Original Article ADDICTIVE
DISORDERS
Suicide Probability Among Tramadol
Addicts
Ahmed Saad Mohamed, MD, Nesreen M. Ibrahim, MD,
Ayat Mazloum, MSc, Rehab M. Naguib, MD, and Lobna Azzam, MD
Abstract
Objectives:
Tramadol addiction is one of the major addiction
problems in growing countries, especially in Egypt.
Moreover, there is a strong relation between suicidal-
ity and addiction even after exclusion of personality
disorders; the burden of suicide adds to the burden
of substance abuse in those individuals and their
families.
Materials and Methods:
A cross-sectional descriptive study was conducted on
72 tramadol-dependent patients who were recruited
randomly in this study from the addiction outpatient
clinic of Okasha Institute of Psychiatry of Ain Shams
University, after obtaining an informed consent. They
are assessed by (1) Structured Clinical Interview for
Diagnostic and Statistical Manual of Mental Disor-
ders, 4th Edition Axis I Disorders for diagnosis of
substance use disorder, (2) Structured Clinical Inter-
view for Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition Axis II Disorders for exclusion
of personality disorders, (3) suicide probability scale,
and (4) Addiction Severity Index.
Results:
Regarding suicidal probability, 44.44% of the sample
showed risk of suicide, which was severe among
19.44%, moderate among 11.11%, and mild among
13.89% of the sample. Regarding “Addiction Severity
Index,” most patients had no real medical problem. In
the employment domain, 38.89% had a slight prob-
lem. In the drug use domain, 80.56% had a moderate
problem.
There is a significant relation between the degree
of medical, drug use, and legal problem and the
severity of suicidal risk. Moreover, the longer dura-
tion of addiction and the advanced age of patients are
risk factors for suicidal probability.
Conclusions:
There is a suicide probability among tramadol ad-
dicts. The duration of tramadol use could be consid-
ered a strong risk factor for suicide, as the longer the
duration of tramadol, the higher the suicidal risk.
Key Words: addiction, substance use disorder, trama-
dol use, suicidality, suicidal ideations
(Addict Disord Their Treatment
2021;20:217–225)
T he magnitude of the problem of
substance use in Egypt has been
growing lately.1 Up to 40% of patients
seeking treatment for substance de-
pendence report a history of suicide
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217
& THEIR
TREATMENT
Volume 20, Number 4
December 2021
attempt(s).2 United Nation reported that
Middle East and North Africa regions
were among the highest areas of trama-
dol/opiate abuse over the world.3
Among all used drugs, tramadol, a
centrally acting analgesic, was the most
heavily used illicit drug in the past decade,
considered by some as youth plague, not
only in Egypt but also in the neighboring
countries. According to the Ministry of
Health report on drug addiction in Cairo,
1.4 million people were addicted to drugs,
particularly tramadol.4 The link between
the risk of suicide and substance use is
well documented.5
Suicide is one of the known mortality
causes among opiate abusers, as attempt to
suicide in opiate-dependent individuals is
nearly 13.5 times more common than that
in the general population.6
Li et al7 showed that the risk of
suicide was 7.5 times higher in males and
11.7 times higher in females with a mental
or substance use disorder (SUD) compared
with males and females with no disorder.
The rate of completed suicide among ad-
dicts is 2 to 3 times higher than among the
males who are not addicts. Among wom-
en, the use of substances increases the risk
of suicide for 6.5 to 9 times compared with
women with no addiction.8
Substance-dependent individuals From the Okasha Institute of
entering into treatment programs are at Psychiatry, Ain Shams
elevated risk for suicide attempts for University, Cairo, Egypt.
various reasons. They often engage into
treatment with depressive symptoms The authors declare no conflict
and a number of severe stressors (rela- of interest.
tionship loss, job loss, health, and finan- Correspondence to: Rehab M.
cial problems) that not only impel them Naguib, MD, Okasha Institute of
Psychiatry, Ain Shams
to seek treatment but also put them at
University, Cairo 11835, Egypt
higher risk for suicidal behavior.6 (e-mails: rehab.naguib@gmail.
Suicidal addicts tend to have certain
emotional problems and behavioral prob-
lems that strongly affect their activities,
com; rehab_naguib@med.asu.
edu.eg).
Copyright © 2020 Wolters
primarily as impulsive reactions and the Kluwer Health, Inc. All rights
inability to control certain behavior.9 reserved.
DOI: 10.1097/ADT.0000000000000222
218 ADDICTIVE Saad Mohamed et al
DISORDERS
& THEIR
TREATMENT
Volume 20, Number 4
December 2021 Suicide is closely linked to sub-
stance use. Therefore, it is very important
to confirm the factors that influence the
possibility of suicidal behavior. As pre-
sented in the literature data, older men
who use drugs are at greater risk for
suicide attempts than younger addicts.10
Tramadol abuse is steadily increas-
ing in Egypt and Middle East countries.
The prevalence of tramadol in these
counties could be attributed to its cheap
price and wide availability. The abuse of
tramadol overdose has also been asso-
ciated with violence and fights, road
accidents, and self-induced unintention-
al injuries. Egypt has one of the highest
death rates owing to road accidents, and
tramadol abuse is associated with 18.7%
of these accidents.11,12
There is also evidence of biological
correlates. Constant substance consumption
alters neurotransmitter levels, including
serotonin receptor,13 which has also been
related to suicidal behavior14 and enhanced
impulsivity, a precipitating factor for suicidal
behavior.15 A polymorphism in the seroto-
nin receptor allele has been related to crav-
ing in alcohol and suicidal behavior.16
Although tramadol was approved in
Egypt for marketing as a safe analgesic in
1995,17 the Egyptian Ministry of Health
listed it as a controlled substance in Octo-
ber 2002; moreover, the Egyptian Ministry
of Health moved it from schedule 3 to 1 for
highly addictive substances in 2012.18
So, we conducted this work to
detect suicidal probability among trama-
dol addicts and study the effect of se-
verity of substance on suicidality.
AIM OF THE WORK
This aim was to assess the suicidal
probability among tramadol addicts and
to correlate the severity of addiction
with suicide probability.
MATERIALS AND METHODS
Type of the Study
This was a descriptive cross-sectional
study.
Place of the Study
The study was conducted at Oka-
sha Institute of Psychiatry, Ain Shams
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University Hospitals. The institute is
located in Eastern Cairo and serves a
catchment area of about the third of
Greater Cairo. It serves both urban and
rural areas, including areas around
Greater Cairo as well.
Ethical Consideration
Written informed consent was ob-
tained from each subject participating in
the study after the study was explained
to them, and they were ensured about
the confidentiality of the information. It
was clearly explained that participation
in the study or withdrawal at any time
would not interfere with the treatment
process. This study was approved from
the Ethical Committee of Neuropsychia-
try Department and the Ethical Commit-
tee of Ain Shams University.
Study period: the study was con-
ducted for 7 months.
Study population: A total of 72
tramadol-dependent patients were re-
cruited randomly in this study from the
Addiction Outpatient Clinic of Okasha
Institute of Psychiatry of Ain Shams
University during the period between
November 2018 and July 2019. Trama-
dol was their only substance or the main
substance of abuse, diagnosed as SUD
according to Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edi-
tion criteria.
Inclusion Criteria
The following were the inclusion
criteria:
(1) Patients fulfilling the criteria of SUD
according to Diagnostic and Statisti-
cal Manual of Mental Disorders,
Fifth Edition using Structured Clin-
ical Interview for Diagnostic and
Statistical Manual of Mental Disor-
ders, 4th Edition Axis I Disorders
(SCID-I).
(2) Age ranged from 18 to 60 years.
(3) Both male and female sexes.
(4) Able to give consent.
(5) Patients with tramadol dependence
as main substance of abuse or only
substance of abuse.
Exclusion Criteria
The following were the exclusion
criteria:
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(1) Refusal to sign the informed con-
sent.
(2) Presence of any serious concomitant
general medical condition or neuro-
logical illness.
(3) Presence of any other psychiatric
illness.
(4) Borderline personality disorder and
histrionic personality disorder.
Procedure of the Study
All participants involved in the
study were subjected to the following:
(1) Full history taking, including socio-
demographic data; family history of
addiction, suicide, and mental illness;
past history of suicidal attempt; mo-
tive of tramadol abuse; and whether it
was the only or main substance
of abuse.
(2) SCID-I,19 Arabic version20: it was
used for excluding psychiatric co-
morbidity and diagnosing SUD.
(3) Structured Clinical Interview for Di-
agnostic and Statistical Manual of
Mental Disorders, 4th Edition Axis
II Disorders (SCID-II),21 Arabic
version22: it was used for exclusion
of personality disorders.
(4) Suicide Probability Scale (SPS),23
Arabic version24: it was used to as-
sess the probability of suicide.
(5) Addiction Severity Index (ASI)25: it
was used for assessment of prob-
lems presented by patients with
SUDs. An Arabic version was used
in this study.26
Sampling Size
The sample size was calculated
using PASS program, setting alpha error
5% and power at 80% with confidence
interval width 0.13. Results from a pre-
vious study27 showed that suicide rate
among opioid addict is 8.6%. On the
basis of this, the needed sample is
72 cases.
Statistical Analysis
Statistical presentation and anal-
ysis of the present study was con-
ducted, using the mean, SD, χ2 and
analysis of variance (ANOVA) tests by
SPSS V20.
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Suicidality in Tramadol Addiction ADDICTIVE 219
DISORDERS
& THEIR
TREATMENT
Volume 20, Number 4
(1) Mean = x/n, where x = sum of obser- December 2021
vations and n = number of observa-
tions.
(2) SD: SD = 1x-x2–n.
χ2 Test the hypothesis that the row
and column variables are independent,
without indicating strength or direction
of the relationship. Pearson χ2 and like-
lihood-ratio χ2 were used.
ANOVA test was done according to
the computer program SPSS for Win-
dows. ANOVA test was used for com-
parison among different times in the
same group in quantitative data.
The statistical probability was set
as follows:
P-value > 0.05 = nonsignificant.
P-value ≤ 0.05 = significant.
P-value <0.01 = highly significant.
RESULTS
This is a descriptive cross-sectional
study conducted in the outpatient clinic
of Okasha Institute of Psychiatry Ain
Shams University Hospitals between
November 2018 and July 2019.
During the study period, 72 pa-
tients with tramadol use disorder were
recruited according to the inclusion and
exclusion criteria mentioned before.
Regarding Suicidal Probability
Scale and Its Severity
In the view of subscales signifi-
cance among the whole study group,
52.78%, 33.33%, 38.89%, and 25% had
significant hopelessness, suicidal idea-
tion, hostility, and negative self-image,
respectively (Table 1).
Among the study group, the ma-
jority (55.56%) were subclinical on SPS
with no probability of suicide.
However, 44.44% of the sample
showed risk of suicide, which was severe
among 19.44%, moderate among 11.11%,
and mild among 13.89% of the sample.
Regarding the ASI
Most patients had no real medical
problem, with no need for treatment
among 63.89%, followed by 13.89%
with a slight medical problem, 13.89%
with moderate medical problem, where-
as those with considerable problem and
220 ADDICTIVE Saad Mohamed et al
DISORDERS
& THEIR
TREATMENT
Volume 20, Number 4
December 2021 In the social domain, most patients
TABLE 1. Suicidal Probability Scale and (38.89%) had a slight problem, where
Degree Among Sample treatment is probable not necessary,
Suicide Probability Scale N (%) followed by 27.78% with no real prob-
lem, 19.44% with moderate problem,
Hopelessness significance and 13.89% with considerable problem
Nonsignificant 34 (47.22) where treatment is necessary.
Significant 38 (52.78) All sample showed no real prob-
lem regarding psychiatric domain.
Suicidal ideation significance
Nonsignificant 48 (66.67)
Significant 24 (33.33)
Negative self-image significance
Regarding Correlation Between
Nonsignificant 44 (61.11)
Addiction Severity and Suicide
Significant 28 (38.89)
Probability
There is a significant relation be-
Hostility significance tween the degree of medical problem
Nonsignificant 54 (75.00) and the severity of suicidal risk
Significant 18 (25.00) (χ2 = 29.219, P<0.001): 12 cases (37.50%)
Suicide Probability Scale degree had no real medical problem and no treat-
Subclinical (nonsignificant) 40 (55.56)
ment indicated, of which 8 cases (66.66%)
were with mild probability of suicide.
Mild 10 (13.89) However, 10 cases (31.35%) had consid-
Moderate 8 (11.11) erable medical problem, and all of them
Severe 14 (19.44) (100%) were with severe probability of
Total 72 (100.00) suicide (Table 3).
There is a significant relation between
the degree of drug use problem and the
necessary treatment were the least severity of suicidal risk (χ2 = 19.238,
(8.33%) (Table 2). P = 0.001): 18 cases (56.25%) had no real
On the employment domain, most drug use problem and no treatment indi-
patients (38.89%) had a slight problem, cated, of which 10 (55.55%) were mild on
with probable need for treatment, fol- SPS. Although 12 cases (37.50%) had mod-
lowed by 30.56% with no real problem, erate drug use problem, among which 10
27.78% with moderate problem, whereas cases (83.33%) were with severe probability
those with considerable problem and nec- of suicide.
essary treatment were the least (2.78%). There is a significant relation be-
In the drug use domain, most pa- tween the degree of legal problem and
tients (80.56%) were with moderate the severity of suicidal risk (χ2 = 21.905,
problem with some treatment indicated, P = 0.005): 12 cases (37.50%) had no real
followed by 16.67% with slight problem legal problem and no treatment indi-
and 2.78% with no real problem. cated, of which 8 (66.66%) were mild
Regarding alcohol domain, most on SPS. However, 8 cases (18.75%) had
patients (50%) were with no real problem considerable legal problem, of which 6
with no treatment indicated, followed by cases (75%) were with severe probabil-
25% with slight problem, 13.89% with ity of suicide.
moderate problem, and 11.11% with Regarding other domains includ-
considerable problem where treatment ing occupational, alcohol, social, and
is necessary. psychiatric, they had no statistically sig-
In the legal domain, most patients nificant correlation with probability of
(66.67%) had no real problem, with no suicide.
treatment indicated, followed by 11.11% Clinically, as long as they have
with a slight problem, 11.11% with medical, drug use, and legal problems,
moderate problem, 8.33% with consid- the probability of suicide increases be-
erable problem where treatment is nec- cause of lack of judgment, planning, and
essary, whereas the least (2.78%) were problem-solving skills among addicts,
having extreme problems, where treat- and they try suicide to escape as an
ment is absolutely necessary. immediate solution or impulsive act.

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 Suicidality in Tramadol Addiction ADDICTIVE 221
DISORDERS
& THEIR
TREATMENT
Volume 20, Number 4
December 2021
TABLE 2. Showing Addiction Severity Index Among Study Group

Addiction Severity Index (Degree of Impairment) N (%)

Medical
No real problem no treatment indicated 46 (63.89)
Slight problem treatment probably not necessary 10 (13.89)
Moderate problem some treatment indicated 10 (13.89)
Considerable problem treatment necessary 6 (8.33)
Employment
No real problem no treatment indicated 22 (30.56)
Slight problem treatment probably not necessary 28 (38.89)
Moderate problem some treatment indicated 20 (27.78)
Considerable problem treatment necessary 2 (2.78)
Drug use
No real problem no treatment indicated 2 (2.78)
Slight problem treatment probably not necessary 12 (16.67)
Moderate problem some treatment indicated 58 (80.56)
Alcohol
No real problem no treatment indicated 36 (50.00)
Slight problem treatment probably not necessary 18 (25.00)
Moderate problem some treatment indicated 10 (13.89)
Considerable problem treatment necessary 8 (11.11)
Legal
No real problem no treatment indicated 48 (66.67)
Slight problem treatment probably not necessary 8 (11.11)
Moderate problem some treatment indicated 8 (11.11)
Considerable problem treatment necessary 6 (8.33)
Extreme problem treatment absolutely necessary 2 (2.78)
Social
No real problem no treatment indicated 20 (27.78)
Slight problem treatment probably not necessary 28 (38.89)
Moderate problem some treatment indicated 14 (19.44)
Considerable problem treatment necessary 10 (13.89)
Psychiatric
No real problem no treatment indicated 72 (100.00)

Regarding Correlation Between DISCUSSION

Suicidal Probability and Addiction
History
Table 4 relates age, age of onset,
and duration of addiction to the severity
of suicidal risk; those with mean age of
46.25 years (F = 3.588, P = 0.041) and
longer duration (F = 5.377, P = 0.010)
of addiction (mean 13.5 y) have severe
suicidal probability.
Clinically, the long duration of ad-
diction and the advance in age of patients
are risk factors for suicidal probability.
There is growing abuse of trama-
dol in some African and West Asian
countries. Abuse of tramadol has be-
come a serious problem in Egypt and
abuse has also been reported by Iran,
Jordan, Lebanon, Libya, Mauritius, and
Saudi Arabia.28
Abuse of tramadol has been re-
ported to be a serious problem in Egypt
during 2011 and 2012. Information
available to the International Narcotics

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 222
Volume 20, Number 4
TREATMENT

DISORDERS
ADDICTIVE Saad Mohamed et al
December 2021

& THEIR
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TABLE 3. The Correlation Between Severity of Addiction and Degree of Suicidal Probability
Suicide Probability Scale Degree [N (%)]

Addiction Severity Index (Degree of Impairment) Mild Moderate Severe Total χ2 P

Medical
No real problem no treatment indicated 8 (80.00) 4 (20.00) 0 12 (37.50) 29.219 <0.001
Slight problem treatment probably not necessary 2 (20.00) 2 (25.00) 0 4 (12.50)
Moderate problem some treatment indicated 0 2 (25.00) 4 (28.57) 6 (18.75)
Considerable problem treatment necessary 0 0 10 (71.43) 10 (31.25)
Employment
No real problem no treatment indicated 2 (20.00) 0 0 2 (6.25) 10.504 0.105
Slight problem treatment probably not necessary 4 (40.00) 4 (50.00) 2 (14.29) 10 (31.25)
Moderate problem some treatment indicated 4 (40.00) 4 (50.00) 10 (71.43) 18 (56.25)
Considerable problem treatment necessary 0 0 2 (14.29) 2 (6.25)
Drug use
No real problem no treatment indicated 10 (10.00) 6 (75.00) 2 (14.29) 18 (56.25) 19.238 0.001
Slight problem treatment probably not necessary 0 0 2 (14.29) 2 (6.25)
Moderate problem some treatment indicated 0 2 (25.00) 10 (71.43) 12 (37.50)
Alcohol
No real problem no treatment indicated 4 (40.00) 2 (25.00) 0 6 (18.75) 10.034 0.123
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Slight problem treatment probably not necessary 4 (40.00) 2 (25.00) 4 (28.57) 10 (31.25)
Moderate problem some treatment indicated 2 (20.00) 2 (25.00) 4 (28.57) 8 (25.00)
Considerable problem treatment necessary 0 2 (25.00) 6 (42.86) 8 (25.00)
Legal
No real problem no treatment indicated 8 (80.00) 4 (50.00) 0 12 (37.50) 21.905 0.005
Slight problem treatment probably not necessary 17 (62.00) 8 (20.00) 2 (17.29) 4 (12.50)
Moderate problem some treatment indicated 0 2 (25.00) 4 (28.57) 6 (25.00)
 Suicidality in Tramadol Addiction ADDICTIVE 223
DISORDERS
& THEIR
TREATMENT
0.102 Volume 20, Number 4
Control Board (INCB) suggests that tra- December 2021

X
madol was smuggled into Egypt from
China and India.29
Our study revealed that the psycho-
logical dimensions within the suicidal
risk, as measured by SPS (hopelessness,
18.712

suicidal ideations, negative self-image,

x

and hostility), were found to be signifi-

cant: significant hopelessness (52.78%),
followed by significant negative self-
image (38.89%), suicidal ideation signifi-
32 (100.00)

cance (33.33%), and hostility significance

8 (18.75)

10 (31.25)
6 (18.75)
6 (18.75)
10 (31.25)
2 (6.25)

(25%).
To the authors’ knowledge, SPS
was recruited for the first time in Egypt
on tramadol addicts. However, some
studies may have examined the suicide
behaviors in heroin addicts.
Bao-Liang et al30 in a Chinese study
14 (100.00)
6 (42.86)

4 (28.57)
4 (75.57)
6 (42.86)

examined the suicidality in heroin ad-

27 (56)

dicts on methadone treatment and

agreed with our results regarding the
suicidal risk, where lifetime suicide at-
tempt was significantly associated with
injecting heroin before methadone main-
tenance treatment (odds ratio = 2.92).
8 (100.00)
2 (25.00)
2 (25.00)
2 (25.00)
2 (25.00)

According to the ASI, the consid-

15 (32)

erable problem in the studied group was

0

the most in the social domain (13.89%),

medical domain (13.89%), legal domain
(13.89%), alcohol domain (11.11%), and
the least considerable domain was em-
ployment (2.78%). The drug use and
10 (100.00)
2 (20.00)

8 (80.00)

2 (20.00)

psychiatric domains were not found to

8 (12)

be with considerable problem.

0
0

Opposing results were obtained

by Shahin and colleagues, who stated
that the considerable degree of impair-
ment in ASI domains were as follows:
medical (5%), occupational (41%), drug
intake (52%), alcohol (20%), legal (5%),
Slight problem treatment probably not necessary
Extreme problem treatment absolutely necessary

social (62.5%), and psychiatry (75%).

Moderate problem some treatment indicated

This can be explained by the fact that

Considerable problem treatment necessary

Considerable problem treatment necessary

the latest mentioned study was among

No real problem no treatment indicated

No real problem no treatment indicated

patients with polysubstance abuse not

necessarily tramadol included, and also
the duration of addiction among them
was 1 to 11 years.1
Moreover, our current study ex-
cluded any psychiatric comorbidity.
The current study revealed a sig-
nificant correlation between severity of
suicidal probability among tramadol ad-
dicts and considerable degree of impair-
ment of each of medical, drug intake,
Psychiatry

and legal domains by 100%, 83.33%, and

Social

75%, respectively. This is contrary to a

study by Dragisic and colleagues, which

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224 ADDICTIVE Saad Mohamed et al
DISORDERS
& THEIR
TREATMENT
Volume 20, Number 4
December 2021
TABLE 4. Correlation Between and Degree of Suicidal Probability and Each of Age of Study
Group, Age of Onset of Tramadol and Duration of Addiction
Suicide Probability Scale Degree
Mild Moderate
Age (y)
Range 31-49 34-55
Mean ± SD 38.143 ± 5.447 42.000 ± 8.055
Age of onset of tramadol use (y)
Range 25-53 24-39
Mean ± SD 32.800 ± 10.779 32.750 ± 5.874
Duration of addiction (y)
Range 2-5 5-10
Mean ± SD 6.857 ± 1.875 9.400 ± 5.147
reported that there was no statistical
significance correlation between legal
domain of ASI and severity of suicidal
probability. This can be explained by
the fact that the previously mentioned
study was conducted among intrave-
nous addicts.31
The present study has shown that
there was a significant relationship be-
tween long duration of tramadol use and
suicidal probability and could be con-
sidered as a strong risk factor for suicide
among tramadol addicts. Our findings
are in accordance with Guiherme et al32
who conducted a large longitudinal
study and found that the long history
of substance use more strongly predicts
suicide attempts in addicts.
The present study has also shown
that there is a significant relationship
between older age of tramadol addicts
and suicidal probability. Our results are
supported by Dragisic and colleagues
who found that older men who use
drugs are at greater risk for suicide
attempts than younger addicts. This
can be explained by the more problems
(financial, social, employment, and le-
gal) tramadol addicts could be subjected
to from long duration of use, causing
(hopelessness, suicidal ideations, and
negative self-evaluation), which may
lead them to suicidal attempt.31
CONCLUSIONS
Our cross-sectional descriptive
study revealed that there is a suicide
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Analysis of Variance
Severe F P
39-58 3.588 0.041
46.250 ± 7.611
26-40 0.164 0.850
31.286 ± 4.531
6-23 5.377 0.010
13.500 ± 6.782
probability among tramadol addicts.
The duration of tramadol use could be
considered a strong risk factor for sui-
cide in tramadol addicts, as the longer
the duration of tramadol, the higher the
suicidal risk.
Study Limitations
The short duration, small size of
sample, and being a single-center (one
hospital) study, suggests that it may not
be representative of all tramadol addicts
in Egypt.
The tools used in the study were
time consuming and this was the main
cause of noncooperativeness of trama-
dol addicts either from the beginning or
shortly after participating in the study.
Recommendations
Careful and systematized psychiat-
ric assessment should be done for these
cases, along with including a protocol
for suicide prevention in those suscepti-
ble groups to be included in the reha-
bilitation programs.
It is recommended to have more
research that can explain the occurrence
of suicide among tramadol addicts.
ACKNOWLEDGMENTS
Our thanks go for the patients who
were motivated to volunteer in the re-
search to enrich the scientific knowl-
edge and improve the clinical practices.
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