• Open access
  • Published: 02 January 2024

Outcomes of the combined lifestyle intervention CooL during COVID-19: a descriptive case series study

  • Ester Janssen 1   na1 ,
  • Nicole Philippens 1 ,
  • Stef Kremers 1 &
  • Rik Crutzen 2  

BMC Public Health volume  24 , Article number:  40 ( 2024 ) Cite this article

Metrics details

The main objective of this nationwide study was to investigate changes in outcomes between baseline and eight months of participation regarding anthropometrics, control and support, physical activity, diet attentiveness, perceived fitness, sleep, and stress of participants in Coaching on Lifestyle (CooL), a Combined Lifestyle Intervention (CLI). Since the study took place when the COVID-19 pandemic emerged, we defined a subobjective, i.e., to address changes in intervention outcomes over time while participants were exposed to pandemic-related restrictions and uncertainties.

Data were collected from November 2018 until October 2021 at different locations across the Netherlands from 1824 participating adults, meeting the CLI inclusion criteria. We collected a broad set of data on anthropometrics (weight, body mass index (BMI), waist circumference), control and support (self-mastery, social support), physical activity (sedentary time on least/most active days, physical active minutes), diet attentiveness (attentiveness to meal composition, awareness to amounts of food and attentiveness to consuming), alcohol consumption, smoking, perceived fitness (perceived health, fitness when waking, fitness during daytime, impact daily stress), sleep and stress.

All outcomes showed improvements after eight months compared to baseline except for social support and smoking. Large effect sizes were found on weight (0.57), waist circumference (0.50) and perceived health (0.50). Behaviour patterns showed small to large effect sizes, with the largest effect sizes on diet attentiveness (i.e., attentiveness to meal composition (0.43), awareness to amounts of food (0.58) and attentiveness to consuming (0.39)). The outcomes of participants pre COVID-19 versus during COVID-19 showed differences on self-mastery (p = 0.01), sedentary time (all underlying constructs p < 0.02), perceived fitness (all underlying constructs p < 0.02) and stress (p < 0.01).

The results show that small changes in multiple behaviours go along with a large positive change in perceived health and health-related outcomes in line with the lifestyle coaching principles. In addition, participating in CooL may have protected against engaging in unhealthier behaviour during the pandemic.

Trial registration

As the CLI is considered usual health care that does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act, this study was exempt from trial registration.

Peer Review reports

In 2021, 50% of Dutch people aged 18 and older, were overweight and approximately 14% were obese [ 1 ]. Obesity is considered a disease according to the World Health Organisation [ 2 ] and the Dutch Health council [ 3 ]. Furthermore, obesity is associated with an increased risk for many other diseases, such as diabetes mellitus type 2, cardiovascular disease, various cancers [ 4 , 5 , 6 ], mental health problems (e.g., depression) [ 7 ] and a diminished quality of life [ 8 ]. Consensus has been reached internationally [ 9 ] on the importance of an integrated approach to target overweight and obesity, including limited energy intake, healthy food choices and regular physical activity. The Dutch national guidelines added stress management and sleep as essential elements to tackle overweight and obesity [ 10 ].

As of January 2019, Combined Lifestyle Interventions (CLIs) are part of basic health insurance in the Netherlands. A CLI is an intervention for people with overweight or obesity, stimulating weight reduction by promoting sustained healthier behaviour. In the intervention, participants are coached towards a healthier lifestyle. The CLIs exist of a combination of group and individual sessions and cover at least the topics of healthy diet, physical activity and behavioural change. Based on the Dutch national guidelines on the treatment of obesity and the relationship between stress and obesity and sleep and obesity, both lifestyle themes are also considered an essential part of the CLI [ 11 , 12 ].

The inclusion criteria for CLIs in the Netherlands are: [ 1 ] being 18 or older; (2a) having a Body Mass Index (BMI) between 25 and 30 kg/m2 in combination with a waist circumference over 88 cm for women or over 102 cm for men, or with comorbidity (increased risk of) diabetes or cardiovascular disease, osteoarthritis or sleep apnea), or (2b) having a BMI > 30 kg/m2 regardless of waist size or comorbidity; and [ 3 ] being sufficiently motivated to complete the two-year intervention as judged by the referrer (e.g., the general practitioner or practice nurse) and the CLI-coach.

The Coaching on Lifestyle intervention (CooL) is one of six CLIs that are approved by the Dutch Institute for Public Health and Environment (in Dutch: RIVM) for being effective in facilitating weight reduction. The intervention has two phases: an intensive behavioural change phase of eight months, followed by a less-intensive 16-month behavioural maintenance phase summing up to a total duration of two years. Baseline measurements are done during intake, followed by measurements after the behavioural change phase (8 months) and after the behavioural maintenance phase (24 months). So far, research on the CLI has been done on Slimmer [ 13 ] and Beweegkuur [ 14 ] and on CooL in a regional setting: the CooL-pilot and the healthyLIFE study [ 15 , 16 ]. All CLI’s are showing comparable weight loss as well as additional benefits in positive health [ 16 ], metabolic risk factors [ 13 , 14 ] and/or health related behaviour [ 13 , 14 , 15 , 16 ]. The main objective of the present nationwide study is to look at the changes in outcomes of participants in the behavioural change phase of the CooL-intervention on the topics of anthropometrics (weight, BMI, waist circumference), control and support (self-mastery, social support), physical activity (sedentary time on least/most active days, physical active minutes), diet attentiveness (attentiveness to meal composition, awareness to amounts of food and attentiveness to consuming), alcohol consumption, smoking, perceived fitness (perceived health, fitness when waking, fitness during daytime, impact daily stress), sleep and stress (see Table  1 ).

The COVID-19 pandemic entered the Netherlands in February 2020, resulting in stringent COVID-19 measures that came into effect from March 2020 onwards. Obesity is considered a risk factor for a COVID-19 infection but also a risk factor for a more severe disease course resulting in higher mortality rates [ 17 , 18 ]. Both Dutch and international studies found that 70–90% of all COVID-19 patients admitted to Intensive Care Units with respiratory failure, were overweight [ 19 , 20 ]. The immune system of patients with obesity is less capable of fighting viruses and bacteria. Lifestyle improvements lead to improvements in the immune system [ 21 ], which might be an additional reason for deployment of the CLI for overweight people.

We expected the pandemic, and the measures aimed to curb it, to have an impact on the CLI-participants [ 22 ]. As the severity of the disease course increased for overweight patients, it led to more stress in this high-risk population [ 23 ]. The COVID-19 pandemic resulted for some people in a higher sense of urgency to start with a weight reduction program. Others, on the other hand, were hesitant to attend group meetings due to their high-risk profile related to a potential COVID-19 infection. The consequences of the COVID-19 restrictions such as a temporary curfew, closing (sports) facilities, working at home and wearing face masks in public areas led to feelings of loneliness but also impacted lifestyle routines [ 23 ]. In addition, CLIs were initially temporarily suspended, pending guidelines on restricted human contact. Some CLI-groups were permanently closed, others restarted in digital modus, providing additional challenges for both coaches and participants. COVID-19 shifted priority for caretakers and participants as there were shortages of staff due to sickness or deployment in more critical roles, impacting availability and attendance of (digital) CLI-sessions [ 24 ].

Therefore, the subobjective of this study was to investigate the effect of COVID-19 implications and restrictions on the intervention outcomes.

CooL-intervention

The CooL-intervention aims for higher perceived quality of life, healthier eating habits (including a focus on healthy food choices, food quantities and eating with attention), more physical activity, less sedentary behaviour, attention for high quality sleep and relaxation, and positive changes in physical outcomes such as weight, BMI and waist circumference. CooL includes an intake (1 h), a behavioural change phase of eight months (phase 1) with a follow-up phase of sixteen months (phase 2). The intervention consists of a combination of individual sessions (six hours in total, divided in 6 to 12 sessions depending on the preferences of the participant and coach) and 16 group sessions (1, 5 h each) all led by one and the same coach. Phase 1 and phase 2 both include eight group sessions with a higher density of sessions in phase 1 compared to phase 2 [ 15 ].

The CooL-intervention is an open CLI, which means that CooL has no strict protocol. Instead, it allows CooL-coaches to adapt the intervention to their target audience and context, within certain boundaries and restrictions. Participants pursue a predefined set of final objectives on knowledge and skills, supported by the coach who secures the main effective elements (e.g., goal setting, mobilizing social support, modelling, self-management and self-monitoring) of the CooL-intervention in implementation [ 15 ]. The CooL-coaches are trained and licensed professionals who coach participants to take responsibility for their personal lifestyle changes by addressing motivation, personal objectives and behavioural change. Participants are stimulated and supported towards more self-steering and self-management by identifying, mapping and putting personal health related behaviour into action. The main objective is to coach and activate participants to a sustained healthier lifestyle in line with their individual needs and goals.

CooL-intervention during COVID-19

The COVID-19 implications and restrictions resulted in adaptations in the way CooL was offered to participants. Some participants finalized the first eight months of CooL completely, before COVID-19 broke out in the Netherlands, others participated in CooL during the COVID-19 pandemic and measures. The first infection was detected in the Netherlands on February 27th, 2020, the first regional restrictions were imposed on March 6th and the ‘intelligent lockdown’ (a semi-lockdown with free human movement but restricted human contact) was introduced as of March 23th [ 25 ]. We used a cut-off date of April 1st, 2020, as participants finishing phase 1 of CooL before this date will have suffered limited to no impact on their lifestyle which cannot be guaranteed for participants finishing phase 1 of CooL after April 1st, 2020. By means of the cut-off date we distinguished between participants that were potentially impacted by COVID-19 while participating in CooL and participants that were not impacted by COVID-19.

The way in which CooL was offered, changed during the COVID-19 pandemic. These changes were inventoried by an additional survey among CooL-coaches and by adding questions related to COVID-19 to the existing CooL-questionnaire.

The open character of CooL provided ample opportunity for CooL-coaches to make adaptations to the content of the intervention, e.g., providing room for pressing topics like COVID-19 or COVID-19-related stress. In addition, the temporary expansion in the CLI-regulations in terms of health insurance coverage made it possible to offer CooL digitally instead of via face-to-face contact only [ 26 ].

Observations from daily practice showed that COVID-19 resulted in higher dropout rates, resulting in financial consequences for the coaches and motivational challenges for the remaining group members and the coach. Some CooL-coaches completely quit executing CooL due to uncertainty, loss of motivation and/or resistance to online coaching thereby leaving their participants no other option than to quit CooL. Others decided to start up CooL, as COVID-19 caused an income drop for self-employed coaches and the CLI offered a basic and stable income. This observed impact of COVID-19 on coaches and participants of CooL, gave rise to the initiation of this subobjective.

Study design and population

As CooL is part of regular health care, a control group receiving no treatment would be unethical, making a descriptive case series study the most appropriate study design in the Dutch context. The participants, all Dutch-speaking adults living in the Netherlands, were included from November 2018 until October 2021 at different locations throughout the Netherlands. Almost all participants met the inclusion criteria for participating in a CLI. In some cases (n = 5, 0.3%), BMI at baseline was below the inclusion threshold, potentially due to lifestyle changes in the time between participant’s application and the start of CooL. Since the waist circumference of these participants was above the threshold for inclusion, these cases were included.

Data collection

We used a questionnaire and anthropometric measurements to collect a broad set of data. The questionnaire was partly based on existing validated questionnaires [ 27 , 28 , 29 ], and partly based on input from a focus group session with the Dutch Association of Lifestyle coaches (BLCN) to define questions that match the scope and working method of the lifestyle coach with a strong focus on manageability of the questionnaire, as CooL is part of basic healthcare. The outcome measures we collected can be divided into the categories anthropometrics (i.e., weight/BMI and waist circumference), control and support (i.e., self-mastery and social support), physical activity (i.e., sedentary time on least/most active days and active minutes), diet attentiveness (attentiveness to meal composition, awareness to amounts of food and attentiveness to consuming), alcohol use and smoking, perceived fitness (i.e., perceived health, perceived fitness when waking, perceived fitness during daytime and impact of stress on daily functioning), sleep and stress.

During the course of the study, the questionnaire was adjusted with textual simplifications in both questions and answers preserving the original essence as much as possible and extended with additional questions covering changes in context (e.g., COVID-19). We collected information on the initiation of CooL during COVID-19, i.e., a digital start or a physical (face-to-face) start, and on the continuation mode of the sessions.

Data were collected at three time points during the CooL-intervention: at the beginning of the intervention, during the intake (T0); after 8 months, at completion of phase 1 of the intervention (T1); and after 24 months, at completion of the intervention (T2). Data from T2 were not yet available at the time of the analysis and are not presented in this article.

Demographics

At baseline, participants were asked to report their personal characteristics such as gender, date of birth, country of birth and highest completed education, marital status, living situation and occupational status. Educational level was categorized as low (i.e., no education, primary education or junior secondary education), intermediate (e.g., senior secondary education) and high (e.g., higher professional and vocational education or university) according to the definitions of the Dutch Central Bureau of Statistics [ 30 ]. The living situation was divided into living together with someone (married or cohabiting) with or without kids and living alone (divorced, unmarried, or widowed) with or without kids. The occupational status was categorized as: working (paid work, voluntary work or self-employed) and not working (homemaker, unemployed/job seeker, retired/in early retirement, disabled or student). Country of birth was categorized into Dutch or non-Dutch.

Anthropometrics

Normally anthropometric data (weight, length and waist circumference) are being measured by the CooL-coaches with professional equipment according to the guidelines provided by the Dutch Association of General Practitioners (Dutch: Nederlands Huisartsen Genootschap, NHG) [ 31 ]. Body weight (kg) was measured in kilogram, rounded off the nearest decimal. Height (m) was measured to the nearest centimetre without shoes. Waist circumference measurements were obtained to the nearest centimetre with a tape measure.

Control and support

Changes in self-management, of which self-mastery is an important aspect, are related to changes in quality of life and self-efficacy [ 32 ]. Self-mastery is defined by Pearlin as the extent to which one regards one’s life-chances as being under one’s own control in contrast to being fatalistically ruled [ 33 ]. The self-mastery questions in the questionnaire were based on the short version of the Pearlin Mastery Scale using four questions (for example “I have little control over the things that happen to me”) and a 5-point Likert scale ranging from strongly agree (1) to strongly disagree (5) [ 27 ]. To identify social support, we questioned the perceived support of close ones using a 5-point Likert scale ranging from no support at all (1) to a lot of support (5).

Physical activity

The outcome measurements on physical activity, diet and perceived fitness were defined in cooperation with the BLCN with the objective to capture the essence and map the desired outcomes of lifestyle coaching in a minimum set of questions. Physical activity was assessed with questions on sedentary behaviour, both on most and least active days (“What is the average number of hours you spent sitting on the day of the week you sit the most?”) and the number of physical activity minutes per day (“What is the average minutes per day that you are physically active (in minimum bouts of 10 minutes)?”).

Diet attentiveness, alcohol use and smoking

We defined questions on diet attentiveness, in line with the input of the BLCN, based on the knowledge that deliberate behaviour changes start with awareness. We used questions on the awareness of participants towards meal composition (How much attention do you usually pay to what you eat?) and meal quantities (How aware are you usually of the amount you eat?) and awareness during the actual consumption of food (With how much attention do you usually eat?) using a 5-point Likert scale from very little attention (1) to a lot of attention (5). In addition, we asked the number of units of alcohol consumed and units smoked per day.

Perceived fitness

Perceived fitness existed of questions, in line with the input of the BLCN, on perceived fitness when waking up and during the day, the impact of stress on daily functioning and on perceived health (i.e., feeling good about oneself, the extent of self-care invested and the perception of one’s general health). Questions were answered using a 5-point Likert scale, ranging from not good at all (1) to very good (5).

We defined a specific set of questions around the sub-constructs: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication and daytime dysfunction, analogous to the validated and widely used PSQI-questionnaire [ 28 ]. Each subconstruct was covered by one or two question(s) using a numerical value or a 4-point Likert scale, ranging from ‘never’ (1) to ‘three times per week or more frequently’ (4).

For stress, the validated Perceived Stress Scale questionnaire was used, which exists of ten questions using a 5-point Likert scale from never (1) to always (5) [ 29 ].

We used a brief survey for the lifestyle coach in retrospect to collect data on the way CooL was offered during COVID-19. The questions were related to the start date of the intervention derived from the date of the intake, the way the intervention was offered and the mode in which the intervention was started (e.g., starting in face-to-face mode versus digital mode). We used four categories to distinguish the way the intervention was offered: face-to-face sessions only, digital sessions only, a combination with more face-to face than digital sessions and a combination with more digital than face-to-face sessions.

As a first step, we recoded some of the variables to facilitate interpretation in the sense that a higher/positive score refers to a desirable trend and a lower/negative score to an undesirable trend in the variable. For constructs based on validated questionnaires (i.e., self-mastery, sleep and stress) we adopted the accompanying approach. Secondly, we performed an exploratory factor analysis using R software and calculated McDonald’s omega to assess the internal structure of items regarding the constructs perceived health (T0: 0.66, T1: 0.75), self-mastery (both T0 and T1: 0.71), sleep (T0: 0.76, T1: 0.74), stress (T0: 0.87, T1: 0.88) and motivation (T0: 0.25). These analyses justified summarizing the lifestyle constructs by item score means for all, except the construct motivation.

For all items and constructs, we ran descriptive analyses (e.g., means, standard deviations). Changes in outcome measures over time were analysed using paired t-tests (T1 versus T0). Effect sizes were calculated using Cohen’s d and the outcomes were interpreted in accordance with Lipsey’s guidelines for each pair of outcomes, i.e., an effect size smaller than or equal to 0.32 is considered small, an effect size between 0.33 and 0.55 is considered medium and an effect size of 0.56 or above is considered large [ 34 ]. To improve comprehensibility effect sizes are represented such that positive values represent change in the desired direction whereas negative values represent change in the undesired direction.

To be considered successful, the target for the CLI (including CooL) is a 5% weight loss after the two years intervention, as set by the Dutch Healthcare Institute (Dutch: Zorginstituut) based on the guidelines set up by the Dutch Institute for Quality in Health Care (Dutch: CBO) as well as their English counterpart (NICE) [ 35 ]. The data in this study covers the first phase of CooL only (8 months), still leaving 16 months to further extend weight loss. We categorized the outcomes on weight: 5% weight loss or more, between 0 and 5% weight loss, weight stabilization or weight gain to map the percentage of participants with weight loss.

Next, we split the dataset in two subgroups: we used the cut-off date of April 1st, 2020, to distinguish between the subgroups pre-COVID and during-COVID. The cut-off date was based on the date the intervention started and derived from that, the date the participants finished phase 1 of CooL. This distinction enabled comparison of differences from T0 to T1 between participants that were potentially impacted by COVID-19 and those that were not impacted by COVID-19. For all these differences we performed independent T-tests comparing subgroups. All T-tests were performed using SPSS- software (version 27). We used a threshold value of p = 0.05 for all t-tests. Missing data were excluded from the statistical analyses because these cases could not be included in the calculation of the differences between T0 and T1.

To explore the assumption that small behavioural changes sum up to medium and large effects in anthropometrics, a post-hoc sensitivity analysis was performed to compare the trend in changes (desired, neutral or undesired) in behaviour components to the trend in changes (desired, neutral or undesired) in the outcome components weight/BMI and waist circumference.

This study was submitted to and approved by the Research Ethics Committee of the Faculty of Health, Medicine and Life Sciences of Maastricht University (FHML-REC/2019/073). All participants gave their informed consent for their anonymised personal data to be used for research purposes.

Participants demographics

A total of 1824 adults participated between November 2018 and October 2021 (dataset A, see Fig.  1 ).

Of all participants a total of 28% were male and 72% female. This ratio is in line with the data from the national CLI-monitor [ 36 ]. Most participants (95%) were born in the Netherlands. Two third of the participants had a lower or intermediate level of education; 25% did not have a steady job (anymore) and over 70% of the participants were living together with a partner (Table  2 ).

Subgroups cool during COVID-19

We defined subgroups of participants that were potentially impacted by COVID-19 and participants that were not (see Table  3 ). A total of 120 participants (7%) finished phase 1 before April 1st, 2020. Most participants (n = 1667, 91%) finished the first phase of CooL after April 1st, 2020, which implies that those participants were potentially affected by the COVID-19 implications and measures when participating in CooL. Both subgroups of respondents are included in dataset B (see Fig.  1 ).

figure 1

Flowchart of study participants

From roughly a quarter of the participants (24%) with a runtime during COVID-19 we received information from the coaches on the way CooL was offered during COVID-19 by means of an additional survey (see Fig.  1 ). 80% of these participants started in face-to-face (physical) mode whereas 20% started digitally. Almost all participants received the individual and group sessions in CooL through a combination of physical and digital mode. Most participants received more physical than digital sessions (83% of the physical starters, 52% of the digital starters), followed by more digital than physical sessions (14% of the physical starters, 47% of the digital starters), 2% of all participants received physical sessions only and 0.5% digital sessions only.

Results on all items and constructs

In the result section all outcomes and effect sizes on the complete dataset (A) are mentioned. When comparing the outcomes of participants pre and during COVID-19 (dataset B) significant findings are mentioned in the text with the corresponding p-value. Table  4 displays all outcome measurements both on dataset A and dataset B including mean values and standard deviations as well as confidence intervals on changes in outcomes.

Weight, BMI and waist circumference all showed a decrease after eight months (T1) compared to baseline (T0). The BMI of the participants was on average 35.97 at T0 and decreased with 1.16 BMI-points at T1. The average weight loss was 3.44 kg at T1, corresponding to a 3.2% average weight loss per participant after eight months. In total 72% of the participants lost weight. 29% lost more than 5% at T1. The average waist circumference of the participants decreased from 116.3 cm at T0 to 112.4 cm at T1. The change in waist circumference demonstrated a medium effect size (0.50) at T1, whereas weight and BMI and showed a large effect size at T1 (0.57 and 0.58 respectively).

Participation in CooL during versus pre COVID-19 did not show a significant difference on weight, BMI or waist circumference of the participants.

Self-mastery showed a decrease at T1 compared to baseline with a small effect size (0.10) in the desired direction. Social support showed no change over time.

Differences in outcomes between participants pre versus during COVID-19 were present for self-mastery with a bigger change for participants pre COVID-19 (p = 0.01).

Sedentary time decreased at T1 both for least and most active days of the week: participants spent on average 49 min less sitting on least active and 34 min less sitting on most active days compared to baseline. The average daily active minutes (in minimum bouts of 10 min) increased from 95 min at T0 to on average 108 min at T1. The effect size on both sedentary (0.25 for least active days and 0.18 for most active days) and active time (0.15) was small.

Comparing the outcomes pre and during COVID-19: participants during COVID-19 showed a decrease in sedentary time compared to baseline whereas participants pre COVID-19 showed a small increase for both least active and most active days (p < 0.02). No difference between both subgroups could be detected on physical active minutes.

Diet attentiveness, alcohol and smoking

Over time the participants showed an increase in attentiveness for meal composition, awareness for the amounts of food selected and attentiveness when consuming food. In addition, the participants showed a decrease in alcohol consumption. The effect size on attentiveness for meal composition and consuming food was medium-sized (0.43 and 0.39 respectively), the effect size for the awareness of the amounts of food selected was large (0.58) and the effect size for the decrease in alcohol consumption was small (0.19) when comparing baseline to T1. Smoking showed no effect on T1 compared to baseline.

The outcomes of participants pre COVID-19 versus during COVID-19 showed no difference on the diet related outcomes, alcohol consumption or smoking.

The perceived fitness factors perceived health, feeling fit when waking up, feeling fit during the day and the impact of stress on daily functioning all showed an effect in the desired direction with a small effect size (between 0.05 and 0.28), except for perceived health which showed a medium effect size (0.50) at T1.

The subgroup comparison showed larger effects from baseline to T1 for participants pre COVID-19 compared to during COVID-19 on all perceived fitness factors (p < 0.02).

Sleep and stress

The constructs sleep and stress both showed a decrease at T1 compared to baseline with a small effect (0.30 and 0.23 respectively) in the desired direction.

The outcomes of participants pre COVID-19 showed a larger reduction at T1 in stress perception compared to the outcomes of participants during COVID-19 (p < 0.01). No differences were found between both subgroups on sleep.

Post-hoc sensitivity analysis

The post-hoc sensitivity analysis showed that on individual level, in general the trend in components related to behaviour (i.e., physical activity, diet attentiveness, sleep and stress) had a similar pattern as the trend in anthropometric outcomes except for smoking and sleep. In short, more physical active minutes, more attentiveness to diet and improved stress management are related to weight loss in CooL.

In this study we analysed changes in various outcomes on participants after eight months of the CooL-intervention as well as differences in outcomes between participants pre and during COVID-19. Looking at the changes in outcomes over eight months of CooL, the analyses showed positive changes compared to baseline. The largest effect sizes were found on weight, BMI, waist circumference, perceived health and diet attentiveness (i.e., attentiveness to meal composition, awareness to amounts of food and attentiveness to consuming). Changes in behaviour and perceived fitness varied between small and medium effect size, whereas changes in anthropometrics showed a medium to large effect size.

Encouraging participants to take responsibility for their personal lifestyle is an essential element of CooL. Participants prioritize their health-related behaviours and define personal actions. The consequence of this set-up is that all participants start working on a behavioural aspect of their choice, which may lead to changes that are averaged out when looking at a population level. The timeframe of this study only covers the first eight months of the intervention implying that participants might not yet have initiated changes in all health-related behavioural domains. Note that during the first eight months of the study, major changes were already found on anthropometrics and perceived health. It is plausible that these small behavioural changes together sum up to medium and large-sized changes in anthropometric outcomes and perceived health. The post-hoc sensitivity analysis gives support to the assumption that the behavioural changes correlate with changes in anthropometrics. Two exceptions are smoking and sleep: in many cases people that quit smoking, gain weight during the first few months of abstinence [ 37 ] and the relation between sleep-related behaviour and weight is likely to be more indirect (i.e., via hormonal pathways and other behaviours) [ 12 ].

The average weight loss per participant was 3.2%, with 29% of the participants losing 5% or more. This corresponds with a decrease of 1.16 points in BMI and an average decrease of 3.44 kg after the first eight months of CooL. Compared to previous research on the CooL-pilot [ 15 ], HealthyLIFE-study [ 16 ] (with respectively an average decrease in weight of 2.3 and 2.4 kg) and research on similar interventions [ 13 , 14 , 38 ], these results are promising. Future research on the two-year results is needed to determine the effect of the CooL-intervention on the total duration of 24 months.

The outcomes of participants pre COVID-19 versus during COVID-19 showed differences only on self-mastery (p = 0.01), sedentary time (all underlying constructs p < 0.02), perceived fitness (all underlying constructs p < 0.02) and stress (p < 0.01). The differences found are partly in line with previous research: a larger decrease of perceived stress when participating pre COVID-19, is in line with the findings of Ammar [ 39 ]. Ammar identified a negative effect on mental-wellbeing, on mood and feelings during COVID-19 [ 39 ]. Especially vulnerable populations have been found to show an increase in stress [ 40 , 41 ]. For alcohol usage and smoking two opposite outcomes were seen during COVID-19: an increase due to distress or boredom and a decrease in usage linked to prevention and health withstanding the threat of COVID-19 or limited access and resources [ 42 , 43 ]. On population level, increases in alcohol usage for some people even out with decreases in alcohol usage for others, leading on population level to changes in alcohol usage close to zero [ 42 ]. A similar reasoning for smoking could explain that no effect on alcohol and smoking was seen for the CooL-participants during COVID-19 [ 43 ]. However, the comparison of this intervention study in active participants with population-level observational studies should be done with great caution as participating in an intervention can trigger behaviour change on lifestyle related topics including alcohol and smoking.

There are also several findings that are not in line with previous research: firstly, research on the effect of COVID-19 on sleep in several European countries showed delayed sleep timing, more time spent in bed and impaired sleep quality [ 44 , 45 ]. It also showed large individual differences in perceived sleep quality mainly depending on pre-pandemic sleep quality. In general, negative affect and feelings of worry linked to COVID-19 restrictions, were associated with changes in sleep quality [ 44 , 45 ]. In contrast, the present study showed that the improvements in perceived sleep quality did not differ prior versus during COVID-19.

Secondly, other studies on the impact of COVID-19 on lifestyle-related behaviour have shown that most health behaviours were largely affected by the pandemic and its related measures. Regarding diet, Huber et al. [ 46 ] showed an increase in food consumption, especially for overweight people. Furthermore, the majority of studies have shown a decrease in physical activity and an increase in sedentary behaviour during COVID-19 lockdowns across several populations [ 25 , 47 , 48 ]. The CooL subgroup analysis showed no differences for both diet and physical activity between the runtime of CooL pre versus during COVID-19. The changes in sedentary time were even more desirable for participants in CooL during the pandemic. In times of a major pandemic consistency in behaviour and/or small improvements in behaviour are likely to be a huge win.

The effect of CooL on the three anthropometric outcomes was not affected by COVID-19 as the subgroup analyses showed no difference between participation in CooL pre or during COVID-19. This is a striking result given the outcomes of previous research on this topic: two studies on weight change during COVID-19 pandemic indicated an average weight gain of 1.5 to 2 kg [ 49 , 50 ], whereas an online questionnaire in The Netherlands even showed an average weight gain of 5.6 kilos [ 51 ]. Overall, the results of this study indicate that the effect on the anthropometric outcomes of the CooL-participants were not affected by COVID-19. Participating in the CooL-intervention may thus have protected against relapsing to unhealthier behaviour despite a decreased sense of self-mastery and increased stress.

Limitations and strengths

During the time of the study the questionnaire was subject to minor revisions. We intended to keep the scope of the questions and answers similar for all versions, but we cannot rule out an effect on the study outcomes. However, as with any observational study, differences in outcomes could also be due to differences in demographics, zeitgeist and the emergence of COVID-19.

The sudden emergence of COVID-19 was unforeseen and can be considered a limitation of the study as it impacted the intervention and outcomes in many ways. At the same time, it can be regarded as an opportunity to study the effects of a large-scale health promotion intervention during a pandemic.

The lack of a control group inhibits us to draw strong conclusions on the effectiveness of the intervention. Results indicate changes in outcomes over time, but inferences regarding intervention effectiveness need to be interpreted with caution.

Motivation was questioned using a scale derived from Self-Determination Theory with six questions. The exploratory factor analysis did not justify summarizing the motivational items in one construct by item score means. Consequently, we looked at these motivation items separately instead of using one summarizing construct, in line with Chemolli and Gagné [ 52 ]. However, this approach led to uninterpretable results. Anecdotal evidence collected by feedback from participants and coaches indicated that the motivational questions caused confusion and were considered difficult to interpret for participants. This led to a major revision of the measurement of this construct in a new version of the questionnaire for future data collection and research. Physical activity, diet attentiveness, smoking and alcohol use were asked in retrospective via questionnaires which entails the risk of overestimation. However, whenever possible we used multiple questions that allowed for cross-checking. In addition, we looked at the difference between T0 and T1, which probably led to an overestimation in both measurements, i.e., with less risk of overestimation in the change scores. Furthermore, we used the same measurements for these constructs in previous studies, supporting comparability.

Despite all attempts to collect additional data, we did not receive enough data to draw strong conclusions on the different ways of implementing CooL during COVID-19 (e.g., digital versus physical contact and starting in digital versus face-to-face mode) and only on whether it was implemented before or during COVID-19. In retrospect, we found that the ratio of participants who started before COVID-19 to those who started during COVID-19 was off balance, but this mainly reflects the number of participants who completed the first phase of CooL in a given period. To draw strong conclusions on the different ways of implementing CooL in digital mode, more data is needed on various implementation modes of CooL. A total of 37 participants in the overall dataset could not be assigned to the subgroups pre or during COVID-19 leading to slightly deviating average outcomes in the subsamples.

In normal conditions anthropometrics are measured by the CooL-coach in order to minimize self-report bias. As COVID-19 restrictions could have changed the measurement method, additional information was gathered from the CooL-coaches that were the main data suppliers (representing data of a quarter of the participants, n = 490). This information indicated that in general, physical measurements took place either by the coach or on a distance of 1.5 m under direct supervision of the coach.

Future recommendations

This study provides insights on the outcomes after participating eight months in CooL and on the possible influence of COVID-19 on the outcomes, but it also provides input on recommendations for future research on CooL and adaptations to the questionnaires used for CooL:

Validation research of the question on social support and the questions on diet attentiveness as well as the newly constructed questions on motivation, initiated by the desire to validate the measurement instruments on these constructs.

Development of an equally effective online CooL-intervention, preserving the existing working elements and objectives of CooL as much as possible.

Effect study of CooL after 24 months participation (including the outcomes on phase 1 and phase 2).

Addition of the CooL questionnaire with questions on the mode of delivery of CooL (physically or digitally).

Conclusions

After eight months of CooL, large effect sizes on changes in anthropometrics and perceived health were found, irrespective of participation during the COVID-19 pandemic. The results show that small changes in multiple behaviours go along with a large positive change in perceived health and health-related outcomes in line with the lifestyle coaching principles. Participating in the CooL-intervention may have protected against engaging in unhealthier behaviours during the pandemic, despite a decreased sense of self-mastery and increased stress.

Data availability

The datasets generated and/or analysed during the current study are not publicly available because the informed consent statement to using data at the individual level was limited to the authors of this article and are only available from the corresponding author on reasonable request.

Abbreviations

Beroepsvereniging Leefstijlcoaches Nederland

Body mass index

Centraal Begeleidingsorgaan

Combined lifestyle intervention

Coaching op Leefstijl

Corona virus disease 19

Ethics review committee of the faculty of health, medicine and life sciences

Nederlands Huisarts Genootschap

National institute for health and care excellence

Pittsburgh sleep quality index

Rijksinstituut voor Volksgezondheid en Milieu

Statistical package for the social sciences

Centrum Gezondheid en Maatschappij van het Rijksinstituut voor Volksgezondheid en Milieu. Volwassenen met overgewicht en obesitas 2021. 2023, January 19 [Available from: https://www.volksgezondheidenzorg.info/onderwerp/overgewicht/cijfers-context/huidige-situatie#node-overgewicht-volwassenen .

James PT, Leach R, Kalamara E, Shayeghi M. The Worldwide obesity epidemic. Obes Res. 2001;9(S11):228S–33S.

Article   PubMed   Google Scholar  

Overgewicht en obesitas. Den Haag: Gezondheidsraad 2003.

Boeing H. Obesity and cancer–the update 2013. Best Pract Res Clin Endocrinol Metab. 2013;27(2):219–27.

Martin-Rodriguez E, Guillen-Grima F, Martí A, Brugos-Larumbe A. Comorbidity associated with obesity in a large population: the APNA study. Obes Res Clin Pract. 2015;9(5):435–47.

Overgewicht. : leeftijd en geslacht volwassenen Bilthoven: RIVM; 2023 [cited 2023 February 13]. Available from: https://www.vzinfo.nl/overgewicht/leeftijd-geslacht .

Luppino FS, de Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx BW, et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010;67(3):220–9.

Taylor VHAPMDP, Forhan MAPP, Vigod SNAPMD, McIntyre RSPMD, Morrison KMAPMD. The impact of obesity on quality of life. Best Pract Res Clin Endocrinol Metab. 2013;27(2):139–46.

Obesity and overweight: World Health Organization. 2021, June 9. [cited 2023 January 24]. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight .

Bos V, van Dale D, Leenaars K. Werkzame Elementen Van Gecombineerde Leefstijlinterventies. Rijksinstituut voor Volksgezondheid en Milieu; 2019.

van der Valk ES, Savas M, van Rossum EFC. Stress and obesity: are there more susceptible individuals? Curr Obes Rep. 2018;7(2):193–203.

Article   PubMed   PubMed Central   Google Scholar  

Lee JH, Cho J. Sleep and obesity. Sleep Med Clin. 2022;17(1):111–6.

Duijzer G, Haveman-Nies A, Jansen SC, Beek JT, van Bruggen R, Willink MGJ, et al. Effect and maintenance of the SLIMMER Diabetes prevention lifestyle intervention in Dutch primary healthcare: a randomised controlled trial. Nutr Diabetes. 2017;7(5):e268.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Schutte BA, Haveman-Nies A, Preller L. One-year results of the BeweegKuur Lifestyle intervention implemented in Dutch primary Healthcare settings. Biomed Res Int. 2015;2015:484823.

van Rinsum C, Gerards S, Rutten G, Philippens N, Janssen E, Winkens B et al. The Coaching on Lifestyle (CooL) Intervention for Overweight and Obesity: A Longitudinal Study into Participants’ Lifestyle Changes. Int J Environ Res Public Health. 2018;15(4).

Philippens N, Janssen E, Verjans-Janssen S, Kremers S, Crutzen R. HealthyLIFE, a combined lifestyle intervention for overweight and obese adults: a descriptive Case Series Study. Int J Environ Res Public Health. 2021;18(22):11861.

Jayawardena R, Jeyakumar DT, Misra A, Hills AP, Ranasinghe P, Obesity. A potential risk factor for Infection and mortality in the current COVID-19 epidemic. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020;14(6):2199–203.

Article   Google Scholar  

de Frel DL, Atsma DE, Pijl H, Seidell JC, Leenen PJM, Dik WA et al. The impact of obesity and lifestyle on the Immune System and susceptibility to Infections such as COVID-19. Front Nutr. 2020;7.

van der Voort PHJ, Moser J, Zandstra DF, Muller Kobold AC, Knoester M, Calkhoven CF, et al. Leptin levels in SARS-CoV-2 Infection related Respiratory Failure: a cross-sectional study and a pathophysiological framework on the role of fat tissue. Heliyon. 2020;6(8):e04696.

Stefan N, Birkenfeld AL, Schulze MB, Ludwig DS. Obesity and impaired metabolic health in patients with COVID-19. Nat Reviews Endocrinol. 2020;16(7):341–2.

Article   CAS   Google Scholar  

van der Zalm IJB, van der Valk ES, Wester VL, Nagtzaam NMA, van Rossum EFC, Leenen PJM, et al. Obesity-associated T-cell and macrophage activation improve partly after a lifestyle intervention. Int J Obes. 2020;44(9):1838–50.

Klerk Md. Een Jaar met corona: Ontwikkelingen in De Maatschappelijke Gevolgen Van corona. Sociaal en Cultureel Planbureau, Den Haag; 2021.

Grannell A, le Roux CW, McGillicuddy D. I am terrified of something happening to me the lived experience of people with obesity during the COVID-19 pandemic. Clin Obes. 2020;10(6):e12406.

Kemper P. Impact coronapandemie op preventie interventies en integrale samenwerking. Rijksinstituut voor Volksgezondheid en Milieu; 2022.

de Haas M, Faber R, Hamersma M. How COVID-19 and the Dutch ‘intelligent lockdown’ change activities, work and travel behaviour: evidence from longitudinal data in the Netherlands. Transp Res Interdisciplinary Perspect. 2020;6:100150.

De gecombineerde leefstijlinterventie tijdens de coronacrisis, Zeist. Zorgverzekeraars Nederland 2020 [cited 2023 January 12]. Available from: https://assets.zn.nl/p/32768/files/De%20gecombineerde%20leefstijlinterventie%20tijdens%20de%20coronacrisis.pdf .

Eklund M, Erlandsson L-K, Hagell P. Psychometric properties of a Swedish version of the Pearlin Mastery Scale in people with mental Illness and healthy people. Nord J Psychiatry. 2012;66(6):380–8.

Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.

Article   CAS   PubMed   Google Scholar  

Cohen S, Kamarck T, Mermelstein R. A Global measure of perceived stress. J Health Soc Behav. 1983;24(4):385–96.

Opleidingsniveau Centraal Bureau voor de Statistiek [cited 2023 January 12]. Available from: https://www.cbs.nl/nl-nl/nieuws/2017/22/vooral-hoogopgeleiden-roken-minder/opleidingsniveau .

Protocol, BMI en middelomtrek meten. : Nederlands Huisartsen Genootschap 2016 [cited 2023 January 12]. Available from: https://www.nhg.org/downloads/protocol-bmi-en-middelomtrek-meten#:~:text=Bij%20 een%20BMI%20die%20rond,risico%20op%20morbiditeit%20duidelijk%20verhoogd.

Dineen-Griffin S, Garcia-Cardenas V, Williams K, Benrimoj SI. Helping patients help themselves: a systematic review of self-management support strategies in primary health care practice. PLoS ONE. 2019;14(8):e0220116.

Pearlin LI, Schooler C. The structure of coping. J Health Soc Behav. 1978:2–21.

Lipsey MW. Design sensitivity: statistical power for experimental research. Newbury Park, CA: Sage Publications; 1990.

Google Scholar  

van der Meer FM, Ligtenberg G, Staal PA. Preventie Bij overgewicht en obesitas: de gecombineerde leefstijlinterventie. College voor zorgverzekeringen; 2009.

Oosterhoff M, de Weerdt A, Feenstra T, de Wit A. Jaarrapportage monitor GLI 2022. Stand van zaken gecombineerde leefstijlinterventie. Annual report – Monitor Combined lifestyle intervention 2022 Combined lifestyle intervention progress report: Rijksinstituut voor Volksgezondheid en Milieu RIVM; 2022.

Aubin H-J, Farley A, Lycett D, Lahmek P, Aveyard P. Weight gain in smokers after quitting cigarettes: meta-analysis. BMJ: Br Med J. 2012;345(7868):14.

Mölenberg F, Mesch A, Burdorf A. Effect studie Samen Sportief in Beweging, een gecombineerde leefstijl interventie gericht op lagere sociaal economische groepen. August: Erasmus Medisch Centrum, Afdeling Maatschappelijke Gezondheidszorg; 2018.

Ammar A, Mueller P, Trabelsi K, Chtourou H, Boukhris O, Masmoudi L, et al. Psychological consequences of COVID-19 home confinement: the ECLB-COVID19 multicenter study. PLoS ONE. 2020;15(11):e0240204.

COVID-19 and your mental health. : Mayo Clinic [cited 2023 January 17]. Available from: https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/mental-health-covid-19/art-20482731 .

Manchia M, Gathier AW, Yapici-Eser H, Schmidt MV, de Quervain D, van Amelsvoort T et al. The impact of the prolonged COVID-19 pandemic on stress resilience and mental health: a critical review across waves2022.

Roberts A, Rogers J, Mason R, Siriwardena AN, Hogue T, Whitley GA, et al. Alcohol and other substance use during the COVID-19 pandemic: a systematic review. Drug Alcohol Depend. 2021;229:109150.

Bommele J, Hopman P, Walters BH, Geboers C, Croes E, Fong GT, et al. The double-edged relationship between COVID-19 stress and Smoking: implications for smoking cessation. Tob Induc Dis. 2020;18:1–5.

Cellini N, Conte F, De Rosa O, Giganti F, Malloggi S, Reyt M, et al. Changes in sleep timing and subjective sleep quality during the COVID-19 lockdown in Italy and Belgium: age, gender and working status as modulating factors. Sleep Med. 2021;77:112–9.

Kocevska D, Blanken TF, Van Someren EJW, Rösler L. Sleep quality during the COVID-19 pandemic: not one size fits all. Sleep Med. 2020;76:86–8.

Huber BC, Steffen J, Schlichtiger J, Brunner S. Altered nutrition behavior during COVID-19 pandemic lockdown in young adults. Eur J Nutr. 2021;60(5):2593–602.

Park AH, Zhong S, Yang H, Jeong J, Lee C. Impact of COVID-19 on physical activity: a rapid review. J Global Health. 2022;12:05003.

Stockwell S, Trott M, Tully M, Shin J, Barnett Y, Butler L, et al. Changes in physical activity and sedentary behaviours from before to during the COVID-19 pandemic lockdown: a systematic review. BMJ open Sport & Exercise Medicine. 2021;7(1):e000960.

Pellegrini M, Ponzo V, Rosato R, Scumaci E, Goitre I, Benso A, et al. Changes in weight and nutritional habits in adults with obesity during the lockdown period caused by the COVID-19 virus emergency. Nutrients. 2020;12(7):2016.

Biamonte E, Pegoraro F, Carrone F, Facchi I, Favacchio G, Lania AG, et al. Weight change and glycemic control in type 2 Diabetes patients during COVID-19 pandemic: the lockdown effect. Endocrine. 2021;72(3):604–10.

Bailey P, Purcell S, Calvar J, Baverstock A. Actions and interventions for weight loss. Paris, France: IPSOS; 2021.

Chemolli E, Gagné M. Evidence against the continuum structure underlying motivation measures derived from self-determination theory. Psychol Assess. 2014;26(2):575–85.

Download references

Acknowledgements

The authors like to thank the CooL-coaches and the CooL-participants for their efforts to make this research possible.

No funding was provided for this research.

Author information

Ester Janssen and Nicole Philippens are joint first authors.

Authors and Affiliations

Department of Health Promotion, NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands

Ester Janssen, Nicole Philippens & Stef Kremers

Department of Health Promotion, CAPHRI, Care & Public Health Research Institute, Maastricht University, Maastricht, The Netherlands

Rik Crutzen

You can also search for this author in PubMed   Google Scholar

Contributions

Conceptualization, N.P., E.J., R.C. and S.K.; Methodology, N.P., E.J., R.C. and S.K.; Validation, R.C. and S.K.; Formal Analysis, N.P., E.J. and R.C; Investigation, N.P. and E.J.; Data Curation, N.P. and E.J.; Writing—Original Draft Preparation, N.P. and E.J.; Writing—Review and Editing R.C., and S.K.; Visualization, N.P. and E.J.; Funding Acquisition, not applicable. Both E.J. and N.P. contributed equally to the study.All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Ester Janssen .

Ethics declarations

Ethics approval and consent to participate.

This study was conducted according to the guidelines of the Declaration of Helsinki. This study was submitted to and approved by the Research Ethics Committee of the Faculty of Health, Medicine and Life Sciences of Maastricht University (FHML-REC/2019/073). Informed consent was obtained from all subjects involved in this study. All participants in CooL are adults except one minor who started the intervention at the age of 16. In the Netherlands adolescents from the age of 16, have the legal right to decide for themselves on medical treatments as they have the same patient rights as adults.

Consent for publication

Not applicable.

Competing interests

Both main authors (E.J. and N.P.) are co-owner of the CooL-intervention. Not applicable for S.K. and R.C.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Janssen, E., Philippens, N., Kremers, S. et al. Outcomes of the combined lifestyle intervention CooL during COVID-19: a descriptive case series study. BMC Public Health 24 , 40 (2024). https://doi.org/10.1186/s12889-023-17501-x

Download citation

Received : 16 February 2023

Accepted : 15 December 2023

Published : 02 January 2024

DOI : https://doi.org/10.1186/s12889-023-17501-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Intervention
  • (Perceived) health

BMC Public Health

ISSN: 1471-2458

case study positive and negative

  • Open access
  • Published: 02 January 2024

Depressive symptoms and daily living dependence in older adults with type 2 diabetes mellitus: the mediating role of positive and negative perceived stress

  • Li Ai Tai   ORCID: orcid.org/0000-0002-7029-541X 1 , 2 ,
  • Le Yu Tsai   ORCID: orcid.org/0000-0003-3570-2662 3 ,
  • Chia Hung Lin   ORCID: orcid.org/0000-0002-4684-444X 4 , 5 &
  • Yi Chen Chiu   ORCID: orcid.org/0000-0002-6726-8517 6  

BMC Psychiatry volume  24 , Article number:  14 ( 2024 ) Cite this article

Metrics details

Higher stress is associated with higher levels of depression and instrumental-activities-of-daily-living (IADL) dependence, and depression is strongly associated with specific IADL disabilities. Accordingly, the aim of this study was to investigate the mediating effect of perceived stress on the association between depression and IADL dependence among older adults with diabetes mellitus (DM).

We examined baseline data collected from a longitudinal study that recruited 110 patients with DM aged ≥ 65 years from the endocrinology outpatient clinic of a district hospital. The instruments used for our measurement processes comprised a demographic data sheet and Chinese versions of the Perceived Stress Scale (PSS), the short form of the Geriatric Depression Scale (GDS-S), and the Lawton IADL Scale. We assessed the mediating effects of positive perceived stress (PPS) and negative perceived stress (NPS) after controlling for five covariates by using a regression-based model run through the SPSS macro PROCESS.

We observed negative correlations between GDS-S scores and PPS and between PPS and IADL dependence; we noted positive correlations between GDS-S scores and NPS and between NPS and IADL dependence (all P  < 0.01). The indirect effect is coefficient = 0.12, [95% confidence interval = (0.0, 0.33)], suggesting that PPS achieves a mediating effect between depressive symptoms and IADL dependence. However, the NPS does not achieve a mediating effect in the relationship between depressive symptoms and IADL dependence (coefficient = 0.06, 95% CI = − 0.03, 0.15).

Conclusions

Personal PPS mediates the association between depression and IADL dependence in older adults with DM. This finding suggests that providing patients with psychological education to promote their PPS may help prevent their functional decline.

Peer Review reports

The number of people with diabetes mellitus (DM) is expected to increase to 640 million by 2040. DM is a metabolic disease characterized by an abnormally elevated blood glucose level [ 1 , 2 ], and among individuals with DM, 50–90% are at an increased risk of several types of disabilities and 23% are dependent regarding instrumental activities of daily living (IADLs). In particular, older patients with DM (aged ≥ 65 years) were reported to exhibit a higher prevalence of mobility and IADL dependence relative to other populations with DM [ 3 ]; moreover, more than 40% of such patients reported difficulties in performing heavy housework [ 4 ]. Disability is associated with increased mortality [ 5 , 6 ] and depression [ 7 ] and a decreased quality of life [ 7 , 8 ]. Therefore, disability places a heavy burden on the global health-care system [ 5 ]. Disability typically begins with an increase in IADL dependence [ 9 , 10 ]. In addition, a study reported a direct correlation between depressive symptoms and perceived stress, which may lead to greater IADL dependence [ 11 ].

Depression is an emotional and psychological state characterized by feelings of sadness and hopelessness and a consistently low mood; hopelessness and sadness are key factors that hinder independent living in older adults [ 8 ]. Approximately 80% of individuals with DM experience depression during disease progression [ 12 ]. Those with depression may exhibit poor disease control, medication use, and social interaction, and may experience difficulties with personal mobility or the performance of independent self-care tasks [ 13 , 14 , 15 , 16 ]. Depression resulting from long-term blood sugar control and treatment [ 9 , 10 ], affects a patient’s dietary and medication behaviors [ 11 , 12 ].

Perceived stress is defined as an individual’s subjective perception of internal and external stress events [ 17 ]. Empirical evidence indicates that stress due to chronic illness affects an individual’s participation in daily activities [ 18 ]. Chronic psychological stress can accelerate biological aging; specifically, high stress responses are often accompanied by depression that directly or indirectly affects a patient’s adaptation to or management of their disease and their ability to cope with stress [ 19 ]. Studies have discovered that chronic stress in individuals with DM can affect their disease prognosis and self-care behaviors, including their dietary control, blood sugar control, physical activity, and adherence to medication and lifestyle modifications [ 20 ]. Therefore, perceived stress in individuals with DM is significantly correlated with IADL dependence [ 8 ].

A study suggested that declines in physical and mental health increase perceptions of stress among older patients [ 21 ]. Perceived stress comprises positive and negative dimensions [ 22 ]. Different types of perceived stress may be independently perceived as threatening or requiring adaptive adjustment [ 17 , 19 , 22 , 23 , 24 ]. These different stress appraisals lead to the development of different behavioral coping strategies [ 25 , 26 ] which can influence an individual’s response to a life event. For example, negative perceived stress (NPS) can induce an individual to adopt an emotion-focused coping strategy that involves maladaptive coping mechanisms. Therefore, NPS can affect an individual’s IADL dependence [ 27 , 28 ]. By contrast, positive perceived stress (PPS) involve a positive appraisal of stressful situations and can prompt an individual to adopt a problem-solving strategy that influences their self-care behaviors. Evidence demonstrates that stressful situations may affect the blood sugar control and physical activity levels of individuals with DM and that perceived stress patterns may affect their stress-coping strategies and self-care. Additionally, the mentioned study confirmed the association between depressive symptoms and physical health and validated the mediating role of perceived stress in this association [ 21 ]. Overall, perceived stress is regarded as a mediator in the association between mental and physical health [ 28 , 29 ]. However, there are very few studies specifically to address the relationships between depression, perceived stress (PPS and NPS) and IADL dependence among older adults with DM. Accordingly, to fill this research gap, the present study comprehensively investigated whether positive and negative perceptions of stress mediate the association between depressive symptoms and IADL dependence in the target population. Our findings can inform future research on the development of personalized interventions aiming at managing perceived stress among older adults with DM.

Study population and procedures

This study employed a cross-sectional design to examine data derived from the baseline data of a longitudinal study. In that longitudinal study, research data were collected between June 2017 and August 2018, and the study was conducted at the outpatient endocrinology clinic of a hospital in northern Taiwan (Project Number: R106-003) [ 30 ]. The longitudinal study was approved by an institutional review board (IRB; IRB number, CTB-106-3-5-011) and was conducted in accordance with the Declaration of Helsinki to protect the rights and well-being of its participants. The purpose of the longitudinal study was to explore multiple risk factors for IADL dependence in older adults with DM and to examine predictors of changes in IADL independence. All candidates were assessed by an attending physician, and eligible candidates were then selected as participants by the investigators. Before completing a questionnaire survey, all participants were informed of the purpose of the study, asked to provide informed consent, and assured that their participation in the study was completely voluntary, anonymous, and confidential.

The inclusion criteria were as follows: (1) being aged ≥ 65 years, (2) having a diagnosis of type 2 DM, and (3) being able to communicate in Mandarin, Taiwanese, or Hakka. The exclusion criteria were as follows:(1) having a terminal illness or (2) scoring < 20 points on the Mini-Mental State Examination [ 31 ]. After data collection was completed, the collected data were exported to Microsoft Excel and subsequently imported into IBM SPSS Statistics for Windows (Version 21.0; IBM, Armonk, NY, USA) for data management and analysis.

Questionnaire for collecting demographic information

A questionnaire was applied to collect information from the participants. The questionnaire required approximately 30–40 min to complete, and it included a demographic information sheet, the Geriatric Depression Scale-Short Form (GDS-S), the Perceived Stress Scale (PSS), and a modified version of the original Lawton IADL Scale [ 32 ]. The collected demographic data comprised information on the participants’ sex, age, educational level, and marital status; the number of chronic diseases that a participant had; whether a participant implemented diabetic dietary control (“yes” or “no” response); and whether a participant exercised regularly (“yes” or “no” response). Considering that caregivers can affect the IADL dependence of patients with DM, binary options (“yes” or “no” response) were provided to enable the participants to clarify their status with respect to daily activity dependence, including whether their primary caregiver was their spouse or child, it relied on patients to provide information about their family caregivers. Furthermore, the present study collected patients’ clinical data on the status of participants’ DM-related neuropathy examined and determined by their physicians. We also collected the total number of diseases that the participants had by considering their systemic disease diagnoses as indicated in their electronic medical records.

The GDS-S comprises 15 questions for evaluating depression in older people, and each question is answered with a “yes” (scored as 1) or “no” (scored as 0) response. The overall score for the GDS-S ranges from 0 to 15, and a higher total score indicates more severe depressive symptoms. A previous study reported that a Chinese version of the GDS-S could correctly distinguish pproximately > 90% of depression cases from noncases in a community survey [ 33 ]. Specifically, the Chinese version of the GDS-S was reported to have internal consistency reliability (Cronbach’s α ) values between 0.89 [ 34 ] to 0.94 [ 35 ] and a test–retest reliability ( r ) of 0.85 [ 35 ]. Therefore, the present study used this Chinese version of the GDS-S because of its sound psychometric properties. In the present study, the Cronbach’s α value of the scale was 0.80.

The 14-item Chinese version of the PSS is a self-rated scale that measures the stress experienced by an individual in the preceding month on a 5-point Likert scale (0, never ; 1, occasional ; 2, sometimes ; 3, often ; 4, always ). Seven of the 14 PSS items are worded negatively (items 1, 2, 3, 8, 11, 12, and 14) to form an NPS subscale; the remaining seven are worded positively (items 4, 5, 6, 7, 9, 10, and 13) to form a PPS subscale. The overall score for the PSS is calculated after reversing the scores for the positive items and then summing the scores for all items to obtain an overall score ranging between 0 and 56 [ 25 ]; a higher score indicates a greater stress. The scale was reported to have a Cronbach’s α value of 0.84–0.86 and a test–retest reliability of 0.85 [ 9 , 25 ]. The Cronbach’s α values of the PSS scale, PPS subscale, and NPS subscale used in the present study were 0.76, 0.80, and 0.71, respectively.

A modified version of the original Lawton IADL Scale [ 32 ] was used to evaluate the IADL dependence of the participants; the modified scale comprises eight items, which pertain to shopping, using the telephone, housekeeping activities, doing laundry, preparing food, using transportation, handling medications, and handling finances. The original scale comprises nine items, whereas the modified version comprises eight items. Specifically, questions 4 (pertaining to doing heavy work at home or nearby) and 5 (pertaining to sweeping, washing dishes, taking out the trash, and other light chores) were combined into a single question, which refers to the activities mentioned in questions 4 and 5 collectively as “housework.” We modified the scoring system such that each item is rated between 0 and 3 (0, independent ; 1, some dependence ; 2, very dependent ; 3, complete dependence ), for a total score ranging between 0 and 24. In the present study, the scale was determined to have a reliability of 0.8–0.9 [ 32 ], a test–retest reliability of 0.90, an internal consistency of 0.86 [ 36 ], and a Cronbach’s α value of 0.90.

Statistical analysis

Statistical analyses were conducted using SPSS version 21.0. Descriptive, categorical variables were expressed as frequency and percentage values, and continuous variables were expressed as mean and standard deviation (SD) values. The analysis strategies are described as follows: (1) Pearson correlation was used to determine relationships among variables. (2) A multiple regression model was used to determine predictive relationships among depressive symptoms, IADL dependence, and perceived stress after adjustment for several demographic variables (i.e., age, exercise, dietary control for DM, neuropathy, and total number of diseases). (3) Through the PROCESS macro in SPSS, we used a multiple regression model to verify the mediating effects of perceived stress on the association between depressive symptoms and IADL dependence [ 37 ]. The two-step method developed by Baron and Kenny [ 38 ] was applied to evaluate the direct and indirect effects of perceived stress on IADL dependence. First, a multiple regression model of IADL dependence was used to preliminarily measure the mediating effects of perceived stress. Second, the bootstrapping method, as defined by Preacher and Hayes [ 39 ], was adopted to test the indirect effects of resilience on IADL dependence. Notably, the results from these analyses revealed significant correlations among the three variables: depressive symptoms, perceived stress (PPS and NPS), as well as IADL independence. The bootstrapping process involved 5,000 repetitions, and 95% confidence intervals (CIs) were calculated. If the range for a 95% CI did not encompass zero, an indirect link was regarded as significant [ 40 ]. In the present study, we regarded a P value of < 0.05 (two-tailed) as a significant result. Baron and Kenny [ 38 ] presented the conditions for mediation as a pathway diagram (Fig.  1 ).

figure 1

Mediating effects of positive and negative perceived stress

* P  < 0.05, ** P  < 0.01, *** P  < 0.001

To determine the role of perceived stress state as a mediator, we employed two methods. First, we conducted a multiple regression analysis in which demographic variables served as covariates. Second, we used the PROCESS macro [ 40 ] and employed one independent variable (depressive symptoms), two mediators (PPS and NPS), and one dependent variable (IADL dependence). The regression coefficients a (depressive symptoms), b (PPS and NPS), and c (depressive symptoms–IADL dependence) were revealed to be statistically significant, and pathway c ’ (depressive symptoms–IADL dependence while controlling for PPS and NPS) was calculated. Finally, the mediating effects of PPS and NPS on the association between depressive symptoms and IADL dependence was tested (pathways c and c’ ). Subsequently, depressive symptoms were used as the predictive variable for predicting IADL dependence (pathway c in Fig.  1 ).

Characteristics of participants and distribution of depressive symptoms, perceived stress, and IADL dependence

Of the 110 participants (Table  1 ), 68 were women (61.8%). The mean age of the participants was 73.43 years (SD = 6.91 years). Of the participants, 52 (47.3%) exercised regularly, 57 (51.8%) adhered to a diabetic dietary plan, 40 (36.4%) had neuropathy, and 74 (67.3%) had their spouses as their primary caregivers. Furthermore, the mean number of comorbidities among the participants was 2.8 (SD = 1.14), and the mean GDS-S, PPS, NPS, and IADL dependence scores were 3.94 (SD = 3.27), 18.34 (SD = 4.68), 10.48 (SD = 4.12), and 2.53 (SD = 4.46), respectively. The participants examined in the present study were all home based.

Correlations between depressive symptoms, perceived stress, and IADL dependence

Results showed that a positive correlation between the GDS-S and IADL dependence ( r  = 0.39, P  < 0.01), a negative correlation between the GDS-S and PPS ( r = − 0.36, P  < 0.01), a positive correlation between the GDS-S and NPS ( r  = 0.49, P  < 0.01), a negative correlation between PPS and IADL dependence ( r = − 0.56, P  < 0.01), and a positive correlation between NPS and IADL dependence ( r  = 0.34, P  < 0.01).

Mediating effects of perceived stress on association between depressive symptoms and IADL dependence

We employed a multiple regression model and bootstrapping sampling to test the indirect effect of depressive symptoms on IADL dependence through perceived stress. Table  2 lists the results obtained from the multiple regression model. Specifically, Model 1 revealed that depressive symptoms were significantly associated with IADL dependence, with the standardized regression coefficient β being 0.223 ( P  = 0.007). In Model 2, we included PPS in the mediating model and found a significant association between depressive symptoms and IADL dependence (β= −0.338, P  < 0.001); when PPS was added, the absolute value of β for depressive symptoms decreased significantly from 0.223 to 0.138, preliminarily demonstrating the mediating role of PPS (Table  2 ).

Regarding NPS, Model 1 revealed that depressive symptoms were significantly associated with IADL dependence, with the standardized regression coefficient β being 0.223, ( P  = 0.007). In Model 2, we included NPS in the mediation model and observed a significant association between depressive symptoms and IADL dependence (β = 0.182, P  = 0.045). When NPS was added, the absolute value of β decreased from 0.223 to 0.182, but the mediating effect of NPS was nonsignificant ( P  = 0.297).

Through the PROCESS macro (Table  3 ; Fig.  1 ), we observed both the direct (coefficient = 0.18, 95% CI = − 0.03, 0.39), and indirect (coefficient = 0.12, 95% CI = 0.0, 0.33]) effects of PPS, suggesting that PPS had a mediating effect on the association between depressive symptoms and IADL dependence.

Through PROCESS, we also determined the direct (coefficient = 0.24, 95% CI = 0.00, 0.48) and indirect (coefficient = 0.06, 95% CI = − 0.03, 0.15) effects of NPS. However, the mediating effect of NPS on the association between depressive symptoms and IADL dependence was nonsignificant because it was not within the 95% CI (Table  3 ; Fig.  1 ).

According to our literature review, the present study is the first to clarify the mediating effects of PPS on the relationship between depressive symptoms and IADL dependence in older adults with DM. The findings of the present study reveal negative correlations between the GDS-S scores and PPS and between PPS and IADL dependence; they also indicate positive correlations between the GDS-S scores and NPS and between NPS and IADL dependence. Collectively, these findings indicate that different types of perceived stress played different mediating roles and that PPS fully mediated the association between depressive symptoms and IADL dependence. However, the mediating effect of NPS on the association between depressive symptoms and IADL dependence was nonsignificant.

Therefore, our results regarding the significant mediating effect of PPS demonstrate the future development of positive psychological interventions for such patients.

Depressive symptoms are associated with exposure to stressful conditions, including psychological distress, emotional disorders, and negative personality traits such as anger and hostility [ 41 ]. Empirical evidence strongly supports the association between depression and disability in the general older adult population [ 42 ]. In addition, a study involving older adults with DM revealed that those with depressive symptoms exhibited more severe disabilities than did those without such symptoms [ 43 ]. Therefore, the results of the present study suggest that clinical interventions aiming at reducing depressive symptoms should be implemented to help promote IADL independence.

Mediating role of perceived stress state on depressive symptoms and IADL dependence

According to our results, the severity of PPS mediated the relationship between depressive symptoms and IADL dependence, whereas NPS directly influenced the relationship between depressive symptoms and IADL dependence. We inferred that an improvement in PPS can reduce IADL disability by reducing obstacles related to depressive symptoms. Moreover, our study validated the findings of a meta-analysis that reported that the presence of comorbid depression in individuals with chronic diseases affects their medication self-management and physical activity behaviors [ 44 , 45 ] and that IADL dependence is significantly associated with depression [ 46 ]. Nonpharmaceutical interventions that can reduce emotional stress, such as interventions involving physical activity [ 47 ], are also key moderators for improving the physical health of patients [ 48 ]. Furthermore, our study extends the literature by using the PPS as a mediator to impact the relationship between depressive symptoms and IADL dependence [ 41 , 44 , 45 , 46 ] because of the effects of psychological pressure; by contrast, NPS had no such effect.

Among the examined variables, perceived stress was identified as a key factor influencing IADL dependence. Individuals with higher levels of perceived stress have been reported to be more prone to negative reappraisals [ 49 ]. Psychosocial and environmental interventions can help prevent or alleviate negative emotions [ 50 ]. Therefore, on the basis of the results of the present study, we propose that problem-oriented stress management strategies should be taught to patients who are undergoing treatment for DM and exhibiting depressive symptoms. These strategies can improve their perceived stress, prevent or alleviate their negative emotions, and prevent them from developing IADL dependence.

Studies have indicated that perceived stress is linked to physical inactivity [ 51 ], that patients with physical impairments and/or disabilities exhibit high levels of perceived stress [ 21 ], and that social support can help individuals to cope with stress, with psychological support playing a crucial role in this process [ 52 ]. In addition, personality and attitudes can contribute to an individual’s ability to cope with stress, which in turn influences the severity of their depressive symptoms; in this context, a positive attitude can be cultivated through the utilization of personal and environmental resources [ 53 , 54 ]. One study reported that when patients experienced depressive symptoms due to long-term exposure to external stressors, they tended to struggle with self-care and exhibit decreased activity levels and poor dietary behaviors or to experience difficulties with medication use [ 54 ]. On the basis of our findings (Fig.  1 ), we suggest that clinicians routinely assess the psychological health of patients with DM and provide individual counseling services for those who experience emotional distress; doing so can prevent the stress and disability engendered by DM as a long-term chronic illness.

A possible explanation for the nonsignificant effects of NPS in the present study is that the cross-sectional design which might be insufficient for observing the changes in its effect on negative emotions. Another explanation is that the direct influence of depression on IADL dependence outweighed the influence of NPS on IADL dependence (Tables  4 and 2 ). Both self-perceived stress and depressive emotions—representing the subjective perceptions of individuals—are likely to be influenced by age and cognitive factors. Therefore, more research should be conducted to re-examine the mediating effect of NPS on the relationship between depressive symptoms and IADL dependence in older patients with DM.

Limitations

The present study had several limitations. First, the present study analyzed only outpatient cases and did not include hospitalized patients who tend to experience greater levels of stress and dependence in relation to activities of daily living. Second, the sample of the present study comprised only patients from a single community hospital who were enrolled through convenience sampling. Therefore, the generalizability of the present study’s results is likely limited. Third, because of the use of self-reported measures, the results were unavoidably affected by participant response bias. Although the effect of NPS was nonsignificant, we must still consider the characteristics and cognitive function of each patient as well as the effects of subjective stress perceptions and emotional distress on IADLs. Therefore, we recommend routinely clinical monitoring of cognitive function, depressive symptoms, NPS and IADL dependency in these patients.

The key finding of the present study is that PPS fully mediates the association between depressive symptoms and IADL dependence in older adults with DM. An improvement in positive emotions can reduce the effects of depressive symptoms on IADL dependence; thus, the effects of perceived stress on depressive symptoms in this population should not be ignored. In future studies, we intend to explore the mediating effect of perceived stress state, which is a key research area.

Relevance for clinical practice

The present study clarified the mediating effects of various types of perceived stress on the association between depression and IADL dependence. In clinical care, strengthening interventions aimed at reducing disease-related stress in patients and facilitating patients’ adaptation to their conditions can help alleviate their negative emotions. PPS plays a mediating role in improving activities of daily living, whereas NPS may interfere with depressive symptoms and aggravate DM-related dysfunction. Therefore, psychological counseling is required in clinical care to alleviate chronic disease–related stress and negative emotions. Individualized measures should be introduced to encourage the adoption of a problem-focused positive attitude among patients with chronic diseases, particularly older adults with DM, thereby helping them alleviate their depression symptoms and reduce their IADL dependence.

Data Availability

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

Klein KR, Buse JB. The trials and tribulations of determining HbA1c targets for Diabetes Mellitus. Nat Rev Endocrinol. 2020;16:717–30.

Article   CAS   PubMed   Google Scholar  

Kowluru RA, Kowluru A, Mishra M, Kumar B. Oxidative stress and epigenetic modifications in the pathogenesis of diabetic retinopathy. Prog Retin Eye Res. 2015;48:40–61.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Cowie CC, Casagrande SS, Menke A, Cissell MA, Eberhardt MS, Meigs JB et al. Diabetes Am. 2018.

Martin LG, Zimmer Z, Hurng BS. Trends in late-life disability in Taiwan, 1989–2007: the roles of education, environment, and technology. Popul Stud. 2011;65:289–304.

Article   Google Scholar  

James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 Diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the global burden of Disease Study 2017. Lancet. 2018;392:1789–858.

Barbour KE, Lui LY, McCulloch CE, Ensrud KE, Cawthon PM, Yaffe K, et al. Trajectories of lower extremity physical performance: effects on fractures and mortality in older women. J Gerontol Series A Biomed Sci Med Sci. 2016;71:1609–615.

Lamb VL. A cross-national study of quality of life factors associated with patterns of elderly disablement. Soc Sci Med. 1996;42:363–77.

Tsai YH, Chuang LL, Lee YJ, Chiu CJ. How does Diabetes accelerate normal aging? An examination of ADL, IADL, and mobility disability in middle-aged and older adults with and without Diabetes. Diabetes Res Clin Pract. 2021;182:109114.

Article   PubMed   Google Scholar  

Yang T, Huang H. An epidemiological study on stress among urban residents in social transition period. Zhonghua Liu Xing Bing Xue Za Zhi = Zhonghua Liuxingbingxue Zazhi. 2003;24:760–64.

PubMed   Google Scholar  

Hung WW, Ross JS, Boockvar KS, Siu AL. Recent trends in chronic Disease, impairment and disability among older adults in the United States. BMC Geriatr. 2011;11:1–12.

Shahimi NH, Goh CH, Mat S, Lim R, Koh VCA, Nyman SR, et al. Psychological status and physical performance are independently associated with autonomic function. Biomed Eng Online. 2022;21:1–19.

Katon W, Von Korff M, Ciechanowski P, Russo J, Lin E, Simon G, et al. Behavioral and clinical factors associated with depression among individuals with Diabetes. Diabetes Care. 2004;27:914–20.

Restivo MR, McKinnon MC, Frey BN, Hall GB, Syed W, Taylor VH. The impact of obesity on neuropsychological functioning in adults with and without major depressive disorder. PLoS ONE. 2017;12:e0176898.

Article   PubMed   PubMed Central   Google Scholar  

Wong E, Backholer K, Gearon E, Harding J, Freak-Poli R, Stevenson C, et al. Diabetes and risk of physical disability in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2013;1:106–14.

Paterson B, Thorne S, Crawford J, Tarko M. Living with Diabetes as a transformational experience. Qual Health Res. 1999;9:786–802.

Abdi S, Spann A, Borilovic J, de Witte L, Hawley M. Understanding the care and support needs of older people: a scoping review and categorisation using the WHO international classification of functioning, disability and health framework (ICF). BMC Geriatr. 2019;19:1–15.

Article   CAS   Google Scholar  

Krause N, Liang J. Stress, social support, and psychological distress among the Chinese elderly. J Gerontol. 1993;48:P282–91.

Tsutsui H, Ojima T, Ozaki N, Kusunoki M, Ishiguro T, Oshida Y. Validation of the comprehensive international classification of functioning, disability and health (ICF) core set for Diabetes Mellitus in patients with diabetic Nephropathy. Clin Exp Nephrol. 2015;19:254–63.

Horiuchi M, Takiguchi C, Kirihara Y, Horiuchi Y. Impact of wearing graduated compression stockings on psychological and physiological responses during prolonged sitting. Int J Environ Res Public Health. 2018;15:1710.

Annor FB, Roblin DW, Okosun IS, Goodman M. Work-related psychosocial stress and glycemic control among working adults with Diabetes Mellitus. Diabetes Metab Syndr Clin Res Rev. 2015;9:85–90.

Moore RC, Eyler LT, Mausbach BT, Zlatar ZZ, Thompson WK, Peavy G, et al. Complex interplay between health and successful aging: role of perceived stress, resilience, and social support. Am J Geriatr Psychiatry. 2015;23:622–32.

Hackett RA, Steptoe A. Type 2 Diabetes Mellitus and psychological stress—a modifiable risk factor. Nat Rev Endocrinol. 2017;13:547–60.

Van Eck M, Berkhof H, Nicolson N, Sulon J. The effects of perceived stress, traits, mood states, and stressful daily events on salivary cortisol. Psychosom Med. 1996;58:447–58.

Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and Disease. JAMA. 2007;298:1685–7.

Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983:385–96.

Lazarus RS, Launier R. Stress-related transactions between person and environment. Perspectives in interactional psychology. Boston, MA: Springer; 1978. 287–327.

Chapter   Google Scholar  

Ding Y, Yang Y, Yang X, Zhang T, Qiu X, He X, et al. The mediating role of coping style in the relationship between psychological capital and burnout among Chinese nurses. PLoS ONE. 2015;10:e0122128.

Chao YY, Zha P, Yang K, Dong X. Association between physical function and perceived stress among US Chinese older adults. Am J Aging Sci Res. 2020;1:12.

PubMed   PubMed Central   Google Scholar  

Zhang Z, Huang Q, Zhao D, Lian F, Li X, Qi W. The impact of oxidative stress-induced mitochondrial dysfunction on diabetic microvascular Complications. Front Endocrinol. 2023;14:1112363.

Tai LA, Tsai LY, Chiu YC. Relation of environmental factors with activity limitations and participation restrictions in older adults with Diabetes Mellitus over time: an international classification of functioning framework perspective. BMC Geriatr. 2023;23:335.

Shyu YIL, Yip PK. Factor structure and explanatory variables of the Mini-mental State Examination (MMSE) for elderly persons in Taiwan. J Formos Med Assoc. 2001;100:676–83.

CAS   PubMed   Google Scholar  

Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–86.

Lee HCB, Chiu HF, Kowk WY, Leung CM. Chinese elderly and the GDS short form: a preliminary study. Clin Gerontol J Aging Mental Health. 1993.

Chan ACM. Clinical validation of the geriatric depression scale (GDS) Chinese version. J Aging Health. 1996;8:238–53.

Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, Leirer VO. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982;17:37–49.

Tong AY, Man DW. The validation of the Hong Kong Chinese version of the Lawton Instrumental Activities of Daily Living Scale for institutionalized elderly persons. OTJR: Occup Particip Health. 2002;22:132–42.

Google Scholar  

Hayes AF. Beyond Baron and Kenny: statistical mediation analysis in the new millennium. Commun Monogr. 2009;76:408–20.

Baron RM, Kenny DA. The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51:1173.

Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 2008;40:879–91.

McEwen BS, Wingfield JC. The concept of allostasis in biology and biomedicine. Horm Behav. 2003;43:2–15.

Deschênes SS, Burns RJ, Schmitz N. Associations between depression, chronic physical health conditions, and disability in a community sample: a focus on the persistence of depression. J Affect Disord. 2015;179:6–13.

Wu CY, Terhorst L, Karp JF, Skidmore ER, Rodakowski J. Trajectory of disability in older adults with newly diagnosed Diabetes: role of elevated depressive symptoms. Diabetes Care. 2018;41:2072–8.

Gonzalez JS, Peyrot M, McCarl LA, Collins EM, Serpa L, Mimiaga MJ, et al. Depression and Diabetes treatment nonadherence: a meta-analysis. Diabetes Care. 2008;31:2398–403.

Sinha R, Jastreboff AM. Stress as a common risk factor for obesity and addiction. Biol Psychiatry. 2013;73:827–35.

Meltzer H, Bebbington P, Brugha T, McManus S, Rai D, Dennis MS, et al. Physical ill health, disability, dependence and depression: results from the 2007 national survey of psychiatric morbidity among adults in England. Disabil Health J. 2012;5:102–10.

Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4.

Smith PJ, Merwin RM. The role of exercise in management of mental health disorders: an integrative review. Annu Rev Med. 2021;72:45–62.

Achterberg M, Dobbelaar S, Boer OD, Crone EA. Perceived stress as mediator for longitudinal effects of the COVID-19 lockdown on wellbeing of parents and children. Sci Rep. 2021;11:2971.

Zhang S, Zou L, Chen LZ, Yao Y, Loprinzi PD, Siu PM, et al. The effect of Tai Chi Chuan on negative emotions in non-clinical populations: a meta-analysis and systematic review. Int J Environ Res Public Health. 2019;16:3033.

Rod NH, Kristensen T, Lange P, Prescott E, Diderichsen F. Perceived stress and risk of adult-onset Asthma and other atopic disorders: a longitudinal cohort study. Allergy. 2012;67:1408–414.

Siu OL, Lo BCY, Ng TK, Wang H. Social support and student outcomes: the mediating roles of psychological capital, study engagement, and problem-focused coping. Curr Psychol. 2021:1–10.

Lehrer HM, Janus KC, Gloria CT, Steinhardt MA. Personal and environmental resources mediate the positivity-emotional dysfunction relationship. Am J Health Behav. 2017;41:186–93.

Zhou J, Yang Y, Qiu X, Yang X, Pan H, Ban B, et al. Relationship between anxiety and burnout among Chinese physicians: a moderated mediation model. PLoS ONE. 2016;11:e0157013.

Abdullah MF, Mohd Nor N, Mohd Ali SZ, Ismail Bukhary NB, Amat A, Abdul Latif L, et al. Validation of the comprehensive ICF core sets for Diabetes Mellitus: a Malaysian perspective. Ann Acad Med Singap. 2011;40:168.

Download references

Acknowledgements

We would like to thank the funding agency, Yonghe Cardinal Tien Hospital, and the participants.

This work was supported by grants from the Yonghe Cardinal Tien Hospital (Grant numbers was R106-003). The data collection for this study was supported by Yonghe Cardinal Tien Hospital.

Author information

Authors and affiliations.

Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan

Department of Nursing, Cardinal Tien Junior College of Healthcare and Management, New Taipei, Taiwan

Department of Endocrinology and Metabolism, Yonghe Cardinal Tien Hospital, New Taipei, Taiwan

Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan

Chia Hung Lin

College of Medicine, Chang Gung University, Taoyuan, Taiwan

School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan

Yi Chen Chiu

You can also search for this author in PubMed   Google Scholar

Contributions

LAT: Conceptualization of the study, data analyses, and writing of the manuscript. YCC: Conceptualization of the project and research design, supervision of the project, writing and editing the manuscript. LYT: Research design, assembly of data. CHL: Critical revision of the manuscript. All authors reviewed the manuscript.

Corresponding author

Correspondence to Yi Chen Chiu .

Ethics declarations

Ethics approval and consent to participate.

This project was reviewed and approved by the Institutional Review Board of the Cardinal Tien Hospital (IRB# CTH-106-3-5-011). Informed consent was obtained from all participants. All procedures contributing to this work complied with the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Tai, L.A., Tsai, L.Y., Lin, C.H. et al. Depressive symptoms and daily living dependence in older adults with type 2 diabetes mellitus: the mediating role of positive and negative perceived stress. BMC Psychiatry 24 , 14 (2024). https://doi.org/10.1186/s12888-023-05273-y

Download citation

Received : 19 April 2023

Accepted : 11 October 2023

Published : 02 January 2024

DOI : https://doi.org/10.1186/s12888-023-05273-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Type 2 Diabetes Mellitus
  • Depressive symptoms
  • Perceived stress
  • Instrumental activities of daily living

BMC Psychiatry

ISSN: 1471-244X

case study positive and negative

  • Open access
  • Published: 03 January 2024

18 F-FAPI PET/CT performs better in evaluating mediastinal and hilar lymph nodes in patients with lung cancer: comparison with 18 F-FDG PET/CT

  • Yuyun Sun 1 , 2 , 3   na1 ,
  • Yun Sun 2 , 3 , 5   na1 ,
  • Zili Li 2 , 3 , 5 ,
  • Shaoli Song 1 , 2 , 3 ,
  • Kailiang Wu 2 , 3 , 4 ,
  • Jingfang Mao 2 , 3 , 4 &
  • Jingyi Cheng 1 , 2 , 3  

European Journal of Medical Research volume  29 , Article number:  9 ( 2024 ) Cite this article

Metrics details

The aim of this study was to evaluate the efficacy of fluorine 18 ( 18 F) labeled fibroblast activation protein inhibitor (FAPI) in identifying mediastinal and hilar lymph node metastases and to develop a model to quantitatively and repeatedly identify lymph node status.

Twenty-seven patients with 137 lymph nodes were identified by two PET/CT images. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of lymph node status were analyzed, and the optimal cut-off value was identified by ROC analysis.

The SUVmax of metastatic lymph nodes on 18 F-FAPI was higher than that on 18 F-FDG PET/CT (10.87 ± 7.29 vs 6.08 ± 5.37, p  < 0.001). 18 F-FAPI presented much greater lymph node detection sensitivity, specificity, accuracy, PPV and NPV than 18 F-FDG PET/CT (84% vs. 71%; 92% vs. 67%; 90% vs. 69%, 84% vs. 52%, and 92% vs. 83%, respectively). Additionally, the diagnostic effectiveness of 18 F-FAPI in small lymph nodes was greater than that of 18 F-FDG PET/CT (specificity: 96% vs. 72%; accuracy: 93% vs. 73%; PPV: 77% vs. 33%, respectively). Notably, the optimal cut-off value for specificity and PPV of 18 F-FAPI SUVmax was 5.3; the optimal cut-off value for sensitivity and NPV was 2.5.

18 F-FAPI showed promising diagnostic efficacy in metastatic mediastinal and hilar lymph nodes from lung cancer patients, with a higher SUVmax, especially in small metastatic nodes, compared with 18 F-FDG. In addition, this exploratory work recommended optimal SUVmax cutoff values to distinguish between nonmetastatic and metastatic lymph nodes, thereby advancing the development of image-guided radiation.

Trial registration ClinicalTrials.gov identifier: ChiCTR2000036091.

Lung cancer is the oncologic disease with the highest mortality rate worldwide, and it accounts for over 20% of cancer-related deaths each year [ 1 ]. For patients with locally advanced lung cancer, regional lymph node staging is very important, as it guides the choice of treatment. Histopathological and imaging examinations are the most commonly used methods to predict mediastinal and hilar lymph node staging in patients with lung cancer.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the “gold standard” for the evaluation of mediastinal and hilar lymph nodes in patients with lung cancer and is recommended by the National Comprehensive Cancer Network [ 2 ]; however, the diagnostic accuracy of EBUS-TBNA is insufficient due to intratumor heterogeneity and endoscopist skills [ 3 , 4 ]. On the other hand, enhanced computed tomography (CT) is a commonly used imaging technique for evaluating mediastinal and hilar lymph nodes in patients with lung cancer, and a cutoff value of 10 mm for the short-axis diameter has been suggested to define abnormal lymph nodes [ 5 , 6 ]. However, a retrospective study involving 2817 mediastinal and hilar lymph nodes revealed that the sensitivities of enhanced CT in diagnosing mediastinal and hilar lymph nodes were only 18.9% and 17.0%, respectively [ 7 ]. 18 F-fluorodeoxyglucose ([ 18 F]-FDG) positron emission tomography/computed tomography (PET/CT) is always recommended for tumor diagnosis and staging [ 8 ], but it is not sufficiently specific for diagnosing lymph nodes, as inflammatory lesions also demonstrate enhanced FDG uptake [ 9 , 10 ].

68 Ga/ 18 F-labeled fibroblast-activation protein inhibitor (FAPI) PET/CT has been used in various kinds of tumors and demonstrated a complementary role in discriminating malignant from benign lesions [ 11 ], and it can reveal more metastatic lymph nodes in various cancers than 18 F-FDG [ 12 , 13 , 14 , 15 ]. A recent case report demonstrated that 68 Ga-FAPI PET/CT scans downstage the TNM stage of squamous cell lung cancer due to the lack of FAPI uptake in the enlarged right lower paratracheal lymph node [ 10 ]. These encouraging results prompted us to compare 18 F-AlF-FAPI-04 ( 18 F-FAPI) PET/CT to 18 F-FDG PET/CT for identifying mediastinal and hilar lymph nodes in lung cancer patients.

This study aims to compare the diagnostic efficacy of 18 F-FAPI PET/CT and 18 F-FDG PET/CT in patients with locally advanced lung cancer for the diagnosis of metastatic mediastinal and hilar lymph nodes. More importantly, an optimal SUVmax cutoff value should be determined to quantitatively and frequently diagnoses lymph nodes, especially in small lymph nodes.

Study participants

Twenty-seven patients diagnosed with lung cancer referred to staging of disease were prospectively recruited and underwent both 18 F-FDG PET/CT and 18 F-FAPI PET/CT scans. The patients were enrolled as part of a larger ongoing study in our institution to evaluate the role of 18 F-FAPI PET/CT in the imaging of mediastinal and hilar lymph node metastasis in lung cancer patients (ClinicalTrials.gov identifier: ChiCTR2000036091). The inclusion criteria were as follows: (i) patients diagnosed with lung cancer pathologically; (ii) paired 18 F-FDG and 18 F-FAPI PET/CT were performed within one week. The exclusion criteria were (i) pregnant patients, (ii) patients with another malignant disease, and (iii) participants who were unwilling to undergo 18 F-FDG or 18 F-FAPI PET/CT examination. This study was approved by the institutional review board (IRB) of the Shanghai Proton and Heavy Ion Center (SPHIC) (ethical code: 2106-49-01) and conducted in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards, and all subjects signed an informed consent form. The final diagnosis was confirmed by EBUS or follow-up. Follow-up contrast-enhanced CT was performed 6 months after treatment. Lymph nodes in the follow-up images were considered malignant based on the following criteria: (i) the morphology, growth pattern and enhancement pattern of the nodes were consistent with the characteristics of malignant tumors, (ii) tumor progression after treatment, and (iii) tumor shrinkage after treatment.

Radiopharmaceuticals and PET/CT imaging

The synthesis of [ 18 F]-FDG was based on a cyclotron (Siemens CTI RDS Eclips ST, Knoxville, TN). 18 F-AlF-FAPI-04 preparation was performed according to a published procedure [ 16 ]. The radiochemical purity was over 95%.

Paired 18 F-FDG and 18 F-FAPI scans were performed within 7 days. For 18 F-FDG PET/CT, patients were required to fast for at least 6 h, and their blood glucose level had to be under 11.1 mmol/L. For 18 F-FAPI PET/CT, no specific preparation was requested. The imaging procedures were carried out on a Biography 16 PET/CT scanner (Siemens Healthcare, Erlangen, Germany) one hour after 18 F-FDG (~ 0.1 mCi/kg, 370 MBq/kg) or 18 F-FAPI (~ 0.1 mCi/kg, 370 MBq/kg) injection. PET image datasets were iteratively reconstructed using an ordered-subset expectation maximization iterative reconstruction by applying CT data for attenuation correction.

Image interpretation

Two experienced nuclear medicine physicians analyzed and interpreted the images in a blinded manner, and in cases of disagreement, a consensus was reached. SUVmax for each lymph node was calculated by placing a spheroid-shaped volume of interest within the node on a multimodality computer platform (Syngo, Siemens, Knoxville, Tennessee, USA). Positive 18 F-FDG and 18 F-FAPI uptake was defined as focal avidity greater than the background of the mediastinal blood pool. Lymph nodes were assessed using enhanced CT scans, and nodes with short-axis diameters less than 10 mm were defined as small lymph nodes; otherwise, they were defined as large lymph nodes.

Statistical analyses

Data were analyzed by SPSS statistical software (version 25.0, SPSS, IBM Inc., New York, USA). Demographic data and PET/CT parameters were summarized as the mean with standard deviation or frequencies with percentages. The Wilcoxon signed-rank test was used to analyze the differences between PET/CT parameters. P < 0.05 was considered statistically significant, and all analyses were two sided.

Patient characteristics

A total of 36 patients with locally advanced lung cancer were registered in the study, and they underwent PET/CT for tumor staging. Four patients had a second primary tumor and 5 patients missed in the follow-up period; these patients were excluded from the study (Fig.  1 ). Finally, 27 patients with 137 mediastinal and hilar lymph nodes were included. Of the 137 lymph nodes, 106 were mediastinal lymph nodes and 31 were hilar lymph nodes. The clinical characteristics of these patients are shown in Table 1 .

figure 1

Flow diagram shows participant selection details. FAPI   fibroblast activation protein inhibitor, FDG fluorodeoxyglucose, 18 F = fluorine 18

In the evaluation of the lymph nodes, histopathological examination or contrast-enhanced CT was used. Fourteen nodes in 6 patients were confirmed with pathologic examination, and 123 nodes in 21 patients were confirmed with contrast-enhanced CT before treatment and the follow-up enhanced CT images. Finally, forty-five out of 137 lymph nodes were found to be cancerous, including 32 mediastinal and 13 hilar lymph nodes. In addition, 85 lymph nodes (62%, 85/137) with a short-axis diameter less than 10 mm were defined as small lymph nodes, including 13 metastatic and 72 nonmetastatic lymph nodes.

Improved metastatic lymph node detection with 18 F-FAPI PET/CT

In all 137 lymph nodes, the 18 F-FAPI-derived SUVmax was 4.80 ± 6.11, and the 18 F-FDG-derived SUVmax was 4.33 ± 3.69, p  = 0.414. In all 45 metastatic lymph nodes, the mean value of SUVmax on 18 F-FAPI PET/CT images was 10.87 ± 7.29, and SUVmax on 18 F-FDG PET/CT images was 6.08 ± 5.37, p  = 0.001, while in 92 benign lymph nodes, the SUVmax of 68  Ga-FAPI PET/CT was 1.87 ± 1.82, and the SUVmax of 18 F-FDG PET/CT was 3.47 ± 2.04, p  < 0.001. In summary, 18 F-FAPI PET/CT showed a much higher SUVmax value than 18 F-FDG PET/CT in metastatic lymph nodes but a much lower SUVmax value than 18 F-FDG in benign lymph nodes. Moreover, in 18 F-FDG PET/CT, the SUVmax values in metastatic and nonmetastatic lymph nodes presented substantial overlap, although the p -value was less than 0.05. However, in 18 F-FAPI PET/CT, there was no overlap, and the p value was less than 0.001, Fig.  2 a.

figure 2

Comparison of the performance of 18 F-FAPI and. 18 F-FDG PET/CT in diagnosing mediastinal and hilar lymph nodes. Comparison of the tracer uptakes a and ROC analysis of SUVmax derived from the two PET/CTs for identifying lymph nodes status b

In addition to the correction between SUVmax and the nature of lymph nodes, the relationship between SUVmax and the diameters of these nodes were compared. However, neither SUVmax of 18 F-FAPI nor SUVmax of 18 F-FDG had significant correction with the size of nodes ( r 2  = 0.26 and 0.28, respectively), Fig.  3 . In summary, there was a difference between SUVmax of 18 F-FAPI and the nature of lymph nodes, but no relationship in SUVmax and lymph node size.

figure 3

The correction between short diameter of lymph nodes and SUVmax. The correction between short diameter of lymph nodes and 18 F-FAPI SUVmax a and. 18 F-FDG PAPI SUVmax b

Additionally, 18 F-FAPI was a superior method in evaluating mediastinal hilar lymph nodes, with a larger area under the receiver operating characteristic (ROC) curve comparing with 18 F-FDG (0.901 vs. 0.721). The optimal cutoff value for diagnosis of 18 F-FAPI and 18 F-FDG PET/CT was 2.5 and 3.4 by ROC analysis, respectively (Fig.  2 b). On 18 F-FAPI PET/CT, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 84%, 92%, 90%, 84%, and 92%, respectively. In 18 F-FDG PET/CT imaging, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 71%, 67%, 69%, 52%, and 83%, respectively (Table 2 ).

18 F-FAPI PET/CT improves the diagnostic accuracy for small metastatic lymph nodes

When small LNs were considered, 18 F-FAPI performed much better than 18 F-FDG PET/CT. A total of 85 lymph nodes with a short-axis diameter less than 10 mm were confirmed to be small lymph nodes, including 13 metastatic and 72 nonmetastatic nodes. In 18 F-FAPI PET/CT, the SUVmax of small metastatic lymph nodes was substantially higher than that of small nonmetastatic lymph nodes (9.29 ± 7.57 vs. 1.67 ± 1.73, p  = 0.001). Similarly, the SUVmax based on 18 F-FDG was greater in small metastatic lymph nodes than in small nonmetastatic nodes (4.37 ± 1.85 vs. 3.10 ± 1.86, p  = 0.001). As a result, 18 F-FAPI presented much higher specificity, accuracy, and positive prediction value (PPV) than 18 F-FDG PET/CT (specificity: 96% vs. 72%; accuracy: 93% vs. 73%; PPV: 77% vs. 33%, respectively). In 18 F-FDG PET, false-positives were observed in 20 patients due to inflammation. However, in 18 F-FAPI PET, only 3 false-positives were observed. The diagnostic efficacies of the two procedures are compared in Table 3 . A typical case showing false-positive 18 F-FDG uptake and true-negative 18 F-FAPI uptake in mediastinal and hilar lymph nodes is shown in Fig.  4 , and a representative case displaying intense 18 F-FAPI but negative 18 F-FDG uptake in small metastatic lymph nodes is shown in Fig.  5 .

figure 4

A 79-year-old man with a diagnosis of lung cancer. Lymph nodes in region 4R and 10L with intense 18 F-FDG uptake ( a , red arrows) and no 18 F-FAPI uptake ( b , red arrows) were confirmed as nonmetastatic lymph nodes pathologically

figure 5

A 58-year-old man with a diagnosis of lung cancer. Small (0.7 * 0.7 cm) metastatic lymph nodes in region 4R showed no 18 F-FDG-avidity ( a , red arrows), but remarkable. 18 F-FAPI-avidity ( b , red arrows)

SUVmax cut-off values for differentiating metastatic from benign lymph nodes

Figure  6 demonstrates the distribution of SUVmax in metastatic and nonmetastatic lymph nodes. In the nonmetastatic group, 90 lymph nodes had the 18 F-FAPI SUVmax smaller than 5.3, and only 2 nodes had SUVmax larger than 5.3, resulting in a high specificity (98%). As a result, we evaluated the diagnostic performance of 18 F-FAPI when choosing 5.3 as a cut-off value. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 73%, 98%, 90%, 94%, and 88%, respectively. Additionally, mean value is commonly used in data analysis, so we investigated the diagnostic performance when SUVmax was 3.5, which was the mean SUVmax value (Table 4 ). As aforementioned, 2.5 was also an optimal cutoff value for diagnosis, so we compared the diagnostic performance when the cutoff values were 5.3, 3.5 and 2.5 (Table 4 ). All the three values demonstrated similar diagnostic accuracy, but when the cut-off value was 5.3, the 18 F-FAPI SUVmax could improve specificity and PPV. When the cutoff value was 2.5, SUVmax could improve sensitivity and NPV.

figure 6

The SUVmax of every lymph node and the optimal cut-off value for the evaluation of metastatic and nonmetastatic lymph nodes. 98% (90/92) nonmetastatic nodes had a 18 F-FAPI-derived SUVmax less than 5.3 and 73% (33 of 45) metastatic nodes showed a 18 F-FAPI-derived SUVmax larger than 5.3 a . The SUVmax of metastatic nodes derived from. 18 F-FDG overlapped that of nonmetastatic nodes b

In FDG PET/CT, the values of 3.5 and 5.3 were inapplicable, because the SUVmax of nonmetastatic lymph nodes overlapped with that of metastatic lymph nodes.

The present study indicated that 18 F-FAPI PET/CT had much higher diagnostic efficacy in mediastinal and hilar lymph nodes in patients with lung cancer, especially in small metastatic lymph nodes (size less than 10 mm), when compared with 18 F-FDG. Additionally, two cutoff values were identified in this study. The optimal cut-off value for specificity and PPV of 18 F-FAPI SUVmax was 5.3; the optimal cut-off value for sensitivity and NPV was 2.5; this result means that a noninvasive and accurate diagnostic model could be established with 18 F-FAPI PET/CT.

A study has shown that intrathoracic nodal status is considered to be positive for metastatic spread if the FDG activity of the node is higher than the mediastinal background [ 17 ]; however, a high level of FDG uptake can also be noted in various benign conditions, such as different infective/inflammatory processes [ 18 , 19 ]. A previous study indicated that a benign mediastinal lymph node with 34.5 mm in size was FDG-avid [ 20 ]. In the present study, metastatic lymph nodes had significantly higher FAPI-derived SUVmax than nonmetastatic lymph nodes, but in 18 F-FDG PET/CT imaging, although metastatic lymph nodes showed higher uptake than nonmetastatic nodes, the SUVmax in metastatic lymph nodes exhibited substantial overlap that in nonmetastatic lymph nodes. This finding suggested that 18 F-FAPI PET/CT may help address the limitation of 18 F-FDG in diagnosing lymph nodes and expand the clinical indications of PET/CT. In addition, our study showed that 18 F-FAPI PET/CT was more sensitive and specific than 18 F-FDG in diagnosing mediastinal and hilar lymph nodes, consistent with previous studies [ 21 ]. The variable positive predictive rate for the assessment of mediastinal lymph node involvement with 18 F-FDG PET/CT has also been recognized, ranging from 32.3% to 89% [ 22 , 23 ]. The low and dispersive predictive rate limits the application of 18 F-FDG in the assessment of mediastinal lymph nodes, and our results suggest that 18 F-FAPI PET/CT might be an alternative imaging technique.

Additionally, according to ACCP evidenced-based clinical practice guidelines, lymph nodes with short-axis diameters larger than 10 mm were considered abnormal lymph nodes [ 6 ]. As a result, in the present study, lymph nodes with short-axis diameters less than 10 mm were defined as small lymph nodes. The size of the lymph nodes was an important factor affecting the diagnostic efficiency on imaging scans, including CT and PET/CT scans. For very small lesions (< 10 mm), visibility is low due to the partial volume effect and low tumor metabolic activity [ 24 , 25 ]. However, previous studies indicated that FAPI PET/CT was better than FDG PET/CT in diagnosing metastatic lymph nodes. A recent study indicated that 68  Ga-FAPI PET/CT had a diagnostic accuracy of 100% in diagnosing metastatic lymph nodes from non-small cell lung cancer, while 18 F-FDG had an accuracy of 30% [ 26 ]. Lijuan Wang et al. showed that 68  Ga-FAPI detected 356 lymph nodes, while 18 F-FDG PET/CT detected 320 nodes, and 22 among the 36 lymph nodes detected only by FAPI PET/CT had a diameter shorter than 10 mm [ 27 ]. In the present study, the number of small positive lymph nodes detected by the two PET/CTs was the same, but the specificity and accuracy for diagnosing small lymph nodes were higher for 18 F-FAPI than for 18 F-FDG. Previous studies indicated that in the earlier stage of metastatic lymph node, the number of tumor cells was small and could not be detected by 18 F-FDG [ 28 , 29 ]. Before tumor cells are located in the lymph nodes, they secrete some factors to promote premetastatic lymph nodes by activating fibroblast reticular cells, which differentiate into CAFs and express high levels of FAP [ 30 , 31 , 32 ]. This may explain why 18 F-FAPI PET/CT is better in detecting small metastatic lymph nodes.

Another important finding of this study is the diagnostic cut-off values. As the pathologic gold standard, the sensitivity of EBUS in mediastinal staging for lung cancer ranges from 45 to 93%, and the NPV was 93% [ 33 ]. In this study, using SUVmax 2.5 as the cut-off value, the sensitivity was 84% and the NPV was 92%, which was similar to that of the EBUS method. When the cut-off was 5.3, the specificity and PPV were highly increased. To the best of our knowledge, cut-off values for SUVmax to identify lymph node status have not been investigated previously. Such a reference value may provide a simple, powerful and repeatable clinical tool for the prediction of lymph nodes in patients with lung cancer.

This systematic study investigated the value of 18 F-FAPI PET/CT in diagnosing mediastinal and hilar lymph nodes in patients with lung cancer and obtained two optimal values for discriminating metastatic from benign nodes. Our results indicated the value of 18 F-FAPI PET/CT in the detection of mediastinal and hilar lymph nodes secondary to lung cancer. However, there were some limitations in this study. First, this was a single-center study with a small sample size. Second, not all lymph nodes were diagnosed by pathology due to the difficulty of obtaining tissue samples. However, the results were obtained with enhanced CT and follow-up.

18 F-FAPI showed promising diagnostic efficiency in metastatic mediastinal and hilar lymph nodes from lung cancer patients with a better sensitivity and negative predictive value, particularly in small nodes (size less than 10 mm), than 18 F-FDG. Additionally, this preliminary study proposed optimal cutoff values of 5.3 to distinguish nonmetastatic from metastatic nodes, which could obtain a similar sensitivity of 94.29% with EBUS and a much higher NPV of nonmetastatic LNs.

Availability of data and materials

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Fibroblast activation protein

Fibroblast activation protein inhibitor

Fluorine 18 fluorodeoxyglucose

Fluorine 18-labeled fibroblast activation protein inhibitor

Maximum standardized uptake value

Positive predictive value

Negative predictive value

Oliver AL. Lung cancer: epidemiology and screening. Surg Clin North Am. 2022;102:335–44. https://doi.org/10.1016/j.suc.2021.12.001 .

Article   PubMed   Google Scholar  

Ettinger DS, Wood DE, Akerley W, Bazhenova LA, Borghaei H, Camidge DR, et al. Non-small cell lung cancer version 62015. J Natl Compr Canc Netw. 2015. https://doi.org/10.6004/jnccn.2015.0071 .

Jalil BA, Yasufuku K, Khan AM. Uses, limitations, and complications of endobronchial ultrasound. Proc (Bayl Univ Med Cent). 2015;28:325–30. https://doi.org/10.1080/08998280.2015.11929263 .

Schmid-Bindert G, Jiang H, Kähler G, Saur J, Henzler T, Wang H, et al. Predicting malignancy in mediastinal lymph nodes by endobronchial ultrasound: a new ultrasound scoring system. Respirology. 2012;17:1190–8. https://doi.org/10.1111/j.1440-1843.2012.02223.x .

Silvestri GA, Tanoue LT, Margolis ML, Barker J, Detterbeck F. The noninvasive staging of non-small cell lung cancer: the guidelines. Chest. 2003;123:147s-s156. https://doi.org/10.1378/chest.123.1_suppl.147s .

Silvestri GA, Gould MK, Margolis ML, Tanoue LT, McCrory D, Toloza E, et al. Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines. Chest. 2007. https://doi.org/10.1378/chest.07-1360 .

Fréchet B, Kazakov J, Thiffault V, Ferraro P, Liberman M. Diagnostic accuracy of mediastinal lymph node staging techniques in the preoperative assessment of nonsmall cell lung cancer patients. J Bronchology Interv Pulmonol. 2018;25:17–24. https://doi.org/10.1097/lbr.0000000000000425 .

Kandathil A, Kay FU, Butt YM, Wachsmann JW, Subramaniam RM. Role of FDG PET/CT in the of TNM staging of non-small cell lung cancer. Radiographics. 2018. https://doi.org/10.1148/rg.2018180060 .

González-Cruz C, Bodet D, Muñoz-Couselo E, García-Patos V. Mediastinal FDG-positive lymph nodes simulating melanoma progression: drug-induced sarcoidosis like/lymphadenopathy related to ipilimumab. BMJ Case Rep. 2021. https://doi.org/10.1136/bcr-2020-237310 .

Article   PubMed   PubMed Central   Google Scholar  

Shang Q, Zhao L, Pang Y, Meng T, Chen H. Differentiation of reactive lymph nodes and tumor metastatic lymph nodes With 68Ga-FAPI PET/CT in a patient with squamous cell lung cancer. Clin Nucl Med. 2022;47:458–61. https://doi.org/10.1097/rlu.0000000000003998 .

Guglielmo P, Guerra L. Radiolabeled fibroblast activation protein inhibitor (FAPI) PET in oncology: has the time come for 18F-fluorodeoxyglucose to think to a well-deserved retirement? ClinTransl Imaging. 2021;9:1–2. https://doi.org/10.1007/s40336-020-00402-z .

Article   Google Scholar  

Çermik TF, Ergül N, Yılmaz B, Mercanoğlu G. Tumor imaging with 68Ga-DOTA-FAPI-04 PET/CT: comparison with 18F-FDG PET/CT in 22 different cancer types. Clin Nucl Med. 2022;47:e333–9. https://doi.org/10.1097/rlu.0000000000004073 .

Kratochwil C, Flechsig P, Lindner T, Abderrahim L, Altmann A, Mier W, et al. (68)Ga-FAPI PET/CT: tracer uptake in 28 different kinds of cancer. J Nucl Med. 2019;60:801–5. https://doi.org/10.2967/jnumed.119.227967 .

Giesel FL, Adeberg S, Syed M, Lindner T, Jiménez-Franco LD, Mavriopoulou E, et al. FAPI-74 PET/CT using either (18)F-AlF or Cold-Kit (68)Ga labeling: biodistribution, radiation dosimetry, and tumor delineation in lung cancer patients. J Nucl Med. 2021;62:201–7. https://doi.org/10.2967/jnumed.120.245084 .

Pang Y, Zhao L. Comparison of (68)Ga-FAPI and (18)F-FDG uptake in gastric. Duodenal Colorectal Cancers. 2021;298:393–402. https://doi.org/10.1148/radiol.2020203275 .

Kou Y, Jiang X, Yao Y, Shen J, Jiang X, Chen S, et al. Physiological tracer distribution and benign lesion incidental uptake of Al18F-NOTA-FAPI-04 on PET/CT imaging. Nucl Med Commun. 2022;43:847–54. https://doi.org/10.1097/mnm.0000000000001563 .

Gunluoglu MZ, Melek H, Medetoglu B, Demir A, Kara HV, Dincer SI. The validity of preoperative lymph node staging guidelines of European society of thoracic surgeons in non-small-cell lung cancer patients. Eur J Cardiothorac Surg. 2011;40:287–90. https://doi.org/10.1016/j.ejcts.2010.11.030 .

Ding RL, Cao HY, Hu Y, Shang CL, Xie F, Zhang ZH, et al. Lymph node tuberculosis mimicking malignancy on (18)F-FDG PET/CT in two patients: a case report. Exp Ther Med. 2017;13:3369–73. https://doi.org/10.3892/etm.2017.4421 .

Maccarone MT. FDG-PET Scan in sarcoidosis: clinical and imaging indications. Curr Med Imaging Rev. 2019;15:4–9. https://doi.org/10.2174/1573405614666180626120832 .

T Fujiwara T Nakajima. The combination of endobronchial elastography and sonographic findings during endobronchial ultrasound-guided transbronchial needle aspiration for predicting nodal metastasis. 2019;10:2000-5. https://doi.org/10.1111/1759-7714.13186

Qin C, Shao F, Gai Y, Liu Q, Ruan W, Liu F, et al. (68)Ga-DOTA-FAPI-04 PET/MR in the evaluation of gastric carcinomas: comparison with (18)F-FDG PET/CT. J Nucl Med. 2022;63:81–8. https://doi.org/10.2967/jnumed.120.258467 .

Lin WY, Hsu WH, Lin KH, Wang SJ. Role of preoperative PET-CT in assessing mediastinal and hilar lymph node status in early stage lung cancer. J Chin Med Assoc. 2012;75:203–8. https://doi.org/10.1016/j.jcma.2012.04.004 .

Nakanishi K, Nakamura S, Sugiyama T, Kadomatsu Y, Ueno H, Goto M, et al. Diagnostic utility of metabolic parameters on FDG PET/CT for lymph node metastasis in patients with cN2 non-small cell lung cancer. BMC Cancer. 2021;21:983. https://doi.org/10.1186/s12885-021-08688-6 .

Spadafora M, Pace L, Evangelista L, Mansi L, Del Prete F, Saladini G, et al. Risk-related (18)F-FDG PET/CT and new diagnostic strategies in patients with solitary pulmonary nodule: the ITALIAN multicenter trial. Eur J Nucl Med Mol Imaging. 2018;45:1908–14. https://doi.org/10.1007/s00259-018-4043-y .

Redondo-Cerezo E, Martínez-Cara JG, Jiménez-Rosales R, Valverde-López F, Caballero-Mateos A, Jérvez-Puente P, et al. Endoscopic ultrasound in gastric cancer staging before and after neoadjuvant chemotherapy a comparison with PET-CT in a clinical series. United Eur Gastroenterol J. 2017;5:641–7. https://doi.org/10.1177/2050640616684697 .

Zhou X, Wang S, Xu X, Meng X, Zhang H, Zhang A, et al. Higher accuracy of [(68) Ga]Ga-DOTA-FAPI-04 PET/CT comparing with 2-[(18)F]FDG PET/CT in clinical staging of NSCLC. Eur J Nucl Med Mol Imaging. 2022;49:2983–93. https://doi.org/10.1007/s00259-022-05818-5 .

Wang L, Tang G. Comparison of (68)Ga-FAPI and (18)F-FDG PET/CT in the evaluation of advanced lung cancer. Radiolog. 2022. https://doi.org/10.1148/radiol.211424 .

Stahlie EHA, van der Hiel B, Bruining A, van de Wiel B, Schrage YM, Wouters M, et al. The value of lymph node ultrasound and whole body (18)F-FDG PET/CT in stage IIB/C melanoma patients prior to SLNB. Eur J Surg Oncol. 2021;47:1157–62. https://doi.org/10.1016/j.ejso.2020.12.007 .

Calais J, Mona CE. Will FAPI PET/CT replace FDG PET/CT in the next decade? point-an important diagnostic, phenotypic, and biomarker role. AJR Am J Roentgenol. 2021;216:305–6. https://doi.org/10.2214/ajr.20.24302 .

Rovera C, Berestjuk I,Lecacheur M. 2022. Secretion of IL1 by Dedifferentiated Melanoma Cells Inhibits JAK1-STAT3-Driven Actomyosin Contractility of Lymph Node Fibroblastic Reticular Cells. https://doi.org/10.1158/0008-5472.CAN-21-0501

Nizri E, Bar-David S, Aizic A, Sternbach N, Lahat G, Wolf I, et al. Desmoplasia in lymph node metastasis of pancreatic adenocarcinoma reveals activation of cancer-associated fibroblasts pattern and T-helper 2 immune cell infiltration. Pancreas. 2019;48:367–73. https://doi.org/10.1097/mpa.0000000000001261 .

Itou RA, Uyama N, Hirota S, Kawada N, Wu S, Miyashita S, et al. Immunohistochemical characterization of cancer-associated fibroblasts at the primary sites and in the metastatic lymph nodes of human intrahepatic cholangiocarcinoma. Hum Pathol. 2019;83:77–89. https://doi.org/10.1016/j.humpath.2018.08.016 .

Vilmann P, Clementsen PF, Colella S, Siemsen M, De Leyn P, Dumonceau JM, et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: european society of gastrointestinal endoscopy (ESGE) guideline, in cooperation with the european respiratory society (ERS) and the European society of thoracic surgeons (ESTS). Endoscopy. 2015;47:545–59. https://doi.org/10.1055/s-0034-1392040 .

Download references

Acknowledgements

We thank all the staff at the Department of Nuclear Medicine in our center for their excellent technical assistance. We would also like to thank the multidisciplinary team in our hospital for the great help to our work.

This research was supported by Pudong New area science and technology development foundation (No. PKJ2018-Y49), Pudong New area science and technology development foundation (No. PKJ 2020-Y56), and Natural Science Foundation of Shanghai (21ZR460300).

Author information

Yuyun Sun and Yun Sun have contributed equally to this work.

Authors and Affiliations

Department of Nuclear Medicine, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, 4365 Kangxin Road, Shanghai, 201321, China

Yuyun Sun, Shaoli Song & Jingyi Cheng

Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China

Yuyun Sun, Yun Sun, Zili Li, Shaoli Song, Kailiang Wu, Jingfang Mao & Jingyi Cheng

Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China

Department of Radiotherapy, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321, China

Kailiang Wu & Jingfang Mao

Department of Nuclear Medicine, Shanghai Proton and Heavy Ion Center, Shanghai, 201321, China

Yun Sun & Zili Li

You can also search for this author in PubMed   Google Scholar

Contributions

YS, YS and JC contributed to the study conception and design; Material preparation, data collection and analysis were performed by all authors. The first draft of the manuscript was written by YS and YS. JC and JM revised the manuscript with constructive ideas. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Jingfang Mao or Jingyi Cheng .

Ethics declarations

Ethics approval and consent to participate.

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the institutional review board (IRB) of the Shanghai Proton and Heavy Ion Center (SPHIC) (Ethical Code: 2106-49-01). Informed consent was obtained from all individual participants included in the study.

Consent for publication

Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Sun, Y., Sun, Y., Li, Z. et al. 18 F-FAPI PET/CT performs better in evaluating mediastinal and hilar lymph nodes in patients with lung cancer: comparison with 18 F-FDG PET/CT. Eur J Med Res 29 , 9 (2024). https://doi.org/10.1186/s40001-023-01494-9

Download citation

Received : 26 June 2023

Accepted : 01 November 2023

Published : 03 January 2024

DOI : https://doi.org/10.1186/s40001-023-01494-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • 18 F-FAPI PET/CT
  • Mediastinal and hilar lymph node
  • Lung cancer
  • 18 F-FDG PET/CT

European Journal of Medical Research

ISSN: 2047-783X

case study positive and negative

Positive and adverse childhood experiences and mental health outcomes of children

Affiliations.

  • 1 University of Central Florida, College of Sciences, Department of Sociology, 4297 Andromeda Loop N., Orlando, FL 32816, United States of America. Electronic address: [email protected].
  • 2 University of Central Florida, College of Sciences, Department of Sociology, 4297 Andromeda Loop N., Orlando, FL 32816, United States of America. Electronic address: [email protected].
  • PMID: 38141478
  • DOI: 10.1016/j.chiabu.2023.106603

Objective: Researchers and policymakers have identified adverse childhood experiences (ACEs) like abuse, neglect, and household dysfunction as a contributing factor to poor mental health outcomes for children. Positive childhood experiences (PCEs) like open family communication styles, having the ability to live and play in a safe, stable, and protective environment, having constructive opportunities for social engagement, and receiving mentorship from adults have been found to improve the mental health of children.

Purpose: This paper explores the role of ACEs and PCEs on the mental health outcomes of children.

Method: A sample of 22,628 children ages 6-17 from the National Survey of Children's Health (2017-2020) was used to explore the relationship between PCEs and ACEs and the mental health of children. Logistic regression analysis is used to model the effect of PCEs and ACEs on the odds of child mental health diagnoses.

Results: Findings indicate that with each additional ACE, there was a significant increase in the odds of reporting a MH condition (OR = 1.25, 95 % CI 1.09-1.43). Conversely, with each additional PCE, there is a significant decrease in the odds or reporting a MH condition (OR = 0.76, 95 % CI 0.68-0.84). There was also evidence that PCEs moderate the relationship between ACEs and reports of mental health conditions. When counts of ACEs are low, PCEs provide a protective effect on reports of mental health. But when the count of ACEs are high, children with higher numbers of PCEs have similar reports of mental health conditions.

Summary: This study provides information about the moderating effect of PCEs on the relationship between ACEs and child mental health diagnosis with the goal of informing policies and interventions focused on ameliorating the growing crisis of children's negative mental health and well-being. WHAT IS KNOWN?: Adverse childhood events (ACEs) like abuse, neglect and household dysfunction are known to negatively impact the mental health and well-being of children. Positive childhood experiences (PCEs), on the other hand, can positively influence the mental health and well-being of children. WHAT DOES THIS ARTICLE ADD?: This study examines the association between adverse and positive childhood experiences to understand how they impact the mental health outcomes of children ages 6-17. Findings indicate that when ACEs are lower, the impact of PCEs are positive, but when ACEs are higher, PCEs do not make much difference in reports of mental health problems.

Keywords: Childhood adversity; Mental health; Positive childhood experiences; Resilience.

Copyright © 2023. Published by Elsevier Ltd.

BrandonGaille.com

Home » Pros and Cons » 12 Case Study Method Advantages and Disadvantages

12 Case Study Method Advantages and Disadvantages

A case study is an investigation into an individual circumstance. The investigation may be of a single person, business, event, or group. The investigation involves collecting in-depth data about the individual entity through the use of several collection methods. Interviews and observation are two of the most common forms of data collection used.

The case study method was originally developed in the field of clinical medicine. It has expanded since to other industries to examine key results, either positive or negative, that were received through a specific set of decisions. This allows for the topic to be researched with great detail, allowing others to glean knowledge from the information presented.

Here are the advantages and disadvantages of using the case study method.

List of the Advantages of the Case Study Method

1. it turns client observations into useable data..

Case studies offer verifiable data from direct observations of the individual entity involved. These observations provide information about input processes. It can show the path taken which led to specific results being generated. Those observations make it possible for others, in similar circumstances, to potentially replicate the results discovered by the case study method.

2. It turns opinion into fact.

Case studies provide facts to study because you’re looking at data which was generated in real-time. It is a way for researchers to turn their opinions into information that can be verified as fact because there is a proven path of positive or negative development. Singling out a specific incident also provides in-depth details about the path of development, which gives it extra credibility to the outside observer.

3. It is relevant to all parties involved.

Case studies that are chosen well will be relevant to everyone who is participating in the process. Because there is such a high level of relevance involved, researchers are able to stay actively engaged in the data collection process. Participants are able to further their knowledge growth because there is interest in the outcome of the case study. Most importantly, the case study method essentially forces people to make a decision about the question being studied, then defend their position through the use of facts.

4. It uses a number of different research methodologies.

The case study method involves more than just interviews and direct observation. Case histories from a records database can be used with this method. Questionnaires can be distributed to participants in the entity being studies. Individuals who have kept diaries and journals about the entity being studied can be included. Even certain experimental tasks, such as a memory test, can be part of this research process.

5. It can be done remotely.

Researchers do not need to be present at a specific location or facility to utilize the case study method. Research can be obtained over the phone, through email, and other forms of remote communication. Even interviews can be conducted over the phone. That means this method is good for formative research that is exploratory in nature, even if it must be completed from a remote location.

6. It is inexpensive.

Compared to other methods of research, the case study method is rather inexpensive. The costs associated with this method involve accessing data, which can often be done for free. Even when there are in-person interviews or other on-site duties involved, the costs of reviewing the data are minimal.

7. It is very accessible to readers.

The case study method puts data into a usable format for those who read the data and note its outcome. Although there may be perspectives of the researcher included in the outcome, the goal of this method is to help the reader be able to identify specific concepts to which they also relate. That allows them to discover unusual features within the data, examine outliers that may be present, or draw conclusions from their own experiences.

List of the Disadvantages of the Case Study Method

1. it can have influence factors within the data..

Every person has their own unconscious bias. Although the case study method is designed to limit the influence of this bias by collecting fact-based data, it is the collector of the data who gets to define what is a “fact” and what is not. That means the real-time data being collected may be based on the results the researcher wants to see from the entity instead. By controlling how facts are collected, a research can control the results this method generates.

2. It takes longer to analyze the data.

The information collection process through the case study method takes much longer to collect than other research options. That is because there is an enormous amount of data which must be sifted through. It’s not just the researchers who can influence the outcome in this type of research method. Participants can also influence outcomes by given inaccurate or incomplete answers to questions they are asked. Researchers must verify the information presented to ensure its accuracy, and that takes time to complete.

3. It can be an inefficient process.

Case study methods require the participation of the individuals or entities involved for it to be a successful process. That means the skills of the researcher will help to determine the quality of information that is being received. Some participants may be quiet, unwilling to answer even basic questions about what is being studied. Others may be overly talkative, exploring tangents which have nothing to do with the case study at all. If researchers are unsure of how to manage this process, then incomplete data is often collected.

4. It requires a small sample size to be effective.

The case study method requires a small sample size for it to yield an effective amount of data to be analyzed. If there are different demographics involved with the entity, or there are different needs which must be examined, then the case study method becomes very inefficient.

5. It is a labor-intensive method of data collection.

The case study method requires researchers to have a high level of language skills to be successful with data collection. Researchers must be personally involved in every aspect of collecting the data as well. From reviewing files or entries personally to conducting personal interviews, the concepts and themes of this process are heavily reliant on the amount of work each researcher is willing to put into things.

These case study method advantages and disadvantages offer a look at the effectiveness of this research option. With the right skill set, it can be used as an effective tool to gather rich, detailed information about specific entities. Without the right skill set, the case study method becomes inefficient and inaccurate.

Related Posts:

  • 25 Best Ways to Overcome the Fear of Failure
  • Monroe's Motivated Sequence Explained [with Examples]
  • Is Mercari Legit and Safe: 15 Tips for Buyers and Sellers
  • Force Field Analysis Explained with Examples

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Advanced Search
  • Journal List
  • Hered Cancer Clin Pract
  • v.10(Suppl 2); 2012

Logo of hccp

Case study: positive outcomes from a negative

1 Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick NSW 2031, Australia

As the work load for clinical genetics escalates and more genetic test are ordered, the potential for errors increase. This report present at the affected patient’s request, the occurrence of an error and its subsequent management.

A BRCA2 large deletion had been detected in a family member and predictive testing had already occurred in other family members. Our client had 50/50 chance of having the mutation and had a negative predictive test. When breast cancer occurred in the patient, the sample was retested and found to be positive. The different results were given in person and a root cause analysis done. The patient requested that the error be discussed at clinical meetings so lessons found could be learnt by the whole genetics community.

Multiple factors impacted on this case. An unclassified variant-considered likely to be benign, had been identified, as well as a pathogenic mutation. Blood was collected from both relatives one day apart and sent for testing at the laboratory which identified the mutation. Although the sample request form requested a predictive test specifying the gene, lab ID and DOB of the proband it did not specify the mutation to avoid transcription errors. A new laboratory staff member incorrectly tested for the unclassified variant. Although duplicate testing was done the samples were not collected independently and the same error occurred. The clinical staff were rushed as there were 2 carriers in the breast clinic, one a newly diagnosed breast cancer and another a possible diagnosis, requesting consultations.

A comprehensive review of the clinic’s genetic testing protocol has tightened protocol to minimize future error; the request form is accompanied by a de-identified copy of the mutation even if the testing laboratory did the mutation search. Although the protocol required predictive test results to be checked against the proband’s result results will now be signed by the doctor and counselor before being given. Cost consideration are ongoing as to whether the second sample will be sent completely separately. Efforts are being made to prevent the clash with the breast clinic.

Errors in genetic testing are rare event and give the opportunity to review procedures. Knowledge of errors allow other clinicians to review their protocols. We have learnt not only from our errors but from the valuable input from other clinicians who have shared their traumatic experiences. We propose that documentation of the extent and cause of genetic testing errors occur at the family cancer clinic day next year or at the COSA meeting. A culture of open disclosure with colleagues as well as the clients affected will help guard against further avoidable errors and help us develop sustainable, attainable and cost effective processes.

A new coronavirus variant is taking over, but its symptoms don't seem any worse

Nurse Sandra Lindsay receives the latest Covid vaccine.

Covid cases appear to be climbing , according to Dr. Mandy Cohen, the director of the Centers for Disease Control and Prevention — and one particular variant seems to be fueling the virus' spread .

JN.1, as the variant is known, now accounts for around 44% of Covid cases  in the U.S., up from 8% just four weeks ago, according to the CDC.

“We are seeing JN.1 quickly become the dominant version of the Covid virus, which tells us it is more transmissible,” Cohen said in a phone interview. “The good news is we don’t see an increase in severity.”

The variant is also picking up steam globally. It accounted for 27% of genetic sequences submitted to a global virus database called GISAID in the week that ended Dec. 3, up from 10% in the week that ended Nov. 19.

The World Health Organization declared JN.1 a "variant of interest" Tuesday — a designation that applies to variants that are driving new cases and have genetic changes that could help them spread or evade immunity.

But so far, the illness caused by JN.1 — which, like all other variants that have gained dominance since early 2022, is a descendant of omicron — doesn't seem any more severe than earlier Covid cases.

Neither the WHO nor the CDC collects regular data on how Covid symptoms are evolving over time, so it's hard to assess whether infections are presenting differently. However, doctors say they haven't noticed a new trend.

“The symptoms of JN.1 seem to be very similar, if not the same, as others,” said Dr. Molly Fleece, a hospital epidemiologist at University of Alabama at Birmingham Medicine.

Many recent Covid patients have reported sore throats as their first symptoms, often followed by congestion. The illness’ past hallmarks, such as a dry cough or the loss of taste or smell, have become less common, according to doctors .

Severe cases, meanwhile, are still characterized by shortness of breath, chest pain or pale, gray or blue skin, lips or nail beds — an indicator of a lack of oxygen.

But on the whole, Covid symptoms are milder than they were early in the pandemic.

Fleece said JN.1 is spreading at an unfortunate time as people travel and gather indoors.

“If we have a variant that is extremely easy to spread among people, that’s extremely important to think about going into the holidays,” she said. “Just the ease of transmissibility, especially being an omicron descendant — we saw how easily omicron spread throughout communities — should make everyone concerned.”

The WHO has warned that JN.1 could cause an uptick in Covid cases this winter and “increase the burden of respiratory infections in many countries.”

The variant's parent lineage, BA.2.86, has a large number of mutations compared to the original version of omicron — and those changes have enabled the virus to sidestep existing immunity . Compared to BA.2.86, the JN.1 variant has an additional mutation in the spike protein that could make it even easier for the virus to invade cells.

However, the WHO said JN.1 isn’t likely to pose an added public health risk compared with other circulating variants. And although the newest vaccines target a different variant — called XBB.1.5 — they seem to be effective against JN.1, as well.

A  preprint study found that updated mRNA shots from Moderna and Pfizer boosted antibody protection against JN.1 up to 13 times, depending on a person's history of vaccination and infection. The study hasn’t been peer-reviewed, however.

The participants in that study had received four or five Covid shots before the updated vaccine, and some had recently gotten Covid. But the researchers found that antibody protection against JN.1 was still relatively low before the new vaccine was administered.

“It would suggest that those people who were not recently boosted probably would not be all that well-protected against JN.1," said an author of the study, Dr. David Ho, a professor of microbiology and immunology at Columbia University.

Antibody levels against JN.1 from the updated vaccine are "quite decent," Ho added, "and should confer some degree of protection."

Just 18% of adults and 8% of children ages 6 months and up have received the new Covid vaccine since it became available in September. So Cohen urged people to stay up to date on their shots.

“That’s exactly why we want folks to get the updated Covid vaccine, because it does map to the changes that we’re seeing in the virus," she said.

Ho acknowledged, however, that scientists expect to continue playing cat and mouse with Covid in the near future.

"We do something, and then the virus finds a solution to go elsewhere, away from our countermeasures," he said. “We’re chasing it the best we can, but we’re always a little behind.”

case study positive and negative

Aria Bendix is the breaking health reporter for NBC News Digital.

  • Case Report
  • Open access
  • Published: 02 January 2024

The co-infection of pulmonary hydatid cyst, lophomoniasis and tuberculosis in a patient with resistant respiratory symptoms; a case report study

  • Mohammad Hadi Tajik Jalayeri 1 ,
  • Rahmat Allah Sharifi far 2 ,
  • Narges Lashkarbolouk 3 , 4 &
  • Mahdi Mazandarani 3 , 4  

BMC Infectious Diseases volume  24 , Article number:  11 ( 2024 ) Cite this article

Metrics details

Lophomonas blattarum is a rare protozoan that causes opportunistic infections, and the co-infection of lophomonas with tuberculosis and human hydatidosis is a serious public problem in the co-endemic areas of developing countries.

Case report

We presented a 58-year-old female with fever, losing weight, and cough with whitish-yellow sputum that started one month ago. Increasing inflammatory markers and hypereosinophilia in laboratory tests, and a cavity with thick, regular walls and undulating air-fluid levels measuring 43 × 30, evident in the upper segment of the right lower lobe (RLL), along with consolidation and the ground glass opacity of the upper segment and posterior basal of the RLL is apparent in CT scan were reported. Then, a bronchoscopy was requested, and the BAL specimen reported a negative fungal and bacterial infection in the samples. Several live and oval flagellated lophomonas protozoa, hydatid cyst protoscoleces (the larval forms of the parasites), and M. tuberculosis were observed in microscopic evaluation. The patient was treated with metronidazole, oral albendazole, and a combination of TB regimen.

Physicians should always consider the possibility of co-infections of lophomonas with tuberculosis and human hydatidosis and investigate patients with risk factors such as immunodeficiency conditions or treated with immunosuppressive medications.

Peer Review reports

Introduction

Lophomonas blattarum ( L. blattarum ) is a rare protozoan parasite found in the intestines of some special arthropods, such as termites and cockroaches. L. blattarum is an opportunistic pathogen that causes bronchopulmonary infections, especially in immunocompromised patients This host-specific protozoan could be spread by waste and dust during the crawling of a host. It can infect various tissues, such as the sinuses and human reproductive and respiratory systems. Clinical manifestations are predominantly non-specific and, in most cases, include cough, sputum expectoration, fever, chest stiffness, and shortness of breath. Radiography findings may show signs of pneumonia, bronchiectasis, pulmonary abscess, and pleural effusion. Microscopic examination of respiratory secretions is the gold standard for diagnosing L. blattarum because this protozoan has similar symptoms to other infections. Therefore, bronchoscopy brush smears, biopsy smears, or bronchoalveolar lavage (BAL) can lead to a diagnosis. Metronidazole or tinidazole is usually prescribed in the treatment regimen for infected patients [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 ].

Hydatidosis ( cystic echinococcosis (CE)) is a zoonotic parasitic infection. The larval stages of Echinococcus granulosus ( E. granulosus ) develop in human internal organs and induce a granulomatous reaction in the host, followed by the development of a fibrous tissue layer. Hydatidosis is endemic in sheep and cattle breeding areas around the world. This parasite has a worldwide geographical distribution and is present in all countries. According to a World Health Organization (WHO) report, about one million people are infected with E. granulosus infection annually worldwide. Clinical findings depend on the organs’ involvement and the extent of infection, but no obvious clinical symptoms are often observed. Respiratory distress, cough, dyspnea, hemoptysis, hydatoptysis, and chest pain are usually reported in pulmonary E. granulosus infection. The radiology findings show homogeneous, round or oval, well-circumscribed lesions, cystic lesions, and consolidation. Diagnosis of E. granulosus infection is based on imaging tests, examination of cyst fluid, or serological tests (immunodiagnostic tests). The asymptomatic nature of the disease makes diagnosis difficult and increases the risk of transmission. Treating pulmonary E. granulosus infection could be pharmacotherapy or surgical intervention, and surgical intervention is the treatment choice. A benzimidazole group (albendazole and mebendazole) could be prescribed for medical treatment [ 4 , 9 , 10 , 11 ].

Mycobacterium tuberculosis ( M. tuberculosis ) is an important infectious disease and one of the leading causes of morbidity and mortality worldwide. According to a 2019 WHO report, the incidence of tuberculosis in Iran is less than 10 cases per 100,000 subjects. M. tuberculosis can involve multiple organ systems, and timely diagnosis is vital because delayed treatment is associated with severe morbidity and mortality. Infectious M. tuberculosis is a respiratory disease associated with cough, sputum production, sweating, weight loss, weakness, malaise, and hemoptysis, which shows the importance of differentiating this disease from other respiratory infections. The gold standard for diagnosing active M. tuberculosis is a culture of M. tuberculosis from tissues or fluids of the affected area. The M. tuberculosis treatment program is known as direct observation of treatment by public health workers (DOTS) and with combination therapeutic regimens (isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin) [ 1 , 12 , 13 , 14 ].

To date, several cases of co-infection with lophomonas and other infectious diseases have been reported. Nevertheless, there is no evidence from around the world of this co-infection. In this case study, we describe the diagnosis and treatment of a 58-year-old woman infected with lophomonas, E. granulosus , and M. tuberculosis simultaneously.

We admitted a 58-year-old female patient to the Department of Respiratory Medicine at Sayyad Shirazi Hospital, Gorgan, Iran. The patient complained of fever, chills, and cough with whitish-yellow sputum that started about one month ago. She had a history of losing significant weight during one month. Her symptoms gradually progressed in the last week, and her symptoms did not completely heal to outpatient treatment. On admission, the patient mentioned weakness, lethargy, and frequent fatigue for a month and had one episode of hemoptysis before admission; she coughed up a clot with ten cubic centimetre (cc).

She had a history of diabetes, a brain tumor, and hypothyroidism. The patient had brain surgery ten years ago and responded to surgical treatment. She is being treated for diabetes and hypothyroidism, which are under control. In physical examination, the patient’s vital signs were stable, and the oxygen saturation level was 96% without supplemental oxygen therapy. The respiratory crackle in the lungs was detected by auscultation, and heart sounds (S1 and S2) had a regular pattern. Surgical scars were visible on examination. The abdominopelvic examination was normal, and splenomegaly and hepatomegaly were not found.

Because the symptoms of the infection have responded and have always improved with outpatient treatment, the patient has not been fully evaluated for the cause of the recurrence of the respiratory infection. However, she was hospitalized due to the persistence of symptoms and abnormal examination findings. For primary evaluation, laboratory tests, chest X-rays requested, and X-rays findings showed pulmonary cavity with patchy consolidation in right lobe. On laboratory tests, the hemogram revealed anemia and leukocytosis with hypereosinophilia. The erythrocyte sedimentation rate (ESR) was 26 mm/s, and a C-reactive protein test (CRP) concentration was reported as + 1.

A consultation with a pulmonologist and infection specialist was requested. Based on increasing of inflammatory markers, hypereosinophilia and abnormal X-rays findings, additional laboratory test with spiral CT scan performed.

The serum levels of perinuclear antineutrophil cytoplasmic antibodies (p-ANCA), antineutrophil cytoplasmic autoantibody, cytoplasmic (c-ANCA), and viral markers (HIV, hepatitis C, and hepatitis B) were normal. The result of galactomannan index was 2.98 (positive > 1). In addition, because of the COVID-19 pandemic, the SARS-CoV-2 polymerase chain reaction (PCR) was done and came negative.

The spiral CT scan of the lungs showed a cavity with thick, regular walls and undulating air-fluid levels measuring 43 × 30, evident in the upper segment of the right lower lobe (RLL). The consolidation and ground glass opacity of the upper segment and posterior basal of the RLL are apparent. The patient had a mild pleural effusion (approximately 100 cc) (Figs.  1 , 2 , 3 and 4 ).

figure 1

Mediastibal view of lung CT scan shows a cavity with thick, regular walls and undulating air-fluid levels measuring 43 × 30, evident in the upper segment of the RLL (blue arrow)

figure 2

Lung CT scan shows a cavity with thick, regular walls and undulating air-fluid levels measuring 43 × 30, evident in the upper segment of the RLL (blue arrow)

figure 3

Mediastinal view of lung CT scan shows consolidation and opacity of the Grand Glass of the upper segment and posterior basal of the Right lower lobe

figure 4

Lung CT scan shows consolidation and opacity of the Grand Glass of the upper segment and posterior basal of the Right lower lobe. Mild plural effusion is seen

Because of the abnormal lung CT scan, we ordered a serological test of E. granulosus , and a fiber optic bronchoscopy for the patient. Three samples of sputum were requested for culture. A BAL specimen was taken to evaluate BK (Bacillus of Koch), lophomonas, bacterial and fungal infections. M. tuberculosis infection was detected in sputum and BAL samples. We confirmed the diagnosis using the GeneXpert MTB/RIF PCR method, which also showed positive results.

Anti-Echinococcus antibodies (IgG and IgM) were detected in the patient’s serum. Fungal and bacterial infections were reported as negative in the BAL samples. The Microscopic examination of BAL revealed several live and oval flagellated lophomonas protozoa (Fig.  5 ), hydatid cyst protoscoleces (Fig.  6 ) (the larval forms of the parasites), and M. tuberculosis . For further evaluation of M. tuberculosis infection, abdominopelvic sonography was performed and it was reported normal.

figure 5

Direct smear bronchoalveolar lavage fluid specimen represent lophomonas trophozoite with irregular long flagella

figure 6

Immunofluorescence microscopic image of Echinococcus granulosus

Due to the positive result of the patient’s BAL and sputum culture samples, the diagnosis of co-infection of M. tuberculosis , E. granulosus , and lophomonas was confirmed. The patient was treated with metronidazole (500 mg thrice a day for two weeks), oral albendazole (400 mg twice daily for at least two weeks before the procedure and six months after surgery), and a combination of TB regimen started. The patient was discharged with oral medication prescriptions, in good general condition, and with improved clinical symptoms.

We admitted a 58-year-old patient with chief complaints of fever, losing weight, and cough with whitish-yellow sputum that started one month ago. Her symptoms gradually progressed, and she did not completely respond to outpatient treatment. We ordered the bronchoscopy according to abnormal laboratory tests, and CT scan findings. After further evaluation, the BAL specimen reported a negative fungal and bacterial infection in the samples. However, the microscopic examination revealed some live and oval flagellated lophomonas protozoa, hydatid cyst protoscoleces (the larval forms of the parasites), and M. tuberculosis . The positive anti-echinococcus antibodies were founded. Finally, the patient was treated with metronidazole, oral albendazole, and a combination M. tuberculosis regimen started.

Clinically significant pulmonary protozoan infections are rare but have been increasingly recognized in recent decades because of individual states of suppressed immunity. Various studies have declared the high prevalence of co-infection of M. tuberculosis and parasitic diseases such as E. granulosus and lophomonas. Furthermore, M. tuberculosis and parasitic diseases were the risk factors for each other. The study by Li X.,et al.2013, found that many factors possibly affect the co-infection of TB and parasitic diseases, such as socio-demographics (gender and age), underlying diseases, and living in co-endemic areas (higher prevalence of M. tuberculosis and parasitic infections). According to a study by Li R.,et al.2016, L. blattarum was considered an opportunistic infection in patients with kidney and liver allograft transplantation under corticosteroid therapy, HIV, E. granulosus and M. tuberculosis infection [ 1 , 2 , 4 , 12 , 13 , 14 ].

In this study, we reported the co-infection of M. tuberculosis , lophomonas, and E. granulosus ; the occurrence of these infections together is rare and has not been previously reported. In endemic areas such as Iran, the diagnosis of E. granulosus and M. tuberculosis infection can often be easily made by clinical findings, serological tests, and radiographic findings [ 1 , 4 , 7 , 12 ].

It could be suspected that the patient first had E. granulosus or M. tuberculosis infection, and in the subsequent period, lophomonas as super infection was added to co-infections. Because lophomonas often occurs in immunocompromised patients, and M. tuberculosis or E. granulosus infection impairs the immune system, making individuals more susceptible to L. blattarum infections and reactivating latent infections. However, considering the patient’s symptoms presented acutely and two months prior to admission, the patient’s previous routine laboratory tests and inflammatory markers were normal. In addition, due to the positive E. granulosus -specific IgM and IgG, active tuberculosis, our patients were more likely to have co-infection M. tuberculosis and E. granulosus with lophomonas. The study by Kalani M., et al. 2022, mentioned that the prevalence of lophomonas infection was relatively high in patients with suspected tuberculosis due to similar clinical manifestations of this co-infection ( 1 , 2 , 3 , 4 , 11 , 12 ).

L. blattarum , M. tuberculosis , and E. granulosus infections present with untypical and non-specific clinical manifestations, such as cough, sputum, sweating, weight loss, weakness, malaise, hemoptysis, and dyspnea. These infections often involve the respiratory tract system with the most likely form of airborne transmission and are similar in terms of clinical patterns and radiographic findings. Notably, these non-specific symptoms might obscure the diagnosis and treatment, and clinical symptoms cannot distinguish these infections from other diseases. Researchers believe these infections should be considered in patients with eosinophilia, severe respiratory infection, immunosuppression, and unsuccessful antimicrobial treatment [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ].

These infections’ X-ray and CT scan findings revealed ground-glass opacity, patchy consolidation, patchy or streaky shadows, cystic lesions, abscesses, and pleural effusion. Using these findings makes it difficult to differentiate this co-infection from other common diseases with similar radiographic findings (such as pneumonia, bronchitis, cancer, or inflammation) [ 1 , 3 , 4 , 9 , 12 ].

A bronchoscopy biopsy smear, sputum smear, or BAL can be performed to detect L. blattarum , tuberculosis, and hydatid in patients. However, it is challenging to differentiate L.blattarum and ciliated epithelial cells based on morphology under a light microscope, which can lead to misdiagnosis [ 2 , 3 , 4 , 5 , 6 , 7 ]. The lung epithelial cells display cilia of uniform size with consistent movement, and a terminal bar is observed at the base of the cilia. These cells also exhibit a slightly slender shape. L. blattarum features two tufts of flagella of varying sizes located in the anterior region, demonstrating a wavy movement. No terminal bar is observed at the base of the flagella, and the parasite is nearly round. Additionally, the morphological characteristics of this parasite were examined using an electron microscope, confirming its presence. Microscopy-based diagnosis often lacks the necessary sensitivity and specificity. Consequently, molecular-based diagnosis (PCR method) was performed in this study to identify Lophomonas spp [ 15 ].

As M. tuberculosis and E. granulosus are common infections in this region, and the true mechanism of lophomonas transmission has not been clearly described, the management and diagnosis of these co-infections are essential in practice. Clinicians should consider this co-infection in differential diagnoses of patients with a chronic dust allergy, unresponsiveness to antibiotic therapy, and recurrent respiratory infections.

Our study had strengths. We reported an extremely rare case of M. tuberculosis , E. granulosus , and lophomonas co-infection in a patient. In addition, according to the patient’s present illness, clinical examination, and initial radiography findings, we initially isolated the patient with the suspicion of possible opportunistic infections. We gave the necessary warnings to all the people in close contact with her and examined them for possible infections. Moreover, we prevented the patient from suffering from complications caused by each mentioned pathogen with timely diagnosis and appropriate treatment. We also faced limitations. We had to send the patient’s sample to another center for a definitive diagnosis of lophomonasis, which was time-consuming.

Co-infection with tuberculosis and parasitic diseases ( E. granulosus and lophomonas) in humans is rare and it mostly presented in co-endemic areas. Patients with risk factors such as immunodeficiency conditions or treating with immunosuppressive medications are at high risk of contracting opportunistic infections or their coexistence. Physicians should always consider the possibility of these co-infections and investigate patients with resistant symptoms.

Data Availability

The datasets used during the current study are available from the corresponding author on reasonable request. All data generated or analysed during this study are included in this article. Further inquiries can be directed to the corresponding author.

Kalani H, Pangh A, Nakhaei M, Hezarjaribi HZ, Fakhar M, Sharifpour A, Banimostafavi ES, Tabaripour R. High occurrence of emerged lophomonas infection among patients suspected of having pulmonary tuberculosis: In-house pcr-based evidence. Interdiscip Perspect Infect Dis. 2022;2022.

Li R, Gao ZC. Lophomonas Blattarum Infection or just the movement of ciliated epithelial cells? Chin Med J. 2016;129(6):739.

Article   PubMed   PubMed Central   Google Scholar  

Meng SS, Dai ZF, Wang HC, Li YX, Wei DD, Yang RL, Lin XH. Authenticity of pulmonary lophomonas blattarum Infection: a case report. World J Clin Cases. 2019;7(1):95.

Jalayeri MH, Zakariaei Z, Fakhar M, Sharifpour A, Banimostafavi ES, Soleymani M. Ruptured pulmonary hydatid cyst and lophomoniasis comorbidity in a young man: a rare case. Oxf Med Case Rep. 2023;2023(3):omad023.

Article   Google Scholar  

Ding Q, Shen K. Pulmonary Infection with Lophomonas Blattarum. Indian J Pediatr. 2021;88:23–7.

Article   PubMed   Google Scholar  

Rao X, Liao Q, Pan T, Li S, Zhang X, Zhu S, Lin Z, Qiu Y, Liu J. Retrospect and prospect of Lophomonas Blattarum Infections and lophomoniasis reported in China. Open Access Libr. 2014;1(9):1.

CAS   Google Scholar  

Zeng H, Kong X, Chen X, Luo H, Chen P, Chen Y. Lophomonas blattarum Infection presented as acute exacerbation of Chronic Obstructive Pulmonary Disease. J Thorac Dis. 2014;6(6):E73.

PubMed   PubMed Central   Google Scholar  

Nakhaei M, Fakhar M, Sharifpour A, Ziaei Hezarjaribi H, Banimostafavi ES, Nazar E. Global status of emerging Lophomonas infection: a systematic review of reported cases (1993–2020). Interdiscip Perspect Infect Dis. 2022;2022.

Baruah A, Sarma K, Barman B, Phukan P, Nath C, Boruah P, Rajkhowa P, Baruah M, Dutta A, Naku N. Clinical and laboratory presentation of hydatid Disease: a study from Northeast India. Cureus. 2020;12(9).

Gessese AT. Review on epidemiology and public health significance of hydatidosis. Vet Med Int. 2020;2020.

Aydin Y, Ulas AB, Ahmed AG, Eroglu A. Pulmonary hydatid cyst in children and adults: diagnosis and management. Eurasian J Med. 2022;54(1):133–44.

PubMed   Google Scholar  

Li XX, Zhou XN. Co-infection of Tuberculosis and parasitic Diseases in humans: a systematic review. Parasites & Vectors. 2013;6(1):1–2.

Article   CAS   Google Scholar  

Caulfield AJ, Wengenack NL. Diagnosis of active Tuberculosis Disease: from microscopy to molecular techniques. J Clin Tuberculosis Other Mycobact Dis. 2016;4:33–43.

MacLean E, Broger T, Yerlikaya S, Fernandez-Carballo BL, Pai M, Denkinger CM. A systematic review of biomarkers to detect active Tuberculosis. Nat Microbiol. 2019;4(5):748–58.

Article   CAS   PubMed   Google Scholar  

Fakhar M, Nakhaei M, Sharifpour A, Kalani H, Banimostafavi ES, Abedi S, Safanavaei S, Aliyali M. First molecular diagnosis of lophomoniasis: the end of a controversial story. Acta Parasitol. 2019;64:390–3.

Download references

Acknowledgements

Not applicable.

The authors declare that no funds, grants, or other supports were received during the preparation of this manuscript.

Author information

Authors and affiliations.

Pulmonary and Critical Care Division, Sayyad Shirazi Medical and Educational Center, Golestan University of Medical Sciences, Gorgan, Iran

Mohammad Hadi Tajik Jalayeri

Infectious Diseases Research Center, Golestan University of Medical Sciences, Gorgan, Iran

Rahmat Allah Sharifi far

Golestan University of Medical Sciences, Gorgan, Iran

Narges Lashkarbolouk & Mahdi Mazandarani

Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran

You can also search for this author in PubMed   Google Scholar

Contributions

MH.TJ and R.S advised the case report study. MM gathered patient’s medical and health records. M.M and N.L wrote the first draft of the manuscript, and all authors commented on previous versions. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Mahdi Mazandarani .

Ethics declarations

Ethics approval and consent to participate.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. The purpose of this case report was completely explained to the patient and she was assured that his information would be keep confidential by the researchers. This case report was performed in line with principles of the declaration of Helsinki.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Jalayeri, M.H.T., Sharifi far, R.A., Lashkarbolouk, N. et al. The co-infection of pulmonary hydatid cyst, lophomoniasis and tuberculosis in a patient with resistant respiratory symptoms; a case report study. BMC Infect Dis 24 , 11 (2024). https://doi.org/10.1186/s12879-023-08907-4

Download citation

Received : 30 June 2023

Accepted : 13 December 2023

Published : 02 January 2024

DOI : https://doi.org/10.1186/s12879-023-08907-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Tuberculosis
  • Pulmonary hydatid cyst
  • Coinfection

BMC Infectious Diseases

ISSN: 1471-2334

case study positive and negative

  • Communication
  • Recreational

You are currently viewing Pros and Cons of case studies

Pros and Cons of case studies

  • Post author: admin
  • Post published: March 27, 2020
  • Post category: Education
  • Post comments: 0 Comments

Case studies are research methodologies that are used and analyzed in order to depict principles; they have been usually used in social sciences. They are research strategies and experiential inquiries that seek to examine various phenomena within a real-life context. Case studies seek to explain and give details in the analysis of people and events. There are several pros that back case studies and there are cons too that criticize them. The pros and cons are listed below.

1 . They show client observations- Since case studies are strategies that are used and analyzed in order to describe principles therefore it seeks to show indeed the client investigated and experienced a particular phenomenon.

2 . Makes practical improvements- Case studies present facts that categorically describe particular people or events in order to make some of the necessary improvements. Case studies data is what supports a particular belief.

3 . They are an influential way of portraying something- If a researcher wants to prove a particular principle to be true, he or she must back it by case studies in order to make the other people and the naysayers believe.

4 . They turn opinions into facts- Case studies present real data on a particular phenomenon. Since facts about various things are presented then it can be verified through this kind of data if the information presented is in the positive or negative development of opinion.

5 . It is relevant to all the parties that are involved- Case studies help the researchers in actively focusing on the data collection process and the participants’ knowledge is bettered. At the end of the process, everybody is able to defend his position through facts.

6 . A number of different research methodologies can be used in case the studies- Case study method goes beyond the interview and direct observations. Secondary data can be obtained from various historical sources that can be used to back the method.

7 . Case studies can be done remotely- It is not essential for a researcher to be present in the specific location of the study in order to effectively use the case study method. Other forms of communication come in to cover that gap for the researcher.

8 . It has a very high cost- If you put this research method in comparison to the others, this one seems more expensive because the cost of accessing data is very high.

9 . Readers can access data from this method very easily- The The format in which case studies present their data is very useful to the readers and easily note the outcomes of the same.

10 . Collects data that cannot be collected by another method- The type of data collected by case studies is much richer and greater in-depth than that of the other experimental methods.

1 . Data collected cannot be generalized- The data collected by the case study method was collected from a smaller population it cannot be generalized to the wider population.

2 . Some of the case studies are not scientific- The weakness of the data collected in some of the case studies that are not scientific is that it cannot be generalized.

3 . It is very difficult to draw a definite cause/effect from case studies- The the kind of data that case studies present cannot be used to draw a definite cause-effect relationship.

4 . Case studies concentrate on one experiment- The problem associated with concentrating on one experiment or a specific group of people is that the data presented might contain some kind of bias.

5 . It takes a lot of time to analyze the data- This process takes longer to analyze the data because there is a very large amount of data that must be collected. Participants might take a lot of time in giving answers or giving inaccurate information.

6 . Case studies can be inefficient processes- Sometimes the researchers are not present in the study areas which means they will not be able to notice whether the information provided is accurate or not terming the whole process inefficient.

7 . Case study method can only be effective with a small sample size- If a very large sample size is involved in the case study it is likely for it to become inefficient because the method requires a small sample size to get the data and analyze it.

8 . The method requires a lot of labor in data collection- The researcher is seriously needed in the data collection of this method. They have to be personally involved in order to be able to identify the quality of the data provided.

9 . There are factors that can influence the data- The method of data collection is meant to collect fact-based data but the power to determine what fact is and what is not is the person who is collecting the data.

10 . There is no right answer in case studies- Case studies do not present any specific answer that is right, the problem arises in the validation of solutions because there is more than one way of looking at things.

You Might Also Like

Read more about the article Pros and Cons of Being a Lawyer

Pros and Cons of Being a Lawyer

Read more about the article Pros and cons transferring colleges

Pros and cons transferring colleges

Read more about the article Pros and cons of secondary research

Pros and cons of secondary research

Leave a reply cancel reply.

Save my name, email, and website in this browser for the next time I comment.

This site uses Akismet to reduce spam. Learn how your comment data is processed .

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

  • Knowledge Base

Methodology

  • What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

The only proofreading tool specialized in correcting academic writing

The academic proofreading tool has been trained on 1000s of academic texts and by native English editors. It's the most accurate and reliable proofreading tool for students.

case study positive and negative

Correct my document

Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

  • Provide new or unexpected insights into the subject
  • Challenge or complicate existing assumptions and theories
  • Propose practical courses of action to resolve a problem
  • Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

  • Exemplify a theory by showing how it explains the case under investigation
  • Expand on a theory by uncovering new concepts and ideas that need to be incorporated
  • Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Normal distribution
  • Degrees of freedom
  • Null hypothesis
  • Discourse analysis
  • Control groups
  • Mixed methods research
  • Non-probability sampling
  • Quantitative research
  • Ecological validity

Research bias

  • Rosenthal effect
  • Implicit bias
  • Cognitive bias
  • Selection bias
  • Negativity bias
  • Status quo bias

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

McCombes, S. (2023, November 20). What Is a Case Study? | Definition, Examples & Methods. Scribbr. Retrieved January 2, 2024, from https://www.scribbr.com/methodology/case-study/

Is this article helpful?

Shona McCombes

Shona McCombes

Other students also liked, primary vs. secondary sources | difference & examples, what is a theoretical framework | guide to organizing, what is action research | definition & examples, what is your plagiarism score.

Cart

  • SUGGESTED TOPICS
  • The Magazine
  • Newsletters
  • Managing Yourself
  • Managing Teams
  • Work-life Balance
  • The Big Idea
  • Data & Visuals
  • Reading Lists
  • Case Selections
  • HBR Learning
  • Topic Feeds
  • Account Settings
  • Email Preferences

What the Case Study Method Really Teaches

  • Nitin Nohria

case study positive and negative

Seven meta-skills that stick even if the cases fade from memory.

It’s been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment, bias recognition, judgement, collaboration, curiosity, and self-confidence.

During my decade as dean of Harvard Business School, I spent hundreds of hours talking with our alumni. To enliven these conversations, I relied on a favorite question: “What was the most important thing you learned from your time in our MBA program?”

  • Nitin Nohria is the George F. Baker Jr. Professor at Harvard Business School and the former dean of HBS.

Partner Center

  • Social Anxiety Disorder
  • Bipolar Disorder
  • Kids Mental Health
  • Therapy Center
  • When To See a Therapist
  • Types of Therapy
  • Best Online Therapy
  • Best Couples Therapy
  • Best Family Therapy
  • Managing Stress
  • Sleep and Dreaming
  • Understanding Emotions
  • Self-Improvement
  • Healthy Relationships
  • Relationships in 2023
  • Student Resources
  • Personality Types
  • Verywell Mind Insights
  • 2023 Verywell Mind 25
  • Mental Health in the Classroom
  • Editorial Process
  • Meet Our Review Board
  • Crisis Support

What Is a Case Study?

An in-depth study of one person, group, or event

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

case study positive and negative

Cara Lustik is a fact-checker and copywriter.

case study positive and negative

Verywell / Colleen Tighe

Benefits and Limitations

Types of case studies, how to write a case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in various fields, including psychology, medicine, education, anthropology, political science, and social work.

The purpose of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, it is important to follow the rules of APA format .  

A case study can have both strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult to impossible to replicate in a lab. Some other benefits of a case study:

  • Allows researchers to collect a great deal of information
  • Give researchers the chance to collect information on rare or unusual cases
  • Permits researchers to develop hypotheses that can be explored in experimental research

On the negative side, a case study:

  • Cannot necessarily be generalized to the larger population
  • Cannot demonstrate cause and effect
  • May not be scientifically rigorous
  • Can lead to bias

Researchers may choose to perform a case study if they are interested in exploring a unique or recently discovered phenomenon. The insights gained from such research can help the researchers develop additional ideas and study questions that might be explored in future studies.

However, it is important to remember that the insights gained from case studies cannot be used to determine cause and effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through the use of individual case studies. Some great examples of case studies in psychology include:

  • Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
  • Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
  • Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language could be taught even after critical periods for language development had been missed. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse had denied her the opportunity to learn language at critical points in her development.

This is clearly not something that researchers could ethically replicate, but conducting a case study on Genie allowed researchers the chance to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might utilize:

  • Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those living there.
  • Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
  • Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
  • Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
  • Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
  • Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic cast study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers utilize depends on the unique characteristics of the situation as well as the case itself.

There are also different methods that can be used to conduct a case study, including prospective and retrospective case study methods.

Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.

Retrospective case study methods involve looking at historical information. For example, researchers might start with an outcome, such as a disease, and then work their way backward to look at information about the individual's life to determine risk factors that may have contributed to the onset of the illness.

Where to Find Data

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

  • Archival records : Census records, survey records, and name lists are examples of archival records.
  • Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
  • Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
  • Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
  • Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
  • Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

  • Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
  • Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
  • Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
  • Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Here are a few additional pointers to keep in mind when formatting your case study:

  • Never refer to the subject of your case study as "the client." Instead, their name or a pseudonym.
  • Read examples of case studies to gain an idea about the style and format.
  • Remember to use APA format when citing references .

A Word From Verywell

Case studies can be a useful research tool, but they need to be used wisely. In many cases, they are best utilized in situations where conducting an experiment would be difficult or impossible. They are helpful for looking at unique situations and allow researchers to gather a great deal of information about a specific individual or group of people.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines that you are required to follow. If you are writing your case study for professional publication, be sure to check with the publisher for their specific guidelines for submitting a case study.

Simply Psychology. Case Study Method .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

By clicking “Accept All Cookies”, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage, and assist in our marketing efforts.

  • Open access
  • Published: 02 January 2024

The value of oral selective estrogen receptor degraders in patients with HR-positive, HER2-negative advanced breast cancer after progression on ≥ 1 line of endocrine therapy: systematic review and meta-analysis

  • Xiewei Huang 1 , 3   na1 ,
  • Yushuai Yu 1 , 3   na1 ,
  • Shiping Luo 1 , 3 ,
  • Wenfen Fu 1 , 3 ,
  • Jie Zhang 1 , 2 , 3 &
  • Chuangui Song 1 , 2 , 3  

BMC Cancer volume  24 , Article number:  21 ( 2024 ) Cite this article

Metrics details

Currently, the value of oral selective estrogen receptor degraders (SERDs) for hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) advanced breast cancer (aBC) after progression on ≥ 1 line of endocrine therapy (ET) remains controversial. We conducted a meta-analysis to evaluate progression-free survival (PFS) and safety benefits in several clinical trials.

Materials and methods

Cochrane Library, Embase, PubMed, and conference proceedings (SABCS, ASCO, ESMO, and ESMO Breast) were searched systematically and comprehensively. Random effects models or fixed effects models were used to assess pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for treatment with oral SERDs versus standard of care.

A total of four studies involving 1,290 patients were included in our analysis. The hazard ratio (HR) of PFS showed that the oral SERD regimen was better than standard of care in patients with HR+/HER2- aBC after progression on ≥ 1 line of ET (HR: 0.75, 95% CI: 0.62-0.91, p = 0.004). In patients with ESR1 mutations, the oral SERD regimen provided better PFS than standard of care (HR: 0.58, 95% CI: 0.47-0.71, p < 0.00001). Regarding patients with disease progression following previous use of CDK4/6 inhibitors, PFS benefit was observed in oral SERD-treatment arms compared to standard of care (HR: 0.75, 95% CI: 0.64-0.87, p = 0.0002).

Conclusions

The oral SERD regimen provides a significant PFS benefit compared to standard-of-care ET in patients with HR+/HER2- aBC after progression on ≥ 1 line of ET. In particular, we recommend oral SERDs as a preferred choice for those patients with ESR1m, and it could be a potential replacement for fulvestrant. The oral SERD regimen is also beneficial after progression on CDK4/6 inhibitors combined with endocrine therapy.

Peer Review reports

Introduction

In the United States, approximately 60-70% of women with advanced breast cancer (aBC) are hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) [ 1 , 2 , 3 ]. Resistance to treatment, acquisition of novel mutations, and altered gene expression are the major challenges in the management of aBC [ 4 , 5 ]. There are established guidelines for first-line treatment of these patients, but a consensus has not yet been reached regarding the choice of second-line treatment [ 6 ].

Endocrine therapy (ET), with either fulvestrant (Fulv) or aromatase inhibitors (AIs), plus a cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) is the recommended first-line standard of care for patients with HR+/HER2- advanced breast cancer [ 7 ]. Compared with endocrine monotherapy, the combination can obtain a higher response rate and progression-free survival benefit [ 8 , 9 , 10 ]. However, the development of resistance to the treatment of aBC is frequent, and its treatment is primarily palliative [ 11 ] In general, there are three main strategies after the failure of CDK4/6i treatment: diversion to chemotherapy, endocrine therapy alone, or combined targeted therapy [ 12 , 13 , 14 ]. Currently, there are no recommended guidelines for the optimal ranking of these options. In any case, ET is still an important treatment strategy.

Estrogen receptor 1 mutations (ESR1m) are one of the common mechanisms of endocrine resistance, accounting for up to 36% of metastatic breast cancers [ 15 , 16 ]. Selective estrogen receptor degraders (SERDs) can bind to estrogen receptors and induce their degradation [ 17 , 18 ] and are considered one of the main ways to address endocrine resistance. Fulvestrant, as an intramuscular SERD, is not only the first-line or second-line treatment option for HR+/HER2- aBC [ 19 , 20 ] but is also a choice for patients with ESR1m, who are still sensitive to it [ 15 , 21 , 22 ]. In recent years, oral SERDs, with their higher bioavailability and pharmacokinetics, have been continuously developed to address the limitations of fulvestrant intramuscular formulations [ 23 ]. However, the value of oral SERDs in patients with HR+/HER2- advanced breast cancer remains controversial. EMERALD [ 24 ] and SERENA-2 [ 25 ] showed positive results, while the other two clinical trials, AMEERA-3 [ 26 ] and acelERA [ 27 ], failed the study endpoints.

In the present meta-analysis, we aimed to assess the value of oral SERDs in patients with HR+/HER2- advanced breast cancer after progression on ≥ 1 line of endocrine therapy.

Search strategy and data extraction

The systematic review of literature and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 28 ]. The corresponding PRISMA checklist is shown in Supplement 2 . A systematic and comprehensive literature search was conducted using Embase, PubMed, and Cochrane Library . Conference proceedings from major oncology meetings (ASCO, SABCS, ESMO, and ESMO Breast) from 2020 up to November 2023 were also carefully reviewed. The following search string was used: “(breast OR mammary) AND (cancer OR carcinoma OR malignant OR neoplasm OR tumour) AND (hormone receptor-positive OR HR-positive OR HR OR estrogen receptor-positive OR ER OR ER-positive) AND (HER-2- OR HER2- OR ERBB2- OR HER-2 negative OR HER2-negative OR ERBB2 negative OR human epidermal growth factor receptor 2-negative) AND (metastasis OR metastases OR metastatic OR advanced OR recurrent OR stage IV) AND (oral selective estrogen receptor degrader OR SERD OR Giredestrant OR Camizestrant OR Imlunestrant OR Elacestrant OR Amcenestrant).” Records from the included studies were screened independently by two investigators. In cases of disagreement, the third investigator was consulted to reach a consensus.

Details about the title, publication date, study design, and trial name were extracted. All relevant randomized controlled trials were identified as the recommendations of the Cochrane Collaboration [ 29 ]. When duplicate publications were identified, only the latest data were extracted in our study. Other details about the first author, country, sample size, menopausal status, oral SERDs used, dose of oral SERDs, treatment regimens used in the control arm, previous treatment regimen, ESR1m status, hazard ratio (HR), progression-free survival (PFS), median progression-free survival (mPFS) and side effects for each arm were extracted. The primary outcome was progression-free survival, which was defined as the time from randomization to death or disease progression, whichever occurred first. The proportion of patients who achieved an overall response according to the Response Evaluation Criteria in Solid Tumours (RECIST) was selected as a secondary outcome [ 30 ]. An exploratory analysis was conducted based on the Common Terminology Criteria for Adverse Events, version 4, reporting the proportion of patients with grade 3-5 adverse events [ 31 ]. All data included in the study were extracted independently by two investigators.

Study selection

Studies had to satisfy the following inclusion and exclusion criteria: (I) phase II or III randomized clinical trials (RCTs) including patients with HR+/HER2- aBC after progression on ≥ 1 line of ET; (II) comparison of oral SERD-treated patients and patients treated with standard-of-care ET; and (III) the publication provided PFS and HR for the experimental and control arms. Systemic reviews, case reports, single-arm studies, exploratory studies, and retrospective studies were excluded. If multiple publications were associated with the same clinical trial, only the latest and complete randomized controlled trial was included.

The primary objective of the study was to compare the efficacy of oral SERDs with standard-of-care ET in patients with HR+/HER2- aBC after progression on ≥ 1 line of ET. The secondary objective was to analyse the subgroup of patients in the population that might benefit from oral SERDs. We planned the subgroup analysis for the following subgroups: patients with disease progression following previous use of CDK4/6 inhibitors or Fulv; patients with ESR1m; patients with visceral metastasis; comparing oral SERDs with fulvestrant; and comparing oral SERDs with fulvestrant in patients with ESR1m.

Statistical analysis

Global PFS was calculated using a random-effects model or fixed-effects model and reported as pooled hazard ratios (HRS) with 95% confidence intervals (CIs). If the 95% CI did not include 1.0 and the two-sided threshold was P < 0.05, the pooled HR was considered statistically significant. The I 2 value was employed for the heterogeneity of included studies. When I 2 > 50%, significant heterogeneity was considered established, and the random-effects model was adopted; otherwise, the fixed-effects model was used. When heterogeneity was high in the pooled results, sensitivity analysis was performed after every single study was excluded. All statistical analysis methods were performed using Review Manager (version 5.3). The Cochrane Collaboration’s Risk of Bias tool in Review Manager (version 5.3) was employed to assess the risk of bias for each eligible study.

A total of 386 potentially relevant manuscripts and 2 additional abstracts were sorted by using the search string mentioned before. Of these, after reviewing the titles and abstracts, 373 manuscripts were excluded. We then performed a full-text review for the remaining 15 articles, 11 of which were excluded for nonconformity with the present inclusion criteria. Eventually, 4 articles from 4 trials were considered eligible for the meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flowchart is shown in Fig. 1 .

figure 1

PRISMA flowchart for the selected studies included in the meta-analysis

Characteristics of studies

Finally, our study involved 4 clinical trials published between February 2022 and November 2023, focusing on different endocrine treatment regimens for HR+/HER2- advanced breast cancer, and included a total of 1,290 patients (Table 1 ). The oral SERD arms included elacestrant (EMERALD), camizestrant 75 mg/camizestrant 150 mg (SERENA-2), amcenestrant (AMEERA-3), and giredestrant (acelELA). The control arms included fulvestrant, anastrozole, letrozole, exemestane, and tamoxifen. All trials compared oral SERDs to standard-of-care ET in patients with HR+/HER2- aBC after progression on ≥ 1 line of ET.

Progression-free survival

In the whole population, patients with HR+/HER2- advanced breast cancer treated with oral SERDs had significantly improved PFS compared to those treated with standard-of-care ET (HR: 0.75, 95% CI: 0.62-0.91, p = 0.004; I 2 : 52%, p = 0.08; Fig. 2 A). For enrolled patients with disease progression following previous use of CDK4/6 inhibitors, the oral SERD regimen was significantly better than standard-of-care ET (HR: 0.75, 95% CI: 0.64-0.87, p = 0.0002; I 2 : 48%, p = 0.10; Fig. 2 B). In HR+/HER2- ESR1m aBC, the two treatment regimens compared, namely, oral SERDs resulted in a better PFS versus standard-of-care ET (HR: 0.58, 95% CI: 0.47-0.71, p < 0.00001; I 2 : 42%, p = 0.14; Fig. 2 C). Regarding enrolled patients with ESR1 mutations, results in arms of oral SERDs were significantly better than in arms of fulvestrant (HR: 0.47, 95% CI: 0.36-0.62, p < 0.00001; I 2 : 0%, p = 0.41; Fig. 2 D). Regarding patients who had previously failed treatment with fulvestrant, oral SERDs as monotherapy were significantly superior to standard-of-care ET (HR: 0.67, 95% CI: 0.47-0.95, p = 0.02; I 2 : 0%, p = 0.93; Fig. 3 A). In patients with visceral disease, the results in arms of oral SERDs were significantly better than the results in arms of standard-of-care ET (HR: 0.60, 95% CI: 0.48-0.74, p < 0.00001; I 2 : 33%, p = 0.22; Fig. 3 B). The results in arms of oral SERDs were significantly better than those in arms of fulvestrant (HR: 0.65, 95% CI: 0.54-0.78, p < 0.00001; I 2 : 0%, p = 0.76; Fig. 3 C).

figure 2

The Forrest plot of PFS for patients with HR+/HER2- advanced breast cancer after progression on ≥ 1 line of endocrine treatment. A PFS pooled result for overall patients; B PFS pooled result for patients with previous use of CDK4/6 inhibitors; C PFS pooled result for patients with ESR1m; D PFS pooled result for comparing oral SERDS with fulvestrant in patients with ESR1m subgroup. Note: PFS, progression-free survival; CI, confidence interval; HR, hazard ratio; HR+/HER2-, hormone receptor-positive and human epidermal growth factor receptor 2-negative; SERDs, selective estrogen receptor degraders; ESR1m, estrogen receptor 1 mutations

figure 3

The Forrest plot for global PFS for patients with ( A ) previous use of fulvestrant; ( B ) visceral metastasis; ( C ) Forrest plot for global PFS comparing oral SERDS with fulvestrant. Note: PFS, progression-free survival; CI, confidence interval; HR, hazard ratio; HR+/HER2-, hormone receptor-positive and human epidermal growth factor receptor 2-negative; SERDs, selective oestrogen receptor degraders

Adverse events (AEs) of grade 3 or higher were more frequent in the oral SERD regimen than in standard-of-care ET (HR: 1.40, 95% CI: 1.03-1.90, p = 0.03; I 2 : 0%, p = 0.99; Fig. 4 ). The proportion of treatment-emergent adverse events (TEAEs) leading to discontinuation was 6.3% (Elacestrant) vs. 4.4% (SOC) in EMERALD's two treatment arms. The most common adverse event was nausea. The proportion of drug discontinuation caused by TEAEs in the three treatment groups of SERENA-2 was 14.9% (camizestrant 75 mg), 21.9% (camizestrant 150 mg), and 4.1% (standard-of-care ET), respectively; common adverse events were photopsia and sinus bradycardia. In AMEERA-3, the proportion of TRAEs ≥ Grade 3 was 4.9% in the experimental arm and 0.7% in the control arm. The most common adverse event was nausea. In acelELA, the incidence of AE ≥ Grade 3 was 12% (giredestrant) vs. 8.6% (physician’s choice of endocrine monotherapy); the most common adverse event was hepatotoxicity.

figure 4

The Forrest plot for AE ≥ Grade 3 for patients with HR+/HER2- advanced breast cancer after progression on ≥ 1 line of ET. Note: AE, adverse event; progression-free survival; CI, confidence interval; HR, hazard ratio; HR+/HER2-, hormone receptor-positive and human epidermal growth factor receptor 2-negative; SERDs, selective estrogen receptor degrader

Bias assessment

In all trials included, the overall risk of bias was low (Supplement 1 Fig. 1). Since these trials were conducted with an open-label design, performance bias that did not affect the results may exist. There was no obvious publication bias (Supplement 1 Figs. 2 and 3).

Our study showed that the oral SERD regimen was superior to standard-of-care ET in patients with HR+/HER2- advanced breast cancer after progression on ≥ 1 line of ET. However, the characteristics of these patients were complex, so it is crucial to select the characteristics of those patients who are likely to have sustained benefits.

Patients with ESR1m develop resistance to ET and exhibit worse overall survival [ 32 , 33 , 34 ]. Our meta-analysis showed that for patients with ESR1 mutations, outcomes in the arms of oral SERDs were significantly better than those in the arms of standard-of-care ET. Surprisingly, in these four clinical trials, oral SERDs were able to provide PFS benefits in ESR1m patients. In addition, patients with ESR1m showed a trend of OS improvement in Elacestrant (HR = 0.59; p = 0.03). AIs not only enhance the acquisition of ESR1 mutations in aBC, but patients with ESR1 mutations also showed a worse prognosis in AI treatment [ 35 ]. However, patients with ESR1 mutations remained sensitive to fulvestrant [ 15 , 21 , 22 ]. As an intramuscular SERD, fulvestrant binds to estrogen receptors and induces their degradation, [ 17 , 18 ] so it still plays a role in patients with ESR1 mutations. A pooled analysis of patients with ESR1 mutations in the EFECT and SoFEA trials (115/383) found no significant difference in PFS in the Fulv group (3.9 months versus 4.1 months) [ 36 , 37 , 38 ]. However, the clinical utilization of Fulv is limited by its intramuscular formation. In the Elacestrant and SERENA-2 trials, the arms of oral SERDs were significantly better than the arms of fulvestrant (HR: 0.47, p < 0.00001). In addition, its better bioavailability and patient preference for oral medication may lead to better compliance. Patient tolerability of the drug also needs to be considered. The overall toxicity of oral SERDs was found to be greater in our analysis. However, considering that a proportion of patients in the control arms were on AI and tamoxifen regimens, the toxicity of AIs and tamoxifen was lower than that of Fulv [ 39 , 40 , 41 ]. Therefore, this does not mean that oral SERDs are more toxic than Fulv. Moreover, treatment resistance to Fulv leading to disease progression remains a major concern for HR+/HER2- aBC. Therefore, both additional endocrine therapy and effective combination therapy are clinically necessary [ 15 , 16 ]. Data from the Elacestrant and acelELA trials also support oral SERD regimens for patients who failed Fulv therapy. Thus, oral SERDs are recommended in HR+/HER2- ESR1m aBC after ET ≥ 1 line progression, and oral SERDs could be a potential replacement for Fulv.

For HR+/HER2- aBC patients who progressed after first-line treatment with ET combined with CDK4/6i, the oral SERD regimen also had a statistically significant PFS benefit. In the event of disease progression during the use of CDK4/6is, ET-based regimens remain an appropriate option [ 12 , 13 ]. Patients' menopausal status, tolerance to drugs, and previous treatment regimens will affect the subsequent selection of endocrine agents [ 42 ]. These enrolled patients had previously used one or two ET regimens, so it is still necessary to find new endocrine agents. Camizestrant therapy may be a new option for these patients. The median PFS in the oral SERDs group was 7.2 (75 mg) and 7.7 (150 mg) months, respectively, while that in the Fulv group was only 3.7 months. Even in the subgroup with previous use of CDK4/6i, there was a significant improvement in PFS [median PFS 5.5 (75 mg) and 3.8 (150 mg) months vs. 2.1 months]. However, the absolute benefit in Elacestrant was very small (median PFS 2.8 months vs. 1.9 months). In ESR1m aBC patients previously treated with CDK4/6i for ≥12 months, elacestrant had a median PFS of 8.6 months and SOC of 2.1 months, which was a clinically and statistically significant improvement. This suggests that a possible indication for elacestrant may be the duration of previous CDK4/6i [ 43 ]. In addition, in those patients with visceral metastasis, oral SERDs also showed advantages (HR: 0.60, P < 0.00001). Endocrine therapy is the preferred option for HR+ breast cancer patients even in the presence of visceral metastases [ 44 ]. Compared with endocrine monotherapy, the combination can obtain a higher response rate and progression-free survival benefit [ 45 ]. Chemotherapy is recommended for patients with visceral crisis. However, chemotherapy is more toxic and causes many side effects in patients [ 46 ]. In contrast, oral SERDs show better efficacy in patients with visceral metastasis and can also reduce the serious side effects caused by chemotherapy.

EMERALD and SERENA-2 showed positive results in these four randomized controlled trials, while the other two trials, AMEERA-3 and acelERA, failed the study endpoints. Due to the heterogeneity of enrolled patients and differences in control settings, indirect cross-comparisons between different trials should be undertaken with caution. First, prior treatment regimens after disease progression varied across the four trials. In the SERENA-2 trial, 31.3% of patients had previously not received ET in the advanced setting, whereas in the other three trials, patients had previously received at least one or two lines of ET. Studies have shown that monotherapy with Fulv had advantages in PFS compared to aromatase inhibitors or tamoxifen monotherapy [ 47 , 48 ]. In the control arm of AMEERA-3 and acelERA, the proportion of patients treated with Fulv was higher (89.8% and 75%, respectively), which may have resulted in prolonged mPFS in the control group. In addition, all patients in the SERENA-2 control group received Fulv, but previous Fulv was not permitted for aBC patients. In EMERALD, however, 30.4% of patients had previously been treated with Fulv; in AMEERA-3, the corresponding value was 9.7%, and in acelERA, it was 26.19%.

Our study is the first to evaluate the value of oral SERDs in patients with HR+/HER2- aBC after progression on ≥ 1 line of endocrine therapy. The characteristics of the population that may benefit are also analysed. Especially for patients with ESR1m, oral SERDs are advantageous. Further screening of advantaged oral SERD groups for stratified treatment is the future development trend. The value of SERDs may not be limited to patients in advanced settings. Studies such as CAMBRIA-1 [ 49 ] are being conducted to assess the potential of oral SERDs in early-stage breast cancer. In addition, oral dosage forms are more convenient. This can save manpower and material resources to a certain extent, and the compliance of patients will be better. It is believed that it will have good application prospects. There are several limitations to our study. First, this was not a network meta-analysis, and we could not directly compare all drugs or drug combinations with each other. As a result, a certain degree of precision was lost. In addition, we could not evaluate the overall survival (OS) benefit due to the unavailability of data. Although OS is the "gold standard" for efficacy evaluation in cancer clinical research, it has certain limitations in practical application. OS as the primary endpoint requires a large sample size, and clinical development is difficult. It is affected by death from nontumour causes. For tumour types with long survival, the duration of the study is extremely long. Therefore, alternative end points are often used for those patients with long survival, and the FDA currently supports the use of PFS as an end point. However, these limitations are unavoidable at present. At present, there are relatively few studies on oral SERDs, and it is hoped that more clinical trials will follow to confirm our experiments.

The oral SERD regimen has a significant PFS benefit compared to standard-of-care ET in patients with HR+/HER2- aBC after progression on ≥ 1 line of ET. In particular, we recommend oral SERDs as a preferred choice for those patients with ESR1m, and it could be a potential replacement for fulvestrant. The oral SERD regimen also benefits after progression on CDK4/6 inhibitors combined with endocrine therapy.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Mariotto AB, Etzioni R, Hurlbert M, et al. Estimation of the number of women living with metastatic breast cancer in the United States. Cancer Epidemiol Biomarkers Prev. 2017;26(6):809–15.

Article   PubMed   PubMed Central   Google Scholar  

Malmgren JA, Mayer M, Atwood MK, et al. Differential presentation and survival of de novo and recurrent metastatic breast cancer over time: 1990–2010. Breast Cancer Res Treat. 2018;167(2):579–90.

Article   PubMed   Google Scholar  

Gong Y, Liu YR, Ji P, et al. Impact of molecular subtypes on metastatic breast cancer patients: a SEER population-based study. Sci Rep. 2017;7:45411.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Almendro V, Cheng YK, Randles A, et al. Inference of tumor evolution during chemotherapy by computational modeling and in situ analysis of genetic and phenotypic cellular diversity. Cell Rep. 2014;6(3):514–27.

Hanker AB, Sudhan DR, Arteaga CL. Overcoming endocrine resistance in breast cancer. Cancer Cell. 2020;37(4):496–513.

Spring LM, Wander SA, Andre F, et al. Cyclin-dependent kinase 4 and 6 inhibitors for hormone receptor-positive breast cancer: past, present, and future. Lancet. 2020;395(10226):817–27.

Article   CAS   PubMed   Google Scholar  

Gao JJ, Cheng J, Bloomquist E, et al. CDK4/6 inhibitor treatment for patients with hormone receptor-positive, HER2-negative, advanced or metastatic breast cancer: a US Food and Drug Administration pooled analysis. Lancet Oncol. 2020;21(2):250–60.

Hortobagyi GN, Stemmer SM, Burris HA, et al. Ribociclib as First-Line Therapy for HR-Positive, Advanced Breast Cancer. N Engl J Med. 2016;375(18):1738–48.

Finn RS, Martin M, Rugo HS, et al. Palbociclib and Letrozole in Advanced Breast Cancer. N Engl J Med. 2016;375(20):1925–36.

Goetz MP, Toi M, Campone M, et al. MONARCH 3: abemaciclib as initial therapy for advanced breast cancer. J Clin Oncol. 2017;35(32):3638–46.

Hart CD, Migliaccio I, Malorni L, et al. Challenges in the management of advanced, ER-positive, HER2-negative breast cancer. Nat Rev Clin Oncol. 2015;12(9):541–52.

Xi J, Ma CX. Sequencing endocrine therapy for metastatic breast cancer: what do we do after disease progression on a CDK4/6 inhibitor? Curr Oncol Rep. 2020;22(6):57.

Huang J, Zheng L, Sun Z, et al. CDK4/6 inhibitor resistance mechanisms and treatment strategies (Review). Int J Mol Med. 2022;50(4):128.

Basile D, Gerratana L, Corvaja C, et al. First- and second-line treatment strategies for hormone-receptor (HR)-positive HER2-negative metastatic breast cancer: a real-world study. Breast. 2021;57:104–12.

Schiavon G, Hrebien S, Garcia-Murillas I, et al. Analysis of ESR1 mutation in circulating tumor DNA demonstrates evolution during therapy for metastatic breast cancer. Sci Transl Med. 2015;7(313):182r–313r.

Article   Google Scholar  

Herzog SK, Fuqua S. ESR1 mutations and therapeutic resistance in metastatic breast cancer: progress and remaining challenges. Br J Cancer. 2022;126(2):174–86.

Lee CI, Goodwin A, Wilcken N. Fulvestrant for hormone-sensitive metastatic breast cancer. Cochrane Database Syst Rev. 2017;1(1):D11093.

Google Scholar  

McDonnell DP, Wardell SE. The molecular mechanisms underlying the pharmacological actions of ER modulators: implications for new drug discovery in breast cancer. Curr Opin Pharmacol. 2010;10(6):620–8.

Li J, Wang Z, Shao Z. Fulvestrant in the treatment of hormone receptor-positive/human epidermal growth factor receptor 2-negative advanced breast cancer: a review. Cancer Med. 2019;8(5):1943–57.

Robertson JF, Llombart-Cussac A, Rolski J, et al. Activity of fulvestrant 500 mg versus anastrozole 1 mg as first-line treatment for advanced breast cancer: results from the FIRST study. J Clin Oncol. 2009;27(27):4530–5.

Fribbens C, Garcia MI, Beaney M, et al. Tracking evolution of aromatase inhibitor resistance with circulating tumour DNA analysis in metastatic breast cancer. Ann Oncol. 2018;29(1):145–53.

Robinson DR, Wu YM, Vats P, et al. Activating ESR1 mutations in hormone-resistant metastatic breast cancer. Nat Genet. 2013;45(12):1446–51.

Pagliuca M, Donato M, D’Amato AL, et al. New steps on an old path: Novel estrogen receptor inhibitors in breast cancer. Crit Rev Oncol Hematol. 2022;180:103861.

Bidard FC, Kaklamani VG, Neven P, et al. Elacestrant (oral selective estrogen receptor degrader) Versus Standard Endocrine Therapy for Estrogen Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer: Results From the Randomized Phase III EMERALD Trial. J Clin Oncol. 2022;40(28):3246–56.

Oliveira M, Pominchuk D, Nowecki Z, et al. Camizestrant, a next-generation oral SERD vs fulvestrant in post-menopausal women with advanced ER-positive HER2- negative breast cancer: Results of the randomized, multi-dose Phase 2 SERENA-2 trial. Cancer Res. 2023;83(suppl 5):GS3–02.

Tolaney SM, Chan A, Petrakova K, et al. AMEERA-3: Randomized Phase II Study of Amcenestrant (Oral Selective Estrogen Receptor Degrader) Versus Standard Endocrine Monotherapy in Estrogen Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer. J Clin Oncol. 2023;41(24):4014–24.

Jimenez MM, Lim E, Mac Gregor MC, et al. Giredestrant (GDC-9545) vs physician choice of endocrine monotherapy (PCET) in patients (pts) with ER+, HER2– locally advanced/metastatic breast cancer (LA/mBC): primary analysis of the phase II, randomised, open-label acelERA BC study. Ann Oncol. 2022;33(suppl 7):S633–4.

Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration. 2011. Available from: www.cochrane-handbook.org .

Eisenhauer E A, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer, 2009,45(2):228-247.

National Cancer Institute. Common terminology criteria for adverse events. https://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm . Accessed 25 June 2018.

Fribbens C, O’Leary B, Kilburn L, et al. Plasma ESR1 Mutations and the Treatment of Estrogen Receptor-Positive Advanced Breast Cancer. J Clin Oncol. 2016;34(25):2961–8.

Chandarlapaty S, Chen D, He W, et al. Prevalence of ESR1 Mutations in Cell-Free DNA and outcomes in metastatic breast cancer: a secondary analysis of the BOLERO-2 Clinical Trial. JAMA Oncol. 2016;2(10):1310–5.

Razavi P, Chang MT, Xu G, et al. The genomic landscape of endocrine-resistant advanced breast cancers. Cancer Cell. 2018;34(3):427–38.

Zundelevich A, Dadiani M, Kahana-Edwin S, et al. ESR1 mutations are frequent in newly diagnosed metastatic and loco-regional recurrence of endocrine-treated breast cancer and carry worse prognosis. Breast Cancer Res. 2020;22(1):16.

Chia S, Gradishar W, Mauriac L, et al. Double-blind, randomized placebo controlled trial of fulvestrant compared with exemestane after prior nonsteroidal aromatase inhibitor therapy in postmenopausal women with hormone receptor-positive, advanced breast cancer: results from EFECT. J Clin Oncol. 2008;26(10):1664–70.

Johnston SR, Kilburn LS, Ellis P, et al. Fulvestrant plus anastrozole or placebo versus exemestane alone after progression on non-steroidal aromatase inhibitors in postmenopausal patients with hormone-receptor-positive locally advanced or metastatic breast cancer (SoFEA): a composite, multicentre, phase 3 randomised trial. Lancet Oncol. 2013;14(10):989–98.

Article   CAS   Google Scholar  

Turner NC, Swift C, Kilburn L, et al. ESR1 Mutations and Overall Survival on Fulvestrant versus Exemestane in Advanced Hormone Receptor-Positive Breast Cancer: A Combined Analysis of the Phase III SoFEA and EFECT Trials. Clin Cancer Res. 2020;26(19):5172–7.

Robertson J, Bondarenko IM, Trishkina E, et al. Fulvestrant 500 mg versus anastrozole 1 mg for hormone receptor-positive advanced breast cancer (FALCON): an international, randomised, double-blind, phase 3 trial. Lancet. 2016;388(10063):2997–3005.

Blackburn SA, Parks RM, Cheung KL. Fulvestrant for the treatment of advanced breast cancer. Expert Rev Anticancer Ther. 2018;18(7):619–28.

Boer K. Fulvestrant in advanced breast cancer: evidence to date and place in therapy. Ther Adv Med Oncol. 2017;9(7):465–79.

Cardoso F, Costa A, Senkus E, et al. 3rd ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC 3). Ann Oncol. 2017;28(1):16–33.

Lipsyc-Sharf M, Tolaney SM. Elacestrant: who are optimal candidates for the first oral SERD?. Ann Oncol. 2023;34(5):449–51.

Cardoso F, Paluch-Shimon S, Senkus E, et al. 5th ESO-ESMO international consensus guidelines for advanced breast cancer (ABC 5). Ann Oncol. 2020;31(12):1623–49.

Giuliano M, Schettini F, Rognoni C, et al. Endocrine treatment versus chemotherapy in postmenopausal women with hormone receptor-positive, HER2-negative, metastatic breast cancer: a systematic review and network meta-analysis. Lancet Oncol. 2019;20(10):1360–9.

Partridge AH, Rumble RB, Carey LA, et al. Chemotherapy and Targeted Therapy for Women With Human Epidermal Growth Factor Receptor 2–Negative (or unknown) Advanced Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2014;32(29):3307–29.

Shimoi T, Sagara Y, Hara F, et al. First-line endocrine therapy for postmenopausal patients with hormone receptor-positive, HER2-negative metastatic breast cancer: a systematic review and meta-analysis. Breast Cancer. 2020;27(3):340–6.

Zhang J, Huang Y, Wang C, et al. Efficacy and safety of endocrine monotherapy as first-line treatment for hormone-sensitive advanced breast cancer: a network meta-analysis. Medicine (Baltimore). 2017;96(33):e7846.

Hamilton E, Loibl S, Niikura N, et al. A phase III randomised open-label study of extended adjuvant therapy with camizestrant vs standard endocrine therapy (ET) in patients with ER+/HER2e early breast cancer (BC) and an intermediate or high risk of recurrence (CAMBRIA-1). Ann Oncol. 2023;34(suppl 2):S323–4.

Download references

Acknowledgements

We thank Yuan Su, MD, PhD from Fujian Medical University for statistics consultation.

The authors state that no funds, grants or other lines of support were received in this manuscript preparation process.

Author information

Xiewei Huang and Yushuai Yu contributed equally to this work and share first authorship.

Authors and Affiliations

Department of Breast Surgery, Fujian Medical University Union Hospital, No. 29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian Province, China

Xiewei Huang, Yushuai Yu, Shiping Luo, Wenfen Fu, Jie Zhang & Chuangui Song

Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China

Jie Zhang & Chuangui Song

Breast Surgery Institute, Fujian Medical University, Fuzhou, 350001, Fujian Province, China

You can also search for this author in PubMed   Google Scholar

Contributions

Xiewei Huang, Yushuai Yu, Shiping Luo, and Wenfen Fu performed the study design, article search, and data collection. Yushuai Yu performed the analysis. Xiewei Huang and Yushuai Yu wrote the first draft of the manuscript. Jie Zhang and Chuangui Song reviewed the article. All authors participated in commenting on the manuscript and read and approved the final manuscript.

Corresponding authors

Correspondence to Jie Zhang or Chuangui Song .

Ethics declarations

Ethics approval and consent to participate.

As the data used in this study were from previously published literature, ethical approval and informed consent were not needed.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1:.

  Supplementary Figure 1. Quality assessment for the bias items of RCTs. (a) Risk of the bias summary. (b) Risk of the bias graph. Supplementary Figure 2. The funnel plot PFS for patients with HR+/HER2- advanced breast cancer after progression on ≥ 1 line of endocrine treatment: (A) The funnel plot PFS for overall patients; (B) The funnel plot PFS for patients with previous use of CDK4/6 inhibitors; (C) The funnel plot PFS for  patients with ESR1m; (D) The funnel plot PFS for comparing oral SERDS with fulvestrant in patients with ESR1m subgroup. Note: PFS, progression-free survival; CI, confifidence interval; HR, hazard ratio; HR+/HER2-, hormone receptor-positive and human epidermal growth factor receptor 2-negative; SERDS, selective estrogen receptor degrader; ESR1m, estrogen receptor 1 mutations. Supplementary Figure 3. The funnel plot PFS for patients with (A) previous use of fulvestrant; (B) visceral metastasis; (C) funnel plot for PFS comparing oral SERDS with fulvestrant. (D) The funnel plot for AE ≥ Grade 3 for patients with HR+/HER2- advanced breast cancer after progression on ≥ 1 line of ET. Note: PFS, progression-free survival; CI, confifidence interval; HR, hazard ratio; HR+/HER2-, hormone receptor-positive and human epidermal growth factor receptor 2-negative; SERDS, selective estrogen receptor degrader; AE, adverse event.

Additional file 2.

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Huang, X., Yu, Y., Luo, S. et al. The value of oral selective estrogen receptor degraders in patients with HR-positive, HER2-negative advanced breast cancer after progression on ≥ 1 line of endocrine therapy: systematic review and meta-analysis. BMC Cancer 24 , 21 (2024). https://doi.org/10.1186/s12885-023-11722-4

Download citation

Received : 24 April 2023

Accepted : 05 December 2023

Published : 02 January 2024

DOI : https://doi.org/10.1186/s12885-023-11722-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Breast cancer
  • Meta-analysis

ISSN: 1471-2407

case study positive and negative

Causes and impacts relating to forced and voluntary migration Case study: Mexico and the USA

There are two types of migration, forced and voluntary. People migrate for many different reasons. Migration has positive and negative impacts on society.

Case study: Mexico and the USA

According to the International Boundary and Water Commission for the United States and Mexico, the border between the USA and Mexico is 1,954 miles long. Illegal migration is a huge problem. U.S. Border Patrol guards the border and trys to prevent illegal immigrants from entering the country. Illegal migration costs the USA millions of dollars for border patrols and prisons.

There are more than 11 million unauthorised immigrants living in the USA.

Many Americans believe that Mexican immigrants are a drain on the economy. They believe that migrant workers keep wages low which affects Americans. However other people believe that Mexican migrants benefit the economy by working for low wages.

Mexican culture has also enriched the USA border states with food, language and music.

Impact on Mexico

The Mexican countryside has a shortage of economically active people. Many men emigrate leaving a majority of women who have trouble finding life partners. Young people tend to migrate, leaving the old and the very young.

Legal and illegal immigrants together send some $6 billion a year back to Mexico. Certain villages such as Santa Ines have lost two thirds of their inhabitants.

There is a large wage gap between the USA and Mexico. Wages remain significantly higher in the USA for a large portion of the population. This attracts many Mexicans to the USA.

Many people find living in rural Mexico a struggle because they have to survive with very little money. Farmland is often overworked and farms are small.

It is estimated that 10,000 people try to smuggle themselves over the border every week. One in three get caught and those that do are likely to continue trying to cross the border at least twice a year.

More guides on this topic

  • Methods and problems of data collection
  • Consequences of population structure

Related links

  • BBC Weather
  • BBC News: Science, Environment
  • BBC Two: Landward
  • SQA: Higher Geography
  • Planet Diary
  • Scotland's Environment
  • Greenhouse Gas Online
  • Geograph British Isles

case study positive and negative

132 Social Media Case Studies – Successes and Failures

Sharing is caring!

Do you think social media is bullsh&t? It is not. But you have to know how to use it. Here is a list of resources with multiple case studies about how businesses are successfully using social media for their business #socialmedia #socialmediatips #socialmediamarketing #socialmediaexamples #marketingexamples #socialmediacasstudies

That is such a short-sighted and limiting point of view.

Social Media Marketing is not sales – but it can help to sell things. And personally, I have to admit that I have several times bought something, booked an event or took part in something because I saw people (friends and acquaintances OR strangers) talking about it on social media. At the same time, I have never bought anything a salesperson tried to sell me on the phone. So yes, you actually can sell me things on Social Media. And I am not the only person.

Click To Tweet

Before you read on - we have various resources that show you exactly how to use social networks to gain massive traffic and leads. For instance, check out the following:

But limiting Social Media Marketing success or failure to the statement: For sales, you need to pick up the phone is simply b%llshi$t. You can use social media for lead generation to fill your sales funnel – but you can also use Social Media for totally different aspects of business like customer management, brand awareness, reputation management, audience building, website traffic and many other things your business can profit from.

Many people do it. I do it and have done so for other projects in the past. The honest answer to “Social Media is not working” is: It is obviously not working the way you are doing it. Try different tactics, learn, adjust, measure, optimize, try something else, try harder, and never stop at “You cannot sell on Social Media!”

So the answer is, yes you can make money with Social Media, but it is not working the same way for each and every business or situation.

Most of the time, if you do not have success with getting ROI out of your Social Media activities, it is not Social Media, which is not working, it is you who are doing something wrong or have the wrong social media strategy.

You can use social media for lead generation to fill your sales funnel – but you can also use Social Media for totally different aspects of business like customer management, brand awareness, reputation management, audience building, website traffic and many other things your business can profit from. here are 132 social media marketing case studies and examples. #socialmediaexamples #socialmediamarketing #socialmediatips #socialmedia #socialmediacasestudies

Social Media cannot simply be done by following a recipe step by step.

That can only get you so far.

In Social Media often the best approaches are already cold coffee when they become common knowledge, and everyone tries to hop on the train. You need to make assumptions, test your assumption, measure success and adjust your marketing strategy according to your results.

Hey, before you read on - we have in various FREE in-depth guides on similar topics that you can download. For this post, check out:

Social media cannot be learned by the book.

But one thing is certain: To shout out sales messages in Social Media is most likely going to fail to give you any return.

What people want and expect from their Social Media activity is so diverse, and there are many Social Media case studies in multiple situations.

Join our  free Email Course  to learn how to start your social media marketing journey:

All the basics in 4 Days, 4 Emails

case study positive and negative

Instead of selecting a handful of case studies for this article, I decided to provide you with a list of resources with multiple case studies about how businesses are successfully using social media for their business success.

1.  15 B2B Case Studies for Proving Social Media ROI

Rob Petersen looks at the special situation of using social media platforms to market to businesses instead of consumers. He provides 15 examples ranging from CISCO and Demand Base to LinkedIn and SAP.

2.  50 Social Media Case Studies you Should Bookmark

SimplyZesty looks at a variety of use cases for the different social networks like Facebook, Twitter, Youtube, Pinterest, Instagram and more.

3.  IBM Turns its Sales Staff Social Media Savvy

I love this example as it shows how sales and Social Media Marketing can work hand in hand. Contrary to the above-mentioned comment on our blog, IBM realized that even sales can profit from Social Media with cost-effective leads.

4.  11 Examples of Killer B2B Content Marketing Campaigns Including ROI

Lee Odden of TopRank Marketing focuses more on the Content Marketing side and provides 11 B2B Content Marketing case studies.

5.  B2B Social Media Case Study: How I made $47 million from my B2B blog

This is a personal success story from AT&T’s experience and success with a content strategy.

6.  How ASOS Use Social Media [CASE STUDY]

The story of how the fashion and beauty store ASOS has become Britain’s largest online retailer with the aid of Social Media for ecommerce and online marketing.

7.  5 Outstanding Social Media Campaigns

The examples include the story from a hairdresser who increased sales by 400% without spending a penny. It is not only the big companies who can profit from Social Media.

8.  3 Small Businesses That Found Social Media Success

The examples range from customer service, brand perception to social engagement.

9.  The Best Social Media Campaigns of 2014

These marketing campaigns are more about creating more engagement, generate more fans and increase loyalty amongst audience members for the brand and not so much about direct ROI. Still, they explain how to get it right.

It is not only the social media success stories you can learn from. Sometimes you can learn from other peoples’ failures at least as much as from their successes. Here are some social media case studies on failed social media activities. The failures tend to be on a smaller scale, resulting from bad communication and reactions turning the Social Media conversation in an unwanted direction. It is rare that a company admits to a complete campaign and a ton of money gone down the drain. Still, even from these smaller examples, we all can learn our lessons for our behavior in Social Media:

1.  Social Media Fails: The Worst Case Studies of 2012

The examples are campaign focused and include examples from McDonald’s and Toyota.

2.  19 horrific social media fails from the first half of 2014

These are examples of how you should not communicate in Social Media and showcase some ways you should not copy on how to jump onto trending hashtags and events in Social Media.

3.  5 Big Social Media Fails of 2013 (and What We Learned)

What people want and expect from their Social Media activity is so diverse, and there are many Social Media case studies in multiple situations. Here are 132 social media examples that you will find interesting and can learn from. #socialmedia #socialmediatips #socialmediamarketing #digitalmarketing #onlinemarketing #marketingstrategy

4.  Top 12 Social Media Marketing Mishaps

These are examples of what can happen to you and how a social media Sh$tstorm can brew up. It makes sense to read some of these and talk about possible reactions before any of this kind happens to you. Simply be prepared.

Final Words

I hope you find some useful marketing tips in my little collection of Social Media case studies – or at least, have some fun browsing through these examples. I find them encouraging as they show the variety of cases where Social Media can help your business. And they show how many humans are in Social Media, making it a place where things can go wrong and go well. It is up to you to leverage the full power of social networks and turn the tide.

If you are looking for even more case studies here you go:

Digital Marketing Case Studies

Content Marketing Case Studies

Instagram Marketing Case Studies

Twitter Marketing Case Studies

Forget Failure. Get the simple process to success:

We show you the exact steps we took to grow our first business from 0 to 500k page views per month with social media and how we got 50k visitors per month from social media to this blog after 6 months. We show you the exact steps you need to take to see traffic success.

You get easy-to-follow step-by-step action plans and you will see the first results after a couple of days. Check out “ The Social Traffic Code ” – there is a special offer for you!

“The Social Ms blog and books have shown us great possibilities of growing on Twitter and via online media. In addition, they actually respond to email reactions. Practicing what they preach gives them the credibility edge.” Guy Pardon, Atomikos

Don’t miss out – make a decision for success! 

case study positive and negative

Susanna Gebauer

  • Imprint/Impressum
  • Privacy Policy
  • Podcast – Marketing in Minutes
  • Get a Coaching Call
  • Courses and Books

Green Garage

Case Study Method – 18 Advantages and Disadvantages

The case study method uses investigatory research as a way to collect data about specific demographics. This approach can apply to individuals, businesses, groups, or events. Each participant receives an equal amount of participation, offering information for collection that can then find new insights into specific trends, ideas, of hypotheses.

Interviews and research observation are the two standard methods of data collection used when following the case study method.

Researchers initially developed the case study method to develop and support hypotheses in clinical medicine. The benefits found in these efforts led the approach to transition to other industries, allowing for the examination of results through proposed decisions, processes, or outcomes. Its unique approach to information makes it possible for others to glean specific points of wisdom that encourage growth.

Several case study method advantages and disadvantages can appear when researchers take this approach.

List of the Advantages of the Case Study Method

1. It requires an intensive study of a specific unit. Researchers must document verifiable data from direct observations when using the case study method. This work offers information about the input processes that go into the hypothesis under consideration. A casual approach to data-gathering work is not effective if a definitive outcome is desired. Each behavior, choice, or comment is a critical component that can verify or dispute the ideas being considered.

Intensive programs can require a significant amount of work for researchers, but it can also promote an improvement in the data collected. That means a hypothesis can receive immediate verification in some situations.

2. No sampling is required when following the case study method. This research method studies social units in their entire perspective instead of pulling individual data points out to analyze them. That means there is no sampling work required when using the case study method. The hypothesis under consideration receives support because it works to turn opinions into facts, verifying or denying the proposals that outside observers can use in the future.

Although researchers might pay attention to specific incidents or outcomes based on generalized behaviors or ideas, the study itself won’t sample those situations. It takes a look at the “bigger vision” instead.

3. This method offers a continuous analysis of the facts. The case study method will look at the facts continuously for the social group being studied by researchers. That means there aren’t interruptions in the process that could limit the validity of the data being collected through this work. This advantage reduces the need to use assumptions when drawing conclusions from the information, adding validity to the outcome of the study over time. That means the outcome becomes relevant to both sides of the equation as it can prove specific suppositions or invalidate a hypothesis under consideration.

This advantage can lead to inefficiencies because of the amount of data being studied by researchers. It is up to the individuals involved in the process to sort out what is useful and meaningful and what is not.

4. It is a useful approach to take when formulating a hypothesis. Researchers will use the case study method advantages to verify a hypothesis under consideration. It is not unusual for the collected data to lead people toward the formulation of new ideas after completing this work. This process encourages further study because it allows concepts to evolve as people do in social or physical environments. That means a complete data set can be gathered based on the skills of the researcher and the honesty of the individuals involved in the study itself.

Although this approach won’t develop a societal-level evaluation of a hypothesis, it can look at how specific groups will react in various circumstances. That information can lead to a better decision-making process in the future for everyone involved.

5. It provides an increase in knowledge. The case study method provides everyone with analytical power to increase knowledge. This advantage is possible because it uses a variety of methodologies to collect information while evaluating a hypothesis. Researchers prefer to use direct observation and interviews to complete their work, but it can also advantage through the use of questionnaires. Participants might need to fill out a journal or diary about their experiences that can be used to study behaviors or choices.

Some researchers incorporate memory tests and experimental tasks to determine how social groups will interact or respond in specific situations. All of this data then works to verify the possibilities that a hypothesis proposes.

6. The case study method allows for comparisons. The human experience is one that is built on individual observations from group situations. Specific demographics might think, act, or respond in particular ways to stimuli, but each person in that group will also contribute a small part to the whole. You could say that people are sponges that collect data from one another every day to create individual outcomes.

The case study method allows researchers to take the information from each demographic for comparison purposes. This information can then lead to proposals that support a hypothesis or lead to its disruption.

7. Data generalization is possible using the case study method. The case study method provides a foundation for data generalization, allowing researches to illustrate their statistical findings in meaningful ways. It puts the information into a usable format that almost anyone can use if they have the need to evaluate the hypothesis under consideration. This process makes it easier to discover unusual features, unique outcomes, or find conclusions that wouldn’t be available without this method. It does an excellent job of identifying specific concepts that relate to the proposed ideas that researchers were verifying through their work.

Generalization does not apply to a larger population group with the case study method. What researchers can do with this information is to suggest a predictable outcome when similar groups are placed in an equal situation.

8. It offers a comprehensive approach to research. Nothing gets ignored when using the case study method to collect information. Every person, place, or thing involved in the research receives the complete attention of those seeking data. The interactions are equal, which means the data is comprehensive and directly reflective of the group being observed.

This advantage means that there are fewer outliers to worry about when researching an idea, leading to a higher level of accuracy in the conclusions drawn by the researchers.

9. The identification of deviant cases is possible with this method. The case study method of research makes it easier to identify deviant cases that occur in each social group. These incidents are units (people) that behave in ways that go against the hypothesis under consideration. Instead of ignoring them like other options do when collecting data, this approach incorporates the “rogue” behavior to understand why it exists in the first place.

This advantage makes the eventual data and conclusions gathered more reliable because it incorporates the “alternative opinion” that exists. One might say that the case study method places as much emphasis on the yin as it does the yang so that the whole picture becomes available to the outside observer.

10. Questionnaire development is possible with the case study method. Interviews and direct observation are the preferred methods of implementing the case study method because it is cheap and done remotely. The information gathered by researchers can also lead to farming questionnaires that can farm additional data from those being studied. When all of the data resources come together, it is easier to formulate a conclusion that accurately reflects the demographics.

Some people in the case study method may try to manipulate the results for personal reasons, but this advantage makes it possible to identify this information readily. Then researchers can look into the thinking that goes into the dishonest behaviors observed.

List of the Disadvantages of the Case Study Method

1. The case study method offers limited representation. The usefulness of the case study method is limited to a specific group of representatives. Researchers are looking at a specific demographic when using this option. That means it is impossible to create any generalization that applies to the rest of society, an organization, or a larger community with this work. The findings can only apply to other groups caught in similar circumstances with the same experiences.

It is useful to use the case study method when attempting to discover the specific reasons why some people behave in a specific way. If researchers need something more generalized, then a different method must be used.

2. No classification is possible with the case study method. This disadvantage is also due to the sample size in the case study method. No classification is possible because researchers are studying such a small unit, group, or demographic. It can be an inefficient process since the skills of the researcher help to determine the quality of the data being collected to verify the validity of a hypothesis. Some participants may be unwilling to answer or participate, while others might try to guess at the outcome to support it.

Researchers can get trapped in a place where they explore more tangents than the actual hypothesis with this option. Classification can occur within the units being studied, but this data cannot extrapolate to other demographics.

3. The case study method still offers the possibility of errors. Each person has an unconscious bias that influences their behaviors and choices. The case study method can find outliers that oppose a hypothesis fairly easily thanks to its emphasis on finding facts, but it is up to the researchers to determine what information qualifies for this designation. If the results from the case study method are surprising or go against the opinion of participating individuals, then there is still the possibility that the information will not be 100% accurate.

Researchers must have controls in place that dictate how data gathering work occurs. Without this limitation in place, the results of the study cannot be guaranteed because of the presence of bias.

4. It is a subjective method to use for research. Although the purpose of the case study method of research is to gather facts, the foundation of what gets gathered is still based on opinion. It uses the subjective method instead of the objective one when evaluating data, which means there can be another layer of errors in the information to consider.

Imagine that a researcher interprets someone’s response as “angry” when performing direct observation, but the individual was feeling “shame” because of a decision they made. The difference between those two emotions is profound, and it could lead to information disruptions that could be problematic to the eventual work of hypothesis verification.

5. The processes required by the case study method are not useful for everyone. The case study method uses a person’s memories, explanations, and records from photographs and diaries to identify interactions on influences on psychological processes. People are given the chance to describe what happens in the world around them as a way for researchers to gather data. This process can be an advantage in some industries, but it can also be a worthless approach to some groups.

If the social group under study doesn’t have the information, knowledge, or wisdom to provide meaningful data, then the processes are no longer useful. Researchers must weigh the advantages and disadvantages of the case study method before starting their work to determine if the possibility of value exists. If it does not, then a different method may be necessary.

6. It is possible for bias to form in the data. It’s not just an unconscious bias that can form in the data when using the case study method. The narrow study approach can lead to outright discrimination in the data. Researchers can decide to ignore outliers or any other information that doesn’t support their hypothesis when using this method. The subjective nature of this approach makes it difficult to challenge the conclusions that get drawn from this work, and the limited pool of units (people) means that duplication is almost impossible.

That means unethical people can manipulate the results gathered by the case study method to their own advantage without much accountability in the process.

7. This method has no fixed limits to it. This method of research is highly dependent on situational circumstances rather than overarching societal or corporate truths. That means the researcher has no fixed limits of investigation. Even when controls are in place to limit bias or recommend specific activities, the case study method has enough flexibility built into its structures to allow for additional exploration. That means it is possible for this work to continue indefinitely, gathering data that never becomes useful.

Scientists began to track the health of 268 sophomores at Harvard in 1938. The Great Depression was in its final years at that point, so the study hoped to reveal clues that lead to happy and healthy lives. It continues still today, now incorporating the children of the original participants, providing over 80 years of information to sort through for conclusions.

8. The case study method is time-consuming and expensive. The case study method can be affordable in some situations, but the lack of fixed limits and the ability to pursue tangents can make it a costly process in most situations. It takes time to gather the data in the first place, and then researchers must interpret the information received so that they can use it for hypothesis evaluation. There are other methods of data collection that can be less expensive and provide results faster.

That doesn’t mean the case study method is useless. The individualization of results can help the decision-making process advance in a variety of industries successfully. It just takes more time to reach the appropriate conclusion, and that might be a resource that isn’t available.

The advantages and disadvantages of the case study method suggest that the helpfulness of this research option depends on the specific hypothesis under consideration. When researchers have the correct skills and mindset to gather data accurately, then it can lead to supportive data that can verify ideas with tremendous accuracy.

This research method can also be used unethically to produce specific results that can be difficult to challenge.

When bias enters into the structure of the case study method, the processes become inefficient, inaccurate, and harmful to the hypothesis. That’s why great care must be taken when designing a study with this approach. It might be a labor-intensive way to develop conclusions, but the outcomes are often worth the investments needed.

CaseQuiz.com

Positive And Negative

  • Harvard Case Studies

Harvard Business Case Studies Solutions – Assignment Help

In most courses studied at Harvard Business schools, students are provided with a case study. Major HBR cases concerns on a whole industry, a whole organization or some part of organization; profitable or non-profitable organizations. Student’s role is to analyze the case and diagnose the situation, identify the problem and then give appropriate recommendations and steps to be taken.

To make a detailed case analysis, student should follow these steps:

STEP 1: Reading Up Harvard Case Study Method Guide:

Case study method guide is provided to students which determine the aspects of problem needed to be considered while analyzing a case study. It is very important to have a thorough reading and understanding of guidelines provided. However, poor guide reading will lead to misunderstanding of case and failure of analyses. It is recommended to read guidelines before and after reading the case to understand what is asked and how the questions are to be answered. Therefore, in-depth understanding f case guidelines is very important.

Harvard Case Study Solutions

Harvard Case Study Solutions

STEP 2: Reading The Harvard Positive And Negative Case Study:

To have a complete understanding of the case, one should focus on case reading. It is said that case should be read two times. Initially, fast reading without taking notes and underlines should be done. Initial reading is to get a rough idea of what information is provided for the analyses. Then, a very careful reading should be done at second time reading of the case. This time, highlighting the important point and mark the necessary information provided in the case. In addition, the quantitative data in case, and its relations with other quantitative or qualitative variables should be given more importance. Also, manipulating different data and combining with other information available will give a new insight. However, all of the information provided is not reliable and relevant.

When having a fast reading, following points should be noted:

  • Nature of organization
  • Nature if industry in which organization operates.
  • External environment that is effecting organization
  • Problems being faced by management
  • Identification of communication strategies.
  • Any relevant strategy that can be added.
  • Control and out-of-control situations.

When reading the case for second time, following points should be considered:

  • Decisions needed to be made and the responsible Person to make decision.
  • Objectives of the organization and key players in this case.
  • The compatibility of objectives. if not, their reconciliations and necessary redefinition.
  • Sources and constraints of organization from meeting its objectives.

After reading the case and guidelines thoroughly, reader should go forward and start the analyses of the case.

STEP 3: Doing The Case Analysis Of Positive And Negative:

To make an appropriate case analyses, firstly, reader should mark the important problems that are happening in the organization. There may be multiple problems that can be faced by any organization. Secondly, after identifying problems in the company, identify the most concerned and important problem that needed to be focused.

Firstly, the introduction is written. After having a clear idea of what is defined in the case, we deliver it to the reader. It is better to start the introduction from any historical or social context. The challenging diagnosis for Positive And Negative and the management of information is needed to be provided. However, introduction should not be longer than 6-7 lines in a paragraph. As the most important objective is to convey the most important message for to the reader.

After introduction, problem statement is defined. In the problem statement, the company’s most important problem and constraints to solve these problems should be define clearly. However, the problem should be concisely define in no more than a paragraph. After defining the problems and constraints, analysis of the case study is begin.

STEP 4: SWOT Analysis of the Positive And Negative HBR Case Solution:

SWOT analysis helps the business to identify its strengths and weaknesses, as well as understanding of opportunity that can be availed and the threat that the company is facing. SWOT for Positive And Negative is a powerful tool of analysis as it provide a thought to uncover and exploit the opportunities that can be used to increase and enhance company’s operations. In addition, it also identifies the weaknesses of the organization that will help to be eliminated and manage the threats that would catch the attention of the management.

This strategy helps the company to make any strategy that would differentiate the company from competitors, so that the organization can compete successfully in the industry. The strengths and weaknesses are obtained from internal organization. Whereas, the opportunities and threats are generally related from external environment of organization. Moreover, it is also called Internal-External Analysis.

STRENGTHS :

In the strengths, management should identify the following points exists in the organization:

  • Advantages of the organization
  • Activities of the company better than competitors.
  • Unique resources and low cost resources company have.
  • Activities and resources market sees as the company’s strength.
  • Unique selling proposition of the company.

WEAKNESSES:

  • Improvement that could be done.
  • Activities that can be avoided for Positive And Negative.
  • Activities that can be determined as your weakness in the market.
  • Factors that can reduce the sales.
  • Competitor’s activities that can be seen as your weakness.

OPPORTUNITIES:

  • Good opportunities that can be spotted.
  • Interesting trends of industry.
  • Change in technology and market strategies
  • Government policy changes that is related to the company’s field
  • Changes in social patterns and lifestyles.
  • Local events.

Following points can be identified as a threat to company:

  • Company’s facing obstacles.
  • Activities of competitors.
  • Product and services quality standards
  • Threat from changing technologies
  • Financial/cash flow problems
  • Weakness that threaten the business.

Following points should be considered when applying SWOT to the analysis:

  • Precise and verifiable phrases should be sued.
  • Prioritize the points under each head, so that management can identify which step has to be taken first.
  • Apply the analyses at proposed level. Clear yourself first that on what basis you have to apply SWOT matrix.
  • Make sure that points identified should carry itself with strategy formulation process.
  • Use particular terms (like USP, Core Competencies Analyses etc.) to get a comprehensive picture of analyses.

STEP 5: PESTEL/ PEST Analysis of Positive And Negative Case Solution:

Pest analyses is a widely used tool to analyze the Political, Economic, Socio-cultural, Technological, Environmental and legal situations which can provide great and new opportunities to the company as well as these factors can also threat the company, to be dangerous in future.

Pest analysis is very important and informative.   It is used for the purpose of identifying business opportunities and advance threat warning. Moreover, it also helps to the extent to which change is useful for the company and also guide the direction for the change. In addition, it also helps to avoid activities and actions that will be harmful for the company in future, including projects and strategies.

To analyze the business objective and its opportunities and threats, following steps should be followed:

  • Brainstorm and assumption the changes that should be made to organization. Answer the necessary questions that are related to specific needs of organization
  • Analyze the opportunities that would be happen due to the change.
  • Analyze the threats and issues that would be caused due to change.

Pest analysis

Pest analysis

PEST FACTORS:

  • Next political elections and changes that will happen in the country due to these elections
  • Strong and powerful political person, his point of view on business policies and their effect on the organization.
  • Strength of property rights and law rules. And its ratio with corruption and organized crimes. Changes in these situation and its effects.
  • Change in Legislation and taxation effects on the company
  • Trend of regulations and deregulations. Effects of change in business regulations
  • Timescale of legislative change.
  • Other political factors likely to change for Positive And Negative.

ECONOMICAL:

  • Position and current economy trend i.e. growing, stagnant or declining.
  • Exchange rates fluctuations and its relation with company.
  • Change in Level of customer’s disposable income and its effect.
  • Fluctuation in unemployment rate and its effect on hiring of skilled employees
  • Access to credit and loans. And its effects on company
  • Effect of globalization on economic environment
  • Considerations on other economic factors

SOCIO-CULTURAL:

  • Change in population growth rate and age factors, and its impacts on organization.
  • Effect on organization due to Change in attitudes and generational shifts.
  • Standards of health, education and social mobility levels. Its changes and effects on company.

case study solutions

case study solutions

  • Social attitudes and social trends, change in socio culture an dits effects.
  • Religious believers and life styles and its effects on organization
  • Other socio culture factors and its impacts.

TECHNOLOGICAL:

  • Any new technology that company is using
  • Any new technology in market that could affect the work, organization or industry
  • Access of competitors to the new technologies and its impact on their product development/better services.
  • Research areas of government and education institutes in which the company can make any efforts
  • Changes in infra-structure and its effects on work flow
  • Existing technology that can facilitate the company
  • Other technological factors and their impacts on company and industry

These headings and analyses would help the company to consider these factors and make a “big picture” of company’s characteristics. This will help the manager to take the decision and drawing conclusion about the forces that would create a big impact on company and its resources.

STEP 6: Porter’s Five Forces/ Strategic Analysis Of The Positive And Negative Case Study:

To analyze the structure of a company and its corporate strategy, Porter’s five forces model is used. In this model, five forces have been identified which play an important part in shaping the market and industry. These forces are used to measure competition intensity and profitability of an industry and market.

porter's five forces model

porter’s five forces model

These forces refers to micro environment and the company ability to serve its customers and make a profit. These five forces includes three forces from horizontal competition and two forces from vertical competition. The five forces are discussed below:

  • THREAT OF NEW ENTRANTS: as the industry have high profits, many new entrants will try to enter into the market. However, the new entrants will eventually cause decrease in overall industry profits. Therefore, it is necessary to block the new entrants in the industry. following factors is describing the level of threat to new entrants:
  • Barriers to entry that includes copy rights and patents.
  • High capital requirement
  • Government restricted policies
  • Switching cost
  • Access to suppliers and distributions
  • Customer loyalty to established brands.
  • THREAT OF SUBSTITUTES: this describes the threat to company. If the goods and services are not up to the standard, consumers can use substitutes and alternatives that do not need any extra effort and do not make a major difference. For example, using Aquafina in substitution of tap water, Pepsi in alternative of Coca Cola. The potential factors that made customer shift to substitutes are as follows:
  • Price performance of substitute
  • Switching costs of buyer
  • Products substitute available in the market
  • Reduction of quality
  • Close substitution are available
  • DEGREE OF INDUSTRY RIVALRY: the lesser money and resources are required to enter into any industry, the higher there will be new competitors and be an effective competitor. It will also weaken the company’s position. Following are the potential factors that will influence the company’s competition:
  • Competitive advantage
  • Continuous innovation
  • Sustainable position in competitive advantage
  • Level of advertising
  • Competitive strategy
  • BARGAINING POWER OF BUYERS: it deals with the ability of customers to take down the prices. It mainly consists the importance of a customer and the level of cost if a customer will switch from one product to another. The buyer power is high if there are too many alternatives available. And the buyer power is low if there are lesser options of alternatives and switching. Following factors will influence the buying power of customers:
  • Bargaining leverage
  • Switching cost of a buyer
  • Buyer price sensitivity
  • Competitive advantage of   company’s product
  • BARGAINING POWER OF SUPPLIERS: this refers to the supplier’s ability of increasing and decreasing prices. If there are few alternatives o supplier available, this will threat the company and it would have to purchase its raw material in supplier’s terms. However, if there are many suppliers alternative, suppliers have low bargaining power and company do not have to face high switching cost. The potential factors that effects bargaining power of suppliers are the following:
  • Input differentiation
  • Impact of cost on differentiation
  • Strength of distribution centers
  • Input substitute’s availability.

STEP 7: Generating Alternatives For Positive And Negative Case Solution:

After completing the analyses of the company, its opportunities and threats, it is important to generate a solution of the problem and the alternatives a company can apply in order to solve its problems. To generate the alternative of problem, following things must to be kept in mind:

  • Realistic solution should be identified that can be operated in the company, with all its constraints and opportunities.
  • as the problem and its solution cannot occur at the same time, it should be described as mutually exclusive
  • it is not possible for a company to not to take any action, therefore, the alternative of doing nothing is not viable.
  • Student should provide more than one decent solution. Providing two undesirable alternatives to make the other one attractive is not acceptable.

Once the alternatives have been generated, student should evaluate the options and select the appropriate and viable solution for the company.

STEP 8: Selection Of Alternatives For Positive And Negative Case Solution:

It is very important to select the alternatives and then evaluate the best one as the company have limited choices and constraints. Therefore to select the best alternative, there are many factors that is needed to be kept in mind. The criteria’s on which business decisions are to be selected areas under:

  • Improve profitability
  • Increase sales, market shares, return on investments
  • Customer satisfaction
  • Brand image
  • Corporate mission, vision and strategy
  • Resources and capabilities

Alternatives should be measures that which alternative will perform better than other one and the valid reasons. In addition, alternatives should be related to the problem statements and issues described in the case study.

STEP 9: Evaluation Of Alternatives For Positive And Negative Case Solution:

If the selected alternative is fulfilling the above criteria, the decision should be taken straightforwardly. Best alternative should be selected must be the best when evaluating it on the decision criteria. Another method used to evaluate the alternatives are the list of pros and cons of each alternative and one who has more pros than cons and can be workable under organizational constraints.

STEP 10: Recommendations For Positive And Negative Case Study (Solution):

There should be only one recommendation to enhance the company’s operations and its growth or solving its problems. The decision that is being taken should be justified and viable for solving the problems.

IMAGES

  1. Positive and Negative Aspects of Case study 4

    case study positive and negative

  2. Positive and Negative Aspects of Case study 3

    case study positive and negative

  3. (PDF) Case study: positive outcomes from a negative

    case study positive and negative

  4. Positive and negative arguments derived from the case study data

    case study positive and negative

  5. 49 Free Case Study Templates ( + Case Study Format Examples + )

    case study positive and negative

  6. CASE STUDY.docx

    case study positive and negative

VIDEO

  1. BIBLE STUDY| POSITIVE EMOTIONS| GALATIANS 5:22

  2. positive negative aspects ex.4.1 lesson social media English book ii for x class

  3. Promoe

  4. Case study Meaning

  5. Case Study Part 3: Developing or Selecting the Case

  6. Positive Psychology Coaching

COMMENTS

  1. Positive and negative aspects of the COVID-19 pandemic among a diverse

    The COVID-19 pandemic had a profound social and economic impact across the United States due to the lockdowns and consequent changes to everyday activities in social spaces. The COVID-19's Unequal Racial Burden (CURB) survey was a nationally representative, online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Latino (English- and Spanish-speaking), Native ...

  2. Evaluating real-world COVID-19 vaccine effectiveness using a test

    An efficient method of evaluating vaccine effectiveness is the test-negative case-control study design (TND) [ 5-8 ], often used for studying influenza vaccines where clinical trials may not be ethical or feasible, and formal testing is not routinely conducted [ 9-12 ].

  3. Outcomes of the combined lifestyle intervention CooL during COVID-19: a

    Background The main objective of this nationwide study was to investigate changes in outcomes between baseline and eight months of participation regarding anthropometrics, control and support, physical activity, diet attentiveness, perceived fitness, sleep, and stress of participants in Coaching on Lifestyle (CooL), a Combined Lifestyle Intervention (CLI). Since the study took place when the ...

  4. Depressive symptoms and daily living dependence in older adults with

    A study suggested that declines in physical and mental health increase perceptions of stress among older patients . Perceived stress comprises positive and negative dimensions . Different types of perceived stress may be independently perceived as threatening or requiring adaptive adjustment [17, 19, 22,23,24].

  5. 18F-FAPI PET/CT performs better in evaluating mediastinal and hilar

    A typical case showing false-positive 18 F-FDG uptake and true-negative 18 F-FAPI uptake in mediastinal and hilar lymph nodes is shown in Fig. 4, and a representative case displaying intense 18 F-FAPI but negative 18 F-FDG uptake in small metastatic lymph nodes is shown in Fig. 5.

  6. Positive and adverse childhood experiences and mental health ...

    This study examines the association between adverse and positive childhood experiences to understand how they impact the mental health outcomes of children ages 6-17. Findings indicate that when ACEs are lower, the impact of PCEs are positive, but when ACEs are higher, PCEs do not make much difference in reports of mental health problems.

  7. Sample size for positive and negative predictive value in diagnostic

    We denote by the number of cases and controls, respectively, with positive test results. Then, the standard estimators of sensitivity and specificity are , respectively. Plugging these estimators into (1.1) and (1.2), for known prevalence, gives consistent estimators of the PPV and NPV:

  8. 12 Case Study Method Advantages and Disadvantages

    Jul 11, 2018 by Brandon Gaille A case study is an investigation into an individual circumstance. The investigation may be of a single person, business, event, or group. The investigation involves collecting in-depth data about the individual entity through the use of several collection methods.

  9. The case study approach

    Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole.

  10. Case study: positive outcomes from a negative

    Background As the work load for clinical genetics escalates and more genetic test are ordered, the potential for errors increase. This report present at the affected patient's request, the occurrence of an error and its subsequent management.

  11. Covid symptoms caused by JN.1 variant: What to know as cases rise

    Severe cases, meanwhile, are still characterized by shortness of breath, chest pain or pale, gray or blue skin, lips or nail beds — an indicator of a lack of oxygen. But on the whole, Covid ...

  12. Case Study Methodology of Qualitative Research: Key Attributes and

    1. Case study is a research strategy, and not just a method/technique/process of data collection. 2. A case study involves a detailed study of the concerned unit of analysis within its natural setting.

  13. The co-infection of pulmonary hydatid cyst, lophomoniasis and

    Due to the positive result of the patient's BAL and sputum culture samples, the diagnosis of co-infection of M. tuberculosis, E. granulosus, and lophomonas was confirmed.The patient was treated with metronidazole (500 mg thrice a day for two weeks), oral albendazole (400 mg twice daily for at least two weeks before the procedure and six months after surgery), and a combination of TB regimen ...

  14. Pros and Cons of case studies

    Pros and Cons of case studies admin March 27, 2020 Education 0 Comments Case studies are research methodologies that are used and analyzed in order to depict principles; they have been usually used in social sciences. They are research strategies and experiential inquiries that seek to examine various phenomena within a real-life context.

  15. What is Negative Case Analysis?

    Example of a negative case. Below is an example of a negative case to help you better understand this concept so you can identify a negative or deviant case when conducting research. Some researchers interviewed women in a small community on the benefits of a new water project in the community center. Most respondents were happy about the ...

  16. What Is a Case Study?

    Revised on November 20, 2023. A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research. A case study research design usually involves qualitative methods, but quantitative methods are ...

  17. What the Case Study Method Really Teaches

    What the Case Study Method Really Teaches. Summary. It's been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study ...

  18. Case Study: Definition, Examples, Types, and How to Write

    A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in various fields, including psychology, medicine, education, anthropology, political science, and social work.

  19. The value of oral selective estrogen receptor degraders in patients

    In the United States, approximately 60-70% of women with advanced breast cancer (aBC) are hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) [1,2,3].Resistance to treatment, acquisition of novel mutations, and altered gene expression are the major challenges in the management of aBC [4, 5].There are established guidelines for first-line treatment of ...

  20. Table 3 Positive and Negative Aspects of Case study 3

    Jan 2005 Robert James McClelland Nick Hawkins Perspectives on the Use of e-Books in Higher Education When Considering the Emphases on Development of e-Learning Materials by Academics and the...

  21. Globalisation

    Globalisation - CCEA Case study: ... This study guide looks at the reasons for globalisation and its positive and negative influences. Part of Geography Contrasts in world development.

  22. Case study: Mexico and the USA

    Causes and impacts relating to forced and voluntary migration Case study: ... Migration has positive and negative impacts on society. Part of Geography Population. Add to My Bitesize Remove from ...

  23. PDF Implementation of Watson's Theory of Human Caring: A Case Study

    This case study is an example of the value of a theory-based nursing practice that can enhance human health and healing in stressful life events, such as "the moment" when the patient in this case study realized her inability to have conceived a much desired child, even with promising ... Expression of positive and negative feelings

  24. Impact of Social Media Towards Society, A Case Study on Teenagers

    The positive impacts identified in this article are gaining knowledge, improving relationship, finding job, keeping in touch with the world, and enhancing social media as e-commerce. Whereas, the ...

  25. 132 Social Media Case Studies

    April 28, 2015 Susanna Gebauer (Last updated: 2021/07/09) Sharing is caring! In a recent comment to one of our blog posts, one of our readers wrote that „Social Media is Bullshit." Social Media would be good for brand and engagement and terrible for conversion.

  26. The Impact of Tourism on Rural Areas: A Case Study (Moeil Village in

    A CASE STUDY (MOEIL VILLAGE IN MESHGINSHAHR COUNTY) ... Those bring around both negative and positive sides of economic, socio-culture, and environment. This was quantitative research and ...

  27. Case Study Method

    List of the Advantages of the Case Study Method. 1. It requires an intensive study of a specific unit. Researchers must document verifiable data from direct observations when using the case study method. This work offers information about the input processes that go into the hypothesis under consideration.

  28. Positive And Negative Case Study Solution & Analysis

    STEP 1: Reading Up Harvard Case Study Method Guide: Case study method guide is provided to students which determine the aspects of problem needed to be considered while analyzing a case study. It is very important to have a thorough reading and understanding of guidelines provided.