Predicting post-treatment symptom severity for adults receiving psychological therapy in routine care for generalised anxiety disorder: a machine learning approach

Approximately half of generalised anxiety disorder (GAD) patients do not recover from first-line treatments, and no validated prediction models exist to inform individuals or clinicians of potential treatment benefits. This study aimed to develop and validate an accurate and explainable prediction model of post-treatment GAD symptom severity. Data from adults receiving treatment for GAD in eight Improving Access to Psychological Therapies (IAPT) services (n=15,859) were separated into training, validation and holdout datasets. Thirteen machine learning algorithms were compared using 10-fold cross-validation, against two simple clinically relevant comparison models. The best-performing model was tested on the holdout dataset and model-specific explainability measures identified the most important predictors. A Bayesian Additive Regression Trees model out-performed all comparison models (MSE=16.54 [95 % CI=15.58; 17.51]; MAE=3.19; R²=0.33, including a single predictor linear regression model: MSE=20.70 [95 % CI=19.58; 21.82]; MAE=3.94; R²=0.14). The five most important predictors were: PHQ-9 anhedonia, GAD-7 annoyance/irritability, restlessness and fear items, then the referral-assessment waiting time. The best-performing model accurately predicted post-treatment GAD symptom severity using only pre-treatment data, outperforming comparison models that approximated clinical judgement and remaining within the GAD-7 error of measurement and minimal clinically important differences. This model could inform treatment decision-making and provide desired information to clinicians and patients receiving treatment for GAD.

Exploring the potential of bacterial-augmented floating treatment wetlands for the remediation of detergent-contaminated water

Due to industrialization and urbanization, the use of detergents inadvertently led to contamination of aquatic environments, thus posing potential threat to aquatic organisms and human health. One of the main components of detergents is linear alkylbenzene sulfonate (LAS), which can cause toxic effects on living organisms, particularly aquatic life in the environment. In this study, floating treatment wetlands (FTWs) mesocosms were developed and augmented with LAS-degrading bacteria. The plant species, Brachiaria mutica (Para grass), was vegetated to establish FTWs and bacterial consortium (1:1:1:1) of Pseudomonas aeruginosa strain PJRS20, Bacillus sp. BRRH60, Acinetobacter sp. strain CYRH21, and Burkholderia phytofirmans Ps.JN was augmented (free or immobilized) in these mesocosms. Results revealed that the FTWs removed LAS from the contaminated water and their augmentation with bacteria slightly increased LAS removal during course of the experiment. Maximum reduction in LAS concentration (94%), chemical oxygen demand (91%), biochemical oxygen demand (93%), and total organic carbon (91%) was observed in the contaminated water having FTWs augmented with bacterial consortium immobilized on polystyrene sheet. This study highlights that the FTWs supported with immobilized bacteria on polystyrene sheets can provide an eco-friendly and sustainable solution for the remediation of LAS-bearing water, especially for developing countries like Pakistan.

Examining bi-directional change in sleep and depression symptoms in individuals receiving routine psychological treatment

BACKGROUND

Sleep disturbance is a common symptom of depression. There is conflicting evidence whether improvements in sleep might impact depressive symptoms, or whether treating the core depressive symptoms might improve sleep disturbance. This study explored the bi-directional impact of sleep and depressive symptom change among individuals receiving psychological treatment.

METHODS

Session-by-session change in sleep disturbance and depressive symptom severity scores were explored in patients receiving psychological therapy for depression from Improving Access to Psychological Therapies services in England. Bi-directional change in sleep disturbance and depressive symptoms was modelled using random-intercept cross-lagged panel models with items from the PHQ-9.

RESULTS

The sample included 17,732 adults that had received three or more treatment sessions. Both depressive symptoms and sleep disturbance scores decreased. Between initial timepoints, higher sleep disturbance was associated with lower depression scores, but after this point positive cross-lagged effects were observed for both the impact of sleep disturbance on later depressive symptoms, and depressive symptoms on later sleep disturbance scores. The magnitude of effects suggested depressive symptoms may have more impact on sleep than the reverse, and this effect was larger in sensitivity analyses.

CONCLUSIONS

Findings provide evidence that psychological therapy for depression results in improvements in core depressive symptoms and sleep disturbance. There was some evidence that depressive symptoms may have more impact on sleep disturbance scores at the next therapy session, than sleep disturbance does on later depressive symptoms. Targeting the core symptoms of depression initially may optimise outcomes, but further research is needed to elucidate these relationships.

Opportunities and constraints for cleaner production policy in the developing world: a case study of Sindh Region, Pakistan

The current industrial and economic activities in Sindh Province, Pakistan, polluted the region's water, air, soil, and marine resources. However, there is a rising demand for eco-friendly production, and it is important to develop new policies and tools to combat environmental degradation and enhance economic development. Cleaner Production (CP) provides opportunities to address many of these issues. Employed method for this study was based on three approaches: a literature review and stakeholder mapping; a collection of data and information from key stakeholders through focal group discussions, consultative workshops, and one-on-one meetings; and analysis and synthesis of data that were gathered from different sources. The analysis of collected information provides an overview of CP strategies moving forward. Participant workshops gave in-depth information on policy implementation, technological impediments to methods that have been employed elsewhere, and needed capacity building as well as financial consequences of policy implementation. Through increasing financial resources and institutional resources, the expansion of CP will help to replace the conventional methods of waste treatment with an eco-efficiency approach to preventing pollution at the source, thus reducing the need for expensive pollution control and management costs for environmental compliance. Experiences, achievements, and implementation pitfalls from this study can provide a lesson to other developing countries to improve their economic and environmental sustainability.

Experience of fibrosing cholestatic hepatitis with hepatitis C virus in kidney transplant recipients

BACKGROUND

Fibrosing cholestatic hepatitis C (FCH-C) is a rare entity that occurs among immune-compromised patients resulting from the direct hepatotoxicity of a high intracellular viral load along with an ineffective immune system ultimately leading to a fatal outcome. We have describes herein 4 renal transplant recipients who were diagnosed with FCH-C at our institution in the last 8 months.

METHODS

Four renal transplant recipients presented with jaundice and deteriorating liver function tests. They were diagnosed to display FCH-C based on the presence of hepatitis C virus (HCV) RNA and characteristic liver biopsy findings; there was no evidence of any other cause of cholestasis or biliary obstruction.

RESULTS

The patients were men of ages 40, 25, 20, and 27 years. The durations after transplantation were 1.5, 10, 1.5 and 2.0 years, respectively. In all cases pretransplantation screening was negative for HCV antibody, HCV RNA, and hepatitis B surface antigen (HBsAg). All 4 patients were infected with genotype 1, whereas case 2 had coinfection with type 3. Cases 1 and 2 who were treated with interferon and ribavirin, showed improvement in cholestasis but did not achieve a rapid virological response. Case 1 developed graft dysfunction secondary to acute cellular rejection at 4 months after initiation of interferon treatment, which was treated with pulse steroids. Interferon-based therapy was stopped prematurely in both cases due to pancytopenia. Case 3 developed florid pyelonephritis and died without receiving therapy for hepatitis C. Case 4 was managed conservatively by decreasing the immunosuppression with regular monitoring.

CONCLUSION

FCH-C is difficult to treat and shows high morbidity and mortality rates. Treatment is associated with a risk of graft rejection.

Implementing a public-private mix model for tuberculosis treatment in urban Pakistan: lessons and experiences

SETTING

Six towns of Karachi, Pakistan.

OBJECTIVES

1) To strengthen the capacity of general practitioners (GPs) in providing tuberculosis (TB) treatment through DOTS; and 2) to enhance collaboration between the public and private sectors in TB management and case reporting.

DESIGN

A quasi-experimental study design was adopted to ensure enrolment of TB patients through trained GPs with the support of laboratory networks and to improve the case detection rate.

RESULTS

The following challenges were faced during implementation of the model in urban settings: no systematic list of GPs was available; the majority of the GPs were untrained health practitioners working in squatter settlements, where formally trained GPs are most needed; the motivation of GPs with high patient loads is very low; and access to a laboratory is difficult. Of 35 patients enrolled in the first quarter (third quarter 2009), 87% completed their treatment successfully.

CONCLUSION

Public-private mix (PPM) DOTS is feasible in the cities of Pakistan. However, the cost, time and effort required to establish the programme is higher than in many other developing countries.

Cyclosporine withdrawal in post-renal transplant thrombotic microangiopathy

INTRODUCTION

Thrombotic microangiopathy (TMA) is a well known complication of cyclosporine (CsA)-treated renal transplantation but optimum treatment strategies are not clearly defined.

PATIENTS AND METHODS

All patients transplanted between January 1996 and December 2001 at our center who had biopsy-proven TMA and in whom CsA was withdrawn were studied retrospectively.

RESULTS

The TMA was found in nine of 688 patients (1.3%). All except one donor were living related. HLA matching was one haplotype in all except one where both haplotypes were different. There were five males and four females and the mean age was 24.9 +/- 9 yr. All of them developed TMA within 3 months of transplant. Five of nine had evidence of microangiopathic hemolysis on peripheral film. Serum creatinine at the time of diagnosis of TMA was 3.1 +/- 1.3 mg/dL. Cyclosporine was discontinued in all and mycophenolate mofetil was substituted for azathioprine. No episode of acute rejection occurred after CsA withdrawal. Graft function did not improve in four who eventually became dialysis-dependent after a mean duration of 12.6 +/- 8.3 months. Remaining patients showed stabilization or improvement in function and all had serum creatinine below 2 mg/dL after a mean follow up of 24 months.

CONCLUSION

The CsA withdrawal in cases with TMA at a stage when significant functional deterioration has not taken place can salvage the graft.

Bullying of junior doctors prevails in Irish health system: a bitter reality

Workplace bullying in health systems is a well known fact. It leads to not only breakdown in teamwork but also has significant affect on the individual's personal life. True prevalence of bullying in junior doctors working in Ireland is unknown. Our aim of study was to find out the prevalence of bullying in junior doctors working hospitals in south and western counties of Ireland and to assess its effects on the productivity of work and family life and to identify the common source of bullying. We carried out a questionnaire survey. A total of 950 questionnaires were sent. Response rate was 51%. Our sample is 15% of the target population of all the hospital junior doctors. 30% of the responders claimed to be subjected to one or more bullying behaviors. Doctors from European Union (EU) reported significantly less rate of bullying compares to non EU doctors. Our results are in line with the results of studies conducted in United Kingdom. This study shows the magnitude and source of the problem. We conclude that bullying is a common problem in Irish health system. Increased awareness and zero tolerance are required to eradicate bullying.

Accuracy of admitting diagnosis in acute surgical patients by non consultant hospital doctors

The incidence of accurate diagnosis made by non-consultant hospital doctors (NCHDs) is unknown in acute surgical admissions. There is a common assumption that reliance is made on excessive and inappropriate investigations. The aim of study was to assess the accuracy of admitting diagnosis by the NCHDs and the appropriateness of radiological investigations ordered. Data were collected on 100 consecutive acute surgical admissions. A final diagnosis was made in all the patients. 79 patients had accurate initial diagnosis (NCHDs). 23 scans were performed which confirmed the initial diagnosis. Out of 21 initial inaccurate diagnoses, final diagnosis was made on repeated clinical examination in 10, on imaging alone in 5 and by endoscopy or surgery in the remaining 6 patients. 11 patients had scans and 7 were appropriate. We conclude that 79% of diagnoses made by NCHDs are the accurate final diagnoses. The utilization of diagnostic modalities especially radiological imaging is highly appropriate. Our study suggests that the physical presence of a consultant on site may not lead to significant improvement to the delivery of health care to the Irish population.

Management of pediatric urolithiasis in Pakistan: experience with 1,440 children

PURPOSE

We evaluated the efficacy and safety of different modalities for pediatric urolithiasis in a developing country in 2 eras, namely before and after the advent of minimally invasive surgery.

MATERIALS AND METHODS

We retrospectively reviewed the records of 1,440 children younger than 14 years treated with various modalities during a 14-year period. From 1987 to 1995, 486 and 50 patients were treated with open surgery, and extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) and minimally invasive methods, respectively. Between 1996 and 2000, 518 and 386 children were treated with surgery and minimally invasive methods, respectively.

RESULTS

Of the 1,440 children 795 (55.2%) had renal, 198 (13.8%) had ureteral and 447 (31%) had bladder calculi. Of the renal stones 556 (70%), 177 (22%) and 62 (7.8%) were treated with open surgery, ESWL and percutaneous nephrolithotomy, respectively. Of the ureteral calculi 85 (43%), 37 (18.6%) and 76 (38%) were managed by ESWL, ureterorenoscopy and open surgery, respectively. Of the bladder calculi 307 (68%), 77 (17.2%) and 63 (14%) were treated with open vesicolithotomy, transurethral pneumatic cystolithotripsy and ESWL, respectively. The renal stone clearance rate was 98% after open surgery, 84% after ESWL and 68% after percutaneous nephrolithotomy monotherapy at 3 months of followup. Similarly the ureteral stone-free rate was 54% after ESWL and 86.9% after ureterorenoscopy. Of the patients with bladder calculi 48% and 93% become stone-free after ESWL and transurethral pneumatic cystolithotripsy, respectively.

CONCLUSIONS

The use of ESWL, percutaneous nephrolithotomy and ureterorenoscopy has resulted in treating a large number of children with a short hospital stay and early return to school. Open surgery is reserved only for complex stones.

Spectrum of pathological lesions in acute renal failure

OBJECTIVE

To determine the spectrum of pathological lesions in percutaneous renal biopsies of patients with acute renal failure (ARF) and to compare our findings with reported literature.

DESIGN

A single center based retrospective observational study.

PLACE AND DURATION OF STUDY

The study was conducted in the Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi over a period of seven years (April 1995 to April 2002).

SUBJECTS AND METHODS

All the patients with ARF who presented to the emergency ward of SIUT between April 1995 and April, 2002 and in whom renal biopsy was performed, were included in this study. Patient's demographic and clinical data were collected from a review of patient's original surgical biopsy reports and case files. Pathological diagnosis was retrieved from a review of biopsy reports. Renal biopsies were received in 10% buffered formalin and processed for paraffin embedding and subsequent histopathological examination under the light microscope.

RESULTS

A total of 158 patients were studied. Of these 57 were males and 101 females. Mean age of the patients in this series was 30.7 years with a range of 6 to 75 years. Of these 61(38.6%) had acute tubular necrosis, 36 (22.7%) acute cortical necrosis and 49(31%) patients had various types of glomerulonephritis (GN). Eight patients (5%) had acute tubulointerstitial nephritis, 3 (1.8%) acute pyelonephritis and one patient had mucormycosis.

CONCLUSION

This study showed that even in the selected population of biopsied ARF cases, there was a high prevalence of ischemic renal disease. A substantial number of cases in unexplained ARF on renal biopsy were due to various forms of glomerulonephritis.

Evaluating the effectiveness of a longitudinal magnetic field in reducing underdosing of the regions around upper respiratory cavities irradiated with photon beams--a Monte Carlo study

The problem of underdosing lesions adjacent to upper respiratory cavities and a proposal to correct it are presented in this work. The EGS4 Monte Carlo code was used to simulate a 6 MV x-ray beam passing through a block of tissues with air cavities 2, 4, and 6 cm wide. The geometry used approximates the tracheal geometry used by previous researchers who investigated the underdosing phenomenon. A uniform longitudinal magnetic field of 0.5 T strength is used to reduce secondary electron outscatter caused by the presence of an air gap, and thus improving the dose at the distal surface of air cavities. We introduce the term "percent dose reduction" (PDR), which is defined as the difference between the dose after the air cavity and the dose at the same depth in soft-tissue phantom normalized to the dose in the tissue phantom, to quantify the reduction in dose after an air gap. We also introduce the term dose improvement ratio (DIR), which is defined as the dose ratio with magnetic field to the dose, at the same point, without magnetic field, to quantify the improvement in dose when the magnetic field is applied. For 2 x 2 x 20 cm3 and 4 x 4 x 20 cm3 air cavities irradiated by 2 x 2 cm2 beams, we found PDRs of 38% and 52%, respectively. This means that for these cavities, there is a 38% and a 52% reduction in dose at the cavity edge compared to the same dose in tissue at the same depth for each cavity. The dose improved by 30% (DIR= 1.3) and 87% (DIR= 1.87), respectively, when applying the magnetic field. The worst effect on dose at the distal side came from larger cavities irradiated with small fields. In these situations, the improvement in dose due to the presence of magnetic field was the largest. This article deals with "ideal" head and neck geometries with a uniform magnetic field. In a paper to follow we will use a CT-based phantom to study the effect in realistic geometries with the presence of a magnetic field from a Helmholtz coil pair.

Analysing collimator structure effects in head-scatter calculations for IMRT class fields using scatter raytracing

The frequent blocking of the irradiated volume in intensity modulated radiation therapy (IMRT) makes the head-scatter fraction of the incident photon fluence more significant than that in conventional therapy with open fields. On the other hand. certain collimator configurations block scatter photons directed to a given observation point while allowing primary photons to be transmitted. The 'anomalous blocking' makes the primary field a poor indicator of the scatter fluence. Since large MU-to-cGy ratios in IMRT can magnify head-scatter uncertainties, it becomes necessary to accurately model both the effective scatter source and the collimator structure that limits the scatter reaching the irradiated volume. First we obtain a dual-source model, using a Taylor series expansion to derive the effective scatter source distribution from the data measured for the Elekta SL20 linac equipped with a multi-leaf collimator (MLC). Then, using a raytracing algorithm, we calculate the transmission of scatter rays from the effective scatter source plane to points in the patient plane. The method can account for the anomalous blocking of scatter by the MLC leaves and the backup diaphragms. For a variety of collimator settings tested, the calculations agree with measurements to an accuracy of 0.002psi10 x 10, where psi10 x 10 is the total (primary + scatter) photon fluence of an open 10 x 10 cm2 field for the same MU delivered. Although the significance of collimator structure in IMRT depends strongly on fields shapes employed for the delivery, potential cumulative errors on the order of a few per cent can be avoided in fluence calculations if the proposed method is used.

Heavy mining vehicle controls and skidding accidents

This paper examines various control locations in heavy mining vehicles. Three trucks have been tested on a skid pad in both clockwise and anticlockwise directions. The skid lengths were measured after each trial. The primary focus of the study was the positioning of various controls and their relevance to various skid lengths. Some additional measures such as NASA-TLX scales were also used to make subjective evaluations. The results are presented in this paper. The findings clearly indicate the relevance of control locations to actual skid lengths. The poorly located controls resulted in greater skid lengths. This is an important finding as skid lengths are related to greater reaction times in a skidding situation and hence greater risk of accidents on relevant trucks. Such accidents can incur large repair bills for damaged equipment whereas more importantly, jeopardizing the life and safety of heavy mining vehicle drivers.

Pericardial effusion as a cause of morbidity in patients on maintenance hemodialysis: is it preventable?

OBJECTIVE

Cardiovascular diseases are the cause for 45% mortality and 20% morbidity in hemodialysis (HD) patients. Pericardial effusion (PE) accounts for 03-04% of all deaths in HD patients as a result of tamponade, arrhythmias or heart failure. This study aims to find out the prevailance and precipitating factors for PE in hemodialysis patients.

PATIENTS AND METHODS

Fifty-five patients were identified for echo-cardiographic assessment on the basis of signs and symptoms suggestive of PE i.e., hypotension during dialysis, dyspnea, globular heart in chest x-ray, raised JVP, soft heart sounds and low voltage ECG. A matched controlled group of 55 patients for age, sex, dialysis schedule, cause of ESRD and dialysis bath, was also studied echocardiographically.

RESULTS

Pericardial Effusion was detected in 12 patients (10.9%), 10 (83.3%) were on 2/week and only two on 3/week dialysis. Of these 75% were non-compliant in fluid intake and 58.3% were irregular in treatment. The morbidity of PE in study group (18.2%) is significantly higher as compared to controls (3.6%) (P = < 0.05). No correlation was found between development of PE and high iPTH and low albumin levels. Ten patients with mild PE responded to vigorous dialysis. Two patients developed cardiac tamponade needing pericardiocentesis.

CONCLUSION

We have identified 2/week dialysis (inadequate dialysis dose), acetate bath and fluid and dialysis non-compliance as factors contributing to development of PE in HD patients.

Reducing loss in lateral charged-particle equilibrium due to air cavities present in x-ray irradiated media by using longitudinal magnetic fields

The underdosing of lesions distal to air cavities, such as those found in upper respiratory passages, occurs due to the loss in lateral charged-particle equilibrium (CPE). The degree of underdosing worsens for smaller field sizes, resulting in more frequent recurrence of the cancer treated. Higher photon energies further aggravate the outcome by producing longer second build-up regions beyond the cavity. Besides underdosing, the larger lateral spread of secondary electron fluence in the air cavity produces diffuse dose distributions at the tissue-air interface for shaped or intensity modulated fields. These disequilibrium effects create undesirable deviations from the intended treatment. The clinical concern is further intensified by the failure of traditional treatment planning systems to even account for such defects. In this work, the use of longitudinal magnetic fields on the order of 0.5 T is proposed for alleviating lateral electronic disequilibrium due to the presence of air cavities in the irradiated volume. The magnetic field enforces lateral CPE by restricting the lateral range of electrons in the air cavity. The problem is studied in a simple water-air-water slab geometry using EGS4 Monte Carlo simulations for 6 MV photons. Electronic disequilibrium is evaluated for beams of various sizes, shapes and intensity distributions constructed by linear superposition of the dose distributions for 0.5 x 0.5 cm2 beamlets. Comparison is also made with 60Co irradiation. The results indicate that the lateral confinement of secondary electrons in the air cavity by sub-MRI strength longitudinal fields is effective in reducing deterioration of dose distributions near tissue-air interfaces. This can potentially reduce recurrence rates of cancers such as the larynx carcinoma.

High-energy microwave thermotherapy in patients in urinary retention

PURPOSE

To study the outcome of high-energy transurethral microwave thermotherapy (TUMT) in patients with obstructive benign prostatic hyperplasia (BPH).

PATIENT AND METHODS

Between September 1995 and March 1998, patients presenting with urinary retention secondary to BPH were recruited into the study. Their mean age was 67.2 years (range 50-85 years). The mean catheterization time prior to treatment was 3 months (range 15 days-1 year). Among the 200 patients treated during this period, 30 were high anesthesia risk (American Society of Anesthesiologists Class III/IV). The patients were treated in a single 1-hour session using high-energy (Prostatron 2.5) software, the range of energy transmitted being 111.9 to 214.2 kJ (mean 196.3 kJ). Symptoms were scored according to the International Prostatic Symptom Score (IPSS). The mean prostate volume subjected to TUMT was 59 cc (range 40-149.7 cc). The patients were followed every 3 months with measurements of peak flow rate, postvoiding residual urine volume estimation, and IPSS.

RESULTS

Of the 200 patients, 33 were lost to follow-up, 155 were responsive (catheter free with physiologically acceptable peak flow rate), and 12 (7%) were nonresponsive. Only 4 patients (2%) experienced deterioration in their flow rates during the follow-up period of 2 years. They underwent transurethral resection. High-energy thermotherapy resulted in irritative voiding complaints in 80% of patients for 2 to 4 weeks.

CONCLUSION

The initial results were encouraging, and the 2-year follow-up has shown appreciable sustainability in the treatment outcome, particularly in patients at high anesthesia risk.

Prediction of renal function recovery in obstructive renal failure due to stones

Two hundred and thirty-nine patients with renal and ureteric calculi associated with renal failure were evaluated for recovery potential before definitive surgery. Ultrasonography was carried out pre-operatively in all, followed by percutaneous nephrostomy (PCN) as an initial management before definitive surgery. Diethylene triamine penta acetic acid (DTPA) scan was done in 125 patients after percutaneous nephrostomy, findings of pre- operative DTPA scan were correlated with post-operative drop in serum creatinine. Urine pH, urine Na+, initial diuresis, creatinine clearance and serum creatinine were measured serially after 24 hours and then every week for 6 weeks. Patients were re-evaluated with serum creatinine after 3 months of surgery. Ultrasonography was found to be reliable in predicting future recovery of renal functions in 76.5% cases and true obstruction of shorter duration (F4-group) on DTPA scan in 81.9% cases. Urine pH of 6 or less, post-PCN diuresis and natriuresis were good prognostic indicators. PCN was found to be most reliable method of predicting future recovery of renal function after relief of obstruction with 97.8% accuracy.

Frequency of metabolic bone disease in haemodialysis patients

The frequency of metabolic bone disease related to secondary hyperparathyroidism was studied in 47 haemodialysis patients, using biochemical, radiological parameters and bone biopsy (30 males, 17 females; mean age 48 years). The duration on dialysis ranged from 1-5 years. Hypocalcemia was found in 47% while 62% had raised phosphorus levels and 49% raised alkaline phosphatase. Serum parathyroid hormone was elevated in 86%, while in 13% it was markedly raised. On radiological examination there was generalized osteopenia in 49% and decreased bone density in 21%. In 30% no radiological abnormality was detected. In 40% bone biopsy revealed osteomalacia, mixed osteodystrophy 21%, osteoporosis 8.5% and in 25% no histological abnormality was observed.

Predictors of mortality in hemodialysis

One hundred and five patients enrolled in the maintenance haemodialysis programme at The Kidney Centre were studied retrospectively to identify patient characteristics associated with increased mortality. Hypertension (relative risk 10.03, P < 0.001), serum albumin < 3 G/dl (relative risk 2.60, p < 0.05), diabetes mellitus as a cause of End Stage renal disease (relative risk 2.54, p < 0.001), age > 55 years (relative risk 1.8, p) were associated with higher risk of mortality, while sex had no statistically significant effect.

Non-compliance to diet and fluid restrictions in haemodialysis patients

Compliance with fluid and dietary instructions is a critically significant factor in the health and well-being of haemodialysis patients. Serial measurement of serum potassium (K) and interdialytic weight gain (IWG) were carried out in 50 haemodialysis patients at the Kidney Centre over a period of one month. Sixty-two percent were males. Ages ranged from 19-69 years (mean 49 years). Duration on dialysis varied from 6 months to 9 years. Patients with an IWG > 1.5 Kg and/or serum K+ > 5.5 m Eq/L were defined as non-compliant. Thirty-two patients (64%) were non-compliant in either diet or fluid. In 13 of these cases, both serum K and IWG were elevated. In the remaining 19, only one value was high. Predictors of non-compliance to diet and fluid regimens were older age (81%), males (68%), less education (75%), single (90%) depression (59%) and not feeling responsible for one's own well-being (85%). Attempts to improve compliance should be aimed by exposing the non-compliant group to nutritional and psychosocial therapy.

Management of urinary calculi associated with renal failure

Three hundred and sixty patients of urinary calculi associated with renal failure were included in this prospective study. The male to female ratio was 4.1:1 while adult to paediatric ratio was 6.5:1. One hundred and eighteen (32.8%) patients presented with calculus anuria while 242 (67.2%) were admitted with symptoms of chronic renal failure. Serum creatinine at the time of first admission ranged from 3-35 mg/100 ml. In the initial management, percutaneous needle nephrostomy was done in 217 cases, dialysis in 106, dialysis and PCN in 22 and retrograde catheterisation followed by JJ stent in 15. Definitive surgical procedures were undertaken in 277 cases; 29 passed stones spontaneously after PCN. At two year follow-up 72% patients of calculus anuria and 49.5% of calculus renal failure improved their renal function and remained with serum creatinine below 2 mg/100 ml. There was 13.6% mortality in calculus anuria group and 17.4% in calculus renal failure. Overall loss to follow-up was 7.6% and 12% in the two groups respectively.

Nutritional assessment of patients on maintenance haemodialysis

Nutritional assessment was carried out on fifty haemodialyzed patients by demographic, anthropometric, biochemical and dietary indices. The mean age of the patients was 49 years with a male to female ratio of 2.3:1. The duration of dialysis ranged from 6 to 40 months with a mean of 25 months. Fifty percent of the patients were moderately nourished based on their body weight 44%, body mass index 40% and mid-arm circumference 66%. Seventy percent patients had albumin and total proteins within the normal range. Blood urea nitrogen, creatinine, cholesterol, potassium and phosphorus did not significantly change from the previous reports. The calorie and protein intake in 60-70% cases was less than recommended. Overall there was a tendency to calorie and to a lesser degree protein malnutrition in our patients. It is suggested that preventing malnutrition by economical, aggressive and ongoing dietary intervention may minimize malnutrition in haemodialyzed patients.

Treatment of ureteric stones. Comparison of laser and pneumatic lithotripsy

OBJECTIVES

To study the treatment of ureteric stones by laser lithotripsy (LL) and pneumatic lithotripsy (PL), and to evaluate the results of the two treatment modalities to assess effectiveness, complications and cost benefits.

PATIENTS AND METHODS

Between January 1993 and February 1994 200 ureteric stones in 194 patients were fragmented intracorporeally, 48 by LL and 152 by PL. The ages of the patients ranged from 31 to 40 years with a male to female ratio of 2:1. All procedures were performed under general/regional anaesthetic in a day-care set-up. Patients were followed at weekly intervals. Re-treatment was carried out at 4 weeks where necessary.

RESULTS

The majority of the stones treated (84%) were in the lower third of the ureter, 69% measured 7-12 mm in diameter, and 61% were composed of calcium oxalate. Ninety-three per cent of the stones were fragmented in one treatment session. The overall stone-free status at 4 weeks was 95% for PL and 84% for LL. The non-fragmentation rate was 10% for LL and 1% for PL. Post-treatment complications were encountered in 8% of the patients treated by LL and 7% by PL.

CONCLUSIONS

Our experience shows that PL and LL both provide a safe and effective means of performing intracorporeal lithotripsy for smaller ureteric stones. However, PL is more effective in fragmenting larger and harder stones. Moreover, PL is more user-friendly and highly cost-effective compared with LL.

Study of forward sloping seats for VDT workstations

The main focus of this study was to identify and evaluate various forward seat inclinations (5, 10, 15 degrees) for Video Display Terminal workstation type seating by constructing a fixture to be fitted to a test chair to achieve various seat angles. The discomfort in critical areas i.e. neck and lower back were evaluated by 25 male university students (avg. age 22 years) with no history of musculoskeletal disorders on a subjective scale for comfort. The comfortable or uncomfortable seat inclinations were identified after a statistical analysis. The heart rate and blood pressure were observed every 5 min for validation purposes. It was recommended that, to avoid neck problems, a chair with a forward incline greater than 5 degrees should not be used and to avoid lower back problems a chair with a seat angle of approximately 10 degrees be used. On the overall comfort criteria it is recommended to use a chair with a seat pan which inclines to approximately 15 degrees (forward). The findings and recommendations from this study can enhance the safety and productivity of the people whose jobs require continuous forward bending in a sitting task involving VDT workstations.

Once weekly subcutaneous administration of erythropoietin in haemodialysis patient

Twenty-five anaemic patients of End Stage Renal Disease (ESRD) on maintenance haemodialysis at the Kidney Centre were studied. Recombinant human erythropoietin (EPO) 50-units/kg body weight was given once a week subcutaneously to see the response to therapy. In 21 cases haemoglobin increased significantly from 7.5 to 9.5 g/dl and haematocrit from 23 to 30.5 l/l with success rate of 84% and marked improvement in their quality to life. Once a week subcutaneous administration of erythropoietin is convenient and cost effective in reversing renal anaemia with minimal complications.

Hepatitis-C virus antibodies (anti HCV) in haemodialyzed vs non-dialyzed patients

Anti HCV was checked using Enzyme Immuno assay (EIA) (C100-3-Abbott) in 68 patients with chronic renal failure (CRF) who were on maintenance haemodialysis and 48 patients on conservative management. Mean age of the patients was 50 years. The duration of illness ranged from 3 months to 18 years (mean 3 years). All patients were Hepatitis B surface antigen (HBsAg) negative. In haemodialyzed group 31 (46%) and in conservative group only 3 (6%) were Anti HCV positive. High Frequency of Anti HCV positivity in haemodialyzed group was related to period on dialysis (1 year) and number of blood transfusions (>4 units). Patients in whom dialyzer was re-used showed 60% positivity as compared to only 17% in those with single use. Anti HCV positivity predominated in females as compared to males, 42.6% vs 20.3%. Nine out of 10 patients with a history of jaundice and six out of 8 patients with raised transaminase levels were Anti HCV positive. Fifteen of 37 Anti HBc (IgG) positive cases were Anti HCV +ve.

A methodology to assess the upper extremity strength in a chair egress posture

In this paper a method is presented which can be used to analyse the force distribution resulting from the application of force on the left and right armrest of a chair during the action of sitting down or standing up. The peak data for both hands can be combined to obtain the maximum for a trial on a specific chair configuration. This method is useful to assess the upper extremity limitations of an elderly or disabled population when rising from a seated position. The method involved the instrumentation, with strain gauges, of armrests of a prototype lounge chair obtained from a manufacturer of seating for the elderly. Provision for hand placement was included and the system was appropriately calibrated. The methodology presented may have a variety of applications, such as the assessment of seating requirements for the elderly or disabled, and the relative evaluation of a range of seats for nursing homes, clinics, hospitals and rehabilitation or recreational lounges.

Study of potassium citrate treatment of crystalluric nephrolithiasis

Patients with crystalluric nephrolithiasis were treated orally with aqueous potassium citrate solution three times a day with a large quantity of water. After administration of potassium citrate, citric acid (P < 0.001) and potassium (P < 0.001) excretion was significantly increased. Increase in protein (P < 0.05) and uric acid (P < 0.05) excretion in urine revealed their association with the crystallization process. Crystals were absent in 12 (71%) out of 17 patients. Calcium excretion in urine was significantly decreased (P < 0.05). A decrease of calcium ions availability to oxalate ions to form calcium oxalate crystals may result in the prevention of calcium oxalate stone formation.