Developing a “Soo Ul Qinya/Pre Dropsy” Diagnostic Tool (SUQDT) in Traditional Persian Medicine Researches by Weighting and Scoring Disease Signs: A Methodological Review Study

Mojdeh Pourhosseini¹, Hossein Moradi¹, Fatemeh Nojavan¹ and Abolfazl Mohammadbeigi^2*
*Correspondence: Abolfazl Mohammadbeigi, Department of Epidemiology, Qom University of Medical Sciences, Qom, Iran, Email:

Keywords

Anemia • Edema • Diagnostic test • Dropsy • Traditional medicine

Introduction

Searching among hundreds of books and subjects which have been written about traditional Persian medicine is difficult thing to do but the most difficult and professional to do is reaching to an equal and stabilized conclusions. Finding the truth among the experts's opinions whose criticized each other's viewpoints during the years, approved some and disapproved others, is a precise thing to do because all of them are respected and there is no comparison between their specialty and intelligence, although some of them are more well-known than the others for some reasons [1].

Meanwhile traditional Persian medicine’s researchers are facing with a challenge that make reaching to the bottom of the truth so difficult for each matter. How to reach to single conclusion among this many theories? This ambiguity about the true value of the causes or symptoms of the disease or definitions of diseases is posing and sometimes the passage of time and the change in the physical condition of patients or the difference between the climate and the geographical area of each author affects the context of the discussion of the disease and adds to this ambiguity in decision making. To strengthen the findings of each research we need to come up with reliable and well-defined weighting and scoring methods that to find the correct position of each cause in the development of disease and any sign in the diagnosis of a disease, away from individual perceptions and individual errors.

Soo ul qinya is a mutation in liver function and appearing weakness in it as liver could not doing its normal function and not producing good and desirable materials for feeding the body and organs are unable to absorb it. In traditional Persian medicine’s valid resources, soo ul qinya/pre dropsy is one of the liver diseases that also named as pre-dropsy. In addition to importance of diagnosing this as one of the silent and progressive diseases, illustration of soo ul qinya as preface of another disease named “Istisqa”, is so important. The search for articles published in journals and databases suggests that the word soo ul qinya, which is one of the major diseases in traditional Persian medicine, is equivalent to the anemia. Yet there is no precise method for diagnosis that and this shows the importance of finding an efficient tool. Therefore, this study aimed to develop a “Soo Ul Qinya/Pre Dropsy” Disease Diagnostic Tool (SUQDT) by defining the weight and score of each criterion (sign) in traditional Persian medicine researches based on a systematic review [2].

Materials and Methods

This review study was conducted to develop a diagnostic tool for “soo ul qinya” disease at 2018. First, 906 books and research projects among credible texts of traditional medicine that have been registered on Noor Islamic software was checked exactly. This software is contained of 80% of original references of traditional Persian medicine.

"Noor", the Islamic science research center that established at Qom on 1989 AHS is analyzing different branches of Islamic sciences with the modern facilities. The librarian software is one of the important offline products of Islamic research center that empower the users to searching in librarian references by using of multilingual terminals and determining different domains. The Islamic and traditional medicine librarian software contains the most important and valuable books in traditional medicine that have been published since now. The time, language and geography frame of references and information presented in this software is not limited to specific time, language and geography [3].

Comprehensive medicine library in traditional medicine is a software that contains creditable medical references that is written by master Islamic medicos mostly. This library containing medicine books (picture of manuscripts or typed kind), 906 book and articles in 1200 objects and details.

First, the title of all books and their contents was reviewed and also the article titles was checked. Then, the related books with article's object was read and note-taken manually and checked with initial texts again. Moreover, "soo ul qinya" and "su ul qinya" and "pre dropsy" and "Sual Al Qaniyyah "and "Pre-Istisqa "keywords was used for strategic searches in international scientific databases include PubMed, Scopus and Since Direct, web of sciences. In addition, these keywords were used in searching Iranian article in Iranian databases such as Scientific Information Database (SID), Iranmedex and Irandoc. Due to our studying object is one of the hepatic diseases, by the studying all of the traditional medicine books and articles in Noor comprehensive Islamic medicine software, the pathology books and articles were selected and rest of books were eliminated. As all of the therapy books proceed hepatic diseases as section of the most important body diseases, these books were assessed critically. In this step, collect of information about "soo ul qinya" disease began specifically. After that, taking note is begun to study more precise with "soo ul qinya" keyword in therapy and pathology books of first to 14th AH century [4].

All of the related books and articles was choose and the contents of books and the abstract of all related articles were checked critically. At first the complete text of "soo ul qinya" disease section was studied in all selected books and then the relations between books and this article's object is checked precisely. Then all of these points were checked with another researcher and the duplications and citations from the original references was exclude. The critical appraisal of books and articles were checked with two main researchers of research team by stretchered checklist. Finally, all of the verified points and up to main researcher opinion were used. Exclusion criteria in this study, were including that the object of book is not related to pathology or is not proceeded to "soo ul qinya" disease. Moreover, since this disease is not have been known before 610 A.D, all of the books out of this time frame is eliminated. Inclusion criteria were pathology books from first to 14^th A.H century or the 7^th to 19^th A.D century with "soo ul qinya" object. In addition, all related articles were searched to last day of March 2018.

After search, critical appraisal and analyzing the quality of related books and articles, only 15 reference books that proceeding of introduce and describe this disease completely and independently, were chosen [5]. These 15 books were included in analysis and deliberated more precisely. All of disease signs specified separately and an importance value was used for each signs based on the way of describing the signs. The included books used some words such as (necessary) or (it is necessary), (as may be seen), (can be present), (sometimes seen), (much to be seen), or (essential), (maybe), (could be),(sometimes), (often) or not using of this limitative words in describing the disease signs. Each sign of disease was recorded in each of foresaid 15 books. Then considering the difference in the value of these expressions, they classify in two groups: "Absolute signs" and "probable signs". Since the mentioned items were considered as absolute signs have higher qualitative value, those signs were weighed twice as likely as probable signs, conventionally.

Weighting and scoring of signs

After extraction of necessary data from qualified books, study findings were presented in 3 different tables. First, the "soo ul qinya" disease signs in traditional persian medicine books was ordered essentially. Overall, 29 extracted signs for "soo ul qinya" disease from the selected books were recorded based on the presence or absence of each sign in each book and the necessity or probability of sign was recorded. The name of selected books and disease signs were tabulated in a table. The existence of an absolute sign in a book shows by (+) and probable sign by (#). In another table, the number of absolute signs and probable ones of "soo ul qinya" disease were presented according to included books [6]. The number of absolute signs and probable signs arranged in columns and signs' names in rows to reaching general statistics of each sign and then "soo ul qinya" disease signs are classified by the group importance. Then the weighting to the "soo ul qinya" disease signs conducted based on the repetition of each signs in studied books and the type of signs. This weighting method is the "inverse of variance weighting" that using in meta-analysis and used in another study. Finally, a score weighting tool was created as a SUQDT. The absolute signs taken twice score more than the probable ones. The number of repetition was multiplied at the sum of signs scores.

Results

Among dozens of subjects that existed in traditional Persian medicine’s book about description, diagnosis and treatment of disease, 15 title had independently and detailed introduction of "soo ul qinya" disease. Among these 15 title, 29 different disease’s signs have been pointed. Number and kind of designation is different in each one of these books. According to the natural history of "soo ul qinya", as it mentioned in Traditional Persian medicine’s books, this disease has two group of signs that are categorized in "essential or absolute signs" and "unessential or probable signs". These two groups of signs separated and were described separately [7].

Absolute signs and probable signs

Table 1 showed the list of essential and unessential signs for this disease based on a precise and detailed studying of included books in review. Those books specifying each disease sign to either essential (absolute) or unessential (probable) as brought in Table 1. The frequency and repetition of each signs based on absolute or probable is presented in Figure 1.

Absolute signs: According to this graph and Table 1, some of the signs such as: "White or pallor of face and body ", "eyelids, face, legs and hands edema" and "borborygmus (abdominal noise) and gas" are described as essential and important signs in most of the books and existing them seems to be so necessary for diagnosis the disease. However, the (borborygmus) sign despite its importance, might delayed or not be seen at all in some cases according to the kind and pathology of "soo ul qinya". So we named that as interstitial sign [8].

An exception in absolute signs: Although the indigestion sign is mentioned as main sign in more than half of the books and sometimes even called “necessary”, but the meaning for digestion could be one of the quadruple digests (according to the theory of traditional Persian medicine), whereas the main point for soo ul qinya’s sign is at second and third digestion and not necessarily the first digestion. First digestion has a role in the stomach’s problems and digestion disorders. So the indigestion is one of the probable signs.

Probable signs

The probable signs were categorized as two groups. First were those signs which are more important and second were those are less important.

First group-more important probable signs: Gastric digestion disorder, heavy feeling or fatigue, defecation disturbance (fluctuation between diarrhea and constipation), rash in gum, all body swelling (edema) and wound healing delay were in second superiority at the studied books and there wasn’t a solidarity on their absolute occurrence and just mentioned to these signs in 5-6 books in all 15 books. These signs often indicate the progression of the disease and its lack of traceability is not a maladaptive diagnosis of soo ul qinya [9].

Second group-less important probable signs: Decrease volume of urine, perspiration decrease, increased appetite, sleep disturbances, weakness of the legs, leg ulcer, gingival irritation, gingival itching, sore of lips, thirst, slow body movements, abdominal wall edema, testicles edema, anorexia, urine colorless and dilution of urine were signs that listed in 5 or fewer than 5 books in studied books and the last rank of importance.

The scoring and weighting method: Table 1 specifies the number of repetitions of each sign in studied books as absolute or probable sign. Based on Table 1 data, a number of signs, such as total body edema and increased appetite, have lower diagnostic value and defined as probable signs. Moreover, some signs such as sleep disturbances or testicular edema are the last group of signs and take the least diagnostic importance and often introduced as probable signs. However, a few books have referred to their contributing role in the "soo ul qinya". The review of searched articles related to the topic yielded no usable information and all articles excluded [10].

Table 1. Separation of absolute sign and probable sign in soo ul qinya based on reference books and ranking based on group importance.

As mentioned earlier, some of the signs have been referred to in traditional Persian medicine sources as absolute and necessary and some as unnecessary and probable. Also, some of the signs are mentioned more frequently in more books as compared to other ones. Some of the signs are listed in all books as the main and essential sign, while others have been referred to using different titles in different books.

Together, these findings will measure and determine the weight of each of the signs in the diagnostic tool. In order to weigh the second and third groups, it is necessary first to decide on the difference in weight of the listed items using necessary or probable classifications.

The inverse-variance method was used as the weighting method according the weighting principle used in review and meta-analysis studies [11]. In other words, the higher in the sample size, the lower the variance will be and therefore the study will earn a greater weight. Therefore, considering the repetitions of a factor in specialized books, the weight of each sign is determined as an absolute or probable sign. Since the items mentioned above have a higher qualitative value as a sign, their weight is two times more than that of the probable ones. For example, if the increased appetite sign is referred to as absolute in 2 books and probable in 3 books, its weight will be calculated using the following formula: (2 × 2)+3=7.

Table 1 shows three groups of signs with that each group and each sign having different weights for "soo ul qinya" and Table 2 also the weight of each sign. Now, the analysis of these two tables will yield new results.

Table 2. The weighting of each soo ul qinya's signs based on developed tool.

In order to determine the weight of each sign in the first group, the same general rule is used and given that all the signs of this group are definite, they are all weighted by the coefficient 2 of the number mentioned in the books. Based on the above information, Table 2 presents the final weighting for each signs of "soo ul qinya" as a standard scoring system for disease.

Finally, based on the number of repetitions of each signs (Table 1) and the sign weight, the final score of each sign will be yielded [12].

Discussion

The current study developed a diagnostic tool for "soo ul qinya" disease for approaching the definitions, causes and signs signs of diseases based on traditional Persian medicine’s books. Therefore, we can find a way to organizing the mass of information in other traditional Persian medicine s researches and reach to a valuable conclusive scientific result.

Based on our results, there were 7 signs in the first group (absolute sign group) that can be subdivided into three groups: Edema of feet, hands, face and eyelids. The second subdivision includes a white or yellow discoloration (pallor) with two subgroups of face and body. The last subdivision of this group is the borborygmus sign that have interstitial importance and means is equal to an absolute sign, but may be absent. To diagnose "soo ul qinya", the first two signs, edema and pallor, are mandatory and if the person does not have one or both of these signs, the person will have excluded from the patient group. The poor digestion is very significant in the second group (unnecessary but important sign group), according to the previous description and the importance of other signs is as follows, respectively: Gastric digestion disorder, heavy feeling or fatigue, defecation disturbance (fluctuation between diarrhea and constipation), all body swelling (edema), wound healing delay and rash in gum.

The second group of signs are considered as probable signs because they have been referred to in lower than half of the books or have been officially referred to as an unnecessary sign. However, as presented in Table 1, some of the books have referred to some of these signs as absolute and others as probable and there is a sequence for these signs depending on the total number of books and the definite numbers.

The third group (unnecessary and low importance sign group) is considered as a probable sign, but they have been only referred 5 times or fewer. Some of books considered them important and some have only referred to their probability of occurrence. These signs are also mentioned according to their level of significance as follows: Decrease volume of urine, perspiration decrease, increased appetite, gingival itching, abdominal wall edema, sleep disturbances, testicles edema, gingival irritation, sore of lips, anorexia, thirst, slow body movements, weakness of the legs, urine colorless, dilution of urine and leg ulcer.

The final result of combining Tables 1 and 2 and considering the weight of each sign is to provide SUQDT for detection of patients with "soo ul qinya". A traditional medicine specialist examined any person who referred and was suspected of "soo ul qinya" using SUQDT. If the person has at least one of signs mentioned for each subgroup of the first group (absolute signs), (s) he will be subjected to questions regarding the second and third groups, and if the person could not obtain the minimum score from the first group, (s) he will be excluded from the review. For example, if a person had a sign of feet edema and pallor of face, even if the face was not swollen or the whole body showed no discoloration, (s) he will still be diagnosed with "soo ul qinya" and the person will be excluded from the study in case of no edema or pallor. In other words, if the person does not have one or both of above factor in the first group, edema and pallor at the same time, the person will be excluded from the patient group.

This person will get a score based on Table 2 after entering the group of patients with "soo ul qinya" as well as passing the stage of essential signs with or without each sign of the second and third group, or the interstitial sign. The final sum of the scores earned by each person will indicate the disease severity, with the higher scores indicating the higher severity rate.

However, we reach to a new innovational method, by gathering our findings and consulting among some of the traditional persian medicine ’s book that had been written about the matter named “soo ul qinya”, that can be a solution to understanding different disease’s signs that has been considered in traditional Persian medicine. The present research also takes into account the timing of the source books in order to review the changes in authors’ opinions on the probable or absolute signs of the disease over time. It seems that the opinions of authors of these books on the absolute and necessary signs of diagnosis "soo ul qinya" have not been changed significantly over the past ten centuries and have emphasized the opinions of the previous researchers; however, there was an increase or decrease in type and frequency of probable and unnecessary signs depending on time and place conditions.

Now, by developing the current tool, "soo ul qinya" diagnosis can be conduct by recognizing its signs and distinguishing the most absolute signs among the various signs that presented in different books over time and weighting them as to reveal their diagnostic value in case of their presence or absence. Based on our search, a few new studies find on "soo ul qinya" that were reported a reliable diagnostic indicator for this disease and according to an unproven hypothesis, this condition is considered as anemia and recognized by anemia diagnostic indexes.

The existence of a diagnostic tool for this disease will lead to more reliable and methodological researches in this regard. However, our main objective in this study was to prepare a solid framework to help the physician's especially traditional medicine specialist in identify and diagnose of "soo ul qinya" as well as its relevant signs to determine frequency and severity of the disease.

It is recommended to carry out specialized groupings to include wider range of scores defined as in weak, moderate, severe or curable, hard-to-cure and incurable groups in the next studies. It is also necessary to examine the psychometric properties of current tool to finalize a more standard tool.

Conclusion

Our review showed that the "soo ul qinya" disease is not a well-defined and known disease and there was not a clear and precise method for diagnosis it. Moreover, there are very contradiction among different reference traditional Persian medicine books about "soo ul qinya". However, a diagnostic tool named SUQDT was developed based on weighting and scoring of different signs of disease among traditional Persian medicine books and a prepared for traditional medicine specialist. Future studies suggested for assessing the psychometric properties of SUQDT.

Contribution of Authors

Mojdeh Pourhosseini: Substantial contributions to the design of the work; or the acquisition, and drafting the work, revising it critically for important intellectual content; and final approval of the version to be published. Hossein Moradi: Substantial contributions to the conception or design of the work; or the acquisition, analysis, interpretation of data for the work and drafting the work or revising it critically for important intellectual content; and final approval of the version to be published. Fatemeh Nojavan: Substantial contributions to the interpretation of data for the work and drafting the work and final approval of the version to be published. Abolfazl Mohammadbeigi: Substantial contributions to the design of the work; analysis, interpretation of data for the work; and drafting the work or revising it critically for important intellectual content; and final approval of the version to be published.

Conflict of Interest

None.

Source of Funding

Qom university of medical sciences.

Acknowledgement

The authors are very grateful for Qom university of medical sciences for supporting this work. This is a part of PhD thesis of Mojdeh Pourhosseini in Iranian medicine major at Qom university of medical sciences. The ethical committee of Qom university of medical sciences approved this project with IR.MUQ.REC.1397.30 code.

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