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

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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

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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

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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

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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

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  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]
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  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

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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

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

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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]

Reform of the National Institute of Mental Health: A Proposal

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DOI: 10.31038/JNNC.2025811

Abstract

In the United States, the primary federal agency for funding mental health research is the National Institute of Mental Health (NIMH). For decades, the NIMH has prioritized research on genetics, biomarkers and related aspects of biological psychiatry, with no meaningful yield. It is time for a radical reorganization, restructuring and reconceptualization of NIMH spending.

Keywords

National Institute of Mental Health, Mental health, Research funding

The 2025 budget of the NIMH will be over 2 billion dollars [1]. After decades of focus on genetics, brain chemistry, biomarkers and related elements of biological psychiatry, and tens of billions of dollars spent, biological psychiatry in its current form has yielded zero findings of direct clinical relevance. The idea that there is an “underlying pathophysiology” to mental illness has been countered by a large body of NIMH-funded, published evidence – by the failure to find anything. Rather than continuing to fund endless efforts to identify biological causes of mental illness, it is time to rethink the paradigm and set a distinctly different research agenda.

This view is consistent with a statement made on the American Psychiatric Association website: “many factors contribute to the risk of mental illness, such as depression. Except in rare cases, genes determine just a small percentage of the risk of illness or response to medication. Age, lifestyle, general health, psychiatric symptoms and severity, and co-occurring conditions are usually more important factors in drug response.” [2]

Simple logic and common sense can tell you that the search for genes contributing to mental illness is futile. For example, genome-wide association studies (GWAS) currently involve tens of thousands of patients and tens of thousands of controls. Rather that demonstrating the advanced nature of such research, these numbers demonstrate that is time to give up on that line of investigation. The huge numbers are required in order to find anything of statistical significance in a given study. The findings are difficult or impossible to replicate from one GWAS to another, and the overall conclusion is that there are hundreds of risk genes, each contributing less than 2% to the clinical picture, as stated in DSM-5 [3]. The same set of risk genes has been identified for schizophrenia, bipolar disorder, depression and autism, proving that there is no genetic specificity to DSM-5 diagnostic categories.

The promise in grant applications and the psychiatric literature is the hope that – with just a few more years of research – something will be found, resulting in a truly scientific personalized psychiatry in which medications will be prescribed to target specific genetic dysregulations. If there are hundreds of risk genes then hundreds of medications targeting the functions and products of those genes would be required and an individual patient would require dozens of medications given that each genetic abnormality only accounts for under 2% of the clinical picture. Each medication will cost the patient thousands or tens of thousands of dollars per year.

The entire enterprise is guaranteed to fail. It is time to give up on it.

If asked, I would recommend the following reforms to the NIMH:

  1. Stop funding biological psychiatry in its current form.
  2. Prioritize psychological and social causes of mental illness, and psycho-social treatments.
  3. Stop all efforts to de-stigmatize mental disorders by saying they are brain diseases.
  4. Mandate that measures of childhood trauma be included in all funded research. This should include psychological, social, cultural and economic forms of trauma.
  5. Set ICD-11 complex-PTSD as the ruling paradigm: a poly-diagnostic response to complex psychological and social trauma accounts for a substantial proportion of serious mental illness.
  6. Dismantle negative attitudes towards dissociative disorders by requiring them, and dissociative symptoms, to be measured in the majority of funded studies. Pair this with explicit efforts to de-stigmatize borderline personality disorder and conceptualize it as an adaptation to psychological trauma – set this as a research funding priority (see 2 above).
  7. Provide extensive public education about the reforms.
  8. If the reforms are met with bureaucratic, committee and procedural barriers, withdraw funding until the NIMH and its bureaucracy complies.
  9. No reduction in the overall NIMH budget, only a re-allocation of resources.

If a reform at all resembling the above was adopted, the predicted response of organized psychiatry would be to decry it as anti-scientific and to say it was setting mental health back 50 years. Actually, it would transfer the focus to scientific study of the psychosocial aspects of mental health – and thereby correct an extreme imbalance that has dominated psychiatric research funding for decades [4].

References

  1. Torrey F, Simmons WW, Dailey L (2023) The NIMH research portfolio: An update. Primary Care Companion CNS Disorders 25(4), 23m03486. [crossref]
  2. https://www.psychiatry.org/news-room/apa-blogs/genetic-testing-to-improve-psychiatric-medication.
  3. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th American Psychiatric Association, Washington, DC, p. 494.
  4. Ross CA, Pam A (1995) Pseudoscience in Biological Psychiatry. Blaming the Body. John Wiley & Sons, New York.

Incidence and Risk Factors of Sepsis in Adult Patients with Trauma: A Systematic Review and Meta-Analysis

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DOI: 10.31038/IJOT.2025811

Abstract

Objective: To conduct a systematic review and analysis of the risk factors linked to sepsis in adult trauma patients, providing evidence-based medical evidence for reducing the incidence of sepsis following trauma.

Methods: Literature searches were conducted in the total of 9 databases from their inception to December 2023 on factors influencing sepsis in trauma patients. Meta-analysis was conducted using the meta package in R, and the model’s heterogeneity was assessed using the I² value.

Results: A total of 10 literatures were included, involving 65,866 adult patients admitted for trauma, with 5,165 cases of sepsis following trauma. The meta-analysis results showed that advanced age (MD=1.31,95%CI: 0.51~ 3.12), male gender (OR=1.21, 95%CI: 0.95~1.54), Injury Severity Score (ISS) (MD=5.99, 95%CI: 3.05~8.93), Glasgow Coma Scale (GCS) score (MD=-1.75, 95%CI: -2.68~-0.81), Acute Physiology and Chronic Health Evaluation (APACHE II) score (MD=4.37, 95%CI: 2.56, 6.17), Sequential Organ Failure Assessment (SOFA) score (MD=2.51, 95%CI: 2.30~2.73), mechanical ventilation (OR=4.71, 95%CI: 3.44, 6.45), blood transfusion (OR=2.20, 95%CI: 1.63~2.96), central venous catheterization (OR=2.74, 95%CI: 1.93~3.89), concurrent shock (OR=2.30, 95%CI: 1.70~3.10), and emergency surgery within 24 hours (OR=2.85, 95%CI: 2.00~ 4.07), were identified as independent risk factors for sepsis among trauma patients.

Conclusion: Sepsis in trauma patients is influenced by a variety of risk factors. Clinical medical staff should intervene early in High-risk patients with these factors should be targeted to reduce sepsis incidence among trauma patients.

Keywords

Trauma, Sepsis, Risk factors, Meta-analysis

Introduction

Trauma represents a major global health burden, accounting for around 9% of annual deaths and ranking among the leading causes of mortality worldwide [1]. The advent of advanced medical technologies has successfully curbed the early mortality rate among trauma patients. However, a significant number of survivors are at risk of developing sepsis in the days or weeks following the initial trauma [2]. Sepsis, a complex clinical syndrome arising from a dysregulated host response to infection, not only can precipitate septic shock and multiple organ failure but also substantially worsens the prognosis [3]. The development of sepsis is associated with an overactive and persistent inflammatory response in trauma patients and is a prevalent complication [4]. Existing studies have reported that the mortality rate among trauma patients with sepsis hovers between 17% and 23% [5], highlighting the gravity of this complication. Despite a plethora of research efforts, the majority of which are based on single-center data, there remains a lack of consensus regarding the identification of specific risk factors for sepsis in trauma patients.

Meta-analysis, a powerful tool that aggregates and quantifies the effect sizes of individual studies through systematic review, emerges as a promising approach to address this issue [6]. By comprehensively reviewing and dissecting the extant literature on the risk factors associated with post-traumatic sepsis, this study aims to systematically organize and deliberate upon these factors. The ultimate goal is to furnish a robust evidence-based foundation for clinical practice, thereby facilitating the early detection and prevention of sepsis in trauma patients and potentially ameliorating their outcomes.

Methods

Protocol and Registration

This research adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [7] and our systematic review protocol was recorded on PROSPERO (International Prospective Register of Systematic Reviews, with the registration number CRD42024537479). As the data utilized were publicly accessible, ethical committee approval was not pursued.

Retrieval Strategy

Literature Sources and Search Strategy Literature was retrieved from databases including China National Knowledge Infrastructure, Wanfang Data, China Science and Technology Journal Database, China Biology Medicine Literature Database, PubMed, Embase, Web of Science, Cochrane, CINAHL, and Scopus from their inception to December 2023. We utilized the keywords included trauma, traumatic, post-traumatic, multiple injuries, polytrauma, septic, sepsis, septicemia, multiple organ failure, factor, and risk. Databases for dissertations and trial registries were not searched. The specific search strategies employed for English databases are detailed in Appendix 1.

Inclusion and Exclusion Criteria

Inclusion criteria: 1) Age ≥18 years; 2) Study population consisting of trauma patients; 3) Sepsis diagnosed according to Sepsis-1, Sepsis-2, or Sepsis-3 criteria; 4) Independent risk factors determined through multivariate regression analysis. Exclusion criteria: 1) insufficient patient baseline data; 2) reviews, meta-analyses, commentaries, case reports, guidelines, letters, conference abstracts, and literature related to animal experiments; 3) abnormal data and/or not conforming to statistical rules. The predominant literature reviewed comprised case- control and retrospective cohort studies, predominantly authored in either English or Chinese. We excluded smaller studies (those with fewer than 50 patients) to avoid potential false negative results. Additionally, patients with burns were excluded because they have distinct risk factors, such as a compromised skin barrier, which could potentially elevate the risk of developing sepsis [8].

Literature Screening and Data Extraction

Search results were imported into EndNote X9 software (Clarivate Analytics, London, UK) for management. Two independent reviewers (Wang B and Shi Y) screened titles and abstracts against predefined inclusion/exclusion criteria, following Cochrane guidelines. Potentially relevant citations were subjected to full-text review. Data extraction was performed independently from all eligible studies using a standardized form, with a third researcher consulted to resolve any discrepancies. The main extracted content included: principal investigator, study design, publication region and year, sample size, characteristics of the study population (age, sex), follow-up period, identified risk factors, and outcomes of multifactorial regression analysis.

Quality Assessment of Literature

Two researchers (Zhu X and Dong C) independently assessed the quality of the literature using the Newcastle-Ottawa Scale (NOS) [9]. NOS scores categorized the literature into three quality levels: ≥7 (high quality), 4-6 (moderate quality), and <4 (lower quality). In the event of any disagreements during the assessment process, the opinion of a third researcher (Cao S) will be sought to resolve them.

Statistical Analyses

Statistical analyses were conducted using Review Manager (version 5.3), STATA (version 12.0), and the ‘meta’ package in R software. The categories of subgroup analyses of incidence included: age, year of publication, research region, diagnostic criteria for sepsis, and duration of follow-up. For categorical variables, the Odds Ratio (OR) and 95% Confidence Intervals (CI) were used to express the statistical effect size, while the Mean Difference (MD) and 95% CI were used for continuous variables. Heterogeneity across studies was evaluated with the intraclass correlation index (I²), which quantifies the proportion of total variation in study outcomes due to between-study variance (τ²) rather than chance [10]. I² ≥ 50% was considered indicative of significant heterogeneity. In these instances, a random-effects model was employed for meta-analysis; otherwise, a fixed-effects model was applied. Publication bias was assessed via Egger’s regression test and funnel plots, with P < 0.05 considered statistically significant.

Results

Study Characteristics

A preliminary collection of 3391 articles was obtained, and a total of 10 articles were ultimately included (Figure 1). The 10 articles included in this study were all retrospective cohort studies [11-20], published between 2004 and 2023. Upon summarizing the literature, there were 12 risk factors with ≥2 articles, including 10 articles on age [11-20] as a risk factor; 9 articles on male gender [11-19] as a risk factor; 8 articles on Injury Severity Score (ISS) [12-18,20] as a risk factor; 5 articles each on Glasgow Coma Scale (GCS) [13,14,17,18,20] Sequential Organ Failure Assessment (SOFA) [11,13-16], mechanical ventilation [13-17], and shock [12,14-17]as risk factors; 4 articles each on Acute Physiology and Chronic Health Evaluation II (APACHE II) [11,13,14,16], number of blood transfusions [13,15-17], and emergency surgery within 24 hours [13,15-17] as risk factors; 3 articles each on central venous catheterization [14-16] and diabetes [11,12,20] as risk factors. The study characteristics are shown in Table 1.

Figure 1: PRISMA diagram for identification of relevant studies. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1: Baseline characteristics of studies included for analysis

Note：① Age (years); ② Sex (Male); ③ Injury Severity Score, ISS; ④ Glasgow Coma Scale, GCS; ⑤ Acute Physiology and Chronic Health Evaluation II, APACHE II; ⑥ Sequential organ failure assessment, SOFA; ⑦ mechanical ventilation, MV; ⑧ blood transfusion; ⑨ Central venous catheterization, CVC; ⑩ Shock: SBP < 90 mmHg at hospital; ⑪ Diabetes; ⑫ Emergency surgery: surgery within 24 hours.
aTR-DGU: Trauma Registry of the German Society for Trauma Surgery
NR: not reported

Outcomes of Incidence and Subgroup Analyses

There were 65,866 trauma inpatients, with 5,165 cases of sepsis and 60,701 cases without sepsis. The I² was 100%, so a random-effects model was used. The results showed that the incidence of sepsis in adult trauma patients was 35.2% (95% CI: 17.8%, 52.7%) (Figure 2). Subgroup analyses were conducted based on age, publication year, study region, sepsis diagnosis criteria, and follow-up duration. The results showed: subgroup analysis by continent demonstrated a pooled incidence rate for the age group 30≤Age < 69 years was the highest at 37.9% (95% CI: 19.8%, 58.0%); when grouped by publication year, the incidence rate for the group after 2020 was 34% (95% CI: 15%, 56%), lower than the incidence rate for the group before 2020, which was 38.6% (95% CI: 22.9%, 55.6%); subgroup analysis by study region, the incidence rate was 60.1% (95% CI: 48.0%, 71.5%) in China, higher than the incidence rate in other regions was 10.3% (95% CI: 4.2%, 18.5%); when grouped by sepsis diagnosis criteria, the incidence rate for the group using the third edition of sepsis diagnosis criteria was 60.1% (95% CI: 48.0%, 71.5%), higher than the group using the first and second editions of sepsis diagnosis criteria; when grouped by follow-up duration, the incidence rate for the group with a follow-up duration of 32 to 72 months was the highest at 45.2% (95% CI: 22.5%, 68.9%). Supplemental Table 1 for details.

Figure 2: Forest plot of the incidence of sepsis in trauma patients

Outcomes of Sepsis Influencing Factors

An analysis was conducted on the 12 included influencing factors. For SOFA, mechanical ventilation, number of blood transfusions, central venous catheterization, shock, and diabetes, the I² was ≤30, so a fixed-effects model was chosen for analysis. For the remaining factors, the I² was ≥50%, so a random-effects model was used. The study results indicated that, except for diabetes, all other factors were statistically significant (P<0.05) (Table 2).

Table 2: Meta-Analysis of Influencing Factors

Sensitivity Analysis

The pooled effect size and heterogeneity for the 12 influencing factors were estimated using both random-effects and fixed- effects models. The statistical results showed that, except for the ISS, the other influencing factors demonstrated good consistency, indicating a high level of reliability in the results of this study (Table 3).

Table 3: Sensitivity Analysis of Influencing Factors

Quality Evaluation and Publication Bias

The NOS scoring results showed that 7 articles scored ≥7 points [11,13-15,17-19] and 3 articles scored 6 points [12,16,20]. Quality evaluation is provided by Supplemental Table 2. Egger’s regression test was used to assess publication bias for the 10 articles that considered age as a risk factor for sepsis. The Egger’s regression test for funnel plot asymmetry supports this observation, yielding a non-significant result (p = 0.32), which indicates a low level of bias in the published findings. The contour-enhanced funnel plot as shown in Supplement Figure 1. For the other 11 influencing factors, the number of included articles did not reach 10, hence no publication bias analysis was conducted for them.

Discussion

The pooled average incidence of sepsis in adult trauma patients calculated from the studies was 35.2%, which is higher to the 31.1% reported by Amina Abliz et al. [21]. The estimation of incidence rates varies by region. This study found that the incidence rate in China is 60.1%, which is significantly higher than the 10.3% in other countries. The reason for this difference may be related to the data sources. Among the five foreign studies included, the data of three studies come from public databases. Such data sources may have a more representative sample of the general population, but issues such as data collection methods and quality control may lead to an underestimation of the incidence rate. In contrast, the data of the five domestic studies all come from hospitals, which means that the data mainly come from patients seeking medical treatment, and there may be selection bias. Hospital – based data tend to be biased towards patients with more severe or symptomatic conditions, which may overestimate the incidence rate. Furthermore, the decrease in the incidence of post – traumatic sepsis over time may be attributed to early diagnosis and intervention, continuous strengthening of hospital infection control measures, improvement of the trauma treatment system, and enhanced self – health awareness of patients after trauma. Finally, compared with previous standards, the Sepsis – 3 diagnostic criteria may have improved sensitivity. This comprehensive assessment method may lead to the diagnosis of more sepsis patients in early or sub – clinical states, thereby resulting in an increase in the incidence rate.

Advanced age is an important risk factor for sepsis in adult trauma patients. The elderly are more susceptible to sepsis due to factors such as immunosenescence, weakened cardiovascular function, poor nutritional status, and comorbidities [22]. Epidemiological studies have shown that the incidence of sepsis is higher in males than in females [23]. The results of this study indicate that the risk of sepsis in male trauma patients is 1.21 times higher than in females, which is close to the 1.3 times reported in a study from the United States [24]. This may be related to differences in sex hormone levels [25]. Although demographic-related influencing factors cannot be directly intervened, the development of sepsis in elderly male trauma patients should be closely monitored. Additionally, APACHE II and SOFA scores are used to assess the severity of patients’ conditions. The risk of sepsis is positively correlated with these scores. The lower the GCS score, the higher the risk of sepsis. Particularly, patients with severe brain injuries and coma have a higher incidence of sepsis and septic shock [26]. The ISS score provides a quantitative measure for assessing soft tissue injuries in trauma patients. This study found that ISS, APACHE II, SOFA, and GCS scores are all helpful for early identification of sepsis in adult trauma patients. Medical staff need to closely monitor patients with abnormal scores and take timely intervention strategies to prevent the occurrence of sepsis. Furthermore, the number of blood transfusions, mechanical ventilation, central venous catheterization, and emergency surgery are associated with an increased risk of sepsis in trauma patients. Blood transfusion may increase the risk of sepsis by suppressing immune responses [27]. Patients on mechanical ventilation are more likely to develop VAP, leading to sepsis [28]. Central venous catheterization increases the risk of central venous catheter-related bloodstream infections, especially in the intensive care unit, where such infections are common and potentially life- threatening [29]. Emergency surgery is also a risk factor for sepsis after trauma. The OR value of this study is 2.55, indicating that the risk of sepsis in patients undergoing emergency surgery is 2.55 times that of those undergoing elective surgery, which is close to the 2 times reported in previous studies [30].

Therefore, in the management of trauma patients, the necessity of blood transfusions, mechanical ventilation, central venous catheterization, and emergency surgery should be carefully assessed to reduce the risk of sepsis. Lastly, shock can predispose patients to sepsis by damaging microcirculation and reducing tissue perfusion, while sepsis can exacerbate shock by triggering widespread inflammatory responses and cardiovascular dysfunction [31]. Therefore, when trauma patients have shock, it should be promptly recognized and treated to reduce the incidence of sepsis.

Limitations

This meta-analysis has several limitations. Firstly, there is a certain degree of heterogeneity in the combined effect sizes of some risk factors, which may be related to factors such as the race, age distribution of the study subjects, and the quality of diagnosis and treatment in different medical institutions, and thus needs further improvement; Secondly, risk factors with less than 10 studies were not assessed for publication bias, so the possibility of bias cannot be ruled out. Moreover, the study did not categorize sepsis by severity, which could affect treatment strategies and outcome predictions.

Conclusion

In conclusion, the incidence of sepsis in adult trauma patients is high and influenced by various factors including age, gender, clinical scoring systems, invasive procedures, as well as comorbid conditions. Clinical medical staff can refer to the results of this study, deal with and prevent risk factors in a targeted manner, reduce the occurrence of sepsis, and thus improve the prognosis and quality of life of trauma patients.

CRediT Authorship Contribution Statement

Bingsheng Wang conceived and designed the study, independently completed database search. Wenhao Qi screening and data extraction and writing. Bing Wang, Xiaohong Zhu and Chaoqun Dong conducted statistical analysis, interpreted the analytical results, and provided technical support for methodological refinement. Yankai Shi, Jiani Yao and Xiajing Lou assisted in optimizing the research. Aili Shi and Shihua Cao reviewed and edited the manuscript.

Acknowledgements

This research was supported by the Medical and Health Technology Plan of Zhejiang Province (grant 2022507615); Key Research Project for Laboratory Work in Zhejiang Province Colleges, ZD202202; Zhejiang Province Traditional Chinese Medicine Inheritance and Innovation Project 2023ZX0950. 2024 research project of Engineering Research Center of Mobile Health Management System, Ministry of Education; First – class Undergraduate Course in Zhejiang Province, 2022, sponsored by the Education Department of Zhejiang Province (No.1133).

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Mycobacterium tuberculosis, Tuberculosis and Cancer

1 Reply

DOI: 10.31038/CST.20251011

Abstract

Tuberculosis (TB) is an infectious disease caused by mycobacteria, principally Mycobacterium tuberculosis. This disease can affect all organs but mainly the lungs, remains a major public health challenge, particularly in low and middle-income countries. TB disease can occur after infection and can cause death. There is evidence of an increased risk of cancer, particularly of the lung, in people with a history of TB or with an active form of the disease. The BCG vaccine, derived from a weakened strain of Mycobacterium bovis, offers protection against severe forms of tuberculosis in children and is also employed in the treatment of bladder cancer. The objective of this article is to examine the associations between Mycobacterium tuberculosis, tuberculosis and cancer.

Keywords

Mycobactium tuberculosis, Tuberculosis, Risk factors, Lung cancer

Introduction

Tuberculosis is an infectious disease caused by a mycobacterium of the tuberculosis group, mainly Mycobacterium tuberculosis, whose usual reservoir is man, more rarely Mycobacterium bovis or africanum. The incidence of tuberculosis remains high in countries with low or middle economic income, and this potentially fatal infectious disease remains a global public health issue. The infection initially remains latent, linked to airborne transmission of bacilli and can progress to tuberculosis disease, mainly in the lungs, with the possibility of poly-visceral extension, particularly via the haematogenous route, in immunodeficient patients. It can also cause sequelae and encourage the development of cancer, particularly lung cancer. However, this mycobacterium can play a role in the treatment of other cancers, and represents an area of research in this field.

Epidemiology

The causative agent of tuberculosis is Mycobacterium tuberculosis. In 2023, tuberculosis (TB) remains a major public health issue worldwide, although it is no longer one of the top ten causes of death on a global scale. However, it is the leading cause of death from infectious agents, ahead of HIV infection, having caused 1.3 million deaths. Of the new cases diagnosed, 70% were of the pulmonary variety. The eight countries accounting for more than two-thirds of global TB cases are India (26%), Indonesia (10%), China (6.8%), Philippines (6.8%), Pakistan (6.3%), Nigeria (4.4%), Bangladesh (3.6%) and Democratic Republic of Congo (2.9%). More than 400,000 people have developed a form of TB resistant to rifampicin, almost 80% of these have developed a multi-drug resistant form [1].

More than 80% of TB cases and 90% of induced deaths occur in low- and middle-income countries. The mortality rate due to tuberculosis is falling by around 3% a year, and an overall decline of 42% was observed over the period 2000-2017 [2]. It is estimated that more than 1.5 billion people (23% of the world’s population) are infected with the tubercle bacillus, and are thus at risk of developing TB [2].

The Tubercle Bacillus

Bacteriological Aspects

Mycobacterium tuberculosis (MBT) is a strict aerobic bacillus. This pathogenic agent has an outer lipid membrane bilayer ; it divides very slowly (16 to 20 hours) and is either very weakly ‘Gram-positive’ or does not retain its colour due to the high lipid and mycolic acid content of its wall. In nature, the bacterium can only develop inside the cells of a host organism. This acid-fast bacillus can be identified under the microscope. The most common staining method is the Ziehl-Nielsen stain, which highlights MBT in bright red. Auramine staining and luminescence microscopy can also highlight it [1-3].

The Mycobacterium tuberculosis complex (MBTC) includes four other mycobacteria responsible for tuberculosis: M. bovis, M. africanum, M. canetti and M. microti [3]. M. africanum is not very widespread, but it is a major cause of tuberculosis in Africa. M. bovis used to be a common cause of tuberculosis, but the pasteurisation of milk has virtually eliminated its responsibility in developed countries. M. Canetti is mainly responsible for tuberculosis in the Horn of Africa, while M. Microti can be implicated in immunocompromised individuals [3].

The other known pathogenic mycobacteria are M. leprae (Hansen’s bacillus), which causes leprosy, and M. avium and M. kansasii, classified as ‘non-tuberculous mycobacteria’ (NTM), which can cause pulmonary infections similar to tuberculosis. [4,5].

Calmette and Guérin bacillus developed from an attenuated strain of Mycobacterium bovis, is the basis of the tuberculosis vaccine. It is used to protect (80% efficacy for more 5 years) young children against serious forms of tuberculosis, such as tuberculous meningitis and miliary tuberculosis [2]. It is much less effective against other forms of TB, particularly pulmonary. It stimulates the immune system so that it can identify and fight the mycobacteria responsible for tuberculosis in the event of exposure. In countries where the incidence of TB is low (United States of America, Canada, Western Europe, Australia) the vaccine is less widely used or reserved for high-risk population groups. On the other hand, it is given to newborns in countries with a high incidence of tuberculosis, and to children living in environments where active cases of tuberculosis may be present. Health professionals or those working in high-risk environments (laboratories, etc.) may also be vaccinated. A single dose by intradermal injection is recommended in the first few weeks of life ; in older children, the absence of tuberculosis infection should be verified by a tuberculin or IGRA test prior to vaccination. This vaccine has a high rate of tolerance, with minor ulceration at the injection site being the only common side effect. Complications are rare, and include local abscesses and adenopathy in the drainage area. In exceptional cases, disseminated infections may occur in immunocompromised individuals [6].

Transmission of Infection

The risk of transmission of the infection from one person to another depends on several factors: the number of small (0.5 and 5 µm) contagious droplets (Flügge droplets) which can remain suspended in the air for up to 9 hours after they are emitted. The transmission of the same clone of bacteria from one patient to another has been proven by genotyping studies of mycobacteria [6].

People who are in frequent, close contact with people suffering from pulmonary, laryngeal or tracheobronchial tuberculosis, especially in a small, poorly ventilated space, are particularly exposed to the risk of infection when patients emit MBT during verbal exchanges, episodes of coughing, spitting or sneezing. It is estimated that a person with active tuberculosis can infect at least 10 to 20 people. People suffering from tuberculosis must therefore be isolated while their sputum is sterilised, and wear a protective mask, as must their carers [6] and any infection should be detected in people contacts.

Natural History of Tuberculosis Infection

Transmission of Infection

Defence mechanism against MBT. Once inhaled, the tubercle bacilli are deposited in the distal alveolar spaces, mainly in the upper parts of the lungs. They are phagocytosed by alveolar macrophages (AMs), accompanied by a local cell-mediated inflammatory response involving CD4 T lymphocytes (Th1), which activate AMs and stimulate the production of cytotoxic CD8 lymphocytes, thereby facilitating the response against intracellular MBT. Numerous cytokines are released, including interferon gamma (INFγ), interleukin 2 (IL2), tumour necrosis factor (TNFα) and the recruitment of circulating mononuclear cells, all of which play a part in the defence mechanism against this infection. Phagocytic dendritic cells carrying antigenic peptides reach the lymph node relays and present these antigens to CD4 T lymphocytes, which return to the lung to organize the formation of an inflammatory granuloma with a satellite lymph node reaction, leading to the formation of a lymph node-lung complex [6,7].

Latent tuberculosis infection (LTI) is characterised by a delayed hypersensitivity reaction to MBT, leading to positive tuberculin and IGRA tests (Interferon Gamma Release Assays), whether Quantiferon- TB Gold Plus or T-SPOT.TB. In 90% of cases, the body’s immune response prevents MBT proliferation and controls the infection in less than 10 weeks, resulting in latent tuberculosis infection. This is generally clinically asymptomatic and poses no risk of contagion. However, MBTs may persist in a quiescent state in macrophages for a long time [6,7].

In the context of tuberculosis (TB), it is important to note that 70% of cases progress to tuberculosis disease within two years of initial infection. Following this, the risk gradually decreases, though it appears to be lifelong. TB disease can occur as a result of a decline in cellular immunity or reinfection with MBT. This risk is increased at the extremes of life, particularly in children under the age of five who have not been vaccinated with the Mycobacterium bacille Calmette-Guérin (BCG) vaccine, and in people over the age of 65. People at particular risk may also develop TB disease, the main clinical symptoms of which are asthenia, weight loss, fever and coughing in the case of respiratory infection. Radiologically, the lesions predominantly affect the upper lungs and can take a variety of forms, including infiltrates, excavations, nodules, disseminated forms, mediastinal lymph node involvement and pleurisy. Extra-thoracic sites may or may not be associated (e.g. laryngeal, peripheral lymph nodes, bone, genitourinary, digestive) An inflammatory biological picture with anaemia is most often identified. Diagnosis is made by detecting MBT in sputum, or by bronchial aspiration using bronchoalveolar lavage. Culture on liquid or solid medium (Löwenstein-Jensen) is used to identify the type of MBT and its resistance to anti-tuberculosis drugs. Once treatment has been initiated, and provided the patient complies and the MBT are not drug-resistant, sputum and cultures can be sterilised in less than 2 months [6,7].

Risk Factors for TB Infection and TB Disease

The development of tuberculosis is influenced by various internal or external risk factors that increase the likelihood of infection or progression from latent infection to disease.

Internal Risk Factors: The innate deficiency of defences against MBT, with deficient production of INFγ or IL4, IL10, IL12, must be taken into account before vaccination with BCG vaccine [8].

Diabetes, which doubles the risk of LTI and quadruples the risk of TB disease, often with severe presentations (pulmonary excavations, disseminated forms, recurrences or resistance to anti-tuberculosis drugs). The explosion in the number of cases of diabetes worldwide could worsen the epidemiological situation for TB [8].

External Risk Factors: The poor socio-economic conditions and social insecurity in which people live, including precarious housing, detention, malnutrition, migration and difficulty in accessing healthcare, favour the development of TB [8-10].

Exposure to outdoor or indoor air pollution involving various pollutants (e.g. CO, CO2, SO2, O3, PM2.5 microparticles, PAHs) are risk factors for MBT infection [8].

Exposure to active or passive smoking causes dysfunction of the mucociliary escalator, which promotes the persistence of germs in the respiratory tract, and impairment of the mechanisms of anti- infectious immunity (reduced function of AMs, reduced release of TNF-α, imbalance in the CD4/CD8 ratio and reduced production of IFN-γ). Tobacco smoke could stimulate grow and/or the virulence of tuberculosis bacilli. In smokers suffering from TM, a reduction in IFN-γ response was noted, which may affect the performance of IGRA tests. In active smokers, the risk of pulmonary tuberculosis was assessed (OR= 2.6; 95% CI: 2.1 – 3.4). This risk is dose-dependent (CR = 4.4 for 10 cigarettes smoked daily; CR = 5 for 10 years of smoking). Smoking increases the risk of death from TB (RR =2.15 ; 95% CI: 1.38- 3.3), of recurrence of TB and of anti-tuberculosis drug-resistant forms (OR = 1.70; 95% CI: 1.3-2.23) [11].

Alcohol abuse, often associated with socio-economic disadvantage, is a risk factor for MBT infection and TB disease. Alcohol alters the immune response and phagocytic function of macrophages. The risk is dose-dependent ; four drinks a day quadruples the risk of developing TB [12].

HIV infection is a major driver of the TB epidemic, particularly in Africa, where almost 10% of TB patients are thought to be living with HIV. Widespread use of screening and antiretroviral treatment (ART) has led to a significant reduction in TB mortality in HIV-infected patients [8,13].

The use of corticosteroids to treat chronic inflammatory diseases is associated with an excess risk of developing TB; this risk is dose- dependent: prednisolone ≤ 15 mg per day (OR=2.8; 95%CI: 1.0-7.9), dose ≥ 15 mg per day (OR=7.7; 95% CI: 2.8-21.4), and increases with prolonged treatment [8].

Immunomodulatory drugs (anti-TNF) used to treat chronic inflammatory diseases may favour the development of TB; screening for LTI and prophylactic treatment are essential prior to their use [8]. Immunosuppressive drugs used during visceral transplantation may also favour the development of TB [8].

Renal failure, with or without dialysis, increases the risk of TB [8].

Finally, there is good evidence that people exposed to silica crystals or suffering from silicosis have a higher risk of TB [14].

Tuberculosis and Cancer

Studies show an association between tuberculosis and cancers. Patients with a history of pulmonary tuberculosis have a higher relative risk of cancer than the general population. Increased rates of lung cancer have been reported in regions where TB is endemic [15,16]. However, the association between TB and cancer is often multifactorial and depends on many factors (environment, comorbidities, smoking, immune status of the patient). In many cases, the co-occurrence of TB and cancer makes it impossible to determine the nature of the association between these two types of disease [15,16].

Tuberculosis is a Risk Factor for Cancer

Tuberculosis can promote the development of certain cancers, the mechanisms involved are complex and multifactorial.

General Mechanisms

Tuberculosis causes chronic inflammation in tissues, especially the lungs. This inflammation can damage the DNA of cells, promoting carcinogenesis. Tuberculosis granulomas cause fibrosis and tissue remodelling, creating a microenvironment conducive to cancer development. AM and immune cells produce reactive oxygen species (ROS) to fight infection, but these damage DNA and increase the risk of carcinogenesis [16-18].

Cofactors may be involved in carcinogenesis. People living with HIV, who are more susceptible to tuberculosis, have a weakened immune system, which can increase the risk of lung cancer, as well as Kaposi’s sarcoma, lymphoma and anogenital cancers. Exposure to substances such as silica, asbestos and polycyclic aromatic hydrocarbons all promote carcinogenesis. Smoking, which is common among TB patients, is a major risk factor for cancer, especially lung cancer [19,20].

Different Types of Cancer

Lung Cancer

Mycobacterium tuberculosis infection may increase the risk of lung cancer, which may be twice as common after TB as in the general population. In particular, squamous cell carcinoma, although other types such as adenocarcinoma and large cell carcinoma have also been reported. The prolonged chronic inflammation, oxidative stress with excessive production of pro-inflammatory cytokines (TNF-α, IL-6) and free radicals observed in TB cause DNA damage that is a factor in carcinogenesis. After TB disease, fibrotic lesions often form in the damaged areas, which are conducive to the growth of cancer cells (‘scar cancer’). By evading the immune system, Mycobacterium tuberculosis can cause local immunosuppression ; the imbalance in the immune response can create a microenvironment favourable to the growth of cancer cells. Finally, certain metabolites or molecules released by MBT may facilitate cell transformation by interfering with normal cell regulation mechanisms [20-23].

Extrapulmonary Cancers

Cancers can develop in the viscera affected by TB (e.g. lymph nodes, bones, peritoneum) by the mechanisms described above. In Denmark, a cohort study of 15,024 patients with tuberculosis (median follow-up 8.5 years) showed the occurrence of 1747 cancers. The risk of cancer 3 months after tuberculosis was 1.83%, reflecting a high standardised incidence ratio (SIR=11.09 ; 95% CI: 9.82- 12.48), particularly for malignant pleural mesothelioma (368.4), lung cancer (40.9), but also Hodgkin’s lymphoma (30.6), ovarian cancer (26.4) and malignant non-Hodgkin’s lymphoma (23.8) [24]. Other studies suggest an association between urogenital TB and an increased risk of bladder cancer, although this association is less well documented [16].

Practical Attitudes

Differential Diagnosis of Cancer and Tuberculosis

Patients with active or past tuberculosis must be carefully monitored, especially if they are smokers or have been exposed to carcinogens, to differentiate recurrent tuberculosis from lung cancer. Symptoms of lung cancer may mimic those of tuberculosis and require a thorough diagnostic work-up. In some cases, the two conditions may occur simultaneously [25-28].

Effects of Anti-tuberculosis or Cancer Chemotherapy

Anti-tuberculosis treatments are effective and cancer chemotherapies have made considerable progress. Both can be a source of immunosuppression or adverse events that interfere with the simultaneous treatment of cancer and TB [29,30]. TB can occur during cancer treatment [31].

Prevention and Patient Follow-up

Primary prevention. It is essential to ensure early diagnosis and treatment of TB, to monitor adherence to treatment and to follow the course of the disease to reduce the incidence of chronic infection and pulmonary sequelae. BCG vaccination in regions where tuberculosis is endemic. Socio-economic conditions and access to health care need to be improved [2,32].

Secondary prevention. Regular monitoring of patients allows early detection of signs of cancer. Chest CT scans are used to monitor scarring, and pulmonary function tests are used to detect dysfunction, especially in persistent smokers who should be helped to quit. Screening and management of diabetes is essential [33-35].

Mycobacteria in Cancer Treatment

The approach is to use the immunostimulatory properties of mycobacteria to activate the body’s immune defences against cancer cells. MBT are not used because of their pathogenicity, but attenuated strains such as the BCG vaccine are used for their anti-tumour effects [36,37].

BCG and Bladder Cancer

Mechanism of Action

Mycobacteria strongly activate macrophages, which secrete pro- inflammatory cytokines (such as TNF-α and IFN-γ), recruit other immune cells and activate T lymphocytes, which are essential for the anti-tumour response. Stimulation of the immune system in the vicinity of the tumour can induce a generalised immune response against cancer cells (bystander effect) [37,38].

Methods of Use

BCG is injected directly into the bladder (intravesical instillation). It causes local inflammation that attracts immune cells (macrophages, T lymphocytes) to the bladder. These immune cells then attack the cancer cells, reducing the risk of recurrence or progression.

Main Indications

Non-invasive bladder cancer (urothelial carcinoma) or following transurethral resection of the bladder. BCG significantly reduces the risk of recurrence and progression to an invasive form of this cancer [38].

Limitations

This treatment is well tolerated, although it can cause adverse effects such as cystitis and haematuria. Local or disseminated infection with BCG is rare [37,39]. Its efficacy is essentially limited to bladder cancer, but its value in other cancers is being investigated [40].

Therapeutic Prospects

Research is underway into genetically modifying mycobacterial strains to enhance their immunotherapeutic potential, while reducing their infectious risks. Genetically modified strains of MBT or M. smegmatis are being studied as experimental therapeutic agents. Components of mycobacteria could improve the efficacy of anti- cancer vaccines. Mycobacteria could be combined with immune checkpoint inhibitors (anti-PD-1 or anti-CTLA-4) to enhance their anti-tumour effect. Finally, the use of certain components, such as the lipids in the cell wall of mycobacteria, could make it possible to develop nanomedicines or targeted delivery systems [41-43].

Conclusion

Mycobacterium tuberculosis is the main cause of tuberculosis, which remains a major public health issue. The International Agency for Research on Cancer (IARC) has classified it as a carcinogen. There is evidence of an increased risk of lung cancer in patients with a history or active form of tuberculosis. The chronic inflammation, immunological disorders and genomic abnormalities induced by MBT infection underline the fact that it is a precursor to carcinogenesis [44]. One hundred years ago, the BCG vaccine against tuberculosis was developed from an attenuated strain of Mycobacterium bovis, and subsequently proved effective in treating bladder cancer. Research is needed to clarify the relationship between Mycobacterium tuberculosis, tuberculosis and cancer in order to improve our knowledge of oncogenesis and cancer prevention and treatment.

Contribution to the Article: All authors contributed to the writing and correction of this article.

Conflict of Interest: The authors declare that they have no conflict of interest.

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Summary About Health Education and Strategies on HIV Prevention Among Adolescents in Schools

1 Reply

DOI: 10.31038/IJNM.2025611

 
 

When analyzing the general vulnerability of the population, we realize that sexual transmission is among the most well-known forms of contagion among adults from 1980 to the present day. Some data from UNAIDS (the joint United Nations program on HIV/AIDS) indicate that there were around 37.7 million people worldwide living with HIV in 2020, of which 36 million were adults and 1.7 million were children (0-14 years old).

In Brazil, in addition to these statistics used as a basis for a study on the subject, some research was carried out by the Ministry of Health itself, which showed that AIDS is growing much more among young people (15-24 years old) than among adults in the last 11 years, confirming that everyone in the health area, specifically nurses, must be able to care for these young people and generate more consistent and comprehensive sexual health education for them. In Brazil, there is a very strong culture stemming from religion, where by simply talking about sex education, parents and guardians judge health professionals as influencing their children to engage in sexual acts, when in reality, we professionals only want to educate them, showing them how to prevent this disease and other events in their lives, such as an unwanted pregnancy. Another barrier found here in Brazil, due to religion, is that many parents and guardians do not talk to their children about sex education at home, leaving them with doubts and fear of talking to responsible adults. As a result, they look for answers on the internet, with friends of the same age, or even older, and end up not receiving all the prevention methods correctly.

In Brazil, we do not have nurses working in schools, as is the reality in many other countries.We believe that if a nurse were on standby in a school, which is where most of these young people (14-19) begin to have their first sexual contacts, we could educate them in a professional manner based on the prevention of sexually transmitted infections. Campaigns using youthful language would also make it much easier to share these prevention measures, thus allowing for easier and continuous communication to clear up any doubts that many people are unable to do at home.With these small changes and actions, the number of adolescents with HIV/AIDS would certainly decrease, as young people would have a safe space and source to talk about their sexual health without suffering prejudice from society or their own family.