Teaching biostatistics and epidemiology in a postgraduate medical institution: are we going in the right direction?

We examined the attitude and knowledge of 40 supervisors and trainees as well as the impact of workshops on statistical thinking and analytical processes in a medical facility in Pakistan: 45% thought that statistics and epidemiology should be left to professional statisticians; 86% of the trainees and 58% of the supervisors, however, thought that statistics should be taught as a full-time subject. The majority of trainees (86%) were dissatisfied with the workshops compared to 33% of supervisors. Our findings indicate an urgent need to revise our approach to teaching statistics and epidemiology.

Sixteen years follow up of achalasia: a prospective study of graded dilatation using Rigiflex balloon

Pneumatic balloon dilatation is the treatment of choice for esophageal achalasia. Rigiflex (Microvasive, Watertown, MA) polyethylene balloon dilators have been used with varying success and complications. The aim of this study was to evaluate the efficacy of graded balloon dilatation, to achieve symptomatic improvement in patients with achalasia. From January 1987 until the end of December 2003, 300 patients were evaluated and treated for achalasia, with 30 mm balloons. Patients who did not achieve satisfactory symptomatic responses during follow up underwent repeat dilatation with 35-mm balloons. They were studied at the onset then at 1 and 6 month intervals and then yearly for postdilatation symptom evaluation for dysphagia, regurgitation, night cough and heartburn. Baseline and 5-min postdilatation barium swallow studies were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. No patients developed cancer of the esophagus in 16 years follow up. Barium height, width, composite symptom score and weight improved significantly during follow up. Two patients, who needed repeat dilatation with 35-mm balloons, developed esophageal perforation; one was successfully managed with intensive medical care management, whereas the other patient died despite surgical intervention. The authors conclude that pneumatic balloon (Rigiflex) dilatation for achalasia of the esophagus is a successful first option, when applied in an incremental balloon size to achieve desired results in symptomatic relief.

Efficacy of Rigiflex balloon dilatation in 12 children with achalasia: a 6-month prospective study showing weight gain and symptomatic improvement

Achalasia cardia is a disease of adolescents and is rare in children. In total, 12 children with primary achalasia, with a mean age of 10.8 +/- 2 years, were prospectively evaluated for the efficacy of a 30-mm-diameter Rigiflex balloon for relief of symptoms and weight gain after 1 and 6 months of follow up. The 12 children were evaluated and treated for achalasia, with pneumatic balloon dilatation, from January 1998 to December 2000. They were studied for basal, 1-, and 6-month post-dilatation composite symptoms for dysphagia, regurgitation, night cough and heartburn. Basal and 5-min post-dilatation barium swallow were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. There were no complications. Barium height, width, composite symptom score and weight improved significantly up to the 6-month follow up. Rigiflex balloon dilatation of 30-mm diameter is safe and effective in children with achalasia.

Correlation of Helicobacter pylori in dental plaque and gastric mucosa of dyspeptic patients

OBJECTIVE

To establish the prevalence of Helicobacter pylori colonization of dental plaque and its correlation with Helicobacter pylori infection of the antral mucosa in patients with symptomatic dyspepsia.

METHODS

Seventy eight adult dyspeptic patients undergoing upper gastrointestinal tract endoscopy were prospectively enrolled. Four air dried dental plaque cytology slides and four gastric antral mucosal biopsies were stained with Giemsa stain. CLO test was used for detection of urease activity of Helicobacter pylori in the dental plaque specimens and antral mucosal biopsies. Data on endoscopic findings and orodental hygiene were recorded.

RESULTS

Dental plaque colonization using CLO test and cytology was found to be 100% and 88% respectively. Antral biopsy for H. pylori was positive in 61% cases by CLO test and 57% cases on histopathology. Forty four out of 69 patients (63%) had both dental plaque and antral biopsy positive for H. pylori. No patient with negative dental plaque cytology was positive for H. pylori in gastric mucosa. A statistically significant correlation was found between H. pylori colonization of dental plaque and gastric antrum. The sensitivity and specificity of dental plaque cytology in diagnosing H. pylori antral colonization was 100% and 26% while the positive and negative predictive values were 64% and 100% respectively.

CONCLUSION

The prevalence of H. pylori in dental plaque of patients with dyspepsia was very high in our patients indicating it to be a major reservoir of infection.

Massively dilated esophagus in achalasia: response to pneumatic balloon dilation

OBJECTIVE

Pneumatic balloon dilation is considered by many to be the treatment of choice for achalasia of the esophagus. Patients with untreated, long standing achalasia may develop massively dilated esophagi, sometimes difficult to dilate with a pneumatic balloon and, rarely, may require esophagectomy. We present our experience with nine such patients out of 110 who underwent pneumatic dilation.

METHODS

Of 110 patients treated for achalasia by pneumatic balloon dilation, from January 1989 until December 1996, nine patients had massively dilated esophagi with transverse diameter >7 cm. Results of these patients are presented with pre- and postdilation symptom scores and barium esophagograms. This study was conducted at the Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan. A Microvasive Rigiflex 35 mm (Boston Scientific, Watertown, MA) pneumatic balloon was used for dilation.

RESULTS

Although it is often tedious to perform pneumatic dilation in massively dilated esophagus, it was possible to dilate adequately, in all nine cases without complications, with good symptomatic improvement at 12-month follow-up.

CONCLUSIONS

We recommend pneumatic balloon dilation in achalasia with massively dilated esophagus as a first line treatment, the failure of which requires surgical intervention.

Helicobacter pylori in dental plaque of Pakistanis

Helicobacter pylori is now generally accepted to play a key role in acid related and neoplastic pathology of gastroduodenal diseases. Recent reports have concluded that dental plaque is not an important reservoir for Helicobacter pylori, however, these studies did not consider the ethnic background of their subjects nor the amounts of dental plaque present. The aim of this study was to explore the association of Helicobacter pylori dental plaque colonisation in 125 males and 53 females (group I) attending a dental clinic in Pakistan. A simultaneous sample of 30 healthy volunteers with good orodental hygiene consisting of 17 males and 13 females was included as a control group (group II). Six dental plaque specimens were obtained from each subject with a sickle scaler; two were inoculated into CLO test gel and the remaining four were used to prepare cytology slides stained with Giemsa's stain. CLO test was positive in all specimens from group I, while cytology for Helicobacter pylori was positive in 173 cases in this group. One hundred and forty two cases had heavy plaque deposits and all of them were positive on cytology. In group II CLO test was positive in 20 and dental plaque cytology was positive in 7 cases. In conclusion, it is important that future studies into the prevalence of Helicobacter pylori in the oral cavity should take into account the levels of oral cleanliness and the ethnic background of the subjects.

Predicting hospital mortality in cirrhotic patients: comparison of Child-Pugh and Acute Physiology, Age and Chronic Health Evaluation (APACHE III) scoring systems

OBJECTIVE

The severity of hepatic abnormalities and extent of dysfunction of other organ systems influences prognosis for cirrhosis. The Child-Pugh system has been used to classify cirrhotic patients into good, intermediate, or poor risk categories in evaluation and therapy. Disregard for cardiorespiratory, renal, electrolyte balance, and acid base status limits its predictive accuracy. We evaluated the accuracy of Acute Physiology and Chronic Health Evaluation (APACHE III) to predict short term hospital mortality in patients with liver cirrhosis.

METHODS

A total of 282 patients were prospectively enrolled. Child-Pugh and APACHE III scores were recorded on day 1 for each patient.

RESULTS

Mean age was 51.7+/-11.3 yr, with 65% men and 35% women; 57% presented with upper GI bleeding, 47% encephalopathy, 9% hepatorenal syndrome, and 7% hepatocellular carcinoma. Sixty-three patients (22%) died. Major causes of death were upper GI bleeding 38%, liver failure 21%, hepatorenal syndrome 19%, hepatocellular carcinoma 4%, and spontaneous bacterial peritonitis 6%. Child-Pugh and APACHE III scores for survivors (8.6+/-2.3 and 58.9+/-35.1) were lower than those for nonsurvivors (10.9+/-2.7 and 87.4+/-30.3) (p < 0.001). Using discriminant analysis, APACHE III correctly identified 75% of cases vs 67% of cases for Child-Pugh (p < 0.05). When information regarding ascites and prothrombin time was added to APACHE III, 81% of cases were correctly classified.

CONCLUSION

The APACHE III scoring system is superior to Child-Pugh for prognosticating short term survival of cirrhotic patients. Prognostic accuracy of APACHE III can be enhanced by incorporating information regarding ascites and prothrombin time prolongation.

Hiatal hernia in achalasia

Barium esophagograms of 89 patients out of 110 with manometrically proven achalasia were reviewed. Only four (4.4%) patients showed association of hiatal hernia, indicative of its rare occurrence. Presence of hiatal hernia, is said to have less likelihood of associated achalasia but this association does exist as per our report and that of others.

Pneumatic balloon dilation in achalasia: a prospective comparison of balloon distention time

OBJECTIVE

Duration of Inflation in pneumatic balloon dilatation as treatment of achalasia has been variable ranging from 15 s to 6 min. A 60 s duration appears to be most often used. We compared the efficacy of dilation of achalasia with either 6- or 60-s inflation duration using a Rigiflex dilator of 3.0 cm diameter.

METHODS

Eighty-one consecutive patients were prospectively studied in a randomized fashion, 41 in the 60-s group (A) and 40 patients in the 6-s group (B). Mean age of group A was 43 +/- 16.2 yr and of group B was 40 +/- 16.4 yr. Symptoms of dysphagia, chest pain, heartburn, regurgitation, and night cough were evaluated at basal (before dilation), 1- and 6-month intervals after dilation in both groups. Barium swallow was done to assess esophageal emptying 1 wk before dilation and 5 min postdilation in both groups.

RESULTS

Significant and sustained improvement was seen for all symptoms in both groups. In addition, the degree of improvement in symptom scores between the two groups was similar. Barium esophagram in both groups at basal and immediately postdilation showed significant improvement in barium emptying but there was no significant difference between the two groups, indicative of equal efficacy in both distention times. Two patients needed repeat dilatation in group A and one in group B, with one drop out from group A, who was lost to follow-up, and was excluded from the analysis. No perforation occurred.

CONCLUSION

Short duration of pneumatic balloon dilatation (6-s) is as effective as longer duration (60-s) in treatment of achalasia.

Hepatocellular carcinoma: analysis of 76 cases

Hepatocellular carcinoma is one of the most common malignancies world wide. We present data on 76 patients admitted to the Shaikh Zayed Hospital. Mean age was 52.2 +/- 11.3 years. Eighty six percent were males and 14% females. Eighty-six percent patients had underlying cirrhosis documented on ultrasound examination. Seventy-five percent were positive for anti HCV, 10% for HBsAg positive, 10% for both HBsAg and anti HCV and 5% cases had negative viral serology. Main clinical features were abdominal pain, weight loss, jaundice, hepatomegaly and ascites. Forty-three percent patients were Child-Pugh class A, 30% class B and 13% class C and 14% were non cirrhotic. Mean alfa fetoprotein levels were 142 +/- 155 ng/ml (range 2.7 to 1470). Diagnosis of hepatocellular carcinoma was established in 60 patients by fine needle aspiration biopsy under ultrasound guidance. Two patients died after biopsy due to uncontrollable bleeding. Fifty-four percent patients had a solitary lesion and 46% had multifocal or diffuse lesions. The average size of lesion was 7.8 x 8.1 cm. Twenty-two patients received intralesional alcohol injection. Fifty-four percent of these with a tumor size greater than 8 cm died during follow up. The major cause of death was liver failure in 8 patients and fatal bleeding occurred in 4 patients. Hepatocellular carcinoma has a high prevalence in middle aged males with a strong association with anti HCV positive cirrhosis. Patients with a tumour size greater than 8 cm have a poor response to intralesional alcohol injection.