Suleyman Demirel University Research and Education Hospital

INTRODUCTION: The EORTC 22922/10925 trial investigated the potential survival benefit and toxicity of elective irradiation of the internal mammary and medial supraclavicular (IM-MS) nodes Accrual completed in January 2004 and first results are expected in 2012. We present the toxicity reported until year 3 after treatment. PATIENTS AND METHODS: At each visit, toxicity was reported but severity was not graded routinely. Toxicity rates and performance status (PS) changes at three years were compared by chi(2) tests and logistic regression models in all the 3,866 of 4,004 patients eligible to the trial who received the allocated treatment. RESULTS: Only lung (fibrosis; dyspnoea; pneumonitis; any lung toxicities) (4.3% vs. 1.3%; p < 0.0001) but not cardiac toxicity (0.3% vs. 0.4%; p = 0.55) significantly increased with IM-MS treatment. No significant worsening of the PS was observed (p = 0.79), suggesting that treatment-related toxicity does not impair patient's daily activities. CONCLUSIONS: IM-MS irradiation seems well tolerated and does not significantly impair WHO PS at three years. A follow-up period of at least 10 years is needed to determine whether cardiac toxicity is increased after radiotherapy.

INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly described virus responsible for the outbreak of the coronavirus disease 2019 (Covid-19), named by the World Health Organization (WHO) in February/2020. Patients with Covid-19 have an incidence of acute respiratory distress syndrome (ARDS) of 15.9-29% and sepsis is observed in all deceased patients. Moreover, disseminated intravascular coagulation (DIC) is one of the major underlying causes of death among these patients. In patients with DIC, there is a decrease in fibrinogen and an increase in D-dimer levels. Some studies have shown that fibrinogen and one of its end products, D-dimer, might have a predictive value for mortality in patients with non-Covid sepsis secondary to complications of DIC. Therefore, anticoagulation, considering its mortality benefits in cases of non-Covid sepsis, may also have an important role in the treatment of Covid-19. METHODS We reviewed the literature of all studies published by April 2020 on patients infected with Covid-19. Our review was limited to D-dimer and fibrinogen changes and anticoagulation recommendations. RESULTS Anticoagulation therapy can be started following the DIC diagnosis in Covid-19 patients despite the bleeding risks. In addition, the current evidence suggests a routine use of anticoagulation, particularly in patients with higher D-dimer levels (> 3.0 μg/mL). CONCLUSION Covid-19 is a systemic, hypercoagulable disease requiring more studies concerning treatment. Aanticoagulation is still an issue to be studied, but D-dimer rise and disease severity are the indicative factors to start treatment as soon as possible.

OBJECTIVE: Approximately 30-45% of patients with familial Mediterranean fever (FMF) have been reported to have attacks despite colchicine treatment. Currently, data on the treatment of colchicine-unresponsive or colchicine-intolerant FMF patients are limited; the most promising alternatives seem to be anti-interleukin-1 (anti-IL-1) agents. Here we report our experience with the off-label use of anti-IL-1 agents in a large group of FMF patients. METHODS: In all, 21 centers from different geographical regions of Turkey were included in the current study. The medical records of all FMF patients who had used anti-IL-1 treatment for at least 6 months were reviewed. RESULTS: In total, 172 FMF patients (83 [48%] female, mean age 36.2 years [range 18-68]) were included in the analysis; mean age at symptom onset was 12.6 years (range 1-48), and the mean colchicine dose was 1.7 mg/day (range 0.5-4.0). Of these patients, 151 were treated with anakinra and 21 with canakinumab. Anti-IL-1 treatment was used because of colchicine-resistant disease in 84% and amyloidosis in 12% of subjects. During the mean 19.6 months of treatment (range 6-98), the yearly attack frequency was significantly reduced (from 16.8 to 2.4; P < 0.001), and 42.1% of colchicine-resistant FMF patients were attack free. Serum levels of C-reactive protein, erythrocyte sedimentation rate, and 24-hour urinary protein excretion (5,458.7 mg/24 hours before and 3,557.3 mg/24 hours after) were significantly reduced. CONCLUSION: Anti-IL-1 treatment is an effective alternative for controlling attacks and decreasing proteinuria in colchicine-resistant FMF patients.

AIMS: This study aims to analyse the novel Coronavirus disease- (COVID-19) related testicular pain in hospitalised patients because of COVID-19 and to review as an aetiological factor for epididymitis, orchitis or both. METHODS: A total of 91 patients were included in the study. A questionnaire was formed for the questioning of testicular pain or epididymo-orchitis in patients with COVID-19. Demographics and past medical history was also recorded. Patients' neutrophil and lymphocyte counts, neutrophil-lymphocyte ratios (NLR), C-reactive protein (CRP) levels and D-dimer values were recorded. Patients with COVID-19 were divided into two groups according to absence or presence of testicular pain or epididymo-orchitis as group 1 and group 2. All results were compared for both groups. RESULTS: The median age of patients was similar in both groups. Testicular pain was occurred in 10.98% of the patients. Clinical presentation of epididymo-orchitis was diagnosed in only one patient. No statistically significant difference was reported in terms of patients' age, levels of CRP and D-Dimer or NLR and results of questionnaire form queries between the two groups (P > .05). CONCLUSION: Testicular pain was observed more frequently in hospitalised COVID-19 cases. While no inflammation marker which is related to predict of testicular pain or epididymo-orchitis was found in patients with COVID-19.

OBJECTIVE: To evaluate the frequency and the specificity of nail changes associated with connective tissue diseases (CTD). METHODS: In a case-control study, 190 patients including those with systemic lupus erythematosus (SLE; 56), rheumatoid arthritis (RA, 47), primary Sjögren's syndrome (pSS; 35), systemic sclerosis (SSc; 39), and dermatomyositis/polymyositis (DM/PM; 13) were enrolled in the study. Patients with SLE and other CTDs were compared with two different control groups. Twenty nails were examined. Nail features were noted and classified. Nail samples were collected for mycological cultures. RESULTS: In patients with SLE, erythema of proximal nailfold (P<0.01), splinter haemorrhages in fingernails (P<0.01), capillary loops in proximal nailfold (P<0.05), periungual erythema (P<0.05), and thin nail plates (P<0.05) were more common than those in controls. Only splinter haemorrhages were associated with the disease activity. In patients with SSc and DM/PM, splinter haemorrhages (P<0.05) and capillary loops in proximal nailfold (P<0.01) in fingernails were common as well. Increase in longitudinal curvature (P<0.001), transverse curvature (P<0.01), and white dull colour in fingernails were other frequent findings in patients with SSc. Increase in transverse curvature was associated with the disease activity in SSc. In patients with RA, splinter haemorrhages (P<0.05), red lunula (P<0.05), and white dull colour (P<0.05) in fingernails were frequent. The sensitivity values of all these changes were very low. However, their specificity values were found to be relatively high. CONCLUSION: Proximal nailfold is the most important site of affection in CTDs. These nail changes can be used in combination with highly sensitive diagnostic modalities to establish an accurate diagnosis.

Abstract Pisidian Antioch was founded as a military base in the Hellenistic period around 300bc. A consecutive archaeological structure, extending 55 m long, mainly includes two adjacent abscissas and a wall remain thought to be a watchtower. An integrated geophysical survey including ground‐penetrating radar (GPR) and electrical resistivity tomography (ERT) techniques was conducted to determine the existence of counterparts of this structure in a small‐scale area. GPR scans acquired via zigzag mode using 500 MHz antenna along 45 parallel lines were evaluated by a series of basic data processing steps. Considering the results obtained, two‐dimensional (2D) ERT data collected in a restricted area using Wenner‐alpha array along 41 parallel lines were inverted using 2D and three‐dimensional (3D) tomographic inversion schemes. On the basis of the findings obtained from various GPR and ERT imaging techniques, the existence of one of the abscissa, displaying dimensional parameters being in good accordance with those of ones still standing on the west side of the survey area was clearly revealed. Moreover, some regular anomalies, which can be attributed to the remains of the watchtower in question and various wall ruins, were successfully traced from the GPR depth slices. The existence of an antisymmetric geometry for the consecutive archaeological structure under investigation was also determined in the survey area. Combining all of that information, a possible 3D virtual image of the military headquarters was then created, and this pointed out a small squarequadriburgiacharacteristic of the structure investigated. Thus, we can conclude that the integration of GPR and ERT and imaging techniques used in the evaluation were quite effective to provide useful prior information for the subterranean targets in the non‐excavated parts of the ancient city. An archaeological evaluation by trial trenching is therefore required to confirm the results of the archaeo‐geophysical survey in the investigation area.

RATIONALE AND OBJECTIVES: To evaluate the potential role of ultrasonography probes and coupling gel for cross-infection in patients undergoing ultrasonography; to describe a cost-effective method of probe handling; and to emphasize the importance of position of the probes in the boxes. METHODS: Cultures were taken from 43 probes used in different scanning regions. Cultures were also taken from probe boxes and coupling gel. RESULTS: After abdominal scanning, cleaning with paper seems to be effective, but even wiping with alcohol is insufficient for inguinal and axillar regions. Before scanning of these areas is started, cleaning the inguinal and axillar regions with alcohol reduces the contamination risk. Placing the probes downward in boxes also increases the risk of contamination. CONCLUSIONS: Wiping the probes with dry paper seems to be effective only for abdominal scanning; for inguinal and axillar scanning, cleaning the region with alcohol before scanning seems more appropriate. Placing the probes downward in boxes may also be a source of contamination.

INTRODUCTION: In the current literature, there has been an upsurge of cases of COVID-19-induced acute myocarditis. In this case-based review, we aimed to describe the clinical characteristics, imaging findings, and in-hospital course of acute myocarditis. In addition, the limitations of the myocarditis diagnosis were discussed since only fulminant myocarditis cases have been mentioned in the current literature. METHODS: We performed a review of the literature of all patients who were diagnosed with COVID-19-induced acute myocarditis using the databases of PubMed, Embase, and the Cochrane. RESULTS: 16 case reports were found to be related to COVID-19-induced acute myocarditis. We observed that the ECG findings in most of the COVID-19 patients were non-specific, including diffuse ST-segment elevation, non-specific intraventricular conduction delay, sinus tachycardia, and inverted T-waves in anterior leads. Echocardiographic findings of COVID-19-induced acute myocarditis patients ranged from preserved left ventricular ejection fraction (LVEF) without segmental abnormalities to reduced LVEF with global hypokinesia. Interestingly, a few patients with COVID-19-induced acute fulminant myocarditis were steroid-responsive and had an amelioration with glucocorticoid and immunoglobulin therapy. CONCLUSION: Despite the COVID-19 pandemic worldwide, a limited number of cases has been shared in the current literature. There are a lot of difficulties in the differential diagnosis of acute myocarditis in the context of COVID-19.

The authors describe three patients with delusional unipolar depression whose delusional thinking worsened markedly following administration of tricyclic antidepressant drugs. The patients had met Research Diagnostic Criteria for major depressive episode and had no evidence of schizophrenia or mania. Since tricyclic antidepressants are known to exacerbate psychosis in schizophrenic patients, it is sometimes suggested that the exacerbation of psychotic thinking in depressed patients indicates schizophrenia. The authors suggest that such an exacerbation does not in itself indicate schizophrenia but may occur in patients with an affective disorder who are prone to depressive delusions. The authors discuss the use of antipsychotic medication in this patient group and present a neurochemical hypothesis to explain the interaction of the drug with the illness, which results in exacerbation of psychotic thinking.

BACKGROUND: Persistent left superior vena cava is a rare but important congenital vascular anomaly. However, PLSVC with absent RSVC (isolated PLSVC) is a very rare venous malformation We report on a rare case of persistent left superior vena cava (PLSVC) with absent right superior vena cava (RSVC). CASE REPORT: This venous malformation was identified incidentally in a 69-year-old woman during chest multi-detector computed tomography (MDCT). On chest MDCT, the SVC was noted on the left side. A bridging vein drained the right jugular and right subclavian veins and joined the left brachiocephalic vein in order to form the PLSVC, which descended on the left side of the mediastinum and drained into the left atrium (LA). The patient had no additional cardiac anomaly. CONCLUSIONS: Isolated PLSVC is usually asymptomatic but it can pose difficulties for establishing central venous access, pacemaker implantation and cardiothoracic surgery. This condition is also associated with an increased incidence of congenital heart disease, arrhythmias and conduction disturbances. A wide spectrum of clinicians should be aware of this anomaly, its variations and possible complications.

AIM: To investigate the causes of the recurrent carpal tunnel syndrome (CTS) and implemented surgical interventions. METHODS: Four hundred and eighty-seven patients, who were diagnosed with CTS and underwent surgical intervention between October 2016 and September 2007, were evaluated in this retrospective study. The age, gender, physical evaluation findings, electrophysiological examination reports and implemented surgical treatment methods were analyzed. RESULTS: Thirty-nine of the cases were operated due to recurrent CTS. Further examination of the patients with recurrent CTS revealed that ten cases had diabetic polyneuropathy, three cases had hypothyroidism, two cases had rheumatoid arthritis and one case had systemic amyloidosis. Postoperative electromyography confirmed the neuropathy was due to systemic diseases. The remaining 23 patients with recurrent CTS did not have any systemic disease and all of them had applied previously to another health center. CONCLUSION: We concluded that the recurrence rates in CTS might be decreased with exploration and incision of the entire transverse ligament. Damage to the motor and sensory branches of the median nerve could be avoided with an incision on the ulnar side.

OBJECTIVE: There is increasing evidence for an association between non-alcoholic fatty liver disease (NAFLD) and an increased risk of cardiovascular morbidity and mortality. The aim of this study was to investigate the association between aspartate aminotransferase-to-platelet ratio index (APRI) and carotid intima-media thickness (IMT) in obese adolescents with NAFLD. METHODS: Seventy-six obese adolescents and 36 lean subjects were enrolled in this cross-sectional single-centre study. The obese subjects were divided into two subgroups based on the presence or absence of fatty liver with high transaminase levels (NAFLD group and non-NAFLD group). Fasting blood samples were assayed for transaminase, glucose, and insulin levels. Insulin resistance was calculated by the homeostasis model assessment (HOMA-IR). RESULTS: APRI values were higher in both obese groups (NAFLD and non-NAFLD) in comparison with the lean group. The NAFLD group had significantly higher APRI values than the non-NAFLD obese group and the lean group. Carotid IMT was higher in both obese groups (NAFLD and non-NAFLD) in comparison with the lean group. The NAFLD group had significantly higher measurements of carotid IMT than the non-NAFLD group and the lean group. APRI was positively correlated with most of the metabolic parameters (total cholesterol, low-density lipoprotein cholesterol, glucose, insulin, HOMA-IR) and with carotid IMT in the NAFLD obese group. CONCLUSIONS: This study demonstrated that a significant relationship exists between APRI and carotid IMT in obese adolescents with NAFLD. We suggest that an increased APRI score in obese adolescents with NAFLD can possibly serve to predict a more adverse cardiovascular risk profile.

AIM: This study aimed to investigate whether or not the toxic leadership behaviours of nurse managers influence nurses' perceptions of professional values. BACKGROUND: Professional values are among the factors that influence the development and the enhancement of the quality of health services. The professional development of nurses at work is particularly shaped by the guidance and counselling of nurse managers. Therefore, it is vitally important to determine the effects of nurse managers' toxic leadership behaviours on nurses' perception of professional values in terms of the development of professional values and the nursing image. METHOD AND MATERIAL: This study was designed as a descriptive and correlational study and was conducted with 244 nurses working in a university hospital between 09.01.2020 and 12.03.2020. The study data were collected using a Personal Information Form (11 questions) designed by the researchers in line with the recent literature, the Nurses Professional Values Scale-Revised (NPVS-R) and the Toxic Leadership Scale. The study data were analysed with SPSS 25.0, and they were evaluated using frequency, percentage, the Mann-Whitney U test and the Kruskal-Wallis H test, one-way ANOVA, the t-test for independent groups, the Cronbach alpha coefficient and Spearman correlation coefficient methods. The significance level was taken as p < 0.001, and p < 0.05 was used to interpret the study results. RESULTS: = 9.971, p < 0.001), whether or not they deliberately chose nursing as a profession (U:7.777, p < 0.05), whether or not they willingly served as a nurse (U:8.458, p < 0.001) and whether or not they willingly served in their current unit (U:8.475, p < 0.05). The total score and the subdimension scores of the Toxic Leadership Scale and NPVS-R Scale were not significantly correlated (p > 0.05). CONCLUSION: The results demonstrated that nurses who deliberately chose nursing as a career option, who willingly served as a nurse and who willingly served in their current units were comparatively less influenced by the managers with toxic leadership attitudes. It was similarly determined that nurses with higher levels of education and those who received in-service training were less influenced by toxic managers. It was finally noted that working with toxic managers had no significant effect on the nurses' perception of professional values. IMPLICATIONS FOR NURSING MANAGEMENT: The results indicated that although toxic leadership and nurses' perception of professional values were not significantly correlated, toxic behaviours may cause a depreciation in nurses' perception of professional values and beliefs, as noted in other relevant studies. It is thus necessary to be aware of the effects of toxic leadership behaviours on nurses and the institution and that precautions be taken by management against any negative effects. Supporting nurses with in-service training and building up resistance against toxic leadership behaviours will be beneficial for the proper and effective functioning of the institution.

Objectives. Frontal plane QRS-T angle is a novel marker of myocardial repolarization, and an increased frontal plane QRS-T angle is associated with adverse cardiac outcomes. Slow coronary flow may cause fatal cardiac arrhythmias by causing electrical abnormalities and altering ventricular repolarization. We aimed to evaluate the frontal plane QRS-T angle in patients with slow coronary flow. Design. A total of 60 consecutive patients with slow coronary flow and 60 consecutive patients with normal coronary flow were enrolled into the study. Laboratory and some electrocardiography parameters including frontal plane QRS-T angle were compared between the two groups. Results. We have found that the angle of frontal QRS-T was higher in the group with slow coronary flow (p < .001). In addition, there was a negative correlation between thrombolysis in myocardial infarction frame count and frontal QRS-T angle (r = −0.496, p < .001). Conclusions. In conclusion, increased frontal plane QRS-T angle might be an important indicator of slow coronary flow.

OBJECT: Epineural fibrosis may complicate peripheral nerve surgeries and currently is considered as one of the main factors responsible for failed surgeries. The authors investigated the postoperative antiscarring effects of topically applied doxorubicin (DXR) on rat sciatic nerves. METHODS: The sciatic nerves were dissected from the surrounding tissue and exposed bilaterally in 20 Wistar albino adult male rats. Abrasion trauma was produced on the exposed surface of the biceps femoris muscle in the vicinity of the sciatic nerves and their main branches in all animals. In the DXR Group, cottonoid pads soaked with DXR (0.5 mg/ml) were placed around the nerves for 5 minutes, whereas cotton pads soaked with saline (0.9% NaCl) were applied to nerves of animals in the Control Group for the same duration. Twelve weeks after the procedure, all of the rats were killed and the sciatic nerves were examined. Epineural adhesions were evaluated histopathologically and ultrastructurally. Additionally, quantitative histological parameters, the scar tissue formation index and the scar density, were calculated in histological evaluation. RESULTS: Gross postsurgical evaluation as well as histopathological and electron microscopic examination of involved nerve segments showed significantly less epineurial adhesions in the DXR Group than in the Control Group. Quantitative analysis of the epineurium revealed a statistically significant reduction in the density and amount of epineural scarring in specimens from the DXR Group than in those from the Control Group. CONCLUSIONS: The results of gross postsurgical anatomical evaluation and histopathological and ultrastructural studies suggested that topical application of DXR effectively reduced epineural scar formation on rat sciatic nerves. These promising findings merit further experimental and clinical studies to determine the efficacy and safe applicability of DXR in human subjects.

The radioelement concentrations of uranium (238U), thorium (232Th) and potassium (40K), as their radionuclides eU, eTh and K, of Cünür Hill in the city of Isparta (Turkey) and its surroundings were measured using gamma-ray spectrometry with a NaI(Tl) detector. The measurements were performed over an area of 2 km × 8 km around Cünür Hill, which forms part of the Isparta volcanic region that has a trachyandesitic composition, and which included the limestone outcrops east of Cünür. The results are mapped as combined radioelement concentrations. The radioelement concentrations of eU, eTh and K measured for Cünür Hill are high because of its trachyandesitic composition, while those measured in the limestone area were low, as would be expected.

AIM: To observe the protective effect of astaxanthin (AST) against hydroquinone (HQ) mediated cell death in the apoptotic cascade and evaluate intracellular Ca2+ release, caspase-3, and -9 activation, reactive oxygen species (ROS) production in ARPE-19 cells. METHODS: We cultured ARPE-19 cells in special mediums and performed MTT tests to determine protective effect of AST, before exposing the cells to HQ in an incubator. We analyzed intracellular Ca2+ release experiments, mitochondrial membrane depolarization, glutathione (GSH), glutathione peroxidase (GSH-Px) and ROS experiments, and apoptosis assay. RESULTS: ROS production ranges depend on the amount of cell death. We computed the correlation between ROS ranges and cell death by 20,70-dichlorofluorescein fluorescence, and Ca2+ levels by Fura-2-AM. HQ-induced cell death found out to rise ranges of caspase-3 and -9, and mitochondrial depolarization. These three steps were delayed by AST management. CONCLUSION: ARPE-19 cells are avoided from HQ-induced ROS production and caspase-3 and -9 activation by AST. AST may limit the range of caspase synthesis, Ca2+ release and excess production of ROS with antiapoptotic effect. This study proposes a new therapeutic approach for the treatment of age-related macular degeneration.

Background Immunosuppressive therapy has been a great concern during the pandemic. This study aimed to evaluate the pandemic's impact on psoriasis patients treated with immunosuppressive drugs.Material and Methods The multicenter study was conducted in 14 tertiary dermatology centers. Demographic data, treatment status, disease course, and cases of COVID-19 were evaluated in patients with psoriasis using the immunosuppressive treatment.Results Of 1827 patients included, the drug adherence rate was 68.2%. Those receiving anti-interleukin (anti-IL) drugs were more likely to continue treatment than patients receiving conventional drugs (OR = 1.50, 95% CI, 1.181–1.895, p = .001). Disease worsening rate was 24.2% and drug dose reduction increased this rate 3.26 and drug withdrawal 8.71 times. Receiving anti-TNF or anti-IL drugs was associated with less disease worsening compared to conventional drugs (p = .038, p = .032; respectively). Drug withdrawal causes were ‘unable to come’ (39.6%), ‘COVID concern’ (25.3%), and ‘physician’s and patient’s co-decision’ (17.4%). Four patients had COVID-19 infection with mild symptoms. The incidence was 0.0022% while it was 0.0025% in the general population.Conclusion Our study shows that psoriasis patients using systemic immunosuppressive do not have a higher, but even lower COVID-19 risk than the general population, and treatment compliance with biological drugs is higher.

AIM: To investigate the effects of gallbladder stones on motor functions of the gallbladder and the dynamics of bile flow in asymptomatic gallstone disease. METHODS: Quantitative hepatobiliary scintigraphy was performed to detect the parameters of gallbladder motor function [gallbladder ejection fraction (GBEF), gallbladder visualization time (GBVT), gallbladder time to peak activity (GBT(max)), gallbladder half emptying time (GBT(1/2)), and transit time of bile to duodenum (TTBD)] in 24 patients with asymptomatic cholelithiasis who were diagnosed incidentally during routine abdominal ultrasonographic examination and 20 healthy subjects with normal gallbladder. RESULTS: Even though there was no significant difference in the clinical and laboratory parameters between the patient and control groups, all parameters of gallbladder function except TTBD were found to differ significantly between the two groups. GBEF in the patient group was decreased (P = 0.000) and GBVT, GBT(max), GBT(1/2) in the patient group were longer (P = 0.000, P = 0.015, P = 0.001, respectively). CONCLUSION: Our results showed that even if there were not any clinical and laboratory findings, gallbladder filling and emptying could be impaired in patients with gallstone disease.

Introduction: This study aims to discuss cultural intelligence levels and intercultural communication apprehension of nurses. Method: This study was designed as a descriptive and cross-sectional study, and it was conducted with 252 nurses working in a hospital in a south city of Turkey. The research data were collected via a “Personal Information Form” designed by the researchers, “The Cultural Intelligence Scale,” and “The Intercultural Communication Apprehension Scale.” Results: It was concluded that nurses had moderate levels of cultural intelligence and intercultural communication apprehension, which were positively correlated ( p < .001). Cultural intelligence levels and intercultural communication apprehension were further correlated with certain variables such as age, gender, job duration, foreign language proficiency, and their experiences in foreign countries ( p < .05). Discussion: In light of the results, it was suggested that moderate levels of intercultural communication apprehension can be a supportive factor in developing cultural intelligence. It was also added that preventing excessive intercultural communication apprehension and supporting nurses to improve language skills and to have abroad experience may be beneficial in developing cultural intelligence.