A Multicenter, Retrospective Study to Evaluate the Effect of Preoperative Stoma Site Marking on Stomal and Peristomal Complications

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1 A Multicenter, Retrospective Study to Evlute the Effect of Preopertive Stom Site Mrking on Stoml nd Peristoml Complictions Zehr Gocmen Bykr, PhD, RN; Sevil Guler Demir, PhD, RN; Ayise Krdg, PhD, RN; Deniz Hrputlu, PhD, RN; Aysel Khrmn, ETN, RN; Sercn Krdg, ETN, RN; Aysel Oren Hin, ETN, RN; Eylem Togluk, ETN, RN; Merl Altinsoy, ETN, RN; Sonc Erdem, ETN, RN; nd Rbi Cihn, ETN, RN Abstrct Even though preopertive mrking of the stom re is considered importnt for the prevention of postopertive complictions, not ll helthcre institutions hve universlly dopted this prctice. A multicenter, retrospective, descriptive study ws conducted to determine the effect of stom site mrking on stoml nd peristoml complictions. The 1-yer study included 748 ptients (408 [54.5%] mle, men ge ± yers) from eight stomtherpy units in Turkey. Ptient dt, including ge, gender, dignosis, type of surgery, history of preopertive stom site mrking, person performing the mrking, nd postopertive complictions, were obtined from ptient records, bstrcted, nd nlyzed. Cncer ws the reson for the opertion in 545 (72.9%) of the cses. In 287 ptients (38.4%), the stom nd wound cre nurse nd/or surgeon mrked the stom re; this occurred 1 dy before or on the dy of surgery ccording to Wound Ostomy Continence Nurses Society nd Americn Society of Colon nd Rectl Surgeons recommendtions. Stoml/ peristoml complictions developed in 248 (33.2%) persons; the most frequently observed complictions in ptients were prstoml skin problems (136, 48.7%), mucocutneous seprtion (52, 18.6%), nd retrction (31, 11.1%). The rte of complictions ws higher mong ptients whose stom site ws not mrked thn mong those whose stom site ws mrked (22.9% nd 46%, respectively; P <0.001). The results of this study confirm the stom re should be mrked preopertively in ll plnned surgicl interventions in order to reduce the risk of postopertive complictions. Additionl prospective nd experimentl studies on effectiveness of preopertive stom site mrking should be conducted with lrger smple groups. Keywords: surgicl stom, postopertive complictions, nursing, multicenter trils, retrospective study Index: Ostomy Wound Mngement 2014;60(5):16 26 Potentil Conflicts of Interest: none disclosed Dr. Bykr nd Dr. Demir re instructors; nd Dr. Krdg is professor, Gzi University, Fculty of Helth Sciences, Deprtment of Nursing, Ankr, Turkey. Dr. Hrputlu is n enterostoml therpy nurse, Dokuz Eylul University Hospitl Stomtherpy Unit, Izmir, Turkey. Ms. Khrmn is n enterostoml therpy nurse, Ege University Hospitl Stomtherpy Unit, Izmir, Turkey. Ms. Krdg is n enterostoml therpy nurse, Turkey High Speciliztion Eduction nd Reserch Hospitl Stomtherpy Unit, Ankr, Turkey. Ms. Hin is n enterostoml therpy nurse, Gzi University Hospitl Stomtherpy Unit. Ms. Togluk is n enterostoml therpy nurse, Istnbul University Cerrhps Hospitl Stomtherpy Unit, Istnbul, Turkey. Ms. Altinsoy is n enterostoml therpy nurse, Istnbul University Cp Hospitl Stomtherpy Unit, Istnbul, Turkey. Ms. Erdem is n enterostoml therpy nurse, Uludg University Hospitl Stomtherpy Unit, Burs, Turkey. Ms. Cihn is n enterostoml therpy nurse, Cukurov University Hospitl Stomtherpy Unit, Adn, Turkey. Plese ddress correspondence to: Sevil Guler Demir, PhD, Gzi University Fculty of Helth Sciences Deprtment of Nursing, Emniyet Mh, Mummer Ysr Bostnci Cd. No: 16 Postl Code Besevler/Ankr, Turkey; emil: sevilgulerdemir@yhoo.com. 16 ostomy wound mngement My

2 Stom site mrking nd stoml/peristoml complictions Stom cretion is procedure widely utilized in gstrointestinl nd urinry system surgery. Stoms creted for cncer, trum, nd inflmmtory intestinl diseses re ssocited with complictions tht cuse difficulties in the dily life of the individul. 1-3 According to the literture, the rte of complictions in ptients with stoms cn vry from 10% to 70% 4-9 ; preopertive mrking of the stom site is effective in reducing the incidence of complictions mong individuls with stom. 10,11 Stom site mrking is performed in ptients who re scheduled to undergo ostomies nd is considered the first stge of dpttion to the stom. 12 The process of mrking the stom site llows individuls in the preopertive stge to obtin informtion on the stom, stom cre, nd products to be used; increses dpttion to the stom nd stom cre; reduces the risk of stoml/peristoml complictions; nd improves qulity of life. 2,13-15 Therefore, the Americn Society of Colorectl Surgeons (ASCRS), the Americn Urologists Assocition (AUA), the Wound Ostomy Continence Nurses Society (WOCN), nd the Turkish Wound Ostomy Incontinence Nurses Society (Yr Ostomi I nkontinns Hems ireleri Derneg i [YOIHD]) recommend the stom site should be determined in ll ptients with plnned ostomies nd mrked preopertively by trined, experienced, uthorized clinicin. 12,16 Furthermore, 2009 guide published by the World Helth Orgniztion 17 emphsized the opertion site hd to be mrked to ensure ptient sfety. The first Turkish stomtherpy unit ws estblished in 2000; currently, there re 16 units. However, stom site mrking is systemticlly performed in only few centers. In Turkey, stom res re mrked by stom nd wound cre nurses in some centers nd stom nd wound cre nurses nd/or surgeons in others. To crete stom in the rectus muscle in n re esily visible nd ccessible by the individul, the individul should be evluted in the stnding, sitting, lying, bending, nd wlking positions, nd the site should be mrked. 2 In ptients who hve not hd their stom re mrked preopertively, the stom re is mrked while the ptient is lying on the operting tble; this is n undesired prctice. In such positions, bdominl creses strighten out, nd stom tht ppers to hve been creted on flt site my be situted between bdominl creses when the ptient is in the seted position. Creting stom between creses compromises pouch nd skin brrier dherence nd my cuse lekge, which negtively ffects the compliction rte nd ptient qulity of life. Becuse preopertive stom site mrking involves considertion of the creses, edges, visible res, incision lines, nd bony edges, it prevents the development of numerous complictions. 10,11 In ddition to dversely ffecting the qulity of life nd ptient dpttion to their stoms, stoml nd peristoml complictions increse helthcre expenses. 2,12 Ostomy Wound Mngement 2014;60(5):16 26 Key Points Preopertive cre of ptients who my require the cretion of stom should include ssessing nd mrking n optiml stom site. The uthors conducted retrospective study to evlute the effect of preopertive stom site mrking on postopertive stoml nd peristoml complictions. Ptients whose stom loction ws not ssessed nd mrked preopertively, regrdless of surgery type, hd significntly higher rte of postopertive complictions thn ptients who underwent preopertive stom site mrking. The results of this study confirm the results of previously published studies. Preopertive stom site mrking should be performed in ll ptients before surgicl procedures tht my result in the cretion of stom. No studies on the effect of stom site mrking on stoml/peristoml complictions hve been conducted in Turkey. Thus, YOIHD cknowledges stom site mrking to be priority medicl issue nd plnned this study to ssess the sttus of stom site mrking in Turkey, increse interest in this issue, nd emphsize its importnce. This purpose of this study ws to evlute nd describe the effect of stom site mrking on stoml nd peristoml complictions. Methods nd Procedures This multicenter, retrospective, descriptive study mong ptients in eight (out of 16) prticipting stomtherpy units in Turkey ws conducted between Jnury nd December Dt were exmined for 1 yer nd included computerized ptient records extrcted nd recorded on dt collection form developed by the reserchers bsed on clinicl experience nd current literture. Dt bstrction for ech ptient ws completed by nurse t ech stomtherpy unit. The dt collection forms comprised 10 questions nd included ptient ge, gender, dignosis, type of opertion, sttus of stom site mrking, person performing the mrking, nd history of complictions since procedure. The forms were exchnged by mil. Dt were evluted using IBM SPSS for Windows 20.0 softwre. Figures, percentile clcultions, chi-squre test, Fisher s exct test, nd the likelihood-rtio (LR) test were used for dt evlution. Becuse ptient dt were complete, no dt extrctions were performed. Ethicl considertion. This study ws plnned by YOIHD. Nurses were provided informtion on the purpose nd method of the study t the IV Stom nd Wound My 2014 ostomy wound mngement 17

3 Tble 1. Descriptive chrcteristics of stom ptients (N = 748) Chrcteristic n (%) Age (27.8) (38.9) (33.3) Men ge (± SD) 56.60±16.73 Gender Femle 340 (45.5) Mle 408 (54.5) Medicl dignosis Cncer 545 (72.9) Inflmmtory bowel disese 58 (7.8) Intestinl obstruction 35 (4.7) Injuries 34 (4.5) Bowel perfortion 14 (1.9) Fistul 13 (1.7) Fmilil denomtous polyposis 11 (1.5) Anorectl mlformtion 6 (0.8) Mesenteric ischemi 6 (0.8) Sigmoid volvulus 6 (0.8) Intr-bdominl bscess 4 (0.5) Other 16 (2.1) Surgery type Emergency 221 (29.5) Plnned 527 (70.5) Stom type Ileostomy 363 (48.5) Colostomy 354 (47.3) Urostomy 21 (2.8) More thn one stom 10 (1.3) Stom nture Temporry 556 (74.3) Permnent 192 (25.7) Sttus of preopertive stom site mrking Mrked 287 (38.4) Unmrked 364 (48.7) Unknown 97 (13.0) Person(s) performing the stom site mrking b Stom nd wound cre nurse 258 (89.9) Doctor 29 (10.1) Sttus of developing stoml/prstoml complictions Developed 248 (33.2) Undeveloped 487 (65.1) Unknown 13 (1.7) Complictions (n=279) Peristoml skin problems 136 (48.7) Mucocutneous seprtion 52 (18.6) Retrction 31 (11.1) Superficil necrosis 11 (3.9) Prolpse 9 (3.2) Edem 7 (2.5) Cynosis 7 (2.5) Stenosis 6 (2.2) Obstruction 5 (1.8) Device relted pressure ulcer 3 (1.1) Hernition 2 (0.7) Bleeding 2 (0.7) Fistul 2 (0.7) Mcertion 2 (0.7) Tumor growth on the stom 2 (0.7) Allergy 1 (0.4) Prstoml indurtion 1 (0.4) Other resons: incontinence, rectl prolpse, cystic fibrosis b Percentge bsed on number of persons with mrked stom sites Cre Nurses Meeting (September 10 11, 2012). Written informed consent ws obtined from the prticipting institutions. Results Dt were extrcted from the records of 748 ptients (408, 54.5% mle; men ge ± yers; 72.2% >50 yers of ge) t eight stomtherpy units in Turkey. Stom types included ileostomy (363, 48.5%), colostomy (354, 47.3%), nd urostomy (21, 2.8%) nd were temporry in 556 (74.3%) ptients. The mjority of ptients (545, 72.9%) hd been dignosed with cncer. The stom ws creted during n emergency procedure in 221 ptients (29.5%) (see Tble 1). In ptients whose stom re ws mrked preopertively, stom nd wound cre nurse nd/or surgeon hd mrked the site 1 dy before or on the dy of the opertion in ccordnce with recommendtions of the Wound Ostomy Continence Nurses Society nd Americn Society of Colon nd Rectl Surgeons. 12 The stom site ws mrked preopertively in 287 (38.4%) study prticipnts; of those, the site ws mrked by stom nd wound cre nurse in 258 ptients (89.9%). The preopertive stom site mrking ws unknown in 97 ptients (13.0%) (see Tble 1). Stoml/peristoml complictions hd developed in 248 study prticipnts (35.2%); the three most frequently observed complictions were peristoml skin problems (136, 48.7%), mucocutneous seprtion (52, 18.6%), nd stoml retrction (31, 11.1%) (see Tble 1). The rte of compliction development ws 46% mong ptients who did not hve their stom sites mrked preopertively nd 22.9% mong ptients who hd their stom sites mrked (χ 2 = , P <0.001) (see Tble 2). In individuls who underwent stom site mrking, the rtes of peristoml skin problems, mucocutneous seprtion, nd stoml retrction were significntly lower thn in individuls with no preopertive stom site mrking (P <0.05) (see Tble 3). Age, stom type, nd person mrking the stom were not found to ffect the rte of stoml nd peristoml compliction development (P >0.05). The rte of stom retrction ws significntly higher in women thn in men (5.9% versus 2.7%, χ 2 = 4.739, P = 0.029). Stoml nd peristoml complictions developed in 60% of individuls with more thn one 18 ostomy wound mngement My

4 Tble 2. Distribution of stoml/peristoml complictions by preopertive mrking sttus Sttus of Sttus of developing preopertive stoml/peristoml complictions stom site mrking Developed (n%) Undeveloped (%) Mrked 65 (22.9) 219 (77.1) Unmrked 163 (46.0) 191 (54.0) Unknown 20 (20.6) 77 (79.4) Sttisticl nlysis X 2 : P <0.001 chi-squre test Tble 3. Distribution of most common stom complictions by site mrking sttus nd type of surgery Chrcteristic Complictions Prstoml skin problems n(%) mucocutneous seprtion n(%) Sttus of preopertive stom site mrking Mrked 34 (11.8) 15 (5.2) 9 (3.1) Unmrked 90 (24.7) 35 (9.6) 22 (6.0) Unknown 12 (12.4) 2 (2.1) - Sttisticl nlysis X 2 : XP: P<0.001 P =0.012 Type of surgery Emergency 43 (19.5) 25 (11.3) 4 (1.8) Plnned 93 (17.6) 27 (5.1) 27 (5.1) Sttisticl nlysis X 2 =0.343 X 2 =9.220 P =0.558 P =0.002 chi-squre test stom, 38.9% of individuls with n ileostomy, 28.9% of individuls with colostomy, nd 14.3% of individuls with urostomy. The higher rtes of complictions mong ptients with n ileostomy or with more thn one stom were found to be sttisticlly significnt (χ 2 = , P = 0.002) (see Figure 1). When the compliction rte ws exmined ccording to stom type, peristoml skin problems were found to develop t higher rte in individuls with n ileostomy nd in those with more thn one stom (χ 2 = , P <0.001). The stom site ws not preopertively mrked in 80% of individuls with more thn one stom, 49.7% of colostomy ptients, 47.7% of ileostomy ptients, nd 33.3% of urostomy ptients. A sttisticlly significnt reltionship ws noted between stom type nd the stom site mrking sttus (LR = , P <0.001). In the sttisticl evlution using the LR test, Stoml retrction n(%) stoml nd peristoml complictions were found to develop in 67.3% of colostomy ptients nd in 64.5% of ileostomy ptients whose stoml sites were not mrked, sttisticlly significnt difference (P <0.05) (colostomy: XP: LR = , P <0.001; ileostomy: LR = , P <0.001). P =0.016 Stoml nd peristoml complictions developed in 40% of stom ptients who underwent emergency surgicl interventions nd in 31.1% of stom p- X 2 =4.303 P =0.038 tients who underwent plnned surgicl interventions, sttisticlly significnt difference (P = 0.019) (see Figure 2). Mucocutneous seprtion ws observed t higher rte mong stom ptients who underwent n emergency surgicl intervention (P = 0.002), wheres stoml retrction ws observed t higher rte mong ptients who underwent plnned surgicl interventions (P = 0.038) (see Tble 3). Sttisticl nlysis showed the higher rte of mucocutneous seprtion observed in ptients who underwent emergency surgicl interventions nd the higher rte of stoml retrction observed in ptients who underwent plnned surgicl interventions Figure 1. Sttus of developing stoml/peristoml complictions by stom type. X 2 =14.421, P = re ssocited with the preopertive mrking of the stoml region. The incidence of peristoml skin problems, mucocutneous seprtion, nd retrction in ptients who underwent preopertive stom site mrking did not vry ccording to the type of surgery (P >0.05) (see Tble 4). 20 ostomy wound mngement My

5 Figure 2. Sttus of developing stoml/peristoml complictions by type of surgery. X 2 =5.501, P = Discussion This study found stoms were creted in ptients mostly due to cncer, which is supported by the literture. 4,18-20 Among the most widespred types of cncer in Turkey, colorectl cncers rnk second for women (12.5%) nd fourth for men (18.2%), nd bldder cncer rnks third for men (21.1%). As these dt indicte, the types of cncer tht necessitte the cretion of ostomies re currently in the top five most common types of cncer in Turkey, 21 incresing the likelihood of regulrly encountering ptients with stom in clinicl prctice. The results of this study show complictions developed in one third of stom ptients nd tht peristoml skin complictions were the most common. This finding is similr to results reported in the literture. In the study conducted by Krdg 5 in similr group of ptients, the compliction rte ws 32.8% nd the most widespred compliction ws peristoml skin irrittion (17.9%). In prospective, descriptive study conducted mong 220 ptients with fecl nd urinry stoms nd in their second postopertive month, Rtliff et l 22 found complictions developed in 35 individuls (16%) with stom nd tht more thn hlf (24, 68.6%) of these complictions were described s irritnt dermtitis. Akçm et l 6 observed compliction rte of 24.1%; the most frequent compliction ws dermtitis (5.8%). Other published studies hve found higher rtes of complictions. In prevlence study conducted on stom complictions nd fctors ffecting the development of stom (n = 330), Mhjoubi et l 23 found reltively high rte of complictions (69.4%) in colostomy ptients, wheres Özydın et l 9 reported the rte of developing complictions ws 48%, nd the most frequently encountered compliction ws skin irrittion (63%). Overll, rtes of stom complictions reported in the literture vry between 10% nd 70%. 4 Complictions reduce the self-cre bility of stom ptients, leding to vriety of psychosocil problems. 13 The type of stom, type of opertion, surgicl technique, preopertive mrking of the stom site, nd generl helth of the individul in ddition to preopertive nd postopertive follow-up cre, pproprite peristoml skin cre, nd ptient eduction influence the development of complictions. The current study ws Tble 4. Distribution of most frequently observed stoml/peristoml complictions by stom site mrking nd type of surgery Sttus of preopertive stom site mrking/complictions Type of surgery Totl n(%) Sttisticl nlysis Emergency n (%) Plnned n (%) Stom site mrked Prstoml skin problems 1 (2.9) 33 ( 97.1) 34 (100.0) P=1.000 b Mucocutneous seprtion 1 (6.7) 14 (93.3) 15 (100.0) P=0.353 b Retrction 1 (11.1) 8 (88.9) 9 (100.0) P=0.227 b Stom site unmrked Prstoml skin problems 34 ( 37.8) 56 (62.2) 90 (100.0) X 2 =0.581 P=0.446 Mucocutneous seprtion 22 (62.9) 13 (37.1) 35 (100.0) X 2 =7.491 P=0.006 Retrction 3 (13.6) 19 (86.4) 22 (100.0) X 2 =7.348 P=0.007 Stom site mrking unknown Prstoml skin problems 8 (66.7) 4 (33.3) 12 (100.0) P=1.000 b Mucocutneous seprtion c 2 (100.0) - 2 (100.0) Retrction chi-squre test; b Fisher s exct chi-squre test.; c expected frequency too low for sttisticl nlysis 22 ostomy wound mngement My

6 conducted in stomtherpy units, where follow-up nd ptient cre were performed regulrly. This my explin lower rte of complictions thn wht hs been reported in the literture. Although this study ws conducted t institutions with stomtherpy units, hlf of the ptients were not mrked preopertively. In individuls without stom site mrking, the rte of complictions ws nerly twice s high s the rte in those with mrking. Likewise, Person et l 24 reported lower compliction rte mong ptients who underwent stom site mrking thn in those without stom site mrking. In jointly published prctice mnul from the ASCRS nd WOCN, 12 mrking of the stom site ws ccepted s proven benefit. Furthermore, in the systemtic review study conducted by Colwell nd Gry, 10 the positive impct of preopertive eduction nd stom site mrking on postopertive ptient outcomes ws ccepted s evidence. The sme study found preopertively determining the stom region reduced compliction development, sttement supported by Level 4 evidence (ie, specilist committee reports nd expert opinions). In the current study, the rtes of peristoml skin problems, mucocutneous seprtion, nd retrction complictions were significntly higher in individuls whose stom sites were not mrked thn in ptients whose stom sites were mrked. In ptients who do not undergo preopertive mrking, the stom cn be creted in between skin creses, ner bony edges, nd ner incision lines, cusing difficulties with pouching systems. Peristoml urine nd stool lekge onto the skin re the min cuses of chemicl irritnt dermtitis in ileostomy nd urostomy ptients. 25 Furthermore, retrction cn develop in stoms not creted properly or in the pproprite region. Stoml retrction generlly cuses mucocutneous seprtion. Stoml retrction nd mucocutneous seprtion mke obtining secure sel between the skin nd the pouch system difficult nd increse the risk of lekge nd skin problems. 26 This, in turn, cretes more problems, becuse it is difficult to plce pouch system on skin with deteriorted integrity. This vicious cycle not only leds to physiologicl problems, but lso to psychosocil problems, dversely ffecting ptient qulity of life. In the current study, mong individuls with more thn one stom or n ileostomy, the rte of developing complictions ws significntly higher, confirming previously reported study results. In retrospective study (N = 1,616 stom ptients), Prk et l 27 found the highest rte of complictions ws ssocited with loop ileostomy (75%), nd the most frequent postopertive erly stge compliction ws skin eruption (12%). Özydın et l 9 found the rte of developing complictions ws 19.3% in individuls with ileostomy. The literture on peristoml skin problems indictes in ileostomy ptients, fecl output with more liquid texture dmges skin integrity t vrious levels. 8,28 One of the most seemingly obvious observtions in the current study ws the rte of developing complictions in ptients with emergently creted stoms (40.0%) ws higher thn in those with plnned ostomies (31.1%). However, dvnced nlyses, which found the stom site is mrked t lower rte in emergency opertions, hve shown this observtion ws relted to the filure to mrk the stom site rther thn to the emergent nture of the opertion. In both emergency nd plnned opertions, the compliction rtes in ptients whose stom region ws not mrked were very similr. Likewise, in prospective study conducted on stoml complictions, Arumugm et l 18 found no significnt difference in the rtes of developed complictions between plnned nd emergency opertions. In prospective study conducted by Robertson et l, 4 the rte of developing stoml complictions in plnned opertions ws similr to tht in unplnned opertions. Mrking the stoml site, which is one of the rights of ptients undergoing stom cretion, is prt of the listed job duties of certified stom nd wound cre nurses working in stomtherpy units in Turkey. 29,30 Nurses mrked most stom sites in the current study. In plnned ostomy surgeries, stom nd wound cre nurses mrk the stom site in coopertion with the surgicl tem. However, stom nd wound cre nurses t stomtherpy units serving s outptient clinics re unble to mrk stom sites in emergency opertions performed on weekends or during night shifts. Furthermore, it is frequently impossible to perform preopertive preprtions in emergencies. In ddition, in emergency opertions, the decision of whether stom will be creted cn be mde during the ctul opertion. Thus, the stom site is not mrked in emergency opertions, which is considered n importnt contributing fctor to the higher rte of stom complictions ssocited with emergency opertions. Limittions This study did not include ll stomtherpy units in Turkey; the study smple is limited to institutions greeing to prticipte in the study. In ddition, the study is retrospective nd s such limited to the ptient records nd record ccurcy t the units where the study ws conducted. Conclusion In this study, the site of stoms creted during emergency surgicl procedures were generlly not mrked, nd the rte of complictions in this ptient smple ws higher thn in ptients who underwent plnned procedure nd hd their stom site mrked preopertively. In ccordnce with these results, the following recommendtions hve been mde for the purpose of decresing stoml nd peristoml complictions: in ddition to meeting ll other preopertive medicl requirements, the stom site should be mrked on ll ptients who will undergo n opertion. 24 ostomy wound mngement My

7 The number of stomtherpy units tht provide ptients with preopertive nd postopertive follow-up nd trining, cre, nd consultncy should be incresed, long with the number of certified stom nd wound cre nurses with the requisite knowledge nd skills for preopertive mrking of the stom site. Trining mterils on stom site mrking, such s trining progrms nd CDs, to increse wreness, knowledge, nd skills of clinicins should be redily vilble. The results of this study confirm previous reports tht the stom site should be identified nd mrked preopertively in ll surgicl interventions tht my result in the cretion of stom. Additionl prospective nd experimentl studies on effectiveness of preopertive stom site mrking to underscore these recommendtions should be conducted with lrger smple groups. n Acknowledgment Sttisticl nlyses were conducted by Associte Professor Dr. Erdem Krbulut, fculty member t the Deprtment of Biosttistics t the Fculty of Medicine in Hcettepe University, Ankr, Turkey. References 1. 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