Exploring Inflammatory Bowel Disease in Familial Mediterranean Fever Patients: Insights From a Retrospective Study

doi:10.21203/rs.3.rs-4960449/v1

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Exploring Inflammatory Bowel Disease in Familial Mediterranean Fever Patients: Insights From a Retrospective Study

https://doi.org/10.21203/rs.3.rs-4960449/v1

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Background

In light of the accepted association between familial Mediterranean fever (FMF) and inflammatory bowel disease (IBD), as well as the limited previous research on this subject, this study aimed to investigate the prevalence of IBD among individuals diagnosed with FMF and to explore the clinical features and genetic mutations present in FMF patients with IBD.

Methods

The study was conducted among patients diagnosed with FMF between 2006 and 2022. Patients diagnosed with IBD were included. Patient records were reviewed for demographic data, presenting symptoms and their duration, laboratory results at the time of initial diagnosis and during follow-up, colonoscopy findings, treatments administered, and post-treatment follow up colonoscopy results.

Results

Among 1176 patients diagnosed with FMF, 9 patients (0.76%) also diagnosed with IBD were included in the study. Genetic analysis showed that all patients had a detected MEFV gene mutation, with the M694V mutation being the most frequently observed. Approximately 44% of FMF and IBD patients exhibit homozygosity for the M694V mutation. Among 1122 FMF patients analyzed for MEFV gene mutations, 19% were homozygous for this variant. The frequency of the M694V homozygous mutation is higher in patients with both IBD and FMF compared to those with only FMF (p = 0.079). In the patients with IBD, diarrhea was the most common presenting complaint. Fever attacks accompanied by abdominal pain were observed in all patients. Further investigations through colonoscopy were conducted on 9 patients, revealing inflammation in the colonic mucosa in the majority (66%). All patients had been receiving colchicine. Methylprednisolone, mesalamine, azathioprine, tumor necrosis factor (TNF) inhibitors, and interleukin-1 (IL-1) inhibitors were among the treatments administered. Following the treatment, all patients experienced a reduction in symptoms, and acute phase reactants were found to be negative in all except one (6.6%).

Conclusion

The prevalence of IBD is increased in FMF patients with M694V homozygous mutation. Therefore, careful monitoring and thorough evaluation, including colonoscopies, are crucial for assessing IBD risk in these individuals.

familial Mediterranean fever

inflammatory bowel disease

pediatric rheumatology

MEFV gene mutation

Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory disease, characterized by recurrent episodes of fever and serositis. Its prevalence in Turkey is considered to be 1/1000, and the carrier rate is 1/5 [1–4]. The MEFV gene responsible for FMF, located on the short arm of chromosome 16, encodes the pyrin protein with anti-inflammatory properties. Pyrin protein plays a crucial role in the natural immune response. It regulates the release of interleukin-1 (IL-1), leukocyte apoptosis, and blocks the nuclear factor-kappa B pathway [5–7]. More than 70 mutations have been identified in the MEFV gene, with the most common mutation being M694V [8]. Mutations in the MEFV gene lead to the activation of the IL-1 β pathway, causing a congenital immune disease. The inflammatory cycle is activated, resulting in severe inflammatory attacks [9].

Inflammatory bowel disease (IBD) is an immunologically mediated disorder involving chronic inflammation of the gastrointestinal tract, encompassing conditions such as Crohn's disease, ulcerative colitis, and indeterminate colitis [9]. The most common symptoms include abdominal pain, diarrhea, weight loss, and fever. While IBD can occur at any age, it is observed in 20–30% of cases during childhood and young adulthood. Although the etiology of the disease is not fully understood, it is believed to be multifactorial. In individuals with genetic predisposition, exposure to environmental triggers can lead to a dysregulated immune response, resulting in the breakdown of the mucosal barrier and the onset of the disease. The gene conferring susceptibility to ulcerative colitis is HLA-DRB1 and HLA-DQB, whereas the NOD2/CARD15 gene located on the 16th chromosome was identified in 2001 as being associated with Crohn's disease [10].

MEFV and NOD2/CARD15 genes, both located on the 16th chromosome, share structural similarities [8, 10, 11]. They play a crucial role in regulating apoptosis, cytokine release, and inflammation. Mutations in these genes can result in similar clinical manifestations such as abdominal pain, diarrhea, arthralgia, arthritis, and fever [12–14]. Although there are numerous studies supporting a potential relationship between FMF and IBD [15–17], there is still limited evidence available.

In this study, we aimed to determine the clinical and demographic characteristics of patients diagnosed with both FMF and IBD, investigate the association between IBD and MEFV gene mutations, and to evaluate the prevalence of IBD in patients diagnosed with FMF.

Patients and definitions

The study was conducted among patients aged 0–18 years diagnosed with FMF between 2006 and 2022 at the Department of Pediatric Rheumatology, Gazi University Faculty of Medicine. The diagnosis of FMF was established based on history, physical examination, laboratory findings, and genetic analysis results of MEFV gene mutations according to the Ankara 2008 criteria. The diagnosis of IBD diagnosis was based on clinical, serological, colonoscopic, and histopathological findings according to European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines. Patient records were retrospectively reviewed for demographic data, presenting symptoms and their duration, laboratory results at the time of initial diagnosis and during follow-up, colonoscopy findings, treatments administered, and post-treatment follow up colonoscopy results. Family history of IBD and FMF was queried and recorded.

MEFV gene mutations in patients with IBD and FMF were compared with those with FMF only. Fisher's exact test was used to compare the frequency of MEFV gene mutations.

Laboratory tests

At the time of diagnosis, erythrocyte sedimentation rate, C-reactive protein and complete blood count was recorded. Genetic analysis of the MEFV gene was conducted for all patients. MEFV gene extraction was performed at the Nephrology and Tissue Laboratory at Gazi University Medical Faculty. The polymerase chain reaction (PCR) workup, revealed with the pyrosequencing DNA analysis system, targeted the 2-3-5-10 exons of the MEFV gene.

Invasive procedures

Colonoscopy under sedation was performed on FMF patients with suspected IBD. Multiple biopsy samples were taken for histopathological examination during the procedure. Following examination of the biopsy samples by the pathologist the subjects who were diagnosed with IBD were included in the study.

Ethics committee approval for the study was given by Gazi University Medical Faculty Clinical Research Ethics Committee with the article number of E-77082166-604.01.02-475052 and with the date of 07.10.2022.

Among 1176 patients diagnosed with FMF, 9 patients (0.76%) also diagnosed with IBD were included in the study. Demographic and clinical characteristics of these 9 patients were examined. The majority of these patients were female (77%). Family history was present in 33% of the patients, with 1 having a family history of IBD and 2 having a family history of FMF. With the exception of Patients 3, 4, and 7, FMF was typically diagnosed at an earlier stage than IBD. Genetic analysis showed that all patients had a detected MEFV gene mutation, with the M694V mutation being the most frequently observed. A substantial proportion, approximately 44%, of FMF and IBD patients were found to exhibit homozygosity for the M694V mutation. Upon evaluating MEFV gene mutations across all FMF patients, data from 1122 individuals were analyzed, revealing that 213 of them (19%) were homozygous for the M694V variant. The frequency of the M694V homozygous mutation was higher in patients with both IBD and FMF compared to those with only FMF (p = 0.079). Demographic characteristics and detailed mutation analyses are summarized in Table 1.

Table 1

Demographic features of patients, genetic results and treatment modalities
Patient	Sex	Family history	Age at FMF diagnosis (months)	Age at IBD diagnosis (months)	Follow- up for FMF (months)	MEFV genotype	Treatment	Need of surgery
1	Male	+	5	8	23	M694V/M694V	C, CS	-
2	Female	-	100	102	40	A744S/-	C	-
3	Female	-	13	12	87	M694V/M694V	C, CS, AZT	-
4	Male	-	167	165	11	A744S/M680I	C, CS, M, AZT	+
5	Female	-	199	217	61	P369S/M694V	C, M, AZT	-
6	Female	+	155	195	12	E148Q/P369S	C, AZT, IL-1i	-
7	Female	+	25	11	153	M694V/M694V	C, CS, M, AZT, IL-1i	-
8	Female	+	180	203	55	M694V/M694V	C, TNFi	-
9	Female	+	22	25	33	M680I+/-	C, CS, M, AZT, IL-1i	-
AZT: azathioprine; C: colchicine; CS: corticosteroid; FMF: familial Mediterranean fever; IBD: inflammatory bowel disease; IL-1i: interleukin 1 inhibitor; M: mesalazine; TNFi: tumor necrosis factor inhibitor

In the patients with both IBD and FMF, diarrhea was the most common presenting complaint. All patients experienced fever attacks accompanied by abdominal pain. Additionally, rectal bleeding was noted in 77% of cases, periodic diarrhea in 44% and chronic diarrhea in 55%. Arthritis, oral ulcers, and weight loss were each observed in 44% of patients (Table 2).

Table 2

Clinical characteristics of patients with FMF and IBD
Patient	Initial complaint	FMF attack intervals, y	Fever	Abdominal pain	Chronic diarrhea	Periodic diarrhea	Arthritis	Rectal bleeding	Oral ulcer	Weight loss
1	Diarrhea	1	+	+	+	-	-	+	+	-
2	Diarrhea	6	+	+	-	+	-	+	-	-
3	Diarrhea	15	+	+	+	-	-	+	-	+
4	Diarrhea	10	+	+	+	-	+	+	-	+
5	Diarrhea	6	+	+	-	+	+	-	-	-
6	Fever	4	+	+	-	+	-	-	+	-
7	Diarrhea	4	+	+	+	-	-	+	+	+
8	Arthritis	6	+	+	-	+	+	+	+	-
9	Arthritis	12	+	+	+	-	+	+	-	+
FMF: familial Mediterranean fever; IBD: inflammatory bowel disease

Further colonoscopic investigations were conducted on 9 patients, revealing inflammation in the colonic mucosa in the majority (66%). Notably, inflammation was also detected in the terminal ileum and jejunum in some cases. The colonoscopic and histopathologic characteristics of these findings are presented in Table 3.

Table 3

Colonoscopic views and biopsy results of patients with FMF and IBD
Patient	Disease location	Colonoscopic view	Colonoscopic biopsy	Tanı
1	Colon	Deep ulcers with a necrotic base and skip lesions	Criptitis and chronic active inflammatory process accompanied by polymorphic leukocytes and eosinophils.	IBD-U
2	Colon	Complete loss of vascularity, apthous ulcers	Chronic active inflammatory process accompanied by polymorphic leukocytes.	UK
3	Colon	Ulcers covered with lokalized white exudate and skip lesions	Criptitis and mixed-type inflammation	IBD-U
4	Colon	Pancolitis, colectomy	Criptitis and mixed-type inflammation	UK
5	Terminal ileum	Multiple ulcers with white exudate	Chronic active ileitis	Crohn
6	Terminal ileum, jejunum	Aphthous ulcers	Chronic active inflammatory process	Crohn
7	Colon	Skip pancolitis	Surface ulcers and mixed-type inflammation	IBD-U
8	Terminal ileum	Deep necrotic ulcers	Chronic active ileitis	Crohn
9	Colon	Deep ulcers with diffuse white exudate, pancolitis	Ulcerative active colitis	UK
FMF: familial Mediterranean fever; IBD-U: inflammatory bowel disease-unclassified; UK: ulcerative colitis

All patients had been receiving colchicine for FMF. Treatments administered included methylprednisolone, mesalamine, azathioprine, tumor necrosis factor (TNF) inhibitors, and IL-1 inhibitors. Only Patient 4 required surgical intervention and a total colectomy was performed (Table 1). Following treatment, all patients experienced a reduction in symptoms, and acute phase reactants were negative in all except Patient 9. In the follow-up colonoscopy of the Patient 9, minimal inflammatory changes were detected in the colonic mucosa. None of the bowel biopsies revealed any signs of amyloidosis and no patients had proteinuria during follow-up.

Our investigation has elucidated an elevated prevalence of IBD within the cohort of FMF patients, underscoring an augmented occurrence in comparison to the general population. While existing literature extensively explores the coexistence of FMF in individuals with IBD, limited attention has been directed towards scrutinizing the prevalence of IBD among FMF patients. In our study, unlike previous studies, the presence of IBD was investigated in a large FMF cohort and these patients were analyzed in detail.

In the study conducted by Yıldız et al., encompassing 686 FMF subjects, an IBD prevalence of 1.45% was established [18]. Similarly, another investigation involving 600 FMF patients revealed IBD in 1.16% of cases [19]. Within the scope of our own inquiry, this proportion was ascertained to be 0.76%. The prevalence of IBD in Turkey has been reported in the range of 6.6–44/100,000 in various studies [18]. Despite the potential onset of IBD at any age, the manifestation of symptoms typically occurs post-childhood, indicating a heightened rate compared to the general population [20]. Our study suggests a definitive association of this disease with FMF in the pediatric population.

In Turkish population, the prevalence of FMF carrier status is known to be 14.8% [21]. According to a study conducted by the FMF research group, which included 2838 patients, FMF disease is observed at a rate of 1 in 1000 individuals. The most common mutations in Turkish individuals diagnosed with FMF are M694V (51.4%), followed by M680I (14.4%) and V726A (8.6%). The M694V homozygous mutation was detected at a rate of 10.7% [22]. In contrast, M694V mutation is observed in healthy individuals at a rate of 3% [23]. In our investigation, the M694V mutation was identified in 5 patients (55%), M694V homozygous mutation in 4 patients (44%) and combined heterozygous mutation in 3 patients (33%) with FMF and IBD. These rates are notably higher compared to the FMF population [22]. It is also noteworthy that the prevalence of M694V homozygous mutation was 44% in the FMF and IBD group, compared to 19% in the entire FMF group in our study (p = 0.079). Due to the small sample size in the IBD and FMF group, we consider this difference to be statistically insignificant.

Pediatric IBD in our country is reported to have an association with FMF in 21.1% of cases. In a study of 597 IBD patients, MEFV mutation was detected in 41.8% of the patients and 21.4% of patients with mutation were reported to have M694V homozygous mutation [16]. According to Uslu et al.'s study, MEFV gene mutations were detected in 25.7% of 33 patients with IBD. While the most prevalent mutation in IBD patients is M694V (10.6%), M694V mutation was identified in 43.7% and M694V homozygous mutation in 18.1% of IBD and FMF patients [10]. In another study involving 53 IBD patients, associated 26.4% of cases with FMF. Among these patients, M694V homozygous mutation was detected in half, and 14.3% exhibited K695R and M694V heterozygous mutations [15]. According to our study, M694V mutation is the most common mutation in FMF and IBD patients and the prevalence of IBD is increased in FMF patients with M694V homozygous mutation.

In previous studies, diarrhea, abdominal pain, and rectal bleeding were reported as the most common symptoms in patients with coexisting FMF and IBD, in that order [15]. Similarly, our study also indicates that diarrhea is the most frequent complaint among patients with both FMF and IBD. Among the nine patients studied, four reported periodic diarrhea attacks, while five presented with chronic diarrhea. Rectal bleeding was observed in 77% of the patients. Those experiencing periodic diarrhea reported episodes with a frequency ranging from once a week to once every two months, with 4–6 attacks per day. These findings suggest that the presence of periodic or chronic diarrhea and rectal bleeding in FMF patients warrants careful evaluation for the potential coexistence of FMF and IBD.

When colonoscopic examinations of patients with FMF and IBD were analyzed, colon involvement was observed in all 11 FMF patients who underwent colonoscopy in a study conducted in our country (17). In the study by Beşer et al., colitis was found in 9 (75%) of 12 FMF and IBD patients, pancolitis in 2 (16.6%) and ileocolitis in 1(8.3%) [8]. In our study, colonoscopy was performed in all 9 patients. Colon involvement was observed in 6 patients (66%) and terminal ileum involvement was observed in 3 patients. This distribution of gastrointestinal involvement emphasizes the predominance of colonic symptoms in FMF and IBD patients and reflects the findings of previous studies.

All patients received colchicine treatment, with 8 colchicine-resistant cases additionally administered immunosuppressive therapies. Favorable outcomes were obtained in all patients except for the Patient 8, who exhibited ongoing minimal inflammatory changes in the colon mucosa during the follow-up colonoscopy. For IBD associated with FMF, it is recommended to administer treatments such as steroids, mesalamine, azathioprine, TNF inhibitors, in addition to colchicine, based on the type, involvement, and severity of IBD [8].

Our study has several limitations, notably its single-center and retrospective design. Despite these limitations, a significant strength of our research is the demonstration of the prevalence of IBD and the influence of the MEFV gene within a cohort of FMF patients. This comprehensive analysis will add valuable information to the understanding of the coexistence of FMF and IBD, potentially guiding future research and clinical management strategies.

In conclusion, our findings indicate an increased prevalence of IBD, particularly in FMF patients carrying the M694V homozygous mutation. Therefore, careful monitoring and thorough evaluation, including colonoscopy, are crucial for assessing IBD risk in these individuals.

ESPGHAN

European Society for Paediatric Gastroenterology,Hepatology and Nutrition

FMF

familial Mediterranean fever

IBD

inflammatory bowel disease

IL-1

interleukin-1

TNF

tumor necrosis factor

Ethical approval
Ethics committee approval for the study was given by Gazi University Medical Faculty Clinical Research Ethics Committee with the article number of E-77082166-604.01.02-475052 and with the date of 07.10.2022.

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests

Funding

No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.

Author contributions

Conceptualization, Y.E.N.; Writing – Original Draft Preparation, Y.E.N., Y.D.G., Ö.H.; Writing – Review & Editing,Y.E.N., Y.D.G., Ö.H., S.S., and S.O.; All the authors have read and agreed to the published version of the manuscript.

Acknowledgements

None.

Data availability

The datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request.

Ozen S. Familial Mediterranean fever: revisiting an ancient disease. Eur J Pediatrics. 2003;162:449–54.
Ozen S, Aktay N, Lainka E, Duzova A, Bakkaloglu A, Kallinich T. Disease severity in children and adolescents with familial Mediterranean fever: a comparative study to explore environmental effects on a monogenic disease. Ann Rheum Dis. 2009;68(2):246–8.
Ozen S, Hoffman HM, Frenkel J, Kastner D. Familial Mediterranean fever (FMF) and beyond: a new horizon. Fourth International Congress on the Systemic Autoinflammatory Diseases held in Bethesda, USA, 6–10 November 2005. Annals of the rheumatic diseases. 2006;65(7):961-4.
Livneh A, Langevitz P, Zemer D, Zaks N, Kees S, Lidar T, et al. Criteria for the diagnosis of familial Mediterranean fever. Arthr Rhuem. 1997;40(10):1879–85.
Ben-Chetrit E, Backenroth R. Amyloidosis induced, end stage renal disease in patients with familial Mediterranean fever is highly associated with point mutations in the MEFV gene. Ann Rheum Dis. 2001;60(2):146–9.
Consortium FF, Bernot A, Clepet C, Dasilva C, Devaud C, Petit J-L, et al. A candidate gene for familial Mediterranean fever. Nat Genet. 1997;17(1):25–31.
Consortium IF. Ancient missense mutations in a new member of the RoRet gene family are likely to cause familial Mediterranean fever. Cell. 1997;90(4):797–807.
Beser ÖF, Kasapçopur Ö, Çokugras FÇ, Kutlu T, Arsoy N, Erkan T. Association of inflammatory bowel disease with familial Mediterranean fever in Turkish children. J Pediatr Gastroenterol Nutr. 2013;56(5):498–502.
Chae JJ, Wood G, Masters SL, Richard K, Park G, Smith BJ et al. The B30. 2 domain of pyrin, the familial Mediterranean fever protein, interacts directly with caspase-1 to modulate IL-1β production. Proceedings of the National Academy of Sciences. 2006;103(26):9982-7.
Uslu N, Yüce A, Demir H, Saltik-Temizel IN, Usta Y, Yilmaz E, et al. The association of inflammatory bowel disease and Mediterranean fever gene (MEFV) mutations in Turkish children. Dig Dis Sci. 2010;55:3488–94.
Ogura Y, Bonen DK, Inohara N, Nicolae DL, Chen FF, Ramos R, et al. A frameshift mutation in NOD2 associated with susceptibility to Crohn's disease. Nature. 2001;411(6837):603–6.
Ayaz N, Özen S, Bilginer Y, Ergüven M, Taşkıran E, Yılmaz E, et al. MEFV mutations in systemic onset juvenile idiopathic arthritis. Rheumatology. 2009;48(1):23–5.
Yurtcu E, Gokcan H, Yilmaz U, Sahin FI. Detection of MEFV gene mutations in patients with inflammatory bowel disease. Genetic Test Mol Biomarkers. 2009;13(1):87–90.
Sari S, Egritas O, Dalgic B. The familial Mediterranean fever (MEFV) gene may be a modifier factor of inflammatory bowel disease in infancy. Eur J Pediatrics. 2008;167:391–3.
Beşer ÖF, Çokuğraş FÇ, Kutlu T, Erginöz E, Gülcü D, Kasapçopur Ö, et al. Association of familial Mediterranean fever in Turkish children with inflammatory bowel disease. Turkish Archives Pediatrics/Türk Pediatri Arşivi. 2014;49(3):198.
Urgancı N, Ozgenc F, Kuloğlu Z, Yüksekkaya H, Sarı S, Erkan T, et al. Familial Mediterranean fever mutation analysis in pediatric patients with inflammatory bowel disease: A multicenter study. Turkish J Gastroenterol. 2021;32(3):248.
Gurkan OE, Dalgic B. Gastrointestinal mucosal involvement without amyloidosis in children with familial Mediterranean fever. J Pediatr Gastroenterol Nutr. 2013;57(3):319–23.
Yildiz M, Adrovic A, Tasdemir E, Baba-Zada K, Aydin M, Koker O, et al. Evaluation of co-existing diseases in children with familial Mediterranean fever. Rheumatol Int. 2020;40(1):57–64.
Özçakar Z, Çakar N, Uncu N, Çelikel B, Yalçınkaya F. Familial Mediterranean fever-associated diseases in children. QJM: Int J Med. 2017;110(5):287–90.
Baldassano RN, Piccoli DA. Inflammatory bowel disease in pediatric and adolescent patients. Gastroenterol Clin N Am. 1999;28(2):445–58.
Soylemezoglu O, Kandur Y, Gonen S, Düzova A, Özçakar ZB, Fidan K, et al. Familial Mediterranean fever gene mutation frequencies in a sample Turkish population. Clin Exp Rheumatol. 2016;34(6 Suppl 102):97–100.
Tunca M, Ozdogan H, Kasapcopur O, Yalcinkaya F, Tutar E, Topaloglu R, et al. Familial Mediterranean fever (FMF) in Turkey: results of a nationwide multicenter study. Med (Baltim). 2005;84(1):1–11.
Yilmaz E, Ozen S, Balcı B, Duzova A, Topaloglu R, Besbas N, et al. Mutation frequency of familial Mediterranean fever and evidence for a high carrier rate in the Turkish population. Eur J Hum Genet. 2001;9(7):553–5.

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You are reading this latest preprint version

Exploring Inflammatory Bowel Disease in Familial Mediterranean Fever Patients: Insights From a Retrospective Study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Patients and definitions

Laboratory tests

Invasive procedures

Results

Discussion

Conclusions

Abbreviations

Declarations

Ethical approval
Ethics committee approval for the study was given by Gazi University Medical Faculty Clinical Research Ethics Committee with the article number of E-77082166-604.01.02-475052 and with the date of 07.10.2022.

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests

Funding

Author contributions

Acknowledgements

Data availability

References

Status:

Version 1

Exploring Inflammatory Bowel Disease in Familial Mediterranean Fever Patients: Insights From a Retrospective Study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Patients and definitions

Laboratory tests

Invasive procedures

Results

Discussion

Conclusions

Abbreviations

Declarations

Ethical approval Ethics committee approval for the study was given by Gazi University Medical Faculty Clinical Research Ethics Committee with the article number of E-77082166-604.01.02-475052 and with the date of 07.10.2022.

Consent for publication Not applicable.

Competing interests The authors declare that they have no competing interests

Funding

Author contributions

Acknowledgements

Data availability

References

Status:

Version 1

Ethical approval
Ethics committee approval for the study was given by Gazi University Medical Faculty Clinical Research Ethics Committee with the article number of E-77082166-604.01.02-475052 and with the date of 07.10.2022.

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests