A retrospective cohort study of the anesthetic management of postpartum tubal ligation

BACKGROUND

Neuraxial anesthesia with reactivation of a labor epidural catheter is commonly utilized for postpartum tubal ligations (PPTL), although the optimal anesthetic approach is unknown. We assessed institutional anesthesia practices for PPTL, and evaluated the failure rates of reactivation of labor epidural catheters, de novo spinal anesthesia, and spinal anesthesia after failed blocks.

METHODS

We conducted a single-center retrospective cohort analysis of 300 consecutive patients who underwent a PPTL and 100 having spinal anesthesia for cesarean delivery. Anesthetic management data (existing labor epidural catheter reactivation, de novo spinal anesthesia or general anesthesia) were collected from electronic medical records. Anesthetic block failure rates were determined for each anesthetic technique.

RESULTS

The failure rate was 15% for de novo spinal anesthesia and 23% after failed reactivation of a labor epidural catheter or spinal anesthesia. The epidural catheter reactivation failure rate was 35%. The failure rate of spinal anesthesia for cesarean delivery was 4%. Drug dosage, epidural catheter use in labor, time since epidural catheter placement or delivery, labor neuraxial technique (combined spinal-epidural, epidural), supplemental top-up doses during labor, and anesthesiologist experience did not predict neuraxial anesthesia failures.

CONCLUSIONS

Our analysis revealed an unexpectedly high neuraxial anesthesia failure rate even when de novo spinal anesthesia was used for PPTL. The results are consistent with other institutions' recent findings, and are higher than spinal anesthesia failure rates associated with cesarean delivery. Further studies are required to determine optimal anesthesia dosing strategies, and to understand the mechanisms behind high neuraxial anesthesia failures for PPTL.

Optical Detection of Lithium Therapeutic Levels in Porcine Interstitial Fluid Collected Using a Hollow Microneedle

Bipolar disorder (BD), a recurrent chronic disorder characterized by mood fluctuating between episodes of mood elevation and depression, is a leading cause of disability worldwide. Lithium is the most widely used medication for management of BD. However, despite its effectiveness in preventing and reducing mood swings and suicidality, it is a potentially hazardous drug. Lithium has a very narrow therapeutic range (0.4-1.2 mmol/L) with the upper limit being uncomfortably close to toxic levels, hence lithium levels should be monitored regularly. The current techniques of monitoring lithium levels require frequent blood tests and elaborate laboratory methods that cannot be translated into point of care devices for personal monitoring. Dermal interstitial fluid (ISF), an underutilized information-rich biofluid, can be accessed using non-invasive techniques and the lithium concentration in ISF has been found to be proportional to concentration in serum. In the current study a microneedle-based sampling method to extract ISF from porcine skin, as it is similar in anatomy to human skin, was employed. Optical determination of lithium therapeutic concentrations in porcine ISF using a colorimetric method based on the reaction between chromogenic agent Quinizarin and Li⁺ ion was then performed. The resulting spectra show spectral variations which are related to lithium concentrations in spiked samples of porcine ISF, hence suggesting the feasibility of utilizing ISF for real-time and minimally-invasive lithium drug monitoring.

Optical Determination of Lithium Levels in Artificial Interstitial Fluid for Treatment Management of Bipolar Disorder

Bipolar Disorder (BD), characterized by mood fluctuating between episodes of mood elevation and depression, is a leading cause of disability worldwide. Lithium continues to be prescribed as a first-line mood stabilizer for the management of BD. However, lithium has a very narrow therapeutic index and it is crucial to carefully monitor lithium plasma levels as concentrations greater than 1.2 mmol/L are potentially toxic and can be fatal. The current techniques of lithium monitoring are cumbersome and require frequent blood tests with the consequent discomfort which results in patients evading treatment. Dermal interstitial fluid (ISF), an underutilized information-rich biofluid, can be a proxy for direct blood sampling and allow lithium drug monitoring as its lithium concentration is proportional to the concentrations in blood. Therefore, in this study we seek to investigate the measurement of lithium therapeutic concentrations in artificial ISF. Our study employs a colorimetric method, based on the reaction between chromogenic agent Quinizarin and Li⁺ ion which can be detected using optical spectroscopy in the visible region (400-800 nm), to determine lithium levels in artificial ISF. The resulting spectra of our experiments show spectral variations which are related to lithium concentrations in spiked samples of artificial ISF, with a correlation coefficient (R) of 0.9. Future work will focus on investigating the feasibility of utilizing ISF for real-time and minimally-invasive lithium drug monitoring.

Outcomes and resource utilization of atrial fibrillation hospitalizations with type 2 myocardial infarction

Background

Patients with atrial fibrillation (AF) are often elderly and have higher rates of comorbidities which may predispose them to an increased risk of myocardial oxygen demand-supply mismatch. Scarce data exist on the prognostic impact of type 2 myocardial infarction (MI) in AF.

Purpose

To examine the association of type 2 MI with outcomes and resource utilization in primary AF hospitalizations.

Methods

We utilized the Nationwide Readmission Database 2018 to identify primary AF hospitalizations with and without type 2 MI. The International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes I48.0, I48.1, I48.2, I48.91 were utilized to identify primary AF hospitalizations within the United States. Of these, AF hospitalizations complicated by type 2 MI were identified using ICD-10 code I21.A1. Comorbidities and outcomes were identified using the corresponding ICD-10 codes. Complex samples multivariable logistic and linear regression models were used to determine the association between type 2 MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions). Predictors of in-hospital mortality in AF with type 2 MI were also determined.

Results

Of 382,896 primary AF hospitalizations included in this study, 7,375 (1.9%) had type 2 MI. Compared to AF hospitalization without type 2 MI, those with type 2 MI are older (74.5 vs. 70.7-years-old) and have higher prevalence of chronic pulmonary disease, dyslipidemia, diabetes mellitus, hypertension, heart failure, peripheral vascular disease, chronic kidney disease, neurological disorders, deficiency anemia, coagulopathy, valvular disease, prior myocardial infarction, prior coronary artery bypass grafting, prior percutaneous coronary intervention, and prior cerebrovascular accident (P for all <0.001). AF with type 2 MI is associated with significantly higher in-hospital mortality (1.3% vs. 0.5%; P<0.001), LOS (4.1 vs. 3.3 days; P<0.001), hospital costs ($10,293.6 vs. $8,820.3; P<0.001), discharges to nursing facility (18.1% vs. 10.2%; P<0.001), and 30-day all-cause readmissions (18.5% vs. 13.5%; P=0.001) compared to AF hospitalizations without type 2 MI (Table 1). Heart failure, chronic kidney disease, neurological disorders, and age (per year) were identified as independent predictors of in-hospital mortality among AF patients with type 2 MI (Figure 1).

Conclusion

In this large nationwide analysis, type 2 MI in the setting of AF hospitalization is associated with higher in-hospital mortality and increased resource utilization compared to AF hospitalizations without type 2 MI.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Two common polymorphic variants of OATP4A1 as potential risk factors for colorectal cancer

Genetic variations in the organic-anion-transporting polypeptide (OATP)-encoding solute carrier of organic anions (SLCO) genes can promote cancer development and progression. The overexpression of solute carrier organic anion transporter family member 4A1 (OATP4A1), a transporter for steroid hormones, prostaglandins, and bile acids, has been previously associated with tumor recurrence and progression in colorectal cancer (CRC). Therefore, the present study aimed to investigate the association between 2 frequent single nucleotide polymorphisms (SNPs) in SLCO4A1 (rs34419428, R70Q; rs1047099G, V78I) and CRC predisposition. Following restriction fragment length polymorphism-PCR analysis in 178 patients with CRC [Union for International Cancer Control (UICC) stage I/II] and 65 healthy controls, no significant difference was observed in allele frequency and the number of heterozygous/homozygous individuals between the groups. Notably, the R70Q minor allele was identified to be associated with the V78I minor allele in the genome. Comparing of the individual genotypes of CRC patients to clinical data, including sex, UICC-stage and relapse revealed no increased risk for CRC. In addition, the OATP4A1 immunoreactivity assay in paraffin-embedded CRC and adjacent non-tumorous mucosa sections, examined using quantitative microscopy image analysis, did not reveal any association with these polymorphisms. No significant differences were observed in the expression levels, localization, and sodium fluorescein transport capacity among the OATP4A1 variants, which was studied using functional assays in Sf9-insect and A431 tumor cells overexpressing the 2 single and a double mutant OATP4A1 SNP variants. These results suggested that the 2 most frequent polymorphisms located in the first intracellular loop of OATP4A1 do not associate with CRC predisposition and tumor recurrence. They are unlikely to affect the outcome of CRC in patients.

A prospective study of tea drinking temperature and risk of esophageal squamous cell carcinoma

Previous studies have reported an association between hot tea drinking and risk of esophageal cancer, but no study has examined this association using prospectively and objectively measured tea drinking temperature. We examined the association of tea drinking temperature, measured both objectively and subjectively at study baseline, with future risk of esophageal squamous cell carcinoma (ESCC) in a prospective study. We measured tea drinking temperature using validated methods and collected data on several other tea drinking habits and potential confounders of interest at baseline in the Golestan Cohort Study, a population-based prospective study of 50,045 individuals aged 40-75 years, established in 2004-2008 in northeastern Iran. Study participants were followed-up for a median duration of 10.1 years (505,865 person-years). During 2004-2017, 317 new cases of ESCC were identified. The objectively measured tea temperature (HR 1.41, 95% CI 1.10-1.81; for ≥60°C vs. <60°C), reported preference for very hot tea drinking (HR 2.41, 95% CI 1.27-4.56; for "very hot" vs. "cold/lukewarm"), and reported shorter time from pouring tea to drinking (HR 1.51, 95% CI 1.01-2.26; for <2 vs. ≥6 min) were all associated with ESCC risk. In analysis of the combined effects of measured temperature and amount, compared to those who drank less than 700 ml of tea/day at <60°C, drinking 700 mL/day or more at a higher-temperature (≥60°C) was consistently associated with an about 90% increase in ESCC risk. Our results substantially strengthen the existing evidence supporting an association between hot beverage drinking and ESCC.

Extramammary Paget ’s disease Of Glans Penis: A Rare Case Report

We present the case of an 83-year-old man with Extramammary Paget’s disease (EMPD) of the penis. He underwent a total penectomy and histopathology confirms the association of underlying invasive high grade urothelial carcinoma. Penile EMPD is rare and can be misinterpreted for benign skin conditions. A high index of suspicion is required for correct diagnosis and appropriate treatment.

Challenges to the census: international trends and a need to consider public health benefits

The Canadian government decision to cancel the mandatory long-form census in 2010 (subsequently restored in 2015), along with similar discussions in the United Kingdom (UK) and the United States of America (USA), have brought the purpose and use of census data into focus for epidemiologists and public health professionals. Policy decision-makers should be well-versed in the public health importance of accurate and reliable census data for emergency preparedness planning, controlling disease outbreaks, and for addressing health concerns among vulnerable populations including the elderly, low-income, racial/ethnic minorities, and special residential groups (e.g., nursing homes). Valid census information is critical to ensure that policy makers and public health practitioners have the evidence needed to: (1) establish incidence rates, mortality rates, and prevalence for the full characterization of emerging health issues; (2) address disparities in health care, prevention strategies and health outcomes among vulnerable populations; and (3) plan and effectively respond in times of disaster and emergency. At a time when budget and sample size cuts have been implemented in the UK, a voluntary census is being debated in the US. In Canada, elimination of the mandatory long-form census in 2011 resulted in unreliable population enumeration, as well as a substantial waste of money and resources for taxpayers, businesses and communities. The purpose of this article is to provide a brief overview of recent international trends and to review the foundational role of the census in public health management and planning using historical and current examples of environmental contamination, cancer clusters and emerging infections. Citing a general absence of public health applications of the census in cost-benefit analyses, we call on policy makers to consider its application to emergency preparedness, outbreak response, and chronic disease prevention efforts. At the same time, we call on public health professionals to improve published estimates of monetary benefit (via either cost-benefit or cost-effectiveness analysis) to a given public health intervention.

The impact of a structured clinical training course on interns' self-reported confidence with core clinical urology skills

BACKGROUND

Undergraduate training in core urology skills is lacking in many Irish training programmes.

AIMS

Our aim was to assess newly qualified doctors' experience and confidence with core urological competencies.

METHODS

A questionnaire survey covering exposure to urology and confidence with core clinical skills was circulated to all candidates. The group then attended a skills course covering male/female catheterisation, insertion of three-way catheters, bladder irrigation and management of long-term suprapubic catheters. The groups were re-surveyed following the course.

RESULTS

Forty-five interns completed the pre-course questionnaire (group 1) and 27 interns completed the post-course questionnaire (group 2). 24/45 (53%) had no experience of catheter insertion on a patient during their undergraduate training. 26/45 (58%) were unsupervised during their first catheter insertion. 12/45 (27%) had inserted a female catheter. 18/45 (40%) had inserted a three-way catheter. 12/45 (27%) had changed a suprapubic catheter. 40/45 (89%) in group 1 reported 'good' or 'excellent' confidence with male urinary catheterisation, compared to 25/27 (92.5%) in group 2. 18/45 (40%) in group 1 reported 'none' or 'poor' confidence with female catheterisation, compared to 7/27 (26%) in group 2. 22/45 (49%) in group 1 reported 'none' or 'poor' confidence with insertion of three-way catheters, compared to 2/27 (7%) in group 2. 32/45 (71%) in group 1 reported 'none' or 'poor' confidence in changing long-term suprapubic catheters, falling to 3/27 (11%) in group 2.

CONCLUSION

This study raises concerns about newly qualified doctors' practical experience in urology. We suggest that this course improves knowledge and confidence with practical urology skills and should be incorporated into intern induction.

Pakistan human resources for health assessment, 2009

Pakistan faces a human resources for health (HRH) crisis. A cross-sectional survey was conducted to overview frontline health workers. A total of 750 health facilities were surveyed across Pakistan. The median estimate of public sector health care workers in the district health system in Pakistan is 417 288, including 46 153 estimate of public sector health care workers in the district health system in Pakistan is 417 288, including 46 153 doctors and 41 032 nurses. Another estimated 20 000 doctors work in public sector tertiary care hospitals across the country. A total of 3549 health care workers were interviewed regarding job satisfaction and work environment. The private sector had better work environment scores compared with the public sector. Policy dimensions showed an absence of robust policies in practice. The public sector is inadequately staffed and job satisfaction and work environment need improvement. HRH crisis countries should share experiences, and developmental partners should support them in overcoming the HRH crisis.

Cerebral Venous Sinus Thrombosis: Unusual Imaging Appearance

Cerebral venous sinus thrombosis (CVST) has widely varied clinical and radiological manifestations ranging from asymptomatic minimal brain oedema to severe haemorrhagic infarcts associated with focal deficits, coma and even death. Cerebral venous sinus thrombosis presenting with lobar or subdural hematomas are rare and the cause may easily be overlooked. We present a case of CVST with an atypical radiological picture of intra-arenchymal, subdural and subarachnoid haemorrhage.

The effect of iron and zinc dietary restriction of pregnant rats on physical growth of litters

Evidence suggests that micronutrient deficiencies may be associated with problems in early growth. Iron (Fe) and Zinc (Zn) deficiency (D) are prevalent during gestation in low-income countries. For pregnant dams, adequate amount of these micronutrients are needed in the diet to ensure the capacity for increased physical growth. In this study, the role of Fe and Zn dietary restriction of pregnant rats on physical growth of litters was investigated. Pregnant rats after to mating were divided to three groups. Control group fed a standard diet and a FeD group fed a diet deficient in Fe and a ZnD group fed a diet deficient in Zn. All the diets were exposed during the last third of pregnancy. The results showed serum Fe and Zn concentration after to exert dietary compared to before to exert dietary in FeD and ZnD groups was significant. There was a significant difference in the physical growth indexes (body weight, body length, tail length, and head length) between FeD and ZnD groups compared to the Control group, but a significant difference in head width and brain weight between FeD and ZnD groups compared to the Control group was not seen. The results of this study suggest that adequate Fe and Zn affect the physical growth of litters.

Isolated bilateral pyramidal tract lesions? An unusual case of demyelination following trauma. A case report

This paper describes the case of a young woman who developed quadriparesis due to isolated bilateral pyramidal tract lesions suggestive of demyelination following trauma.

Statins may reduce episodes of exacerbation and the requirement for intubation in patients with COPD: evidence from a retrospective cohort study

INTRODUCTION

Statins have diverse anti-inflammatory effects in addition to their lipid-lowering ability. This study assesses the rate of chronic obstructive pulmonary disease (COPD) exacerbation and intubations in patients taking statins.

METHODS

This is a retrospective cohort study of 185 patients with COPD exacerbation, with a 1-year follow-up. Outcomes examined were repeat hospitalisation and intubations for COPD exacerbation. Baseline characteristics for which the p-value was < or = 0.10 were considered as covariates for inclusion in a multivariate model.

RESULTS

The statin group had fewer episodes of exacerbation and required intubation fewer times than the subjects not receiving statins (p < 0.0001 for both outcomes). Unadjusted odds ratios (OR) for no statin use vs. statin use were 9.54 (95% CI: 4.54-20.02) for exacerbation and 10.47 (CI: 4.56-24.01) for intubation. The OR, adjusted for the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ORa), were 2.35 (CI: 1.01-5.50) for non-statin users exhibiting an exacerbation and 10.36 (CI: 2.77-38.76) for this group requiring intubation, compared with statin users. Similarly, ORa for long-acting beta(2) agonists as a covariate were 3.01 (CI: 1.46-6.10) for exacerbation and 8.89 (CI: 3.67-21.32) for intubation. Time to outcome during the observation period was reduced by statins with the hazard ratio (HR) for exacerbation of 0.19 (CI: 0.06-0.14); HR for statins reducing intubation was 0.14 (95% CI: 0.10-0.30).

CONCLUSIONS

These data suggest that the use of statins may be associated with lower incidence of both exacerbations and intubations in patients with COPD.

Normal measurement of orbital structures: implications for the assessment of Graves' ophthalmopathy

Compute tomography anatomy of the orbits is well described, but only a few reports are available on normal measurements of the extraocular muscles (EOM) and globe position (GP). We obtained CT images from patients who were referred to our department for CT of the paranasal sinuses using a standard protocol for evaluation of normal orbital measurements. Our study suggests that optimum results are attained with the use of a coronal scan at a window level and width setting that results in an optimum image at the maximum muscle width for assessment of EOM and an axial scan at the mid-GP for GP and interzygomatic line. Based on our normal values, a right-to-left ratio of more than 1.4 for EOM diameter or 1.2 for GP is indicative of asymmetry. An absolute diameter of EOM > 8 mm and GP < 2 mm are abnormal.

Utility of volume adjusted prostate specific antigen density in the diagnosis of prostate cancer in Arab men

BACKGROUND

This study was undertaken to assess the utility of prostate specific antigen (PSA) and PSA density (PSAD) in discriminating between benign and malignant prostate disease in the Kuwaiti Arab population.

METHODS

A total of 100 consecutive patients suspected of having prostate cancer because of serum PSA > 4 ng/ml, or detection of a prostatic nodule on rectal examination were further investigated by determination of PSAD, TRUS of prostate, sexant prostatic biopsy and histological analysis to establish the correct diagnosis. Other diagnostic measures included the determination of the area under the receiver operating characteristic (ROC) curve, sensitivity and specificity.

RESULTS

Of the 100 prostate biopsies that were performed, 33 cases were confirmed to be prostate cancer and 67 were described as benign lesions comprising benign prostatic hyperplasia (BPH) with or without prostatitis. The age range for patients with prostate cancer was 42-90 years, and 52-90 years for those without prostate cancer. The mean prostate volume was 58.82 cc (range 9-177 cc) and 62.60 cc (range 15-140 cc), the mean PSA value was 36.65 ng/ml (range 5.8-200 ng/ml) and 16.49 ng/ml (range 1.4-46.0 ng/ml), while the mean PSAD was 0.92 (range 0.046-5.714) and 0.452 (range 0.034-2.294) for patients with prostate cancer and patients without prostate cancer respectively. Patients with PSA less than 4 ng/ml (3 cases) all had benign prostate lesions, and 7 cases with PSA more than 50 ng/ml all had prostate cancer and were excluded because values above 50 ng/ml have close to 100% specificity for prostate cancer. Further analysis was done on the remaining 90 cases which were patients with a PSA between 4 and 50 ng/ml. The discriminating power of serum PSA for detecting prostate cancer as estimated by the area under ROC was 0.686 while that for PSAD was 0.732. The maximum likelihood for a positive PSA was at a PSAD cut-off point of 0.32. For the PSA cut-off point of l0 ng/ml, the sensitivity was 80%, and specificity was 42.2%. For the PSAD cut-off point of 0.32, the sensitivity was 58% and the specificity 76.6%.

CONCLUSIONS

Determination of PSAD is not a useful adjunct to serum PSA values in the range of 10-50 ng/ ml in our population. PSAD value less than 0.32 with PSA less than l0 ng/ml strongly suggests benign disease.

Relationship between Serum Prostate Specific Antigen and the Pattern of Inflammation in Both Benign and Malignant Prostatic Disease in Middle Eastern Men

To determine the effect of prostatitis on serum prostate specific antigen in the diagnosis of prostate cancer in Middle Eastern men, H&E-stained sections of all consecutive prostate specimens were reviewed for diagnosis (malignant or benign) and pattern of inflammation. Inflammation was categorized into acute, active chronic and chronic inactive and graded semi-quantitatively according to previously published criteria. Results were correlated with serum PSA obtained from patients' records. Of 513 prostate specimens reviewed; 435 (84.8%) were benign and 78 (15.2%) were malignant. Chronic inactive prostatitis was present in 259 (204 benign, 55 malignant) and active chronic prostatitis in 221 (204 benign, 17 malignant). Acute prostatitis alone was not observed and prostatitis was absent in 33 (27 benign, 6 malignant). There was no significant difference in the prevalence of inactive chronic prostatitis between benign and malignant specimens (p < 0.071), but active chronic prostatitis was more prevalent in benign specimens (p < 0.001). Increasing serum PSA was observed for increasing grades of both inactive and active chronic prostatitis in both benign and malignant disease. Prostate cancer showed higher serum PSA levels than benign, at different cut-off points (4 ng/ml = p < 0.0001; 8 ng/ml = p < 0.0001; 12 ng/ml = p < 0.0001). However, significant numbers of patients with benign prostate biopsies presented with PSA above 12 ng/ml (82/260 = 32%). We conclude that active chronic prostatitis is common in Middle Eastern men with benign prostatic disease and a significant number of these present with very high PSA levels, some over 300 ng/ml.

Renal artery stenosis in patients with peripheral vascular disease in Kuwait

OBJECTIVE

The aim of this study was to identify the incidence of atherosclerotic renal artery stenosis (RAS) in patients with peripheral vascular disease (PVD) and its relation to any known risk factors.

SUBJECTS AND METHODS

This prospective study was conducted on 212 patients who were subjected to peripheral angiography for symptoms of PVD over a 3-year period from 1995 to 1998 at the Mubarak Al-Kabeer Hospital, Kuwait. Angiographic evidence of atherosclerotic disease and its severity was recorded in renal, abdominal aorta, iliac, femoral, popliteal and below-knee arteries. In addition, a detailed search of identifiable risk factors was done using history, clinical examination and laboratory studies.

RESULTS

The incidence of significant atherosclerotic RAS (more than 50% diameter stenosis) in patients with PVD was 15/212 (7.07%) with no significant difference in ratio between males and females (p = 0.3) compared to that of PVD alone. Patients with common iliac and femoral artery lesions had a high incidence of RAS (93.3 and 86.7%, respectively) with more than 80% probability in RAS patients with involvement of these vessels. There was significant renal impairment (p < 0.005), as assessed by serum creatinine levels, in patients with RAS compared to those who did not have it. There was a high incidence of smoking in patients with RAS (p = 0.02), and smoking was the only risk factor identified in these subjects.

CONCLUSIONS

Patients with iliac or femoral atherosclerotic disease have a high probability of associated RAS. Presence of renal impairment in patients with PVD is highly indicative of RAS. Smoking is the only identified risk factor for RAS in association with PVD in our population.

Predictors of programme adherence and weight loss in women in an obesity programme using meal replacements

OBJECTIVE

To explore predictors of programme adherence and weight loss in patients participating in a weight management programme using meal replacements (MR).

DESIGN

One hundred and fifty healthy obese women, age 48.5 years (s.d. = 8.3); weight, 97.6 kg (13.4); body mass index (BMI) 36.5 (3.7), participated in a longitudinal study with a 16-week acute weight loss phase (Phase 1) followed by 1 year of a trial of weight-loss maintenance (Phase 2). Energy intake during Phase 1 totaled 900 kcal (3.7 MJ) a day from a diet including two MR. Energy intake during Phase 2 consisted of either MR or a low-fat diet with a calculated energy deficit of 600 kcal/day (2.5 MJ).

METHODS

Weight, height and waist circumference were measured and body composition assessed by air plethysmography (Bodpod). Glucose and insulin were measured by standard immunoassays and insulin sensitivity assessed by homeostatic model assessment.

RESULTS

At the end of 16 weeks, 114 subjects (76%) completed Phase 1 and achieved a mean weight loss of 8.95 kg (3.38). Adherence to Phase 1 was predicted by weight loss over the first 2 weeks (p < 0.001). Weight loss during Phase 1 was predicted by initial weight and initial systolic blood pressure. Adherence to Phase 2 was not predicted by physiological measures. Weight loss maintenance in Phase 2 (not gaining more than 3% of the weight at start of phase 2) was predicted by cholesterol and triglyceride measured at the start of Phase 2 but otherwise was not predicted by the physiological measures. Initial insulin sensitivity did not predict weight loss in either phase.

CONCLUSION

Participants whose weight loss over the first 2 weeks falls in the bottom third may need additional intervention if they are to continue in this type of programme. A battery of physiological measures at entry to a MR weight loss and maintenance programme explains only a very small proportion of the variation in weight loss.

Contrast-enhanced three-dimensional fast-spoiled gradient magnetic resonance angiography of the renal arteries for potential living renal transplant donors: A comparative study with digital subtraction angiography

Preoperative assessment of the arterial anatomy of prospective renal donors is essential. Various non-invasive techniques are used for such evaluation. We conducted this study using contrast-enhanced 3-D fast-spoiled gradient (CE 3-D FSPGR) magnetic resonance angiography (MRA) on a 1.0 Tesla magnet, for preoperative definition of the renal arteries. Forty-five preoperative living renal donors underwent CE 3-D FSPGR MRA of the renal vessels and the results were compared with conventional digital subtraction angiography (DSA). The renal vascular anatomy, both normal and with variations, was satisfactorily defined in all 45 cases with CE 3-D FSPGR MRA. Fifteen cases showed an accessory or aberrant arterial supply. A small aneurysm was shown in one case. All cases compared well with conventional DSA. Our study revealed that CE 3-D FSPGR MRA on a lower field strength magnet is accurate in defining the renal vascular anatomy and its variations.

High serum prostate-specific antigen levels in the absence of prostate cancer in Middle-Eastern men: the clinician's dilemma

OBJECTIVE

To investigate the common causes of total serum prostate-specific antigen (PSA) values of> 10 ng/mL in an Arab population, as in the USA and Europe the risk of prostate cancer is considered high in men with such PSA levels.

PATIENTS AND METHODS

Serum total PSA was measured in men presenting to our hospital as part of the investigation for prostate cancer screening and/or in elderly men with prostatism. Men with a serum PSA level of> 10 ng/mL were further investigated by transrectal ultrasonography (TRUS) of the prostate and biopsy of suspicious lesions for histological diagnosis. In addition, the percentage of free PSA, PSA velocity and PSA density were determined. All the patients included in this study were men of Arab origin residing in Kuwait.

RESULTS

In all, 1700 men (mean age 55.6 years, range 35-94) were assessed; of these, 161 had a serum PSA of> 10 ng/mL, attributable to benign prostatic hyperplasia (BPH) in 110 (68%), BPH with histological features of prostatitis in 33 (21%) and prostate cancer in 18 (11%). TRUS of the prostate in 143 of the 161 men with either BPH or BPH with prostatitis showed varying grades of intraprostatic calcifications in 22 (15%). Both PSA density and percentage free PSA did not contribute to determining the causes of total PSA levels of> 10 ng/mL. There was a progressive decline in PSA in all patients with BPH and prostatitis, except one who at re-biopsy had prostate cancer (T1N0M0, G1).

CONCLUSION

Total PSA values of> 10 ng/mL in Arab men may be a result of BPH, BPH with prostatitis or prostate cancer, in that order. A gradual decline in total PSA (decreased PSA velocity) with time to < 4 ng/mL often confirms the diagnosis of BPH with prostatitis. The percentage of free PSA and PSA density may not be helpful in diagnosing prostate cancer with certainty in these patients. Compared with Caucasians in the USA and Europe, BPH and BPH with prostatitis appear to be more frequent causes of serum PSA levels of> 10 ng/mL in Arab men.

Ischemic renal disease in Kuwait

Ischemic renal disease (IRD) is a frequent cause of end-stage renal disease. Its prevalence is mainly known from autopsy or retrospective arteriographic studies. This prospective study was conducted in 115 subjects selected from 732 patients with advanced chronic renal failure (CRF). Only patients with clinical features suggestive of IRD were selected for this study. In addition to detailed clinical and laboratory evaluation, captopril renal scintigraphy was performed in selected cases. All subjects underwent renal arteriography and all were followed up for 18.4 +/- 11.4 months. Renovascular disease was seen in 15 patients and significant bilateral renal artery disease leading to IRD was observed in 13 (11.3%). Hence the prevalence of IRD in the advanced CRF patients was 1.7%. The majority of patients with IRD (8 [61%]) were above 46 years of age and there were more men than women (10:3). Atherosclerotic renovascular disease was the most common (10 [77%]), even though arthritis (1 [7.6%]), and fibromuscular dysplasia (2 [15.3%]) were also observed. Serum creatinine at time of presentation was significantly higher in patients with IRD (784 +/- 292, p = 0.043) compared to those who did not have IRD (359 +/- 126). Corrective procedures were performed in 5 patients. After treatment the improvement in serum creatinine in patients with IRD at 3 and 6 months (166 +/- 32 and 173 +/- 47, respectively) was significantly different (p < or = 0.05) compared to those who were not treated (610 +/- 194 and 645 +/- 220, respectively). Hyperlipidemia, coronary artery disease and peripheral vascular disease were more prevalent in patients who had IRD compared to those with renal failure. The incidence of diabetes mellitus were similar in both groups. This study denotes a lower prevalence of IRD in the advanced CRF population; they had more severe renal failure at presentation but specific corrective treatment delayed progression of renal disease significantly.

Lipid-lowering efficacy, safety, and costs of a large-scale therapeutic statin formulary conversion program

STUDY OBJECTIVE

To assess the lipid-lowering efficacy, safety, and costs of a large-scale statin formulary conversion program.

DESIGN

Prospective, observational study.

SETTING

Tertiary academic medical center.

PATIENTS

A total of 980 patients consented to participate; 942 patients completed the study.

INTERVENTION

Patients were converted from their current statin therapy to either cerivastatin 0.4 or 0.8 mg/day, or simvastatin 80 mg/day, using a conversion algorithm.

MEASUREMENTS AND MAIN RESULTS

Efficacy and safety were evaluated at baseline and after 6 weeks of therapy; costs were also measured. Overall attainment of the National Cholesterol Education Program (NCEP) goal for low-density lipoprotein cholesterol (LDL) increased from 64.8% to 74.5% of patients (p<0.001); mean LDL decreased from 115+/-30 mg/dl to 106+/-25 mg/dl (p<0.001). Adverse events occurred in 3% of patients, and included myositis (0.6%) and increased hepatic transaminases (0.1%). Overall costs were reduced by $115/patient treatment-year.

CONCLUSION

Statin therapeutic interchange can improve lipid control at reduced costs. The possibility of uncommon but potentially serious adverse effects suggests that these programs require appropriate monitoring.

Cholecystokinin (CCK) secretion in patients with severe short bowel syndrome (SSBS)

This study examined the effects of a liquid meal on cholecystokinin (CCK) secretion in patients with severe short bowel syndrome (SSBS) receiving home total parenteral nutrition (TPN) support for 5-19 years after massive small bowel resection. Five patients with SSBS due to superior mesenteric artery or vein thrombosis were included. Five healthy volunteers served as controls. Blood was drawn before and 1 hr following consumption of 250 ml of a liquid diet containing 232 kcal with 8 g fat and 8 g protein. Plasma CCK activity was evaluated by amylase bioassay. All patients had stable weight with a normal BMI and serum albumin level, although there were mild abnormalities in their liver function tests. CCK secretion after stimulation was significantly decreased in patients. These results suggest that reduction in intestinal length influences CCK secretion in response to meal stimulation in SSBS patients.

Alteration of sonographic texture of the endometrium in post-menopausal bleeding. A guide to further management

BACKGROUND

The purpose of this study was to assess the utility of transvaginal ultrasonography in the evaluation of endometrial morphology in addition to the standard criterion of endometrial thickness for selecting patients for endometrial sampling.

METHODS

Two hundred and seven consecutive cases of postmenopausal bleeding were evaluated by transvaginal ultrasound. Endometrial thickness was measured as the maximum anteroposterior thickness of the endometrium including both the anterior and posterior layers, in the sagittal long axis view. The morphology of the endometrium was studied and categorized as homogeneous, focally increased echogenecity, diffusely increased echogenecity or diffusely inhomogeneous. Patients were followed up for clinical course and endometrial histopathology.

RESULTS

Textural inhomogeneity was observed in all the three cases of endometrial cancers with endometrial thickness of less than 6 mm, and, in ten out of 11 cases of a more than 6 mm thick endometrium. On the other hand the endometrial texture was homogeneous in all cases of endometrial atrophy/tissue inadequate for diagnosis, with thickness of less than 6 mm.

CONCLUSION

This study adds the dimension of abnormal echogenecity of the endometrium to the currently followed criterion of endometrial thickness with a view to enhance accuracy, both for a better prediction of atrophy and a higher prediction for endometrial cancer. Expectant management can be offered to patients with a homogeneous endometrium which is 6 mm thick or less. Aggressive evaluation for a malignancy must be made if there is a focal increased echogenecity or a diffuse increased echogenecity even in a thin endometrium.

Deep-seated thoracic and abdominal masses: usefulness of ultrasound and computed tomography guidance in fine needle aspiration cytology diagnosis

Fine needle aspiration cytology (FNAC) was performed under ultrasound and CT guidance in 120 cases. These included abdominal masses (85 cases) and thoracic masses (35 cases) biopsied over a two and a half year period (March 1996 to September 1998). The aim of this study was to assess the contribution of clinico-imaging evaluation and image-guided FNAC to the management of patients with deep-seated mass lesions. Aspirations in the abdomen were performed from various anatomic sites such as liver (56 cases), lymph nodes (18 cases), gastrointestinal tract (three cases), pancreas (six cases), and kidney (two cases). In the thorax, biopsy was performed in the lung (19 cases) and mediastinum (13 cases). In 112 cases (93.4%) FNAC was diagnostic. Of the lesions that were successfully aspirated, 85% were < or = 5 cm in size. No major complication was encountered. All the successful aspirates could be defined as malignant or non-malignant, but tissue differentiation was possible in 63.7% of malignant lesions and 53.8% of benign lesions. Combined clinical and imaging evaluation for malignancy showed 80% sensitivity and 59% specificity. Although clinicoradiological parameters themselves have certain limitations in diagnosing benign versus malignant lesions, in conjunction with guided FNA they are very accurate and safe in diagnosing deep-seated mass lesions in the thorax and in the abdomen. However, the role of FNA in tissue differentiation of solid lesions such as lymphoma requires further study.

Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis: a study of 29 cases

FNAC is a simple diagnostic tool for the initial evaluation of various deep seated pathological lesions. This study describes the applicability and practical aspects of the technique in establishing the diagnosis of spinal tuberculosis (TB) with the aid of radiographic guidance. The study was conducted in a major teaching hospital in Kuwait between the years 1985 and 1994. Twenty-nine patients (M:F = 18:11 and age range 8-72 years) with clinically and/or radiologically suspected spinal TB were seen in the Department of Cytology, Mubarak Al Kabeer Hospital. The patients were re-examined by either computed tomography (CT) scanning (n = 19) or fluoroscopy (n = 10) to localize the lesion for FNAC. FNAC smears were routinely stained with Papanicolaou and Diff Quik stains and one smear of each case was stained with Ziehl-Neelsen (Z-N) stain for acid-fast bacilli (AFB). Aspirated purulent material or syringe washings of dry aspirates were also submitted for microbiological cultures including AFB. Radiological and cytological findings were recorded in each case. Radiological findings included: bony rarefaction and destruction (93.1%), narrowed disc space (89.7%), soft tissue calcification (65.5%) and para-vertebral abscess formation (51.7%). Cytological findings included: epithelioid cell granulomas (89.7%), granular necrotic background (82.8%) and lymphocytic infiltration (75.9%). Smears were positive for AFB in 51.7% of cases. A positive AFB culture was obtained in 82.8% of cases, including all cases with positive AFB on smear by Z-N stain. Radiologically guided FNAC with AFB culture is a simple, reliable and practical approach to diagnosing spinal TB lesions. With a high diagnostic yield, it allows immediate initiation of specific treatment, helps to avoid invasive diagnostic procedures, and decreases hospitalization time.

Blunt abdominal trauma: comparison of ultrasonography and computed tomography in a district general hospital

Ultrasonography has been proposed as a screening method for blunt abdominal trauma, but its specific role in comparison with other diagnostic modalities has yet to be defined. The aim of the present retrospective study was to compare the results of ultrasonography and CT of the abdomen in blunt trauma in a district general hospital. The hospital records of 25 patients who were admitted with blunt abdominal trauma to Southland Hospital, Invercargill, New Zealand, between January 1991 and November 1996 and who had both ultrasound and CT of the abdomen within 48 h of admission were reviewed. Ultrasound missed seven lesions in seven patients (7/25, 28%) compared with CT. Three of these were intestinal lesions that needed laparotomy. Ultrasound had a usefulness index of 1, 0.76, 0.72, 0.69 and 0, respectively, for detecting lesions of the kidneys, free intraperitoneal fluid, the liver, the spleen, and intestines. Although ultrasound can be used as an initial screening method for blunt abdominal trauma, CT is still the imaging modality of choice for detecting intra-abdominal lesions for stable patients in a district general hospital.

Ultrasonographic diagnosis in abdominal tuberculosis

Sonographic findings were retrospectively analysed in 39 patients with proven abdominal tuberculosis (TB). The patients were treated over 15 years at a major teaching hospital, Mubarak Al-Kabber Hospital, in Kuwait. The findings included clear or complex ascites with fine strands, loculations and debris. The other findings were lymphadenopathy, bowel wall thickening, omental mass, focal lesions in the liver and spleen and psoas abscess. The sonographic findings in abdominal TB are not specific but may give valuable information to prevent unnecessary laparotomy.

Giant cell tumour of the temporal bone: case report and review of the literature

This paper presents an expansile lesion of the temporal bone, in a 14-year-old boy, that was initially diagnosed as intra-osseous meningioma from CT appearance. At histopathology a final diagnosis of giant cell tumour was made. A brief review of the literature is presented for this rare case.

Surface-associated protein from Staphylococcus aureus stimulates osteoclastogenesis: possible role in S. aureus-induced bone pathology

OBJECTIVE

Staphylococcus aureus is the cause of bone destruction in osteomyelitis, bacterial arthritis and orthopaedic implant failure. We have previously shown that gentle saline extraction of S. aureus has revealed the presence of an extremely potent stimulator of osteoclast activation in both the murine calvarial bone resorption assay and the isolated chick osteoclast resorption assay. In order to investigate the mechanism of action of this surface-associated material (SAM), we have investigated its capacity to recruit osteoclasts.

METHODS

The murine bone marrow osteoclast recruitment assay was used. The ability of the recruited cells to resorb dentine slices was also investigated. Results. The SAM from S. aureus dose dependently stimulated tartrate-resistant acid phosphatase (TRAP)-positive osteoclast formation and pit formation on dentine slices. Neutralization of the cytokines tumour necrosis factor alpha and interleukin (IL)-6 totally inhibited, but antagonism of IL-1 only partially blocked, the stimulated maturation of osteoclast-like cells.

CONCLUSION

These findings suggest that bone destruction associated with local infection by S. aureus is due to the stimulation of osteoclast formation induced by the action of the easily solubilized SAM, and could explain the large numbers of osteoclasts found in infarcted bone in osteomyelitis.

Role of ultrasonography in blunt abdominal trauma: a prospective study

OBJECTIVE

To evaluate the role of ultrasonography in screening for blunt abdominal trauma in a general hospital.

DESIGN

Prospective study.

SETTING

University hospital, Kuwait.

SUBJECTS

53 patients (44 male and nine female) with suspected blunt abdominal trauma or decreased consciousness were studied in the period between March 92 and April 93.

INTERVENTIONS

Real time ultrasonography of the abdomen during resuscitation.

MAIN OUTCOME MEASURES

The sensitivity and specificity of ultrasonography as an investigative tool and predictor of clinical outcome.

RESULTS

Ultrasonography was 85% sensitive, 100% specific, and 96% accurate. The positive predictive value was 100% and the negative predictive value was 95%. The sensitivity was less in the hands of the surgeon than the radiologist (67% compared with 90%).

CONCLUSION

Ultrasonography is an accurate, safe method for screening patients with blunt abdominal trauma even in general hospitals.

Abdominal tuberculosis: comparison of sonography and computed tomography

Sonographic and computed tomography findings were retrospectively compared in 13 patients with proven abdominal tuberculosis who had both diagnostic modalities in their workup. The patients were treated over 9 years in two general hospitals in Kuwait. Ultrasound could detect the same findings as CT in 9 of 13 patients. Both had the same accuracy in detecting the type of ascites (in 6 patients) and solid organ tuberculosis (four lesions). Ultrasound gave useful information but could not completely replace CT as it detected less bowel thickening (3 of 5 lesions) and abdominal tuberculous lymphadenopathy (1 of 4 lesions) than CT scanning.

Regulation of pml messenger-RNA expression in human breast-carcinoma cells

We examined the mRNA expression profile of PML, a novel nuclear protein recently characterized from acute promyelocytic leukemia (APL) blast cells, in a number of breast carcinoma cell lines. PML mRNA was found to be differentially expressed among the cell lines examined. A correlation of borderline significance between PML mRNA expression and the proliferative capacity of the cell Lines was noted. Serum stimulation significantly elevated the PML mRNA levels in the T47D and MDA-MB-231 cells. These results would suggest that PML may function as a positive regulator of cellular proliferation in breast carcinoma cells.

Expression of the retinoic Acid nuclear receptors (rars) and retinoid x-receptor (rxr) genes in estrogen-receptor positive and negative breast-cancer

Retinoid inhibition of breast carcinoma growth correlates with the estrogen receptor (ER) positivity and elevated retinoic acid nuclear receptor (RARalpha) mRNA levels. We therefore examined retinoid nuclear receptor mRNA levels in patient breast carcinoma biopsy specimens to determine if such a correlation exists between ER positivity and RARalpha mRNA levels. We have now shown that RARalpha mRNA levels are significantly higher in ER positive samples. RARgamma mRNA is expressed at relatively high levels in a majority of the tumor samples independent of the ER-status while RARbeta mRNA was expressed at low levels in only one tumor sample. We also found high RXRalpha mRNA levels in all of the tumor samples examined while RXRgamma mRNA could not be detected. Our study demonstrates that RARalpha mRNA levels are either low or absent in ER-negative patient samples and that RARalpha levels may serve as a potential marker to determine patient responsiveness to RA therapy.

Hybrid molecules containing the A-domain of insulin-like growth factor-I and the B-chain of insulin have increased mitogenic activity relative to insulin

Two synthetic insulin-like compounds consisting of the B-chain of insulin linked via disulfide bonds to A chains corresponding to the A-domain or the A- and D-domains of insulin-like growth factor I (IGF-I) have been evaluated for mitogenic activity and for binding to IGF receptors and IGF carrier proteins. Both compounds are 3- to 5-fold more potent mitogens than insulin, and have a comparably increased affinity for the type I IGF receptor that mediates these mitogenic effects in chick embryo fibroblasts. Neither compound interacts with IGF carrier proteins. These results indicate that the A-domain of IGF-I is importantly involved in its growth-promoting properties.