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Biomedical subjects

B Cakir

Publications and source records attributed to B Cakir.

At least 19 recordsLinked to original sources
PubMed2007

Evaluation of the Tokuhashi prognosis score and its modifications in 217 patients with vertebral metastases.

AIM: The Tokuhashi prognosis score consists of six parameters. The sum of points rated for each parameter can be correlated with the prognosis. This study evaluates the score variations that have been done by different authors and Tokuhashi et al. themselves. METHODS: Two hundred and seventeen consecutive patients, surgically treated for vertebral metastases, were studied retrospectively. We calculated the original and modified score of Tokuhashi and evaluated the predictive value for the individual life expectancy. RESULTS: The original and modified Tokuhashi score assured a significant predictive value. Modified criteria by the authors showed the highest reliability between the predicted and real survival, and the patients could be allocated correctly to the desirable instrumentation. CONCLUSION: The original and modified Tokuhashi score showed a significant predictive value. The modified criteria by the authors showed the highest reliability between predicted and real survival.

Biopsy↗
PubMed2006

Leptin inhibits gastric emptying in rats: role of CCK receptors and vagal afferent fibers.

Leptin regulates energy homeostasis and body weight by balancing energy intake and expenditure. It was recently reported that leptin, released into the gut lumen during the cephalic phase of gastric secretion, is capable of initiating intestinal nutrient absorption. Vagal afferent neurons also express receptors for both CCK and leptin, which are believed to interact in controlling food intake. The present study was undertaken to investigate the central and peripheral effects of leptin on gastric emptying rate. Under anesthesia, male Sprague-Dawley rats (250-300 g) were fitted with gastric Gregory cannulas (n=12) and some had additional cerebroventricular cannulas inserted into their right lateral ventricles. Following recovery, the rate of gastric emptying of saline (300 mOsm/kg H(2)O) was determined after instillation into the gastric fistula (3 ml, 37 degrees C, containing phenol red, 60 mg/l as a non-absorbable dilution marker). Gastric emptying rate was determined from the volume and phenol red concentrations recovered after 5 min. Leptin, injected intraperitoneally (i.p.; 10, 30, 60, 100 microg/kg) or intracerebroventricularly (i.c.v.; 5, 15 microg/rat) 15 min before the emptying, delayed gastric emptying rate of saline at the dose of 30 microg/kg or 15 microg/rat (p<0.001). When CCK(1) receptor blocker L-364,718 (1 mg/kg, i.p.), CCK(2) receptor blocker L-365,260 (1 mg/kg, ip) or adrenergic ganglion blocker bretylium tosylate (15 mg/kg, i.p.) was administered 15 min before ip leptin (30 microg/kg) injections, leptin-induced delay in gastric emptying was abolished only by the CCK(1) receptor blocker (p<0.001). However, the inhibitory effect of central leptin on gastric emptying was reversed by adrenergic blockade, but not by either CCK antagonists. Our results demonstrated that leptin delays gastric emptying. The peripheral effect of leptin on gastric motility appears to be mediated by CCK(1) receptors, suggesting the release of CCK and the involvement of vagal afferent fibers. On the other hand, the central effect of leptin on gastric emptying is likely to be mediated by adrenergic neurons. These results indicate the existence of a functional interaction between leptin and CCK receptors leading to inhibition of gastric emptying and short-term suppression of food intake, providing an additional feedback control in producing satiety.

Animals↗
PubMed2006

Effects of percutaneous laser ablation treatment in benign solitary thyroid nodules on nodule volume, thyroglobulin and anti-thyroglobulin levels, and cytopathology of nodule in 1 yr follow-up.

OBJECTIVE: To investigate the effects of ultrasound (US)-guided percutaneous laser ablation (PLA) in the treatment of benign solid hypoactive thyroid nodules on nodule volume, thyroid functions, nodule cytology and patients' complaints. MATERIAL AND METHOD: Criteria for enrollment in the study were as follows: patients with euthyroid, benign, hypofunctional nodule who had compressive symptoms or cosmetic complaints, but considered inoperable, or who rejected surgical treatment. PLA procedure at 3-5 watts (W) was applied to 15 thyroid nodules of 12 patients (4 male and 8 female; age range 20-78 yr, mean age 47.42+/-17.05 yr), and patients were followed up for 12 months. Thyroid functions and nodule volumes (ultrasonographically) were evaluated. US-guided fine needle aspiration biopsy (FNAB) was performed before and after the procedure, and biopsy specimens were cytologically evaluated. RESULTS: The mean nodule volume before the procedure was 11.97 ml (min-max 0.95-26.30 ml). However, 12 months after the procedure the mean nodule volume was 2.21+/-2.32 ml (min-max 0.10-7.65 ml). The mean reduction in nodule volumes was 82%. Thyroglobulin levels reached peak values at 1 month after the procedure, and anti-thyroglobulin levels at 3 months after the procedure. FNAB performed at 12th month showed neutrophil polymorphs, macrophages, abundant cell debris, colloid, multinucleated giant cells, and small fragments of fibrous stroma which indicated that PLA procedure led to degenerative changes in nodules. CONCLUSION: US-guided PLA is a new, successful treatment method which is reliable in the long term in benign solid thyroid nodules for selected patients who are inoperable or do not prefer surgery.

Adult↗
PubMed2006

Evaluation of neurologic complications by brain MRI in kidney and liver transplant recipients.

The aim of this study was to retrospectively analyze brain magnetic resonance imaging (MRI) findings in patients who developed neurologic complications after liver and kidney transplantation. The results in 216 organ transplant recipients, who had brain MRI were evaluated retrospectively. We performed 187 brain MRI on kidney recipients and 29 liver recipients. Neuroradiologic findings were classified in three groups: group 1 findings were related to transplantation; group 2 findings, to chronic parenchymal disease; and group 3 to neither transplantation nor chronic parenchymal disease. In group 1, six patients (20.6%) after liver and three (1.6%) after kidney transplantation had posterior reversible encephalopathy syndrome; two patients (1.1%) after renal and one (3.4%) after liver transplantation had tuberculosis granulomas; one patient (0.5%) after renal transplantation had osmotic demyelination syndrome; one patient (0.5%) had a Nocardia abcess and one (0.5%) focal cerebritis after renal transplantation. Among group 2, 38 patients (20.3%) had brain atrophy; 37 (20%), white matter changes; 3 (1.6%), sinus thrombosis; 8 (4.3%), lacunar infarct; 1 (0.5%), had renal osteodystrophy in the cranial bones; and 4 (2.2%), had intracranial hemorrhage secondary to end-stage renal disease. Brain atrophy in nine patients (31%), hyperintensity in the globus pallidus on T1-weighted MR images owing to manganese deposits in nine patients (31%), hyperintensity in basal ganglia on T2-weighted MR images owing to copper depositions in one patient (3.4%) were seen secondary to chronic liver disease. In group 3, three patients (1.6%) had intracranial lipomas; one (0.5%), mesial temporal sclerosis; and one (0.5%), an anterior cerebral artery aneurysm in renal transplant patients. Periventricular and subcortical white matter hyperintensities were observed on T2-weighted MR images in six liver transplant patients (20.7%). Neurologic complications after organ transplantation may be secondary to transplantation itself, to chronic parenchymal disease, or to neither transplantation nor chronic parenchymal disease.

Adult↗
PubMed2006

Use of topical misoprostol to reduce radiation-induced mucositis: results of a randomized, double-blind, placebo-controlled trial.

Radiation-induced mucositis is an acute reaction of the mucosa of patients undergoing head and neck radiotherapy. It can have debilitating and dose-limiting consequences. There is no consensus on an accepted intervention that significantly reduces its severity. Misoprostol is a synthetic prostaglandin E1 analogue, with properties of a mucosal cytoprotectant. We designed a randomized, double-blind, placebo-controlled trial of misoprostol in patients with head and neck cancer. The aim of this study was to determine if topical misoprostol was effective in reducing the severity of radiation-induced mucositis in patients receiving radical dose radiotherapy. The effect of this intervention on a patient's general well-being was also investigated. The primary end-point of the study was the incidence of Radiation Therapy Oncology Group grade 3 mucositis. Between 1999 and 2002, 83 patients were recruited into the study at Westmead and Nepean Hospitals, Sydney. Forty-two patients were randomized to receive misoprostol and 41 to receive a placebo. Most patients received radiotherapy in the adjuvant setting (52 of the 83) and had either an oral cavity (42 of the 83) or an oropharyngeal (16 of the 83) cancer. We could not identify any significant difference in the incidence of severe mucositis based on whether patients were allocated to receive misoprostol or placebo. There was no significant difference in the mean area under the mucositis curve (13.2 vs 16.6; P = 0.1). Patients allocated to misoprostol did report slightly increased soreness (7.6 vs 6.9; P = 0.04) and a greater use of analgesics. However, this difference did not translate into a worse feeling of general well-being as measured by a simple visual analogue scale (5.8 vs 5.2; P = 0.3). In conclusion, we were unable to identify a reduction in radiation-induced mucositis in patients receiving misoprostol. There is a paucity of high-level evidence on potentially useful interventions and a continued need for new and innovative research, incorporating quality-of-life measurements, in patients experiencing radiation-induced mucositis.

Administration, Topical↗
PubMed2006

Cutaneous mastocytosis: demographic aspects and clinical features of 55 patients.

BACKGROUND: Mastocytosis is a rare, heterogeneous group of disorder with abnormal increase of mast cells in one or more organ systems. OBJECTIVE: To evaluate the demographic and clinical features of cutaneous mastocytosis (CM). METHODS: Records of 55 patients with cutaneous mastocytosis were retrospectively analysed. RESULTS: Of the 22 females and 33 males, 80% had urticaria pigmentosa/maculopapular CM and 20% had mastocytoma. Of all cases, 81.8% had first lesions in childhood. The most common presentation was involvement of trunk together with extremities. Thirteen (23.6%) patients had history of bulla; Darier's sign was positive in 34 of 38 patients. Itching was the most common complaint, provocated by hot weather/bath. CONCLUSION: Clinical presentations of urticaria pigmentosa/maculopapular CM and mastocytoma are similar regarding gender, age of onset, age of diagnosis, and presence of Darier's sign and history of bulla. In contrast to mastocytoma, urticaria pigmentosa/maculopapular CM lesions were frequently located on trunk together with extremities.

Adolescent↗
PubMed2005

Cement leakage during vertebroplasty: an underestimated problem?

Overall, vertebroplasty has a low complication rate. Nevertheless, severe complications can occur. The majority of these are related to cement extrusion. The rate of cement leakage is often obtained by X-ray, with only a single leak registration per vertebra. Detection rate of leaks in comparison with CT and inter-observer reliability for X-ray is, in large parts, unknown. We conducted this study to determine the value of fluoroscopy and X-ray used to detect cement leakage as compared to CT scans. Intraoperative findings in lateral fluoroscopy by the surgeon, and postoperative findings in X-rays by two orthopaedic surgeons, were compared with CT scans for the same study group. Multiple cement leakage was considered, and agreement rate was determined. The detection rate for leaks was 34% for lateral X-ray and 48% for lateral and AP view. Additional AP views only enhanced the detection of leaks in the segmental veins. The agreement rate between fluoroscopy/X-ray and CT scans ranged between 66% and 74%, while inter-observer reliability showed only fair agreement. The rate of cement leaks in vertebroplasty is high if multiple leaks are considered in CT scans. Detection rates using X-rays are low and complicated by only fair inter-observer agreement. Leaks in the basivertebral veins are frequently misinterpreted and can lead to severe complications. Therefore, CT scans should be obtained to calculate the exact leakage rate and to assess persistent or new pain occurring postoperatively.

Aged↗
PubMed2005

Plasma total homocysteine level and its association with carotid intima-media thickness in obesity.

BACKGROUND: Elevated plasma concentrations of total homocysteine (tHcy) and obesity are risk factors for cardiovascular disease. The relationship between hyperhomocysteinemia and obesity has not been totally elucidated. OBJECTIVE: The first aim of the study was to investigate whether anthropometric measurements and insulin resistance contribute to the variation in homocysteine levels in obese adults. Our second aim was to determine if any relationship exists between the carotid intima-media thickness (IMT) and plasma tHcy levels in obese subjects without traditional cardiovascular risk factors. MATERIAL AND METHODS: Fifty-five obese (15 male, 40 female) and 30 (11 male, 19 female) age- and sex-matched apparently healthy volunteers were included. Exclusion criteria were smoking, hypertension, diabetes, vitamin ingestion, hyperlipidemia, renal failure, liver disease, pregnancy, menopause and secondary obesity such as Cushing's syndrome, hypothyroidism. tHcy, folate, vitamin B12 levels, fasting insulin, glucose, total cholesterol, triglycerides, HDL, LDL particles, uric acid, creatinine and creatinine clearance were measured. Non-invasive ultrasound measurements of carotid IMT were performed. RESULTS: tHcy levels and carotid IMT were comparable between obese and non-obese subjects. Waist/hip ratio (WHR) was related to tHcy and carotid IMT. Hyperhomocysteinemic subjects (tHcy >19.2 micromol/l) had greater WHR than normo-homocysteinemic subjects. Both tHcy levels and carotid IMT were higher in male subjects both in obese and non-obese subjects. No association was observed between insulin resistance and tHcy and carotid IMT. Renal function and abdominal obesity were significant predictors of plasma tHcy levels. CONCLUSIONS: We concluded that, in obese subjects who are free from atherosclerosis and impaired renal function, plasma tHcy levels do not differ from healthy subjects. Plasma tHcy concentrations are not related to carotid IMT in obese subjects during the non-atherogenic stage. Although no significant difference was observed between insulin-resistant and insulin-sensitive subjects compared to the plasma tHcy levels, the relationship between tHcy levels and some components of the insulin resistance syndrome may support the opinion that tHcy may be considered a component of the insulin resistance syndrome.

Adult↗
PubMed2005

[Diabetic muscle infarction-an orthopedic disease pattern?].

Diabetic muscle infarction (DMI) is a largely unfamiliar disease. It affects mainly patients around 40 years of age with long-standing diabetes and concomitant end-organ complications. The symptoms represent a classic pattern of a musculoskeletal disease with muscle pain without trauma, swelling, and functional impairment. Although its short-term prognosis is good, with improvement of the symptoms over weeks or months under analgesia and rest, a high recurrence rate of up to 60% can be observed. Additionaly, the long-term survival of patients after DMI is reduced mostly due to major vascular complications. Since many diabetic patients are in orthopedic care for musculoskeletal disorders, the orthopedic surgeon should be aware of this disease to avoid unnecessary invasive diagnostic procedures and initiate suitable therapy. Furthermore, a better knowledge of the disease could lead to definite conclusions regarding its real incidence and aid in establishing new therapeutic measures for prophylaxis and better long-term survival.

Diabetic Angiopathies↗
PubMed2005

Sequential pulmonary effects of radiotherapy detected by functional and radiological end points in women with breast cancer.

AIMS: To determine the pulmonary effects of locoregional irradiation on clinical and sub-clinical radiographic and functional end points in women with breast cancer, and whether the course of these end points is affected by laterality. MATERIALS AND METHODS: Twenty patients (10 irradiated on the left side and 10 irradiated on the right side) were prospectively evaluated for changes in pulmonary function tests, Tc-99m DTPA (diethylenetriamine pentaacetic acid) lung clearance scintigraphy and high-resolution computed tomography (HRCT) at 6, 16 and 52 weeks after radiotherapy. Tc-99m DTPA clearance, expressed as the biological half-time, T(1/2), was computed from the time-activity curves for 10 min for each lung. The irradiated lung volume was calculated for each patient. RESULTS: The mean irradiated lung volume was 6.4% +/- 2 (range 3-11%) for the entire population. In the whole study population, two (10%) patients, who were irradiated on the left side, had mild symptomatic radiation pneumonitis in the follow-up period. There was a statistically significant gradual reduction in all pulmonary function test values during the follow-up period. For patients irradiated on the left side, Tc-99m DTPA clearance T(1/2) values were statistically significantly decreased during the follow-up period (P = 0.03), but the decrease was not statistically significant for patients irradiated on the right side (P = 0.62). Tc-99m DTPA clearance T(1/2) values were statistically significantly decreased in the irradiated lung compared with the opposite lung, and no improvement was seen at week 52 after radiotherapy. The number of patients with changes on HRCT scans increased after radiotherapy, reaching a maximum at 16 weeks, when 80% of patients had changes. There was subsequent partial recovery 52 weeks after radiotherapy. CONCLUSION: Locoregional irradiation for breast cancer may cause sub-clinical irreversible impairment of radiological and functional pulmonary parameters. The increase in clearance rate of Tc-99m DTPA may be more prominent for patients with left-sided breast cancer.

Adult↗
PubMed2005

Imaging of hepatic arterial anatomy for depicting vascular variations in living related liver transplant donor candidates with multidetector computed tomography: comparison with conventional angiography.

AIMS: The aim of this study was to evaluate liver arteries to depict variations by using multidetector computed tomography (CT) in donor candidates for living related liver transplantation. METHODS: Computed tomographic hepatic angiography was carried out using a multidetector 16-row CT scanner (Sensation 16; Siemens) in 48 candidates between April 2003 and August 2004. Multidetector CT was performed after intravenous injection of 150 mL of contrast material at a rate of 4 mL/s. Arterial phase images were acquired after contrast injection. Afterward, maximum intensity projections and volume-rendered images were produced from the axial image data. Twenty-eight of these patients underwent conventional catheter angiography. RESULTS: Excellent arterial opacification was shown on multidetector CT scans in all patients; arteries up to tertiary branches were identified with CT. Of 28 patients who had both multidetector CT angiography and conventional angiography, only a branch of hepatic artery originating from superior mesenteric artery that supplied the posterior segment of the right lobe was not identified on multidetector CT angiography. In 27 donors, hepatic arterial anatomy depicted at multidetector CT angiography was identical to that at conventional angiography. We identified hepatic vascular variants in 22 of 48 patients with multidetector CT. The most common arterial variant was an accessory hepatic artery arising from the left gastric artery. CONCLUSIONS: Preoperative imaging evaluation of hepatic vascular anatomy is crucial for surgical planning in living related transplant donors. Multidetector CT is useful to depict hepatic arterial anatomy with high accuracy.

Adolescent↗
PubMed2005

[Vertebroplasty--basic science, indications and technique].

INTRODUCTION: Vertebroplasty is a relatively new procedure for the treatment of vertebral body fractures of different origin. Due to early promising results the rate of performed procedures increases constantly. Indeed an increasing number of partially severe complications are reported. A summary of the existing findings seems therefore necessary. METHODS: On the basis of a medline inquiry important aspects of vertebroplasty in the fields of basic science, diagnostics, indications, contraindications, technique, results and complications were compiled. RESULTS: Especially for the field of indications, possible longterm effects and for the "ideal" technique open questions exist, mainly due to missing prospective, randomized long-term clinical trials. CONCLUSIONS: A final assessment of the significance of vertebroplasty for osteoporotic fractures in comparison to conservative treatment is actually not possible. In contrast vertebroplasty is a therapeutical option for malignomas in selected cases.

Biomechanical Phenomena↗
PubMed2005

Outcome following radiotherapy for loco-regionally recurrent non-small cell lung cancer.

Local and regional recurrence of non-small cell lung cancer is reported to occur in 13-20% of treatment failures after resection. Reported post-recurrent median survival following radiotherapy ranges from 9 to 14 months. This study examines survival following radiotherapy alone for patients with loco-regionally recurring non-small cell lung cancer after initial surgery. Fifty-five patients, receiving radiotherapy at Westmead Hospital between 1979 and 1997, were eligible for study. Data were collected retrospectively by reviewing patient records. The end-point was overall survival. Symptom control was also recorded. Prognostic factors for analysis included age, sex, original presenting stage, disease-free interval (DFI), performance status, site of recurrence, treatment intent and dose. The median overall survival was 11.5 months (95% confidence interval: 8.1-13.0). Survival following treatment with radical intent was 26 months compared to 10.5 months for patients treated with palliative intent (P = 0.025). There was no significant difference in survival for short (< or = 2 years) or long DFI, performance status, radiation dose, age, sex, site of recurrence or stage. Most patients (55%) had partial or complete resolution of symptoms. Radiotherapy results in overall post-recurrence median survival of nearly 1 year, consistent with previous published data. Radical treatment intent predicts better prognosis as a result of patient selection and higher dose. Radiotherapy is effective at palliating symptoms of this disease.

Aged↗
PubMed2005

Exogenous melatonin delays gastric emptying rate in rats: role of CCK2 and 5-HT3 receptors.

Pineal hormone melatonin is proposed as a potential treatment for severe sleep disturbances, and various gastrointestinal disorders. It was shown that melatonin increases intestinal motility and influences the activity of myoelectric complexes of the gut. The aim of the study was to evaluate the mechanisms of the effect of exogenous melatonin on gastric emptying rate. Male Sprague-Dawley rats were fitted with gastric cannulas under anesthesia. The rate of gastric emptying of saline was determined after instillation into the gastric fistula, from the volume and phenol red concentrations recovered after 5 min. Melatonin injected intraperitoneally (ip; 0.001-100 mg/kg) delayed gastric emptying rate of saline at 3 and 10 mg/kg doses. When administered ip 15 min before melatonin (10 mg/kg) injections, CCK2 (L-365,260, 1 mg/kg) or 5-HT3 receptor (ramosetrone, 50 microg/kg) blockers abolished melatonin-induced delay in gastric emptying rate, while the blockade of sympathetic ganglia (bretylium tosylate, 15 mg/kg) significantly reduced the delay in gastric emptying rate. CCK1 receptor blocker (L-364,718, 1 mg/kg) had no significant effect on the delaying action of melatonin. Our results indicate that pharmacological doses of melatonin delay gastric emptying via mechanisms that involve CCK2 and 5-HT3 receptors. Moreover, it appears that exogenous melatonin inhibits gastric motility in part by activating sympathetic neurons.

Adrenergic Antagonists↗
PubMed2004

A new dorsal modular fixation device allows a modified approach in cervical and cervico-thoracic neoplastic lesions.

INTRODUCTION: The aim of this study was to improve the management of cervical tumor osteolysis. A new modular rod-screw implant system for the posterior instrumentation of the occipito-cervical, cervical and cervico-thoracic spine (neon occipito cervical system, Ulrich, Germany) is available since 2000. K-wire guided pedicle screws are used, CT-guided instrumentation is possible. Previous studies have demonstrated increased biomechanical stability compared to established posterior cervical systems. METHODS: The cervical and cervico-thoracic spine of 8 patients (6 males, 2 females, mean age 62 years, range 48-77 years) with osteolysis due to plasmocytoma (n=2), bronchial (n=2), mammary (n=2), esophageal (n=1) and pancreatic (n=1) carcinoma were instrumentated since June 2001. RESULTS: A stable fixation without loosening or failure of the fixation system was achieved in all cases. No impairment of the neurogical status was observed. CONCLUSION: Posterior instrumentation of the cervical spine including the occipito-cervical and the cervico-thoracic region with a new modular angle-stable rod-screw implant system offers good stabilization and allows simultaneous decompression. Since tumor masses are predominantly located in the anterior portion of the spine blood loss can be reduced.

Aged↗
PubMed2004

Driving and patients with brain tumours: a postal survey of neurosurgeons, neurologists and radiation oncologists.

This study was aimed at evaluating the consistency of driving advice given by treating clinicians to patients diagnosed with brain tumours. Secondary aims include assessing the awareness of current driving guidelines and whether or not there was a need for more specific guidelines in this group of patients. This was undertaken utilizing a scenario-based postal survey. The results show an overall poor consistency in the answers provided for each case scenario. 73.1% respondents were not aware of any current driving guidelines. Of those who were aware of driving guidelines, 67.7% wanted more specific guidelines to be developed. Possible explanations for this are a lack of awareness of the existence of any driving guidelines and a lack of objective criteria in the current driving guidelines. The authors recommend that the current driving guidelines be comprehensively distributed to clinicians who treat patients with brain tumours, as well as forming a multi-disciplinary working party to develop more specific and objective driving guidelines.

Adult↗
PubMed2004

Seroprevalence and some correlates of Helicobacter pylori at adult ages in Gülveren Health District, Ankara, Turkey.

The purpose of the study was to detect the frequency and distribution of Helicobacter pylori in the Gülveren Health Centre service area among residents aged between 25 and 64 years and to evaluate the relation of H. pylori infections with general health status, socioeconomic status, and some lifestyle habits. The study included a representative sample of Gülveren Health Centre residents, aged between 25 and 64 years. A stratified random sample of 1672 individuals was selected for study purposes out of 10,569 residents, stratified by age and gender. A standardized questionnaire was completed for all study participants using a face-to-face interview and all participants were invited to the local health centre for a thorough physical examination and blood tests. The overall prevalence of H. pylori was found to be 77.5 % among individuals aged between 25 and 64 years. The frequency of H. pylori was higher among individuals with low socioeconomic status; those who migrated to Ankara after the age of 20 years; members of large families (household size of 4 or above); non-alcohol drinkers; and those who regularly drink tea.

Adult↗