Experiences, awareness, perceptions and attitudes of women and girls towards menstrual hygiene management and safe menstrual products in Pakistan

Background

The taboo of menstruation, lack of discussion on puberty, misinformation and poor awareness on menstrual hygiene management and limited access to safe menstrual products can negatively impact the physical and mental health of women and girls residing in low middle income countries.

Aim

The aim of the study was to explore the experiences, awareness, perceptions and attitudes of women and girls towards menstrual hygiene management in Pakistan. Moreover, the study also assessed consumer satisfaction towards locally manufactured organic menstrual products.

Methods

A descriptive cross-sectional study design was used with a sample of 400 women and girls selected through convenience sampling from high schools, universities, outpatient department and gynaecological clinics located in 2 cities, i.e., Islamabad and Rawalpindi, Pakistan. A pre-structured questionnaire was used to explore experiences, awareness, perceptions and attitudes of women and girls towards menstrual hygiene management. Moreover, each respondent was provided with sample of locally designed and manufactured organic menstrual hygiene & wellness kit by a group of women researchers named "FemPure" including organic sanitary pads, feminine wellness mist and feminine wellness wash. The respondents were asked to use the products and a telephonic follow-up was conducted to assess consumer satisfaction for the products after a period of 1 month. Data was analyzed statistically using SPSS 21.

Results

The results of the study reported that 86.2% (n = 345) of the respondents had normal periods. Out of 400 respondents, 58.5% (n = 234) knew about any health conditions related to abnormal menstrual cycle while 88.3% (n = 353) were aware of female menstrual hygiene. Majority of the respondents 78.7% (n = 315) felt ashamed while buying sanitary pads. Out of 400 respondents, 5.4% (n = 22) were interested in getting awareness regarding menstrual hygiene. The results of the study showed that all the respondents (100%, n = 400) were satisfied with FemPure organic menstrual products.

Conclusion

The study concluded that majority of women and girls faced menstrual hygiene issues during and after the cycle and were eager to receive information on MHM and use organic rash free menstrual wellness products which could be ordered via mobile app. The respondents were satisfied after the use of FemPure organic menstrual products.

Perceptions of community pharmacists regarding their role in antimicrobial stewardship in Pakistan: A way forward

Background

Antimicrobial resistance is one of the biggest challenges to healthcare resulting in increased morbidity and mortality, and associated with drug resistant infections. Community pharmacists (CPs) can play a key role in antimicrobial stewardship (AMS) programs to aid the prudent use of antibiotics, and in infection prevention and control.

Objective

The aim of this study was to assess perceptions of CPs regarding their role, awareness, collaboration, facilitators and barriers towards effective AMS practices in Pakistan.

Method

ology: A descriptive, cross-sectional study design was adopted, where convenience and snowball sampling methods were applied to enroll respondents (pharmacists working at these community pharmacies in different cities of Pakistan) of the study. After sample size determination, n = 386 CPs were enrolled. A pre-validated questionnaire was used regarding CPs roles and perceptions in association with AMS. Statistical analysis was performed using SPSS v. 21.

Results

The results of the study reported that 57.3% (n = 221) of CPs had strong familiarity with term AMS. 52.1% (n = 201) of CPs agreed that they require adequate training to undertake activities in AMS programmes in their setting. The results of the study showed that 92.7% (n = 358) of the pharmacists thought real time feedback would be helpful. Significant association was observed in AMS awareness, approach, collaboration and barriers with regards to the respondents' gender, age groups and levels of experience in a community pharmacy.

Conclusions

The study concluded that CPs were aware of AMS programmes, their relevance and necessity of AMS in their everyday practice, but had inadequate training and resources to implement it in Pakistan.

Barriers to gender equity for female healthcare academicians and researchers in Pakistan: Is it still an issue?

Introduction

Gender inequity in healthcare academia is rising. Female healthcare professionals are struggling to balance their work and family leading to reduced productivity and disparity in three main areas of academic evaluation including teaching, service and research.

Objective

The objective of the current study was to explore perceptions of healthcare academicians regarding gender equity and its associated barriers in healthcare academia in Pakistan.

Methodology

A qualitative study design was used. Study site for this research included medical colleges, pharmacy schools and healthcare educational institutes. Study respondents included healthcare professionals including doctors and pharmacists working as faculty members. Snow ball sampling was used and interviews were conducted till saturation point was achieved. All interviews recorded were transcribed verbatim. Transcribed interviews were then subject to thematic analysis and were analyzed for relevant content.

Results

Thematic analysis of the study yielded many themes and sub themes. The main themes include: Gender equity an issue for healthcare academicians; Barriers toward promoting gender equity among healthcare academicians; Perceived teaching effectiveness among female healthcare academicians; Professional relationship of female healthcare academicians; Representation of female healthcare academicians at leadership positions; Research opportunities for female healthcare academicians; impact of academia as profession on married life and Strategies for improving gender equity disparities in academia of healthcare profession. The results showed that almost all the females as well as male healthcare academicians were of the view that female academicians are competent, hardworking and committed with their jobs. Mixed responses were observed regarding teaching effectiveness of female academicians. Half of the females as well male healthcare academicians thought that female were more effective teachers while other half was of the view that teaching effectiveness is based on individual trait irrespective of gender.

Conclusion

The results of the present study concluded that majority of the male as well as female healthcare professionals perceived gender equity as an issue in academia in Pakistan, especially in underprivileged areas. Non-conducive work environment, harassment at workplace and cultural issues were the main barriers identified toward gender equity in healthcare academia in Pakistan.

Effectiveness of Community Pharmacy Diabetes and Hypertension Care Program: An Unexplored Opportunity for Community Pharmacists in Pakistan

Background: The effective management of patients diagnosed with both Diabetes as well as Hypertension is linked with administration of efficacious pharmacological therapy as well as improvement in adherence through counseling and other strategies. Being a part of primary healthcare team, community pharmacists can effectively provide patient care for chronic disease management. The objective of the study was to evaluate the impact of pharmacist counseling on blood pressure and blood glucose control among patients having both hypertension and diabetes attending community pharmacies in Pakistan. Method: A randomized, controlled, single-blind, pre-post-intervention study design was used. The respondents included patients diagnosed with diabetes mellitus (Type I or II) and hypertension visiting community pharmacies to purchase their regular medicine. A simple random sampling technique using the lottery method was used to select community pharmacies in groups A (intervention, n = 4) and group B (control, n = 4). The total number of patients was 40 in each group, while estimating a dropout rate of 25%. The patients in the intervention group received special counseling. Blood pressure and blood glucose were checked after every 15 days for 6 months. Prevalidated tools such as the hypertension knowledge level scale, the diabetes knowledge questionnaire 24, and a brief medication questionnaire was used. Data were coded and analyzed using SPSS 21. Wilcoxon test (p < 0.05) was used to compare pre-post intervention knowledge regarding the disease, while the Mann-Whitney test (p < 0.05) was used to find differences in medication adherence among control and intervention groups. Results: A significant improvement in mean knowledge scores of patients with diabetes (16.02 ±2.93 vs. 19.97 ±2.66) and hypertension (15.60 ±3.33 vs. 18.35 ±2.31) in the intervention group receiving counseling for 6 months than control group (p < 0.05) was noted. Furthermore, the fasting blood glucose levels (8.25 ±1.45) and systolic BP (130.10 ±6.89) were significantly controlled after 6 months in the intervention group. Conclusion: The current study results concluded that community pharmacists' counselling has a positive impact on blood glucose and blood pressure management among patients suffering with both diabetes and hypertension.

Expectations and experiences of women regarding maternal healthcare services in Pakistan: challenges and lessons to be learnt

BACKGROUND

Access to maternal healthcare services is an essential pre-requisite for improving women's health. However, due to poor access and underutilization, women in developing countries remain vulnerable to various complications. Evaluation of quality maternal healthcare services in any country must include the opinions of the women being as a key stakeholder utilizing maternal healthcare services.

AIM

The present study was designed to evaluate the experiences, perceptions and expectations of pre-birth and post-birth women regarding utilization and delivery of maternal healthcare services in Pakistan.

METHODOLOGY

A qualitative study design was used. Snow ball sampling technique was adopted to identify the respondents. Interviews were conducted using semi-structures interview guide till saturation point was achieved. The sample size at saturation point for different respondents was: pre-birth women (n = 9) and post-birth women (n = 9). All interviews were recorded after getting permission from the respondents. The interviews were transcribed verbatim and were then subjected to thematic analysis.

RESULTS

The age group for the pre-birth respondents was 23-43 years while for post-birth group it was 23-32 years. Most of the respondents from both groups were from urban setting. Most of them were either first time pregnant or were having experience of one pregnancy. Thematic analysis of the interviews yielded different themes and sub-themes including birth experience, maternal treatment pathway, identified barriers for quality maternal care, involvement in healthcare decision-making, impact of Covid 19, payment dynamics, role of digital health and recommendations for improving maternal care services.

CONCLUSION

The results of the present study concluded that the overall quality of the maternal care services provided in Pakistan was not up to the mark. High rate of caesarian section was prevalent. Majority of the women were not involved in the decision-making process or provided with any birth plan or counselling regarding birth signs, family planning, danger and birth signs. The cost of maternal care was quite high and not affordable for all.

Racial disparities in the use of mechanical circulatory support devices in cardiogenic shock

Background

Racial bias has always been a concern for healthcare. Lack of guideline directed utilization of mechanical circulatory support (MCS) devices in cardiogenic shock (CS) may lead to implicit and racial bias.

Purpose

To identify the racial differences in the use of mechanical circulatory support in cardiogenic shock and its association with outcomes.

Methods

National Inpatient Database from 2015–2018 using ICD 10 codes was used. Patients &gt;18 years of age admitted for cariogenic shock were included.

Results

Among 1,021,274 patients hospitalized for cardiogenic shock, overall MCS was utilized in 11.4% (N=116,539). Use of MCS for patients stratified by race was 12.2% white (N=85543), 8% Blacks (N=14688), 11.3% Hispanics (N=11067), 13.8% Asian (N=4417), 12.3% Native American (N=825). IABP was the most commonly used MCS device, followed by Impella, ECMO and LVAD. Overall odds of MCS insertion was significantly higher in white population [1.18 (1.13–1.23) &lt;0.001] and significantly lower in Blacks [0.65 (0.61–0.69) &lt;0.001] and Hispanics [0.89 (0.83–0.97) 0.004]. Among black patients with CS requiring MCS, odds of LVAD insertion were similar compared to other races [1.03 (0.89–1.19) 0.714], while odds of all other types of MCS devices including ECMO [0.83 (0.72–0.95) 0.009], IABP [0.63 (0.59–0.68) &lt;0.001] and Impella [0.61 (0.54–0.70) &lt;0.001] were significantly lower compared to other races. This trend also holds true for patients with CS associated with acute myocardial infarction. Among all patients with CS, the odds of mortality were significantly lower among white patients [0.92 (0.90–0.95) &lt;0.001], on the contrary, odds of mortality were significantly higher in Blacks [1.06 (1.02–1.10) 0.001] and Asians [1.11 (1.02–1.20) 0.012]. Interestingly, when only comparing patients who underwent MCS utilization for CS, odds of mortality were similar in black population compared to other races. [1.03 (0.91–1.17) 0.636].

Conclusion(s)

There still exist significant racial differences in the use of mechanical circulatory devices for cardiogenic shock potentially leading to significantly higher mortality in black population compared to whites. This difference in mortality is mitigated with equal use of MCS devices in cardiogenic shock among all races.

Funding Acknowledgement

Type of funding sources: None.

Folate supplementation to prevent birth abnormalities: evaluating a community-based participatory action plan for refugees and migrant workers on the Thailand-Myanmar border

Objectives

Preconception folic acid (PFA) taken at least 3 months before conception can decrease the incidence of neural tube defects (NTDs) by approximately 46%. NTDs contribute significantly to neonatal morbidity and mortality in migrant and refugee populations on the Thailand-Myanmar border (incidence 1.57/1000 live births). This audit aimed to assess uptake of PFA among migrant and refugee women, evaluate knowledge about PFA among local healthcare workers and implement a participatory community intervention to increase PFA uptake and decrease NTD incidence in this population.

Study design

A mixed-methods baseline evaluation was followed by an intervention involving health worker education and a community outreach program. A follow-up audit was performed 18 months post-intervention.

Methods

Data were gathered via surveys, short interviews and focus group discussions. The intervention program included community-based workshops, production and distribution of printed flyers and posters, and outreach to various local organisations.

Results

Uptake of PFA was <2% both before and after the intervention. Despite a substantial increase in local healthcare worker knowledge of PFA, no significant improvement in PFA uptake after the intervention was detected. Most pregnancies in this local community sample were reported to be unplanned.

Conclusions

High rates of NTDs with low PFA uptake remains a major public health challenge in this transient population. Results indicate that improved health worker knowledge alone is not sufficient to enhance PFA uptake in this population. Integration of PFA education within expanded family planning programs and broad-based food fortification may be more effective.

•

Audited preconception folic acid (PFA) campaign on Thai-Myanmar border.

•

Low awareness of PFA among health workers and migrant/refugee pregnant women.

•

Improved local health worker PFA knowledge after campaign and follow-up held after 18 months.

•

Overall, campaign proved ineffective in increasing PFA uptake among pregnant women.

Age and mortality after injury: is the association linear?

INTRODUCTION

Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists.

METHODS

We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p < 0.05.

RESULTS

A total of 1,107 patients were included in the analysis. One-third required intensive care unit (ICU) admission and 48 % had traumatic brain injury. 229 patients (20.6 %) were 84 years of age or older. The overall mortality was 7.2 %. Our model indicates that mortality is a quadratic function of age. After controlling for confounders, age is associated with mortality with a regression coefficient of 1.08 for the linear term (p = 0.02) and a regression coefficient of -0.006 for the quadratic term (p = 0.03). The model identified 84.4 years of age as the inflection point at which mortality rates begin to decline.

CONCLUSIONS

The risk of death after injury varies linearly with age until 84 years. After 84 years of age, the mortality rates decline. These findings may reflect the varying severity of comorbidities and differences in baseline functional status in elderly trauma patients. Specifically, a proportion of our injured patient population less than 84 years old may be more frail, contributing to increased mortality after trauma, whereas a larger proportion of our injured patients over 84 years old, by virtue of reaching this advanced age, may, in fact, be less frail, contributing to less risk of death.

Pediatric kidney transplantation in the developing world: challenges and solutions

The prevalence of pediatric RRT and transplantation are low in developing countries, 6-12 and <1 to 5 per million child population (pmcp), respectively. This is due to low GDP/capita of <$10 000, government expenditure on health of <2.6-9% of GDP and paucity of facilities. The reported incidence of pediatric CKD and ESRD is <1.0-8 and 3.4-35 pmcp, respectively. RRT and transplantation are offered mostly in private centers in cities where HD costs $20-100/session and transplants $10 000-20 000. High costs and long distance to centers results in treatment refusal in up to 35% of the cases. In this backdrop 75-85% of children with ESRD are disfranchised from RRT and transplantation. Our center initiated an integrated dialysis-transplant program funded by a community-government partnership where RRT and transplantation was provided "free of cost" with life long follow-up and medication. Access to free RRT at doorsteps and transplantation lead to societal acceptance of transplantation as the therapy of choice for ESRD. This enabled us to perform 475 pediatric transplants in 25 years with 1- and 5-year graft survival of 96% and 81%, respectively. Our model shows that pediatric transplantation is possible in developing countries when freely available and accessible to all who need it in the public sector.

Using whole-exome sequencing to identify inherited causes of autism

Despite significant heritability of autism spectrum disorders (ASDs), their extreme genetic heterogeneity has proven challenging for gene discovery. Studies of primarily simplex families have implicated de novo copy number changes and point mutations, but are not optimally designed to identify inherited risk alleles. We apply whole-exome sequencing (WES) to ASD families enriched for inherited causes due to consanguinity and find familial ASD associated with biallelic mutations in disease genes (AMT, PEX7, SYNE1, VPS13B, PAH, and POMGNT1). At least some of these genes show biallelic mutations in nonconsanguineous families as well. These mutations are often only partially disabling or present atypically, with patients lacking diagnostic features of the Mendelian disorders with which these genes are classically associated. Our study shows the utility of WES for identifying specific genetic conditions not clinically suspected and the importance of partial loss of gene function in ASDs.

A renal transplantation model for developing countries

The estimated incidence of end-stage renal disease (ESRD) in Pakistan is 100 per million population. Paucity and high costs of renal replacement therapy allows only 10% to get dialysis and 4-5% transplants. Our center, a government organization, started a dialysis and transplant program in 1980s where all services were provided free of charge to all patients. It was based on the concept of community government partnership funded by both partners. The guiding principles were equity, transparency, accountability and development of all facilities under one roof. This partnership has sustained itself for 30 years with an annual budget of $25 million in 2009. Daily 600 patients are dialyzed and weekly 10-12 receive transplants. One- and 5-year graft survival of 3000 transplants is 92% and 85%, respectively. The institute became a focus of transplantation in Pakistan and played a vital role in the campaign against transplant tourism and in promulgation of transplant law of 2007, and also helped to increase altruistic transplants in the country. This model emphasizes that in developing countries specialized centers in government sector are necessary for transplantation to progress and community support can make it available to the common man.

Need for a new trial to evaluate postoperative radiotherapy in renal cell carcinoma: a meta-analysis of randomized controlled trials

BACKGROUND

A meta-analysis was conducted to assess the impact of postoperative radiotherapy (PORT) in renal cell carcinoma (RCC) on overall survival (OS), disease-free survival (DFS) and locoregional failure (LRF).

MATERIALS AND METHODS

The Medline, CANCERLIT, Cochrane library database and search engines were searched to identify randomized controlled studies comparing radical nephrectomy alone with radical nephrectomy followed by PORT for localized RCC. Further, radiotherapy techniques and associated side-effects were evaluated.

RESULTS

Seven controlled trials with a total patient population of 735 were identified. Pooled results from these trials showed a significant reduction of LRF in patients treated with PORT (P < or = 0.0001). However, there was no difference in OS (P = 0.29) and DFS (P = 0.14). The majority of patients was treated with larger field sizes with parallel-opposed anteroposterior fields. PORT was generally well tolerated; in total, six PORT-related deaths were seen. The resultant funnel plot was broader (Egger test P = 0.14) due to low number of patients.

CONCLUSIONS

PORT significantly reduces LRF but has no effect on OS and DFS. However, due to poor patient accrual and older radiotherapy techniques in previous studies, there is a need for a new trial to evaluate PORT using conformal and intensity-modulated radiotherapy techniques.

Improving kidney and live donation rates in Asia: Living donation

Organ transplantation started with organs donated by living subjects. Increasing demands brought cadaveric organ donation. The brain-death law, mandatory for this procedure, is prevalent in all countries involved in organ transplantation except Pakistan. Spain is the leading country in cadaveric organ donation (32.5 pmp). Despite the sources of living and cadaveric organs, both heart-beating and non-heart-beating, the gap between the demand and supply has widened. An example is the United States, where the numbers of patients on the waiting list for kidney transplantation have risen from 30,000 in 1988 to more than 116,000 in 2001. This has caused a resurgence in living donors all over the world. These can be related, unrelated, spousal, marginal, or ABO-incompatible donors. Family apprehensions, medical care costs, and nonexistent social security can be barriers to this form of organ donation. Unrelated organ donation can open the doors to commercialism. To make this process more successful, transplantation should be made reachable by all sectors of the population. This is possible when transplantation is taken to the public sector institutions and financed jointly by the government and community. To increase living organ donation especially in Asian countries, which face barriers of low literacy rates, ignorance, and cultural and religious beliefs, more efforts are needed. Public awareness and education play an important role. Appreciation and supporting the donors is necessary and justified. It is a noble act and should be recognized by offering job security, health insurance, and free education for the donor's children.

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.

Pediatric urolithiasis: developing nation perspectives

PURPOSE

We evaluated epidemiology, etiology, dietary and urinary risk factors, and the composition of calculi in pediatric stone formers in Pakistan.

MATERIALS AND METHODS

This retrospective study includes 1,440 children treated between 1987 and 2000. Case records were reviewed for demographics, etiology and clinical symptoms. Dietary and urinary risk factors were analyzed prospectively in idiopathic stone formers. Stone composition was analyzed by infrared spectroscopy.

RESULTS

There were 1,075 males and 365 females for a male-to-female ratio of 3:1. The peak age for renal and bladder stones was 6 to 10 and 1 to 5 years, respectively. Overall 795 stones (55%) were renal, 198 (14%) were ureteral and 447 (31%) were vesical. Bladder stones were present in 60% of cases in the mid 1980s but decreased to 15% in the mid 1990s. The clinical symptoms were abdominal pain in 511 patients (51%) and fever in 193 (19.5%). There were anatomical abnormalities in 96 patients (12%), metabolic abnormalities in 206 (25%), infection stones in 60 (7%) and idiopathic stones in 444 (55%). Urinary analysis in idiopathic stone formers revealed hypercalciuria in 17 (11%), hyperoxaluria in 62 (40%), hyperuricosuria in 41 (27%) and hypocitruria in 97 (63%). Diet involved a low intake of protein in 60 cases (44%), calcium in 45 (33%), potassium in 105 (77%) and high oxalate in 75 (55%). The composition was calcium oxalate in 362 stones (47%), ammonium hydrogen urate in 210 (27%) and struvite in 49 (6.4%). Stones recurred in 30 patients (2%).

CONCLUSIONS

The pattern of calculous disease changed from a predominantly lower tract site in the mid 1980s to the upper tract in the mid 1990s. Stone composition, urinary risk factors and dietary analysis suggest that diet, dehydration and poor nutrition are the main causative factors of stone disease.

Pediatric urolithiasis: developing nation perspectives

PURPOSE

We evaluated epidemiology, etiology, dietary and urinary risk factors, and the composition of calculi in pediatric stone formers in Pakistan.

MATERIALS AND METHODS

This retrospective study includes 1,440 children treated between 1987 and 2000. Case records were reviewed for demographics, etiology and clinical symptoms. Dietary and urinary risk factors were analyzed prospectively in idiopathic stone formers. Stone composition was analyzed by infrared spectroscopy.

RESULTS

There were 1,075 males and 365 females for a male-to-female ratio of 3:1. The peak age for renal and bladder stones was 6 to 10 and 1 to 5 years, respectively. Overall 795 stones (55%) were renal, 198 (14%) were ureteral and 447 (31%) were vesical. Bladder stones were present in 60% of cases in the mid 1980s but decreased to 15% in the mid 1990s. The clinical symptoms were abdominal pain in 511 patients (51%) and fever in 193 (19.5%). There were anatomical abnormalities in 96 patients (12%), metabolic abnormalities in 206 (25%), infection stones in 60 (7%) and idiopathic stones in 444 (55%). Urinary analysis in idiopathic stone formers revealed hypercalciuria in 17 (11%), hyperoxaluria in 62 (40%), hyperuricosuria in 41 (27%) and hypocitruria in 97 (63%). Diet involved a low intake of protein in 60 cases (44%), calcium in 45 (33%), potassium in 105 (77%) and high oxalate in 75 (55%). The composition was calcium oxalate in 362 stones (47%), ammonium hydrogen urate in 210 (27%) and struvite in 49 (6.4%). Stones recurred in 30 patients (2%).

CONCLUSIONS

The pattern of calculous disease changed from a predominantly lower tract site in the mid 1980s to the upper tract in the mid 1990s. Stone composition, urinary risk factors and dietary analysis suggest that diet, dehydration and poor nutrition are the main causative factors of stone disease.

Living-related pediatric renal transplants: a single-center experience from a developing country

We retrospectively analyzed the results of 75 living-related pediatric renal transplants performed at our center between January 1986 and December 1999. The major causes of end-stage renal disease (ESRD) were glomerulonephritis (26%) and nephrolithiasis (16%), while the etiology was unknown in 50%. The mean age of the recipients was 12 yr (range 6-17 yr) and that of the donors was 39 yr (range 20-65 yr). The majority (73%) of donors were parents. Eighty five per cent of donors were one-haplotype matched and the rest identical. Immunosuppression was based on a triple drug regimen. Thirty per cent of recipients were rapid metabolizers of cyclosporin A (CsA) (area under the curve [AUC]: < 6,000 ng/mL/h), while 16% were slow metabolizers (AUC: > 8,000 ng/mL/h). Forty three (57%) children encountered 59 rejection episodes, the majority of which (59%) were recorded in the first month post-transplant. Seventy-four per cent of the rejection episodes were steroid sensitive and the rest, except two, were resolved by therapy with antithymocyte globulin (ATG) or orthoclone thymocyte 3 (OKT3). After a mean follow-up of 37 months, 17 (22%) grafts had chronic rejection and 76% of these recipients had previously experienced acute rejection episodes. The overall infection rate was high, necessitating two hospital admissions/patient/year. The majority (53%) of the infections were bacterial. Urinary tract infections (UTIs) were seen in 17 (23%) recipients. Twelve of these had ESRD as a result of stone disease and eight grafts were lost because of UTIs. Eight per cent of recipients developed tuberculosis (TB), and extra-pulmonary lesions were seen in 50%. Surgical complications were encountered in eight patients. Free medication to all recipients and parental support ensured a compliance rate of 93%. Baseline growth deficit was seen in children of the two groups studied (the 6-12 yr and 13-17 yr age-groups), with Z-scores of - 2.39 and - 2.12, respectively. No growth catch-up was observed at 12 and 24 months in either group. Post-donation complications were seen most commonly in donors > 50 yr of age and included: proteinuria (> 300 mg/24 h, four patients), hypertension (three patients), and diabetes (one patient). Twenty-four grafts were lost, 54% as a result of immunological and the rest as a result of non-immunological causes, and 17 recipients died during the follow-up period. Infections were the main cause of patient and graft loss. Overall 1- and 5-yr graft and patient survival rates were 88% and 65%, and 90% and 75%, respectively.

Ambulatory blood pressure monitoring after renal transplantation in children

Hypertension occurs commonly following renal transplantation and may cause end organ damage, such as cardiac hypertrophy. This study seeks to determine which features of hypertension are related to cardiac hypertrophy in children after renal transplantation. Ambulatory blood pressure monitoring (ABPM) was performed in 45 pediatric patients, 4.9+/-3.0 years after renal transplantation. ABPM data were related to clinical features and echocardiographic measurements. Hypertension was demonstrated in 33% of patients by casual blood pressure (BP) measurement and in 40% by ABPM. The mean percentage nighttime decline in BP (dipping) was 8.9+/-5.0% for systolic and 13.9+/-7.7% for diastolic BP. Abnormal dipping (<10%) was seen in 58% of patients. BP load (percentage of BP recordings above 95th percentile) was >30% in 44% of patients. Patients taking antihypertensive medication had more abnormal dipping and greater nighttime BP load. The prevalence of left ventricular hypertrophy was 72% before transplantation, 75% after transplantation, and 54% near to ABPM. Left ventricular mass (LVM) indexed to height(3) decreased significantly after transplantation. (40.2+/-14.7 vs. 35.0+/-8.3 g/m(3), P=0.0002). There was no significant relationship between ABPM data and LVM. ABPM was not able to differentiate those patients with persistently elevated LVM. The results suggest that hypertension is not always associated with cardiac hypertrophy following pediatric renal transplantation.

Cardiovascular risk factors after Kawasaki disease: a case-control study

OBJECTIVES

To determine cardiovascular risk profiles of patients with Kawasaki disease and to relate them to a noninvasive measure of endothelial function.

STUDY DESIGN

Case-control study. Cardiovascular risk assessment including brachial artery reactivity was performed in 24 patients 11.3 +/- 1.8 (mean +/- SD) years after Kawasaki disease and in 11 subjects in a normal control group.

RESULTS

The case versus control groups were similar regarding age, sex, race, body mass index, and percentage of ideal body weight, although cases had a higher mean z score of body mass index than normal (+1.00 +/- 1.18; P <.001). Cases had normal fasting total cholesterol levels but a higher mean z score of triglyceride levels (+1.35 +/- 2.04; P <.004). The case group had significantly higher mean systolic and diastolic resting blood pressure z scores (+0.76 +/- 1.06; P <.01 and +0.96 +/- 1.19; P <.01, respectively) than the control group and population norms. Endothelial function as indicated by brachial artery reactivity was not significantly different between the case versus control groups. In the case group higher blood pressure, increasing adiposity, and higher fasting triglyceride levels were significantly interrelated but did not relate to brachial artery reactivity or coronary artery abnormalities.

CONCLUSIONS

Patients after Kawasaki disease tend to have a more adverse cardiovascular risk profile potentially indicative of an increased predisposition to premature atherosclerotic changes.

Comparison of two transcatheter closure methods of persistently patent arterial duct

A randomized trial of arterial duct occlusion with a double umbrella (DU) or wire coil (WC) was undertaken for patients <18 years of age, weighing >10 kg with isolated ducts < or = 3 mm in diameter. Baseline, procedural, and outcome characteristics were compared in an intention-to-treat analysis according to randomization group. From 40 consecutively screened patients, 2 were not enrolled due to a ductal diameter of >3 mm on initial aortography, 38 patients were randomized to either the DU (n = 20) or WC (n = 18) groups. The groups did not differ significantly with respect to age, weight, gender, duct size, type, or branch pulmonary artery diameters. Crossover occurred only in the DU group, where 4 patients (20%) had a ductal diameter of < or = 1 mm and could not be entered for umbrella placement. All remaining DU group patients had ductal diameters of > or = 1.3 mm (p <0.0001). There were no embolizations or secondary implants in the DU group, but in the WC group there was 1 early and 1 late embolization, with 6 patients (33%) with > or = 2 coils. Mean times for the procedure (DU 68+/-19 minutes; WC 65+/-27 minutes; p = 0.70) and fluoroscopy (DU 14+/-4 minutes; WC 11+/-6 minutes; p = 0.22) did not differ significantly. Angiographic duct closure was documented in 4 of 13 patients (31%) of the DU group and 4 of 18 patients (22%) of the WC group (p = 0.69). Combined with an echocardiogram, closure in 11 of 17 patients with DU (65%) and 13 of 18 patients with WC (72%) (p = 0.64) was documented before hospital discharge. One WC group patient received thrombolytic therapy for a femoral artery thrombus. Follow-up at a median of 6.5 months (range 3.2 to 37) showed closure by Doppler echocardiography in 15 of 19 patients with DU (79%) versus 14 of 18 patients with WC (78%) (p = 1.0). Thus, with a tendency toward similar procedural characteristics and outcomes, the higher cost of the DU system compared with coil implants favors the use of coils for closure of the small arterial duct.