Non-melanoma skin cancer of the head and neck

Skin cancer is the most common malignancy in the world, and the majority of cases affect the skin of the head and neck. The face is a particularly emotive area for patients who often present with a lesion that is causing them concern. This article reviews the identification, diagnosis and principles of management of non-melanoma skin cancer of the head and neck. There are many lesions of the skin which are benign and mimic skin cancer. The differential of head and neck skin lesions and how to determine their nature is discussed. The vast majority of non-melanoma skin cancer are basal cell carcinoma, followed by squamous cell carcinoma. These and the other types of non-melanoma skin cancer are described and illustrated. Current methods of clinical identification, diagnosis and evaluation of skin cancers are clarified, and contemporary treatment paradigms are presented.

Changing epidemiology and trends in incidence of thyroid cancer in England, 1985-2019

Background

Thyroid cancer is 2-3 times more common in females and is currently the fastest growing cancer worldwide. Exposure to ionizing radiation is the only established risk factor for thyroid cancer. Other factors include obesity, history of benign thyroid conditions, and family history. We conducted a retrospective population-based cohort study to examine whether there have been changes in the incidence of thyroid cancer in England during the past four decades.

Methods

Individual level data for patients diagnosed with thyroid cancer in England during 1985-2019 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by two age categories (0-49, 50+ years) and all ages combined during the seven five-year time periods (1985-89 to 2015-19). The percentage change in incidence was calculated as change in the average annual incidence rate from the first (1985-89) to the last time period (2015-19).

Results

During the 35-year study period, a total of 58,710 new cases of thyroid cancer were registered in England (27.3% males, 72.7% females). In young people aged 0-49 years, the average annual incidence rates increased by 375% in males and 438% in females (from 0.4/100,000 in 1985-89 to 1.9/100,000 in 2015-19 in males and from 1.3/100,000 in 1985-89 to 7.0/100,000 in 2015-19 in females). In older people aged 50+ years, the rates increased by 146% in males and 171% in females (from 2.4/100,000 in 1985-89 to 5.9/100,000 in 2015-19 in males and from 4.1/100,000 in 1985-89 to 11.1/100,000 in 2015-19 in females).

Conclusions

There has been a steady and substantial increase in the incidence of thyroid cancer in England over the past four decades. The largest increase in incidence was observed in young people aged 0-49 years. Some of this increase is due to enhanced surveillance and sensitive diagnostic methods, but other factors (e.g., obesity and history of benign thyroid conditions) need to be considered.

Key messages

Changing epidemiology and trends in incidence of kidney cancer in England, 1985-2019

Background

Kidney cancer is the 7th most common cancer in the UK, accounting for 4% of all new cancer cases. The risk factors for kidney cancer include obesity, smoking, hypertension, and exposure to certain environmental and occupational carcinogens. We conducted a retrospective population-based cohort study to examine whether there have been changes in the incidence of kidney cancer in England during the past four decades.

Methods

Individual level data for patients diagnosed with kidney cancer in England during 1985-2019 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by two age categories (0-49, 50+ years) and all ages combined during the seven five-year time periods (1985-89 to 2015-19). The percentage change in incidence was calculated as change in the average annual incidence rate from the first (1985-89) to the last time period (2015-19).

Results

During the 35-year study period, a total of 197,819 new cases of kidney cancer were registered in England (62.4% males, 37.6% females). In young people aged 0-49 years, the average annual incidence rates increased by 164% in males and 144% in females (from 1.4/100,000 in 1985-89 to 3.7/100,000 in 2015-19 in males and from 0.9/100,000 in 1985-89 to 2.2/100,000 in 2015-19 in females). In older people aged 50+ years, the rates increased by 129% in males and 147% in females (from 24.5/100,000 in 1985-89 to 56.0/100,000 in 2015-19 in males and from 11.9/100,000 in 1985-89 to 29.4/100,000 in 2015-19 in females).

Conclusions

There has been a steady and significant increase in the incidence of kidney cancer in England over the past four decades. The largest increase (164%) was observed in young males aged 0-49 years, which was unexpected. Considering the risk factors for kidney cancer, further research is needed to understand the role of environmental/occupational exposures in causing kidney cancer.

Key messages

Trends in incidence of cervical cancer in England, 1985-2019

Background

Worldwide, cervical cancer is the 4th most common cancer in women. The highest incidence is observed in Africa (25.6/100,000) and the lowest in North America (6.1/100,000). Over 99% of cases are caused by human papillomavirus (HPV). In the UK, HPV vaccination has been offered to school children aged 12-13 years since 2008. We conducted a retrospective population-based cohort study to examine whether there have been changes in the incidence of cervical cancer in England during the past four decades.

Methods

Individual level data for women diagnosed with cervical cancer in England during 1985-2019 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by two age categories (0-49, 50+ years) and all ages combined during the seven five-year time periods (1985-89 to 2015-19). The percentage change in incidence was calculated as change in the average annual incidence rate from the first (1985-89) to the last time period (2015-19). Index of Multiple Deprivation (IMD) quintiles (2015-19) were examined to determine the social gradient of the disease.

Results

During the 35-year study period, a total of 100,303 women with cervical cancer were registered in England. In women aged 0-49 years, the average annual incidence rates declined by about 20% (from 11.6/100,000 in 1985-89 to 9.3/100,000 in 2015-19), and in women aged 50+ years, the rates declined by about 64% (from 26.1/100,000 in 1985-89 to 9.5/100,000 in 2015-19). At all ages combined, the rate declined by 43%. With regard to the social gradient, about half of the cases occurred in women in the most deprived quintiles.

Conclusions

There has been a steady decline in the incidence of cervical cancer in England over the past four decades. These findings are consistent with reports from other Western countries. The finding of relatively increased risk of cervical cancer among women from most deprived communities needs further investigation.

Key messages

• Considering that over 99% of cervical cancers are potentially preventable, there is an urgent need to support low- and middle-income countries to roll out HPV vaccination programme.

• The difference in risk of cervical cancer by social gradient highlights the importance of reducing health and social inequalities.

Changing epidemiology and trends in incidence of oesophageal cancer in England, 1985-2017

Background

The incidence of oesophageal cancer has been steadily increasing over the past 30 years in many countries. The UK has the highest incidence of oesophageal adenocarcinoma in the world which is associated with obesity and gastro-oesophageal reflux disease. The study aimed to determine trends in the incidence of oesophageal cancer in England between 1985-2017.

Methods

Individual-level data for patients diagnosed with oesophageal cancer in England were obtained from the Office for National Statistics/Public Health England. The national population-based cancer registry data were analysed to determine changes in oesophageal cancer incidence (ICD-10 code: C15) by sex, age (0-49, 50+) and histological subtype. Percentage change in incidence rates was calculated using the change in average annual incidence rate from the first (1985-89) to the last time period (2015-17).

Results

During the 33-year study period, 199,489 cases of oesophageal cancer were registered in England (63.5% males, 36.5% females) with adenocarcinoma accounting for 50.9% of cases. The average annual number of cases increased from 4595/year in 1985-89 to 7612/year in 2015-17. The average annual incidence rates increased by 42%, from 9.7/100,000 in 1985-89 to 13.8/100,000 in 2015-17. The incidence of adenocarcinoma increased by 77%, from 4.6/100,000 in 1985-89 to 8.1/100,000 in 2015-17. The incidence of squamous-cell carcinoma was unchanged. The steepest increase in adenocarcinoma was observed in males (more than two-folds as compared to females).

Conclusions

Over the study period, there was an increase in the incidence of oesophageal cancer in England. The largest increase was seen in rates of adenocarcinoma. Considering obesity has a strong temporal association with oesophageal adenocarcinoma, further research is needed to understand the biological mechanisms of this association to inform public health efforts to reduce the prevalence of obesity.

Key messages

Further research and analysis of routinely collected data on histological subtypes of oesophageal cancer can provide insight into the increasing trend in incidence. Considering the strong association between obesity and oesophageal adenocarcinoma, this research highlights the benefits of reducing the prevalence of obesity.

Trends in incidence of uterine cancer in England, 1985-2017

Background

Cancer of the corpus uteri (hereafter, uterine cancer) is the fourth most common cancer in women in the UK, accounting for 5% of all cancers in women. We conducted a retrospective population-based cohort study to examine whether there have been changes in the incidence of uterine cancer in England during the past four decades.

Methods

Individual level data for women diagnosed with uterine cancer in England during 1985-2017 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by two age categories (0-49, 50+ years) and all ages combined during the six five-year time periods (1985-89 to 2010-14) and the recent three-year period (2015-17). The percentage change in incidence was calculated as change in the average annual incidence rate from the first (1985-89) to the last time period (2015-17). Index of Multiple Deprivation (IMD) quintiles (2015-17) were examined to determine the social gradient of the disease.

Results

During the 33-year study period, a total of 169,768 women with uterine cancer were registered in England. In women aged 0-49 years, the average annual incidence rates increased by about 51% (from 1.8/100,000 in 1985-89 to 2.8/100,000 in 2015-17), and in women aged 50+ years, the rates increased by about 74% (from 39.0/100,000 in 1985-89 to 67.7/100,000 in 2015-17.). At all ages combined, the rates increased by 88%. With regard to the social gradient, in the young age group the highest proportion (46%) of cases occurred in women from the most deprived areas, whereas in the older age-group the highest proportion (43%) occurred in women from the least deprived areas.

Conclusions

There has been a steady and substantial increase in the incidence of uterine cancer in England over the last four decades. The observed dichotomy in risk between the young and older women by social gradient needs further investigation.

Key messages

Considering that 34% of the cases of uterine cancer in the UK are associated with obesity, the study informs formulation of public health programmes to reduce the prevalence of obesity. The difference in risk between the young and older women by social gradient highlights the importance of reducing health and social inequalities.

COVID-19 infection in ethnic minorities: A systematic review of age and gender distribution

Background

Currently, there have been 135,646,617 cases of COVID-19 infection and 2,930,732 deaths in the world. Compared with the White populations, members of the ethnic minorities living in Europe and North America are disproportionately diagnosed, hospitalized and dying from COVID-19. The reasons for this relatively increased risk of infection and adverse outcome are poorly understood. The aim of this review is to summarise current epidemiological evidence on age and gender distribution in ethnic minority patients hospitalized with COVID-19 infection.

Methods

Multiple electronic databases were searched. Data from studies, published in any language, reporting the risk factors, incidence and outcomes of COVID-19 infection in hospitalized White and ethnic minorities patients were extracted, reviewed and compiled.

Results

36 studies reporting data on age and 26 on gender were included in the review. Ethnic minority patients hospitalized with COVID-19 were relatively younger than White patients. Within the different minority groups, a greater proportion of Black patients were female, whereas a greater proportion of Asian patients were male.

Conclusions

This review confirms findings from individual studies that with regard to age, the ethnic minority patients hospitalized with COVID-19 infection are relatively younger than the White patients. There is also a disparity with regard to gender within the different minority groups.

Key messages

There is a disparity with regard to age and gender between the different ethnic groups affected with COVID-19 infection in Europe and North America. Potential factors for disparities are genetics, vitamin D deficiency, BCG vaccine, comorbidities, occupation, social gradient, housing, PPE access and understanding/compliance to protection measures.

Prevalence of autism in Europe, North America and Oceania, 2000-2020: A systematic review

Background

Since the first study of the prevalence of autism spectrum disorder (ASD) in 1966, several studies from across the world have reported increasing prevalence of ASD in children. This has led to a debate whether childhood ASD cases are increasing in real time or the increase is essentially due to improved accessibility/referral to health services or changes in diagnostic criteria and accuracy.

Methods

MEDLINE and PSYCINFO databases were searched for studies of ASD prevalence estimates in Europe, North America and Oceania published during 2000-2020 (including prevalence data for 1993-2019). Data including age at diagnosis, gender, ethnicity, diagnostic criteria/tools, method(s) of case detection and prevalence per 10,000 population were extracted.

Results

75 studies, reporting a wide range of prevalence estimates, were included in the review. Overall, there was a steady and substantial increase in the prevalence of ASD in Europe, North America and Oceania during the last three decades. For Europe, the median prevalence was 59 per 10,000 population (range, 8 to 420; mean, 80). For North America, the median prevalence was 86 per 10,000 population (range, 11 to 247; mean, 95). For Oceania, the median prevalence was 47 per 10,000 population (range, 10 to 390; mean, 112). Overall, the prevalence was higher in White children compared to other ethnic groups.

Conclusions

It appears that several factors can be attributed to increasing prevalence of ASD in Europe, North America and Oceania. Some of the increase is likely due to increased case ascertainment, but other factors need further investigation to determine the reason(s) for increasing prevalence of ASD.

Key messages

There is a wide variation in the prevalence of ASD in populations of Europe, North America and Oceania. This is partly explained by differences in case ascertainment and sociodemographic factors. The differences in prevalence between ethnic groups need further investigation.

Trends in Incidence of Primary Liver Cancer in the Elderly (Aged 65+ Years) in England, 1971-2010

Background: About 45% of the cases of liver cancer in England are diagnosed in the elderly. Since the 1990s, there has been a substantial increase in the incidence of liver cancer, and it has been projected that the incidence of rates will continue to increase to 15/100,000 by 2035. Aim: To determine the trends of incidence of liver cancer in the elderly in England during the period 1971-2010. Methods: Population-based national cancer registration data (obtained from the Office for National Statistics) were analyzed to determine the incidence of liver cancer (ICD-9 code: 155, ICD-10 code: C22) by age, gender, morphologic subtype and level of deprivation. Microsoft Excel and SPSS software were used for the analysis. Results: During the 40-year period, a total of 42,800 cases of liver cancer in the elderly were registered in England (58% male, 42% female). The number of cases increased by 462% - from 2,019 in 1971-75 (404 cases/year) to 11,345 in 2006-10 (2269 cases/year). The incidence rate (per 100,000) increased from 9.0 in 1971-75 to 37.4 in 2006-10 in males (316% increase); and from 4.6 to 19.6 in females (326% increase). In males, the incidence rates of liver cell carcinoma (ICD-10 code: C22.0) increased by 140% and the intrahepatic bile duct carcinoma (ICD-10 code: C22.1) by 2467%; whereas in females the incidence rates increased by 22% and 2260%, respectively. As for level of deprivation, the largest increase in incidence was observed in the least deprived population (721% in males, 690% in females). Conclusion: During the past four decades, there has been a remarkable increase in the incidence of liver cancer in the elderly in England. The relatively large increase in liver cell carcinoma in males, those in the least deprived category, and substantial increase in intrahepatic bile duct carcinoma in both genders warrant further investigation. These findings are also relevant for the planning of oncology services, resource allocation, screening for early diagnosis and public health education for primary prevention of liver cancer.

Parent's use of the Internet in the search for healthcare information and subsequent impact on the doctor-patient relationship

BACKGROUND

The Internet is an unavoidable source of healthcare information. This information, both reliable and unreliable, has previously been shown to influence carer's decisions.

AIMS

Our aim was to evaluate this information seeking behavior among parents and its subsequent potential impact on the doctor-patient relationship.

METHOD

We undertook a cross-sectional questionnaire-based survey of paediatric outpatients. Enrollment took place over 4 weeks in March 2015. There were no inclusion or exclusion criteria and enrollment was voluntary. In total 100 questionnaires were completed.

RESULTS

General Practitioners were the most common source of healthcare information. The Internet ranked third as a reliable source of healthcare information. The Internet was commonly used as an educational resource to learn about causes, treatment, and medications. A significant percentage of our population expressed concern regarding Internet information reliability. A small percentage of parents were concerned that disclosing Internet usage may worsen the relationship with their doctor.

CONCLUSIONS

Parents showed a willingness to learn about diseases and treatments, and felt that the Internet was a good resource to do so. This study shows that open discussion about Internet usage between parents and doctors is not common and carers feel at risk of judgment should they admit to Internet usage. The Internet should be seen as a positive adjunct to patient education which can improve understanding, thus strengthening the doctor-patient relationship. The Internet will never replace the role of healthcare professionals but must be seen as an integral part of a multi-disciplinary approach.

Anaplastic Thyroid Cancer: a Retrospective analysis of 120 cases

INTRODUCTION

Anaplastic Thyroid Cancer (ATC) is one of the most lethal malignancies with very short survival and extremely poor treatment outcome. ATC accounts for 2-5% of all thyroid cancers worldwide with an annual incidence of about 2 million.

OBJECTIVE

To review the natural history and treatment outcome of ATC patients treated at King Faisal Specialist Hospital and Research Centre (KFSH and RC) located at Riyadh, Saudi Arabia.

MATERIAL AND METHODS

Retrospective review of 120 Saudi cancer patients collected from registry data at KFSH & RC from 1976-2008. Search key words included: thyroid cancer, anaplastic, undifferentiated and not otherwise specified. Search was not restricted to particular age, gender, treatment or tumor size. Demographic information, baseline patient characteristics including date of diagnosis, type of treatment and date of death were obtained from KFSH & RC registry data and Saudi death registry.

RESULTS

A total of 120 cases were identified at our cancer centre from 1976 to 2008. Of these total, 73 were females (60.8%) and 47 were males (39.2%). The average age at diagnosis was 63.34 +/- 12.8 years. Thirty-four patients underwent surgery (28.3%), 52 had a palliative radiation treatment (43.3%) and only 5 had chemotherapy (4.2%). The median survival was 53 days (0-457).

CONCLUSION

Our review proves that ATC is rapidly fatal cancer and is unresponsive to currently available therapeutic options. More research is needed to understand the tumor biology and novel treatment options.

KEYWORDS

thyroid cancer, anaplastic, undifferentiated, radiation treatment, chemotherapy, median survival, Riyadh and Saudi Arabia.

Connecting with connexins

We describe a case of an 18-year-old woman with congenital sensorineural deafness who presented to the dermatology clinic with asymptomatic thickening of the skin over the palmar aspect of her hands and feet. An examination revealed palmoplantar keratoderma of the palms and soles of the feet with no pseudoainhum. Her father wore a hearing aid and his deafness had been thought to be acquired. Mutation analysis of the connexin 26 gene revealed that she carried a paternally inherited mutation, p.Asp46Glu and a maternally inherited M34T variant. The p.Asp46Glu mutation has been described in a family exhibiting non-syndromic autosomal dominant deafness. Although the M34T variant has been described as a non-pathogenic variant or with a very mild phenotype only, its combination with the p.Asp46Glu mutation may account for her mild cutaneous phenotype with later clinical presentation.

Recurrent primary paediatric herpetic whitlow of the big toe

A 9-month-old baby girl presented multiple times with an erythematous, papular and pustular big toe in an otherwise healthy infant. A diagnosis of cellulitis was made and she was started on oral antibiotics, and bacterial swabs were taken. After 2 weeks of worsening appearance she was admitted for intravenous antibiotics. Inflammatory markers remained normal and viral swabs were taken. No improvement was seen after 2 days and she was referred for orthopaedic and dermatological opinions. The orthopaedic team recommended debridement whereas the dermatologist suspected a primary herpetic whitlow and recommended intravenous acyclovir in addition to intravenous antibiotics. A viral swab for Herpes simplex virus type 1 (HSV1) was positive by PCR on day 3. The toe continued to improve clinically and the patient received 21 days of acyclovir in total. 27 days after discharge the infection relapsed. She was treated with a further 14 days of oral acyclovir and recovered completely.

THE SIGNIFICANCE OF EPIDERMAL GROWTH FACTOR RECEPTOR AND SURVIVIN EXPRESSION IN BLADDER CANCER TISSUE AND URINE CYTOLOGY OF PATIENTS WITH TRANSITIONAL CELL CARCINOMA OF THE URINARY BLADDER

OBJECTIVE

To assess whether epidermal growth factor receptor (EGFR) and survivin immunostaining of tumour cells in urinary cytology and tissue of patients with bladder cancer has a prognostic significance.

DESIGN

Prospective study

SETTING

Department of Surgery (Division of Urology), Mubarak Al-Kabeer Teaching Hospital and Faculty of Medicine, Kuwait University, Kuwait

SUBJECTS

Urine cytology smears obtainedpriorto cystoscopy in patients with transitional cell carcinoma (TCC) of the bladder were immunostained for EGFR and survivin. Bladder cancer tissue resected at surgery was also immunostained for EGFR and survivin expression. Tissue expression of EGFR and survivin in TCC of the bladder was compared to their expression in urine cytology and relationship to tumour grade and stage.

RESULTS

178 patients were studied (43 newly diagnosed bladder cancer, 58 with recurrent TCC and 77 in disease remission). Twenty five patients with normal urothelium served as controls. The mean sensitivity of urine cytology, tissue survivin immunohistochemistry (IHC) and tissue EGFR IHC was 30.5%, 62% and 59% respectively. The corresponding mean specificity was 95%, 79% and 38% respectively. For grades 1, 2 and 3 bladder tumors, tissue expression positivity for EGFR was 47.8%, 92.9%, 100% and for tissue survivin it was 27.8%, 18.2% and 33.3% respectively. For grades 1, 2 and 3 bladder tumors, urine expression positivity for EGFR was 35.7%, 40% and 67.7% and for urine survivin it was 8.3%, 42.9% and 33.3% respectively.

CONCLUSION

Positive EGFR immunostaining of urine cytology specimen or tumour tissue increases with histological grade of TCC of the bladder. Survivin expression is less consistent in both urine cytology specimen and tissue samples. EGFR immunostaining may provide a useful tool in the grading of bladder TCC and aid in the selection of patients that may benefit from administration of EGFR inhibitors.

Sonographic fetal biometry charts for a Pakistani cohort

This study aimed to develop growth centiles at different gestational weeks for fetal biparietal diameter, abdominal circumference, femur length and head circumference in a Pakistani cohort. Data were collected at a tertiary referral hospital from pregnant women at gestational ages 13-40 weeks referred for obstetric ultrasound as a part of routine antenatal care. A total of 1599 fetal sonographic biometric measurements were collected after screening for the inclusion criteria. For each measurement, separate regression models were derived to estimate the mean, standard deviation and reference percentiles at each week of gestational age for this cohort. The best fitting model for each variable was selected. These charts will help radiologists and clinicians in predicting dates of delivery, assessing fetal growth and identifying intrauterine fetal insufficiency in the Pakistani population.

Staging of prostatic adenocarcinoma with radical prostatectomy specimens in Pakistan

OBJECTIVES

Data for pathological staging of radical prostatectomy specimens reported in the Section of Histopathology of a large tertiary care hospital in Pakistan were compared with sextant biopsy findings to determine whether clinically localized disease is actually localized pathologically.

DESIGN

A study was conducted of radical prostatectomy specimens reported in the Section of Histopathology from Jan 2001 to July 2008, with cases staged according to the pathologic TNM staging system. Other variables such as amount of tumor in prostatectomy specimens and lobes affected were also determined.

RESULTS

Out of 65 cases, 83.3% were clinical stage TIc. 29.2% were pT3a, 24.6% were pT3b and 3.1% were pT4. Therefore, in the majority of cases, disease was not localized to the prostate and perineurial invasion was seen in all. Comparison with biopsy results showed Gleason's grade to be altered in 20% cases.

CONCLUSIONS

The large majority of prostatic carcinomas in Pakistan are advanced cancers with pathologic stage more advanced than evident on clinical staging. On average, tumors involved 35-40% of the prostate with a particular preponderance in posterior lobes.

High-risk behaviours among juvenile prison inmates in Pakistan

OBJECTIVES

To assess the sexual- and drug-use-related risk behaviours of male juvenile detainees in Karachi, Pakistan.

DESIGN

Cross-sectional study.

METHODS

A cross-sectional study was conducted of prison inmates aged 15-21 years in Karachi Juvenile Prison in 2002. In total, 321 inmates were interviewed about sexual orientation and behaviours, and knowledge about human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). Urine specimens were collected and tested for Chlamydia trachomatis and Neisseria gonorrhoeae using ligase chain reaction.

RESULTS

A substantial proportion (n=111, 34.6%) of the participants were sexually active. Sixty-two (19%) and 67 (21%) had had sex with a male or female before incarceration, respectively. Twenty-seven (8.4%) participants had an STI, and 50% of the 109 sexually active participants had had multiple sexual partners. Use of addictive substances was associated with sexual activity. The mean knowledge score computed from the sum of 16 items was 4.7, with a median of 2.9. A large proportion (40%) of participants knew about condoms, but very few (3.4%) had ever used one. The mean+/-standard deviation risk score from nine items was 2.4+/-1.7. On the basis of behavioural and biological markers, 117 (36.4%) participants had high-risk behaviour. In multivariate logistic regression analysis, knowledge, risk perception and age were predictive of higher risk.

CONCLUSIONS

HIV risk behaviours are common among adolescent inmates. Although inmates do have knowledge about modes of transmission and condom use, the use of condoms is significantly low. Interventions are needed for behavioural change among this group.

Severe acute maternal morbidity and intensive care in a public sector university hospital of Pakistan

BACKGROUND

The study was planned to review the case series of pregnant women requiring intensive care due to severe acute maternal morbidity in the public sector university hospital, in order to identify failures and priorities in maternal health care provision in Pakistan.

METHODS

A retrospective case series study was performed of critically ill obstetrics patients admitted to general intensive care unit of Liaquat University Hospital Hyderabad, Pakistan, from January 1st to 31st December 2006. Data included demographics, disease responsible for critical illness, complications that prompted ICU admissions, intervention required, length of ICU stay and the resulting foeto-maternal mortality and morbidity.

RESULTS

Over the study period, 30 obstetric patients were transferred to general ICU, representing 1.34% of 2224 deliveries. Seventy three % of women belonged to rural areas, 96% were un-booked while history of surgical intervention was present in 87% of cases. Hypertensive disorders of pregnancy (50%) and sepsis (17%) were the two main obstetrical conditions responsible for maternal illness. Respiratory failure (57%) and haemodynamic instability (40%) were the major indications for ICU transfer. Mechanical ventilatory support was the commonest intervention required in the ICU followed by the ionotropic support (33%). The foetal mortality rate was 43%, while maternal mortality rate was 33%.

CONCLUSION

Maternal morbidity and mortality can be reduced by meticulous adaptation of safe motherhood initiative, provision of separate ICU services for critically ill obstetrical patients and early assessment and aggressive intervention through a team approach involving obstetricians, intensivists and anaesthetists.

Renal lymphangiectasia

Renal lymphangiectasia is a benign disorder of renal lymphatics. Seldom observed, the pathophysiology is unclear. The clinical course may vary, and management alternatives range from percutaneous drainage in symptomatic cases to pharmacological substitutes in the form of anti-hypertensives and diuretics. We present a case of bilateral perinephric collections on imaging, which presented with gross ascites, abdominal pain and reversible hypertension. Ultrasound examination indicated ascites. Computerized tomography revealed bilateral symmetrical large perinephric collections. This is consistent with the appearance of renal lymphangiectasis (enlarged kidneys with fluid collections seen to be abutting the surrounding structures) reported in the literature. Needle aspiration of the perinephric fluid was undertaken, and laboratory analysis was carried out, which revealed a protein level of 643 mg dl(-1) and a total leucocyte count of 50, of which 80% were lymphocytes. Thereafter, a diagnosis of renal lymphangiectasia was made, and conservative treatment with diuretics and anti-hypertensives was initiated. Reassessment at subsequent follow up visits showed improvement in the patient's clinical condition.

Prostate Cancer Risk: The Significance of Differences in Age Related Changes in Serum Conjugated and Unconjugated Steroid Hormone Concentrations Between Arab and Caucasian Men

INTRODUCTION

Factors responsible for the low incidence of clinical prostate cancer (3-8/100,000 men/year) in the Arab population remain unclear, but may be related to changes in steroid hormone metabolism. We compared the levels of serum conjugated and unconjugated steroids between Arab and Caucasian populations, to determine if these can provide a rational explanation for differences in incidence of prostate cancer between the two populations.

PATIENTS/METHOD

Venous blood samples were obtained from 329 unselected apparently healthy indigenous Arab men (Kuwaitis and Omanis) aged 15-80 years. Samples were also obtained from similar Arab men with newly diagnosed prostate cancer or benign prostatic hyperplasia (BPH). The samples were taken between 8:00 am and 12:00 noon. Serum levels of total testosterone, (TT), sex hormone binding globulin (SHBG), free androgen index (FAI); adrenal C19-steroids, dehydroepiandrosterone sulphate (DHEAS) and androstenedione (ADT) were determined using Immulite kits (Diagnostic Systems Laboratories Inc, Webster Texas, USA). The results obtained in Arab men were compared with those reported for similarly aged Chinese, German and White USA men.

RESULTS

In all four ethnic groups, median TT and FAI declined with age, while SHBG increased with age. However, the mean TT and SHBG was significantly lower (p < 0.01) and the FAI significantly higher in Arab men (p < 0.01) compared to German men only in 21-30 years age group. In the other age groups the levels of TT and SHBG were higher in the Germans but the differences were not statistically significant. In all the racial groups serum levels of DHEAS and ADT reached a peak by about 20 years of life, and then declined progressively. The mean DHEAS in American Caucasians aged 20-29 years was 11.4 micromol/l compared to 6.22 micromol/l in the Arabs (p < 0.001). The mean DHEAS in USA Caucasians aged 70-79 years was 2.5 micromol/l compared to 1.8 micromol/l (p < 0.03) in the Arabs. There was no significant difference in mean serum levels of DHEAS between German and USA men. Similarly, there was no significant difference in the level of the hormones between Arab and Chinese men. Arab men with newly diagnosed prostate cancer had high serum TT, SHBG and DHEAS compared to those without the disease.

CONCLUSIONS

The mean TT and SHBG was significantly lower in Arab men compared to Caucasian men especially in early adulthood. Caucasians have significantly higher serum levels of the precursor androgens DHEAS and ADT especially in early adulthood compared to Arab men. These observations of low circulating androgens and their adrenal precursors in Arab men may partially account for the decreased risk for prostate cancer among Arab men.

Prevalence of HIV, hepatitis B and C amongst health workers of Civil Hospital Karachi

OBJECTIVE

To determine the prevalence of HIV, Hepatitis B (HBV) and Hepatitis C (HCV) amongst the health workers of Civil Hospital Karachi (CHK).

MATERIAL AND METHODS

Prospective study. A precoded Proforma was filled out which included questions regarding the knowledge, attitude and practices (KAP) of HIV, HBV and HCV.

SETTING

Departments of a tertiary health care facility at CHK. Antibodies to HIV, HCV and Hepatitis B surface antigen (HBsAg) were done using enzymes linked immunosorbent assay [ELISA].

RESULTS

Uptake of screening was 98% to those offered. The prevalence was 5.6% for antibodies to HCV, 2.4% for HBsAg, while none of those studied had antibodies to HIV.

CONCLUSION

Our results show the prevalence of antibodies to HCV in health workers are 20 folds higher than health workers in the developed countries. Similarly, the prevalence of HBV although not as high as HCV is significant. Seroprevalence of HIV does not exist in this group. We need to ensure better training; regulations regarding preventive and safety measures also need to be enforced (JPMA 52:92; 2002).

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Unilateral poliosis of the eyelashes in children associated with vitiligo

Two children developed sudden progressive unilateral poliosis of their eyelashes during the course of a 1-month period. The poliosis occurred in the absence of any associated condition apart from vitiligo, both of which have remained isolated findings after 2 and 4 years of follow-up, respectively. Although it is important to exclude associated conditions, poliosis of the eyelashes may be a benign condition that may remain unilateral.

Pattern and determinants of dyslipidaemia in type 2 diabetes mellitus patients in Kuwait

We conducted a clinical study to assess the pattern of dyslipidaemia in type 2 diabetic patients and to examine the demographic and clinical factors associated with dyslipidaemia. The study population comprised 206 consecutive type 2 diabetic patients attending the out-patient clinic at a major hospital in Kuwait. Clinical history and physical examination were done and fasting blood samples were taken to determine HbA1c and lipid levels. American Diabetes Association criteria were applied to define clinical targets for lipid levels and coronary heart disease risk categories. Stepwise multiple linear regression was conducted to identify the demographic and clinical factors associated with lipid levels outside of the clinical target. The large majority of the patients were either over-weight (32%) or obese (57%); the mean BMI was 32.6 kg/m2. Serum total cholesterol, LDL-cholesterol, and triglycerides were above optimal levels in 67%, 86%, and 25% of patients, respectively. For HDL-cholesterol, 63% of men and 71% of women had values below the corresponding optimal level. Only 14 patients (6.8%) had all three lipid values within the respective target level. The percentages of patients with one, two, or all three lipid values outside of target were 31%, 46%, and 16%, respectively. The most frequent (41%) pattern of dyslipidaemia was a combination of LDL-cholesterol level above target with HDL-cholesterol level below target; the second most common pattern was an isolated increase in LDL-cholesterol, observed in 21% of the patients. In the stepwise regression analyses, glycaemic control was strongly associated with dyslipidaemia (i.e. high total- and LDL-cholesterol and triglycerides); female gender were associated with low HDL-cholesterol. Kuwaiti type 2 DM patients have a high prevalence of dyslipidaemia and obesity. Weight reduction, increased physical activity, improved glycaemic control, and increased HDL-cholesterol levels, along with reduced LDL-cholesterol, should be important goals of therapy in these patients to reduce the risk of coronary heart disease.

Changes in blood levels of eosinophil cationic protein and tryptase after exercise challenge in adolescents with exercise-induced asthma

BACKGROUND

Exercise-induced asthma (EIA) is increasingly encountered among school children in Kuwait. Available evidence has shown that inflammatory mediators may be involved in the pathogenesis of EIA. Studies on release of inflammatory mediators have been carried out in adult patients with asthma in Kuwait, but no study on EIA involving children has taken place in this region.

OBJECTIVE

To investigate changes in the concentration of some of the mediators involved in EIA in adolescent school children, using exercise challenge.

DESIGN

Prospective, case control study.

SETTING

Respiratory and Cardiology units Mubarak Hospital, Kuwait, between January and June 2001.

SUBJECTS

Nine EIA and 14 non-EIA and 10 normal control subjects, designated as groups one, two and three aged between 13 and 17 years, who were non-smokers, were enrolled for the study.

MAIN OUTCOME MEASURES

Blood eosinophils (EOS), eosinophil cationic protein (ECP) and tryptase were estimated pre-exercise, 5 and 30 minutes after exercise. Spirometry was measured at the same period.

RESULTS

In group one, ECP and tryptase levels fell after exercise, but significant difference in the levels were obtained only in tryptase between pre-exercise and 30 minutes after exercise (4.1 microg/L Vs 3.8 microg/L) P <0.05, while the difference for ECP was not significant (P=0.09). In group two, both tryptase (6.0 microg/L Vs 5.7 microg/L) P < 0.05, and ECP (21.8 microg/L Vs 12.1 microg/L) P<0.01, fell after exercise. However, in group three, no appreciable difference was observed between pre and post exercise. Correlation between tryptase and EOS (r=0.770; P<0.05) and between tryptase and ECP (r=0.850; p<0.05) was observed pre-exercise and after exercise in groups one and two.

CONCLUSION

A fall in the level of the mediators was observed after exercise challenge, but the relevance of this finding in the pathogenesis of EIA remains unclear. Further studies are required to verify this finding.

Family history of benign thyroid disease and cancer and risk of thyroid cancer

In a population-based study of 313 case-control pairs in Kuwait, we evaluated whether a family history of benign thyroid disease (BTD) and thyroid or other cancers was associated with an increased risk of thyroid cancer, the second most common neoplasm among women in this and several other Arab countries in the Gulf region. Family history of BTD was reported by 78 (24.9%) cases and 40 (12.8%) controls in 132 and 57 relatives, respectively. There was an approximately 2-fold increased risk of thyroid cancer in individuals who had a mother (Odds Ratio (OR)=2.3; 95% Confidence Intervals (95% CI): 1.1-5.1), sister(s) (OR=2.6; 95% CI: 1.3-5.3) or aunt(s) (OR=2.1; 95% CI: 0.9-5.3) with BTD; there was also a significant trend in increasing risk with an increasing number of affected female relatives (P<0.0001). Stratification by age at diagnosis of the case showed that individuals aged </= 35 years, who had an affected first- or second/third-degree relative(s), had an approximately 3-fold increased risk of the cancer. Family history of thyroid cancer was reported by 9 (2.9%) cases in 13 relatives (11 females, 2 males) and by 3 controls in 3 relatives (all females) (OR=3.0; 95% CI: 0.8-11.1). The OR for all hormone-related cancers combined was 1.5 (95% CI: 0.8-2.6). There was no clear association with family history of breast or any other common cancer. Our data suggest that a family history of BTD is associated with an increased risk of thyroid cancer, and point to the role of familial susceptibility to BTD and thyroid cancer in the Kuwaiti population.

Dental health knowledge, attitudes and behaviour among students at the Kuwait University Health Sciences Centre

OBJECTIVE

The aim of the study was to determine the extent of dental health knowledge among students at the Kuwait University Health Sciences Centre (HSC), as well as their attitudes toward dental health and their oral hygiene habits.

METHODS

A structured questionnaire was distributed to 450 of the 800 students enrolled in 3 faculties of the HSC from March to April 2000. The questionnaire was completed anonymously by the students.

RESULTS

Four hundred and ten students (91.1%) completed the questionnaire. Of these, 64.6% believed that the main cause of tooth decay was 'not brushing properly'. Only 19.3% of the students believed that sugar could cause dental decay. Half of the students did not know if sugar-free drinks are harmful to their teeth, and 29.5% did not know about any measures to prevent gums from bleeding. Self-assessment questions showed that 84.5% of the students were satisfied with their dental health. A large majority of the students (94.8%) brushed their teeth at least once a day. Female students brushed their teeth more frequently than male students, as did those students who had visited a dentist in the past 6-12 months and those who rated their dental health to be very good. The main reason given for a dental visit was toothache (70.0%). Coffee was consumed daily by 68.9% of students, 76.6% of whom added sugar to their coffee.

CONCLUSIONS

The findings indicate that although most of the students at the HSC seem to be satisfied with their dental health, they did not have correct knowledge about the causes and prevention of dental diseases. In general, female students were more aware and concerned about dental health issues and more engaged in dental behaviour than male students.

Three-dimensional visualization of the craniofacial patient: volume segmentation, data integration and animation

The research goal at the Craniofacial Virtual Reality Laboratory of the School of Dentistry in conjunction with the Integrated Media Systems Center, School of Engineering, University of Southern California, is to develop computer methods to accurately visualize patients in three dimensions using advanced imaging and data acquisition devices such as cone-beam computerized tomography (CT) and mandibular motion capture. Data from these devices were integrated for three-dimensional (3D) patient-specific visualization, modeling and animation. Generic methods are in development that can be used with common CT image format (DICOM), mesh format (STL) and motion data (3D position over time). This paper presents preliminary descriptive studies on: 1) segmentation of the lower and upper jaws with two types of CT data--(a) traditional whole head CT data and (b) the new dental Newtom CT; 2) manual integration of accurate 3D tooth crowns with the segmented lower jaw 3D model; 3) realistic patient-specific 3D animation of the lower jaw.

Sampling variability on percutaneous liver biopsy in patients with chronic hepatitis C virus infection

BACKGROUND

Sampling variability on liver biopsy has been demonstrated in a variety of liver diseases. The objective of this study was to determine whether sampling variability exists on percutaneous liver biopsy in patients with chronic HCV infection.

METHODS

Two separate tissue samples were obtained from the right lobe of the liver, through a single skin puncture, in 29 patients (22 M, mean age 43.4 +/- 8.1 years) with chronic HCV infection. The biopsies were assessed using a descriptive histological reporting system and Knodell's Histological Activity Index (HAI) and compared for differences in necroinflammatory activity (grade) and fibrosis (stage).

RESULTS

Thirteen (44.8%) patients had a difference of > or = 1 grade between the 2 biopsies on the descriptive system and 13 differed by > or = 1 stage. On the HAI, 20 (69.0%) patients had a difference of > or = 2 in the necroinflammatory activity score and 10 (34.5%) had a difference of > or = 4; whereas, 11 (38.0%) patients had a difference of > or = 1 in the fibrosis score and 6 (20.7%) had a difference of > or = 2. The mean difference between the two sets of biopsies was 2.4 +/- 2.1 (range 0-7) for the necroinflammatory activity and 0.6 +/- 0.9 (range 0-3) for fibrosis. Spearman's correlation coefficient (r) was moderate for both necroinflammatory activity (r = 0.53, P < 0.01) and fibrosis (r = 0.62, P < 0.0001).

CONCLUSIONS

Sampling variability exists on percutaneous liver biopsy in patients with chronic HCV infection and should be taken into consideration when decisions regarding prognosis and therapy are made based on biopsy, and when defining histological response to antiviral regimens.