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Sexually Transmitted Diseases:
doi: 10.1097/OLQ.0b013e3181c0d51f
Original Study

Gastric Syphilis: A Systematic Review of Published Cases of the Last 50 Years

Mylona, Eleni E. MD*; Baraboutis, Ioannis G. MD†; Papastamopoulos, Vasilios MD*†; Tsagalou, Eleftheria P. MD‡; Vryonis, Evangelos MD†; Samarkos, Michael MD*†; Fanourgiakis, Panagiotis MD*†; Skoutelis, Athanasios MD, PHD*†

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From the *Fifth Department of Internal Medicine, and †Division of Infectious Diseases, Evangelismos General Hospital, Athens, Greece; and ‡Department of Clinical Therapeutics, Alexandra University Hospital, Athens, Greece

Correspondence: Eleni E. Mylona, MD, 5th Department of Internal Medicine, Evangelismos Hospital, 45–47 Hipsilantou St, Kolonaki, GR-106 76 Athens, Greece. E-mail: emylon@med.uoa.gr.

Received for publication April 29, 2009, and accepted September 2, 2009.

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Abstract

The authors conducted a systematic review of the English literature for cases of Gastric Syphilis (GS) in the last 50 years. The 34 studies which met selection criteria included 52 patients with GS. Of the reviewed patients, only 13% had a history of syphilis diagnosis and 46% had prior or concurrent clinical manifestations of the disease. Epigastric pain/fullness was the most common presenting symptom (92%) and epigastric tenderness being the most common sign. Gastric bleeding of variable intensity was documented in 35% of the cases. In the radiologic examinations, fibrotic narrowing and rigidity of the gastric wall was the most common finding (43%), followed by hypertrophic and irregular folds, while in endoscopy the most common lesion types were multiple ulcerations (48%), nodular mucosa, and erosions. The antrum was the most commonly affected area (56%). The majority of the patients received penicillin (83%) with a rapid resolution of their symptoms. Seventeen percent of the patients were treated surgically either due to a complication or due to strong suspicion of infiltrating tumor or lymphoma. The nonspecific clinical, radiologic, and pathologic characteristics of GS can establish it as a great imitator of other gastric diseases. GS should be considered in the differential diagnosis in patients at risk for sexually transmitted diseases who present with abdominal complaints and unusual endoscopic lesions and no other diagnosis is made, irrespective of the presence of H. pylori. The absence of primary or secondary luetic lesions should not deter one from considering GS.

Syphilis has been clearly described since the 15th century, as it has sexual mode of transmission. In the early 20th century, syphilis was a leading cause of neurologic and cardiovascular disease and a major public health concern. Soon after, the introduction of penicillin along with organized public health measures in areas like the United States led to a decline in syphilis rates. Those low rates persisted from the mid-1950s to the early 1980s, when the disease became more common again and was linked epidemiologically with human immunodeficiency virus (HIV) infection.1

To guide therapeutic decisions and disease-intervention activities, syphilis is divided into a series of clinical stages. Clinical staging, despite its usefulness, is imprecise since many patients with late stages of disease may have no recollection of earlier stage manifestations, either because the lesions are painless or are clinically inapparent. In addition, there is considerable overlap between stages.1

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Historical Data

Gastric involvement in syphilis is well documented. Morton refers that the first 2 cases of (supposed) gastric syphilis (GS) were reported in 1834 by Andral.2 Early studies of the 20th century, based on clinical, serologic, and radiologic evidence, reported a high incidence of syphilitic gastritis.3,4 Graham reported the first histologically proven case in which tissues had been removed surgically.5 Later on, autopsy statistics revealed a low incidence of the disease6,7 emphasizing the significance of histologic proof of the diagnosis. Moreover, even though GS initially had been viewed by the authors as a complication of tertiary syphilis,8,9 subsequent reports indicated that the stomach was commonly affected in early syphilis.3,10

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Methods

Literature Search

Our goal was to review clinical, laboratory, and therapeutic data in patients with documented GS in the last 50 years. For that purpose, we searched the English medical literature from 1957 until 2007. In our Medline search, we used the keywords “syphilitic gastritis,” “syphilitic gastropathy,” “gastric syphilis,” and “syphilis of the stomach.” The results were limited to human studies published in the English language. Manual searches of reference lists from relevant papers and book chapters were also performed to identify any additional studies that may have been missed using the computer-assisted method. The literature search yielded 148 scientific articles. After detailed review, 49 items were identified as potentially relevant. We were finally able to recover 52 cases of GS from a total of 34 articles from that time period.11–44

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Study Selection Criteria

Two investigators independently reviewed the titles and abstracts of all citations identified by the literature search and evaluated them for eligibility for our analysis. We included all studies where the diagnosis was documented by any combination of compatible serology, pathologic findings, imaging studies, and Treponema pallidum detection. Studies without histologic and serologic tests were not included.

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Data Extraction

Two reviewers extracted the data independently. Any disagreement was resolved by consensus. The reviewers extracted the following data from each study: Demographic, clinical, and serological characteristics of patients (age, gender, race, previous history, or clinical characteristics of syphilis such as genital ulcer, rash, or lymphadenopathy, syphilis stage at diagnosis, serologic tests [nontreponemal tests-Venereal Diseases Research Laboratory-VDRL or Rapid Plasma Reagin-RPR or Kolmer test and specific treponemal tests- fluorescent treponemal antibody absorption {FTA-abs} and/or agglutination assays for Treponema pallidum{TPHA and MHA-TP}], central nervous system [CNS] involvement, and HIV positivity), clinical characteristics of gastric involvement, radiologic and endoscopic findings, histologic findings, and T. pallidum detection, therapy, and outcome. For categorical variables, we calculated their incidence, taking into account the number of subjects involved. For continuous variables, we calculated means, medians, and range.

With regard to the syphilis staging we considered it as follows:

* Concurrent manifestations of primary only: primary.

* Concurrent manifestations of secondary (±primary): secondary.

* Documented duration of syphilis infection (by serology) of less than 1 year with or without prior manifestations of secondary and/or primary: early latent.

* Documented duration of syphilis infection (by serology) of more than 1 year with or without prior manifestations of secondary and/or primary or unknown duration of infection in asymptomatic patient, with normal physical examination, cerebrospinal findings, and a chest radiograph: late latent (LL).

* Concurrent manifestations of tertiary syphilis: tertiary.

For descriptive reasons, we collectively named primary, secondary, and early latent stages “early disease,” whereas late latent and tertiary stages were named “late disease.” The term “luetic” was used interchangeably with the term “syphilitic” in the text.

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RESULTS

Demographic Characteristics

Median age of the patients was 39 years (range, 21–78 years). A total of 63% of all GS occurred in males and 61% of the affected patients were of the black race (Table 1). There was minimal information on details of high-risk sexual contacts and behaviors possibly related to syphilis acquisition in the reviewed cases.

Table 1
Table 1
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Clinical and Serological Characteristics of Syphilis in the Affected Patients

Of the affected patients, only 13% had a history of syphilis diagnosis11,18,30,32,41,42 and 46% had prior (13%) or concurrent (33%) clinical manifestations of the disease. Of the concurrent clinical manifestations, genital ulcer was found in 35%, rash in 65%, and lymphadenopathy in 53% of the cases (Table 1). In some cases (5/17) more than one clinical characteristic could be detected (2 with genital ulcer and rash and 3 with rash and lymphadenopathy). In the congenital case, especially, several signs such as saddle nose, absent nasal septum, deformed palate, interstitial keratitis, and complete neurosensory hearing loss were present.18 Syphilis stage at diagnosis is shown in Table 1. As already explained in the methods' section, we also categorized cases as early and late disease for simplicity reasons. Concurrent CNS involvement was reported in 11.5% of the cases.15,17,23,28,41,42 Serology data were available for all cases reviewed except one.33 In all those cases, nontreponemal tests (VDRL, RPR) and/or Kolmer) were positive. Treponemal tests were reported to be positive (FTA-abs or MHA-TP/TPHA) in 35 of the 52 cases reviewed. No information on specific syphilis tests was available for 17 cases (33%). There were 29 cases with positive FTA-abs15–20,23–25,29–32,34–37,39,44 and 11 cases with positive MHA-TP/TPHA.20,23–27,37,38,42,43 Only 2 of the cases involved HIV-positive patients,30,41 while a comment on HIV status was found in 13 articles (corresponding to a total of 22 patients).

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Clinical Presentation of Gastric Involvement

Epigastric or abdominal pain/fullness was by far the most common presenting symptom (92%), followed by vomiting, weight loss, and early satiety (Table 2). Interestingly, weight loss was prominent in several cases, namely in 65% of early disease and in 53% of late disease cases. Anorexia was reported in the 15% of the cases, more frequently in late disease (25% vs. 10% in early disease). The single congenital case presented with epigastric pain/fullness, vomiting, and significant weight loss.18 Epigastric pain was alleviated by food in 2 cases11 and by antiulcer regimens in 4 cases.12,14,17,22 No improvement with food or antacids was clearly reported in 2 other cases,24,27 while no data were given for the remaining 44 cases (data not shown). Clinical examination revealed epigastric tenderness in 52% of the cases (most common sign) with equal percentages in early and late disease, while hepatomegaly was rarely found23,31 (Table 2). Diffuse adenopathy was present in 9 of 52 (17%) cases, a rash compatible with secondary syphilis was present in 11 of 52 (21%), while in no more than 12% (6/52) of patients a concomitant chancre was found (Table 1). The complication of gastric bleeding, in the forms of hematemesis, coffee-ground emesis, or melena, was documented in 14%,18%, and 16%, respectively (Table 2). Heme was detected in the stool of 35% of the patients for whom there was available data (33% suffering from early and 40% of late disease) and anemia was found in 20% (14% early and 31% late disease) (Table 2). Physical examination revealed no epigastric tenderness in the congenital case, while stool was positive for occult blood and a microcytic anemia was present.18 The mean duration of symptoms was reported in 42 cases and ranged from 1 week to 48 months (Table 2). There were no statistically significant differences in any presenting symptom or sign between early and late disease (analysis not shown).

Table 2
Table 2
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Radiologic and Endoscopic Findings

Of the 52 patients reviewed, 27 were subjected to radiologic (16 with early and 11 with late disease, 24 with no individual data available) and 49 to endoscopic examination (25 with early and 17 with late disease, 6 with no individual data available) (Table 3). The congenital case was subjected only to radiologic examination since the attempts for gastroscopy were unsuccessful.18 Of the 27 radiologic examinations, only one was negative for any lesion,33 while the rest showed fibrotic narrowing and rigidity of the gastric wall as the most common finding (43%), followed by hypertrophic and irregular folds (26%), multiple polypoid filling defects representing mucosal nodules (22%), mass lesion in 2 cases21,34 and finally, 1 case with fibrosis and shrinkage of the entire stomach resulting in linitis plastica.20 In several cases, more than one deformities coexisted. The radiologic examination of the congenital case showed the stomach to be shrunken and deformed, with significant narrowing of the pyloric channel, giving the impression of linitis plastica.18 Fibrotic narrowing and rigidity were more often reported in late disease (73% vs. 25%). The antrum seemed to be the most commonly affected area (56%), followed by mid-body to pylorus (26%), the whole stomach (15%), and upper body (4%) (data not shown).

Table 3
Table 3
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With regard to endoscopic findings, most patients were reported to have more than one lesion type, including multiple ulcerations/ulcerative gastritis (48%), nodular mucosa (26%), erosions (24%), large ulcer (24%), thickened folds (17%), narrowing and rigidity (17%), and mass lesion (2%) (Table 3). Fibrotic narrowing and rigidity, in line with the radiologic findings, were more often detected in late disease (24% vs. 12%), while ulcerative gastritis was almost equally reported in both. In 4 cases gastric lesions were reported to have a reddish-purple color, which is thought by some authors to be characteristic of GS.14,20,32,34 Gastric parts most commonly affected were the distal body and antrum (82%), while the gastric body and fundus were less frequently affected (33% and 12%, respectively) (data not shown). There were no statistically significant differences in any of the radiologic or endoscopic findings between early and late disease (analysis not shown).

Regarding the pH of the gastric aspirate, hypo- or achlorhydria was documented in 4 cases (2 late, 1 congenital with late deformities, and 1 early stage),11,12,15,18 while hyperchlorhydria was reported in 4 patients, all suffering from early syphilis (data not shown).13,29

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Histologic Findings and T. pallidum Detection

Histologic findings of the gastric lesions were reported in 50 of the 52 reviewed cases (29 early, 20 late disease, the 1 congenital case and 2 with no individual data available) (Table 3). In all of them, chronic gastritis with dense plasmacytic and lymphocytic infiltrates was observed. In addition, shallow erosions were reported to be present in 18%,12,13,15,20,25,30,42 vasculitis in the form of proliferative endarteritis or endophlebitis in 4%14,16,19,24 and atrophic gastritis in 2%.20 In the single case with congenital syphilis, squamous cell carcinoma was detected along with coexistent diffuse atrophic gastritis.18 In 5 of 50 cases, the dense plasmacytic infiltrate was reported to exhibit a perivascular distribution (perivascular cuffing).11,13,14,24,43

Data on T. pallidum detection were given in 44 cases (28 early and 16 late disease, for the remaining 8 cases no data were available), of which T. pallidum was detected in 36 cases. In the remaining 8 patients spirochetes failed to be detected, although investigated (Table 3). Of the 44 cases with available data, silver staining was used in 31 (24 positive and 7 negative),11,16,17,19,22–24,27–32,34–38,40–44 immunofluorescence microscopy in 11 (10 positive and 1 negative),17,19,24,25,29,37,42,43 polymerase chain reaction (PCR) in 3,37,43 dark-field microscopy on fresh tissue in 1,15 and immunohistochemistry on paraffin-embedded tissue in 1.25 In 11 cases (8 positive and 3 negative) the detection method was not reported (Table 4).21,26,29,33 In several cases, the authors used more than one method to detect T. pallidum due to limitations in the sensitivity and specificity of the various techniques. Silver staining failed to detect T. pallidum in 7 cases and in 3 of them other methods gave positive results.37,43 Interestingly, in one case T. pallidum was detected by PCR, while the rest of the aforementioned techniques had failed to detect it.37 There were no statistically significant differences in any of the histologic or T. pallidum detection findings between early and late disease (analysis not shown).

Table 4
Table 4
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In 9 of the 44 cases, the simultaneous presence of T. pallidum and Helicobacter pylori was demonstrated.31,33,36–38 There was no investigation for H. pylori mentioned in the remainder of the cases.

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Treatment and Outcome

The majority of the patients reviewed received antibiotics (penicillin) (83%) and all but one experienced a rapid resolution of their symptoms (Table 4). Only 1 patient presented with gastric perforation after he had already received treatment for early syphilis.29 The remaining 9 patients (17%) (3 early, 5 late, 1 congenital), were treated surgically either because of a complication, namely gastric perforation, obstruction, or chronic aspiration (3 patients), or due to strong suspicion of infiltrating tumor or lymphoma (6 patients, congenital included).11,12,14,16,18,29,32,36,44

Follow-up radiologic examination was performed in 11 patients, usually showing improvement, although some residual antral deformity was documented in almost half of them (55%) (data not shown). Follow-up endoscopy was performed in 25 cases between 1.5 and 24 weeks after onset of treatment and showed partial or near complete healing in 15 patients (with residual ulcerations, hyperemia, thickened folds) and complete healing in the rest of them (10 patients).

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DISCUSSION

We performed a systematic review of GS case reports and identified 52 patients with GS. On the basis of information on these patients, we tried to study demographic, clinical, and serologic characteristics of the disease, the contribution of various diagnostic procedures and imaging studies in reaching the diagnosis, as well as information on treatment given and its impact on outcome.

Most cases of GS involved black men. The median age was 39 years. The clinical presentation of the disease seemed to be nonspecific, characterized by epigastric and abdominal pain or fullness, anorexia, nausea, vomiting, weight loss, and early satiety. Upper gastrointestinal hemorrhage was almost equally observed in both early and late disease, although one would expect it more frequently in early syphilis, before the mucosa is deprived of its blood supply due to obliterative endarteritis. Anemia was more often met in late disease. Complications such as perforation or obstruction were rarely reported.18,30

The physical examination was usually non contributory. Epigastric tenderness was reported in half of the reviewed cases and other clinical findings suggestive of syphilis were infrequently noted. The majority of patients reviewed had neither a history (87%) nor physical examination (56%) suggestive of syphilis.

On the contrary, serology was nearly always positive (when data were available). Based on the above, one realizes how elusive the diagnosis of GS can be. First, one needs to be aware of the possibility of gastric insult in cases of syphilis, a knowledge not so widely spread. Second, the diagnosis of syphilis itself can be very elusive. Third, patients with this syndrome may seek medical help and be evaluated by a variety of medical specialties, primary care/family physicians, internal medicine physicians, gastroenterologists, even surgeons, to name a few. A combination of a complete history, including sexual history, a thorough physical examination and a high index of suspicion is required to make the diagnosis.

HIV positivity rate among GS cases reviewed was relatively low. Of course, testing for HIV infection begun in the early 1980s. Additionally, a variety of gastrointestinal complaints due to multiple, sometimes simultaneous, causes has always been encountered in the HIV population during both the era before the advent of highly active antiretroviral therapy and the highly active antiretroviral therapy era. Other than that, one would expect a much higher number of GS reports for several reasons such as the similar epidemiology of these 2 sexually transmitted diseases and the resulting aggressiveness in pursuing the diagnosis of syphilis in HIV-infected patients.

The radiologic abnormalities described included hypertrophic and irregular folds, mucosal nodules, fibrotic narrowing and rigidity of the gastric wall, mass-like lesion, and fibrosis of the entire stomach resulting in linitis plastica. Although the endoscopic appearance was variable, diffuse edema, erythema, friability, multiple erosions, or ulcerations and nodularity were usually present. Rugal hypertrophy as well as rigidity were also frequently reported. Jones and Lichtenstein believe that primary syphilis normally has no radiologic manifestations, secondary stage may be accompanied by nonspecific gastritis with diffusely thickened folds that may become nodular, with or without detectable ulcers and, as the infection becomes more chronic, a mass-like lesion may develop and the inflammation results in fibrotic narrowing of the gastric wall. Constrictive lesions involving the body of the stomach may give rise to the “hourglass” or “dumbbell shaped” stomach, while, if they involve the entire organ, result in linitis plastica.45 In our review and in accordance with the above-mentioned authors, hypertrophic folds and nodular mucosa were more often detected in early disease, while radiologic and endoscopic findings of fibrotic narrowing and rigidity were more frequently encountered in late disease. Interestingly, ulcerative gastritis was almost equally reported in both early and late stages, while large ulcers were mainly observed in early disease. Linitis plastica was observed only in patients with chronic disease (late stage and congenital). Finally, large, irregularly shaped ulcers with brownish or purple borders would sometimes develop, exclusively in late disease.14,20,32,34 The etiology of this discoloration is unknown and has been hypothesized to result either from fibrosing and obliterative panvasculitis of the submucosa46 or from high density of spirochete microorganisms since gastric biopsies after penicillin therapy have demonstrated resolution of this discoloration coinciding with the elimination and absence of spirochetes.34 With regards to the location, the antrum was almost always involved with distal stomach area following. Although by radiology, endoscopy, and even pathologic examination GS can be confused with lymphoma, tuberculosis, carcinoma, or Crohn disease, gastric involvement in syphilis is reported to abruptly end at the pylorus, while other types of lesions typically extend into the duodenum.45

The histologic features of routine hematoxylin and eosin staining were considered to be suggestive but not diagnostic of syphilis. A diffuse gastritis containing a dense plasma cell or lymphocytic infiltrate was invariably observed in both early and late disease, sometimes with concomitant shallow erosions and prominent perivascular cuffing. Vasculitis, manifested as marked proliferative endarteritis or endophlebitis, typical of syphilitic involvement in other sites, was rarely found in gastric biopsies. One explanation for the absence of vascular lesions may be that most gastric biopsies do not sample the submucosa where these vessels are located.47 Squamous cell carcinoma was found to complicate GS in the single congenital case.18

Even though the diagnosis of GS has been frequently based on the combination of upper gastrointestinal symptoms unresponsive to standard antiulcer therapy, endoscopic, and radiologic abnormalities consistent with the disease and a positive syphilis serology, there is general agreement that demonstration of T. pallidum in biopsy specimen provides the absolute proof. All modalities used have their own limitations. Dark-field microscopy requires fresh, unfixed tissue and, since the diagnosis is seldom considered early, the examination may not be done before pathologic examination has been completed. Of the reviewed cases, the diagnosis was made by dark-field microscopy in only one.15 Silver stains can be applied on formalin-fixed tissue. However, detection of spirochetes by silver staining is difficult in a background of elastic and reticulum fibers and differentiation from other species of intestinal spirochetes cannot be done. Nevertheless, a positive silver stain for mucosal spirochetes is considered by some authorities diagnostic of GS in the context of absence of an alternative diagnosis, suggestive endoscopic findings, positive syphilis serology, and a rapid response to antibiotic therapy. When available, immunofluorescence microscopy may be used as a specific technique for the detection of T. pallidum in both frozen and paraffin-embedded tissue. Initially reported cross-reactivity issues with other spirochetal organisms such as Borrelia burgdorferi were subsequently ameliorated with the introduction of monoclonal antibodies against a specific T. pallidum antigen.48,49 More recently, PCR was used to detect T. pallidum DNA in formalin-fixed, paraffin-embedded gastric biopsy.37,43 Although PCR is considered more sensitive than the above-mentioned techniques (ranging from 94.7% in early syphilis to 80% in secondary stage), it still has a 20% reported rate of false-negative results, mainly in the late phases of the disease.50 According to our review, there were 3 cases where PCR proved to be more sensitive than either silver staining37,43 or both silver staining and immunofluorescence microscopy.37

Regarding T. pallidum detection, available literature suggests that spirochetes are rarely visualized on microscopic examination of the lesions of late disease.51 Nevertheless, according to the presents review's findings, T. pallidum was detected in a smaller but still significant proportion of late disease lesions (69% vs. 89% in early disease), highlighting that T. pallidum detection cannot be used as a reliable indicator of a relatively new syphilis infection.

In addition, the concomitant finding of H. pylori in some patients31,33,36–38 raises the question as to whether T. pallidum affects the antrum with the assistance of H. pylori, which has already caused damage on gastric tissue. None of those patients was reported to have received anti-H. pylori treatment.

Gastric acid could also play a role in syphilitic ulceration. Roen and Thorner reported that early GS is accompanied by normal acidity or hyperchlorhydria that progresses with time to hypo- or achlorhydria,52 which agrees with our review results where hyperchlorhydria was mostly reported in patients suffering from early syphilis13,29 while hypo/achlorhydria was mainly observed in patients with gastric deformities of late disease.11,12 These findings are in line with the reported alleviation of epigastric pain by antiulcer regimens in 3 patients with early syphilis,14,17,22 justifying the recommendations of some authors for addition of antisecretory therapy to the antibiotic regimen for GS.30

In the majority of cases, irrespective of earlier or later stage, the gastric involvement by syphilis raised the suspicion of malignancy. In a significant proportion of the reviewed cases (19%) the intense radiologic, endoscopic, or even pathologic suspicion for carcinoma or lymphoma or, less often, the need for intervention to treat complications such as ulcer perforation or obstruction, led to surgical treatment. Finally, 9 patients had surgery. Coexistent malignancy was detected in one of those (congenital syphilis).

Finally, a few comments on antibiotic therapy used for treatment in the GS cases reviewed. Needless to say we observed a variety of regimens administered, mainly in terms of duration of treatment. Since most authors were faced with the syndrome for the first time, many of them elected to administer more penicillin doses than usual. In 4 cases, patients received intravenous penicillin without clear-cut evidence of CNS involvement. As expected, there have been no studies specifically addressing the appropriate dose and duration of penicillin treatment of GS. Since there is limited experience with this disease and most cases have been overtreated in the past, we recommend that, if the treatment regimen is given according to the syphilis stage, an early reevaluation should be done to document response.

The nonspecific clinical, radiologic, and pathologic characteristics of GS can safely establish it as a great imitator of other gastric diseases just as syphilis in general, as a multisystemic disease, can mimic many other diseases. GS is an entity almost unknown to an entire generation of physicians. However, since syphilis rates may be on the rise, GS may become a more frequent clinical challenge which we have to become familiar with. Thus, GS should be considered in the differential diagnosis in patients at risk for sexually transmitted diseases who present with abdominal complaints and unusual endoscopic lesions and no other diagnosis is made. The absence of primary or secondary luetic lesions should not deter one from considering GS. The diagnosis should also be considered in patients with peptic ulcer disease resistant to antiulcer therapy irrespective of the presence of H. pylori and in whom the histopathologic examination suggests syphilis. Clinicians, endoscopists, and pathologists have to become familiar with this entity, maintain a high index of suspicion and aggressively look for it when suspicion arises since it is treatable and making the diagnosis can save the patient further testing, morbidity, and anxiety.

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