{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T07:24:26Z","timestamp":1783409066114,"version":"3.54.6"},"reference-count":41,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2023,6,3]],"date-time":"2023-06-03T00:00:00Z","timestamp":1685750400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2023,6,3]],"date-time":"2023-06-03T00:00:00Z","timestamp":1685750400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100009827","name":"Alexandria University","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100009827","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Nephrol"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Introduction<\/jats:title>\n                <jats:p>Uremic pruritus (UP) is a common and distressing symptom in end stage renal disease (ESRD) patients. Many approaches have been tested to improve UP without a clear success. We aimed to assess the effect of sertraline on UP in hemodialysis (HD) patients.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>This research is a double-blinded, placebo-controlled, multicentric randomized clinical trial which included sixty patients maintained on regular HD. Patients were allocated to receive sertraline 50\u00a0mg twice daily or placebo for 8\u00a0weeks. The Visual analogue scale (VAS) and the 5-D itch scale were used to assess pruritus before and after the course of treatment.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>At study end in sertraline group, there was a significant decrease from baseline findings in the VAS score (<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001), and the 5-D itch scale (<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001). On the other hand, in placebo group the VAS score showed a slight non-significant decrease (<jats:italic>p<\/jats:italic>\u2009=\u20090.469), and the 5-D scale (<jats:italic>p<\/jats:italic>\u2009=\u20090.584) increased from baseline measurements. The percentage of patients with severe and very severe pruritus decreased significantly in the sertraline group in both scores [(VAS score: <jats:italic>p<\/jats:italic>\u2009=\u20090.004), (5-D itch score: <jats:italic>p<\/jats:italic>\u2009=\u20090.002)] with no significant change in the placebo group [(VAS score: <jats:italic>p<\/jats:italic>\u2009=\u20090.739), (5-D itch scale: <jats:italic>p<\/jats:italic>\u2009=\u20090.763)]. There was a significant positive relation between the VAS and 5-D itch scores and serum urea with <jats:italic>p<\/jats:italic> value of 0.002 and 0.001 respectively, and serum ferritin with <jats:italic>p<\/jats:italic> value of\u2009&lt;\u20090.001 with both.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>Patients treated with sertraline had a significant improvement in pruritus as compared with those who received placebo suggesting a potential role for sertraline to treat uremic pruritus in HD patients. Larger randomized clinical trials are needed to confirm these findings.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Trial registration<\/jats:title>\n                <jats:p>ClinicalTrials.gov NCT05341843. First registration date: 22\/04\/2022.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12882-023-03212-3","type":"journal-article","created":{"date-parts":[[2023,6,3]],"date-time":"2023-06-03T09:02:02Z","timestamp":1685782922000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["The effectiveness of sertraline in alleviating uremic pruritus in hemodialysis patients: a randomized clinical trial"],"prefix":"10.1186","volume":"24","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7656-7116","authenticated-orcid":false,"given":"Mohamed Mamdouh","family":"Elsayed","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iman Ezzat","family":"Elgohary","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heidi Hesham Said","family":"Abdelhamid","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sherif Aziz","family":"Zaki","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,6,3]]},"reference":[{"key":"3212_CR1","unstructured":"Zemaitis MR, Foris LA, Chandra S, Bashir K. Uremia Treasure Island. FL: StatPearls Publishing; 2020."},{"issue":"12","key":"3212_CR2","doi-asserted-by":"publisher","first-page":"2000","DOI":"10.2215\/CJN.03280317","volume":"12","author":"HC Rayner","year":"2017","unstructured":"Rayner HC, Larkina M, Wang M, Graham-Brown M, van der Veer SN, Ecder T, et al. International comparisons of prevalence, awareness, and treatment of pruritus in people on hemodialysis. Clin J Am Soc Nephrol. 2017;12(12):2000\u20137.","journal-title":"Clin J Am Soc Nephrol"},{"issue":"7","key":"3212_CR3","volume":"11","author":"MZ Satti","year":"2019","unstructured":"Satti MZ, Arshad D, Javed H, Shahroz A, Tahir Z, Ahmed MMH, et al. Uremic Pruritus: prevalence and impact on quality of life and depressive symptoms in hemodialysis patients. Cureus. 2019;11(7): e5178.","journal-title":"Cureus"},{"issue":"10","key":"3212_CR4","doi-asserted-by":"publisher","first-page":"699","DOI":"10.3390\/medicina55100699","volume":"55","author":"IU Rehman","year":"2019","unstructured":"Rehman IU, Chohan TA, Bukhsh A, Khan TM. Impact of pruritus on sleep quality of hemodialysis patients: a systematic review and meta-analysis. Medicina (Kaunas). 2019;55(10):699.","journal-title":"Medicina (Kaunas)"},{"issue":"3","key":"3212_CR5","doi-asserted-by":"publisher","first-page":"1000","DOI":"10.1159\/000490689","volume":"43","author":"CH Weng","year":"2018","unstructured":"Weng CH, Hu CC, Yen TH, Hsu CW, Huang WH. Uremic Pruritus is Associated with two-year cardiovascular mortality in long term hemodialysis patients. Kidney Blood Press Res. 2018;43(3):1000\u20139.","journal-title":"Kidney Blood Press Res"},{"issue":"3","key":"3212_CR6","doi-asserted-by":"publisher","first-page":"i23","DOI":"10.1093\/ckj\/sfab200","volume":"14","author":"S Schricker","year":"2021","unstructured":"Schricker S, Kimmel M. Unravelling the pathophysiology of chronic kidney disease-associated pruritus. Clin Kidney J. 2021;14(3):i23\u201331.","journal-title":"Clin Kidney J"},{"issue":"4","key":"3212_CR7","doi-asserted-by":"publisher","first-page":"685","DOI":"10.1038\/ki.2013.454","volume":"87","author":"T Mettang","year":"2015","unstructured":"Mettang T, Kremer AE. Uremic pruritus. Kidney Int. 2015;87(4):685\u201391.","journal-title":"Kidney Int"},{"issue":"3","key":"3212_CR8","doi-asserted-by":"publisher","first-page":"277","DOI":"10.1016\/j.det.2018.02.007","volume":"36","author":"R Reszke","year":"2018","unstructured":"Reszke R, Szepietowski JC. End-stage renal disease chronic itch and its management. Dermatol Clin. 2018;36(3):277\u201392.","journal-title":"Dermatol Clin"},{"key":"3212_CR9","doi-asserted-by":"publisher","first-page":"205435812095402","DOI":"10.1177\/2054358120954024","volume":"7","author":"CE Martin","year":"2020","unstructured":"Martin CE, Clotet-Freixas S, Farragher JF, Hundemer GL. Have we just scratched the surface? a narrative review of uremic pruritus in 2020. Can J Kidney Health Dis. 2020;7:2054358120954024.","journal-title":"Can J Kidney Health Dis"},{"issue":"8","key":"3212_CR10","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0071404","volume":"8","author":"MJ Ko","year":"2013","unstructured":"Ko MJ, Wu HY, Chen HY, Chiu YL, Hsu SP, Pai MF, et al. Uremic pruritus, dialysis adequacy, and metabolic profiles in hemodialysis patients: a prospective 5-year cohort study. PLoS ONE. 2013;8(8): e71404.","journal-title":"PLoS ONE"},{"issue":"4","key":"3212_CR11","doi-asserted-by":"publisher","first-page":"100","DOI":"10.3390\/ph11040100","volume":"11","author":"Z Xie","year":"2018","unstructured":"Xie Z, Hu H. TRP Channels as Drug Targets to Relieve Itch. Pharmaceuticals (Basel). 2018;11(4):100.","journal-title":"Pharmaceuticals (Basel)"},{"key":"3212_CR12","doi-asserted-by":"publisher","first-page":"205435811982839","DOI":"10.1177\/2054358119828391","volume":"6","author":"C Ho","year":"2019","unstructured":"Ho C, Martinusen D, Lo C. A review of cannabis in chronic kidney disease symptom management. Can J Kidney Health Dis. 2019;6:2054358119828391.","journal-title":"Can J Kidney Health Dis"},{"key":"3212_CR13","doi-asserted-by":"publisher","first-page":"205435811667534","DOI":"10.1177\/2054358116675345","volume":"3","author":"D Jaiswal","year":"2016","unstructured":"Jaiswal D, Uzans D, Hayden J, Kiberd BA, Tennankore KK. Targeting the opioid pathway for uremic pruritus: a systematic review and meta-analysis. Can J Kidney Health Dis. 2016;3:2054358116675345.","journal-title":"Can J Kidney Health Dis"},{"issue":"5","key":"3212_CR14","doi-asserted-by":"publisher","first-page":"638","DOI":"10.1053\/j.ajkd.2017.05.018","volume":"70","author":"E Simonsen","year":"2017","unstructured":"Simonsen E, Komenda P, Lerner B, Askin N, Bohm C, Shaw J, Tangri N, Rigatto C. Treatment of uremic pruritus: a systematic review. Am J Kidney Dis. 2017;70(5):638\u201355.","journal-title":"Am J Kidney Dis"},{"issue":"1","key":"3212_CR15","doi-asserted-by":"publisher","first-page":"45","DOI":"10.2340\/00015555-0553","volume":"89","author":"S St\u00e4nder","year":"2009","unstructured":"St\u00e4nder S, B\u00f6ckenholt B, Sch\u00fcrmeyer-Horst F, Weishaupt C, Heuft G, Luger TA, et al. Treatment of chronic pruritus with the selective serotonin re-uptake inhibitors paroxetine and fluvoxamine: results of an open-labelled, two-arm proof-of-concept study. Acta Derm Venereol. 2009;89(1):45\u201351.","journal-title":"Acta Derm Venereol"},{"issue":"3","key":"3212_CR16","doi-asserted-by":"publisher","first-page":"666","DOI":"10.1002\/hep.21553","volume":"45","author":"MJ Mayo","year":"2007","unstructured":"Mayo MJ, Handem I, Saldana S, Jacobe H, Getachew Y, Rush AJ. Sertraline as a first-line treatment for cholestatic pruritus. Hepatology. 2007;45(3):666\u201374.","journal-title":"Hepatology"},{"issue":"9","key":"3212_CR17","doi-asserted-by":"publisher","first-page":"949","DOI":"10.3390\/medicina57090949","volume":"57","author":"A Kubanek","year":"2021","unstructured":"Kubanek A, Paul P, Przybylak M, Kanclerz K, Rojek JJ, Renke M, et al. Use of Sertraline in Hemodialysis Patients. Medicina (Kaunas). 2021;57(9):949.","journal-title":"Medicina (Kaunas)"},{"issue":"1","key":"3212_CR18","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1111\/hdi.12540","volume":"22","author":"M Pakfetrat","year":"2018","unstructured":"Pakfetrat M, Malekmakan L, Hashemi N, Tadayon T. Sertraline can reduce uremic pruritus in hemodialysis patient: A double blind randomized clinical trial from Southern Iran. Hemodial Int. 2018;22(1):103\u20139.","journal-title":"Hemodial Int"},{"key":"3212_CR19","doi-asserted-by":"publisher","first-page":"114","DOI":"10.1097\/BLO.0b013e3180342802","volume":"457","author":"I Alexander","year":"2007","unstructured":"Alexander I. Electronic medical records for the orthopaedic practice. Clin Orthop Relat Res. 2007;457:114\u20139.","journal-title":"Clin Orthop Relat Res"},{"issue":"3","key":"3212_CR20","doi-asserted-by":"publisher","first-page":"587","DOI":"10.1111\/j.1365-2133.2009.09586.x","volume":"162","author":"S Elman","year":"2010","unstructured":"Elman S, Hynan LS, Gabriel V, Mayo MJ. The 5-D itch scale: a new measure of pruritus: The 5-D itch scale. Br J Dermatol. 2010;162(3):587\u201393.","journal-title":"Br J Dermatol"},{"issue":"1","key":"3212_CR21","doi-asserted-by":"publisher","first-page":"117","DOI":"10.1053\/j.ajkd.2016.07.031","volume":"69","author":"JS Scherer","year":"2017","unstructured":"Scherer JS, Combs SA, Brennan F. Sleep Disorders, Restless Legs Syndrome, and Uremic Pruritus: Diagnosis and Treatment of Common Symptoms in Dialysis Patients. Am J Kidney Dis. 2017;69(1):117\u201328.","journal-title":"Am J Kidney Dis"},{"issue":"1","key":"3212_CR22","first-page":"15","volume":"42","author":"G Gilsanz","year":"2022","unstructured":"Gilsanz G, Ossorio Gonz\u00e1lez M, Selgas GR. Pruritus in dialysis patients. Review and new perspectives Nefrologia. 2022;42(1):15\u201321.","journal-title":"Review and new perspectives Nefrologia"},{"issue":"6","key":"3212_CR23","doi-asserted-by":"publisher","DOI":"10.1002\/brb3.964","volume":"8","author":"XD Wang","year":"2018","unstructured":"Wang XD, Yang G, Bai Y, Feng YP, Li H. The behavioral study on the interactive aggravation between pruritus and depression. Brain Behav. 2018;8(6): e00964.","journal-title":"Brain Behav"},{"key":"3212_CR24","doi-asserted-by":"publisher","DOI":"10.1155\/2012\/363901","volume":"2012","author":"M Shakiba","year":"2012","unstructured":"Shakiba M, Sanadgol H, Azmoude HR, Mashhadi MA, Sharifi H. Effect of sertraline on uremic pruritus improvement in ESRD patients. Int J Nephrol. 2012;2012: 363901.","journal-title":"Int J Nephrol"},{"issue":"8","key":"3212_CR25","doi-asserted-by":"publisher","first-page":"966","DOI":"10.1089\/jpm.2012.0504","volume":"16","author":"KY Chan","year":"2013","unstructured":"Chan KY, Li CW, Wong H, Yip T, Chan ML, Cheng HW, et al. Use of sertraline for antihistamine-refractory uremic pruritus in renal palliative care patients. J Palliat Med. 2013;16(8):966\u201370.","journal-title":"J Palliat Med"},{"key":"3212_CR26","doi-asserted-by":"publisher","first-page":"749","DOI":"10.1093\/ndt\/gfi204","volume":"21","author":"M Kimmel","year":"2006","unstructured":"Kimmel M, Alscher DM, Dunst R, et al. The role of micro-inflammation in the pathogenesis of uraemic pruritus in haemodialysis patients. Nephrol Dial Transplant. 2006;21:749\u201355.","journal-title":"Nephrol Dial Transplant"},{"key":"3212_CR27","doi-asserted-by":"publisher","first-page":"1558","DOI":"10.1093\/ndt\/17.9.1558","volume":"17","author":"T Mettang","year":"2002","unstructured":"Mettang T, Pauli-Magnus C, Alscher DM. Uraemic pruritus\u2014New perspectives and insights from recent trials. Nephrol Dial Transplant. 2002;17:1558\u201363.","journal-title":"Nephrol Dial Transplant"},{"issue":"3","key":"3212_CR28","doi-asserted-by":"publisher","first-page":"917","DOI":"10.1016\/j.intimp.2013.09.020","volume":"17","author":"M Taraz","year":"2013","unstructured":"Taraz M, Khatami MR, Dashti-Khavidaki S, Akhonzadeh S, Noorbala AA, Ghaeli P, et al. Sertraline decreases serum level of interleukin-6 (IL-6) in hemodialysis patients with depression: results of a randomized double-blind, placebo-controlled clinical trial. Int Immunopharmacol. 2013;17(3):917\u201323.","journal-title":"Int Immunopharmacol"},{"issue":"5","key":"3212_CR29","doi-asserted-by":"publisher","first-page":"469","DOI":"10.2340\/00015555-3164","volume":"99","author":"E Weisshaar","year":"2019","unstructured":"Weisshaar E, Szepietowski JC, Dalgard FJ, Garcovich S, Gieler U, Gim\u00e9nez-Arnau AM, et al. European S2k guideline on chronic pruritus. Acta Derm Venereol. 2019;99(5):469\u2013506.","journal-title":"Acta Derm Venereol"},{"key":"3212_CR30","doi-asserted-by":"crossref","unstructured":"Fishbane S, Jamal A, Munera C, Wen W, Menzaghi F; KALM-1 Trial Investigators. A phase 3 trial of Difelikefalin in hemodialysis patients with pruritus. N Engl J Med. 2020;382(3):222\u2013232.","DOI":"10.1056\/NEJMoa1912770"},{"issue":"3","key":"3212_CR31","doi-asserted-by":"publisher","first-page":"281","DOI":"10.4103\/IJPC.IJPC_212_19","volume":"26","author":"A Ravindran","year":"2020","unstructured":"Ravindran A, Kunnath RP, Sunny A, Vimal B. Comparison of Safety and Efficacy of pregabalin versus gabapentin for the treatment of uremic pruritus in patients with chronic kidney disease on maintenance haemodialysis. Indian J Palliat Care. 2020;26(3):281\u20136.","journal-title":"Indian J Palliat Care"},{"key":"3212_CR32","doi-asserted-by":"crossref","unstructured":".Zhao JH, Zhu QS, Li YW, Wang LL. Determinants of the intensity of uremic pruritus in patients receiving maintenance hemodialysis: A cross-sectional study. PLoS One. 2021;16(1):e0245370.","DOI":"10.1371\/journal.pone.0245370"},{"issue":"2","key":"3212_CR33","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0246765","volume":"16","author":"CG Bolanos","year":"2021","unstructured":"Bolanos CG, Pham NM, Mair RD, Meyer TW, Sirich TL. Metabolomic analysis of uremic pruritus in patients on hemodialysis. PLoS ONE. 2021;16(2): e0246765.","journal-title":"PLoS ONE"},{"issue":"12","key":"3212_CR34","doi-asserted-by":"publisher","first-page":"2164","DOI":"10.1093\/ndt\/17.12.2164","volume":"17","author":"G Virga","year":"2002","unstructured":"Virga G, Visentin I, La Milia V, Bonadonna A. Inflammation and pruritus in haemodialysis patients. Nephrol Dial Transplant. 2002;17(12):2164\u20139.","journal-title":"Nephrol Dial Transplant"},{"key":"3212_CR35","first-page":"1","volume":"7","author":"K Ramakrishnan","year":"2013","unstructured":"Ramakrishnan K, Bond TC, Claxton A, et al. Clinical characteristics and outcomes of end-stage renal disease patients with self-reported pruritus symptoms. Int J Nephrol Renovasc Dis. 2013;7:1\u201312.","journal-title":"Int J Nephrol Renovasc Dis"},{"key":"3212_CR36","doi-asserted-by":"publisher","first-page":"42","DOI":"10.1186\/s12882-019-1234-0","volume":"20","author":"NA Ersoy","year":"2019","unstructured":"Ersoy NA, Akyar \u0130. Multidimensional pruritus assessment in hemodialysis patients. BMC Nephrol. 2019;20:42.","journal-title":"BMC Nephrol"},{"key":"3212_CR37","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1016\/j.semnephrol.2015.06.009","volume":"35","author":"SA Combs","year":"2015","unstructured":"Combs SA, Teixeira JP, Germain MJ. Pruritus in kidney disease. Semin Nephrol. 2015;35:383\u201391.","journal-title":"Semin Nephrol"},{"key":"3212_CR38","doi-asserted-by":"publisher","first-page":"11","DOI":"10.2147\/IJNRD.S108045","volume":"10","author":"S Shirazian","year":"2017","unstructured":"Shirazian S, Aina O, Park Y, et al. Chronic kidney disease-associated pruritus: impact on quality of life and current management challenges. Int J Nephrol Renovasc Dis. 2017;10:11\u201326.","journal-title":"Int J Nephrol Renovasc Dis"},{"issue":"2","key":"3212_CR39","first-page":"964","volume":"18","author":"T Hu","year":"2019","unstructured":"Hu T, Wang B, Liao X, Wang S. Clinical features and risk factors of pruritus in patients with chronic renal failure. Exp Ther Med. 2019;18(2):964\u201371.","journal-title":"Exp Ther Med"},{"key":"3212_CR40","doi-asserted-by":"publisher","first-page":"1410","DOI":"10.2215\/CJN.00100110","volume":"5","author":"VS Mathur","year":"2010","unstructured":"Mathur VS, Lindberg J, Germain M, Block G, Tumlin J, Smith M, et al. A longitudinal study of uremic pruritus in hemodialysis patients. Clin J Am Soc Nephrol. 2010;5:1410\u20139.","journal-title":"Clin J Am Soc Nephrol"},{"issue":"8","key":"3212_CR41","volume":"13","author":"MS Asghar","year":"2021","unstructured":"Asghar MS, Avinash F, Singh M, Siddiqui MA, Hassan SA, Iqbal S, et al. Associated Factors With Uremic Pruritus in Chronic Hemodialysis Patients: A Single-Center Observational Study. Cureus. 2021;13(8): e17559.","journal-title":"Cureus"}],"container-title":["BMC Nephrology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12882-023-03212-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12882-023-03212-3\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12882-023-03212-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,6,3]],"date-time":"2023-06-03T09:03:20Z","timestamp":1685783000000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcnephrol.biomedcentral.com\/articles\/10.1186\/s12882-023-03212-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,6,3]]},"references-count":41,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2023,12]]}},"alternative-id":["3212"],"URL":"https:\/\/doi.org\/10.1186\/s12882-023-03212-3","relation":{},"ISSN":["1471-2369"],"issn-type":[{"value":"1471-2369","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,6,3]]},"assertion":[{"value":"18 December 2022","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 May 2023","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"3 June 2023","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The study protocol was approved by the medical ethics committee of the Faculty of Medicine, Alexandria University. This study was conducted in accordance with the ethical guidelines of the Declaration of Helsinki and informed consent was obtained from each patient.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no conflicts of interest.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"155"}}