning of my courses. Based on student concerns and my acquired insight into the difficulties associated with lack of familiarity with the Kritik platform, I believe that during the first week of coursework all students should participate in a mandatory orientation to Kritik that includes completion of a mock Kritik peer review assignment with no marks assigned.

Anonymity cannot be assured if students upload a composition, completed in a format such as MS Word, to Kritik. To ensure that anonymity is maintained throughout the course, all compositions must be uploaded to the Kritik application text box and the file type submission option disabled by course instructor. Students need to be advised of the requirement to edit composition(s) after upload to ensure assignments are formatted appropriately in advance of peer evaluation.

Some peers failed to exercise due diligence when evaluating composition(s) and instead assigned inaccurate score(s). To ensure accurate assignment of scores, it is crucial that a timely and thorough review be conducted of all peer evaluation commentary and score(s) assigned, particularly when significant variation exists among the assigned peer evaluation scores. In circumstances of inaccurate score(s) allocation, fairness in grading is assured by adjustment of Kritik assigned scores for both student who completed the composition and the peer who conducted the inaccurate evaluation.

Kristen’s experiences also led to several conclusions about how to better implement Kritik. Having every written assignment for a course submitted and assessed via Kritik was not a popular option with students; maintaining at least one major activity as instructor-graded seems to have satisfied students who were concerned over the degree of instructor involvement in the process. Regular spot-checking with at least brief comments acknowledging an instructor’s or TA’s reading of the work has also made a significant difference with students’ expressions of dissatisfaction. Instructor visibility and responsiveness to disputes, combined with reassurance and proactive training and support of students in the use of the platform, are perhaps the leading factors noted by Kristen in improving students’ receptiveness to the use of Kritik.

Kristen is of the opinion that there are also some learning activities for which Kritik simply does not work very well. Specifically, for activities such as the REL-2507 film analysis that involves a set of common questions for each student on the same media, peer evaluation resulted in additional frustration. Students experienced less variety and more repetition in the materials they were required to assess, while offering less ‘reward’ in terms of exposure to different perspectives and ideas. It is also very challenging to design an effective rubric for assessing multiple questions effectively within the context of an individual activity, since only one rubric per activity may be used, and any marks assigned apply to the entire submission.

Although instructors have the option to adapt one of Kritik’s rubric templates, for those instructors who decide to design their own, a significant degree of effort is required to design an effective rubric. Students, most of whom will be new to doing rubric-based assessment themselves, require a rubric that is clear, minimally complex, explains the specifics that students should use to determine assignment of scores for each criterion and an explanation of how peer evaluation scores align with the course grading scale. Since the rubric also needs to guide students on how to evaluate solid-but-not-exceptional papers, determining whether a composition that addresses all required criteria quite well should be assigned full marks, or not, is also important. Investing additional effort into this stage translates into more-accurate marks, less frustration, and complaints among peer evaluators, as well as less revisions to peer scoring by the instructor.

One area that remains a concern when using Kritik is identifying plagiarism. Despite being encouraged to contact us in situations where peer evaluators suspected plagiarism or other forms of academic dishonesty, no students did so. In contrast, spot-checking by both of us did reveal some instances of plagiarism.

Kritik representatives have shared plans for integration with the plagiarism-detection software such as Turnitin which may be of use for some courses. However, as is the case for traditional assessment methods, the easy availability of new automatic ‘paraphrasing’ applications to circumvent automated detection systems, is still a concern. Ultimately, diligent spot-checking by the instructor seems to be the most-effective way to monitor, detect, and correct academic integrity issues.

Use of Kritik in the Future

Based on our experiences thus far and with consideration of our lessons learned, both Kristen and I have decided to incorporate the use of Kritik into our upcoming courses. It is noteworthy to share that our decision to use the platform will cost students a fee ranging from $18.00 to $24.00 Canadian per term. The lower fee is associated with adoption of Kritik by multiple faculty members at the same learning institution. Given we both concur that peer evaluation is a beneficial pedagogical approach to learning and instruction and that our experiences with Kritik have for the most part been positive, we believe adoption of Kritik for use in our courses will be money well spent.

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Monthly Fluctuation of Spike Protein-specific IgG Antibody Level against COVID-19 after COVID-19 Vaccination and Booster Shot

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DOI: 10.31038/IJNM.2022331

Abstract

We investigated the spike protein-specific IgG antibody levels against COVID-19 in a 64-year-old male medical staff periodically after two doses of COVID-19 vaccination and a third booster shot during a one-year period. The antibody levels increased after the two doses vaccination; however, it rapidly decreased in the first 3 months. The antibody levels increased again after the third booster vaccination. The antibody levels were remarkably higher than that after the two doses of vaccination and remained high for several months. We demonstrated that the third booster shot was significant in maintaining a high level of immunity against COVID-19.

Keywords

COVID-19, Vaccine, Antibody, Spike protein, Booster

Introduction

The COVID-19 pandemic [1], which began in early 2020, affected the examination and treatment of patients in hospitals, healthcare, and nursing care facilities in various ways. Vaccination for COVID-19 [2-4] initially started in the United Kingdom in December 2020 and subsequently started in Japan in February 2021, which has been effective in preventing the onset and reducing the severity of the disease [5-7] owing to its high immune induction potency [8]. However, some cases of breakthrough infections have been reported [9-11], and it has been pointed out that one of the causes is a decrease in the levels of antibodies against the disease over time [12]. However, booster vaccination has been shown to be effective in preventing the onset of the disease and reducing the risk of severe disease [13-15]. Therefore, we consider it meaningful to assess COVID-19 antibody levels periodically after vaccination and booster shots to prevent such infections. We measured the antibody levels of our medical staff against COVID-19 monthly after COVID-19 vaccination and examined changes in antibody levels after administration of additional vaccination during a one-year period.

Materials and Methods

Subjects

The subject was a 64-year-old male medical staff of our corporation who received the COVID-19 vaccine by Pfizer-BioNTech twice and received an additional vaccine dose by Moderna eight months after the second vaccine dose and was administered COVID-19 antibody testing monthly for a year.

Ethical Principles

The present study was conducted in accordance with the Declaration of Helsinki, and the Seikokai Group Ethics Committee approved the study protocol. Informed consent was obtained from the staff.

Methods

The staff member received two doses of the COVID-19 vaccine by Pfizer-BioNTech between 10 June and 1 July 2021 and was subsequently administered COVID-19 antibody testing over time. Following that, he received an additional booster COVID-19 vaccine by Moderna on 21 February 2022 and was subsequently administered COVID-19 antibody testing over time. Antibody levels were measured monthly: one month after the completion of the second vaccination [16], two months after the second vaccination, and three months after the second vaccination. Subsequently, the fourth, fifth, and sixth measurements were performed every one month. An additional vaccine dose was administered eight months after the second vaccination. The seventh antibody level was measured one month after the additional vaccine dose, and the eighth, ninth, and tenth measurements were performed every one month, respectively. In total, the fluctuation of antibody levels was monitored for a year. Antibody levels were measured by quantification of spike protein-specific IgG antibodies, which have neutralizing activity against the receptor-binding domain of the virus. Abbott SARS-CoV-2 IgG (Abbott Japan, Minato-ku, Tokyo, Japan; cutoff value: 50 AU/mL) was used to perform this measurement.

Results

The time course of the antibody levels after two doses of the vaccine for the first 6 months is shown in Figure 1. The antibody level at one month after the second vaccine dose was 3,337 AU/mL, but that at the next month was 1,510 AU/mL, which is a decrease of 55%. The antibody level at three months after the vaccination was 749 AU/mL, a 78% decrease from that at the first measurement. Antibody levels at 4, 5, and 6 months after treatment were 455, 287, and 245 AU/mL, respectively. The decline in antibody levels was relatively slow compared with that in the first three months (Figure 1: arrows). The time course of the antibody levels from six months to 12 months after two doses of the vaccine is shown in Figure 2. After the administration of booster vaccine dose, the antibody level was remarkably increased to 22,900 AU/mL (at 9 months) and declined to 17,100 AU/mL (at 10 months), 12,900 AU/mL (at 11 months), and 7,990 AU/ml (at 12 months). However, the antibody level after the additional vaccine dose was relatively higher than that after the second dose. The total course of vaccination and antibody levels for a year period are shown in Figure 3.

Figure 1: Time course of the antibody levels for six months after administration of a second vaccine dose

Figure 2: Changes in the antibody levels after administered an additional vaccine dose

Figure 3: Total time course of vaccine doses and antibody tests for a-year period

Discussion

How antibody levels change after COVID-19 vaccine dose is now a matter of concern not only for healthcare professionals but also for the general population. In this study, we evaluated the antibody levels of our medical staff following vaccination and booster shot for COVID-19 every month during a one-year period. After two doses of the vaccine, the antibody level at three months decreased by 78% from baseline and at six months, decreased by 93% from baseline. This result indicates that the degree of decrease in antibody levels in the first three months was higher than that in the second three months, and the current results support our previous study [17]. We also demonstrated that after the administration of the booster shot, the antibody levels were remarkably increased and significantly higher than that after the second vaccine dose (Figure 3). Notably, the antibody levels remained high even after several months of the booster shot. Our current data also showed similar results to those of the previous studies [18-21]. It has been thought that the vaccinations increased at the same time as the outbreak of the delta strain that began in May last year from India [22-24], contributing to the convergence [25] of COVID-19 worldwide; however, the subsequent decrease in antibody levels may have contributed to the new omicron strain outbreak. However, the administration of additional doses of the vaccine is considered a significant countermeasure against COVID-19 because it was shown that the antibody levels against the disease increased again after the additional doses and that the severity and mortality rate from COVID-19 were reduced by the additional vaccine doses [26,27]. This remarkable increase in antibody levels after the additional vaccine dose may also contribute to the convergence of the omicron strain. We believe that the current data may help infection measures against COVID-19 for doctor, nurse, and other medical staff.

Study Limitations

The serum sample was obtained from one medical staff, and a large-sample investigation is needed to confirm our current study.

Conclusion

We measured the antibody levels of our medical staff over time after COVID-19 vaccination and examined changes in antibody levels after the administration of the booster vaccination for a year. Although the antibody levels declined with time after vaccination, we showed that the antibody levels significantly increased again after booster vaccination and remained high for several months.

Acknowledgment

The authors deeply indebted Saeki Ishiwata for providing serum samples and technical assistance for this research. The authors also thank to Bio Medical Laboratories Incorporated (BML, Inc.) for valuable support.

The preliminary data of this study was presented at a 4th European Congress on Infectious Diseases via live on 11 November 2022 at Paris, France, and on demand web streaming.

Funding

The authors declare that they have nothing to disclose regarding funding.

Conflict of Interest

The authors state that they have no conflict of interest to declare.

Author Contributions

Ikuma Kasuga conceived the work and designed the study protocol. Yuko Ishii contributed to the data curation and laboratory analysis. Yoshimi Yokoe and Osamu Ohtsubo supervised the project. Ikuma Kasuga contributed to the writing of the original draft, and all authors contributed to the revision of the manuscript and approved the final manuscript version.

References

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Demographic and Clinicopathological Evaluation of Colorectal Adenocarcinoma in Bangladesh at a Tertiary Level Hospital

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DOI: 10.31038/CST.2023811

Abstract

Background and aim: Colorectal Cancer (CRC) is the third leading cause of global cancer death in humans and its incidence is gradually rising in developing nations including Bangladesh. The study was carried out to unveil the demographic and clinicopathological profile of CRC cases in Bangladeshi patients.

Methods: A cross-sectional study was conducted among purposively selected 50 patients irrespective of age and sex with histologically proven colorectal cancer at a tertiary level hospital for a period of 2 years. Large bowel resection specimens of CRC made the samples. Demographic and clinical information were recorded in a pre-tested, structured case record. Relevant macroscopic and microscopic features of tumors were recorded during gross and microscopic examinations of the specimen.

Results: Mean age of the CRC patients was 48.60±14.6 years. Adult active males (35-54 years old) were significantly affected by CRCs (p=0.0001). Per rectal bleeding (38.7%) and generalized weakness and pallor (38.98%) were the most frequent findings in distal and proximal CRCs, respectively. Adenocarcinoma NOS was the most commonly observed histologic type. Occurrence of CRC and tumour grades were significantly (p=0.0001) related where Grade-II and Grade-III tumour occurred in 72% and 24% of cases, respectively. Majority of the cases were presented at stage pT3 (68%) and pN0 (48%). Tumors in adult active age showed a higher tendency to be presented at advanced stages.

Conclusions: Bangladeshi adult active males of 35-54 years old were predominantly affected by a locally advanced stage of CRC. Routine screening programs are proposed for early detection and treatment of the cases.

Keywords

Colon cancer; Bangladeshi patients; Clinical features; Demographic characteristics; Intestinal tumor

Introduction

Colorectal cancer is one of the most common cancers globally. It is the second most common malignancy among women and the third most common malignancy in men [1]. The global burden of colorectal cancer is expected to increase by 60% by 2030. Its incidence shows a 10-fold variation across the world [2]. The prevalence of colorectal cancer is lower in Asia than in Western countries. But the incidence has been alarmingly increasing in countries of the Asia-Pacific region during the last two decades due to the westernization of lifestyles [3]. In Bangladesh, 5-year prevalence of colon and rectal cancer are 3.28 and 3.1 per 100,000 population, respectively [4]. There are variations in risk factors, mode of disease presentation, sub-site distribution, tumor morphology, grade and stage at presentation. These tumors grow insidiously and remain undetected for long periods remaining potentially curable, premalignant lesions over several years. Therefore, screening procedures provide a unique opportunity for cancer prevention [5]. However, in the long run, the tumor cells metastasize to lymph nodes and in the other organs. The treatment, prognosis and survival rate largely depend on the stage of disease at diagnosis.

The development of both familial and sporadic colorectal cancers can be influenced by genetic factors [6]. Age is another major risk factor for sporadic CRC. The diagnosis is rare before the age of 40 years. The incidence starts to increase significantly between 40 to 50 years and the age-specific incidence rates raise in each succeeding decade thereafter [7]. Although patients over 50 years of age represent 90% of newly diagnosed cases [8], the trend is changing with the increasing incidence among the younger population who present in a more advanced stage [9]. In recent years, tumor location has also been suggested to be a valuable predictor, which has added to the difficulty of discussing its clinicopathological features and outcomes [10]. The majority of colorectal cancers belong to classical adenocarcinomas, with several histological variants associated with specific molecular characteristics [11,12]. Understanding these features could guide the proper management and prognosis of the patient. But unfortunately, there is a scarcity of data regarding the demographic and clinicopathological patterns of colorectal cancers in Bangladeshi patients. Therefore, the present study was undertaken to understand the demographic and clinicopathological profiles of patients with colorectal carcinoma in Bangladesh.

Methods

Ethical Approval

This study was approved by the local Ethics Committee (Institutional Review Board) at Bangabandhu Sheikh Mujib Medical University (BSMMU) and informed consent was obtained from all participants.

Study Design, Period and Sample

This cross-sectional, descriptive, hospital based, study was conducted in the Department of Pathology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh during the period of March 2019 to February 2021. Large bowel resection specimen histologically diagnosed as adenocarcinoma at the department of Pathology, BSMMU were included in this study. A total of 50 primary colorectal carcinoma cases irrespective of ages and sexes were included in the study. Clinically suspected colorectal carcinoma subsequently proved to be non-epithelial tumors of the colon were excluded from this study. Patients’ attendants were interviewed for demographic and clinical information, which were recorded in a performed questionnaire.

Gross and Microscopic Evaluation of Samples

During gross examination tumor site and macroscopic features of tumors were noted. Splenic flexure was taken as demarcating point of proximal and distal lesions. After that representative tissue blocks were submitted for routine processing and paraffin embedding. Standard protocol was maintained during tissue processing and staining. Microscopic examination of tissue sections stained with hematoxylin and eosin was carried out and relevant points were recorded. The tumors were classified following World Health Organization classification of tumor and grading of tumor was done by using AJCC specified four-tiered grading system. Staging was performed following TNM Classification of Colorectal Carcinoma American Joint Committee on Cancer (AJCC).

Statistical Analysis

Data was entered in MS Excel and analyzed by using SPSS software version 21. Categorical variables were expressed as percentages and analyzed using the Chi-square test or Fisher’s exact test. Continuous variables were expressed as mean or median and analyzed using the Mann-Whitney test. Demographic factors and clinical characteristics were summarized with percentages for categorical variables and median for continuous variables.

Results

A total of 50 patients with CRC were enrolled in this study. Age of the study population varied from 19-85 years with a mean of 48.60±14.6 (SD) years. All the 50 cases were categorized into four age groups where samples from patients belonging to 15-34 years, 35-54 years, 55-74 years and 75-94 years were considered as young, adult, elderly and old age groups, respectively. Figure 1 illustrates the distribution of CRC cases in different age groups.

Figure 1: Distribution of CRC cases in different age groups of Bangladeshi patients

As shown in Figure 1; half (50%) of the CRC cases belonged to adult active age group (35-54 years), followed by 28% cases in elderly (55-74 years), 18% cases in young (15-34 years) and 4% cases in old age group (75-94 years). A chi-square test of independence was performed to examine the relationship between age groups and the frequency of occurrence of CRCs. The relation between these variables was significant, X2 (3, N=50)=22.48, p=.0001 at α=0.05. The adult active age group (35-54 years) was more likely to be affected by colorectal carcinoma than the other groups.

Sex-wise distribution of CRC cases of this study revealed that almost two-thirds (64%) of the study cases were male while around one-third (36%) cases were female. The occurrence of male cases was numerically high in all age groups except the old age where the percentage of both cases was equal (Figure 2). The relation between the occurrence of CRS and sexes was weakly significant, [X2 (1, N=50)=3.92, p=.048 at α=0.05]. Males were more likely to be affected by colorectal carcinoma than females (Figure 2).

Figure 2: Sex-wise distribution of CRC cases in different age groups of Bangladeshi patients

Per rectal bleeding was the most frequent clinical presentation of CRC among the study population that was documented in 30% of cases followed by generalized weakness and pallor (26%), abdominal pain with or without features of obstruction (16%), altered bowel habit (12%), weight loss (12%) and abdominal mass (4%). Only one study case had a positive family history of colon cancer. None of the cases was presented with a history of extra-colonic malignancy. When the site of occurrence was considered, the tumor was located in the distal colon and proximal colon in 62% and 36% of cases, respectively. Only one (2%) of cases were recorded to have synchronous tumors involving both colons. However, no signification relation was observed between the tumor sites and the occurrence of CRC [X2 (1, N=50)=2.880, p=.090 at α=0.05]. The distribution of study cases based on tumor location along with presenting complaints is shown in Table 1.

Table 1: Distribution of study cases based on tumor location along with presenting complaints

P/R Bld: Per rectal bleeding; Ab Pain: Abdominal pain; Alt bowl: Altered bowel habit; Wt loss: Weight loss; Ab mass: Abdominal mass; Gw & pal: Generalized weakness and pallor; Cc: Cecum; Asd. col: Ascending colon; Trns col: Transverse colon; Dsd col: Descending colon; Sg col: Sigmoid colon; Rec junc: Rectosigmoid junction; Rec: Rectum: Asd. col. & rec.: Ascending colon & rectum (synchronous)

The exophytic pattern was the most common gross morphology which was observed in more than half (60%) of the cases, followed by ulcerating and infiltrative patterns, seen in 30% and 10% of the cases, respectively. In our study, the frequency of the Exophytic pattern was significantly higher than the other two patterns based on the chi- square test of independence, [X2 (2, N=50)=19.00, p=.0001 at α=0.05] indicating that Exophytic pattern was more likely to occur in CRC cases (Table 2).

Table 2: Distribution of study cases based on tumor morphologies

In this study, only two variants of adenocarcinoma were observed; the commonest one being adenocarcinoma (NOS) (76%) followed by mucinous adenocarcinomas (24%). The frequency of adenocarcinoma (NOS) in relation to CRC cases was highly significant [X2 (1, N=50)=13.52, p=.0001 at α=0.05] compared to mucinous adenocarcinoma. It seemed that adenocarcinoma (NOS) was the more frequent variant of CRC in Bangladeshi patients (Table 2). Among the 50 selected cases, majority (72%) of the tumours belonged to grade II (moderately differentiated) tumors. Remaining 24% and 4% cases were categorized as grade III (poorly differentiated) and grade I (well differentiated) tumors, respectively. There was a highly significant relation between the occurrence of CRC the and grade of tumours [X2 (2, N=50)=36.640, p=0.000 at α=0.05]. However, no significant relationship was seen between the tumour grades and age groups [X2 (6, N=50)=2.702, p=0.845 at α=0.05] or sex [X2 (2, N=50)=1.292, p=0.524 at α=0.05]. It seemed that Grade-II CRCs were more likely to occur in case of colorectal carcinoma in Bangladeshi patients irrespective of age and sex. Figure 3 illustrates the graphical presentation of grades of tumours according to age groups and sexes whereas Table 3 summarizes the frequency of tumours according to grades, age groups and sexes with their relationship.

Figure 3: Graphical presentation of grades of CRC cases according to age groups and sexes. Grade-I: well differentiated tumors; Grade-II: moderately differentiated tumours; Grade-III: poorly differentiated tumours.

Table 3: Frequency of tumours according to grades, age groups and sexes with their relationship

No.: Number of occurrence; %: Percentage of occurrence;
^a: X2 (2, N = 50) = 36.640, p = 0.000 at α = 0.05; ^b: X2 (6, N = 50) = 2.702, p = 0.845 at α = 0.05; ^c: X2 (2, N = 50) = 1.292, p = 0.524 at α = 0.05

According to the pathological depth of invasion, studied CRC cases were ranked into 4 stages namely PT-I, PT-II, PT-III and PT- IV starting from lowest to highest invasion. Stage-3 (PT-III) was the most commonly recorded stage of tumour which was seen in 68% of the cases followed by PT-II, PT-IV and PT-I which were recorded in 22%, 8% and 2% cases, respectively. A highly significant relation was observed between the occurrence of CRC and the stage of tumours based on pathological invasion [X2 (2, N=50)=36.640, p=0.000 at α=0.05]. It seemed that PT-III is more likely to occur in Bangladeshi CRC cases. A highly significant relation was also observed between the pathological invasion of tumours and age groups [X2 (6, N=50)=2.702, p=0.845 at α=0.05] where adults are more likely to be affected by Stage-3 (PT-III) CRCs. However, no significant relationship was seen between the tumour stages and sex [X2 (2, N=50)=1.292, p=0.524 at α=0.05]. A graphical presentation of stage of tumours according to age groups and sexes has been depicted in Figure 4 and the summary of the frequency of tumours according to stages, age groups and sexes with their relationship is shown in Table 4.

Figure 4: Graphical presentation of stages of tumours according to age groups and sexes. PT-I: low pathological invasion; PT-II: moderate pathological invasion, PT-III: fair pathological invasion; PT-IV: high pathological invasion.

Table 4: Frequency of tumours according to stage of tumor based on the pathological depth of invasion. age groups and sexes with their relationship.

PT-I; PT-II; PT-III; PT-IV; No.: Number of occurrence; %: Percentage of occurrence;
^a: X2 (2, N = 50) = 36.640, p = 0.000 at α = 0.05; ^b: X2 (6, N = 50) = 2.702, p = 0.845 at α = 0.05; ^c: X2 (2, N = 50) = 1.292, p = 0.524 at α = 0.05

Studied CRC cases were further classified based on the involvement of regional lymph nodes by the tumor (PN) where cases with no lymph node involvement was grouped in PN0, metastasis in one to three regional lymph nodes in PN1, metastasis in four or more regional lymph nodes in PN2 and the cases where Lymph nodes could not be assessed was grouped in PNx. Almost half (48%) of the study cases was categorized in PN0 followed by PN2, PN1 and PNx in 26%, 22% and 4% cases, respectively. The involvement of regional lymph nodes was highly related to the occurrence of CRCs [X2 (3, N=50)=19.600, p=0.000 at α=0.05]. It is more likely that regional lymph nodes were not involved in CRC cases. However, no significant relationship was seen between the lymph node invasion and age groups [X2 (9, N=50)=6.915, p=0.646 at α=0.05] or sex [X2 (3, N=50)=2.620, p=0.454 at α=0.05]. Figure 5 illustrates the graphical presentation of different classes of CRC cases based on the involvement of regional lymph nodes according to age groups and sexes whereas Table 5 summarizes the frequency of different classes of CRC cases based on the involvement of regional lymph nodes according to stages, age groups and sexes with their relationship.

Figure 5: Graphical presentation of different classes of tumours based on involvement of regional lymph nodes according to age groups and sexes. PNO: no lymph node involvement; PN1: metastasis in one to three regional lymph nodes; PN2: metastasis in four or more regional lymph nodes; PNx: lymph nodes could not be assessed.

Table 5: Frequency of tumours according to involvement of regional lymph nodes by the tumor, age groups and sexes with their relationship

N1: ; N2: ; N3: ; N0: ; No.: Number of occurrence; %: Percentage of occurrence;
^a: X2 (3, N = 50) = 19.600, p = 0.0001 at α = 0.05; ^b: X2 (9, N = 50) = 6.915, p = 0.646 at α = 0.05; ^c: X2 (3, N = 50) = 2.620, p = 0.454 at α = 0.05

Discussion

Although CRC is more likely to occur at old age, nowadays, younger patients are increasingly affected by different types of CRCs [13]. In this study, half (50%) of the cases belonged to the 35-54-years age group, with a mean of 48.60 ± 14.6 years which is lower than that reported age from the Western world [13-15]. Salminen, et al., 2005 recorded 59 years as the mean age of CRC in their study in the Finnish population and Turner, 2014 observed only 20% cases to occur below the age of 50 years [14,15]. However, Saha et al., 2016 and Raza et al., 2016 recorded the mean age as 50.77 years and 47 ± 14.8 years, respectively in Bangladeshi colorectal cancer patients [16,17], which are in good agreement with this study. The occurrence of CRCs specially in relatively young age group may be attributed to the recent change in food habits of Bangladeshi active-aged people (35-54 years) who have shifted to western diets that ae well documented as a contributor to colon cancer. It has been reported that consumption of red or processed meats is associated with an increased risk of colon cancer [18]. Consumption of high fat containing foods like red or processed meats induces increased bile acids secretion that in turn results in altered microbial composition in gut [19, 20]. Such alternation in microbial community contributes to the production of different metabolites that might influence the development of colon cancer [20]. Moreover, geographical and environmental factors of the study population may have influenced the findings as well. However, the higher incidence of CRCs in the younger age group of Bangladeshi patients in comparison to western studies is alarming. This interesting finding necessitates the importance of cancer screening program and this report may be considered in future studies to evaluate predisposing and genetic factors for CRCs in this region.

In the current study, there was male preponderance (64%) with a male to female ratio 1.8:1. Studies conducted elsewhere also showed higher incidence of CRC among male patients [14,16,17]. Urbanization and changes in lifestyles might have contributed to the transformation in food habit from native to western diets rich in high fat which are known to trigger colon cancer. In association with altered food habit, higher incidence of smoking, alcohol consumption or genetic factors might be responsible for this male predominance.

Clinical presentations are different for proximal and distal CRC. In our study, per rectal bleeding was the most frequent finding (38.7%) in distal CRCs whereas, generalized weakness and pallor were the chief complaints of the patients with CRCs in proximal colon (38.98%). These features are consistent with the findings of reported elsewhere [5].

The most commonly observed location of CRC in this study is distal colon (62%). Rectum was most frequently observed site (28%). Other Bangladeshi studies conducted also found similar findings [17,21,22]. Occurrence of CRC in Bangladeshi population is higher in distal colon due to some unknown etiology which may be related to some genetic factors.

The exophytic pattern was the most common gross morphology observed in 60% cases followed by ulcerating (30%) and infiltrative pattern (10%). In this study, only two histological types of colorectal adenocarcinoma: adenocarcinoma (NOS) and mucinous adenocarcinoma were observed. Adenocarcinoma (NOS) comprises the majority (76%) of the total cases. These findings were consistent with the findings of other studies indicating common gross and histopathological feature of CRCs [17,21-23].

Among the 50 cases, 72% cases were Grade II tumours, 24% were Grade III and 4% were Grade I tumours. All of the mucinous adenocarcinoma was considered poorly differentiated (grade III). Several studies suggest that CRCs occuring in younger patients (less than 50 years of age) are less differentiated [24]. In the present study, 34% of Grade-II and 14% of Grade III tumours were observed in 35- 54 years of age whereas 22% Grade-II and 4% Grade III tumours were recorded in 55-74 years of age. Present study findings are in close agreement with previous findings that documented less differentiated CRCs are likely to occur within 50 years of age [23]. However, a statistically significant association between age group and tumor grade was not observed possibly due to a smaller sample size.

We also categorized study cases according to the PT and PN stage of the tumor. Our study revealed that PT3 (68%) and PN0 (48%) were the most commonly reported stages of tumor in CRC cases based on the depth of invasion and lymph node metastasis, respectively. Studies conducted elsewhere reported that colorectal cancers in young patients (<50 years of age) are biologically aggressive and present at advanced stage [9,25]. In our study, PT3 and PT4 stages were recorded in 34% and 6% cases, respectively in 35-54 years age group in comparison to 20% PT3 and 2% PT4 stages in 55-74 years age group. In the case of nodal staging, metastasis in one to three regional lymph nodes (PN1) was observed in 12% of cases in 35-54 years age group which was double of the observed cases (6%) in the 55-74 years age group. Our study findings for pathological invasion and metastasis in lymph nodes in CRC cases clearly support previous study reports that documented biological aggressiveness and advanced stage in colorectal cancers in patients under 50 years of age. All these studies suggest that patients with colorectal adenocarcinomas usually present with advanced morphology in histopathology.

Conclusion

Present study findings on colon cancer were different from that described in the western countries. Active aged people (35-54 years old) were found to be significantly affected by CRC in our study. In majority of the cases, the tumour presented at a locally advanced stage. Quick urbanization, fast shifting to western food, lack of proper knowledge on CRC might account for some of these differences. Routine screening program is proposed for early detection and treatment of the cases to reduce the burden of morbidity and mortality. Genetic tests should also be carried out to unveil the cause of young age presentation of CRCs. However, this study had its own limitations. The study reflects to the findings of a specific geographical area with a small sample size. Therefore, further studies should be conducted all over the country with a larger sample size for a more comprehensive understanding on demographic and clinicopathological profiles of CRCs in Bangladesh.

Acknowledgements

The authors gratefully acknowledge the logistics and grant support to conduct the research activities from Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh.

Availability of Data and Materials

Raw data, supplemental data and materials are available on request.

Conflict of Interests

The authors declare that they have no conflict of interests in publishing the article.

Ethical Consideration

Written consent from individual patient/representative of patients was obtained for using the samples for research purposes. No personal data/information of patients was shared in public.

Author’s Contributions

SSUM planned, designed and performed the study. She also wrote the manuscript (MS). FB, MMR & AZ helped in planning & designing of the study and developing the research question. PR, TI, USS, UTN, SA and NA helped in data collection and processing. KBMS helped in study design, data screening and performed data analyses, interpretation and MS writing. All authors read and approved the final manuscript.

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Bilateral Optic Neuropathy Induced by COVID-19

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DOI: 10.31038/IMROJ.2023812

Abstract

Introduction: Bilateral optic neuropathy caused by the novel coronavirus SARS-CoV2 (COVID-19).

Case report: A 25 years old female COVID-19 (+) applied to our clinic with complaints of bilateral progressive visual loss. Two weeks prior to onset of eye and vision symptoms, she had tested positive for coronavirus disease (COVID-19) virus by nasopharyngeal polymerase chain reaction (PCR) after developing symptoms of shortness of breath and cough. One week prior to her admission, bilateral blurred and vision loss progresivvely. In her ophthalmological examination; right and left visual aquity were 10/200 with blurred vision and ocular tensions were 15 mmHg and 16 mmHg, right and left, respectively. Anterior segment in both eyes were natural, there were no active cells, however, there were optic disc edema and retinal edema in both eyes. The diffusion cranial MR was normal.

Discussion: Optic neuropathies is a clinical diagnosis based on the history and examination findings, generally. Because important findings on funduscopic examination help differentiate typical from atypical cases of optic neuritis, an ophthalmologic examination can be considered in the clinical evaluation. Our patient is believed to have acute bilateral optic neuropathies induced by COVID-19 infection. Ispite of optic neuropathies in young ages are usually associated with MS, our patient is an interesting and rare case induced by COVID-19 infection with bilateral optic neuropathies.

Keywords

The novel coronavirus SARS-CoV2 (COVID-19), Optic neuropathy

Introduction

Optic neuropathies in adults are usually unilateral and commonly linked to multiple sclerosis (MS). It usually occurs as sudden onset of visual loss associated with pain on eye movement and progress in its course to reach its maximum deficit in a week [1]. Diagnosis is usually clinical based on history and examination findings. Brain and orbital imaging such as magnetic resonance imaging (MRI) help in the diagnosis in most cases. After confirmation, treatment is usually standart. Bilateral acute optic neuropathies are seen rarely, particularly in individuals without known systemic inflammatory or autoimmune disorders.

Case Presentation

A 25 years old female COVID-19 (+) (the novel coronavirus SARS-CoV2) patient came to our clinic with bilateral vision loss in august 2021. Two weeks prior to onset of eye and vision symptoms, she had tested positive for coronavirus disease (COVID-19) virus by nasopharyngeal polymerase chain reaction (PCR) after developing symptoms of shortness of breath and cough. She was quarantined at her home and treated symptomatically with improvement; she never required hospitalization for his respiratory illness nor medications including hydroxychloroquine.

One week prior to her admission, bilateral blurred and vision loss progresivvely. She has no past medical history presented from clinic with bilateral eye pain and vision loss and family history of any neurological or immunological diseases. In her ophthalmological examination; right and left visual aquity were 10/200 with blurred vision and ocular tensions were 15 mmHg and 16 mmHg, right and left, respectively. Anterior segment in both eyes were natural, there were no active cells, however, there were optic disc edema and retinal edema in both eyes (Figures 1 and 2), and also seen in optic coherence tomography (OCT) (Figures 3 and 4). The diffusion cranial MR was normal.

Figure 1: Right eye fundus photography

Figure 2: Left eye fundus photography

Figure 3: Optic coherence tomography of right eye

Figure 4: Optic coherence tomography of left eye

Our patient was started on methylprednisolone 1 g every 24 hours for a total of 5 days/doses. Within 48 hours, his vision and eye pain had shown significant improvement. By day of discharge, our patient had complete restoration of vision in the left eye with remarkable but not complete vision recovery in the right eye. He was discharged on a tapering dose of prednisone over 4 weeks with planned follow-up with ophthalmology and neurology.

Discussion

Optic neuropathy is defined as a demyelinating, inflammatory condition that causes acute, usually monocular, visual loss. It is highly associated with MS, and it is the presenting feature in 15% to 20% of these patients and occurs in 50% of them at some time during their illness [2].

It is believed that the demyelination in optic neuropathies is immune-mediated, but the exact targeted antigens remain unknown [3].

Optic neuropathies is a clinical diagnosis based on the history and examination findings, generally. Because important findings on funduscopic examination help differentiate typical from atypical cases of optic neuritis, an ophthalmologic examination can be considered in the clinical evaluation. MRI of the brain and orbits with gadolinium contrast provide a better assessment of the diagnosis in most cases. Further diagnostic testing, such as lumbar puncture, is done to exclude other causes of visual loss in atypical cases. However, around 60% to 80% of patients with acute optic neuropathies have nonspecific findings in the CSF such as lymphocytes and elevated proteins [4].

Our patient is believed to have acute bilateral optic neuropathies induced by COVID-19 infection. Once the diagnosis of optic neuropathies is made, treatment is usually straightforward with intravenous methylprednisolone (typically 1 g per day for 3 days) often followed by oral prednisone (1 mg per kg per day for 11 days), with subsequent tapering over a period of 4 days [2]. Treatment is associated with a more rapid recovery of vision by 2 to 3 weeks with no impact on long-term visual function. Therefore, a follow-up with neurology and ophthalmology after discharge is recommended to reach a final diagnosis in cases like this.

Ispite of optic neuropathies in these young ages are usually associated with MS, our patient is an interesting and rare case induced by COVID-19 infection with bilateral optic neuropathies.

Conclusion

Our patient described in this clinical vignette has signs and symptoms typical of acute bilateral demyelinating optic neuritis on his presentation. His evaluation with brain and orbital MRI along with lumbar puncture to determine the possibility of MS or other autoimmune disease was negative as well as other laboratory assessment. Therefore, we believe his infection with COVID-19 virus has triggered his immune system to present these findings. COVID-19 virus infection is causing a huge impact in the world as pandemic; its extent as clinical disease is still poorly understood and explained.

Declaration of Interest

I have no declaration of interest.

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