Health-related quality of life and complications of corticosteroid treatment in patients with immune thrombocytopenia in two teaching hospitals in Ethiopia: A cross-sectional study

Health-related quality of life and complications of corticosteroid treatment in patients with immune thrombocytopenia in two teaching hospitals in Ethiopia: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health-related quality of life and complications of corticosteroid treatment in patients with immune thrombocytopenia in two teaching hospitals in Ethiopia: A cross-sectional study Dessale Abate Beyene, Eskinder Ayalew Sisay, Atalay Mulu Fentie, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3906006/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Treatment of immune thrombocytopenia (ITP) is difficult and has a significant impact on health-related quality of life (HRQoL), and prolonged use of corticosteroids may have a negative impact on HRQoL. The prepuse of this study was to evaluate the impact of ITP on HRQoL in patients with ITP at Tikur Anbessa Specialized Hospital (TASH) and St. Paul's Hospital Millennium Medical College (SPHMMC). Methods The institutional-based cross-sectional study was conducted from November 15, 2022 to March 15, 2023 to recruit 214 study participants. Descriptive statistics were used to summarize the sociodemographic data and clinical and treatment-related characteristics. Linear regression analysis models were also used to identify predictive factors for HRQoL. A p-value of less than 0.05 was generally considered statistically significant. Results Most of the study participants were female 161(75.5%). Regarding treatment, the majority 172(80.4%) of study participants were taking prednisolone only, and 143(66.8%) of study participants had at least one side effect of corticosteroids during the entire treatment period. Predictive factors for a higher impact of ITP on HRQoL; all correlated variables explained 36.5% (adjusted R-squared = 0.365, P < 0.0001) of the variance and had a moderate impact on HRQoL. Of these, 15.4% of the variance (adjusted R-squared = 0.154, β = 0.392, P < 0.0001) was accounted for by emotion-related corticosteroid side effects. Furthermore, predictive factors for an increasingly higher impact of ITP on HRQoL were the development of emotionally related corticosteroid side effects (β = 0.392, 95% CI: 5.160–9.961, P < 0.001), the presence of fatigue during the assessment (β = 0.326, 95% CI: 4.394–9.475, P < 0.001), patients not taking cotrimoxazole prophylaxis treatment (β = 0.236, 95% CI: 2.236–6.570, P < 0.001), living far from the hematology clinic (outside Addis Ababa) (β = 0166, 95% CI: 1.107–5.114 P = 0.003), having epistaxis and wet purpura (mucosal bleeding) (β = 0.191, 95% CI: 0.091–4.259, P = 0.001), and skin symptoms (petechiae and ecchymosis) (β = 0.041, 95% CI: 0.091–4.259 P = 0.041) during diagnosis. Conclusion The impact of ITP on their energy levels and work life was high compared to the impact of ITP on daily life. The side effects of corticosteroids also affect the HRQoL of ITP patients. Immune thrombocytopenia health-related quality of life platelet count immune thrombocytopenia life quality index corticosteroids Ethiopia Figures Figure 1 Figure 2 1. Introduction Immune thrombocytopenia (ITP) is an acquired form of thrombocytopenia and bleeding disorder caused by autoantibody-mediated and cell-mediated destruction of platelets, resulting in accelerated platelet clearance and impaired thrombopoiesis ( 1 – 3 ). It is described as a transient or persistent reduction in platelet count < 100 x10 9 /L and an increased risk of bleeding that depends on the degree of thrombocytopenia ( 4 , 5 ). ITP requires lifelong treatment in a significant proportion of adult patients, which has a negative impact on patients' health-related quality of life (HRQoL) ( 6 , 7 ). According to the ITP world impact survey, the most common clinical presentations at diagnosis were petechiae (64%) and bruising of unknown origin (65%) ( 8 ). Many patients experience a range of physical and emotional symptoms due to their medical condition. Research shows that, for a significant portion of patients, maintaining a stable platelet count is a major concern. This is because low platelets can result in bleeding, which can be a serious health risk. Patients also commonly report feeling fatigued, anxious, and fearful of bleeding. These symptoms can significantly impact patients' health-related quality of life (HRQoL)in various ways, including their ability to perform daily activities, their emotional well-being, their energy levels, their ability to work, and their overall productivity ( 9 – 12 ). ITP treatment is challenging, and treatment outcomes are assessed based on the clinical response rate, treatment relapse rate, platelet count before and after the treatment, HRQoL, and adverse events of the treatment/procedure ( 4 , 13 – 18 ). Therefore, treatment should be tailored to the individual patient, considering factors such as age, lifestyle, comorbidities, compliance, patient preferences, the presence and severity of bleeding, and the potential treatment side effects ( 19 ). For this reason, the improvement of HRQoL parameters was named as an important treatment goal in the 2019 updated guidelines of the American Society of Hematology (ASH) and in the international consensus report ( 13 , 20 ). In resource-limited countries like Ethiopia, physicians face high patient burden and limited clinic time ( 21 , 22 ); due to this treating physicians usually prioritize addressing low platelet counts and avoiding life-threatening bleeds over HRQoL. Patients with ITP, on the other hand, are concerned with how the disease affects their lives, specifically how they feel and function ( 7 , 23 ). Fatigue, along with anxiety, fear, and frustration, was one of the most debilitating aspects of ITP patients' HRQoL on their condition ( 8 ). Prolonged use of corticosteroids in adults may have a negative impact on HRQoL due to the effects on sleep disturbances, weight gain, and mental health ( 24 ). As patient-reported HRQoL provides information from the patient's perspective, it has become an important tool to understand the effects of both ITP and its treatments. ( 25 , 26 ). Several studies have assessed the HRQoL of ITP patients using different instruments, such as the 36-item Short-Form Health Survey, the EuroQol Questionnaire with five dimensions, the ITP Patient Assessment Questionnaire (ITP-PAQ), and the ITP Life Quality Index (ILQI) ( 11 , 12 , 27 – 29 ). The more recently developed instrument for assessing HRQoL in ITP patients was the ILQI tool. The content and psychometric validity of the ILQI were established in 14 countries (the United States, China, the United Kingdom, France, Germany, Italy, India, Canada, Turkey, Japan, Colombia, Spain, Egypt, and Ethiopia) ( 30 , 31 ). To our knowledge, there is still no published evidence-based literature performed in Ethiopia or Africa that assesses the impact of ITP on the HRQoL of ITP patients. The cornerstone of most ITP treatments was corticosteroid common side effects, and the impact on HRQoL was not assessed. Hence, this study aimed to investigate the impact of ITP on HRQoL of ITP patients and to determine the factors associated with HRQoL of ITP patients in Tikur Anbessa Specialized Hospital (TASH) and St. Paul's Hospital Millennium Medical College (SPHMMC). 2. Materials and Methods 2.1. Study design and participants This institutional-based cross-sectional study was conducted to evaluate the impact of ITP on the HRQoL of ITP patients treated in the hematology clinic at TASH and SPHMMC during the study period from November 15, 2022 to March 15, 2023. The hospitals provide specialized comprehensive and clinical services.The outpatient departments of both hospitals have many specialty clinics, and the hematology clinic serves patients with many hematologic disorders. According to the hospital's Health Management Information System (HMIS) data of TASH and SPHMMC, an average of 50 ITP and 20 ITP patients visit the hematology clinic per month, respectively. All patients attending both hospitals during the study period who had a confirmed diagnosis of ITP according to the guidelines of ASH of 2019 and the standardization of terminology, definitions, and outcome criteria in ITP of adults and children (primary, secondary, newly diagnosed, persistent, chronic and severe ITP) ( 4 , 20 ), patients aged ≥ 14 years and patients willing to participate in the study were included. Patients who did not start treatment and incomplete medical records were excluded. A consecutive sampling method was used to select study participants, and all patients who received ITP treatment during the study period (4 months) and met the eligibility criteria were included in the study; due to the rarity of the event. 2.2. Instrument I. Data abstraction form The data abstraction format is designed to extract information from the medical record or directly from the patient, such as sociodemographic characteristics (age, sex, educational status, place of residence, marital status, and health care costs), clinical characteristics (type of ITP, duration of symptoms, comorbidity, physical, and clinical findings at diagnosis, presence of bleeding, and phase of ITP), and treatment-related characteristics (type, frequency, and duration of treatment). After conducting an extensive literature review ( 24 , 25 , 32 , 33 ) and with the help of experts, structured questionnaires were designed to evaluate the side effects of corticosteroid treatment in patients with ITP. II. ITP Life Quality Index (ILQI) The ILQI was created by clinical experts in the field of ITP and was originally thought to be unidimensional, producing a single score ( 30 ). This is a 10-item patient questionnaire with a recall period of 'last month." Responses range from 'never' to 'always." Three questions (questions 1, 2, and 5) have additional response options that allow the patient to indicate that the question is irrelevant to them or that they do not wish to answer. For the additional responses, 'I am not currently working/studying due to ITP', the value 4 applies, and for the responses 'I am not currently working/studying due to other reasons or does not apply/prefer not to say", the value 0 applies. A total sum score between 7 and 40 was originally proposed, where a lower score indicates a lower impact and a higher score indicates a higher impact of ITP on HRQoL. The content and psychometric validity of the ILQI was assessed in 13 countries ( 30 ). The acceptability, reliability, and validity of the psychometric properties of the Amharic version were also assessed and validated in the Ethiopian population ( 31 ). 2.3. Data quality assurance and Outcome measurements The validated Amharic version of the ILQI was used to assess the HRQoL of patients treated for ITP ( 31 ). A pretest was then administered to 5% of ITP patients. The purpose of the pretest was to ensure that respondents understand the questions and can review the wording, logic, and skip order in a way that makes sense to respondents. Based on the results of the pretest, appropriate corrections were made before the actual study was conducted. Data collectors were recruited by two clinical pharmacists and one nurse, and a half-day training was given by the principal investigator about the objectives of the study and how to use the tool to collect data directly from the patient and medical records/charts. To ensure completeness and consistency of the data, all data were reviewed daily by the principal investigator to ensure the quality of the data. HRQoL scores were calculated using the ILQI tool. According to the instructions for use, raw scores for the ranges of ILQI were calculated and trans-formed to a scale of 0 to 100 by using the formula for mean transformation. $$\text{D}\text{o}\text{m}\text{a}\text{i}\text{n} \stackrel{̄}{x}=\raisebox{1ex}{$100$}\!\left/ \!\raisebox{-1ex}{$(MAXs - N) x (\sum x̄ - N)$}\right.$$ Where Domain x̄: domain mean transformed to 100; MAXs: maximum score; N: number of items; ∑ x̄: sum of means; 100 is the highest impact of ITP on HRQoL, and 0 is the lowest impact of ITP on HRQoL. 2.4. Data Analysis Data were entered and analyzed using SPSS version 26. Descriptive statistics such as frequency, median, and range were used to summarize the sociodemographic data and clinical and treatment characteristics. After checking the assumptions, univariate analysis was performed to obtain candidate variables for the multivariate regression model to determine possible predictors of the HRQoL variables. In the univariate analysis, factors associated with HRQoL that showed a marginal association at p < 0.2 after univariate analysis and all clinically relevant variables were considered candidate variables for multivariate linear regression model to identify strong factors associated with and HRQoL, respectively. A p value < 0.05 was considered to indicate statistical significance. 3. Results 3.1. Sociodemographic characteristics of the study participants A total of 214 study participants took part in this study; the majority 153(71.5%) of them were from TASH. Most 161(75.5%) were female patients with a female-to-male ratio of 3 to 1. Regarding the age distribution, the median age of the study participants was 30 years and ranged from 15 to 88 years, and most 78(36.4%) participants were in the 25–34 years age group. One-third of the study participants had a university degree or more 76(35.5%) and were also self-employed 59(27.6%). Most participants 197(92.1%) lived with their family, and half of them 109(50.9%) lived far from the hematology clinic (outside Addis Ababa). In addition, more than half of the health care costs of the study participants 133(62.1%) were borne by the patients themselves or by their relatives (Table 1 ). Table 1 Sociodemographic characteristics of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). Variables Frequency Percentage Study site TASH 153 71.5 SPHMMC 61 28.5 Sex Female 161 75.2 Male 53 24.8 Age 14–24 58 27.1 25–34 78 36.5 35–44 40 18.7 45–54 20 9.3 55 and above 18 8.4 Marital status Married 149 69.6 Never married 58 27.1 Widowed 4 1.9 Divorced 3 1.4 Educational level Unable to read and write 7 3.3 Enable read and write 12 5.6 Primary education (grades 1–8) 33 15.4 Secondary Education (grades 9–12) 54 25.2 Diploma/Certificate 32 15.0 Degree and above 76 35.5 Occupational status Employed 59 27.6 Housewife 47 22.0 Self-Employed 45 21.0 Student 41 19.2 Unemployed 20 9.3 Retired 2 0.9 Residence Outside Addis Ababa 109 50.9 Addis Ababa 105 49.1 Health service charge With cash 133 62.1 With health insurance 56 26.2 With free 25 11.7 With whom do you live? With family 197 92.1 Alone 17 7.9 TASH: Tikur Anbessa Specialized Hospital, SPHMMC: St. Paul's Hospital Millennium Medical College 3.2. Clinical characteristics of ITP patients during diagnosis The clinical characteristics of the study participants are shown in Table 2 . Of the 214 study participants, only 91 (42.5%) had comorbidities. The median age of study participants at diagnosis of ITP was 27 years (ranging from 9 to 86 years), the median duration of ITP since diagnosis was 24 months (ranging from 3 to 240 months). During the assessment, the most common symptom of ITP was fatigue 53(25.2%), followed by headache 14 (6.5%). Common physical findings during diagnosis include epistaxis and wet purpura (mucosal bleeding) 166 (77.6%), followed by fatigue 157 (73.4%) and skin manifestations (petechiae and ecchymosis) 120 (56.1%). Table 2 Clinical characteristics of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). Variables Frequency Percentage Comorbidity Yes 91 42.5 No 123 57.5 Current symptoms of ITP Fatigue 54 25.2 Headache 14 6.5 Depression 8 3.7 Weight loss 3 1.4 Bleeding 1 0.5 Physical findings during diagnosis Epistaxis and wet purpura 166 77.6 Fatigue 157 73.4 Skin manifestation 120 56.1 Heavy menstrual bleeding 59 27.6 Signs of anemia (pallor) 54 25.2 Severe bleeding* 12 5.6 The Median (range) of age Age at Diagnosis in a year 27(9–86) years Duration since ITP diagnosis in a month 24 (3-240) months Severe bleeding* gastrointestinal bleeding, Intracranial bleeding, rectal bleeding, retinal hemorrhage. Iron deficiency anemia 20 (22.0%), followed by HIV 15 (16.5%), hepatitis B virus (HBV) 7 (7.7%), and systemic lupus erythaematous (SLE) 7 (7.7%), accounted for the highest proportion of comorbidities in ITP patients attending TASH and SPHMMC during the study period (Fig. 1 ). Figure 1 : Comorbidities in ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). Two-thirds 153 (71.5) of study participants had chronic ITP; in addition, 24 (11.2%) and 15 (7.0%) of study participants had corticosteroid-dependent and corticosteroid-resistant ITP, respectively. After completing the first-line treatment of ITP, 55 (25.7%) patients relapsed within a median time of 12 months (Fig. 2 ). Figure 2 : Classification of ITP according to the 2019 ASH guidelines of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). 3.3. Treatment-related characteristics of ITP For the treatment of ITP, the majority 172 (80.4%) of study participants took prednisolone alone, followed by combinations of prednisolone and dexamethasone 31 (14.5%) for first-line treatment in this study setting. [Azathioprine or rituximab] + prednisolone 20 (36.4%) were used as second-line treatment options for ITP. Approximately 63 (29.4%) of the study participants received platelet transfusions to prevent bleeding, and 27 (12.6%) took tranexamic acid to stop bleeding. In addition, approximately 121 (56.5%), 100 (46.7%), and 45 (21.0%) study participants took cotrimoxazole prophylaxis (CPT), proton pump inhibitors (PPI), and calcium with vitamin D3 supplement as prophylaxis to prevent immunosuppression-related infections, peptic ulcers, and osteoporosis, respectively (Table 3 ). Table 3 Treatment-related characteristics of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). First-line treatment of ITP Variables Frequency Percentage Prednisolone alone 172 80.4 Prednisolone + Dexamethasone 31 14.5 Dexamethasone alone 6 2.8 Prednisolone + Methylprednisolone 5 2.3 Second-line treatments of ITP [Azathioprine or Rituximab] + Prednisolone 20 36.4 [Rituximab alone] or [Prednisolone alone] or [Azathioprine alone] 10 18.2 Rituximab + Splenectomy + [Azathioprine or Prednisolone] 8 14.5 [Rituximab + Azathioprine] ± Prednisolone 7 12.7 [Splenectomy + Prednisolone] or [Splenectomy + Rituximab] 6 10.9 [Splenectomy + Azathioprine + Prednisolone] ± Rituximab 4 7.3 Other medications to stop bleeding Platelet transfusion 63 29.4 Tranexamic acid 27 12.6 For prophylaxis of corticosteroid Complications Cotrimoxazole prophylaxis treatment 121 56.5 Proton pump inhibitors 100 46.7 Calcium with Vitamin D3 supplementation 45 21.0 3.4. Corticosteroid side effects in ITP Patients Regarding the side effects of corticosteroids, 143 (66.8%) of the study participants experienced at least one side effect from corticosteroids throughout their treatment period. Of the physical appearance-related factors, weight gain/increased appetite 86 (40.2%), followed by a moon face, bloating, and swelling 72 (33.6%) accounted for the highest proportion. Among emotional corticosteroid side effects, insomnia, restlessness, and/or sleep disturbances 70 (32.7%) and physical symptoms related to corticosteroid side effects, general weakness/fatigue 102(47.7%) and muscle weakness 30(14.0%) accounted for the largest proportion. On the other hand, corticosteroid-related complications, such as increased blood glucose 19 (8.9%), increased blood pressure 15(7.0%), iatrogenic Cushing's syndrome 9(4.2%), and osteoporosis 5 (2.3%), occurred in the study participants (Table 4 ). Table 4 Corticosteroid side effects in ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). At least one Side effect of corticosteroid Variables Frequency Percentage Yes 143 66.8 No 71 33.2 Physical appearance-related corticosteroid side effects Weight gain ⁄ increased appetite 86 40.2 Moon face, bloating, swelling 72 33.6 Stretch mark 11 5.1 Acne 7 3.3 Hair loss 6 2.8 Emotional-related corticosteroid side effects Insomnia, restlessness, and/or trouble sleeping 70 32.7 Depression and/or stress 17 7.9 Anxiety and/or nervousness 12 5.6 Anger and/or irritability 8 3.7 Physical symptoms related to corticosteroid side effects Generalized weakness, fatigue 102 47.7 Muscle weakness 30 14.0 Visual problems (light sensitivity⁄ decreased visual acuity) 12 5.6 Dizziness, headaches 34 15.9 Nausea, upset stomach, vomiting, diarrhea 10 4.7 Other corticosteroid-related complications/Side effects Increase blood glucose 19 8.9 Increase blood pressure 15 7.0 Iatrogenic Cushing's syndrome 9 4.2 Osteoporosis 5 2.3 3.5. Mean scores for the impact of ITP on health-related quality of life The impact of ITP on their energy levels accounts for the highest mean value (2.53 ± 1.17), followed by the impact of ITP on their working lives or studies (2.51 ± 1.10). On the other hand, the impact of ITP on their sex life (1.04 ± 0.71) was lower than other parameters in the IQLI tool (Table 5 ). Table 5 Mean scores for the impact of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). Item ITP life quality index tool Mean ± SD Item-1 How often has your ITP impacted your working life or studies? 2.51 ± 1.10 Item-2 How often have you taken me off work or education because of your ITP? 2.49 ± 1.11 Item-3 How often has your ITP impacted your ability to concentrate on everyday tasks? 2.00 ± 1.10 Item-4 How often has your ITP impacted your social life? 1.86 ± 1.08 Item-5 How often have your ITP impacted your sex life? 1.04 ± 0.71 Item-6 How often have your ITP impacted your energy levels? 2.53 ± 1.17 Item-7 How often has your ITP impacted your undertaking of daily tasks? 2.00 ± 1.27 Item-8 How often has your ITP impacted your ability to support people close to you? 1.88 ± 1.14 Item-9 How often has your ITP negatively impacted your hobbies? 1.87 ± 1.12 Item-10 How often has your ITP negatively impacted your normal capacity to exercise? 2.48 ± 1.15 The overall mean score for the impact of ITP on HRQoL according to the IQLI tool was 35.41 ± 9.27. The mean score for the impact of ITP on their work or study was 50.01 ± 2.17, and the impact of ITP on daily life was 31.69 ± 7.38 (Table 6 ). Table 6 Domain-transformed mean score of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). Variables Likert scale Mean ± SD The formula for domain mean* Domain mean of 100 Impact of ITP on work or study (Items 1 and 2) 2.50 ± 1.09 100/(8 − 2) x (5.00–2) 50.01 ± 2.17 Impact of ITP on daily live (Item 3 to Item 10) 1.95 ± 0.92 100/(32 − 8) x (15.6-8) 31.69 ± 7.38 The overall mean score 2.06 ± 0.93 100/(40 − 10) x (20.64-10) 35.41 ± 9.27 *Domain mean transformed to 100 = 100/(maximum score – no of items) x (sum of means – no of items). 3.6. Association between health-related quality of life of ITP patients and explanatory variables A one-way ANOVA was performed to compare the effects of sociodemographic and clinical characteristics and the corticosteroid side effect variables on HRQoL, and the results of the comparative statistical analysis of the mean values of the HRQoL IQLI domains as a function of the categorical sociodemographic and clinical characteristics and the corticosteroid side effect variables are shown in Table 7 . Patients who had skin manifestations (petechiae and ecchymosis) and epistaxis and wet purpura (mucous membrane bleeding) during diagnosis (P < 0.0001), patients not taking CPT (P < 0.0001), patients taking PPI (P = 0.007) and calcium with vitamin D3 supplementation (p = 0.034), patients who developed iatrogenic Cushing's syndrome (p = 0.02), physical appearance, emotional symptoms, and physical symptoms related to corticosteroid side effects (P < 0.0001), patients who had fatigue during the assessment (P < 0.0001) and patients living far from the hematology clinic (outside Addis Ababa) (P = 0.038) had statistically significant associations with the higher impact of ITP on HRQoL. Table 7 Comparative statistical analysis of IQLI domain mean scores among patients treated for ITP at TASH and SPHMMC, according to the Categorical Sociodemographic, Clinical Characteristics, treatment-related and corticosteroid-related side effects Variables, Mean ± SD HRQoL Work Daily live 1 Place of residence Addis Ababa 19.3 ± 8.9 4.7 ± 2.2 14.6 ± 7.1 Out of Addis Ababa 21.9 ± 9.5 5.3 ± 2.2 16.7 ± 7.5 P value 0.038 0.083 0.036 2 Fatigue during assessment No 18.5 ± 8.2 4.7 ± 2.0 13.9 ± 6.4 Yes 26.8 ± 9.6 6.0 ± 2.4 20.9 ± 7.6 P value < 0.0001 < 0.0001 < 0.0001 3 Headache during assessment No 20.1 ± 9.1 4.9 ± 2.1 15.2 ± 7.2 Yes 29.0 ± 7.9 6.5 ± 2.3 22.5 ± 6.0 P value < 0.0001 0.007 < 0.0001 4 Skin manifestation (petechiae and Ecchymosis) No 17.9 ± 8.3 4.4 ± 2.1 13.5 ± 6.5 Yes 22.8 ± 9.5 5.5 ± 2.1 17.3 ± 7.6 P value < 0.0001 < 0.0001 < 0.0001 5 Epistaxis and wet purpura (mucous membrane bleeding) No 16.1 ± 6.8 4.0 ± 2.0 12.1 ± 5.1 Yes 21.9 ± 9.5 5.3 ± 2.1 16.7 ± 7.6 P value < 0.0001 < 0.0001 < 0.0001 6 Cotrimoxazole prophylaxis treatment (CPT) No 22.9 ± 9.3 5.6 ± 2.0 17.3 ± 7.5 Yes 17.8 ± 8.4 4.2 ± 2.1 13.5 ± 6.7 P value < 0.0001 < 0.0001 < 0.0001 7 Proton pump inhibitors (PPI) No 22.5 ± 9.7 5.5 ± 2.0 16.9 ± 7.9 Yes 19.0 ± 8.6 4.6 ± 2.2 14.5 ± 6.7 P value 0.007 0.002 0.013 8 Calcium with Vitamin D3 supplementation No 19.9 ± 9.1 4.8 ± 2.1 15.1 ± 7.2 Yes 23.2 ± 9.6 5.8 ± 2.1 17.5 ± 7.8 P value 0.034 0.009 0.058 9 Iatrogenic Cushing's syndrome No 20.33 ± 9.1 4.9 ± 2.2 15.4 ± 7.3 Yes 27.67 ± 9.3 6.4 ± 2.2 21.2 ± 7.9 P value 0.02 0.042 0.02 10 Physical appearance-related corticosteroid side effects No 17.5 ± 7.5 4.4 ± 2.0 13.2 ± 5.8 Yes 23.6 ± 9.9 5.6 ± 2.1 18.0 ± 8.0 P value < 0.0001 < 0.0001 < 0.0001 11 Emotional-related corticosteroid side effects No 17.9 ± 8.3 4.4 ± 2.1 13.6 ± 6.6 Yes 25.5 ± 8.9 6.2 ± 1.8 19.3 ± 7.3 P value < 0.0001 < 0.0001 < 0.0001 12 Physical symptoms related to corticosteroid side effects No 17.2 ± 7.8 4.2 ± 2.0 12.9 ± 61 Yes 23.3 ± 9.5 5.6 ± 2.1 17.7 ± 7.6 P value < 0.0001 < 0.0001 < 0.0001 Abbreviations : HRQoL: health-related quality of life, SD: standard deviation 3.7. Factors affecting health-related quality of life in ITP patients Univariate analysis In the univariate analysis, 13 of the variables examined showed an association with HRQoL measured by the ILQI. Of these candidate variables, all were categorical variables, 12 of which were binary variables (place of residence, fatigue during the assessment, headache during the assessment, epistaxis and wet purpura (mucosal bleeding), skin manifestations (petechiae and ecchymosis), CPT, PPI, calcium with vitamin D3 supplementation, iatrogenic Cushing's syndrome, physical appearance-related corticosteroid side effects, emotional-related corticosteroid side effects, and physical symptoms related to corticosteroid side effects); the rest were multicategorical variables (education level). Multivariate linear regression analysis Of the 13 variables used for multivariate linear regression analysis, six variables were identified as correlated with HRQoL by stepwise and forward multivariate linear regression methods and cross-validated by the hierarchical regression method. When the number of patients experiencing emotional-related corticosteroid side effects increased by one, the impact of ITP on patients' HRQoL increased by 0.392 (β = 0.392, 95% CI: 5.160–9.961, P < 0.001). The number of patients with fatigue during assessment increased by one, and the impact of ITP on patients' HRQoL increased by 0.236 (β = 0.326, 95% CI: 4.394–9.475, P < 0.001). In patients who did not take CPT, the impact of ITP on patients' HRQoL increased by 0.236 (β = 0.236, 95% CI: 2.236–6.570, P < 0.001). In addition, the number of patients with epistaxis and wet purpura (mucosal bleeding) increased by one during diagnosis, and the impact of ITP on patients' HRQoL increased by 0.191 (β = 0.191, 95% CI: 0.091–4.259, P = 0.001). The number of patients living far from the hematology clinic (outside Addis Ababa) increased by one, the impact of ITP on patients' HRQoL increased by 0.166 (β = 0166, 95% CI: 1.107–5.114 P = 0.003), and the number of patients with clinical presentations of skin symptoms (petechiae and ecchymosis) of ITP patients increased by 0.041 (β = 0.041, 95% CI: 0.091–4.259 P = 0.041). All correlated variables explained 36.5% (adjusted R-squared = 0.365, P < 0.0001) of the variance and had a moderate influence on the dependent variable (HRQoL). Of these, 15.4% of the variance (adjusted R-squared = 0.154, β = 0.392, P < 0.0001) was accounted for by emotion-related corticosteroid side effects. The tolerance of all independent variables ranged from 0.848 to 1. Thus, there were no multicollinearity problems in the models because all were above 0.2. All standardized residuals in the models were normally distributed (P < 0.05), meeting the assumptions of the linear regression model (Table 8 ). Table 8 Factors associated with the HRQoL of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n = 214). Model Predictor variables R-square Adjusted R square R square change Change statistics P- value Predictor variables β (95% CI) SE F-change Df1 Df2 1 Emotional-related corticosteroid side effects 0.154 0.154 0.154 38.549 1 212 0.000 Emotional-related corticosteroid (ref: No) 0.392 (5.160–9.961) 1.218 2 Fatigue during assessment 0.256 0.249 0.102 28.949 1 211 0.000 Fatigue during assessment(ref:No) 0.326 (4.394–9.475) 1.289 3 CPT 0.309 0.299 0.053 16.038 1 210 0.000 CPT (ref: No) 0.236 (2.236–6.570) 1.099 4 Epistaxis and wet purpura 0.343 0.331 0.034 10.951 1 209 0.001 Epistaxis and wet purpura (ref: No) 0.191 (0.091–4.259) 1.281 5 Residence 0.370 0.355 0.027 9.027 1 208 0.003 Residence (ref: Addis Ababa) 0.166 (1.107–5.114) 1.024 6 Skin manifestation 0.383 0.365 0.013 4.236 1 207 0.041 Skin manifestation (ref: No) 0.041(0.091–4.259) 1.057 Note: CPT; Cotrimoxazole prophylaxis treatment, β; Beta coefficient, SE; standard error, DF; degree of freedom, CI; confidence interval 4. Discussion The aim of this study was to investigate the HRQoL of patients with ITP and the factors associated with HRQoL. The updated international consensus report indicates that there are differences in the clinical presentation of ITP, clinical outcomes and response to treatment ( 20 ). Therefore, the assessment of HRQoL, complications of corticosteroid treatment, and the impact of corticosteroid side effects on the HRQoL of ITP patients plays an important role in the quality of outcomes and measuring the success of treatment. The most common clinical presentation at diagnosis of ITP was epistaxis and wet purpura (mucosal bleeding) (77.6%), followed by fatigue (73.4%), skin manifestations (petechiae and ecchymosis) (56.1%), and heavy menstrual bleeding (27.6%). This was similar to studies conducted in Mexico ( 8 , 34 ), in Spain ( 35 ), in France ( 36 ), and in Turkey ( 37 ). Corticosteroid side effects may affect HRQoL or treatment response, and in this study population, 71.5% of study participants had chronic ITP. There is a significant association between the duration of corticosteroid treatment and the average number of adverse events experienced ( 24 ). Emotional corticosteroid side effects, such as insomnia, restlessness, and/or sleep disturbances (32.7%), physical symptoms, including general weakness/fatigue (47.7%), and muscle weakness (14.0%), accounted for the largest proportion. In a study conducted in the United States, patients treated with corticosteroids reported that the number and severity of corticosteroid side effects increased significantly when the treatment duration was extended from 3 months to 12 months ( 24 ). According to the ITP World Impact Survey, approximately 50% of study participants suffered from fatigue during the survey ( 8 ), and in this study, general weakness/fatigue (47.7%) was also the most common corticosteroid side effect in ITP patients. This can severely affect HRQoL domains, such as energy levels to perform activities. On the other hand, 56.5%, 46.7%, and 21.0% of the study participants took CPT, PPI, and calcium with vitamin D3, respectively. This supportive treatment reduced the immunosuppression and gastrointestinal side effects of corticosteroids as well as the extent of osteoporosis. In general, to decrease corticosteroid-related side effects, prednisone should be rapidly tapered and usually stopped in responders, and non-responders stop the medications after 4 weeks of initiation ( 38 ). In this study, the total impact of ITP on HRQoL is 35.41 ± 9.27, and the impact of ITP on work or study is 50.01 ± 2.17, which is greater than the impact of ITP on daily life (31.69 ± 7.38); this is consistent with the ITP World Impact Survey data ( 8 , 39 ) and survey data reported from Switzerland, Austria, and Belgium ( 40 ). Our study is also similar to the studies conducted in China ( 41 ), the United States of America ( 11 ), and Serbia ( 9 ), in which physical function was more impaired than in the other domains of HRQoL. On the other hand, an Indian study showed that the impact of ITP on patients' work/study was less than the impact of ITP on their daily lives ( 42 ). A systematic review conducted in 2018 suggests that patients with ITP experience negative effects on their sexual activities, including decreased libido and bruising and bleeding during intercourse ( 17 ). In this study, the mean impact of ITP on patients’ sex life was rated as 1.04 ± 0.71, which is lower than all other IQLI domains, and the result is similar to a qualitative study in the United Kingdom, which found that the impact of ITP on sex life was less relevant ( 43 ). Predictive factors for a higher impact of ITP on HRQoL included emotional-related corticosteroid side effects, fatigue during the assessment, not taking CPT, epistaxis and wet purpura (mucosal bleeding), place of residence, and skin symptoms (petechiae and ecchymosis). These were significantly correlated with a greater impact of ITP on HRQoL, with emotion-related corticosteroid side effects accounting for the highest value with 15.4% of the variance (adjusted R-squared = 0.154, β = 0.392). When the number of patients experiencing emotional-related corticosteroid side effects increased by one, the impact of ITP on patients' HRQoL increased by 0.392 (β = 0.392, 95% CI: 5.160–9.961, P < 0.001). This might be due to the emotional side effects of steroids, such as insomnia, depression, anxiety, restlessness, and anger, which directly affect work capacity and concentration in daily activities and reduce the energy capacity to perform a given activity, greatly affecting HRQoL. In addition, the number of patients with epistaxis and wet purpura (mucosal bleeding) during diagnosis increased by one, the impact of ITP on patients' HRQoL increased by 0.191 (β = 0.191, 95% CI: 0.091–4.259, P = 0.001), and the number of patients with clinical presentations of skin symptoms (petechiae and ecchymosis) of ITP patients increased by 0.041 (β = 0.041, 95% CI: 0.091–4.259 P = 0.041), which is in line with other studies conducted in China and Serbia ( 9 , 27 ). A study conducted in the United States of America ( 44 ) and China ( 41 ) showed that fatigue was one of the most debilitating aspects of the HRQoL of ITP. Moreover, in this study, the number of patients with fatigue during assessment also increased by one, and the impact of ITP on patients' HRQoL increased by 0.236 (β = 0.326, 95% CI: 4.394–9.475, P < 0.001). The number of patients who did not take CPT increased by one, and the impact of ITP on patients' HRQoL increased by 0.236 (β = 0.236, 95% CI: 2.236–6.570, P < 0.001). This may be because immunosuppressive therapy, especially high-dose corticosteroids, predisposes patients to infections, which may also affect HRQoL in ITP patients. A study conducted in China found that infections are a common problem in patients with primary ITP, with an incidence of 24% in the first month of treatment, possibly due to immunosuppressive therapy. The number of patients living far from the clinic of hematology (out of Addis Ababa) increased by one, and the impact of ITP on patients' HRQoL increased by 0.166 (β = 0166, 95% CI: 1.107–5.114 P = 0.003), which is in line with a study conducted in Serbia ( 9 ). This study evaluated the impact of ITP on HRQoL in the Ethiopian population. In addition, the study assessed the impact of corticosteroid side effects on the HRQoL of ITP patients. The authors recommended that in this study the use of corticostriod was not limited and that it strongly affected HRQoL domains. To reduce corticosteroid-related side effects, prednisone should be rapidly tapered and usually discontinued in responders, and in non-responders, medication should be discontinued after 4 weeks of initiation. Finally, this study had certain limitations. The maximum time period (4 months) was used to recruit the study participants, but the event is rare; therefore, the sample size was small, and it is difficult to generalize the whole population. 5. Conclusion The impact of ITP on their energy levels and work life was high as compared with the impact of ITP on daily life. The study on HRQoL domains and predictive factors for increasing impact of ITP on their HRQoL was the development of emotionally related corticosteroid side effects, presence of fatigue during the assessment, not taking CPT, living far from the hematology clinic (outside Addis Ababa), epistaxis and wet purpura (mucosal bleeding), and skin symptoms (petechiae and ecchymosis) during diagnosis. The side effects of corticosteroids also affect the HRQoL of ITP patients. In general, concerted efforts must be made to reduce the impact of ITP on HRQoL and prevent/manage corticosteroid side effects. Abbreviations HMIS: Health Management Information System, HRQoL: Health-Related Quality of Life, ILQI: ITP Life Quality Index, ITP: Immune Thrombocytopenia, ITP-PAQ: ITP-Patient Assessment Questionnaire, IVIgs: Intravenous Immunoglobulin’s, LS: Laparoscopic splenectomy, MGL: Morisky Green Levine scale, SPHMMC: St Poulos Hospital Millennium Medical College, TASH: Tikur Anbessa Specialized Hospital. Declarations Ethical consideration Ethical approval for the study and study protocol was obtained from AAU, CHS, School of Pharmacy ethical review board (approval number: ERB/SOP/487/14/2022). Before data collection, a written permission letter was obtained from the hematology/oncology unit of TASH and SPHMMC. The aims of the study were clearly explained to the study participants. The information was collected after obtaining written informed consent from each participant and taken from participants’ family/legal guardian for participants whose age was between 14-18 years. The right was given to the study participants to refuse or discontinue participation at any time they wanted and the chance to ask anything about the study. For obscurity, the participant’s name was not used at the time of data collection, all other personnel information was kept entirely obscure, and confidentiality was assured throughout the study period. Data sharing statement The datasets used during the current study are available from the corresponding author upon reasonable request. Competing interests All the authors declare that there are no competing interests. Funding Funding was not received from any organization, and the authors are from a low-income country. Acknowledgments The authors would like to thank all the study participants for their time and willingness to participate in the study. We would also like to express our sincere gratitude to the outpatient hematology clinic TASH and SPHMMC, Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Science, Addis Ababa University, and the data collectors for their support throughout the study period. Authors' contributions DAB contributed to the study design, performed the statistical analysis; wrote, reviewed, and edited both the original draft and final manuscript. EAS, AMF, and AG conceptualized and participated in the study design, critically reviewing, modifying, and analyzing the draft of the manuscript. All the authors have read and approved the final version of the manuscript. References Marini I, Zlamal J, Pelzel L, Bethge W, Faul C, Holzer U, et al. Autoantibody Mediated Desialylation Impairs Human Thrombopoiesis and Platelet Life Span. American Society of Hematology Washington, DC; 2019. Omar IM, Abuelela S, Emam N. 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Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019;3(22):3780–817. Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ open. 2017;7(10):e017902. Organization WH. World health statistics 2020. 2020. Terrell DR, Neunert CE, Cooper N, Heitink-Pollé KM, Kruse C, Imbach P, et al. Immune thrombocytopenia (ITP): current limitations in patient management. Medicina. 2020;56(12):667. Guidry JA, George JN, Vesely SK, Kennison SM, Terrell DR. Corticosteroid side-effects and risk for bleeding in immune thrombocytopenic purpura: patient and hematologist perspectives. Eur J Haematol. 2009;83(3):175–82. Brown TM, Horblyuk RV, Grotzinger KM, Matzdorff AC, Pashos CL. Patient-reported treatment burden of chronic immune thrombocytopenia therapies. BMC blood disorders. 2012;12(1):1–8. 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Viana R, D’Alessio D, Grant L, Cooper N, Arnold D, Morgan M, et al. Psychometric Evaluation of ITP Life Quality Index (ILQI) in a Global Survey of Patients with Immune Thrombocytopenia. Adv Therapy. 2021;38(12):5791–808. Beyene DA, Sisay EA, Fentie AM, Gebremedhin A. Reliability and validity of the Amharic version of immune thrombocytopenia life quality index tool for assessment of the health-related quality of life in Ethiopian patients of immune thrombocytopenia: Cross-sectional study. SAGE Open Medicine. 2023;11:20503121231199869. Trotter P, Hill QA. Immune thrombocytopenia: improving quality of life and patient outcomes. Patient Relat Outcome Measures. 2018:369–84. Matzdorff A, Meyer O, Ostermann H, Kiefel V, Eberl W, Kühne T, et al. Immune thrombocytopenia-current diagnostics and therapy: recommendations of a joint working group of DGHO, ÖGHO, SGH, GPOH, and DGTI. Oncol Res Treat. 2018;41(Suppl 5):1–30. Jaime-Pérez JC, Aguilar-Calderón P, Jiménez-Castillo RA, Ramos-Dávila EM, Salazar-Cavazos L, Gómez-Almaguer D. Treatment outcomes and chronicity predictors for primary immune thrombocytopenia: 10-year data from an academic center. Ann Hematol. 2020;99(11):2513–20. Palau J, Sancho E, Herrera M, Sánchez S, Mingot ME, Upegui RI, et al. Characteristics and management of primary and other immune thrombocytopenias: Spanish registry study. Hematology. 2017;22(8):484–92. Grimaldi-Bensouda L, Nordon C, Michel M, Viallard J-F, Adoue D, Magy-Bertrand N, et al. Immune thrombocytopenia in adults: a prospective cohort study of clinical features and predictors of outcome. Haematologica. 2016;101(9):1039. Pamuk G, Pamuk Ö, Başlar Z, Öngören Ş, Soysal T, Ferhanoğlu B, et al. Overview of 321 patients with idiopathic thrombocytopenic purpura: retrospective analysis of the clinical features and response to therapy. Ann Hematol. 2002;81:436–40. Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood The Journal of the American Society of Hematology. 2010;115(2):168–86. Cooper N, Kruse A, Kruse C, Watson S, Morgan M, Provan D, et al. Immune thrombocytopenia (ITP) World Impact Survey (I-WISh): Impact of ITP on health‐related quality of life. Am J Hematol. 2021;96(2):199–207. Rovó A, Cantoni N, Samii K, Rüfer A, Koenen G, Ivic S, et al. Real-world impact of primary immune thrombocytopenia and treatment with thrombopoietin receptor agonists on quality of life based on patient-reported experience: Results from a questionnaire conducted in Switzerland, Austria, and Belgium. PLoS ONE. 2022;17(4):e0267342. Yang R, Yao H, Lin L, Ji J-m, Shen Q. Health-related quality of life and burden of fatigue in Chinese patients with immune thrombocytopenia: a Cross-sectional study. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3906006","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270374631,"identity":"7d3568b6-6f0b-4ff0-b747-de08725ac4b3","order_by":0,"name":"Dessale Abate Beyene","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDCCAyCigEGOjZmx8QGQycNHnBYDBmN+dubDBiAtbMRqSZzZz5YmAWIT1MJ3vP3xhx8GNowbDvOYVX7NsZNhY2B++OgGHi2SZ86YSfYYpDEbALXclt2WDHQYm7FxDh4tBjdy2Bh4DA6zgbVIbmMGauFhk8ar5f7zxx//GPznAWkpltxWT4SWGwwG0jwGByQkm9nSGD9uO0xYi+SZHDNpGYNkA35m5sPSjNuO87AxE/AL3/Hjjz++qbCrb+M/2Pjx57Zqe3725oeP8WlBAcw8YJJY5SDA+IMU1aNgFIyCUTBiAABZKkU2wvEXhAAAAABJRU5ErkJggg==","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"prefix":"","firstName":"Dessale","middleName":"Abate","lastName":"Beyene","suffix":""},{"id":270374632,"identity":"5eeb6b08-0a04-41a7-852d-3945c6d795e0","order_by":1,"name":"Eskinder Ayalew Sisay","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Eskinder","middleName":"Ayalew","lastName":"Sisay","suffix":""},{"id":270374633,"identity":"220aff95-efff-4d9f-b5ee-bcec71aa7012","order_by":2,"name":"Atalay Mulu Fentie","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Atalay","middleName":"Mulu","lastName":"Fentie","suffix":""},{"id":270374634,"identity":"1f70f709-9116-4dab-ba21-7077a89ebe94","order_by":3,"name":"Amha Gebremedhin","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Amha","middleName":"","lastName":"Gebremedhin","suffix":""}],"badges":[],"createdAt":"2024-01-28 14:20:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3906006/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3906006/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50568589,"identity":"c6e76142-9731-492f-84ad-cc2f397df66c","added_by":"auto","created_at":"2024-02-02 15:25:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":71610,"visible":true,"origin":"","legend":"\u003cp\u003eComorbidities in ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n=214).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3906006/v1/20d9b6f0ef8631c50dedf013.png"},{"id":50568588,"identity":"cb003451-a30f-489f-8e74-9437fbadf8eb","added_by":"auto","created_at":"2024-02-02 15:25:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":54457,"visible":true,"origin":"","legend":"\u003cp\u003eClassification of ITP according to the 2019 ASH guidelinesof ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n=214).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3906006/v1/79d16eaad838b0afd2fe459f.png"},{"id":50632853,"identity":"5ac74f2b-c64e-4452-a204-80de4d073f7e","added_by":"auto","created_at":"2024-02-05 01:54:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":965198,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3906006/v1/0b206b20-e8ae-4e5d-a952-561badf762c5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health-related quality of life and complications of corticosteroid treatment in patients with immune thrombocytopenia in two teaching hospitals in Ethiopia: A cross-sectional study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eImmune thrombocytopenia (ITP) is an acquired form of thrombocytopenia and bleeding disorder caused by autoantibody-mediated and cell-mediated destruction of platelets, resulting in accelerated platelet clearance and impaired thrombopoiesis (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It is described as a transient or persistent reduction in platelet count\u0026thinsp;\u0026lt;\u0026thinsp;100 x10\u003csup\u003e9\u003c/sup\u003e/L and an increased risk of bleeding that depends on the degree of thrombocytopenia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eITP requires lifelong treatment in a significant proportion of adult patients, which has a negative impact on patients' health-related quality of life (HRQoL) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). According to the ITP world impact survey, the most common clinical presentations at diagnosis were petechiae (64%) and bruising of unknown origin (65%) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Many patients experience a range of physical and emotional symptoms due to their medical condition. Research shows that, for a significant portion of patients, maintaining a stable platelet count is a major concern. This is because low platelets can result in bleeding, which can be a serious health risk. Patients also commonly report feeling fatigued, anxious, and fearful of bleeding. These symptoms can significantly impact patients' health-related quality of life (HRQoL)in various ways, including their ability to perform daily activities, their emotional well-being, their energy levels, their ability to work, and their overall productivity (\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eITP treatment is challenging, and treatment outcomes are assessed based on the clinical response rate, treatment relapse rate, platelet count before and after the treatment, HRQoL, and adverse events of the treatment/procedure (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Therefore, treatment should be tailored to the individual patient, considering factors such as age, lifestyle, comorbidities, compliance, patient preferences, the presence and severity of bleeding, and the potential treatment side effects (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). For this reason, the improvement of HRQoL parameters was named as an important treatment goal in the 2019 updated guidelines of the American Society of Hematology (ASH) and in the international consensus report (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn resource-limited countries like Ethiopia, physicians face high patient burden and limited clinic time (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e); due to this treating physicians usually prioritize addressing low platelet counts and avoiding life-threatening bleeds over HRQoL. Patients with ITP, on the other hand, are concerned with how the disease affects their lives, specifically how they feel and function (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Fatigue, along with anxiety, fear, and frustration, was one of the most debilitating aspects of ITP patients' HRQoL on their condition (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Prolonged use of corticosteroids in adults may have a negative impact on HRQoL due to the effects on sleep disturbances, weight gain, and mental health (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). As patient-reported HRQoL provides information from the patient's perspective, it has become an important tool to understand the effects of both ITP and its treatments. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral studies have assessed the HRQoL of ITP patients using different instruments, such as the 36-item Short-Form Health Survey, the EuroQol Questionnaire with five dimensions, the ITP Patient Assessment Questionnaire (ITP-PAQ), and the ITP Life Quality Index (ILQI) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The more recently developed instrument for assessing HRQoL in ITP patients was the ILQI tool. The content and psychometric validity of the ILQI were established in 14 countries (the United States, China, the United Kingdom, France, Germany, Italy, India, Canada, Turkey, Japan, Colombia, Spain, Egypt, and Ethiopia) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo our knowledge, there is still no published evidence-based literature performed in Ethiopia or Africa that assesses the impact of ITP on the HRQoL of ITP patients. The cornerstone of most ITP treatments was corticosteroid common side effects, and the impact on HRQoL was not assessed. Hence, this study aimed to investigate the impact of ITP on HRQoL of ITP patients and to determine the factors associated with HRQoL of ITP patients in Tikur Anbessa Specialized Hospital (TASH) and St. Paul's Hospital Millennium Medical College (SPHMMC).\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1. Study design and participants\u003c/h2\u003e\n \u003cp\u003eThis institutional-based cross-sectional study was conducted to evaluate the impact of ITP on the HRQoL of ITP patients treated in the hematology clinic at TASH and SPHMMC during the study period from November 15, 2022 to March 15, 2023. The hospitals provide specialized comprehensive and clinical services.The outpatient departments of both hospitals have many specialty clinics, and the hematology clinic serves patients with many hematologic disorders. According to the hospital\u0026apos;s Health Management Information System (HMIS) data of TASH and SPHMMC, an average of 50 ITP and 20 ITP patients visit the hematology clinic per month, respectively.\u003c/p\u003e\n \u003cp\u003eAll patients attending both hospitals during the study period who had a confirmed diagnosis of ITP according to the guidelines of ASH of 2019 and the standardization of terminology, definitions, and outcome criteria in ITP of adults and children (primary, secondary, newly diagnosed, persistent, chronic and severe ITP) (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e), patients aged\u0026thinsp;\u0026ge;\u0026thinsp;14 years and patients willing to participate in the study were included. Patients who did not start treatment and incomplete medical records were excluded. A consecutive sampling method was used to select study participants, and all patients who received ITP treatment during the study period (4 months) and met the eligibility criteria were included in the study; due to the rarity of the event.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2. Instrument\u003c/h2\u003e\u003cspan\u003e\n \u003cp\u003e\u003cstrong\u003eI. Data abstraction form\u003c/strong\u003e\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003eThe data abstraction format is designed to extract information from the medical record or directly from the patient, such as sociodemographic characteristics (age, sex, educational status, place of residence, marital status, and health care costs), clinical characteristics (type of ITP, duration of symptoms, comorbidity, physical, and clinical findings at diagnosis, presence of bleeding, and phase of ITP), and treatment-related characteristics (type, frequency, and duration of treatment). After conducting an extensive literature review (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) and with the help of experts, structured questionnaires were designed to evaluate the side effects of corticosteroid treatment in patients with ITP.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e\u003cstrong\u003eII. ITP Life Quality Index (ILQI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003eThe ILQI was created by clinical experts in the field of ITP and was originally thought to be unidimensional, producing a single score (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). This is a 10-item patient questionnaire with a recall period of \u0026apos;last month.\u0026quot; Responses range from \u0026apos;never\u0026apos; to \u0026apos;always.\u0026quot; Three questions (questions 1, 2, and 5) have additional response options that allow the patient to indicate that the question is irrelevant to them or that they do not wish to answer. For the additional responses, \u0026apos;I am not currently working/studying due to ITP\u0026apos;, the value 4 applies, and for the responses \u0026apos;I am not currently working/studying due to other reasons or does not apply/prefer not to say\u0026quot;, the value 0 applies. A total sum score between 7 and 40 was originally proposed, where a lower score indicates a lower impact and a higher score indicates a higher impact of ITP on HRQoL. The content and psychometric validity of the ILQI was assessed in 13 countries (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). The acceptability, reliability, and validity of the psychometric properties of the Amharic version were also assessed and validated in the Ethiopian population (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3. Data quality assurance and Outcome measurements\u003c/h2\u003e\n \u003cp\u003eThe validated Amharic version of the ILQI was used to assess the HRQoL of patients treated for ITP (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). A pretest was then administered to 5% of ITP patients. The purpose of the pretest was to ensure that respondents understand the questions and can review the wording, logic, and skip order in a way that makes sense to respondents. Based on the results of the pretest, appropriate corrections were made before the actual study was conducted. Data collectors were recruited by two clinical pharmacists and one nurse, and a half-day training was given by the principal investigator about the objectives of the study and how to use the tool to collect data directly from the patient and medical records/charts. To ensure completeness and consistency of the data, all data were reviewed daily by the principal investigator to ensure the quality of the data.\u003c/p\u003e\n \u003cp\u003eHRQoL scores were calculated using the ILQI tool. According to the instructions for use, raw scores for the ranges of ILQI were calculated and trans-formed to a scale of 0 to 100 by using the formula for mean transformation.\u003c/p\u003e\n \u003cdiv id=\"Equa\" class=\"Equation\"\u003e\n \u003cdiv class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e$$\\text{D}\\text{o}\\text{m}\\text{a}\\text{i}\\text{n} \\stackrel{̄}{x}=\\raisebox{1ex}{$100$}\\!\\left/ \\!\\raisebox{-1ex}{$(MAXs - N) x (\\sum x̄ - N)$}\\right.$$\u003c/div\u003e\n \u003c/div\u003e\n \u003cp\u003eWhere Domain x̄: domain mean transformed to 100; MAXs: maximum score; N: number of items; \u0026sum; x̄: sum of means; 100 is the highest impact of ITP on HRQoL, and 0 is the lowest impact of ITP on HRQoL.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4. Data Analysis\u003c/h2\u003e\n \u003cp\u003eData were entered and analyzed using SPSS version 26. Descriptive statistics such as frequency, median, and range were used to summarize the sociodemographic data and clinical and treatment characteristics. After checking the assumptions, univariate analysis was performed to obtain candidate variables for the multivariate regression model to determine possible predictors of the HRQoL variables. In the univariate analysis, factors associated with HRQoL that showed a marginal association at p\u0026thinsp;\u0026lt;\u0026thinsp;0.2 after univariate analysis and all clinically relevant variables were considered candidate variables for multivariate linear regression model to identify strong factors associated with and HRQoL, respectively. A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1. Sociodemographic characteristics of the study participants\u003c/h2\u003e\n \u003cp\u003eA total of 214 study participants took part in this study; the majority 153(71.5%) of them were from TASH. Most 161(75.5%) were female patients with a female-to-male ratio of 3 to 1. Regarding the age distribution, the median age of the study participants was 30 years and ranged from 15 to 88 years, and most 78(36.4%) participants were in the 25\u0026ndash;34 years age group. One-third of the study participants had a university degree or more 76(35.5%) and were also self-employed 59(27.6%). Most participants 197(92.1%) lived with their family, and half of them 109(50.9%) lived far from the hematology clinic (outside Addis Ababa). In addition, more than half of the health care costs of the study participants 133(62.1%) were borne by the patients themselves or by their relatives (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic characteristics of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy site\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTASH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSPHMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u0026ndash;54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNever married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnable to read and write\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnable read and write\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary education (grades 1\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary Education (grades 9\u0026ndash;12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiploma/Certificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDegree and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupational status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-Employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOutside Addis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth service charge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWith cash\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWith health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWith free\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith whom do you live?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWith family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eTASH: Tikur Anbessa Specialized Hospital, SPHMMC: St. Paul\u0026apos;s Hospital Millennium Medical College\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2. Clinical characteristics of ITP patients during diagnosis\u003c/h2\u003e\n \u003cp\u003eThe clinical characteristics of the study participants are shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Of the 214 study participants, only 91 (42.5%) had comorbidities. The median age of study participants at diagnosis of ITP was 27 years (ranging from 9 to 86 years), the median duration of ITP since diagnosis was 24 months (ranging from 3 to 240 months). During the assessment, the most common symptom of ITP was fatigue 53(25.2%), followed by headache 14 (6.5%). Common physical findings during diagnosis include epistaxis and wet purpura (mucosal bleeding) 166 (77.6%), followed by fatigue 157 (73.4%) and skin manifestations (petechiae and ecchymosis) 120 (56.1%).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical characteristics of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent symptoms of ITP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeadache\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical findings during diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEpistaxis and wet purpura\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin manifestation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeavy menstrual bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSigns of anemia (pallor)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere bleeding*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe Median (range) of age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge at Diagnosis in a year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e27(9\u0026ndash;86) years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDuration since ITP diagnosis in a month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e24 (3-240) months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eSevere bleeding* gastrointestinal bleeding, Intracranial bleeding, rectal bleeding, retinal hemorrhage.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eIron deficiency anemia 20 (22.0%), followed by HIV 15 (16.5%), hepatitis B virus (HBV) 7 (7.7%), and systemic lupus erythaematous (SLE) 7 (7.7%), accounted for the highest proportion of comorbidities in ITP patients attending TASH and SPHMMC during the study period (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e: Comorbidities in ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n \u003cp\u003eTwo-thirds 153 (71.5) of study participants had chronic ITP; in addition, 24 (11.2%) and 15 (7.0%) of study participants had corticosteroid-dependent and corticosteroid-resistant ITP, respectively. After completing the first-line treatment of ITP, 55 (25.7%) patients relapsed within a median time of 12 months (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e: Classification of ITP according to the 2019 ASH guidelines of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3. Treatment-related characteristics of ITP\u003c/h2\u003e\n \u003cp\u003eFor the treatment of ITP, the majority 172 (80.4%) of study participants took prednisolone alone, followed by combinations of prednisolone and dexamethasone 31 (14.5%) for first-line treatment in this study setting. [Azathioprine or rituximab]\u0026thinsp;+\u0026thinsp;prednisolone 20 (36.4%) were used as second-line treatment options for ITP.\u003c/p\u003e\n \u003cp\u003eApproximately 63 (29.4%) of the study participants received platelet transfusions to prevent bleeding, and 27 (12.6%) took tranexamic acid to stop bleeding. In addition, approximately 121 (56.5%), 100 (46.7%), and 45 (21.0%) study participants took cotrimoxazole prophylaxis (CPT), proton pump inhibitors (PPI), and calcium with vitamin D3 supplement as prophylaxis to prevent immunosuppression-related infections, peptic ulcers, and osteoporosis, respectively (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTreatment-related characteristics of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eFirst-line treatment of ITP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrednisolone alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrednisolone\u0026thinsp;+\u0026thinsp;Dexamethasone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDexamethasone alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrednisolone\u0026thinsp;+\u0026thinsp;Methylprednisolone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecond-line treatments of ITP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[Azathioprine or Rituximab]\u0026thinsp;+\u0026thinsp;Prednisolone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[Rituximab alone] or [Prednisolone alone] or [Azathioprine alone]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRituximab\u0026thinsp;+\u0026thinsp;Splenectomy + [Azathioprine or Prednisolone]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[Rituximab\u0026thinsp;+\u0026thinsp;Azathioprine]\u0026thinsp;\u0026plusmn;\u0026thinsp;Prednisolone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[Splenectomy\u0026thinsp;+\u0026thinsp;Prednisolone] or [Splenectomy\u0026thinsp;+\u0026thinsp;Rituximab]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[Splenectomy\u0026thinsp;+\u0026thinsp;Azathioprine\u0026thinsp;+\u0026thinsp;Prednisolone]\u0026thinsp;\u0026plusmn;\u0026thinsp;Rituximab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther medications to stop bleeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlatelet transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTranexamic acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eFor prophylaxis of corticosteroid Complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCotrimoxazole prophylaxis treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProton pump inhibitors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalcium with Vitamin D3 supplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4. Corticosteroid side effects in ITP Patients\u003c/h2\u003e\n \u003cp\u003eRegarding the side effects of corticosteroids, 143 (66.8%) of the study participants experienced at least one side effect from corticosteroids throughout their treatment period. Of the physical appearance-related factors, weight gain/increased appetite 86 (40.2%), followed by a moon face, bloating, and swelling 72 (33.6%) accounted for the highest proportion. Among emotional corticosteroid side effects, insomnia, restlessness, and/or sleep disturbances 70 (32.7%) and physical symptoms related to corticosteroid side effects, general weakness/fatigue 102(47.7%) and muscle weakness 30(14.0%) accounted for the largest proportion. On the other hand, corticosteroid-related complications, such as increased blood glucose 19 (8.9%), increased blood pressure 15(7.0%), iatrogenic Cushing\u0026apos;s syndrome 9(4.2%), and osteoporosis 5 (2.3%), occurred in the study participants (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCorticosteroid side effects in ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eAt least one Side effect of corticosteroid\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical appearance-related corticosteroid side effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight gain \u0026frasl; increased appetite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMoon face, bloating, swelling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStretch mark\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcne\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHair loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional-related corticosteroid side effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsomnia, restlessness, and/or trouble sleeping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression and/or stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety and/or nervousness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnger and/or irritability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical symptoms related to corticosteroid side effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeneralized weakness, fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle weakness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVisual problems (light sensitivity\u0026frasl; decreased visual acuity)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDizziness, headaches\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNausea, upset stomach, vomiting, diarrhea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther corticosteroid-related complications/Side effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncrease blood glucose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncrease blood pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIatrogenic Cushing\u0026apos;s syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoporosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.5. Mean scores for the impact of ITP on health-related quality of life\u003c/h2\u003e\n \u003cp\u003eThe impact of ITP on their energy levels accounts for the highest mean value (2.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17), followed by the impact of ITP on their working lives or studies (2.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10). On the other hand, the impact of ITP on their sex life (1.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71) was lower than other parameters in the IQLI tool (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMean scores for the impact of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eITP life quality index tool\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often has your ITP impacted your working life or studies?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often have you taken me off work or education because of your ITP?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often has your ITP impacted your ability to concentrate on everyday tasks?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often has your ITP impacted your social life?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often have your ITP impacted your sex life?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often have your ITP impacted your energy levels?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often has your ITP impacted your undertaking of daily tasks?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often has your ITP impacted your ability to support people close to you?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often has your ITP negatively impacted your hobbies?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItem-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow often has your ITP negatively impacted your normal capacity to exercise?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eThe overall mean score for the impact of ITP on HRQoL according to the IQLI tool was 35.41\u0026thinsp;\u0026plusmn;\u0026thinsp;9.27. The mean score for the impact of ITP on their work or study was 50.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17, and the impact of ITP on daily life was 31.69\u0026thinsp;\u0026plusmn;\u0026thinsp;7.38 (Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDomain-transformed mean score of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLikert scale Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eThe formula for domain mean*\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDomain mean of 100\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImpact of ITP on work or study (Items 1 and 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100/(8\u0026thinsp;\u0026minus;\u0026thinsp;2) x (5.00\u0026ndash;2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImpact of ITP on daily live (Item 3 to Item 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100/(32\u0026thinsp;\u0026minus;\u0026thinsp;8) x (15.6-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.69\u0026thinsp;\u0026plusmn;\u0026thinsp;7.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe overall mean score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100/(40\u0026thinsp;\u0026minus;\u0026thinsp;10) x (20.64-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.41\u0026thinsp;\u0026plusmn;\u0026thinsp;9.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e*Domain mean transformed to 100\u0026thinsp;=\u0026thinsp;100/(maximum score \u0026ndash; no of items) x (sum of means \u0026ndash; no of items).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e3.6. Association between health-related quality of life of ITP patients and explanatory variables\u003c/h2\u003e\n \u003cp\u003eA one-way ANOVA was performed to compare the effects of sociodemographic and clinical characteristics and the corticosteroid side effect variables on HRQoL, and the results of the comparative statistical analysis of the mean values of the HRQoL IQLI domains as a function of the categorical sociodemographic and clinical characteristics and the corticosteroid side effect variables are shown in Table \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e. Patients who had skin manifestations (petechiae and ecchymosis) and epistaxis and wet purpura (mucous membrane bleeding) during diagnosis (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), patients not taking CPT (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), patients taking PPI (P\u0026thinsp;=\u0026thinsp;0.007) and calcium with vitamin D3 supplementation (p\u0026thinsp;=\u0026thinsp;0.034), patients who developed iatrogenic Cushing\u0026apos;s syndrome (p\u0026thinsp;=\u0026thinsp;0.02), physical appearance, emotional symptoms, and physical symptoms related to corticosteroid side effects (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), patients who had fatigue during the assessment (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and patients living far from the hematology clinic (outside Addis Ababa) (P\u0026thinsp;=\u0026thinsp;0.038) had statistically significant associations with the higher impact of ITP on HRQoL.\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparative statistical analysis of IQLI domain mean scores among patients treated for ITP at TASH and SPHMMC, according to the Categorical Sociodemographic, Clinical Characteristics, treatment-related and corticosteroid-related side effects\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariables, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHRQoL\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWork\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDaily live\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003ePlace of residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOut of Addis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eFatigue during assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eHeadache during assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eSkin manifestation (petechiae and Ecchymosis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eEpistaxis and wet purpura (mucous membrane bleeding)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eCotrimoxazole prophylaxis treatment (CPT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eProton pump inhibitors (PPI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eCalcium with Vitamin D3 supplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eIatrogenic Cushing\u0026apos;s syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.67\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003ePhysical appearance-related corticosteroid side effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eEmotional-related corticosteroid side effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003ePhysical symptoms related to corticosteroid side effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003cstrong\u003eAbbreviations\u003c/strong\u003e: HRQoL: health-related quality of life, SD: standard deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e3.7. Factors affecting health-related quality of life in ITP patients\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eIn the univariate analysis, 13 of the variables examined showed an association with HRQoL measured by the ILQI. Of these candidate variables, all were categorical variables, 12 of which were binary variables (place of residence, fatigue during the assessment, headache during the assessment, epistaxis and wet purpura (mucosal bleeding), skin manifestations (petechiae and ecchymosis), CPT, PPI, calcium with vitamin D3 supplementation, iatrogenic Cushing\u0026apos;s syndrome, physical appearance-related corticosteroid side effects, emotional-related corticosteroid side effects, and physical symptoms related to corticosteroid side effects); the rest were multicategorical variables (education level).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate linear regression analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOf the 13 variables used for multivariate linear regression analysis, six variables were identified as correlated with HRQoL by stepwise and forward multivariate linear regression methods and cross-validated by the hierarchical regression method. When the number of patients experiencing emotional-related corticosteroid side effects increased by one, the impact of ITP on patients\u0026apos; HRQoL increased by 0.392 (\u0026beta;\u0026thinsp;=\u0026thinsp;0.392, 95% CI: 5.160\u0026ndash;9.961, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The number of patients with fatigue during assessment increased by one, and the impact of ITP on patients\u0026apos; HRQoL increased by 0.236 (\u0026beta;\u0026thinsp;=\u0026thinsp;0.326, 95% CI: 4.394\u0026ndash;9.475, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In patients who did not take CPT, the impact of ITP on patients\u0026apos; HRQoL increased by 0.236 (\u0026beta;\u0026thinsp;=\u0026thinsp;0.236, 95% CI: 2.236\u0026ndash;6.570, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In addition, the number of patients with epistaxis and wet purpura (mucosal bleeding) increased by one during diagnosis, and the impact of ITP on patients\u0026apos; HRQoL increased by 0.191 (\u0026beta;\u0026thinsp;=\u0026thinsp;0.191, 95% CI: 0.091\u0026ndash;4.259, P\u0026thinsp;=\u0026thinsp;0.001). The number of patients living far from the hematology clinic (outside Addis Ababa) increased by one, the impact of ITP on patients\u0026apos; HRQoL increased by 0.166 (\u0026beta;\u0026thinsp;=\u0026thinsp;0166, 95% CI: 1.107\u0026ndash;5.114 P\u0026thinsp;=\u0026thinsp;0.003), and the number of patients with clinical presentations of skin symptoms (petechiae and ecchymosis) of ITP patients increased by 0.041 (\u0026beta;\u0026thinsp;=\u0026thinsp;0.041, 95% CI: 0.091\u0026ndash;4.259 P\u0026thinsp;=\u0026thinsp;0.041).\u003c/p\u003e\n \u003cp\u003eAll correlated variables explained 36.5% (adjusted R-squared\u0026thinsp;=\u0026thinsp;0.365, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) of the variance and had a moderate influence on the dependent variable (HRQoL). Of these, 15.4% of the variance (adjusted R-squared\u0026thinsp;=\u0026thinsp;0.154, \u0026beta;\u0026thinsp;=\u0026thinsp;0.392, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) was accounted for by emotion-related corticosteroid side effects. The tolerance of all independent variables ranged from 0.848 to 1. Thus, there were no multicollinearity problems in the models because all were above 0.2. All standardized residuals in the models were normally distributed (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), meeting the assumptions of the linear regression model (Table \u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab8\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFactors associated with the HRQoL of ITP patients attending the TASH and SPHMMC hematology clinics in Addis Ababa, Ethiopia, 2022 (n\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eModel\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ePredictor variables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eR-square\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eAdjusted R square\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eR square change\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eChange statistics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP- value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ePredictor variables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026beta; (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF-change\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDf1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDf2\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotional-related corticosteroid side effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.549\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotional-related corticosteroid (ref: No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.392 (5.160\u0026ndash;9.961)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.218\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue during assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e211\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue during assessment(ref:No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.326 (4.394\u0026ndash;9.475)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.289\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCPT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.309\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCPT (ref: No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.236 (2.236\u0026ndash;6.570)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.099\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEpistaxis and wet purpura\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.331\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.951\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEpistaxis and wet purpura (ref: No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.191 (0.091\u0026ndash;4.259)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.281\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.370\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResidence (ref: Addis Ababa)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.166 (1.107\u0026ndash;5.114)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin manifestation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin manifestation (ref: No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.041(0.091\u0026ndash;4.259)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.057\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"12\"\u003e\n \u003cp\u003e\u003cem\u003eNote: CPT; Cotrimoxazole prophylaxis treatment, \u0026beta;; Beta coefficient, SE; standard error, DF; degree of freedom, CI; confidence interval\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe aim of this study was to investigate the HRQoL of patients with ITP and the factors associated with HRQoL. The updated international consensus report indicates that there are differences in the clinical presentation of ITP, clinical outcomes and response to treatment (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Therefore, the assessment of HRQoL, complications of corticosteroid treatment, and the impact of corticosteroid side effects on the HRQoL of ITP patients plays an important role in the quality of outcomes and measuring the success of treatment. The most common clinical presentation at diagnosis of ITP was epistaxis and wet purpura (mucosal bleeding) (77.6%), followed by fatigue (73.4%), skin manifestations (petechiae and ecchymosis) (56.1%), and heavy menstrual bleeding (27.6%). This was similar to studies conducted in Mexico (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), in Spain (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), in France (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), and in Turkey (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCorticosteroid side effects may affect HRQoL or treatment response, and in this study population, 71.5% of study participants had chronic ITP. There is a significant association between the duration of corticosteroid treatment and the average number of adverse events experienced (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Emotional corticosteroid side effects, such as insomnia, restlessness, and/or sleep disturbances (32.7%), physical symptoms, including general weakness/fatigue (47.7%), and muscle weakness (14.0%), accounted for the largest proportion. In a study conducted in the United States, patients treated with corticosteroids reported that the number and severity of corticosteroid side effects increased significantly when the treatment duration was extended from 3 months to 12 months (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). According to the ITP World Impact Survey, approximately 50% of study participants suffered from fatigue during the survey (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), and in this study, general weakness/fatigue (47.7%) was also the most common corticosteroid side effect in ITP patients. This can severely affect HRQoL domains, such as energy levels to perform activities. On the other hand, 56.5%, 46.7%, and 21.0% of the study participants took CPT, PPI, and calcium with vitamin D3, respectively. This supportive treatment reduced the immunosuppression and gastrointestinal side effects of corticosteroids as well as the extent of osteoporosis. In general, to decrease corticosteroid-related side effects, prednisone should be rapidly tapered and usually stopped in responders, and non-responders stop the medications after 4 weeks of initiation (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the total impact of ITP on HRQoL is 35.41\u0026thinsp;\u0026plusmn;\u0026thinsp;9.27, and the impact of ITP on work or study is 50.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17, which is greater than the impact of ITP on daily life (31.69\u0026thinsp;\u0026plusmn;\u0026thinsp;7.38); this is consistent with the ITP World Impact Survey data (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) and survey data reported from Switzerland, Austria, and Belgium (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Our study is also similar to the studies conducted in China (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), the United States of America (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and Serbia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), in which physical function was more impaired than in the other domains of HRQoL. On the other hand, an Indian study showed that the impact of ITP on patients' work/study was less than the impact of ITP on their daily lives (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). A systematic review conducted in 2018 suggests that patients with ITP experience negative effects on their sexual activities, including decreased libido and bruising and bleeding during intercourse (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In this study, the mean impact of ITP on patients\u0026rsquo; sex life was rated as 1.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71, which is lower than all other IQLI domains, and the result is similar to a qualitative study in the United Kingdom, which found that the impact of ITP on sex life was less relevant (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePredictive factors for a higher impact of ITP on HRQoL included emotional-related corticosteroid side effects, fatigue during the assessment, not taking CPT, epistaxis and wet purpura (mucosal bleeding), place of residence, and skin symptoms (petechiae and ecchymosis). These were significantly correlated with a greater impact of ITP on HRQoL, with emotion-related corticosteroid side effects accounting for the highest value with 15.4% of the variance (adjusted R-squared\u0026thinsp;=\u0026thinsp;0.154, β\u0026thinsp;=\u0026thinsp;0.392). When the number of patients experiencing emotional-related corticosteroid side effects increased by one, the impact of ITP on patients' HRQoL increased by 0.392 (β\u0026thinsp;=\u0026thinsp;0.392, 95% CI: 5.160\u0026ndash;9.961, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This might be due to the emotional side effects of steroids, such as insomnia, depression, anxiety, restlessness, and anger, which directly affect work capacity and concentration in daily activities and reduce the energy capacity to perform a given activity, greatly affecting HRQoL. In addition, the number of patients with epistaxis and wet purpura (mucosal bleeding) during diagnosis increased by one, the impact of ITP on patients' HRQoL increased by 0.191 (β\u0026thinsp;=\u0026thinsp;0.191, 95% CI: 0.091\u0026ndash;4.259, P\u0026thinsp;=\u0026thinsp;0.001), and the number of patients with clinical presentations of skin symptoms (petechiae and ecchymosis) of ITP patients increased by 0.041 (β\u0026thinsp;=\u0026thinsp;0.041, 95% CI: 0.091\u0026ndash;4.259 P\u0026thinsp;=\u0026thinsp;0.041), which is in line with other studies conducted in China and Serbia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study conducted in the United States of America (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) and China (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) showed that fatigue was one of the most debilitating aspects of the HRQoL of ITP. Moreover, in this study, the number of patients with fatigue during assessment also increased by one, and the impact of ITP on patients' HRQoL increased by 0.236 (β\u0026thinsp;=\u0026thinsp;0.326, 95% CI: 4.394\u0026ndash;9.475, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The number of patients who did not take CPT increased by one, and the impact of ITP on patients' HRQoL increased by 0.236 (β\u0026thinsp;=\u0026thinsp;0.236, 95% CI: 2.236\u0026ndash;6.570, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This may be because immunosuppressive therapy, especially high-dose corticosteroids, predisposes patients to infections, which may also affect HRQoL in ITP patients. A study conducted in China found that infections are a common problem in patients with primary ITP, with an incidence of 24% in the first month of treatment, possibly due to immunosuppressive therapy. The number of patients living far from the clinic of hematology (out of Addis Ababa) increased by one, and the impact of ITP on patients' HRQoL increased by 0.166 (β\u0026thinsp;=\u0026thinsp;0166, 95% CI: 1.107\u0026ndash;5.114 P\u0026thinsp;=\u0026thinsp;0.003), which is in line with a study conducted in Serbia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study evaluated the impact of ITP on HRQoL in the Ethiopian population. In addition, the study assessed the impact of corticosteroid side effects on the HRQoL of ITP patients. The authors recommended that in this study the use of corticostriod was not limited and that it strongly affected HRQoL domains. To reduce corticosteroid-related side effects, prednisone should be rapidly tapered and usually discontinued in responders, and in non-responders, medication should be discontinued after 4 weeks of initiation. Finally, this study had certain limitations. The maximum time period (4 months) was used to recruit the study participants, but the event is rare; therefore, the sample size was small, and it is difficult to generalize the whole population.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe impact of ITP on their energy levels and work life was high as compared with the impact of ITP on daily life. The study on HRQoL domains and predictive factors for increasing impact of ITP on their HRQoL was the development of emotionally related corticosteroid side effects, presence of fatigue during the assessment, not taking CPT, living far from the hematology clinic (outside Addis Ababa), epistaxis and wet purpura (mucosal bleeding), and skin symptoms (petechiae and ecchymosis) during diagnosis. The side effects of corticosteroids also affect the HRQoL of ITP patients. In general, concerted efforts must be made to reduce the impact of ITP on HRQoL and prevent/manage corticosteroid side effects.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eHMIS: Health Management Information System, HRQoL: Health-Related Quality of Life, ILQI: ITP Life Quality Index, ITP:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Immune Thrombocytopenia, ITP-PAQ: ITP-Patient Assessment Questionnaire, IVIgs: Intravenous Immunoglobulin\u0026rsquo;s, LS: Laparoscopic splenectomy, MGL: Morisky Green Levine scale, SPHMMC: St Poulos Hospital Millennium Medical College, TASH: Tikur Anbessa Specialized Hospital.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical consideration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study and study protocol was obtained from AAU, CHS, School of Pharmacy ethical review board (approval number: ERB/SOP/487/14/2022). Before data collection, a written permission letter was obtained from the hematology/oncology unit of TASH and SPHMMC. The aims of the study were clearly explained to the study participants. The information was collected after obtaining written informed consent from each participant and taken from participants\u0026rsquo; family/legal guardian for participants whose age was between 14-18 years. The right was given to the study participants to refuse or discontinue participation at any time they wanted and the chance to ask anything about the study. For obscurity, the participant\u0026rsquo;s name was not used at the time of data collection, all other personnel information was kept entirely obscure, and confidentiality was assured throughout the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sharing statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author\u0026nbsp;upon\u0026nbsp;reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors declare\u0026nbsp;that\u0026nbsp;there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding was not received from any organization,\u0026nbsp;and the authors are from a low-income country.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the study participants for their time and willingness to participate in the study. We would also like to\u0026nbsp;express\u0026nbsp;our sincere gratitude to the outpatient hematology clinic TASH and SPHMMC, Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Science, Addis Ababa University, and the data collectors for their support throughout the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDAB contributed to the study design, performed the statistical analysis; wrote, reviewed, and edited both the original draft and final manuscript. EAS, AMF, and AG conceptualized and participated in the study design, critically reviewing, modifying, and analyzing the draft of the manuscript. All the authors have read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMarini I, Zlamal J, Pelzel L, Bethge W, Faul C, Holzer U, et al. Autoantibody Mediated Desialylation Impairs Human Thrombopoiesis and Platelet Life Span. American Society of Hematology Washington, DC; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOmar IM, Abuelela S, Emam N. Value of Pre-and Post-Treatment Platelet Indices in Patients with Immune Thrombocytopenic Purpura. J Biosci Med. 2018;6(09):11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrozovsky R, Hoffmeister KM, Falet H. Novel clearance mechanisms of platelets. Curr Opin Hematol. 2010;17(6):585.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. 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Efficacy and safety of the combination treatment of rituximab and dexamethasone for adults with primary immune thrombocytopenia (ITP): a meta-analysis. BioMed research international. 2018;2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrotter P, Hill QA. Immune thrombocytopenia: improving quality of life and patient outcomes. Patient Relat Outcome Measures. 2018;9:369.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrainger JD, Young NL, Blanchette VS, Klaassen RJ. Quality of life in immune thrombocytopenia following treatment. Arch Dis Child. 2013;98(11):895\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVecchio R, Intagliata E. Idiopathic thrombocytopenic purpura: current therapeutical strategies and review of the literature on outcome after splenectomy. Annals of Laparoscopic and Endoscopic Surgery. 2020;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProvan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019;3(22):3780\u0026ndash;817.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIrving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ open. 2017;7(10):e017902.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. World health statistics 2020. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTerrell DR, Neunert CE, Cooper N, Heitink-Poll\u0026eacute; KM, Kruse C, Imbach P, et al. Immune thrombocytopenia (ITP): current limitations in patient management. Medicina. 2020;56(12):667.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuidry JA, George JN, Vesely SK, Kennison SM, Terrell DR. Corticosteroid side-effects and risk for bleeding in immune thrombocytopenic purpura: patient and hematologist perspectives. Eur J Haematol. 2009;83(3):175\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown TM, Horblyuk RV, Grotzinger KM, Matzdorff AC, Pashos CL. Patient-reported treatment burden of chronic immune thrombocytopenia therapies. BMC blood disorders. 2012;12(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathias SD, Gao SK, Miller KL, Cella D, Snyder C, Turner R, et al. Impact of chronic Immune Thrombocytopenic Purpura (ITP) on health-related quality of life: a conceptual model starting with the patient perspective. Health Qual Life Outcomes. 2008;6:1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Z, Yang L, Chen Z, Chen X, Guo Y, Wang X, et al. Health-related quality of life measured by the Short Form 36 in immune thrombocytopenic purpura: a cross‐sectional survey in China. Eur J Haematol. 2007;78(6):518\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorge JN, Mathias SD, Go RS, Guo M, Henry DH, Lyons R, et al. Improved quality of life for romiplostim-treated patients with chronic immune thrombocytopenic purpura: results from two randomized, placebo‐controlled trials. Br J Haematol. 2009;144(3):409\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathias SD, Gao SK, Rutstein M, Snyder CF, Wu AW, Cella D. Evaluating clinically meaningful change on the ITP-PAQ: preliminary estimates of minimal important differences. Curr Med Res Opin. 2009;25(2):375\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViana R, D\u0026rsquo;Alessio D, Grant L, Cooper N, Arnold D, Morgan M, et al. Psychometric Evaluation of ITP Life Quality Index (ILQI) in a Global Survey of Patients with Immune Thrombocytopenia. Adv Therapy. 2021;38(12):5791\u0026ndash;808.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeyene DA, Sisay EA, Fentie AM, Gebremedhin A. Reliability and validity of the Amharic version of immune thrombocytopenia life quality index tool for assessment of the health-related quality of life in Ethiopian patients of immune thrombocytopenia: Cross-sectional study. SAGE Open Medicine. 2023;11:20503121231199869.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrotter P, Hill QA. Immune thrombocytopenia: improving quality of life and patient outcomes. Patient Relat Outcome Measures. 2018:369\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatzdorff A, Meyer O, Ostermann H, Kiefel V, Eberl W, K\u0026uuml;hne T, et al. Immune thrombocytopenia-current diagnostics and therapy: recommendations of a joint working group of DGHO, \u0026Ouml;GHO, SGH, GPOH, and DGTI. Oncol Res Treat. 2018;41(Suppl 5):1\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaime-P\u0026eacute;rez JC, Aguilar-Calder\u0026oacute;n P, Jim\u0026eacute;nez-Castillo RA, Ramos-D\u0026aacute;vila EM, Salazar-Cavazos L, G\u0026oacute;mez-Almaguer D. Treatment outcomes and chronicity predictors for primary immune thrombocytopenia: 10-year data from an academic center. Ann Hematol. 2020;99(11):2513\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalau J, Sancho E, Herrera M, S\u0026aacute;nchez S, Mingot ME, Upegui RI, et al. Characteristics and management of primary and other immune thrombocytopenias: Spanish registry study. Hematology. 2017;22(8):484\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrimaldi-Bensouda L, Nordon C, Michel M, Viallard J-F, Adoue D, Magy-Bertrand N, et al. Immune thrombocytopenia in adults: a prospective cohort study of clinical features and predictors of outcome. Haematologica. 2016;101(9):1039.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePamuk G, Pamuk \u0026Ouml;, Başlar Z, \u0026Ouml;ng\u0026ouml;ren Ş, Soysal T, Ferhanoğlu B, et al. Overview of 321 patients with idiopathic thrombocytopenic purpura: retrospective analysis of the clinical features and response to therapy. Ann Hematol. 2002;81:436\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProvan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood The Journal of the American Society of Hematology. 2010;115(2):168\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooper N, Kruse A, Kruse C, Watson S, Morgan M, Provan D, et al. Immune thrombocytopenia (ITP) World Impact Survey (I-WISh): Impact of ITP on health‐related quality of life. Am J Hematol. 2021;96(2):199\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRov\u0026oacute; A, Cantoni N, Samii K, R\u0026uuml;fer A, Koenen G, Ivic S, et al. Real-world impact of primary immune thrombocytopenia and treatment with thrombopoietin receptor agonists on quality of life based on patient-reported experience: Results from a questionnaire conducted in Switzerland, Austria, and Belgium. PLoS ONE. 2022;17(4):e0267342.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang R, Yao H, Lin L, Ji J-m, Shen Q. Health-related quality of life and burden of fatigue in Chinese patients with immune thrombocytopenia: a Cross-sectional study. Indian J Hematol Blood Transfus. 2020;36(1):104\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChakrabarti P, George B, Shanmukhaiah C, Sharma LM, Udupi S, Ghanima W. How do patients and physicians perceive immune thrombocytopenia (ITP) as a disease? Results from Indian analysis of ITP World Impact Survey (I-WISh). J patient-reported outcomes. 2022;6(1):1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooper N, Cuker A, Bonner N, Ghanima W, Provan D, Morgan M, et al. Qualitative study to support the content validity of the immune thrombocytopenia (ITP) Life Quality Index (ILQI). Br J Haematol. 2021;194(4):759\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrace RF, Klaassen RJ, Shimano KA, Lambert MP, Grimes A, Bussel JB, et al. Fatigue in children and adolescents with immune thrombocytopenia. Br J Haematol. 2020;191(1):98\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Immune thrombocytopenia, health-related quality of life, platelet count, immune thrombocytopenia life quality index, corticosteroids, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-3906006/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3906006/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTreatment of immune thrombocytopenia (ITP) is difficult and has a significant impact on health-related quality of life (HRQoL), and prolonged use of corticosteroids may have a negative impact on HRQoL. The prepuse of this study was to evaluate the impact of ITP on HRQoL in patients with ITP at Tikur Anbessa Specialized Hospital (TASH) and St. Paul's Hospital Millennium Medical College (SPHMMC).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe institutional-based cross-sectional study was conducted from November 15, 2022 to March 15, 2023 to recruit 214 study participants. Descriptive statistics were used to summarize the sociodemographic data and clinical and treatment-related characteristics. Linear regression analysis models were also used to identify predictive factors for HRQoL. A p-value of less than 0.05 was generally considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMost of the study participants were female 161(75.5%). Regarding treatment, the majority 172(80.4%) of study participants were taking prednisolone only, and 143(66.8%) of study participants had at least one side effect of corticosteroids during the entire treatment period. Predictive factors for a higher impact of ITP on HRQoL; all correlated variables explained 36.5% (adjusted R-squared\u0026thinsp;=\u0026thinsp;0.365, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) of the variance and had a moderate impact on HRQoL. Of these, 15.4% of the variance (adjusted R-squared\u0026thinsp;=\u0026thinsp;0.154, β\u0026thinsp;=\u0026thinsp;0.392, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) was accounted for by emotion-related corticosteroid side effects. Furthermore, predictive factors for an increasingly higher impact of ITP on HRQoL were the development of emotionally related corticosteroid side effects (β\u0026thinsp;=\u0026thinsp;0.392, 95% CI: 5.160\u0026ndash;9.961, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), the presence of fatigue during the assessment (β\u0026thinsp;=\u0026thinsp;0.326, 95% CI: 4.394\u0026ndash;9.475, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), patients not taking cotrimoxazole prophylaxis treatment (β\u0026thinsp;=\u0026thinsp;0.236, 95% CI: 2.236\u0026ndash;6.570, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), living far from the hematology clinic (outside Addis Ababa) (β\u0026thinsp;=\u0026thinsp;0166, 95% CI: 1.107\u0026ndash;5.114 P\u0026thinsp;=\u0026thinsp;0.003), having epistaxis and wet purpura (mucosal bleeding) (β\u0026thinsp;=\u0026thinsp;0.191, 95% CI: 0.091\u0026ndash;4.259, P\u0026thinsp;=\u0026thinsp;0.001), and skin symptoms (petechiae and ecchymosis) (β\u0026thinsp;=\u0026thinsp;0.041, 95% CI: 0.091\u0026ndash;4.259 P\u0026thinsp;=\u0026thinsp;0.041) during diagnosis.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe impact of ITP on their energy levels and work life was high compared to the impact of ITP on daily life. The side effects of corticosteroids also affect the HRQoL of ITP patients.\u003c/p\u003e","manuscriptTitle":"Health-related quality of life and complications of corticosteroid treatment in patients with immune thrombocytopenia in two teaching hospitals in Ethiopia: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-02 15:25:34","doi":"10.21203/rs.3.rs-3906006/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0fe1160c-7aef-460e-aaf0-210b44b111a6","owner":[],"postedDate":"February 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-05T01:46:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-02 15:25:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3906006","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3906006","identity":"rs-3906006","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}