Author Archives: author

Clear Aligners in Maxillary First Premolar Extraction Case with Space Closure: Biomechanics Studied Using Three-Dimensional Finite Element Analysis

DOI: 10.31038/JDMR.2024724

Abstract

Background: The biomechanics of clear aligner (CA) orthodontics in maxillary first premolar extraction cases with space closure are not yet fully understood. This study aimed to investigate the biomechanics of en-mass retraction(EMR)(0.2mm) of maxillary anterior teeth after first premolar extraction using a CA system, employing the finite element model (FEM). The goal was to provide a more comprehensive theoretical foundation for both clear aligner treatment (CAT) and its design for cases with EMR of maxillary anterior teeth.

Methods: Using Cone-Beam Computed Tomography (CBCT), an adult volunteer with normal occlusion who met the modelling standards in the Stomatological Hospital of Nankai University was scanned. Models including a maxillary dentition without first premolars, the periodontal ligament (PDL), alveolar bone, and a CA were established using Mimics 17.0, Geomagic Studio 12.0, and UG NX software packages. ANSYS Workbench 19.0 was used for preprocessing, parametric design, mesh generation, and data analysis.

Results: The maxillary anterior teeth exhibited distal and palatal tipping, accompanied by extrusion and torque loss. Mesial tipping, intrusion and anchorage loss of the posterior teeth were observed. This is a typical roller coaster effect (RCE) in orthodontics. Stress distribution within the PDL and alveolar fossa was concentrated in the cervical and apical regions, aligning with the trend of tipping tooth movement. The entire CA showed tendencies to dislocate and bow bend with more pushing stress distribution on the labial aspect of the CA’s anterior region and mesial wall of the canine area suggesting a pushing device. In addition, the premolar extraction junction area and posterior regions were identified as primary stress-bearing components.

Conclusion: In treatments involving premolar extraction using the CA technique, it is crucial to implement strategies to counteract RCE caused by CA bow bending during retraction. Moreover, it is imperative to enhance torque control in the anterior teeth and protect anchorage in the posterior teeth.

Keywords

EMR, Biomechanics, CA, RCE, FEM

Introduction

Both fixed and removable orthodontic appliances correct malocclusion, characterized by uneven teeth or misalignment of dental arches, through tooth movement using the premolar extraction protocol in most cases [1-3]. This approach poses challenges to controlling precise tooth movement in three-dimensional directions [4]. In 1999, Align Technology, Inc. (San Jose, CA, USA) introduced clear aligner treatment (CAT), leveraging computer-aided design (CAD) and manufacturing. Based on virtual tooth movement designs created by CAD software [5], aligners incrementally induce tooth movements through a series of aligners to achieve intended outcomes [6]. CAT offers several advantages over traditional wire-bracket systems, such as aesthetic appeal, reduced discomfort, lower forces, and improved time efficiency with fewer visits and emergencies [6]. However, the efficacy of CAT, particularly in complex malocclusions requiring extractions, especially for premolar extraction protocol, is subject to debate due to unclear force interplay and biomechanics mechanisms [7-12]. Unlike fixed orthodontics where tooth movement results from wire-bracket interactions, CAT relies on force from aligner-teeth shape mismatches [11], and the complete coverage of tooth crowns by aligners complicates the assessment of force and moment application on the tooth [12]. Although introducing auxiliary devices such as attachments improves the control of the clear aligner (CA) on tooth movements, its effectiveness remains unsatisfactory. In CAT, normally, treatment strategies adopt a step-by-step movement to reduce side effects, such as roller coaster effect (RCE) [13,14] in premolar extraction cases. Although this method is effective, it inevitably leads to an extension of the treatment cycle. To enhance efficiency and shorten the treatment span, the technique of en-mass retraction (EMR) has become a future trend in the development of CAT. EMR is particularly suitable for cases requiring minimal to moderate anchorage but is also frequently used in most cases to close small gaps in the progress and refinement stages of treatment. From these perspectives, EMR will play an important role in future CAT and be used in many cases. However, the biomechanics of EMR in practice are not fully understood, and the related side effects, as well as how to effectively prevent and manage them, have not been fully resolved. Therefore, investigating the biomechanics of EMR, along with gaining a deeper understanding of the biomechanics of CAT to prevent unwanted tooth movements, is crucial. Such endeavors establish a significant foundation for enhancing clinical CAT and supporting further scientific studies.

Finite element model (FEM) analysis, known for its non-invasive precision, is crucial in examining mechanical impacts of orthodontic devices (including clear aligners) and quantifying stresses and movements in orthodontic studies [15-17]. This study aims to elucidate the biomechanical principles and side effects of EMR without auxiliary equipment, providing a scientific basis for optimizing CAT. The objectives are to prevent unwanted tooth movements,  refine treatment planning, reduce duration, minimize patient discomfort, establish a foundation for future research, and contribute to the advancement of CA orthodontics.

Methods

Model Construction

Jaw and Dentition Scanning: The jaw and dentition of the volunteer were scanned using cone-beam computed tomography (CBCT) (EW00-VATECH, South Korea). The exposure settings were as follows: 15×15 cm field of view, 10.0 mA, 90 kVp, total scanning time of 15.0 seconds, effective radiation time of 4.0 seconds, and voxel size of 0.3 mm. During image acquisition, the subject was seated upright, and an ear rod was used to stabilize their heads so that the Frankfort horizontal plane was parallel to the floor. The acquired Digital Imaging and Communications in Medicine (DICOM) format data were imported into Mimics 17.0 (Materialise, Belgium). The alveolar bone and teeth data were extracted using threshold segmentation in the 900–3095 HU range. Following grey value selection, region growing, noise reduction, and binarization, a three-dimensional (3D) model of the maxillary dentition and jaw was developed. This model was refined, smoothed, and glossed in Geomagic Studio 12.0 (Raindrop, USA) to create a high-precision solid 3D model. It was then imported into UG NX 12.0 (UGS, USA) to solidify the geometric structure. The bilateral maxillary first premolars were removed in this software to create premolar spaces, and the dentition without first premolars was remarked as initial dentition M. High-precision geometric models were obtained (Figure 1), serving as the foundation for subsequent experimental models, ensuring no software error superposition. According to the scientific literature, the roots of the teeth are spread uniformly along the outer surface to obtain the PDL (continuous 0.25 mm) [7]. Research indicates that tooth movement per step in CAT ranges from 0.20 to 0.33 mm, typically designed as 0.2 mm per step in both clinical and scientific studies [18]. Therefore, based on the initial dentition (M), the maxillary anterior teeth were retracted bodily by 0.2 mm in the sagittal direction (Consistent with the Z-axis), and the obtained new dentition was marked as N [19]. Next, N was imported into Geomagic Studio 12.0 software to process the space between every two teeth separately. The outer surface of the crown was extracted as the inner surface of the CA and sliced through the boundary curve of the crown. The template thickness was 0.5 mm, and the Boolean operation was carried out with N to obtain a solid geometric model of CA (Figure 1). These solid models were assembled (Figure 1) and imported  into ANSYS Workbench 19.0 (ANSYS, USA) for parameter setting, mesh generation, loading, and other simulations. The EMR of the maxillary anterior teeth was simulated with a bodily displacement of 0.2 mm (per aligner) in the sagittal direction. The postprocessing function was used to evaluate the data. For the baseline, no auxiliary devices (like attachments) were introduced in this study. All experimental procedures conformed to the guidelines of the Stomatological Hospital Medical Ethics Committee of Nankai University, and informed consent was obtained from the volunteer.

Figure 1: The three-dimensional finite element models of maxillary teeth, alveolar bone, PDL and CA. Maxillary teeth (A), Periodontal ligament (B), Assembly (C), Maxillary alveolar bone (D), Maxillary clear aligner (E), Assembly section (F).

Material Properties, Interaction, and Boundary-Settings

The model substances were defined as continuously homogeneous and isotropic, and the orbital floor of the maxillary alveolar bone served as a fixed constraint. A frictional interaction between the crown and the CA was set, with a coefficient of 0.2. Binding restrictions were applied between the teeth, PDL and alveolar bone. The elastic moduli for the alveolar bone, teeth, PDL, and CA were set to 2,000, 20,000, 0.05, and 450 Mpa, respectively, with Poisson’s ratios of 0.30, 0.30, 0.35 and 0.40, respectively [20].

Mesh Division and Results

The CA used triangular six-node shell elements, and the other models adopted tetrahedral ten-node elements, both of which have properties such as plasticity, wiggling ability, large deformation, and high tensility. Node counts for the entire model, alveolar bone, teeth, PDL, and CA were 1138046, 257810, 569455, 117193, and 193598, respectively, with component counts of 726808, 162931, 390852, 58026, and 114999, respectively.

Coordinate System Setting

The global coordinate system was used to define the direction of x, y, and z axes. The X-axis is positively directed to the patient’s left side, parallel to the occlusal plane. The Z-axis positively directed perpendicularly to the X-axis towards the tooth root apex. The Y-axis, positive in the direction perpendicular to both X- and Z-axes, pointed towards the incisor. Opposite directions corresponded to their respective negatives.

Calculation and Analysis

The bilaterally symmetrical model was analyzed using the right maxillary model. The analysis focused on tooth displacement, periodontal tissue stress distribution, CA deformation, and CAbearing stress distribution.

Results

Maxillary Dentition, PDL, CA, 3D-FEM

High-quality 3D FEMs of the maxillary teeth, PDL, alveolar bone, CA, along with their assembly were obtained in this study (Figure 1).

Initial Displacement Trend and Value of Teeth

Figure 2 shows the teeth displacement trend and Table 1 presents measurements of the incisor edge midpoint, canine cusp, buccal cusp of the second premolar, and both buccal and palatal cusps of the first molar, as well as the tooth root apex. The initial displacement value of the maxillary teeth corresponded with the movement trend, exhibiting tipping movements in the opposite direction of the crown and root. The incisor crown has tipped distally, and the palatally root is inclining labially and mesially. A similar pattern was observed in the canine. The central incisor, lateral incisor, and cuspid showed increasing distal tipping, decreasing palatal tipping, and occlusal extrusion. Posterior crowns tipped mesially and palatally, with roots on the distal and buccal sides. Vertically, the second premolar was intruded, the mesial cusp of the first molar was intruded, while the distal cusp extruded. These tooth movement patterns align with a typical side effect of RCE. RCE occurs during canine retraction with a light, flexible NiTi (nickel-titanium) wire. Due to its insufficient stiffness, the wire bends under retracting forces, causing the molar and premolar crowns to tip mesially and extrude distally. This bending leads to the canine crown tipping distally, which, influenced by the orientation of the canine bracket, results in the extrusion of the incisors and a deepened bite [21]. Significant 3D movement was also observed in the lateral incisor, along with notable buccal movement of the cuspid and palatal movement of the second premolar.

Table 1: Initial displacement of maxillary anterior teeth on X,Y and Z axes(mm)

Tooth

Position X-axis Y-axis

Z-axis

Central incisor crown

-0.02597

0.13336

-0.23133

root tip

0.00724

0.04616

-0.08820

Lateral incisor crown

-0.21951

-0.22496

-0.15497

root tip

0.08623

0.07647

-0.05400

Canine crown

-0.27002

-0.03771

-0.01360

root tip

0.03566

0.03715

-0.02142

Second premolar crown

0.08141

0.30111

0.01008

root tip

-0.03286

-0.13297

-0.00267

First molar Mesial buccal cusp

0.05133

0.03523

0.02731

Mesial lingual cusp

0.04913

0.02863

0.01610

Distal buccal cusp

0.04857

0.02082

-0.02108

Distal lingual cusp

0.07070

0.02105

-0.02410

Mesial apex

-0.04498

-0.02054

0.00088

Distal apex

-0.04719

-0.01927

-0.00143

Palatal apex

-0.02016

-0.00962

-0.00055

Note: The left side of the X-axis is positive; the direction of the central incisor on the Y-axis is positive; the direction of the apex of the tooth on the Z-axis is positive.

Figure 2: Initial displacement trend of maxillary teeth. Central incisor (A), Lateral incisor, Canine (B), Second premolar (C), First molar (D). The front, middle, and back rows represent the palatal, mesial, and distal views, respectively. The direction and length of the arrows indicate the displacement direction and magnitude, as well as the deformation extent.

Stress Distribution of Periodontal Tissue

Figure 3 depicts PDL stress concentrated in the cervical and apical regions of the maxillary teeth. Anterior teeth stress is primarily located on the palatal and distal surfaces in cervical areas and the buccal and mesial zones in apical regions. Posterior teeth stress predominated in the mesial cervical areas and the distal apical regions. Figure 4 illustrates PDL’s tensile and compressive stresses, defined as the negative and positive maximum principal stress, respectively. Incisors exhibited compressive stress on the palatal-distal cervical and labial-mesial apical regions, and tensile stress on the labial-mesial cervical areas and palatal-distal apical areas. The canines showed similar stress patterns as the incisors. For the posterior teeth, compressive stress appeared in the mesial cervical and distal apical regions, while tensile stress was found in the distal cervical and mesial apical areas. Notably, in the lateral incisor, stress concentrations were also observed in the labial and mesial cervical surfaces and palatal and distal apical regions. According to Figure 3 and Table 2, the highest stress appeared in the anterior teeth’ distal and palatal cervical regions, the mesial cervical regions of the second premolar and the first molar, and the apical areas. Figure 5 shows stress in the alveolar socket localized in the cervical regions and not evident in other areas. Table 2 indicates that the absolute value of peak tensile stress was more significant than that of compressive stress, with high stress on both sides of the extraction region. Moreover, the stress in posterior teeth was evidently greater than that in anterior teeth.

Table 2: Comparison of peak PDL stress in maxillary teeth (MPa)

Tooth

Equivalent stress Tensile stress

Compressive stress

Central incisor

0.025

0.013

-0.007

Lateral incisor

0.023

0.020

-0.006

Canine

0.037

0.018

-0.013

Second premolar

0.042

0.037

-0.011

First molar

0.046

0.021

-0.008

Figure 3: The equivalent stress distribution of PDL in maxillary. Central incisor (A), Lateral incisor (B), Canine (C), Second premolar (D), First molar (E).

Figure 4: The tensile and compressive stress of periodontal ligament in maxillary teeth. Central incisor (A), Lateral incisor (B), Canine (C), Second premolar (D), First molar (E).

Figure 5: The equivalent stress distribution of alveolar socket. Central incisor (A), Lateral incisor (B), Canine (C), Second premolar (D), First molar (E).

Figure 6: Overlay of CA: The grey is the original CA, and the colour is the stretched CA. Right (A), Front (B), Left (C).

Figure 7: CA deformation trend. Anterior region (A), Posterior region (B). The direction and length of the arrows indicate the displacement direction and magnitude, as well as the deformation trend.

Figure 8: The equivalent stress distribution of CA. Labiolingual side of anterior area (A and B), Buccal and palatal sides of posterior area (C and D).

CA Displacement Deformation and Stress Distribution

Figure 6 indicates that the entire CA exhibited typical bow bending, characterized by distal-palatal tipping of the anterior region with occlusal disengagement, and the posterior part shifting palatalmesial and detaching occlusally. Figure 7 illustrates the propensity for deformation and detachment of the CA. The mesial region of the second premolar was intruded, the second molar area was poorly dislocated, and the extraction segment was the most severely deformed. The deformation prosperities of CA directly contribute to RCE. Table 3 reveals the average movement values of the mesial, distal, and middle edges of CA in each tooth location on the X-, Y-, and Z-axes, reflecting the displacement of CA and the 3D shift of CA margins. As per Figure 8, CA stress was primarily concentrated at the junctions, widespread in the posterior region, with the highest peak value at the mesial junction of the second premolar. Stress was almost absent on the palatal side of the CA incisor region and the distal side of the CA canine area, but prevalent in the labial area of the CA incisor region and mesial region of the CA canine area, suggesting that the CA functions as a pushing orthodontic appliance.

Table 3: Initial displacement of CA on X, Y and Z axes (mm).

Position

X-axis Y-axis Z-axis
labial/buccal lingual/palatal labial/buccal lingual/palatal labial/buccal

lingual/palatal

Central incisor

-0.014

-0.016 0.128 0.174 -0.047

0.061

Lateral incisor

-0.083

-0.097 0.095 0.173 -0.024

0.051

Canine

-0.053

-0.125 -0.167 -0.177 -0.025

0.037

1st premolar

-0.009

-0.003 0.074 0.118 -0.019

-0.052

2nd premolar

-0.016

-0.075 0.209 0.181 -0.029

-0.040

1st molar

-0.015

-0.037 0.198 0.137 -0.120

-0.072

Note: The left side of the X-axis is positive; the direction of the central incisor on the Y-axis is positive; the direction of the apex of the tooth on the Z-axis is positive.

Discussion

FEM analysis is the only method for studying the biomechanics of CAT that includes the periodontium, allowing the calculation of stresses and movement in any part of the loaded model. The validity of the FEM analysis is confirmed when its calculated outcomes align with actual clinical situations. In FEM analysis, the traditional loading method was shorting the aligner directly, which was not compatible with the actual design and manufacture of aligners [22]. Our loading approach referred to related research in the field. Firstly, we developed the CA based on the dental model (N) with a 0.2 mm em-mass retraction of maxillary anterior teeth in the sagittal direction (Specific descriptions included in the model construction part). Subsequently, the constructed CA from the first step was loaded into the initial dentition (M) to complete the loading [20]. The CA and teeth were designed to be in frictional contact, with a coefficient of 0.2 [23]. The outcomes of this study align with those of clinical practice [11,19], supporting its validity of FEM analysis. Numerous clinical studies have identified the RCE phenomenon in premolar extraction cases treated with CAT [24], consistent with the findings of this study. The RCE is observed under large forces when a light, flexible, round NiTi archwire of low strength is used for retracting anterior teeth. NiTi does not have the stiffness to remain rigid when a retracting force, such as an elastic chain, is stretched from the molar to the canine. The molar and premolar crowns tend to tip mesially and extrude distally. The flexible NiTi then bends gingivally and, as a result, tends to tip the canine crown distally. The orientation of the canine bracket when the crown tips distally tends to extrude the incisors and deepen the bite. The CA functions similarly to the described NiTi wire.

Limitations in achieving 3D orientation of teeth with CAT can diminish orthodontic treatment efficiency and hinder the development of a healthy, balanced, stable, and aesthetically pleasing stomatognathic system [25-27]. In this study, the central incisor, lateral incisor, and cuspid exhibited an increase in distal tipping and a decrease in palatal tipping during EMR. This pattern indicates a predominant palatal tipping of the incisors and a primarily distal tipping of the cuspids. It has been proposed that CA cannot perform root-controlled tooth movement because retraction forces are applied to crowns, bypassing the occlusal side of the resistance center [28,29]. For another, from a biomechanical perspective, it is also challenging for CAs to produce an effective counterclockwise moment (The counterclockwise moment is from the CA deformation facilitating resisting the tipping) on incisors during retraction. These effects lead to more clockwise than counterclockwise moments on anterior teeth and finally cause inadequate torque control and resultant palatal tipping of the incisors. Such limited torque control may also result in increased gingival exposure of incisors, reduced overjet, and occlusal interference, which in turn could lead to diminished smile aesthetics, hindered retraction, and potentially cause buccal open bite or even anchorage loss [30,31]. In addition, tipping movement has been linked to an increased risk of root resorption, particularly in cases with maximal retraction and a root apex near the labial cortical bone [32,33]. It is natural to conclude that the effective expression of torque in upper incisors is crucial for controlling root movement in the sagittal plane. However, the CA covers the incisor crowns, and the elasticity of the gingival margin makes it difficult to apply force in this region [34]. These challenges, along with the limited properties of the materials used and irregular morphology of anatomical crowns, contribute to a torque control efficiency that is reduced to around 35.21%. To overcome this weakness, Invisalign has introduced power ridges. These ridges improve torque control by utilizing the elastic force generated from the aligner’s reversible deformation near the gingival margin and the counterforce produced by tooth movement against the inner opposite surface of the aligner at the incisor edge. Additionally, research indicates that using attachments can provide similar effectiveness in controlling torque. However, aligners are prone to detachment during torquing, significantly affecting the fit between the incisor edge and the aligner. Consequently, the force couple generated by the CA may be insufficient. Torque loss can be avoided within a 10° range, but a 50% loss still exists beyond the range of 10°. Furthermore, research indicates that maxillary incisor torque control error can be as high as 8.5° [30], even with conventional fixed orthodontic appliances, torque control is not complete even when using thick steel wires. I would mention this for completeness, with adults more susceptible to torque loss than adolescents [35], and the actual amount of incisor tipping often exceeds predictions [36]. Therefore, besides using power ridges and attachments, enhancing torque control through overcorrection, adding steps, maintaining scattered spaces in incisor regions, and increasing CA wrapping is recommended. In canine retraction, the canine can be first pushed distally against by incisors, followed by incisor retraction [25]. This approach maintains a space between the canine and lateral incisor, enhancing the aligner’s wrapping for better canine translation, and ensures a good fit between the aligner and incisors, thereby increasing torque expression. Additionally, the G6 root-control attachment can be applied to cuspids to create a counterclockwise moment, preventing distal tipping. However, studies have reported an accuracy error of 0.6 to 5° with this attachment. Consequently, some researchers recommend designing an additional 5–10° of cuspids root distal tipping or crowns mesial tipping for overcorrection and using a power arm (combine CA and fixed appliance) to support bodily cuspid movement. There is a belief among some experts that a smaller tipping force is beneficial for anchorage protection and periodontal health. CAT might take cues from the Begg orthodontic technique [37], which allows initial anterior teeth tipping followed by axis uprightness. Yet, there are concerns that uprighting can cause periodontal stress in the alveolar crest and root apex, potentially leading to bone height loss and root resorption in these areas. Moreover, the effectiveness of this technique in reducing molar anchorage burden remains a topic of debate and warrants further research. Combined fixed orthodontics is thought to extend treatment duration and be less aesthetically pleasing [38].

This study also noted mesial tipping in posterior teeth, especially the second premolar, indicating that the CA might not produce a sufficient clockwise moment. This tendency increases the risk of anchorage loss (posterior mesial tipping results in inadequate anchorage mean anchorage loss), particularly in adolescents, who are more prone to physiological anchorage loss when using invisible orthodontics. To counteract this, Invisalign introduced the G6 anchorage attachment for the first premolar extraction solution [39]. The play between the small functional plane of the attachment and the aligner generates a maximum force arm by activating force perpendicular to the tangent of the tooth’s rotational circle, thereby creating a substantial clockwise moment to resist mesial tipping. However, when the generated clockwise moment is inadequate to counter mesial tipping, it can lead to aligner detachment in the attachment zone, particularly in the vertical direction. This detachment disrupts the critical force-generating alignment between the aligner and the vertical functional plane of the anchorage attachment, ultimately resulting in a diminished effective clockwise moment. Horizontal rectangular attachments, due to their large vertical stress surface and good retention, provide more effective clockwise movement than vertical rectangular attachments, which achieve less movement due to their smaller vertical force surface and poor aligner wrapping and retention. Both 3 mm and 5 mm horizontal rectangular attachments offer better anchorage control than a 3 mm vertical rectangular attachment. Despite these strategies, achieving optimal anchorage control remains a challenge, as mesial tipping can be more significant than predicted [36], and anchorage control is influenced by multiple factors [40]. To enhance anchorage control, it is recommended to perform posterior crown distal tipping and draw on Tweed-Merrifield method [41] (A distalizing force is applied to the maxillary second molar, the distalization force is supported with Class II elastics, anterior vertical elastics, and a high-pull headgear) for anchorage preparation, including a 6.6° distal tipping preparation of the first molar for bodily movement. Additionally, employing Class II intermaxillary elastics, mini-implants, and designing stepwise anterior tooth movement strategies like two-step internal or frog-pattern retraction can be beneficial [42,43]. For optimal anchorage using CA alone, employing stepwise movement for anterior retraction is preferable to reduce the anchorage burden. Additionally, initial anchorage preparation is a good choice. Combining both approaches can effectively protect the anchorage and minimize the burden.

Regarding vertical movements, this study found that anterior teeth were extruded and posterior teeth were intruded, which is in line with other research. The CA’s insufficient vertical control, due to material stiffness limitations and lack of tooth support at extraction sites, leads to anterior tooth extrusion and deepening of the overbite [44]. It’s noteworthy that anterior tooth torque loss can exacerbate a deep overbite. The study showed a decreasing trend in extrusion for central incisors, lateral incisors, and cuspids. And researchers have found that maxillary incisor extrusion often exceeds expectations and the intrusion realization rate of maxillary central incisors and lateral incisors in non-extraction casers were only 51.83% and 58.12%, respectively [45]. Therefore, intruding and overcorrecting anterior teeth, particularly central incisors, is essential for enhanced vertical control in the digital solution. CAs apply a downward force along the incisor tooth axis assisted by pressure areas located at the palatal cingulum. Importantly, when retraction is combined with intrusion, it will further result in a shorter aligner length. This, in turn, increases the palatal force exerted on the incisors and the mesial force on the posterior teeth [24]. Therefore, evaluating the incisor torque and root-bone relationships to prevent palatal tipping of the incisors and cortical anchorage formation is crucial. Equally important is maintaining the cuspid axis upright and enhancing both posterior anchorage and aligner retention. Additionally, for anterior tooth intrusion, a mini-screw can be placed between the central incisors, and an elastic device connecting the precision cuts of the aligner palatal side, bypassing beneath the aligner incisal edge to the mini-screw, can facilitate intrusion while enhancing palatal root torque. It presents a posterior open bite and an intrusion of the first molar by 1 mm more than expected during the closure of premolar spaces using CAs. Posterior intrusion is attributed to aligner sagging and the occlusal splint effect; thus, designing heavy posterior occlusal contacts or vertical elastics to resist sagging [46] and cutting the distal portion of the aligner to allow vertical tooth eruption are recommended strategies.

Teeth are linked to alveolar bone via the PDL, forming a structural unit with standardized form and function. Orthodontic forces on teeth transmit appropriate mechanical forces to periodontal tissues, generating tissue modification and tooth movement [47]. In our study, the stress distribution on tooth PDL aligned with tooth movement patterns. Additionally, the compressive-tensile distribution was also consistent with the tooth movement trend. The evidence again demonstrates the rationality of our study and the reliability of our findings. Consistent with our results, other studies using 3D-FEMs to analyze the sagittal movement of anterior teeth have observed that PDL compressive stresses are distributed in the distal cervical and mesial apex areas, with tensile stresses in the mesial cervical and distal apex. However, for the lateral incisor, the forces on PDL do not entirely correspond with the direction of tooth movement. This suggests a change in the direction of force transmission, resulting in inefficient utilization of force and ultimately leading to inefficient tooth movement towards its target position. In this study, significant stress concentration was observed in the apical periodontium. This indicates a higher stress level at the root apex of the counterpart tooth, raising concerns for potential hyaline degeneration-like periodontal injuries, which necessitate preventive measures in clinical settings. Notably, the stress levels in the posterior region were substantially higher than in the anterior region. This finding underscores the need for enhanced anchorage protection and prevention of CA dislocation. It suggests the utilization of attachments to modify tooth morphology and contact areas for improved anchorage control and CA retention.

A material’s stiffness (E) is inversely related to its susceptibility to deformation forces. The E value of a similar size CA is 40–50 times lower than that of a typical NiTi archwire [48] indicating that CA material is not sufficiently stiff. In this study, the CA exhibited bow bending due to the shortening of the aligner with a force similar to that of a wooden bow with relative pull at both ends. This effect, compounded by insufficient material stiffness and lack of tooth support in the extraction area, led to the observed bow bending of the aligner (Figure 9). This deformation produces a clockwise moment on the anterior segment, leading to palatal tipping and extrusion, intrusion pressure on the middle part, and a counterclockwise moment on the posterior segment, causing mesial tipping. The interference located in anterior teeth resulted in a buccal open bite. These features are the typical RCE effects observed in closing premolar extraction gaps with thin NiTi wires. Fixed orthodontics resolves this issue with larger, stiffer arch-wires. In CAs, due to the uniformity of material in all stages, it is recommended to modify aligner structure to prevent bow bending. Strategies such as designing CAs of maxillary compensating curve shape and incorporating anti-bending elements in extraction areas can help reduce sagging. Changing beam geometry significantly impacts beam properties; for instance, doubling a beam’s length halves its strength and reduces its stiffness eightfold [2]. Designing tooth movement steps can indirectly enhance the stiffness of the aligner, the CA and teeth are similar to a beam, the smaller the distance between the teeth, the greater the CA stiffness, especially in the extraction area. In maximum anchorage cases, the anterior teeth should be retracted in stages. For medium anchorage cases, the cuspids and second premolars can be designed to move alongside each other before moving the other teeth. This approach increases the steps followed by reducing the aligner span without tooth support, and minimizes the step distance, preventing aligner bending and facilitating the continuous application of orthodontic force. CAs, being viscoelastic, can permanently deform under small forces. The larger the force applied (the larger the step distance), the faster the decay, and ultimately, the shorter the effective orthodontic force maintained. With the development of 3D printing technology, biomechanically oriented CAs can be designed using different materials at varied orthodontic stages and in various parts of the CA [49]. This study also found substantial aligner dislocation, with significant 3D movement in lateral incisor and a tendency to lose grip, attributed to inadequate inversion of the lateral incisor crown, suggesting designing attachment for better retention, and lowering tooth movement speed for preventing tooth derailment. Remarkable buccal movement of the cuspid and palatal movement of the second premolar may stem from poor aligner stability on either side of extraction areas, altering stress distribution. Clinically, attachments and intra-maxillary elastics can bolster appliance strength and reduce changes in the direction of force transfer. Enhancing CA retention involves strengthening attachment design and modifying diaphragm material structure, such as forming a natural chemical bond between the diaphragm and teeth through saliva. The displacement values indicated a labial-buccal shift in the CA edge, consistent with the CA’s deformation, as the body and edge of the CA rotated in opposite directions, which further proves the CA undergoes bow bending during the retraction of anterior teeth and also provides strong evidence for the RCE we observed in our study. The CA stress distribution suggested the extraction area is susceptible to damage and the material is easily fractured. Therefore, aligner structural design in extraction areas should be reinforced to prevent mechanical system disruption through CA fracture, affecting force transmission and aligner effectiveness. During retraction, stresses in the CA’s incisal region are primarily labially distributed, with almost no palatal stress, and more stress areas are in the mesial region of the cuspid than in the distal region. This differential stress distribution suggests that during anterior teeth retraction, the CA primarily exerts a pushing force, indicating that it functions as a pushing orthodontic appliance rather than a pulling one, and employing the aligner pushing technique is advantageous for facilitating canine translation.

Figure 9: The bowing bending of CA causes the roller coaster effect. Clear aligner sagging (A), Counterclockwise moment (B), Clockwise moment (C).

Conclusions

This study determined that RCE occurs during premolar space closure with CAs, primarily due to the biomechanical properties of the aligners themselves. During space closure, a noticeable occlusal detachment of the CA was observed, accompanied by characteristic bow-bending deformation. Additionally, this study identified that CAs function as a pushing device, exerting a direct pushing force on the teeth. Thus, understanding the biomechanics of CAT is crucial for optimizing clinical outcomes. This includes enhancing torque control and anterior tooth intrusion, improving anchorage, increasing resistance to tipping and intrusion of posterior teeth, preventing bowbending deformation, and improving appliance retention.

Abbreviations

CBCT: Cone-Beam Computed Tomography; CA: Clear Aligner; CAT: Clear Aligner Treatment; FEM: Finite Element Model; 3D: Three-Dimensional; PDL: Periodontal Ligament; RCE: Roller Coaster Effect; EMR: En-Mass Retraction.

Availability of Data and Materials

The datasets used and or analysed during the current study are available from the corresponding author upon reasonable request.

Authors’ Contributions

Song Cang, Xiaosong Xiang, and Chunlin Wang conceptualized and designed the study, contributed to the manuscript framework, collected and analyzed the data, and drafted and revised the manuscript. Xiaosong Xiang and Chunlin Wang contributed equally as co-first authors. C. Maarten Suttorp and Frank A. D. T. G. Wagener revised the manuscript. Zhihao Wang assisted with data collection and analysis. All authors reviewed and approved the final manuscript..

Competing Interests

The authors declare that they have no competing interests.

Consent for Publication

Not applicable.

References

  1. Council of Orthodontics Professors (2020). Textbook of Orthodontics, 4th ed.; Daehan Narae Publishing House: Seoul, Korea.
  2. Profitt, W (2020). Contemporary Orthodontics, Elsevier: Amsterdam, The Netherlands.
  3. Bergomi M, Wiskott HW, Botsis J, Mellal A, Belser UC (2010). Load response of periodontal ligament: assessment of fluid flow, compressibility, and effect of pore pressure. J Biomech Eng.132: 014504. [crossref]
  4. Cao WQ, Chen FY, Gu YJ (2014). Three-dimensional finite element analysis of maxillary incisors with high traction pressure of J-hook. Stomatology.34: 257-260.
  5. Savignano R, Barone S, Paoli A, Razionale AV (2017). Advances on Mechanics, Design Engineering and Manufacturing.Springer International Publishing AG: Cham.405-414.
  6. Kim WH, Hong K, Lim D, Lee JH, Jung YJ, et al. (2020). Optimal Position of Attachment for Removable Thermoplastic Aligner on the Lower Canine Using Finite Element Analysis. Materials (Basel). 13: 3369. [crossref]
  7. Cortona A, Rossini G, Parrini S, Deregibus A, Castroflorio T (2020). Clear aligner orthodontic therapy of rotated mandibular round-shaped teeth: A finite element study. Angle Orthod. 90: 247-254.[crossref]
  8. Schupp W, Haubrich J, Neumann I (2010). Class II correction with the Invisalign system. J Clin Orthod. 44: 28-35.
  9. Barone S, Paoli A, Razionale AV, Savignano R (2017). Computational design and engineering of polymeric orthodontic aligners. Int J Numer Method Biomed Eng.33: e2839. [crossref]
  10. White DW, Julien KC, Jacob H, Campbell PM, Buschang PH (2017). Discomfort associated with Invisalign and traditional brackets: A randomized, prospective trial. Angle Orthod. 87: 801-808. [crossref]
  11. Gomez JP, Peña FM, Martínez V, Giraldo DC, Cardona CI (2015). Initial force systems during bodily tooth movement with plastic aligners and composite attachments: A three-dimensional finite element analysis. Angle Orthod.85: 454-60. [crossref]
  12. Mariko G, Wakana Y, Hitoshi K, Norio I, Koutaro M (2017). A method for evaluation of the effects of attachments in aligner-type orthodontic appliance: Three-dimensional finite element analysis, Orthodontic Waves.76: 207-214.
  13. Lu W, Li Y, Mei L, Li Y (2023). Preformed intrusion bulbs on clear aligners facilitate active vertical control in a hyperdivergent skeletal Class II case with extraction: A case report with 4-year follow-up. APOS Trends Orthod.13: 46-54.
  14. Roberts WE, Chang CH, Chen J, Brezniak N, Yadav S (2022). Integrating skeletal anchorage into fixed and aligner biomechanics. J World Fed Orthod.11: 95-106. [crossref]
  15. Rossini G, Schiaffino M, Parrini S, Sedran A, Deregibus A, et al. (2020). Upper second molar distalization with clear aligners: a finite element study. Applied Sciences.10: 7739.
  16. Schmidt F (2022). 3D Quantification of Orthodontic Tooth Movements for Treatment Planning and Monitoring[D]. Universität Ulm.
  17. Cattaneo PM, Dalstra M, Melsen B (2005). The finite element method: a tool to study orthodontic tooth movement. J Dent Res. 2005; 84: 428-33. [crossref]
  18. Vlaskalic V, Boyd R (2001). Orthodontic treatment of a mildly crowded malocclusion using the Invisalign System. Australian orthodontic journal. 17: 41-46.[crossref]
  19. Jiang T, Wu RY, Wang JK, Wang HH, Tang GH (2020). Clear aligners for maxillary anterior en masse retraction: a 3D finite element study. Sci Rep. 10: 10156. [crossref]
  20. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C (2014). Treatment outcome and efficacy of an aligner technique–regarding incisor torque, premolar derotation and molar distalization. BMC Oral Health.14: 68.[crossref]
  21. Venugopal A, Manzano P,Rengalakshmi S (2020). A Novel Temporary Anchorage Device Aided Sectional Mechanics for Simultaneous Orthodontic Retraction and Intrusion. Case reports in dentistry.
  22. Iliadi A, Koletsi D, Eliades T (2019). Forces and moments generated by aligner-type appliances for orthodontic tooth movement: A systematic review and meta-analysis. Orthod Craniofac Res. 22: 248-258. [crossref]
  23. Sheng Y, Guo HM, Bai YX, Li S (2020). Dehiscence and fenestration in anterior teeth: Comparison before and after orthodontic treatment. J Orofac Orthop.81: 1-9. [crossref]
  24. Zhu Y, Hu W, Li S (2021). Force changes associated with differential activation of en-masse retraction and/or intrusion with clear aligners. Korean J Orthod.51: 32-42. [crossref]
  25. Machado RM (2020). Space closure using aligners. Dental Press J Orthod. 25: 85-100.
  26. Jiang T, Jiang YN, Chu FT, Lu PJ, Tang GH (2021). A cone-beam computed tomographic study evaluating the efficacy of incisor movement with clear aligners: Assessment of incisor pure tipping, controlled tipping, translation, and torque. Am J Orthod Dentofacial Orthop. 159: 635-643. [crossref]
  27. Baldwin DK, King G, Ramsay DS, Huang G, Bollen AM (2008). Activation time and material stiffness of sequential removable orthodontic appliances. Part 3: premolar extraction patients. Am J Orthod Dentofacial Orthop.133: 837-45. [crossref]
  28. Buschang PH, Ross M, Shaw SG, Crosby D, Campbell PM (2015). Predicted and actual end-of-treatment occlusion produced with aligner therapy. Angle Orthod. 85: 723-7. [crossref]
  29. Liu L, Zhan Q, Zhou J, Kuang Q, Yan X, et al. (2021). Effectiveness of an anterior mini-screw in achieving incisor intrusion and palatal root torque for anterior retraction with clear aligners. Angle Orthod. 91: 794-803. [crossref]
  30. Lombardo L, Arreghini A, Ramina F, Huanca Ghislanzoni LT, Siciliani G (2017). Predictability of orthodontic movement with orthodontic aligners: a retrospective study. Prog Orthod.18: 35.[crossref]
  31. Mehta S, Patel D, Yadav S (2021). Staging Orthodontic Aligners for Complex Orthodontic Tooth Movement. Turk J Orthod. 34: 202-206. [crossref]
  32. Liu W, Shao J, Li S, Al-Balaa M, Xia L et al. (2021). Volumetric cone-beam computed tomography evaluation and risk factor analysis of external apical root resorption with clear aligner therapy. Angle Orthod.91: 597-603. [crossref]
  33. Li Y, Deng S, Mei L, Li Z, Zhang X, et al. (2020). Prevalence and severity of apical root resorption during orthodontic treatment with clear aligners and fixed appliances: a cone beam computed tomography study. Prog Orthod. 21: 1. [crossref]
  34. Hahn W, Zapf A, Dathe H, Fialka-Fricke J, Fricke-Zech S, et al. (2010). Torquing an upper central incisor with aligners–acting forces and biomechanical principles. Eur J Orthod. 32: 607-13. [crossref]
  35. Dai FF, Xu TM, Shu G (2019). Comparison of achieved and predicted tooth movement of maxillary first molars and central incisors: First premolar extraction treatment with Invisalign. Angle Orthod. 89: 679-687. [crossref]
  36. Dai FF, Xu TM, Shu G (2021).Comparison of achieved and predicted crown movement in adults after 4 first premolar extraction treatment with Invisalign. Am J Orthod Dentofacial Orthop. 160: 805-813. [crossref]
  37. Swain BF, Ackerman JL (1969). An evaluation of the Begg technique. Am J Orthod. 55: 668-87.[crossref]
  38. Papadimitriou A, Mousoulea S, Gkantidis N, Kloukos D (2018). Clinical effectiveness of Invisalign® orthodontic treatment: a systematic review. Prog Orthod. 19: 37.[crossref]
  39. Lie Ken, Jie RKP (2018). Treating Bimaxillary Protrusion and Crowding with the Invisalign G6 First Premolar Extraction Solution and Invisalign Aligners. APOS Trends in Orthodontics. 8: 219-224.
  40. Geron S, Shpack N, Kandos S, Davidovitch M, Vardimon AD (2003). Anchorage loss–a multifactorial response. Angle Orthod.73: 730-7.
  41. Klontz HA (1996). Tweed-Merrifield sequential directional force treatment. Seminars in orthodontics. 2: 254-267. [crossref]
  42. Lin LY, Chang CH, Roberts WE (2020). Bimaxillary protrusion and gummy smile treated with clear aligners: Closing premolar extraction spaces with bone screw anchorage. APOS Trends in Orthodontics. 10: 120-131.
  43. Ojima K, Dan C, Nishiyama R, Ohtsuka S, Schupp W (2014). Accelerated extraction treatment with Invisalign. J Clin Orthod. 48: 487-99. [crossref]
  44. Upadhyay M, Arqub SA (2022). Biomechanics of clear aligners: hidden truths & first principles. J World Fed Orthod.11: 12-21. [crossref]
  45. Al-Balaa M, Li H, Ma Mohamed A, Xia L, Liu W, et al. (2021). Predicted and actual outcome of anterior intrusion with Invisalign assessed with cone-beam computed tomography. Am J Orthod Dentofacial Orthop.159: e275-e280. [crossref]
  46. Khosravi R, Cohanim B, Hujoel P, Daher S, Neal M, et al. (2017). Management of overbite with the Invisalign appliance. Am J Orthod Dentofacial Orthop. 2017; 151: 691-699. [crossref]
  47. Bertossi D, Galzignato PF, Conti G, Luciano U, Gualdi A, et al. (2018). Histological evaluation of periodontal ligament in human after orthodontic treatment with piezosurgery and monolateral tooth dislocation and ligament distraction technique: a first morphologic and histologic evaluation. J Biol Regul Homeost Agents. 32: 9-13. [crossref]
  48. Skaik A, Wei XL, Abusamak I, Iddi I (2019). Effects of time and clear aligner removal frequency on the force delivered by different polyethylene terephthalate glycol-modified materials determined with thin-film pressure sensors. Am J Orthod Dentofacial Orthop. 155: 98-107. [crossref]
  49. Tartaglia GM, Mapelli A, Maspero C, Santaniello T, Serafin M, et al. (2021). Direct 3D Printing of Clear Orthodontic Aligners: Current State and Future Possibilities. Materials (Basel). 14: 1799. [crossref]

Personal Traits that Influence Resilience in Women Who Completed Chemotherapy for Breast Cancer

DOI: 10.31038/CST.20251012

Abstract

Background: In Ghana, chemotherapy is the primary treatment for breast cancer, often leading to significant physical and emotional challenges due to drug side effects. While global literature highlights improved breast cancer survival rates, there is limited research on the personal traits influencing resilience in Ghanaian women who undergo chemotherapy for breast cancer, despite their remarkable ability to navigate treatment challenges and its aftermath.

Methods: This exploratory descriptive qualitative study investigated the perspectives of 14 breast cancer survivors in Accra who endured chemotherapy- related distress. Participants were recruited purposively, meeting specific criteria, and interviewed in English using a semi-structured guide. Data collection and analysis were conducted concurrently. Data were analyzed inductively to uncover themes without predefined frameworks. Trustworthiness was ensured through strategies like member checking, triangulation, and reflexivity. Ethical approval was obtained from Noguchi Memorial Institute for Medical Research (NMIMR), and participants provided informed consent before being audio-recorded. Interviews lasted 45–60 minutes, achieving saturation by the 12th interview, with two additional sessions confirming findings. Identified codes were grouped into sub-themes and themes with findings highlighting survivors’ lived experiences and the care they received.

Results: Four (4) themes; hope, optimism, self-esteem, and confidence and 13 sub-themes emerged from the data.

Conclusions: In the absence of structured support systems, resilience in surviving breast cancer treatment is primarily shaped by individual personality traits such as hope, optimism, self-esteem, and confidence and emotional responses to the illness. A more structured support system aimed at fostering resilience and boosting personal traits among women receiving chemotherapy for breast cancer is highly recommended.

Keywords

Personal traits, Resilience, Women, Breast cancer, Chemotherapy

Background to the Study

Breast cancer remains one of the most prevalent cancers affecting women globally. According to the [1], breast cancer accounts for 12.5% of all new cancer cases worldwide, making it a significant public health challenge. Advances in treatment, including surgery, radiation therapy, and systemic therapies such as chemotherapy, have significantly improved survival rates over the past decades. Despite these advancements, chemotherapy—a cornerstone in breast cancer treatment—is often associated with severe physical and psychological burdens, including fatigue, nausea, emotional distress, and disruption of daily life [2]. For women undergoing chemotherapy, these challenges can impact their overall quality of life and mental health.

In low- and middle-income countries (LMICs), including sub- Saharan Africa, the burden of breast cancer is compounded by late- stage diagnoses, limited access to healthcare resources, and cultural stigmas surrounding cancer [3]. In Ghana, breast cancer is the leading malignancy among women, with an estimated incidence rate of 20.4 per 100,000 women [4]. The increasing survival rates call for a shift in focus from merely treating the disease to addressing the psychosocial and emotional needs of survivors [5].

Women who complete chemotherapy for breast cancer often exhibit remarkable resilience, enabling them to navigate the challenges posed by the treatment and its aftermath. Resilience, defined as the ability to recover from or adapt to adversity, is a multidimensional construct influenced by personal, social, and environmental factors [6]. However, while there is an expanding body of literature on resilience in cancer survivors, the specific personal traits that influence resilience in women who have completed chemotherapy for breast cancer remain underexplored. Existing research highlights the importance of psychological factors such as optimism, emotional regulation, and self-efficacy, as well as the role of social support and lifestyle choices in fostering resilience [7,8].

In the Ghanaian context, breast cancer survivors often face unique cultural and socioeconomic challenges, including limited access to psychosocial support services and societal expectations of stoicism [9]. The lack of context-specific studies addressing the personal traits that contribute to resilience in this population limits the ability of healthcare providers to develop effective, tailored interventions. Understanding these traits is crucial for designing psychosocial programs that enhance the well-being and survivorship experiences of women who have undergone chemotherapy for breast cancer.

Aim of the Study

This study aims to explore the personal traits that influence resilience in women who have completed chemotherapy for breast cancer.

Methods

Research Design

The study utilized an exploratory descriptive qualitative research design, deemed suitable for providing detailed insights into the perspectives of women who survived breast cancer and endured chemotherapy-related distress, supported by the care they received [10,11].

Participants and Setting

The research was conducted in Accra, targeting women aged 18 and older diagnosed with breast cancer and residing within the Accra Metropolis. Participants met specific inclusion criteria: a breast cancer diagnosis, completion of chemotherapy, and fluency in English. Exclusion criteria included newly diagnosed breast cancer patients, those with altered mental status, and individuals who were acutely ill or in pain. A total of 14 participants were recruited using purposive sampling.

Data Collection Method

Individual qualitative interviews were conducted with the 14 participants. Permission was obtained from the Teaching Hospital where the study took place. Eligible participants were recruited and provided with information sheets explained in simple terms. Interview sessions were arranged through phone calls. A semi- structured interview guide ensured the focus of the study. Face-to-face interviews, conducted in English at participants’ convenience, were audio-recorded with their consent and lasted between 45 minutes and an hour. Saturation was achieved after interviewing 12 participants, with two additional interviews conducted to confirm saturation.

Data Analysis

Data were analyzed using inductive content analysis [12]. This method involves deriving categories, subthemes, and themes directly from the data without relying on pre-existing frameworks, allowing for the emergence of new insights. Data analysis was conducted concurrently with data collection [12,13]. Transcriptions were performed verbatim and reviewed multiple times by the first author to extract meaning. Codes representing similar concepts were grouped into subthemes, and related subthemes were organized into overarching themes. To ensure objectivity, the second and third authors reviewed the process to eliminate potential biases.

Trustworthiness and Reflexivity

To ensure rigor, trustworthiness, and reflexivity, various strategies were employed [14-16]. Member checking involved seeking participant clarification on unclear responses and confirming their statements during interviews. Data triangulation compared field notes with transcripts to accurately represent participants’ experiences. Dependability was reinforced by involving impartial reviewers—the second and third authors, who supervised the first author’s process. Reflexivity was maintained through bracketing, separating the researchers’ personal experiences from the study to minimize biases. Confirmability was achieved by meticulously reviewing transcripts before interpretation, while an audit trail documented raw data, analysis notes, field diaries, and recordings.

Ethical Considerations

The study received ethical approval from the Noguchi Memorial Institute for Medical Research in Ghana (NMIMR), under reference number NMIMR-IRB CPN 111/15-16. Participants were provided with detailed information about the study’s objectives, procedures, risks, and benefits. Informed consent was obtained through signed or thumb-printed forms, ensuring inclusivity for participants of varying literacy levels.

Results

Demographic Characteristics of Participants

The study involved 14 women aged 38 to 78 years. Specifically, 3 participants were in their late 30s, 5 in their early 40s, 3 in their early 50s, 1 in their early 60s, and 2 in their late 70s. The mean age was approximately 49.5 years, with a standard deviation of 13.6 years. Educational backgrounds varied, with 4 participants having secondary education, 2 with vocational training, and 8 with tertiary education. Regarding religious affiliations, 10 participants were Christians, 3 Muslims, and 1 Traditionalist.

The majority of participants (79%) were married, with marriage durations ranging from 1 to 38 years; 1 participant was single, and 2 were widows. The number of children ranged from 1 to 5. Participants’ occupations included teachers, nurses, fashion designers, bankers, and businesswomen. Breast cancer diagnoses were made between 2013 and 2016, with treatments completed between 2014 and 2017. The participants represented various tribes, including Ga, Akan, Adangbe, Ewe, Hausa, and Dagaare. For more details, refer to Table 1.

Table 1: Demographic characteristics of participants.

Synonyms

Age Level of education Religion Marital status No. of children Occupation Date of diagnosis Date of completing treatment

Tribe

P1

44

Tertiary Christian Married

3

Teacher

2015

2016

Ga

P2

77

Secondary Traditional Widow

5

Trader

2014

2015

Ga

P3

50

Tertiary Christian Married

4

Nursing

2013

2014

Ga

P4

38

Vocational Christian Married

1

Fashion designer

2016

2017

Adangbe

P5

61

Secondary Christian Married

2

Pensioner

2013

2014

Ewe

P6

38

Tertiary Christian Married

2

Fashion designer

2016

2017

Ga

P7

44

Secondary Muslim Married

2

Textile telephones

2014

2015

Dagaare

P8

50

Tertiary Christian Married

3

Teacher

2016

2015

Aka

P9

44

Tertiary Muslim Married

4

Teacher

2013

2014

Hausa

P10

43

Tertiary Christian Married

2

Banker

2015

2016

Akan

p11

43

Vocational Muslim Married

5

Fashion designer

2013

2014

Hausa

P12

39

Tertiary Christian Married

2

Teacher

2016

2017

Akan

P13

78

Tertiary Christian Widow

3

Pensioner

2015

2016

Ewe

P14

51

Secondary Christian Single

2

Business women

2014

2015

Akan

To answer the research question, what are the personal traits that influence resilience among breast cancer women who received chemotherapy for breast cancer, four (4) themes and fourteen sub- themes emerged from the data. The themes are: hope, optimism, self- esteem, and confidence. See Table 2 for details.

Table 2: Themes and Sub-themes.

Themes

Sub-themes

 

 

1.         Hope

•    Hope in nurses

•    Hope in doctors

•    Hope in patients themselves

•    Breast cancer survivors

•    Hope in God

 

2.         Optimism

•    Focus on positive mindset

•    Avoidance coping

•    Acceptance coping

3.         Self-esteem •    Strong inner voice/Self-motivation,

•    Setting of new goals

 

4.         Confidence

•    Self-reliance

•    Preparedness

•    Confidence in health care practitioners

Theme One: Hope

After the analysis of data, the personal trait that influenced resilience in women who completed chemotherapy for breast cancer were; hope in nurses, hope in doctors, hope in patients, themselves, hope in breast cancer survivors and hope in God.

Hope in Doctors

The participants expressed hope and expectations in the doctors that took care of them during chemotherapy. They expressed that they were hopeful that doctors were going to help them to recover because they were under their cared.

“I put my trust in the doctors because I wanted recovery and they were those to care for me and so they became my only hope”. P1

“…so, when I came to the hospital and then the treatment started, I trusted and also had expectation that the doctors were going to help me through my chemotherapy”. P14

Hope in Nurses

Participants narrated that prior to their chemotherapy they were scared based on the unknown outcome of their treatment. However, they reported that their experiences with nurses on the first day at the hospital changed their believe as they received warm reception from nurses. To the participants, that gave them hope that their treatment journey will be smooth and probably end well

“my experience with the first nurse on my first day gave me hope and this expectation kept repeating itself till I finished my treatment”. P10

“…. formerly I perceived nurses as unintelligent workers who don’t care about patients but my chemo provided me with an opportunity to really know them. They offered me hope throughout my days during hospitalization. I can say from day one at the OPD what the nurse there counselled me on gave me hope athat my cancer journey was going to smooth”. P2

“For me, I was hopeful and this was placed within the context of finding meaning in my suffering, the pain and sadness I experienced every day during my chemo was too much but I didn’t give-up. I knew I was going to get hope due to the good relationship the nurses were offering to us, that was quiet assuring”. P4

Hope in Participants Themselves

Majority of the participants also placed their hope in themselves for recovery, as they believed that they are winners and can persevere throughout the treatment.

…so, all days I kept hoping for the best. I didn’t look down upon myself no, no way. I kept telling myself you are a conqueror; you are more than a conqueror”. P2

“I am one person who hardly quit. I persevere. Within me is full of hope”. P8

“I took it easy and I have to, because all I have at that time was hope. Personally, I take everything in my life easy although I was anxious initially, I later told myself that if I am worried, I can’t change anything and so, I have to just hope for the better.”. P6

Hopes in Breast Cancer Survivors

Other participants placed their hopes in breast cancer survivors who reassured them and wished them a speedy recovery. The personal testimonies of the survivors were sources of hope, which took away participants fears.

“There was this organisation called Breast Cancer Survivors Association, whose members came to give me and my family hope by offering us more information about breast cancer and how I can contribute to my survival, after all, they were living testimonies for us”. P9

“…so, I was not afraid, after all some patient had recovered from same condition and others from similar diagnosis and they were all there to offer us any information we wanted. That gave many of us hope because here are people who suffered what I am suffering and if they recovered from it that is assuring”. P12.

Hope in God

Other participants were hopeful that God will see them through their chemotherapy. They believed and trusted in the blood of Jesus.

There were instances when I used to sing this song, “my hope is built on nothing less than Jesus blood and righteousness” (long laugh) oh yeah and you feel God’s presence around you. So, I was hopeful God will do something”. P13

“ Hope is belief and beliefs are found in God. So, all I needed at that time was hope in God so that even if i die as they say it can lead to, i will go to heaven and that if I live I live for Him. So, my hope was only on Christ and Christ alone (laughter)”. P8

Theme Two: Optimism

The second theme that emerged from the data was optimism with the sub-themes; focus on positive mindset, avoidance coping and acceptance coping.

Focus on Positive Mindset

Participants indicated that they looked at the positive side of their conditions. They reported that by focusing on what they could do to keep healthy rather than on the negative circumstances of life kept them moving on with life.

I was inclined to look on the more positive side of my condition and to expect the greatest result from treatment since many women who came to the hospital had recovered, so I tuned my mind that surely I can recover”. P8

“…. believing in myself with much focus enables me to look more on what I could do to help myself. So, I kept saying I can overcome”. P7

Avoidance Coping

Participants narrated that they adopted avoided coping mechanism during their chemotherapy journey because of some misconceptions about breast cancer and it causes.

“…In fact, I was stable in mind that am going to get well. I tried as much not to let my church people know about it except my pastor and even at my work place only my brother-in-law knew about it because I trusted him. People gossip a lot and some of them don’t even think cancer can be cured and I never wanted any bad advice so I kept it to myself because I believed I was going to be healed”. P10.

“…. you know the misconceptions of Ghanaians about cancer. Most of them believed it is gotten through fornication and adultery, and others it is a curse and all that, but with my background as a health worker I was quite certain about the future that I will be well after all, we have discharged many with complete recovery from breast cancer”. P5.

Acceptance Coping

Some participants also narrated that they were able to cope with cancer and treatment duress by acceptance their present condition as a natural phenomenon, a circumstance they have no control of.

“…you know!! a condition like cancer, if you are not a person that is willing to accept that it is a condition you have no control of, it will be difficult to adjust to its treatments…I initially had a similar challenge till my second cycle of thermotherapy when I came to terms with the fact that I need to accept my present situation (cancer diagnosis) and move on. That really did the trick for me”. P14

Without first accepting to the fact that hey, this is the impact of cancer and chemotherapy…my brother, you will run away from the chemo, the drugs are many and come with a lot of side effects and for me to think I can take all these medications and get well, then I needed to be optimistic and accept all the effects knowing that its but for a while”. P12

Self-Esteem

Participants narrated that they were able to cope with cancer and its treatment through a feeling of strong inner voice/self-motivation and setting of new goals.

Strong Inner Voice/Self-Motivation

Participants indicated that their ability to even stretch their hands and switch on their phones was enough motivation for them to trust that their treatment journey will be successful. Other participants revealed that there was a strong inner voice encouraging them to keep going

“To the extent that I find it’s helpful to spend time to switch on my phone and take a selfie and forward it to my loved ones like before was enough for me, actually I had a strong feeling that I am fine and anything from someone to me is the person’s opinion”. P3

“I’m a person with deep feelings; I could hear an inner voice saying to me, this is nothing, God will help you out. It is that voice that kept encouraging me, so I had a positive feeling that I will get well, yeah”. P13

Setting of New Goals

Participants narrated that they never bordered to compare themselves to those who could not successfully recover from breast cancer. According to these participants, they set new goals and tune their minds on happy moments in order to overcome the effects of the chemotherapy and the disease burden.

“Hmmm, I did so many things to help me, like …. I never compare myself to any one…. I mean those who couldn’t make it through treatment, no. I know people died from breast cancer so I set new goals and thought for myself with the feeling, I am born to win. I tell you with that opinion I could move mountains”. P2.

“You see many people focus on the problem and cry and complain meanwhile those you complain to can’t help you out. As for me, the secret has been that this breast cancer is just one of many problems in life so just this specific situation can’t stop me from going on with life, so I set new goals for myself”. P1

Confidence

Confidence is another positive factor that influenced resilience among women with breast cancer who received chemotherapy. Participants revealed that they were self-reliant, prepared and had Confidence in health care practitioners

Self-reliant

participants expressed confidence in themselves and that contributed to their recovery. They said that self-confidence is needed to manage the effect of chemotherapy treatment.

“I needed confidence my-self, because to take chemo for a whole year (long laugh) my son, you need confidence, yes, else you can’t finish the chemo, you will stop because of its effects”. P3

“…to take chemo for almost one year it’s very important to be confident else I couldn’t have been able to finish my treatment. When you are not confident you will say is ok, I won’t take the treatment again because the side effects are a lot”. P5

Confidence is what got me here. I needed confidence to enable me stay and complete my treatment. When you are on chemo, and you are not confident in yourself you can’t stay to complete the chemo the side effects are just too many”. P7.

Preparedness

Participants narrated that they used past experiences from their mensural pains to cope with chemotherapy effects.

“…my mensural cycle pains have not been different from my cancer experiences…so for me I have learn how to cope with pain and life struggles since I started menstruating”. P4

“My past experience on menstrual pains has been a blessing in disguise. It has taught me how to cope with pain, so, I see this cancer experiences as similar to my monthly cycle pains and that helping me adjust to treatment”. P6

Confidence in Health Care Practitioners

Others expressed the opinion that they survived due to the confidence they had in doctors and nurses during the chemotherapy. They were of the conviction that the competence of the health team will help them, most importantly after their first chemotherapy dose.

“I was of the conviction that I needed confidence from the health care team to be able to stay through after receiving my first dose of chemo. My whole system changed and I could feel am no more the same and at this point all I need was to be sure the nurses and doctors knew what they were about’’. P9.

“…So, all I needed was to see them (nurses and doctors) confident in their procedures to assure me I will be fine because of the drug’s effects I was experiencing; and when I saw the confidence level the nurses showed (xxxx name mentioned) to me during my chemo I became ok throughout in my mind and that helped”. P1

Discussion

The findings of this study revealed four themes that encapsulate the personal traits influencing resilience among women who received chemotherapy for breast cancer: hope, optimism, self-esteem, and confidence. These themes are further enriched by fourteen sub- themes that provide deeper insights into the various ways these traits manifest. This discussion examines these findings in the context of existing literature, emphasizing their alignment with prior studies while acknowledging areas of divergence.

Hope

Hope emerged as a pivotal trait, with participants expressing reliance on sources such as nurses, doctors, themselves, breast cancer survivors, and God. This aligns with studies that highlight hope as a critical component of psychological resilience in cancer patients [17]. Hope in healthcare providers, particularly doctors and nurses, was tied to trust in their expertise and care quality. Similar findings are reported by [18], who found that positive patient-provider interactions bolster hope and treatment adherence. Hope derived from breast cancer survivors further supports prior research, such as [19,20], which underscores the impact of peer support on emotional well-being and resilience.

However, the centrality of hope in God reflects cultural and spiritual dimensions unique to the participants. Studies like those of Nyarko and colleagues affirm the significant role of spirituality in the resilience of African cancer patients [21,22], underscoring the interplay between cultural beliefs and coping mechanisms. Conversely, research in predominantly secular contexts [23] places less emphasis on spiritual hope, highlighting a cultural variance.

Optimism

Optimism, expressed through positive mindsets, avoidance coping, and acceptance coping, was another prominent trait. Participants’ ability to focus on the positives aligns with [24] conceptualization of optimism as a vital trait fostering resilience. Avoidance coping, despite its occasional association with negative outcomes, was viewed positively here by participants as a means of reducing exposure to stigma and misconceptions-a finding supported by [25,26] in the context of Ghanaian cancer patients. While participants viewed avoidance as protective, broader literature often critiques avoidance as counterproductive in resilience [27]. This suggests that the efficacy of avoidance coping may be context-dependent, influenced by cultural factors and individual perceptions of stigma and support.

Acceptance coping, where participants embraced their condition as a natural phenomenon, echoes findings of [28,29], who emphasize the role of acceptance in mitigating emotional distress during cancer treatment. However, some literature, such as that of [30], highlights that excessive avoidance can hinder emotional processing and long- term resilience, suggesting a potential area for further exploration.

Self-esteem

Self-esteem emerged as a cornerstone for resilience, with participants citing strong inner voices and goal-setting as pivotal. These findings resonate with studies by Campbell-Sills and colleagues [31]], which emphasize the role of self-motivation and personal agency in building resilience. The emphasis on setting new goals as a way to maintain focus and motivation is supported by the goal-setting theory of resilience [32].

While the study highlights self-esteem as a positive force, it contrasts with findings by Lim colleagues [33], who observed that individuals with lower self-esteem were more likely to experience prolonged emotional distress post-treatment. This divergence underscores the importance of understanding individual differences in resilience pathways.

Confidence

Confidence, encompassing self-reliance, preparedness, and trust in healthcare practitioners, was also crucial. Participants’ self-reliance aligns with [34] self-efficacy theory, which identifies belief in one’s abilities as essential for overcoming adversity. Preparedness, as shaped by prior experiences such as menstrual pain, highlights the role of experiential learning in resilience building, corroborating findings of [35] on post-traumatic growth.

Confidence in healthcare practitioners was tied to perceived competence and empathy, echoing findings of [36,37], which emphasize the significance of trust in healthcare teams. However, this study’s emphasis on cultural variance, such as reliance on healthcare practitioners’ confidence, offers a fresh perspective that is less emphasized in Western-centric studies.

Conclusion

In the absence of structured support systems, resilience in surviving breast cancer treatment is primarily shaped by individual personality traits such as hope, optimism, self-esteem, and confidence and emotional responses to the illness. While most findings resonate with prior studies, the positive framing of avoidance coping introduces a valuable area for further exploration, particularly in culturally diverse populations.

Declarations

Ethics Approval and Consent to Participate

The Noguchi Memorial Institute for Medical Research Institutional Review Board at the University of Ghana (NMIMR-IRB CPN017/17- 18) granted ethical approval for this study. All participants provided informed consent, and the research adhered to the relevant guidelines and regulations by Helsinki Declaration.

Consent for Publication

Not applicable.

Availability of Data and Materials

The datasets utilized and analyzed during this study can be obtained from the corresponding author upon reasonable request.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

This study was not supported by any specific funding or grants from commercial or public entities.

Authors’ Contributions

All authors contributed to the conceptualization of the study. SG was responsible for data collection, and all authors participated in data analysis. SG drafted the manuscript, while LAO, and provided critical revisions. All authors reviewed and approved the final version of the manuscript.

Acknowledgments

The authors extend their heartfelt gratitude to the women who participated in this study.

References

  1. World Health Organisation (2024) Breast cancer Key
  2. America Cancer Society (2023) Breast Cancer Facts & Figures.
  3. Anyigba C, Awandare G, Paemka L (2021) Breast cancer in sub-Saharan Africa: The current state and uncertain future. Experimental Biology and Medicine. [crossref]
  4. Ministry of Health Ghana (2023) Annual health sector performance report. Accra: Ministry of Health.
  5. Foster C, Wright D, Hill H, Hopkinson J, Roffe L (2009) Psychosocial implications of living 5 years or more following a cancer diagnosis: a systematic review of the research European Journal of Cancer Care. [crossref]
  6. Southwick SM, Pietrzak RH, Tsai J, Krystal JH, Charney D (2015) Resilience: an PTSD Research Quarterly.
  7. Bonanno GA (2004) Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist.
  8. Carver CS, Scheier MF (2017) Optimism, coping, and well-being. The handbook of stress and health: A guide to research and Hoboken, NJ, US: Wiley Blackwell.
  9. Iddrisu M, Aziato L, Ohene LA (2021) Socioeconomic impact of breast cancer on young women in Ghana: A qualitative study. Nursing Open. [crossref]
  10. Polit D, Beck C (2020) Essentials of nursing research: Appraising evidence for nursing practice: Lippincott Williams & Wilkins.
  11. Hammarberg K, Kirkman M, De Lacey S (2016) Qualitative research methods: when to use them and how to judge them. Human Reproduction. [crossref]
  12. Vears DF, Gillam L (2022) Inductive content analysis: A guide for beginning qualitative Focus on Health Professional Education: A Multi-Professional Journal.
  13. Kyngäs H (2020) Inductive Content In: Kyngäs H, Mikkonen K, Kääriäinen M, editors. The Application of Content Analysis in Nursing Science Research. Cham: Springer International Publishing.
  14. Olmos-Vega FM, Stalmeijer RE, Varpio L, Kahlke R (2023) A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Medical Teacher. [crossref]
  15. Shenton AK (2004) Strategies for ensuring trustworthiness in qualitative research Education for Information.
  16. Stahl NA, King JR (2020) Expanding approaches for research: Understanding and using trustworthiness in qualitative Journal of Developmental Education.
  17. Vartak J (2015) The Role of Hope and Social Support on Resilience in Cancer Indian Journal of Mental Health (IJMH)
  18. Lichwala R (2014) Fostering hope in the patient with cancer. Clinical Journal of Oncology Nursing. [crossref]
  19. Jiang L, Liu Z, Liao Y, Wang J, Li L (2021) Influence of peer support education on psychological adaptation of breast cancer patients. Chinese Journal of Practical Nursing.
  20. Hu J, Wang X, Guo S, Chen F, Wu Y-y, Ji F-j, et (2019) Peer support interventions for breast cancer patients: a systematic review. Breast Cancer Research and Treatment. [crossref]
  21. Sheppard VB, Walker R, Phillips W, Hudson V, Xu H, Cabling ML, et al. (2018) Spirituality in African-American Breast Cancer Patients: Implications for Clinical and Psychosocial Care. Journal of Religion and Health. [crossref]
  22. Ofei SD, Teye-Kwadjo E, Amankwah-Poku M, Gyasi-Gyamerah AA, Akotia CS, Osafo J, et (2023) Determinants of Post-Traumatic Growth and Quality of Life in Ghanaian Breast Cancer Survivors. Cancer Investigation. [crossref]
  23. Zandi S, Ahmadi F (2025) Religious/Spiritual Coping and Secular Existential In: Liamputtong P, editor. Handbook of Concepts in Health, Health Behavior and Environmental Health. Singapore: Springer Nature Singapore.
  24. Gallagher MW, Long LJ, Richardson A, D’Souza JM (2019) Resilience and Coping in Cancer Survivors: The Unique Effects of Optimism and Cognitive Therapy and Research. [crossref]
  25. Boatemaa Benson R, Cobbold B, Opoku Boamah E, Akuoko CP, Boateng D (2020) Challenges, coping strategies, and social support among breast cancer patients in Advances in Public Health.
  26. Kudjawu S, Agyeman-Yeboah J (2021) Experiences of women with breast cancer undergoing chemotherapy: A study at Ho Teaching Hospital, Nursing Open. [crossref]
  27. Livneh H (2019) The use of generic avoidant coping scales for psychosocial adaptation to chronic illness and disability: A systematic Health Psychology Open. [crossref]
  28. McCracken LM (1998) Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain. [crossref]
  29. Curyło M, Rynkiewicz-Andryśkiewicz M, Andryśkiewicz P, Mikos M, Lusina D, Raczkowski JW, et al. (2023) Acceptance of Illness and Coping with Stress among Patients Undergoing Alcohol Addiction Journal of Clinical Medicine. [crossref]
  30. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K (1996) Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and Journal of Consulting and Clinical Psychology. [crossref]
  31. Campbell-Sills L, Cohan SL, Stein MB (2006) Relationship of resilience to personality, coping, and psychiatric symptoms in young adults. Behaviour Research and Therapy. [crossref]
  32. Locke E, Latham G (1991) A Theory of Goal Setting & Task Performance. The Academy of Management Review.
  33. Seiler A, Jenewein J (2019) Resilience in Cancer Frontiers in Psychiatry.
  34. Bandura A (1997) Self-efficacy: The exercise of control: Freeman.
  35. Sanki M, O’Connor S (2021) Developing an understanding of post-traumatic growth: Implications and application for research and intervention. International Journal of Wellbeing.
  36. Brennan N, Barnes R, Calnan M, Corrigan O, Dieppe P, Entwistle V (2013) Trust in the health-care provider–patient relationship: a systematic mapping review of the evidence International Journal for Quality in Health Care. [crossref]
  37. Hall MA, Dugan E, Zheng B, Mishra AK (2001) Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? The Milbank Quarterly.

Core Shell Quantum Dot Solar Cells: Recent Advances and Future Perspectives

DOI: 10.31038/NAMS.2025811

Abstract

Core-shell quantum dot solar cells (CSQDSCs) have emerged as a promising technology in the field of photovoltaics, offering unique advantages such as tunable bandgaps, enhanced charge carrier dynamics, and improved stability. The core-shell structure mitigates surface defects, passivates dangling bonds, and reduces non-radiative recombination, thereby significantly improving efficiency. Recent advancements in material synthesis, device fabrication, and tandem architectures have demonstrated the potential of CSQDSCs to achieve higher power conversion efficiencies and address the limitations of traditional quantum dot solar cells. However, challenges such as material toxicity, scalability, and long-term stability remain barriers to their commercialization. This mini review highlights the recent progress in CSQDSC research, explores challenges like environmental concerns and cost-effectiveness, and discusses future prospects, including the development of lead-free materials, advanced passivation strategies, and scalable manufacturing techniques. With continued interdisciplinary efforts, CSQDSCs hold great promise for driving sustainable and efficient solar energy solutions.

Keywords

Quantum dot; Core-shell; Solar cell; Nanomaterials

Introduction

Solar energy has unbridled potential to veer the energy sector from pollution causing non-renewable energy sources to the unending renewable source, the sun causing lesser environmental pollution. This transformation of energy requires the materials which can control the flow of current under different circumstances and the research shows that the semiconductors have innate ability to do this. It was in 1954 when Daryl Chaplin, his physicist friend Gerald Pearson and chemist friend Calvin Fuller made the first significantly efficient silicon solar cell [1]. As per a report of April 26, 1954 issue, the Times, it was the beginning of a new era which would eventually lead to the mankind’s most cherished dream of harnessing unlimited power of sun [2]. Fast forward through 68 years of continuous efforts and today we see four generations of solar cells under the light. After exploring the first and second generation solar cells for decades and achieving a saturation of efficiency, the third generation solar cells came into the picture. Every newer generation comes with the hopes of high efficiency, low cost and more environment friendly. The latest generations with the introduction of nanotechnology in the field has given it a new horizon. It has provided us an unparalleled sea of opportunities for synthesizing novel materials which are stable, economical, non-toxic and suitable for absorbing large spectrum of solar radiations. The third generation includes a variety of solar cells made up of materials besides silicon, including dyes, organic materials, perovskite materials and quantum dots. Tremendous research is under the progress to increase the efficiency of these solar cells with low cost. It was not long ago when dye sensitized solar cells (DSSCs) came into the picture as a promising candidate for low-cost efficient solar cells. Here dye acts as a light absorbing material which has the tendency to replace traditional expensive silicon solar cells. In the last decade, DSSCs are largely explored while the research of other solar cells has just begun.

Among all, quantum dot solar cells draw much attention due to unprecedented properties of quantum dots like size dependent tunable band gap, Multiple Exciton Generation (MEG), Hot Electron Extraction (HEE) and wide range of absorption from visible to infrared region. These factors are of much importance as they are helpful in increasing the short circuit current, depicting the possibility of solar cell of 44.7% efficiency (theoretically reported) [3]. The maximum reported efficiency as of yet for QDSCs is 18.1% [4]. Moreover, quantum dots can be used to fabricate low-cost multiple junction solar cells as the different layers can be made up of same material of different band gaps. However, there are some disadvantages associated with quantum dot solar cells. The major problem associated with quantum dots is non-radiative recombination centres or traps causing recombination. Due to these traps, the interfacial charge transportation suffers which decreases the current and thus, efficiency of solar cells. To overcome this problem associated with quantum dots, an idea of covering it with another material was proposed and tested. The covering of quantum dot by another material called shell overcome this problem and the efficiency of solar cells can be increased. Thus, exploring the properties of core shell materials by varying different parameters like concentration of materials, temperature, pH, etc. is an open area of research and the solar cell fabricated using these materials are expected to have good efficiency.

The emergence of core shell nanomaterials and their successful synthesis has taken the research of efficient electronic devices to a new horizon. One material with some properties enveloped by another material having different properties to form a hybrid structure showing enhanced properties has amazed scientists for a long time. The study of the unique properties of core shell nanomaterials, their applications in different fields and their synthesis methods are still at its infant stage and the researchers have a long way to go. Numerous arguments can be given in the favour of the need of core shell materials. These include the enhancement of quantum efficiency, photoluminescence efficiency, fluorescence, thermal stability and chemical stability. The list continues with the reduced toxicity, tuned band gap and passivated dangling bonds [5]. The surface passivation by reduction in the dangling bonds by shell covering is an important reason of the emerging research in this field. The surface traps decrease the free flow of electrons and thus the current. The shell reduces the traps enabling the free flow of electrons and thus opportunity to increase the efficiency of solar cells [6]. This review paper is an attempt to throw light on the recent advances and future perspectives of core shell quantum dot solar cells.

Increased efficiency of Core Shell QD Solar Cells

Many papers have reported the increased efficiency and open circuit voltage of core shell solar cells in comparison to only core. The reason can be successfully attributed to the surface passivation by shell. Quantum dots are generally capped by a ligand viz. oleylamine, oleic acid, etc to be in stable state. However, these ligands create a barrier for charge carriers. Thus, to reduce the barrier, the QD film is exposed to a shorter ligand viz. mercaptopropionic acid, halide anions, etc. Though ligand exchange process reduces the band gap, it introduces several surface defects, vacancies and dangling bonds producing non radiative recombination centres on the surface. These recombination centres trap the charge carriers and reduces the carrier mobility, thus reducing the open circuit voltage and current. One of the proposed ways of eliminating these traps is to envelop the quantum dots by shell [7].

Speirs et. al. [8] have demonstrated solar cells made from PbS@CdS CSQDs and have shown a 147 mV increase in VOC as compared to only core. They have investigated the physical reason behind this enhancement and found the same as the improved passivation of core by the shell and thus lower electron trap density. To demonstrate this, they have fabricated PbS and PbS@CdS Schottky solar cells using layer by layer deposition as reported [9,10]. The current density versus voltage responses of these devices is obtained as shown in Figure 1. It can be seen that though short circuit current is higher for core only i.e. PbS, open circuit voltage is higher for core shell device.

Figure 1: Current density versus voltage curve of PbS and PbS@CdS devices. Reproduced from ref. [8] with permission from Royal Society of Chemistry.

Neo et. al. [11] have shown the effect of surface passivation on PbS@CdS core shell colloidal quantum dot solar cells. The CSQDs have been synthesized using cation-exchange process and used as an active layer in solar cell. The whole process of layer deposition is done using spin coating technique on ITO substrate as reported. Using CSQDs, an improvement in open circuit voltage from 0.42 V (while used pristine core) to 0.66 V has been observed and the power conversion efficiencies of 5.6 ± 0.4 % have been achieved. Figure 2 shows the current density versus voltage curves of PbS and different PbS@CdS devices from different ligand exchange process. Here, we have seen that although short circuit current is lower in PbS@CdS device, open circuit voltage is higher.

The efficiency of a solar cell is not only dependent of formation of shell around the core but also the thickness of the shell. Dana et. al. have shown the relation between excitonic and efficiency of solar cell.

Figure 2: Current density versus voltage curve of PbS@CdS device from different ligand exchange treatments. Reproduced with permission from ref. [12] Copyright © 2014 American Chemical Society.

Challenges and Future Prospects

Despite the promising advantages of CSQDSCs, several challenges need to be addressed to advance their real-world application. A significant hurdle lies in the toxicity of materials used, particularly in lead-based quantum dots such as PbS and PbSe, which raise environmental and safety concerns. Efforts to synthesize lead-free or environmentally benign alternatives, such as tin-based or copper-based quantum dots, have shown potential, but these materials often suffer from lower efficiency and stability, necessitating further research [13]. Another challenge is the long-term stability of core-shell quantum dots. While the shell improves passivation and reduces non-radiative recombination, the overall durability of devices remains a concern under real-world conditions, such as exposure to moisture, oxygen, and ultraviolet (UV) light. Encapsulation techniques and the development of more robust shell materials are critical to overcoming these issues. Additionally, shell thickness plays a crucial role in determining device performance. A very thin shell might fail to effectively passivate the core, while an overly thick shell could hinder charge transport, leading to reduced efficiency. Achieving the optimal shell design requires precise control during synthesis, which can be challenging on a large scale [14].

The scalability of CSQDSCs for commercial production presents another barrier. Current fabrication techniques, such as spin-coating and layer-by-layer deposition, are not easily scalable for mass production. Developing cost-effective and scalable methods, such as roll-to-roll printing or inkjet printing, will be essential for translating laboratory advancements into commercial viability. Furthermore, ligand exchange processes used to improve charge transport often introduce surface defects, which compromise the performance of the solar cells [15]. Alternative methods that maintain surface integrity while enhancing carrier mobility need to be explored. Finally, economic competitiveness remains a challenge for CSQDSCs. While they promise lower costs compared to silicon-based solar cells, the high price of certain precursor materials and the complexity of fabrication processes limit their market potential. The integration of these solar cells into existing energy systems will require further cost reductions and infrastructure adaptation.

The future of core-shell quantum dot solar cells lies in addressing these challenges through innovative materials, advanced fabrication techniques, and enhanced device architectures. Research into lead-free and cadmium-free quantum dots is expected to accelerate, with materials such as perovskite quantum dots, carbon-based quantum dots, and other non-toxic alternatives gaining traction [16]. These materials, coupled with optimized core-shell designs, could lead to highly efficient and environmentally sustainable devices. Machine learning and artificial intelligence (AI) are emerging as valuable tools in the optimization of quantum dot materials and device performance. By analyzing large datasets from experimental and simulation studies, AI can identify patterns and predict optimal material compositions, synthesis parameters, and device configurations, significantly accelerating the development process. Another promising direction is the integration of CSQDSCs with tandem solar cell technologies. Combining core-shell quantum dot layers with perovskite or silicon-based layers can leverage the broad spectral absorption of quantum dots while benefiting from the higher efficiencies of other materials, potentially surpassing the efficiency limits of standalone quantum dot solar cells [17].

Additionally, research into advanced passivation strategies and robust encapsulation materials will play a vital role in improving the stability of these devices. Techniques such as atomic layer deposition (ALD) for ultra-thin and conformal coatings can enhance both stability and efficiency. On the industrial front, efforts to scale up production through automated and high-throughput fabrication techniques are expected to lower manufacturing costs and improve commercial feasibility [18]. Governments and private industries could play a crucial role in driving this transition by investing in pilot projects and providing incentives for renewable energy technologies based on CSQDSCs. While challenges persist, the unique properties of core-shell quantum dots position them as a promising candidate for the next generation of solar cells. Continued multidisciplinary research and collaboration between academia, industry, and policymakers will be essential to unlock the full potential of this technology, ensuring its contribution to a sustainable energy future.

Conclusion

Core-shell quantum dot solar cells offer a promising solution for next-generation photovoltaics by enhancing efficiency and stability through surface passivation and improved charge dynamics. Despite challenges like material toxicity, stability, and scalability, advancements in lead-free materials, synthesis techniques, and tandem architectures provide pathways for improvement. Their potential for high efficiency, cost-effectiveness, and environmental sustainability positions them as a key technology for renewable energy. Collaborative efforts across research, industry, and policy will be crucial to unlocking their full potential for a sustainable energy future.

Acknowledgement

The authors acknowledge the support and guidance of Prof. Anand Srivastava, Vice Chancellor, Netaji Subhas University of Technology and Prof. Ranjana Aggarwal, Director, CSIR-NIScPR.

References

  1. L. Sopori BL (2004) Silicon Solar Cell Turns 50.
  2. This Month in Physics History 2022.
  3. Alharbi FH, Kais S (2015) Theoretical limits of photovoltaics efficiency and possible improvements by intuitive approaches learned from photosynthesis and quantum coherence. Renewable and Sustainable Energy Reviews 43: 1073-1089.
  4. Shilpa G et al. (2023) Recent advances in the development of high efficiency quantum dot sensitized solar cells (QDSSCs): A review. Mater Sci Energy Technol 6: 533-546.
  5. Dwivedi A, Anuradha A, Srivastava M, Srivastava A, Kumar R et al. (2023) Enhance photoluminescence properties of Ca-Eu: Y2O3@SiO2 core–shell nanomaterial for the advanced forensic and LEDs applications. Spectrochim Acta A Mol Biomol Spectrosc 299: 122782. [crossref]
  6. Liu Z, Lin Y (2024) Testing trap states in polymer solar cells. Polym Test 132: 108387.
  7. Ning Z et al. (2011) Role of surface ligands in optical properties of colloidal CdSe/CdS quantum dots. Physical Chemistry Chemical Physics 13: 5848-5854.
  8. Speirs MJ et al. (2014) Origin of the increased open circuit voltage in PbS–CdS core–shell quantum dot solar cells. J Mater Chem A Mater 3: 1450-1457.
  9. Szendrei K, Gomulya W, Yarema M, Heiss W, Loi MA (2010) PbS nanocrystal solar cells with high efficiency and fill factor. Appl Phys Lett 97: 203501.
  10. Piliego C, Protesescu L, Bisri SZ, Kovalenko MV, Loi MA (2013) 5.2% efficient PbS nanocrystal Schottky solar cells. Energy Environ Sci 6: 3054-3059.
  11. Neo DCJ et al. (2014) Influence of shell thickness and surface passivation on PbS/CdS Core/Shell colloidal quantum dot solar cells. Chemistry of Materials 26: 4004-4013.
  12. Neo DCJ et al. (2014) Influence of shell thickness and surface passivation on PbS/CdS Core/Shell colloidal quantum dot solar cells. Chemistry of Materials 26: 4004-4013.
  13. Gidwani B et al. (2021) Quantum dots: Prospectives, toxicity, advances and applications. J Drug Deliv Sci Technol 61: 102308.
  14. Sahu A, Kumar D (2022) Core-shell quantum dots: A review on classification, materials, application, and theoretical modelling. J Alloys Compd 924: 166508.
  15. Nozik AJ, Beard MC, Luther JM, Law M, Ellingson RJ et al. (2010) Semiconductor quantum dots and quantum dot arrays and applications of multiple exciton generation to third-generation photovoltaic solar cells. Chem Rev, 110: 6873-6890. [crossref]
  16. Wang HC, Bao Z, Tsai HY, Tang AC, Liu RS (2018) Perovskite Quantum Dots and Their Application in Light-Emitting Diodes. Small, 14: 1702433. [crossref]
  17. Ren Y et al. (2024) A new type of core-shell nanowire array structured quantum dot-composite perovskite solar cell with near full-spectrum absorption. Physica E Low Dimens Syst Nanostruct, 160: 115937.
  18. Hu L, Qi W, Li Y (2017) Coating strategies for atomic layer deposition. Nanotechnol Rev 6: 527-547.

Association of the Extent of Exposure to Environmental Tobacco Smoke with Exhaled Nitric Oxide and Eosinophils: a Cross-Sectional Study Based on the NHANES 2007–2012 Database

DOI: 10.31038/GEMS.2025714

Abstract

Background: Previous studies have demonstrated that exposure to environmental tobacco smoke is associated with a reduction in fractional exhaled nitric oxide (FeNO) levels, elevation in eosinophil (EOS) counts and alterations in airway inflammation patterns, influencing the efficacy of glucocorticoid therapy for TH2 inflammation. No previous study has investigated the association of the extent of exposure to environmental tobacco smoke with FeNO levels. This study aimed to investigate the association of the extent of exposure to environmental tobacco smoke with FeNO level and EOS count.

Methods: In this retrospective cohort study, we included 12766 individuals from the National Health and Nutrition Examination Survey 2007–2012. The extent of exposure to environmental tobacco smoke was assessed by measuring serum cotinine levels. Participants were categorised into quintiles based on their cotinine levels. Logistic regression models were developed to evaluate the association of serum cotinine levels with FeNO levels and EOS count.

Findings: In the unadjusted and adjusted models, the highest quintile of serum cotinine levels (>105 ng/ml) was significantly negatively associated with FeNO levels. However, low-to-moderate quintiles of serum cotinine levels were not significantly associated with FeNO levels. Based on sensitivity analyses, the negative associations between the highest quintile of serum cotinine levels and FeNO levels remained consistent among participants with asthma, chronic bronchitis and respiratory symptoms within 7 days. Increased serum cotinine levels were significantly associated with increased EOS counts, which in turn were significantly associated with increased FeNO levels. EOS significantly mediated 7.59% of cotinine-associated reductions in FeNO levels.

Conclusions: Our findings indicated that high levels of tobacco smoke exposure are associated with a decrease in FeNO levels and an increase in EOS count. The smoking status should be considered when evaluating type 2 airway inflammation based on FeNO levels and EOS count.

Introduction

The subtypes of airway inflammation include neutrophilic, eosinophilic, mixed and oligocytic inflammation. Airway eosinophilic inflammation is defined as a blood eosinophil (EOS) count ≥300 cells·μL−1 and/or a sputum EOS count ≥3% [1]. Airway eosinophilic inflammation is sensitive to inhaled corticosteroids (ICS) [2]. In particular, in patients with asthma and chronic obstructive pulmonary disease (COPD) exhibiting airway eosinophilic inflammation, treatment with ICS can ameliorate symptoms, reduce acute attack frequency and improve lung function [3]. Therefore, diagnosing airway eosinophilic inflammation is important. Fractional exhaled nitric oxide (FeNO) levels, along with blood EOS counts, are considered indicators of airway eosinophilic inflammation [4]. Moreover, FeNO levels are closely associated with an individual’s response to allergens, airway hyper-responsiveness and impaired lung function [5,6], thus enabling the diagnosis of airway eosinophilic inflammation. They are helpful for guiding ICS and IgE-targeted therapies for patients with COPD, asthma and chronic cough. Therefore, FeNO and eosinophils are of great significance in the management of airway diseases. Nitric oxide (NO) serves as an endogenous regulatory molecule whose production is regulated by NO synthase (NOS), which is predominantly produced by inducible NOS in bronchial epithelial cells. Exhaled NO levels can be measured by quantifying NO concentration in exhaled breath.

Smoking induces alterations in airway inflammation types, thereby affecting the efficacy of ICS therapy in patients with asthma and COPD. Consequently, investigating the influence of smoking on type 2 airway inflammation has become a focal point of research. Previous studies have grouped light and heavy smokers together, making it difficult to determine the specific extent of tobacco smoke exposure that leads to changes in airway inflammation types, thus resulting in contradictory research findings. No previous study has investigated the association of the extent of exposure to environmental tobacco smoke with FeNO levels. Furthermore, although FeNO and EOS are associated with airway eosinophilic inflammation and act through different pathways, it remains unknown whether EOS play a mediating role in reducing FeNO levels induced by tobacco smoke exposure. Cotinine is the primary metabolite of nicotine and is significantly positively correlated with the extent of tobacco smoke exposure [7]. The estimated elimination half-life of cotinine (approximately 15–20 h) is longer than that of nicotine [8]. Therefore, cotinine has been widely used as a biomarker for tobacco exposure [9-12], as explained in detail in the NHANSE database (https://wwwn.cdc.gov/Nchs/Nhanes/2011-2012/COTNAL_G.htm). In the current study, cotinine was used to determine the level of tobacco smoke exposure.

Materials and Methods

Study Design and Population

The National Health and Nutrition Examination Survey (NHANES) is a programme of studies designed to assess the health and nutritional status of adults and children in the United States (US). During each survey cycle, a sample of participants is selected from the US non-institutionalised civilian population using a complex, stratified, multistage probability cluster sampling design. We analysed data from the participants of the NHANES from 2007 to 2012. A total of 16,784 participants aged ≥18 years had available data on cotinine. The National Center for Health Statistics (NCHS) Institutional Review Board (Hyattsville, MD) approved the study protocols, and all participants provided written informed consent.

FENO

FENO was measured using Aerocrine NIOX MINO®, which features a dynamic flow restrictor that stabilises the flow rate at 50 ml/s. The NHANES protocol required two reproducible FENO measurements in accordance with the testing procedures recommended by the manufacturer and similar to those published by the American Thoracic Society and European Respiratory Society. If either or both of the first two valid FENO measurements are <30 ppb and the measurements differ by ≤2 ppb or if both measurements are >30 ppb and within 10% of each other, then the test was considered reproducible and complete. Two values below or above the limit of detection were also considered reproducible.

Cotinine

Serum samples were processed, stored and shipped to the Division of Laboratory Sciences, National Center for Environmental Health and Centers for Disease Control and Prevention for analysis. Serum cotinine level was measured via isotope dilution–high-performance liquid chromatography–atmospheric pressure chemical ionisation–tandem mass spectrometry (ID–HPLC–APCI–MS/MS). Briefly, the serum sample was spiked with methyl-D3 cotinine as an internal standard, and after an equilibration period, the sample was applied to a basified solid-phase extraction column. Cotinine was extracted from the column with methylene chloride; the organic extract was concentrated, and the residue was injected into a short C18 HPLC column. The eluant from these injections was monitored using APCI–MS/MS, and the m/z 80 daughter ion from the m/z 177 quasi-molecular ion was quantitated, along with additional ions for the internal standard, external standard and confirmation. Cotinine levels were calculated from the ratio of native to labelled cotinine in the sample based on a comparison with a standard curve.

Other Variables of Interest

Age, sex and race/ethnicity were self-reported. Body mass index (BMI) was calculated using the height and weight measured at the mobile examination centre. Race and ethnicity were categorised as non-Hispanic Black, other Hispanic, non-Hispanic white and non-Hispanic other race, based on categories provided by NHANES investigators. Self-reported data on engaging in strenuous exercise within 1 h, consumption of NO-rich vegetables within 3 h , consumption of NO-rich meat within 3 h, use of oral or inhaled steroids within 2 days and development of respiratory symptoms within 7 days were collected using a computer-assisted personal interview system. Asthma and chronic bronchitis were defined according to self-reported diagnosis by a physician. A complete blood count was performed using the Beckman Coulter MAXM instrument in MECs, and all participants underwent blood cell analysis.

Selection of the Study Population

We conducted a cross-sectional study using aggregated data from three NHANES cycles (2007/2008, 2009/2010 and 2011/2012) in which serum cotinine was tested. A total of 16,784 adults completed the serum cotinine test during this survey period (Figure 1). Among them, 3280 were excluded due to missing data on exhaled NO (3227) and EOS (53). Additionally, 738 participants were excluded due to the following missing covariate data: asthma; chronic bronchitis; engaging in strenuous exercise within 1 h; consumption of NO-rich vegetables within 3 h; consumption of NO-rich meat within 3 h; use of oral or inhaled steroids within 2 days and development of cough, cold or respiratory illness within 7 days. Finally, 12766 participants were included in the study. The participants were categorised into five groups based on cotinine levels: Q1 (first quintile), Q2 (second quintile), Q3 (third quintile), Q4 (fourth quintile) and Q5 (fifth quintile).

Figure 1: Flow diagram of the study. Abbreviations: FeNO: fractional exhaled nitric oxide; EOS: eosinophils; ICS: inhaled corticosteroids; CI: confidence interval; OR: odds ratio; SD: standard deviation.

Statistical Analysis

Continuous variables of age, BMI at enrolment and laboratory findings were expressed as median (interquartile range) or mean ± standard deviation (SD). The remaining categorical variables were expressed as n (%). The participants were categorised into quintiles based on the cotinine levels provided by NHANSE: Q1 (0.011), Q2 (0.011–0.027), Q3 (0.027–0.104), Q4 (0.104–105) and Q5 (≥105). Quintiles based on cotinine levels can effectively reflect the distribution of tobacco smoke exposure levels among the participants. Participants in the highest quintile (Q5) were considered to have high levels of tobacco smoke exposure. Logistic regression models were used to investigate the odds ratios (ORs) and 95% confidence intervals (CIs) of FeNO levels according to serum cotinine levels (quintiles). In adjusted model 1, the adjusted covariates included cotinine, age, , BMI and ethnicity. In adjusted model 2, the adjusted covariates were asthma, chronic bronchitis, EOS, engaging in strenuous exercise within 1 h, consumption of NO-rich vegetables within 3 h, consumption of NO-rich meat within 3 h, use of oral or inhaled steroids within 2 days, development of respiratory symptoms within 7 days and covariates included in model 1. A sensitivity analysis was conducted using the logistic regression model among participants with such as chronic bronchitis , asthma, and respiratory symptoms within 7 days prior to testing. After weighting the data with the sample weights (full sample 2-year interview weight) obtained from the NHANS 2007–2012 demographics file, logistic regression analysis was performed to explore the relationship between tobacco exposure and FeNO levels in the US population. Additionally, logistic regression models were utilised to explore the association between cotinine levels (quintiles) in the participants and higher EOS counts (≥0.3 × 103 cells/µl). Logistic regression models were also used to analyse the association between EOS counts in the participants and higher FeNO levels (>25 bbp). Correlation coefficients (Spearman’s rho and Kendall’s tau) were calculated to investigate the cotinine–EOS association. This study examined the proportion of mediation through EOS in the associations of cotinine levels and FeNO using the R (R4.2.1) based on the mediation method recommended by Hayes [13]. The data were analysed using R (R4.2.1) and SPSS version 21.0 (IBM Corp., Armonk, NY, USA). The statistically significant cut-off of the two-sided P-value was 0.05.

Results

Characteristics of the Participants

Table 1 describes the socio-demographic, anthropometric, race, primary disease and laboratory data of the participants. Approximately 17.5% (2446/13,945) of the participants had FeNO levels >25 bbp, and approximately 21.5% (3194/13,945) had EOS counts ≥0.3 × 103/µl. The median age of the participants was 43 (20, 60) years. In total, 2844 (20.4%) participants had cough, cold or respiratory illness within the past 7 days, 1721 (12.4%) had asthma, and 459 (4.1%) had chronic bronchitis. In order to ensure that the survey results can represent the entire US population, we weighted the data. The characteristics of the US adults were showed in the Table S4.

Table 1: Characteristics and laboratory data of the participants according to cotinine levels (n = 12766).

Association of Cotinine Levels with FeNO Levels

Table 2 presents the risk of higher FeNO levels (>25 bbp) associated with serum cotinine levels categorized into quintiles among participants. In the unadjusted models, participants with the highest quintile of serum cotinine levels (>105 ng/ml) showed decreased FeNO levels compared with those with the lowest quintile of serum cotinine levels (0.011 ng/ml) (OR, 0.24 [0.20, 0.29]). There were no significant differences in FeNO levels of participants between Q3 and the lowest quantile of cotinine levels (21.6% vs 19.5%) as well as between Q2 and the lowest quantile of cotinine levels (21.7% vs 19.5%) (Table 2). After adjusting for potential confounders, similar results were observed in models 1 and 2. In model 2, a 1 SD increase in cotinine level was associated with lower FeNO levels (OR, 0.47 [0.42, 0.517]) (Table 2). Sensitivity analyses performed among participants with asthma, recent respiratory symptoms, and chronic bronchitis yielded consistent findings (Tables S1-S3). After weighting the sample, the negative association between cotinine and FeNO levels remained consistent across the US population (Table S5).

Table 2: Adjusted ORs and 95% CIs for the association of cotinine levels with the risk of high FeNO level (n = 12766).

#P > 0.05 Abbreviations: FeNO: fractional exhaled nitric oxide; EOS: eosinophils; CI: confidence interval; OR: odds ratio; SD: standard deviation.

Logistic regression model 1 included covariates of cotinine, age, sex, BMI, race and EOS count. Logistic regression model 2 included covariates of use of oral or inhaled steroids within 2 days, development of respiratory symptoms within 7 days, consumption of NO-rich food within 3 h, engaging in strenuous exercise within 1 h, asthma, chronic bronchitis and covariates in model 1.

Association of Cotinine Levels with EOS Levels

Compared with participants with the lowest quintile of cotinine levels, those with the highest quintile of cotinine levels had higher EOS count (≥0.3 × 103 cells/µl) (OR 1.82 [1.61, 2.06]). The ORs were 1.87 (1.64, 2.13) and 2.39 (2.09, 2.74) in models 1 and 2, respectively (Table 3). However, no statistically significant difference in EOS counts was observed between Q3 and the lowest quintile of cotinine levels and between Q2 and the lowest quintile of cotinine levels. This study revealed that higher cotinine levels were positively associated with EOS count in all models (Table 3). A 1 SD increase in cotinine levels was associated with elevated EOS count (ORs of 1.14, 1.14 and 1.24 in the unadjusted model, model 1 and model 2, respectively). Correlation analyses revealed significant positive correlations between cotinine and EOS levels (Spearman’s rho: r = 0.074, P < 0.0001; Kendall’s tau: r = 0.097, P < 0.0001).

Table 3: Adjusted ORs and 95% CIs for the association of cotinine levels with EOS count (n = 12766).

#P > 0.05 Abbreviations: FeNO: fractional exhaled nitric oxide; EOS: eosinophils; ICS: inhaled corticosteroids; CI: confidence Interval; OR: odds ratio.

Logistic regression model 1 included covariates of cotinine, age, sex, BMI, race and FeNO level. Logistic regression model 2 included covariates of use of oral or inhaled steroids within 2 days, development of respiratory symptoms within 7 days, consumption of NO-rich food within 3 h, engaging in strenuous exercise within 1 h prior to testing, asthma, chronic bronchitis and covariates in model 1.

Association of EOS Count with FeNO Levels

This study revealed a positive association between EOS count and FeNO levels. The participants were categorized into quintiles based on the EOS counts (Table 4). The results showed that a 1 SD increase in EOS count was significantly associated with higher FeNO levels (>25 bbp) (OR 1.55 [1.48, 1.62], 1.53 [1.46, 1.60], 1.35 [1.29, 1.43] and 1.43 [1.15, 1.59] in the unadjusted model, model 1, model 2 and model 3, respectively).

Table 4: Adjusted ORs and 95% CIs for the association of EOS count with FeNO levels (n = 12766).

#P > 0.05 Abbreviations: FeNO: fractional exhaled nitric oxide; EOS: eosinophils; ICS: inhaled corticosteroids; CI: confidence interval; OR: odds ratio; SD: standard deviation

Multivariate linear regression model 1 included covariates of EOS, age, sex, BMI, race and cotinine level. Multivariate linear regression model 2 included covariates of use of oral or inhaled steroids within 2 days, development of respiratory symptoms within 7 days, consumption of NO-rich food within 3 h, engaging in strenuous exercise within 1 h prior to testing, asthma, chronic bronchitis and covariates in model 1.

Mediation Analyses

As shown in Table 5, significantly mediated effects by EOS were observed on the association of cotinine levels with FeNO levels. Increased EOS count significantly mediated 13% of the cotinine-associated reduction in FeNO levels. Mediation analyses were conducted using the R programming language.

Table 5: Mediated effects by EOS on the association of cotinine levels with FeNO levels (n = 12766).

Abbreviations: FeNO: fractional exhaled nitric oxide; EOS: eosinophils; CI: confidence interval; OR: odds ratio; SD: standard deviation.

Discussion

This study revealed that participants with the highest quintile of cotinine levels (≥105 ng/ml) exhibited decreased FeNO levels compared with those with the lowest quintile of cotinine levels (0.11 ng/ml, indicating no tobacco exposure). Compared with participants with the lowest quantile of cotinine levels, no significant difference was observed in FeNO levels in those with Q2, Q3 and Q4 cotinine levels (P > 0.05). Sensitivity analyses conducted among participants with asthma, recent respiratory symptoms and chronic bronchitis revealed consistent findings. Similar results were obtained across the US population after the data were weighted. A positive association between high tobacco exposure and EOS count was observed. EOS mediated the cotinine-associated decrease in FeNO levels. Chronic airway inflammation and acute airway inflammation are associated with increased FeNO levels [14-17]. Additionally, exercise [18-20] and consumption of NO-rich foods [21-22] can cause changes in FeNO levels. Therefore, in this study, we included variables such as engaging in strenuous exercise within 1 h, consumption of NO-rich foods within 3 h, asthma, chronic bronchitis and with respiratory symptoms within 7 days as covariates in the model.

Some studies have indicated that smoking can lead to a decrease in FeNO levels [23,24] and alter airway inflammation types. These studies confirm our research findings. However, another study showed no remarkable difference in FeNO levels between smokers and non-smokers [8]. Previous studies have categorised participants into smokers, former smokers and non-smokers but failed to assess the extent of tobacco exposure. Consequently, various studies may yield conflicting conclusions. Furthermore, previous studies employed small samples that lacked representativeness. In our research, we utilised a nationally representative large sample of the adult population in the US to explore the association of tobacco exposure with FeNO levels. We employed serum cotinine level as a reliable measure to evaluate the extent of exposure to environmental tobacco smoke. Participants were categorised into quintiles based on cotinine levels: Q1 (0.011–0.0185), Q2 (0.0185–0.075), Q3 (0.075–125), Q4 (125–309) and Q5 (≥309). This approach allows us to understand the distribution of tobacco exposure levels among participants across different quintiles. We can effectively understand the trend in the effect of cotinine levels on FeNO levels by investigating the regression relationship across different quantiles. Our study demonstrated that high exposure to tobacco smoke is associated with lower FeNO levels. Ashley et al. [25] used data from the NHANES 2007–2012 to investigate the association of tobacco exposure with FeNO levels in non-smoking adolescents and found that tobacco exposure was associated with lower FeNO levels, consistent with the results of the current study. The research population in their study was a specific cohort of non-smoking adolescents. Our study further explored the effects of smoking on EOS count and the mediating role of EOS, providing a reference for the mechanism by which tobacco exposure leads to lower FeNO levels.

EOS and FeNO have been utilised as indicators of type 2 airway inflammation as well as for identifying patients experiencing asthma exacerbations [26,27], guiding corticosteroid therapy during the exacerbation of COPD 28 and determining the suitability of ICS therapy regimens [29-32]. Their importance in COPD treatment is paramount [33,34]. Considering that smoking can influence airway inflammation, there has been increasing interest in exploring the association between blood EOS counts and smoking habits. Current smoking is significantly associated with EOS counts ≥210 cells·μl−1 (OR, 1.72). Colak et al. [35] reported that a history of smoking is associated with a blood EOS count ≥300 cells·μl−1; however, the association between current cumulative tobacco exposure and EOS count remains uncertain. Our study revealed that EOS counts were elevated in participants with Q4 and Q5 serum cotinine levels. In a study involving the Copenhagen general population, Pedersen et al. [36] showed that high cumulative and daily tobacco consumption in current smokers was associated with substantial increases in EOS counts in a dose-dependent manner. However, their minimum reference value was <10 g/day of tobacco consumption. The reference for our study was the absence of tobacco exposure.

Although EOS and FeNO serve as markers for type 2 airway inflammation, they represent different aspects of this condition [37-40]. FeNO level reflects airway IL‐13 activity, whereas blood EOS count reflects systemic IL‐5 activity [22]. FeNO level is correlated with increased induced sputum levels of airway type 2 cytokines, chemokines and alarmins. In contrast, blood EOS counts are only correlated with serum IL‐5 levels in the sputum [41]. Tobacco exposure may cause a decrease in FeNO levels and an increase in EOS count through different signalling pathways. The exact mechanism underlying this effect remains unclear. The mediated analysis in the current study showed that EOS counts mediated the cotinine-associated reduction in FeNO levels, But more research is needed to confirm this. First, the effect of tobacco exposure on type 2 airway inflammation was corroborated, and the range of tobacco exposure levels that influence changes in airway inflammation types was further analysed. Second, the potential mechanism underlying the alterations in EOS counts and FeNO levels induced by tobacco exposure was investigated, revealing that EOS mediated the cotinine-associated reduction in FeNO levels. This result provides valuable insights for further elucidation of related mechanisms. Third, previous studies [23-24] have employed past and current smoking as indicators for classifying tobacco exposure. Such an approach is considered overly general and overlooks second-hand smoke exposure. In contrast, our study substituted serum cotinine levels to assess tobacco exposure levels, yielding results with increased accuracy. Finally, relevant adjustments were made by incorporating potential confounders.

Inevitably, this study had certain limitations. First, the effect of long-term smoking accumulation and duration of quitting smoking on EOS count was not considered (21). Environmental pollutants are associated with FeNO levels [42-45]. Furthermore, allergic rhinitis, eosinophilic esophagitis, atopic rhinitis and food allergy are associated with elevated levels of FeNO [46-50]. However, the NHANES 2007–2012 database lacks data on environmental pollution, allergic rhinitis, eosinophilic esophagitis, atopic dermatitis and food allergies. Second, smoking induces neutrophilic inflammation. The effect of smoking-related neutrophil inflammatory factors on FeNO levels requires further investigation. Third, disease history relies on self-reporting, which is susceptible to individual subjectivity. Finally, the utilisation of retrospective data may lead to data loss, measurement errors and inaccuracies. In conclusion, this study demonstrated that tobacco exposure can cause a decrease in FeNO levels and an increase in EOS counts. The smoking status should be considered when evaluating type 2 airway inflammation using FeNO and EOS count. The reduction in FeNO levels due to tobacco exposure is partially mediated by EOS. High levels of tobacco exposure can lead to a distinct type of airway inflammation characterised by elevated EOS count but decreased FeNO levels. This airway inflammation type should be classified as a subtype separate from typical airway eosinophilic inflammation. These findings provide clinicians with a scientific basis for the diagnosis, treatment and management of patients with airway inflammation.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Funding

This study was supported by Scientific Research Fund Project of Hunan Provincial Health Commission of China (No. D202303028856).

Data Availability

The data underpinning this article were obtained from the National Health and Nutrition Examination Survey (NHANES) 2007–2012. The datasets utilized and analyzed in the present study are available from the corresponding author upon reasonable request.

Authors’ Contributions

Xingfang Hou, Shufen Hou, Chenggong Hou, Xuelian Chen, and Yuling Tang conducted this study. Xingfang Hou was responsible for the conceptualization, methodology, investigation, formal analysis, preparation of the original draft, provision of resources, and visualization. Shufen Hou and Chenggong Hou contributed to data curation and investigation. Yuling Tang and Xuelian Chen provided supervision, reviewed the manuscript, and managed project administration. Xingfang Hou, Yuling Tang, and Xuelian Chen were designated as guarantors of the paper, ensuring the integrity of the work from inception to publication. All authors reviewed and approved the final manuscript.

References

  1. Cosío BG, Pérez De Llano L, Lopez Viña A, Torrego A, Lopez-Campos JL, et al. (2017) Th-2 signature in chronic airway diseases: towards the extinction of asthma-COPD overlap syndrome? The European Respiratory Journal. 49. [crossref]
  2. Janin S,Rochat T (2007) Phenotypes of severe persistent asthma in adults. Revue Medicale Suisse. 3: 2663-2667.
  3. Lea S, Higham A, Beech A, Singh D (2023) How inhaled corticosteroids target inflammation in COPD. European Respiratory Review. 32. [crossref]
  4. Soter S., Barta I.Antus B (2013) Predicting sputum eosinophilia in exacerbations of COPD using exhaled nitric oxide. Inflammation. 36: 1178-1185. [crossref]
  5. Thorhallsdottir A. K., Gislason D., Malinovschi A., Clausen M., Gislason T., et al. (2016) Exhaled nitric oxide in a middle-aged Icelandic population cohort. Journal of Breath Research. 10. [crossref]
  6. Nerpin E, Ferreira DS, Weyler J, Schlunnsen V, Jogi R, et al. (2021) Bronchodilator response and lung function decline: Associations with exhaled nitric oxide with regard to sex and smoking status. The World Allergy Organization Journal. 14. [crossref]
  7. Sepkovic DW, Haley NJ (1985) Biomedical applications of cotinine quantitation in smoking related research. American Journal of Public Health. 75: 663-665. [crossref]
  8. Jarvis MJ, Russell MA, Benowitz NL, Feyerabend C (1988) Elimination of cotinine from body fluids: implications for noninvasive measurement of tobacco smoke exposure. American Journal of Public Health. 78: 696-698. [crossref]
  9. Hecht SS (2004) Carcinogen derived biomarkers: applications in studies of human exposure to secondhand tobacco smoke. Tobacco Control. 13 Suppl 1(Suppl 1): i48-56. [crossref]
  10. Benowitz NL (1996) Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiologic Reviews. 18: 188-204. [crossref]
  11. Benowitz NL (1983) The use of biologic fluid samples in assessing tobacco smoke consumption. NIDA Research Monograph. 48: 6-26. [crossref]
  12. Etzel RA (1990) A review of the use of saliva cotinine as a marker of tobacco smoke exposure. Preventive Medicine. 19: 190-197. [crossref]
  13. Hayes Andrew F (2017) Introduction to mediation, moderation, and conditional process analysis: A regression-based approach: Guilford publications.
  14. Delen FM, Sippel JM, Osborne ML, Law S, Thukkani N, et al. (2000) Increased exhaled nitric oxide in chronic bronchitis: comparison with asthma and COPD. Chest. 117: 695-701. [crossref]
  15. Kharitonov SA, Yates D, Robbins RA, Logan-Sinclair R, Shinebourne EA, et al. (1994) Increased nitric oxide in exhaled air of asthmatic patients. Lancet. 343: 133-135. [crossref]
  16. Kharitonov SA, Wells AU, O’connor BJ, Cole PJ, Hansell DM, et al. (1995) Elevated levels of exhaled nitric oxide in bronchiectasis. American Journal of Respiratory and Critical Care Medicine. 151: 1889-1893. [crossref]
  17. Mormile M, Mormile I, Fuschillo S, Rossi FW, Lamagna L, et al. (2023) Eosinophilic Airway Diseases: From Pathophysiological Mechanisms to Clinical Practice. International Journal of Molecular Sciences. 24. [crossref]
  18. Persson MG, Wiklund NP, Gustafsson LE (1993) Endogenous nitric oxide in single exhalations and the change during exercise. The American Review of Respiratory Disease. 148: 1210-1214. [crossref]
  19. Maroun M. J., Mehta S., Turcotte R., Cosio M. G.,Hussain S. N (1985) Effects of physical conditioning on endogenous nitric oxide output during exercise. J Appl Physiol. 79: 1219-1225. [crossref]
  20. Massaro AF,Drazen JM (1985) Exhaled nitric oxide during exercise: site of release and modulation by ventilation and blood flow. J Appl Physiol. 80: 1863-1864. [crossref]
  21. Olin AC, Aldenbratt A, Ekman A, Ljungkvist G, Jungersten L (2001) Increased nitric oxide in exhaled air after intake of a nitrate-rich meal. Respiratory Medicine. 95: 153-158. [crossref]
  22. Duncan C., Dougall H., Johnston P., Green S., Brogan R., et al. (1995) Chemical generation of nitric oxide in the mouth from the enterosalivary circulation of dietary nitrate. Nature Medicine. 1: 546-551. [crossref]
  23. Silkoff PE, Singh D, Fitzgerald JM, Eich A, Ludwig-Sengpiel A (2017) Inhaled Steroids and Active Smoking Drive Chronic Obstructive Pulmonary Disease Symptoms and Biomarkers to a Greater Degree Than Airflow Limitation. Biomarker Insights. 12. [crossref]
  24. Nagasaki T, Matsumoto H, Nakaji H, Niimi A, Ito I, et al. (2013) Smoking attenuates the age-related decrease in IgE levels and maintains eosinophilic inflammation. Clinical and Experimental Allergy: Journal of the British Society for Allergy and Clinical Immunology. 43: 608-615. [crossref]
  25. Merianos AL, Jandarov RA, Cataletto M, Mahabee-Gittens EM (2021) Tobacco smoke exposure and fractional exhaled nitric oxide levels among U.S. adolescents. Nitric Oxide. 117: 53-59. [crossref]
  26. Oshikata C, Tsuburai T, Tsurikisawa N, Ono E, Higashi A, et al. (2008) [Cutoff point of the fraction of exhaled nitric oxide (FeNO) with the off-line method for diagnosing asthma and the effect of smoking on FeNO]. Nihon Kokyuki Gakkai Zasshi. 46: 356-362. [crossref]
  27. Smit LA, Heederik D, Doekes G, Wouters IM (2009) Exhaled nitric oxide in endotoxin-exposed adults: effect modification by smoking and atopy. Occupational and Environmental Medicine. 66: 251-255. [crossref]
  28. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, et al. (2008) Global strategy for asthma management and prevention: GINA executive summary. The European Respiratory Journal: Official Journal of the European Society for Clinical Respiratory Physiology. 31: 143-178. [crossref]
  29. Bafadhel M., Mckenna S, Terry S, Mistry V, Pancholi M, et al. (2012) Blood eosinophils to direct corticosteroid treatment of exacerbations of chronic obstructive pulmonary disease: a randomized placebo-controlled trial. American Journal of Respiratory and Critical Care Medicine. 186: 48-55. [crossref]
  30. Pavord I. D., Lettis S., Locantore N., Pascoe S., Jones P. W., et al. (2016) Blood eosinophils and inhaled corticosteroid/long-acting β-2 agonist efficacy in COPD. Thorax. 71: 118-125. [crossref]
  31. Pascoe S, Locantore N, Dransfield MT, Barnes NC, Pavord ID (2015) Blood eosinophil counts, exacerbations, and response to the addition of inhaled fluticasone furoate to vilanterol in patients with chronic obstructive pulmonary disease: a secondary analysis of data from two parallel randomised controlled trials. Lancet Respir Med. 3: 435-442. [crossref]
  32. Siddiqui S. H., Guasconi A., Vestbo J., Jones P., Agusti A., et al. (2015) Blood Eosinophils: A Biomarker of Response to Extrafine Beclomethasone/Formoterol in Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine. 192: 523-525. [crossref]
  33. Hartl S., Breyer M. K., Burghuber O. C., Ofenheimer A., Schrott A., et al. (2020) Blood eosinophil count in the general population: typical values and potential confounders. The European Respiratory Journal: Official Journal of the European Society for Clinical Respiratory Physiology. 55. [crossref]
  34. Pavord ID, Chanez P, Criner GJ, Kerstjens HAM, Korn S, et al. (2017) Mepolizumab for Eosinophilic Chronic Obstructive Pulmonary Disease. The New England Journal of Medicine. 377: 1613-1629.
  35. Çolak Y, Afzal S, Nordestgaard BG, Marott JL, Lange P (2018) Combined value of exhaled nitric oxide and blood eosinophils in chronic airway disease: the Copenhagen General Population Study. The European Respiratory Journal: Official Journal of the European Society for Clinical Respiratory Physiology. 52. [crossref]
  36. Pedersen KM, Çolak Y, Ellervik C, Hasselbalch HC, Bojesen SE, et al. (2019) Smoking and Increased White and Red Blood Cells. Arteriosclerosis, Thrombosis, and Vascular Biology. 39: 965-977. [crossref]
  37. Couillard S., Laugerud A., Jabeen M., Ramakrishnan S., Melhorn J., et al. (2022) Derivation of a prototype asthma attack risk scale centred on blood eosinophils and exhaled nitric oxide. Thorax. 77: 199-202. [crossref]
  38. Couillard S, Do WIH, Beasley R, Hinks TSC, Pavord ID (2022) Predicting the benefits of type-2 targeted anti-inflammatory treatment with the prototype Oxford Asthma Attack Risk Scale (ORACLE). ERJ Open Res. 8. [crossref]
  39. Shrimanker R, Keene O, Hynes G, Wenzel S, Yancey S (2019) Prognostic and Predictive Value of Blood Eosinophil Count, Fractional Exhaled Nitric Oxide, and Their Combination in Severe Asthma: A Post Hoc Analysis. American Journal of Respiratory and Critical Care Medicine. 200: 1308-1312. [crossref]
  40. Ortega HG, Yancey SW, Mayer B, Gunsoy NB, Keene ON, et al. (2016) Severe eosinophilic asthma treated with mepolizumab stratified by baseline eosinophil thresholds: a secondary analysis of the DREAM and MENSA studies. Lancet Respir Med. 4: 549-556. [crossref]
  41. Couillard S., Shrimanker R., Chaudhuri R., Mansur A. H., Mcgarvey L. P., et al. (2021) Fractional Exhaled Nitric Oxide Nonsuppression Identifies Corticosteroid-Resistant Type 2 Signaling in Severe Asthma. American Journal of Respiratory and Critical Care Medicine. 204: 731-734. [crossref]
  42. Fan Z, Pun VC, Chen XC, Hong Q, Tian L, et al. (2018) Personal exposure to fine particles (PM(2.5)) and respiratory inflammation of common residents in Hong Kong. Environmental Research. 164: 24-31. [crossref]
  43. Maestrelli P., Canova C., Scapellato M. L., Visentin A., Tessari R., et al. (2011) Personal exposure to particulate matter is associated with worse health perception in adult asthma. Journal of Investigational Allergology & Clinical Immunology: Official Organ of the International Association of Asthmology (INTERASMA) and Sociedad Latinoamericana de Alergia e Inmunologia. 21: 120-128. [crossref]
  44. Xu T, Hou J, Cheng J, Zhang R, Yin W, et al. (2018) Estimated individual inhaled dose of fine particles and indicators of lung function: A pilot study among Chinese young adults. Environ Pollut. 235: 505-513. [crossref]
  45. Zhang Z, Zhang H, Yang L, Chen X, Norbäck D, et al. (2022) Associations between outdoor air pollution, ambient temperature and fraction of exhaled nitric oxide (FeNO) in university students in northern China – A panel study. Environmental Research. 212(Pt C). [crossref]
  46. Huang Q, Li Y, Li C, Zhang X, Du X, et al. (2023) Cigarette smoke aggravates asthma via altering airways inflammation phenotypes and remodelling. The Clinical Respiratory Journal. 17: 1316-1327. [crossref]
  47. Saranz RJ, Lozano NA, Lozano A, Alegre G, Robredo P, et al. (2022) Relationship between exhaled nitric oxide and biomarkers of atopy in children and adolescents with allergic rhinitis. Acta Otorrinolaringol Esp (Engl Ed). 73: 286-291. [crossref]
  48. Guida G, Rolla G, Badiu I, Marsico P, Pizzimenti S, et al. (2010) Determinants of exhaled nitric oxide in chronic rhinosinusitis. Chest. 137: 658-664. [crossref]
  49. Kaur P, Chevalier R, Friesen C, Ryan J, Sherman A, et al. (2023) Diagnostic role of fractional exhaled nitric oxide in pediatric eosinophilic esophagitis, relationship with gastric and duodenal eosinophils. World Journal of Gastrointestinal Endoscopy. 15: 407-419. [crossref]
  50. Galiniak S, Rachel M (2022) Fractional Exhaled Nitric Oxide in Teenagers and Adults with Atopic Dermatitis. Adv Respir Med 90(4): 237-245. [crossref]

Extremely 13C-rich Diamond in Orthorhombic Cassiterites in the Variscan Erzgebirge, Saxony/Germany

DOI: 10.31038/GEMS.2025713

Abstract

Raman studies on a large cassiterite sample from Zinnwald, E-Erzgebirge/Germany, brought some surprising results to light. To these belong the 13C-rich diamonds and graphite, as well as other minerals, first and foremost as high-pressure and high-temperature orthorhombic cassiterite. Because there are also 12C-rich diamonds in the root zones in a crystal present, especially in a large cassiterite crystal from Ehrenfriedersdorf, we assume at least two distinct pulses with varying isotopes of carbon (12C versus 13C) in the supercritical fluids (SCGF) coming from the earth’s mantle. First came 12C-rich and later 13C-rich supercritical fluids. If so, other isotopes can also effectively be separated in supercritical fluids.

Keywords

Raman spectroscopy, 13C-rich diamond, Orthorhombic cassiterite, Variscan tin deposits, Supercritical fluids, Isotope separation

Introduction

A presentation about the 800 years of mining activity and 450 years of geological research in the Erzgebirge/Krǔsné hory region given by Breiter (2014) [1] shows, among other things, the extensive tin exploration and the origin and relationship of tin deposits with granite magmatism. According to this classic work by many scientists, there are no questions about the genesis of this type of ore deposit. It seems that all problems are solved, which is not the case. Thomas (2024a and 2024b) [2,3] has, however, shown that the origin of the Variscan tin deposits must be newly scrutinized. The first doubts came from the intensive work on the tin deposit Ehrenfriedersdorf presented in Schütze et al. (1983) [4]. However, their conclusions are not conclusive, at least speculative. The first concrete proof came from Thomas (2024a) [2]. In this publication, we will show that the proofs of mantle participation via supercritical fluids or melts up to now are no exceptions. We classify the supercritical fluids or melts according to Ni et al. (2024) [5] as supercritical geofluids (SCGF).

Sample Materials Microscopy and Raman Spectroscopy: Methodology

Sample Material

A sample from Zinnwald (Figure 1) clearly shows two parts of cassiterite composed of an opaque part (2/3 in volume) and a transparent cassiterite-brown nearby pale part (1/3 in volume). This cassiterite contains fluid inclusions that homogenized at about 386°C (see Thomas 1982) [6] in the liquid phase (with 15 equivalent % NaCl). In the black part, no fluid inclusions are present.

Figure 1: Cassiterite sample (Sn-23) from Zinnwald, E-Erzgebirge/Saxony. All black parts are orthorhombic cassiterite (about 2/3 in volume). The transparent brown zones contain tetragonal cassiterite parts.

The pale part of cassiterite contains many small black to colorless (~10 µm in diameter) spherical crystals of graphite and diamond. The black part of that cassiterite contains pyrrhotine and pyrite, as well as diamond and graphite inclusions, which are relatively stable against hydrothermal activity. The sample is from the Mining Academy Freiberg. At this place, it is essential to emphasize that graphite-like material in Variscan cassiterites is typical. A description of another cassiterite sample used in this short contribution is from Ehrenfriedersdorf (Sn-70), described in Thomas 2024a [3].

Microscopy and Raman Spectroscopy

We performed all microscopic and Raman spectroscopic studies with a petrographic polarization microscope (BX 43) with a rotating stage coupled with the EnSpectr Raman spectrometer R532 (Enhanced Spectrometry, Inc., Mountain View, CA, USA) in reflection and transmission. The Raman spectra were recorded in the spectral range of 0–4000 cm−1 using an up-to-50 mW single-mode 532 nm laser, an entrance aperture of 20 µm, a holographic grating of 1800 g/mm, and spectral resolution ranging of 4 cm−1. Generally, we used an objective lens with a magnification of 100x: the Olympus long-distance LMPLFLN100x objective (Olympus, Tokyo, Japan). The laser power on the sample is adjustable down to 0.02 mW. The Raman band positions were calibrated before and after each series of measurements using the Si band of a semiconductor-grade silicon single-crystal. The run-to- run repeatability of the line position (based on 20 measurements each) is ±0.3 cm−1 for Si (520.4 ± 0.3 cm−1) and 0.4 cm−1 for diamond (1332.7 cm−1 ± 0.4 cm−1 over the range of 80–2000 cm−1). The FWHM = 4.26 ± 0.42 cm−1. FWHM is the Full-Width at Half Maximum. We also used a water-clear natural diamond crystal (Mining Academy Freiberg: 2453/37 from Brazil) as a diamond reference (for more information, see Thomas et al. 2022 [7] and 2023 [8]).

Results

Diamond in Cassiterite

During the microscopic study of the cassiterite sample Sn-23 from Zinnwald, we found (besides fluid inclusions) many spherical mineral inclusions. Often, these inclusions were, according to Raman spectroscopy, diamond and/or graphite. Figure 2 shows such typical inclusion (insert right above in Figure 1) and the accompanying Raman spectrum. Conspicuously is the Raman doublet at 1309 and 1514 cm−1, which is characteristically for a very 13C-rich diamond (see Blank et al. 2016) [9]).

Figure 2: Raman spectrum of lonsdaleite in pale-colored cassiterite (Sn-23). The photomicrograph shows the 13C-rich diamond crystal (30 µm deep) in the cassiterite matrix as well as 13C-rich graphite (G-band at about 1514 cm-1). The Raman spectrum was taken with 5.0 mW laser power on the sample (15 minutes exposure) – see Blank et al. 2016 [9].

Because this type of diamond and graphite is currently untypical, we have performed further Raman measurements. The results on 18 different diamond inclusions and the belonging graphite are in Table 1 compiled.

  1. See Methodology
  2. According to Gutierrez et 2014 [10] and Thomas et al. (2021) [11].
  3. Gr – graphite (about 73 µm deep)

Table 1: Results on diamond and graphite in the cassiterite (Sn-23) from Zinnwald and references.

Mineral

First-order Raman line (cm-1) FWHM

(cm-1)

n

(number of crystals)

13C-rich Diamond

1313.9 ± 6.1

59.4 ± 19.1

18

12C-rich Diamond1)

1332.7 ± 0.4

4.26 ± 0.42

20

13C-rich Graphite

1521.5 ± 8.5

70.0 ± 26.0

10

13C-rich Gr needle

1518.8 ± 1.1

39.3 ± 14.7

6

12C-rich Graphite2)

1581.5

3.5

13C-rich Graphite2)

1519.0

Besides the diamonds with a marked G-band at about 1522 cm−1, there are also diamonds without such a G-band (Figure 3).

Figure 3: 13C-rich diamond in cassiterite (Sn-23) from Zinnwald without graphite band. The Raman spectrum was taken with 1.0 mW laser power on the sample (15 minutes exposure).

Figure 4 shows a Raman spectrum of 13C-rich diamond with an outlined 13C-rich graphite G band at 1527 cm−1.

Figure 4: Raman spectrum of 13C-rich diamond in cassiterite (Sn-23) from Zinnwald (30 mW on sample). The Raman band at 1527 cm-1 is the G band from the 13C-rich graphite (see Gutierrez et al. (2014) [10]).

Figure 5 shows the relationship between the laser energy on the sample and the band position of the first-order diamond band. We see clearly that the values at the low energy (0.92 mW) represent the best values for the estimation of the 13C concentration. The data in Figure 5 shows a linear correlation: Band position = 1310.53 + 0.16871 * mW. The extrapolation to the lowest value of 0.92 mW results in a value of 1310.7 cm−1. According to Anthony and Banholzer (1992), the first-order Raman peak position has a 13C content of the diamond of about 50%. For a natural diamond that is very high, and if we assume that this diamond represents the quasi-frozen state from the deep, it follows, according to Schiferl et al. (1997) [12], a minimum pressure of about 7 GPa.

Figure 5: Correlation of the Raman shifts with the laser energy used on the sample

Orthorhombic Cassiterite Bearing 13C-rich Diamond

The relatively large cassiterite crystal aggregate (Figure 1) from Zinnwald/Erzgebirge/Germany, sample Sn-23, contains large parts of different orthorhombic cassiterites. Tetragonal cassiterite is not present or only in traces in the whole sample Sn-23. It is well known that the polymorphs of cassiterite can easily be transformed into another (Balakrishnan et al., 2022) [13]. Therefore, different polymorphs can be present side by side, which makes the differentiation difficult. Figure 6 is an example of a more tetragonal cassiterite (with dominant indications of the Pbcn-type: 75.0, 124.8, 245, and 472.6 cm−1). The strong Raman band at 75.0 cm−1 is untypical for tetragonal cassiterite (see Figure 5 in Thomas 2024b) [3].

Figure 6: Raman spectrum of light cassiterite from the edge of sample (Sn-23)

Figure 7 shows the Raman spectrum of more dark cassiterite from the center of the plate (Sn-23 from Zinnwald). The strong band at 75.0 cm−1 corresponds, according to Thomas 2024b, to a pressure of about 10.5 GPa.

Figure 7: Raman spectrum of dark cassiterite from the center of the crystal plate (Sn-23 from Zinnwald)

Figure 8: Raman spectrum of diamond in orthorhombic cassiterite from Ehrenfriedersdorf – sample Sn-70 (size 4 x 2 cm). The Raman band at 1284 cm-1 corresponds to an almost isotopic pure 13C diamond, which is according to Enkovich et al. 2016 at 1283.1 cm-1. The G-band is at 1519 cm-1.

The very strong Raman band 121.4 cm−1 (122.7 ± 1.02 cm−1; n = 6) results in a pressure of 21.9 GPa (see also Helwig et al. 2003 [14] and Thomas 2024b [3]). By the mixture of different parts of high-pressure and high-temperature SnO2 polymorphs of rutile-type→CaCl2– type pyrite-type ZrO2 orthorhombic phase I cotunnite- type (Balakrishnan et al. (2022) [13] and Shieh et al. (2006) [15]) demonstrate that high-pressure phases (CaCl2– and cotunnite-type) are essential pieces of evidence for the transport of this ore mineral from mantle depths to the crust region. The presence of 13C-rich diamonds in all parts of this Zinnwald cassiterite sample (Sn-23) supports this statement. Noteworthy is also the general presence of graphite and traces of Fe, Ta, Nb, Ti, Mn, Fe, and Zr (Betechtin, 1964) [16], which make the determination of the polymorphs of cassiterite a little bit difficult by the shift of the Raman bands.

Interpretation

The clear evidence of 13C-rich diamonds in orthorhombic cassiterite from Zinnwald demonstrates clearly that a lot of cassiterite or tin comes directly from the mantle range. The old genetic thinking about the origin of the Variscan tin deposits of the Erzgebirge/Germany alone from the surrounding granite is, therefore, questionable.

Up to now, we have found mainly 12C-rich diamonds in cassiterite (Thomas 2024a, 2024b – [2,3] and Thomas and Rericha 2025) – [17] from Ehrenfriedersdorf in the Central Erzgebirge/Germany, in the cotunnite-type cassiterite from Krupka (Krušné hory Mining District/ Czech Republic, and the Slavkovský les, North Bohemia (Czech Republic). Figures 2 and 4, as well as Table 1, clearly show that the diamond in the here-discussed case is 13C-rich because the typical G band of graphite lies at significantly lower values. That is also valid for the main crystal of cassiterite Sn-70 from Ehrenfriedersdorf in the central Erzgebirge.

Table 2 shows the measured data on the 13C-rich diamond in cassiterite from Ehrenfriedersdorf, Central Erzgebirge, Germany, as well as the data for isotope pure diamond and graphite according to Enkovich et al. (2016) – [18] and Gutierrez et al. (2014) – [10].

Table 2: Raman bands of 13C- and 12C-rich diamonds and graphite, according to Gutierrez et al. (2014) [10] and Enkovich et al. (2016) [18]. The values for the diamonds in cassiterite from the Sauberg mine near Ehrenfriedersdorf (Sn-70) are based on this work (6 crystals).

 

13C-rich

diamond

12C-rich

diamond

13C-rich

graphite

12C-rich

graphite

Pure 13C phase

1283.1 cm-1

1519 cm-1

Pure 12C phase

1332.7 cm-1  

1581 cm-1

Sn-70

1286.7 ± 6.5 cm-1

1318.8 ± 0.9 cm-1 1518.1 ± 0.8 cm-1

From a first approximation, according to Enkovich et al. (2016) [18], the 12C-richer cassiterite Sn-70 has a value of 12.6C (12.5C has an isotopically mixed 1:1 composition). The finding of clear proofs for 13C-rich diamond and graphite in cassiterite from Zinnwald forces the assumption of two different pulses of supercritical fluid (SCGF): the first one is in 12C enriched, and the second one is in 13C enriched. In the Sauberg mine near Ehrenfriedersdorf, we found diamonds in a cassiterite crystal that were very rich in 13C. However, the root zone of the same crystal dominates in 12C-rich diamonds (Thomas 2024a) [2].

Discussion

The presence of orthorhombic cassiterite up to the cotunnite polytype, as well as the frequent occurrence of 12C- and 13C-rich diamonds in different minerals, here in cassiterite, forces a re- thinking of the old genetic concept of the formation of the Variscan tin deposits in the Erzgebirge/Germany and the Krušné hory Mining District/Czech Republic. Furthermore, if so, other isotopes can also effectively be separated in supercritical fluids (SCGF). Also, another point is essential: with the widespread SCGFs in the whole Variscan Erzgebirge region, an enormous amount of water comes from the mantle into the crustal region.

Acknowledgment

For the samples, I thank Professor Ludwig Baumann (1929-2008) from the Mining Academy Freiberg, who initiated my interest in the genetic aspects of the Variscan tin deposits, too. Paul Davidson (Hobart, Tasmania) and Jim D. Webster (AMNH; New York) stimulated my critical thinking regarding supercritical fluids. The nearby daily discussion with Adolf Rericha (Falkensee) forced my intense Raman work.

References

  1. Breiter K (2014) 800 years of mining activity and 450 years of geological research in the Krušné Hory/Erzgebirge Mountains, Central Bol Mus Para Emilio Goeldi. Ciências Naturais 9: 105-134.
  2. Thomas R (2024a) The CaCl2-to-rutile phase transition in SnO2 from high to low pressure in nature. Geol Earth Mar Sci 6: 1-4.
  3. Thomas R (2024b) Rhomboedric cassiterite as inclusions in tetragonal cassiterite from Slavkovský les – North Bohemia (Czech Republic). Geol Earth Mar Sci 6: 1-6.
  4. Schütze H, Stiehl G, Wetzel K, Beuge P, Haberland R, et al. (1983) Isotopen- und elementgeochemische sowie radiogeochronologische Aussagen zur Herkunft des Ehrenfriedersdorfer Granits. – Ableitung erster Modellvorstellungen. ZFI- 76: 232-254.
  5. Ni H, Xiao Y, Xiong X, Liu X, Gao C, et al. (2024) Formation and evolution of supercritical Science China Earth Sciences. 67: 1-13.
  6. Thomas R (1982) Ergebnisse der thermobarometrischen Untersuchungen an Flussigkeitseinschlussen in Mineralen der postmagmatischen Zinn-Wolfram- Mineralisation des Erzgebirges. Freiberger Forschungshefte C370, Pg: 85.
  7. Thomas R, Davidson P, Rericha A, Recknagel U (2022) Water-rich coesite in prismatine-granulite fromWaldheim/Saxony. Veröffentlichungen Naturkunde Chemnitz. 45: 67-s80.
  8. Thomas R, Davidson P, Rericha A, Recknagel U [2023] Mineral inclusions in a crustal granite: Evidence for a novel transcrustal transport mechanism. Geosciences. 13.
  9. Blank VD, Kulnitsky BA, Rerezhogin IA, Tyukalova EV, Denisov VN, et (2016) Graphite-to-diamond (13C) direct transition in a diamond anvil high-pressure cell. Int. J. Nanotechnol. 13: 604-611.
  10. Gutierrez G, Le Normand F, Aweke F, Muller D, Speisser C, et al. (2014) Mechanism of thin layers graphite formation by 13C implantation and Appl Sci. 4: 180-194.
  11. Thomas R, Rericha A, Davidson P, Beurlen H (2021) An unusual paragenesis of diamond, graphite, and calcite: A Raman spectroscopic Estudos Geológicos 31: 3-15.
  12. Schiferl D, Malcolm N, Zaug JM, Sharma SK, Cooney TF, et (1997) The diamond 13C/12C isotope Raman pressure sensor system for high-temperature/pressure diamond-anvil cells with reactive samples. J. Appl Phys 82: 3256-3265.
  13. Balakrishnan K, Veerapandy V, Fjellvag H, Vajeeston P (2022) First-principles exploration into the physical and chemical properties of certain newly identified SnO2 ACS Publ. 7: 10382-10393.
  14. Hellwig H, Goncharov AF, Gregoryanz E, Mao H, Hemley RJ (2003) Brillouin and Raman spectroscopy of the ferroelastic rutile-to CaCl2 transition in SnO2 at high Physical Review B 67: 174110-1174110-7.
  15. Shieh SR, Kubo A, Duffy TS, Prakapenka VB, Shen G (2006) High-pressure phases in SnO2 to 117 Phys. Rev. B 73: 014105-1–014105-7.
  16. Betechtin AG (1964) Lehrbuch der speziellen VEB Deutscher Verlag für Grundstoffindustrie, Leipzig, PG: 679.
  17. Thomas R, Rericha A (2025) Extreme element enrichment by the interaction of supercritical fluids from the mantle with crustal rocks. Minerals. 15: 1-10.
  18. Enkovich PV, Brazhkin VV, Lyapin SG, Novikov AP, Kanada H, et (2016) Raman spectroscopy of isotopically pure (12C, 13C) and isotopically mixed (12.5C) diamond single crystals at ultrahigh pressures. Journal of Experimental and Theoretical Physics. 123: 443-451.

Interpretation of the Lorentzian Distribution of Tin in the Variscan Ehrenfriedersdorf Deposit/Germany

DOI: 10.31038/GEMS.2025712

Abstract

The Lorendian distribution, also known as the Cauchy distribution, is commonly used in statistical physics and geostatistics to describe here the distribution of some aspects of elements. When applied to the study of tin in the Ehrenfriedersdorf deposit, the Lorendian distribution provides valuable insights into the spatial distribution and concentration patterns of tin within this historic mining area. Furthermore, the Lorendian distribution shows that Sn is extraordinarily soluble and concentrated in the fluid/melt on the critical point corresponding to 25.7% H2O of the pegmatite solvus curve (T vs. H2O in the melt) and in the immediate vicinity of this point, determined by maximal concentration Ic at the critical point xc and the width (half width at half maximum (HWHM) of the curve in the melt-H2O system). The strong Lorendian relationship between Sn and water and especially the strong relationship to the critical point (C.P.) of the silicate melt shows convincing that Sn is related to the supercritical fluid coming from mantle depth, also instigated by the occurrence of diamond, lonsdaleite, 13C-rich graphite, and orthorhombic cassiterite, e.g., as cotunnite-type cassiterite. We also show that other elements (Be, B, P, Cl, Zn, As, Cs, Sn, Ta, and W) have similar behavior in water-rich silicate melt systems.

Keywords

Lorentzian curve, Sn distribution, Solvus curve, Rb and Cs enrichment, Sauberg mine, Ehrenfriedersdorf/Germany

Background

The origin of tin deposits and the nature of the Sn transport in the past are often discussed controversially (e.g., Kosals 1976 [1], Liu et al. 2020 [2]). Before Liu et al. (2020) [2], the discussion was mostly restricted to the solubility of SnO2 in water-rich solutions up to 400°C. Ehrenfriedersdorf, located in the Central Erzgebirge region of Germany, has a rich history of tin mining dating back to the medieval period [3]. The deposits around them have very complex geology and mineralization patterns, which make them an ideal candidate for applying advanced analytical and statistical methods such as the Lorentzian distribution to analyze their tin content and its origin. The surrounding granite was discussed, in the past, exclusively as the source of Sn (primarily cassiterite). At the beginning of the intensive analytical study of melt inclusions in granite and pegmatite quartz from the Ehrenfriedersdorf, starting in 1995 [4], we often observed high runaway trace element data that could not interpreted. With time, the amount of such runaway data increases significantly. A correlation with other elements was not possible at that time [5]. Beginning with the determination of water in glasses and melt inclusions (Thomas, 2000) [6], the situation improved from year to year (see also Thomas 2024a) [7]. It appears fast that many main and trace elements in melt inclusions show strong correlations with the water in them. Thomas et al. (2019 and 2022) – [8,9] showed that many elements correlate with water of the melt inclusions according to Gaussian and manly Lorentzian curves. Furthermore, it was revealed that often, the critical point (C.P.) of the solvus curves (correlation of the water concentration in the silicate melt and the homogenization temperature) and the sharp peak of the Lorentzian curve coincide. The connection between the solvus curve and the Lorentzian curve is illustrated by Thomas and Rericha (2024a) [10] in Figure 2b in there.

Characteristics of the Lorentzian Distribution for Tin

The Lorentzian curve (according to Hendrik Antoon Lorentz (1853-1928), a Dutch physicist) is a mathematical function that describes a peak (here the maximal Sn concentration in ppm) centered at a specific position (here the critical water concentration (25.7 %) in the silicate melt) and is characterized by w, which is the half-width at half maximum (HWHM).

The Lorentzian curve is, in our case:

I(x) = Ic * (w/2)2/((x-xc)2 + (w/2)2)                                 (1)

With:

I(x) height of the Sn concentration (ppm) at the water concentration x (%),

Ic     maximal concentration of the Sn (ppm) at xc (center), identical with the C.P. of the complete system,

w    width is the half-width at the half-maximum (HWHM). x water concentration (%),

xc    water concentration (%) at the critical point (solvus and Lorentzian curves),

y0 offset is the shift of the curve from its original position along the y-axis), which is the Clarke value for Sn (3 ppm according to Rösler and Lange, 1975 [11],

A area – is the result of integrating the Lorentzian curve over all values of x,

R2     correlation coefficient.

The following Figure 1 shows the typical form of the Lorentzian distribution of tin (in ppm) versus water concentration (in %) in melt inclusions from the pegmatite system in the Sauberg tin deposit near Ehrenfriedersdorf. For the Lorentzian fitting, we used the Origin 6.1 program. As we can see from Table 1, using equation (1), the calculated Lorentzian curve is identical.

Figure 1: Tin distribution in melt inclusions in quartz from the granite-pegmatite system (Sauberg mine near Ehrenfriedersdorf). The maximal Sn concentration is 16300 ppm at a water concentration of 25.7%.

Figure 1 shows the Lorentzian distribution of Sn vs. H2O, and in Table 1 are the resulting data summarized. The center (25.7 % H2O) is the position of the peak’s center, which corresponds to the critical point of the solvus curve and the maximum (height) of the Sn concentration (here, 16400 ppm Sn). Width is the half-width at half-maximum (HWHM). The offset refers to the displacement of the Lorentzian curve from its original position along the x-axis (H2O concentration) corresponding to 644 ppm.

Table 1: Lorentzian fit of Sn, determined in silicate melt inclusions from the pegmatite system of the Sauberg mine near Ehrenfriedersdorf (46 measuring points). Each point is the mean of 5 to 10 single measurements. The values in the second data row are calculated using Equation 1.

Area Center Width Offset Height R2
  A xc w yo

Io

 
Measured

57799 ppm2

25.7% H2O 2.3% H2O 644 ppm Sn 16295 ppm Sn

0.9843

Calculated

58871 ppm2

25.7% H2O 2.3% H2O (603 ppm Sn) 16295 ppm Sn

1.0000

The offset of the calculated data is, of course, zero – the value of 603 ppm Sn results from the average difference between measured and calculated Sn values. By the way, equation (1) of the Lorentzian curve can be advantageously used for the analyses of analytically determined outlayers. The offset for the calculated case is zero. However, the difference between measured and calculated Lorentzian curves results in a value of 603 ppm Sn. The error (standard deviation) of the offset is ± 348 ppm Sn and results mainly from the values at the tails. The offset represents the concentration of Sn in the surrounding rocks, introduced by the supercritical fluids/melts.

Interpretation of the Results

The application of the Lorentzian distribution to the analytically determined tin and water concentrations in the Ehrenfriedersdorf deposit reveals a significant clustering of tin-rich zones. The location parameter “center” indicates the central area of the highest Sn concentration of 16300 ppm and corresponds with the solvus crest (C.P.) of the water-silicate system, which lies for Sn at 25.7 % H2O in the silicate melt. The low value for the C.P. of the solvus is beside the water content in the melt, the result of the sum of further compounds (Be, B, F, P, rare alkalis, and others) in the volatile-rich melt. The position of the critical point varies a little bit by the variation of the critical elements and compounds. For Be, BO3, PO4, Cl, Zn, As, Cs, Sn, Ta, and WO4, the result from 355 measurements for the critical point lies at 26.9 ± 1.30 % H2O in the silicate melt (see Table 2 and Thomas et al. 2022 [9], and Thomas and Rericha 2023) [12]. Besides H2O, B, rare alkalis (Rb, Cs), and P, fluorine likewise has a determining meaning for the position of the solvus crest as well as the maximum of the Gaussian and Lorentzian curves in the granite-pegmatite system in the Ehrenfriedersdorf district.

Table 2: Lorentzian fit of elements and compounds, determined in silicate melt inclusions from the pegmatite system of the Sauberg mine near Ehrenfriedersdorf. Each point (n) is the mean of 5 to 10 single measurements. For the calculation, we used the Origin 6.1 program. The units are in Table 1.

Element/Compound

Area Center Width Offset Height

n

Be

131560

26.0 8.88 284 11810

14

BO3

153500

25.5 7.67 0 12730

23

PO4

1331000

28.5 7.49 13001 13100

29

Cl

147040

27.2 4.98 902 18782

63

Zn

208400

27.0 5.78 0 22950

9

As

46433

30.2 3.19 521 9266

20

Cs

266000

26.0 5.63 1300 30000

18

Cs1)

25082

26.0 5.31 1340 30060

119

Sn

59124

25.7 2.30 704 16414

35

Ta

50148

27.4 9.87 86 3236

18

WO4

73258

26.8 7.41 303 6292

7

Average  

26.9 ± 1.3

     

Sum 355

Cs in granite from Ehrenfriedersdorf; n – the sum of measurements.

In contrast, the scale parameter “width” (2.3 % water for Sn) provides information on the spread and extent of these high- concentration zones related to the C.P. and the influx of the supercritical fluid at this point. The “offset” is the shift in direction y (Sn-concentration) of the Lorentzian curve from the original position along the x-axis (water concentration). The value of the offset (644 ppm Sn) interprets we as the minimum enrichment of Sn against the value of tin in the surrounding Sn-poor granite system, which is, according to Hösel (1994) [13], ≤ 200 ppm Sn (as a result of redistribution and ore deposit formation. The “height” represents the solved maximal Sn concentration in the supercritical fluids (SCGF). Note that the SCGF also carries solid minerals like orthorhombic cassiterite, diamond, and graphite. The interpretation of the “area” is a bit difficult. The area under the Lorentzian curve represents, in our case, the total concentration of Sn, here 57799 ppm2 in the studied granite-pegmatite system. If we take the Clarke value of Sn for granites, which is three ppm (Rösler and Lange, 1975) [11], then we have an exceptional enrichment of tin in the considered granite-pegmatite system of nearby 20.000 fold. That is remarkably high. Alone, the Sn concentration comes directly with a supercritical fluid, which is about the 5500-fold amount of the Clarke number, is dramatically high. The regular presence of carbon (as C, CO2, CH4 ) in the SCGF shows plausibly that the Sn transport occurs as Sn2+, probably as hydroxocomplexes like ([Sn(OH)x]n-) or as Sn4+ in more complicated compounds as (Na, K)[Sn(OH, Cl, F)3CO3] (Kosals, 1976). Rb and Cs can take the place of Na and K (see Thomas and Rericha, 2023) [14]. Cs increase the number of the H2O molecules in the surrounding OH shell (Pietsch, 1938) [15] up to 13. It is necessary to stress that SCGFs show very different solvency caused by density- dependent solubility, enormously changed polarizability, strongly increased diffusion rates and reactivity, and extremely low viscosity.

One point is here also important: if, for example, one element is in two compounds with different anions present, then the formation of overlapping Lorentzian curves with different xc values is possible (see Figure 3 in Thomas and Rericha, 2024b) [16,17]: the distribution of Be in two distinct species, beryllonite versus hambergite with xc1 at 25.5 % H2O and xc2 at 31.0 % H2O. From the Lorentzian curve type for some elements, it follows clearly that their solubility is not directly related to the water concentration in the melt. The highest solubility is clearly associated with the H2O concentration, representing the critical point (C.P.). At this point, the melt inclusion-bearing quartz grows very fast and traps “samples” of the surrounding medium as melt inclusions. Through fast processes, the boundary layer composition changes steadily (fast diffusion in a low viscous SCGF). Therefore, the composition of the single melt inclusions changes too (see, e.g., Borisova et al., 2012 [18], Table 2 in them, representing two different melt inclusions lying together in one growth zone). Lorentzian distributions of elements are not only water-rich silicate melt-related. Another example is the relationship of Cs, Rb, and B in the Ehrenfriedersdorf granite. Figure 2 shows such a plot. As Table 3 shows, the concentration of the rare alkalis Rb and Cs is very high in granite from the Sauberg mine near Ehrenfriedersdorf.

Table 3 shows the data for this passable Lorentzian plot and demonstrates that B- Rb and Cs-rich melt fractions are generated and penetrate the present granite rock. An exact interpretation of this remarkable plot (Figure 2) is, at the moment, not possible. More analytical, microscopical, and Raman work is necessary.

Figure 2: Lorentzian distribution of Cs versus boron obtained from melt inclusions in granite quartz from the Sauberg mine near Ehrenfriedersdorf.

Table 3: Cs and (Rb + Cs) distribution in melt inclusions in quartz from the granite- system (Sauberg mine near Ehrenfriedersdorf). The maximal Cs and Rb + Cs concentrations are 58477 and 65756 ppm (sum = 12.4%) at a boron concentration of 2.26%.

Measured

Area Center Width Offset Height

R2

 

A

xc w yo

Io

 
Cs-B

53529 ppm2

2.26% B2O3 0.58% B2O3 13113 ppm Cs 58477 ppm Cs 0.928

Cs+Rb-B

62463 ppm2 2.26% B2O3 0.60% B2O3 23854 ppm Rb + Cs 65756 ppm Rb + Cs

0.905

Rb gives no Lorentzian distribution with B2O3 – therefore, the low R2 value using the sum of Rb and Cs.

Alone from the small number of examples, we see that the geochemistry of the Variscan Sauberg mine is highly complex. The standard correlation of elements gives no satisfactory answers to the complex processes working at the formation of this tin deposit (see Author Collective, 1963) [19]. Regardless of the input of SCGF, the genetic origin of this tin deposit is not solvable. Primary the tin mineralization in Ehrenfriedersdorf is not uniformly distributed but instead concentrated in specific geological structures, here pegmatites or pegmatite-like bodies, influenced or generated by supercritical fluids or melts (in short, geofluids (SCGF)). The classic idea of the hydrothermal origin of cassiterite is now untenable. The sharp Lorentzian peak related to the critical point of the solvus curve is a strong hint of the impact of supercritical fluids coming from mantle deeps (with temperatures >1000°C). This idea is supported by orthorhombic polymorphs of cassiterite (e.g., the cotunnite-type cassiterite inclusions in cassiterite crystallized at a pressure of about 10 – 40 GPa (Thomas 2025) [20]. Note, however, that orthorhombic cassiterite is metastable at low pressures. The transition into tetragonal cassiterite is mostly irreversible by kinetic barriers. Such a barrier may be the “shock-like” transition from the supercritical to the under- critical state. The occurrence of orthorhombic cassiterite is supported by the occurrence of diamond, lonsdaleite, and graphite inclusions with extreme isotope composition: 13C-rich diamond and graphite versus 12C-rich ones. The SCGFs are excellent media for the potent and selective separation of isotopes (e.g., 12C/13C or H/D by diffusion effects and solubility differences (see Thomas 2024b [16,17], 2025 [20] and Thomas and Rericha 2024a) [10].

Implications for Mining and Exploration

Understanding the Lorentzian distribution of tin in the Sauberg deposit has practical implications for mining and exploration in the whole Variscan Erzgebirge/Krušnohořy region. By identifying the central and peripheral zones of tin concentration, mining operations are optimizable to target the most economically viable areas. That can lead to more efficient extraction processes and reduced operational costs. The highest Sn concentration is related to rock parties rich in pegmatites or pegmatite-like bodies (see Schröcke, 1954) [21]. Furthermore, the substantial input of Sn by SCGF changed the old ideas of the dominance of tin granites for the generation of workable deposits. The high level of tin in the granites in question is the result of the interaction between SCGF and the granites. The high water and Sn content at the critical point (C.P.) favor the formation of pegmatites and pegmatite-like structures with this element and others (see above). It is quite conceivable that under the famous Pb-Zn deposit of the Freiberg mining district (Rösler et al. 1968) [22] is a large tin deposit. Hints are REE-rich fluorite globules like that from Zinnwald (Thomas 2024c) [23] in yellow low-temperature fluorite from Halsbrücke near Freiberg and the reverse of very high concentration of Pb (1790 ppm) [as cotunnite], Zn (85120 ppm) [as (K, Pb, Cs)2 Zn(Cl, Br)4] and Ag (100 ppm) [as chlor-, brom- and iodargrite] in high-temperature fluid inclusions in quartz of the Sauberg mine (see Boriosova et al. 2012 [18] and Thomas et al., 2019 [8]). The Clarke values for Pb, Zn, and Ag are, according to Rösler and Lange (1975) [11], 20, 40, and 0.05 ppm, respectively [24].

That interpretation results from the Lorentzian distribution, which offers insights into the geological processes that led to the formation of the tin deposits. The distribution pattern may reflect the influence of SCGF, their way from the mantle into the crustal regions, which later formed fault structures and other geological factors that concentrated tin in specific areas over geological periods via hydrothermal re- deposition and crystallization as cassiterite. Tin is highly soluble in SCGFs, as we can see from their Lorentzian distribution. However, an essential part of tin comes from mantle depths (10 – 40 GPa) as solid phases like the cotunnite polymorph of cassiterite. It is well- known that the high-pressure and high-temperature polymorphs of cassiterite, e.g., orthorhombic phases, are formed at 10 – 40 GPa or higher. Typically, they transform back to tetragonal cassiterite upon decompression. As we see in many examples (Thomas, 2025 [25] and Thomas and Rericha, 2023 [12,14]), this process can be inhibited by fast cooling, particularly by the transition from the supercritical to the critical and under-critical state outwit.

Conclusion

The Sauberg tin deposit provides a robust framework for understanding the spatial variability and clustering of tin mineralization. The insights gained from this statistical approach can inform both current mining practices and future exploration efforts, ultimately contributing to the efficient and sustainable exploitation of this valuable resource (at the moment, this is an abandoned mining district). However, we can learn a lot from the two-dimensional element distribution (elements versus water concentration. The distribution of the trace elements in melt inclusions in granites and pegmatites in relationship with the water content of the same inclusions shows clearly Lorentzian curves with the maximum concentration at the critical point of the solvus and that of the Lorentzian curves. These results give robust hints for the origin of Sn and other elements via supercritical fluids (SCGF). A critical rethinking of the origin of this and other analog mineral deposits is necessary.

Acknowledgment

The Author thanks the members of the working group, which builds up for the first time a usable measuring chamber at DESY for the study of micrometer-large fluid and melt inclusions in a quartz matrix. Besides the Author, the following scientists belong to this group: Prof. A. Knöchel (DESY Hamburg), Dr. J. Walter, Prof. Althaus (both from Karlsruhe), Dr. M. Haller, Dr. M. Radtke (both from DESY Hamburg), Dr. W. Klemm, TU Bergakademie Freiberg. Thanks also go to Dr. D. Rhede (GFZ Potsdam) for the longstanding cooperation in the microprobe analysis of melt inclusions and to Dr. J.D. Webster (AMNH New York) for performing the SIMS analyses.

References

  1. Kosals Ja A (1976) Main features of geochemistry of rare metals in granitic melts and solutions. Nauka, Novosibirsk. 232 p. (in Russian).
  2. Liu Y, Li, J, Chou IM (2020) Cassiterite crystallization experiments in alkali carbonate aqueous solutions using a hydrothermal diamond-anvil cell. American Mineralogist. 105: 664-673.
  3. Breiter K (2014) 800 years of mining activity and 450 years of geological research in the Krušné Hory/Erzgebirge Mountains, Central Europe Bol Mus Para Emílio Goeldi Cienc Nat Belém. 9: 105-134.
  4. Thomas R, Haller M, Knöchel A, Radtke M (1995) First results of studies on melt inclusions in geological samples using SYXRF-microprobe. Hamburger Synchrotronstrahlungslabor am Deutschen Elektronen-Synchrotron (HASYLAB), Annual Report II: 961-962.
  5. London D, Evensen JM (2002) Beryllium in silicic magmas and the origin of beryl- bearing pegmatites. In: Beryllium – Mineralogy, Petrology, and Geochemistry. (ed): E.S. Grew. Chapter 11: 445-486.
  6. Thomas R (2000) Determination of water contents of granite melt inclusions by confocal laser Raman microprobe spectroscopy. American Mineralogist. 85: 868-872.
  7. Thomas R (2024a) Vom Schmelzeinschluss zum superkritischen Fluid – Ergebnisse und Folgen der Befahrung der Grube Sauberg bei Ehrenfriedersdorf. Veröffentlichungen Museum für Naturkunde Chemnitz. 47: 59-66.
  8. Thomas R, Davidson P, Appel K (2019) The enhanced element enrichment in the supercritical states of granite-pegmatite systems. Acta Geochim. 38: 335-349.
  9. Thomas R, Davidson P, Rericha A, Voznyak DK (2022) Water-rich melt inclusions as “frozen” samples of the supercritical state in granites and pegmatites reveal extreme element enrichment resulting under non-equilibrium Mineralogical Journal (Ukraine). 44: 3-15.
  10. Thomas R, Rericha A (2024a) Extreme element enrichment by the interaction of supercritical fluids from the mantle with crustal rocks. Minerals 33: 1-10.
  11. Rösler HJ, Lange (1975) Geochemische Tabellen. Leipzig. Pg: 675.
  12. Thomas R, Rericha A (2023) Extreme element enrichment by the interaction of supercritical fluids from the mantle with crustal rocks. Minerals 33: 1-10.
  13. Hösel G (1994) Das Zinnerz-Lagerstättengebiet Ehrenfriedersdorf/Erzgebirge (1994). Freiberg. Pg: 195.
  14. Thomas R, Rericha A (2023) Extreme enrichment of Cs during the crystallization of the Ehrenfriedersdorf pegmatite melt related to the Variscan tin Geol Earth Mar Sci 5: 1-4.
  15. Pietsch E (1938) Gmelins Handbuch der anorganischen Chemie. Edition 8. Verlag Chemie, GmbH Berlin. Pg: 104.
  16. Thomas R (2024b) 13C-rich diamond in a pegmatite from Ronne, Bornholm Island: Proofs for the interaction between mantle and crust. Geol Earth Mar Sci. 6: 1-3.
  17. Thomas R, Rericha A (2024b) Extreme element enrichment, according to the Lorentzian distribution at the transition of supercritical to critical and under-critical melt or Geol Earth Mar Sci 6: 1-6.
  18. Borisova AY, Thomas R, Salvi S, Candaudap F, Lanzanova A, Chemeleff J (2012) Tin and associated metal and metalloid geochemistry by femtosecond LA-ICP-QMS microanalysis of pegmatite-leucogranite melt and fluid inclusions: new evidence for melt-melt-fluid Mineralogical Magazine. 76: 91-113.
  19. Author Collective (1983) Isotopen- and elementgeochemische sowie radio- geochronolgische Untersuchungen an der Zinnlagerstätte Ehrenfriedersdorf. AdW of the GDR, ZFI-Mittelungen 76, 271 p.
  20. Thomas R (2025) Extremely 13C-rich diamond in orthorhombic cassiterites in the Variscan Erzgebirge, Saxony/Germany. Geol Earth Mar Sci 7: 1-5.
  21. Schröcke H (1954) Zur Paragenese erzgebirgischer Zinnlagerstätten. Neues Jahrbuch Mineralogie, Abhandlungen 87: 33-109.
  22. Rösler HJ, Baumann L, Jung W (1968) Postmagmatic mineral deposits of the northern edge of the Bohemian Massif (Erzgebirge-Harz). Guide to Excursion 22 AC, International Geological Congress XXIII Session Prague, ZGI Berlin. 3-57.
  23. Thomas R (2024c) REE-rich fluorite in granite from Zinnwald/East Erzgebirge/ Geol Earth Mar Sci 6: 1-5.
  24. Thomas R, Rericha A (2024) Meaning of supercritical fluids in pegmatite formation and critical-element Geol Earth Mar Sci 6: 1-5.

Sinai… The land of Turquoise – Egypt’s Strategic Stock of Mineral Wealth

DOI: 10.31038/GEMS.2025711

 

Let us first emphasize some important facts about the mining and mineral resources sector in Egypt:

  1. Despite the great potential of the mineral wealth sector in Egypt and the spread of many mineral ores in most Egyptian deserts and in large proportions, this sector does not participate in the national product except by a very small percentage represensing not more than 1% in the country’s national product.
  2. Experts and specialists emphasize that mineral wealth represents the third side in building the economies of countries along with agriculture and industry, and from here it is necessary to exploit these resources optimally, according to procedures and measures to activate research and exploration operations, and use the best ways to extract and exploit them in an economic manner.

Sinai Peninsula is a triangle-shaped peninsula located in Egypt that has an area of about 60,000 square kilometers between the Mediterranean Sea (to the north) and Red Sea (to the south). Its land borders are the Suez Canal to the west and the Palestine-Egyptian border to the northeast. The Sinai Peninsula is in Southwest Asia while the rest of Egypt is in North Africa (Figure 1).

Figure 1: Location Map of Sinai Peninsula in the Arab Republic of Egypt

The Sinai Peninsula in the Arab Republic of Egypt is the crossroads of continents and the land of turquoise and the incubator of the most beautiful natural reserves on the planet not only that, God has blessed it with many mineral riches represented in many mineral ores, whether industrial such as cement industry raw materials (limestone, shale, gypsum, iron oxides, sand and gravel), ceramic industry raw materials (feldspar, albyte and kaolin) and ornamental stones (marble and granite) as well as metal ores that are involved in advanced technological industries (copper, lead, zinc, tungsten, molybdenum and manganese) and recently discovered in Sinai some of the precious metals (gold and silver). Sinai is famous for the presence of energy raw materials other than oil, which is coal ore, which is found in many areas, especially the G. Al-Maghara area in North Sinai, as well as the areas of Badaa and Thawra near the Abu Zenima area.

There are also a number of natural salts on the northern coasts of Sinai near the El-Arish City, which produce large quantities of table salt and other industrial salts. The Sinai Peninsula also contains the largest reserves of ultra-pure white sand, which is used in many important industries.

Based on the interest in the reconstruction of Sinai, it was necessary to draw attention to pay attention to its mineral resources and its many treasures and attract investment and reconstruction opportunities to it, so many geological, geophysical and mineralogical studies have tended to discover these mineral resources that can be developed and estimate the reserves of them and the work of many feasibility studies to exploit them optimally.

In this article, the researcher tries to shed light on the most important mineral wealth spread in the Sinai Peninsula in terms of their type and quantities, in order to direct decision-makers and those wishing to invest in the mining sector to the most important mining projects that can be established in the land of Sinai, which helps the emergence of new communities, provide job opportunities and increase the national income of the country.

Among the most important hidden mineral riches in the Sinai Peninsula are:

Turquoise

It is the most famous mineral of the Sinai Peninsula, and is found in the mountains of Wadi Al-Maghara and Sarabit in the city of Al-Tur, and was the first to think about mining turquoise in the last century, Major MacDonald, a retired English officer, in Wadi Al-Maghara in 1854 and built him a house at the foot of a hill inhabited by old miners, and he lived his wife there for five years in collecting the metal, but he did not achieve the success he begged for and died in 1870.

Oil

Petroleum is the most important mineral resource in Sinai. There are many oil fields, including the Gulf of Suez, Belayim, Assal and Abo Rdis, and the region’s reserves are estimated at about 237 million barrels of crude oil and natural gases.

White Sand

White sand is found in the Sinai Peninsula in the area of G. Abu Hittat – Paradise Plateau on the Nuweiba – Saint Catherine road and the Abu Zenima area with a total reserve of up to (155 million cubic meters or 330 million tons) of ultra-pure sand. These sands are involved in many important industries, including: luxury glass types – tableware – white glass – transparent packaging – optical glass – crystal – colored glass and others.

Ornamental Stones

Ornamental stones, especially granite of various kinds, are spread in the areas of Saint Catherine and Nubia, while marble of sedimentary origin and consisting of hard limestone rocks is found in the areas of Al-Hassana in central Sinai and these raw materials are used for many purposes, including: decorating buildings and facilities – floors – stairs – the manufacture of antiques and statues.

Kaolin

It is one of the distinctive raw materials in Sinai and is located on Nuweiba – Saint Catherine road and the proven reserves of it are estimated at about 15 million tons, as well as the Abu Zenima area, and the reserves are estimated at about 80 million tons and kaolin ores are used in many industries such as: ceramics and Chinese – white cement – medical industries – plastic – refractory bricks and refractories – sanitary ware.

Limestone

It is found in G. Labani, G. Al-Halal, Raysan Unaizah, G. Al-Maghara and G. Al-Jifjafa and is used in the manufacture of cement, chemical industries, fertilizers, paints and in construction and road construction.

Dolomites

It is found around the edges of G. Al-Maghara and G. Al-Halal and is used in construction, road construction and protection of port docks and has many uses, the most important of which are: the production of aggregates necessary for road paving and reinforced concrete, agriculture to improve the soil and restore its acid balance, cement industry, refractories for lining furnaces and molds used in steel production.

Coal deposits

Coal deposits are located in Sinai in G.Al-Maghara area and the proven reserves of it in G. Al-Maghara are 27 million tons, of which about 21 million tons can be mined, and there is also located in Abu Zenima and Oyoun Moussa areas, and the proven reserve has been estimated at about 18.5 million tons, it is used as fuel for power plants and cement factories.

The Carbon Baby

They are natural deposits containing carbon-coal materials, found east of Abu Zenima, and used as fuel in power plants and cement manufacturing. Its reserves are about 75 million tones per square kilometer.

Manganese Deposits

Manganese ores are found in South Sinai in the Um Bojmeh area, and appear as lenses associated with dolomite limestone rocks in the Middle Carboniferous Age, and this area has reserves of about 3 million tons, and is currently exploited by the wholly-owned Sinai Manganese Company, which replaced the British Sinai Company more than 66 years ago. There are also deposits of manganese ore in the Sharm el-Sheikh area of South Sinai, associated with iron ore, and the percentage of manganese in this area is about 45%, and this area is considered to have an estimated reserve of about 30 thousand tons, according to information documented by the Mineral Resources Authority. It is used in many important industries such as: pharmaceutical industries – battery industry – aluminum – bronze.

Lead, Zinc, Silver and Gold

Lead, zinc, silver and gold spread in the Sinai Peninsula in the area of Um Zureik and Al-Kid near the city of Dahab, it has been discovered high concentrations of lead and zinc in the area of Um Zureik west of the Gulf of Aqaba and about 45 km from the city of Sharm el-Sheikh . These concentrations exist in the form of ranges in sedimentary rocks and concentrations range from 1% to more than 12% for lead and from 1% to 8% for zinc . This has been monitored these concentrations superficially and in depth where monitoring it at a depth of 79 m in the form of a carrier layer and the results showed the presence of galena metal by between 1-3% and the main zinc mineral, which is sphalerite by between 1-8% with the monitoring of other high concentrations of silver (3000 ppm). There are also some studies that refer to the discovery of gold ore in the vicinity of sedimentary rocks near the Abu Zenima area, as well as some areas in the city of Taba.

Copper

The Sinai Peninsula is famous for the presence of copper ore, which has been exploited since the era of the pharaohs, and the most important areas that contain ore are the Samra area near the city of Dahab, Al-Ruqaita near Saint Catherine, and the monument and Sarabid Al-Khadem near the city of Abu Zenima. Copper is used in many important economic industries as well as in many alloys and in the manufacture of paints.

Sulphur

Sulfur and pyrite ores are among the raw materials that are used in many industries, especially the fertilizer industry, and sulfur ore is found in two areas, the first in north El-Arish, which is of sedimentary origin, and the second region, which is the Mount Ferrani area in South Sinai, where sulphur is present in the form of pyrite ore in large quantities.

Feldspar

It is located in South Sinai and is used in many important industries such as: glass industry – ceramics – toothpaste – sandpaper materials – borsillin – paint and polishing materials.

Black sand

The beaches of the city of El-Arish abound and contain a lot of heavy and important metals such as magnetite, illuminate, rutile, zircon and are used in many important iron industries such as the manufacture of paints – alloys dyes – textiles – paper – leather – glass and refractory bricks.

Gypsum Deposits

Gypsum deposits are located in the Ras Al-Malab area and Wadi Al-Seih in South Sinai and are used in many industries, the most important of which are: the manufacture of fertilizers – cement and other construction purposes.

Shale Sediments

Shale deposits are widely spread in the area of Abu Zenima, the area of Wadi Firan, the area of Al-Tur and the area of Oyoun Musa. It is used in many industries, including: ceramic industry – as a filter material – brick industry – cement industry – drilling fluids – refractories industry – cosmetics and some pharmaceutical preparations.

Sand and Gravel Deposits

Sand and gravel deposits are spread in various places in the Sinai Peninsula and these deposits are included in many purposes such as: the manufacture of building and construction materials and as filter agents in water purification plants.

Salt

Sodium chloride (table salt) is found around Lake Bardawil in the form of salts and is used in the production of table salt, food industries, chemical industries and drilling oil wells. The most recent use of salt is the use of rock salt mines as a safe place for burying nuclear waste.

Bentonite

It has economic importance in the drilling of oil and groundwater wells, and is located between the areas of Oyoun Moussa and Ras Sidr. Reserves are estimated at hundreds of millions of tons.

Groundwater

North Sinai Governorate enjoys a huge reserve of groundwater in a group of deep aquifers, which opens up investment opportunities in the agricultural and industrial fields and the subsequent reconstruction and other economic activities.

By reviewing the wealth of the Sinai Peninsula, it becomes clear to us the importance of benefiting from these riches from the establishment of industrial projects that increase the value of these raw materials, which absorb a lot of labor and establish new urban communities aimed at reconstructing Sinai and increasing its effectiveness in supporting national income, especially with the presence of various energy sources, road network, ports and other elements of infrastructure.

Treacher Collins Syndrome Type II with Cleft Palate: A Case Report

DOI: 10.31038/JDMR.2024723

Abstract

Treacher Collins syndrome (TCS) is a rare congenital craniofacial dysplasia characterized by malformations of the jaw, eyes, and ears, with an incidence of approximately 1 in 50000.This study reported a case of a 4-year-old male TCS patient presenting with cleft palate. The patient exhibited facial asymmetry, flat zygomatic bone and zygomatic arch, mandibular hypoplasia, and eye and ear abnormalities. Genetic testing confirmed a POLR1 D gene mutation, leading to a diagnosis of TCS type II. The patient underwent cleft palate repair surgery and demonstrated significant recovery postoperatively. Follow-up evaluations showed significant improvement in speech and palatal function. The diagnosis of TCS relies on clinical manifestations, imaging examinations, and genetic testing. Effective treatment necessitates multidisciplinary collaboration, encompassing craniofacial reconstruction, hearing enhancement, and speech therapy. A comprehensive treatment plan should be tailored to the patient’s age and severity of deformities to address the physiological function and psychological needs. Future efforts should focus on enhancing the application of molecular genetics in the diagnosis and treatment of TCS to improve prenatal diagnostic capabilities.

Keywords

Treacher Collins syndrome, Cleft palate

Introduction

Treacher Collins syndrome (TCS) is a rare congenital craniofacial dysplasia characterized by malformations of the jaw, eyes, and ears, with an incidence of approximately 1 in 50000 [1]. First reported by Edward Treacher Collins in 1900 [2], the syndrome can be classified into four clinical subtypes. Its primary clinical features include blepharophimosis, zygomatic dysplasia, conductive deafness, and mandibular dysplasia or micrognathia, with cleft palate cases being particularly rare [3,4]. This paper presents a case of a TCS patient with cleft palate, detailing the symptoms, diagnosis, treatment process, and follow-up results to provide a reference for clinicians in the diagnosis and treatment of this condition.

Case Report

A 4-year-old male patient was identified with facial deformity and cleft palate at birth. Examination revealed facial asymmetric, flat bilateral zygoma and zygomatic arch, a short mandibular ramus, wide orbital spacing, oblique palpebral fissures, absence of the lower eyelid, and missing lower eyelid eyelashes (Figure 1). The patient also exhibited bilateral auricle deformity, external auditory canal atresia with preauricular fistula (Figure 2), and a cleft palate extending from the uvula to the incisive foramen, with a maximum width of 2.5 centimeters (Figure 3). Hearing tests indicated moderate conductive hearing loss in both ears. Genetic analysis identified a heterozygous spontaneous mutation in the POLR1 D gene, leading to a diagnosis of TCS type II. The patient’s speech was unclear due to the cleft palate. Upon admission, the patient underwent cleft palate repair surgery under general anesthesia with tracheal intubation. Postoperative recovery was successful (Figure 4), and voice training commenced three months post-surgery. Follow-up evaluations at 6 months, 12 months, and 24 months post-operation showed well-recovered palate morphology, normal soft palate movement, significantly improved pronunciation, and no coughing during meals.

Figure 1: Facial asymmetric, flat bilateral zygoma and zygomatic arch, a short mandibular ramus, wide orbital spacing, oblique palpebral fissures, absence of the lower eyelid, and missing lower eyelid eyelashes.

Figure 2: Bilateral auricle deformity, external auditory canal atresia with preauricular fistula.

Figure 3: A cleft palate extending from the uvula to the incisive foramen, with a maximum width of 2.5 cm.

Figure 4: The palate healed well

Discussion

TCS is a rare craniofacial malformation with autosomal dominant inheritance, also known as maxillofacial dysplasia and deafness syndrome. It presents a highly variable phenotype, with about 40% of patients having a family history [3]. The cause of TCS is attributed to disrupted ribosome synthesis in cranial neural crest cells and neuroepithelial cells between the 2nd and 8th weeks of embryonic development. This disruption leads to a reduction in the number of neural crest cells migrating to the craniofacial region, resulting in hypoplasia of the first and second branchial arches [5].

TCS can present with various clinical types. According to studies by Splendor (2000), Teber (2004), and Vincent [6-8], the clinical features of TCS patients can be summarized as follows: (1) Craniofacial abnormalities: These include facial asymmetry, a low hairline, and facial hypoplasia, particularly affecting the mandibular and zygomatic complex. (2) Eye abnormalities: These are characterized by oblique palpebral fissures and lower eyelid defects. (3) Ear abnormalities: These include atresia of the external auditory canal, microtia, and conductive hearing loss, contributing to a characteristic ‘fish-like ‘ facial appearance. (4) Other rare clinical features: Dental abnormalities such as missing teeth (tooth dysplasia), tooth discoloration (enamel opacity), excessive tooth spacing, abnormal permanent teeth (eg, ectopic maxillary first molars), and occlusal disorders. Palatal abnormalities such as high-arched palate and cleft palate. Respiratory and feeding difficulties may arise from posterior nostril stenosis or atresia. Cardiac malformations are also possible in some cases [9,10]. Patients with a mild phenotype of TCS may exhibit almost no obvious clinical features and may require genetic testing for identification. Conversely, those with a severe phenotype may experience life-threatening ventilatory disorders due to obstruction of the posterior nasal foramen, glossoptosis, and other complications [11].

The clinical diagnosis of TCS is primarily based on clinical manifestations, imaging examinations, and pathogenic gene detection. X-ray imaging typically reveals several characteristic features: increased density of small mastoid bones, nasal protrusion with a wide, flat frontonasal angle, maldevelopment or defects in the zygomatic bone and zygomatic arch, narrow maxillary protrusion, small maxillary sinus, mandibular dysplasia with a short body and ascending ramus, and a deepened anterior corner notch. Ultrasound examination is valuable for the intrauterine diagnosis of TCS, with the fetus often presenting with polyhydramnios, absence of fetal swallowing activity, and poor development of the bilateral parietal diameter and head circumference. Known pathogenic genes associated with TCS include TCOF1, POLR1C, and POLR1D. Mutations in these genes can lead to reduced ribosomal RNA transcription and ribosome synthesis, which subsequently affect the development and differentiation of neural crest cells during the embryonic stage [6,7,12].

The clinical manifestations of TCS are similar to those of several other syndromes, necessitating differential diagnosis. These syndromes include Nager syndrome, Miller syndrome, Goldenhar syndrome, and Pierre Robin syndrome [13,14]. The facial features of Nager syndrome are similar to those of TCS, but Nager syndrome also presents with typical limb deformities such as thumb dysplasia or absence, polydactyly, and radial ulna bony fusion [15]. Miller syndrome is characterized by asymmetric upper and lower eyelid ectropion and defects, dysplasia of the fifth finger (toe), and a higher prevalence of cleft lip and palate compared to TCS [16]. Goldenhar syndrome is marked by hemifacial atrophy affecting the development of the ears, mouth, and mandible, and may also include vertebral abnormalities and dermoid cysts on the outer layer of the eye [14]. Pierre Robin syndrome is distinguished by micrognathia, glossoptosis, dyspnea, and cleft palate [17].

The comprehensive sequential treatment of TCS typically begins at birth and continues until growth and development are complete. Treatment should be tailored to the patient’s growth pattern, physiological function, and psychosocial needs. It is recommended to ensure and maintain basic life functions before the age of 2 years. If there is persistent corneal exposure between the ages of 2 and 5 years, orbital wall reconstruction should be performed for correction. If the mandible is underdeveloped between the ages of 6 and 10 years, mandibular traction should be performed. Speech therapy, craniofacial fracture reconstruction, and external ear reconstruction should be completed before the age of 12. Orthodontic-orthognathic treatment, correction of upper and lower jaw and nasal deformities, and social psychotherapy should be carried out between the ages of 13 and 18 years. Future treatment should incorporate molecular genetics, utilizing genetic tests for prenatal examinations in high-risk groups and monitoring fetal growth and development during the first three months of pregnancy.

The phenotypes of TCS vary greatly, ranging from mild to severe deformities. For example, airway obstruction caused by mandibular deformity can affect breathing, and eyelid defects can expose the cornea. Therefore, TCS treatment should follow a multidisciplinary comprehensive sequence approach, involving oral and maxillofacial surgery, plastic surgery, orthodontics, ophthalmology, otolaryngology, speech therapy, psychology, genetics, and nursing. Individualized treatment measures should be selected based on the patient’s age and degree of deformity.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Statement

The studies involving human participants were reviewed and approved by the ethics committee of Qingdao Women and Children’s Hospital

Informed Consent

The patient ‘s legal guardian provided written informed consent to participate in this study.

Author’s Contribution

Ting li: Conception and design of study, Acquisition of data, Data analysis and interpretation, Drafting of manuscript and critical revision, Approval of final version of manuscript.

Yuelin qin: Conception and design of study, Acquisition of data, Data analysis and interpretation, Drafting of manuscript and critical revision, Approval of final version of manuscript.

Ziyan lu: Acquisition of data.

Xuecai yang: Drafting of manuscript and critical revision, Approval of final version of manuscript.

Junwei wang: Drafting of manuscript and critical revision, Approval of final version of manuscript.

References

  1. Nguyen PD, Caro MC, Smith DM, et al. (2016) Long-term orthognathic surgical outcomes in Treacher Collins patients. J Plast Reconstr Aesthet Surg 69: 402-408. [crossref]
  2. Treacher Collins E (1900) Case with symmetrical congenital notches in the outer part of each lower lid and defective development of the malar bones. Trans Opthalmol Soc 20: 190-192.
  3. Shinde CV, Kohli S (2018) Treacher Collin’s syndrome: a case report with an augmented review! International Journal of Advanced Research 6: 141-146.
  4. Renju R, Varma BR, Kumar SJ, et al. (2014) Mandibulofacial dysostosis (Treacher Collins syndrome): A case report and review of literature. Contemporary Clinical Dentistry 5: 532-534.
  5. van Gijn DR, Tucker AS, Cobourne MT (2013) Craniofacial development: current concepts in the molecular basis of Treacher Collins syndrome. Br J Oral Maxillofac Surg 51: 384-388.
  6. Splendore A, Silva EO, Alonso LG, et al. (2000) High mutation detection rate in TCOF1 among Treacher Collins syndrome patients reveals clustering of mutations and 16 novel pathogenic changes. Hum Mutat 16: 315-322. [crossref]
  7. Teber OA, Gillessen-Kaesbach G, Fischer S, et al. (2004) Genotyping in 46 patients with tentative diagnosis of Treacher Collins syndrome revealed unexpected phenotypic variation. Eur J Hum Genet 12: 879-890. [crossref]
  8. Vincent M, Geneviève D, Ostertag A, et al. (2016) Treacher Collins syndrome: a clinical and molecular study based on a large series of patients. Genet Med 18: 49-56. [crossref]
  9. Campos PSSL, Taitson PF, Pinto da Silva LC, et al. (2022) Dental and health aspects in the co-occurrence of Treacher Collins and Down syndromes: Case report. Spec Care Dentist 43: 94-98. [crossref]
  10. Kadakia S, Helman SN, Badhey AK, et al. (2014) Treacher Collins syndrome: the genetics of a craniofacial disease. Int J Pediatr Otorhinolaryngol 78: 893-898. [crossref]
  11. Islam F, Afroza A, Rukunuzzaman M, et al. (2008) Treacher Collins Syndrome-A Case Report. Bangladesh Journal of Child Health 32: 33-36.
  12. Bowman M, Oldridge M, Archer C, et al. (2012) Gross deletions in TCOF1 are a cause of Treacher–Collins-Franceschetti syndrome. European Journal of Human Genetics 20: 769-777. [crossref]
  13. Thomas P, Krishnapillai R, et al. (2019) Treacher Collins Syndrome: A Case Report and Review of Literature. Oral Maxillofac Patho J 10: 90-94.
  14. Shete P, Tupkari J, Benjamin T, et al. (2011) Treacher Collins syndrome. Journal of Oral and Maxillofacial Pathology 15: 348-351.
  15. Rosa RF, Guimarães VB, Beltrão LA, et al. (2015) Nager syndrome and Pierre Robin sequence. Pediatrics international: official journal of the Japan Pediatric Society 57: e69-72. [crossref]
  16. Trainor PA, Andrews BT (2014) Facial dysostoses: Etiology, pathogenesis and management. American Journal of Medical Genetics Part C Seminars in Medical Genetics 163: 283-294.
  17. Shen YF, Vargervik K, Oberoi S, et al. (2012) Facial Skeletal Morphology in Growing Children With Pierre Robin Sequence. Cleft Palate Craniofac J 49: 553-560.

Exploring Barriers to Continuing Nursing Education Among Nurses: A Descriptive Qualitative Study

DOI: 10.31038/IJNM.2025613

Abstract

Introduction: Rapid changes in health care, innovative technologies and the emergence of new knowledge have led to the need for nurses to continue to learn and develop throughout their careers to keep their knowledge, skills, and competencies up to date. However, nurses are confronted by various barriers to continuing their professional education. There is limited research about these barriers in the Eswatini context. Therefore, this study explored the barriers to continuing nursing education among nurses in one hospital in the Lubombo region of Eswatini.

Methods: A descriptive qualitative design was employed. Ten purposively selected nurses participated in the study. Face-to-face, in-depth, semi- structured interviews were used to collect data. The audio-recorded interviews were transcribed verbatim. Thematic analysis guided by Braun and Clarke’s method was applied.

Findings: Participants understood the value of continuing nursing education. However, participants encountered barriers which included lack of time, staff shortages, poor remuneration, lack of distance learning options, and absence of training leave. Lack of job security was also a barrier reported by participants. Participants suggested that employing more nurses, job security assurance, and financial support could motivate nurses to further their studies.

Conclusions: There is a need for the Ministry of Health to collaborate with healthcare facilities and nursing education institutions to create an enabling environment for continuing professional education for nurses. Further research needs to investigate factors that hinder employers from allowing nurses to further their education.

Keywords

Barriers, Competencies, Continuing nursing education, Employer, Nurses

Introduction

In the rapidly changing healthcare context, continuing professional education (CPE) is essential for healthcare professionals to provide person-centered, safe, and effective care. King et al. (2021) [1]. Continuing professional education is a life-long learning approach whereby healthcare professionals acquire knowledge and skills to maintain competency in their field of practice [2]. The goal of CPE is to contribute to healthcare professionals’ career advancement, improved financial income, professional networks, and personal skills [3]. Continuing professional education is central to nurses’ lifelong learning and is vital for keeping their knowledge and skills up-to-date [4]. In nursing practice, CPE is essential to improve quality of care, promote nurses’ resilience and increase readiness to face emerging and re-emerging healthcare challenges [5].

Studies show that knowledge gained through basic professional education has a half-life of 2.5 years and needs to be updated at the end of this period. Moreover, such training will expire five years after graduation; hence, deprivation of CPE can lead to poor quality patient care and death [6]. Identifying continuing professional development needs is the nurse’s responsibility, and interpreting those needs is the nurse manager’s responsibility [5]. Self-motivation, relevance to practice, preference for workplace learning, strong enabling leadership, and a positive workplace culture are key factors that positively influence CPE for nurses. Moreover, nurses embark on continuing education when they have a reason to do so [7]. For nurses, engaging in CPE can be mandatory or voluntary. Mandatory CPE occurs when regulatory organizations set compulsory conditions for nurses to transition from their initial to higher qualifications [4]. CPE promotes motivation, commitment, and nurses’ retention and performance [7]. Evidence has shown that nurses do not always engage in continuing education and that CPE does not always address nurses’ real needs (Vázquez-Calatayud et al., 2021). Reasons for not engaging in nursing CPE include time limitations, fatigue, lack of motivation, and poor working conditions. Additional reasons include an organizational culture characterized by a lack of leadership and collegial support, an inability to apply new knowledge in practice, distant learning sessions from the workplace, and educational programs not adapted to nurses’ needs [8]. Barriers to continued nursing education have several negative consequences for the nursing profession. Limited access to ongoing education can hinder career advancement opportunities for nurses, leading to decreased job satisfaction and lower professional retention rates [4]. The lack of updated knowledge and skills may result in suboptimal patient care outcomes, affecting patient safety and the quality of healthcare delivery [9]. Additionally, the profession’s overall growth and development may be stunted when nurses cannot contribute to research, innovation, and the adoption of new evidence-based practices [7]. To fulfil the primary goal of enhancing quality care, international organisations recommend strengthening the human capital by engaging in professional development initiatives for nurses. Basic nursing training alone is insufficient, especially because nurses are occasionally confronted with unpredictable care situations in highly complex patient-care environments. Thus, there is an unequivocal global consensus regarding nurses’ need for continuing education [9]. Continuing nursing education will protect the public and improve the quality of care and services. Lack of nursing CPE negatively influences quality of patient care, job satisfaction, recruitment, and retention [10]. Although continuing nursing education is beneficial [4], there is a paucity of research on the barriers to CPE in Eswatini. Therefore, the study explored barriers to continuing nursing education in Eswatini. Exploring barriers to CNE in a resource-limited country provides insight into the socio-politico-economic climate that influences professional development for nurses.

Methods

Research Question

The central question in this study was: “What are the barriers to continuing nursing education in one hospital in Eswatini?”

Study Design

This was a descriptive qualitative study. This design was chosen to paint a clear picture of a little-known phenomenon. The descriptive qualitative design recognizes the phenomenon’s subjective nature and helps researchers contribute to change and quality improvement in clinical settings [11]. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used to report this qualitative study [12].

Research Setting

The study was conducted in a public regional referral hospital in the Kingdom of Eswatini. The hospital has 400 beds and approximately 500 outpatients seen by healthcare professionals daily. The following services are provided in the hospital: psychiatric and mental healthcare, outpatient care, maternal and child healthcare, surgery, oncology, general medicine, HIV testing, and treatment. The hospital also provides palliative care, dental, audiology, physiotherapy, and occupational therapy services. The setting was conveniently selected because it is the lead author’s clinical placement hospital. Different nursing cadres, which include nursing assistants, general nurses, and specialist nurses, are employed in the hospital.

Sampling Method and Procedure

The participants included nurses who were full-time employees at the hospital, working at least 40 hours per week, and had been working for more than six months. Participants were purposively sampled to select participants in the best position to answer the research question [13]. Following permission from the hospital to conduct the study, the lead author recruited the participants by visiting the different hospital units to explain the purpose and value of the study. Nurses willing to participate were given an information leaflet, and dates and times were scheduled to answer questions related to the study, sign informed consent, and plan a venue and time for the interviews.

Data Collection and Management

The lead author, a male university lecturer with a postgraduate qualification and clinical experience in critical care nursing, visited the participants who volunteered in their units. This visit aimed to explain the value of the study and answer participants’ questions before signing the informed consent form. Before primary data collection, the second author conducted two pilot face-to-face interviews with participants in the same research setting using a semi-structured interview guide developed by the research team. The flexible nature of face-to-face interviews allows researchers to explore in-depth information from participants [14]. Pilot interviews help identify and rectify poorly structured or offensive questions that reveal researcher biases [15]. The interview guide contained questions that explored the barriers to continuing nursing education. No questions were changed after the pilot interviews; therefore, the data were included in the data analysis. The questions were: 1) What is the value of continuing nursing education? 2) What are the barriers to continuing nursing education in your view?. The interviews were conducted at times that the participants selected to avoid disrupting patient care. Data saturation was attained after the ninth interview, and an additional interview was conducted to verify the saturation. After data collection, all the interviews were transcribed verbatim and sent to the lead author for review. The second author has clinical experience in community and mental health nursing. The second author was not a supervisor to the participants; hence, the participants did not feel coerced to participate in the study. Following data collection, the interview transcripts and audio recordings were encrypted and stored in a password-protected computer accessible only to the research team.

Data Analysis

The interviews were transcribed verbatim using Microsoft Office Word 365. Thematic analysis guided by the Braun and Clarke (2006) [16] method was applied (Table 1).

Table 1: Application of Braun and Clarke’s data analysis method.

Braun and Clarke’s steps

Application in the present study

Step 1: Familiarizing oneself with the data The co-authors read and reread the transcripts, listened to the interview recordings, and wrote down word-for-word what was captured in the audio recordings.
Step 2: Generating initial codes The co-authors used short phrases to code the data. Similar codes were then sorted into categories.
Step 3: Searching for themes The co-authors searched for themes by identifying shared categories in participants’ responses.
Step 4: Reviewing themes The co-authors reviewed the themes to refine and discard unnecessary themes.
Step 5: Defining and naming themes The co-authors defined and assigned names to themes to clarify emerging findings.
Step 6: Writing a descriptive research report The second author wrote the research report, which the lead author reviewed.

Trustworthiness

Trustworthiness was maintained using Lincoln and Guba’s (1985) credibility, dependability, confirmability, and transferability strategies. Credibility was maintained through prolonged engagement, whereby the researcher met with nurses before data collection and during the interviews. Member checking was performed when the interview transcripts were verified with the participants, who confirmed that the findings reflected their perceptions and experiences. Transferability was enhanced through purposive sampling and by describing the participants’ demographic profile and the research setting. Additionally, the research methodology was described in detail. An audit trail that comprehensively described steps for collecting, organizing, and analyzing the data was provided to enhance dependability. Confirmability was maintained by providing adequate and relevant direct verbal quotations from the participants to support the findings.

Ethical Considerations

Ethical approval was granted by the Eswatini Health and Human Research Review Board (FWA00026661/IRB00011253/SHR004/2024). The hospital’s administration also granted permission to conduct the study, and participants received oral and written information concerning the study. Participants further signed consent forms indicating their willingness to participate. The participants were informed that participation was completely voluntary and that they could withdraw their informed consent at any time when they desired to do so. To maintain anonymity and confidentiality, participants were assured that pseudonyms would be used in the research report. Furthermore, the lead author did not ask questions that caused emotional or psychological harm to participants.

Findings

Participants’ Characteristics

Ten face-to-face interviews were conducted with diverse nursing cadres from January 2024 to June 2024, each lasting approximately 30 to 45 minutes. Table 2 shows the participants’ demographic characteristics.

Table 2: Summary of participants’ demographic characteristics.

Participant

 

Age (in years) Sex Highest qualification

Work Experience

1

34

Female Diploma in General Nursing

10 years

2

29

Male Diploma in General Nursing

3 years

3

27

Female Certificate in Nursing Assistance

3 years

4

29

Male Certificate in Nursing Assistance

1 year

5

26

Male Diploma in General Nursing

3 years

6

27

Female Certificate in Nursing Assistance

4 years

7

32

Female Diploma in General Nursing

6 years

8

34

Female Diploma in General Nursing

7 years

9

25

Female Certificate in Nursing Assistance

3 years

10

34

Male Diploma in General Nursing

10 years

Themes and Subthemes

The data analysis revealed three themes and 10 associated subthemes (Table 3).

Table 3: The data analysis revealed three themes and 10 associated subthemes.

Themes

Subthemes

Understanding the value of continuing nursing education Updating professional knowledge
Improving clinical skills
Perceived barriers to continuing education Staff shortage and lack of time
Remuneration mismatch
Financial difficulties
Lack of training leave and open distance learning opportunities
Uncertain job security
Suggestions for recognition of nurses’ continuing education Ensuring adequate nursing staff
Provision of study leave and job security
Financial support

Theme 1: Understanding the Value of Continuing Nursing Education

This theme describes the participants’ understanding of the value of continuing nursing education. Participants revealed that continuing education improved their professional competencies and skills in providing patient care. Two subthemes were developed, namely 1) updating professional knowledge and 2) improving clinical skills.

Subtheme 1: Updating Professional Knowledge. Participants verbalised that continuing nursing education is meant to enhance their professional knowledge in patient care. This view by participants reflects the recognition of using up-to-date and evidence-based knowledge to provide patient care:

“…. nursing is dynamic and one needs to equip him or herself with the current knowledge, current guidelines and the technology, new drugs that are introduced, and new procedures” [Participant 8].

“Basically, since nursing is a dynamic sector… and evolving, so as a healthcare practitioner you have to be up to date and be updated on the current standards of the profession for you to be able to continue providing quality care” [Participant 5].

The participants responses demonstrate an understanding of the ever-evolving nature of healthcare that requires up-to-date knowledge to improve patient outcomes.

Subtheme 2: Improving Clinical Skills. The participants verbalised that continuing nursing education contributes to improvement of clinical skills. The participants’ reports highlight the significance of updating nursing skills to enhance patient assessment, diagnosis, and treatment of diverse diseases:

“…I’ll make an example with us nursing assistants it happens that there are procedures that we want to do but our scope restricts us …so by furthering our studies we will be more qualified to do those procedures which we are currently restricted from doing… we will be able to learn new things that are occurring in health… indeed it is important” [Participant 6].

“…to get updated skills and be competent so that they [nurses] can be able to render nursing care to save patients’ lives” [Participant 8].

These collective responses by participants demonstrate the nature of continuing education in enhancing performance of nursing skills that match their current qualifications to enhance holistic patient care.

Theme 2: Perceived Barriers to Continuing Education

This theme related to participants’ perceived barriers to continuing their education. The perceived barriers hinder their attempts to improve competencies in providing quality patient care. Five subthemes emerged: 1) staff shortage and lack of time, 2) remuneration mismatch, 3) financial difficulties, 4) lack of training leave and open distance learning opportunities, and 5) uncertain job security.

Subtheme 1: Staff Shortage and Lack of Time. Participants voiced that staff shortages in the hospital resulted in a lack of time and opportunities to further their education. The insights highlight that a shortage of staff leads to tight work schedules that hinder professional development:

“… currently in our facility, we have shortage with the staff which makes it difficult for one to pursue their studies because of the shortage” [Participant 2].

“…it can be the issue of staffing ratio…you find that there are these nurses who want to further their studies in the facility, but they can’t leave the work and continue with their education … and the schedule is not friendly” [Participant 4].

Collectively, the participant’s responses reflect the role played by staff shortages and tight work schedules in inhibiting professional development opportunities.

Subtheme 2: Remuneration Mismatch. The participants expressed the mismatch between the upgraded qualifications and salary hindered their professional development. According to the participants, this situation discouraged them from continuing their education. These perceptions reflect poor recognition of upgraded education by the employer:

“…another thing it’s the lack of motivation, since people who go and further their studies are doing the very same job…and getting the same salary” [Participant 1].

“Like I said in the beginning, the first barrier is that you will go to further your education and come back here to earn a lower salary… let me make an example, they will hire you as a degree nurse and you will do that degree job yet you get paid for a diploma qualification” [Participant 3].

The responses by participants jointly indicate that poor remuneration demotivates nurses from engaging in professional development trainings.

Subtheme 3: Financial Difficulties. Shortage of finances was reported by participants as a barrier to their professional development. Hence, participants would not be able to keep up with higher education costs as there were no scholarships to assist them:

“I think it’s…our government and the ministry of health…they do not [financially] support part-time education…whereby you are still working and still studying” [Participant 5].

“Another barrier could be finances…most of us nurses want to enrol for education and continue to learn but we are breadwinners… then it becomes difficult for one to continue [with their education] because you have to provide for your family, and you have to pay for your school fees at the same time” [Participant 9].

These participant responses reflect that higher education fees and increased family responsibilities do not favour continuing education endeavours among nurses.

Subtheme 4: Lack of Training Leave and Open Distance Learning Opportunities. The participants verbalised that lack of open distance learning opportunities hindered their continuing education endeavours. These views demonstrate that the nature of nursing programmes offered by higher education institutions was instrumental in enhancing professional development among nurses:

“…my only barrier is that for nursing assistants, you need to resign completely and then you go back to school because there is no study leave for us…and the nursing degree is offered full-time [Participant 4].

“…when you want to continue with nursing education you need to resign first and there is no study leave or distance learning for nurses, so it becomes difficult…” [Participant 10].

These responses jointly reflect that study leave is essential for all nursing cadres in hospitals to enable them to engage in their professional development initiatives.

Subtheme 5: Uncertain Job Security. Participants reported that uncertain job security hindered them from continuing their education. According to the participants, there was no assurance that they would still return to their jobs after upgrading their education. These insights highlight lack of support from employers concerning nurses’ professional development:

“… also, there is no job security…so you ask yourself so many times that should I resign and go to study…and then when I come back who is going to employ me, where and when, who is going to take care of my kids, who is going to take care of my family whilst I am looking for a [new] job?” [Participant 2]

“…and the job security – you can’t just leave your post and go to further your studies because you might not know whether you will be employed or not when you come back, so for me it’s that.” [Participant 5].

These participant responses jointly demonstrate that employers are not visionary regarding nurses’ professional development. Job insecurity reflects an unsupportive working environment in the hospital.

Theme 3: Suggestions for Recognition of Nurses’ Continuing Education

This theme describes suggestions from participants concerning the recognition of nurses’ continuing education by employers and the Ministry of Health. An environment that supports professional development recognises the need to implement interventions to improve patient outcomes. Three subthemes were developed: 1) ensuring adequate nursing staff, 2) providing study leave and job security, and 3) financial support.

Subtheme 1: Ensuring Adequate Nursing Staff. Participants verbalised that employers need to hire more nursing staff. According to the participants, this would create room for other nurses to continue their education while others fill their spaces in the working area:

“…it lies with the employer to try as much as possible to…to employ more nurses in order to cover up the shortage” [Participant 8].

“I think…this facility…with the nursing management board has to consider the issue of the staffing ratio so that nurses can have some spare time and continue with their education…” [Participant 4].

These responses jointly highlight that adequate nursing staff is important as nurses are able to take turns and partake in continuing education.

Subtheme 2: Provision of Study Leave and Job Security. Participants verbalised that employers’ assurance of job security can promote continuing education among nurses. According to the participants, they would be motivated to learn because they would still return to their jobs immediately after completing their studies:

“…they have to allow the nurse to go study, maybe they pay like 75% of the salary while the nurse is studying and then when he or she comes back he will be able to get his job back with an agreement which says maybe you can work for 4 years before you look for greener pastures” [Participant 2].

“…let them (nurses) go and study then hire them when they return and deduct funds from their salaries [while they are studying] – yes, I think that can work out” [Participant 3].

The collective participants’ insights reflect that motivation to engage in continuing education relies on efforts by employers who need to provide job security for nurses.

Subtheme 3: Financial Support. The participants expressed the need for financial support from the government and the Ministry of Health to assist in their professional development. These views indicate that governments need to support nurses in continuing education to improve the citizens’ quality of care:

“… government can provide the finances for the nurses for their extra educational courses… I think in that way we can bridge the current problem within nursing education my sister…” [Participant 4].

“…they [health institutions and government] should fund nurses, especially nursing assistants – let them go and study” [Participant 3].

Collectively, the participants’ responses show the role that the government can play in meeting the need for nurses to engage in continuing education.

Discussion

The study has provided insight into barriers to continuing nursing education in a developing country. Despite the obstacles to continuing education, participants clearly understood its value. The findings of this study support those of research conducted by Tachtsoglou et al. (2020) [17] among Greek nurses, which reported that the main reason for continuing education was acquiring new professional knowledge. Additionally, the findings of this study support those of another study conducted in two hospitals in southeast Morocco, which revealed that participants’ motivation for continuing education was mainly intrinsic factors, which included improving professional competence and knowledge [9]. These findings highlight the dynamic nature of healthcare and nursing practice, which always places a need upon nurses to upgrade their knowledge to keep up with developments in healthcare. Additionally, nurses’ desire for continuing professional education needs to be met with appropriate in-service education programs and workshops and a supportive environment to enable their professional development. Continuing nursing education is necessary in the face of scientific and technological advancements, which require the acquisition of new knowledge, improved skills, and the renewal of clinical practices [6]. In their examination of nurses’ motivation to continue their education, [18] found that the most crucial reason was improving professional competence, skills, and patient care. This finding suggests that nurses value enhancing their knowledge and skills to provide patients with the best care.

In line with the findings of this study, [18] found that the high workload resulting from staff shortages in nursing care units was one of the main reasons for nurses not to further their studies, resulting in exhaustion and lack of time to focus on studies. Similarly, [19] revealed that people with a heavy workload and family responsibilities might struggle to find time to further their studies. These findings reflect the need for nurse managers and employers to reduce nurses’ workload by proportionately distributing tasks in the different units. Additionally, Mbombi and Mothiba (2020) [19] reported that participants felt that the Department of Health attached no value to postgraduate qualifications because they did not increase one’s salary upon completion of the degree and, therefore, were demotivated to enrol for an advanced nursing degree. Career progression and financial rewards have been established as the most important motives for nurses to enrol in further studies [4]. Therefore, a lack of remuneration for nurses after acquiring additional nursing qualifications may discourage other nurses from enrolling in programmes meant to increase their qualifications as there are no increased financial benefits after obtaining an additional qualification. The findings of this study also support the assertion that advanced nursing courses may be costly, and as a result, lack of finances becomes a significant barrier to enrolling in an additional qualification [21,22]. Financial constraints due to minimal salaries and insufficient financial support from healthcare institutions hinder nurses from furthering their studies. Additionally, tuition, textbooks, and travel expenses often deter nurses from continuing their education.

Barriers to enrolment in further studies can also be institutional. According to Lhbibani et al. (2021) [6], barriers to continuing education that can be imposed by learning institutions include scheduling problems; lack of interesting, practical or relevant courses; procedural problems, time requirements; and inadequate information about programs and procedures. Hence, lack of workplace policies supporting educational leave can discourage nurses from pursuing further education. Lack of security of continuing to be employees of the organization after completing their education is also a barrier to nurses’ professional development. The requirement for nurses to resign from their posts in order to pursue further studies has become a significant barrier because, as the World Bank (2023) [23] noted, due to low recruitment post-training, employment opportunities for newly qualified nurses are limited in most sub-Saharan countries, including Eswatini. The barriers to continuing nursing education, from the personal to the national level, have dire consequences for patients and the healthcare system. Patient care errors can result from inadequately qualified nurses, and the healthcare system may fail to sufficiently meet the population’s needs.

In line with our findings, nurses in another study verbalized the need for their management to hire more staff to deal with staff shortages in order to avoid nurses missing out on important workshops and education programs [21]. Moreover, a study conducted by Munasinghe et al. (2023) [24] to explore the opportunities and challenges in lifelong learning and continuing professional development among nurses in Sri Lanka found that expanding the workforce to address shortage of nurses and provide more opportunities for professional development was viewed as one of the most essential strategies for facilitating increased participation of nurses in continuing education. Therefore, adequate staffing and flexible work shifts are important enablers or facilitators for nurses furthering their education. The availability of sufficient support systems, including management support, mentorship programs, realistic opportunities for professional development, and workplace policies for awarding study leave, are significant enablers for continuing professional education among nurses. Therefore, there is a need for organizational policies that promote and facilitate nurses’ continued education. Sponsorship from employment organizations is a major facilitator of continuing nursing education among nurses [25]. Governments and financial institutions must support nurses in furthering their education.

Implications of the Study

The study findings highlight the need for employers to develop training plans, promotional strategies, and reward systems that can enable nurses to further their education. Moreover, the Ministry of Health needs to formulate policies that enable nurses to continue their education, including providing financial support, adequate staff, and the award of study leave. Nurses also need to develop a desire to continue their education and identify programmes that will meet their professional development needs.

Strengths and Limitations

One strength is that the study has provided insight into the barriers to continuing nursing education in a developing country characterised by resource limitations. Moreover, the qualitative approach has provided an in-depth exploration of the barriers from the nurses’ perspectives. One limitation is that the study included only nurses; hence, factors that hinder other healthcare professionals from furthering their education were not explored. The qualitative approach also limited the generalisability of the findings to the entire population of nurses.

Conclusions

Although participants understood the value of continuing education, they encountered barriers which included staff shortages, financial challenges, lack of job security, time, and distance education. Absence of study leave was also identified as a barrier. Personal, workplace, and health system challenges hinder nurses from continuing their education. Nurses who do not further their education are more likely to provide poor quality care that is not evidence-based. Therefore, poor patient outcomes occur, thus bringing the nursing profession to disrepute. Governments need to design frameworks that enable nurses to further their education while being able to retain their employment. Nurse-training institutions should design flexible programmes that allow nurses to further their education while employed. Future research needs to investigate employers’ factors that hinder nurses from furthering their education.

References

  1. King R, Taylor B, Talpur A, Jackson C, Manley K, et al. (2021) Factors that optimise the impact of continuing professional development in nursing: A rapid evidence review. Nurse Education Today 98. [crossref]
  2. Curran V, Gustafson DL, Simmons K, Lannon H, Wang C, et al. (2019) Adult learners’ perceptions of self-directed learning and digital technology usage in continuing professional education: An update for the digital age. Journal of Adult and Continuing Education. 25: 74-93. [crossref]
  3. Julian JFE, Ruiz FB (2020) Continuing professional development (CPD) among educators in selected Colleges of Nursing: Perceived importance, impact, and challenges. Enfermería Clínica 30: 60-64.
  4. Mlambo M, Silén C, McGrath C (2021). Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature. BMC Nursing. 20: 1-13. [crossref]
  5. Longhini J, Rossettini G, Palese A (2021) Massive open online courses for nurses’ and healthcare professionals’ continuous education: A scoping review. International Nursing Review. 68: 108-121. [crossref]
  6. Lhbibani A. Lamiri A, Lotfi S, Tridane M, Belaaouad S (2021) Factors hampering the participation of nursing staff in the continuing education activities of hospitals centers in the Casablanca-Settat region. The Open Nursing Journal 15.
  7. Vázquez-Calatayud M, Errasti-Ibarrondo B, Choperena A (2021). Nurses’ continuing professional development: A systematic literature review. Nurse Education in Practice 50. [crossref]
  8. Bit-Lian Y, Woei-Ling T, Nachiappen S, Jajali NFM (2022). Factors affecting participation of registered nurses in continuing nursing education among selected private pospital in Penang, Malaysia. The Malaysian Journal of Nursing (MJN). 14: 82-89.
  9. Ait Ali D, Fazaz M, Ounaceur B, El Houate B, El Koutbi M, et al. (2023). Motivational factors influencing nurses’ participation in continuing education sessions: A hospital-based study. Journal of Adult and Continuing Education. 29: 395-407.
  10. Hakvoort L, Dikken J, Cramer-Kruit J, Molendijk-van Nieuwenhuyzen K, van der Schaaf M, et al. (2022). Factors that influence continuing professional development over a nursing career: A scoping review. Nurse education in practice 65. [crossref]
  11. Doyle L, McCabe C, Keogh B, Brady A, McCann M (2020). An overview of the qualitative descriptive design within nursing research. Journal of Research in Nursing, 25: 443-455. [crossref]
  12. Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 19: 349-357.
  13. Nanjundeswaraswamy T, Divakar S (2021) Determination of sample size and sampling methods in applied research. Proceedings on Engineering Sciences. 3: 25-32.
  14. Gray JR, Grove SK (2024) Burns & Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence. St. Louis, Missouri, Elsevier, Inc.
  15. Naz N, Gulab F, Aslam M (2022) Development of qualitative semi-structured interview guide for case study research. Competitive Social Science Research Journal 3: 42–52.
  16. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative research in psychology. 3: 77-101.
  17. Tachtsoglou, K., Zioga, O., Iliadis, C., Frantzana, A., & Lambrini, K. (2020). Factors affecting nurses ‘ lifelong learning. International Journal of Health Administration and Education Congress (Sanitas Magisterium) 6: 1-9.
  18. Tsirigoti A, León-Mantero C, Jiménez-Fanjul N (2024) Motivation for continuing education in nursing. Educación Médica 25.
  19. Mbombi M, Mothiba T (2020) Exploring barriers that nurses experience to enrolment for a postgraduate nursing qualification at a higher education institution in South Africa. African Journal of Health Professions Education, 12: 41-45.
  20. Fang, D., Bednash, G. D., & Arietti, R. (2016). Identifying barriers and facilitators to nurse faculty careers for PhD nursing students. Journal of Professional Nursing. 32: 193-201. [crossref]
  21. Nyelisani M, Makhado L, Luhalima T (2023) Professional nurses’ experiences regarding continuing professional development (CPD) opportunities at public hospitals of Limpopo province, South Africa. Sage Open 13.
  22. Rocco TS, Smith MC, Mizzi RC, Merriweather LR, Hawley JD (2023) The handbook of adult and continuing education. Taylor & Francis.
  23. World Bank (2023). Global healthcare workers: Education, mobility, and financing.
  24. Munasinghe HK, Suraweera KAVS, Weerakkody WADH, Hiruni Kanchana U, Marikar FMMT (2023) Opportunities and challenges in lifelong learning and continuing professional development among nurses at a cancer hospital in Sri Lanka. Journal of Healthcare Administration 2: 61-85.
  25. Palma JAFS, Oducado RMF, Palma BS (2020) Continuing professional development: Awareness, attitude, facilitators, and barriers among nurses in the Philippines. Nursing Practice Today. 7: 198-207.

Impact of Care-Seeking Delay on Hospital Treatment and Clinical Outcomes in Patients with Chronic Heart Failure

DOI: 10.31038/IJNM.2025612

Abstract

Objective: To investigate the relationship between care-seeking delay and hospital treatment as well as clinical outcomes in patients with chronic heart failure (CHF).

Methods: This retrospective cohort study included 265 heart failure patients who visited the Department of Cardiology at Peking University Third Hospital from January 2019 to December 2022. Patients were divided into two groups based on the median care-seeking delay time (7 days): the care-seeking delay group and the non-care-seeking delay group. The study analyzed demographic basic information, hospital treatment information (length of stay, average daily cost, medication use), and information related to clinical outcome (including HF-related symptoms, mortality, readmission rate within 3 months, cardiac function classification, left ventricular ejection fraction, BNP/NT-proBNP, etc.) between the two groups.

Results: The median care-seeking delay time for the 265 patients was 7 days (P25=2 days; P75=58 days). Statistical analysis showed that the average length of hospital stay and hospitalization costs were significantly higher in the care-seeking delay group than in the non-care-seeking delay group, with statistical significance (P<0.05). There were statistically significant differences between the two groups in the presence of exertional dyspnea, lower limb edema, decreased exercise tolerance, and dyspnea during sleep on admission (P<0.05). The use of SGLT2i, intravenous diuretics, MRA, and NOACs during hospitalization also showed statistically significant differences (P<0.05). In terms of clinical outcomes, there was no statistically significant difference in the readmission rate within 3 months between the two groups, the BNP level on discharge was lower in the care-seeking delay group than in the non-care-seeking delay group (P=0.015), and the proportion of patients with EF<40% was significantly higher in the care-seeking delay group (P=0.032).

Conclusion: Care-seeking delay significantly increases the length of hospital stay and hospitalization costs for patients with chronic heart failure and is closely related to hospital treatment and clinical outcomes.

Keywords

Chronic heart failure, Care-seeking delay, Hospital treatment, Clinical outcomes, Retrospective study

Heart failure is a complex clinical syndrome caused by various reasons leading to abnormal changes in cardiac structure and/or function, representing a severe manifestation or advanced stage of cardiac diseases, with high incidence and mortality rates [1]. The China Cardiovascular Health and Disease Report 2023 Summary indicates that in China, the prevalence of heart failure among adults aged ≥35 years is 1.3%, reaching 8.9 million, and this number has shown an upward trend over the years [2]. The main reason for hospital admission of heart failure patients is the exacerbation of symptoms, and care-seeking delay is an important cause of symptom progression leading to hospital admission. Studies have found that more than 50% of heart failure patients will not seek medical help before their symptoms become unbearable [3,4].

The care-seeking delay time for heart failure patients mainly refers to the total time consumed from the first presentation of heart failure symptoms to hospital admission, as well as the time interval from the presentation of subacute heart failure symptoms or early signs of heart failure deterioration to seeking medical help [5,6]. It can be divided into two stages, namely patient delay and transportation delay [7], among which the patient delay stage can more truly and accurately reflect the patients’ own care-seeking behavior. Surveys have shown that the shortest patient delay in seeking medical care for heart failure patients is 1 day, the longest is 243 days, and the average care-seeking delay time is 7.5 days [8]. This duration is affected by a variety of factors, including symptom burden, depressive state, limitations of medical resources, and support from family members. In addition, individual characteristics such as educational level and socioeconomic status can also affect the care-seeking delay time [9,10]. Care-seeking delay can seriously affect the diagnosis and treatment, clinical outcomes, and quality of life of patients after hospitalization, such as length of hospital stay, medical costs, complications, mortality rate, and the use of related drugs during hospitalization [11,12]. Studies have pointed out that accurately identifying the influencing factors of the behaviors that cause care-seeking delay in heart failure patients, thus curbing such behaviors, can effectively reduce the readmission risk and mortality rate of heart failure patients [13].

Currently, researches on care-seeking delay in chronic heart failure patients mainly focus on current situation surveys and analyses of influencing factors, and there are few studies exploring the impact of care-seeking delay on the hospital treatment and clinical outcomes of chronic heart failure patients. This study aims to explore the impact of care-seeking delay on the hospital treatment and clinical outcomes of chronic heart failure patients, in order to provide a basis for the formulation of clinical practice strategies related to care-seeking delay.

Materials and Methods

Research Subjects

Clinical data of inpatients diagnosed with chronic heart failure and admitted to the Department of Cardiology of Peking University Third Hospital from 2019 to 2022 were collected, and a retrospective cohort study was conducted. The inclusion criteria for patients in this study are as follows: ① Patients diagnosed with heart failure according to the 2018 Chinese Guidelines for the Diagnosis and Treatment of Heart Failure; ② Heart failure was the primary diagnosis for the patient’s current hospitalization; ③ According to the New York Heart Association (NYHA) functional classification, the patient’s cardiac function was class II-IV; ④ Age ≥18 years. Exclusion criteria for patients are as follows: ① Pregnant patients; ② Patients with a history of mental illness; ③ Patients without detailed medical records; ④ Patients participating in other studies related to heart failure treatment during the period from 2019 to 2022.

Research Methods

This study was approved by the Peking University Third Hospital Medical Science Research Ethics Committee (IRB00006761-M2024110). Clinical data of patients were retrospectively obtained from the hospital’s electronic medical record system and the medical records management office, mainly including: ① Basic information: age, gender, education level, occupation, marital status, living situation, medical payment method, length of hospital stay, and average daily cost of hospitalization; ② Admission-related information: The time of the patient’s first presentation of heart failure symptoms during the hospitalization and the time of the patient’s first medical visit as calculated through the initial course of illness record, also includes ejection fraction, BNP/NT-proBNP, NYHA functional classification, and symptoms related to heart failure such as shortness of breath/dyspnea, decreased exercise tolerance, and lower limb edema; ③ Medication usage during hospitalization: Digitalis, beta-blockers (Luoer class), mineralocorticoid receptor antagonists (MRAs), diuretics, SGLT2 inhibitors (SGLT2i), and non-vitamin K antagonist oral anticoagulants (NOACs); ④ Discharge-related information: Ejection fraction, BNP/NT-proBNP, NYHA functional classification, and symptoms related to heart failure such as shortness of breath/dyspnea, decreased exercise tolerance, and lower limb edema; ⑤ Whether the patient was alive on discharge and the number of readmissions within 3 months after this discharge. Each patient’s care-seeking delay time was calculated based on the time of the patient’s first medical visit and the time of the patient’s first presentation of heart failure symptoms, according to which the patients were divided into the care-seeking delay group and the non-care-seeking delay group. The basic information, admission and discharge data, hospital treatment, and clinical outcomes were analyzed between the two groups.

Data Collection Methods

Two cardiology nurses who had undergone unified training reviewed the medical records for data collection and verification. In case of any discrepancies during the review process, the data query would be conducted again.

Statistical Methods

Statistical analysis was performed using SPSS 24.0 software. Normality tests were conducted on the data. Normally distributed continuous data were described using mean and standard deviation, while non-normally distributed continuous data were represented by median and interquartile range. For comparisons between groups, independent samples t-tests or Mann-Whitney U tests were used as appropriate. Categorical data were presented as frequencies and percentages, and analyzed using chi-square tests or Fisher’s exact tests. Since the proportion of missing values for all variables was less than 10%, missing continuous data were imputed using mean or median, and missing categorical data were imputed using mode. All statistical inferences were conducted using two-tailed tests, with a significance level of P<0.05.

Results

Basic Clinical Information

①Among the 265 patients with chronic heart failure, there were 183 males and 82 females, with an average age of (71.12±13.73) years. Han ethnicity accounted for 243 cases (91.7%); retired individuals accounted for 191 cases (72.1%); 239 (90.2%) of the patients were married, 4 (1.5%) were unmarried, 7 (2.6%) were divorced, and 15 (5.7%) were widowed. 91.7% of the patients lived with family/friends. The primary method of medical payment was various types of insurance, with only 6 patients (2.3%) paying fully self-funded. There were no statistically significant differences between the two groups in terms of age, gender, occupation, marital status, living situation, and medical payment method (P>0.05). General information of heart failure patients is detailed in Table 1. ② The proportion of patients with exertional dyspnea, lower limb edema, fatigue, and dyspnea during sleep on admission was significantly higher in the care-seeking delay group than in the non-care-seeking delay group, with statistical significance. See Table 2 for details.

Table 1: General information of heart failure patients

Variables

Total (n=265) Non-care-seeking delay group (n=123) Care-seeking delay group (n=142)

P

Gender (%)      

0.678

Male

183 (69.1)

87 (70.7)

96 (67.6)

 
Female

82 (30.9)

36 (29.3)

46 (32.4)

 
Age (mean (SD))

71.12 (13.73)

69.87 (13.83)

72.21 (13.60)

0.167

Ethnicity (%)      

0.445

Han

243 (91.7)

115 (93.5)

128 (90.1)

 
Minority

22 (8.3)

8 (6.5)

14 (9.9)

 
Living situation (%)      

0.751

Living alone

22 (8.3)

9 (7.3)

13 (9.2)

 
Live with family/friends

243 (91.7)

114 (92.7)

129 (90.8)

 
Occupation (%)      

0.328

Government official

10 (3.8)

5 (4.1)

5 (3.5)

 
Professional technician

15 (5.7)

5 (4.1)

10 (7.0)

 
Business services personnel

6 (2.3)

4 (3.3)

2 (1.4)

 
Worker

16 (6.0)

7 (5.7)

9 (6.3)

 
Farmer

27 (10.2)

8 (6.5)

19 (13.4)

 
Retiree

191 (72.1)

94 (76.4)

97 (68.3)

 
Marriage (%)      

0.070

Married

239 (90.2)

116 (94.3)

123 (86.6)

 
Unmarried

4 (1.5)

0 (0.0)

4 (2.8)

 
Divorced

7 (2.6)

1 (0.8)

6 (4.2)

 
Widowed

15 (5.7)

6 (4.9)

9 (6.3)

 
Health insurance (%)      

0.057

Basic medical insurance for urban employees

174 (65.7)

85 (69.1)

89 (62.7)

 
Basic medical insurance for urban residents

37 (14.0)

21 (17.1)

16 (11.3)

 
The new rural cooperative medical system

6 (2.3)

3 (2.4)

3 (2.1)

 
Commercial medical insurance

31 (11.7)

6 (4.9)

25 (17.6)

 
Fully covered by public funds

11 (4.2)

6 (4.9)

5 (3.5)

 
Fully self-funded

6 (2.3)

2 (1.6)

4 (2.8)

 

 

Other Social insurance

6 (2.3)

0(0.0)

6 (4.2)

 

Table 2: Symptom presentation of the patients on admission

Variables

Symptom presentation Total (n=265) Non-care-seeking delay group (n=123) Care-seeking delay group (n=142) P

Exertional dyspnea (%)

no 120 (45.3) 72 (58.5) 48 (33.8)

0.041

yes

145 (54.7) 51 (41.5)

94 (66.2)

 
Orthopnea (%)

no

236 (89.1) 107 (87.0) 129 (90.8) 0.421
  yes 29 (10.9) 16 (13.0)

13 (9.2)

 
Paroxysmal nocturnal dyspnea (%)

no

199 (75.1) 97 (78.9) 102 (71.8) 0.239
  yes 66 (24.9) 26 (21.1)

40 (28.2)

 
Chest tightness (%)

no

153 (57.7) 77 (62.6) 76 (53.5) 0.171
  yes 112 (42.3) 46 (37.4)

66 (46.5)

 
Chest pain (%)

no

232 (87.5) 107 (87.0) 125 (88.0) 0.946
  yes 33 (12.5) 16 (13.0)

17 (12.0)

 
Lower limb edema (%)

no

145 (54.7) 82 (66.7) 63 (44.4) <0.001
  yes 120 (45.3) 41 (33.3)

79 (55.6)

 
Fatigue (%)

no

194 (73.2) 99 (80.5) 95 (66.9) 0.019
  yes 71 (26.8) 24 (19.5)

47 (33.1)

 
Decreased exercise tolerance (%)

no

173 (65.3) 88 (71.5) 85 (59.9) 0.062
  yes 92 (34.7) 35 (28.5)

57 (40.1)

 
Abdominal distention and Poor appetite (%)

no

222 (83.8) 103 (83.7) 119 (83.8) 1.000
  yes 43 (16.2) 20 (16.3)

23 (16.2)

 
Sleep apnea (%)

no

230 (86.8) 113 (91.9) 117 (82.4) 0.037
  yes 35 (13.2) 10 (8.1)

25 (17.6)

 
Syncope/loss of consciousness (%)

no

259 (97.7) 120 (97.6) 139 (97.9)

1.000

 

yes

6 (2.3) 3 (2.4)

3 (2.1)

 
Other symptoms (%)

no

205 (77.4) 92 (74.8) 113 (79.6) 0.435
  yes 60 (22.6) 31 (25.2)

29 (20.4)

 

The Relationship Between Care-Seeking Delay Time and Hospital Treatment in Heart Failure Patients

① The average length of hospital stay for both groups of patients was 9.65 days, and the average hospitalization cost was 26,567.19 yuan. Patients in the care-seeking delay group had significantly longer hospital stays and higher hospitalization costs than those in the non-care-seeking delay group, with statistical significance (P<0.05). See Table 3 for details. ② In terms of medication use, there were no statistically significant differences between the two groups of patients in the proportion of using digitalis, beta-blockers, ACEI/ARB/MRA/ARNI, warfarin, and oral diuretics. However, patients in the care-seeking delay group had a lower proportion of SGLT2i medication usage and a higher proportion of spironolactone, intravenous diuretics, and NOACs usage, with statistical significance (P<0.05). See Table 4 for details.

Table 3: Length of hospital stay and hospitalization costs of patients

Variables

Mean Non-care-seeking delay group (n=123) Care-seeking delay group (n=142)

P

Length of hospital stay (mean (SD))

9.65 (6.29)

8.11 (5.88) 11.11 (6.61)

0.038

Hospitalization costs in Yuan (mean (SD))

26,567.19 (34,687.52)

20,303.51 (28,935.87)

32,394.18 (38,872.17)

0.044

Table 4: Medication use of patients during hospitalization

Variables

Medication use Total (n=265) Non-care-seeking delay group (n=123) Care-seeking delay group (n=142)

P

Digitalis (%) no

239 (90.2)

114 (92.7) 125 (88.0)

0.288

  yes

26 (9.8)

9 (7.3)

17 (12.0)

 
Beta-blockers (%) no

62 (23.4)

34 (27.6) 28 (19.7)

0.174

  yes (1 kind)

195 (73.6)

87 (70.7)

108 (76.1)

 
  yes (2 kinds)

8 (3.0)

2 (1.6)

6 (4.2)

 
ACEI/ARNI (%) no

156 (58.9)

72 (58.5) 84 (59.2)

0.160

  yes (1 kinds)

105 (39.6)

51 (41.5)

54 (38.0)

 
  yes (2 kinds)

4 (1.5)

0 (0.0)

4 (2.8)

 
ARB (%) no

234 (88.3)

106 (86.2)

128 (90.1)

0.418

  yes

31 (11.7)

17 (13.8)

14 (9.9)

 
MRA (%) no

144 (54.3)

79 (64.2)

65 (45.7)

0.049

  yes

121 (45.7)

44 (35.8)

77 (54.2)

 
SGLT2i (%) no

239 (90.2)

103 (83.7)

136 (95.8)

0.002

  yes

26 (9.8)

20 (16.3)

6 (4.2)

 
Ivabradin (%) no

264 (99.6)

122 (99.2)

142 (100.0)

0.943

  yes

1 (0.4)

1 (0.8)

0 (0.0)

 
Oral diuretics (%) no

37 (14.0)

19 (15.4)

18 (12.7)

0.270

  yes (1 kind)

171 (64.5)

84 (68.3)

87 (61.3)

 
  yes (2 kinds)

47 (17.7)

16 (13.0)

31 (21.8)

 
  yes (3 kinds)

10 (3.8)

4 (3.3)

6 (4.2)

 
Intravenous diuretics (%) no

137 (51.7)

76 (61.8)

61 (43.0)

<0.001

  yes (1 kind)

92 (34.7)

27 (22.0)

65 (45.8)

 
  yes (2 kinds)

21 (7.9)

7 (5.7)

14 (9.9)

 
  yes (3 kinds)

13 (4.9)

11 (8.9)

2 (1.4)

 
  yes (4 kinds)

2 (0.8)

2 (1.6)

0 (0.0)

 
Tolvaptan (%) no

260 (98.1)

121 (98.4)

139 (97.9)

1.000

  yes

5 (1.9)

2 (1.6)

3 (2.1)

 
Warfarin (%) no

237 (89.4)

112 (91.1)

125 (88.0)

0.549

  yes

28 (10.6)

11 (8.9)

17 (12.0)

 
NOACs (%) no

193 (72.8)

91 (74.0)

102 (71.8)

0.033

  yes (1 kinds)

67 (25.3)

27 (22.0)

40 (28.2)

 
  yes (2 kinds)

5 (1.9)

5 (4.1)

0 (0.0)

 

Note: ACEI, Angiotensin-Converting Enzyme Inhibitors; ARNI, Angiotensin Receptor, Neprilysin Inhibitors; ARB, Angiotensin Receptor Blockers; MRA, Mineralocorticoid Receptor Antagonists; SGLT2i, Sodium-Glucose Co-Transporter 2 Inhibitors; NOACs, Novel Oral Anticoagulants.

The Relationship Between Care-Seeking Delay Time and Clinical Outcomes in Heart Failure Patients

①Among the 265 patients, there were 3 in-hospital deaths (1.13%), and the proportion of patients with readmission times within 3 months ≥1 was 34% (90/265) overall, and respectively 31% (44/142) in the care-seeking delay group, and 37.4% (46/123) in the non-care-seeking delay group, which have no statistically significant difference. ②There were no statistically significant differences between the two groups in terms of cardiac function classification, ejection fraction, and BNP levels on admission. However, the proportion of patients with EF<40% on discharge was significantly higher in the care-seeking delay group (45/142) than in the non-care-seeking delay group (26/123). The mean BNP level on discharge was also significantly lower in the care-seeking delay group (1714.5) compared to the non-care-seeking delay group (3186.2), with statistical significance. See Table 5 for details.

Table 5: Changes on Cardiac Function Classification, Ejection Fraction, and BNP in the Two Groups

Variables

Total (n=265) Non-care-seeking delay group (n=123) Care-seeking delay group (n=142)

P

Cardiac function classification on admission (%)      

0.321

2

162 (61.1)

81 (65.8)

61 (57.0)

 

3

84 (31.7)

32 (26.0)

52 (36.6)

 

4

19 (7.2)

10 (8.1)

9 (6.3)

 
Cardiac function classification on discharge (%)      

0.621

2

179 (67.5)

87 (70.7)

92 (64.8)

 

3

71 (26.8)

29 (23.6)

42 (29.6)

 

4

15 (5.7)

7 (5.7)

8 (5.6)

 
Ejection fraction (mean (SD))        
On admission

46.91 (16.24)

46.80 (14.98) 47.01 (17.31)

0.920

On discharge

49.17 (15.56)

48.71 (14.80) 49.56 (16.23)

0.656

Ejection fraction difference

2.25 (8.03)

1.90 (7.03) 2.56 (8.82)

0.510

Ejection fraction group on admission (%)      

0.175

<40%

91 (34.3) 36 (29.3)

55 (38.7)

 

≥50%

104 (39.2) 49 (39.8)

55 (38.7)

 

40 ~ 50%

70 (26.4) 38 (30.9)

32 (22.5)

 
Ejection fraction group on discharge (%)      

0.032

<40%

71 (26.8) 26 (21.1)

45 (31.7)

 

≥50%

120 (45.3) 54 (43.9)

66 (46.5)

 

40 ~ 50%

74 (27.9) 43 (35.0)

31 (21.8)

 
BNP (mean (SD))        
On admission

3,222.21 (5,223.88)

3,776.39 (6,915.73) 2,742.18 (3,035.08)

0.108

On discharge

2,397.61 (4,946.84)

3,186.20 (6,855.82) 1,714.54 (2,034.08)

0.015

Difference

-824.60 (4,014.16)

-590.19 (5,247.74) -1,027.65 (2,500.52)

0.377

Note: BNP, Brain Natriuretic Peptide

General Information of Heart Failure Patients with Class III/IV Cardiac Function

This study conducted a statistical analysis of heart failure patients with Class III/IV cardiac function on admission, totaling 103 individuals, of which 61 (59.2%) were in the care-seeking delay group. Compared to patients without care-seeking delay, those in the care-seeking delay group had a higher proportion of female patients, higher average age, and lower proportion with basic medical insurance. See Table 6 for details.

Table 6: General information of heart failure patients with cardiac function Class Ⅲ/Ⅳ

Variables of interest

Total (n=103) Non-care-seeking delay group (n=42) Care-seeking delay group (n=61) P

Gender (%)

     

0.022

Male

69 (67.0)

34 (81.0)

35 (57.4)

 
Female

34 (33.0)

8 (19.0)

26 (42.6)

 
Age (mean (SD))

74.68 (13.36)

71.14 (15.26) 77.11 (11.37)

0.025

Ethnicity (%)      

0.194

Han

94 (91.3)

36 (85.7)

58 (95.1)

 
Minority

9 (8.7)

6 (14.3)

3 (4.9)

 
Living situation (%)      

0.778

Living alone

7 (6.8)

2 (4.8)

5 (8.2)

 
Live with family/friends

96 (93.2)

40 (95.2)

56 (91.8)

 
Occupation (%)      

0.743

Government official

6 (5.8)

2 (4.8)

4 (6.6)

 
Professional technician

3 (2.9)

1 (2.4)

2 (3.3)

 
Business services personnel

1 (1.0)

1 (2.4)

0 (0.0)

 
Worker

4 (3.9)

1 (2.4)

3 (4.9)

 
Farmer

10 (9.7)

3 (7.1)

7 (11.5)

 
Retiree

79 (76.7)

34 (81.0)

45 (73.8)

 
Marriage (%)      

0.502

Married

92 (89.3)

38 (90.5)

54 (88.5)

 
Unmarried

1 (1.0)

0 (0.0)

1 (1.6)

 
Divorced

1 (1.0)

1 (2.4)

0 (0.0)

 
Widowed

9 (8.7)

3 (7.1)

6 (9.8)

 
Health insurance (%)      

0.003

Basic medical insurance for urban employees

71 (68.9)

30 (71.4)

41 (67.2)

 
Basic medical insurance for urban residents

12 (11.7)

9 (21.4)

3 (4.9)

 
The new rural cooperative medical system

6 (5.8)

3 (7.1)

3 (4.9)

 
Commercial medical insurance

13 (12.6)

0 (0.0)

13 (21.3)

 
Fully covered by public funds

1 (1.0)

0 (0.0)

1 (1.6)

 
Fully self-funded

0 (0.0)

0 (0.0)

0 (0.0)

 

 

Other Social insurance

0 (0.0)

0 (0.0)

0 (0.0)

 

Discussion

The care-seeking delay time for heart failure patients mainly refers to the total time consumed from the first appearance of heart failure symptoms to hospital admission. Since there is no standard cut-off point, the median value is often used to divide the delay time into shorter and longer categories. This is one of the methods used in previous studies to investigate care-seeking delay in heart failure patients [14]. In this study, the median care-seeking delay time was 7 days, which is not significantly different from the median delay time of 7.5 days found in previous studies. This duration is influenced by a variety of factors, including symptom burden, depressive state, limitations of medical resources, and support from family members. A longer care-seeking delay time is closely related to the hospital treatment and clinical outcomes of patients.

Heart Failure Patients in the Care-Seeking Delay Group had More Severe Symptoms on Admission

The most common symptom leading to hospital admission in heart failure patients is dyspnea, followed by chest pain, fatigue, and lower limb edema [15], etc. The results of this study show that the proportion of heart failure patients in the care-seeking delay group who presented with exertional dyspnea, lower limb edema, fatigue, and dyspnea during sleep on admission was significantly higher than that in the non-care-seeking delay group. This indicates that the patients who have poor recognition capability or low level of concern on common symptoms of heart failure are more likely not to consider the symptoms as emergencies, thus lead to more cases of care-seeking delay. Similar results have been found in studies worldwide, where patients’ misperception of the severity of heart failure symptoms leads to delayed care-seeking [16]. Altice and Madigan reported [4] that patients with more acute heart failure symptoms are more likely to seek medical attention promptly, while those with chronic symptoms are more likely to delay their care-seeking. Therefore, in the management of heart failure patients, emphasis should be placed on intervention strategies for improving symptom recognition, symptom assessment, and timely response to symptoms, thus patients’ perception of symptoms can be enhanced. The American Heart Association (AHA) has published a self-check plan for heart failure management [17], which proposes different responses based on changes in patients’ exercise tolerance, weight, edema, and respiratory rate, and recommends that patients who perceive a worsening of heart failure symptoms seek medical attention immediately. In addition, remote monitoring devices can be used to help patients monitor heart failure symptoms and remind them to seek medical attention in a timely manner when necessary [18].

Care-Seeking Delay Increases the Burden of Hospitalization for Heart Failure Patients

In developing countries, the medical expenses for heart failure patients are the highest among all patients with various diseases, with an average cost of approximately $4,080 per patient per year. Hospitalization costs account for 66% of the total annual expenditure for heart failure (HF) patients [19,20]. Considering the high treatment costs and high incidence rate, heart failure imposes a significant economic and social burden in China. The results of this study show that the average length of hospital stay for heart failure patients in the care-seeking delay group was 11.11 days, with hospitalization costs of 32,394.18 yuan, which were significantly higher than the 8.11 days and 20,303.51 yuan for the non-care-seeking delay group. This is consistent with previous studies that found care-seeking delay leads to higher hospitalization rates [21], which may be related to the more severe symptom presentation on admission. Care-seeking delay also affects the use of medications during hospitalization. According to the results of this study, the proportion of patients who used intravenous diuretics, mineralocorticoid receptor antagonists (MRAs), and non-vitamin K antagonist oral anticoagulants (NOACs) during hospitalization was significantly higher in the care-seeking delay group compared to the non-care-seeking delay group. Conversely, the proportion of patients who used sodium-glucose co-transporter 2 inhibitors (SGLT2i) was lower in the care-seeking delay group. Diuretics and MRAs are both guideline-recommended medications that can improve patient prognosis [22], and are used to alleviate symptoms of dyspnea and reduce the degree of edema. These two medications have higher usage rate in the care-seeking delay group, corresponding to a finding in this study that the patients in the care-seeking group statistically have more severe symptoms on admission. Therefore, reducing the care-seeking delay time and helping patients seek treatment in a timely manner is an important factor for relieving the symptoms and improving the survival rate of heart failure patients, thereby reducing the economic and social burdens caused by the disease.

Care-Seeking Delay Seriously Affects the Clinical Prognosis of Heart Failure Patients

Cardiovascular death is an important indicator for evaluating the prognosis of patients with chronic stable heart failure, and the number of cardiovascular-related readmissions is a key indicator for assessing the frequency of acute exacerbations in patients with chronic stable heart failure [23]. In previous studies, care-seeking delay has been shown to increase the risk of cardiac death and readmission in heart failure patients [24,25]. However, in the samples included in this study, there was no statistically significant difference in the 3-month readmission rate between the two groups. The possible reasons may be the insufficient number of samples and the retrospective nature of the study, which lacks long-term follow-up of patients outside the hospital. And, The method of medical record review alone may result in significant differences in the statistics of cardiovascular-related mortality and readmission rates. BNP, as an important indicator for prognostic assessment in heart failure patients, showed in this study that the mean BNP level on discharge for heart failure patients in the care-seeking delay group (1714.5) was significantly lower than that in the non-care-seeking delay group (3186.2). However, other studies [26] have indicated that care-seeking delay leads to higher BNP levels. The possible reason is that BNP is influenced by various cardiovascular factors/diseases, especially comorbidities such as advanced age, atrial fibrillation, and renal insufficiency. Another finding of this study showed that the proportion of patients with EF<40% on discharge in the care-seeking delay group (45/142) was significantly higher than that in the non-care-seeking delay group (26/123), indicating that heart failure patients in the care-seeking delay group had lower cardiac function levels on discharge, more severe heart failure conditions, and poorer clinical prognosis. Our study results provide evidence for the potential adverse consequences of care-seeking delay, proving the importance of seeking medical help in a timely manner when heart failure symptoms worsen to improve the clinical prognosis of heart failure.

Heart Failure Patients with NYHA Class Ⅲ/Ⅳ had a Higher Proportion of Care-Seeking Delay

Another finding of this study revealed that patients with poorer NYHA status on admission (Class III/IV) had a higher proportion of care-seeking delay (59.2%), which is consistent with previous heart failure research results [27,28]. The care-seeking delay group had higher proportion of female patients, higher average age, and lower proportion with basic medical insurance. Possible reasons may include that patients with poorer NYHA functional status are more accustomed to moderate to severe symptoms, are less likely to perceive the worsening of heart failure symptoms, feel desperate about heart failure due to long-term medical visits and are reluctant to visit hospitals, and are concerned about the cost of treatment. While a longer care-seeking delay time may lead to poorer clinical outcomes for patients. Therefore, it is necessary to conduct qualitative research to investigate the reasons for care-seeking delay in patients with poorer NYHA functional status.

Conclusion

The phenomenon of care-seeking delay is relatively common among heart failure patients and is influenced by a variety of factors. In addition to the patients’ own perception of symptoms, health literacy, and depression levels, it is also closely related to the medical environment and the support of caregivers. The results of this study show the following points: ① The median care-seeking delay time for heart failure patients in this study was 7 days; ② Heart failure patients in the care-seeking delay group had more severe symptoms on admission, and had higher proportions of exertional dyspnea, lower limb edema, fatigue, and dyspnea during sleep; ③ Care-seeking delay significantly increased the length of hospital stay and hospitalization costs for heart failure patients, and also caused higher use of intravenous diuretics, MRAs, and NOACs during hospitalization; ④ The proportion of patients with EF<40% on discharge was higher in the care-seeking delay group. On the other hand, this study has the following limitations: ① The onset time description of heart failure symptoms in the electronic medical records is not accurate enough. The recording of onset time of symptoms mainly relies on the patients’ recall. However, symptom perception is subjective, thus the calculation of care-seeking delay time still needs to be refined; ② The size and variety of the sample coming from one tertiary hospital in Beijing is insufficient. In addition, there are many limitations such as the lack of standardized and long-term follow-up outside the hospital, the absence of heart function-related evaluation indicators, and no attention to the psychological state assessment of patients. In future studies, research can be carried out on the development of risk assessment tools and models for care-seeking delay in heart failure patients. By implementing effective intervention measures, the care-seeking delay time of patients can be reduced, and the clinical prognosis of patients can be improved.

References

  1. Wang Hua, Liang Yanchun (2018) Chinese guidelines for the diagnosis and treatment of heart failure. Chin J Cardiol Med 46: 760-789. [crossref]
  2. Liu M B, He X Y, Yang X H, et al. (2021) Summary of China Cardiovascular Health and Disease Report 2023 [J]. Chin J Interventional Cardiology 32: 541-550.
  3. Ivynian SE, Ferguson C, Newton PJ, Michelle D, et al. (2020) Factors influencing care seeking delay or avoidance of heart failure management: a mixed-methods study. Int J Nurs Stud 108. [crossref]
  4. Altice NF, Madigan EA (2012) Factors associated with delayed care seeking in hospitalized patients with heart failure. Heart Lung 9: 244-254. [crossref]
  5. Takei M, Harada K, Shiraishi Y, Junya M, Yoichi I, et al. (2020) Delay in seeking treatment before emergent heart failure readmission and its association with clinical phenotype. J Intensive Care 8. [crossref]
  6. Meng Zhaoxuan, Li Chong, Zhao Xin, et al. (2023) Research progress on the status and influencing factors of medical delay in cancer patients. Chin J Modern Nursing 29: 5025-5029.
  7. Yu L Q, Guo T, Xiong C Y, et al. (2024) Research progress on influencing factors of hospital seeking delay in patients with acute myocardial infarction. Nursing Research 38: 2538-2543.
  8. Mengqi Xu, Tiantian Ruan, Xiaoli Huang, Beibei Han, Yingqi Li, et al. (2024) Care-seeking delay of patients with heart failure in China: a mixed-method study. ESC Heart Failure 11: 2086-2099. [crossref]
  9. Xu Mengqi, GONG Jinghuan, Luo Zhenlan, et al. (2021) Research progress of medical treatment delay in patients with heart failure. Chinese Journal of Nursing 36: 95-98.
  10. SE Ivynian, M DiGiacomo, PJ Newton (2015) Care-seeking decisions for worsening symptoms in heart failure: a qualitative metasynthesis. Heart Fail Rev 20: 655-671.
  11. Akiko Okada MN, Miyuki Tsuchihashi-Makaya, JungHee Kang, Yoshiyuki Aoki, et al. (2019) Symptom Perception, Evaluation, Response to Symptom and Delayed Care Seeking in Patients With Acute Heart Failure. Journal of Cardiovascular Nursing 34: 36-43. [crossref]
  12. National Center for Cardiovascular Disease Medical Quality Control Expert Working Group on heart failure.2020 report on medical quality control of heart failure in China. Chin J Circulation36: 221-238.
  13. Li Shaoling, Lu Xiaohong, Wei Lili, et al. (2021) Reasons for delayed medical treatment in patients with heart failure: a qualitative study. Chin J Modern Nursing 27: 3234-3238.
  14. Lin CY, Hammash M, JM, Jennifer LM, Melanie S, Gia MM, et al. (2021) Delay in seeking medical care for worsening heart failure symptoms: Predictors and association with cardiac events. Eur J Cardiovasc Nurs 20: 454-463. [crossref]
  15. Heidenreich PA, Bozkurt B, Aguilar D, Larry AA, Joni JB, et al. (2022) 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 145: 876-894. [crossref]
  16. Darling C, Saczynski JS, McManus DD, Darleen L, Frederick AS, et al. (2013) Delayed hospital presentation in acute decompensated heart failure: clinical and patient reported factors. Heart Lung; One 1-286.
  17. American Heart Association. Managing Heart Failure Symptoms (2020).
  18. Brahmbhatt DH, Cowie MR (2019) Remote management of heart failure: An overview of telemonitoring technologies. Card Fail Rev 5: 86-92. [crossref]
  19. Huang J, Yin H, Zhang M, Qian Ni, Jianwei Xuan, et al. (2017) Understanding the economic burden of heart failure in China: Impact on disease management and resource utilization. J Med Econ 20: 549-553. [crossref]
  20. Cook C, Cole G, Asaria P, Richard J, Darrel PF, et al. (2014) The annual global economic burden of heart failure. Int J Cardiol 171: 368-376. [crossref]
  21. Johansson P, van der Wal M, van Veldhuisen DJ, Tiny Jaarsma (2012) Association between prehospital delay and subsequent clinical course in patients with/hospitalized for heart. J Card Fail 18: 202-207. [crossref]
  22. Chinese Heart Failure Center Alliance, Cardiovascular Health Research Institute of Suzhou Industrial Park, China Cardiovascular Health Alliance. Work report of China Heart Failure Center (2021): current status of diagnosis and treatment of patients with heart failure. Chin J Interventional Cardiology 30: 328-336.
  23. The Cardiovascular Disease Branch of the China Association of Chinese Medicine. Expert consensus on the selection and application of outcome indicators in clinical research of chronic heart failure. Chinese Journal of Traditional Chinese Medicine, 2024, 65: 1196-1200.
  24. Takahashi M, Kohsaka S, Miyata H, et al. Association between prehospital time interval and short-term outcome in acute heart failure patients[J]. J Card Fail, 2011 17: 742-747.
  25. Mebazaa A, Yilmaz MB, Levy P, Tsutomu Yoshikawa, Atsutoshi Takagi, et al. (2015) Recommendations on pre-hospital & early hospital management of acute heart failure: A consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine. Eur J Heart Fail 17: 544-558. [crossref]
  26. McDonagh TA, Metra M, Adamo M, Roy SG, Andreas B, et al. (2021) 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 42: 3599-3726.
  27. Nieuwenhuis MMW, Jaarsma T, van Veldhuisen DJ, Martje H L van der Wal (2011) Factors associated with patient delay in seeking care after worsening symptoms in heart failure patients. J Card Fail 17: 657-663. [crossref]
  28. Chin-Yen Lin, Muna Hammash, Jennifer L, Melanie S, Gia Mudd-Martin, et al. (2021) Delay in seeking medical care for worsening heart failure symptoms: predictors and association with cardiac events[J]. European Journal of Cardiovascular Nursing 20: 454-463. [crossref]